Trisha O'Hehir ODA 5mm pockets · 2016-01-22 · Achieve Health in 5mm Bleeding Pockets with Scoops, Not Scalers Trisha O’Hehir, RDH, MS 1 Trisha O'Hehir ODA 5mm pockets - May 12,

Achieve Health in 5mm Bleeding Pockets with Scoops, Not Scalers

Trisha O’Hehir, RDH, MS

1 Trisha O'Hehir ODA 5mm pockets - May 12, 2015

It is the policy of the Ontario Dental Association that all practice-related speakers at any program sponsored by the Ontario Dental Association shall complete a conflict of interest statement regarding any interest in a company or a product related to the program as a part of the Speaker’s Agreement with the Ontario Dental Association. Further, any portion of the following information can be shared with the membership and/or attendees to gain perspective of the program. In accordance with this policy, I, Ms. Trisha O’Hehir, declare that I have no proprietary, financial or other personal interest of any nature or kind in the product, service and/or company that will be discussed or considered during the proposed program, except the following:

•  O’Hehir University – The Toothpaste Secret Book I declare that I have no proprietary, financial or other personal interest of any nature or kind in any firm beneficially associated with any product and/or service that will be discussed or considered during the proposed program. I declare that I have no past or present financial interest, consulting position or other involvement of any nature or kind related to the program that could give rise to even a suspicion of a conflict of interest, except the following:

•  Xleur/Spry, Sunstar Butler, Sonicare, Waterpik, Rowpar, PDT Instruments. Furthermore, I understand and agree that as a condition for participating as a speaker at an Ontario Dental Association sponsored program, I will exercise particular care that no detriment to the Ontario Dental Association will result from conflicts between my interests and those of the Ontario Dental Association. Please note that in accordance with ADA CERP, we are required to publish any declared commercial affiliations. Having read and understood the Ontario Dental Association’s policy and having completed this statement to the best of my knowledge and belief, I agree to be bound by the terms hereof.

CONFLICT OF INTEREST STATEMENT


Current Employment


U of Minn 1967



I became an oral health detective!

We are all oral health detectives! 6 Trisha O'Hehir ODA 5mm pockets - May 12, 2015

Use our detective skills to help achieve health in 5mm bleeding pockets


Discuss the research rationale for instrumentation

Learn to read the tissue to identify subgingival deposits

Observe a radical change in instrument design

Describe various treatment approaches for biofilm

Develop a strategy for treating non-responding areas

Course Objectives


Achieve health in 5mm bleeding pockets

Incorporate time saving approaches

Make your clinical days easier and better

With today’s information you’ll

•

Read the tissues to determine presence of calculus New Millennium curettes for better access Effective daily biofilm control by the patient

Dry brushing inside first to prevent calculus formation Cleaning between the teeth daily to prevent infection Subgingival air polishing with glycine powder

Healthier patients are happier and make your work easier



Learn to read the tissue to identify subgingival deposits


Describe various treatment approaches for biofilm


Course Objectives

Biofilm and Pathogenesis

Scoops not scalers

Air polishing subgingivally - polish first

Read the tissues

Control oral pH and biofilm

Why do we have 5mm pockets that bleed?


Why do we have 5mm pockets that bleed?

Probing

Calculus

Biofilm control


Patient scenario• Two years since last DH visit

• Scheduled for a “cleaning”

• You review medical history

• Not much supragingival calculus

• Probe parallel to long axis, at the line angles

• Begin instrumentation

•find 4-5mm in interproximals

•find subgingival calculus

•Now what? It’s no longer a “cleaning”


The problem - probing line angle vs interproximal

Aim for the mid-interproximal - col area13 Trisha O'Hehir ODA 5mm pockets - May 12, 2015

Probing: Line angle vs interproximal

Hold side of the probe against the contact


Probing: Alignment and Calibration


Photo: Perio-Data.com

Probing scores can vary 2mm between clinicians

Probe size will add to that difference


Disease starts interproximally Communicate this fact to patients

Probe brushing and flossing surfaces separately


Numbers 1 to 3 are healthy, 4 and above are not.

