It`s All About Balance: Emerging Biofilm Science

Transcription

Earn
1 CE credit
This course was
written for dentists,
dental hygienists,
and assistants.
It’s All About Balance:
Emerging Biofilm Science
Written by Stacy McCauley RDH, MS
Abstract
Throughout history, medicine and dentistry have continually
evolved via advances in technology and research. Breakthroughs
in science allow dental professionals the opportunity to practice
in new and exciting directions. What if breakthrough research
assessed the benefits of an oral care device beyond just the visual
inspection of brushing outcomes? What if the use of a power
toothbrush could change the composition of dental biofilm to
benefit the patient’s oral health? Dental biofilms are one of the
major contributing factors for both periodontal diseases and caries infections. Through emerging research, we now know not all
dental biofilm is bad. Novel and compelling science from Philips
Sonicare demonstrates the ability of Sonicare* to transition the
biofilm composition from a pathogenic state towards a benign
state and eventually to a beneficial state. These research findings
could significantly impact self-care regimens and long-term oral
health. New technologies in novel chairside diagnostic/assessment products will also be explored.
Publication date: Feb. 2011
Expiration date: Jan. 2014
Learning Objectives:
The course participants at the conclusion of the course will
be able to:
1. Discuss the evolution of medicine and dentistry as it relates
to treatment, prevention, and risk assessment paradigms.
2. Explain the current limitations of the clinical assessment
indices utilized in dentistry today.
3. List the 2 biofilm associated diseases impacting Americans
in epidemic proportions.
4. Describe the biofilm composition, potential for impact
on oral and systemic health, and strategies for achieving
dental biofilm balance.
5. Explain the novel research supporting biofilm balance as it
relates to the Sonicare power toothbrush.
6. Discuss new chairside diagnostic/assessment tools
currently available for dental practices.
Author Profile
Stacy McCauley, RDH, MS
Stacy is a graduate of Kellogg Community College with
16 years of clinical practice experience. After completing
her Bachelor of Science Degree at Siena Heights College
in Adrian, Michigan she relocated to Chapel Hill, North
Carolina to obtain her Master of Science degree in Dental
Hygiene Education. She is a former clinical assistant
professor at the University of North Carolina School of
Dentistry, has published research in various dental hygiene
journals, and has conducted clinical research. She currently
serves on the editorial review board for Modern Hygienist
magazine and the Journal of Dental Hygiene, and is a
member of the American Dental Hygienists’ Association
and North Carolina Dental Hygienists’ Association. Stacy is
the Manager of Professional Education and e-Learning for
Philips Sonicare in the Carolinas.
Go Green, Go Online to take your course
PennWell designates this activity for 1 Continuing Educational Credit
Supplement to PennWell Publications
This course was written for dentists, dental hygienists and assistants, from novice to skilled.
Educational Methods: This course is a self-instructional journal and web activity.
Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any
products or services discussed or shared in this educational activity nor with the commercial supporter.
No manufacturer or third party has had any input into the development of course content.
Requirements for Successful Completion: To obtain 1 CE credit for this educational activity you must pay
the required fee, review the material, complete the course evaluation and obtain a score of at least 70%.
This course has been made possible through an educational grant provided by Philips Sonicare.
CE Planner Disclosure: Michelle Fox, CE Coordinator does not have a leadership or commercial interest with
Orapharma, the commercial supporter, or with products or services discussed in this educational activity.
Educational Disclaimer: Completing a single continuing education course does not provide enough information
to result in the participant being an expert in the field related to the course topic. It is a combination of many
educational courses and clinical experience that allows the participant to develop skills and expertise.
Registration: The cost of this CE course is $39.00 for 1 CE credit.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a
full refund by contacting PennWell in writing.
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It’s All About Balance: Emerging Biofilm Science
Program Overview
Target Audience
Throughout history, medicine and dentistry have continually evolved via advances in technology and research.
Breakthroughs in science allow dental professionals the
opportunity to practice in new and exciting directions.
What if breakthrough research assessed the benefits of
an oral care device beyond just the visual inspection of
brushing outcomes? What if the use of a power toothbrush could change the composition of dental biofilm to
benefit the patient’s oral health? Dental biofilms are one
of the major contributing factors for both periodontal
diseases and caries infections. Through emerging
research, we now know not all dental biofilm is bad.
Novel and compelling science from Philips Sonicare
demonstrates the ability of Sonicare* to transition the
biofilm composition from a pathogenic state towards a
benign state and eventually to a beneficial state. These
research findings could significantly impact self-care regimens and long-term oral health. New technologies in
novel chairside diagnostic/assessment products will also
be explored.
The target audience for this course is Dentists, Dental
Hygienists and Dental Assistants from novice to
advanced professional.
