Shifting the Clients Focus: Closing the Oral- Systemic Gap

Transcription

1 Shifting the Clients Focus: Closing the Oral- Systemic Gap James Hyland, DDS Your Presenters: Kerry Lepicek, RDH

2 Periodontal Disease Is NOT a Little Bleeding! 75% of population have some form of periodontal disease Infectious biofilm/bacterial disease Whole mouth biofilm disease Oral/Systemic Health Impact Socially transmissible disease Chronic and persistent #1 cause of tooth loss and the new epidemic: Peri-implantitis

3 The Goal Of Periodontal Care Is To Eliminate The Cause Of Oral Infection We must do more than manage disease. We must treat the cause of the infection. Just Pull Out The Sliver

4 Current Diagnosis and Treatment Modalities: Questioning the Perio Status Quo Why do 75% of clients have gum disease in spite of our best efforts? Does brushing and flossing prevent periodontal disease? Is periodontal disease controlled by calculus/stain removal 4 times a year or is daily & professional biofilm control more important?

5 Current Diagnosis and Treatment Modalities: Questioning the Perio Status Quo Why do we use scalers from infected sites to clean healthy sites? Which is a greater health risk: blood in the urine or blood in the saliva? Do you tell your clients how they catch periodontal disease? How can you prevent a disease without knowing the cause?

6 Elimination of Bacteria/Biofilm NSPT Brushing Interproximal Brushing Flossing Topical Antibiotics Rinses (DDS Rx) Antimicrobial Rinses (DDS Rx) Systemic Antibiotics (DDS Rx) Oral Irrigation Lasers

7 What is the OraVital System A combination of new and effective modalities for the diagnosis and treatment of oral infections that complement your existing programs Ongoing coaching program for clinicians to help implement a new paradigm successfully Whole mouth microbiology testing with BiofilmDNA and BiofilmGS at a lower cost than other lab tests Periodontal disease/peri-implantitis, halitosis, and caries treatment via antibiotic rinses, 0.2% Chx and maintenance rinses Periodontal maintenance program

8 The OraVital Philosophy We treat whole mouth biofilms not subgingival ones Our treatment goals are to provide a cleansable environment free from pathogenic biofilms Inspire clients to prevent their periodontal disease, breath odour, decay and oral-systemic risks Why achieve this by killing, disturbing, and disrupting the biofilms causing the disease on a daily basis for life-long health Treat the cause not the symptoms do it once and do it right

9 The OraVital Philosophy Use objective tests at the start of every hygiene visit (do a perio chart or PSR, count the # of BOP, do a Papillary Bleeding Score and disclose). Copy genius techniques don t create mediocre ones. Implement one oral biofilm control system protocol. Every hygienist can t have a different one. Treat early and aggressively to avoid the oral systemic risk. Revaluate regularly.

10 Why Do We Need Something More? The Oral Systemic Link is directly related to periodontal disease bacteria Studies show that the mouth can be a source of chronic infection that affects systemic health. Debridement is essential but does not eliminate oral pathogens therefore periodontal breakdown continues over time. We need to change the hygiene appointment focus from calculus removal to biofilm disruption Wellness begins with a health biofilm We must treat the CAUSE of oral infection, rather than just manage symptoms. We must engage, reach and empower our clients to achieve greater oral health.

11 How Can We Accomplish This? Get out of your comfort zone! Co-diagnose (show and share) disease at the BEGINNING of the appointment. Use analogies to reach clients. Connect emotionally. Modify the order of the hygiene services you provide. Recommend INTERDENTAL brushing aids, rather than floss Offer NEW knowledge, techniques and treatments Screen to assess for presence of harmful pathogens.

12 Control Oral Systemic Risks Give clients hope they can control gum disease and decay. Relationship is needed to engender change. You must be able to get predictable results with care. Educate clients about the risks and demonstrate the risk to them Become a wellness/health focused practice not a procedure driven one. Employ the 85/15 rule.

