Hi Ron,

I have a big problem with my ‘non-surgical’ (meaning no-flap and no sutures) perio approach.  The problem is that it’s TOO effective.  Damn!  I LOVE, LOVE, LOVE perio surgery and bone regeneration procedures.  And now I just don’t get much chance to do them.

I don’t follow all the ‘rules’.  I don’t expect ANYbody to follow my lead, because I don’t have any formal publications/studies/scientific numbers, etc.  This is one of these things that makes sense to ME, works for ME, is used by ME, and I’m NOT suggesting that anyone try this if they are very ‘evidence’ based regarding scientific literature.

To me, root planing is numero uno!  Even before the diode laser, I’ve gotten incredible results with non-surgical.  Not uncommon to take 7-8 mm pockets to a 2 or 3.  Yes, I’m assuming I get a long junctional epithelial attachment, but I’ve found them to be, in general, very durable if the patient continues proper home care.

There’s root planing, and then there’s ROOT PLANING.  The ‘star’ of my technique is the Zeza ultrasonic curette insert.  It’s actually a REAL curette in the form of a 25K ultrasonic (Cavitron type) insert.  Gotta be SURE not to get the ‘surgical’ version — otherwise you’ll cut grooves in the roots.

When I say these root plane, I ain’t kiddin’.  Holy moly!  I use Arestin liberally, however I do NOT subscribe to the recommendation to avoid flossing.  Why?  If the Arestin is say, 7 mm into a pocket, how is floss gonna remove it?  So I have my patients floss, with the idea that anywhere they could remove the Arestin by flossing, they don’t need Arestin anyway.  Heck, you just took the time to do all this non-surgical treatment, and now you’re gonna tell the patients NOT to floss for a week or more?  No way.  Your most important healing is taking place during that first week.

Next (I’d better hide on this one), I put all my patients on doxycycline for two weeks.  I insist we complete their mouth within the first week so that they still have a full week of doxycycline after we are totally finished.

Doxycycline is not only antibacterial, but it reduces natural collagenase.  It’s also been shown to enhance root attachment of fibroblasts.  Now, I’m not saying we’re gonna get a fibrous attachment, but in my book, any medication that can be shown to enhance fibroblast attachment has GOT to be making the tissues ‘happy’, and I’ll take ‘happy’ tissue any day.  

So anyway, killer SRP and Arestin.  Before the Arestin I use the diode.  I use it at 1 watt continuous with the tip initiated well.  I don’t fool around.  I get in there and paint out the epithelium from the pocket.  Yeah, I know, it was clearly shown at the 1989 World Workshop in Perio at Princeton that removal of sulcular epithelium is ineffective.  I see otherwise.  I’ll tell ya, there ain’t no way you can remove the epithelium as effectively without a laser.

I use the laser on that visit, and that’s it!  I do NOT go back in to decomtaminate.  I just don’t see the reason.  Even though the Arestin will be gone within 7-10 days, there is substantivity and the effect will last much longer.  And I’ve got them on doxycycline for 2 weeks, and doxy is partially excreted, unchanged, through the sulcus/pocket.

I’ve got my patients using the Hydrofloss after 10 days also.  But ONLY after diligent brushing and flossing.  I’ve got them on Peridex, including use in the Hydrofloss.  I turn them into homecare fanatics.  I scare the holy **** out of the patients by telling them the TRUTH about what will happen in the future if they don’t perform proper home care.  Are these ‘scare tactics’?  Well, if telling them the truth is scary, then so be it.  And I tell them exactly that.

Anyway, I keep kinda hoping (not really) that on re-eval there will be seen a need for surgery (because I love doing it), but usually we are so amazed at the results that our jaw drops.  It continues to flip me out each and every time.

Anyway, from what I’ve seen, the laser simply makes my routine more effective.  It’s not a magic bullet on it’s own.  I can’t say for other types of lasers, but I would not even CONSIDER laser perio treatment without killer SRP.

Someday, I hope to get around to checking out Bob’s laser more closely. Now THAT sounds major cool! Like some others, I do have some skepticism about actual bone regeneration, but only because I just haven’t had the time to really look into it deeply.

Like that rfw guy, I’ve seen selected cases of bone regeneration simply from root planing (the ‘unusual’ case). So seeing a case here and there with apparent bone regeneration with Bob’s laser isn’t enough to get me to buy one — yet. And I WISH I wasn’t so damned busy so that I could investigate it more, ’cause I just have the feeling that it may be a major deal. Like I said, someday.

