Controlling Periodontal Biofilm with Perio Protect Adjunctive Therapy

According to the Centers for Disease Control, approximately half of American adults suffer from periodontits - an oral bacterial infection localized in the space (or pocket) between the teeth and the gum tissue. Many people ignore periodontal disease because the symptoms are often subtle or not particularly painful - red, swollen or bleeding gums, spaces developing between the teeth, receding gums, bad breath or loosening/ flaring teeth.

However, left untreated, periodontal disease can lead not only to bone destruction and tooth or dental implant loss, but to many other serious health concerns. There is abundant research evidence showing a connection between gum disease and many chronic conditions including Type 2 diabetes, cardiovascular disease and Alzheimer's disease, as well as low birth weight babies.  

Gum disease starts when bacteria attach to the tooth surface, multiplying to form a biofilm covered by a slimy protective layer. As this growth continues, the colony becomes larger and more complex and that change favors the emergence of certain types of bacteria (such as P. gingivalis, T. denticola and T. forsythia)  that are more destructive, both through their ability to breach natural tissue barriers and spread into the bloodstream, and through the inflammatory reaction they stimulate (Friedewald 2009).  Although inflammation is part of the body's immune defense against such pathogens, an excessive inflammatory reaction (such as that triggered by specific types or high quantities of bacteria present in the tissues, or in the presence of certain genetic traits) leads to the gum and bone destruction characteristic of periodontal disease, in addition to vascular endothelial damage - thickening of the arteries and an increased risk of hypertension and plaque rupture.

Oral bacteria have been found in the heart, brain, lungs and arteries, as well as the blood clots responsible for heart attacks and strokes. Species such as A. actinomycetemcomitans, P. gingivalis and P. Intermedia have been shown to invade the coronary endothelium, while live A. actinomycetemcomitans and P. gingivalis have been found in human atherosclerotic plaque (Spahr 2006).  Research shows that transient bacteremia (bacteria entering the blood stream) is routinely happening with eating, brushing and flossing activities, amounting to a total of 5370 minutes (3.7 days) per month (Legout 2012).  The total surface area of the periodontal tissue separating the oral environment from the bloodstream is 8-20 cm2 - a biological barrier that some bacterial species can breach more readily, and which becomes more permeable in the presence of periodontal tissue destruction (Spahr 2006).  Since it is impossible to avoid this routine passage of oral bacteria into the bloodstream, it becomes important to minimize the number of bacteria present in the periodontal tissue.

Perio Protect Therapy
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While regular home hygiene (brushing and flossing), in-office scaling and root planing and periodontal surgery are still essential to mechanically remove the existing plaque and calculus, mechanical treatments alone cannot completely eliminate the presence of bacteria on tooth surfaces - so an additional approach is needed to prevent these residual bacteria from rapidly recolonizing periodontal tissues in between office visits, especially in patients with high systemic risk and/or with limited home care ability (arthritis, post-stroke, Down syndrome, etc). While the majority of patients can be adequately managed with conventional therapy, a number of controlled clinical trials as well as over 10 years worth of individual case studies suggest that selective addition of Perio Protect therapy to standard periodontal approaches may be beneficial in some patients as a means to disrupt and reduce periodontal biofilm on a daily basis in order to minimize the effects of transient bacteremia. 

Periodontist / Prosthodontist Dr. Bruce Cochrane discussing  Perio Protect therapy
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Perio Protect therapy (American Dental Association code D5994 - "periodontal medicament carrier with peripheral seal – laboratory processed") uses FDA-approved custom-made prescription dental trays with a laboratory  seal that hold an antibacterial medication deep into the periodontal pocket, resisting the wash-out effect due to crevicular fluid flow. The recommended treatment duration is 10-15 min at a time, with an initial frequency of 2-4 times/day for several weeks, after which the maintenance frequency may be reduced to as little as once/day, depending on the initial condition and response.  The medicated gel (Perio Gel) does not rely on antibiotics for its effect, but on the unique ability of hydrogen peroxide to penetrate the complex biofilm matrix and kill the microbes through modification of proteins, breakdown of the bacterial cell wall and other actions. A naturally occurring antimicrobial agent found in saliva and breast milk, hydrogen peroxide breaks down the protein pellicle that forms on tooth surfaces, decreases inflammation and enhances wound healing without the risk of producing allergic reactions or antibiotic resistance. The Perio Gel formulation contains both a low concentration hydrogen peroxide and free-radical trapping agents to optimize the healing response, and may be combined with 2-3 drops of  doxycycline (subclinical dose) to inhibit bone resorption and stimulate bone regeneration. 

Patients with rapidly progressing or refractory periodontitis (which suggest the presence of more aggressive bacteria), patients with Type 2 diabetes, cardiovascular or autoimmune diseases, pregnant or immunocompromised patients as well as those with limited dexterity, dental implants, artificial joints or prosthetic heart valves may wish to discuss supplemental therapies such as Perio Protect with their primary physician and dental team in order to minimize adverse effects from the periodontal biofilm.



Oral Biofilm

Friedewald, Vincent E., et al. "The American Journal of Cardiology and Journal of Periodontology Editors' Consensus: Periodontitis and Atherosclerotic Cardiovascular Disease♦." Journal of periodontology 80.7 (2009): 1021-1032.

Legout, L., et al. "Antibiotic prophylaxis to reduce the risk of joint implant contamination during dental surgery seems unnecessary." Orthopaedics & Traumatology: Surgery & Research 98.8 (2012): 910-914.

Spahr, Axel, et al. "Periodontal infections and coronary heart disease: role of periodontal bacteria and importance of total pathogen burden in the Coronary Event and Periodontal Disease (CORODONT) study." Archives of internal medicine 166.5 (2006): 554-559.

Perio Protect

Putt, Mark S., and Howard M. Proskin. "Custom tray application of peroxide gel as an adjunct to scaling and root planing in the treatment of periodontitis: results of a randomized controlled trial after six months." J Clin Dent 24.3 (2013): 100-107.

Dunlap, Tanya, et al. "Subgingival delivery of oral debriding agents: A proof of concept." Journal of Clinical Dentistry 22.5 (2011): 149. 

Schaudinn, Christoph, et al. "Periodontitis: an archetypical biofilm disease."The Journal of the American Dental Association 140.8 (2009): 978-986.

Additional Studies:

Case Studies:   

The Orkos Award: