1 Perio in Practice Neil Paterson BDS MDS FDS DRDRCS MScDent ImpSpecialist in Periodontics General Dental Practitioner with special interest in Implants

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3 What is a Treated Patient ?Patient comfortable All pockets less than 5mm Stable attachment levels Consistently low Bleeding on probing Consistently low Plaque scores Cleansable restorations & gums

4 What is treatment failure ?Uncomfortable Persistent pockets 5mm+ Persistent bleeding/suppuration Continued attachment loss

5 Failure; How do we monitor success / failure? Audit; ? What to measure3 2 4 19 2 1 3 13 2 1 8 How do we monitor success / failure? Audit; ? What to measure ? No 6mm+ sites ? 2mm+ attachment loss ? Plaque score 20%+ BPE scores 2 1 3 4 15 3 1 4 2 16 2 1 3 4 17

6 Tooth Loss in Maintenance PhaseTooth Related Factors; Baseline bone loss Furcation involvement Used as abutment Eickholz et al J Clin Perio 2008

7 Tooth Loss in Maintenance PhasePatient Related Factors; Poor OH Irregular visits Age Diagnosis wrong Genetic predisposition (IL-1, Fcγ, IL-6) Smoking Male Eickholz et al J Clin Perio 2008

8 Tooth loss 100 Compliant pts, 9-11 years, mod-adv perio 2436 teeth1.5% extracted during SPT 75% of these uncertain, poor, hopeless 25% good @ baseline 8% teeth prognosis worsened during study Fardal et al JCP 2004

9 Tooth loss 500 teeth, no ortho/8s Perio only reasons37% att levels 50-69% Forceps Level threshold seems too low Splieth et al JCP 2002

10 Genetics * Hirschfelt & Wasserman 1978 McFall 1982 McLeod 1997Minimal Tooth loss 77-84% Moderate Tooth loss 12-15% High tooth loss 3-8%

11 II. Chronic PeriodontitisA: Localised (<30% of sites involved) B: Generalised (>30% of sites involved) Also: Mild 1-2 mm CAL Moderate 3-4 mm CAL Advanced  5 mm CAL

12 III. Aggressive PeriodontitisA: Localised B: Generalised Also: Mild 1-2 mm CAL Moderate 3-4 mm CAL Advanced  5 mm CAL

13 Generalised Aggressive PeriodontitisUsually affecting patients <30, but may be older Poor serum antibody response to infecting agents Pronounced episodic pattern of destruction of attachment and alveolar bone Generalised interproximal attachment loss affecting at least 3 permanent teeth other than incisors and first molars

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15 Oscillation of the tip has more to do with;the shape of the tip (straight or curved) How much you lean on it than whether magnetostrictive (cavitron) or piezon scaler. Lea et al 2009 J Clin perio

16 Poor Access Tortuous pocket / flutes Anatomy Fircations Close RootsRestorations

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18 Full Mouth DisinfectionDefinition: One stage full mouth “disinfection”, obtained by performing all scaling and root planing within 24 hours together with repeated application of chlorhexidine to all intra-oral niches Quirynen et al J Dent Res 1995, 74,

19 Full Mouth Disinfection - ProcedureRinsing x 2, with chlorhexidine solution 0.2% for 1 minute Dorsum of tongue brushed for 60 secs with 1% chlorhexidine gel Pharynx sprayed x3- 4 with 0.2% chlorhexidine spray Full mouth scaling / root surface instrumentation (ultrasonic) All pockets irrigated x 3 in 10 minutes with 1% chlorhexidine gel.

20 Full Mouth SterilisationDecreased Malodour Improved clinical parameters Quirynen et al 1998 J Per Decreased/eliminated pathogens up to 4/12 Boller et al 1998 JCPer Extra attachment gain 0.9mm single tooth; mm multi-rooted tooth Mongardii et al 1999 J Per

21 Full Mouth Sterilisation7mm pockets; LESS; Recession 1.9mm control; ,0.7mm test MORE; PD reduction 1mm extra Clinical attachment gain; 1.9mm Control; 3.7mm test Bone levels superior Vanderkerkhove et al 1996 J per

22 Evaluated in patients with advanced diseaseEvaluated in patients with advanced disease (Quirynen et al J Clin Periodontol 2000, 27, 8 months after treatment ; 35% reduction in probing depth 20% reduction with conventional periodontal therapy B.O.P. FMD = 72% reduction SRP = 44% reduction Gain in clinical attachment of 2mm for probing depth >7mm Useful in aggressive / advanced periodontitis associated with BOP +++ / suppuration

23 Full Mouth DisinfectionFMD + CHX v SRP within 24 hours NO DIFFERENCE Major effect due to thorough scaling Quiynen et al 2000 Apalzidou 2004 Kinane 2004 Additional effect due to chemicals Quirynen 2007 *

24 Full Mouth Disinfection@3/12; 60% sites still need retreatment 50 mins both techniques @6/12 ; 75% closed pockets 50% Deep sites remain Tomasi & Wennstrom 2004 *

25 Full Mouth DisinfectionFMD v 4Q 65% more TIME EFFICIENT Decreased sensitivity BOP 29% v 32% Pockets closed 25% v 36% Tomasi & Wennstrom 2004 *

26 FMD Could use Essential oil m/w insteadPlaque and gingival inflammation reduced T forsythensis reduced Pg no effect Cortelli et al J Clin Periodontol 2009; 36: 333–342.

27 Must go FASTER Root planing; removal of plaque, calculus, ‘infected’ cementum Root debridement; removal of plaque, calculus; no intention to remove root surface Chapple; J Dent Res abstract 2002 No touch ultrasonic removal of biofilm only; just as effective. ‘FMUD’

28 1 second/mm² of root surface= average 17 seconds/toothFMUD Smart 1990; 1 second/mm² of root surface= average 17 seconds/tooth Koshy et al 2005; FMUD (30-40 minutes) v QSRP (3-4 hours) as effective. Retreatment ‘ 3 months produced similar additional benefits for both groups. ‘…justified initial treatment approach that offers tangible benefits for the chronic periodontitis patient.’ Wennstrom et al J Clin Perio 2006;

29 FMD in Practice FMD Review Pocket chart OHI 1/52 2/52 2/12 20 mins1x60 mins or 2x30mins 20 mins

30 Perio-Flow Less noise, Less damage more comfortAIR-FLOW® handy Perio offers the unique opportunity of regular implant prophylaxis by 100% biofilm removal and no alteration of the implant surface, even by multiple treatments (Influence of different air-abrasives powders on the re-establishment of the biocompatibility of contaminated titanium implant surfaces Dr Schwarz et al., J Periodontol Nov;77(11):1820-7)

