LGP Secrets to Patient Compliance.key - Trisha O'Hehir

Ultimate Guide to Achieving Periodontal Health

Secrets to Patient Compliance

Liz Graham Presents *** Trisha O’Hehir

Trisha E. O’Hehir, MS, RDH Phone: 520-444-2279 [email protected]

Liz Graham, BS, RDH Phone: 707-769-8887

[email protected]

Understand complex ecosystem of biofilm

Describe infection and inflammation

Recognize role of sugar in inflammation

Interpret Common Cause Theory

Understand how xylitol changes biofilm

Compare interdental tools for biofilm control

Apply health behavior change techniques

Understand protocol for GBT

Objectives1. 2. 3. 4. 5. 6. 7. 8.

U of Minn 1967

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

15,000 in 1967 200,000 today NEW VISION

What would it look like if all your patients effectively removed or prevented bacterial

biofilm everyday.

No pockets, no bleeding, no caries! Happier, healthier, more confident patients.

DH school and board exams: the vision is calculus removal

…with grades based on competencies

grasp, fulcrum, insertion, activation…

No requirement that patients achieve health

Not based on health outcomes! Take out a piece of paper

Is dental disease preventable? Periodontal Health Index (PHI)

With the PHI, you can calculate your success rate

Periodontal Health Index (PHI)Simple number - like blood pressure

Number of pockets number of bleeding points

Goal: 0/0

Ideal is 0/0

24/38 - means more than just a few 4s and bleeding in the posterior

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

Patient played tennis with a dentist friend

3/5 is his current score86/122 was his baseline

How successful is your treatment?

My guess was 85%

What is your success rate with periodontal therapy?

30 patients 1,916 pockets — 139 pockets

139 divided by 1,916 = .07 1.0 minus .07 = 93% of pockets eliminated

Periodontal Health Index (PHI)!

With the PHI, you can calculate your success rate!

The Bola Story…

Daniel Brownwood Tina Long, RDH Cleaning!

Teeth !

BIOFILM & PATHOGENESIS

American Academy of Periodontology Website

Probing underestimates disease levels

Patient Scenario•Two years since last DH visit •Scheduled for a “cleaning” •You review medical history •Not much suprag. calculus •Probing looks fine •Begin instrumentation and find 4-5mm interproximal sites

!What Happened?

Probing: Line angle vs interproximal

GC America Tri Plaque ID Gel

New, Mature, Acid Producing Biofilm

GC America Tri Plaque ID Gel

New, Mature, Acid Producing Biofilm

Pink is new plaque

Blue is old plaque

Light blue is acid plaque

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

Too bad plaque biofilm isn’t

green!

What do your teeth feel like

when you wake up?

Does it feels like the teeth

are wearing

Does it feels like the army marching through?

Does it feels like

the bottom of a bird

Or does it feel just

plain fuzzy!

fimbria

fibrillsText

Quorum sensing

Biofilm Formation fimbria

fibrillsText

Biofilm Formation

Quorum sensing

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

Biofilm grows in a fluid environment: saliva and crevicular fluid

Bacterial toxic waste subgingivally includes endotoxins that penetrate pocket walls and trigger the immune response destroying tissue and bone

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

Would you agree?

Pathogenesis Infection & inflammation

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

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

Review of Histology

Bacterial endotoxin and antigen

Permeation Agents VSCs Volitle Sulfur Compounds

hydrogen sulfide and

methal mercaptan

Translate cell

biology into

cartoons

bacterial endotoxins bacterial antigens

• Signals alert the immune system

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

• PMNs are sent to the area

•

Vasodilation

Endotoxins also trigger a cascade of immune

responses to protect the body from bacteria and

viruses

PMN

Endothelial cells separate to allow PMNs to exit the

blood vessel

PMN

PMN

PMN

PMN

MMP

prostaglandin(pre-term birth) interleukin

collagenase

Breakdown of the active transport

system

PMNs release chemical machetes

In aggressive cases, the PMNs are over active

and produce more than the normal

amount of destructive chemicals

PMNs release chemical machetes

Breakdown of GAGS Glue glycosamino-

glycans

Breakdown of active the

transport system

Krebs CycleATPs

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

Mitochondria

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

Inflammation research…Mitochondria

•Uses sugar and oxygen to generate energy for the cell

•Energy stored as chemical bonds

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

Mitochondria Goal is equilibrium

•Oxidation - giving away an electron

•Reduction - gaining an electron REDOX reactions

Generate unstable free radicals = ROS ROS will strip electrons from other molecules

Leaving more unstable free radicals = domino effect


With adequate oxygen and good nutrition, the antioxidant defenses will control free radicals the keep

ROS within the cells where they were produced.

When free radicals and ROS exit the cell = inflammation


Too much refined carbohydrate = mitochondrial dysfunction

•Oxidative stress

•DNA alternations in the mitochondria

•Reduced numbers of mitochondria

Oxygen debt

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

Limited ATPs of energy

requires a big decision

Immature epithelial

cells

granulation tissue

• pocket epithelium

• scar formation in connective tissue

• bone loss

• small band of connective tissue attachment

• capillary formation

Infection and Inflammation

WARNINGBiofilm outside the body

photo courtesy of Dr. Randall Wolcott

Medicine Learns from Dental Hygiene

photos courtesy of Dr. Randall Wolcott

Biofilm causes ear infections Look at your Toes Squirt your Nose

Nathan, please tell us why you have three nasal sprays?

All are biofilm diseases

ORAL SYSTEMIC LINK

There is an oral-systemic connection with chronic periodontitis

The Common Cause: Sugar The pathogenesis of heart disease

• Leading cause of death in the Western world

• Atherosclerosis - plaque on vessel walls

• Becomes fibrous, obstructs blood flow

• Plaque surface ruptures, allowing leakage

• Leakage is thrombus, blocks there or travels to other blood vessels and blocks

The pathogenesis of heart disease The pathogenesis of diabetes

• A person gets fat - eating sugar and flour

• Their cells become inflamed

• Inflammation causes insulin resistance

• Body has to make more insulin

• Eventually the pancreas stops making insulin and diabetes follows

Thomas Van Dyke, Scientific American, 2016

Dr. Robert Lustig - the connection is sugar

SUGAR

How many of you see patients like this, who also have good oral hygiene?

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

Sugar is the reason gums bleed

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 sucrose drinks upon sulcus depth. J Oral Ther Pharmacol 2:195-202.

Sugar = carbohydrate Nearly every packaged food contains sugar

sucrose high fructose corn syrup

dextrose honey

maple syrup

• Panocha• Powdered sugar

• Raw sugar• Refiner's syrup• Rice syrup• Saccharose• Sorghum Syrup• Sucrose• Sugar (granulated)• Sweet Sorghum• Syrup• Treacle• Turbinado sugar• Yellow sugar

• Confectioner's sugar• Corn sweetener• Corn syrup• Corn syrup solids• Date sugar• Dehydrated cane juice• Demerara sugar• Dextrin• Dextrose• Evaporated cane juice• Free-flowing brown sugars• Fructose• Fruit juice• Fruit juice concentrate• Glucose• Glucose solids

61 Names for Sugar

Golden sugar• Golden syrup• Grape sugar• HFCS (High-Fructose Corn Syrup)• Honey• Icing sugar• Invert sugar

Malt syrup• Maltodextrin• Maltol

Maltose• Mannose• Maple syrup• Molasses• Muscovado• Palm sugar

Agave nectar• Barbados sugar• Barley malt• Barley malt syrup• Beet sugar• Brown sugar• Buttered syrup• Cane juice• Cane juice crystals• Cane sugar• Caramel• Carob syrup• Castor sugar• Coconut palm sugar• Coconut sugar

Topical and Systemic Effects

Topically, sugar feeds acid producing bacteria leading to caries

Topically, sugar also feeds subgingival bacteria through wicking -

triggering periodontal diseaseNew evidence shows that sugar comes out in

the gingival crevicular fluid

Systemically, sugar impacts inflammation -

leading to gingival bleeding

Excessive consumption of fermentable carbohydrates led first to dental diseases and then systemic diseases. Dental disease is the alarm bell for systemic disease.

1950-1960

The Common Cause Theory

Dental disease is the alarm bell for systemic disease.

1950-1960


Two researchers - Cleave and Yudkin

“My research on coronary heart disease has convinced me beyond doubt that sugar plays a considerable part in this terrifying modern epidemic.” 1972

John Yudkin (1910-1995)

•


“From an evolutionary point of view, the refined carbohydrates…are always the foods most likely to be at fault (for the diseases of civilization), and not the fats.” 1975

Thomas Cleave(1906-1983)


They considered refined carbohydrates (white flour and sugar) to be the most transformed or refined food, and therefore the most dangerous.

The Common Cause Theory flour and sugar cause both

dental diseases and systemic diseases

The opposing theory Fat was the culprit

Ancel Keys, 1904-2004

He was a scientist, studied business, political science,

zoology and oceanography.

He researched

starvation, created K-rations.

Ancel Keys was charismatic, popular

and had a big following.

He was so popular at the time that he was

featured on the cover of Time Magazine.

Saturated fat makes you fat and caused heart disease

He postulated that fats caused systemic disease, thus advocating a diet high in fruits, veggies and fermentable carbohydrates instead.

Based on the Low Fat Diet

• No more steak, bacon, butter, eggs or cheese

• Take fat out of processed food and add sugar

Ancel Keys, 1904-2004 Ancel Keys, 1904-2004He was a scientist, who studied business, political science, zoology and oceanography. He researched starvation, created K-rations for the military and with his wife, popularized the Mediterranean Diet.

Increased risk of cancer, heart disease, stroke, intestinal disorders – just about any illness – the

standard American Diet has them all.

Standard American

Diet (SAD)

Ancel Keys studied 6 countries

Data was collected from 22

countries!

He selected data from only 6 countries showing a linear relationship.

Masai - S Kenya Inuit - Arctic Rendille - NE Kenya Todelau - S Pacific

He bullied other professionals.

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

“My research on coronary heart disease has convinced me beyond doubt that sugar plays a considerable part in this terrifying modern epidemic.”

Yudkin, 1972 (1910-1995)

•


The evidence for sucrose as the “greatest killer” in Western societies is “utter nonsense” and “would never pass an acceptable term paper in an undergraduate course in home economics.” Ancel Keys, 1975

Ancel Keys destroyed the careers of both Cleave and Yudkin

Dental disease was simply a necessary side effect for the greater good of preventing heart disease by decreasing fats and increasing sugars.

Saturated fat made you fat and caused heart disease

Ancel Keys, 1975

Dental disease considered a local infection to be treated/prevented with fluoride, OHI, restorations, sealants, etc.

Saturated fat made you fat and caused heart disease

The Caries Research Foundation (CRF)

Sugar Industry

Dental Association

It’s not about reducing sugar in the

diet - all about improving oral hygiene!

National Institute for Dental Research

1971 National Caries Program - eradicate caries within a decade

Sugar industry documents from 1959-71 adopted strategies to deflect attention away from sugar

Funded studies on enzymes to break up plaque and a vaccine with questionable potential

National Institute for Dental Research

78% of sugar industry submissions were incorporated into the NIDR call for research applications

Research harmful to the sugar industry was omitted

Opportunity missed to develop scientific strategies to reduce sugar consumption

From then on, research conclusions focused on brushing, flossing, fluoride and restorative dentistry - not on sugar!

In 2009, Cristin Kearns, DDS uncovered sugar industry papers from

the 1950s-1980s

She gave up dentistry to become an investigative journalist, historian and health researcher at UCSF.

Big Sugar worked to influence journalists,

scientists, regulator and clinicians

1967, three Harvard Medical School researchers were paid ($50,000.00) by the sugar industry to write literature reviews that focused on fat as the cause of heart disease rather than sugar. Published in the NEJM.

Stanton Glantz, a professor of medicine at U.C.S.F., author of the 2016 JAMA Internal Medicine article that documented sugar industry efforts to minimize the link between sugar and heart disease.

