Hygiene drive philosophy handout

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Each and every team member must know what their doctor’s philosophical approach to their practice is and this is

essential in how All therapies fit into each patients paradigm

• Every appointment is customized for each patient

• Success is based on “Caring”

• Success is based on “Organized”

• Success is based on the “Team”

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Prevention at All Ages…how does your office customize? Caries Evaluation on Non restored teeth, caries evaluation on old restorations?Minimally Invasive Procedures…what are the protocols?How does occlusion fit into your philosophy? What role do the hygienists play? How do various periodontal phases fit into treatment planning?Comprehensive Periodontal ApproachesOral Cancer screening…what are the 1/2/3 steps each much followRestorative concepts: composites versus crowns, implants versus bridges, orthodontics versus aggressive crown on bridge on natural dentitions How does esthetics fit into your approach?How does esthetics fit into your approach?Sleep ApneaBotox, Anterior Orthodontics with 6 month smiles and Invisalign

•Every Day has to be planned we review•Where patients are in various phases of hygiene care•Where patients are in their restorative treatment plans, work that still needs to be completed•Which patients on the doctors schedule are due for hygiene!•Who is do lab deliveries•Updates of the DAY and pass offs•Who requires a two-hour reminder for their appt or pre-medication via Smile Reminders•Room for emergenciesRoom for emergencies•Who is do for charting, Velscope, periodontal and periodic exams, radiographs, and more

Green is hygiene, Yellow is for doctors and assistants, Blue is front team

If pure direct operative, no double books and my production is still geared per hour…so yes I bill per hour with direct restorativeWhen I get up to do hygiene checks….all the hygienists have to be ready and this can only be done if they do their exams first (including review of medical and history changes)…a busy day … IT HAS TO FLOW!Growth Beyond a Value based practice…includes changing with the times more non insured procedures such as Invisalign Six the times, more non insured procedures, such as Invisalign, Six Month Smiles, Sleep Apnea and Botox. Equally, building a specialist role as part of your growth strategy was an option we adapted

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Build Relationship

Establish Credibility

Clinical Screenings

Share Findings

Dr. Exam

Either 50 or 60 minutes routinely….building Value

Oral Hygiene

Instrumentation

Create Value

Hand-Off

Op Break Down

Build Relationship


Clinical Screenings

Share Findings

Dr. Exam

Oral Hygiene

Instrumentation

Create Value

30 minutes max

The key is allowing the hygienist enough time to be a total oral care provider

Hand-Off

Op Break Down

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X rays: individualized per patient: This is determined by periodontal and caries susceptibility along with age….Bite Wings Yearly, FMX every 4-5 years, Panorex, and coming… Cone BeamsPeriodontal exam: absolutely annually with full probing and more Clinical Attachment levels, fremitus, mobility, BOP, inflammation, infectionRestorative/Occlusal Exam with both the doctor and hygienist working together, this can include Diagnodent and Spectra (when appropriate), Intra Oral imaging, and now the world of CariVu appropriate), Intra Oral imaging, and now the world of CariVu (may alternate with X-rays) transillumination, articulating paper, tooth sleuth, pulp vitality tester…..and more

Build Relationship


Clinical Screenings

Share Findings

Dr. Exam

Oral Hygiene

Instrumentation

Create Value

H d OffHand-Off

Op Break Down

Saliva Testing for Strep Mutans and Xerostomiaand far more coming….DNA testing for those patients whom we have to know what are bugs behind the diseaseSleep Apnea with written questions and a visual examination (Mallamapati)Oral Cancer the essentials of a 1/2/3 screening program…one of the most important responsibilities

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Build Relationship


Clinical Screenings

Share Findings

Dr. Exam

Oral Hygiene

Instrumentation

Create Value

Hand-Off

Op Break Down

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SDI’s Radii LightMandatory: Loupes and Lights

Hygienist Responsibility

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Helps find decay, cracks, examine restorations, tartar sub-gingival and more!For the doctors, it’s a great add on to simply remove their LED curing tip and pop this on to exam their preps for decay and cracks root canal orifices decay and cracks, root canal orifices, and their exams!

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Routinely, poor hygiene Food traps, plaque issues, poor margins in many restorationsPeriodontal issues, restorative issues that can affect their daily livesWhere do you start?

