Running Time: 54 min
Review the Rationale for SRP Understand the need for sequential treatment therapy (Power to manual) Discuss local anaesthetic indications Explain use of Antimicrobial and Antibacterial Agents Release: 9/26/2014 | Expires: 9/26/2017
Release Date: September 30, 2014Subtitle:
Welcome back to the Nonsurgical Periodontal Therapy module number two. My name is Karima Bapoo-Mohamed. And it’s my pleasure to share with you this section of the module where we are going to discover a few different phases of the treatment of periodontal disease. I’m a dental hygienic with a clinical practice as well as teaching experiences at the University of Alberta. And I’m happy to share some of my findings, some of my revelations with you in this module. The learning outcome for this module is to quickly review the rationale for scaling and root planing therapy as part of periodontal treatment. We want to understand the need for sequential treatment therapy. And we’re going to discuss power instrumentation as well as manual instrumentation, and really look at some of local anaesthetic indications as we provide our periodontal therapy treatment to our patients. And we’ll finish up this module with antimicrobial and discuss some antibacterial agents, as well as antibiotic indications for our patients with periodontal therapy. So starting out with a rationale for scaling and root planing. Tooth scaling is done by the dental care provider and, of course, it is aggressively going after specifically the subgingival debridement of the necrotic cementum area, which requires manual instrumentation and sometimes sonic or ultrasonic instrumentation. Despite all the evidence of biofilm– in fact, because of the evidence of the biofilm research, scaling and root planing is still the gold standard for nonsurgical treatment of periodontitis. There have been multiple clinical studies that demonstrate that it effectively reduces the microbial load, and it actually leads to the reduction of bleeding points and bleeding on probing, as well as it has shown that the probing depths are diminished as far as a clinical attachment goes over time. So there is a definite need and relevancy for conducting scaling and root planing therapy in our patients’ mouth. Performing this debridement under local anesthetic, actually, really helps with the comfort level. And what we’re trying to do, basically, is really limit the progression or stop the progression of periodontal disease. There are also the pharmacotherapeutic agents that we can use in combination, in parallel, to really supplement our manual and sonic ultrasonic scaling root planing therapies. So we’re going to actually talk about that a little later on too, as well as the chemotherapeutic agents, along the lines of any kind of antimicrobial rinses, and fluorides, chlorhexidine, and so on. The professionally applied microbial agents will have sustained delivery. And that merits attention as well. So the tail end of the slides in this module will speak to some of those agents, as well as the host modulating drug. We’re going to talk about daily home care and the frequent recall as really being paramount for the long-term success of the treatment we’re providing intraorally. And then the frequent re-evaluation and careful monitoring– you’ve done all this hard work of scaling root planing, and really if you don’t monitor this patient, all your hard work, I feel, goes to waste, and to really monitor that disease activity and the pathogenesis of the bacteria there. Mechanical removal of the deposits, you know, is tough. It is time-consuming. It is operator patient-dependent. And let’s face it. It’s difficult to master. It’s very tedious as well. And so the most widely used method is instrumentation. And we do want to understand that that instrumentation is helping that patient, as tedious as it may be for us. There is notion that it does re-colonize, and the pathogens will resurface in about 60 days after we’ve done the scaling and the root planing process. So again, supplementing them with chemotherapeutic agents, depending on the case, of course, to complement the mechanical cleaning that we’re giving them and the debridement function that we’re providing will really help out. Another study to the Cobb study really revealed that this nonsurgical, mechanical periodontal therapy actually has helped reduce the probing depth in patients, as well as improved the clinical attachment. So that’s fairly significant and really gives us a good rationale for why we do the nonsurgical periodontal therapy in patients now. Ready for this? This is probably the worst case patient I have ever seen in my years and years of practice. And this new patient presented in our office looking like this. And it is absolutely shocking to see that the progression of the periodontal disease got to a stage where the patient is now actually not even functional anymore. And I’m curious to find out like why is it that this patient waited this long and did not come in and see us or solicit any help or treatment for the periodontal disease. And the top on the list was they were worried that it would hurt. And right after that is embarassment– how can I show this to anybody? We ended up doing a full clearance, of course, and had tooth replacement therapy using dental implants for this patient. But sometimes patients have this really past negative experience. And then they just shy away and keep away. Now this is probably a very extreme case. However, I felt it merits the final end points of periodontal disease and where it could actually lead to. This is, again, a very severe, advanced form of periodontal disease. So really, I just want to say that rationale for that scaling root planing is definitely here and here to stay. And what we’re