Humans do not need sugar No physical need to consume sugar

2009 - Stone Age Diet - Switzerland • 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 fishing

2009 - Stone Age Diet

• No oral hygiene products or tools

• Stone Age clothes, tools and huts

• Filmed for a TV special

• Sports medicine physicians monitored

• Dental examinations before and after

2009 - Stone Age Diet

• Plaque increased, as expected

• Surprised by reduction in gingivitis & probing depths

• Bleeding upon probing reduced from 35% to 13%

• Bacteria changed to a balance favoring health rather than disease

Oral hygiene became necessary when the Western Diet of refined

carbohydrates was introduced.

Hunter/Gatherers did not feed their oral bacteria, no oral hygiene needed

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

Western Diet

Pottenger’s Cats A Study of Nutrition-Cooked vs Raw Meat

First generation - end of life, lazy with degenerative diseases

Second generation - degenerative diseases by mid-life, loosing coordination

Third generation - degenerative diseases early in life, born blind, weak, shorter lifespan, fewer offspring

All died out by fourth generation

Pottenger’s Cats Milk: raw, pasteurized, evaporated or

sweetened condensed

Cats on raw mild did better than the others that showed degeneration similar to the meat study

Conclusion: missing protein necessary for growth and development of healthy cats

Topical and Systemic Effects People don’t know how much sugar they eat

How many sweets are in the break room at your office?

XYLITOL - THE GOOD SUGAR

… we need an alternative to sugar for the occasional

sweet.

Xylitol the good sugar Best alternative

• Looks and tastes like “sugar” • broad category: carbohydrate • narrow category: polyol • 2.4 calories per gram • 40% fewer calories than other

carbohydrates

• Xylitol - 5 carbon polyol

• Erythritol - 4 carbon polyol

• Stevia - extracted from stevia leaves

Alternatives to sugar you will like

Acesulfame potassium (Ace-K) Aspartame Saccharin Sucralose (Splenda)

Artificial Sweeteners to Avoid

Biggest Game Changer in DH?

Reduces plaque biofilm by 50%!

Biggest Game Changer in DH?

Reduces plaque biofilm by 50%! Doesn’t feed bacteria

Reduces acid production No insulin needed

Enhances remineralization

• Discovered in 1891 by German & French chemists

• Benefits remained dormant for several decades

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

• 1960 for diabetics, 1970 for caries prevention

Xylitol the good sugar• Crystaline carbohydrate • Found in tree bark, plants, fruits and vegetables

• The body makes 5-10 grams of xylitol every day

Xylitol the good sugar


• Most common source today is corn cobs and corn stalks

• They contain no corn

Xylitol the good sugar• Side Effects • dangerous for dogs

• drop in blood sugar • liver damage

Never give your pets: * chocolate, coffee, caffeine * alcohol * avocado * macadamia nuts * grapes and raisins * yeast dough * raw or undercooked meat, eggs * onions, garlic and chives * milk

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

• Xylitol triggers release of insulin in dogs

• Remedy: give them sugar

• Take them to the vet - the vet will give IV glucose

• Side Effects

• gastric upset when

eaten in large amounts

too quickly


• Side Effects

• digested as a fiber

• pulls water out of tissue

cells, thus diarrhea

Xylitol the good sugar•Glycemic level of 7

Glucose 100 Table sugar 68

Honey 55 Fructose 19

Xylitol 7

http://www.glycemicindex.com/


• Does not raise insulin levels

• Does not use insulin for metabolism

• Safe for diabetics


• How it works • 5 carbon, not 6 carbon like

sorbitol, mannitol, maltitol

• Passes through bacterial membrane; not metabolized

• Bacteria uses energy to pump the xylitol molecule out


• How it works

• Bacteria like acid environment

• When bacteria cannot make acids

• cannot stick to each other or the teeth • bacterial communication disturbed • biofilm structure is compromised

• Bacteria slide down the digestive & nasal tracks

Xylitol the good sugar Xylitol prevents biofilm formation

Metabolism and Communication

Xylitol dissolves established biofilm

Metabolism and Communication

Addiction to Pharmaceutical Nasal Spray

Nasacort

Affrin

Zicam

Flonase

Rhinocort

Simply Saline

NeilMed

Side effects of oxymetazoline hydrochloride

• blurred vision• fast, irregular or pounding

heartbeat• headache,dizziness, drowsiness or

lightheadedness• high blood pressure• increase in runny or stuffy nose• nervousness• trembling

Xylitol - research in Finland• 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

Xylitol - research in Finland

• Two-year meal replacement study - 85% reduction in caries

• Difficult study to undertake and monitor

Turku Sugar Studies

Three test groups: Xylitol

Fructose Sucrose

Xylitol - research in Finland

• One-year chewing gum study 6.7 grams vs 67 grams resulted in 85% reduction in caries incidence compared to sucrose group

6.7 grams 67 grams

Inhibits Plaque Accumulation and Cariogenic Bacteria

• Two-week study • S mutans digest sorbitol • Gum chewed 5/day • Gums: 100% xylitol xylitol/sorbitol 100% sorbitol

-40

-20

0

20

40

60

xylitol/ sorbitol

100% xylitol

Change in plaque weight(%)

How Xylitol Fights Tooth Decay

100% sorbitol

0.0

2.5

5.0

7.5

10.0

Control Fluoride Xylitol

DMFS Caries Increment

Hungarian Study of 1981-1984


• 3 year study

• 690 Hungarian students

• Test groups:

• Control - fluoridated toothpaste

• Fluoride in milk

• Xylitol 20 grams/daily in candy spread out during the day

Belize City Xylitol Chewing Gum Study 1989-1994

• Belize study conducted by the U of Michigan • 1277 students divided into 4 groups• 40 month study

• 100% xylitol gum- dramatic decrease in tooth decay


Mäkinen, K., J Dent Res, 1995

Belize City Xylitol Chewing Gum Study 1989-1994

• Five years later, follow-up study by University of Washington

• 70% reduction in tooth decay - xylitol

• Xylitol changes oral micro-flora


What’s the difference between a

train

and a teacher? while a train says "CHEW CHEW!"

Teacher says "spit out your gum"

0.0

0.6

1.2

1.8

2.4

Control 1 Gum 2 Gums 3 GumsXylitol Control

Frequency of xylitol use is important

• Two-year study in Finland

• 172 students

• Best - three times daily

• Better - Strive for Five

How much? How often?Frequency of xylitol use is important

• Chew only five minutes or less

• Not a recreational chewing gum

• When flavor is gone, all the xylitol is released

• With a high carbohydrate diet - more xylitol

needed

How much? How often?

Tooth Eruption

• Xylitol enhances early mineralization • Xylitol inhibits initial colonization by S. mutans

Opportunity to establish long-term protection


• Avoid Strep mutans until age two = less decay

• Harmless, non-acidogenic bacteria will colonize

• Harder for the Strep mutans to get a foot-hold

Xylitol and the Mother-Child Relationship Mother chews xylitol for child’s first two years

• Parent xylitol use stops vertical transmission of Strep mutans

• Restorative need at age five, 70% lower with xylitol use

• Control group 5X the risk of Strep mutans colonization

Söderling, E., J Dent Res, 2000; Caries Res 2001; Finnish Dent J, 2006

Xylitol and the Mother-Child Relationship Mother chews xylitol for child’s first two years

Preventing The Vertical Transmission of the Streptococcus mutans Bacteria

• Two year study • 169 new mothers • Varnishes at 6,12, & 18 months

• Xylitol used 3-5 times a day

• Children: no varnish, no xylitol 0.0

17.5

35.0

52.5

70.0

fluoride chlorhexidine xylitol

Colonization Percentages

Söderling, E., JDR Vol 79 # 3, 2000

Xylitol use by mothers has long-term benefits

Xylitol Superior to Fluoride Varnish & CHX Varnish

Child’s first dental visit Benefits of xylitolReduces 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

Put some Windex on it!

CloSYS

CloSYSAs effective as

CHX no stain

& no taste

alterationPre-Flavored

Just RIGHT Mild MintOriginal

Unflavored

CloSYS - chlorine dioxide

Penetrates and dissipates biofilms that harbor oral pathogens

Inhibits re-growth of bacteria for 36 hours

Kills 99% of Streptococci in 10 seconds

Kills 99% of perio pathogens in 10 seconds

CloSYS - chlorine dioxide Bad Breath

Perio

PerioTongue Coating

Bad Breath Smells

Perio

PerioTongue Coating

Bad Breath Smells

!191

Perio

PerioTongue Coating

Bad Breath Smells

CloSYS - Fresh BreathADA Seal: Safe and Effective for

eliminating bad breath

• Sensitivity • Dry Mouth • Fresh Breath • Perio Health

CloSYS - Reasons for Use

ClōSYS is less toxic than CHX to human gingival cells

When used as a lavage in ultrasonic scaling, ClōSYS safely reduced the exposure to microbial aerosols by 60%

CloSYS - chlorine dioxide

CloSYS - Available Here:

amazon.com Walmart

CVS Health Walgreens Safeway Kroger Meijer

Albertsons H-E-B

Kinney Drugs Pharmaca

Face Values

INTERDENTAL CLEANERS• Interdental brushes of various sizes

• Interdental picks and sticks

• Oral irrigation

More effective interdental options

US Department of Health and Human Services

Removed flossing as a recommended practice after being questioned by the Associated Press regarding the lack of scientific research supporting floss to prevent periodontal disease and caries. 2016

Time to “Toss the Floss”

Are brushing and flossing working for your patients?

Tossing flossing? Robert H. Shmerling, MD

Editor, Harvard Health Publications

Archie Cochrane, MD

Flossing for the management of periodontal diseases and dental caries in adults

Dario Sambunjak, Jason W Nickerson, Tina Poklepovic, Trevor M Johnson, Pauline Imai,

Peter Tugwell, Helen V Worthington First published: 7 December 2011

Twelve studies show flossing in addition to tooth-brushing reduces gingivitis compared to tooth-brushing alone.

Weak, unreliable evidence from 10 studies that flossing plus toothbrushing shows a small reduction in plaque at 1 and 3 months.

No studies reported the effectiveness of flossing plus

toothbrushing for preventing dental caries in adults as studies were not

long enough.

• 8% reduction in gingivitis with floss Insufficient evidence to claim plaque reduction

• In another review study -

• 40% reduction in caries risk for kids 4 to 13 years with professional flossing on school days

• (why not 100%)

Feeling Guilty About Not Flossing? Maybe There’s No Need

Haven't flossed lately? Don't feel too bad: Evidence for the benefits of flossing is

'weak, very unreliable’

Associated Press

Guilty No More: Flossing Doesn’t Work

An AP investigation finds weak evidence that flossing

helps.

WILL GREENBERGAUG 2016

This is why flossing doesn’t work… This is why flossing doesn’t work…

This is why flossing doesn’t work… Flossing is difficult

Ong, J of Clinical Perio, 1990, Carter-Hanson, J of Clinical Perio Berchier, et al, Int J of Dent Hygiene 2008

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

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

No benefit over brushing alone

Flossing Compliance is Poor

• 18 out of 258 reported daily flossing - 7%

• Any gains seen at 2 weeks - lost at 4 weeks

• Instruction alone doesn’t work

J Clin Perio 33: 612-619, 2006

CONCLUSIONS While flossing with any type of floss is substantiated within this literature as an effective method of interproximal plaque removal, for some clients and/or for certain oral sites, other methods of interdental cleansing are warranted.

MAY - JUNE 2006, VOL. 40, NO. 3 CANADIAN JOURNAL OF DENTAL HYGIENE (CJDH)

Flossing will not prevent caries at the contact area. The caries begins just below the contact - not at the contact.

Biofilm forms below the contact

•

Concavities are Difficult to Reach Concavities are Difficult to Reach

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

BREAKOUT SESSION

Straight better on lingual than tampered design

Interdental brushes, picks, sticks, etc

Water Flossing

Cut out added sugars

Xylitol to replace sugar

Dry Toothbrushing and various toothbrushes

Offer AlternativesWater Flossing

Oral IrrigationCutler 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 modification of ROH - 14 days C: Water irrigation plus ROH - 14 days

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

Cutler et al, 2000 - Results

“The addition of oral irrigation with water to the subjects’

routine oral hygiene (ROH) for 14 days resulted in a significant

reduction in PPD, BOP, GI, and PI at interproximal sites with mild

to moderate (4 - 7 mm) periodontal disease”

Cutler et al, 2000 - BOP

0.3

0.44

0.58

0.72

0.86

1

Baseline 14 Days

No OH

ROH

ROH+OI

Sonic-Fusion

Dental Floss

If patients are flossing effectively, support them and encourage them to continue.