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What do you do…He hates his smile, teeth are in occlusal trauma…

3 periodontal visits which included an overall debridement then 2 appointments for full mouth therapy with lasers. We pre-medicated him based on his periodontal health, not per his medical historyPeridex pre-treatment rinses, today we use OraCareLots of hygiene discussions with care giverExtracting teeth that were not salvageable 3 and 14New Crowns 24,25 and 29Upper Radica Bridge for the rest of his life….

1330 REVIEW OF ORAL HYGIENE0180 COMPREHENSIVE PERIODONTAL EXAM

Potential DNA, Genetic, Saliva Testing, Occlusal Evaluation, Restorative Evaluation,Sensitivity

First Therapy4355

Full Mouth Debridement with laser in decontamination setting

Therapies 2 and 343414341

Half mouth Debridement with lasers Systemic antibiotics were given

Therapy 4 4341Re-debride the areas treated that have deep pockets, these do not have to be in the same quadrant, use laser in either decontamination mode or debridement and apply

Arestin at this point and or both

Therapies 5 and 6 followed the same profileRe-evaluation 6 weeks later…NO probing

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First Therapy4355


Pre-medicated

Therapies 2 and 34341

Half mouth Debridement with lasersReview of Oral Hygiene with patient and care provider

The opportunity to remove the biofilm from the root surface in a systematic approachThe deeper the presenting pockets the greater the opportunity for failure to remove such biofilms Unless your office is doing open flap procedures, multiple sequential appointments become the standard fof care in debridement therapy

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You will be debriding the most significant pockets (>6mm) after the initial debridement. This can include multiple quadrants in one appointment. The concept is to have subsequent opportunities to additionally fully debride these pockets in sequential visits. We use lasers at every appointment in one of two modes…Decontamination or De-epithelialization…depends if the laser is activated and where we are in therapywhere we are in therapyEvery hygienist in my practice has their own laser and is laser certified…every patient gets the same quality of care

In Full Mouth Cases, the approach is to an initial debridement with laser decontamination

Then 2 visits of ½ full mouth scalings/planing'sand then if necessary begin systemic antibiotics followed by further sequential therapy, re-entering deeper pockets to complete debridement in 1-3 additional visits if required

Simple cases may only require 1-3 visits post the initial debridement due to only specific areas requiring treatmentThe more complex cases often need 3-6 visits because the disease process is more extensive and omnipresentWE treatment plan more and if less….great!This is variable based on their periodontal history, number of pockets, severity and more!Customized sensitivity treatments that may be prescribed y y pinclude MI PASTE, ReMin Pro or other custom treatments for sensitivity prior to beginning treatment

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Oral-B Vitality

Baseline

n=50

n=50

Week 4ADA Manual

Klukowska M et al. IADR 2010 Abstract 3695

•4-Week study comparing an Oral-B Oscillating-Rotating brush to an ADA manual brush

•Assessment of gingivitis, gingival bleeding, and plaque at baseline and 4 weeks

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70

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Oral-B VitalityADA Manual

ent R

educ

tion

From

Bas

elin

e

Plaque Index (RMNPI)

0

10

Interproximal Whole Mouth Gingival Margin

Perc

Differences Statistically Significant*P<0.001

Klukowska M et al. IADR 2010 Abstract 3695

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40,000 gentle in-and-out pulsations per minute reach deep to loosen

8,800 Side to Side oscillations per minute sweep plaque away 48 800 ill tideep to loosen

plaqueplaque away

Brush Head Design along with Oscillating-Rotation-Pulsation Technology Lead to

Outstanding Clinically Relevant Performance

48,800 oscillating-rotating-pulsating

movements/minute

Smart coaching informspatient to brush next quadrant

Pressure sensor informspatient excess pressure

is being applied

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Stannous fluoride is a broad-spectrum antimicrobialBactericidal

Gram positive and gram negative bacteriaBacteriostatic

Metabolic inhibition – toxin reductionsReductions in plaque mass

Strep Mutans

Reacts with teeth to protect against cariesBlocks dentin tubules to reduce tooth sensitivityKills bacteria and inhibits plaque metabolism. Reduces gingivitis and caries.Reduces Malodor

Bioavailability of Stannous Fluoride in original Crest formulation

Bioavailability of Stannous Fluoride in Crest Pro-Health

FF

F F

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Currently available on the marketSelf-applied topical fluoride treatments

