A fresh look at preventing periodontal disease
“The first condition for successful establishment of needs-related tooth-cleaning habits is a well-motivated and well-educated patient,” says Dr. Per Axelsson in a commentary published in the October 2014 issue of the Journal of Periodontology.
Dr. Axelsson, professor emeritus, University of Gothenburg, Sweden, explained how since 1965 investigators have established and validated the basic principles required to prevent periodontitis and its reoccurrence after treatment.
He includes findings from his own research and from that of others, pointing to early evidence that prevention of gingivitis should be based on plaque control. He also cites later findings showing that established measures to complement improved self-care can prevent further loss of periodontal attachment and reduce the development of new caries. Also, excellent self-care habits, including self-diagnosis, can be successfully established in adults.
Separating prevention and control of periodontal diseases into three categories—primary, secondary and tertiary—he said research shows that both primary and secondary prevention goals are achievable. The aim of primary prevention programs is to prevent the initiation and development of periodontal diseases, whereas secondary prevention is aimed at preventing the recurrence of disease after successful treatment and is accomplished through supportive (maintenance) care programs.
He defined tertiary treatment as the elimination of disease through treatment and asserted, “Once initial cause-related therapy has been successfully completed, it is critical that the clinician consider risk factors for the recurrence of periodontitis and prescribe adequate treatments and intervals of treatment to fulfill the goals of PM [periodontal maintenance].”
The dental profession, he advised, must provide preventive care on an individualized basis to address risk factors demanding new approaches to complement the preventive maintenance program. The following are just a few of those risk factors:
• irregular dental care;
• low socioeconomic and educational level;
• concurrent infectious diseases;
• acquired diseases;
• side effects of medication or radiation as part of immunosuppressive therapy;
• poor dietary habits;
• genetic factors;
• impaired host factors;
• reduced salivary flow and quality.
Consulting Editor: Dr. Eros Chaves
Professor and Chair,
Department of Periodontics
University of Oklahoma Health Sciences Center
College of Dentistry
The Consulting Editor assists in the selection of scientific editorial content but has no connection with any product mentioned or any advertising that appears in this newsletter.
Implant outcomes and patients with aggressive periodontal disease
The literature suggests that patients with aggressive periodontal disease have a greater risk of developing peri-implant diseases and that they experience higher implant failure rates compared with patients who have chronic periodontitis (CP) or patients who are healthy.
Scientists from the University of Michigan and University of Lisbon sought to clarify the effect a history of aggressive periodontal disease has on implant treatment outcome.
To investigate, researchers explored human clinical trials, either prospective or retrospective, that compared implant survival rates and marginal bone loss in patients with a history of generalized aggressive periodontitis (GAP) with those who were healthy or had CP. They searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Cochrane Oral Health Group Trials Register databases for articles published from 2000 to 2013.
The researchers found six articles that met the study inclusion criteria. All were comparative prospective controlled trials assessing implant treatment outcomes in patients with GAP compared with healthy patients and/or those with CP.
The findings showed no significant difference in implant survival rates for the GAP group when compared with the CP or healthy group. Implant survival rates ranged from 83.3 percent to 100 percent for the GAP group, 96.4 percent to 100 percent for the CP group and 96.9 percent to 100 percent for the HP group.
However, when researchers analyzed failure rate they found statistically significant differences between patients with GAP versus healthy patients (overall risk ratio of 4.00) or those with CP (overall risk ratio of 3.97).
The researchers said that because of the small sample size of the failed implants group, it was not possible to draw conclusive statements regarding the risk ratio.
Also, although the systematic review showed that individuals with a history of GAP displayed higher marginal bone loss when compared with healthy patients or those with CP, authors said those results should be interpreted cautiously because the amount of bone loss was small (0.28 to 0.43 millimeters) and might not have clinical significance.
Unmodifiable conditions might play a determinant role in both GAP and peri-implantitis processes, authors observed. They encouraged a comprehensive implant maintenance program to identify peri-implant bone loss early, specifically in patients with a history of generalized aggressive periodontal disease.
The report was published in the October 2014 issue of the Journal of Periodontology.
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Implant position and long-term success
What are the clinical guidelines for achieving long-term success in implant placement? A report reviewing recommendations for a stable, esthetic and functional implant-supported restoration was published in the August 2014 issue of Clinical Advances in Periodontics.
The three-dimensional (3D) position of implants in the dental arch appears to play an important role in long-term success rates, the authors said. Finding few studies relating the success of dental implants to their 3D position, the research team investigated the literature and also proposed optimal decision-making processes for implant positioning in the anterior and posterior region. They explored and illustrated optimal positioning via a flow chart for bucco-palatal, mesio-distal and apico-coronal positioning. Patient case reports illustrating applications and outcomes in the clinical setting were presented.
In summary, the scientists said that buccal bone thickness of 2 millimeters anterior to the implant is best in the maxillary anterior region, where esthetics is of paramount importance, to avoid peri-implant mucosal recession and bone loss. In the posterior region, a minimum of 1 mm of buccal bone around the implant ensures stability of the buccal plate.
“Placement of dental implants in an ideal 3D position aids in maintaining hard- and soft-tissue levels over time,” authors concluded. “Associative relationships are drawn between the effect of implant positions and their long-term stability.”
AAP celebrates its first century
Meeting in San Francisco last month, the American Academy of Periodontology celebrated its 100th anniversary and installed new officers.
“I am excited about the opportunity to serve the specialty of periodontics as it enters its second century,” said AAP’s new president, Dr. Joan Otomo-Corgel, of Manhattan Beach, Calif.