Those who do no interdental cleaning, offer two alternatives to floss and let them choose which one they want to use.

Interdental brushes, picks, sticks, etc

Water Flossing

Cut out added sugars

Xylitol to replace sugar

Dry Toothbrushing and various toothbrushes

Offer Alternatives

Recognize the limitation of oral hygiene lectures

Education

Does Education Work?

38 million still smoke18% of men and 14% of women


EducationThis is our first instinct -

what we were taught in school

Education is often one-sided Education is often one-sided

Giving information vs raising awareness

The “Righting Reflex”

Clinician wants to fix the patient

Patients tend to push back

Conversation is more of a dance…

Traditionally, we blame the patientfor poor oral hygiene.

Traditionally, we blame the patientfor poor oral hygiene.

Research shows people only remove 42% of plaque with a manual

toothbrush and 46% with a power toothbrush.

J Clin Perio, Van der Weijden, et al, Efficacy of homecare regimens for mechanical plaque removal in managing gingivitis a meta review. 2015

J Perio, DeVore, C. et al, Plaque Score Changes Based Primarily on Patient Performance at Specific Time Intervals

50% plaque reduction

buccal 30% 15%lingual 40% 20%interproximal 80% 40%

Baseline Post-op

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 flossing instructions have been going on for over 100 years.

Is it working? Shift from educator to advocate

Take the patient’s side - blame someone else

Solve a problem for the patient

Steps needed to engage the patient in planning for change

1.

2.

3.

Shift from educator to advocate

Take the side of the patient -

avoid being the adversary

avoid simply educating

Take the patient’s side

To avoid blaming the patient —

find someone orsomething else to blame.

Blame the toothpaste

Most people brush with their

eyes closedDROOLING

andDAY DREAMING

30 seconds seems like 3

minutes

#1 People brush longer without toothpaste

Reasons why dry brushing works

Toothpaste makes so many

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

#2 People brush more evenly around the mouth

Toothpaste flavor and

wetting agents numb your

tongue so your teeth feel clean

when they really aren’t.

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

Shift from educator to advocate

Take the patient’s side - blame someone else


Steps needed to engage the patient in planning for change

1.

2.

3.


Lingual calculus removalbad breath…


Do you like when I scrape off the buildup behind your lower front teeth?

Brushing times 38 to 60 seconds

Erratic pattern of brushing ✓Returning several times to starting place

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

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

✓ Reduced lingual calculus 63%

✓ Reduced lingual bleeding 55%

O’Hehir, Suvan, JADA 1998 129:614

Dry Brush Inside First

My brother-in-law, Billy — my sister Peggy

Blame the toothpaste - not the patient

Toothpaste is the reason for 30 second brushing and lingual calculus


Education

The Goal: Behavior Change

Change is difficult

Ask any married couple

Change is difficult

I want others to change, but I don’t want to change!

I want my patients to change,but I don’t want to change!

Change is difficult

It happens outside your operatory

Limits to education alone

Roll with resistance

Start with this assumption:the patient did the best they could!

Continuing to educate patients the same way and expecting different

results is the

definition of insanity!

If we want different results,we have to change.

First Change: Skip the lecture

Skip the Lecture! The brush and floss message

isn’t getting through to all our patients!

Ask permission to educate

Ask permission to educate

• Action Research - 10 patients asked• 7 said NO• 3 said “…only if you want to…”

Understand why education is not enough

Describe steps in planning for change

Compare approaches to behavior change

Use open-ended questions to begin conversation

Observe changes in patient commitment

Objectives

1.

2.

3.

4.

5.

Transtheoretical Model of Change

1

2

3

4

5

Motivation

Stephen Rollnick

“You can’t instill motivationto change

into someone else.”

Change comes from within

Some behavior changes are yes or nofastening your seat-belt

Oral Health Behaviors depend on quality not quantitynot all flossing is effectivenot all brushing is effective

more of the same isn’t always better

1. Skip patient education2. Keep your info a secret3. Solve a problem for the patient

Trisha’s Theory of Change

Trisha’s Theory of Change

Solve Problems

Skip OHI

Keep Secrets

NEW VISION COACHING

NEW VISIONfor Oral Health Promotion Oral Health Coaching

NEW VISIONfor Oral Health Promotion

Action Research Quantitative - lot of statistics, graphs, etc

Qualitative - feeling, opinions, interviews

Action Research - researcher makes the change

TYPES OF RESEARCH

External - Avoid Bias

Internal - Include Bias

Action Research Question Development – changing something you are doing with patients to achieve better oral health.

Identify a problem with patient oral healthWhat are 3 potential causes of this problem?What are 3 potential solutions to this problem?

Pick one solution you think will improve oral health.

Action ResearchAction Research Question:

If I do this (the change you want to make), oral health as measured by this (how will you measure change), will improve.

Action Research Question:

If I introduce an alternative to flossing, patient behavior will change and interdental bleeding will be reduced.

Flossing Alternatives

ACTION RESEARCH

• Examples of OHU studies on interproximal cleaning

Is it…

• important – will it make a difference• manageable – not adding a lot of work for you• contextual – easily fits into your schedule• focused – not a PhD project• opened-ended – not a yes/no question• reflective – looking at the patient’s response and also

how the research impacts you

Action Research

Is it…

• important – will it make a difference• manageable – not adding a lot of work for you• contextual – easily fits into your schedule• focused – not a PhD project• opened-ended – not a yes/no question• reflective – looking at the patient’s response and also

how the research impacts you

You are already doing Action Research

NEW VISIONAre you willing to accept this new vision - focused on health

outcomes?

If we want different results,we have to change.

First Change: Skip OHISecond Change: Open-ended questions

Open ended questions get a conversation going.

Patients don’t care how much you know until they know how much you care!


Caring enough to ask,shows empathy.

Motivational Interviewing

one tool for behavior change

Opened ended questionsAffirm the patientReflective listeningSummarize the plan

OARS


Open-ended questionthe answers to which

you do not know.


Do you floss? Not open-ended and you

know the answer.


What do you use to clean between your teeth?

Open Ended Questions

What do you use to clean between your teeth?


Follow-up:Tell me more about…



OARS


On a scale of 1 to 10How healthy is your mouth?

Partner up with a colleaguein a breakout room

Try this open-ended question with your partner.



If you could change anything about your mouth, what would it be?



If you could change anything about your mouth, what would it be?

Tell me more about…



If a patient says “8” beforetrying to get them to “9”

ask what they did to movefrom “7” to “8”



OARS

The Plan

• Offer alternatives to floss

• Offer secrets to solve problems

• Help the patient to make their plan



OARS

Tell me what you like to eat for breakfast?



Tell me about your favorite snacks?



Tell me about your favorite snacks?

Tell me about your favorite drinks?


On a scale of 1 to 10

…how healthy is your diet?

…how healthy is your mouth?

Open Ended QuestionsConversations with

patients about sugar

Be brave - ask a questionand see what you learn!

Conversations with patients about sugar

Action Research Projects• Benefits of reducing fermentable carbohydrates

• Reduced plaque biofilm formation • Reduced acid production by bacteria • Stronger blood vessels and capillaries • Better general health • Weight loss

Benefits of reducing sugar and flour

Help the patient make the planWhich of these two interdental cleaners do you think you would be most likely to use?

When in the day do you think you are most likely to use it?

Recommended Reading…

• Asking open-ended questions• Actively listening to the patient’s needs

• Asking closed questions• Giving instructions to patients

Changes you may want to try

Traditions you may want to avoid

EMS - GUIDED BIOFILM THERAPY

Guided Biofilm Therapy (GBT)

AirFlow with Glycine/Erythritol

Removal of supragingival biofilm

80% less abrasive, safe & comfortable

�  Powder gently enters the sulcus

�  Cleans up to 4mm � Makes calculus visible

Hu-Friedy

Scientific evidence shows it is safe, effective and 3 times faster than

rubber cup polishing

Despite the evidence, DH schools still favor rubber cup polishing

Hu-Friedy

How will erythritol powder be used?

Air Flow first to remove biofilm - then easier to

remove calculus

Reaches 9mm

Safe on root surfaces

Effective biofilm removal

PerioFlow

PerioFlow Tip

HAND INSTRUMENTS

•

Imagine the11/12 Gracey

•

Instruments designed to reach interproximal areas

Problem

blade too big for

subgingival space

off-set blade harms tissueStandard Mini design

•

Need for the O’Hehir Curettes

•

•

•

•

Radical Change in Instrument Design The O’Hehir Curettes

•

PDT Queen of Hearts

SusanWingrove,RDH,BSTitaniumImplantInstruments

• PDT will accept old, used instruments regardless of the manufacturer

• For any 12 instruments, PDT will send FREE stainless steel curette or scaler.

• PDT craftspeople recondition the instruments and donate to over 400 dental missions throughout the world!

Have a Heart and give back!

“I help people change behaviors to achieve optimal

oral health.”

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.

· 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

BYE BYEBIOFILM.

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

Now you can have the industries best for lessand it could be the most cost efficient procedure performed in your office this year.

MicroClear breaks up biofilmbuildup in waterline tubingreducing harmful aerosols.

kills 99.9% of harmful bacteria in 10 seconds.

CloSYS Pre-Treatment Rinse in Chair Side bottle & pump: CloSYS Ultra-Sensitive Unflavored Pre-Rinse is a simple and

effective pre-treatment rinse perfect for all your patients thanks to Cloralstan®, a powerful but gentle, patented ingredient that...

• Naturally activated by saliva

• Breaks up harmful biofilm

• Destroys microbes & toxins

• Gentle Un-flavored formula

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

SPLATTERMATTERS.Why Pre-Rinse:

Now more than ever,

During any dental procedure patient splatterwill happen. Reducing the harmful bacteria in dental aerosol reduces the chance for cross-infection to patients & staff. Antimicrobial pre-rinsing should be part of every dental office PPE protocal.

MAKE ME SMILE.

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GUIDED BIOFILM THERAPY

CARIES AND PERIO PREVENTION AND MAINTENANCE

Evidence-based protocols for biofilm management on teeth, soft tissues and implants.

1. MAKE BIOFILM VISIBLE2. AIRFLOW® FIRST3. PS INSTRUMENT FOR REMAINING CALCULUS4. LESS POWER AND HAND INSTRUMENTS 5. NO MORE RUBBER CUPS, NO MORE PASTE

MINIMALLY INVASIVE MAXIMALLY PREVENTIVE

2

AIRFLOW®

PERIOFLOW®

PIEZON PS®MAKE ME SMILE.

MAKE ME SMILE.

MAKE ME SMILE.

