The CDM Treatment System Presentation - A Guided Tour of The CDM Treatment System Presentation - A Guided Tour of The CDM Homecare Program PerioWellness- the oral systemic protocols for dentistry The good news is that the Oral Systemic Connection has arrived. $Millions will be spent by the ADA, Colgate, Cigna and other major players to promote the connection between Oral and Systemic Disease, and patients are being exposed to the concept by the media daily. The bad news is that the latest statistics from Roger Levin’s Practice Survey from Dental Economics October 2007 shows that periodontal treatment is still only 5% of Dental treatment, and while practice production is growing in general, hygiene production is not growing. The reason for this is likely because traditional perio treatment, be it perio surgery or “Soft Tissue Management” has not been a highly satisfactory approach from the patients perspective, therefore acceptance of treatment and long term compliance has been minimal. “You have periodontal disease as evidenced by bleeding gums and several deep periodontal pockets. The pockets indicate an advanced state where destruction is taking place. This also means that the plaque, calculus and bacteria hide deep in the pockets and you can no longer keep yourself healthy with home care. You will need an initial series of appointments for scaling and root planing and thereafter you will probably need to come in on at least a 3-4 month intervals to maintain your health. This treatment will reduce the problem, and hopefully it will not get worse or we will need to refer you to the periodontist for surgery”. In fact the FDA approved statistics from Ora Pharma show In other words of the pockets that began as 5mm or greater between 36% and 47% were reduced to a normal 3 mm with SRP alone, and adding Arestin brought that only to between 41% to 58% depending on the study. Therefore with current STM procedures only about half of the bad pockets can be expected to resolve which does mean perio visits forever. Additionally research by Moritz shows that SRP alone had no effect on Aa and only 40% of patients improved in their P.gingivalis score. This has important implications for those involved in Oral Systemic treatment since the periodontal pathogens such as P.gingivalis have been implicated directly in diabetic control and heart disease, and therefore allowing the pocketing to persist, even with mechanical cleaning every 3 months, means that the patient is still at risk for systemic disease. Constant treatment with antibiotics, risks creating resistances and other systemic problems. Additionally while some dentists believe that STM is a practice builder because of regular 3 month visits, there are leading management consultants who caution their clients that because of the negative, no-win situation , STM actually discourages referrals. PerioWellness- the oral systemic protocols for dentistry I realize that because of the statistics on STM, the fact that even surgical treatment often relapses, and over 70% of people who have been once well, contract the disease, it is almost blasphemy to suggest that periodontal disease might be “cured” While we may not be able to use the word “Cure” we should have as a goal, bringing the patient to health and not contributing to systemic disease, with their active cooperation 1. Lack of bleeding 2. All pockets less than 4mm 3. All periodontal pathogens at zero or “Below Threshold” (where their normal immune system is sufficient to combat the bacteria) 4. Patients maintain their health with homecare and return for regular 6 month cleanings Now we recognize that perio is not like a broken leg that the doctor can “fix” since all humans are constantly being assailed by plaque, calculus, anaerobic bacteria and volatile sulfur compounds, that after you are fixed you still need to be vigilant with your home care, but we now find that true of all health considerations. Therefore we have chosen the term “Wellness” – defined by the Merriam Webster Dictionary as: ...The condition of good physical and mental health, especially when maintained by proper diet, exercise, and habits PerioWellness is a Periodontal treatment system far more, acceptable, efficacious and profitable than ever before. It is now feasible to offer painless, effective, lasting, periodontal treatment that attacks all four causes of periodontal disease: • Plaque and calculus • Anaerobic Bacteria • Volatile Sulfur Compounds • Reduced defense systems It Includes: • Normal Scaling & Root Planing at the initiation of active treatment. • Laser Decontamination and laser pocket therapy. • Targeted systemic antibiotics use only as a last resort if pathogens are still present after active treatment • Irrigation with Closys Rinse and Hydrofloss • Superior toothbrushing using Hydrabrush and Closys toothpaste • Targeted nutritional supplements • Wellness counseling to improve lifestyle factors relative to immune system, cardiovascular disease and diabetes. This system has been shown to be over 90% effective in reducing 4,5& 6 mm pockets to normal in three months of treatment. (14) DataProj.doc. The homecare program has been shown to be 98% effective over one year. The CDM process begins with Laser decontamination to eliminate the anaerobic bacteria that infest the periodontal pockets. Laser decontamination prior to the Scaling and Root Planning is the first step in bacteria control but also prevents cross contamination and bacteremia during the treatment process.  