31 Treatment of peri-implantitisPerio Flow; air abrasive using glycine (amino acid) powder; washes away Decreased BOP; laser / Perioflow Decreased Pus; laser 62%, Perioflow 54% Decreased PPD; laser 25%, Perioflow 38%

32 Can we do biofilm removal even faster?Perio Flow v u/s debridement 5-8mm pockets PPD reduction, BOP, red complex reduction No sig 2 days or 2 months Much less perceived discomfort Wennstrom et al J Clin Perio 2011

33 Mouthwashes as Adjuncts to Mechanical Oral HygieneMore efficacy providing up to 30% greater reduction on plaque (EOM) EOM as effective as flossing in removing interproximal plaque Honey mouthrinse (antibacterial properties) supresses perio pathogens and plaque formation; nearly as good as CHX Aparna et al J Perio Sep 2012

34 WaterPik v AirFlosser The Waterpik Water Flosser is significantly more effective than the Sonicare Air Floss Pro for reducing clinical signs of inflammation. (J Clin Dent 2015;26:55–60) This study was supported by a research grant from Water Pik, Inc., Fort Collins

35 Biofilms Bacteria in biofilm are up to 1500 times more resistant to antibacterial agents than bacteria in suspension Biofilms must be physically disrupted Costerton JW et al. Annu Rev Microbiol 1995;49: Walker C, Karpinia K. J Periodontol 2002;73:

36 Local Delivery Agents Disrupt biofilm before placementLocal delivery systems should be applied 1 week after root surface instrumentation (absence of bleeding) Periochip- chlorhexidine 2.5 mg x4pa Elyzol – metronidazole 25% x2 Tetracycline fibres x1 Atridox gel – doxycycline 8.5% x1 Dentomycin – minocycline 2mg x ¾ Arestin; minocycline microspheres Chlosite chx gel + xanthum gum Photodynamic Therapy

37 Journal of Clinical Periodontology The scientific evidence supports the adjunctive use of local antimicrobials to debridement in deep or recurrent periodontal sites, mostly when using vehicles with proven sustained release of the antimicrobial. Matesanz-Pérez et al Systematic review Journal of Clinical Periodontology Volume 40, Issue 3, pages 227–241, March 2013

38 Systemic Antibiotics Metronidazole 200mg tds → 400mg bd 3-7 daysTetracycline 250mg gds 7-21days* Doxycycline 200mg 100mg/day 7 days Metronidazole (200mg) and amoxicillin (250mg) tds for 7 days

39 46 different pathogenic complex combinations 9 major complexes Aa, Pg, Ec, T Forsythensis, Pi, Pnigrescens 37 minor complexes At least 10 different antibiotic regimes to specifically target these Beikler et al J Per 2004

40 Antibiotic SensitivityFlagyl + Amoxicillin 55% cases “ “ /clavulanic acid or “ cuprofloxacin % cases Amoxicillin % cases Doxycycline % cases Flagyl % cases Amoxicillin / clarulanic acid 2.9% cases Clindamycin % cases Cuprofloxacin % cases Tetracycline % cases Beikler et al J Per 2004

41 Management; ? Antimicrobial adjucts?YES; Doxycycline or amoxicillin + metronidazole works equally well Machtei & Younis Quintessence Int 2008 Nov 39(10): No re-growth of Aa at 30,60,90 days Akincibay et al Quintessence Int 2008 Feb; 39(2): 33-39

42 Management; ? Antimicrobial adjucts?YES; NSM + 500mg amox + flagyl 1/52 1.4mm greater ↓PD Disease progression; 1.5% sites v 3.3% (NSM only) sites Shift from ≥5mm pockets to ≤ 4mm 74% (test) v % (NSM only) Guerrero et al J Clin Per 2005 Oct; 32(10):

43 Management; ? Antimicrobial adjucts?YES; NSM + Periochip v NSM+amox+flagyl Generalised AP Periochip; after 3/12 PD↑again Amox+flagyl; 3and 6/12 ↑CAL gain ↓deep pockets Kamer et alJ Clin Per 2007 Oct; 34(10):

44 Management; ? Antimicrobial adjucts?YES; quadrant v FMD + 500mg amox+250mg flagyl 1/52 + chx m/w 2/12 generalised AP Quadrant v FMD same results, no 7mm+ pockets remained Moreira & Feres-Filho J Per 2007 Sept; 78(9):

45 Management; ? Antimicrobial adjucts?Which? Pg most resistant to penicillins Penicillin, tetracycline, erythromycin poor Amoxicillin/clavulanate, amoxicillin, ampicillin, doxycycline work better Suggested 2 antibiotics together Lakhssassi et al Oral Microbiol Immunol 2005 Aug; 24(4):

46 Management; ? Antimicrobial adjucts?When? Generalised AP study NSM then Ab immediately then 3/12 NSM reinstrumentation NSM then 3/12 NSM re-instrumentation then Ab Immediately after first NSM better results Kaner et al J perio 2007 July; 78(7): Herrerra et al J Clin Per 2008 Sept; 35(8sippl): 45-66

47 Systemic antibiotics + APAggressive Periodontitis (14 days 400mg metronidazole+500mg amoxicillin) 1 year double blind trial Marked improvement with dual antibiotics. Mestnik et al J Clin Perio Oct 2012 Dual antibiotics benefitted ALL periodontitis patients, not just those harbouring AA. (relatively short course 3/7 500mg metronidazole +375mg amoxicillin) Mombelli et al J Perio Aug 2012.

48 Systemic AntimicrobialsZandbergen et al J Perio 2013 Systematic Review, 35 studies; 28 clinical trials, CAP SRP +/- amox + metronidazole Full mouth weighted mean change; PD mm additional improvement CAL gain mm “ “ ‘systemic amoxicillin and metronidazole as adjunct to SRP can enhance the clinical benefits of NSM in otherwise healthy adults.