doing is monumentous as far as the task goes, but as far as the impact goes as well in helping our patients save their teeth and keep their teeth in their mouth. Let’s move on and talk about the sequential treatment therapy for our patients that we’re providing the nonsurgical periodontal therapy to. And we’ll probably spend a fair amount of time on this / we want to have a sequence of treatment which is starting from the growth debridement of the deposits, moving on to fine scaling. And usually, we start the debridement process, of course, with power instrumentation. It could be piezo. It could be magnetostrictive, and then move onto our hand instrumentation. So we’re going to talk a little bit about all these categories. Starting with the power instrumentation, what are some of the effective strategies for removing very tenacious subgingival calculus? A lot of times it starts when we pick up our– whether it’s an ultrasonic tip or a piezo tip– select the right tip. It’s amazing to me. And I attended a workshop on it. I thought I knew everything there was to know about piezo ultrasonic tips. Well, I find my efficiency has really increased by understanding and selecting the right tip for the right location of that deposit. Another advice I also learned is use the tip on a medium power. You know how you have a tendency if it’s tenacious calculus, you yank up the power button and go to the highest volume? The medium power actually provides a much better result there in removal, or actually agitation, of the tenacious calculus. Having proper control adaptation– this we know is a factor– attacking the deposit actually from all directions. Unlike our hand instrumentations where we want to go apical to the deposit and then have a upward oblique movement with the nice fulcrum close to that surface, in an ultrasonic situation, you want to try to go multi-directionally to try and loosen up that tenacious calculus. Using the correct surface of that power tip, as well, becomes important. Tendency to use the tip part of an ultrasonic tip is where a lot of students, I find, go wrong. And what you want to use is a lateral border of that power tip because that’s where the power is actually. Changing to a different tip– you know, a lot of times we’ll start with something and then carry on, get so engrossed in what we’re doing. Take the time to actually say, OK the surface area is actually changed in topography. And the tip that I used to start with may not be meeting the needs of the surface I’m looking at now. So stop and actually change that tip as well will give you a more effective result. How about the use of files is something definitely want to talk about a little later on. And then I will progressively increase the power on my ultrasonic as we progress forward. Let’s talk about advantages of power instrumentation. Of course, it’s great for that effective removal, especially when you have a tenacious calculus formation for plaque biofilm, as well. Because as we know, plaque biofilm does attach the host aggressively. What’s nice about the power instrumentation is it will penetrate into the pocket. I kind of like the areas of frication what I can access with my lateral border of the ultrasonic tip. And irrigation– this is great. A lot of patients will ask what is that irrigation for? And I kind of like the idea of it just flushing it through. You want to keep the instrumentation time a lot shorter with the power instrumentation as you are constantly moving your instrumentation tip. Limitations with power instrumentation is it is a skill acquisition, right? I mean, it is something you don’t get right away. The more you do, the better you get at it. So that can be a limitation sometimes. Of course, with the power instrumentation, you don’t have a tactile sense. So you’re really reliant on your visual manifestation of the deposit, especially as you flush it into the subgingival pocket. All of a sudden, the deposit of calculus becomes evident with the flushing motion of the water. So there’s no tactile sense. But you maybe have a little improved visibility, depending on the pocket depth and location. There are some occupational risks with using power instrumentation, and definite contraindications for using power instrumentation, which we’ll talk about. But the risks include infection control because you do have [INAUDIBLE] production of about less than 50 micrometers in diameter is the [INAUDIBLE] diameter there. So really, you want to make sure you’re protecting yourself and the patient from this potentially infectious disease issue. And really, if used inappropriately, you could have some muscular, skeletal, or auditory damage as well on the patient. So I don’t think I’ve ever heard too much stats on that. But it is an occupational risk we should label and outline. Contraindications for power instrumentation– patients with communicable diseases, absolutely. It’s contraindicated for that. Also patients who are asthmatic– you know, I always have the updated medical history, have the patient not only have their [INAUDIBLE] in or whatever their mode of medication is available, either on their lap or on the counter in the dental hygiene off. But if they’re asthmatic, I probably want to stay away from creating an aerosol with those microdroplets there. Any patient who has a high susceptibility of infection is somebody you don’t want to use power instrumentation on. Anyone who has any kind of respiratory diseases, including the asthma, even if they’re not incidental at that point in time, may be contraindicated for that. You want to understand what kind of pacemaker this patient has. And that may be a contraindication, coupled with the patient who has a gag reflex that’s very strong and powerful. Or ever have patients that are really macroglossia– and