Ultimate Guide to Achieving Ultimate Guide to Achieving Periodontal Health Periodontal Health Secrets to Patient Compliance Secrets to Patient Compliance

Trisha E. O’Hehir, MS, RDH Phone: 520-444-2279 Compliance — requires behavior change [email protected]

Liz Graham, BS, RDH Phone: 707-769-8887 Education = behavior change [email protected] Liz Graham Presents *** Trisha O’Hehir

Look for the Reactions Button The Future on the bottom of your Zoom screen I help people achieve with the Thumbs Up choice optimal oral health

Cleaning! Thumbs up if you want to help patients Teeth ! achieve oral health rather than just clean teeth U of Minn NEW VISION 1967 Achieving Oral Health!

How healthy do you want this patient to be? How healthy does the patient want to be?

15,000 in 1967 200,000 today DH school and board exams: the vision is calculus removal

Health Manpower, United States, 1965-1967, National Center for Health Statistics, Series 14:1, 1968. Bureau of Labor Statistics, Occupational Employment and Wages, 2018. …with grades based on competencies

grasp, fulcrum, insertion, activation…

No requirement to help patients achieve health

Not based on health outcomes! Focused on competencies

How much of what we were taught in school was true? DH School didn’t teach me how to measure success Time for a Poll How successful is your treatment?

My guess was 85%

How successful is your treatment? Has anyone asked this of you?

Periodontal Health Index (PHI) What is your success rate with periodontal therapy?

30 patients 1,916 pockets — 139 pockets 139 divided by 1,916 = 7% of pockets remained 93% of pockets were eliminated With the PHI, you can calculate your success rate Periodontal Health Index (PHI) Ideal is 0/0 Simple number - like blood pressure 24/38 - means more than just a few 4s and

Number of pockets bleeding in the posterior number of bleeding points

Goal: 0/0 Worst possible score - 168/168 Perio scores are often 25/100 to 85/140

Patient played tennis with a dentist friend

Current score = 3/5 Baseline score = 86/122

Pocket reduction: 97% Bleeding reduction: 96% Evidence Based Dentistry

Slot, DE, Van der Weijden, F. Insuffcient evidence to determine the effects of routine scale and polish treatments. 2014

Bader, J. Insuffcient evidence to understand effect of routine scaling and polishing. 2005

Cochrane Review

Routine Scale and Polish for Periodontal Health in Adults - 2018

Scale and polish every 6-12 months vs no DH visits for three years

-makes little or no difference in gingivitis, probing depths, bleeding upon probing and oral health-related quality of life The Future Poll Time

What keeps you from achieving health for your I help people achieve patients? optimal oral health Too much calculus to remove Too much periodontal disease Not enough time Lack of adequate instruments/equipment Cleaning! Poor patient compliance Teeth ! Something else

Breakout Rooms If there is one thing that would make your work Three secrets to make your easier and more successful what would it be? workday easier and I know some of you would like to fre the dentist and work independently, and I’m all for perio patients healthier. independence, but just for now, what would make working in your current position better and more successful in achieving health for all your Are you interested? patients?

Do you and your breakout colleagues agree on the one change or does it vary signifcantly among you? Secrets Three secrets to make your workday easier and 1. Improve oral/systemic health perio patients healthier. 2. Prevent interdental bleeding Are you interested? 3. Prevent supragingival calculus

How can we help patients achieve optimum oral health? 1.Bioflm good or bad

2.Impacting the bioflm

3.Health behavior change Bioflm - it’s a complex ecosystem worthy of our respect 1.Bioflm good or bad

1.Bioflm good or bad

2.Impacting the bioflm

3.Health behavior change

Bioflm - it’s a complex ecosystem worthy of our respect

Too bad 1.Bioflm good or bad plaque Caries Periodontal Diseases biofilm Bad Breath isn’t green! What do Does it your teeth feels like feel like the teeth when you are wake up? wearing

Does it Does it feels like feels like the army the bottom marching of a bird through? Or does it feel just plain fuzzy!

fmbria Bioflm Formation

fbrills Text

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

Bioflm grows in a fuid environment: saliva and crevicular fuid Bacterial toxic waste subgingivally includes endotoxins that penetrate pocket walls and trigger the immune response destroying tissue and bone

Bioflm - it’s a complex ecosystem Bioflm - it’s a complex ecosystem worthy of our respect worthy of our respect

DH School didn’t me teach this Pathogenesis Review of Histology Infection & infammation

• outer epithelium • rete pegs • junctional epithelium • connective tissue • capillaries • bone

Diagram from text: Periodontal Disease, Page, Schluger and Youdalis.