KEINE GUMMIKELCHE MEHR KEINE BÜRSTCHEN MEHR KEINE POLIERPASTE MEHR WENIGER SCHALL, ULTRASCHALL

UND HANDINSTRUMENTE

AB JETZT NUR NOCH MINIMALINVASIV

ONLY THE VERY BEST FOR MY PATIENTS ONLY THE SWISS ORIGINALS

GBT - THE NEW AND MODERN WAY

3

FÜR MEINE PATIENTEN NUR DAS BESTE NUR DAS ORIGINAL

PATIENTEN MÖGEN’S GERN MODERN

RR

EXPOSED DENTINESUBGINGIVAL

10MM

SUPR

A & SUBGINGIVAL

GBT SAVES TEETH, IMPLANTS AND MUCH MORE

4MM

AROUND IMPLANTS

9MM

AROUND IMPLANTS

3MM

AROUND IMPLANTS

9MM

SUBGINGIVAL SUPRA & SUBGINGIVAL

ABOV

E CEMENTO-ENAMEL JUNCTION

SUPRAGINGIVAL

IN ROOT FURCATIONS

4

22 APPLICATIONS

OF GBT

*

* Approved for 5 mm in the U.S. - 9 mm in Canada

*

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ON PRIMARY TEETH TONGUE AND PALATEON PRIMARY TEETH

GBT SAVES TEETH, IMPLANTS AND MUCH MORE

ON RESTORATIONS

ON RESTORATIONS

IN PITS AND FISSURESINTERDENTAL

AROUND BRACKETS AROUND BRACKETSPS

BEFORE BLEACHING

BEFORE COMPOSITE RESTORATIONS

5

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6

08 RECALLGESUNDER PATIENT = GLÜCKLICHER PATIENT

Bestellen Sie Ihren Patienten risiko-abhängig zum Recall

Fragen Sie, wie ihm oder ihr die Behandlung gefallen hat

07 CONTROLPATIENTEN ZUM STRAHLEN BRINGENPrüfen Sie abschließend, ob der

Biofilm vollständig entfernt wurde Wurden Zahnstein und

Konkremente vollständig entfernt? Untersuchen Sie Zähne auf

kariöse Läsionen Schützen Sie die Zähne mit Fluorid

06 PIEZON®VERBLEIBENDEN ZAHNSTEIN ENTFERNEN

Verwenden Sie supragingival und bis zu 10 mm subgingival das minimal-inva-

sive EMS PS Instrument Reinigen Sie Taschen

>10 mm mit einer Minikürette Verwenden Sie

um Implantate und implantat-getragene Restaurationen das EMS PI Instrument

05 PERIOFLOW®BIOFILM ENTFERNEN IN TASCHEN >4 BIS 9 MM

Natürliche Zähne und Implantate, verwen-den Sie PLUS Pulver Entfernen Sie den

Biofilm auch interdental Verwenden Sie die tiefenmarkierten PERIOFLOW® Düsen

DIE 8 SCHRITTE DES GBT PROTOKOLLSTHE GBT COMPASS AND ITS 8-STEP PROTOCOL08 RECALL

HEALTHY PATIENT = HAPPY PATIENT Schedule recall frequency

according to risk assessment Ask your patient if he

or she liked the treatment

07 CHECKMAKE YOUR PATIENT SMILE

Do a final check for remaining biofilm Ensure calculus is fully removed

Accurately diagnose caries Protect with fluoride

06 PIEZON® PSREMOVE REMAINING CALCULUS

Use the minimally invasive EMS PIEZON® PS Instrument supra- and

subgingivally up to 10 mm Clean > 10 mm pockets with mini curette

Use EMS PIEZON® PI Instrument around implants up to 3 mm

subgingivally and on restorations

05 PERIOFLOW®REMOVE BIOFILM IN >4 TO 9 MM POCKETS*

Use AIRFLOW® PLUS Powderon natural teeth in deep pockets and root

furcations and on implants Use new and slimmer PERIOFLOW® Nozzle

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7

01 DIAGNOSEBEFUNDERHEBUNG BEI JEDEM PATIENTEN Gesunde Zähne, Karies, Gingivitis,

Parodontitis Gesunde periimplantäre

Gewebe, Mukositis, Peri-Implantitis Patient zuerst

mit BacterX spülen lassen

02 DISCLOSEANFÄRBEN UND BIOFILM

SICHTBAR MACHEN Zeigen Sie Ihrem Patienten den

angefärbten Biofilm Die Farbe steuert die Biofilm-Entfernung Ohne Biofilm ist

Zahnstein

03 MOTIVATEINSTRUIEREN UND MOTIVIEREN

Prävention ist wichtig! Lehren Sie geeignete Mundhygiene Empfehlen

Sie Philips Sonicare und Interdentalbürsten oderPhilips AirFloss Ultra

04 AIRFLOW®BIOFILM, VERFÄRBUNGEN UND

JUNGEN ZAHNSTEIN ENTFERNEN Natürliche Zähne, Restaurationen und

Implantate Entfernen Sie supra- und subgingivalen Biofilm mit PLUS

Pulver Entfernen Sie restliche Schmelz-Verfärbungen mit CLASSIC COMFORT Pulver

Entfernen Sie Biofilm auch von Gingiva, Zunge und

Gaumen

DIE 8 SCHRITTE DES GBT PROTOKOLLS RTHE GBT COMPASS AND ITS 8-STEP PROTOCOL RR

01 ASSESSPROBE AND SCREEN EVERY CLINICAL CASE

Healthy teeth, caries, gingivitis, periodontitis Healthy

implants, mucositis, peri-implantitis Start by rinsing with BacterX® Pro

mouthwash

02 DISCLOSEMAKE BIOFILM VISIBLE

Highlight to patients the disclosed biofilm and their problematic areas

with EMS Biofilm Discloser The color will guide biofilm removal Once biofilm is removed, calculus

is easier to detect

03 MOTIVATERAISE AWARENESS AND TEACH

Emphasize prevention Instruct your patients

in oral hygiene EMS recommends Philips Sonicare toothbrushes,

interdental brushes and Airfloss Ultra

04 AIRFLOW®REMOVE BIOFILM, STAINS

AND EARLY CALCULUS Use AIRFLOW® for natural teeth,

restorations and implants Remove biofilm supra- and subgingivally up to 4 mm using AIRFLOW® PLUS 14 μm Powder

Also remove biofilm from gingiva, tongue and palate Remove remaining stains on enamel using AIRFLOW® CLASSIC

Comfort Powder

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8

BEFORE DISCLOSING

BEFORE DISCLOSING

AFTER DISCLOSING

GINGIVITISEMS Biofilm Discloser visibly reveals the presence of early and mature biofilm. The sulcus area (gingival margin) shows mature biofilm due to an inappropriate brushing technique leaving biofilm untouched.In this case, GBT was limited to AIRFLOW® PLUS Powder up to 3mm. Some bleeding from the gingival margin (red line) indicates low-grade gingivitis. GBT fosters the patient’s motivation to use correct tooth brushing techniques. GBT prevents and treats gingivitis

IMPLANTSIn this sequence of peri-implantitis, AIRFLOW® removes supra- and subgingival biofilm up to 4mm. The EMS Biofilm Discloser helps to minimize treatment time. PERIOFLOW® removes biofilm in peri-implant pockets up to 9mm*. Finally, the PIEZON® PI Instrument removes the remaining calculus around the implant. GBT contributes to the treatment of peri-implantitis in a

minimally invasive way.

CARIES DETECTIONAccurate caries detection requires clean teeth. Here, the EMS Biofilm Discloser shows the presence of biofilm, interdentally as well as at the gingival margin. Finally, GBT reveals interdental caries at an advanced stage. GBT helps detect caries with precision. No more biofilm: No more caries.

BEFORE DISCLOSING

THE AIM OF GBT IS


Photos: Courtesy, Prof. Magda Mensi


Photos: Courtesy, Beverly Watson

9

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AFTER DISCLOSING

AFTER DISCLOSING AFTER GBT

AFTER GBT

AIRFLOW® PERIOFLOW® PIEZON®


TO ELIMINATE ALL BIOFILM ON TEETH,IMPLANTS AND SOFT TISSUES.

10

CHILDRENIn this case, using a 2-tone disclosing agent visibly reveals cariogenic biofilm and helps motivate the young patient. Children love AIRFLOW® – it is “cool” and they lose the fear of the treatment. The pain-free GBT method motivates

children and helps prevent caries.

EXPOSED DENTINE Biofilm and calculus removal on exposed dentine surfaces is usually critical in terms of patient comfort (dentine hypersensitivity) and risk of over instrumentation. The disclosed biofilm helps to minimize AIRFLOW® treatment and to save time. No more color (of the disclosing agent) - no more biofilm. AIRFLOW® PLUS Powder and PIEZON® NO PAIN with PS Instrument are the best assurance for high quality and painfree treatments. GBT preserves exposed dentine preventing sensitivity. BEFORE DISCLOSING

BEFORE DISCLOSING

BEFORE DISCLOSING

STAINS AND CALCULUSAIRFLOW® removes stains and facilitates further calculus removal with PIEZON® PS Instrument, minimizing power instrumentation.

GBT will make your patient smile again.

BEFORE GBT

BEFORE DISCLOSING

ORTHODONTICSOrthodontic appliances are a challenge for patients and professionals performing biofilm management. Using a 3-tone disclosing agent reveals cariogenic biofilm (pH < 4,5) in areas difficult to access during home care and helps to motivate the young patient. AIRFLOW® PLUS Powder during GBT reveals demineralized white spots which were impossible to identify before. GBT prevents caries during orthodontic treatment. GBT maintains orthodontic appliances.

GUIDED BIOFILM THERAPY MORE CASES

Photos: Courtesy, Dr. Gleb Aseev


Photos: Courtesy, Dr. Gleb Aseev

Courtesy of Beverly Watson

11

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AFTER GBT


AFTER GBT

GUIDED BIOFILM THERAPY MORE CASES

WHY GBT IS THE...

This shows that dental biofilm is not always visible.

12

Dental biofilm is the main etiological factor for caries, periodontitis and peri-implant infections. Periodontitis may increase the risk of systemic diseases, such as cardiovascular and respiratory disorders, arthritis or diabetes. Regular oral hygiene, combined with professional measures, keeps biofilm under control –

for a better oral and systemic health. Axelsson and Lindhe pioneered preventive dentistry in the 1970‘s with studies and clinical protocols based on prophylaxis in “recall hours”.1–2

GBT follows the recommendations on Professional Mechanical Plaque Removal (PMPR) and Oral Hygiene Instructions (OHI) for Home Care issued by the European Federation of Periodontology (EFP).3–5 . “Periodontal Health for a Better Life!”

PROFESSIONAL TOOTH CLEANING CAN BE A PAINFUL EXPERIENCE

1 Removing calculus with hand instruments can often be painful for the patients. Dental surfaces and implants often will be scratched.

2 Polishing with rotary rubber cups and brushes is time-consuming and often messy.With many areas not reachable, the gingiva will be affected mechanically. Dental hygienists and assistants know that traditional cleaning may be a painful experience. For this reason, patient compliance is not often very high. Now, almost fifty years later, it is time for change.

PATIENTS DO NOT LIKE IT AND OFTEN STAY AWAY FROM RECALLS

1. Axelsson P. Preventive Materials, Methods and Programs: Quintessence Publishing, 2004. │ 2. Axelsson P, Nystrom B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. Journal of Clinical Periodontology 2004;31:749-757. │ 3. Tonetti MS, Chapple ILC, Jepsen S, Sanz M. Primary and secondary prevention of periodontal and peri-implant diseases. Journal of Clinical Periodontology 2015;42:S1-S4. │ 4. Tonetti MS, Eickholz P, Loos BG, Papapanou P, van der Velden U, Armitage G, et al. Principles in prevention of periodontal diseases. Journal of Clinical Periodontology 2015;42:S5-S11. │ 5. Sanz M, Bäumer A, Buduneli N, Dommisch H, Farina R, Kononen E, et al. Effect of professional mechanical plaque removal on secondary prevention of periodontitis and the complications of gingival and periodontal preventive measures. Journal of Clinical Periodontology 2015;42:S214-S220.

Der dentale Biofilm ist der wichtigste ätio- logische Faktor für Karies, parodontale und peri-implantäre Entzündung. Parodontitis kann das Risiko für systemische Erkrankungen erhöhen, zum Beispiel für kardiovaskuläre und respiratorische Erkrankungen, Arthritis und Diabetes. Gute Mundhygiene, in Verbindung mit regelmäßiger professioneller Zahnreinigung (PZR), hält den Biofilm unter Kontrolle – für bessere orale und systemische Gesundheit. Axelsson und Lindhe haben in den 1970er Jahren die präventive Zahnheilkunde mit den “Recall- Stunden” begründet. } 1–2

GBT folgt den Empfehlungen zur Professional Mechanical Plaque Removal (PMPR) und den Oral Hygiene Instructions (OHI) der Euro-pean Federation of Periodontology (EFP). } 3–5

“Periodontal Health — for a better life!”

ZAHNREINIGUNG WIRD TRADITIONELL IN DIESER REIHENFOLGE DURCHGEFÜHRT:1 Zahnstein-Entfernung mit Hand-instru-menten und elektrischen Scalern. Dies kann schmerzhaft und invasiv sein und Zahn- und Implantatoberflächen beschädigen.

