Implant-Supported Restorations Impacting Dentistry's "Traditional" Approach
Q: As implants grow in popularity, what has become of treating periodontal disease?
A: Dr. Serio
Implant-supported restorations have changed the way dentists approach the treatment planning and care for patients who have either questionable teeth or edentulous spaces. As the outcomes of implant-supported restorations have become more predictable, both periodontal and restorative heroics seem to be—if you’ll pardon the expression—headed to the museum. After all, when was the last time anyone saw, let alone completed, a pin-ledge maxillary splint? Implant therapy has come to the forefront, not just because of better success, but because general dentists and specialists alike are receiving more training in the placement and restoration of implants and less training in many aspects of “traditional” dentistry, including conventional nonsurgical and surgical periodontics.
From many years of examining candidates for the American Board of Periodontology oral examination at the Louisiana State University annual perio course, I have observed that newly minted periodontists are knowledgeable about growing bone where it has never been grown before for implant placement. However, they don’t possess nearly as much practical know-how about saving natural teeth by treating periodontal disease using conventional methods. For sure, not all conventional therapy will be successful, but many patients would prefer to maintain their natural teeth in health and comfortable function or are not in a position to afford expensive and sometimes complex implant-driven therapy. In discussions I’ve had with general dentists, it seems they often make their periodontal referrals based on desired therapeutic outcomes, sending patients to more veteran clinicians when saving teeth is the goal and to younger colleagues for guided bone regeneration in conjunction with implant placement.
This trend toward less clinical training in conventional periodontics has continued into predoctoral dental education. As clinical education has moved from a requirement-based system to a competency-based structure, dental students are doing less hands-on dentistry in school, not just in periodontics but in almost all disciplines. The thinking among students and some faculty members is that if a student passes a clinical competency examination, no further training for that particular procedure is needed. The idea of doing more of something in order to become more proficient and efficient is not considered. Students pay attention to that which is emphasized in their coursework. As conventional periodontal therapy instruction becomes minimized and gives way to more implant instruction on the predoctoral level, it is easy to see the direction in which clinical dentistry is shifting.
A: Dr. Rethman
While research suggests that endodontically treated and periodontally “hopeless” teeth can often be maintained for many years, these reports are sometimes useless to individuals who seek a problem-free, fully functional, attractive, and pain-free oral complex. Dental implants can be used to help certain patients achieve such outcomes. Indeed, in the elderly or patients who have salivary dysfunction resulting from drug side-effects or other etiologies, implants are a godsend because they are insusceptible to caries.
However, in most patients, maintaining natural dentition makes better sense than implants. Optimal periodontal therapy (OPT) aims to eliminate signs of inflammation by successfully treating periodontal infections and preventing recurrences. OPT necessitates tobacco cessation (since tobacco is a major risk factor), motivated self-care, and expert professional care. OPT entails scaling and root planing (SRP) for professional removal of subgingival biofilms, which are often protected by tightly adhering and hard-to-detect calculus. Pharmacotherapeutic adjuncts can be useful. Lifelong self-care and professional maintenance are designed to prevent disease recurrence. OPT may also help improve systemic health.
In healthy nonsmokers, a reliable sign of inflammation is bleeding on probing (BOP). Studies confirm sites that consistently display no BOP are unlikely to lose additional attachment. This makes achieving and maintaining the absence of BOP at every site a seminal clinical goal. Therapists must not confuse an overall improvement in gingival appearance and tone with the successful treatment of site-specific underlying periodontal lesions. In other words, decreasing the percentage of sites that show BOP is admirable, but is largely meaningless if the few remaining sites that continue to bleed on probing demonstrate periodontitis. Thus, in my opinion, a patient with any site that he or she is keeping plaque-free at home but still shows BOP in the office needs additional attention or referral—regardless of probing depth. This is because something is still occurring at such a site(s) that the patient cannot manage on his or her own. Repeat treatments of SRP and/or surgery by a periodontist are often appropriate at sites where supragingival plaque appears under control but the efforts of the general practice have not achieved a sustained lack of BOP.