Bacterial endotoxin and antigen bacterial endotoxins Translate bacterial antigens

Permeation Agents VSCs cell Volitle Sulfur biology Compounds into hydrogen sulfde and cartoons methal mercaptan • Signals alert the immune system Vasodilation

• Mast cells around the blood vessels Endotoxins also trigger a cascade of immune release histamine, responses to protect the causing body from bacteria and vasodilation viruses

• PMNs are sent to the area •

PMNs release chemical machetes or Cytokines

PMN MMP PMN Endothelial cells separate PMN to allow PMNs to exit the prostaglandin blood vessel PMN (pre-term birth) PMN interleukin collagenase

PMNs cytokines

Breakdown of GAGS Glue glycosamino- glycans

MyPerioID® Breakdown of IL-6 active the transport system Krebs Cycle Mitochondria ATPs

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

Not just one mitochondria per cell, but as many as 2,000 in each liver cell

• Mitochondria

•Uses and oxygen to generate energy for the cell

•Energy stored as chemical bonds oxidative stress

•With too much “sugar” there is an increase in oxidative stress which leads to infammation

Mitochondria Goal is equilibrium

With adequate oxygen and good nutrition, the antioxidant defenses will control free radicals and keep ROS within the cells where they were produced.

When free radicals and ROS exit the cell = infammation Mitochondria Goal is equilibrium

Too much refned carbohydrate = mitochondrial dysfunction

•Oxidative stress

•DNA alternations in the mitochondria

•Reduced numbers of mitochondria

Infammation

Bleeding is not normal It’s a sign of infection Too much sugar in the blood stream damages blood vessels.

Endothelial cells take in too much glucose - causing damage Bleeding is not normal Bleeding is not normal in the Too much sugar in It’s a sign of infection It’s a sign of infection blood stream bond the blood stream with protein or fat damages blood producing vessels. advanced glycation end-products Endothelial cells (AGEs) take in too much glucose - causing - 10 X damage glycation than DH School didn’t teach me this glucose

Infection and Bleeding is not normal Sugars in the It’s a sign of infection blood stream bond Infammation with protein or fat • pocket epithelium producing • scar formation in advanced glycation connective tissue end-products • bone loss (AGE) • small band of connective tissue Fructose - 10 X attachment glycation than • capillary formation Oxidative Stress glucose WARNING Bioflm outside the body

photo courtesy of Dr. Randall Wolcott

After Treatment with Xylitol Medicine Learns from Non-Healing Chronic Wound and Lactoferrin Dental Hygiene

photos courtesy of Dr. Randall Wolcott Biofilm causes ear infections Biofilm causes ear infections

Bioflm Look at your Toes causes ear infections Squirt your Nose

Bacteria and viruses Infammation and Airway Study Dr. Talal Nsouli, Georgetown Univ, 2015

Trisha - text Nathan SNOT-20 (Sino-Nasal Outcome Test) Score reduced 25%

Peak Airfow Increased 36%

SNOT-20 Bacterial Adhesion Study (Sino-Nasal Outcome Test, 0 to 5 score) Dr. Tero Kontiokaria, et al - 1998

1. Need to blow nose 11. Diffculty falling asleep 2. Sneezing 12. Wake up at night Bacterium 3. Runny nose 13. Lack of sleep Streptococcus 4. Cough 14. Wake up tired Pneumoniae 5. Post-nasal discharge 15. Fatigue 6. Thick nasal discharge 16. Reduced productivity Reduced from 7. Ear fullness 17. Reduced concentration 41 bacteria 8. Dizziness 18. Frustrated/restless per cell to 13 per cell 9. Ear pain 19. Sad/irritable 10. Facial pain/pressure 20. Embarrassed 68% reduction Addiction to Side effects of oxymetazoline hydrochloride

Pharmaceutical Nasal Spray • blurred vision • fast, irregular or pounding Nasacort heartbeat

Affrin Simply Saline • headache,dizziness, drowsiness or lightheadedness Zicam NeilMed • high blood pressure Flonase • increase in runny or stuffy nose • Rhinocort nervousness • trembling

Polymerase Chain Reaction (PCR) Polymerase Chain Reaction (PCR) Invented by Kary Mullis Invented by Kary Mullis Nobel Prize in Chemistry - 1993 Nobel Prize in Chemistry - 1993

• PCR - photocopy the virus Cycle Threshold (CT) • LSD was involved • Currently 40 CT • So was a talking fuorescent • More accurate at 30CT raccoon (63% no long positive) Nose is the source of 90% of SARS-CoV-2 Xylitol and SARS-CoV-2 University of North Carolina - Chapel Hill - 2020 Conclusion: nasal lavages, topical antivirals or immune modulation might be benefcial. Utah State University Destroys University of Geneva COVID in

University of Tennessee 15 minutes

Xylitol and COVID19 Symptoms of COVID 19

Case Reports - Published in Cureus, 2020 Case Reports - Published in Cureus, 2020

16 year old Hispanic girl - history of anemia, obese 16 year old - stuffy nose, lost of taste and smell, tired, cough, congestion, oxygen saturation 98% 60 year old Hispanic man - obese, history of leukemia, heavy smoker 60 year old - fever, stuffy nose, sneezing, congestion, watery eyes, oxygen saturation 97% 38 year old Hispanic man - history of heart disease 38 year old - runny/stuffy nose, tired, cough Xylitol and COVID 19 Nathan Jones, please give us an Case Reports - Published in Cureus, 2020 update on your COVID19 research

After testing positive for COVID 19, two sprays per nostril every six hours - four times in 24 hours

Symptoms reduced for all subjects

Negative COVID 19 test at day 7 Day 14, no symptoms and again a negative test

Infammation - Oxidative Stress

ORAL SYSTEMIC LINK

Sugar is the Cause There is an oral-systemic connection Infammation - Oxidative Stress with chronic periodontitis