really this tongue that’s everywhere– may not be a candidate for power instrumentation. Or patients who exhibit or mention that they have dysphagia and very difficulty in swallowing, you don’t want too much water accumulating at the back of their throat. What is a stroke pattern for power instrumentation? You do want to have this wonderful overlapping design of stroke. And they should be very close to each other. I remember attending the [INAUDIBLE] workshop. And in that, she says actually the effective area for the ultrasonic is about two human hairs. That’s not a very huge surface area. So really the overlapping of the strokes ensure the completeness of removal of calculus in this area. We want to use long, sweeping motions. Sometimes we want to use very short, vertical motions. And as we mentioned earlier, it could be multi-directional. It could be horizontal or oblique, and going in different directions, depending on the dental anatomy that you’re presented with, including frication. The important thing is you want to keep the tip moving all the time. Because guess what? There’s a lot of frictional heat being developed. And I’ll explain that to our patients. Actually, the water is a cooling system for this tip, which is moving at up to 36,000 rev per second. So really, we want to keep the cheap tip moving all the time so that it’s most comfortable for the patient. And because it’s powered, it’s not like hand instrumentation where we need a lot of force. It’s very light force. And maybe start with that moderate or medium power, moving progressively to the high power. We have a variety of tips, as we mentioned. And we already talked about the overheating aspect of the ultrasonic tip, and really want to make sure that we are having an even spray, really, to dislodge the debris. There should be a mist around the tip of that. So the water is great, not only for overheating or cooling the tip that may overheat. But I kind of like the flushing effect that it’s creating also for the loosened debris that may accumulate or be dislodged, deep subgingivally somewhere. So the water’s nice because it flushes it out. What’s interesting is patients say they really enjoy that experience as well. I think so long as you prepare and alert the patient as to what you’re doing, how you’re feeling, that there’s going to be water, to there’s going to be this high-pitched sound. A good point is if patients have a hearing aid, for example, I may have them turn it down or remove it, because especially when you’re working around the sign that says their ear canal area– sound can be amplified for a lot of these patients– so really looking at it from the patient comfort and safety perspective. Here is a picture of a nice, juicy, healthy chunk of calculus. Us hygienists get excited about getting in there and removing it. And this is just showing with the use of magnetostrictive ultrasonic tip, we were able to then remove it. And this is just debridement. There are still little spicules. The thing with ultrasonic tips is if you can’t go subgingivally. They’re not very specific to small surface areas here. Notice the bleeding edematous tissue here too. And this is in response to this deposit that caused and incited an inflammatory reaction on the gums. This is another picture showing calculus deposit, usually the mandibular anterior incisor area, especially on the lingual surfaces. It’s based on the Wharton’s duct from the submandibular glands– has a lot of calcium and phosphate deposits. And so this would be a good indication for using ultrasonic. I get asked questions about power instrumentation. Is it advisable to use it if you don’t have hard deposit of calculus present subgingivally. And I feel with the evidence of biofilm and how it’s attaching onto the whole surface that I would be quite comfortable and very frequently will bring out my power instrumentation tip and just give a full mouth lavage, even in the absence of heavy supra gingival calculus deposits. So we mentioned a little bit about the contraindications. But I want to highlight it here. Patients with certain types of pacemaker is absolutely contraindicated. And you want to check that out with their medical doctor or the nurse when you’re doing your comprehensive medical exam. A lot of the cases with HIV positive, AIDS positive patients, you want to limit the dental aerosols that you’re creating because of the infectious nature of the disease that that may be a contraindication. And I’ve read studies on osseointegration, actually first-year post-insertion of an implant placement. Because there is a lot going on as far as osteogenesis that the ultrasonic energy albeit it’s not as high or as powerful, may be contraindicated for that first year post-insertion of a dental implant. When I present that fact to a lot of audiences worldwide, they ask the question oh, but what about Sonicares or power toothbrushes? The reps per second in the home care regiment of a power toothbrush does not match what we use in office for our powered instrumentation. So power toothbrushes are not contraindicated, necessarily, for osseointegration. But we just want to be vigilant and aware of any implants that have just been recently placed prior to using power instrumentation in our offices. Studies support that effective removal of subgingival supra gingival calculus is very much complemented with strict program of the patient as well. So our treatment goal with scaling and root planing is, of course, to arrest and control the progression of the disease. We also want to make sure that we’re leaving the periodontal tissues in such a way that the patient can easily manage and maintain the status as well. And really, what we want to do is restore the supporting structures of the bone and the alveolar