Every dental clinician knows patients who cannot seem to get inflammation or bleeding on probing under control despite every effort. Bleeding gums may be a risk indicator for early death and the longer the bleeding continues, so does the risk for a life-threatening event. Bacteremia is the culprit and by making these three changes in your DSO, you have the potential to save more than just a smile.
Dentists and Dental Hygienists are traditionally known as the ‘gatekeeper’ of oral health. However, today, we recognize that they are also gatekeepers to prevent life-threatening events that are caused by bacteremia that come from gum and teeth infections. Bacteremia from the mouth can cause life and death situations. Here are a few stories that may remind you of a patient you know.
1. While in his dental training, Dr. Nabors recalls a nursing student who died within 4 days of an extraction. Her cause of death was due to pathogenic bacteria from her mouth that got into her blood steam and infected her cavernous sinus.
2. A 32-year-old young mother suffered the need for open heart surgery twice and still almost died. Her heart valves were infected due to bacteria from her long-term periodontal infections that created a long-term bacteremia.
Dr. Tim Pranger, of Alton, IL (retired), remembers two different patient stories, one was a friend who wanted a new smile before his wedding. Restorations were prepped and excitement for delivery day was high. Unfortunately, the patient died of a heart attack before he was able to see his completed new smile. After this patient Dr. Pranger implemented perio therapy trays before SRPs for all high-risk patients. The next patient had uncontrolled diabetes and an HbA1c of 9.5. The patient wore perio therapy trays for three weeks for SRPs and his HbA1c dropped to 6.8.
Dr. DeWitt Wilkerson, Founder of the Integrative Dental Medicine (IDM) Scholar Society, remembers a delightful gentleman named Bob, in his mid 50’s, who was seen as a new patient in December of 2019. He had the “co-morbidities” of decayed and abscessed teeth, periodontal disease, diabetes, high blood pressure, cardiac arrhythmia, elevated cholesterol and poor sleep. He had been prescribed several medications by his physician. Following a thorough evaluation, Dr. Wilkerson’s treatment plan included root canal therapy, non-surgical periodontal therapy, teeth restorations, an oral sleep appliance, and counseling with a nutritionist/health coach. Bob agreed with all the recommendations and said he was ready to turn his health around. Tragically, on March 28, 2020, Bob succumbed to Covid-19.
Step One: Test for pathogenic bacteria
Research has revealed that there are “High-Risk” bacteria in the mouth called oral pathogens. These cause periodontitis, bleeding, bacteremia, and infections of other organs. When bleeding occurs, bacteria enters the circulatory system. These “High-Risk” pathogens include (abbreviated) Aa, Pg, Tf, Td, and Fn. Testing early allows for early intervention to kill these pathogens before they can harm (1)(2)(3).
Another important recent finding is that tissues that look healthy may not be. Even very shallow pockets of ≤3mm with inflammation should be tested. Medical Research Methodology states, “Clinical exposure definitions of periodontal disease should incorporate relatively shallow pockets to best reflect whole mouth exposure to bacteria burden.” The most significant definition of a dangerous bacterial burden is defined as four periodontal microbes: Aa, Pg, Td, Tf (4).
These same causative agents of periodontal alveolar bone loss are recognized as independent and direct risk for increased hypertension, systemic inflammation, increased risk for heart attack and stroke, and many other systemic diseases (5)(6)(7)(8)(9)(10)(11)(12).
Direct Diagnostics has a simple, affordable and potentially life-saving saliva test.
This test is called HR5 meaning High-Risk 5. These High-Risk pathogens should be managed to a health-oriented level. It is also important to know that these bacteria are resistant to traditional models of therapy including brushing and flossing home routines. Since they are invasive, they live in the tissues and can evade mechanical therapy as well as the host immune system.
Step Two: Eliminate bacteria at the source, daily
Lasers, SRPs and LDAs are amazing hygiene protocols. Lasers and LDAs are critical in office treatment modalities but these bacteria return to high levels if the patient cannot reach and clean the infected location. When they are in deep pockets, research shows bacteremia can occur even while brushing and flossing and while chewing. When these infections persist, millions of harmful bacteria can enter the blood stream every day and night.
However, today, this can be prevented with both knowing the risk and using appropriate treatment early. A daily treatment that helps to kill these types of bacteria is PerioRestore®. This system includes a custom made perio therapy tray and a 1.7% hydrogen peroxide gel that will break down and release oxygen slowly and consistently. It is inexpensive and easy to use. The tray is designed with tooth-to-tooth engagement that keep the peroxide in place. The delivery of oxygen to the infected sites creates an environment that kills high-risk pathogens. Along with removing these bacteria, this type of treatment supports white blood cell function and the formation of new blood vessels. Topical oxygen therapy is widely used in the medical model to treat chronic infections and now modern dentistry can do the same.
After two years into Covid-19 many dentists have noticed a significant increase in the number of perio patients, and hygiene appointments are still at risk of being interrupted, making it more imperative for practices to provide additional perio treatments that can be applied at home. Perio treatment systems like Perio Restore can help solve the gaps between office treatment.
In addition, Perio Restore can provide an excellent source of production revenue and wide operational margins for a practice. Adding an effective adjunctive at-home treatment to these protocols can dramatically enhance hygiene production and operational margins. When implemented successfully, as part of a practice’s regular hygiene protocol, systems such as Perio Restore can generate significant production revenue for a practice. These tray and gel systems have high patient acceptance due to the easy at-home application. The retail price of the fabricated tray is around $800 and the 3oz tube of gel retails for $20-$25. Typically, a patient will need 8-12 tubes a year depending on their level of perio. Just 120 patients treated per year in 1 practice results in over $100K in production revenue with a gross profit margin of 60 to 80%. Many practices combine this adjunctive therapy with other perio protocols and offer their patients a package price for comprehensive hygiene treatment. It should be noted that treatment such as Perio Restore is a fee for service treatment.
Step Three: Commit to a healthier lifestyle!
Oral health is a key component of complete health. These type of infections from the mouth stimulate an “Inflammatory Cascade”, both locally and throughout the whole body. Assessment of oral infections begins with visual inspection, radiographs, periodontal probing measurements and HR-5 salivary testing.
After appropriate in-office therapy, on-going maintenance therapy is recommended for these types of infections. Daily use of Perio Restore provides a safe and effective way to manage them.
DSOs can have perio protocols that are safer for patients and will potentially lower the risk of liability of a DSO while increasing hygiene revenue. These steps are simple to implement. DSO oral healthcare teams should test for specific oral bacteria that cause local infections and harmful bacteremia. Use Perio Restore at home to continue the healing process and to protect against re-infections. Finally, encourage patients and team to a healthier lifestyle. These three easy steps can stop bleeding, stop bacteremia, save a smile and maybe even a life.
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3. Front. Cell. Infect. Microbiol., 22 September 2021 | https://doi.org/10.3389/fcimb.2021.711282
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5. Desvarieux, et. al., Changes in Clinical and Microbiological Periodontal Profiles Relate to Progression of Carotid Intima-Media Thickness: (INVEST); J Am Heart Assoc. 2013;2:e000254
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