Sugar is the Cause DH School didn’t teach me this

The Common Cause: Sugar The pathogenesis of diabetes

• A person gets fat eating sugar and four • Their cells become infamed-mitochondria • Infammation causes insulin resistance • Body has to make more insulin • Eventually the pancreas stops making insulin and diabetes follows

Thomas Van Dyke, Scientifc American, 2016 Ivor Cummins, The Fat Emperor

655,000 people die from heart disease each year 2020 deaths from COVID19 253,242 2018 all deaths 2,839,205 Ivor Cummins, The Fat Emperor 2020 all deaths 2,654,825 Dr. Robert Lustig - the connection is sugar

Secrets

1. Improve oral/systemic health

2. Prevent interdental bleeding SUGAR

3. Prevent supragingival calculus How many of you see patients like this, who also have good oral hygiene?

flm sugar! We feed bioSUGAR

Sugar is the reason gums bleed Sugar = carbohydrate

In humans, add two sugary drinks per day and increase pocket depth by 0.4mm

Cheraskin E, Ringsdorf WM Jr (1963). Gingival tenderness and carbohydrate metabolism. Am J Med Sci 246:727-733.

Cheraskin E, Ringsdorf WM Jr, Setyaadmadja AT (1965). Periodontal pathosis in man. Effect of drinks upon sulcus depth. J Oral Ther Pharmacol 2:195-202. Nearly every packaged food contains sugar • - building blocks of carbs

• Glucose - body’s preferred carbohydrate sucrose high fructose • Fructose dextrose • • Sucrose = glucose + fructose = table sugar

61 Names for Sugar

Agave nectar • Confectioner's sugar Golden sugar • Panocha • Barbados sugar • Corn sweetener • Golden syrup • Powdered sugar • Barley malt • Corn syrup • Grape sugar • Barley malt syrup • Corn syrup solids • HFCS (High-Fructose Corn Syrup) • Beet sugar • Date sugar • Honey • Raw sugar • • Dehydrated cane juice • Icing sugar • Refner's syrup • Buttered syrup • Demerara sugar • Invert sugar • Rice syrup • Cane juice • Dextrin Malt syrup • Saccharose • Cane juice crystals • Dextrose • Maltodextrin • Sorghum Syrup • Cane sugar • Evaporated cane juice • Maltol • Sucrose • Caramel • Free-fowing brown sugars Maltose • Sugar (granulated) • Carob syrup • Fructose • Mannose • Sweet Sorghum • Castor sugar • Fruit juice • Maple syrup • Syrup • Coconut palm sugar• Fruit juice concentrate • • Treacle • Coconut sugar • Glucose • Muscovado • Turbinado sugar • Glucose solids • Palm sugar • Yellow sugar Topically, sugar feeds acid producing bacteria leading to caries Topical and Systemic Effects

Topically, sugar also feeds subgingival New evidence shows that dietary sugars bacteria through wicking - come out in the gingival crevicular fuid triggering periodontal disease Systemically, Excessive consumption of fermentable sugar impacts carbohydrates led frst to dental diseases and infammation - then systemic diseases. Dental disease is the leading to alarm bell for systemic disease. gingival 1950-1960 bleeding

The Common Cause Theory The Common Cause Theory

Two researchers - Cleave and Yudkin Dental disease is the alarm bell for systemic disease.

1950-1960 The Common Cause Theory The Common Cause Theory

“From an evolutionary point of view, the refned “My research on coronary heart disease has carbohydrates…are always the foods most likely convinced me beyond doubt that sugar plays a to be at fault (for the diseases of civilization), considerable part in this terrifying modern and not the fats.” 1975 epidemic.” 1972 Thomas Cleave (1906-1983) (1910-1995)

•

The Common Cause Theory They considered four and sugar cause both refned carbohydrates dental diseases and systemic diseases (white four and sugar) to be the most transformed or refned food, and therefore the most dangerous. The opposing theory Research using rabbits beginning in 1908 in Russia Fat was the culprit connected dietary cholesterol and fat with heart disease

Does anyone see a Does anyone see a problem with this? problem with this? Ancel Keys, 1904-2004

He was a scientist, studied business, political science, zoology and oceanography.

He researched starvation, created K-rations.

Saturated fat makes you fat and caused heart disease Ancel Keys was charismatic, popular He postulated that fats caused systemic and had a big following. disease, thus advocating a diet high in fruits, veggies and fermentable carbohydrates instead. He was so popular at the time that he was featured on the cover of Time Magazine. Based on the Low Fat Diet Ancel Keys, 1904-2004 • No more steak, bacon, butter, eggs or cheese

• Take fat out of processed food and add sugar

Standard Ancel Keys, 1904-2004 American Diet He was a scientist, who studied business, (SAD) political science, Increased risk of cancer, heart disease, stroke, zoology and intestinal disorders – just about any illness – the oceanography. He standard American Diet has them all. researched starvation, created K-rations for the military and with his wife, popularized the Mediterranean Diet. He selected data from only 6 countries Ancel Keys studied 6 countries showing a linear relationship.

