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Interview with Dr. Richard Nagelberg

Jan. 1, 2009
Periodontal disease is a hot topic today. This month I talk with Richard Nagelberg from Plymouth Meeting, Pa.

by Jeffrey B. Dalin, DDS, FACD, FAGD, FICD

For more on this topic, go to and search using the following key words: periodontal disease, Dr. Richard Nagelberg, oral-systemic medicine, Dr. Jeff Dalin.

Periodontal disease is a hot topic today. This month I talk with Richard Nagelberg from Plymouth Meeting, Pa., about some of the new advances taking place in this field.

Dr. Dalin: We are becoming aware of the relationship between periodontal disease and systemic problems such as heart attack, stroke, diabetes, pregnancy problems, and respiratory conditions. Would you review this relationship for our readers?

Dr. Richard Nagelberg
Click here to enlarge image

Dr. Nagelberg: It is certainly true that periodontal disease is a hot topic. This is due to a variety of reasons, including the rapid pace of research that has increased our understanding of the mechanisms involved in periodontal disease. We now have a much better understanding of how bacterial invasion of gingival tissue and bone resorption occurs. A large body of global research makes it apparent that there is a relationship between oral and systemic conditions. The common element appears to be the infectious nature of periodontal disease and the resultant immuno-inflammatory response.

Other possible mechanisms include the bacteremia and endotoxemia that occurs when oral bacteria enter the circulation. The risk for all of the systemic events you mentioned appear to be elevated in perio patients; however, the strongest connection is between periodontal disease and diabetes.

The well-established connection between these two noncurable chronic diseases makes blood sugar control a critical issue for dental providers. It will at least indicate the likelihood of perio disease and the predictability of treatments.

Further research, in particular interventional studies, will indicate the effect of periodontal treatment on reducing the incidence and severity of systemic events.

Dr. Dalin: Despite the slowdown in our economy, dentists still continue to work diligently on their internal and external marketing plans. Thus, communicating about this perio-systemic link should be of great value. Also, I think this could be an ideal way to work with area physicians. What do you believe is the best approach to use to communicate this perio-systemic connection, as well as develop a relationship with physicians for encouraging mutual referrals?

Dr. Nagelberg: There are several ways to cultivate a relationship with medical providers. This starts with face-to-face discussions with physicians, nurses, and other medical professionals with whom we interact. Other possibilities include inviting area medical professionals to a roundtable discussion. This can foster an exchange of ideas on the best ways to provide truly comprehensive patient care.

Some dental offices have prepared a letter outlining information on the oral-systemic connection, suggesting improved communication between the patient's dental and medical providers. These various initiatives to improve communication between health-care professionals can only improve the level of care. There does not appear to be any downside to these efforts, and they should be encouraged.

Dr. Dalin: Let's talk now about some of the new tools at our disposal to use in office periodontal programs. What is your opinion about using Arestin® with scaling and root planing programs?

Dr. Nagelberg: In my opinion, Arestin is one of the best tools we have. The standard of care for nonsurgical periodontal therapy is mechanical biofilm removal with adjunctive use of chemotherapeutic agents, including locally applied antimicrobials such as Arestin. Research has shown significantly improved treatment outcomes when it is used, compared to mechanical plaque removal alone.

Other tools include a variety of power toothbrushes such as the Philips Sonicare. This toothbrush also improves perio treatment outcomes over time since these results are dependent on biofilm control.

As research continues, and further details of the etiology of periodontal disease are revealed, other treatment modalities will become available. Promising areas include anti-inflammatory agents to arrest the destructive effect of the immuno-inflammatory response.

Dr. Dalin: What do you think about the use of irrigating solutions in office and at home?

Dr. Nagelberg: The use of various irrigating solutions in the office certainly has merit in helping reduce the amount of pathogenic bacteria in periodontal pockets. Some research, though, has indicated that the home use of irrigating solutions is less effective. A likely explanation for this effect includes the difficulty patients have directing the tip of the irrigation syringe to the base of the pocket where the action is. Home-care recommendations should be monitored at periodontal maintenance visits with the addition or removal of home-care devices to improve biofilm control.

