Enough of ENAP...do your zapping in the kitchen

Like a Phoenix, ENAP (Excisional New Attachment Procedure) has risen from the ash heap of the 80s. As before, this "revolutionary" breakthrough claims to eliminate gum pockets - this time using a patented Laser technique. Even though this form of ENAP has little merit, it needs closer scrutiny because it has the sainted blessing of the FDA.

To date, only 57 patients in four published human studies have been used to evaluate the effects of subgingival Laser application. True, ENAP demonstrated a reduction in the disease-producing bacteria in all four studies, but root damage was reported in two of the papers (while the other two didn't evaluate root damage). Considering that one of the main goals for using the ENAP procedure is to remove the epithelium lining the pockets facing the teeth, no study found that this was accomplished. Furthermore, no study found that regeneration of periodontal tissues resulted from the ENAP. The studies went further, stating that use of the Laser for ENAP and/or gingival curettage may damage root surfaces and cause additional bone loss.

Why would anyone use a Laser to accomplish what conventional scaling and root planing do, when performed by dental hygienists and dentists? One reason might be the allure and appeal of having the latest "technological" treatment for gum disease. Another reason is that LASER machines are costly and dentists are looking for different ways to amortize their investment. Our recommendation? Use Lasers for eye surgery, skin treatments, etc., but not for treating the gums.

Mitral Valve Prolapse ain't what it used to be

The prevalence of Mitral Valve Prolapse (MVP) has been estimated to range from 5-35 percent of the population, with the predominance occurring in women. Furthermore, people with MVP have been told that they are at greater risk for a myriad of problems including stroke, atrial fibrillation, heart failure, mitral valve regurgitation requiring surgery, and infections from dental procedures, in particular. Now a study coming out of the well-known, long-term Framingham Heart Study challenges many of these notions.*

Researchers in this study examined 1845 women and 1646 men for MVP using more precise methods - three dimensional imaging rather than two dimensional imaging - used in previous studies. Their results were striking. Only 47 subjects had classic MVP and 37 subjects had non-classic MVP (this adds up to 84 subjects, or 2.4 percent of those in the study). Fifty out of the 84 subjects diagnosed with MVP were women and thirty-four were men. Distribution by age was equal in all decades of life from the twenties to the eighties. When it came to being vulnerable to the various risks such as stroke, etc., the MVP group had no greater frequency of problems than the other 3407 subjects (without MVP) in the study. The study concluded that the numbers of persons with MVP was lower than previously reported and that the sequelae commonly associated with this diagnosis was also low.

Knowing this does not change the need for patients with MVP to premedicate with antibiotics when receiving dental treatment, and the current American Heart Association standards still apply. What this study does imply is that further testing may reverse a previous diagnosis of MVP that will eliminate exposure to antibiotics and undue concerns.

*Freed, L.A., et all: Prevalence and clinical outcome of mitral-valve prolapse. New Eng J Med 341: 1-7, 1999.

Show me the money...before your gums go Chapter 11

Many studies have correlated stress to poor oral health and increased caries, and one study even found patients with periodontal disease scoring higher on levels of depression than the control group. The trouble with these studies is that their conclusions were based on limited numbers of subjects. So researchers at SUNY Buffalo investigated 1,426 subjects to determine how stress and coping skills affected dental health.*

The subjects ranged in age from 24-74 years, and were from a cross-section of socio-economic groups. They were found to have a wide range of periodontal disease. Various health factors were studied, including smoking habits, and different parameters for periodontal health and disease were measured. After baseline data were obtained, each participant was given a set of psycho-social questions to answer. Coping skills were studied by standard psycho-social measures. The results were interesting.

The researchers found that stress related to financial strain and depression were associated with greater levels of periodontal disease. Those individuals with good coping skills (no matter what they were) - even when they were under great financial strain - exhibited no more periodontal disease than subjects not under financial strain. Job strain didn't appear to correlate to increased periodontal problems. The authors concluded that since periodontal disease is a long-term health outcome, chronic adverse psychological stress is able to impact on gum and bone tissues.

