Title	Prescription Custom Trays with Hydrogen Peroxide Gel as an Adjunct to Frequent Maintenance Appointments May Be Beneficial for Adult Patients with Refractory Periodontitis
Clinical Question	In an adult patient with refractory periodontitis, does using prescription custom trays with 1.7% hydrogen peroxide gel as an adjunctive therapy to routine maintenance visits enhance reduction of bleeding index (BI) and probing pocket depths (PPDs) more than recall periodontal maintenance visits alone?
Clinical Bottom Line	Patients using prescription trays with hydrogen peroxide gel 1-2 times daily as an adjunct to maintenance therapy every 2-4 months exhibit reduced bleeding on probing (BOP) compared to patients who have maintenance visits alone. This is based on a case series report of 66 refractory maintenance patients. More research is needed to determine the efficacy of periodontal trays on reduction of BI and PPDs.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 26856017 Cochrane/2015 66 adult patients with refractory periodontitis Case series Key results While a significant decrease in BI was found at all three PPD levels (shallow 3 mm [p<0.0001], moderate 4-6 mm [p<0.0001], and severe 7 mm or greater [p=0.0003]), BI scores showed that bleeding reductions were not uniform but instead greater for the shallower PPD levels. No significant effect was seen for the number of treatments per day (1X vs. 2X) on change in BI (p=0.323). No significant difference in the distribution of PPDs was noted (p=0.2095).
Evidence Search	(“Prescription Tray Application” [Mesh] AND Periodontitis [Mesh]) AND “Hydrogen Peroxide Gel” [Mesh]
Comments on The Evidence	Validity: The study had a representative patient sample with similar groups at baseline. Sixty-six patients with chronic periodontitis (with consistent periodontal maintenance therapy every 2 to 4 months) who were considered to be failing refractory patients were included in the study. Sixty-five patients finished the study, giving a 98% completion rate with adequate compliance with wearing trays 1 to 2 times daily for 10 minutes. There were 34 bleeding points from the distal of tooth #1 to the distal of #16, and from the distal of #17 to the distal of #32. Pockets were probed to the base of the pocket, and any pocket that bled over a 15-second period was considered positive. All subjects were informed of the study’s purpose and potential risks (sensitivity and bleaching). Follow-up time was adequate. BI was recorded at baseline, at 3 months, 3 months, 1 year, and then yearly as indicated. PPDs were charted at baseline, at 1 year, and every 2 years as indicated. In predicting periodontal disease, BOP to the base of the pocket has a low sensitivity (due to high incidence of false positives) and a higher specificity (failure to bleed indicates health). From a clinical perspective, the beneficial effects of this adjunctive therapy over an extended period of time for failing refractory patients are encouraging. From the evidence, I believe that Perio Trays/ PerioProtect with hydrogen peroxide gel can aid patients with refractory periodontitis in restoring health by reducing bleeding. However, additional adjunctive therapy will be needed to aid in reduction of pocket probing depths. Perspective: Although results are encouraging, more research is needed to determine if hydrogen peroxide gel trays as an adjunctive treatment are a viable treatment option for patients with chronic periodontitis.
Applicability	All subjects were between the ages of 43-78 and were considered to be failing refractory maintenance patients. The evidence of reduction of bleeding on probing using prescription trays of hydrogen peroxide gel in this study population can be applied to most refractory periodontal patients. Patients will benefit depending on long-term compliance with using the trays once or twice daily for 10 minutes and maintaining periodontal maintenance visits every 2 to 4 months.
Specialty	(General Dentistry) (Periodontics)
Keywords	Hydrogen Peroxide Gel, Perio Tray, PerioProtect, Chronic Periodontitis, Periodontal Maintenance
ID#	3264
Date of submission	08/21/2017
E-mail	Gonzalezc10@livemail.uthscsa.edu; carolyngonzalezrdh@yahoo.com
Author	Carolyn Gonzalez
Co-author(s)	Oanh Pham
Co-author(s) e-mail	oanhrdh@yahoo.com
Faculty mentor	Carol Nguyen, RDH, MS
Faculty mentor e-mail	nguyenc@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available