Periodontists: Evolving but still saving teeth

Sept. 1, 2010
Recently, there has been speculation about a change in the mindset of periodontists – one that could have a major impact ...

Editor’s Note: In the column "Where did all the periodontists go?" published in the June 2010 issue, author Louis Malcmacher, DDS, MAGD, expressed his opinions and observations on several issues affecting dental specialty care and the specialty of periodontology in particular. On behalf of the American Academy of Periodontology, President Sam Low, DDS, MS, and President-Elect Don Clem, DDS, offer their thoughts on the current state of periodontology.

Recently, there has been speculation about a change in the mindset of periodontists – one that could have a major impact on patient care and treatment outcomes. Some have implied that today’s periodontists are forgoing traditional periodontal therapy that aims to preserve natural dentition in favor of extracting diseased teeth and replacing them with dental implants.

Most periodontists would agree that a paradigm shift is occurring, but not one that discourages traditional periodontal treatment. Instead, the specialty has turned its focus to the etiology and pathogenesis of periodontal disease and its impact on other systems of the body. As a result of this changing thought process and the emerging science that supports it, periodontists have become increasingly essential partners in helping patients achieve oral and overall health.

From bacteria to inflammation

For many years, periodontics was focused primarily on bacterial etiology. Most periodontists were confident that if periodontal pathogenic bacteria could be minimized and patients were urged to commit to excellent plaque control, periodontal disease could be arrested or prevented.

This philosophy provided a simple equation for achieving periodontal health, and the concept of "soft tissue management" took hold. If periodontal disease progressed, there could be only two possible explanations: the education of patients failed to motivate them to better care for their teeth and gums, or adequate mechanical therapy was not performed.

However, in recent years, the periodontal community has turned its attention to the role of inflammation in the progression of periodontal disease. Over the past few decades, scientific literature has identified the inflammatory process as a primary modifier of many chronic diseases, including periodontitis. Consequently, the presence of inflammation has become more widely accepted in the specialty as the basis for explaining the perio-systemic link, and treatment planning has evolved beyond simple soft-tissue management.

Periodontists now understand that the inflammatory response is genetically predetermined; it has been estimated that up to 50% of chronic adult periodontitis has a strong genetic component. Also, this predisposition to inflammation and disease may change over a patient’s lifetime as susceptibility is modified by environment, stress, nutrition, or the onset of other diseases of aging such as cardiovascular disease or diabetes – a process known as epigenetics.

Treating the periodontal patient

This new line of thinking has had a significant impact on how periodontists treat patients. The concept of plaque as the sole determinant of periodontal disease and the strong emphasis on soft-tissue management have been challenged by enhanced understanding of individual differences in inflammatory response.

In addition, mounting research has suggested that simply diagnosing existing disease is no longer sufficient in determining which patients may benefit from advanced periodontal care. Essentially, not all periodontal disease cases are the same. Risk assessment, microbial testing, and genetic screening may also be necessary to help identify those patients who can be effectively treated by the general dental team and those who would likely benefit from periodontal specialty care early on.

Treatment by a periodontal specialist in concert with the general dentist is increasingly critical as patients live longer, experience more chronic disease, and take more medications than ever before in history. This partnership is particularly important in light of the growing body of evidence linking periodontal disease and other systemic disease.

In this era of modern health care, information technology, and medical-legal case law, general dentists should not be expected to do it all. Dental specialists are available to help manage risk – both the patient’s and the referring general dentist’s. Patient co-management can be an incredibly effective and rewarding relationship, reaping benefits for both care providers and their shared patients.

General dentists and their hygienists are often the front line in terms of diagnosing existing periodontal disease and determining the appropriate course of treatment; however, published data on tooth survival have consistently demonstrated that treatment rendered in a timely manner by periodontists is highly successful. These published, repeated studies have tracked therapy rendered by periodontists over 10 to 50 years.

Additionally, treatment options offered by periodontists have evolved dramatically. Advancements in periodontal bone and soft-tissue regeneration have enabled countless patients to regain health, function, and esthetics for their natural teeth. Periodontists have embraced the latest innovations in dentistry in their efforts to save teeth, including …

  • growth factors and biologics
  • bone grafting
  • biologic membranes
  • root coverage techniques
  • functional and esthetic crown lengthening procedures
  • antimicrobial and anti-inflammatory pharmaceuticals
  • newly designed instrumentation

The dental implant: friend or foe?

It is an undisputed fact that the dental profession has seen an explosion of implant companies, designs, and surfaces; however, the growing availability of dental implant solutions should not suggest that periodontists are arbitrarily removing teeth and replacing them with implants.