tissue, as well as the periodontal ligament, as well as the gum tissue, to as healthy a state as possible, including the periodontal ligament. And this is just a quick slide to highlight– and this is more for patient education purposes. Every so often I get asked the question so what’s the difference? Why are you charging me a different code for scaling and a different code for root planing? And I think there’s a price differential between the two codes as well. So again, for our clarity purposes, explaining to our patients that any dental deposit removal that I’m doing above the gum line is scaling, and anything below the gum line actually show the degree of difficulty in removal. Because access is an issue. Retention of this deposit is a little bit more tenacious than above the gum line. And in some cases, it’s very tenacious. That actually will reflect on the type of treatment root planing becomes. And so it’s also reflected in possibly a higher cost than the scaling cost would be. What are some of the other hand instrumentations, moving onto our curettes? So we have a case where we’ve now done the full mouth ultrasonic. We’ve got the advantage of the lavage and the flushing of the water to remove any loosened debris subgingivally. We’re now going to take our explorer and understand where are the remaining residual deposits, following which we’ll make our instrument selection. We have a plethora of selection on our periodontal scaler trays. And curettes usually are something that we do for our fine scaling, for fine debridement, and helps remove deposit. But also helps leave the tissue in as clinically smooth state as possible. So they are designed for subgingival scaling and root planing. And they will help with that necrotic cementum removal. Scalers can actually also have some inadvertent curettage effect, as well, which we’ll talk about a little later on. Sickle scaler, of course, is a heavy-duty scaler. It’s most definitely stronger than the curette scalar. It is a double-beveled blade instrument. And this, again, is our first choice go-to instrument for a large chunk of calculus deposit. A lot of the time, it will be supra gingival so the access to it is easier. This is going to be a more upward activation stroke or a pull stroke as we try and remove that deposit of calculus there. And this is again showing the adaptation of that sickel scalar subgingival to that supra gingival deposit. And then you’re going to do the upward oblique pull stroke in order to remove the calculus from under there. Supra gingival and subgingival debridement can happen. Both of them can happen with a sickel. So here is demonstrating a sickel. I’m just using the tow end of the sickel here and actually going subgingivally and covering the line angle of this dentition below the crown margin to remove the deposit that I’m chasing to get it out of there. Files are another great adjunct to tenacious calculus, especially removal of tenacious calculus. And what I like about the files– it has that crushing action. So a lot of times before I pick up that file and use it intraorally, I’ll mention to the patient you may feel a little pushing sensation. It’s like someone just giving you a little nudge. And so that’s very normal. And what you’re doing is actually applying a lot of lateral force, especially for that burnished calculus where you want to create a roughness or an unevenness to that burnished calculus. So that it can be detected and then effectively be removed with your scalers and your curettes. So really the primary purpose of the files is to roughen the root surface or that deposit surface so that you can commence or move on to your fine scaling. The after five curettes are phenomenal because they go subgingival. As we all know, the features of the after five is that there is a long terminal shank. And actually the blade length is half that of a standard curette. So this, for the frication areas, is wonderful because of you have a six-millimeter CAL– clinical attachment loss– and that frication area is just in that little deformity or the concavity area, all you need is a little tow end of the blade to access that space there. So it’s wonderful for narrow pockets, for fricatios, as we were mentioning, any kind of grooves or pits we might have on the teeth. I love it for line angles as well, especially with the pockets. They’re really tight around the line angle. Because it’s not as invasive, but it will do the work of accessing and removing the deposit. Next, I have a series of slides with clinical manifestations of before and after scaling root planing therapy. And as you can see, it’s fairly heavy deposit, again, in one of our favorite areas– the mandibular anterior areas is always heavily laden for most patients– and just a difference in removing it from before and after. If you have intraoral cameras, I encourage you to use it. Because I will capture before– as anxious as I am to get in there and remove all of legions of calculus– I’ll quickly take a picture, and then take a picture after so that the patient has a memory of that visual, of wow, what a difference that has made. Because this is all pathogenic disease activity actively going on in your mouth as you’re here talking to me. And we’ve been able to remove that. And tissue condition, again, is not ideal. But this is just after the raw removal of the deposit. This is, again, showing another example on the lingual surfaces of mandibular anterior. Look at the tissue here– very [INAUDIBLE] looking. And you can see the effects from before and after just a scaling and root planing. And in this situation, the ultrasonic would be a huge reliant factor for me would be the [INAUDIBLE]. Some of these cases are actually from some work I’ve done in Africa. So you’ll see some pigmentation on