0.4% Stannous Fluoride GelGel-Kam®, Oral-B Stop®, Omnii Gel™

Rinses (Rx)0.63% Stannous Fluoride Oral Rinse

PerioMed™, Gel-Kam® Oral Care RinseDentifrice (OTC)Dentifrice (OTC)

Crest Pro-Health ToothpasteEnamelON

In addition to caries benefits, stannous fluoride is also effective against:

PlaqueGingivitisDentin hypersensitivityMalodor

Stannous fluoride is the only fluoride that has been shown to provide a benefit against caries, plaque & gingivitis,malodorand dentin hypersensitivity

Caries protection

Plaque & gingivitis control

Sensitivity protection

Freshens breath

Calculus protection

Extrinsic stain removal

Extrinsic stain protection

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Inserts, solublize, & weakens cell membrane.

CPC interacts with bacteria walls

--

--

-

-

---- -

-

--

+

++

++

+

Cetylpyridinium Chloride (CPC): Potent, broad spectrum antibacterial

Cellular pressure disrupts cell membrane – killing bacteria

--

Effective against a broad range of bacteria commonly associated with plaque and gingivitis, including:

• Actinomyces viscosus• Fusobacterium nucleatum• Porphyromonas gingivalis• Prevotella intermedia• Campylobacter rectus• Eikenella corrodens• Streptococcus sanguinis

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Daytime Plaque Effects of Power Brush, Therapeutic Paste and Rinse”

Presented by Gerlach et al at the American Association for Dental Research Washington, DC March 6, 2010

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Dentifrice 0.454% SnF2 Regular

Brush Power (R/O) Manual

Treatment Groups

Two-week, randomized, examiner-blind, N=43 with 2 minute brushing and Digital Plaque Imaging

endpoints-24 hr plaque

Brush Power (R/O) Manual

Rinse 0.07% CPC None (no floss)

MorningBrushing

EveningBrushing

Acclimation

MorningBrushing

EveningBrushing

MorningBrushing

EveningBrushing

Timing of Digital Plaque Imaging Measurement

PlaqueMeasurement

Baseline Day 7 Day 14

PlaqueMeasurement

PlaqueMeasurement

Digital Plaque Imaging Measurement Performed

Morning Prebrushing - Baseline Day 1

Standard manual brushing

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Morning Postbrushing - Day 1


Night Prebrushing - Day 1(Daytime Plaque Accumulation)


Morning Prebrushing – Day 2(Overnight Plaque Accumulation)


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24-Hour Anti-Microbial Effects of PRO-HEALTH Paste and Rinse

Sodium Fluoride Stannous Fluoride +Cetylpridinium Chloride

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Long term provisionalization system...Comparable to indirect composites with highstrength, wear propertiesOutstanding long term esthetics

Glass ionomer provisional luting cementVery retentiveWill stick too tooth, so avoid on lower molars!Releases fluoride (1600 μg/cm2 over 30 days)Easy clean upLow film thicknessMay help in reducing tooth sensitivity

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Eugenol freeHigh bond strengths to tooth structure, very retentive for long term provisionalsEasy clean upBUT…you have to mix power and liquid

The Regimen of Crest Pro Health:Elimination of the majority of plaque and gingivitis

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1. Helps Prevent Caries

2. Helps Prevent Gingivitis

3. Treats Sensitivity

Stabilized SnF2 (970 ppm) Preventive Treatment Gel

1. Independent Testing Data: Therametric Technologies, Inc. 20142. Negative Control (Water) recorded an uptake of 8 ppm

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*In-Vitro Testing on Surface Human Dentin

1. Stabilized stannous fluoride (970 ppm F) 2. ACP technology3. Substantivity Enhancers

1. Ultramulsion® patented technology*2. Gantrez®

4. Spilanthes

*Ultramulsion is a trademark of Whitehill Technologies, Inc.

