The Extreme Cleaning Makeover in Dentistry

Most of us have watched the reality TV show Extreme Makeover at least once on ABC. Settling down after a grueling day at work, our eyes are glued to the TV screen as we follow the stories of two lucky individuals whose looks are permanently altered in a way that makes their wishes come true. An Extreme Team is called in to assess participantsÌ bodily flaws, and we follow them through to the end of their amazing transformations, wishing that we, too, could experience some of the show's magic. When the candidates reveal their new selves to their family and friends, we are mesmerized at the results and sit there with mouths agape as we stare at the incredible change in appearance.
What is an "extreme cleaning makeover"  in dentistry? Where did this idea originate  from, and why should you offer this service to your patients?
Before defining the extreme cleaning makeover, including specific details of this particular protocol, letÌs begin by discussing what we now know about periodontal infection that we didnÌt know during the era of soft tissue management* (1970s to 1980s).
Periodontal diseases are now understood as being ecogenetic diseases that are strongly influenced not only by anaerobic bacteria but also by genetic susceptibility, host immune and inflammatory responses, local and systemic environmental factors, and various medications that affect gingival and connective tissues.1 Does this etiology sound so complex to you that you scratch your head and wonder how you can possibly unravel this mystery and turn it into a practical and effective therapy? Here's the key to your success: even though we know that the etiology of periodontal disease is complex and based on risk for disease, a majority of susceptible individuals respond well to nonsurgical periodontal therapy targeted at periodontal pathogens that reside in the gingival sulcus and in connective tissue.2,3 
This is indeed very good news, and periodontal researchers now know that only a small percentage of the population that develops periodontal disease is resistant to conventional, anti-infective, nonsurgical therapy.3 In other words, this small percentage of patients doesnÌt get better under our care, and there are cases in which these patients need to be referred to a periodontist for specialist care.
As a way of introducing the extreme cleaning makeover to general dentists, I interviewed Dr. John Y. Kwan, a board-certified periodontist, whose periodontal and implant practice is located in the Oakland/Berkeley area of northern California. I recently visited Dr. Kwan and his 2 hygienists and asked him about the exceptional nonsurgical care he offers to his patients.

INTERVIEW

Figure 1. Eyes on screen.

Figure 2. Two-handed technique.

Figure 3. Bilateral pedal operation.

Figure 4. Camera and micro ultrasonics for endoscopic instrumentation.

Figure 5. Initial, 6-week, and 18-month probings (from top to bottom).

Figure 6. No. 30 mesial before treatment (top), and then 18 months after treatment (bottom).

LS: Dr. Kwan, what is the extreme cleaning makeover?

JK: Lynne, when patients are diagnosed with periodontal disease, they typically require some form of subgingival debridement. Most nonsurgical or closed periodontal debridement is performed by the registered dental hygienist, and this is typically a tactile/blind treatment. Surgical periodontal debridement is most commonly performed by the periodontist, and open debridement provides us with the ability to see the roots for thorough cleaning. What we are doing now is endoscopically visualizing the roots, and in this closed environment we are using micro ultrasonics to clean diseased roots thoroughly.
Ample evidence indicates that when you combine nonsurgical debridement with some form of disinfection, the results are better than cleaning alone. So, we typically combine our debridement with some form of local and/or systemic antibiotics. The extreme cleaning makeover is this new hybrid of open and closed debridement combined with some form of disinfection. It is minimally invasive and can be performed by the dentist, periodontist, or registered dental hygienist.

LS: How long have you been doing this type of treatment, and which members of your team provide it?

JK: The periodontal endoscope (Perioscope [Dental-View]) has been available for more than 7 years. The version we use is the DV2, and this version has been in use since mid-2001. In our practice, we have been performing endoscopic debridement for almost 5 years. I perform this treatment on full-mouth and sedation patients, whereas my hygiene team treats localized, split-mouth, and limited full-mouth cases. We have treated well over 1,000 cases, and I estimate that I have endoscopically cleaned more than 10,000 teeth (Figures 1 to 3). Our office currently operates 2 endoscopes, treating 15 to 20 patients per month with pocketing anywhere from 4 mm to 12 mm. In essence, we are visually per-forming this subgingival de-bridement nonsurgically at magnifications from 20x to 40x (Figure 4).