“Periodontics is a dynamic specialty,” she said. “What an exciting time for the AAP to expand its knowledge to best care for the health of the public we serve.”
In addition to her private periodontal practice, Dr. Otomo-Corgel is chair of research at the Great Los Angeles Veteran’s Affairs Health Care Center.
She also is an associate clinical professor in the in the Department of Periodontics at the UCLA School of Dentistry, where she earned her dental degree in 1979.
An AAP member since 1977, Dr. Otomo-Corgel has served on the boards of trustees for both the AAP and the AAP Foundation.
Other newly installed AAP officers:
• Dr. Wayne A. Aldredge, of Holmdel, N.J., president-elect;
• Dr. Terrence J. Griffin, of Boston, Mass., vice president;
• Dr. Steven R. Daniel, of Knoxville, Tenn., secretary/treasurer;
• Dr. Stuart J. Froum, of New York City, immediate past president.
Attached to each tooth is a person
Dr. Bard J. Levey
I’m a second-generation dentist who learned that dentists treat patients, not teeth. The patient centric focus has expanded over the years to include a more comprehensive, whole-health understanding of dentistry. This is particularly true for periodontal disease.
In 1991, when I graduated from the School of Dentistry in Chapel Hill, dentists knew that untreated periodontal disease led to tooth loss and corresponding restorative needs. Ten years later, the emerging science linking periodontal infections to systemic inflammatory responses changed my perspective. Periodontal disease needs to be treated with greater urgency.
The science linking periodontal disease to cardiovascular diseases especially captured my attention because I have a strong family history of CVD. Although I am a fit, 49 year old, I take a statin drug to address hereditary high cholesterol. I want to make the healthiest choices possible, and I want to offer these choices to my patients.
In 2008, I bought my first laser in an attempt to provide more comfortable and more effective care for my perio patients. Laser treatment produces good results and patients appreciate the technology, but 12 to 18 months after treatment, I often notice a deterioration of periodontal health. The hygiene protocol in my office includes regular plaque analysis under a phase contrast microscope. When I looked at samples from patients a year plus after laser therapy, the microscope almost always revealed a robust microflora symptomatic of periodontitis. Antibiotics and localized delivery of antimicrobials did not help.
The only localized delivery technique that has helped long-term is Perio Tray delivery of Perio Gel with 1.7 percent hydrogen peroxide. When the low concentration of peroxide is held deep in the pocket with the customized Perio Tray, which is specially sealed against the gingiva to overcome crevicular fluid flow, the peroxide oxidizes the biofilm matrix and most exposed biofilm cells. It also oxygenates the pocket’s microenvironment. This delivery has made all the difference for my patients. Those using the Perio Trays with peroxide have the clearest plaque samples.
The results were so good in the patients with active disease that I decided to use Perio Tray delivery myself for prevention. Although I don’t have traditional symptoms of gum disease that are measured in terms of damage, my plaque sample indicated I was at risk, and this mattered to me in light of my elevated CVD risks (Figure 1: Pre-treatment plaque sample).
A month after starting the delivery, which I did two times a day for 10 minutes, my sample was clear (Figure 2: Two-weeks post Perio Tray delivery plaque sample). I’ve checked it regularly ever since. Although many of my patients can maintain healthy conditions with once-a-day usage, for me, two times a day works best.
For my patients who need better biofilm management, like me, the Perio Tray has been an effective and convenient tool. Generally, response has been very positive. Once you incorporate the tray into your routine, it is as easy to use as a toothbrush. Patient health takes priority, because ultimately we are treating the whole patient.
To learn more about prescription tray delivery visit www.periotray.com or www.perioprotect.com/doctor.
Dr. Levey was not compensated for this editorial. The Perio Tray by Perio Protect was cleared by the FDA to place doctor-selected medication subgingivally. Successful Perio Protect treatment depends on patient compliance and patient conditions. Your results may vary. Doctors use Perio Protect in conjunction with scaling and when necessary with surgery. Learn more about Perio Protect at one of our upcoming training sessions www.perioprotect.com/training.
Perio Trays by Perio Protect
Prescription Perio Trays are innovative tools for adjunctive periodontal care. They have internal peripheral seals to deliver medication into shallow and deep pockets (>6mm), ideal for patients with generalized pocketing or struggling between maintenance visits. Research shows Perio Tray delivery of 1.7% hydrogen peroxide gel combined with SRP achieves better results than SRP alone. They are comfortable, convenient, easy-to-use. To learn more visit http://www.perioprotect.com/doctor
ADA offers discount on top periodontal brochure
Now through Nov. 15, the ADA is offering members free shipping on all patient education brochures with a minimum order of $75.
Members can order “Periodontal Disease: Don’t Wait Until it Hurts” (W121) through the ADA Catalog and receive free shipping with a minimum $75 order using promo code 14368E The 12-page booklet is available in packets of 50 for $30; retail price $45. Discounts are also available in higher quantities.
Written for the dental patient, the brochure is top rated among ADA patient materials. It provides an overview of periodontal disease, from prevention to treatment. Features include illustrations of probing, SRP and periodontal surgery, along with bone loss x-rays and “stages of perio” photos.
Members can preview this and other ADA brochures online at adacatalog.org. Orders can be placed online or by calling the ADA Member Service Center at1- 800-947-4746. Remember to use promo code 14368E to get free shipping with a minimum $75 order.
What is Specialty Scan?
This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on periodontics, the fourth in the series on this topic for 2014. Other Specialty Scan issues are devoted to endodontics, orthodontics, oral and maxillofacial radiology and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own divisions of Science and Legal to assist with these newsletters. We welcome your feedback on this and all Specialty Scan issues.
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