Author Bio & Contact Information
Stacy McCauley, RDH, MS
Stacy is a graduate of Kellogg Community College with
16 years of clinical practice experience. After completing
her Bachelor of Science Degree at Siena Heights College
in Adrian, Michigan she relocated to Chapel Hill, North
Carolina to obtain her Master of Science degree in Dental
Hygiene Education. She is a former clinical assistant
professor at the University of North Carolina School of
Dentistry, has published research in various dental
hygiene journals, and has conducted clinical research.
She currently serves on the editorial review board for
Modern Hygienist magazine and the Journal of Dental
Hygiene, and is a member of the American Dental
Hygienists’ Association and North Carolina Dental
Hygienists’ Association. Stacy is the Manager of
Professional Education and e-Learning for Philips
Sonicare in the Carolinas.
Effective Date: February 1, 2012
Expiration Date: January 31, 2014
Format: Self Instructional - Text based Web Activity
Stacy McCauley may be reached at:
[email protected]
Educational Objectives
Recognition and Credits
Upon completion of this course, the clinician should
have a better understanding of:
n Discuss the evolution of medicine and dentistry as
it relates to treatment, prevention, and risk assessment paradigms.
n Explain the current limitations of the clinical
assessment indices utilized in dentistry today.
n List the 2 biofilm associated diseases impacting
Americans in epidemic proportions.
n Describe the biofilm composition, potential for
impact on oral and systemic health, and strategies
for achieving dental biofilm balance.
n Explain the novel research supporting biofilm
balance as it relates to the Sonicare power
toothbrush.
n Discuss new chairside diagnostic/assessment
tools currently available for dental practices.
PennWell is an ADA CERP recognized provider.
ADA CERP is a service of the American Dental
Association to assist dental professionals in identifying quality providers of continuing dental education.
ADA CERP does not approve or endorse individual
courses or instructors, nor does it imply acceptance of
credit hours by boards of dentistry.
PennWell designates this activity for 1 credit hour of
continuing education credits.
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Online Examination & CE Verification Form:
Caution: Completing a single continuing education
course does not provide enough information to give the
participant enough information to give the participant
the feeling that s/he is an expert in the field related to
the course topic. It is a combination of many educational courses and clinical experience that allows the
participant to develop skills and expertise.
To receive credit for your participation in this course you
will be required to complete the online program examination. To complete the online examination participants
must be registered and signed-in to ineedce.com and
have added the program to their user account (MyCE
Archives). Once added to your user account, a Take
Exam link will be displayed from within the MyCE
Archives section of the website. Upon selection of the
Take Exam link, participants are provided access to the
online examination form. Once completed and
submitted an immediate grade report will be displayed.
All participants scoring at least 70% on the examination
will receive a Letter of Credit (CE Verification Form) verifying 1 CE credit. Letters of credit may be viewed and
printed immediately as well as accessed anytime in the
future (24/7) from within the MyCE Archives user
records page of this website.
Not enough time to complete your online examination? No problem, online examinations may be
completed anytime during the effective period of the
program. Participants requiring more time to complete
an examination may return to this website, sign-in and
complete the online examination.
Cancellation/Refund Policy:
Any participant who is not 100% satisfied with this
course can request a full refund by contacting PennWell
in writing.
Hardware and Software Requirements
To access CME-University materials users will need:
n A computer with an Internet connection.
n Internet Explorer 7.x or higher, Firefox 3.x or
higher, Safari 3.x or higher, or any other W3C
standards compliant browser.
n Adobe Acrobat Reader or Apple Preveiw.
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playback.
Disclosure Declaration
Presenter Disclosure: Stacy McCauley has no
relevant financial interests with any products or
services discussed in this presentation.
Provider Disclosure: PennWell's Dental Group does not
have monetary or other special interest in any products
or services discussed or shared in this educational
activity. CE Planner/Organizer, Michelle Fox does not
have a relevant financial interests with any products or
services discussed in this presentation.
Image Authenticity: No images in this educational
activity have been modified or altered.
Scientific Basis: All content has been derived from
references listed and the author’s clinical experience.
Research references are provided in the bibliography
and/or supplemental materials.
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Hello, and welcome to this virtual CE event.
I’m your course facilitator, Stacy McCauley.
One of the things I find most exciting and
at the same time most challenging in
dentistry is the daunting task of keeping
current with the latest advances in
research. One of the fastest growing
aspects in the profession of dentistry’s
evolving science is the area of emerging
biofilm research. The concept of dental
biofilms was pushed to the forefront in
early 2000, in part by Philips Sonicare
researchers and the research coming out
of the Montana State University’s Center
for Biofilm Engineering. Since that early
research, both dentistry and medicine have
both continued to grow the body of
evidence. Let’s look at how closely medicine and dentistry are dovetailing their scientific advances.