After the SRP, Laser Guided Tissue Regeneration vaporizes the diseased tissue, cauterizes the blood vessels and nerve ending to provide a more comfortable experience (15) and conditions the tooth surface encouraging the formation of fibroblasts. (16). This process normally reduces the pocket depth by 1mm per visit. Having the longest wavelength, 10,600nm, the CO2 laser is the least invasive and safest to use for soft tissue procedures. (17). LasersSc.htm Having the smallest focal spot size of .1mm, it can be used in continuous, non pulsed mode and is therefore the easiest laser to learn to use.(18) LaserCom.doc A Diamond Age exclusive is the PD100 Periodontal Handpiece which delivers defocused Energy directly to the pocket or root canal for decontamination and ablation. The energy will not cut tissue and is unique in the Handpiece is Autoclavable.   We follow the SRP with Irrigation with ClosysII to complete the decontamination and combat the volatile sulfur compounds. ClosysII is a Chlorine Dioxide system of toothpaste and mouthwash which has an extraordinary kill rate for anaerobic bacteria(19) and chemically neutralizes sulfur compounds. This has been shown to remove halitosis for 8 hours (20) , reduce bleeding sites by over 70% (21) and significantly reduce pocket depth (22). The fundamental cause-effect process is the relationship between certain anaerobic oral Microflora and chemicals we call volatile sulfur compounds (VSC's) which include H2S and Methyl Mercaptan (CH3SH), in the presence of a reduced defense system. (23) Once the bacteria are able to penetrate the epithelial tissue, especially if bleeding is present the disease process may now be extended to the entire body, attacking the veins, arteries and bodily functions. The volatile sulfur compounds form naturally in the mouth since epithelial tissue contains sulfur. They can be produced from normal turnover of tissue, presence of food debris and even more importantly by the bacteria themselves. The clinical manifestations of the VSC's are - halitosis - the smell of H2S gas, and that the VSC&'s attack the gums and allow the permeation of the gingival tissue by the anaerobic bacteria.(24) Without the VSC's the bacteria are essentially harmless.  See http://www.Rowpar.com   Why do 60 year olds get more periodontal disease than teen-agers? Is it because they are less diligent in brushing and flossing? No it is because as we age our ability to absorb nutrients from our food and our defense systems are not what they once were. Pharmaden is a special formulation of nutritional supplements  which have been demonstrated to reduce pocket depth, bleeding and periodontal indices (25) by building up the immune system, promoting healing and reducing inflammation. In fact the statistics show that Nutrition alone can be more effective at reducing pocket depth than SRP's and antibiotics combined. This targets and removes the fourth and final cause of periodontal disease - a reduced defense system, keeping the disease in remission forever. It has been shown to  reduce C-Reactive Protein by over 50% on it's own! See Finally we can do something about Plaque and Calculus- Are the tooth brush and dental floss as we know them obsolete? The first real revolution in toothbrush technology. Essentially a car wash for your teeth brushing 3 surfaces, uppers and lowers, gums and teeth all at once. Reduces a difficult two minute job to a no-brainer in 40 seconds! (26) Has been shown to be more effective than the leading power toothbrushes with a quarter of the effort. (27). See http://www.Hydrabrush.biz Not just another irrigator, Hydrofloss utilizes magnetic water treatment for de-scaling of mineral deposits and prevention of plaque buildup. Building on the benefits of  full mouth irrigation for removing food particles, Hydrofloss has been shown to reduce the build up of plaque by 34% and calculus by 64% over non magnetized irrigators. (28)Works with ClosysII mouth rinse for maximum effectiveness. See http://www.hydrofloss.com Patient Conversion A system of patient conversion that will produce over $25,000 per month in production from your existing patients and includes education, systemic risk assessment, financing and reimbursement from medical insurance. The CDM treatment system is presented to the type 3&4 moderate-severe periodontal patient as an all encompassing one year treatment plan including four quadrants of scaling and root planing, laser treatment as necessary, 3 checkup visits all needed homecare products for one year.  Patients with gingivitis and minimal pocketing receive lesser treatments varying from 3 to six months for lesser fees. (29) PerioTx.doc Using our Patient presentation materials and coaching, the typical Center for Dental Medicine should be able to start 8 to 10 of these cases per month resulting in periodontal production of $25,000 per month or more. In many states the entire treatment can be completed in the hygiene department. A breakthrough periodontal diagnostic and patient communication system, allows a complete periodontal probing and recording including bleeding sites and exudates in less than 10 minutes. The output is a beautiful communicative "co-discovery" of the patient problem for presentation to the patient, family  or medical referral. The 15g constant force probe has been shown to be much more consistent than standard manual probing (30) see http://www.Floridaprobe.com An important CDM concept is the testing of the systemic risk factors C-Reactive Protein (heart attacks, stroke, Alzheimer's, Colon Cancer) and