13 Gingivitis & Periodontitis Are Oral Wounds! Gingivitis: a surface of 10 to 20 cm 2 when compared with a body wound surface. That s 1.5 to 3 in 2 Periodontitis with 50% loss of attachment a surface area of 30 to 40 cm 2 when compared with a body wound surface. That s 4 to 6 in 2

14 The Oral-Systemic Link: A Network of Infection Periodontal Disease Bacteria & Toxins Inflammatory mediators Pneumonia Cancer Diabetes Blood stream Cardiovascular Disease Alzheimer s Disease Low Birth Weight Osteoporosis Rheumatoid Arthritis Life Span Mortality

15 Cleaning Teeth Doesn t Prevent Infections! Bacteria regroup after 3 days in areas where biofilm is not sufficiently removed/disturbed Periodontal disease will return after 3 days of poor oral care Pathogenic activity following re-care: 87 days of pathogenic activity in a 3 month re-care. What is the solution?

16 Periodontal Disease: Not to be Ignored! Is a serious and potentially life threatening medical condition that dental professionals are responsible for diagnosing and treating

17 Periodontitis and Premature Death: A Longitudinal, Prospective Trial Results: Women with periodontitis and missing molars died 36.1 years sooner than the average life expectancy. Men with periodontitis and missing molars died 31.6 years sooner than the average life expectancy. WHY? Bacteria, wound size, infection, duration, systemic effect Birgitta Soder, Karolinska Institutet, Stockholm Sweden Can J Dent Hyg, 2009, 43, N

18 Oral Infections and Cardiovascular Disease Recommendation A: clients with moderate to severe periodontitis should be informed that there may be an increased risk for atherosclerotic CVD associated with periodontal disease. If You Have Heart Disease See Your Dentist. Recommendation B: clients with moderate to severe periodontal disease who have one known major atherosclerotic CVD risk factor, such as smoking, immediate family history of CVD, or history of dyslipidemia, should consider a medical evaluation if they have not done so in the past 12 months. If You Have Active PDD See Your Physician. Friedewald et al. Editors Consensus: Periodontitis and Atherosclertic Cardiovascular Disease. American Journal of Cardiology 2009: 104:59-68.

19 The Oral Systemic Connection: Spirochete Diseases Leprosy: Mycobacterium leprae/lepromatosis Syphilis (T. pallidum) Historical crisis with present day implications Lyme Disease (B. burgdorferi) Present day crisis Alzheimer's Disease: - A neurospirochetosis. As adequate antibiotic and anti-inflammatory therapies are available one might prevent and eradicate dementias. Periodontal Disease: 75% of population is infected Miklossy J of Neuroinflammation 2012 Alzheimer s a neurospirochetosis

20 Rheumatoid Arthritis and PDD RA and gum disease Mary Anne Dunkin Such a high prevalence of pdd in RA clients highly plausible biological connection between the two. These findings suggest that bacteria in the mouth could actually be the cause of RA. Genetic susceptibility to RA, citrullination of cell wall proteins on Pg create an immune response against those proteins. These same proteins line the synovial joints.

21 Early Childhood Decay Novel bacterial fungus relationship transforms an inoquious organism into a fierce stimulator of cariogenic bacteria Animals fed Ampicillin did not get decay These findings have relevance because bacterial-fungal interactions occur throughout the body and for periodontal disease. OraVital tests for yeast + Sm Decay rinses contain nystatin + Amoxicillin Falsetta. iai.asm.org Infection and Immunity May 2016 pg Symbiotic Relationship between Streptococcus mutans and Candida albicans Synergizes Virulence of Plaque Biofilms In Vivo

22 Oral Pathogens and Cancer 36% increase in risk of lung cancer* 49% increase in risk of kidney cancer* 57% increase in risk of pancreatic cancer* 30% increase in risk of hematologic cancers non-hodgkin s lymphoma (very significant), leukemia and multiple myeloma.* 82% of all Esophageal cancers contain Pg. Healthy Esophageal tissues don t** *Michaud DS,et al. Periodontal disease, tooth loss, and cancer risk in male health professionals: A prospective cohort study Lancet Oncology 2008; 9: **Bacterial signatures in thrombus aspirates with MI Circulation 14/2/13

