Benefits of periodontal trays

Trays Offer Customized Approach To Periodontal Disease

BY CARLA GANTZ, RDH

A table talk at CareerFusion this past January had my full attention. Tanya Dunlap, the program development director for Perio Protect, LLC, was talking about a prescription tray that places medication into periodontal pockets. Perio Protect was new to me, even though I had practiced as a clinical hygienist from 1996 until July 2011. But Tanya had my full attention as soon as she set out these trays.

Why the interest when I had never heard of this company? Several years ago while working with a very receptive dentist, I asked to make customized trays (kind of like fluoride trays) for a very difficult periodontal patient who had neglected his oral hygiene to the point of losing several anterior teeth. The patient had deep periodontal pockets (I recall several being 9 mm), severe bleeding, and calculus deposits, and the patient declined the recommendation for a periodontist.

After root scaling, re-evaluation, and systemic antibiotics, the patient showed improvement — just not the improvement I sought. Something else was needed.

Then came the idea presented to the dentist. What if I made the patient a custom tray to use with hydrogen peroxide, an oral debriding agent, for two to three minutes each day before brushing to help cleanse these areas? The doctor agreed and the trays were made. After a week of treatment, the patient returned with a cleaner feeling mouth and decreases in bleeding and inflammation on the upper arch, but not so much with the lower one.

Here was the problem. The hydrogen peroxide product was not viscous, and the tray couldn’t keep it in place. So rather than staying around the tooth or in the sulcus, the peroxide flowed out into the patient’s mouth. After a couple of attempts to improve the lower fit, we decided to discontinue the trays and to apply the peroxide product with a toothbrush.

This case was why Tanya had my full attention. She showed how this special tray (Perio Tray) could maintain medication in the pockets. When peroxide was used, treatment results were significantly better than debridement and scaling alone.

Because the medication will not flow out of this tray, it will make your job easier. With that statement I should have your attention, for the Perio Tray is the hygienist’s new BFF.

Bacteria: Our Antagonist

Dental hygienists are in a continuous, endless battle with bacteria. We know bacteria lives in communities called biofilm, and periodontitis is the host response to a biofilm disease. Biofilm is a layering of exopolysaccharides, proteinaceous materials, bacteria, bacterial chemotoxins, enzymes, and related products. While biofilm continues to grow, some of its layers can become anaerobic (cocci, long rods, treponema, and spirochetes) and harbor more dangerous, pathogenic bacteria.

Researchers have shown that antibiotics were able to penetrate the biofilm, but they did not kill the bacteria.¹ People with periodontal disease are unable to control biofilm with just brushing and flossing as their maintenance package. Dental hygienists understand that scaling and root planing has significant limitations since it is performed with restricted vision into the pocket; it is mechanically impossible to remove all bacteria from grooves, furcations, dentinal tubules, and soft tissues. Viable bacteria that remain after SRP regenerate and bacteria introduced into the oral cavity result in new biofilm formation.^2,3 , 4 We attempt to control biofilm by repeating SRP time after time and, like my scenario underscores, what we need is an adjunctive that will work.

What Medications Are Used?

The Perio Protect Method (see sidebar) allows the dentist to use any antimicrobial or antioxidant that is proven effective. Research demonstrates that a 1.7% hydrogen peroxide gel (Perio Gel) is a highly effective agent and it is, according to Perio Protect, the most common debriding agent used with the prescription Perio Tray.⁸ Hydrogen peroxide is the only biocompatible antimicrobial capable of penetrating a biofilm and killing the microbes.9

Research has found that hydrogen peroxide is active in human saliva and helps break down the protein of the bacterial cell wall. A randomized, controlled, three-month clinical trial showed the use of the prescription tray delivery of peroxide as adjunctive debridement care — compared with SRP alone — exhibited significant activity at all sites examined throughout the mouth and was effective in reducing severity in both shallow (5mm) and deep (>5 mm) pockets, significantly decreasing PPD in the latter by 1.57 mm versus 0.58 mm for SRP alone after 10 weeks.10

Doxycycline syrup has also been used with the prescription tray system during treatment for patients with severe periodontal disease because natural antioxidants in saliva are depleted; the depletion is due to excess polymorphonuclear leukocytes releasing free radicals. Yes, it is an antibiotic; however, it is being used for the antioxidative properties in a subclinical dosage of two to three drops per arch.

Doxycycline syrup may be used for:

• Controlling the oxidative stress for acute and inflamed tissues
• Controlling collagenase to stop connective tissue degeneration
• Managing osteoclastic/osteoblastic activity.

Delivery Of Medication Before Scaling

We have all witnessed patients with dense, rock-hard calculus, and bleeding so profusely that we think “jackhammer and transfusion?” Normally, treatment for this type of patient means entering an infected area with grueling scaling before us, while dealing with the patient’s apprehension. By implementing Perio Protect Method before scaling procedures, both you and your patient benefit. Case studies illustrate how a low concentration of hydrogen peroxide modifies and softens the calculus for easier removal, decreases inflammation and bleeding, and thus reduces the risks of bacteremia. Another plus is that Perio Trays can delivery topical anesthetics.

The proposed treatment plan depends on the patient’s disease condition. While patients with gingivitis may need to wear their trays two times a day for 10 minutes, patients with periodontitis may need to wear them three times a day for 15 minutes at the start of treatment. Patients return after the first two weeks of treatment, and the times for wearing trays are adjusted according to the improvements in bleeding and pocket probing depths.