Most periodontists feel that dental implants provide a useful and predictable option for patients whose natural dentition cannot be preserved; however, it is important to be careful in quoting the success rates of implants. Some tout a 94% survival rate, but success is largely dependent on the type of dental implant, when and where it is placed, and how it is managed surgically and restoratively.

With proper care and maintenance, dental implants can be an excellent way to restore a patient’s function and esthetics after losing a tooth. The same advancements in periodontal bone and soft-tissue regeneration that have supported retention of natural teeth have also been responsible for achieving success for implants placed in partially edentulous sites, especially in the esthetic zone.

But dental professionals must remember that implants are not impervious to disease. In fact, rates of implant complications, such as peri-mucositis and peri-implantitis, may be on the rise. This is why most periodontists believe so strongly in evidence-based treatment planning when determining if and when implants are an option in the overall treatment plan for an individual patient’s condition.

Today’s surgical and nonsurgical treatment – when managed by the periodontal specialist using a predictable, conservative, and comfortable approach – can do something dental implants cannot – restore the bone, periodontal ligament, and cementum, and regenerate soft tissue around natural teeth. Thousands of patients have been treated successfully with these evidence-based therapies, as documented in peer-reviewed scientific journals over several decades.

This combination of disease management and regeneration has enabled periodontists to provide functional, esthetic dental implants that complement, not replace, periodontal therapy. The periodontal community believes it is this full scope of periodontal treatment that is in the best interests of patients and the dental profession as a whole.

Periodontists have not gone anywhere with respect to preserving their patients’ natural dentition. They are committed to working with their general dentist and hygiene colleagues to optimize treatment outcomes and are indispensable partners in preserving the lifelong health and well-being of our mutual patients.

This unique partnership should be celebrated.

Author’s response from Dr. Louis Malcmacher

I greatly appreciate Dr. Low and Dr. Clem responding to my column "Where did all the periodontists go?" in the June 2010 issue of Dental Economics®. Both Dr. Low and Dr. Clem are very well-respected, esteemed periodontists, and I greatly appreciate the time they have given to this important issue before us.

I most certainly agree with most of what Drs. Low and Clem write in their letter. There seems to be a great debate within periodontology of "teeth vs. implants." My column was purely an observation from many periodontists whom I speak to after my lectures over the course of the last couple of years. By no means am I taking a position in the "teeth vs. implants" debate; my thoughts in my column were purely anecdotal based on many conversations that I have had with periodontists around the country.

Obviously, this has become a hot-button issue among periodontists. Since Drs. Low and Clem describe "evidence-based treatment planning" in their letter, I was amazed to find that every periodontist that has responded to me about this article has widely ranging views – and all of them back up their philosophy with evidence-based scientific research. Some of the periodontists who responded decried the use of implants and called any periodontists who disagreed with them "ignorant," while other periodontists who supported implant use over traditional periodontal therapy suggested that those "on the other side were not knowledgeable" of the latest techniques available to patients. Somehow, both camps had managed to find evidence-based support for their own personal philosophy.

I am all for evidence-based treatment planning as Drs. Low and Clem suggest in their letter, but it may be unclear as to exactly where the evidence really lies. Even in their letter, Drs. Low and Clem take us through a history of how evidence-based treatment planning and periodontics have changed significantly and will continue to change with more knowledge becoming available about epigenetics.

With all of the discussion going on, I do feel there is one important element – it may be the most important element – in proper treatment planning, and that is the patient. I refer to this in my column as well. You can claim to have all the evidence-based periodontal and dental treatment planning available, but you must involve the patient who is sitting in front of you in the treatment planning process. If we are going to retain teeth, will they (patients) keep up with proper oral hygiene, recall visits, improve their nutrition, reduce their health risks, and a myriad of other factors to maintain their periodontal and overall health? Or, will they be able to take better care of dental implants because they have given up on their natural dentition? Many clinicians don’t like to hear that, but anyone who really understands patients knows how important this factor really is.

I think that Drs. Low and Clem may have missed this very important point – to me as a wet-gloved practicing general dentist – it is equally important to assess the personality of patients in terms of how they take care of their dental and overall health, as well as their desire as to what they want to accomplish with their overall treatment plan. Perhaps that is even more important than evaluating the scientific evidence, patients’ periodontal condition, the type of bone they have, and their overall bone support. That has somehow been left out of the conversation, and to me this is one of the most salient points when determining treatment plans for the patients of my own practice.

I once again thank Drs. Low and Clem for joining this discussion, and I certainly hope it continues as it brings important periodontal issues once again to the forefront.

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