When "conservative" periodontal treatment means surgery

Rather than lump patient results together as most previous studies have done, this study compared the response of individual teeth to treated vs. untreated periodontal lesions. Here's the way they tested it. Patients treated in the same practice (by the same practitioner) over a 24-year period were divided into two categories: compliant and non-compliant. The compliant group (control group in this study) had all recommended periodontal therapy including surgeries. In addition, the group received all their periodontal maintenance therapies. The non-compliant group was further divided into two groups: those who did not follow through with their initial treatment recommendations (including SRP with/without periodontal surgery) and those who had some but not the entire course of recommended therapy. In addition, a prerequisite to be included in this study was that all patients had an exhaustive amount of clinical data collected twice: at their initial examination and at least 12 months afterwards.

The following information was collected on all teeth: prognosis (good, fair, poor, or hopeless), pocket depths, mobilities, and what sort of treatment they received, including root planing, bite adjustment, surgery, bone grafts, and soft tissue grafts. Tooth prognosis was based on projected treatment outcomes:

1. Good prognosis = retained in function with little or no treatment.
2. Fair prognosis = retained in function after treatment completed.
3. Poor prognosis = even with treatment, tooth would be lost in 1-2 years.
4. Hopeless prognosis = tooth should be removed during the course of treatment.

Patients. Ninety-one (91) patients qualified for this study. While periodontal surgery was recommended for each of them, only 41 completed their treatment plans and actually had the surgery. They became the surgical treatment group.

Twenty (20) patients consented only to the non-surgical phase of their treatment plan, deciding (for themselves) not to follow through with surgical recommendations. These patients constituted the non-surgical treatment group.

Thirty (30) patients refused any treatment at all, but consented to a comprehensive examination at least one-year after they were initially examined. These patients became the non-treated group.

Results. Put simply, both the non-treated and non-surgically treated groups fared worse than the surgical treatment group. For example, the overall periodontal status improved 82% for the surgically treated group, but only 13% for all others. Individual tooth prognoses improved 48% in the surgically treated group, but only 3% in the non-surgical group and 18% in the untreated group. Similar magnitudes of improvement were noted with tooth mobilities as well as progress bone loss of between the roots of molars (furcation problems).

It is important to note that all surgically treated patients were treated on an average of 8.8 (+4.6) years while the non-surgical patients were treated an average of 5.9 (+3.8) years and the untreated patients had their initial exam separated from their final evaluation by an average of 3.2 (+2.4) years.

The significance of these time frames is telling. The surgically treated patients not only received all recommended treatment, but they received ongoing periodontal maintenance therapy. This maximized and maintained treatment benefits. On the other hand, the non-surgical patients were treated for a shorter time, with inconsistent maintenance treatments, and the untreated patients received no benefit of periodontal care.

There were glaring differences in the results for the different groups in this study. For example, mobilities increased four-fold in both the untreated and non-surgically treated groups when compared to the surgically treated group. When existing furcation problems were analyzed, the non-surgically treated group worsened by a factor of 80 times; the untreated group worsened by more than 100 times. In both the untreated and non-surgically treated group, pocket depths worsened, while they improved in the surgically treated group.

Conclusions. While the summary presented here is by no means complete, this study provides compelling data that supports what clinicians have known for many years:

1. 1. Untreated periodontal disease worsens over time
2. Non-surgically treated periodontal disease worsens over time when associated with a lack of compliance with periodic maintenance care.
3. Surgically treated teeth demonstrated an improved periodontal status over time.

*Harrel S.K. and Nunn M.E.: Longitudinal comparison of the periodontal status of patients with moderate to severe periodontal disease receiving no treatment, non-surgical treatment, and surgical treatment utilizing individual sites for analysis. J Perio 72:1509-1519, 2001.

Pregnancy + diabetes + gum disease = trouble*

Pregnancy and gums have always been inextricably linked together. It's common knowledge that gums often enlarge (swell) when a woman becomes pregnant, and it's been documented that teeth may become loose during pregnancy, too. Both conditions tend to regress once the baby is born. We also know that hormonal changes can stimulate the growth of benign tumors - called "pregnancy tumors" - that usually disappear by themselves post-partum. In some cases, these "tumors" need to be surgically removed. Collectively, these common examples demonstrate how the hormonal changes of pregnancy affect the mother-to-be's gums. But what about the reverse? Can gum problems affect the developing fetus?