Dental professionals talk about being a team and the effort that is required from each team member. However, if the proper equipment is not made available for the members, then all of the exertion by the team is looked upon as trouble for nothing. I believe Perio Protect has the proper equipment just waiting for your office. Everyone will benefit from Perio Protect: The patient will be pleased with the noninvasive treatment they can use at home, and the hygienist’s SRP will be less laborious. Perio Protect Trays are something our patients can sink their teeth into. RDH

What Is Perio Protect?

Perio Protect is a treatment method combining mechanical and chemical debridement. Hydrogen peroxide, an oral debriding agent, is placed into periodontal pockets via the prescription Perio Tray as an adjunctive aid to help manage biofilms better for patients with gingivitis and periodontitis.

The FDA has cleared the Perio Tray as a subgingival delivery medical device, meaning the tray will deliver a specific antimicrobial medication deep into the periodontal sulcus. One reason the Perio Tray has success is due to the special seal and customized extensions. This design directs the medication deep down into the sulcus, while the seal overcomes the crevicular flow.

Keep in mind, a normal crevicular fluid is replaced about 40 times an hour, making spontaneous inflow in a pocket almost impossible.⁵ In inflamed tissue, the crevicular fluid flow increases significantly, up to 30 times more than it does in healthy tissue. The constant outflow of crevicular fluid explains the extremely fast clearance of any topically applied product.⁶ Under these conditions, the expected life of an agent in the gingival pocket is about one minute.7

With the Perio Tray, however, medication can be held in the pocket longer. When this delivery of medication is used in conjunction with our mechanical and laser therapies, it helps better manage the biofilm during treatment. Once the periodontal disease is managed, the Perio Protect Method becomes part of the long-term home-care solution to control biofilm.

Before the lab can construct the sealed tray, the lab needs a copy of the periodontal exam on any patients with pockets over 3 mm. They will create the seal and extensions around each tooth from the six-readings periodontal exam. Without the periodontal exam, the lab would be unable to know the thickness of the seal, the length, or the extensions for the trays. The trays must be manufactured by an FDA registered dental laboratory.

Hydrogen Peroxide

Advantages as an antimicrobial agent:

• Breaks down the bacterial cell wall, thereby facilitating killing the bacteria
• Naturally occurring antimicrobial agent found in saliva, breast milk, polymorphonuclear leukocytes, etc.
• No known resistant bacterial strains
• No host allergic reactions
• Functions by an irreversible cleavage or conversion of amino acids in protein chains
• Breaks down the protein pellicle that forms on the tooth surface
• Decreases inflammation by inhibiting IL-8mRNA
• Decreases plaque and gingivitis indices
• Economical as an on-going home-care medicament
• Whitens teeth
• Freshens the host breath
• Decreases gingival bleeding
• Decreases gingival inflammation

References

1. Mah TF, Pitts B, Pellock B, Walker GC, Stewart PS, O’Toole GA. Genetic basis for Pseudomonas aeruginosa biofilm antibiotic resistance. Nature.2003 Nov 20:426(6964): 306-10.
2. Adriaens P, Adriaens L. Effects of nonsurgical periodontal therapy on hard and soft tissues and soft tissues. Periodontal 2000 2004; 36:121-45.
3. Resposo S, Tobler J, Alfant B, Gollwitzer J, Walker C, Shaddox L. Poster presentation: Differences between Biofilm Growth Before and After Periodontal Therapy. AADR 37th Annual Meeting. April 3, 2008. Abstract available online.
4. Zijnge V, Meijer HF, Lie MA, Tromp JA, Degener JE, Harmsen HJ, AbbasF. The recolonization hypothesis in a full mouth or multiple-session treatment protocol: a blinded, randomized clinical trial. J Clin Periodontol 2010; 37:518-25.
5. Binder TA, Goodson JM, Socransky SS. Gingival fluid levels of acid and alkaline phosphatase. J. Periodontal Res.1987 Jan: 22(1): 14-19.
6. Goodson JM. Gingival crevice fluid flow. Periodontol. 2000.2003;31;43-54.
7. Goodson JM. Offenbacher S, Farr DH, Hogan PE. Periodontal disease treatment by local drug delivery. J Periodontol. 1985 May: 56(5): 265-72.
8. Personal communication with Tanya Dunlap, PhD, Program Development Director, Perio Protect LLC. CAREERfusion, January 2012.
9. Marshall MV, Cancro LP, Fischman SL. Hydrogen peroxide: a review of its use in dentistry. J Periodontol. 1995 Sep: 66(6964):306-10.
10. Putt M, Proskin H. Custom Tray Application of Peroxide Gel as an Adjunct to Scaling and Root Planing in the Treatment of Periodontitis: A Randomized, Controlled 3-Month Clinical Trail. The Journal of Clinical Dentistry. 2012.

CARLA GANTZ, RDH, has a combination of 30 years of experience as a dental assistant, clinical hygienist, treatment coordinator, and business/office manager. She is a HygieneFusion consultant, 2012 Sunstar Award of Distinction recipient, an author, speaker, and webinar presenter. A graduate of the Western Kentucky University Dental Hygiene Program, she is a member of the American Dental Hygienists’ Association, CAREERfusion, and the American Academy of Dental Hygiene. She can be contacted at [email protected].