LS: Is this technique difficult to learn?

JK: We use and teach the 2-handed technique. The endoscope is used in the nondominant hand (much like the dental mirror), and the micro
ultrasonic instrument is used in the dominant hand. Proficiency requires regular use and practice, a motivated and skilled technician, powered instrumentation, and a lot of patience, which is not unlike many other aspects of dental and dental hygiene treatment! It takes quite a bit of practice to become proficient with the dental mirror, periodontal debridement instruments, periodontal surgical procedures, dental restorative procedures, and many other technically difficult tasks that we perform every day.
The biggest difficulty I see in the performance of periodontal endoscopy is that there is minimal comprehensive training available for those who want to become proficient at this new skill. I teach an introduction to periodontal endoscopy to postdoctoral periodontal residents at UCSF. I find that they grasp the fundamentals of the 2-handed technique quite rapidly, but if they get limited treatment time it becomes very difficult to become proficient. Since I am there only part time, the students really have to be motivated to practice and teach themselves, as is the case with private practice. Unless dental and dental hygiene programs develop competencies for these skills as part of graduation requirements, students will not master these skills and reach higher levels of proficiency. I have been doing this for almost 5 years, and I still discover new ways to apply and teach this technology.
I have helped teach other offices our techniques and find that some have been stuck using a view-instrument-view technique, using the dominant hand to place the endoscope and then switching hands so that they can view their debridement or use hand instruments, all of which slows down the procedure considerably. We are practicing techniques and instrument protocols that allow our hygiene team to treat split-mouth and limited full-mouth cases in 90 to 120 minutes, and I am able to treat full-mouth cases in 90 to 120 minutes. Hygiene treatment varies from 1 to 4 teeth per quadrant, and I typically treat 4 to 7 teeth per quadrant. Simultaneously viewing and instrumenting while moving the scope and micro ultrasonic around the tooth/pocket is a must and allows you to perform with maximum efficiency.

LS: What kind of results are you getting? Do you do less surgery?

JK: We have been extremely happy with our results, and so have our patients and referring offices! In fact, IÌm hopeful that one of my postdoctoral students will assist me in evaluating our clinical data. We have hundreds of patients with at least 1 year (or more) of follow-up. I find that we rarely have to treat periodontal disease infection surgically anymore. Since our hygiene team treats most of the scope patients, I find I have much more time to treat implant-related problems and perform other microsurgical treatments (Figures 5 and 6).

LS: Tell me about the micro ultrasonic instruments that your office uses?

JK: We use 25K manually tuned magnetostrictive ultrasonic machines. Manual tuning is the best option to tailor your ultrasonic vibrations for any type of cleaning, from the sensitive tooth to hard, tenacious subgingival calculus. In my opinion, based on years of ultrasonic instrumentation, 25K seems to clean faster than 30K. I have tried piezo ultrasonics and really don't like having to screw the inserts in and out, in and out, when I can just pop them in and out of the ultrasonic handpiece as needed. Piezo ultrasonics also have greater power differences between the front/back and the sides of the inserts, and they are not made with the manual tuning option, both of which are disadvantages. We use inserts from the Tony Riso Company because they are very durable and can be rebuilt/recycled for half the cost of a new one. We also have them custom made into diamond-coated tips of various diameters, shapes, and angles, made from other company inserts and hand instruments. We use the diamonds for shaping roots, opening areas of root proximity, and for cleaning and shaping furcations. We also use diamond-coated tips to remove overhangs and bonded cement, shallow caries, enamel projections, enamel pearls, globular cementum, and on occasion extremely hard-to-remove subgingival calculus.

LS: You mentioned disinfection as part of the extreme cleaning makeover. Can you elaborate on the disinfection portion of the procedure?

