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Endo tips    Better Endo    Endo abstracts    Endo discussions


  Bleeding on Scaling

From: Jack Stueve
Sent: Thursday, May 10, 2001 8:57 AM
Subject: Bleeding during scaling

I have used Dr. Larry's bleeding index for years, and find it 
to be very helpful in long term maintenance of perio patients.  
I have wondered for a long time, though, what is the significance 
of bleeding during scaling?  It came to mind today when I saw this 
patient for the 2nd time.  He is Type 2 diabetic, and has
typically had lots and lots of bleeding and pockets, and other 
hygienists had not been successful in getting him to come in often 
enough.  I saw him 6 months ago, and convinced him to get a water 
irrigation device, and use it with Dr. Larry's baking soda recipe. 
When I saw him today, he reported that he had been doing the water 
irrigation 2 times a week.  His perio chart showed much improvement, 
much less BOP, decreased pocket depths.  But when I started to 
scale/ultrasonic this guy - he had so much bleeding!  How
do I explain this to someone when I have just given them such high
praise on their improved perio chart. What does all this bleeding 
during scaling mean?? - Karen, RDH in OH

From: Larry Burnett
Sent: Thursday, May 10, 2001 7:10 AM
Subject: Bleeding during scaling

I'll take a crack at answering this if you can put up with some of 
my guesswork as opposed to research based evidence.

Before I start, let me suggest something about the irrigation 
prescription. There is good evidence that many or most people will do 
just as well using plain water instead of baking soda or any antimicrobial.
So if either the expense, the hassle or even taste of antimicrobials 
were to deter compliance it wouldn't be worth adding the anti-microbial 
to the high power blasting  interproximally technique. I think that's
because of the way the water pik effects the pocket environment.  Using 
the Pik Pocket or other subgingival delivery device is another story.

OK back to the "bleeding upon Scaling question" Uh oh, I feel a long 
answer coming on because when I answer a question like this, I like to 
use it as an opportunity to pass information on to some of the
silent majority on this list that don't really know a lot of the things 
that some of the "experienced" people on this list know.  So if someone 
thinks I'm wasting time with something obvious and elementary,
try to remember that I have been constantly reminded by people attending 
my lectures that not everyone knows all the newer stuff that at lot of us 
here know.  And they appreciate learning it.

I think one must really understand what "bleeding upon mechanical 
stimulation " actually is.  It is the immune response in action.  
Bleeding upon probing means that in response to an antigen ( the pathogenic
bacteria), the body has a set response.  The blood flow in the immediate 
vicinity of the antigen slows down as is exhibited by the redness and swelling 
you sometimes see.  The capillaries actually become more porous letting the 
products of the immune system exit from the capillaries into the surrounding 
area to fight the bugs that engendered this response.  That in itself is a 
pretty great diagnostic tool because when you see "bleeding upon probing"  
it's like the pathogenic bacteria are sticking a red flag up from
inside the pocket, yelling "here we are, here we are!"  "Don't waste your 
whole appointment scrapping a roundhouse full of root surfaces needlessly".  
Come on down here and clean us out".  Of course different levels of bleeding 
give you varying types of information about the relative numbers and virulence 
of the offenders.

So here come the guesses about people like Karen's patient who bleed profusely 
when scaled despite bleeding upon probing looks within tolerable limits.

1.  The immune response is staying on high alert under the gum but not emptying 
    blood into the pocket itself through the very outer surface.

2.  There is a significant infection of bacteria that have penetrated beyond 
the pocket through the surrounding tissue and are hiding in there trying to come 
out and repopulate the pocket itself.  Well the patient is doing a pretty good job, 
and with irrigation is keeping the actual pocket FREE of the bacteria, toxins and 
cytokines the stimulate those surface capillaries to bleed there contents into the
pocket, just from some surface stimulation with the probe.  But perhaps the scaler 
is damaging the deeper porous capillaries which are in inflammation mode fighting 
the imbedded bacteria.

The only way to reach and perhaps stop this problem of imbedded in the tissue 
bacteria, is with a round of systemic antibiotics.

I have witnessed this same problem many times, but it quit worrying me when I 
observed these patients weren't loosing bone (going downhill) while they were 
under effective maintenance care, despite the bleeding.

I'm open to hearing more guesses or facts about this observation.  Anyone else?

P.S.  I will be gone from Sat., May 12, until Sun. May 27th but I'll read all the 
posts when I get back. Somebody tell Rob it's normal for little spicules of bone 
to work their way out from under the skin over time after an extraction and not 
to worry.

