Antibiotics are a staple in dental. Disrupting Biofilm: Beyond Antibiotics. 88 APRIL 2018 // dentaltown.com

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Disrupting Biofilm: Beyond Antibiotics Hydrogen peroxide treatment demonstrates decrease in bacterial infections by Milton Marshall, PhD, DABT, and Tanya Dunlap, PhD Toxicologist and biochemist

1 Disrupting Biofilm: Beyond Antibiotics Hydrogen peroxide treatment demonstrates decrease in bacterial infections by Milton Marshall, PhD, DABT, and Tanya Dunlap, PhD Toxicologist and biochemist Milton Marshall, PhD, DABT, researched safety data on the use of hydrogen peroxide in dentistry, which was presented to the FDA and ADA. He has also worked to examine the biocompatibility and safety of dental materials. Tanya Dunlap, PhD, is the managing director for Perio Protect, where she has worked since She coordinates clinical research involving prescription tray delivery. She also offers CE courses on the science behind prescription tray delivery and the important implications of the research data. Antibiotics are a staple in dental offices to counter bacterial infections. For the treatment of periodontal disease, antibiotics have been widely used to fight gingival infections and the resulting inflammatory responses, and the antibiotics can help. Efficacy is often short-lived, however, because periodontitis is a biofilm-based disease that, like other biofilm infections, is refractory to antibiotics. 1 Nevertheless, the underlying problem is inflammation prompted from a bacterial infection, and we are taught that antibiotics are the right course. When they don t work well or when the results are not long-lasting, we often think that we just need the right antibiotic. But what if antibiotics aren t the best option? Paradigms that shape our views are often so ingrained that we don t realize how they frame our thoughts or our treatment approaches. It s time to challenge the antibiotic treatment default for periodontal therapy. This means not that antibiotics shouldn t be used but that they need to be used more judiciously. 2 The underlying premise of the challenge: If our current mechanical, surgical and antibiotic treatments worked well, then 47 percent of American adults would not have chronic periodontitis. But they do, and millions more have gingivitis. 3 We want to find fault with patients, and home care is a clear fault line where most patients 88 APRIL 2018 // dentaltown.com

stumble; they need to be trained in home care technique, and that training often needs to be checked and retaught. But even with the best technique, it s often not the patient s fault.

Beating biofilm The human mouth is the perfect environment for biofilm growth it s moist and warm, with an ample food supply and various concentrations of oxygen.

The regular removal of biofilms from periodontal pockets via periodontal therapy is a benefit to treatment of this chronic disease, but the communities often just repopulate.

2 stumble; they need to be trained in home care technique, and that training often needs to be checked and retaught. But even with the best technique, it s often not the patient s fault. Toothbrushes, rinses and floss often don t get deep enough into the periodontal pocket where bacteria proliferate. This is a biofilm problem. Beating biofilm The human mouth is the perfect environment for biofilm growth it s moist and warm, with an ample food supply and various concentrations of oxygen. In one study, biofilm colonized sterile carriers placed into 5 6mm pockets within 48 hours. 4 The potential to form colonies is clearly strong in this environment. The regular removal of biofilms from periodontal pockets via periodontal therapy is a benefit to treatment of this chronic disease, but the communities often just repopulate. This is why mechanical intervention has temporary benefits and dental professionals want adjunctive treatment options to supplement the mechanical removal. 5 Chlorine-based products and peroxides have potential to help. Unlike antibiotics, they cut through the slime matrix that covers and protects bacterial communities. And unlike antibiotics, bacteria are not known to develop resistances to these antimicrobials. Chlorhexidine disrupts bacterial cell walls and is widely used to treat gingivitis and as an antimicrobial irrigant. Its long-term uses in home care have been limited by staining. Clorastan, a stabilized chlorine dioxide and SnF 2, is used to treat dental-unit water lines and remove biofilm; it is FREE FACTS, circle 22 on card dentaltown.com \\ APRIL

Fig. 1a Fig. 1b Figs. 1a c: Pretreatment patient. Fig. 1c also used in dentifrices and mouth rinses to provide antimicrobial activity.

this problem. 7 Peroxides at low concentrations ( 3 percent) have long been recommended to reduce plaque and gingivitis with a good safety record.

The problem that researchers identified in using peroxide for the treatment of periodontal disease is mechanical access to the pocket.

The challenge is not just getting medication deep into periodontal pockets, but also holding it there long enough for therapeutic effect.