Data was collected from 22 Masai - S Kenya countries! Inuit - Arctic Rendille - NE Kenya Todelau - S Pacifc

Not only did Ancel Keys cheat on the research, he was a bully!

He bullied other professionals. The Common Cause Theory Ancel Keys destroyed the careers of both Cleave and Yudkin

“My research on coronary heart disease has The evidence for sucrose as the convinced me beyond doubt that sugar plays a “greatest killer” in Western societies considerable part in this terrifying modern is “utter nonsense” and “would epidemic.” never pass an acceptable term paper in an undergraduate course Yudkin, 1972 in home economics.” (1910-1995) Ancel Keys, 1975

•

Saturated fat made you fat and Saturated fat made you fat and caused heart disease caused heart disease

Dental disease was simply a Dental disease considered a local infection to necessary side effect for the greater be treated/prevented with fuoride, OHI, good of preventing heart disease by restorations, sealants, etc. decreasing fats and increasing sugars.

Ancel Keys, 1975 The Caries Research Foundation (CRF) From then on, research conclusions Sugar Industry focused on brushing, fossing, fuoride Dental Association and restorative dentistry - not on sugar!

It’s not about in the diet - all about improving oral hygiene!

In 2009, Cristin Kearns, DDS 1967, three Harvard Medical uncovered sugar industry papers from School researchers were paid the 1950s-1980s ($50,000.00) by the sugar industry to write literature Big Sugar worked to reviews that focused on fat as the cause of heart disease infuence journalists, rather than sugar. Published in scientists, regulator and the NEJM. clinicians

Stanton Glantz, a professor of medicine at U.C.S.F., author of the 2016 JAMA She gave up dentistry to become an investigative journalist, historian and health Internal Medicine article that documented sugar industry efforts to minimize the researcher at UCSF. link between sugar and heart disease. Humans do not need sugar 2009 - Stone Age Diet - Switzerland No physical need to consume sugar • 10 subjects in a controlled Stone Age environment

• Provided a small supply of whole grain barley, wheat and spelt, some salt, herbs, honey, milk and meat from domestic goats and hens.

• Not enough food for the 4 week study

• They foraged for berries, • edible plants and fshing

2009 - Stone Age Diet 2009 - Stone Age Diet

• No oral hygiene products or tools • Plaque increased, as expected

• Stone Age clothes, tools and huts • Surprised by reduction in gingivitis & probing depths

• Filmed for a TV special • Bleeding upon probing reduced from 35% to 13%

• Sports medicine physicians monitored • Bacteria changed to a balance favoring health rather than disease • Dental examinations before and after Something I wasn’t taught in school Secrets

• Bleeding reduces without oral hygiene when you take sugar out of the diet. 1. Improve oral/systemic health

2. Prevent interdental bleeding

3. Prevent supragingival calculus

Oral hygiene became necessary when the Western Diet of refned Hunter/Gatherers did not feed their oral carbohydrates was introduced. bacteria, no oral hygiene needed Dr. Weston Price Dr. Weston Price

1930s traveled the world to discover how nutrition impacted dental caries

1939 published his book: Nutrition and Physical Degeneration

Western diet led to oral/ systemic disease

Dr. Weston Price Dr. Weston Price After Parents Adopted a After Parents Adopted a Western Diet Western Diet A diet high in sugar leads to mouth breathing to exhale excessive carbon dioxide. Mouth breathing leads to a high, narrow vaulted palate; crooked teeth; ADHD; bed wetting; More than 50% of kids today are mouth breathers. asthma; snoring, etc.

The common issue is sugar People don’t know how much sugar they eat

Topically, Sugar feeds supra and subgingival bacteria

Systemically, Sugar in crevicular fuid feeds subgingival bacteria

Sugar weakens blood vessels, compromises mitochrondia producing oxidative stress How many sweets are in the … we need an alternative to break room at your offce? sugar for the occasional sweet.

Artifcial Sweeteners to Avoid Alternatives to sugar you will like

• Xylitol - 5 carbon polyol

• Erythritol - 4 carbon polyol Acesulfame potassium (Ace-K) Aspartame • Stevia - extracted from stevia leaves Saccharin Sucralose (Splenda) Xylitol the good sugar Best alternative

• Looks and tastes like “sugar” • broad category: carbohydrate Biggest Game Changer in DH? • narrow category: polyol • 2.4 calories per gram • 40% fewer calories than other Reduces plaque bioflm by 50%! carbohydrates

Xylitol the good sugar Xylitol the good sugar

• Discovered in 1891 by German & • Crystaline carbohydrate French chemists • Found in tree bark, plants, fruits and vegetables

• Benefts remained dormant for • The body makes 5-10 grams of xylitol every day several decades

• Xylitol production began at the Finnish Sugar Co, Ltd.