2 Politur mit rotierenden Gummikelchen und Bürstchen. Dies dauert relativ lange und ist eine schmierige

Angelegenheit. Viele Bereiche werden nicht erreicht und die Gingiva kann verletzt werden. Dentalhygienikerinnen und Prophylaxe-Assistentinnen wissen, dass traditionelle PZR eine schmerzhafte Erfah-rung sein kann. Viele Patienten erscheinen des-halb nicht zum Recall. Jetzt, fast fünfzig Jahre später, ist es Zeit für Veränderungen.

1. Axelsson P. Preventive Materials, Methods and Programs: Quintessence Publishing, 2004. } 2. Axelsson P, Nystrom B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. Journal of Clinical Periodontology 2004;31:749-757. } 3. Tonetti MS, Chapple ILC, Jepsen S, Sanz M. Primary and secondary preventi-on of periodontal and peri-implant diseases. Journal of Clinical Periodontology 2015;42:S1-S4. } 4. Tonetti MS, Eickholz P, Loos BG, Papapanou P, van der Velden U, Armitage G, et al. Principles in prevention of periodontal diseases. Journal of Clinical Periodontology 2015;42:S5-S11. } 5. Sanz M, Bäumer A, Buduneli N, Dommisch H, Farina R, Kononen E, et al. Effect of professional mechanical plaque removal on secondary prevention of periodontitis and the complications of gingival and periodontal preventive measures. Journal of Clinical Periodontology 2015;42:S214-S220.

WARUM GBT EIN GAME CHANGER IST

BEFORE DISCLOSING AFTER DISCLOSING

GAME CHANGER R

13

GBT IS THE NEW AND PATIENT ORIENTED CONCEPT1 Before removal, biofilm is always disclosed with a dye solution. Biofilm and early calculus are easily removed with AIRFLOW® and PERIOFLOW® – supra- and subgingivally.

2 If needed, this is followed by debridement with PIEZON® PS NO PAIN piezoceramic instruments.

3 Guided Biofilm Therapy means that the clinician is guided by the disclosed biofilm during tooth cleaning procedures.

4 Guided Biofilm Therapy is truly minimally invasive and reduces the need for hand and sonic/ultrasonic instrumentation. It is safe, effective and gentle to teeth and soft tissues, implants and restorations.1–4

5 GBT is very comfortable for patients and practitioners.5 It is efficient and timesaving.6 This also valid for primary caries and perio prevention in children and teenagers.

6 GBT is part of a comprehensive preventive concept – to preserve your patients’ oral health – and to make the patients feel good.

7 Since 1982 EMS has provided dental practices all over the world with AIRFLOW® air polishing and PIEZON® PS NO PAIN piezoceramic scaling technology.

8 In 2012 EMS added the high-tech erythritol-based AIRFLOW® PLUS Powder with a particle size of only 14 μm.

9 Guided Biofilm Therapy is based on clinically proven technologies invented by EMS. It was developed in cooperation with highly respected and experienced periodontologists, caries specialists and dental hygienists.

10 GBT is a systematic, predictable, risk-oriented and user-friendly treatment for all age groups and each individual patient.

SMILE IS IN THE AIR

1. Wennstrom JL, Dahlen G, Ramberg P. Subgingival debridement of periodontal pockets by air polishing in comparison with ultrasonic instrumentation during maintenance therapy. Journal of Clinical Periodontology 2011;38:820-827. │ 2. Ronay V, Merlini A, Attin T, et al. In vitro cleaning potential of three implant debridement methods. Simulation of the non-surgical approach. Clinical Oral Implants Research 2017;28:151-155. │ 3. Bühler J, Amato M, Weiger R, Walter C. A systematic review on the effects of air polishing devices on oral tissues. International Journal of Dental Hygiene 2016;14:15-28. │ 4. Barnes CM, Covey D, Watanabe H, et al. An in vitro comparison of the effects of various air polishing powders on enamel and selected esthetic restorative materials. The Journal of Clinical Dentistry 2014;25:76-87. │ 5. Aslund M, Suvan J, Moles DR, et al. Effects of two different methods of non-surgical periodontal therapy on patient perception of pain and quality of life: a randomized controlled clinical trial. Journal of Periodontology 2008;79:1031-1040. │ 6. O‘Hehir TE. How subgingival air polishing will turn dental hygiene upside down. Interview with Prof. Dr. Thomas Flemmig. dentaltown.com 2014:94-96. │ 7. Flemmig TF, Arushanov D, Daubert D, et al. Randomized controlled trial assessing efficacy and safety of glycine powder air polishing in moderate-to-deep periodontal pockets. Journal of Periodontology 2012;83:444-452.

GUIDED BIOFILM THERAPY IST DAS NEUE KONZEPT NACH DEM STAND DER TECHNIK1 Zunächst wird der Biofilm immer mit Färbelösung sichtbar gemacht. Dann werden Biofilm und junger Zahnstein effizient mit AIRFLOW® und PERIOFLOW® entfernt – supra- and subgingival.

2 Wenn notwendig, wird verbleibender Zahnstein mit dem piezo-keramischen Scaler PIEZON® PS No Pain abgetragen.

Guided Biofilm Therapy bedeutet, dass der Behandler während der Zahnreinigung vom angefärbten Bio-film geleitet wird. Guided Biofilm Therapy ist wahr-

haft minimal-invasiv: Sie reduziert den Einsatz von Handinstrumenten und Schall- oder Ultraschall-Scalern auf ein Minimum. GBT ist sicher, effektiv und scho-nend für Zähne, Weichgewebe, Implantate und Restaurationen.} 1–4

GBT ist angenehm für Patienten und Behandler.}5 Sie ist zudem effizient und zeitsparend.} 6 Das gilt auch für Karies- und paro-dontale Prävention bei Kindern und Jugendlichen. GBT ist Teil eines umfassenden präven-

tiven Konzepts. Damit Ihre Patienten oral gesund bleiben – und damit sie sich gut fühlen.

GBT IST EIN KLINISCH BEWÄHRTES UND PATIEN-TENORIENTIERTES KONZEPT Seit 1982 liefert EMS Air-polishing mit

AIRFLOW® und piezokeramisches Scaling mit PIEZON® PS No Pain in zahnärztliche Praxen weltweit: Im Jahr 2003 erfand EMS PERIOFLOW®

für die subgingivale Biofilm-Ent-fernung – kombiniert mit AIRFLOW® Pulver PERIO auf der Basis von Glyzin.} 7 Das war ein wichtiger Paradigmenwechsel in der parodon-talen und präventiven Zahnheilkunde. Im Jahr 2012 kam AIRFLOW® Powder

PLUS hinzu, ein High-Tech-Pulver

auf Erythritol-Basis mit einer Partikelgröße von nur 14 μm. Guided Biofilm Therapy basiert auf klinisch

bewährten Technologien von EMS Dental. Sie wurde entwickelt in Zusammenarbeit mit renommierten und erfahrenen Parodontologen, Kario- logen und Dentalhygienikerinnen. GBT ist ein systematisches, voraus-

sagbares, risiko-orientiertes und anwender-freundliches Behandlungs-konzept. Es lässt sich für alle Altersstufen und jeden Patienten individuell anpassen.

1. Wennstrom JL, Dahlen G, Ramberg P. Subgingival debridement of periodontal pockets by air polishing in comparison with ultrasonic instrumentation during maintenance therapy. Journal of Clinical Periodontology 2011;38:820-827. } 2. Ronay V, Merlini A, Attin T, et al. In vitro cleaning potential of three implant debridement methods. Simulation of the non-surgical approach. Clinical Oral Implants Research 2017;28:151-155. } 3. Bühler J, Amato M, Weiger R, Walter C. A systematic review on the effects of air polishing devices on oral tissues. International Journal of Dental Hygiene 2016;14:15-28. } 4. Barnes CM, Covey D, Watanabe H, et al. An in vitro comparison of the effects of various air polishing powders on enamel and selected esthetic restorative materials. The Journal of Clinical Dentistry 2014;25:76-87. } 5. Aslund M, Suvan J, Moles DR, et al. Effects of two different methods of non-surgical periodontal therapy on patient perception of pain and quality of life: a randomized controlled clinical trial. Journal of Periodontology 2008;79:1031-1040. } 6. O‘Hehir TE. How subgingival air polishing will turn dental hygiene upside down. Interview with Prof. Dr. Thomas Flemmig. dentaltown.com 2014:94-96. } 7. Flemmig TF, Arushanov D, Daubert D, et al. Randomized controlled trial assessing efficacy and safety of glycine powder air polishing in moderate-to-deep periodontal pockets. Journal of Periodontology 2012;83:444-452.

WARUM GBT EIN GAME CHANGER IST

This 14 year old patient has a significant lack of oral hygiene. Disclosing agent reveals massive acidogenic biofilm.

PROBABLY THE BEST PROFESSIONAL TOOTH CLEANING EVER...

2. WHY AIRFLOW® FIRST? AIRFLOW® removes biofilm, stains and colorations first as well as the thin

layers of early forming calculus. Now you will see the remaining calculus better and it will be easier to eliminate it with the PIEZON® NO PAIN PS Instrument. With GBT the removal of calculus in supra- and subgingival areas is easier,

faster and truly minimal invasive. This pain free and comfortable GBT treatment method, if done correctly by

trained GBT dental professionals will help create happy and loyal patients for your recall practice. AIRFLOW® = CASH FLOW.

1. WHY MAKE BIOFILM VISIBLE? With GBT we intend to eliminate all the biofilm, including

areas which are difficult to access. If biofilm is made visible, it is removed much faster with GBT. What you see is what you remove.

Color removal = Biofilm removal. Also on soft tissues. The users of hand instruments, rubber cups and “polishing”

paste do not like to disclose biofilm as they would need much more time to finish the treatment. The German Stiftung Warentest reported that the conventional

prophylaxis only removes 50% of Biofilm in the difficult to access areas. Colored teeth and gums will also help motivate the patient to

improve their homecare – OHI.

14

Courtesy, Dr. Gleb Aseev

PROBABLY THE BEST PROFESSIONAL TOOTH CLEANING EVER...3. WHY ONLY THE PS INSTRUMENT? The PIEZON® PS (Perio Slim) Instrument is slim and smooth like a probe.

It is gum-friendly, minimally invasive, maximally preventive and preserves the epithelium due to its absolute linear movements. By using only one instrument to do 95% of the work, things will be easier.

For the 5% that remain we recommend our new curved PIEZON® PSL and PSR (Perio Slim Left and Right) Instruments. The PIEZON® PS Instrument gives the clinician a good haptic and secure feeling when working subgingival.

The treatment with the PS instrument is Pain Free if used the correct way. A Pain Free and pleasant treatment is the dream of every patient.

This is the key for patient loyalty and satisfaction. The cost of a PS instrument is only 5 cents per treatment and per patient!

It is absolute nonsense to buy copy or “compatible” tips. If EMS handpieces get damaged (e.g. the thread) with a “compatible“ tip you will

lose your EMS warranty. The PIEZON® PS Instrument, the PIEZON® Handpiece and the PIEZON® NO PAIN

electronic module were made/matched for each other. This Trilogy works in harmony.

4. WHY NO MORE „POLISHING“ PASTE?

THE GLASS PLATE TEST: Touch the glass plate with the PS instrument on its side as shown on the left, set the Piezon to medium power, apply gentle pressure, turn on the spray and you won’t hear anything – acoustic proof that you have the right instrument in your hand.Now allow a small lump of dental cement to harden on the glass plate. Then lay the instrument to one side on the glass plate as in the previous test and guide it towards the “tartar”. You will notice that it disappears instantly. That is precisely what makes it so different from other instruments which do not move in such a controlled and consistent fashion.