Unfortunately, this is a real concern. Offenbacher et al (J Perio 67:1103-1113, 1997) described how periodontal infections are a possible risk factor for pre-term low birth weight. And while we always knew that diabetes is a risk factor for periodontal disease, a recent study examined how type-1 diabetes affected the periodontal status of pregnant women…with important results.

Methods. Thirty-three (33) patients were studied with a range from 20-39 weeks of gestation. Thirteen patients (13) had type-1 diabetes defined as having an abnormal fasting plasma glucose (3-hour glucose tolerance test) of >105mg/dl or two of the values at the 1, 2, or 3 hour intervals that were > than 190mg/dl, 165 mg/dl, or 145mg/dl respectively. The mean age range for the diabetics was 28.5 + 7.1 years and for the non-diabetics, it was 27.0 + 7.3 years.

Each patient received a thorough periodontal examination, including pocket probings at six sites, plaque index, gingival index, attachment levels, etc.

Results. The plaque and gingival indexes for diabetics were significantly higher than in non-diabetics. Diabetics also had more sites with deeper pockets.

Discussion. When all parameters were considered, pregnant diabetics had more gingival inflammation and greater periodontal defects as compared to non-diabetics. Even after the plaque was reduced in the diabetics, they still exhibited more inflammation, deeper pockets, and more attachment loss.

Gestational diabetes bears its own risks. Patients are more susceptible to infections, which can affect glucose control. Respiratory and urinary infections are associated with hyperglycemia, which can lead to episodes of diabetic ketoacidosis. This can pose a serious risk to both mother and fetus. Poor diabetic control can also affect preeclampsia/eclampsia, larger babies requiring Caesarean delivery, increased risk of perinatal death, respiratory distress, pre-term delivery, anomalies, neonatal morbidity, and in the end, a predisposition to continuing diabetes after delivery.

While we know diabetes comes with its own set of problems, how does it affect periodontal health? It appears that diabetics have an amplified cytokine response that results in greater periodontal inflammation. This, in turn, makes it more difficult to control blood glucose. Each process - diabetes and periodontitis - feeds off the other in a spiraling deterioration. However, if periodontal treatment can reduce the bacterial load, cytokine production would diminish, thereby reducing insulin resistance. Treating the gums in a gestational diabetic (and in all diabetics) creates a win: win situation.

Conclusions. How can we use this information? For starters, it is important that all dentists and physicians understand the relationship pregnancy has to a woman's periodontal status. Good dental health should become part of all prenatal counseling, and once gestational diabetes is diagnosed, proper dental care (including appropriate antibiotic therapy) should be initiated.

*Guthmiller JM, Hassebroek-Johnson JR, Weenig DR, Johnson GK, Kirchner HL, Kohout FJ, and Hunter SK: Periodontal disease in pregnancy complicated by type-1 diabetes mellitus. J Perio 72:1485-1490. 2001.

Minocycline microspheres = Micro-results? Perhaps not.

While it is known and accepted that periodontal treatment needs to not only be definitive in order to achieve beneficial long-term results (read the first article in this newsletter), it must also be on-going for the rest of a person's life. Even with the best of care, some patients experience a slippage in their periodontal condition - which is possible and may be expected in chronic conditions - that requires more care. Through the years, a host of materials have been introduced claiming to enhance the results of SRP. Chlorhexidine, PerioChips, and Periostat, are recent examples of such products; each has their place (along with their limited benefits) in a therapist's armamentarium. The latest product to reach us that promises to augment the benefits of SRP is Arestin®. Arestin® is microencapsulated spheres of the antibiotic minocycline.

Methods. Nearly two dozen researchers from 18 dental schools participated in a study that treated 748 patients with moderate to advanced periodontitis. Divided into 3 groups, one group only received SRP, another received SRP along with a placebo, and the third group received SRP along with minocycline microspheres.

Results. Minocycline microspheres plus SRP won hands-down. This was dramatically demonstrated in pockets >6mm (though there were too few studied to be statistically significant), which shrunk an average of 2mm when compared to the SRP group alone or the SRP group with the placebo. Odds ratios were calculated that SRP + minocycline microspheres would reduce pockets > 6mm to <5mm nearly three-fold when compared to the other two groups. Bleeding on probing was also reduced more in the SRP + minocycline microsphere group than in the other two groups. In this study, non-smokers showed a greater improvement than smokers.

Conclusions. Given the limitations of SRP, delivery of microencapsulated spheres of minocycline needs to be considered as part of an "optimum non-surgical therapeutic regimen."*

*Williams RC et al: Treatment of periodontitis by local administration of minocycline microspheres: a controlled trial. J Perio 72:1535-1544, 2001.

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