Dear Dr. Malcmacher,

I am writing in response to your commentary in the Dental Tribune posted on May 7, 2010, entitled “Where did all the periodontists go?”1 In answer to this question, I would say “We’re still here.” Your observation that there have been changes in all specialties (you cite orthodontics, endodontics and periodontics in your article) is of course accurate. Any specialty that has not undergone change in light of all of the new emerging information, technologies and materials would certainly be failing our patients and profession.

One of the most significant changes in the periodontal specialty has been that clinical diagnoses, treatment planning and treatment procedures are now decided, wherever possible, on evidenced-based data and controlled clinical studies as reported in peer-reviewed scientific literature. As such, your reporting that you are being told by many periodontists whom you “spoke to over the last couple of years” that “they would rather remove teeth and place implants than actually treat patients through traditional periodontal surgery and try having them maintain their dentition” is quite disconcerting.

As a periodontist who treats patients in private practice, and as a clinical professor in the Department of Periodontology and Implant Dentistry at New York University Dental Center who teaches periodontics and implant dentistry to periodontal residents in training, I feel that the periodontists you are quoting are at the very least misguided, and should be made aware of a number of facts that may change their opinions.

First, by and large, most of the periodontists I meet in my lectures and travels around the country realize the value of attempting to save a tooth or teeth that can be retained in a healthy functional and an esthetic state. In fact, traditional periodontal treatment including both non-surgical and surgical techniques, have very high success rates in accomplishing this goal as shown in longitudinal studies (see Hirshfeld and Wasserman  J Perio 1978, Oliver  J West Society Perio 1969, Goldman MJ et al. J Perio 1986 , etc.) over 20–50 years. It has been known for over three decades that periodontal surgery, when not followed by good professional and personal care, will in many cases fail (Nyman et al. J Clin Perio 1977).

That is why successful surgical treatment designed to save teeth requires meticulous and regular professional maintenance. Becker et al. (J Perio 1984) and others have shown that when this maintenance is provided, a surgical approach to treatment of moderate and advanced periodontitis is highly successful. Patient compliance, even when not optimal, must be reinforced by frequent maintenance and recall. This requires a team effort by the referring dentists, hygienist and periodontist , which will result in tooth retention and successful treatment in most cases.

To extract teeth and place implants is not the panacea that you and those periodontists that you spoke to believe it is. First, the 94 percent implant success rates you quote should be qualified. You mean a 94 percent implant survival rate because success implies implants that lose no more then 0.2 mm of bone per year following final restoration and remain esthetically pleasing to the patient.

By the way, these long-term survival rates that are often quoted are based on use of implants with surfaces that are no longer available (i.e., machined surface implants) and no longer being placed. Therefore, to compare long-term success of implants versus treated teeth is not possible because long-term data on currently used implants is lacking. However, as I stated above, there are many long-term studies showing natural teeth, when treated with traditional periodontal surgery, have excellent long-term prognoses (Lindhe and Nyman, J Clin Perio1984). The fact that implant surfaces and designs are changing so rapidly, makes it difficult to find any comparable long-term statistics for implants currently being placed.

Moreover, currently used implants like natural teeth can and do develop bone loss (peri-implantitis), which has been documented to be more prevalent than formerly believed. In fact, in a recent consensus report and literature review authored by Lindhe and Meyle and published in the Journal of Clinical Periodontology 2008, they cite two cross-sectional studies documenting that peri-implant mucositis occurred in 80 percent of the subjects and in 50 percent of the implant sites. Peri-implantitis was identified in 28 percent and more than 56 percent of the subjects.

This was corroborated by a more recent study (Koldstand, J Perio 2010) that documented a prevalence of peri-implantitis of 11.3 to 47.1 percent. This, combined with the results of two long-term studies — Pjetursson (2004), who reported that 38.7 percent of patients had complications in the first five years after implantation; and Lang (2004), who reported that biological and technical complications with implant-supported restorations occurred in about 50 percent of the cases after 10 years in function — should dispel any beliefs that implants are a trouble-free panacea when compared to retention of teeth that require periodontal treatment.

As for your contention that new procedures, i.e., wavelength optimized periodontal therapy (WPT) and the LANAP procedure using a Nd:YAG (Neodymium: Yttrium AluminumGarnet) laser present minimally invasive alternatives for patients who want to keep their teeth without “heavily invasive periodontal surgery,” I again refer to the dental profession’s reliance on evidence-based data before recommending new treatment modalities. I ask you: Where’s the proof that these modalities are as or more effective than what has been proven through evidence?

Before using any new modality, any dentist should have histological, clinical and long-term proof that these procedures are effective. Many therapies are “minimally invasive” but useless for effective periodontal treatment.