the slides, which really relates to the patient base. But this is actually a 23-year-old male patient in Africa. And look at the type of periodontal disease and progression that they have here– so quite a difference in pathology and the pathogenesis of periodontal disease in this cohort of population. This, I believe, is a smoker patient of mine. And you can see not only do you have heavy calculus deposit. But you actually have staining on this deposit here too. Stain is actually a good parameter, especially on the extraoral or the supra gingival calculus. Because it’s actually showing me the age of the calculus. If it’s really heavily stained, it’s probably been there a lot long than something that’s not so stained. So it’s probably been a while. And it’s probably been awhile since they last seen their dental hygienist because of the gross amount of deposit that exists in this clinical situation. Here is showing another slide on the lingual aspects of stain. It’s pretty much the gingival third has the stain in the deposit. But look at the periodontal manifestation based on the pathogens that have accumulated and chronically infected the gum line around here. Moving on to different kinds of cases– here is a heavy calculus deposit case right in the anterior region. I guess I have a lot of anterior region slides because they’re easy to photograph and capture. And you can see the visible difference in just the tissue. It almost feels like the tissue’s relieved from all that pressure of the heavy deposit that was sitting on there. This is fairly extreme case of heavy– pretty much 2/3 of the tooth structure is covered with a supra gingival calculus. And interestingly, I mean, look at what the residual effect there. That tooth was actually fairly mobile as well. So now the patient has a different kind of a visual to deal with, compared to this diseased visual. And that will require some attention and care based on this clinical manifestation. So this kind of gives you an idea of really the power instrumentation, coupled with hand instrumentation, which talk about lasers also are absolutely existent in our realm of periodontal therapy. I know some periodontists that use it all the time. But I also know of periodontists that don’t care for it too much. But it is a technology and a modality that’s out there for part of nonsurgical periodontal therapy we should mention. So when we look at the phases, what we want to do is really have different approaches. It may just require a deep debridement of nonsurgical scaling, root planing, curretage. It may require surgery because some of these deep pockets may not be able to be reduced just by the extent of hygiene session that we’re giving it. Perhaps the patient’s going to need some antibiotics, both systemic and topical. And maybe the patient will have to be on a very aggressive maintenance plan will be part of the treatment phases that we’re going to be discussing with our patients. And again, dependent on the calculus deposit, based on one to three, one being light to granular, you may be able to complete it in one appointment, ranging all the way, actually, up to six appointments. And I have a treatment sequencing slide of what those six appointments could look like for this patient. Quadrant therapy versus sextant therapy– we absolutely want to plan and control periodontal disease using both of these therapy modalities. And this is part of the sequence of therapies that we want to use. As far as quadrant therapy– my only caution would be if you’re using local anesthetic, and using two quadrants to treat the patient for one appointment, maybe stick to quadrant one and four and two and three, instead of quadrant one and two. Because what can happen is if you’re using local anesthetic, at least the patient is only frozen on half of their mouth and not the other half. Sextant therapy usually requires local anesthetic as well. And it will have a different type of manifestation we’ll talk about. Curettage– I mentioned that very briefly earlier that we are scaling, root planing, removing the [INAUDIBLE] cementum with the notion of leaving the surface as clinically smooth as possible. But inadvertently, we may also be doing some gingival curettage. And gingival curettage is actually the removal of the soft tissue lining along the periodontal pocket, especially if your currete or your after five instrument is below the gum line. And it’s not even the working blade or the sharp side of the blade. It is the dull end of your instrument that’s actually removing this dead, necrotic, inflammatory tissue inadvertently. So that is definitely part of the phenomena that is part of the treatment that we provide here. Evidence indicates, however, that removing the inflammatory tissue using gingival curettage– there’s some studies that show it doesn’t show any additional benefits to the time you take in just doing the scaling and the root planing therapy. But it’s a good proviso to know. A periodontist will do an intentional gingival curettage, and its available code. But for ours hygiene purposes, you may be doing some inadvertent one. After scaling and root planing therapy, we want to check and monitor the pocket depth around the teeth to see if the cleaning process actually has helped support our end goal of controlling or removing periodontal disease in the mouth. We want to check the inflammation status to see if that’s removed, is any more treatment required or needed, and when is that going to happen beyond these initial sessions. If there’s abscesses or any other periodontal involvement, we want to do our referrals appropriately. It may require surgery. And really that thorough home care– that has to be so hand in hand and parallel to the removal of the deposits that we’ve done in office. So really