Bleeding points are a sign of infection.

Photo: Perio-Data






•

Read the tissues to determine presence of calculus New Millennium curettes for better access Effective daily biofilm control by the patient

Dry brushing inside first to prevent calculus formation Cleaning between the teeth daily to prevent infection Subgingival air polishing with glycine powder

Healthier patients are happier and make you work easier


How much perio is there?


How much perio is there?

How many perio patients do you see each day?21 Trisha O'Hehir ODA 5mm pockets - May 12, 2015

CHICAGO—September 21, 2010

The prevalence of periodontal disease in the United States may be significantly higher than originally estimated.

Research suggests that the prevalence of periodontal disease may have been underestimated by as much as 50 percent.

The implication is that more American adults may suffer from moderate to severe gum disease than previously thought.

American Academy of Periodontology

Prevalence of Periodontal Disease


Partial-mouth probing vs full-mouth probing

Underestimation of periodontal disease

Ramfjord teeth

Mesial surfaces

Selected teeth

Holding the probe parallel to the

long axis of the tooth


American Academy of Periodontology Website



Is half of your schedule perio procedures?25 Trisha O'Hehir ODA 5mm pockets - May 12, 2015


Or maybe, this is the half of the population that doesn’t visit the dental office?


Why is the prophy appointment never long enough?

Medical History BP and Vital Signs

Oral Cancer Screening Dental Records

Periodontal Records Radiographs

Intraoral Camera OHI

Instrumentation Polishing Fluoride

Schedule Next Visit Infection Control, etc.


A 30 minute prophy is not all bad

CAMBRA pH testing

DNA testing Remineralization Desensitization Breath advice

Xylitol discussions Xerostomia tx Tongue thrust

TMD, clenching, bracing... etc.

as we now add:


Separate prevention from periodontal therapy


A 30 minute prophy is not all bad

CAMBRA pH testing

DNA testing Remineralization Desensitization Breath advice

Xylitol discussions Xerostomia tx Tongue thrust

TMD, clenching, bracing... etc.

as we now add:

separate prophy and treatment


Any bloody prophies in your schedule?


Undercover periodontal therapy

providing instrumentation without telling the patient and without charging for it = bloody prophy


Definition of Disease

Gingivitis PeriodontitisHealth

The missing link: Diagnosis


IDC9 Dental Diagnostic Codes 520 Disorders of tooth development and eruption 521 Diseases of hard tissues of teeth 522 Diseases of pulp and periapical tissues 523 Gingival and periodontal diseases 524 Dentofacial anomalies including malocclusion 525 Other diseases and conditions of the teeth and supporting structures 526 Diseases of the jaws 527 Diseases of the salivary glands 528 Diseases of the oral soft tissues excluding lesions specific for gingiva and tongue 529 Diseases and other conditions of the tongue


IDC9 Diagnostic Codes 523.0 Acute Gingivitis 523.1 Chronic Gingivitis 523.2 Gingival Recession 523.3 Acute Periodontitis 523.4 Chronic Periodontitis 523.5 Periodontosis 523.6 Accretions on the teeth 523.8 Other specified perio 523.9 Other unspecified perio


523.0 Acute Gingivitis 523.00 plaque induced 523.01 non plaque induced

523.1 Chronic Gingivitis 523.10 plaque induced 523.11 non-plaque induced

523.2 Gingival Recession 523.21 minimal 523.22 moderate 523.23 severe 523.24 localized 523.25 generalized

523.3 Acute/Aggressive Periodontitis 523.31 localized aggressive 523.32 generalized aggressive 523.33 acute

523.4 Chronic Periodontitis 523.41 localized 523.42 generalized

523.5 Periodontosis 523.6 Accretions on the teeth 523.8 Other specified perio 523.9 Other unspecified perio


523.6 Accretions on the teeth * 523.6 is a specific code that can be used to specify a diagnosis * 523.6 contains 13 index entries 523.6 also known as:

* Dental calculus: subgingival supragingival * Deposits on teeth: betel materia alba soft tartar tobacco * Extrinsic discoloration of teeth

523.6 excludes:

* intrinsic discoloration of teeth (521.7)


IDC9 Procedure Codes

D1110 Prophylaxis D1330 Oral hygiene instr D0170 Perio reevaluation D0180 Perio evaluation D4341 SRP by quadrant D4342 SRP 1-3 teeth D4355 Gross scale to probe D4381 Local drug delivery




No treatment codes for treating gingivitis




No treatment codes for treating gingivitis

Gingivitis


What is periodontal therapy?

