Non Surgical Perio
Written By: Craig A. Zunka, DDS
When I graduated from dental school in 1975, our initial diagnosis and treatment of periodontal disease was determined by a physical examination for bleeding, color, smell and pocket depth on probing. Initial treatments included brushing, flossing, deep scaling, curettage and a variety of surgical procedures. In my practice over the past 25 years, I have found that there are several factors that effect the periodontium and our success rate. The following factors appear to be of major importance:
• Utilization of the phase microscope.
• Biochemical factors.
• Personal habits.
• Systemic problems and diet.
• Stress factors.
In this article, I will discuss how I utilize the phase microscope and work with the other four factors to greatly increase our rate of success with our periodontal patients.
Over the past years of treating periodontal patients, I have utilized the original Keyes technique of baking soda, salt, and hydrogen peroxide and the work done by the periodontist, Dr. Doug Neuman of Tennessee. The techniques have been very enlightening and informative but it was not until I got my first phase microscope in 1982 that I truly started to get a handle on treating periodontal disease.
Using a phase microscope, it is very simple procedure to take a sample from a periodontal pocket, make a slide and view this through a phase microscope. The type and amount of bacterial activity in the periodontal pocket is immediately seen. The type of bacteria present (cocci, rods, vibrios, spirochetes, amebas, trichomonas, white and red blood cells) will clearly indicate how advanced the periodontal disease is.
Through the use of the phase microscope, we have also been able to monitor our patients more closely. We can monitor how well they are doing with the different techniques that are available today to treat periodontal disease and we can clearly see which ones work for them and how well the techniques are working.
Since 1982, most of our periodontal patients have received blood chemistries. The reason for this is because we may be looking at a host resistance problem as much as the invasive quality of the bacteria that is causing the problem. With all of the work that has been done on osteoporosis today and our knowledge of calcium metabolism, it behooves us to see if we are looking at the early stage of osteoporosis that is showing up in the alveolar process (bone around the teeth) long before it will ever show up in the long bones of the body. When we look at a blood chemistry, we look for certain factors. Many times, it is not the amount of a mineral that we have but the ratio to the other minerals. The main mineral that we always look at is the calcium level. Depending on the laboratory you use, there may be a wide range of "normal" values. Ideally, we like to see a calcium level of 10 and a phosphorus level of 4. This is a 2.5 to 1 ratio. If the calcium to phosphorus ratio is off, the individual may not be able to absorb calcium into the cell or calcium may be leaking out of the cells.
Another aspect that dramatically effects the ability to absorb calcium is the stomach acid level. Calcium has to be absorbed in an acid medium. If the stomach is not acidic enough, calcium, taken as a supplement or from the food that we eat, is not absorbed. One of the simple monitors that can be looked at for stomach acid level is the albumin to globulin ratio. This ratio should be 1.8 or higher.
Magnesium levels must also be checked. The serum magnesium levels should ideally range between 2.1 and 2.3. It has been known for a long time that serum magnesium levels are not very accurate. The intracellular red blood cell magnesium is the most accurate. The intracellular levels should range between 5.4 and 5.6. The intracellular magnesium levels can be down by 30% before it will show up in the serum magnesium level.
These are but a few of the areas that directly affect periodontal health. Other areas of supplementation that we look at are Vitamin C, Zinc, B Complex, Antioxidants, Co-Q10 and Essential Fatty Acid levels.
Personal Habits can dramatically effect periodontal health. The most destructive habit is smoking. Research shows that smokers have a 10 times greater incidence of periodontal disease than nonsmokers. Smokers also have a 10 times greater incidence of osteoporosis than nonsmokers. The New England Journal of Medicine in 1990 stated that the systemic effect of smoking causes an inhibition of the production of a hormone by the pituitary gland that is essential for the absorption of calcium out of the stomach into the blood. There are also numerous articles written about the topical effects that tobacco smoke has on periodontal tissues.
In an individual affecting the increased incidence of periodontal disease would be:
Do they have a bite discrepancy from centric relation to centric occlusion?