• 1960 for diabetics, 1970 for caries prevention Xylitol the good sugar Xylitol the good sugar • Side Effects • Most common source • dangerous for dogs today is corn cobs and • drop in blood sugar corn stalks • liver damage • All Xlear/Spry xylitol is Never give your pets: * chocolate, coffee, caffeine non-GMO * alcohol * avocado • They contain no corn * macadamia nuts * grapes and raisins * yeast dough * raw or undercooked meat, eggs * onions, garlic and chives * milk

Xylitol the good sugar Xylitol the good sugar • Side Effects • Under nourished dogs are at greatest risk

• Xylitol triggers release of insulin in dogs • gastric upset when eaten in large amounts • Remedy: give them sugar too quickly • Take them to the vet - the vet will give IV glucose Xylitol the good sugar Xylitol the good sugar • Side Effects •Glycemic level of 7 • digested as a fber

• pulls water out of tissue Glucose 100 Table sugar 68 cells, thus diarrhea Honey 55 Fructose 19 Xylitol 7

http://www.glycemicindex.com/

Xylitol the good sugar Xylitol the good sugar

• How it works • Does not raise insulin levels • 5 carbon, not 6 carbon like • Does not use insulin for metabolism sorbitol, mannitol, maltitol

• Safe for diabetics • Passes through bacterial membrane; not metabolized

• Bacteria uses energy to pump the xylitol molecule out Xylitol the good sugar Xylitol prevents bioflm formation

• How it works

• Bacteria like acid environment

• When bacteria cannot make acids

• cannot stick to each other or the teeth • bacterial communication disturbed • bioflm structure is compromised • Bacteria slide down the digestive & nasal tracks Metabolism and Communication

Xylitol dissolves established Xylitol - research in Finland bioflm • 1970 xylitol containing caramels, sweet rolls and beverages reduced 4-day plaque mass by 50% • 1972 similar results after a 5-day study, dental students, no oral hygiene - SIMILAR RESULTS

Metabolism and Communication Xylitol - research in Finland Xylitol - research in Finland

• Two-year meal replacement study - 85% reduction in caries • One-year chewing gum study 6.7 grams vs 67 grams resulted in 85% reduction in caries incidence compared • Diffcult study to undertake and monitor to sucrose group

Three test groups: Xylitol Fructose Sucrose

Turku Sugar Studies 6.7 grams 67 grams

How Xylitol Fights Tooth Decay How Xylitol Fights Tooth Decay

Hungarian Study of 1981-1984 Inhibits Plaque Accumulation and Cariogenic Bacteria 10.0

Change in plaque weight(%) • 3 year study 7.5 60 690 Hungarian students 100% • • Two-week study sorbitol 40 • S mutans digest sorbitol • Test groups: 5.0 • Gum chewed 5/day • Gums: 20 Control - fuoridated toothpaste • 2.5 100% xylitol/ 100% xylitol xylitol sorbitol xylitol/sorbitol 0 • Fluoride in milk 100% sorbitol 0.0 -20 Control Fluoride Xylitol • Xylitol 20 grams/daily in candy DMFS Caries Increment spread out during the day -40 How Xylitol Fights Tooth Decay How Xylitol Fights Tooth Decay

Belize City Xylitol Chewing Gum Study Belize City Xylitol Chewing Gum Study 1989-1994 1989-1994 • Five years later, follow-up • Belize study conducted by the U of Michigan study by University of Washington • 1277 students divided into 4 groups • 40 month study • 70% reduction in tooth decay - xylitol • 100% xylitol gum- dramatic decrease in tooth decay • Xylitol changes microfora Mäkinen, K., J Dent Res, 1995

What’s the difference between a Teacher says "spit out your gum" train

and a teacher? while a train says "CHEW CHEW!" How much? How often? How much? How often?

Frequency of xylitol use is important Frequency of xylitol use is important

2.4

• Two-year study in Finland 1.8 • Chew only fve minutes or less

• 172 students 1.2 • Not a recreational chewing gum

• Best - three times daily 0.6 • When favor is gone, all the xylitol is released

• Better - Strive for Five 0.0 • With a high carbohydrate diet - more xylitol needed Control 1 Gum 2 Gums 3 Gums Xylitol Control

How Xylitol Fights Tooth Decay Xylitol and the Mother-Child Relationship Mother chews xylitol for child’s frst two years

Tooth Eruption Avoid Strep mutans until age two = less decay Opportunity to establish long-term protection Harmless, non-acidogenic bacteria will colonize • Xylitol enhances early mineralization • Xylitol inhibits initial colonization by S. mutans Harder for the Strep mutans to get a foot-hold Preventing The Vertical Transmission of the Xylitol and the Mother-Child Relationship Streptococcus mutans Bacteria Mother chews xylitol for child’s frst two years Colonization Percentages Xylitol Superior to Fluoride Varnish & CHX Varnish 70.0 Parent xylitol use stops vertical transmission of Strep 52.5 mutans • Two year study

• 169 new mothers 35.0 Restorative need at age fve, • Varnishes at 6,12, & 18 months 70% lower with xylitol use 17.5 • Xylitol used 3-5 times a day

Control group 5X the risk of • Children: no varnish, no xylitol 0.0 fluoride chlorhexidine xylitol Strep mutans colonization

Söderling, E., JDR Vol 79 # 3, 2000

Söderling, E., J Dent Res, 2000; Caries Res 2001; Finnish Dent J, 2006 Xylitol use by mothers has long-term benefts

