A respectful conversation

A discussion on periodontal disease treatment using Perio Protect reveals more.

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A discussion on periodontal disease reveals more

Last month I participated in a meaningful online chat. Eighteen clinicians participated in a discussion that lasted for a few days. People posed great questions, and others supplied honest, clinically-applicable answers. My contribution was twofold: to bring forward the scientific support regarding the therapy in question, and to explain why achieving and maintaining homeostasis is the long-term goal. Magic happened because we conversed in an open, respectful manner, learning from each other.

Karen started the discussion by asking if anyone had used the Perio Protect system. She wanted to know three things: the active ingredient, why trays have to be processed in a lab, and the average cost. Dave chimed in that the system uses a 1.7% hydrogen peroxide gel in an FDA-approved, patented tray design that can only be made at an authorized lab. Elizabeth said that her practice prescribes the tray therapy often and that Perio Protect—the company—offers comprehensive customer support. Kimberly added that the lab prescription needs to include a full periodontal chart as well as full mouth impressions or scans. She also pointed out that these custom trays are specifically designed to deliver the medicated gel directly into the sulcus.

Armed with new information, Karen inquired about the results. Arianna said her patients who use Perio Protect tray therapy have shown improvement, most getting amazing results. She said patients love the side effects: whiter teeth and fresher breath. Gretchen asked if compliance was a key factor in getting results, a great question that deserves a straightforward answer.

It was clear the conversation was taking place between clinicians who really wanted to learn from each other. For years, I’ve understood the pathway to homeostasis is the most effective way to stop and even reverse the disease process. The Perio Protect therapeutic system is based on creating and maintaining homeostasis, thus putting periodontal pathogens at a complete disadvantage to create disease.

As the conversation continued, I chimed in, suggesting that tray therapy is a long-term strategy, much like exercise. Significant results are gained when trays are used on a daily basis. Successful users typically tie their tray time to another daily activity, like taking a shower. Dave concurred that compliance is the key. “I have dozens of periodontal patients wearing them daily, and the results are fantastic when they use the trays as prescribed.” Dave encouraged everyone to read the article "Tray basics", published in the March 2018 issue of RDH. According to Dave, the article covered the pro and cons of the protocol in-depth.

Once again, my educator gene kicked in, and I contributed the following information about this unique approach to treating periodontal disease. The patented Perio Protect tray design is an FDA-cleared medical device. The inner seal creates a localized hyperbaric chamber that delivers the 1.7% hydrogen peroxide gel into pockets as deep as 9 mm. Within 10 minutes, the subgingival anaerobic pathogens are no longer vital. Wearing the trays an additional five minutes allows the user to reach the maximum oxygen potential in the sulcus. Water and oxygen are the final byproducts from the 15-minute wear time. Daily exposure using this specific gel-based oxygen therapy allows aerobic organisms to proliferate in the pocket, thus creating an ecologically stable environment that supports health, not disease.

Julie talked about a patient who does very little home care other than using Perio Protect trays daily. She reported seeing tremendous improvement, and his oral health has stabilized. Her patient’s success is a direct reflection of how of oxygen, delivered on a regular basis for an adequate time period, can support the growth of healthy aerobic microbes. Both Julie and her patient are winning. He is staying healthier and she does not have to do as much aggressive scaling.

Susan added an interesting perspective. “I don’t know. My patients still have pockets. Some have still have bleeding even after a few years of wearing trays. I understand the concept, but I'm not encouraged by what I see, especially in two patients who do wear them daily.” Kudos to Susan for saying what was on her mind. The tone of the conversation was focused on learning from each other, and Susan felt free to express her doubts and keep the conversation going.

Again, I put my educator hat on and added: “Susan, one can't expect tray therapy to decrease pocket depth. It is a non-surgical treatment that focuses on decreasing inflammation. The goal is to change the microbial environment so anaerobes can't survive, thus reducing the body’s inflammatory load. When a patient does not have an optimal outcome, it is important to consider that there may be many other confounding factors that can reduce the effectiveness of treatment.”

Inflammation is the body’s response to what is often very complex situation. Perio Protect tray therapy is a powerful tool, but there are many other factors involved in the success of this system. For example, inflammation will still be present if there is residual deposit. A perioscope is the best way to confirm retained calculus, but very few clinicians have access to this technology. Some additional confounding factors could include:

  1. Is the patient actually using the trays as prescribed?
  2. Does a locally delivered antibiotic need to be added into the tray for a short period of time?
  3. What is the status of the patient's immune system?
  4. Is the patient taking nutritional supplements or NSAIDS that potentiate bleeding?
  5. What is the patient's stress level?
  6. Is the bleeding generalized or localized? Localized bleeding could be a sign of retained deposits, a combined endo-perio lesion, or possibly a cracked root.