giving patients good solid instruction, something that’s manageable, something that’s realistic for them is a really good strategy to make us successful after all our tedious, hard work of scaling and root planing. And don’t forget to give patients post-operative instructions as well. So that they know what to do once they get home. So we covered a large part of the learning objective for this module, which was need for the therapy and the sequential treatment plan that we came up with for patients requiring scaling root planing therapy. What about local anesthetic? In the province where I work, we are licensed if you’ve taken the training as hygienists to administer local anesthetic. And also actually pharmaceutical prescriptions is part of scope of care for some hygienists in some parts of the world. We use local anesthetic routinely in my practice for periodontal debridement. And this is just showing the greater palatine frame– a nasal palatine and a greater palatine frame in here. And really it’s a great advantage to have the patient frozen because you can actually go ahead and do the definitive debridement that you need to do. And sometimes patients are really apprehensive, and it’s the needle, and what have you. But I think if you could just calm their fears and have this as part of your nonsurgical periodontal therapy, I think you will actually get higher compliance for the patient, as opposed to the patient squirming and moving all the time. So I feel it’s very much indicated. I mentioned earlier about the sextant therapy. So this would be the calculus index class three. And what I’m going to do is have the patient come back for six separate appointments. At each appointment, I’m going to administer local anesthetic of different locations, different areas, of course. And at that point, the sequence of appointment will include something like a power scaling. Then I’m going to go ahead and probe. Interesting– I want to re-probe to make sure I am at the junctional epithelium, and that the probe measurements that I’ve captured ahead of time actually are accurate now that the big ledge of calculus is not in the way. So it’s a good idea to be checking for probe readings as well. Then I’m going to do the scaling root planing, now that the tissue’s all anesthetized. And we’re ready to go. I would follow that for each one of the six appointments, and probably start in a logical order, or depending on if the patient’s fully dentate or not. Or actually what the patient’s chief complaint is– if they are concerned about one particular sextant, maybe start out with that sextant. Because by the time you come to appointment four or six, you have the advantage to see the progression of the disease in that first area you worked on, what’s the response time like, and how’s the patient feeling about the therapy that you’ve done so far. Let’s talk a little bit about antimicrobial, antibacterial agents as they relate to nonsurgical periodontal therapy. It is an approach that is part and parcel of periodontal therapy for many years. And really, the prevalence and severity of these diseases is reduced, not only with that mechanical plaque removal, with the supra gingival subgingival removal of deposits, the hard deposits, the soft deposits. But then topically applying antimicrobial agents has shown to be useful in inhibiting the pathogenic bacteria. Just for definition purposes, antiseptics is something that’s not an antibiotic. It’s more of a disinfectant. It’s just something that may be used topically. It could be used subgingivally. And it doesn’t have a rebound reaction like an antibiotic does. And that’s sometimes desirable in patients where we don’t want to put them on systemic antibiotics time after time after time. Because antiseptics, in comparison, don’t have a rebound reaction like antibiotics do. Antiseptics are successful in killing some microorganisms that cause gingivitis, and periodontisis, and caries. When we think of that microflora, it’s complex. There are 300 spaces of bacteria from one of the studies that has shown that. But really of critical nature for our purposes is probably these handful of bacteria– P. gingivalis, Aa, S. sanguinis, S. mitis, S. salivarius, and the P. gingivatis, actually, again. So we want to make sure we are vigilant on that. We talked about salivary diagnostics actually isolating, really isolating what these microflora are present in the patient’s mouth. The P. gingivalis is of importance because it does have a lining on its bacteria that induces immune response of its own. It also has a fimbriae, which is a finger-like tentacle, as I explain to our patients, that can trigger immune response, and hence the inflammatory response. And the presence of P. gingivalis is really evident. Rinses and irrigations can be used to complement the mechanical therapy that we’re providing our patients. ADA approval of Listerine and Peridex are both really demonstrated to be successful. Because what they do is really affect a broad spectrum of the bacteria. Both in vivo and vitro studies have shown that. So it’s a good adjunct to actually recommend– case dependent, patient dependent. And of course, there has been a lot of randomized, double-blind studies that show on a six-month trial there is efficacy and improved reductions in the microflora by uses of rinses. Chlorhexidine is another staple that we use in our practices of course. 