Rod

(Edited by Rod at 1:19 pm on Mar. 23, 2003)

Quote: from Rod on 1:10 pm on Mar. 23, 2003
…….
To me, root planing is numero uno!  Even before the diode laser, I’ve gotten incredible results with non-surgical.  Not uncommon to take 7-8 mm pockets to a 2 or 3.  Yes, I’m assuming I get a long junctional epithelial attachment, but I’ve found them to be, in general, very durable if the patient continues proper home care. [/quote]

Pt kept on 3 month recall then?

Quote: from Rod on 1:10 pm on Mar. 23, 2003
Next (I’d better hide on this one), I put all my patients on doxycycline for two weeks.  I insist we complete their mouth within the first week so that they still have a full week of doxycycline after we are totally finished.

Doxycycline is not only antibacterial, but it reduces natural collagenase.  It’s also been shown to enhance root attachment of fibroblasts.  Now, I’m not saying we’re gonna get a fibrous attachment, but in my book, any medication that can be shown to enhance fibroblast attachment has GOT to be making the tissues ‘happy’, and I’ll take ‘happy’ tissue any day.[/Qoute]

Any followup drug therapy? I know many advocate 3mths on Periostat, then 3 mths off,etc. 

Quote: from Rod on 1:10 pm on Mar. 23, 2003I use the laser on that visit, and that’s it!  I do NOT go back in to decomtaminate.  I just don’t see the reason.  [/Quote]
What about wanting to heal ‘bottom up’ and prevent epithelial down growth?

Quote: from Rod on 1:10 pm on Mar. 23, 2003 I scare the holy **** out of the patients by telling them the TRUTH about what will happen in the future if they don’t perform proper home care.  Are these ‘scare tactics’?  Well, if telling them the truth is scary, then so be it.  And I tell them exactly that.
[/Quote]

Is this where that ‘surgery’ word comes in?

Quote: from Rod on 1:10 pm on Mar. 23, 2003Someday, I hope to get around to checking out Bob’s laser more closely.  Now THAT sounds major cool!  Like some others, I do have some skepticism about actual bone regeneration, but only because I just haven’t had the time to really look into it deeply. [/Quote]

Make sure you see the histology slides he has of fibers reattaching/bone fill. I used to hate those slides in school thinking they were really all ink blot tests , but those I saw Bob show were impressive .

I know you advocate use of the Oral B 3d excel , do you have your patients using both the hydrofloss and  3D?

Thanks once again for sharing,

Ron,

Yes, I keep the patients on the same recall schedule that I do any of my perio patients, including bone regeneration cases. 3 mo at first. When I see they are continuing to be stable at 3 mo, I extend it to 4.5 mo. And then when stable at 4.5, I go to 6 mo.

As far as Periostat: No, as long as everything is looking good and the patient has killer hygiene, I don’t do the Periostat. Periostat is supposed to inhibit endogenous release of collagenase. But collagenase is released in response to bacteria, and if we’re successful with treatment and homecare, I’ve not found it necessary.

I know many say they have a dickins of a time getting home care compliance. For some reason I don’t usually. Maybe it’s because I practice in a higher income/highly educated area — or maybe not.

And regarding healing bottom up and inhibiting epithelial downgrowth, I don’t see that ‘decontamination’ is gonna do that. If that were to happen, does that mean we get a fibrous ‘true’ attachment? I dunno. I’d say that the main intent of the continued use of the laser is antibacterial. I feel I’ve got that covered with other things, and I prefer not to ‘mess around’ in the sulcus/pocket once I’ve treated.

As far as ‘scaring’ the patients — yes, the ‘surgery’ word comes in. I tell ’em the truth. I give them options before we start treatment. I discuss surgery as an option when indicated. And if the case is 5mm or less, I tell them if it were to get worse, surgery could be indicated. I tell them that surgery has come a long way and isn’t the horror that it once was, but still, most want to avoid it. So continued problems that need addressing, potential need for surgery, and even future loss of teeth — these are all discussed.

Yes, I have my patients on the Oral-B 3D, Hydrofloss, and J&J Dentotape.

Rod

Nice treatment and welcome back from Atlanta(100 miles north of my hometown)!!!

Did you see any white sparking when you lasered the porcelain? I know Mark Colonna has posted some photos where it did appear the Waterlase cut feldspathic porcelain. He reported “sparking” so I’m afraid to try this with mine.

Al