Promotes sustained release of ingredients calcium, phosphate, tin, fluoride, flavorProvides substantivity

Slow dissolving silicone copolymersPolydimethylsiloxanePoloxamers 407 and 338

Long lasting in the oral environmentReduces surface tension

Reduces dental plaque adhesionInhibits biofilm attachment, staining

M dh i M i t i l Mucoadhesive - Moisturizes oral mucosa Beneficial for dry mouth patientscoats the soft tissue creating a smooth, slippery, feel

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Provides substantivityspecifically made for denture adhesives Not the same Gantrez as in TotalFunctionalized with calcium

Promotes sustained release of ingredients calcium, phosphate, tin, fluoride, flavor

Mucoadhesivesticks to the hard and soft tissue in the mouth

Flowering Herb

Naturally enhances salivation

Enhances flavor

Provides a tingling, cooling sensation

Safe for all age groupsSafe alternative to 5000 ppm fluoride pastes Option for young children without increased risk of fluorosis

Nonabrasive (RDA 8)Saliva-stimulating No SLSNo dyes, gluten, or dairy-based ingredientsClinical Studies shows very effective for root caries

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Saves waste

Saves money

Controlled dose delivery

After whitening in tray

Fluoride varnish works by increasing the concentration of fluoride in the outer surface of teeth, thereby enhancing fluoride uptake during early stages of demineralization. The varnish hardens on the tooth as soon as it contacts saliva, allowing the high concentration of fluoride to be in contact with tooth enamel for an extended period of time (about 1 to 7 days). This is a much longer exposure compared to

What are the advantages of using a FL varnish over other topical fluorides?

What are the advantages of using a FL varnish over other topical fluorides?

PPM Type

900 MI Paste Plus

This is a much longer exposure compared to other high-dose topical fluorides such as gels or foams, which is typically 10 to 15 minutes.The amount of fluoride deposited in the tooth surface is considerably greater in demineralized versus sound tooth surfaces.*The benefits of fluoride varnish are greatest for individuals at moderate-risk or high-risk for demineralization or tooth decay.** Can we say Geriatrics!

Source: Fluoride Varnish: an Evidence-Based Approach Research Brief Association of State and Territorial Dental Directors Fluorides Committee September 2007 * (Skold-Larsson, Modeer, Twetman, 2000; ten Cate, Featherstone, 1991) - ** (Marinho et al, 2004; Marinho et al, 2004a; ADA 2006)

900 -1,500 OTC Toothpaste

5,000 Prescription Toothpaste

12,300 Fluoride Gel

22,600 Fluoride Varnish

MI Varnish GCAmericaEmbrace Varnish CxP PulpDent

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MI Varnish is a natural Casein and the phosphopeptides(CPP) binds to the oral surfaces, Amorphous Calcium

Phosphate (ACP), which is found in the RECALDENT™, is also a source of calcium and phosphate.

• Embrace Varnish is a resin-based varnish containing 17.6% Xylitol, sodium fluorideֽ calcium, phosphate, and less than 20% ethanol.

• It too releases fluoride, calcium and phosphate ions over a four hour period

EMBRACE™ Varnish CXP

The nano-coated calcium and phosphate salts are encapsulated with Xylitol and do not react prior to

exposure to saliva. As a result, the calcium, phosphate and fluoride are bioavailable and provide all the

benefits of fluoride varnish.

Nano-Coated with Xylitol:Bioavailable, Sustained Time-release

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These varnishes will remain on the teeth for 3-4 hours. This is the critical time for fluoride release and fluoride uptake by

enamel.

Sustained Time-release of Fluoride

Cumulative Fluoride Release of Leading Fluoride Varnishes(measured in micrograms mcg] per 55 mg of solid weight)

700

800

900

1000

se in

mcg

3M Omni White Varnish

Preventech Vella

3M Vanish with TCP

MPL Varnish America

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500

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1 hr 2 hr3 hr

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Premier Clear Enamel Pro Varnish

PULPDENT EMBRACE VARNISH

PULPDENT EMBRACE VARNISHPremier Clear Enamel Pro

MPL Vanish America

3M Vanish with TCP

Preventech Vella

3M Omni White Varnish

1. Dry the teeth with a gauze pad. It is best if teeth are at least minimally clean, but it is not necessary to do a prophylaxis.For Geriatrics…if they can’t tolerate traditional hygiene visits…we are trying to bring them in for a 30 minute prophy and Varnish

2. Remove the brush and peel off the foil seal, exposing the varnish.3. Use the brush to apply a thin film of varnish on all surfaces of the

teeth. It is not necessary to use all the varnish. Discard any unused material.

4. Patients should refrain from eating hard foods or drinking hot liquids or alcohol for 3-4 hours after treatment. Eating soft foods for the rest of the day is advantageous. Not brushing teeth until the

Instructions for Use

morning after treatment may also be beneficial. 5. The majority of varnishes can be removed by brushing and

flossing.