Medicine has its historical roots deeply
seated in the treatment of diseases. The
idea that doctors and medicine can fix
whatever is ailing you has been commonplace for hundreds of years. As we all
know, healthcare continues to struggle
with getting patients to commit to compliance with proactive, preventive behaviors
such as improved nutrition, healthier food
choices, eliminating risky behaviors such
as smoking, committing to regular exercise, even the idea that flossing daily
improves your overall health. These
behavior changes have all been identified
as ways to help prevent a disease from
manifesting. However, getting people to
become committed to a healthy prevention-oriented lifestyle has been a challenge, to say the least. In a moment, we will also look at this scenario of
disease treatment versus disease prevention as it relates to dentistry. And we’ll get to that in just a moment.
Healthcare is now beginning to use risk assessment, which you see here in the third box. Risk assessment strategies are used to help identify those patients with significant risk factors. If risk factors are identified, then intervention can happen early, possibly early enough to prevent the disease from taking over the patient’s body. For now, if
we look at the first box on the left on this slide, this depicts the medicine evolution. We see disease treatment as
the foundation of medicine.
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Historically, medicine used an approach of
what I call “cleaning house” when it came
to the treatment of various diseases and
conditions. Specifically, with bacterial
infections, individuals were routinely
treated with broad spectrum antibiotics to
completely obliterate the bacterial populations. This was based on the popular
notion of the day that all bacteria was bad.
That is demonstrated here on the left side
of your slide. Historically, medicine wanted
to eliminate all bacteria. Today, with the
emergence of new science, we see medicine using antibiotics much more judiciously. Many in the medical community
are not only embracing the fact that sometimes the body’s natural immune defenses
are the best intervention. So, for example, that would be letting nature take its course to rid the body of infection
through things like a fever. But the medical community is also dramatically changing their position on the use of
antibiotics. Modern medicine, in part due to antibiotic overuse of the past decades, has dramatically changed the
prescribing protocols when it comes to antibiotic prophylaxis and the use of antibiotics without a definitive diagnosis,
meaning, before they even know if it’s a viral infection or bacterial infection. This is a major shift from the previous
20 years when physicians wrote prescriptions for antibiotics just in case they were dealing with a bacterial infection.
So what you’ll see today on the slide on the right, the bacterial balance and management concept is the current paradigm compared to the paradigm of historical medicine, and that was total bacterial elimination.
Dentistry, too, has evolved in the theories
behind our clinical decision making. If you
began practicing prior to the 1970s, now I
doubt anyone was practicing when this
picture was taken, but just for a perspective’s sake, if you practiced prior to the
1970s you likely focused your career on
eradicating disease. Medicine did the same
thing. In dentistry, it meant we were doing
a great job of getting people healthy via
intervention or treatment strategies only.
This meant we extracted infected teeth or
we filled decayed teeth.
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Moving on, the 1970s through about the year
2000, dentistry began to add disease prevention into the standard of care. Dentistry
started utilizing things such as topical and
systemic fluoride to not only reduce current
caries incidence but to also help prevent
future disease. Dentistry also began to treat
caries much earlier, thanks to the diagnostic
assistance of bitewing radiographs. Now
dentists could restore insipient lesion before
it had a chance to spread deep through the
enamel into the dentin. Sealants are yet
another example of the post-1970s prevention-focused paradigm.
Now if you look on the slide you can see
the evolution of treatment-focused to
prevention-focused and where we are
today is in the final box. The final box is
risk assessment and risk modification.
Today is yet another opportunity for
dentistry to once again advance its standard of care. We are not only treating
disease; we are not only preventing
disease; we are now predicting disease.
This is the foundation of risk assessment.
If we wait until evidence of disease is
present, for many patients that is just
simply too late. They are now in a cycle of
disease that lasts a lifetime, regardless of
our best efforts with prevention and treatment interventions.
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If we look at dentistry, we have a progression in how we’ve viewed biofilm. If we
look at historical dentistry, the total Plaque
Elimination Model, which you see here on
the left, was pretty much the mainstay.
The total Plaque Elimination Model has
now been deemed as old science because
your patients will never be able to
completely remove all the plaque anyway.