HbA1c (diabetes). This allows the patient and their Physician to directly evaluate the systemic effects of the patient's periodontal disease before and after treatment. While this testing \can be performed by an outside laboratory, Cholestech is the first company to provide in office CRP and HbA1c testing with a simple finger stick Will tremendously increase the CDM image and patient acceptance. Through American financial services to provide affordable monthly payments for the complete treatment program. We also have EPCheckNow! A safe patient payment program that involves neither credit card nor finance company charges to the patient or office. From simple on-line Q&A software generates medical insurance forms for periodontal procedures and follows up until collection. Collecting from medical insurance is an incredible practice builder for the Center for Dental Medicine The question is how does all this work in practice, and how does it compare to other methods. The answer to this is a work in progress because we are actively collecting data from our practices who are applying for recognition as a certified CDM which requires the submission of 20 consecutive completed cases with at least 2 pockets of 5mm or greater, including records before treatment, after two months of active laser/SRP therapy and after one year of perio maintenance. The first practice to complete this process is Dr. Greg Richards of Houston TX. His initial results showed that 95% of 4-6 mm pockets reduced to a normal 3mm with treatment and 98% of the pocket reduction held after one year. The usual means of comparison of probe score results involve three measures: The average reduction of pocket depth in mm The % of pockets that reduced to a normal 3mm The % of pockets that reduced at least 2mm   Perhaps the most interesting comparative data is supplied by Ora-Pharma for their Arestin product which is readily available on their product insert: Based upon cases with original pocket depth 5mm+ Treatment Baseline Ave. mm Red. % Red To 3mm % Red 2mm+ DAS* 5.59 mm 2.27 mm 87.5% 95% SRP+ Arestin 5.81mm 1.63 mm 58.0% 51% SRP Only 5.79 mm 1.32 mm 47.3 % 42.2% *Statement not approved by the FDA Thus we see what we have come to expect with the traditional "Soft Tissue Management" program, that with SRP alone less than half of the pockets are resolved, that adding a topical antibiotic such as Arestin can increase the effectiveness to near 60% while with the full DAS program we are approaching 90% resolution. This is not to say that the patient is "cured" and can go the rest of their lives with the same  causal relationships as those that brought on the perio in the first place. But if we can address the causes with the fill DAS home care program we can keep the disease in remission for the vast majority of patients. The following is a live reference list. Whenever possible there are live links to the research on the Internet, and links to complete Diamond Age memos which will activate when the memos are kept in the same folder with this document. Therefore a Zip file including all memos is normally included with this document. (15) Sulcular Debridement with Pulsed Nd: YAG" Lasers in Dentistry January 2002 http://www.millenniumdental.com/research/jan-02.html (16) Effects of CO2 Laser Treatment on Fibroblast Attachment to Root Surfaces. A Scanning Electron Microscopy Analysis / Crespi, et.al  1308-1312 Journal of Periodontology 2002; 73 (4) http://www.fo.usp.br/lelo/congress/abstracts.htm (17) Lasers in dentistry-Separating Science from hype-D. Dederich & R. Bushick  JADA February 2004 LasersSc.htm   (19) Ratcliff P., Bolin V. Antimicrobial capacity of chlorine dioxide based toothpaste. Presented at IADR meeting, 1993. (20) Efficacy of a Chlorine Dioxide-containing Mouthrinse in Oral Malodor, J. Frascella et al, TKL Research, Inc., Paramus, NJ, Journal of Dental Research, , (IADR Abstracts) 1999, p. 356, Article 2004, http://www.rowpar.com/professionals/oralhealth/research/5.html (21) Reduction of Bleeding on Probing by Oral Care Products, Chapek et al, Compendium, Vol. 16, No. 2, 1995, 188-196 http://www.rowpar.com/professionals/oralhealth/research/7.html (22) ) Management of Periodontitis with Oral Care Products, Chapek et al, Compendium Vol. XV No 6, 740-746, 1994  http://www.rowpar.com/professionals/oralhealth/research/6.html  (24) Ng,W, Tonjetich,J.: Effect of Hydrogen Sulphide and Methyl Marcaptan on the Permeability of Oral Mucosa. J. Dent Res 63(7):994-997, 1974 (25) Clinical Evaluation of a Nutraceutical for the Treatment of Periodontal Disease LLU-99-014  By Carlos A. Munoz, DDS, MSDDirector of the Center for Dental Research Principal Investigator Robert Kiger, DDS, MS Chair of the Periodontics Department, LomaLindaUniversity  (27) Efficacy of the Hydrabrush powered toothbrush as an adjunct to the Treatment of Gingivitis and Periodontitis- FinalReportUniversity of Tennessee, HealthScienceCenter November 14, 2002. (28) The effectiveness of a magnetized water oral irrigator (Hydro Floss® ) on plaque, calculus and gingival health Johnson KE, Sanders JJ,  Clin Periodontol 1998; 25: 316-321 http://www.hydrofloss.com/oral_health.htm#ISSN%200303-6979 (30) Marcelo W.B. Araujo, Kathleen M. Hovey, Janice R. Benedek, Sara G. Grossi, Joan Dorn, Jean Wactawski-Wende, Robert J. Genco, and Maurizio Trevisan, "Reproducibility of Probing Depth Measurements Using a Constant-Force Electronic Probe: Analysis of Inter- and Intraexaminer Variability", Journal of Periodontology, Vol. 74, No.12: pp1736-1740, April 2003.