0.12% or 0.2% are both the ones used for dental indication for prescription purposes. And they do tend to stain teeth. There’s of course new formulations that the non-stain Chlorhexidine is something that we use all the time in our practice. And really the instructions we give the patients is a 30-second rinse in a very small amount on a daily basis– again, case dependent. In my practice, I use a Chlorhexidine in a gel formulation. It’s something I’ve developed with the pharmacist next door. And the reason I like it in that formulation in-office is that I can actually put it on my curette or my [INAUDIBLE] scaler or my sickles and actually, physically, site-specifically introduce it in the deep pocket areas. So I like the idea of the viscosity of this material that actually goes into those spaces. It’s, of course, the third molar areas as well, depending on the [INAUDIBLE] situation may be indicated. I know of doctors that use it actually for root canal therapy as well. And of course for our purposes, the intra sulcus for perio readings. So a lot of times, I’ll actually use it with my instruments. Here it is just showing me with a plastic probe that I’m going to insert in a perio implant sulcus. So it has many indications. We mentioned Listerine earlier, and I just want to say it is a over the counter microbial rinse that’s available for patients– so easy access. And it has a great efficacy, actually, in removing plaque bacteria. And so if patients like the taste of it– I know, initially, it had the alcohol one. But there is a new– it’s not so new, but there is a non-alcohol Listerine formulation. And that is what I recommend patients to go with the non-alcohol Listerine formulation. In one of my other modules, I mentioned it’s a great rinse for just reducing the microflora nonselectively in the mouth. But a lot of the time, if there is a sextrant or a quadrant which has deep pockets, I may encourage patients for their home care to actually use Listerine with a dry toothbrush, for example, and saturate the brush with the Listerine, and place it in that area of concern. And then use the toothbrush with Listerine, instead of toothpaste. And again, it’s that mechanical but it’s also the chemical advantage of introducing that into those periodontal tissues or perio implants sulcuses. Antimicrobial agents like triclosan– this is just stuff you find even in antibacterial lotions and soaps. We now have it in a dentifrice formulation such as Colgate Total. And there is evidence that shows that actually helps with the antibacterial effect, because it attaches up to 12 hours. It helps release that effect. Let’s talk about long-term sustained effects of antimicrobial, antibiotic agents. And this is what we’re talking about host modulation therapy. In disease of the periodontium, you know it’s initiated by the bacteria. And it’s clear that the host in the individual that’s harboring the pathogens– this we know. What wasn’t clear for many years that it’s possible to modulate the host response to these pathogens. So host modulation therapy using chemotherapeutic agents really is an exciting adjunct to a therapeutic option for perio implantitus and periodontal diseases. There are a few that are approved by the FDA. For example, let’s talk about the perio chip, which is that orange-brown biodegradable rectangular chip. And it is placed subgingivally. The active ingredient is a Chlorhexidine glutanate in there. And it is released in the pocket depth for up to 10 days. And it has shown to suppress the pocket microflora for up to 11 weeks, some of the studies have shown. And clinical evidence of that is that it’s reduced the pocket depth and maintained clinical attachment levels from the baseline for up to nine months. So it is desirable, and absolutely may be indicated for some of our patients with advanced periodontal disease. When using antimicrobials, we want to saturate the area based on the dosage. So really be careful because you are sustaining it for a longer period of time. And high doses of drugs can be achieved locally. And this has been checked actually with a serum quality as well. So there is also the singly applied tetracycline fibers that can be used as an adjunct to our scaling root planing therapy. And that has also proven to be very effective in giving us the desirable end result of managing periodontal disease. Actisite is another nonresorbable polymer that actually will release a tetracyclene. And it has a higher dose in the pocket areas there. So that high concentration really helps eliminate most of the pathogenic bacteria that are associated with periodontal disease. Atridox, which is a doxycycline, is approved by FDA. And I’ve clinically used this in our office for deep pocket areas. It is in a syringe in a fairly liquid format. But one of my experiences was to really make sure that you’re limiting the amount of curricular fluid that’s in that pocket space. Because as soon as it comes in contact with that saliva, it goes very hard and it becomes very wax-like. So you want to make sure it’s super, super, super dry before you’re plunging the syringe subgingivally. And as soon as you dispense it, it actually molds and forms around that bony defect or the pocket defect. So it will stay there. It will sustain. And interesting results as well– your post-op instructions for the patient also is not to brush in that area right away. But it does have some positive effect on reduction of anaerobic pathogens in this area– for up to six months, some of the studies have shown with Atridox. Arestin is another agent that can be used subgingivally. And it’s actually little microspheres in a form of a powder almost. And again, it’s an adjunct to the scaling root planing procedure that we’ve done. And it’s helped in the reduction of pocket depth. In parallel to all this, you want to make sure our patient is maintaining a good home care oral hygiene habit, as well. And with Arestin, actually, there’s been 20% improvement of mild periodontal disease, and up to 40% for moderate diseased site. So it has an indication. And again, it’s very case based as to whether you’re going to use the microspheres or you’re going to