Health Disease

What is health?


What is

Health?


Change due to biofilm accumulation


Definition of Health No bleeding No probing depths over 3mm


Def in i t ion of Heal th . . . A little bit of gingivitis - how much? A few 4mm pockets - how many?


Health or Disease?


Health or Disease?

menstuff.org


Health or Disease?

menstuff.org


Health or Disease?

menstuff.org


Health or Disease?

menstuff.org


Generalized vs Localized


Generalized vs Localized Gingivitis or Periodontitis


Generalized vs Localized Gingivitis or Periodontitis

Early, Moderate or Severe 53 Trisha O'Hehir ODA 5mm pockets - May 12, 2015



Early Moderate Severe



PeriodontitisHealth


Gingivitis


Bacterial Infection: Gingivitis

“Gingivitis is defined as the marginal inflammation of the gingiva comprising an inflammatory cell infiltrate, reversible destruction of collagen and the clinical appearance of redness and swelling.”

The distinction between the two is bone loss. Van Dyke, JIAP, 1999



PeriodontitisHealth


Gingivitis

Prophylaxis



Gingivitis Periodontitis


D i s e a s e

Health





D i s e a s e





Prophylaxis



Gingivitis Periodontitis

Health


Prophylaxis

Bloody Prophy


providing instrumentation without telling the patient and without charging for it

Avoid doing undercover periodontal therapy


pocket epitheliumscar formation in connective tissuebone losssmall band of connective tissue attachment

capillary formation

Rationale for instrumentationPeriodontal Infection


UntreatedTreated

CalculusSupragingival and Subgingival


CalculusSubgingival - result of infection


The result of infection, not the cause

Biofilm is the cause of infection

Rationale for instrumentation

Subgingival Calculus


Set the stagefor instrumentation


Biofilm Formation

Biofilm = plaque seen through laser confocal microscopy

Set the stagefor instrumentation


Too bad plaque biofilm

isn’t green!


What do your teeth feel like

when you wake up?


Does it feels like the teeth

are wearing sweaters?


Does it feels like the army

marching through?


Does it feels like the

bottom of a bird cage?


Or does it feel just

plain fuzzy!


Babies are born nearly germ-free

How do I getbacteria in my mouth?

• 75 Trisha O'Hehir ODA 5mm pockets - May 12, 2015

Bacteria: transferred from parent to child


Bacteria: transferred with shared food


Bacteria: transferred with shared food


What happens when it falls on the floor?


Bacteria are spread by the

family dog



Bacteria are spread

between partners by

kissing

Troil-Lindén et al JCP, 1996


Dr. Alan H Goldstein83 Trisha O'Hehir ODA 5mm pockets - May 12, 2015

fimbria

fibrillsText

Quorum sensing

Biofilm Formation


85 Trisha O'Hehir ODA 5mm pockets - May 12, 2015 86 Trisha O'Hehir ODA 5mm pockets - May 12, 2015


1/3 bacteria 2/3 slime - to absorb water and trap particles



Bacterial toxic waste includes lactic acid causing a drop in pH and demineralizing enamel:

resulting in caries


Biofilm grows in a fluid

environment: saliva and

crevicular fluid

• 91 Trisha O'Hehir ODA 5mm pockets - May 12, 2015 92 Trisha O'Hehir ODA 5mm pockets - May 12, 2015