Child’s frst dental visit Benefts of xylitol Reduces bacterial plaque 50%

Reduces caries from 60% to 85%

Elevates pH - saliva remineralizes enamel

Prevents acid production by bacteria

Promotes mineralization and remineralization

Prevents ear infections, allergies and asthma

Promotes healing of open wounds My Big Fat Greek Wedding Altering Bioflm

1. Professionally 2. At home

Cervitec Plus OptraGate makes your work easy

Protective varnish containing 1% chlorhexidine diacetate and thymol

Reduces sensitivity Reduces bacterial activity GC America Tri Plaque ID Gel Tabetha Magnuszewski, RDH from Ivoclar Vivadent Light blue is acid plaque Pink is new plaque Transparent protective varnish containing 1% chlorhexidine diacetate and thymol

Reduces sensitivity Reduces bacterial activity Blue is old plaque New, Mature, Acid Producing Bioflm

Breakout Rooms ClōSYS

As effective as Think about a change you would like to make in CHX your clinical practice based on new technology or new science. What change would you like to see no stain with a shift from “cleaning” to achieving optimal & oral health? What change have you wanted to make in this direction but haven’t yet? Think no taste about a change you would like to make to help alteration your patients achieve predictable periodontal Original Pre-Flavored health. Unflavored Just RIGHT Mild Mint Clorastan (stabilized chlorine dioxide) ClōSYS - chlorine dioxide ClōSYS - chlorine dioxide

Kills 99% of Streptococci in 10 seconds Penetrates and dissipates bioflms that harbor oral Kills 99% of perio pathogens in 10 seconds pathogens

Inhibits re-growth of bacteria for 36 hours - lab

Bad Breath Bad Breath Smells

Perio Tongue Coating Perio Bad Breath Bad Breath Smells Smells

Perio Perio Tongue Coating Tongue Coating Perio Perio

226

ClōSYS - Fresh Breath ClōSYS - Fresh Breath

ADA Seal: Safe and Effective for ADA Seal: Safe and Effective for eliminating bad breath eliminating bad breath ClōSYS - Reasons for Use ClōSYS - chlorine dioxide

ClōSYS is less toxic than CHX to human gingival cells • Sensitivity When used as a pre-treatment rinse • Dry Mouth the aerosol levels of CFU is • Fresh Breath signifcantly reduced • Perio Health When used as a lavage in ultrasonic • Viruses scaling, ClōSYS safely reduced the exposure to microbial aerosols by 60%

BYE BYE BIOFILM. MicroClear breaks up biofilm buildup in waterline tubing reducing harmful aerosols. Easy to use- MicroClear is non-toxic and designed to remain in the waterline overnight More effective than without the need to air or water purge at the end of the day. MicroClear does not require mixing and comes with a callibrated pump alkaline peroxide to reduce waste and save time. solution in DUWL

· Powerful Antimicrobial formula ClōSYS effective inactivating COVID19 in lab studies. · Non-staining, Non-Corrosive on equipment · pH balanced completely safe if ingested · Does not alter water taste or odor · Calibrated pump for easy usage Wirthlin, et al. Formation and · Maintains less than 10 cfu/mL Excellent for pretreatment rinsing and gargling. (ADA standard <200cfu/mL) · EPA Registration #87117-1 Decontamination of Bioflms

To order, or for more in Dental Unit Waterlines. J of information, just call your dental supplier, Periodontology. 2003. Eliminates 98.4% in 30 seconds. or call us.

Now you can have the industries best for less Clorastan® trade name for stabilized chlorine dioxide. and it could be the most cost efficient procedure performed in your office this year. ClōSYS - Available Here:

amazon.com Walmart CVS Health Walgreens Safeway Kroger Meijer Albertsons H-E-B Kinney Drugs Pharmaca Face Values

Andy Gritti, what’s new with CloSYS BYE BYE BIOFILM. MicroClear breaks up biofilm buildup in waterline tubing reducing harmful aerosols. Easy to use- MicroClear is non-toxic and designed to remain in the waterline overnight without the need to air or water purge at the end of the day. MicroClear does not require mixing and comes with a callibrated pump to reduce waste and save time. INTERDENTAL CLEANERS

· Powerful Antimicrobial formula · Non-staining, Non-Corrosive on equipment · pH balanced completely safe if ingested · Does not alter water taste or odor · Calibrated pump for easy usage · Maintains less than 10 cfu/mL (ADA standard <200cfu/mL) · EPA Registration #87117-1

To order, or for more information, just call your dental supplier, or call us.

Now you can have the industries best for less and it could be the most cost efficient procedure performed in your office this year. Secrets More effective interdental options

1. Improve oral/systemic health • Interdental brushes of various sizes 2. Prevent interdental bleeding • Interdental picks and sticks 3. Prevent supragingival calculus

• Oral irrigation

Bioflm forms below the contact Concavities are Diffcult to Reach

• Concavities are Diffcult to Reach Straight better on lingual than tapered design

Heather Kelly - can you give us some tips on sizing a patient? Heather Kelly - can you give us some tips on sizing a patient?