49 Systemic AntimicrobialsSgolastra et al J Perio (10) Systematic Review; 4 randomised control trials CAP patients SRP +/- amox + metronidazole ‘seems to support the effectiveness of SRP +systemic amoxicillin and metronidazole ‘

50 Systemic AntimicrobialsHarks et al J Clin Per Aug Prospective Double blind placebo controlled multi-centre RCT Mod-severe CAP patients SRP +/- amox 500mg+ metronidazole 400mg 7 days ‘highly effective in terms of PD reduction Sites with further attachment loss over 27.5 month follow up; Placebo; 7.8% test; 5.3% ‘small absolute but stat signif additional reduction of attachment loss’

51 Systemic AntimicrobialsSgolastra et al J Perio (6) 6 randomised control trials Aggressive periodontitis patients SRP +/- amox + metronidazole ‘seems to support the effectiveness and clinical safety of (ie no adverse effects) of SRP +systemic amoxicillin and metronidazole ‘

52 Smokers 2.9x greater tooth loss 2x bone loss 2-3x appointmentsMore relapses Lower oxygen tension encourages anaerobes 5

53 Smokers Nicotine; Vasoconstriction Decreased vascular permiabilityDecreased PMN deformation Slower PMN migration Cadmium levels; Increase inflammation

54 Combined risks * Non-smoker, IL-1 –ve; 7% tooth lossie. 3-7x increased risk Axellsson 2000 *

55 Smoking Cessation Significant additional effect on NSM outcome.Chambrone et al JCP June 2013 Limited systematic review (only 2 articles selected)

56 Vaping Nicotine topical effect No measure of strength/ amountIncreased Inflammation; similar to smoking cessation Wadia et al Br Dent J Dec 9;221(11): Improved clinical parameters Tatullo et al Medicine (Baltimore) Dec;95(49):e5589. Proinflammatory effects on in vitro epithelial/fibroblast cells, DNA damage, dysregulated repair Sundar et al Oncotarget Nov 22;7(47):

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58 Destructive Matrix Metalloproteinases (MMPs) in PeriodontitisCollagenase; Dominant MMP in diseased gingival tissues;3 mediates pathologic bone loss4 Bone and Epithelium MMP-13 Gelatinase; Also dominant in gingival crevicular fluid2 Polymorphonuclear leukocyte (PMN) MMP-9 A dominant MMP in gingival crevicular fluid1 MMP-8 Description Primary Cellular Source Enzyme 1 Sorsa et al. J Periodontal Res 1988;23: 2 Golub et al. J Clin Periodontology 1995;22: 3 Uitto et al. Am J Pathology 1998;152: 4 Greenwald et al. Bone.1998;22:33-38 7

59 Increased MMP8 levels; Periodontitis + diabetes PeriodontitisNo periodontitis/no diabetes Hardy et al J Clin PerioOct 2011

60 Systemic Periostat Sgolastra et al J Perio 2011 82 (11)3 randomised control trials CAP patients SRP +/- periostat ‘significant differences were observed for all investigated clinical parameters in favour of SRP +submicrobial dose doxycycline.

61 Doxycycline Plasma Concentrations - Steady-StateSlide 6 HOURS 200 400 600 800 1000 1200 1400 2 4 6 8 10 12 14 16 18 20 22 24 20 mg BID 50 mg QD Minimum anti-microbial level Sub-antimicrobial dose Antimicrobial dose Doxycycline Concentration (ng/mL) Doxycycline Plasma Concentrations at Steady State Key in the development of Periostat was determining a safe daily dose regimen that would produce subantimicrobial plasma concentrations to avoid the emergence of resistant microorganisms while retaining clinical efficacy. Viewing the graph: The minimum anti-microbial level of doxycycline plasma concentration is 1000 ng/ml (or 1.0 g/ml); plasma concentrations above this threshold produce sufficient tissue concentration for an antimicrobial effect. Doxycycline 20 mg twice daily and 50 mg once daily were compared in a steady state pharmacokinetic study. A 50 mg dose exceeds the minimal threshold plasma levels required for doxycycline to produce an antimicrobial effect (i.e., 1.0 g/ml). A 20mg dose taken twice daily is below the antimicrobial plasma level threshold and therefore does not produce an antimicrobial effect. Subsequent clinical trials confirmed that the 20 mg twice daily yielded optimal clinical efficacy in terms of pocket reduction and clinical attachment gains. A patient given Periostat 20 mg twice daily for up to 18 months experiences no shifts in the normal oral microflora, no changes in the colonization or overgrowth of periodontal pathogens, or no changes antibiotic resistance. Nine month clinical studies also conclude there are no shifts in the gastrointestinal and vaginal microflora. Caution of daily dosages above 20 mg twice daily: The safety of long-term therapy with doxycycline in daily dosages above 20mg twice daily (e.g., 25mg twice daily or 50mg once daily) for adult periodontitis have not been evaluated in clinical trials. Patients may therefore be at risk for development of antibiotic-resistant microorganisms, as well as adverse events normally associated with long-term antibiotic therapy. 20 mg dose taken twice daily is below the antimicrobial plasma level threshold and therefore does not produce an antimicrobial effect Caton J, et al. J Periodontol 2000;71: Periostat® Package Insert. Thomas J., Walker C, et al. J Periodontol 2000;71: Walker C., et al. J Periodontol 2000;71:

62 Patient Information Keep up excellent home care; continue regular maintenance visits Patient should have a routine e.g. Take at the same time as brushing or flossing Miss a dose? Ignore Sunburn ; increase skin factor

63 Drug Interactions (Tetracycline Class Labelling)Slide 10 Drug Interactions (Tetracycline Class Labelling) Warfarin Penicillins Oral contraceptives Calcium, iron, magnesium supplements Warfarin-Follow “Class labeling” instructions. Because tetracyclines have been shown to depress plasma prothrombin activity, patients who are on anticoagulant therapy may require a downward adjustment of their anticoagulant dosage. Warfarin has been reported to interact with a host of other drugs, foods and nutritional substances. For this reason, it is advisable to consult with a warfarin patient’s prescribing physician prior to initiating Periostat therapy. Penicillins-Follow “Class labeling” instructions. Since bacteriostatic antibiotics, such as the tetracycline class of antibiotics, may interfere with the bactericidal action of members of the ß-lactam (e.g. penicillin) class of antibiotics, it is not advisable to administer these antibiotics concomitantly. It may be suitable to withdraw Periostat medication for a time if antibiotics are needed. Patients may resume Periostat therapy after the completion of antibiotic treatment. Oral Contraceptives- Follow “Class Labeling” instructions. According to the Periostat prescribing information, the concurrent use of tetracycline may render oral contraceptives less effective. With respect to the proposed mechanism of this drug interaction, Periostat a sub-antimicrobial agent, has no significant effects on the intestinal microflora during short and long-term therapy. Therefore, Periostat would not be expected to affect the normal enterohepatic recirculation of estrogen in patients receiving oral contraceptives. Although no reports or studies suggest that the concomitant use of Periostat with oral contraceptives may result in contraceptive failure, it is prudent to counsel female patients taking oral contraceptives about the potential low level risk of pregnancy and about the use of additional methods of contraception. Calcium, iron, magnesium supplements- Follow “Class labeling” instructions. Absorption of tetracyclines is impaired by antacids containing aluminum, calcium, or magnesium, and by iron-containing preparations. To ensure absorption and therapeutic effects, it is recommended that Periostat be taken at least 1 hour before or 2 hours after antacids, or any other products or nutritional supplements which contain aluminum, calcium, magnesium, iron, and bismuth subsalicylcate. Penthrane- Follow “Class labeling” instructions. The concurrent use of tetracycline and Penthrane (methoxy-fluorane) has been reported to result in fatal renal toxicity. Although Penthrane is still used in veterinary medicine, according to the Federal Drug Administration, FDA, in the United States, Penthrane (methoxy-fluorane) has been discontinued for use in humans.