Yet health is sustainable with incomplete
plaque removal. I think all of us have seen
cases in our practices of patients with less
than stellar oral hygiene. They present for
the dental hygiene appointment with
moderate, even heavy plaque but interestingly, we don’t see a lot of inflammation;
we don’t see a high bleeding index. So
that’s to the point that just because the patient has biofilm present doesn’t necessarily mean they’re going to
develop disease. And conversely, you can have patients with pristine oral hygiene and they present with absolutely
a plaque-free mouth that day and they still have a presentation of a high bleeding index or a high gingival index. The
understanding that there are good bugs and bad bugs has resulted in the current paradigm, the paradigm that most
of us were practicing under until very recently. The current paradigm is called Biofilm Control, and that’s in the
middle section of this slide. We are now understanding that the Biofilm Control Model is only seeing half the equation because the other half of the equation focuses on how to manipulate the surrounding biofilm environment to
promote the good bacterial growth. Another aspect of the current approach seems to be a reactive approach in the
fact that we are waiting for disease to happen before we intervene. The current paradigm of Biofilm Control,
however, does differentiate the fact that there are good bugs in the biofilm and there are bad bugs in the biofilm and
the current paradigm really focuses on eliminating the bad bugs only. If you move to the right side of the slide, this
is the future paradigm and for those of you that are attending the webinar today, you’re some of the first dental
professionals in the country to hear about the future paradigm, which is Biofilm Management. This is a proactive
approach aimed at maintaining a healthy or health promoting oral balance, avoiding the tipping point into disease.
Research is continuing to uncover the facets of biofilm composition. Some of the dental biofilm constituents aren’t
just benign. The new paradigm goes further to say there are constituents that are actually beneficial and help keep
the pathogenic bacteria at bay, thus maintaining a normal healthy oral flora. The biofilm management concept takes
biofilm control one step further by not just focusing on removing bad bacteria, but also physically altering the ecological environment in such a way that growth and proliferation of good bugs is actually favored. Through actively
promoting beneficial bacteria while keeping the pathogenic bugs suppressed, a healthy biofilm homeostasis is
constantly maintained. The net effect of a balanced biofilm is long term oral health. This also supports the idea of
probiotics. I think we’ve all seen the advertisements on television for the various probiotic products available on the
market related to GI health. Dentistry is also starting to manufacture and use products that are based on probiotics,
the idea of restoring oral balance. Our new treatment protocols will be using oral balance as a goal for achieving
and/or sustaining oral health both for short term but also for attaining long term oral health.
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Before we get into all of the cutting-edge
science related to biofilm management, let’s
take a look at one more piece of dental history.
Traditionally, research has been measured via
subjective
outcomes
assessments.
Subjective outcomes assessments can be
variable due to human interpretation. So what
are we talking about? Well, it’s the clinical
indices that we use almost on a daily basis
with our patients. Things like plaque scores,
probing depths, and bleeding index. A limitation of this traditional historical assessment
protocol is the fact that it was limited in what
it told us. It simply said if plaque was present
or not. It does nothing to determine the pathogenicity of the plaque, or what we’re going to
call dental biofilm, it also didn’t tell us what
was happening on a cellular level regarding the immune response. Subjective analysis is also variable due to human interpretation. How many of you remember from dental hygiene school probing your patient’s mouth only to have your instructor
come over and get completely different measurements? We both were doing the same technique but we got different
outcomes - they’re subjective. Or bleeding index, or a plaque score. Science has shown us that traditional plaque studies have
inherent flaws in their design based on their two dimensional representation of a three dimensional object. We have seen
through confocal scanning laser microscopy that dental biofilm is actually three dimensional with a highly irregular surface.
So, if we’re just simply using a plaque score it’s really not telling us the whole story. Just this information alone is enough to
skew our outcomes. And when you combine the use of human subjects within plaque studies, the variability within each
person’s plaque accumulation and their homecare behaviors can make for very weak research, repeatability and reliability.
Now I want you to look at this picture of an
iceberg. How many of you would say this is a
huge iceberg? Go ahead, raise your hands.
Now don’t you feel sort of silly raising your
hands in the privacy of your own home? You
can go ahead and put your hands down.
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Now, what if I show you the real picture? The
entire picture. Now I wonder how many of you
think it’s a really huge iceberg. Traditionally,
dentistry has just been able to see the tip of
the iceberg when it came to assessing disease
and/or health in our patients. If we limit our
view of the patient to just what is visible on the
surface, we are not seeing the entire picture.
So another way to look at this from our day to
day clinical perspective is this: you know, I
wonder what’s under this patient’s iceberg. Or
even further, what’s going on within this
biofilm ecosystem. If we use traditional clinical assessment, I’m only seeing what’s on the
surface. Clinically, I see evidence of pathogenic biofilm due to the obvious signs of
inflammation and caries infection. Later in the
program I will briefly introduce you to some of
the newest chairside diagnostic items we can
utilize to look below the surface into this
biofilm to definitively determine what’s going
on in the ecosystem. When we know what
we are dealing with we have a better game
plan on how to devise a plan for managing the
biofilm and the disease process.