Warning!Outside the body view of biofilm


photo courtesy of Dr. Randall Wolcott94 Trisha O'Hehir ODA 5mm pockets - May 12, 2015

photos courtesy of Dr. Randall Wolcott


•Acute Infection - single bacterial species •easily treated with an antibiotic

•Chronic Infection - multiple species •antibiotics are not effective


Biofilm causes ear infections


Look at your Toes Squirt your Nose

•


All are biofilm diseases


•Bacterial toxins from biofilm penetrate junctional epithelium

•White blood cells are called to the area to fight the bacteria

•Matrix metalloproteinases and cytokines are chemical machetes

•Cytokines destroy healthy connective tissue and bone

•Kreb cycle goes into oxygen debt

•Pocket epithelium forms due to lack of oxygen

•Micro-capillary formation to deliver oxygen

From biofilm to bleeding


White blood cells destroy connective tissue and bone on the way to the sulcus

diagram from text: Periodontal Disease, Page,

Schluger and Youdalis,

Pathogenesis


Translate cell biology

into cartoons

Bacterial endotoxins


Endotoxin from bacteria

✓Toxic waste of the bacteria ✓Triggers the immune response

How do toxins pass through the JE?

Bacterial endotoxins


! Signals alert the immune system

! Mast cells around the blood vessels release histamine, causing vasodilation

! PMNs are sent to the area


Vasodilation


Text

PMN

PMN

PMN

PMNPMN

PMN


MMP

prostaglandin(pre-term birth) interleukin

collagenase

Breakdown of the active transport

system

PMNs release chemical machetes


MMP

prostaglandin(pre-term birth)

interleukin

collagenase

Chemical Machetes


Breakdown of GAGS Glue

glycosamino-glycans

Breakdown of

active the transport system


Krebs CycleATPs

With oxygen - 24-28 ATP molecules from one molecule of glucose converted to pyruvate, plus the 4 molecules from glycolysis.


Oxygen debt

No oxygen - 4 molecules of ATP from each glucose molecule in glycolysis


Limited ATPs of energy requires a big decision



Immature epithelial cells

granulation

tissue



capillary formation

Pathogenesis

Advanced Lesion


Two-Hit Model Infection is triggered by bacteria, but tissue destruction is caused by the inflammatory

response of the person’s own immune system

Infection and Inflammation118 Trisha O'Hehir ODA 5mm pockets - May 12, 2015

You can have inflammation without infection, but you can’t have infection

without inflammation

In Clinical Practice Use the word “infection” not

“inflammation”


The stage is now set for instrumentation




Observe a radical change in treatment approaches

Set goals for improvement in instrumentation outcomes


Course Objectives



capillary formation

Rationale for instrumentationAdvanced Lesion


UntreatedTreated

CalculusSupragingival and Subgingival


CalculusSubgingival - result of infection


Review calculus formation...

Calculus is calcified dental plaque, composed primarily of calcium phosphate mineral salts deposited between and within remnants of formerly viable microorganisms.

Bacterial plaque biofilm covers mineralized calculus deposits.

Subgingival calculus is the result, not the cause of periodontal disease


Calculus

is a hotel

for biofilm


Review calculus formation...

Before calculus forms, it’s a soft, sticky plaque biofilm that can be removed with oral hygiene

The problem is, patients can’t see it - same color as the teeth



Perioscope Research











metal shield

tissue

enamel

tissue

cementum

CEJ


Rationale for instrumentationtissue

•Bleeding upon Probing (BOP) related to endoscopic identification of biofilm and calculus



•Bleeding upon Probing (BOP) related to endoscopic identification of biofilm and calculus

•Following blind SRP •biofilm was found on 55% of surfaces •calculus found on 38% of surfaces



Extraction Study: SEM evaluation• 42 teeth, 210 sites• Teeth instrumented with endoscope • Teeth extracted and SEM evaluated1.2% of endoscope aided SRP had residual calculus – mostly at CEJ

Similar studies without endocope showed 10 – 50% residual calculus remaining



Endoscopic SRP • 46 patients, 73 quadrants– Sites treatment planned for surgery – Used endoscope and SRP first – 1 year follow-up every 3 months • Treated by same hygienist At 1 year, 72 quadrants required no flap surgery. Attachment gain of 2.06mm