use the gel, and so on and so forth. But you do have what’s amazing is a selection criteria. This chart just shows all the different types of prescriptions that are available. It’s a good summary slide, actually, of everything we’ve talked about– what it is, why is it used, and how do we use it. What’s the modality of treatment for these different medications or antimicrobial agents that we talked about? I do want to finish off this module by talking about some of the natural remedies. Vitamin C, for example, has been indicated for collagen formation. So really, I would want to understand what’s the patient antioxidant intake like. And perhaps, while you’re performing the nonsurgical periodontal therapy for the patient, supplementing or complimenting that with extra vitamin C may be indicated. Vitamin D, of course, reduces the susceptibility of gum disease as well. It’s shown in many cases for anti-inflammatory effect that it has. So that may be indicated. I live in Edmonton, which is a very cold winter city. So in winter, if there’s not enough sunlight, maybe something that we may want to use as an adjunct to our patients’ therapy of periodontal disease. Stress is a big one– so really, the post immunity and the host ability to cope with the therapy– stress reduction is a large part of it. So really understanding that I will do the hard work in your mouth to remove all these deposits, to help you achieve optimum health as best as we can. But you’ve got to do your part, and what would that look like? And perhaps, being calm and reducing the stressors in your life may help me compliment what we’re trying to achieve in the dental office here. A lot of patients– I know you’ve probably noticed– come and ask, hey what do you think of the Tom’s toothpaste, or some of these alternative natural remedies, like tea tree oil or Melaleuca. These are all natural antibiotic agents that occur in nature. And really, there has been six of one, and half a dozen of the other as far as the proof and validity of this. But I’m thinking it’s not going to do any harm. And if the patient’s liking it, and really at the end of it, I think of it, if the patient likes it it’s going to do it more often, my compliance rates are going to increase with this patient doing it. And if there’s no risks or damage being done, I don’t have a problem with the patient using those natural remedies and products. Use of cranberry was actually another area that I learnt about recently. And again, we’re not to sure of but there is some evidence that cranberry juice can help with the gum disease progression or arresting gum disease. So this brings us to end of nonsurgical periodontal therapy. We starting out with talking about components of nonsurgical periodontal therapy. What is the rationale for actual scaling root planing? We needed to understand what’s the sequence for this treatment therapy? Well we started with power instrumentation for growth debridement of deposits, coming down to fine scaling, including inadvertent curettage. And we finished up our discussion with some alternative therapies complimenting our scaling root planing, including antimicrobials and antibiotic therapy. I’d like to end today’s module with a cathedral story. This is not the exact picture of a cathedral, but it reminds me of a beautiful cathedral that I’d seen in one of my presentations in Sydney, Australia– beautiful city, beautiful people– loved the teaching experience there. But it did remind me of a cathedral story I’d heard years ago. I’d like to share with you. It’s about a construction site, actually, where there’s people working on this construction site. And this person just going for a walk, out and about, asking this person who was taking that jackhammer and digging a hole on the floor, and so they say, sorry to disturb you but what’s going on here? What are you doing? And this person is very busy, and is just irritated by this interruption and says, I’m digging a hole. Can’t you see? I’m just digging a hole– kind of, leave me alone. And the person picked up on that nonverbal cue, and says, I’m sorry, and just carries on. Now on the same construction site, he sees a bricklayer. So he goes over and says, excuse me sir. But what are you doing here? He says, you know what? I am building this beautiful wall. I’m taking little pieces of bricks. And I’m creating this incredible wall. It’s going to look wonderful when it’s done. Then in the distance of the same construction site he sees this person with a wheelbarrow of heavy, heavy load. And this person is actually pushing this wheelbarrow uphill, and is just bent over, and trying to push it uphill, and sweat pouring out of the forehead, and look like he was putting in a lot of work and struggling with this load he was carrying uphill. So the same person goes over and asks, I am so sorry to disturb you sir, but I’m just so curious about what’s going on here. And the person puts the wheelbarrow down, wipes the sweat off the forehead, gives him the biggest smile, and says to this person, I am building a cathedral here. This is going to be the House of God where people are going to come and pray. I would like to take this analogy to our dental practices. A lot of the times we have the attitude of I’m just digging a hole. Leave me alone. This is what I do, and this is what I did yesterday, and this is what I’m doing tomorrow. But really reflecting on what is that hole for, and what is the end outcome of what it is that I do? Why do I wake up and service my patients’ needs? Why do I take the time to do continuing education and be current and retool myself and learn more so that you can build that cathedral for your patients and give them the optimum best care possible so they may have healthy, happy, long lives. I thank you for your time.