23 American Academy of Periodontology Guidelines for the treatment of Periodontal Disease as outlined by the American Academy of Periodontology 1.Collect microbial samples from selected sites 2.Administer an appropriate antibiotic regimen 3.Use antimicrobial regimen and periodontal therapy 4.Re-evaluate with microbial testing as indicated 5.Continue with maintenance with microbiological retesting as needed Position Paper Systemic Antibiotics in Periodontics J. Periodontal :

24 A New Paradigm In Diagnosis & Treatment Inspire dental teams to control the cause of the disease vs treating the symptoms Gain complete client buy-in and overcome objections with new techniques and verbal skills using objective test to assess and diagnose the infection not subjective ones Biofilm testing Provide preventive/periodontal treatments & Prescribe antibiotic rinses Re evaluation

25 Infections We Treat With OraVital Periodontal disease gingivitis, mild to moderate (90% of clients) and severe Peri-implantitis the newest epidemic with great risks for clients and professionals Improving treatment results with periodontal surgery, implant placement and laser care Breath odor Decay ECC, root and interproximal/smooth surface Restorative dentistry ( bleeding and decay )

26 The OraVital System-Five Step Program 1.Diagnosis Review medical history, periodontal charting, # of BOP, Papillary Bleeding Score (PBS) and disclosing. Take microbiology samples and assess biofilm for infection 2.Treatment Complete scaling and root planing then Rx non-invasive antibiotic and chlorhexidine rinses 3.Re-evaluation 4 weeks later, Measure the change in tissues, # of BOP and pocket depth, disclose, PBS, Polish clients teeth 4.Maintenance OTC rinses maintain balance of oral biofilm, a prerequisite for oral health 5.Monitoring your client Periodontal and microbial monitoring as required. Regular hygiene appointments are essential

27 Antibiotic Rinse Effectiveness Pocket Depth Before After Difference #teeth with pockets 4mm % 5mm % 6mm % 7mm % Bleeding on Probing BOP % Halitosis Reduction 80% Number of Subjects N= 649 p. value: Dr. Ken Southward The Academy of General Dentistry July 2013

28 Antibiotic Rinse Effectiveness* Effect of OraFresh Antibiotic Mouthrinse on Number of Pockets per Patient No. of Pockets/patient Data from 649 Patients Before After 0 4 mm 5 mm 6 mm 7 mm Pocket Depth

29 Antibiotic Antifungal Rinses Topical Antibiotic Antifungal Rinses: Are colloidal suspensions of antibiotic particles that are highly effective Contain less then half the systemic dose of the antibiotic Have 3 to 4,000 X the concentration of the same oral dose in saliva because the medication is directly applied to the site of infection without dilution, absorption or metabolism issues. Are used 3 times a day for two weeks (3 ml per rinse)

30 Antibiotic Antifungal Rinses Topical Antibiotic Antifungal Rinse Advantages: Using a rinse and spit method eliminates systemic side effects. Rinsing with the antibiotic will decrease pathogens throughout the entire mouth (throat, tongue, gums, tonsils and teeth) decreasing risk of re-infection after treatment Preparations are proprietary compounded formulations with an antifungal agent to control for opportunist yeasts. clients are used to taking medications for infections

31 Antibiotic Antifungal Rinse Options FM4 (Adult) + FM2 (Pediatric) Metronidazole Nystatin MOST COMMONLY USED FM4 + Amox Metronidazole Amoxicillin Nystatin Purpose Gingivitis Periodontal Disease (mild & moderate) Halitosis Tonsillitis Hypertrophy during Ortho Less than ½ of equivalent systemic dose Narrow spectrum rinses with Anti-fungal Post Debridement FM2 Halitosis and Gingivitis for Children(1/2 strength of FM4) Severe and refractory Periodontal Disease Pre -Surgery Implants Anti-fungal Must be refrigerated Post Debridement TET2 Tetracycline Nystatin Gingivitis (mild - Moderate) Halitosis Anti-fungal Caries Treatment