3 Fig. 1a Fig. 1b Figs. 1a c: Pretreatment patient. Fig. 1c also used in dentifrices and mouth rinses to provide antimicrobial activity. 6 Its limited shelf life created concerns for patients, but in recent years activated chlorine dioxide stored in dual chambers and mixed by the patient immediately before use as a rinse has overcome this problem. 7 Peroxides at low concentrations ( 3 percent) have long been recommended to reduce plaque and gingivitis with a good safety record. Disruption of the biofilm occurs after exposure to hydrogen peroxide likely a combination of chemical and mechanical processes. The problem that researchers identified in using peroxide for the treatment of periodontal disease is mechanical access to the pocket. 8 The rinsing and brushing just doesn t reach deep enough for patients with pocketing greater than 3mm. The challenge is not just getting medication deep into periodontal pockets, but also holding it there long enough for therapeutic effect. Sealed prescription trays provide effective delivery deep into periodontal pockets (up to 9mm) for concentrations of peroxide as low as 1.7 percent. The oxygenation of the periodontal pockets via a daily 10-minute tray application is hypothesized to modify the microenvironment of the periodontal pocket to modify biofilm regrowth. 9 Chlorine-based products have not been used in the tray because of concerns for taste, staining and gingival irritation. Prescription tray therapy Clinical trials have shown that use of hydrogen peroxide, delivered in a sealed prescription tray as an adjunct to scaling, reduces bleeding and pocket depth better than scaling alone. 10 Evaluations of refractory maintenance patients from a periodontal office tracked patients for up to five years demonstrating that the addition of sealed prescription tray therapy helped reduce inflammation by 75 percent more than 90 APRIL 2018 // dentaltown.com

Fig. 2a Fig. 2b traditional maintenance. 11 The key to successful reduction and modification in biofilm by hydrogen peroxide can be ascribed to the precise seal of the prescription tray.

12 Repeat applications of 10 15 minutes remove additional layers and also expose the periodontal pocket to oxygen as peroxide activates.

regrowth. 13 The benefits of this approach can be seen in a case study featuring a patient who wanted an implant.

1), and refused to provide the implant without periodontal therapy first. The patient left the office but later returned to ask for more information.

Within weeks of starting treatment, there was a 77 percent decrease in bleeding, less plaque, and much healthier gum tissue tone and color (Fig. 2).

This case illustrates points proven in clinical trials that the regular delivery of a low concentration of peroxide via a sealed prescription tray as an adjunctive therapy offers significant

Managing the bacterial Dear Dentist, If your lease is coming up for renewal in the next 18 months (or you re opening a new practice) call or email us to book a no-obligation telephone

4 Fig. 2a Fig. 2b traditional maintenance. 11 The key to successful reduction and modification in biofilm by hydrogen peroxide can be ascribed to the precise seal of the prescription tray. This tray allows oxygen released from the peroxide gel to penetrate deep into periodontal pockets over 10 minutes, and the exposed surface layer of the biofilm is debrided. 12 Repeat applications of minutes remove additional layers and also expose the periodontal pocket to oxygen as peroxide activates. The change in the microenvironment of the periodontal pocket, through the release of oxygen, creates a hostile environment for anaerobes and a favorable environment for healthier bacterial regrowth. 13 The benefits of this approach can be seen in a case study featuring a patient who wanted an implant. The patient presented requesting the implant, but the dental team explained that the infected tissues likely would not support the implant (Fig. 1), and refused to provide the implant without periodontal therapy first. The patient left the office but later returned to ask for more information. He consented to periodontal therapy, which consisted of scaling and prescription tray delivery of 1.7 percent hydrogen peroxide gel (Perio Tray and Perio Gel, respectively). Within weeks of starting treatment, there was a 77 percent decrease in bleeding, less plaque, and much healthier gum tissue tone and color (Fig. 2). The healthier tissue should support the implant long into the future (Figs. 3 and 4). This case illustrates points proven in clinical trials that the regular delivery of a low concentration of peroxide via a sealed prescription tray as an adjunctive therapy offers significant patient benefit. Managing the bacterial Dear Dentist, If your lease is coming up for renewal in the next 18 months (or you re opening a new practice) call or us to book a no-obligation telephone consultation and receive a complimentary autographed copy of our new book. It s the best investment you can make in your practice. The Lease Coach Services Lease Negotiations (new & renewal) Midterm Rent Reductions Site Selection (& site evaluation) Building & Property Acquisitions Document Reviews (39 point inspection) Coaching and Consulting (One on One) Lease Assignments Operating Cost Analysis / Auditing Services Space Measurement & Rent Recapture Available at Barnes & Noble, Amazon or online at TheLeaseCoach.com FREE FACTS, circle 30 on card Figs. 2a b: Images for patient two weeks after first scaling procedure and prescription trays were started. Dale Willerton@TheLeaseCoach.com (U.S.) JeffGrandfield@TheLeaseCoach.com (Canada) 1 (800) dentaltown.com \\ APRIL

Fig. 3a Fig. 3b Fig. 3c Figs. 3a c: Images taken two months after scaling and prescription trays started. Rx trays are used daily to manage biofilm. Fig. 4a: Healthier tissue ready to support an implant.

This helps solve a problem in treatment that clinicians and patients have faced for decades. The solution is an old and affordable drug.

W. McCreight and Jessica Berthelson, RDH, from McCreight Progressive Dentistry, Steamboat Springs, Colorado Endnotes 1 Schaudinn et al. Periodontitis: An Archetypical Biofilm Disease.