64 Systemic Periostat Sgolastra et al J Perio 2011 82 (11)3 randomised control trials CAP patients SRP +/- periostat ‘significant differences were observed for all investigated clinical parameters in favour of SRP +submicrobial dose doxycycline.

65 Genetics; Bacterial Control factorsFc४ gene variation STRONGEST bacterial challenge 5% cases refractory WEAKEST bacterial challenge 62% cases refractory *

66 Genetics; Inflammatory Control factorsmore Interleukin-1 gene variation STRONGEST inflammatory challenge High levels of inflammatory mediators 14 studies agree, 4 disagree Periostat may help *

67 Mast Group Ltd.

68 Genetics; Bacterial Control factorsIL-6 polymorphisms; IL assoc with AP all ethnic groups IL “ localised AP “ “ “ IL “ “ “ Caucasians Nibali et al J Clin Perio 2008 Mar; 35(3): 193-8

69 Genetics; Bacterial Control factorsIL6-174HH gene variation Increased phagocytosis/decreased Aa detected IL6-174GG gene variation Increased inflammation Increased Aa , Pg, Aa+Pg detected (Nibali 2007,2008,2009)

70 Biochemistry / physiologyLifestyle Environment Biochemistry / physiology Genetics GENETICS loads the gun ENVIRONMENT pulls the trigger 70-90% Inflammation

71 Periodontitis and…. Depression Nutrition Cancer Alzheimer's Diabetes Cardiovascular disease Chronic kidney disease Low Birth Weight / Premature Babies Lifestyle Ageing

72 Risk of Chronic disease Stress management Weight management Regular Physical activity Healthy nutrition All 4 healthy living factors; 78% less chance of Diabetes,MI, Stroke,cancer Ford et al Annals Int Medicine 2009

73 Stress & GIT Noradrenaline & adenosineEnteric nervous system releases; Noradrenaline & adenosine Mast cells degranulate Tryptase Histamine Inflammatory mediators Gut Mucosa gets soft & puffy Bacteria soak into gut mucosa Exposed to immune system and dealt with, but…. Long-term stress LPS binds toll-like receptor 4 Changes insulin signalling & more inflam mediators Drives weight gain / DM2/ depression High levels of LPS seen in obese/DM pts.

74 LPS conc assoc with severity of depression IgM responses against LPS higher in depression Antibiotics make them less depressed. Maes et al J Affet Disord 2011 Hung et al Psychiatry res 2014

75 Social Isolation & HealthLoneliness is as bad as; 15/cigarettes/day Alcoholic Never exercising 2x worse than; Obesity 4 friends you can call on if you get bad news?

76 Social Isolation & HealthHopeless, isolated, depressed 27000 female pts 52 countries Stronger risk of MI than; DM BP Smoking Obesity Rosegren Lancet

77 Nutrition Affects specific genes that influence;Inflammatory mediators Resolution of inflammation Bone and ct integrity

78 Nutrition Some nutrients affect chronic disease mechanisms;Alter signals for gene activation/deactivation Omega 3 Polyphenols Antioxidants

79 Inflammation Pushes Krebs cycle harderProduces more O²¯= Oxidative stress Switches on/off genes controlling redox signalling/control O²¯ there as natural defence; programmed neutrophil death releases sticky dna ‘web’ better killing than phagocytosis

80 Antioxidants Bacteria stimulate PMNs to release O²¯free radicals causing inflammation & destruction Sheikhi et al 2001 Antioxidant levels lower in GCF in periodontitis Brock et al 2004 Vit C levels lower in plasma/PMNs in periodontitis Kuzmarova et al J Clin Perio Oct 2012 Antioxidant (Liposome encapsulated superoxide Dismutase) suppresses perio inflammation in beagles

81 Antioxidants Vit C WEAK association with perio destruction only in smokers/former smokers Nishada et al 2000 Elm Cortex inhibits MMPs & periodontopathic proteases Song et al 2003 Green tea catechin bacteriocidal to perio pathogens and GCF peptidases partially suppressed Hirasaw et al 2002 Tomatoes assoc with increased protection from periodontitis Wood & Johnson 2004

82 Nutrition Nuclear factor kB (NFkB)Central mediator of inflammatory response (volume control) If high for too long; Suppresses genes controlling p53 tumour suppressors Normal slowing/killing of tumour cells suppressed.

83 Nutrition Inhibitors of Nuclear factor kB (NFkB) Green teaTurmeric; VAST inflammatory inhibitor Turmerone; boosts brain cell production by 80% Curcumin; anti-inflammatory, anti-cancer; dissolves amyloid tissue in the brain; prevents onset of Alzheimers. Alone; stays in GIT; anti-colon cancer With lipid (iperine) systemic effects. Gomes et al Nutr J 2014

84 Turmeric; VAST inflammatory inhibitorTurmerone; boosts brain cell production by 80% Curcumin; anti-inflammatory, anti-cancer; dissolves amyloid tissue in the brain; prevents onset of Alzheimers.