Susan thanked me for this detailed explanation, and I was grateful that we could have this open discussion. My comments were meant to encourage everyone to look at the bigger picture. And I challenged Susan to speculate what conditions these patients would be in if they weren’t in tray therapy. Complex cases are one of the reasons dental hygiene is so fascinating. Susan agreed, saying, “I just need to think out of the box sometimes. The gray areas are hard. I’m such a black and white thinker."

Then Dave shared his thoughts with the group. “I think when it comes to treating perio we always need to be looking outside the box. Periodontitis is anything but simple. Sometimes doing 'standard' treatment is all that is required, but often it is a puzzle that must be pieced together—biofilm, host response, systemic disease (diagnosed or undiagnosed), diet, pH, patient home care, patient abilities, clinician skill, tools available to clinician, and more. Breaking out of the barriers of 'routine' treatment will allow us to bring more patients toward health.”

Dave admitted that every day he has one or two patients who really puzzle him. He believes the more tools he has in his belt, the more successful he will be in figuring out how to bridge the gap between disease and health. According to Dave, Perio Protect has been a very powerful tool that has helped bridge the gap with dozens of patients. Candi won Perio Protect training for her entire office at the RDH Under One Roof conference. Candi had spent years treating a particular patient every five weeks. With tray therapy, this man has finally achieved health.

Ashley agreed that periodontal disease is highly complex, and the patient treatment plan should be individualized and utilize multiple strategies. Her office is most comfortable recommending tray therapy for a patient who has undergone pathogen screening using a test like MyPerioPath, which is based on salivary diagnostics. The screening provides information about the presence and relative quantity of eleven known periodontal pathogens. Ongoing screening over time provides information about changes in pathogen levels.

Erin tried to have a discussion with her doctors about tray therapy. She met resistance on two levels. The doctors felt Perio Protect was expensive and they questioned how they could get patients to invest? Erin lamented, “All things considered, shouldn’t we be doing all we can to provide the best outcomes for our perio patients. I’m frustrated.”

Taking the role of devil’s advocate, I commented on several of the discussion themes. Scientists now report hundreds of species may be involved in periodontal disease, many of which can't be cultured. So, while testing can provide information, there are limitations.

The mindset of practices that have good compliance is interesting. Typically, everyone is on board and patient selection is key. The benefits of tray therapy are realized when users and prescribers understand using the Perio Protect system tray is a lifestyle change, like exercise, rather than a short-time treatment modality.

PerioProtect is not a magic bullet, but rather another tool in our arsenal. As clinicians we must take many other factors into account, but we have an ethical responsibility to information patients of all treatment options, not just what we think they will agree to or what we feel they can afford financially. If we shift our focus and frame the discussion honestly, patients may just surprise us and commit to a protocol that is based on creating a healthy subgingival ecological environment.

It was an honor to participate in this exchange of ideas. People can spend an enormous amount of time participating in an online discussion without gaining much new information. This discussion showed that colleagues can participate in a lively, informative exchange, consider a different perspective, and walk away with information on how to care for patients in a different way.


Resources

Bale BR, Donen AL, Vigerust DJ. High risk periodontal pathogens contribute to the pathogenesis of athrerosclerosis. Postgrad Med J. Published November 29, 2017.

Cochrane RB, 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.

Dunlap T, et al. Subgingival Delivery of Oral Debriding Agents: A Proof of Concept. The Journal of Clinical Dentistry. 2011;22(5):149-158.

Flemming HC, Wingender J, et al. Biofilms: an emergent form of bacterial life. Nat Rev Microbiol. 2016;14(9):563-575.

Hajishengallis G. Periodontitis: from microbial immune subversion to systemic inflammation. Nature Reviews Immunology. 2015;15(1):30-44.

Han YW, Wang X. Mobile Microbiome: Oral Bacteria in Extra-oral Infections and Inflammation. Journal of Dental Research. 2013;92(6):485-491.

Herrero ER, Slomka V, et al. Antimicrobial effects of commensal oral species are regulated by environmental factors. J Dent. 2016;4(47):23-33.

Marshall MV, Cancro LP, Fischman SL. Hydrogen peroxide: a review of its use in dentistry. J Periodontol. 1995;66(9):786-796.


Putt MS, Mallatt ME, Messmann LL, Proskin HM. A 6-month clinical investigation of custom tray application of peroxide gel with or without doxycycline as adjuncts to scaling and root planing for treatment of periodontitis. Am J Dent. 2014;27(5):273-284.

Putt MS, Proskin HM. Custom tray application of peroxide gel as an adjunct to scaling and root planing in the treatment of periodontitis: a randomized, controlled three-month clinical trial. J Clin Dent. 2012;23(2):48-56

Szewzyk U, Steinberg P, et al. Dysbiosis by neutralizing commensal mediated inhibition of pathobionts. Sci Rep. 2016.


Anne Nugent Guignon, MPH, RDH, 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 anne@anneguignon.com.

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