Dr. Malcmacher, I’ve been performing and teaching periodontal therapy for over 35 years and have seen trendy, minimally invasive and “easy” therapies fall by the wayside when clinically tested in randomized controlled studies. The Keyes technique, many time released local antibiotics (i.e., chlorhexidine in a gelatin chip, tetracycline fibers, doxycycline hyclate in a polymer carrier or minocycline microspheres) and even lasers were tested scientifically and found to yield little, if any, improvement over traditional scaling and root planning (without surgical therapy).

Utilizing ineffective therapies to avoid traditionally effective ones oftentimes results in progression of the disease around teeth that, when finally referred to a periodontist, are truly hopeless and have no other option but extraction. However, the proper use of surgical regenerative procedures, with a variety of grafts and membrane barriers, have shown that bone and soft tissue that had been lost due to periodontal disease can be regenerated and questionable teeth saved. This has been well documented over the last 30 years. New products, i.e., tissue healing modulators, growth factors (BMP-2) and even stem cells, are promising additions to currently proven materials and techniques but require evidence-based research, which in many cases is currently being performed before being recommended as replacement materials.

I feel that general practitioners and periodontal specialists should be co-therapists in patient treatment. The decision to extract or attempt to save a tooth should be made by the dental team not by one quarterback. I feel the periodontal specialist is in the best position to advise the referring dentist of the risks, options and treatment required to save a tooth or teeth. I don’t see many patients who come to my office or the New York University Dental Center clinic who would rather have an implant than a healthy functioning tooth. That’s why I advocate saving teeth, and periodontists are trained to save teeth.

There certainly are circumstances where extraction and implant placement is indicated and, here too, periodontists should be part of the team involved in these decisions and procedures. Periodontists have always been involved with soft and hard tissue esthetics around teeth and implants, and certainly have the experience and expertise in both areas. It would be best for the patient and treating team to be on the same page when it comes to knowing the options, risks, benefits, anticipated results and potential complications before any implant treatment option is considered.

You concluded with the statement: “You  are the dental clinician, so it is for you, the periodontist and the patient to decide.” I couldn’t agree more, but the decision should be based on sound evidence-based data that is currently available rather than promises or hype from any company with minimal scientific long-term data to back up their claims.

So again, to answer your question, “Where did all the periodontists go?”

“We’re here and available for a team approach to predictable dentistry.”

I urge you and your readers to attend the Joint Periodontal-Restorative Dentist Conference that will be held in Chicago April 2011 to see first hand how this collaboration can work.

I also direct you to a book I edited, “Dental Implant Complications — Etiology, Prevention and Treatment,” that will be published by Wiley-Blackwell within the next 2 months (www.wiley.com/WileyCDA/WileyTitle/productCd-0813808413.html ). The latter is a comprehensive textbook discussing potential implant complications and how to avoid them. This should be of interest to all dental practitioners be they general dentists or specialists. The book emphasizes the team approach to avoiding unwanted complications and results.

CLICK ON LINK BELOW TO READ ACTUAL ARTICLE:

“Where Did All The Periodontists Go?”

http://www.dental-tribune.com/articles/content/id/2045/scope/specialities/region/usa

That evening I flew to San Diego to attend the California Society of Periodontology meeting at which my friend and colleague, Joan Otomo-Corgal, was inducted as President. Board of Trustees member Rich Kao was kind enough to introduce the candidates to the membership. That evening I attended the “Pirate Dinner” organized by the CSP. This was on a sailing vessel which fortunately stayed docked. It was a costume dinner and most came dressed to the teeth.

The lectures at the CSP meeting which took place at Paradise Point Resort in San Diego were very interesting and well attended. On Saturday the lecturers ( Drs. Wilco and James Rutkowski) spoke about Periodontal Accelerated Osteogenic Orthodontics and Hormone and Osteoporosis Therapy.

I was invited by Dr. Joseph Fiorellini (Professor and Chair of the Periodontics Department) to lecture next week to the post-graduate  periodontal students at the University of Pennsylvania Dental School on the topic of Guided Bone Regeneration. I look forward to sharing ideas and techniques.

As you are probably aware, I am running for Secretary/Treasurer of the AAP in the upcoming elections in June of 2010.  You can read my statement of purpose at the AAP website at the following link:

http://www.perio.org/members/nea/candidate-letter_Froum.htm

Please vote.

 Please vote for me for Secretary/Treasurer in the June 2010 AAP election

online June 1 to July 1 2010 at: https://www.esc-vote.com/aap2010

I find the replies in “Inside Dentistry” of all 3 panelists to the question “Whatever happened to treating periodontal disease?”, interesting. For the most part, I agree with all 3 in their assessment of the goals of periodontal treatment. The one I think is closest to the mark regarding actions that our Board may consider is Dr. Serio.

