Anne Guignon, RDH, advocates the Perio-Protect system as an alternative for patients who oppose traditional periodontal treatments.
Setting the stage for perio success with prescription trays
Anne Guignon, RDH, MPH
FDA-cleared prescription trays are fabricated with a custom inner seal that allows the 1.7% peroxide gel to penetrate up to 9mm.
Imagine pulling into the parking of your favorite dental office. The team energy is great. Everyone in the practice is focused on doing their best for the patients and for each other.
During the morning huddle, you and your teammates review the charts and game plan how to best take care of each patient coming in that day. As you take a quick glance at the schedule, two names pop out—Charlotte and Bob.
Everyone loves Charlotte, she is bubbly, compliant, and easy to work with. Charlotte has had periodontal scalings numerous times. She had a consult with a periodontist last year, and she thought the fees were too high and does not want to return. Her health history appears to be insignificant, and her home care is impeccable. No matter what you recommend, her gingivitis and periodontitis never seem to respond. Every three months, you and your doctor deliver one more bad report. Nothing seems to be working.
Bob is a different challenge. He is an old curmudgeon. He challenges every recommendation and questions every fee. He doesn’t believe his persistent gingivitis and periodontitis issues are a serious threat to his overall health, and refuses to come in more than twice a year.
A different option
We’ve all had patients like Charlotte and Bob. Every clinician faces the dilemma of trying to help a patient who is not willing to be treated by conventional methods or who has lost faith in our recommendations. What about those unwilling to undergo more periodontal scaling procedures or those who refuse to have surgery? Is there a way to help a patient whose financial situation will not support an advanced periodontal treatment? What can you offer a patient who insists on taking an all-natural approach? What about the patient whose oral inflammation is fueling other systemic conditions?
You and the doctor are going to propose today prescription tray therapy to both Charlotte and Bob. The dental team will share new information about a modality that can set the stage for a healthier outcome. The tray therapy (The Perio Tray by Perio Protect) offers a nonsurgical, adjunctive approach that patients use at home daily to address biofilm, the source of inflammation. The trays are an FDA-cleared medical device. Only five dental laboratories are licensed to fabricate these unique prescription trays. The design features an inner seal to help deliver the medication deep into the pockets, allowing the gel to penetrate defects and pockets that are as deep as 9 mm. Devices such as mouth guards, sports guards, aligners, and fluoride trays are not fabricated with a seal, so they can’t be used for this protocol.1 The seal also ensures that the peroxide concentration is held in place long enough to gain a therapeutic benefit. The research shows that 15 minutes provides a therapeutic dose of oxygen, creating and maintaining an environment inhospitable for periodontal pathogens.2Everyone in the office is excited to share this information with Charlotte and Bob. It’s rewarding to have an option that is not based on having the patient come in for more procedures. The approach that can bring the patient a healthy outcome in a noninvasive manner.
While Charlotte and Bob may be interested in a new approach, what happens if they don’t agree immediately or they want time to think about it before committing? Clinicians face these issues regularly. Some take these setbacks personally. Others work in practices where they are expected to “educate” the patient until they agree to the proposed treatment plan. This approach often does not sit well if the process seems forced. Patients end up feeling badgered or coerced, an outcome that does not foster a solid patient-clinician relationship. It is important to proceed at their pace.
Juxtaposed against the patients’ needs and frustrations are our professional responsibilities. We have an ethical responsibility to inform patients of all possible treatment approaches. A patient has the right to accept or decline, even if it means no treatment. It is easy to get frustrated when patients decline treatment, but are patients receiving a full spectrum of options, especially options that go beyond traditional home care routines? The entire practice needs to be aligned philosophically and ethically.
Range of patients benefiting from trays
It is not about selling a new treatment; it is about caring for the patient. Think creatively. Think about who can benefit from this system. Do you have patients with these challenges?
• Limited manual dexterity
• Cognitive impairment
• Fear of pain
• Compromised, fragile immune system
• High cardiovascular disease risks
• Focused on prevention strategies
• Auto immune disorders
• Transportation/travel difficulties
• Refuses periodontal referral
• Limited finances for advanced therapies
• Interested in supporting wellness
• Complicated to treat in a traditional setting
• Requires supervision of a caregiver
• Fear of surgery
• Declines periodontal scaling therapies
• Frustrated with traditional recommendations
• Want more comfortable hygiene appointments
It’s appropriate to review the current science surrounding periodontal microbes when considering an ecological concept for disease control and prevention.