Water Flossing Oral Irrigation Cutler et al, 2000 - Study Design

52 subjects with 4 - 7 mm pockets and BOP randomized into 3 groups A: Cessation of ROH - 14 days B: No modifcation of ROH - 14 days C: Water irrigation plus ROH - 14 days

Outcome measures: PI, GI, PPD, CAL, BOP

Cutler et al, 2000 - Cutler et al, 2000 - BOP Results

“The addition of oral irrigation 1 with water to the subjects’ 0.86 routine oral hygiene (ROH) for 14 No OH 0.72 days resulted in a signifcant ROH

reduction in PPD, BOP, GI, and 0.58 ROH+O I

PI at interproximal sites with mild 0.44 to moderate (4 - 7 mm) 0.3 periodontal disease” Baseline 14 D ays Sonic-Fusion Ultimate Guide to Achieving Periodontal Health Secrets to Patient Compliance Josleyn Espinoza, RDH 1.Bioflm good or bad What is your favorite Waterpik product? 2.Impacting the bioflm 3.Health behavior change

Liz Graham Presents *** Trisha O’Hehir

Recognize the limitation of oral hygiene lectures Does Education Work?

Education

38 million still smoke 18% of men and 14% of women Recognize the limitation of oral hygiene lectures

Education

This is our frst instinct - what we were taught in school

Education is often one-sided The “Righting Refex”

Patients tend to push back Clinician wants to fx the patient

Giving information vs behavior change Traditionally, we blame the patient Conversation is more of a dance… for poor oral hygiene.

50% plaque reduction Traditionally, we blame the patient for poor oral hygiene. Baseline Post-op Research shows people only remove buccal 30% 15% 42% of plaque with a manual lingual 40% 20% toothbrush and 46% with a power interproximal 80% 40% toothbrush. J Clin Perio, Van der Weijden, et al, Effcacy of homecare regimens for J Perio, DeVore, C. et al, Plaque Score Changes Based Primarily mechanical plaque removal in managing gingivitis a meta review. 2015 on Patient Performance at Specifc Time Intervals Patients actually think they removed all the plaque from their teeth before coming to see you.

They really do!

Do your patients ever blame genetics?

Toothbrushing and fossing instructions have been going on for over 100 years. Is it working? Steps needed to engage the patient in Shift from educator to planning for change advocate

1. Shift from educator to advocate Take the side of the patient -

Take the patient’s side - blame someone else 2. avoid being the adversary 3. Solve a problem for the patient avoid simply educating

Take the patient’s side Blame the toothpaste To avoid blaming the patient —

fnd someone or something else to blame. Reasons why dry brushing works

Most people Toothpaste brush with their eyes closed makes so many DROOLING bubbles, you and can’t see what DAY DREAMING you’re doing.

30 seconds seems like 3 minutes

People brush more evenly around the mouth #1 People brush longer without toothpaste #2 Steps needed to engage the patient in Toothpaste planning for change favor and wetting agents numb your 1. Shift from educator to advocate tongue so your teeth feel clean when they 2. Take the patient’s side - blame someone else really aren’t. 3. Solve a problem for the patient

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

Solve a problem for the patient Solve a problem for the patient Do you like when I scrape off the buildup behind your lower front teeth? Lingual calculus removal or bad breath Brushing times 38 to 60 seconds Dry Brush Inside First Erratic pattern of brushing

✓Returning several times to starting place ✓ Reduced lingual calculus 63% Rarely brushing lingual surfaces

If so - only 10% of time spent on linguals ✓ ✓ Reduced lingual bleeding 55%

MacGregor, Rugg-Gunn JPR 1979 14:225-230 O’Hehir, Suvan, JADA 1998 129:614

Blame the toothpaste - not the patient

Toothpaste is the reason for 30 second brushing and lingual calculus My brother-in-law, Billy — my sister Peggy Secrets

1. Improve oral/systemic health

2. Prevent interdental bleeding

3. Prevent supragingival calculus Gum Deep Clean Toothbrush Ultimate Guide to Achieving Recognize the limitation of oral hygiene lectures Periodontal Health Secrets to Patient Compliance

1.Bioflm good or bad Education 2.Impacting the bioflm 3.Health behavior change The Goal: Behavior Change Tie the Secrets Together

Change is diffcult Change is diffcult

Ask any married couple I want others to change, but I don’t want to change! I want my patients to change, Change is diffcult but I don’t want to change! It happens outside your operatory

Limits to education alone

Roll with resistance

Continuing to educate patients the same way and expecting different Start with this assumption: results is the the patient did the best they could! defnition of insanity! Skip the Lecture!

If we want different results, The brush and foss message we have to change. isn’t getting through to all our patients! First Change: Skip the lecture

Ask permission to educate

• Action Research - 10 patients asked • 7 said NO • 3 said “…only if you want to…” Transtheoretical Model of Change 1

2

Motivation 3 5

4

“You can’t instill motivation Change comes from within to change into someone else.”

Stephen Rollnick Some behavior changes are yes or no Trisha’s fastening your seat-belt Theory of Skip Change OHI

Oral Health Behaviors depend on Solve quality not quantity Problems not all fossing is effective Keep not all brushing is effective Secrets more of the same isn’t always better

NEW VISION for Oral Health Promotion Oral Health Coaching If we want different results, we have to change.

First Change: Skip OHI NEW VISION Second Change: Open-ended questions Are you willing to accept this new vision focused on health outcomes - not calculus?