85 Cancers Affected by Inflammatory ControlOesophagus Stomach Colorectal Pancreas Liver Bilary system Rasch et al Clin Exp Gastroenterology 2014

86 Asprin blocks prostaglandins Prostanoids (resolvins) last longer Other NSAIDs reduce PGs, deplete resolvins Omega 3 encourages resolvins Critical for tissue healing

87 900mg Omega 3 + 81mg asprin; @6/12 Just NSM test <4mm 55% 80%7mm+ 5% none El-Sharkany et al 2010

88 Inflammation Increases energy metabolism Depletes antioxidantsChanges hard/soft tissue remodelling CRP level = indicator of inflammation

89 Decrease Cholesterol, or Decrease Inflammation; CRP Decrease both; Decrease CV events equally Decrease both; much less CV events Inflammation / Cholesterol equal effect on CV events Ridker 2008 (Jupiter study)

90 Atherosclerosis Risk in Communities StudyHigh attachment loss (>10 3mm+) + High tooth loss Severe PD (30+ sites) Increased odds of CHD Increased odds of thickened carotid arteries Adjusted for age, gender, diabetes, smoking, hypertension, lipids Beck et al (PAVE study)

91 AHA Statement Poor perio status was associated with MI in 8 clinical studies Self-reported studies; no link Tooth loss; no link (3 studies) Microflora assessment (4 studies)assocated with MI IgG link for at least Pging (2) Lockhart et al. Circulation

92 AHA Statement Association with stroke;Tooth loss inconclusive (6v6studies) Poor perio status ; (11 v 3) Serology Ig; inconclusive/conflicting (3) Lockhart et al. Circulation

93 AHA Statement Association with corotid arterial thickening (cIMT);Severe perio, high conc of specific bact + IgG levels associated (3 studies) Severe perio + carotid arterial calcifications Beckstrom et al 2007 Severe perio in women Söder et al 2007

94 AHA Statement Association with chronic kidney diseaseSignif increased cIMT and c-rp levels Franeck et al 2006 Renal pts + any level of PD raised cIMT Genctoy et al 2007 Lockhart et al. Circulation

95 Mortality + severe periodontitis Doesn’t apply to 65y+ cohort Severe PD 25 65 Mortality + severe periodontitis Doesn’t apply to 65y+ cohort BUT if severe periodontitis at young age; High correlation with fatal CVD Yu et al Atherosclerosis based on NHANES III data

96 Does treating PD help? Treating Chronic Adult Periodontitis reduces CRP levels in 38% of the treated subjects 4% rise in control group Bokhari et al Journal of Clinical Periodontology Volume 39, Issue 11, pages 1065–1074, November 2012

97 Inflammation; systemic effectsHigh inflammation associated with 2-3x risk of Alzheimers Tan 2007 COPD patients with perio; Treat perio = reduced COPD exacerbations Kucikcoskun et al J Perio Sept 2012 Chronic Kidney Disease associated with periodontitis Treat periodontitis= reduced kidney disease Chambrone et al JCP May 2013 systematic review papers.

98 What to say ? ‘Seymour Index’I; Established CHD + Moderate-adv perio II; Established CHD +Minimal perio III; No CHD but risk factors + mod-adv perio IV; No CHD risk factors + moderate perio V; No CHD minimal perio

99 I; Established CHD + Moderate-adv perioMAY have contributed to CHD MAY be able to reduce further CAD event

100 II; Established CHD +Minimal perioUnlikely to have contributed to CHD MAY be able to reduce further CAD event

101 III; No CHD but risk factors + mod-adv perioHigh risk for CAD MAY be able to reduce CAD event

102 IV; No CHD risk factors + moderate perioMay be general health benefits for preventing CAD

103 Inflammation; systemic effectsLiver cells stimulated by IL-1β increased CRP Block with Rose hip extract Blueberry Blackberry Grape vine (RESVERATOL)

104 Adipose tissue Active endocrine organ Regulates appetite/metabolismSecretes cytokines (eg IL-6, TNFα) Secretes LEPTIN; enhances monocyte differentiation; ie PROinflammatory Secretes ADIPOLECTIN; inhibits TNFα, IL-8 ie ANTIinflammatory

105 Anti-inflammatory Adipoleptin reduced in obese/ DM2DM2 more likely in morbidly obese More likely to have periodontitis Increased serum Leptin in DM2 + periodontitis

106 Perio & DM Severe periodontitis assoc with 93% increase in odds of impaired glucose tolerance NHANES III Arora et al J Clin Per 2014 Impaired immune response to sg mf Increased insulin resistance & impaired glycaemic control Advanced glycation end products exacerbate periodontal inflammation Papapanou 2011

107 Does perio treatment help DM?Mexican American population (DM 50% pop) 150DM2 pts NSM or OHI in mod-severe periodontitis HbA1c levels reduced by 0.6; controls by 0.3 in only 4 weeks. Gay et al J Clin Per 2014 NSM reduced HbA1c by Manouchehr-Pour et al. 1981, Kiran et al. 2005, Koromantzos et al. 2011, Chen et al. 2012). Manouchehr-Pour et al. 1981, Kiran et al. 2005, Koromantzos et al. 2011, Chen et al. 2012).

108 Omega3 + low dose asprin +NSM better than just NSMObesity; BMI 25-30; 3.4x periodontitis risk BMI > 30; 8.6x risk Fruit/veg reduces perio risk Low polyunsaturates reduces perio risk Omega3 + low dose asprin +NSM better than just NSM Omega 3 promotes resolvins; critical in tissue healing

109 BMI BUT High BMI + normal waist; more likely to SURVIVE MINormal BMI + central obesity (big gut) more likely NOT TO SURVIVE MI Deep visceral fat around organs acts as an endocrine organ

110 Prolonged exposure to Fructose;GIT permiability increased Insulin Resistance increased Uric acid increased Adipolectin decreased Carbohydrate/lipid metabolism genes altered.

111 Typical US breakfast…. Pop tarts + orange JuiceMassive carbohydrate load OK if running around all morning, but… Sitting at school; don’t burn it Then eat lunch…. Cells become less responsive to insulin Becomes harder to drive sugar into cells

112 Fill a car with fuel; drive it all morningPut more in at lunch; OK Fill car with fuel ; park it up all morning; Have to force the fuel in at higher pressure Collateral damage

113 25g sugar/day Glycaemic loadKetchup 4g Low fat Greek yoghurt 13g Raisins 20g Fries 25g Baked potato 28g Sports gel (20ml) 32g Snickers 35g Can of pop 40g Fat free crisps 49g Average American consumes 22 tsp added sugar/day =350cal

114 25g sugar/day Glycaemic Load1 slice wholemeal 5g 1 slice white bread 10g Bagel 24g Choc doughnut 25g Spaghetti 38g Olive Garden spag 171g (portion size)

115 Insulin-like GROWTH factors (IGF)Assoc with cancers; Turns genes on that aren’t designed to operate at this high sugar level IGF1/IGF2; assoc with tumour growth in multiple studies.