It is well known that certain microbes are found in abundance in the periodontal pocket. Research today confirms that the periodontal pocket is teeming with a much larger array of microbes than we ever imagined.3,4 Pathogen testing can identify the presence of 11 pathogens known to be associated with periodontal disease. This information does not tell the whole story. Recent reports indicate scientists are now finding fragments of additional microbes that are likely contributing to the disease process; however, it is very costly and laborious to identify many of these species.
While it is likely that it will be a long time before all microbial culprits are known, there is a good understanding of the activity of a select few, and scientists can now describe the environmental conditions found in both health and disease.5 Understanding the environmental conditions is a key concept that supports the PerioProtect system.
Periodontal pathogens thrive and survive in complex polymicrobial biofilm communities. Microbes are protected by thick layers of slime.6 Many species cooperate and support each other via chemical signaling, known as quorum sensing. Microbes can rapidly change gene expression, providing further protection against antimicrobial agents.
Current scientific thinking implicates gram-negative anaerobes as the primary culprits in the development of gingivitis and periodontitis.5 Anaerobic organisms require very low levels of oxygen to survive. In addition, each microbial species has specific oxygen and pH requirements, resulting in complex, layered communities within a single biofilm.
Periodontal disease is now being classified as an inflammophilic condition, a term that will redefines how we think about and treat periodontal disease. Inflammophilic microbes require the byproducts of inflammation to survive and thrive, creating what is now called a dysbiotic microbial community.8 Dysbiosis is a term used to describe a stable microbial community that is in symbiosis, however a dysbiotic biofilm community is populated with pathogens, not the diverse microbial community as is found in health.9
P. gingivalis is now classified as a keystone pathogen. While it is not the only microbe contributing to the disease process, it appears to be a key initiator.3,8,10,11 Extensive research over the past few years has shown that P. gingivalis contributes to the disease process in many ways and is found in periodontal pockets in early, middle, and late disease stages It is also present as early as four hours after periodontal scaling.12
While P. gingivalis is considered a low abundance microbe, if left unchecked it can have a profound effect on the development of a dysbiotic community.3,13 Initially, it interferes with the body’s immune system, critically weakening a person’s ability to fight an infection.14,15 P. gingivalis has the capacity to cover itself with polysaccharide, a sugar coating that makes the microbe invisible to a person’s immune system. In addition, it has the capacity to convert non-pathogenic, commensal microbes to a pathogenic state. The new recruits are now termed pathobionts, further increasing the virulence of the dysbiotic microbial community.16,17 The at-risk patient is now more vulnerable than ever for developing a “non-resolving, tissue-destructive host response.”3
Other periodontal pathogens contribute to the resident imbalance in the oral microflora. P. gingivalis and T. denticola are found in superficial biofilm as well as in subgingival plaque. Both microbes are present in chronic periodontitis lesions, and help increase bioifilm biomass and thickness.18 T. denticola is motile and moves easily through the viscous biofilm environment. Surface projections on T. denticola create pathways in the biofilm that allow fluids and nutrients to flow within the slimy mass, enhancing the dispersal of both wastes and nutrients within the dysbiotic community.19
There is mounting evidence that antibiotics have been overused. The first antibiotic discovered was penicillin. The year was 1928. More and more microbes are becoming antibiotic resistant, resulting in so-called superbugs, microbes that create serious disease risks, especially in those who are medically compromised or who have additional immune system overloads. Prescribing an antibiotic is not a cure, it is a short-term treatment modality, when faced with a chronic condition.
Two years ago, Harvard University scientists created a very easy-to-understand video that highlighted recent research on antibiotic resistance. National Public Radio first aired the video on September 16, 2016, which is readily accessible in the archives. The narrator describes how scientists created a giant 4-foot by 6-foot petri dish that had parallel bands of agar contained increasing levels of antibiotics, from zero concentration to 1,000 times the normal dose. A time-lapse video demonstrates it took only 11 days for the test E coli strain to mutate to the point where the microbes could survive at an antibiotic dose that was 1,000 times higher that a single dose.20,21 Studies like this are easy to share with patients and reinforce the need to take a dramatically different approach to managing pathogens.