Do they clinch and grind?
Do the back teeth touch when moving the jaw side to side? These are called working and balancing contact.
Diet has a tremendous effect on periodontal conditions. For years in dentistry we focused on the intake of sugar. What we are finding out now is that, not only is there a topical effect of what we eat, but there are also systemic effects that affect our periodontal health. Many papers have been published on how sugar, refined carbohydrates and carbonated drinks disrupt the calcium to phosphorus ratio in the blood. This draws calcium out of the bones and in essence, makes the bone more susceptible to the acid produced by the bacteria.
Stress Factors include both physical stress and mental stress. We have known for some time that stress affects periodontal health but we did not know why or how. New research has given us tremendous insight into the adrenal glands, cortisol, and DHEA. I believe the biggest breakthrough in dentistry in the past 15 years has been in understanding the systemic effect stress has on periodontal disease. When we know that an individual is under stress (physical or mental) for a period of time, the adrenal glands produce cortisol to compensate and keep the individual in a state of readiness. When these states continue for long periods of time (these long periods of time are different for each individual – sometimes weeks, sometimes months), the cortisol levels that are elevated, stay elevated. Research shows that the cortisol production by the adrenal gland is on a circadian rhythm. Normally, the levels are highest at 8:00 in the morning, dropping steadily to noon, staying level from noon to 6:00 in the evening and dropping to their lowest level at midnight. If the cortisol levels stay high at night, the individual does not go through protein or collagen synthesis. This is the key to the repair of the periodontal tissues. With the absence or slowed protein and collagen synthesis, the bone and periodontal connective tissue does not repair. Contact Diagnos-Techs, Inc., (800) 878-3787 in Washington or Great Smokies Diagnostic Laboratory, (800) 522-4762 in Ashville, North Carolina for information on the test.
There is an ever-increasing understanding of hormone imbalance of estrogen and progesterone in women and osteoporosis. The change in periodontal (gum) health can be the first sign of hormonal imbalances or problems.
Treatment: I find that the frequency and timing of treatments set out by the periodontist, Dr. Doug Neuman have been very effective. In my practice, I consistently see six and seven millimeter pockets shrink to a level of three millimeters over the treatment period. Treatment protocol is consistent – a weekly treatment for one month and then every other week for another two months. From a microscopic evaluation, we know what type of bacteria we are treating. The infected pocket areas are then curettaged, cleaned, and irrigated. On subsequent appointments, we can go back and evaluate with the microscope to see exactly how well we are doing as far as eliminating the bacteria.
During an individual's initial treatments, their pockets will start to heal for approximately one week to 10 days. The bacteria can work its way back down into the pocket after 10 days and the infection can start all over again. That individual needs to be seen in a week for a second treatment, a week later for a third treatment, and then a week later for a fourth treatment. When we do weekly treatments for one month and then every two to three weeks for the following two months, the pockets heal and shrink.
On the mechanical end of this treatment, the key to treating these pockets is irrigation. There are numerous irrigation units on the market. Two good units that we use are the Viajet Irrigator® and the Waterpik®. These irrigators works very well except for the problem that none of the tips that come with the Waterpik® and Viajet® can go subgingival and get into the pocket areas far enough to deliver the irrigation solution. To solve this, we give our patients a special cannula tip that will reach into the pocket. Our office uses the Viajet® irrigator most of the time. It is easier to use and has controlled pressure into the pockets. This unit still needs a special canula tip that needs to be supplied by the dentist.
In our practice, we use a number of different materials to irrigate pockets. We use salt, baking soda, hydrogen peroxide, Therasol®, tea tree oil, Vitamin C, homeopathic remedies, Oxyfresh®, L. Salivaris, Ipsab® and Under the Gum Irrigant®. The individual and their systemic situation determines which irrigation we would prescribe.
Depending on the blood chemistry, the patient may also be placed on nutritional supplements. Some of the very first work done on coenzyme Q10 was done on the treatment of periodontal disease. We may also utilize Dr. Emanuel Cheraskin's work using Vitamin C or suggest calcium and magnesium supplementation depending on what the blood chemistry shows.