116 ‘Infectobesity’ ? Gut mf of obese pt more efficient at digesting food/increased energy uptake Selenomonas noxia; if > 1.05% of oral mf associated with overweight in 98% pts. Mf levels drastically reduced after weight loss programme

117 Atkins Diet (revised) Grains+ Fruit ++ Veg +++ Fish/chicken ++Decreases cholesterol Useful if sedentary lifestyle Humans process fat better than sugars/carbs ‘healthy fats’ veg Fish/chicken

118 Mediteranean Diet 1 1/2lbs fruit/veg/dayIncluding olive oils; 35% of calorie intake Lots of fish Minimal red meat/ sweets EXERCISE Decreased CRP, IL-6, IL-7, IL-8, Insulin resistance Esposito JAMA Olive oil has similar anti-inflammatory effect to Iboprofen 4% difference between statins and med diet

119 eating more of some fats may be good for our health…..Systematic review 80 studies No evidence that; eating saturated fats leads to greater risk of heart disease. Margaric acid saturated fat in milk and dairy products associated with a lower risk of heart disease. handful of oily nuts a few times a week will reduce your risk of heart disease Chowdhury et al 2014 Annals of Internal Medicine

120 Low dairy fat intake; assoc with high risk central obesity 1782 pts 12 year follow-up Low dairy fat intake; assoc with high risk central obesity High dairy fat intake; assoc with low risk of central obesity Holmberg & Thelin Scand J Primary Healthcare

121 Nano-particle Resolving medicineLigature induced periodontitis in pigs; bony defects Treat with surgery+ benzolipoxinA4 (suppresses inflammation and prostaglandins) attached to nanoparticles Bugs revert to normal microflora!! Bone/attachment grows back NOT TO LEVEL OF DISEASE DAMAGE BUT REGENERATES TO NORMAL!!!!!!! i.e. control inflammation, tissue can regenerate

122 Lifestyle Minimal walking; 1.7x ageing effectsRegular car travel; 1.6x “ “ Not climbing stairs; 4.5x “ “ Smoking; x “ “ High Intensity Interval training; 10 weeks, 2-3x/week, 20mins Decreased IL-6, C-RP, Leptin As effective as aerobic group; less drop-out (60%v15%) Bartlett et al in press

123 Inflammaging; Up to 25% T cells obsessed with cytomegalovirusi.e. getting side-tracked Fletcher et al J Immunol 2005 PMNs decrease phagocytosis Decreased killing power Butcher et al J Leukoc Biol 2001

124 Inflammaging PMNs decrease phagocytosis Decreased DNA netsDecreased reactive oxygen species Decreased killing power Butcher et al J Leukoc Biol 2001

125 Inflammaging Chemotaxis; older PMNs move as fast but erratically‘lost sat nav/drunk’ Increased bystander damage 40% more tissue destruction

126 Inflammaging Pneumonia; 2x C-RP PMN related damage; 5x C-RPImprove chemotactic migration ; inhibit Pl3komega “ “ “ “ Farnesyl group with STATINS Periodontitis improved in elderly with Statins Lindy et al BMC Oral health 2008

127 Inflammaging Exacerbates age-related chronic diseases; CA CVDOsteopenia Cognitive dysfunction Chronic renal failure Osteoarthritis Bartlett

128 Inflammaging Respiratory disease; e.g. flu;Age 45-64; v unlikely to hospitalise/die Age 65-74; hospitalised/ die 75+; in 3 die

129 Local Modulation Alter responsiveness of genes to activation(epigenetics) Diet/stresses during pregnancy/Adult life Local severe infection Modify life-long gene expression Page; healthy site wide range of fibroblasts Diseased site narrow range of fibroblasts ?nature of bacterial challenge could be permanently altered in a local site.

130 In Summary... Inflammation has as big an effect as cholesterol on CV events Inflammation associated with 2-3x increased risk of Altzheimers Rheumatoid arthritis associated with increased risk of mod-severe periodontitis Treat periodontitis reduces rh arthritis symptoms “ “ “ COPD exacerbations

131 SUPERGLUE !! RSI deep pockets Coepack; stabilises coagulumProtects during eating/talking Coepack as adjunct for Agreesive periodontitis Sigusch et al 2005 Coepack as adjunct for Mod-Advanced CAP Genovassi et al 2012

132 Superglue !! RSI v RSI + CoepackLess deep residual pockets in coepack group Control; 41.7% patients moved to low risk group Test; % “ “ “ “ “ “ Keesta, Coucke, Quirynen JClinPerio Feb 2014.

133 Risk Assessment Family history of significant periodontitisUp to 4 1 3 4 2 Family history of significant periodontitis Smoking <10/day Smoking >15/day Stress; major life event in last 3 yr Previous perio treatment; <35yrs >35yrs Rodger Mosedale 2000

134 Risk Assessment X Rays; alveolar bone loss; horizontal <35yrsVertical < 35 yrs Horizontal >35yrs Vertical >35 yrs Complex root anatomy 1 4 3

135 Risk Assessment Systemic factors medication, IHD, xerostomiaOther risk factors Plaque retentive factors Occlusal overload 2 Up to 4

136 Risk Assessment < 5 = Low Risk 5-10 = Medium Risk>10 = High Risk

137 Low Risk Disclose OHI Scaling / polishing Rev 6,12 months

138 Medium Risk Indices OHI Scaling / polishing 1/12 Review; 3/12 Review

139 High Risk / BPE 3-4 OHI Scaling / root planing? Full mouth disinfection 4-6/52 review with pocket chart / OHI Review 3/12 ? Antimicrobials Periostat

140 Commonest MDU Problems :Failure to Diagnose; Periodontal Assessment Diagnosis Treatment Planning Failure to Treat Inadequate Treatment Response to treatment Explanations and warnings MDU commonest probs Biggest probs when defending clients

141 7.4% of all cases are perio related Of these; 90% failure to diagnose/treat Failure to INFORM, TREAT, MONITOR Average £15-20k Up to £90-110k ‘…the method of treating periodontal disease is now implants, especially via a lawyer’ ‘If I see good perio records ther’s a 75% likelihood they will be a forgery…’ John Tiernay, Dental Protection 2012

142 Records BPE? Pocket chart? Plaque score? Radiographs, Photos?GDC Advice given/discussion Benchmark position Changes in status Treatment plan Follow-up advice BPE? Pocket chart? Plaque score? Radiographs, Photos? Diagnosis Assessment of risk? Treatment plan Outcome of treatment Patient cooperation