Dental professionals are in an ideal position to recommend alternative approaches to creating a healthy, stable biofilm community, one where anaerobic pathogens cannot proliferate. One safe tool is hydrogen peroxide, a compound found in human saliva, breast milk, and the liver. On a cellular level, commensal microbes in the oral cavity produce hydrogen peroxide at levels which help keep pathogen levels in check. As the microbial community in the sulcus becomes more dysbiotic, levels of naturally-produced hydrogen peroxide are insufficient to counteract the inflammophilic environment.22
Hydrogen peroxide is an antiseptic. Concentrations of hydrogen peroxide at 3% or less are approved for oral use by the FDA. It can debride an area and help reduce inflammation. There is no known bacterial resistance to hydrogen peroxide and no known allergic reactions. All five attributes are key to why a stabilized hydrogen peroxide gel, administered in the right concentration, is an effective approach for managing complex, recalcitrant periodontal conditions.23
When liquid hydrogen peroxide is poured on a wound, there is an initial burst of activity, resulting in a rapid spike in oxygen levels. The challenge lies with keeping hydrogen peroxide in contact with the pathogens for enough time to kill the microbes in the biofilm. Recent research demonstrates that this takes 10 minutes for a 1.7% hydrogen peroxide to create a complete kill. In addition, the gel continues to release oxygen for an additional five minutes.1 This proof of concept demonstrates that anaerobes in the periodontal pocket can’t survive aerobic conditions created by prescription tray therapy delivery of peroxide when used for 15 minutes per session.
The tray process
Implementing tray therapy into your practice is relatively easy. One of the most exacting processes is getting patients fitted for custom, prescription trays. Offices can use alginate, PVS, putty, or digital systems to create the impressions. The prescribing dentist sends two items to the laboratory—a complete periodontal chart documenting probing depths and bleeding points and full arch impressions.
The delivery appointment is simple. It is important to check the fit of the trays. Some minor adjustments many be necessary to ensure a comfortable fit. Patients should also receive the treatment gel, a storage container, and instructions on how to care for the appliances.
Since each case is different, this is the ideal time to review the prescribed wear times that correspond to the initial treatment goals for a patient. Some will need to use tray therapy several times a day during the first few weeks, while others may only need one session a day. Refractory patients or those who present with severe inflammation may be advised to add several drops of Vibramycin syrup to the gel in the trays, an amplified therapeutic approach that is typically is prescribed for only a few weeks.23,24
Results and fees
Like all other individualized therapies, results are going to be based on patient compliance and the severity of the patient’s initial disease state. Tray therapy allows the patient to disrupt microbes more deeply than a toothbrush, flossing, or rinsing. This treatment modality can stop the inflammatory process from progressing and allow the patient’s body to begin to heal.
Some patients will be able to avoid repetitive periodontal scaling or surgery by using this approach. Others may still need these additional interventions, but successful tray therapy can reduce the extent and severity for many.
Patients using trays daily will spend around $200 per year for the 1.7% gel. Based on the initial cost of the trays, the annual expenditure over a five-year period averages around $400 per year, a very modest fee for supporting a healthier oral cavity. An increasing number of third party carriers are now providing coverage for PerioProtect therapy.
Like regular exercise, tray therapy is a logical approach to creating an environment that can support health, but it requires regular use to ensure the continuation of an aerobic subgingival environment. Patients who succeed are ones who accept tray therapy as part of their daily routine. The additional bonuses are whiter teeth and fresher breath.
All members of the dental team need to be on board when presenting tray therapy to a patient. Not every patient is not a good candidate for this approach. Patient selection is critical, and patients need to be committed. When patients and practices are working towards the same goals, more teeth will be saved and more will have healthy mouths that are contributing to overall systemic health. Imagine having this option for your patients the next time you see patients like Charlotte and Bob.
ANNE NUGENT GUIGNON, RDH, MPH, CSP, provides popular programs, including topics on biofilms, power driven scaling, ergonomics, hypersensitivity, and remineralization. Recipient of the 2004 Mentor of the Year Award and the 2009 ADHA Irene Newman Award, Anne has practiced clinical dental hygiene in Houston since 1971, and can be contacted at email@example.com.
1. Dunlap T, Keller D, Marshall M, Costerton J, Schaudinn C, Sindelar B, and Cotton J. Subgingival Delivery of Oral Debriding Agents: A Proof of Concept. The Journal of Clinical Dentistry. 2011 Nov;XXII(5):149-158.
2. Keller DC, Buechel M. Direct medication delivery modifies the periodontal biofilm. Oral Biol Dent. 2017; 5:1.
3. Hajishengallis G., Lamont RJ. Beyond the red complex and into more complexity: the polymicrobial synergy and dysbiosis (PSD) model of periodontal disease etiology. Mol Oral Microbiol. 2012 Dec: 27(6);407-19.