JK: I have been using various forms of disinfection adjunctive to periodontal debridement for more than 15 years. Currently, we will use local antibiotics like Arestin (Ora-Pharma) for patients who have localized pocketing, or sometimes we will use it in conjunction with systemic antibiotics for the localized tooth that has a very deep pocket. The systemic antibiotics we commonly use are either metronidazole/amoxicillin in combination or azithromycin on its own. Systemic antibiotics are used only for short courses (3 to 7 days) and only in conjunction with some form of debridement. We generally do not do subgingival bacterial evaluations like culture and sensitivity, DNA probes, or PCR testing because periodontal  pathogens are known to be sensitive to the regimens we use. Eliminating this step proves to be less invasive to our patientsÌ pocketbooks!

LS: When you provide this treatment, is it done with local anesthesia, and what is it like for patients after you are finished?

JK: We typically use some form of anesthesia for micro ultrasonic endoscopic de-bridement. If we are using injection anesthetics, we typically use articaine on the upper arch. That limits the need for palatal anesthesia, since articaine will anesthetize more of the soft tissue from buccal/facial injection only. On the lower arch, we typically use lidocaine blocks. If we are treating localized sites, we may use intrasulcular topical anesthetics like Oraqix (DENTSPLY Pharma-ceutical) or Profound (Steven's Pharmacy).
We routinely premedicate patients with 2 Aleve (Bayer HealthCare) or some other OTC pain medicine at the time of the procedure. We give our patients Aleve to take if needed after the procedure, and most of the time they donÌt even need it. We find patients may have some tenderness in the soft tissues when brushing, flossing, or water irrigating the next day, but overall the post-procedure recovery is uneventful.
I should mention that we typically see patients for re-evaluation and supportive periodontal treatment (SPT) 3 months post-treatment. We see our patients or alternate  every 3 to 4 months with their general dentist for the first year, and then I will re-evaluate and provide SPT after a full year. If retreatment is needed, we may "re-scope" a site before recommending surgical treatment.

LS: How do you bill for this type of treatment?

JK: We generally try to bill by the hour. We are billing an average of $500/hour for hygiene treatment and $1,000/hour for doctor treatment. We bill dental benefit plans for partial and full quadrants of periodontal debridement (4341, 4342) and try to maximize benefits, since unspecified periodontal procedures (4999) are typically not covered, and that is how we designate endoscopy fees (4999). We have found that patient acceptance for this type of treatment is excellent. In addition, we have been able to cover the cost of an equipment lease, recurring costs of disposables, and the occasional cost of new endoscope fibers while producing an excellent return on investment.

LS: What are the disposables you mentioned, and how long does the endoscope fiber last?

JK: Each time you use the periodontal endoscope, you must isolate the endoscope fiber in a sterile sheath. These cost $37 per procedure, so the more treatment you can do at one visit, the better. The endoscope is placed in the pocket attached to an explorer, which is an instrument that resembles a probe and holds the camera in the subgingival environment so you can look at the roots. We use a set of 4 explorers that are shaped to help visualize around various surfaces of the roots, and periodically they require replacement at $60 per explorer. The endoscope fiber will cost $900 to replace. If well cared for, the endoscope fiber will generally provide you with ex-cellent visualization for 70 to 80 cases.

LS: Why donÌt all periodontists have a Perioscope?

JK: I think the periodontal practice is in a great position to embrace periodontal endoscopy. We are the experts at treating periodontal disease, and we should be on the leading edge of treatment options. Medicine does more and more visualization endoscopically every time I stop to look. I am continually amazed at what can be accomplished endoscopically with such specialized visualization equipment and innovative adjunctive instrumentation. We already use micro ultrasonics in our everyday practices (or most of us do), so why wouldnÌt you want to see what you are doing?
We know that change is often difficult. But for most of us, we realize that we cannot grow unless we change. Change requires us to think differently, and when we begin to think differently about how to approach the treatment of periodontal diseases, we will have more periodontists doing periodontal endoscopy in periodontal practices. We have plenty of patients in our supportive periodontal treatment pool with localized pocketing that can be helped with endoscopic debridement versus repeat surgery. If we have a hygienist who is willing to "see" his or her way to a higher level of therapy, the practice and patients can really benefit  from endoscopic debridement. So many hygienists would love to be able to visualize what they have been blindly doing for decades if only dentists and periodontists would provide the appropriate equipment. Periodontal practices can afford the investment even if the periodontist is not the primary user. I feel that the periodontal endoscope should be an integral part of our vision for the future, and I am hopeful that our specialty can catch up to our medical colleagues.