32 Antibiotic Antifungal Cream Metronidazole/Nystatin and Flavouring in a Cream Base Used for localized areas of bleeding, pockets or odours that remain after using an antibiotic rinse Very effective after laser treatment, around implants with implantitis, and after periodontal surgery Can be dispensed into pockets with a syringe. An acid etch syringe is easy to load and dispense. Very effective in treating denture stomatitis and will reduce severely infected areas within 2 weeks when used 2x a day

33 Chlorhexidine Rinses Purpose Cx220 or Cx % chlorhexidine gluconate non alcohol Mint Flavour (Cx220) Mint or Cherry Flavour (Cx620) Controls Streptococci Rebalances biofilm Non Staining Anti-Caries Used twice daily for two weeks Chlorhexidine is ordered at the same time as the antibiotic rinse

34 Maintenance Rinses Purpose 1. CDLX Sodium Chlorite Chlorine Dioxide 3.1% Xylitol 2. CPCx Cetylpyridinium Chloride 3.1% Xylitol 3. Smart Mouth Sodium Chlorite Zinc Chloride Maintenance Phase Rinse used twice daily Action is bacteriostatic Intercepts enzymes that breakdown amino acids and neutralizes Volatile Sulphur Compounds Perio and Breath clients Available in light mint flavouring and in nonflavoured, colour-free options Maintenance Phase Rinse used twice daily Disrupts the bacterial cell membrane, leading to cell death Active against wide variety of aerobic and anaerobic bacteria Suppresses bacteria causing caries Perio, caries and dry mouth clients Maintenance Phase Rinse used twice daily Mixing the two components results in ionized Zinc (Zn++) and table salt as well as some residual zinc chloride. Bacteriostatic plugs up protein receptors on bacteria

35 Micro Sampling And Reports

36 When Should You Sample the Biofilm? As a part of a new client exam. Clients with periodontal disease. For every client complaining of breath odor. During hygiene visits to establish the biofilm baseline before beginning treatment and to monitor biofilm shifts. After treatment if client continues to exhibit some infection. Implants: pre-surgical, mucositis, peri-implantitis. Clients that show a compromised health history.

37 BiofilmDNA This test provides information on the presence and numbers of the following microorganisms throughout the whole mouth biofilm: Red Complex Bacteria: o Porphyomonas gingivalis o Treponema denticola o Tannerella forsythia Agregatibacter actinomycetemcomitans Peptostreptococcus micros Fusobacterium nucleatum Streptococcus mutans to determine caries susceptibility Candida albicans. New research on yeast, decay and PDD.

38 BiofilmDNA Report Result summary: High and Moderate risk pathogens detected The black bars indicate normal levels of each pathogen. High Risk Periopathogens Moderate Risk Periopathogens and Yeast High Risk Cariogenic Pathogen Pg Td Tf Aa Fn Pm Ca Sm Td Aa Pg Tf Abbreviations of bacteria names and normal absolute counts of test species pathogen per biofilm sample Treponema denticola Aggregatibacter actinomycetemcomitans Porphyromonas gingivalis Tannerella forsythia 5 ( ) 2 ( ) 4 ( ) 5 ( ) Fn Pm Ca Sm Fusobacterium nucleatum Peptostreptococcus micros Candida albicans Streptococcus mutans 6 ( ) 4 ( ) 3 ( ) 6 ( ) BiofilmDNA Analysis Result Details Periodontal risk: The high-risk pathogen A. actinomycetemcomitans was identified above the normal threshold, P. gingivalis at monitor level and T. forsythia within normal range. T. denticola was not detected. Moderate-risk pathogens F. nucleatum and P. micros were found above normal levels. Caries risk: S. mutans was detected in the sample above the normal range and that may increase the risk for development of dental caries. Candidiasis: C. albicans was detected at higher numbers than normal level and that may predispose to oral yeast infections. Treatment should be based on medical history, periodontal charting and this report.

