September 2013, Volume 9, Issue 9
Published by AEGIS Communications
Question: What is the latest thinking on conventional periodontal treatment?
Conventional mechanical debridement—professional and personal biofilm disruption and scaling and root planing—are sine qua non aspects of periodontal therapy. But the question has been and remains: “Is mechanical therapy alone enough to control both gingivitis and periodontitis?” The definitive answer is, “Most of the time, but not always.” Certainly, in most cases of gingivitis, removal of biofilm and calculus alone reverses the disease process. As there is no cure for the biofilm-induced inflammatory gingival and periodontal disease, daily vigilance to keep healthy biofilm from converting to pathogenic biofilm is paramount to maintaining health. Even with gingivitis, adjunctive measures such as chemotherapeutic mouthrinses (chlorhexidine gluconate, essential oils) are sometimes necessary to completely eliminate the inflammation.
In the treatment of chronic periodontitis, mechanical therapy is the starting point and may be successful in the control of early cases of disease, but the patient may need either adjunctive nonsurgical or surgical treatment as well. The adequate removal of calculus, particularly in pockets deeper than 5 mm, remains the single biggest challenge to therapy. Control of the biofilm is a close second. Several other nonsurgical modalities, such as local antibiotic delivery for isolated residual defects, systemic antibiotics (with new evidence that a combination of amoxicillin and metronidazole may be effective over a 6-month time frame in controlling both inflammation and pathogenic biofilm), and the use of povidone-iodine irrigation during scaling and root planing should be considered to help control biofilm and eliminate inflammation.
Conventional periodontal therapy will not disappear anytime soon. So, keep those curettes and scalers sharp, but remember that there are other approaches for those hard-to-manage situations.
As a periodontist, I have always been proud of our specialty because we do not work at getting current results more easily, but rather we strive to get exceptional results even when it requires a great deal more effort. There are some in the dental profession attempting to simplify periodontics by controlling the bacteria with various simplified techniques, but they are not taking the high road of restoring or reconstructing the periodontium. To make this point, it appears the goal of periodontal treatment has been reduced to a goal of bacteria control via soft-tissue management. This is like caries removal being the goal of restorative dentistry, possibly adding the use of topical fluoride to reduce the risk of further decay. In restorative dentistry, it would be malpractice to remove the caries and leave the hole in the tooth, asking the patient to keep it clean and use fluoride. The defect in the tooth needs to receive further treatment to make it maintainable. The exact same principle applies to periodontics. Bacteria control is initial therapy, but a reconstructive surgical phase of treatment is needed to complete the treatment when the bone morphology has been damaged, surgery that will restore the area with as much tooth support as possible and will provide an environment for efficient bacteria control.
With respect to research, some of the present research is being quoted as supporting “easier” or “quicker” techniques. This “research” is primarily manufacturer-driven in the effort to sell proprietary hardware. I, personally, am not interested in easier or quicker. I am interested in research that shows the most superior results, restoring the most bone the disease process has taken away. This research is primarily university-driven or has biologics as its foundation. We have made significant progress in the use of bioactive materials in our regenerative procedures, but much more research is needed to unlock the secrets of osteogenesis for periodontal regeneration. Present research still points out that increased probing depths provide an anaerobic environment in which periodontal pathogens persist in the disease progression. Easier and quicker techniques should not be the goal of our research or our treatment.
Current periodontal research suggests an increasing interrelationship between a patient’s medical conditions and medications and the clinical presentation of chronic periodontitis. These medical issues influence treatment of periodontitis and dental implant procedures. In my private practice, I have seen a large increase in root caries diagnosis in the aging adult patient population. This may be a result of the increased number of medications our patients now take, many of which result in xerostomia. The xerostomia combined with ineffective marginal plaque control is a recipe for the destructive nature of root caries. I encourage my restorative colleagues to update the patient medical history on a yearly basis and review the list of medications with the patient, identifying ones that may influence the periodontal or dental condition. Look for diuretics, anti-anxiety meds, gastroesophageal reflux disease medications, thyroid medication, and others that result in reduced salivary flow. In addition, consider the drying effects of tobacco use and alcohol consumption.
We also see research related to the oral clinical manifestations of diabetes and how this prevalent endocrine disorder can influence our periodontal treatment and expected outcomes of wound healing.
Conventional periodontal therapy still requires the clinician to evaluate the patient with a thorough clinical and radiographic examination, review the interrelationships of the patient’s medications, establish the diagnoses of those findings, determine the etiologic factors related to the diagnoses, establish the team treatment plan approach, and deliver the required procedures necessary to return the patient to improved periodontal health and function. I think the best way to share this new information, for the benefit of the patient, is through online journal reading, CE courses, study clubs, the large quantity of print material available to our profession, and, finally, attending the state and Academy meetings readily available to all of us.
About the Authors
Francis G. Serio, DMD, MS, MBA | Dr. Serio is dean at the new Bluefield College School of Dental Medicine and a diplomate of the American Board of Periodontology.
Mark K. Setter, DDS, MS | Dr. Setter is an adjunct faculty member at The University of Michigan, a clinical assistant professor at Temple University, and on the faculty of The Misch International Implant Institute. He has a private practice limited to
periodontics in Port Huron, Michigan.
Cary A. Shapoff, DDS | Dr. Shapoff is a Diplomate of the American Board of Periodontology, and has
a private practice limited to periodontics and implantology.