TOOTH ENAMEL x2000

BEFORE CLEANING,RESIDUAL BIOFILM

The enamel prisms of the natural tooth enamel are easily recognizable. The photo shows the remnants of the bacteria killed off with sodium hypochlorite.1

The vital enamel prisms have been „polished“ away. Pastes have caused scratches. Biofilm has spread into natural crevices. Overall abrasive pastes cause

a loss of valuable enamel. No improvement of the dental surface.1

AFTER CLEANING WITHAIRFLOW® PLUS POWDER

The biofilm has been removed with AIRFLOW®. The surface is clean down to the pores. No abrasion. The enamel prisms remain intact and the surface is perfectly smooth.The tongue no longer feels any roughness - no need to „polish“ with abrasive paste. Save enamel and treatment time.1

1 Camboni S, Donnet M. The Journal of Clinical Dentistry 2016;27:13-18.

15

TOOTH ENAMEL x2000 TOOTH ENAMEL x2000

AFTER „POLISHING“ WITHLOW-ABRASIVE PASTE RDA 27

R

R

ONE POWDER ONLY

OPTIMAL COMFORTMINIMALLY INVASIVEMAXIMALLY PREVENTIVE

TEETH Primary and permanent teeth Interdental spaces Crowded teeth Exposed dentine Pits and fissures Demineralized enamel

CARIES MANAGEMENT Before caries detection Before sealing Before fluoridation

SOFT TISSUES Sulcus Shallow pockets up to 4mm Deep pockets >4 to 9mm* Tongue and palate

ORTHODONTICS Orthodontic brackets Patients with Invisalign

AESTHETIC DENTISTRY Crowns and veneers Before placing restorations Before bleaching

IMPLANTS Peri-implant sulcus Deep peri-implant pockets

FOR 90% OF ALL CASES

116* Approved for 5 mm in the U.S. - 9 mm in Canada

OPTIMAL COMFORTMINIMALLY INVASIVEMAXIMALLY PREVENTIVE

SUPRAGINGIVAL Primary and permanent teeth Best interproximal access1

Crowded teeth Exposed dentine

SUBGINGIVAL Sulcular deposits Preserves the epithelium Pockets up to 10mm

ORTHODONTICS Around orthodontic brackets

FOR 95% OF ALL CASESONE INSTRUMENT ONLY

1 Clinical Reasearch Associates, Newsletter.

17

THE AIRFLOW® PROPHYLAXIS MASTER

THE SWISS ORIGINAL.

The original from the Inventor. Guaranteed Swiss precision and superb design. Highest performance, reliability and know-how. Experts in prophylaxis since 1981.

18

1 GOOD DESIGN®, one of the most important design awards in the world from the Chicago Athenaeum Museum of Architecture and Design.

THE CHICAGO ATHENAEUM

2018

1

GOODDESIGN

DAS AIRFLOW® PROPHYLAXIS MASTER TISCHGERÄT

Das Original vom Erfinder. Garantierte Schweizer Präzision und unvergleichliches Design. Zuverlässigkeit und Know-How seit 1981.

THE SWISS MASTER.THE PROPHYLAXIS STATION

The Swiss-Made AIRFLOW® Prophylaxis Master was developed at the EMS Research Centre with more than100 000 hours of technical and clinical testing in collaboration with leading dental professionals worldwide.

19

1 GOOD DESIGN®, one of the most important design awards in the world from the Chicago Athenaeum Museum of Architecture and Design.

DIE STAND-ALONE AIRFLOW® STATION

Der Swiss Made AIRFLOW® Prophylaxis Master wurde im EMS Research Centre in mehr als 100.000 Stunden technischer und klinischer Testdauer entwickelt – in Zusammenarbeit mit führen-den Zahnmedizinern weltweit.

R

04 AIRFLOW®

AIRFLOW® REMOVES BIOFILM, STAINS & EARLY CALCULUS.CLEANS AND POLISHES AT THE SAME TIME. After the use of AIRFLOW® no extra polishing with rubber cups/paste is

necessary any more. Dental practices using AIRFLOW® and GBT have more and happier recall patients. Professional prophylaxis is becoming an important economic factor.1

AIRFLOW® removes biofilm and early calculus in all these situations. It also cleans the gingival or peri-implant sulcus to a depth of 4mm.2–4 At the same time AIRFLOW® is fast, efficient and comfortable for the patient. Fine tune the air pressure/power for all clinical situations.

1. O‘Hehir TE. dentaltown.com 2014(1):94-96. │ 2. Patil SS, et al. J Intern Soc Prev & Commun Denti2015;5:457-462. │ 3. Flemmig TF, et al. J Periodontol 2007;78:1002-1010. │ 4. Botti RH, et al. Eur J Paediatr Dent 2010;11:15-18.

20

04 AIRFLOW®

BIOFILM UND JUNGEN ZAHNSTEIN ENTFERNEN. REINIGEN UND POLIEREN IN EINEM SCHRITT. Nach Anwendung von AIRFLOW® ist keine separate Politur mit Gummkelchen und Paste

mehr notwendig. Praxen, die AIRFLOW® und GBT verwenden, haben mehr und glücklichere Recall-

Patienten. Professionelle Zahnreinigung wird für die Praxis zu einem wichtigen wirtschaftlichen

Faktor.} 1

DOPPEL-SPRAYPulver innen

Spülung aussen

Viele Bereiche können mit Gummikelchen und Polierpasten nicht gereinigt werden: Approximalflächen, besonders bei engstehenden Zähnen Freiliegende Zahnhälse (Dentin wird abradiert) Fissuren und Grübchen Orthodontische Brackets

AIRFLOW® entfernt Biofilm und jungen Zahnstein in allen diesen Bereichen.} 2–4 AIRFLOW® reinigt auch den gingivalen und peri-implantären Sulkus bis zu einer Tiefe von 4 mm. Zugleich ist die Technik schnell, effizient und angenehm für Patienten.1. O‘Hehir TE. dentaltown.com 2014(1):94-96. } 2. Patil SS, et al. J Intern Soc Prev & Commun Denti2015;5:457-462. } 3. Flemmig TF, et al. J Periodontol 2007;78:1002-1010. } 4. Botti RH, et al. Eur J Paediatr Dent 2010;11:15-18.

TONGUE AND PALATE

ABOV

E CEMENTO-ENAMEL JUNCTION

SUBGINGIVALAROUND BRACKETS

THE MULTITASKER

ON PRIMARY TEETH

INTERDENTAL

EXPOSED DENTINE

ON RESTORATIONS

4MM

AROUND IMPLANTSBEFORE BLEACHING

IN PITS AND FISSURES


21

x2000 x2000 x2000

SCHMELZOBERFLÄCHE MIT BIOFILMRESTEN VOR DER REINIGUNG. Die natürlichen Schmelzprismen

sind leicht zu erkennen. Das Bild zeigt die Reste von Bakterien, die mit Natriumhypochlorit abgetötet wurden.} 5

SCHMELZOBERFLÄCHE NACH POLITUR MIT GERING ABRASIVER PAS-TE (RDA 27). Die Schmelzprismen wurden

wegpoliert. Die Paste hat zu Kratzern geführt, Biofilm wurde in die natürlichen Vertiefungen poliert. Abrasive Pasten können zum

Verlust von wertvollem Schmelz führen.} 5 Von wegen Glättung und Vergütung.

SCHMELZOBERFLÄCHE NACH REINIGUNG MIT AIRFLOW® POWDER PLUS Der Biofilm wurde mit

AIRFLOW® vollständig entfernt. Die Oberfläche ist porentief sauber. Keine Abrasion: Die Schmelzpris-men sind intakt und die Oberfläche ist glatt. Die Zunge fühlt keine Rauigkeit mehr und die Oberfläche muss nicht mit (abrasiven) Polier-pasten gereinigt werden. Das spart Zahnsubstanz – und Behandlungs-zeit.} 5

5. Camboni S, Donnet M. The Journal of clinical dentistry 2016;27:13-18.

OBERHALB SCHMELZ-ZEMENT-GRENZE

SUBGINGIVAL BIS 4 MM

SUBGINGIVAL BIS 4 MM UM IMPLANTATE AIRFLOW® PLUS

BEVOR AIRFLOW® NACH AIRFLOW®

ABRASIV? VON WEGEN! R

AIRFLOW® POWDERS

OSSPRAYCALCIUM SODIUM

PHOSPHOSILICATE1EMS AIRFLOW® PLUS

POWDER ERYTHRITOL2

EFFECT OF 5 SEC AIR POLISHING ON HUMAN ENAMEL

EFFECT OF 5 SEC AIR POLISHING ON GLASS IONOMER

EMS SODIUMBICARBONATE3

1. Barnes CM, et al. J Clin Dent 2014;25:76-87. │ 2. For AIRFLOW® PLUS Powder, complimentary tests have been submitted to the J Clin Dent (Barnes CM, et al.). │ 3. Barnes CM, et al. J Clin Dent 2014;25:76-87. The EMS sodium bicarbonate had a particle size of 65 μm. New Powder AIRFLOW® CLASSIC Comfort has 40 μm particle size, for more smoothness and patient comfort.

22

Objective: The purpose of this study1 was to investigate the effects of each of the commercially available air polishing powders on the surface characterization of human enamel, hybrid composite, and glass ionomer using a highly standardized protocol. The air polishing powders utilized in the study included aluminum trihydroxide, calcium carbonate, calcium sodium phosphosilicate, glycine, and sodium bicarbonate.

THERE ARE DAMAGING POWDERS IN THE MARKET Based on the results of this study, the air polishing powders that are compatible with use on hybrid

composite and glass ionomer cements are EMS glycine and EMS sodium bicarbonate. The air polishing powders that are compatible for use on enamel include EMS glycine, Dentsply sodium bicarbonate, and EMS sodium bicarbonate. In the study a particle size of 65μm of the EMS powder was used.Since 2013, EMS has reduced the particle size of its Comfort sodium bicarbonate Powder to only 40μm. “The results of this research indicate that there are air polishing powders that are significantly less abrasive

than others, even with similar ingredients, specifically sodium bicarbonate.“ Please read the full study, just

download the QR code below.

ERYTHRITOL 14μm PLUS POWDER Today, EMS offers an even better

erythritol based prophylaxis powder, which enables supra- and subgingival treatment with superior comfort and efficiency than glycine powder.

Download full study

STUDY FROM BARNES, ET AL J CLIN DENT 2014, 25-76-87 ON POWDER ABRASITIVITY.AIRFLOW® PULVER PLUS IST DAS ERSTE HIGH-TECH-PULVER ZUR ENTFERNUNG VON BIOFILM UND JUNGEM ZAHNSTEIN VON: Schmelz Dentin Weichgeweben Zunge und Gaumen Milchzähnen Orthodontischen Brackets Implantatoberflächen Restaurationen

AIRFLOW® PULVER

WETTBEWERB-PRODUKT EMS POWDER PLUS

EFFEKT VON 5 SEKUNDEN AIRPOLISHING AUF SCHMELZ}1,2

EFFEKT VON 5 SEKUNDEN AIRPOLISHING AUF

EMS NATRIUM-

1. Barnes CM, et al. J Clin Dent 2014;25:76-87. } 2. Note: In the study by Barnes, J Clin Dent 2014, the EMS sodium bicarbonate had a particle size of 65 μm. New Powder CLASSIC COMFORT has 40 μm particle size, for more smoothness and patient comfort. } 3. Note: For Powder PLUS complimentary tests have been submitted to the J Clin Dent (Barnes CM, et al.)

EMS POWDER GUIDE

RECOMMENDED

OTHER EMS POWDERS

Name

Ref

Flavor

Composition

Particle size

pH

Teeth

Soft tissues

Restorations

Implants

Orthodontics

With 2 chemical laboratories in Germany and Switzerland, EMS is the only company producing its own powder. With 35 years of clinical research and testing, many scientific studies and millions of patients treated, EMS recommends the following 2 powders for all clinical cases.

PLUS

DV-082

NEUTRAL

ERYTHRITOL

~14μm

~7

CLASSICCOMFORT

DV-048

LEMONMINT

CHERRYNEUTRAL

SODIUMBICARBONATE

~40μm

~8.1

CLASSIC

DV-048/LEM/65

LEMON

SODIUMBICARBONATE

~65μm

~8.1

SOFT

DV-071

NEUTRAL

GLYCINE

~65μm

~6

PERIO

DV-070

NEUTRAL

GLYCINE

~25μm

~6

Stains and early calculus

Enamel

Enamel white spots

Pits and fissures

Dentine

Gingiva

Tongue and palate

Hybrid composite

Glass ionomer

...and peri-implant tissues

Brackets and appliances

23

Use only EMS powders with your EMS devices. The use of not authorized powders by EMS will result in a loss of warranty.

