Translated from the Journal L’Implantologie, May 2004 Bone One Session Treatment (BOST): A “Key” for Complex Periodontal Treatments William Hoisington, Guy Morioussef, Didier Hugot Summary: In daily practice, the approach to complex cases presents in our view a veritable dilemma: either a laborious course of treatment to regain a state of health permitting prosthetic treatment never reaches its end as the patient drops out, or a large intial program of immediate extraction and implants that is often rejected by the patient because of the cost and lack of guaranteed outcome. This article proposes a “key” that opens up a direction that is easy for the patient to accept even for complex treatment plans. With comfort and confidence restored and seeing very quickly positive changes in oral health, the patient starts to consider their “dental capital” an investment with immediate dividends. Introduction: The convergence of the education of the population about health matters and the maximum exploitation of recent advances in microbiology, biology, genetics, and internal medicine is allowing dentists to to propose less invasive and more conservative treatments ( air abrasion, microscopic endodontics, medical periodontal treatments). For complex cases what patients want, usually expressed from the first consultation, is to keep their own teeth, and to feel confident that we can solve their problems. They want to quickly see the proof of this with initial treatment that is pain free and restoring of well being. After this trial period is successful the patient won’t hesitate to go further. Often though we are confronted with the dilemma: 1. I extract and implant because I believe more in my implants than in the patients teeth. 2. I decide to save teeth but have to go through a long and maybe painful and traumatic course of periodontal treatment if it includes surgery. With the BOST approach these problems disappear while proposing comfort, speed and favourable results. BOST, A technique and a philosophy Bone One Session Treatment brings together standard and new techniques. The whole mouth is treated in one session of about 4 hours to limit reinfection. The use of antibiotics is greatly reduced. Before the actual periodontal treatment the occlusal aspect is addressed to limit occlusal trauma and to splint teeth where necessary. Even if the litterature( Swedish among others) shows that occlusal trauma by itself cannot be the etiology of periodontal disease, each clinician will admit with us that addressing these problems with selective grinding or
splinting improves patient comfort, reduces fear of losing loose teeth, and makes teeth easier to treat. Often esthetic improvements can be made simultaneously ( see photos). These additions to the basic treatment for comfort and a quality smile increases patients initial happiness and acceptance of the overall treatment plan. Also, one takes better care of that which is beautiful! The periodontal technique starts with a "stretch flap" access technique that allows us to reach down into deep pockets (6-9 millimeters) and to the surface of the damaged bone. This stretching rather than incisions avoids cutting off circulation and exposing the bone to the drying effects of air, the combination that leaves necrosed bone after surgical flaps. With good access after the stretching the roots can be freed of bacterial plaque and biofilm. Some microscopic calculus will remain as research shows. The bone surface is freed of granulation tissue. Bacteria and chemicals trapped in the porosities are removed by an osseous plasty and fresh bleeding. Sutures are not necessary. That saves time and allows the new hygiene routine to start the next day.The patient uses a tool called a perioaid to disrupt the initial mucopollysaccharide sticky layer coming from the saliva. Without that initial layer bacteria can't recolonize, reducing the need for disinfectants, aggressive for tissue ready to heal and causing a drop in immune effectiveness. This hygiene routine keeps the tissue a little bit open. This stops the epithelial attachment similar to a membrane, favoring the slower healing from the bottom up. Thus a new kind of attachment forms from differentiated osteoblasts. They move up the prepared root surfaces at the rate of 1/2 millimeter per day for 8 days. They lay down a new mineralized layer that walls in any microscopic calculus and closes dentin tubules to reduce sensitivity. This acellular mineralized layer serves to join a new acellular mineralized layer over the bone with the gingival connective tissue. This creates a layer of protection for the bone that allows it to regrow a new cortical layer of bone. It also reduces the pocket depth down to 2-3 mm in 4-6 weeks time. This new mineralized acellular attachment (MAC) is more resistant than epithelial attachment. The continuation of the perio-aid after the healing period prevents bacterial proliferation and gives the patient feedback as to the effectiveness of efforts. The sometimes demoralizing work of plaque control is replaced by the easier job of stopping the sticky layer. Lifestyle of patients is examined and suggestions made to favor healing. The beginning of periodontal disease is explained as coming from a drop in immune effectiveness linked to life events and not simply a question of hygiene negligence on the part of the patient. This reality excludes notions of guilt and creates a climate favorable to improve healing and to set the stage for acceptance of the entire treatment plan. Comparison Table: Arguments for patients Surgical treatment: slow, many sessions, often painful, hygiene blocked by sutures, packs, daily hygiene is complicated, frequent maintenance necessary, frequent reinfections, very sensitive teeth, cause lack of
hygiene, antibiotics often, months of healing, often severe recession Non surgical treatment: slow, many treatment sessions, not much discomfort, hygiene possible but difficult, frequent maintenance, often reinfects or pockets reopen, sensitive teeth, cause lack of hygiene, antibiotics often, months of healing, significant recession BOST: rapid one session, little discomfort, hygiene easier with perioaid, less frequent maintenance, less reinfection, less sensitivity, cause immune depression, antibiotics rarely, heals quickly in a few weeks, minimal recession Comparison Table: Arguments for Practitioners Surgical treatment: patients often reject treatment, patients stop treatment in the middle often,incisions and sutures, unstable scar tissue attachment, chronic inflammation and repocketing often, unstable occlusion with mobility, fewer teeth saved, more recession with long teeth hard to restore, additional bone loss, uncertain prognosis. Non surgical treatment: patients accept, patients stop in the middle often, no incisions or sutures, unstable epithelial attachment, hidden chronic inflammation in teh bone, unstable occlusion, saves teeth, recession causes esthetic problems, bone gain possible, uncertain prognosis. BOST patients accept, treatment always finished because in one session, no incisions or sutures, stable minealized acellular attachment MAC, resistant to inflammation, occlusion more stable, more teeth saved, less recession, bone gain possible, more certain prognosis. Conclusion: The BOST treatment brings a logical and effective aid to solve daily clinical problems in complex cases, offering many advantages for both patients and practitioners. Clinically satisfying results on more than 1500 cases over more than 15 years are important. The most important though is the histological explanation of the new healing sequence and attachment that provided some answers as to why this technique is of interest. The acquiring of the BOST technique which is delicate, done blind and must be done efficiently to treat the whole mouth in one session. requires training, patience and dexterity.