In the past, gingivectomies or osseous recontouring of alveolar bone with apically positioned flaps were commonly performed. The goal was to eliminate periodontal pockets to ostensibly facilitate subsequent supragingival care in the hope that periodontal attachment loss could be halted. However, these procedures can potentially result in compromised esthetics, food impaction, sensitive teeth, and root caries. Traditional surgical procedures still have their uses, especially on the palate in conjunction with less aggressive “replaced flap” surgical approaches that may include attempts at periodontal regeneration by utilizing graft/regenerative materials. However, the therapeutic goals for periodontal surgery remain the same, namely leaving the patient with a stable and maintainable postsurgical anatomy. (The topic of gingival grafting for esthetics is different and is not discussed here.)
In my opinion, better ways are needed for performing SRP in both general and periodontal practices. Conventional nonsurgical SRP is conducted blindly, typically performed by feel. In contrast, today’s physician-surgeons routinely perform myriad minimally invasive procedures elsewhere in the body via endoscopes, which enable them to visualize the sites. Unfortunately, periodontal endoscopes are seldom used by those treating periodontitis, even though such devices exist. Indeed, if I was a new periodontist entering practice today, periodontal endoscopy would be a staple of my practice, with only the occasional site that failed to respond becoming a candidate for periodontal surgery.
In conclusion, chronic (or “adult”) periodontitis (unlike, for example, a toothache) progresses slowly and is seldom noticed by patients until it becomes severe. Hence, people with periodontitis are more susceptible than those with toothaches (or other symptomatic oral maladies) to suboptimal management, either by practitioners or the patients themselves. OPT is outlined above. Implants have a place in an OPT paradigm, but for most patients, only as a last resort—even when costs are not a consideration.
A: Dr. Duello
The treatment of chronic periodontitis and the goal of modern periodontology is to preserve the natural dentition throughout the patient’s life. When a bacteriologic etiology for periodontal disease was established in the early 1960s, the use of nonsurgical, chemotherapeutic, and surgical treatments became the recommended course for patients needing periodontal therapy. Numerous studies have documented the success of comprehensive periodontal therapy when active therapy is followed-up with supportive periodontal maintenance therapy.
However, despite these developments in periodontics, select subsets of periodontal patients continue to lose periodontal attachment, subsequently losing teeth. They are, thus, left with significant partial or totally edentulous situations. In some instances, patients require periodontal retreatments due to intrinsic and extrinsic risk factors that may preclude favorable long-term periodontal outcomes. With increased human longevity achieved by medical sciences in the 20th century, patients have significantly longer periods in which they may be affected by recurrent periodontitis.
Historically, when patients were faced with the prospect of losing their teeth, dentistry could offer only removable prosthetics to replace multiple missing teeth. Some patients’ needs can be met with removable prostheses. However, most studies on the quality of life of an edentulous patient document less-than-satisfactory outcomes for the use of a removable prosthesis. In order to solve the dilemma of edentulism, Professor Brånemark put forth the theory of osseointegration for prosthetic reconstruction using dental implants. For the past 50 years, dentists have been able to offer fixed dental prostheses anchored in the bone to preserve bone and increase function for edentulous patients.
In my opinion, periodontal therapy and modern dental implant therapy are complementary treatments for dental patients. Both seek to preserve bone by either the maintenance of the natural dentoalveolar apparatus or through osseointegration with dental implants. Dental practitioners need to carefully guide patient discussions on the therapeutic options available with appropriate informed consents that acknowledge the discipline of evidence-based care. Ultimately, the patient must choose the appropriate treatment for his or her dental health based on the principles of dental ethics practiced by the dentist.
ABOUT THE AUTHOR
Francis G. Serio, DMD, MS, MBA
Dean, Bluefield College School of Dental Medicine, Bluefield, Virginia; Diplomate, American Board of Periodontology
Michael P. Rethman, DDS, MS
Diplomate, American Board of Periodontology; Adjunct Associate Professor, Baltimore College of Dental Surgery, University of Maryland, Baltimore, Maryland; Adjunct Assistant Professor, College of Dentistry, The Ohio State University, Columbus, Ohio; Former Chair, Council on Scientific Affairs, American Dental Association; Past President, American Academy of Periodontology
George V. Duello, DDS, MS
Private Practice, St. Louis, Missouri; Diplomate, American Board of Periodontology