Retrospective look at endoscopic treatment outcomes after three years (626 sites)

Pockets 4 – 6mmPD reduction of 2mm with endoscope as compared with 1mm without


Rationale for instrumentation tissue

Retrospective look at endoscopic treatment outcomes after three years (626 sites) Pockets over 6mmPD reduction of 4.4mm with endoscope compared to 2.2mm without


Judy at work


Regenerative Periodontal Endoscopy™

tissue

The skilled use of a periodontal endoscope, micro-ultrasonic piezo technology,

and regenerative proteins can eliminate the need for aggressive surgery. When

used properly, endoscope technology allows for pinpoint precision and the

complete removal of gum infection and calculus in deep pockets without

surgery. Emdogain, a natural regenerative protein, is then placed on properly

prepared root surfaces in all periodontal pockets to stimulate the body’s own

regenerative stem cells, reduce inflammation, inhibit growth of bacteria, aid in the

reattachment of the gums, and promote bone fill. Safe and effective anti-

inflammatory medication is used to promote more rapid healing and stability of

the gums by resetting the inflammatory response and boosting activation of

regenerative cells.

Judy Carroll, RDH

PerioPeak.com



tissue

before RPE℠ 10-12mm pockets #2, #3 6 mo’s after RPE℠ – bone fill, no pockets


before RPE – 7mm 3 years after RPE – 3mm




tissue

Before RPE℠ – 10mm 3 months after – 3mm



tissue

What we have learned from research, endoscopy and from Judy Carroll -

we have to get the calculus off calculus can feel smooth - tissues tell all


Hand vs Power Scalers


Hand vs Ultrasonic

• Moderate pockets •106 pockets start • 13 - 4-7mm post op •92% success rate

• Deep pockets • 305 pockets start • 43 - 7mm or greater • 86% success rate

Healing continued during first 9 months then stabilized


There is no longer a pocket depth beyond which conservative therapy can be effective.

It’s about access -- not probing depth


According to the research, no power scaler is superior to another

Similar healing hand vs power

Dr. Badersten in 1981 and 1984 Dr. O’Leary in 1986 Dr. D’Haese in 2003 Dr. Rühling in 2003 Dr. Obeid in 2004


No#More#Egg#Beater#Strokes#Slow,#Overlapping#Strokes


• Deepest&part&of&pocket&

• Furca/ons&–&even&in&earliest&stages&

• Between&non8overlapping&strokes&

• CEJ&

• Root&concavi/es&

• Line&Angles&–&root&prominences

Where#Deposits#Are#Le<


Research is stronger for oral hygiene than for instrumentation

Without instrumentation, 0.1mm of attachment lost/year

Instrumentation and poor oral hygiene, 1mm lost/year

After scaling and root planing: Subgingival bacteria return to baseline levels in 4 to 8 wks

3, 4 and 6 month recalls may work for some, but not most

Magnusson, J Clin Perio 1984


Maintenance Intervals

1. 2 weeks

2. 2-3 months

3. 6 months

4. 12 months


2-week maintenance interval for several months following treatment


Subgingival Recolonization

! 8 to 25 weeks depending on the patient - 1978 ! 90 days in another study - 3-months

! 1991 study in Italy !FM instrumentation, 2 hours, anesthesia, no OHI !3 sites tested - 7 days, 21 days, 60 days

"7 days - healing, 1.5 mm pocket depth reduction "21 days - gingivitis - but plaque compatible with health "60 days - shift back to baseline levels


• Weekly - Every other week

• Monthly - Every two months

• Three months or 12 months

Set recall intervalbased on individual

patient needs







Course Objectives


Radical Change in Instrument Design The O’Hehir Curettes

• Scoops not Scalers


Problem

blade too big for

subgingival space

off-set blade harms tissue

Radical Change in Instrument Design



•

Scoop#blades#with#310°#radius#cuEng#edges

Push,#pull#in#any#direcHon


Radical Change in Instrument Design


O’Hehir Debridement Curettes

! Hu-Friedy ! G. Hartzell and Son ! Paradise Dental Technologies (PDT) ! Dental USA ! Zoll Dental