But taking it one at a time and looking at the questions through our “Strategic Plan” (SP) glasses, I would say the following:

(1)   All agree that bleeding on probing (BOP) is our best clinical tool to assess inflammation. However, as we all know when clinically measured (BOP) can be subjective. I’ve seen charts of patients that GPs did not refer but presented to my office on their own or on the advice of a friend or family member and there is no indication of any BOP and the probing depths (PD) were much more shallow than my examination indicated.

I agree with Dr. Levine about the systemic link but feel that the success and limitations of scaling and root planning (SRP) PDs > 5mm has been well documented (see Waerhaug, Stambaugh, etc.). However, even patients with these inaccessible PDs > 5mm are not being referred to periodontists today. I feel risk assessment must be stressed in our SP and we must start the Diabetes-Periodontal Study asap. The results of that study has the potential to bring in a good number of new patients and referrals to our membership (best evidence our SP is working). Personally, I feel the local use of antibiotics (Atridox/Arestin) is very limited (see Greenstein JP) and we should not jump on that bandwagon. Oftentimes, these local antibiotics act as a “profit center” (both for the company manufacturing the product and GP) and do little to alter the disease progression. Shotgun approaches to full mouth disinfection are good but we ought to be careful with repeated doses of systemic antibiotics (resistant strains, host tolerance, etc.). I would save this approach for aggressive forms of periodontitis (again the need for Risk Assessment and Proper Diagnosis). I think our SP should include an individualized approach to the diseases based on risk assessment, type of disease, patient compliance, the ability to access the biofilms, plus the need for regenerative or auxillary procedures (ie orthodontics, endodontics, etc.).

As for Dr. Rethman’s comments, I feel he is correct in his observations on the attractiveness of implants for “Patients seeking a problem-free, fully functional, attractive, and pain-free oral complex.” But we should stress in our (SP) that implants are certainly not problem free and carry their own set of risks. How many periodontal procedures result in partial or full paresthesia compared to these which include implant placement? Dr. Rethman’s discussion of  OPT and PTMPs assumes control of the key factor – Patient Compliance. And as Wilson and others have shown, we are fortunate when that percentage approaches the 19% mark. I think we must come out strongly against “Miracle Therapies”. Unfortunately, the “Keyes Technique”, “Perio Protect” and other types of miracle treatments take years to prove lack of effectiveness compared to time tested evidence based approaches, and during those years our membership suffers from a decrease in patients seeking proven care. When our specialty criticizes these “simplified miracle treatments”, we are labeled as self serving. So we have to confront that conundrum. Minimally invasive surgery using the microscope maybe the way of the future but to date has not been proven in long term RCT. Those who have tried the endoscope (and I have) find that the instruments and skills required are rarely as attainable as is the microscope.

As I stated previously, I think Dr. Serio is on the right track in his identifying the problems facing the AAP and our SP. Many dentists see “Soft tissue management” programs as revenue centers and will go no further to monitor their results which is what is necessary for the OPT that Dr. Rethman writes about. Moreover, using soft tissue management as an endpoint without monitoring does not result in patient referrals. It is here where our “Outreach Program” and PR efforts will be tested. I have several ideas that may be effective in breaking through but I think the entire board has to share their thoughts with each other and the PR firm representing us. Our “Guidelines” for referral frightened many GPs, especially the AGD. I feel a more educated and informational approach might have better results. Our PR firm must stress the systemic perio link, risk assessment, the limits of soft tissue management programs and treatment tailored to the needs of the patient. Again, none of the 3 dentists interviewed touched on the necessity of the GP and restorative dentist to accurately access the need for referral. Moreover, some of our most valuable services (soft tissue grafting, bone grafting, and other regenerative procedures) were not even mentioned. There’s a very large gap between SRP (soft tissue management) and extraction and implants. Unfortunately, allowing periodontal disease to progress from the SRP phase performed by the GP to extraction/implantation present our membership with little chance to perform the treatments Drs. Levine and Rethman write about.  I feel that all of these items should be discussed at our next AAP Board of Trustees meeting relative to strategic planning with the public relations firm that the Board has employing.

The value of experience was recently demonstrated by a pilot for US Airways.  On January 15, 2009, US Airways flight 1549 took off from La Guardia Airport in New York City, when after several minutes in flight a flock, of birds collided with the engines and both engines shut down.  The pilot, Chesley Sullenberger, could not return to La Guardia airport nor fly to a nearby airport to land the plane which had completely lost power.  Instead, he safely landed the plane on the Hudson River, thus saving all 155 people aboard.  When asked how he managed to do this, Mr. Sullenberger replied: “For 42 years, I had made small, regular deposits of education, training, and experience and the experience balance was sufficient that on January 15^th, I could make a sudden, large withdrawal.”