Common Periodontal Questions Answered, But Everythings Open for Debate

In my 27 years as a periodontist, my colleagues-restorative dentists and periodontists alike-and I have debated some of the most basic questions surrounding periodontal disease, its prevention, diagnosis and treatment.

Leonard S. Tibbetts, DDS, MSD

We dentists, myself included, yearn for definitive answers to all of our treatment questions.

In my 27 years as a periodontist, my colleagues-restorative dentists and periodontists alike-and I have debated some of the most basic questions surrounding periodontal disease, its prevention, diagnosis and treatment.

Because we seek the logical, predictable answer when it comes to treating our patients, periodontal disease represents one of our greatest challenges.By its very nature, the disease does not fit easily into a step-by-step diagnostic or treatment process. Each time we experience success with a specific treatment modality on many patients, an individual comes along who shows no improvement whatsoever with that same treatment.

To me, that`s one of the things that makes periodontics so interesting. For all the advances and fancy gadgetry that have come our way, often times our most colorful study group questions focus on things that seem, well, simple. Here are five sure-fire discussion starters.

How many adults have gum disease? Depending on whom you talk to or what you read, it could be as low as 50 percent or higher than 90 percent. How can we impress upon our patients and the general public the widespread nature of the disease if we can`t agree on an answer?

According to the American Dental Association and The American Academy of Periodontology, 75 percent of adults have some form of the disease. Gingivitis is included in this 75 percent.

In terms of exactly how many adults have gingivitis, our best estimate comes from a 1985-86 study conducted by the National Institute of Dental Research, which revealed 43 percent of working adults had bleeding gums and 84 percent had calculus deposits. Based on gingival bleeding alone, prevalence of gingivitis among American adults may be 43 percent or higher. This is the best gauge we have in light of the lack of more recent clinical data. (A consumer survey in 1993 revealed that 70 percent of American adults admit to having at least one symptom of the disease.)

Some practitioners might think these numbers are not reflected in their practice. I suspect they`d come close, however, if they were able to conduct a thorough periodontal examination on each patient at every recall visit.

Should I provide periodontal exams to patients at every visit? An emphatic yes. Again, determining the periodontal health of patients each time they`re in the chair is critical to both detection and patient understanding of the disease.

At present, probing is one of the best tools we have to screen patients for periodontal diseases. Despite questions raised about its sensitivity and reproducibility, both the AAP and ADA fully support the use of probing to aid in the detection of periodontal diseases.

The Periodontal Screening & Recording™ (PSR®) system is a direct result of our belief in this technique.

PSR® is not meant to be a diagnostic tool. Rather, it is a quick and effective way to evaluate periodontal health and determine the need for a more comprehensive examination.

This exam should include but not be limited to identification of probing depths, mobility, gingival recession, mucogingival problems, and furcation invasions as well as appropriate radiographs. A diagnosis of periodontal disease should be made only after considering all of these factors.

Obviously, for the periodontal purists among us, a comprehensive probing and charting of patients during every visit is best. However, for regular patients who basically are in good periodontal health, PSR® is an excellent time saver for your practice and your patients.

How often does gingivitis recur after treatment? There is no pat answer. Treatment responses vary from patient to patient depending on the type of therapy provided, effectiveness of the patient`s oral hygiene habits and systemic conditions that affect disease susceptibility and progression.

That`s why regular dental visits that critically evaluate these factors are vital. As in medicine, we need to rely on our expertise to evaluate each patient on a case-by-case basis.

In some cases, prophylaxis may be all that is necessary to reduce inflammation associated with gingivitis. Other patients may be required to use an oral rinse in conjunction with their daily home regimen, while others may require scaling and root planing. Whatever the case, the patient must be willing to commit to a sustained, daily oral hygiene program and comply with an effective periodontal maintenance program.

What can be done about recurring periodontal disease? Sometimes, periodontal breakdown occurs despite everyone`s efforts. In cases where bone loss is suspected or detected, practitioners should consult with their referring periodontist if there are questions regarding appropriate treatment. As with all aspects of health care, the sooner a problem is caught, the better.

When should I refer a patient to the periodontist? For all the complex issues we face in periodontal treatment, this is one area where there are no definitive answers. Some periodontists will tell you that patients should be referred at the first indication of a problem.

Some restorative dentists might recommend referring only for work in specific quadrants on the most advanced cases. Everything else should be handled in the general practitioner`s office.

A contractor friend of mine once summed up the referral process best for me. He was working on a home addition and notified the homeowner it was time to solicit bids for a painter. The owner asked why the contractor couldn`t do it; the contractor explained that he could, but "I don`t like to paint." He then gave the owner the names of painters he had worked with in the past.

Decisions to treat and refer are very personal. Some general practitioners "like to paint;" others prefer to refer.

It is up to each of us to develop working relationships with colleagues. Do all you can to keep pace with the latest findings to provide the best care possible.

That`s what dentistry is all about.

The author is past president of The American Academy of Periodontol-ogy and maintains a private periodontal practice in Arlington, Texas.

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