4. Hiranmayi KV, Sirisha K, Ramoji Rao MV, Sudhakar P. Novel Pathogens in Periodontal Microbiology. J Pharm Bioallied Sci. 2017 Jul-Sep;9(3):155-163.
5. Larsen T, Fiehn NE. Dental biofilm infections - an update. APMIS. 2017 Apr;125(4):376-384.
6. Costalonga M1, Herzberg MC2. The oral microbiome and the immunobiology of periodontal disease and caries. Immunol Lett. 2014 Dec;162(2 Pt A):22-38.
7. Biradar B, Devi P. Quorum sensing in plaque biofilms: challenges and future prospects.P. J Contemp Dent Pract. 2011 Nov 1;12(6):479-85.
8. Hajishengallis G. The inflammophilic character of the periodontitis-associated microbiota. Mol Oral Microbiol. 2014 Dec;29(6):248-57.
9. Petersen C, Round JL. Defining dysbiosis and its influence on host immunity and disease. Cell Microbiol. 2014 Jul;16(7):1024-33.
10. Hajishengallis G, Lamont RJ. Breaking bad: manipulation of the host response by Porphyromonas gingivalis. Eur J Immunol. 2014 Feb;44(2):328-38.
11. Lamont RJ, Hajishengallis G. Polymicrobial synergy and dysbiosis in inflammatory disease. Trends Mol Med. 2015 Mar;21(3):172-83.
12. Periasamy S, Kolenbrander PE.Mutualistic biofilm communities develop with Porphyromonas gingivalis and initial, early, and late colonizers of enamel. J Bacteriol. 2009 Nov;191(22):6804-1.
13. Sakanaka A, Takeuchi H, Kuboniwa M, Amano A. Dual lifestyle of Porphyromonas gingivalis in biofilm and gingival cells. Microb Pathog. 2016 May;94:42-7.
14. Hajishengallis G, Maekawa T, Abe T, Hajishengallis E, Lambris JD. Complement Involvement in Periodontitis: Molecular Mechanisms and Rational Therapeutic Approaches. Adv Exp Med Biol. 2015;865:57-74.
15. Hajishengallis G, Abe T, Maekawa T, Hajishengallis E, Lambris JD. Role of complement in host-microbe homeostasis of the periodontium. Semin Immunol. 2013 Feb;25(1):65-72.
16. Hajishengallis G, Lamont RJ. Dancing with the Stars: How Choreographed Bacterial Interactions Dictate Nososymbiocity and Give Rise to Keystone Pathogens, Accessory Pathogens, and Pathobionts. Trends Microbiol. 2016 Jun;24(6):477-89.
17. Hajishengallis G, Liang S, Payne MA, Hashim A, Jotwani R, Eskan MA, McIntosh ML, Alsam A, Kirkwood KL, Lambris JD, Darveau RP, Curtis MA. Low-abundance biofilm species orchestrates inflammatory periodontal disease through the commensal microbiota and complement. Cell Host Microbe. 2011 Nov 17;10(5):497-506.
18. Zhu Y, Dashper SG, Chen YY, Crawford S, Slakeski N, Reynolds EC. Porphyromonas gingivalis and Treponema denticola synergistic polymicrobial biofilm development. PLoS One. 2013 Aug 26;8(8):e71727.
19. Ng HM, Kin LX, Dashper SG, Slakeski N, Butler CA, Reynolds EC. Bacterial interactions in pathogenic subgingival plaque. Microb Pathog. 2016 May;94:60-9.
20. Chen A. Bacteria Invade Antibiotics And Transform Into Superbugs http://www.npr.org/sections/health-shots/2016/09/08/492965889. Accessed February 8, 2018.
21. Baym M, Lieberman TD, Kelsic ED, Chait R, Gross R, Yelin I, Kishony R. Spatiotemporal microbial evolution on antibiotic landscapes.
Science. 2016 Sep 9;353(6304):1147-51.
22. Herrero ER, Slomka V, Boon N, et al. Dysbiosis by neutralizing commensal mediated inhibition of pathobionts. Scientific Reports. 2016;6:38179.
23. Cochrane RB and Sindelar B. Case Series Report of 66 Refractory Maintenance Patients Evaluating the Effectiveness of Topical Oxidizing Agents. The Journal of Clinical Dentistry 2015;26:109-114.
24. Putt M, Mallatt M, Messmann L, and Proskin H. A 6-month clinical investigation of custom tray appli- cation of peroxide gel with or without doxycycline as adjuncts to scaling and root planning for treatment of periodontitis. American Journal of Dentistry. 2014;27:273-284.