39 effective interdental cleansing and a daily mouthwash such as Smartmouth, CPC or CDLx. Red Complex Bacteria: Porphyromonas gingivalis prominent player in progressive periodontal disease, known to invade, destroy the tissues supporting the tooth that may lead to tooth loss. Treponema denticola oral spirochete, strongly associated with poly-microbial periodontal infections and chronic periodontal disease progression. Its motility plays a pivotal role in tissue invasion and proteolytic activity in tissue destruction and host immunosuppression. Tannerella forsythia strongly associated with the pathogenesis and progression of destructive forms of periodontitis: advanced and recurrent periodontitis; known to adhere to host cells, invade tissues and contribute to host immunosuppression. Aggregatibacter actinomycetemcomitans (A.a) - aggressive bacterium associated with juvenile periodontitis and advanced adult periodontal disease. This pathogen has the ability to stimulate cytokines that are capable of stimulating bone destruction. Orange Complex Bacteria: Fusobacterium nucleatum - it has been recognized as part of the subgingival microbiota, prevalent in patients with periodontal disease. It is known to invade epithelial cells. Peptostreptococcus micros (Parvimonas micros) - is a recognized pathogen associated with progressive periodontal disease and endodontic abscesses. Caries Risk Streptococcus mutans - one of the key etiologic agents involved in the onset and progression of carious lesions resulting in rampant destruction of the smooth surfaces of the teeth. Yeast Candida albicans - opportunistic fungal, commonly found in the oral cavity; often participates in the formation of polymicrobial biofilms on the soft tissues and acrylic surfaces. Frequently detected along with periodontal and cariogenic pathogens in a bacterium-fungus symbiotic relationship that enhances the transition from a healthy to a disease state. The bacteria in this sample are tested by quantitative polymerase chain reaction (qpcr).

40 BiofilmGS Sampling Biofilm samples with a mirror and Soft-Picks

41 BiofilmGS Sampling Microbiology Report Tongue Base Tongue Teeth Dorsum OV1 OV1 OV1 OV1 OV1 OV1 Gram +ve Q1 Q2 Q3 Q4 Cocci VH VH VH VH VH VH Bacilli H M VH VH VH H Gram ve Cocci VH H VH VH VH VH Bacilli H M H H H M Fusiforms M L M M L L Spirochetes L L L Vibrio L H H H L Yeast M L M M L L Amoebae WBC H H H Notes: OV1: The tongue dorsum and quadrant 4 have a normal borderline biofilm. Both the tongue base and the other teeth have high levels of Gram-negative bacilli and many fusiforms, together with dense vibrios and high numbers of white blood cells in the teeth samples, indicating that there is infection. Treatment should be based on the medical history, periodontal charting and this report. Treatment Recommendations: Michael will benefit from FM4 rinse and should use it 3 times a day until completed, rinsing vigorously for 20 seconds and gargling for 10 seconds. Even though the tongue biofilm is normal, tongue cleaning is recommended prior to rinsing. Michael should use Soft-Picks that are coated with FM4 rinse to clean between the teeth. This is an important step that will help break up the biofilm and also move particles into the sulcus. After completing the antibiotic rinse, Michael should rinse with chlorhexidine (CX220) for two weeks and continue to use Soft-Picks wet with CHX to clean between the teeth. The Soft-Picks will clean interdentally and also release some chlorhexidine into the sulcus. Maintenance should consist of effective interdental cleaning and a daily mouthwash such as Smartmouth or CDLx.

42 Re-evaluation and Maintenance Evaluation is completed 4 weeks after the diagnosis/treatment appointment. Usually 30 minute appointment Complete another periodontal charting, BOP, Papillary Bleeding Score Disclose and review oral hygiene techniques Compare pre-post treatment results Prescribe additional care as needed Place client on a Maintenance rinse Polish teeth

43 Helping clients understand Periodontal Charting Tell your client about what you are calling out/measuring - 1-3mm are healthy readings - 4-5mm readings mean you have areas of infection/inflammation and we treat them like a yellow light - Caution - 6+mm readings are like a red light - you have many areas of concern and we might have to change your treatment plan - During this exam I will also be calling out all the areas with bleeding. We like your total score to be less than 10. If the bleeding score is between we need to improve your home care and if there are more than 30 bleeding points we need to figure out what is causing your infection.

