Bone regeneration ... in the hands of the dental hygienist?
The author says it is an exciting time to employ adjunctive regenerative methodologies in the hygienist’s ever-expanding armamentarium.
“…In the future, regenerative therapies could be as simple as the local delivery of regenerative molecules placed subgingivally to promote repair of periodontal and gingival defects. New drug delivery systems to stimulate wound repair of soft tissue and extraction defects may be as simple as applying medicaments directly to wounds..."
-- William Giannobile, DDS, MS, Dimensions of Dental Hygiene, April 2007.
While top periodontal researchers like Dr. Giannobile continue to push the envelope for ever more simplified methods to regenerate periodontal tissues, at this time, the challenges of such a simplified approach to regeneration are still present. The periodontium has unique characteristics found nowhere else in the human body. Where else do you have hard structures poking though soft tissues with the constant barrage of oral pathogens, inflammation, toxins, chemicals, food debris, and potentially damaging forces? Where else do you have hard- and soft-tissue structures so entirely dependent on their anatomical features they are crucial for symbiotic foundational health? Nowhere else in the body do you have such a unique set of circumstances and challenges for the potential goal of regeneration.
While there have been many advances in regenerative methods over the past 20 years, doctor-dedicated surgery is still the gold standard for repairing and regenerating bony defects, either with GTR, regenerative proteins placed with flap and osseous surgery, laser surgery, or a combination of these methodologies. There is one regenerative product, however, which has gained a lot of attention recently for its non-surgical use in the hands of a hygienist.
Exciting possibilities – topically applied bioactive molecules
In 1997, an easy-to-use regenerative protein gel received FDA approval for use in surgical bone and periodontal tissues repair. Porcine derived enamel matrix derivative (EMD), or Emdogain™, emerged on the scene and was readily adopted by periodontists for adjunctive use with flap or osseous surgery. 90% of Emdogain contains powerful bioactive molecules (amelogenin protein), these proteins activate the body’s own stem cells to proliferate and become regenerative cells (cementoblasts, fibroblasts, and osteoblasts) which, in turn, promotes periodontal defect repair. According to the research, the numerous therapeutic benefits of EMD also include prolonging osteoblast growth, inhibiting the growth of periodontal pathogens, delaying the growth of epithelial cells, increasing vascular growth, and limiting the release of inflammatory cytokines.
But what about the non-surgical use of these bioactive molecules in the hands of a dental hygienist? Could local delivery of regenerative proteins placed into a periodontal pocket enhance healing of certain periodontal defects without surgery? Over a decade ago, clinical pioneers set out to answer this question and today the answer is a resounding yes! While formal research for successful histologic evidence of bone regeneration using Emdogain in non-surgical periodontal therapy is limited at this time (1), many clinicians have been using Emdogain off label with remarkable success.
Overcoming challenges for the successful use of Emdogain in non-surgical periodontal therapy involves several important considerations, such as complete removal of calculus and associated toxic biofilm from the root surface, removal of the smear layer using Pref Gel (edetic acid), sufficient removal of granulation tissue from the defect, exposing connective tissue fibers, controlling inflammatory response and bleeding via the adjunctive use of host modulated therapy and/or antibiotics, synergistically promoting regenerative cells with adjunctive use of host modulated therapy, and using periodontal dressing materials. Clinicians routinely using Emdogain with success have developed methods they have observed deliver more predictable results in their hands.
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A new therapeutic goal
The undisputed holy grail of successful clinical outcomes following any form of periodontal therapy is seeing bone-fill on the X-rays, especially with advanced bony defects compromising structural integrity. While healthy tissues and remission of disease is traditionally the basic goal of non-surgical periodontal therapy, bone regeneration could become an exciting new objective, with radiographic bone-fill more routinely and intentionally achieved by the dental hygienist; promoting a healthier, more stable foundation for the patient. The time has come to dispel some of the preconceived notions about the clinical limitations of non-surgical approach. Scientific advances in regenerative proteins have created a new world with more options for the patient with advanced bony defects and even hopeless prognosis. Surgery and extractions are no longer the only option. Non-surgical bone regeneration at the hands of dental hygienists placing proteins via local delivery is not only possible, as Dr. Gionnobile had envisioned, it is fairly predictable in the thousands of cases carefully observed by the many clinicians routinely witnessing it.
While more formal research, and even further product development and protocols are needed, it is already an exciting time to employ adjunctive regenerative methodologies in the dental hygienist’s ever-expanding armamentarium – the future is NOW!
Literature for non-surgical use of Emdogain
“Periodontal Disease: Engineering the Future of Care”
Case studies of non-surgical bone regeneration
1. Clinical and Histologic Evaluation of Non-Surgical Periodontal Therapy With Enamel Matrix Derivative: A Report of Four Cases James T. Mellonig,* Pilar Valderrama,* Holly J. Gregory,* and David L. Cochran J Perio September 2008 volume 80, number 9)
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About the author: Judy Carroll, RDH, is the founder and clinical director of PerioPeak Innovations, an independent non-surgical periodontal therapy practice exclusively focused on providing Regenerative Periodontal Endoscopy (RPE) and integrative treatment methodologies. Her clients fly in from around the globe seeking her pioneering treatment and comprehensive approach to periodontal care. Ms. Carroll’s 25 years in clinical dental hygiene has fueled her determined focus in providing and teaching definitive clinical treatment strategies and more personalized oral-systemic periodontal medicine.
Ms. Carroll currently lectures and teaches advanced endoscopic techniques and integrative care utilizing multi-disciplinary approach to Periodontists, Dentists, and Registered Dental Hygienists. She offers valuable hands-on and didactic training and is available by appointment for her interesting and informative lectures. She can be reached at www.periopeak.com.