PPPS I'm going to try to put a little post about the occlusion discussion from 
my hygienist's point of view before I leave. I don't want anyone thinking your 
periodontal therapy will be compromised if you don't include occlusal equilibration 
in the treatment plan.  If occlusal idealization were actually necessary for success, 
that would completely destroy my opinion that no one can deliver better
periodontal therapy than a dental hygienist. - Larry Burnett

From: Laura
Sent: Thursday, May 10, 2001 6:29 PM

<< But when I started to scale/ultrasonic this guy - he had so much bleeding!
 How do I explain this to someone when I have just given them such high
praise on their improved perio chart.  What does all this bleeding during
scaling mean??  >>

Dear Karen, Check his list of medications and make sure it is complete. 
Is he on Coumadin? I have found that even the patients who are on an aspirin 
a day have much more bleeding. They often forget to tell you this because 
it is an OTC drug. Ask him about aspirin usage. - Laura

From: IDHF
Sent: Thursday, May 10, 2001 8:29 PM
Subject:Bleeding during scaling

Dear Karen, It sounds as if your patient is getting the superficial areas 
of infection, but not deep in the pockets.  What type of irrigator tip is 
he using?  He may need to switch to a cannula. Hydrofloss has plastic 
cannuale and the rounded metal tips.  It would be great if you had a 
microscope because you would be sable to sample these deep pockets and 
know for sure what is going on.  He may also be a candidate for 2 weeks 
old metronidazole.  Diabetics have decreased vascular function.and are 
more prone to bacterial colonization. They need more agressive therapy, 
but without microbiological diagnosis, therapy is blind.  I would also 
recommend that he be put on chlorhexidine 0.2% irrigation.  You can get 
it at the Medicine Shoppe in York, PA.  He should also be irrigating 
every day. - Dan Watt

Karen; I have also found in treating perio patients that they may have pocket
reduction... and all is improved at recall visits.. But, I have encountered
the same problem with the bleeding upon scaling ..Along with asking for any
changes in med history or meds that are taken,

I also have them review thier flossing technique ..I am amazed.. at the
people who floss incorrectly .even after I have shown them at thier last
appointment ..I feel proper flossing (all the way down and curving the floss
around to the front and back of the tooth ) provides excellent stimulation
and reduction in gingivitis and perio etc.. bleeding .. try reviewing the
flossing technique again along with hhx quiestions again possibly introducing
a mouthrinse perio guard .. listerine ,oxyfresh ..whatever it is you prefer
along with the STRESS put on the importance of flossing.. to reduce the
bleeding ....good luck and keep us posted  on his progress - beth