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Clinically, we know a disease characteristic
when we see it. You can see obvious signs
of disease evident on the left photo.
Additionally, we also assume, by clinical
observation only, that after periodontal
therapy this patient is now healthy as
evidenced by the after picture on the right.
But how do you really ever know if health is
established in your patients after intervention? Moving beyond just our clinical
subjective observations, what if we could
know what was going on at a subclinical
level, or below the surface of the tip of the
iceberg?
I showed you a version of this slide earlier in
the program. I’d like to come back to the
concept of subjective assessments and the
added benefit of utilizing objective assessments as well. The iceberg analogy hopefully
makes sense when we think about our traditional means of data gathering. We routinely
gather information from our patients via
medical history, visual inspection of the oral
cavity, periodontal measurements, radiographic interpretation, and so on. Like the
iceberg, if we don’t know what lies beneath,
we do not have an accurate picture of our
patients. So, what’s in the mouth, or the top
section of this slide, those clinical endpoints
are subjective. It does not tell us anything
about what’s going on under the surface.
Meaning, what sort of impact does our intervention therapy have or maybe what sort of impact does the oral care products
I’m recommending have on my patients, other than just what I see present in the mouth? Sonicare has been at the forefront
of moving beyond the traditional outcomes assessment into a new arena: Biomarker Assessment. So in addition to seeing
the benefit of the intervention of the power toothbrush through traditional measurements, such as plaque score reduction,
pocket depth reduction, the reduction of bleeding index, Sonicare is now adding the assessment of biomarkers to the
research assessment criteria. Well, what is a biomarker? Well for example, gingival crevicular fluid samples – that’s a
biomarker. And as we know, in patients with active periodontal disease and an inflammatory response, they have a higher
gingival crevicular fluid flow. There are also opportunities for us to now use chairside diagnostic tools to not only do a microbiological or physiological assessment, but we also now have an opportunity to actually do a genetic assessment on our
patients chairside. And we will talk about that in a few minutes.
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Like medicine, dentistry historically took an allor-nothing approach when it came to treating
infection via the total elimination approach.
After focusing our energy on achieving a
plaque-free mouth, we would think that we
would have completely obliterated all bacteriarelated oral infections. So, how are we doing
with that? Well, according to the American
Academy of Periodontology, they estimate
that 75% of Americans have some form of
periodontal disease. So we look at our traditional paradigm of removing all of the plaque
possible or the traditional model, it might not
be working so well because we still have a
majority of the population suffering from this
biofilm associated disease. So we need to
probably think about changing our paradigm.
Another reason I think it’s important for us to
sort of have a serious conversation with
holding on to the historical plaque-free mouth
approach, is the fact that we now see dental
caries infections in our most vulnerable population - children ages 0-5 – at absolutely
epidemic proportions in this country. I’m just
going to read a few of these bullet points. I
think they’re pretty shocking. Dental caries is
the most common chronic childhood
disease. It is more common than the
common cold and it is five times as common
as asthma. Three times more children have
unmet needs for dental care than for medical
care. One-fourth of children, by age four, will
have experienced early childhood caries
infection, and half of children by second
grade. And you can see the breakdown on the final box on the slide, caries ages 2-5. In 1988-1994, 24% incidence and
now that has jumped to 28% 1999-2004. I hate to see the next set of data statistics on this because I think we’re going to
see yet another jump. So, periodontal disease is a biofilm-associated oral infection and dental caries infection is a biofilmassociated disease of the mouth. So the idea that we need to start changing our paradigm on how we approach biofilm
management is of the most importance for us at this time.
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Okay, so it’s time for a little history lesson.
I’m going to ask you this question and I
wonder what your response is going to be.
Now, I think if anybody walked up on the
street and asked you, as the dental hygienist,
“Hey, how many times a year do I need to
have my teeth cleaned?” probably most of us
would have the knee-jerk response of, “Well,
you should have your teeth cleaned every six
months or twice a year.” But have you ever
wondered how that protocol was ever established? I mean, I guess I just assumed somebody much smarter than myself established
this protocol based on research or science. I
was really shocked when I found out protocol
for having a checkup and prophylaxis every
six months was actually established in the
1950s on a radio commercial for Ipana toothpaste. They would sing this little jingle, “Brush-a, brush-a, brush-a, with the
new Ipana” and the jingle would continue on and say “and see your dentist twice a year.” Well, folks, that is exactly how
the six month Recall Prophy Frequency was established and I’m sorry to say in this year, we still are practicing based on
the recommendations from a toothpaste commercial from the 1950s. So, if dentistry is going to move forward and not
get stuck in tradition, we should start practicing based on risk assessment. Some patients with evidence of disease and
multiple risk factors would need an evaluation and a preventative maintenance appointment maybe at every two or three
months. Conversely, some patients with extremely low risk factors may absolutely do well with a preventative maintenance
recall and exam at maybe every 12 months or 18 months. So again, if we stay stuck in our old traditions, we’re not practicing based on best evidence. The same thing rings true with how often you take bitewings? So many offices in the US
still expose patients to bitewing radiographs no matter what, every 12 months. It doesn’t matter if the patient has a history
of caries infection or not. Well, this is a time to take a look at what the American Dental Association said about four years
ago. The ADA came out with a position paper on radiographic exposure and it said dentistry must stop exposing patients
every 12 months to bitewings simply because insurance reimburses for it. It is important that we make our decisions
based on patients’ individual risks. Low caries risk patients, the ADA says, every 18-36 months would be appropriate.