LS: I heard that DentalView is not making the DV2 anymore.

JK: DentalView has stopped marketing and production of the DV2. They are continuing to serve the many offices providing periodontal endoscopic services and are considering their options regarding an updated version of the Perioscope. I really donÌt know what the DV3 will be like, but I do have my wish list. Take cell phones for example. They get smaller, the visual resolution gets better, and they become more affordable. Hopefully, within the next year I will know more about the next version of the Perioscope. Over time, there should be more competition in this area of practice. Laser technology in the past 10 years has placed many more options on the table, and in the future there should be more players in the endoscopy game.

LS: Dr. Kwan, I want to thank you for sharing your expertise and opinions regarding this fascinating new treatment you call the "extreme cleaning makeover."

JK: I am so thankful for this opportunity to share some details about our use of micro ultrasonic periodontal endoscopy. Sometimes it is difficult to make significant practice changes. I have been fortunate to have a team that embraces change, and we have been really happy with what we have been able to accomplish for the health of our patients and for our own professional development. Dental and dental hygiene education needs to embrace this major change in periodontal instrumentation, and you have my pledge that I will remain passionate about the practice and teaching of the extreme cleaning makeover.

CONCLUSION

TomorrowÌs general dental practices are expected to follow a wellness approach that involves treating the whole patient. Varon talks about a health-focused dental practice and defines it, in part, as enhancing the quality of daily life for our clients.4 Dentists can no longer continue to focus only on the health of teeth without looking at the entire picture, including quality-of-life issues such as chronic illness and cognitive and physical impairments. Advanced hygiene initiatives like periodontal endoscopy and micro ultrasonics will continue to grow in emphasis as the US population grows older. Assessing patients for gingival and periodontal diseases is important not only to save teeth but because these infections may sometimes signal an undiagnosed systemic illness that could be life-threatening (ie, diabetes). Steadily mounting evidence cites periodontitis as one of many risk factors for systemic diseases such as cardiovascular disease. Can we look our patients in the eye and feel worthy of their trust if we fail to examine the periodontium on a regular basis? Do we choose to ignore early signs of gingival/periodontal diseases and tell our clients that we will re-evaluate in 6 months? Or do we diagnose and treatment plan based on a comprehensive periodontal exam?
Implementing an extreme cleaning makeover philosophy is not rocket science, nor does it have to be prohibitively expensive. It must, however, be supported by an evidence-based approach to non-surgical periodontal therapy, and the entire team needs to be on board from start to finish. It begins with early diagnosis of gingival and periodontal diseases for every patient and a commitment to appropriate therapeutic outcomes. The era of evidence-based advanced hygiene initiatives has arrived. Dr. Kwan excels at these new initiatives and is a true inspiration to the dental and dental hygiene profession worldwide.


*Note: Soft Tissue Management is a trademark of ProDentec.


References

1. Bartold PM. Periodontal tissues in health and disease: introduction. Periodontol 2000. 2006;40:7-10.
2. Bonito AJ, Lux L, Lohr KN. Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review [published correction appears in J Periodontol. 2006;77:326]. J Periodontol. 2005;76:1227-1236.
3. Suvan JE. Effectiveness of mechanical nonsurgical pocket therapy. Periodontol 2000. 2005;37:48-71.
4. Varon F. The health-focused dental practice. Woman Dentist Journal. 2006;4:26-29.


Ms. Slim is the perio therapy columnist for RDH magazine, an award-winning writer, and a dental practice management consultant who specializes in coaching dental teams to adopt advanced hygiene initiatives. She can be reached at (770) 947-2496, This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or by visiting periocdent.com

Dr. Kwan welcomes visitors to observe his periodontal endoscopy and microsurgery techniques and he also welcomes phone or e-mail questions about his equipment and treatment regimens. He can be reached at (510) 547-1300, This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or by visiting peri-Eau.com.