There are several different electric toothbrushes on the market: Interplak®, Rotadent® and Braun®. The latest electric toothbrush is the Sonicare®. As we have watched evaluated our patients over the past 15 years, we have seen that all of the mechanical brushes tend to help. There is something special about the Sonicare® and its ultrasonic vibrations. We have a number of people using the Sonicare® brush. They are seeing very positive and quick changes.
The key to a successful outcome for a periodontal case is the elimination of the pockets, the bleeding, and the bacteria (except for the normal cocci bacteria of the mouth). The constant evaluation with a microscope has been an eye opening experience for me. I see pockets shrink to three or four millimeters that still have spirochete infection. The elimination of these bacteria is necessary for these individuals to gain control of their periodontal status.
Work done at NIH, OraTec, and many universities reveals that using different antibiotics such as Tetracycline, Ampicillin, Metronidazole and Periostat® have positive effects. Until we look at these cases over a long time period, we do not know how well they work. I personally feel that today's long term antibiotic use is more damaging than helpful. We may be killing some bacteria in the periodontal pockets but causing tremendous systemic problems. Often we see allergies, resistant strains of bacteria to antibiotics, and chronic yeast infections with long term antibiotic use. I do not like to use these treatments unless conservative treatments have failed. There are no known resistant strains of spirochetes to Metronidazole. When a patient is placed on Metronidazole for a week and then re-evaluated, usually all of the pockets are free of spirochetes. But with a one-month microscopic follow-up, the bacterial slide many times shows a return of the spirochetes. We also have the same experience with the Actisite® treatment. The top of the tissue looks very good but we have still find spirochetes in the pockets that will ultimately cause failure. L-Salivaris and Under the Gum Tonic® have been very beneficial in keeping the spirochetes out of the periodontal pockets and knocking down the overall motility of these pockets.
We test the effectiveness of irrigation materials by placing a drop of the different test irrigation solution on a microscopic slide and then we evaluate the bacterial activity on the video monitor. This has been very enlightening and educational for me. I can immediately see the effect of the different materials on the bacteria and thus can choose the most effective treatment. Nothing surpasses the microscopic viewing as a teaching modality for the patient. It is also one of the best motivators for our patients. The acceptance for the periodontal treatment has greatly improved.
After intensive non-surgical periodontal treatment, the patient is then re-evaluated. If there are areas that need surgical attention, these patients are referred to a periodontist. My periodontist's states that our patients are the best prepared and have the best treatment success rates of any patients that he sees in his office.
A follow-up with my hygienist is customized to the individual for what they need. The individual may need to be seen every two, three, or four-months to maintain their periodontal health.
Let me relate a patient history of which we are all very familiar. We have all had patients in our practice that we have monitored for years that have relatively good periodontal health. During their six-month continuing care appointment, we notice that certain areas now have five and six millimeter pockets. They seem to have sprung up overnight. We have to scratch our head and ask, why all of a sudden is this individual having massive breakdown of the periodontal tissues?
On a patient history, we would want to know what is happening with this individual as far as stress factors. Are they experiencing long term physical or mental stress and do they have any chronic pain of any kind? I would order an adrenal stress index test (ASI). A blood chemistry is needed on this individual to see what their system is doing with calcium and magnesium. Have they become diabetic? Laboratory tests such as the Trace Mineral Analysis (hair analysis) and the Female Hormone Profile can be very valuable tools and the key to the diagnosis and treatment of the patient.
Often times, they do not respond to deep curettage, scale and irrigation. In these individuals, if I do not find the edeology behind the breakdown, it can be very frustrating to watch their bone dissolve away and ultimately lose their teeth. This is where the microscope is invaluable to see if my treatment is working. Looking at the microscope, I can tell exactly what type of bacteria flora I am treating. On return visits, if the individual consistently has advanced microbial and spirochete activity in the periodontal pockets, I have to look deeper into the systemic