From a dental hygienist...
"...My second story relates to this column, so please bear with me as I share one of my success stories with an appreciative patient. About two years ago, I saw a middle-aged, male patient for the first time. Mr. Ed (fictitious name) was friendly, but a bit anxious and ready to tell me his woes. I’m a good listener and was eager to find out what was troubling him. He had already been through two rounds of periodontal surgery and was an active patient with a local periodontist. The periodontist had diagnosed him with aggressive periodontitis, and he was taking Periostat b.i.d. as directed. I questioned him about his home care and he rattled off the usual names of several oral hygiene home-care implements that hygienists associate with good oral hygiene, such as the interdental brush, rubber tip, dental tape, and power brush. This patient was new to me but had been in this particular general dental practice for several years.
I reviewed the recare letters from the periodontist’s hygienist, and she noted that he was maintaining well with good home care on each of about a dozen reports. The patient was very nervous in my chair and was convinced he would lose his teeth in spite of two rounds of full-mouth periodontal surgery. Mr. Ed cried when he told me that he feared losing his teeth, and he wanted me to give him hope. In performing a comprehensive periodontal exam, I noticed immediately that he was still healing from the second round of surgery.
What shocked me the most, however, was my immediate impression that his home care was poor. Upon disclosing, I found significant amounts of biofilm along the gingival margin and interdentally, though he insisted that he was using his brushes and rubber tip according to directions. I told him I thought I could help but that I would need to see him a couple of times for detailed home-care instructions. My immediate thought was to focus on a new home-care procedure that would be easy to implement. So I sent him to the pharmacy for an oral irrigator and told him to purchase a bottle of 10 percent povidone iodine. I also told him to irrigate with a diluted povidone
solution (one part povidone iodine to nine parts water) once a day and return in a month. (I prefer diluted povidone iodine to other antimicrobial agents because of its broad-spectrum antimicrobial activity, low potential for developing resistance and adverse reactions, wide availability, ease of use, and affordability.)
A gamble with povidone iodine
I was a bit concerned about recommending povidone iodine because I had heard it was not approved by the FDA for intraoral use, and its safety as a self-applied adjunctive irrigant was not established. I decided to recommend it for a short time in an effort to heal his surgical wounds. When giving oral irrigation instructions, I always recommend a cannula-type tip for patients with moderate to deep pockets rather than the standard tip that does not penetrate as deeply into the pockets.1
When Mr. Ed returned the next month, there was marked improvement in surgical wound healing, and for the first time in a very long time (I’d say 10 years or so), Mr. Ed felt encouraged. Neither he nor I could fully comprehend the dramatic change from inflamed, bleeding gingival tissues to a healthy and firm condition.
What caused this change in tissues from diseased to healthy in such a short time? Most of us understand that elimination or adequate suppression of periodontopathic bacteria in subgingival microbiota is absolutely essential for wound healing. According to the literature, conventional mechanical root debridement (and pocket reduction surgery repeated twice in this case) does not eliminate all periodontopathic bacteria from the subgingival ecosystem.2 Sites with deep periodontal pockets, grooves, furcations, and concavities are difficult to access with periodontal instruments, and periodontal bacteria can even invade dentinal tubules and live on the mucosa, tongue, tonsils, and gingiva.2
In Mr. Ed’s case, I theorized that the povidone iodine (which is a broad-spectrum antimicrobial) suppressed the bacteria that assist in the formation of soft-tissue biofilms. Supragingivally, biofilms form on a single surface, but subgingivally they form in three areas: on the tooth side of a pocket, on the epithelium lining of the pocket, and within the pocket, which is the loosely adherent plaque zone where the antimicrobial can easily destroy and wash away periodontopathogens that are not caught up in thick intracellular matrix.
I explained to Mr. Ed that we were trying to remove “gum bugs” that make up a sandwich between the teeth and under the gum line. These periodontopathogens live in and around the two slices of bread in a sandwich. (Not very appetizing, that’s for sure!) The tooth side of the pocket is one slice of bread, the pocket epithelium is the other slice of bread, and the loosely adherent plaque is located between the two. You can call it peanut butter or jelly, but make sure the patient understands it’s a layer filled with bacteria..."