143 Exam 1; Item 1a Clinical examination (including monitoring of periodontal status) and report

144 Exam 2; Item 1b Extensive clinical examination (including charting of periodontal status) and report

145 Of course we always use BPE……1/5 of practices carry out any form of perio screening BDJ 2001, 191 (8) New Adults; 91% sometimes 56% always Recall Adults; 84% sometimes 22% always

146 And now?......... 30% still no BPE in last 2 yearsCole & McMichael 2009 Primary Dental Care 16(3):85-93 Note writing; 25% sub-standard Soft tissues; 36% no record

147 Exam 3; Item 1c Full case assessment (including full charting and report of periodontal status) treatment planning and report i) in connection with 10c (non-surgical treatment of chronic periodontal disease) where a report on periodontal status is required , including full pocket depth charting of each standing tooth;

148 What records; and When? BPE Pocket chart Attachment level Who?Radiographs; Bitewings Vertical bitewings Full mouth periapicals OPG Diagnosis Treatment Plan

149 Long Term Management Axelsson & Lindhe 1981 ; 6 year studyPts maintained 3/12 recalls 1% sites had attachment loss 2mm+ Pts on 6/12 recalls with GDP 56% sites had attachment loss 2mm+ Half sites attachment loss without deeper PD Need to measure attachment levels Long term responsibility is with GDP

150 What records; and When? BPE Pocket chart Attachment level Who?Radiographs; Bitewings Vertical bitewings Full mouth periapicals OPG Diagnosis Treatment Plan

151 What records; and When? BPE Pocket chart Attachment level Who?Radiographs; Bitewings Vertical bitewings Full mouth periapicals OPG Diagnosis Treatment Plan

152 No. Visits Recall Frequency S&P Gross scale Root Debridement Authorised for LA; ____________________ TBI ETB Sonicare tape floss superfloss Ultrafloss Bottle brushes air floss Areas of concern;______________________________ Fissure sealants diet advice smoking cessation sensitivity_______ Full mouth disinfection irrigate pockets with chx gel/chlosite/PDT/ Perio Flow Diagnosis health, gingivitis, ANUG, mild, moderate, advanced Chronic adult periodontitis, Aggressive periodontitis Peri-implantitis aggravated by; Smoking, Diabetes, Calcium channel blockers, Stress, Occlusal factors Risk level (low, medium, high, refractory) Other treatment;_________________________________

153 Records BPE? Pocket chart? Plaque score? Radiographs, Photos?Diagnosis Assessment of risk? Treatment plan Outcome of treatment Patient cooperation

154 Item 3; Intra-oral photographs‘fees for colour clinical photographs in connection with treatment under…. Items 10&11 [periodontics] 16 [veneers] 17 [crowns] 18 [bridges] 32 [ortho] 1 photo; £4.25 Max (3 photos); £8.70 camera; £2000 229 patients 46 weeks <5/week

155 Periodontal Treatment; Item 10a;Scaling, polishing, simple periodontal treatment, including oral hygiene instruction Normally 3/12 2 1 1

156 1 Just OHI……. Item 6 Intensive instruction in the prevention of dental disease Including advice on diet and on oral hygiene techniques, and NORMALLY requiring more than 1 visit per course of treatment £9.45 No 10a, 10b or 10c for 6/12

157 Periodontal Treatment; Item 10b;Treatment of periodontal diseases requiring more than one visit including oral hygiene instruction, scaling, polishing and marginal correction of fillings; 10/12 since last item 10b or 10c. 2 3 1

158 Periodontal Treatment; Item 10cNon-surgical treatment of chronic periodontal diseases, including oral hygiene instruction, over a minimum of 3 visits, with not less than 1/12 between first and third visit and re-evaluation of the patients condition (to include full periodontal charting) at a further visit not less than 2/12 after active treatment is complete

159 Periodontal Treatment; Item 10c10/12 since last Item 10b or 10c Exam 3 in last 2 years Appropriate radiographs available ?

160 Affected Teeth Sextant Total 1-4 £42.10 £8.55 £50.65 5-9 £51.40 £17.10 £68.50 10-16 £60.80 £ £34.20 £ £95.00 17+ £68.05 £ £51.30 £ £119.35

161 Periodontal Treatment; Item 10c17+ teeth 10c; 4 visits Exam 1c =£27.15 Panoral x ray = £13.25 10c (6 sextants) = £119.35 TOTAL= £159.75

162 Periodontal Treatment; Item 10c£/hour 10a (minutes) 10b (minutes) 10c (minutes) £60/hr 13 32 160 30+30 £100/hr 8 19 95 £150/ hr 5 64

163 Periodontal Treatment; Item 10c£/hour 10a (minutes) 10b (minutes) 10c (minutes) £20/hr 30mins 30 £50/hr 16 15 39 20+20 10+ 159m m 30+ 21

164

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166

167

168 Consent What treatment proposed Why treatment necessary & risksConsequences of no treatment Alternative treatment & risks Costs What patient can expect/limits

169 Perio Consent During your examination today we have been monitoring your gum health. The BPE score today was which is no better/worse than your last score. Most people have a low but manageable level of gum inflammation, but the rising score indicates that’s a more intensive gum management programme is required at this stage to try and bring you back to a stable level.

170 Your Periodontal Risk Score is presently _____ and the most appropriate follow-up programme for this score is; 1-5 (Low Risk) (Medium Risk 11+ (HighR isk) Oral hygiene advice Oral hygiene advice Oral hygiene advice Scaling/polishing Scaling/polishing Scaling/polishing Review 6 or 12 months Review 1 month Root planing Review 3 monthly (Full Mouth disinfection) Review 4-6 weeks Pocket charting Review 3 monthly (Antimicrobial therapy) (Periostat therapy) (Dentalyse testing)

171 The consequences of not being able to stabilise your gum problems can lead to;Loose, drifting teeth Loss of teeth Spread of infection to other structures (e.g. Dental implants) Long-term chronic inflammation of the gums can affect diabetic control and heart disease and strokes in susceptible patients Alternative treatments and risks are;

172 The success of this management programme is dependent on the level of home care you are able to carry out. If you are having difficulty cleaning any area of your mouth please discuss this with us and we will recommend a different technique. Whilst most of our patients with gum problems can be managed well within our Practice, if we are concerned that your gum condition is not stabilising we can offer a referral to a periodontal Specialist.

