Incorporating Periodontal Disease Into the General Practice

Most of us would agree that periodontal disease isn't much fun to treat. There's no fancy equipment involved, and afterwards we're lucky if we see a smile from the patient whose gums no longer bleed. But if we are going to consider ourselves true oral health providers, it is incumbent upon us to properly diagnose and treat this serious disease.

Severe periodontal disease, or periodontitis, is a chronic bacterial infection that affects the gum tissue, ligament, and bone supporting the teeth. It affects approximately 15 percent of Americans over the age of 18.¹ The Surgeon General has reported the incidence in older Americans (age 65 to 74) to be 23 percent.² Recent evidence supports strong links between periodontal disease and heart disease, stroke, diabetes, preterm babies, and respiratory infections and emphysema in immune-compromised and/or elderly adults.

General practice responsibilities

Some general dentists may believe periodontal disease should be the sole responsibility of periodontists. Numbers show how impossible that is. There are about 4,000 practicing periodontists in the United States. Assuming their calendars were completely booked with patients throughout the year, they might be able to treat 4 million patients based on a three-month continuing-care schedule. That would still leave a potential 46 million Americans with nowhere to go. At least half will seek out a dentist, demonstrating the vast opportunity for you and your colleagues to properly diagnose and treat these patients.

Treatment

The first step involves a comprehensive perio examination to determine the proper diagnosis and treatment for each patient. Once diagnosed, the standard treatment protocol is scaling and root planing, the standard of periodontal care for most of the last century into the new millennium.

Effectiveness of SRP

While SRP continues to be the initial, gold standard treatment for periodontal disease, we do know it has limitations. Some of these include the depth of the pocket relative to the tooth/pocket location, furcations, root proximity, root flutings, CEJ relationships, and faulty restorations. SRP is intended to remove the build-up of bacterial films, toxins, and accretions of calculus. It doesn't do so well when it comes to reducing pocket depth.

Dr. Charles Cobb summarized average pocket depth reductions noted in the dental literature before 1996 following SRP only. The average pocket depth reduction was 1.29 mm.³ Pre-1996 data consists of mostly smaller, single-site studies where a relative lack of controls and standardization may have contributed to a higher potential for investigator bias (leading to the higher probing depth reduction values). Similarly summarized measurements from 1997 to 2000 revealed an average pocket depth reduction of 1.03 mm. This shows definitive benefit to SRP, but the benefit is limited when it comes to pocket depth reduction. In addition, SRP may not address the bacteria that are buried deep in the periodontal tissues. While systemic health disease and links to oral health have not yet been established, researchers theorize it has to do with the bacteria that enters the blood stream and affects other body systems.

Over time, multiple techniques have been tried in an attempt to improve pocket depth and bacterial load reductions without the use of surgical intervention. Unfortunately, many of these techniques were difficult to reproduce clinically. One of the most promising areas of research and development has involved the use of chemotherapeutic agents placed directly in periodontal pockets.

The concept was that if the bacteria could be better controlled and/or destroyed, greater pocket depth and bacterial load reductions could be obtained. Many such products have reached the dental marketplace and are referred to as locally applied antibiotics/antimicrobials (LAAs).

The problem is that, until just a few years ago, LAAs tended to be difficult to use. Dentists and hygienists complained that they were often messy, difficult to place, had to be removed later, and/or required special storage. These initial experiences soured many dental professionals to the idea of LAAs. Many don't realize that the LAA used by most dentists and periodontists today, Arestin^®, has none of the difficulties associated with earlier-generation products. Arestin^® uses microsphere technology that encapsulates and delivers a low dose (1 mg) of the antibiotic minocycline to the site of the periodontal infection. It's a powder that comes in premeasured doses and is easily placed into the pocket following SRP. It requires no mixing and no special storage such as refrigeration. It won't leak out of your patient's gums because it is bio-resorbed into the gingiva where the antibiotic is released over a period of up to 21 days.

In strictly controlled FDA studies, Arestin^® and SRP were shown to consistently reduce pocket depths to greater degrees than SRP alone and significantly reduce pocket depths over time compared to SRP alone.³

Sixty-one percent of pockets treated with Arestin^® and SRP showed pocket depth reductions of 2 mm or more. Twenty-six percent more pockets dropped below the 5 mm threshold.

Arestin^® and SRP were shown to reduce pocket depths to greater degrees than SRP in all clinically relevant subgroups: molars, furcation areas, various age groups, medically compromised patients, and smokers. In addition, because the minocyline used in Arestin" does not obtain therapeutic blood levels, many of the side effects observed with the oral or enteral administration of antibiotics do not occur.

Comprehensive care is critical

If you are not already diagnosing and treating periodontal disease in your practice, there are good reasons to start now. When patients step into your practice, they are entrusting you with their health, and that means a lot more than a better smile. First and foremost, a dentist is a doctor. By incorporating periodontal care into your patients' standard care, you are telling them you're treating their health, not just their teeth.

Arestin^® is a very easy and effective way to do this. It requires no special training or level of expertise on your part. For your patient, there is no special commitment of time and no inconvenience. Yet the results are inarguable — an out-of-control infection can now be treated fast and easily.

A dentist, just like other doctors, also has business considerations. Periodontal care is a simple and practical way to expand a dental practice.

Hemorrhage-free dental treatment

We are very spoiled in our practice. When we prepare a tooth for a restoration — whether it is for a full-porcelain crown, porcelain onlay, or two-surface composite — our patients' gums rarely bleed. That's because we don't perform these procedures where there is infected gingiva. And when the gingiva are infected, we perform SRP followed with Arestin^® first.

The importance of doing so cannot be understated. At the very least, if the gums don't bleed, we can predict preparation times. Also, patients appreciate not having to experience the typical discomfort following the cord placement that crushes the connective tissue at the base of the pocket.

General practitioners represent the first line of defense for a patient's oral health. New, nonsurgical advancements such as Arestin^® make it easy to treat periodontal disease. The sooner you start diagnosing and treating periodontal disease in your practice, the sooner your patients can begin to enjoy the benefits of a healthy, life-long smile.

References

1. Brown LJ, Loe H. Prevalence, extent, severity and progression of periodontal disease, Periodontal 2000 1993; 2:57-71.
2. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General — Executive Summary Rockville, Md.: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
3. Cobb CM. Nonsurgical pocket therapy: mechanical. Ann Periodontal 1996; 1:443-490.
4. Williams RC, Paquette DW. Topical minocycline treatment of periodontitis, J Periodontal Nov. 2001.

Isabelle Farmer, DDS
Dr. Farmer is a member and Fellow of the Academy of General Dentistry. She lectures around the country on the treatment of periodontal disease and managing a general practice.