Beware of so-called „EMS compatible“ powders in the market, which can damage oral tissues and the device. See here a nozzle completely damaged by such aggressive powders.



3 PULVERSPRAY-

DÜSEN+ Wasser

PERIOFLOW® UND PLUS PULVER SIND INDIZIERT FÜR: Entfernung von subgingivalem Biofilm (Debridement)

in parodontalen}1 und peri-implantären}2 Taschen von >4 bis 9 mm Initiale Parodontaltherapie und Nachsorge (UPT)}3 Prävention von Mukositis und Peri-Implantitis4} 4 Initiale Therapie und Nachsorge von Mukositis und Peri-Implantitis} 5

05 PERIOFLOW®

1. Sculean A, et al. Quintessence Int 2013;44:475-477. } 2. Schwarz F, et al. Quintessence Int 2016;47:293-296. } 3. Flemmig TF, et al. J Periodontol 2012;83:444-452. } 4. Muller N, et al. J Clin Periodontol 2014;41:883-889. } 5. Riben-Grundstrom C, et al. J Clin Periodontol 2015;42:462-469

R

3 POWDER SPRAYS

+ water rinsing

05 PERIOFLOW®

1. Sculean A, et al. Quintessence Int 2013;44:475-477. │ 2. Schwarz F, et al. Quintessence Int 2016;47:293-296. │ 3. Flemmig TF, et al. J Periodontol 2012;83:444-452. │ 4. Muller N, et al. J Clin Periodontol 2014;41:883-889. │ 5. Riben-Grundstrom C, et al. J Clin Periodontol 2015;42:462-469

R

NEW PERIOFLOW®

NOZZLE

24

Subgingival biofilm removal (debridement) in >4 to 9 mm* periodontal1 and peri-implant2 pockets Initial and follow-up (SPT) periodontal therapy3 Prevention of mucositis / peri-implantitis4 Initial and follow-up treatment of mucositis / peri-implantitis5


NEW PERIOFLOW® NOZZLE

PERIODONTAL POCKETS PERI-IMPLANT POCKETS

The new PERIOFLOW® Nozzles are thinner and more flexible and able to adapt to the topography of periodontal/peri-implant pockets. A pressure release groove limits pressure in periodontal/peri-implant pockets.

PERIOFLOW® APPLICATIONS

9 mm7 mm5 mm3 mm

25

FIRST TO GO SUBGINGIVAL

9MM

AROUND IMPLANTS

9MM

SUBGINGIVAL IN ROOT FURCATIONS

ROOT FURCATION

EMS invested in research on safety matters before it decided to offer the subgingival PERIOFLOW® application.EMS‘ main concern was to limit risks of emphysema.In 2019 at IDS, EMS will offer for sale the third generation new PERIOFLOW® exchangeable nozzle - slimmer, safer and easier to use.

*

*

R


06 PS INSTRUMENT

1. NO PAIN: when used in accordance with EMS instructions and/or the training by the Swiss Dental Academy.2. CRA, Clinical Research Associates, USA. Newsletter June 1998.

AFTER USINGAIRFLOW®,REMOVE REMAINING SUPRA- AND SUBGINGIVAL CALCULUS WITH THE PIEZON® NO PAIN1 PS INSTRUMENT. Linear movement of the PS Instrument

= no damage to tooth surfaces and soft tissues. Minimally invasive with regard to root cementum. Dynamic power setting. “EMS PS (Perio Slim) Instrument delivers the best

interproximal and subgingival access.”2

Patients will be surprised as the treatment with the PIEZON® PS Instrument will be entirely Pain Free when used in the correct way by Dental Professionals.

26

06 PIEZON® PS NO PAIN

*No PAIN: wenn verwendet gemäss EMS Gebrauchsinformation und/oder Trainingskursen der Swiss Dental Academy.**CRA, Clinical Research Associates, USA

NACH BIOFILMENTFERNUNG MIT AIRFLOW® ENT-FERNEN SIE VERBLEIBENDEN SUPRA- UND SUB-GINGIVALEN ZAHNSTEIN MIT PIEZON® NO PAIN* UND DEM PS INSTRUMENT. Lineare Bewegung des PS Instruments = intakte Zahnoberfläche

und intaktes Weichgewebe. Minimal-invasiv gegenüber Wurzelzement. Dynamische Leistungsanpassung. “EMS Perio Slim Instruments hatten den besten approximalen und

subgingivalen Zugang.”**

CALCULUS REMOVAL WITH EMS PIEZON® PS INSTRUMENT

PHOTOS: COURTESY, PROF. MAGDA MENSI

AFTERAIRFLOW®

AFTERPIEZON®

95% OF ALL CASES

27

EMS PS PERIO SLIM INSTRUMENT IS INDICATED FOR 95% OF ALL CASES.

ON PRIMARY TEETH

10MM

SUPR

A & SUBGINGIVAL

PS - THE ONE AND ONLY

DAS INSTRUMENT

ZAHNSTEIN-ENTFERNUNG MIT DEM EMS PIEZON® PS INSTRUMENT

PRÄZISE KARIESDIAGNOSE

MIT FREUNDLICHER GENEHMIGUNG VON DR. WOLFGANG GUTWERK

MIT FREUNDLICHER GENEHMIGUNG VON PROF. MAGDA MENSI

VOR ANFÄRBUNG

VOR GBTKariöse Läsionen können verborgen sein

NACHAIRFLOW®

NACH GBTLäsionen gut sichtbar auf sauberen Zähnen

NACHPIEZON®

NACH ANFÄRBUNG

EMS PI INSTRUMENT

IMPLANTATREINIGUNG

EMS PS PERIO SLIM INSTRUMENT INDIZIERT IN 95 % ALLER FÄLLE.

R

07 CARIES CHECKThe following dental surfaces are most at risk for caries1,2: 1 - Occlusal. 2 - Approximal. 3 - Cervical areas.

In these areas: GBT helps effectively remove the biofilm and prevent

caries in a minimally invasive way.

CARIES DETECTION REQUIRES CLEAN TEETH

COURTESY, PROF. DENT. ADRIAN LUSSI , BERN/SWITZERLAND

BEFORE GBTIn this case: biofilm, no white spot.

AFTER GBTIn this case: white spots are revealed.

BEFORE TREATMENTCarious lesions may be hidden

AFTER GBTLesions are fully visible on clean teeth

COURTESY, DR. WOLFGANG GUTWERK ASCHAFFENBURG/GERMANY

1 OCCLUSAL

2 APPROXIMAL

3 CERVICAL

AFTER GBTDentine caries is revealed

At an early stage of demineralization, caries is often hard to detect even with X-rays. Biofilm and calculus may conceal them. The International Caries Detection and Assessment System - ICDAS (2011) underscores the importance of „clean and dry“ surfaces for accurate detection.

COURTESY, PROF. DENT. HERVÉ TASSERY , MARSEILLE/FRANCE

BEFORE GBTThe caries is not detectable

3

1

2

28

3

AIRFLOW® BEFORE COMPOSITE RESTORATIONS

The width of occlusal fissures of cavities is often less than 100μm. This is less than toothbrush bristles and any hand instrument.

Disclosing + AIRFLOW® sequence supporting early caries treatment: After an initial biofilm disclosure, the fissure is cleaned with AIRFLOW® PLUS 14μm Powder. If needed, enlarge the fissure with 40μm CLASSIC Comfort Powder and polish with PLUS Powder. Burs can be used selectively in addition to AIRFLOW® if the lesion is still present. Clean with AIRFLOW® erythritol prior to sealing enables optimal adhesion.


14µm PLUS POWDER AND EARLY TREATMENT

AND EARLY TREATMENT

DISCLOSED


SUBGINGIVAL

IN PITS AND FISSURES

INTERDENTAL


29

BEFORE GBT DISCLOSED AIRFLOW® MAGNIFIED SEALED

R

GBT IS COOL...*

“With the EMS devices, we can motivate our patients in terms of prophylaxis. Through a pleasant feeling in the mouth – WELLNESS factor. Removal of stains – BEAUTY factor. 100% plaque removal – HEALTH factor.” MICHAELA GRUL

“Due to the small particle size of the product, especially the Plus powder, there is practically no traumatic gingivitis anymore…We were able to increase turnover in the area of prophylaxis by approx. 50 percent from 2015 to 2016, which is surely also due to the now much more pleasant treatment. The reactions were positive without exception.” DIRK PALME, DENTIST

“I do not want to do without Airflow technology or air-polishing in my everyday work. Gentle on substance, clean, pleasant for patients and quicker, particularly in the interdental spaces. The results are accordingly good. Less inflammation, and the tooth necks are no longer sensitive after treatment.”PETRA NATTER, DENTAL HYGIENIST

“I’m so happy with GBT, I could not accept any other tooth cleaning method anymore. Due to GBT I see my dentist regularly and gladly for my prophylaxis. And each time I leave the office I’m happy with my clean and brilliant white smile! To me prophylaxis with GBT has become a great experience and I dearly recommend it!”SABINE PAVICIC, PATIENT

“The devices of the company EMS helped us very much to simplify the procedure protocol of our “prophylaxis sessions”, to make it more gentle on substance and more patient-friendly (less pain). After more than 3 years, prophylaxis has become a technically and economically very important part of our dental practice thanks also to the scientific and technical competence (e.g. NO PAIN with PS tip, PLUS Powder) of EMS.”

DR. NADINE STRAFELA-BASTENDORF, DENTIST

“Patients started to book in particularly with me. They thought I was more gentle than the other hygienists and their mouths were feeling better than ever.The bosses had also noticed a seemingly higher standard of treatment being delivered with lower bleeding scores and cleaner mouths coming from my surgery.They thought it was me. They thought I was more skilled. A better motivator. An exceptional communicator.It wasn’t me. It was the AIRFLOW®.” FAYE DONALD, BEST UK DENTAL HYGIENIST 2014 AND 2017

30

PATIENTS AND USERS ARE FANS

MORRIS MEYER (9 YEARS)

“AIRFLOW®

IS COOL -

SUPER

COOL.”

31

R

01 ASSESSAnamnesis: review the case history1 of your patient and raise awareness of caries promoting and reducing factors2.Pre-rinse with BacterX® Pro3.After patient and clinician preparation4, perform the periodontal probing and screening5.

02 DISCLOSEApply disclosing solution6,7, then rinse with water.

03 MOTIVATEShow your patients the disclosed biofilm6,7 and provide appropriate oral hygiene instruction6. EMS recommends Philips Sonicare8,9.

04 AIRFLOW®

Remove stains10, biofilm11,12 and early calculus supra- and subgin-givally up to 4mm on natural teeth13, implants14, restorations, orthodontic brackets13, dentine15 and soft tissues16,17,18.

05 PERIOFLOW®

Remove biofilm in 4-9 mm* periodon-tal and peri-implant pockets11,17,18,19.

06 PIEZON®

Remove calculus20,21 on natural teeth up to 10 mm subgingi-vally22,23 with PS Instrument NO PAIN24 and on implants up to 3 mm subgingivally with PI Instrument.

07 CHECKCheck for any remaining biofilm, stains and calculus. Diagnose caries2 and other dental hard-tissue defects, protect with fluoride25 and inform the patient on personal preventive measures26.

08 RECALLSchedule next recall appointment adapting recall frequency to individual risk27,28.

CLINICAL EVIDENCE

32* Approved for 5 mm in the U.S. - 9 mm in Canada

33

1 ADHA – Standards for clinical dental hygiene practice (page 6)American Dental Hygienists’ Association, adopted March 2008, revised 2016 / Stainbach P, Smith M, Burch S. “A health history assessment includes multiple data points that are collected through a written document and an oral interview. The process helps build a rapport with the patient and verifies key elements of the health status. Information is collected and discussed in a location that ensures patient privacy and complies with the Health Insurance Portability and Accountability Act (HIPAA).”