• Designed in 1991 - Thompson Dental

• Hu-Friedy makes them in 1993

• Small disc shaped spoon - blades

• Blade curves into the tooth for easy adaptation into furcations, developmental grooves, and line angles

• No off-set blade to hurt tissue

Hu-Friedy


Use a push or pull stroke in all

directions - vertical,

horizontal or oblique

New Instrument Design


Less tissue distention and

more comfortable for the patient

during and after procedure

New Instrument Design


Small blade reaches deep narrow defects


Blade curves into the tooth for easy adaptation into furcations, developmental grooves, and line angles


• Entire rim of blade provides cutting edge

• Use a push or pull stroke in all directions - vertical, horizontal or oblique

Scoop Design

Paradise Dental Technology (PDT)

PDT makes them with improved design



• Uses the hardest steel - stays sharper longer • Made completely in the USA




Young MD from Calcutta







Course Objectives


Polish First before any instrumentation

Avoid doing undercover periodontal therapy


•Similar results

•Another option for patients

FMD vs quadrants







Course Objectives


Set Goals

• Diagnosis: health, gingivitis, periodontitis

• generalized or localized; slight, moderate or severe

• Treatment - based on diagnosis

• Patient’s responsibility controlling biofilm

• Goals of treatment - expected outcomes

• Re-evaluation

• Maintenance interval

Treatment Plan


• Determine PHI

• (periodontal health index)

–# of pockets over # of bleeding points

–Goal = 0/0

–Provides bottom line number for DDS & patient

Set Goals


– Let bleeding be your guide

– Instrument the areas with bleeding, not the other areas

Set Goals


Read the tissues


Read the tissues


EIBI Eastman Interdental Bleeding Index


EIBI Eastman Interdental Bleeding Index

Sunstar Butler GUM Soft-Picks


How healthy can you get this area?



How healthy do you want this area? 185 Trisha O'Hehir ODA 5mm pockets - May 12, 2015


What is your goal?186 Trisha O'Hehir ODA 5mm pockets - May 12, 2015


What is your success rate?187 Trisha O'Hehir ODA 5mm pockets - May 12, 2015

What is your perio philosophy?



What do you believe you can accomplish with perio treatment?



What do you believe you can accomplish with perio treatment?

What do you want to do?







Course Objectives


Strategy: Instrumentation

Frequent DH Visits Daily Biofilm Control

pH Control 192 Trisha O'Hehir ODA 5mm pockets - May 12, 2015

Ways to change the oral environment

Mechanical Disruption of biofilm

Interdental cleaning Toothbrushing Tongue cleaning

Change the oral pH Xylitol

Change the balance of bacteria Oral probiotics and nasal breathing

Chemical attack of bacteria Toothpaste with fluoride and other chemicals


Metabolism - blocks production of acid

Communication-blocks bacterial docking stations needed for communication

Xylitol


Eat Bacteria: Oral Probiotics - Replacement Therapy

Live microorganisms that confer beneficial effects

on the balance of bacteria in the mouth


Probiotics - Replacement Therapy

2009 (NIH) survey on probiotic use 38% of adults 12% of children




Dr. Jeffrey Hillman

•Genetically altered Strep mutans •30 years of research so far •Dr. Jeffrey Hillman - researcher •Evora mints for kids and adults •Also impacts antibiotic research

Lantibiotic Production

Probiotics - Replacement

Therapy



How it Works

Dr. Jeffrey Hillman

Competitive exclusion

Antimicrobial production

Toxic by-products

Hindering adhesion sites

Competition for nutrients


Lactobacillus reuteri Prodentis from BioGaia, a Swedish biotechnology company


100 million colony forming units (CFU) Probiora3

S uberis KJ2 S oralis KJ3 S rattus JH145


containing BLIS K12

Streptococcus salivarius K12Otago University, Dunedin, NZ

BLIS K12


Maintain with KForce containing BLIS K12


Antibiotics

MICMinimum Inhibitory

Concentration


Systemic antibiotics are ineffective against biofilm

✓Cell variations due to environmental changes

✓Bacteria in biofilm are genetically different from floating species - triggered by antibiotics