Moderate to high risk patients, that may be every 6 months or every 9 months. So again, we need to move forward with
new protocols. Think about recommendations of home care products. Probably many of you listening to this webinar
personally use a power toothbrush because you know not only does the research support effectiveness, but you’ve tried
it yourself and you know there is a significant difference in the brushing experience. But I’m going to ask you how many
of you power brushers out there listening to this program are giving your patients a manual toothbrush every six months
when they’re in for their preventative maintenance? I just encourage you to make recommendations and practice based
on best evidence, not on tradition. And if you know it to be true in the research and you’ve experienced it yourself, why
would you give your patient a substandard means of brushing? Let’s take a look at scaling and root planing. Dentistry is a
very interesting bird, because we are the only profession that pre-determines the number of visits of therapy and we are
assuming that after the last visit of therapy the patient will be healthy. Let me give you an example: if you have an injury
and you go to a physical therapist to rehab your knee, I’m going to tell you I doubt anyone out there had the physical therapist look at their MRI and feel the knee at that first visit, and at that first visit the PT said, “Mr. Smith, I’m going to guarantee you I’m going to do four manipulations and four sessions of physical therapy and your knee will be healthy and you
will be out of pain.” That’s not how it works. The physical therapist never pre-estimates when you will be done. You are
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finished with therapy when your knee doesn’t hurt and when you’re fully functional. But that’s not what we do in dentistry.
Open-ended therapy is a new approach. We don’t tell the patient when they are going to be finished. They are finished
when we see no bleeding. They are finished when we see no pocket progression, and they are finished when they meet
our criteria of health. Finally, dentistry is starting to move forward because we now are going to embrace the idea of biofilm
management, not the idea that we need to eradicate all of the biofilm in the mouth.
I’d like to walk you through this process.
And this is a process we’re all very well
familiar with. If you look at the picture on
the upper left of your slide, this is a
diagram showing biofilm on a tooth surface
and in this case we have obviously an
unhealthy composition of biofilm. Why do
I say it’s obviously an unhealthy composition? Because look at how the tissue is
responding. That biofilm is releasing
unhealthy endotoxins. Now, you might
have another patient presenting with just
as much biofilm on their tooth but the
biofilm probably doesn’t contain the pathogenic bacteria and the pathogenic bacterial
byproducts. So they won’t have this
response from the tissue. In this instance,
you can see how we start to get tissue breakdown of the epithelium and this is the idea for how potentially, periodontal disease infections can play a role in systemic health. So if you think about the model of seeing a patient
twice a year for their preventative maintenance or prophy appointment, if you look on the right side of the slide, I’m
going to walk you through the rationale for why we need to modify or to support your current oral homecare procedures and protocols. If the patient comes in to see the dental hygienist twice a year, you think about an annual year
– 365 days – so we have two days, two chances, to make a difference in that biofilm composition. Wouldn’t it be
smart to get the patient an oral care device that has been proven to not only disrupt and dismantle the biofilm, but
it’s also been shown in the research to encourage a healthy biofilm regrowth. And this is what you see here in the
looping video on the lower right of the screen. This is the Sonicare brush being used in the mouth. It’s disrupting
and dismantling the biofilm via mechanical bristle contact. So the brush strokes, extra soft, are brushing 31,000
brush strokes per minute, but the brush is also augmenting its effectiveness by the fact that it can patently move
fluids in the mouth at a high enough velocity that it actually disrupts and dismantles the biofilm. In a moment, I’m
going to show you some very interesting novel research that looks at the shift in biofilm composition.
