by Lynne H. Slim RDH, BSDH, MSDH
Jack and Grimsby are two of the best dogs I’ve ever had. The miniature wirehair pups were six months old when they first came home. Almost immediately I noticed that Grimsby’s gums were inflamed. On the other hand, when Jack was the same age, his gums were healthy, and as a pup his breath was actually pleasant. Jack is a bit of a Casanova who’s always trying to kiss me, but I don’t want his bacteria-laden tongue anywhere near my mouth! What is it about Grimsby’s immune response that makes him more susceptible to periodontal inflammation? Chronic periodontal infections require microbial stimuli (periodontal pathogens and perhaps even herpes viruses) which trigger an innate immune response and inflammation. What causes the exacerbation of inflammation in some hosts like the mighty Grimsby?
Judy Carroll, RDH, has something important to say about this matter because she augments nonsurgical periodontal therapy with subantimicrobial dose doxycycline (SDD). But that’s not all that she does. Judy is tops in the art of healing patients, and she follows the literature closely to try to separate opinion from scientific principle.
Let’s explore Judy’s journey and clinical discoveries, as she ended up practicing a unique nonsurgical periodontal therapy which she calls "Regenerative Periodontal Endoscopy," or RPE™. (Note: Judy’s nonsurgical periodontal protocol has not been rigorously tested, but Judy recognizes the importance of clinical trials to test her assumptions. See Judy’s Web site at www.periopeak.com for more details.)
How did Judy get started down this unique career path that led to RPE?
She said, "I was driven to learn periodontal endoscopy early in its development. In addition, I was given the freedom to innovate endoscopy protocols using lasers, piezo ultrasonics, local delivery antimicrobials, and systemic antibiotics. I came to a simple conclusion. Much of what we did clinically in periodontics was only a small part of the true etiology of periodontal disease for many individuals. No matter how well I removed calculus or how good the patient’s home care was, the chronic inflammation would return in many individuals.
"After several years of performing periodontal endoscopy in an excellent surgical periodontal practice, I changed gears and started working in a periodontal practice that focused on host modulated therapy. I was able to divide my time as a clinical endoscopy specialist between the two well-established periodontal practices, and was able to observe 25-year case histories.
"The treatment outcomes I observed were as different as night and day. Patients who were taking SDD as directed had less overall inflammation, less root sensitivity, less bleeding, less purulence, less attachment loss, less mobility, and less tooth loss, even with host obstacles such as smoking and diabetes. It was at this point in my career that I discovered the powerful effect of low-dose doxycycline. I realized that SDD was the missing piece of the puzzle. If we are to arrest periodontal diseases, we must address host response. I was excited by the removal of clinical limitations with a nonsurgical approach. The clinical results I observed utilizing SDD were encouraging. I had never seen tissue so healthy, so I proceeded to push the envelope with periodontal endoscopy using SDD as an adjunct."
She added, "Within a brief time span, I found that starting the patient on SDD two weeks before periodontal endoscopy achieved the best results. Placing the patient on SDD before SRP/periodontal endoscopy reduced bleeding and inflammation significantly, and it was easy for me to clearly see my work. By visualizing the subgingival habitat with my endoscope, I noticed that in two short weeks I could see new PDL fibers forming. This demonstrated the powerful regenerative properties of SDD. In addition, the gingiva was no longer fragile during therapy, which seemed to reduce postoperative discomfort while enhancing and accelerating healing. It seemed only logical to add regenerative proteins to the protocol soon thereafter. My clinical expectations were correct, and the radiographic bone fill (regeneration) I observed was more rapid than anything reported in the literature with surgical techniques.
"Nonsurgical regeneration is enhanced with the synergistic use of SDD by allowing the newly formed collagen and bone to mature unimpeded. In addition, placing the patient on SDD two weeks before endoscopy (combined with SRP) creates 'invisible’ sutures, which allows the sulcus to close and heal rapidly. This is crucial for overall success.
"Using a dental endoscope daily helped me to discover a myriad of undiagnosed problems lurking below the gum line — such as undiagnosed decay, undetected calculus, excess cement, unknown root anomalies, unseen bone loss, and undiagnosed root fractures. But even more importantly, I discovered that there is unrecognized and underestimated chronic inflammation in many individuals with periodontal disease, which we can effectively treat with SDD."
Judy believes that host response — via a hyperinflammatory reaction to bacteria (and perhaps even viruses in severe cases) — is the true etiology of periodontal disease in many individuals. She insists that, once the host response is changed, the course of the disease is changed. Judy is indeed an agent of change driving a paradigm shift. She looks forward to the day when the synergistic effect of host modulated therapy combined with definitive debridement becomes the new "gold standard."
To date, there is only one systematic review of the literature on adjunctive low-dose doxycycline, which was published in 2003.1 That review showed limited but statistically significant improvements in clinical attachment level (CAL) outcomes following SRP when SDD is used, compared with SRP alone. Clinical significance and relevance are still unknown.
A recent study combined SRP, host modulation therapy (SDD), and topical antimicrobial therapy doxycycline hyclate gel (10% in pockets >/=5 mm) and compared it to SRP plus placebo. Clinical outcomes included mean changes in probing depth, CAL, bleeding on probing, and a gingival index at baseline and at three and six months. In 171 subjects with moderate to severe chronic periodontitis, combination therapy provided significantly better benefits than control therapy for all clinical measures at three and six months.2
Judy is one of those dental hygiene mavericks that I love to write about.
1 Reddy MS, Geurs NC, Gunsolley JC. Periodontal host modulation with antiproteinase, anti-inflammatory and bone sparing agents. A systematic review. Annals of Periodontology 2003; 8: 33-41.
2 Novak JM et al. Combining host modulation and topical antimicrobial therapy in the management of moderate to severe periodontitis: a randomized multicenter trial. J Periodontol 2008; 79(1): 33-41.
About the Author
Lynne Slim, RDH, BSDH, MSDH, is the CEO of Perio C Dent, a dental practice management company. Lynne is also the owner and moderator of the periotherapist yahoo group www.yahoogroups.com/group/periotherapist. She can be reached at [email protected] or www.periocdent.com.