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Vertical bitewings every year and full mouth X-rays every 3 yearsHygiene visits every 3 months (weather is an issue) with pre rinse of OraCare (ACTIVE CHLORINE DIOXIDE)Varnish application Every Visit, MI Varnish from GCA , Embrace Varnish from Pulp DentCustomized Home Care treatments…routinely Oral B Brush and appropriate pastes and rinses Perio Protect, customized treatment for both perio and caries, so many indications in this population for preventionmany indications in this population for preventionLooking into xerostomia product lines for long term benefits

Why is this so

Important?

An activated oral cleanser and health rinse… not just a mouthwash

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Oracare is comprised of a two-part Halex OC system containing Natural EnhanceMint and Activated ClO2ClO2 is safe and has been used for over 125 yearsUsed by over 1000 US municipalities to purify drinking

waterSterilized wounds and surgical instruments in the

militarySanitize water in canteens for hikers

Anti-Bacteria Exceptional Exceptional

Anti-Virus Good Poor

Anti-Fungal Exceptional Fair

Neutralizes VSCs Exceptional Poor

Disrupts unhealthy Exceptional Poorbio-film layer

Chlorhexidine

Oxidizes Pro-inflammatory Exceptional NoneCytokines

As a daily preventive care rinse for all patientsPre and Post operative rinsingPeriodontitis, Gingivitis, Pericoronitis rinsePre-root plane sulcular irrigationPost root plane & laser curettage carePost oral surgery care rinsing for one week

Apthus Ulcer, Chemotherapy oral mucositisand Lichen Planus care and Lichen Planus care Treatment of Dry Socket AND POTENTIALLY PREVENT

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Kills all 10 of the most virulent oral bacteria and the C. albicans fungus faster and in greater numbers than rinses already on the market, creating a sanitary oral environment for routine and complex procedures

Eradicates 99% - 100% of all volatile sulfur compounds (VSCs)

Breaks down unhealthy bio-film

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98%of bad breath is caused

by bacteria and bacteria toxins, (VSCs)

What Causes Bad Breath?

Reduction of Volatile Sulfur Compounds (VSCs) that cause bad breath.

Bacteria from bad breath to periodontal disease to tooth decay, are the primary causes of most oral health diseases and problemsViruses: thought to have a role in periodontal disease, can cause Oral Cancer (HPV), oral herpes, and oral warts.Fungi: cause of Candida Infections; very common in denture patients and can be a factor in in denture patients and can be a factor in Periodontal disease.

Activated Chlorine Dioxide is unique because it has been used to kill a wide range of Bacteria, Fungi, Bacteria Toxins (VSCs), viruses and breaks down unhealthy bio-film.

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When left on the tongue or in the periodontal pocket, the anaerobic bacteria can yield the "rotten egg" smell of volatile sulfur compounds (VSCs) such as hydrogen sulfide, methyl mercaptan, allyl methyl sulfide, and dimethyl sulfide.

VSC toxins may also contribute to periodontal VSC toxins may also contribute to periodontal disease.

Implant placement care and bone graft and membrane careImplant maintenance and failure careCandida infectionsHalitosis care and sore throatsImmediate denture care and healingCanker sores, and oral viral infectionsCleaning your toothbrushSoaking and Scrubbing denturesSoaking and Scrubbing dentures

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69 year old: Smoker and the nicest guy!Long history of periodontal issues and few restorationsLast visit to the dentist 3 years agoOcclusion with fremitus: 4/5, 7/8Literally no occlusion on the left sideDecay:3D,8D,14DHe wants to save his teeth!Where do you start????? Does he have what it takes????

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Full Exam including Periodontal ExamPicturesDiagnostic CastsDiscussion of current oral hygieneDNA CulturingDNA CulturingExpectations and Desires

Microbial Challenge

• Connective Tissue and Bone

Host Immuno-Inflammatory

Response

• Clinical Signs of Disease

Increased AntigensIncreased Antigens

Increased LPSIncreased LPScytokinescytokines

MMPMMP’’ssMetabolism

pPMNPMN’’ss

AntibodiesAntibodies

MMPMMP ss

prostanoidsprostanoids

Genetic Component and Genetic Component and Environmental and Acquired Environmental and Acquired Risk FactorsRisk Factors

Kornman 97

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First Therapy4355


2nd and 3rd Therapies43414341

Half mouth Debridement, with lasers if you can,Systemic antibiotics were given

4th Therapy 4341Re-debride the areas treated that have deep pockets if required, these do not have to be

in the same quadrant, use laser in either decontamination mode or debridement and apply Arestin at this point and or both.