Thanks for all the responses to my query on bleeding during scaling. I know that part of this guy's problem is that he does not follow home care as he should, and he also has in the past been very sporadic in coming in - but now I am making sure that he stays on my schedule because I seem to have made a connection with him. And Larry - I too believe that he is not losing bone. We have tried systemic antibiotics about a year ago, but this was before he was on my schedule, so I am going to bring these suggestions in to the doc and we will plan from there. Any thoughts on Perio Stat for this patient? This was my thought before I posted....Karen, RDH in OH Any thoughts on Perio Stat for this patient? This was my thought before I posted.... Larry replies:Since Periostat is to slow down bone loss by interfeering with the immune response, I wouldn't consider it for this patient who isn't loosing any bone - Karen, RDH in OH PS - What kind of microscope do any of you recommend - and do I need to have training, etc.? I have not previously used one in practice, but I do agree that on some patients it sure would help with TX planning. I have a guy from Swift who has put one together without high priced overkill, delivers it for less than $3500 including video camera and monitor and the scope is guaranteed for life. Contact me privately for info Karen and I'll have him send you some brochures. Best way to learn is from another hygienist who is using it. I know plenty of them. - Larry First, have allergies been ruled out? I have seen several patients with spongy, bleeding on probing tissue, that did not bear out the other signs of disease. I always test these sites for elevated sulfide activity which indicates active infection. If the tissue is exhibiting signs of inflammation, without elevated sulfide activity, I investigate other causes of inflammation. Several toothpastes and alcohol based mouth rinses have been culprits. My experience with Periostat, especially for diabetic patients has been excellent. The soft tissue response has exceeded my expectations, plus, in consulting with several MD's, the patient's insulin needs were reduced, as perio health was restored. I would not hesitate to contact the patient's physician, and suggest Periostat. For patients with compromised immune systems, I don't want to wait for signs of advancing bone loss, I prefer to be proactive. Another adjunctive TX might be to follow Dr. Connie Drisko's regimen of ultrasonic instrumentation with povodine iodine. Her research has shown greatly improved soft tissue health in diabetic patients following the administration of povodine iodine irrigation via ultrasonic delivery. - Beth Thompson From: Jack Stueve Sent: Friday, May 11, 2001 9:16 AM Subject:Bleeding upon scaling Dear Karen , It sounds as if your patient is getting the superficial areas of infection, but not deep in the pockets. What type of irrigator tip is he using? He may need to switch to a cannula. Hydrofloss has plastic cannuale and the rounded - Dan Watts Just FYI - I had recommended the Water Pik Pik pocket tips for home irrigation, but as I said, he was only doing it about twice a week. I sent him home with instructions to use the regular tips twice a week for 5 seconds in between, and the Pik Pocket tips twice a week. I plan on emailing him and letting him know that he can just use water, if the baking soda is stopping him from using the irrigation more often. I usually just tell patients to use water, but this guys gums were so spongy and red and yucky that I wanted him to try it with the baking soda to see if that would help. Any thoughts on why use the Pik Pocket tips as compared to the regular tips? I have heard both ways, and still don't have strong feelings for one or the other. Karen, RDH in OH Regular tips can be used on full power and when directed at right angles between the teeth ( not apicaly into the gums) there is the suggestion that hydrodynamic effects tend to suck out loosely attached bacteria and the destructive chemicals related to the bacterial infection. The Pik Pocket, on the other hand is a LOW POWER delivery system enabling the patient to easily and routinely delive medications well under the gum tissue by placing the soft rubber tip as deeply as possible into the pockets. - Larry From: Larry Sent: Friday, May 11, 2001 9:39 PM Subject: re bleeding on scaling I've never scaled a pt where there wasn't some bleeding. Now that I got that off my chest I would Llike to pick Larry's brain. Oh Oh here I go agen with one of my ideas! Larry have you eaver seen a "soaker hose" in the harware store? We could make little "soaker hose" tips for an irrigater that will deliver an even pressure and concentration to the area with out the micro-trauma of the high pressure pulse. What do you think? Pontic(Dan if you will) I think the high pressure pulse contributes to the beneficial effect. I haven't seen any evidence of micro or macro trauma from the pulse. I have seen research showing no damage of any kind from the pulse, even at max pressure (setting of 10 on the irrigator). I hate to be an idea party pooper so keep the ideas coming. - Larry Beth says: My experience with Periostat, especially for diabetic patients has been excellent. The soft tissue response has exceeded my expectations, plus, in consulting with several MD's, the patient's insulin needs were reduced, as perio health was restored. I would not hesitate to contact the patient's physician, and suggest Periostat. For patients with compromised immune systems, I don't want to wait for signs of advancing bone loss, I prefer to be proactive. Larry replies: You must have a lot of patients on Periostat. So you use it as a preventative medicine? Is that cost effective. How long do you keep them on it? Another adjunctive TX might be to follow Dr. Connie Drisko's regimen of ultrasonic instrumentation with povodine iodine. Her research has shown greatly improved soft tissue health in diabetic patients following the administration of povodine iodine irrigation via ultrasonic delivery. Larry replies: Many of us use ultrasonic delivery of medicaments like this as our prevention as well as treatment. I like local delivery of medication whenever possible as opposed to flooding the entire body with medication. Especially when the medicine has some question marks. I mean if it stops the immune response in the mouth from doing it's bone resorbtion, what might it be doing in the rest of the body? Our bones are constantly undergoing resorbtion and re-mineralization as normal physiologic function These are some of my thoughts which suggest using Periostat as a last resort only. - Larry From: Lisa Sent: Friday, May 11, 2001 9:11 AM Karen, Vitamin E also causes bleeding by prolonging clotting times. Lisa, RDH in NY From: IDHF Sent: Saturday, May 12, 2001 1:36 PM We do have cannulae that do just about the same as a soaker hose. I like the HydroFloss irrigator because it does not have as much pressure as Wtaer Pic anmd the pulsitile ossilation is not as much. Using a hydroFloss with a cannula can be highly effectve. HydroFloss has them (800) 635-3594 From: Larry Burnett Sent: Sunday, May 13, 2001 8:12 AM I like Hydrofloss too. They have a great selection of tips and I can't even count how many years mine has been reliably working; A real workhorse. - Larry If you determine that a Pt's bleeding is not comiserate with the inflamation that they have, then inform the pt and review the medical hx. This is the time to stop the treatment and ask a few questions. Something is going on that they should be aware of. Don't scale amy further untill you are shure that this bleeding will not be a significant risk. I have a friend that got his teeth cleaned by a Dentist and that evening he called me long distance because he was still bleeding from the last area the Doc had worked on. To make a long story short, My friend had developed anemia from a recient respiratory infection. So a little detictave work can save some problems. The pt might do better if treatment is delayed and the pt get evaluated by an MD. If there is something wrong they will thank you for it.- Pontic From: Shirley Sent: Sunday, May 13, 2001 6:54 PM Subject: Bleeding on Scaling Karen you sure got some really good advise on how and why bleeding can become profuse during scaling when there isn't much on probing. Part of your original question regards what to tell the patient after you give them a gold star for no BOP then practically need to call for a unit of blood when you finish scaling. First my thoughts on why it happens on patients that are not diabetics. Generally speaking think of the soft tissue wall of the pocket, maybe it has a thin covering of epithelial tissue. A probe may not instigate bleeding. The same way floss may not instigate bleeding in a patient that doesn't experience bleeding at home. The top part of the pocket isn't prone to excessive hem. A Cavitron tip or curette will disrupt that thin wall and allow all the wrath of infection fighting compounds out, along with the blood. So, I started to do a two part perio screening. First probing to establish history of disease. Because, as we know, bone loss is a past event. When we measure, we're establishing a history of disease. The second step is to go round with a curette, and place the instrument. Just put it in and take it out (some people use a toothpick). If bleeding is to occur it will now, before you praise the patient for having good numbers. The dialogue can begin now as the patient has had a proper screening for active disease. Diabetes is a confounding factor in this case. He may not be well controlled, which you will not know unless you speak to his MD. HgA1C is the test number you're looking for. It is the number that let's patients and their health care provider know how the diabetic is controlling their blood glucose over a quarter (or 3 months) - Shirley
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