Whiteley, Nature, 2001, J Perio 2002


Antibioticstrigger various gene expression

Need to be 1,000 to 1,500 times stronger


Ways to change the oral environment

Chemical attack of bacteria delivered in

toothpastes

mouthrinses

fluoride antibacterial agents desensitizing agents anti-tarter agents

Chemicals:


Chemicals

Some are specific to bad bacteria - others are broad

spectrum and attack all bacteria.


CloSYS

Attacks just the bad bacteria.


Biggest scientific goof - conclusions based on planktonic bacteria versus

bacteria in a biofilm.

Dr. J. William Costerton Godfather of Biofilm Research


Key areas to focus on:

1. Prevent supragingival calculus formation

2. Prevent interproximal bleeding/infection


Plaque vs Calculus

Do I have a lot of that hard

plaque to scrape off?


More research details

Manual toothbrush - 42% reduction in plaque 30% reduction with Quigley & Hein plaque index 50% reduction with the Navy Plaque Index

Various bristle designs reduced plaque scores 24 to 61%

Toothbrushing time impacted plaque removal One minute = 27% reduction Two minutes = 41% reduction

Slot, D., Wiggelinkhuizen, L., Rosema, N., Van der Weijden, G.: The Efficacy of Manual Toothbrush Following a Brushing Exercise: A Systematic Review. Int J Dent Hygiene 10: 187-197, 2012


Why is toothbrushing so ineffective?

1. Total brushing time

2. Reaching all areas of the mouth

3. Feedback on effectiveness is wrong


Brushing times 38 to 60 seconds Erratic pattern of brushing ✓Returning several times to starting place

Rarely brushing lingual surfaces ✓ If so - only 10% of time spent on linguals

MacGregor, Rugg-Gunn JPR 1979 14:225-230


✓ Reduced lingual calculus 63%

✓ Reduced lingual bleeding 55%

O’Hehir, Suvan, JADA 1998 129:614

Dry Brush Inside First


Most people brush with their

eyes closedDROOLING

and DAY DREAMING

30 seconds seems like 3

minutes

#1 People brush longer without toothpaste

Reasons why dry brushing works


Toothpaste makes so many

bubbles, you can’t see what you’re doing.

#2 People brush more evenly around the mouth


Toothpaste flavor and

wetting agents numb your

tongue so your teeth feel clean

when they really aren’t.

#3 People have a way to measure plaque removal with the tongue


Power Brush Timer


Power Brush Timer 2 minutes more than 3X times current brushing time

Quadpacer equal time around the

mouth


Stop using the F word


Flossing does not work

Ong, 1990, J of Clinical Perio, Carter-Hanson, J of Clinical Perio)

✓ Flossing removes only 18-35% of interproximal plaque (Ong, 1990, J of CP)

✓ Only 13% of adults and 6% of kids floss daily


Use Alternatives


Cutler et al, 2000 - BOP

0.3

0.44

0.58

0.72

0.86

1

Baseline 14 Days

No OH

ROH

ROH+OI


Floss with water

Sonicare Air Floss

Found Superior


Ways to raise oral pH

XylitolSalivaXylitol

Water Baking Soda

Oral probiotics - good bacteria








Course Objectives







Course Objectives

Biofilm and Pathogenesis

Scoops not scalers

Air polishing subgingivally - polish first

Read the tissues

Control oral pH and biofilm231 Trisha O'Hehir ODA 5mm pockets - May 12, 2015







Documents

Trisha O'Hehir ODA 5mm pockets · 2016-01-22 · Achieve Health in 5mm Bleeding Pockets with Scoops, Not Scalers Trisha O’Hehir, RDH, MS 1 Trisha O'Hehir ODA 5mm pockets - May 12,