5th-6th Therapies follow the same profileThis all depends on how many pockets and severity

First Appointment, DNA Test and an overall debridement to remove all the tartar supra-gingivally and just into the pockets, Oral Hygiene instructions and Oral B power brushOcclusal Equilibration and impressions for initial mouth guard2nd and 3rd appointments were for full mouth debridement therapies (laser each visit) and more visits to follow. Placement of Antibiotics after 3rd appointment4th,5th and appointments were for further debridement along with lasers and Arestin as a further option

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DNA(bacterial) Testing (MyPerioPath®) establishes bacterial risk and can help guide therapy based on causation

DNA (genetic) Testing (MyPerioID® PST®) establishes genetic risk and can help guide therapy based on genetics

DNA (viral) Testing (OraRisksm HPV) identifies HPV status

Bacteria Load

Genetic Susceptibility

Clinical Signs and

Symptoms

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Label: Put Name and DOB on Barcode Label, and place Barcode Label lengthwise on Collection Tube.Swish: Ask Patient to Swish for 30 seconds.Expectorate: Ask Patient to spit

into Collection Tube. Seal tube.

Note: Specimen should be collected prior to cleaning (e.g. debridement or rinsing with antimicrobials); probing and other evaluations ok. antimicrobials); probing and other evaluations ok.

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Crack open the seal, swish and spit into the Spitoon!

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Compliance: Is the patient taking the medication as prescribed?Drug ResistanceDrug InteractionSide Effects…This is a huge issue todayWe only use systemic antibiotics in periodontal treatment when we have moderate to severe periodontal issues that are often omnipresent in our new patients or occasionally in our omnipresent in our new patients or occasionally in our refractory patients who require “active therapy”

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Are the medications reaching MIC levels for the appropriate pathogens? That’s why we wait until after the debridement phase

5 visits with lasers were set up after initial examSynchronizing treatment essentialOcclusal Adjustment and night-guardsHome Care that changed drastically

He liked Sensodyne…Brushed 4 times daily with an Oral B electric brush (the head size distinguishes it here)Flossed twice dailyWe added a Hydrofloss and loved it! Used every nightSent an e-mail to me detailing his daily protocolContinued to smokePictures then taken with follow up…his hygiene was awesome!

Occlusal adjustment on 4/5/7/8 and opposing teeth to remove fremitusHe instantly felt the difference2nd appointment and beyond…continued adjustmentsD li f b i liDelivery for bruxism applianceSoft night guard while we made him a traditional full upper mouth guard

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Phase 2Lower right osseous surgery and extraction of 30 (finances were very important)

Phase 3 Final restorative with 2 implants for the upper left and upper right bicuspid areas and lower cast partial

OngoingSPT every 3 months and Perio Protect Trays after Upper SPT every 3 months and Perio Protect Trays after Upper Implants Delivered because with all that he does…he still bleeds, still smokes and has some 5’s

Th U Bi id/M l The Upper Biscuspid/Molar Dilemma

You would have loved more space, but the reality…you only had room for one implant

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Note the emergence profiles…easy to cleanse

The cement upon removal off the silicone abutments is more towards the deeper internal aspects and not near the marginsOnce inserted, I immediately spray light water at the marginsThick Floss (Easy Floss from Butler) is then brought around the crownsWater spray againWater spray againFinal explorer removal of any cement

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PERIO PROTECT

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3months

3 th3 th

3months

3months3months

Can we find approaches to shorten treatment time and enhance both long term outcomes?

Can we find better ways to compliment patients homecare beyond brushing, flossing and rinsing?

P i P t tPerio Protect….

Patients after our sequential, laser therapy that still have BOP and inflammation and often good oral hygienePatients after surgery that still have pocketing and BOPPatients with on-going implant issues and now…to prevent such issues!Patients who want to bleach and have been to sensitiveHigh caries risk patients, especially xerostomic patients, and the geriatric groupOral Cancer patients with radiation portsOral Cancer patients with radiation portsPatients who don’t want to have required periodontal surgery

Hygiene drive philosophy handout

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