*Genco, R.J. et al: Relationship of stress, distress and inadequate coping behaviors to periodontal disease. J Perio 70:711-723, 1999.

Should we treat smokers?

It's not that we don't want to help patients who smoke with their periodontal problems, but are we wasting their time. . . and ours? We all know that careful removal of plaque and calculus from root surfaces in concert with improved oral hygiene measures go a long way in improving most patients' gum condition. Besides uncontrolled diabetics, the single biggest group of patients who do not respond as well to this treatment is smokers. So if that's the case, should we treat smokers at all? The answer is a resounding "Yes," as long as the best treatment options are rendered.

Thirty-five smokers and 35 non-smokers with periodontal pockets >6mm, received treatment consisting of meticulous subgingival root planing over six-eight appointments, with each appointment being followed by 2-3 days of rinsing with chlorhexidine gluconate (Peridex). The results were evaluated 6-12 weeks after therapy was completed, at which time additional treatment (surgery) was planned when needed.

The results support our own clinical findings. In this study, smokers presented with deeper pockets at their first exam visit than non-smokers. While the results in non-smokers improved all areas of the mouth except the maxillary (upper) molars and mandibular (lower) second molars, smokers had fewer initial benefits from scaling and root planing. Standard techniques in decision analysis were applied to which treatment techniques worked best for non-smokers vs. smokers. The analysis indicated that selective surgery worked best for all patients with resistant pockets in those who smoked.

While this study demonstrates that smokers receive added benefit from gum surgery when needed, how should their treatment be modified if their periodontal problem continues to worsen? Söder, B. et al** found that prescribing metronidazole (Flagyl) for one week following initial scaling treatments improved smokers short-term periodontal health with improvements lasting five years.

As studies confirm that smokers heal differently than non-smokers, clear evidence and clinical experience dictate that smokers can expect the best results from periodontal treatment when it is definitive and combined with antibiotics.

*Papantonopoulos, G.H.: Smoking influences decision making in periodontal therapy: a retrospective study. J Perio 70:1166-1173, 1999.

**Söder, B., Nedlich, U. and Jin, L.J.: Longitudinal effect of non-surgical treatment and systemic metronidazole for 1 week in smokers and non-smokers with refractory periodontitis: A 5-year study. J Perio 70:761-771, 1999.

Oh Honey, my bones are shrinking!

If a major component of periodontal disease is bone loss, doesn't suffering from osteoporosis mean a worsening dental condition? Though one would think so, the studies do not provide a clear-cut answer. . . until now. In the past, studies have related the rapidity of systemic bone loss to the rate of alveolar (jaw) bone loss. The converse was also found, that postmenopausal women with greater bone density retained more teeth than those with osteoporosis. But these studies and others were equivocal because some researchers concluded that systemic bone mass was not an important factor in the progression of periodontal disease. Who's right?

Weyant, R.J. et al* designed a study to overcome many of the limitations inherent with most studies researching the relationship between osteoporosis and periodontal disease. Some studies included too few subjects to validate sweeping conclusions, study populations that were too young, or lacked the ability to study age-related changes. Weyant's group studied 2,401 women who were at least 65 years old, with an average age of 71.7 years. Each subject had her bone mineral density (BMD) measured. All oral examinations included a periodontal assessment. In addition, other covariates were studied, including their education, smoking habits, alcohol consumption, exercise history, current physical activity, water fluoridation history, age at menopause, use of estrogen supplements, use of birth control pills, parturition history, mental status, and history of bone fractures.

The study did not find a statistically significant association between the measures of bone mineral density or the other covariates studied, when compared to the progression of periodontal disease. In other words, there was no convincing evidence that osteoporosis in older, non-black women, is a risk factor for gum disease. The link between the two is a weak one, at best.

*Weyant, R.J. et al: The association between osteopenia and periodontal attachment loss in older women. J Perio 70:982-991, 1999.

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