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This is one of the new products I
mentioned at the beginning of the program
relating to chairside diagnostics. This is
the CariScreen caries susceptibility test
and I think this is really innovative technology. Now, this product has several
products in their lineup for maintaining a
healthy oral balance for your at-risk
patients, but for right now I want you to
focus on the lower right of the screen
where you see that little black device with
the digital display. This test is very quick
and is very painless. The clinician simply
takes a swab sample of the biofilm or
plaque from your patient’s teeth, and then
you combine it with a special chemical
agent. And then, you place that swab in
that little black handheld device and it is going to give you a score between 0 and 9,999. A score under 1,500 is
considered relatively healthy, while above that shows considerable risk for decay. This technology not only allows
the clinician to measure the patient’s risk for decay today, but it also helps measure the progress as they follow the
recommended protocols for reducing risk. So here’s where I see it really being a huge benefit chairside in a practice.
To that second point about being able to follow the progress of the patient, you can easily track the benefit of the
oral healthcare regimens you prescribe. So you would do an initial caries risk test and then you would continue to
do caries screen risk tests after that. So, if the patient is using the prescription fluoride toothpaste, they are using
their power toothbrush, you should absolutely begin to see a shift from their baseline of moderate to high risk to low
risk. And I think, to me, that is such a teachable moment with our patients and it again supports the products that
we are dispensing in the practice. So that could be xylitol products, that could be fluoride products, that could be
power toothbrush products, and I think this is a great asset for us to have as a chairside diagnostic tool.
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Saliva-Check Mutans is another chairside
diagnostic tool. I think this is a really
exciting piece of technology. It sort of
looks like, if you look at the lower part of
the screen, the test itself actually to me
looks like a home pregnancy test. So, if we
look at this patient with obvious biofilm
control issues, if we took a sample of the
biofilm and we could quickly mix it chairside and drop three drops into that chairside test, the test that sort of looks like a
home pregnancy test, if you see the red
line illuminate where the letter “T” is, that
will tell you that you have a positive result.
So if the patient has a positive result, it
means the patient has a level of strep
mutans equal or above 500,000 CFUs. The
CariScreen product and the Saliva-Check Mutans are just two ways we can begin to incorporate objective analyses
into our daily chairside protocols. And, for many offices, this is a nice addition to the hygiene services available to
patients. It’s also a way to increase our revenue production.
We saw this slide at the beginning of my
program. How do you really know how
much health was restored after your periodontal therapy? I mean, gosh, he looks
good to me, but it doesn’t mean he’s no
longer at risk. Even if things look okay
today on the surface, again, we have to go
back to the idea that we have no idea
what’s going on below the surface or
below the tip of the iceberg.
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So another potential chairside diagnostic
tool, so we can see below the surface,
could be the use of the Oral DNA Labs
product, MyPerio Path. What you see here
on this slide, under the name John Doe,
you will see the word “result.” And next to
it in red lettering, the word “positive.” And
it says five pathogenic bacteria reported
above threshold. And it’s also telling us
that the patient has a bacterial risk of “high”
and it means very strong evidence of
increased risk for attachment loss. So, if
you go back to the previous picture I
showed you of the before and after scaling
and root planing or periodontal therapy, this
is a way that we can actually assess the
outcome of our periodontal therapy. And it
will also help us reinforce our recommendations for not only periodontal therapy but the protocol for periodontal
maintenance with our patients. Really great, new, novel technology.
Some of you may be familiar with Dr. Jane
Forrest’s evidence-based decision making
model in the process of dental hygiene
care, shown here on this slide. In this
model, in order to practice based on
current evidence, we have to embrace
current
scientific
evidence,
the
client/patient preferences and values, the
clinical or client circumstances, and also
the dental professional’s personal experience and judgment.
You don’t see
anywhere on this slide the circle that says
“History” or the circle that says “Because
that’s the way I like to do it.” And that’s one
of the pieces I hope that we can encourage
all dental professionals to look at is,
breaking out of tradition and breaking out
of your comfort zone in order to practice based on best evidence.
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Sonicare is the first power toothbrush
company with research going beyond just
the longstanding objective visual inspection to make its product claims. Let’s go
into the future of dental research. Dr.
Purnima Kumar from the Ohio State
University is currently researching biofilm
composition through objective assessments. Dr. Kumar and her research team
were interested in understanding the
process of shifts in microbial composition
concurrent with the clinical changes
following the routine use of the Sonicare
power toothbrush. So they not only looked
at our typical clinical indices like plaque
reduction, bleeding index reduction,
gingival index reduction, but they took it a
step further to help move forward the science and they included objective analysis. In this research, she induced
experimental gingivitis over a period of 21 days in a high-risk population of current smokers. Then, after 21 days,
subjects were provided with the Sonicare toothbrush to use twice daily for two minutes for two weeks. I want you
to take a look at the changes in the biofilm composition. So at baseline, meaning after they were induced into
gingivitis at 21 days, when they did a baseline assessment the research team concluded that when they looked at
the biofilm – they didn’t just look at how much biofilm was there, they said, “Let’s take it one step further and let’s
see what lies beneath.” They found the explosion in growth of pathogenic bacteria in the biofilm. There was some
growth in beneficial bacteria and there was slight growth in a category called “other bacteria.” Now, the patients
went home, there was no dental hygiene intervention, no scaling or root planing, no periomaintenance, no prophylaxis. They went home and brushed with their Sonicare toothbrush for two weeks, twice daily for two minutes.