44 6 Site BOP Score when Periodontal Charting BOP Value Mouth Rinse that Fits Less Than 10 Stable Disclose and review oral hygiene suggest Maintenance Rinse (CDLx, or SmartMouth) Disclose and review oral hygiene Maintenance rinse (CDLx, or SmartMouth) may be sufficient depending on risk factors May need to consider antibiotic & antimicrobial Suggest Microbiology slide 30 + Disclose and review oral hygiene suggest Antibiotic rinse and Antimicrobial rinse Maintenance rinse (CDLx, or SmartMouth) Suggest microbiology slide Tip: Discuss Bleeding Indices as a Wound Size

45 Flossing vs. Soft-Picks/Interdental Brushes Primary Prevention Of Periodontitis: Managing Gingivitis Results: Data support the belief that professionally administered plaque control significantly improves gingival inflammation and lowers plaque scores, with some evidence that reinforcement of oral hygiene provides further benefit. Re-chargeable power toothbrushes provide small but statistically significant additional reductions in gingival inflammation and plaque levels. Flossing cannot be recommended other than for sites of gingival and periodontal health, where inter-dental brushes (IDBs) will not pass through the interproximal area without trauma. Otherwise, IDBs are the device of choice for interproximal plaque removal. J Clin Periodontol 2015; 42 (Suppl. 16): S71 S76 doi: /jcpe.12366

46 PBS Score PBS Score Mouth Rinse that Fits 0 Stable no bleeding 1 Light localized bleeding Maintenance rinse 2 Moderate bleeding Maintenance rinses may be sufficient depending on risk factors May need to consider antibiotic & antimicrobial rinses 3 Heavy bleeding Antibiotic and antimicrobial rinses followed by maintenance rinse Tip: Explain bleeding as being Infectious

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48 Always Disclose! This is critical so your clients can see where THEY need to clean Can I show you some areas you are having trouble reaching.

49 The role of a dental hygienist Changing our focused from scaling to health Clients have to know that you care about their health and at every visit try to show/teach them something new. This way it doesn t look like you are selling/pushing periodontal therapy but encouraging/promoting oral health and overall health

50 Motivating Clients Via Show and Share This helps the client make a decision In hygiene we can use the following: Word Pictures Intraoral Camera Disclosing PBS Using Soft-Picks BEFORE you start scaling Microbiology Mirror X-rays

51 Discuss that the goal is no bleeding and that healthy skin never bleeds. Talk about the oral systemic link. Demonstrate the infection/inflammation visually Move OHI to the beginning of EVERY appointment Disclose after every periodontal chart How to improve your assessment and get started Always assess with PBS prior to scaling. If there is bleeding think about using irrigation Take microbiology samples Suggest a mouth wash for your clients that will target their concerns (decay, perio, dry mouth, bad breath) Discuss how you get gum disease. Now bleeding matters!

52 Verbiage For Interdental Cleaning Remember the client doesn t have a LITTLE bleeding, they ARE bleeding. It is not a little crack, the tooth HAS a crack. The client doesn t have a little cavity, they have a cavity. When you see your family doctor they don t say you have a little cancer, you have cancer or your do not. When we use the word little it minimizes the problem. We need maximize the problem and simplify the treatment.

53 Create a healthy foundation which is fundamental for comprehensive Restorative dentistry and Implant placement Use prior to extractions (PDD and health compromised) Use with NSPT Improve treatment results with periodontal surgery and local treatments. (Arestin, Laser and FM3 cream)

54 Achieve Long Term Success Educate about risk Treat infected spouse at the same time Focus on daily biofilm disruption Use of a daily anti-bacterial rinse Maintain 3month perio maintenance intervals Disclose and coach your client to improve their homecare at each visit Treat local remaining sites with local modalities after WHOLE MOUTH treatment.

55 What are your risks? Many dental professional are highly infected when microbiology sampling is taken. This is due to the air borne particles that remain in our operatory after our clients leave. RDH s need to have excellent OH to stay ahead of the biofilm infection. Due to our working environment we are a great risk of reinfection. Control your client s infection and decrease your risk as well! Note: In Toronto, an RDH was asked to leave a grocery store because she was shopping in scrubs

56 For more information please call or Predictably healthy clients with the help of OraVital