2 WHITE PAPER ON DENTAL CARIES PREVENTION AND MANAGEMENT: A summary of the current evidence and the key issues in controlling this preventable disease (pages 23-25) FDI World Dental Federation 2016 / Pitts N, Zero D.Risk assessment must be considered as an essential component in the clinical decision-making process in dental practice to determine the appropriate level of patient care.

3 REDUCTION OF SALIVARY BACTERIA BY PRE-PROCEDURAL RINSES WITH CHLORHEXIDINE 0.12%Journal of Periodontology 1991, 62(11) / Veksler AE, Kayrouz GA, Newman MG.Pre-procedural rinsing with CHX has a profound and sustained effect on the aerobic and facultative flora of the oral cavity, which may contribute to a variety of clinical benefits. Pre-procedural rinsing may also be of value in protecting patients and dental professionals during dental manipulations.

4 AEROSOL, A HEALTH HAZARD DURING ULTRASONIC SCALING: A clinico-microbiological study Indian Journal of Dental Research 2016, 27(2) / Singh A, Shiva Manjunath RG, Singla D, Bhattacharya HS, Sarkar A, Chandra N. The aerosols and splatters produced during dental procedures have the potential to spread infection to dental personnel. Therefore, proper precautions should be taken to minimize the risk of infection to the operator.

5 ADHA – Standards for clinical dental hygiene practice (page 7) American Dental Hygienists’ Association, adopted March 2008, revised 2016 / Stainbach P, Smith M, Burch S. A comprehensive periodontal examination is part of clinical assessment.

6 EFFECT OF VISUAL METHOD VS PLAQUE DISCLOSURE IN ENHANCING ORAL HYGIENE IN ADOLESCENTS AND YOUNG ADULTS: a single-blind randomized controlled trial American Journal of Orthodontics and Dentofacial Orthopedics 2014, 145(3) / Peng Y, Wu R, Qu W, Wu W, Chen J, Fang J, Chen Y, Farella M, Mei L. The use of images showing the severe consequences of biofilm accumulation enhanced the oral hygiene of patients treated with fixed appliances.

7 EFFECTIVENESS OF PLAQUE INDICATORS AND AIR POLISHING FOR THE SEALING OF PITS AND FISSURESEuropean Journal of Paediatric Dentistry 2010, 11(1) / Botti RH, Bossù M, Zallocco N, Vestri A, Polimeni A.Disclosing agent is a must before cleaning pits and fissures. Air polishers ensure complete removal of plaque from the tooth before placing a sealing material.

8 IN VITRO TOOTH CLEANING EFFICACY OF ELECTRIC TOOTHBRUSHES AROUND BRACKETSEuropean Journal of Orthodontics 2010, 32(5) / Schätzle M, Sener B, Schmidlin PR, Imfeld T, Attin T.

9 THE EFFECT OF USE OF A SONIC POWER TOOTHBRUSH AND A MANUAL TOOTHBRUSH CONTROL ON PLAQUE AND GINGIVITISThe Journal of Clinical Dentistry 2017 Mar;28(1 Spec No A):A1-6 / Delaurenti M, Ward M, Souza S, Jenkins W, Putt MS, Milleman KR, Milleman JL.

10 CLINICAL COMPARISON OF THE STAIN REMOVAL EFFICACY OF TWO AIR POLISHING POWDERSEuropean Journal of Dental Education 2017 Jul-Sep;11(3):370-375 / Shukla HR, Mathur A, Shetty N, Makhijani B, Manohar B.The 40 μm sodium bicarbonate powder removed dental stains as efficiently as the 65-μm powder. Powder handling and patient acceptance were comparable between grain sizes of 65 and 40 μm.

11 CLINICAL OUTCOMES FOLLOWING SUBGINGIVAL APPLICATION OF A NOVEL ERYTHRITOL POWDER BY MEANS OF AIR POLISHING IN SUPPORTIVE PERIODONTAL THERAPY: a randomized, controlled clinical studyQuintessence International 2013 Nov-Dec;44(10):753-61 / Hägi TT, Hofmänner P, Salvi GE, Ramseier CA, Sculean A.The new erythritol powder applied with an air-polishing device can be considered a promising modality for repeated instrumentation of residual pockets during supportive periodontal therapy.

12 BIOFILM REMOVAL AND ANTIMICROBIAL ACTIVITY OF TWO DIFFERENT AIR-POLISHING POWDERS: AN IN VITRO STUDY Journal of Periodontology 2014, Nov;85(11) / Drago L, Del Fabbro M, Bortolin M, Vassena C, De Vecchi E, Taschieri S.Biofilm removal with air polishing could be achieved with the combination of erythritol and chlorhexidine as it seems to be a good alternative to the traditional glycine treatment.

13 AIR POLISHING: A REVIEW OF CURRENT LITERATUREThe Journal of Dental Hygiene 2013, 87(4) / Graumann SJ, Sensat ML, Stoltenberg JL.The effect of air-powder polishing on hard and soft tissues, restorative materials, sealants, orthodontic appliances and implants, as well as health risks and contraindications to air polishing are discussed.

14 A NEW MULTIPLE ANTI-INFECTIVE NON-SURGICAL THERAPY IN THE TREATMENT OF PERI-IMPLANTITIS: A CASE SERIESMinerva Stomatologica 2017, 66(6) / Mensi M, Scotti E, Calza S, Pilloni A, Grusovin MG, Mongardini C.Within the limits of this study, the MAINST protocol showed improvement of clinical parameters for the treatment of peri-implantitis, which were maintained for up to 12 months.

15 A BIOFILM POCKET MODEL TO EVALUATE DIFFERENT NON-SURGICAL PERIODONTAL TREATMENT MODALITIES IN TERMS OF BIOFILM REMOVAL AND REFORMATION, SURFACE ALTERATIONS AND ATTACHMENT OF PERIODONTAL LIGAMENT FIBROBLASTS PLoS One 2015 Jun 29;10(6):e0131056 / Hägi TT, Klemensberger S, Bereiter R, Nietzsche S, Cosgarea R, Flury S, Lussi A, Sculean A, Eick S.Compared to hand instrumentation the application of ultrasonication and of air-polishing with erythritol prevents from substance-loss and results in a smooth surface with nearly no residual biofilm that promotes the reattachment of periodontal ligament fibroblasts.

16 AN IN VITRO COMPARISON OF THE EFFECTS OF VARIOUS AIR POLISHING POWDERS ON ENAMEL AND SELECTED ESTHETIC RESTORATIVE MATERIALSThe Journal of Clinical Dentistry 2014, 25(4) / Barnes CM, Covey D, Watanabe H, Simetich B, Schulte JR, Chen H.Air polishing powders compatible with enamel are EMS glycine and EMS sodium bicarbonate powders.

17 A PARADIGM SHIFT IN MECHANICAL BIOFILM MANAGEMENT? SUBGINGIVAL AIR POLISHING: a new way to improve mechanical biofilm management in the dental practiceQuintessence International 2013, 44(7) / Sculean A, Bastendorf KD, Becker C, Bush B, Einwag J, Lanoway C, Platzer U, Schmage P, Schoeneich B, Walter C, Wennström JL, Flemmig TF. Subgingival air-polishing with glycine powder is efficient, fast, comfortable and safe.

18 RANDOMIZED CONTROLLED TRIAL ASSESSING EFFICACY AND SAFETY OF GLYCINE POWDER AIR POLISHING IN MODERATE-TO-DEEP PERIODONTAL POCKETSJournal of Periodontology 2012 Apr;83(4):444-52 / Flemmig TF, Arushanov D, Daubert D, Rothen M, Mueller G, Leroux BG. The results indicate that supragingivally applied glycine powder air polishing is more efficacious in removing subgingival biofilm in moderate-to-deep periodontal pockets than scaling and root planing. Furthermore, full-mouth glycine powder air polishing may result in a beneficial shift of the oral microbiota and appears to be well tolerated.

19 SUBGINGIVAL AIR-POLISHING WITH ERYTHRITOL DURING PERIODONTAL MAINTENANCE: randomized clinical trial of twelve monthsJournal of Clinical Periodontology 2014, 41(9) / Müller N, Moëne R, Cancela JA, Mombelli A.Repeated subgingival air-polishing reduced the number of pockets >4 mm similar to ultrasonic debridement. It was safe and induced less pain.

20 PENETRATION DEPTHS WITH AN ULTRASONIC MINI INSERT COMPARED WITH A CONVENTIONAL CURETTE IN PATIENTS WITH PERIODONTITIS AND IN PERIODONTAL MAINTENANCEJournal of Clinical Periodontology 2008, 35(1) / Barendregt DS, Van der Velden U, Timmerman MF, Van der Weijden F.In untreated periodontitis patients, the ultrasonic tip penetrated the pocket deeper than the pressure-controlled probe and the Gracey curette.

21 SUBGINGIVAL DEBRIDEMENT OF PERIODONTAL POCKETS BY AIR POLISHING IN COMPARISON WITH ULTRASONIC INSTRUMENTATION DURING MAINTENANCE THERAPYJournal of Clinical Periodontology 2011 Sep;38(9):820-7 / Wennström JL, Dahlén G, Ramberg P. This short-term study revealed no pertinent differences in clinical or microbiological outcomes between subgingival air polishing and ultrasonic debridement of moderate deep pockets in supportive periodontal therapy patients.

22 A CLINICAL COMPARAISON OF THE EFFICACY AND EFFICIENCY OF TWO PROFESSIONAL PROPHYLAXIS PROCEDURES IN ORTHODONTIC PATIENTSEuropean Journal of Orthodontics 1999, 21 / Ramaglia L. In orthodontic patients, use of air polishing is a lot more safer, efficient and effective to remove stains and dental plaque in comparison to rubber cup and pumice.

23 IN-VITRO STUDY OF SURFACE CHANGES IN FIXED ORTHODONTIC APPLIANCES FOLLOWING AIR POLISHING WITH CLINPROTM PROPHY AND AIRFLOW®

Journal of Orofacial Orthopedics 2009, 70 / Benedict W, Shervin V, Dieter D AIRFLOW® is unproblematic due to minimal increase in friction. Use of glycine and sodium bicarbonate powders is suitable on metal and ceramic brackets. When plastic brackets are used, glycine is recommended due to its lower abrasiveness. Sodium bicarbonate causes greater roughness and subsequent plaque accumulation.

24 PAIN PERCEPTION DURING DEBRIDEMENT OF HYPERSENSITIVE TEETH ELICITED BY TWO ULTRASONIC SCALERS Clinical Oral Investigations 2017, 21(5) / Müller S, Huber H, Goebel G, Wimmer G, Kapferer-Seebacher I. Both ultrasonic devices showed very small pain intensities during debridement of highly hypersensitive teeth and can therefore be recommended for supportive periodontal therapy.

25 FDI - Promoting Oral Health Through FluorideFDI World Dental Federation, revised August 2017

26 EXPOSURE TIME OF ENAMEL AND DENTINE TO SALIVA FOR PROTECTION AGAINST EROSION: a study in vitroCaries Research 2006, 40(3) / Wetton S, Hughes J, West N, Addy M. Salivary pellicle offered proportionately greater protection to enamel than dentine. Cautiously extrapolating these in vitro data suggests that pellicle should offer erosion protection to individuals who imbibe acidic drinks at frequencies of 1 h or less.

27 ADHA - Clinical Practice Guidelines for Recall and Maintenance of Patients with Tooth-Borne and Implant-Borne Dental Restorations. American Dental Hygienists’ Association / Brida AS, Daubert DM, Garcia LT, Kosinsky TF, Nenn CA, Olsen JA, Platt JA, Wingrove SS, Chandler ND, Curtis DA Baseline for recall regimen, professional maintenance regimen and at-home maintenant regimen for patients with tooth- and implant-borne removable and fixed restorations.

28 DENTAL RECALL: recall interval between routine dental examinations – appendix G National Collaborating Centre for Acute Care. 2004 Oct. A Azaripour et al Guideline to select the appropriate recall interval for an individual patient.

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