Open ended questions get a Open ended questions get a conversation going. conversation going.

Patients don’t care how Caring enough to ask, much you know until they shows empathy. know how much you care! Motivational Open ended questions get a Interviewing conversation going. one tool for behavior change

Opened ended questions Open-ended question Affrm the patient OARS the answers to which Refective listening Summarize the plan you do not know.

Open ended questions get a Open ended questions get a conversation going. conversation going.

Do you foss? What do you use to clean Not open-ended and you between your teeth? know the answer. Open ended questions get a Open Ended Questions conversation going.

What do you use to clean between your teeth? Follow-up: Tell me more about…

On a scale of 1 to 10 If a patient says “8” before How healthy is your mouth? trying to get them to “9” ask what they did to move If you could change anything about your mouth, what would it be? from “7” to “8” Tell me more about… Help the patient make the plan The Plan

Which of these two interdental cleaners do you think you would be most likely to • Offer interdental cleaning tools use? • Offer secrets to solve problems When in the day do you think you are • Help the patient to make their plan most likely to use it?

Open Ended Questions Conversations with patients about sugar Tell me what you like to eat for breakfast? Be brave - ask a question and see what you learn! Tell me about your favorite snacks?

Tell me about your favorite drinks? Fructose High Fructose is metabolized in the Liver Corn Syrup Commonly Fruit 55% fructose and 45% glucose - but no requirement to Juice provide that info on products High Fructose Corn Syrup

Recommended Daily Allowances Recommended Daily Allowances

Women - 6 teaspoons, 25 grams 5%-10% of daily calories from Men - 9 teaspoons, 38 grams added sugars

Children - 3-6 teaspoons, 12-24 grams

American Heart Association & World Health Organization American Heart Association & World Health Organization How Much is Too Much? 12 oz Coke contains 9 teaspoons of HFCS 38 grams of

Women - 6 teaspoons, 25 grams Men - 9 teaspoons, 38 grams Children - 3-6 teaspoons, 12-24 grams

Open Ended Questions

Breakout Rooms Tell me what you like to eat for breakfast? Ask open ended questions about sugar Tell me about your favorite snacks?

Tell me about your favorite drinks? Benefts of reducing Traditions you may want to avoid sugar and four • Asking closed questions • Giving instructions to patients • Benefts of reducing fermentable carbohydrates • Reduced plaque bioflm formation • Reduced acid production by bacteria • Stronger blood vessels and capillaries Changes you may want to try • Better general health • Asking open-ended questions • Weight loss • Actively listening to the patient’s needs

The Future of DH - Secrets •Guided Bioflm Therapy

•Buteyko Breathing-Patrick Mckeown The Future

•Myofunctional Therapy

•Endoscope for Perio Treatment

•Laser Treatment AirFlow with Glycine/Erythritol

Removal of supra and subgingival bioflm

80% less abrasive, safe & comfortable

Hu-Friedy Scientifc evidence shows it is safe, effective and 3 times faster than rubber cup polishing Guided Bioflm Therapy (GBT) Continue learning and embrace new technology

Buteyko Breathing

Patrick McKeown

Teach mouth breathers to become nasal breathers

• nasal congestion • watery and itchy eyes Palatal development depends on the tongue Signs and Symptoms of • runny nose Mouth Breathing • allergies resting in the palate when swallowing • asthma • enlarged tonsils • bad breath • dry cough • sleep disturbances • snoring and sleep apnea • tongue thrust • abnormal swallowing habits • poor palate development • crooked teeth • ortho relapse • altered speech patterns • weak, faccid lips • low energy level • high stress level • addiction to Chap Stick or lip gloss • chewing with the mouth open www.mkdentalcare.com Facial growth changes Facial growth changes

Kelly 7 years Samantha 8 ½ years

Yosh Jefferson, DMD, MAGD

Nathan Facial growth changes Hadn’t slept through the night for fve years

Kelly Samantha

Lips together

Teeth apart After he fell asleep, gently pinched his Tongue lipsup for 1 hour, three

7 years old Squirted 3 days nights - he slept morning and night through the night! Yosh Jefferson, DMD, MAGD • Nathan He now gets 18% more oxygen to his brain Co-author: Tim Ives

Lips together

Teeth apart

Tongue up 7 years old 8 years old 9 years old lipzipbook.com •

Endoscope for Perio Treatment Clinician - Advanced Perio

Uses an endoscope to treat Judy Carroll - PerioPeak.com periodontitis. Created an She has a tiny camera inside the pocket, effective treatment protocol for magnifying the surface 48X advanced bone loss. RPE Regenerative Periodontal Endoscopy Clinician - Advanced Perio

This molar was scheduled for extraction 12mm extraction & implant suggested

10mm probe depth 3 months — 3mm 3 months 3mm RPE Regenerative Periodontal Endoscopy no mobility no extraction

RPE Regenerative Periodontal Endoscopy Laser Treatment The Future I help people achieve

Bachelor’s Degree Completion Program optimal oral health

6-months, one hour each week online, $3,999 Cleaning! Class size is 5 students, refection and inquiry Teeth ! www.ohehiruniversity.com - Classes starting in Feb!