173 Gum disease and its management can be made considerably more unpredictable by the following;Some medications (we will advise you if this applies to you) Long-term stress Diabetes (especially if poorly controlled) Smoking (3-7 times more risk of tooth loss) I have read and understood the above and request / decline the recommended gum management programme; Signed ___________________________ Date __/__/__ Name; ____________________________

174 Magnusson et al 1984; Poor plaque control Pocket repopulates 4-8 weeks Good plaque control Pocket repopulates 3/12 Can maintain most pockets with 3/12 debridement

175

176 Peri-implantitis TreatmentMucositis; OH Scaling Soft tissue excision Peri-implantitis; Antimicrobial therapy Regenerative surgery Resective Surgery Explantation

177 peri-implantitis 192 periodontitis 148. Koyanagi et al Journal of Clinical Periodontology Volume 40, Issue 3, pages 218–226, March 2013 BACTERIAL COLONIES peri-implantitis 192 periodontitis 148. Microbial composition of peri-implantitis was more diverse than periodontitis. Fusobacterium spp. and Streptococcus spp. were predominant in both peri-implantitis and periodontitis, Parvimonas micra only detected in peri-implantitis. The prevalence of periodontopathic bacteria was not high, but in most cases, prevalence was higher at peri-implantitis sites than at periodontitis sites.

178 How to Refer History; Initial Indices Treatment carried outPlaque Scores Bleeding Index Pocket charts / BPE Treatment carried out Patient cooperation Radiographs

179 How to Refer Relevant Specific problem which is to be addressedRadiographs Medical History Final Indices Allows correct allocation of patient Specific problem which is to be addressed Advice only? Treatment if suitable?

180

181 Peri-implantitis TreatmentMucositis; OH Scaling Soft tissue excision Peri-implantitis; Antimicrobial therapy Regenerative surgery Resective Surgery Explantation

182 Survival rate non-perio group; 96.5% perio group; 90.5% Peri-implantitis non-perio group; 5.8% Perio group; 28.6% Karoussis et al Clin Oral Impl Res 2003 53 patients, ITI, 10 years Periodontitis associated with increased Implant Failure (delayed or immediate placement) Evian et al 2004

183 53.5% pts and 31.1% implants had peri-implantitis Fardal & Grytten JCP June 2013 43 pts, 119 implants, 847 teeth 53.5% pts and 31.1% implants had peri-implantitis 53.4% pts and 7.65 teeth had periodontitis Maintenance cost of implants approx 5x teeth.

184 Communication LessonsCustomer wants the end product Involve the Customer in the process Believe in the value of your product ‘My feeling is that the reason so many people do not want to pay for their periodontal care is not because they don’t value it- it’s because we as a profession don‘t value it highly enough’ Ian Pearce Periodontist Nottingham

185 Compliance The extent to which patient’s behaviour coincides with practitioner’s recommendations Clinician knows best

186 Adherence 15-93% patients don’t act on recommendations (even when life threatening) Rovelli 1989

187 Adherence Medication; 20-25% Exercise; 37% Regular BP monitoring; 34%Smoking; % Diet; % Heart transplant patients fully adhered to recommendations % Rovelli 1989

188 Motivational Interview‘Righting reflex’ See problem fix it If WE change our style; PATIENT’s style changes

189 ? Neighbour on doorstep in tears? Teach friend’s child to drive a car? Follow Direct Guide Teach Instruct Lead Listen Understand Go along with Draw out Encourage Motivate ? Neighbour on doorstep in tears? Teach friend’s child to drive a car? ? Teach our own child to drive a car? i.e. OUR emotional state affects how we handle our approach with patients…….

190 ? Clinician knows best…. YOU cannot MAKE them changeYOU haven’t got all the RIGHT ANSWERS YOU haven’t got all the BEST ANSWERS Draw out whys etc. from patient ‘What for you might be the best way to look after your teeth/gums….’ ‘How might you change the way you clean in-between the teeth?’ Be curious….

191 Importance & Confidence scalingHOW? WHY? Information Confidence Why should I ? I want to but…. What will I gain/lose? Will I be able to? What skills do I need? Will I be able to cope in x,y,z situations

192 How CONFIDENT are you that you succeed? very not Why have you put yourself there? What would have to happen to move this to the right? How can I help you to “ “ “ “ “

193 Concordance Patient & health educator agree about the nature of illness and need for treatment ‘Go alone, go faster Go together, go further’ South African proverb Motivational interview produced better plaque score reduction than standard consultation (21% reduction v 4%) Godard et al J Clin Perio Dec 2011

194 Who’s problem is it anyway?Jargon v Plain English Body Language Ownership of the Problem Reason for buying the Product Blame v Encouragement

195 Who’s problem is it anyway?White Teeth Firm teeth Fresh breath No bother Motivate patient Periodontal health Eliminate pockets Scale calculus Reduce plaque score to zero Patient to Change brushing technique Floss every day Return for regular reviews

196 Psychosocial Impact NSM significantly impacts quality of life and how patients feel about themselves Jowlett et al J Clin Perio 2009

197 GDP Communication Greeting 56% Preliminary chat 48% Explanation 19%Business % Summary % Health education % Dismissal,closure,goodbye 30%

198 Motivation; Change beliefsNormal recall <25% Increase by; Questions that make them summarise Repeat important bits +15% Make specific to them +35% 20x more likely to remember narrative; ‘…I have a dream…’ My experience was…… Written info increased adherence up to 60%; but….not personal/specific to them 8

199 Motivation; Change beliefsYou have TWENTY SECONDS to make an impression when they arrive You have ONE MINUTE to engage with them when they walk into your treatment room. 8

200 FIND THE HOT BUTTONS INFORM CLOSE THE DEALIs there anything about your mouth that concerns you? If you had a magic wand is there anything you would change? INFORM Do you know why that is? CLOSE THE DEAL If we could help you to fix that would you be interested?

201 * 25% total recall 40% of first info 15% extra by REPEATINGCHUNKS of info; 7 +/- 2 CUES; leaflet /spoken words similar Font size 12+ Proportional spacing Non-justified *

202 Verbal 5% Paralinguistic (tone) 30% Non-verbal 65%

203 Who’s problem is it anyway?Jargon v Plain English Body Language Ownership of the Problem Reason for buying the Product Blame v Encouragement

204 What to say? Show Pictures? Plaque on crackers? You’ve got gum diseaseWhat a disgusting tip I’m not putting my hands in there Will you do that for me?

205 What to say? Your actually doing rather wellLike most people you miss bits Show healthy bits Show diseased bits Use patient’s mouth Use their x rays