When they returned to the research lab at Ohio State, they did another assessment of the biofilm. And again, they
weren’t focused this time on how much biofilm did it remove, they were focused on what happened to the regrowth
of the biofilm, or in this case, what’s the change in the biofilm composition? In just two weeks, that biofilm went
from predominantly pathogenic to predominantly beneficial. The pathogenic bacteria was suppressed significantly.
And you can see here we now have a much healthier biofilm composition.
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If any of you are interested in learning more
about beneficial biofilm and biofilm management, please visit sonicare.com/dp, “D” for
dental, “P” for professional.
As I conclude, I hope you feel a new sense
of understanding on how to better address
biofilm management with your patients. I
think many times, we all get into a routine
with patients and we unintentionally go on
autopilot. We need a fresh perspective on
how to uncover potential risk factors for
both periodontal disease and dental caries
infections; both biofilm-associated oral
disease. I hope you feel compelled to not
only reassess your assessment strategies
when diagnosing and treatment planning
patients based on what we talked about
today, I hope you continue to work on evaluating and addressing factors that can
potentially shift your patients from health
to disease. It is all about balance and
management. Remember to look well below the surface for what lies beneath. Remember the new science of
biofilm management in order to achieve healthy biofilm balance. Remember that Sonicare is able to promote a
healthy biofilm balance in just two weeks in a gingivitis population. If we remember all those things, we will not only
attain oral heath today for our patients, but the goal of long-term oral health for all of our patients. I would like to
thank you so much for participating in this webinar event.
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Examination Review
This page is provided for review only. To access the online post-exam you must be “Registered” and “Signed In.”
and have completed the course selection/purchase process in its entirety. Once selected/purchased the course title
will be added to your MyCE Archives page where a Take Exam link will be displayed directly across from the course
title. A letter of credit will be issued upon successful completion of the post-exam with a score of 70% or higher.
Please note: Credit may not be claimed if completed after the course expiration date.
1) Please indicate which of the following is not a component of the evidence-based decision making
model:
A) Patient preference
B) Clinician judgment and personal preference
C) Cost of product and/or treatment
D) Research findings
2. All forms of biofilm are considered extremely pathogenic and must be completely removed in order to
prevent oral diseases.
A) True
B) False
3. The American Academy of Periodontology estimates the incidence of periodontal diseases in the U.S. at
75% of the population.
A) True
B) False
4. Dentistry has evolved through many stages. Which of the following correctly describes the evolution of
dentistry?
A) Began with utilization of risk assessment, then focused on treatment of oral disease, currently focused
on prevention of oral diseases
B) Began with prevention of oral diseases, then focused on risk assessment, currently focused on treatment of oral diseases
C) Began with treatment of oral diseases, then focused on prevention of oral diseases, currently focused
on risk assessment
5. Which of the following is NOT considered a type of subjective assessment?
A) DNA salivary analysis
B) Plaque score
C) Bleeding index
D) Periodontal probing
6. Novel research demonstrated the ability of the Sonicare power toothbrush to alter biofilm composition
in which way?
A) Shift the bacteria in the biofilm from cariogenic to caries-preventing
B) Shift the bacteria in the biofilm from gram negative to gram positive
C) Shift the bacteria in the biofilm from pathogenic to beneficial in just two weeks
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7. What happens to gingival crevicular flow when a patient deteriorates from health to disease?
A) Flow increases
B) Flow decreases
8. The current paradigm of biofilm differs from the future paradigm of biofilm management in which ways?
A) Current paradigm focuses on good bugs versus bad bugs
B) Current paradigm focuses on eliminating bugs
C) Current paradigm is not focused on allowing some bacteria to proliferate in hopes of creating a beneficial biofilm environment
D) All of the above
9. Sonicare technology utilizes high speed bristle action along with ________ in order to achieve superior
biofilm management.
A) Electric pulses
B) Multidirectional fluid forces
C) Kinetic energy
10. The total plaque elimination paradigm has been extremely successful as evidenced by the complete
elimination of dental caries infections and periodontal diseases in the U.S.
A) True
B) False
19

It`s All About Balance: Emerging Biofilm Science

Transcription

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