2 Fluent et al Considerations for responsible antibiotic use in dentistry. Jour Am Dent Asso. 147;8:683 686. Dental antibiotic prescribing rates are likely underestimated.

Maria Bye, Tory Whitten, Stacy Holzbauer; Antibiotic Prescribing for Dental Procedures in Community-Associated Clostridium difficile cases, Minnesota, 2009 2015, Open Forum Infectious Diseases,

Prevalence of Periodontitis in Adults in the United States: 2009 and 2010. J Dent Res. Published online 30 August 2012:1 7.

5 Fig. 3a Fig. 3b Fig. 3c Figs. 3a c: Images taken two months after scaling and prescription trays started. Rx trays are used daily to manage biofilm. Fig. 4a: Healthier tissue ready to support an implant. Fig. 4b: Shade matching. Fig. 4a Fig. 4b loads by managing the microenvironment of the periodontal pocket helps address the bacterial causes, deep in periodontal pockets. This helps solve a problem in treatment that clinicians and patients have faced for decades. The solution is an old and affordable drug. It just has a new and comfortable delivery that is easy for patients to use. Case courtesy of Dr. James W.W. McCreight and Jessica Berthelson, RDH, from McCreight Progressive Dentistry, Steamboat Springs, Colorado Endnotes 1 Schaudinn et al. Periodontitis: An Archetypical Biofilm Disease. Jour Am Dent Asso. 2009; 140(8): Sauer K, Thatcher E. et al. Neutral super-oxidised solutions are effective in killing P. aeruginosa biofilms. Biofouling 2009;25(1): Fluent et al Considerations for responsible antibiotic use in dentistry. Jour Am Dent Asso. 147;8: Dental antibiotic prescribing rates are likely underestimated. Stewardship programs should address dental prescribing and alert dentists to CDI subsequent to antibiotics prescribed for dental procedures. Maria Bye, Tory Whitten, Stacy Holzbauer; Antibiotic Prescribing for Dental Procedures in Community-Associated Clostridium difficile cases, Minnesota, , Open Forum Infectious Diseases, Volume 4, Issue suppl_1, 1 October 2017, Pages S1, 3 Eke PI, Dye B, Wei L, Thornton-Evans G, Genco R. Prevalence of Periodontitis in Adults in the United States: 2009 and J Dent Res. Published online 30 August 2012: SEM Results of Periopathogenic Control with the Perio Protect Method, Keller et al. J Dent Res 86(A): 1186, Poster presentation at IADR/AADR/CADR (March 21-24, 2007), New Orleans. 5 A flowcell for the study of plaque removal and regrowth. Palmer RJ and Caldwell DE. J Micro Methods 1995;24(2): Smiley et al. Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with our without adjuncts. JADA. 2015(146)7: Van Dyke, T. Inflammation and Periodontal Diseases: A Reappraisal. J Periodontol Aug;79(8s): Watamoto T. et al. Clinical evaluation of chlorine dioxide for disinfection of dental instruments. Int J Prosthodont Nov-Dec;26(6): Sellers K and DiGangi P. Matching rinses to individuals. RDH 2014 March;34(3). 8 Marshall MV, Cancro LP, Fischman SL. Hydrogen peroxide: a review of its use in dentistry. J Periodontol Sep;66(9): Keller DC and Buechel M. Direct medication delivery modifies the periodontal biofilm. Oral Biol Dent. 2017; 5:1. dx.doi.org/ / Putt M, Mallatt M, Messmann L, and Proskin H. A 6-month clinical investigation of custom tray application of peroxide gel with or without doxycycline as adjuncts to scaling and root planning for treatment of periodontitis. Am J Dent. 2014;27: Putt M and Proskin H. Custom Tray Application of Peroxide Gel as an Adjunct to Scaling and Root Planing in the Treatment of Periodontitis: Results of a Randomized, Controlled Trial after 6 months. J Clin Dent. 2013;24: Putt M and Proskin H. 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): 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: Dunlap T. Prescribing Hydrogen Peroxide in the Treatment of Periodontal Disease. Oral Health 2016;Dec: Keller and Buechel. 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 Nov;XXII(5): Marx, RE, Johnson RP. Problem wounds in oral and maxillofacial surgery: The role of hyperbaric oxygen. In: Davis JC, Hunt TK, editors. Problem Wounds - the role of oxygen. New York: Elsevier, 1988; Knighton DR, Halliday B, Hunt TK. Oxygen as an antibiotic. The effect of inspired oxygen on infection. Arch Surg 1984; 119(2): APRIL 2018 // dentaltown.com

Dental Water Jet. By: Jennifer Buffington, Lindsay Hunt, Ruth Gardner

Dental Water Jet. By: Jennifer Buffington, Lindsay Hunt, Ruth Gardner Dental Water Jet By: Jennifer Buffington, Lindsay Hunt, Ruth Gardner What is a Dental Water Jet? A home, dental self-care device that uses a stream of pulsating water to irrigate the subgingival sulcus