Dr. Dalin: Are you a proponent of soft-tissue diode lasers (such as those from Ivoclar Vivadent, KaVo, Biolase, Zap, and Sirona), ND-YAG lasers (such as the Millennium Periolase or Lares Powerlase), or the CO2 lasers? How effective are these lasers?

Dr. Nagelberg: Soft-tissue lasers have their place for soft-tissue procedures. They provide effective treatment for a variety of conditions, including periodontitis, frenum attachment correction, and excisional procedures, among others. In my opinion, it is important to understand that peer-reviewed research indicates lasers have the same efficacy as traditional soft-tissue treatments. This includes surgical and nonsurgical periodontal treatment. This being said, other considerations such as reduced bleeding and patient comfort considerations ensure that lasers are here to stay.

Dr. Dalin: Should dentistry look into performing minor medical tests, such as blood C-reactive protein levels, as part of its periodontal programs?

Dr. Nagelberg: Undertaking monitoring programs in the dental office, including C-reactive protein levels, may have merit; however, it is critically important to understand that many other behaviors and conditions can elevate CRP levels. These include cigarette smoking, high blood pressure, diabetes, low HDL, high triglycerides, hormone replacement therapy, chronic infections such as bronchitis, and chronic inflammatory conditions such as rheumatoid arthritis.

Similarly, some medications reduce CRP levels. Despite the fact that periodontitis patients have elevated CRP levels as compared to healthy patients, it is difficult to attribute elevated or declining CRP levels to periodontal disease status. Other clinical or subclinical conditions and medications complicate analysis of blood test results. Prior to implementing medical testing in the dental setting, it is vitally important to understand the benefits and limitations of the test to reduce the likelihood of making diagnostic and treatment decision errors based on the test results.

Dr. Dalin: Is there anything else you would like to share?

Dr. Nagelberg: Unraveling the mechanisms of hard- and soft-tissue destruction that are the hallmarks of periodontal disease provides enhanced opportunities to develop new treatments. For example, it has recently been determined that the majority of periodontal tissue destruction is caused by the immuno-inflammatory response. In other words, the body is doing it to itself. The efficacy of anti-inflammatory agents in addition to biofilm control is being investigated, and may become the standard of care. The association between periodontal disease and a variety of systemic conditions illustrates daily the impact we have as dental professionals beyond the oral cavity.

Dr. Richard Nagelberg has been practicing general dentistry in suburban Philadelphia for more than 26 years. He has international practice experience, having provided dental services in Thailand, Cambodia, and Canada. Dr. Nagelberg has served on many boards and advisory panels and is a member of the Georgetown University Board of Governors and the National Multiple Sclerosis Society Advisory Panel. He is a cofounder of PerioFrogz, an information services company. You can contact Dr. Nagelberg at [email protected].

Jeffrey B. Dalin, DDS, FACD, FAGD, FICD, practices general dentistry in St. Louis. He is the editor of St. Louis Dentistry magazine, and spokesman and critical-issue-response-team chairman for the Greater St. Louis Dental Society. Dr. Dalin is a cofounder of the Give Kids A Smile program. Contact him at [email protected].


The project team for the design and construction of the suite of Dr. Bradley Olson in the October 2008 issue of Dental Economics® was inaccurate. In addition to Ms. Kim McCarl of Interior Concepts, architectural services were provided by Jacob Weaver of Jacob Weaver Architects (301-261-4911) in Harwood, Md. Suite construction was executed by Mark Hurley of Tri-State General, Inc. (301-420-4982) in Suitland, Md. All members of the project team are active in the design and construction of facilities for medical practitioners in the Washington, D.C., metropolitan area. DE apologizes for any inconvenience caused by this error.

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