A NEW LOOK AT PERIODONTAL THERAPY
TRUTH OR CONSEQUENCES?
Everyone goes to their dental office today to protect their "smile". That "cleaning" every six months was a
small sacrifice for "fresh breath" and "white teeth". Why six months? Because the Pepsodent Tooth Paste
marketing campaign picked six-month intervals to promote their product in the 1930's. There was no
scientific basis, but it "seemed to be reasonable". That empirical practice continues unchallenged in some
offices to this day. In our office, we stress evidence-based dentistry. We want our patients to know the
scientific facts so they can understand their disease and understand the factors that make them susceptible.
This will give them an accurate mental model of the disease to guide their decisions outside our office.
Periodontal disease does not just go away. Once you have it, it's a lifelong problem you need to manage
365 days per year.
FLOSS OR DIE!!
Patients often hear oral hygiene instruction and anxiously process it as the expected background noise during a "cleaning". Our professional admonitions were repetitively focused on that "smile and breath" over the years but now we know there is more to tell.
Periodontal disease is:
- modestly associated with atherosclerosis (hardening of the arteries), myocardial infarctions (heart attacks) and cardiovascular disease. (7.9x)
- It is a risk factor for pre-term and low birth weight babies. (18%)
Present periodontal care in nursing home environments has reduced the incidence of pneumonia by 40%. A major insurance company that provided dental and medical coverage is presently funding a study to investigate why patients who received dental cleanings had substantial savings in cardiac care expenditures.
It's not just about teeth anymore. Your health and healthcare dollars are at stake.
Our physician colleagues recognize high-risk patients who are pregnant, have diabetes, coronary artery disease or CVS (stroke) will lower their risk if they seek dental care early. The insurance companies agree when the bean counters report. Stay abreast with the developments.
IT'S NOT JUST ABOUT "BAD BUGS"
Some patients have a lot of plaque and no gum disease. Other patients have minimal plaque and extreme outbreaks of gum disease. The odds ratio of a smoker having periodontal lesions is 5.3 to 1 for a nonsmoker. The odds ratio of greater disease in a diabetic patient is 2.8 to 1. Bruxers (tooth grinders) have faster progressing advanced disease than those with good bite habits do. Habits need to be controlled and medical issues need to be addressed.
NEVER IN MY HOUSE!
Family organization and behavior have been key to good oral health habits. Who is the teacher? Who is the role model? Who is the enforcer? What are the "expectations"? Social training is only a part. Periodontal bacteria are contagious. Spouses transmit the bacteria between each other. Couples including one with an advanced disease patient have similar bacteria in their mouth. Spouses of advanced periodontal patients have worse periodontal health than the spouses of healthy subjects. Bugs from parents are found in children and amongst siblings. Periodontal disease aggregates in families.
"BUT I BRUSH AND FLOSS"
Successful brushing and flossing represent an ever-necessary life skill for patients. Skill and motivation must co-exist, but does "perfect plaque removal" ever occur even then? Unfortunately the bad bacteria that cause disease in the gums are on the teeth, tongue in your saliva and even the tonsil areas. After brushing and flossing they just return to reform as new organized disease machines. They want to survive too. They pick the best and most protected areas to live and breed in the areas a patient misses routinely. A brush and floss work well in healthy mouths because the tooth crown is smooth and convex above healthy gum attachment. Unfortunately with disease and recession the newly exposed roots are rough and concave. Disease reduces the efficiency of brushing and flossing. Patient care is directed at breaking down the disease machine before the bacteria can regroup and mount another attack. The hygienist is the coach providing an analysis of the problem and a strategy with the available skills. The disease focuses its attacks at specific vulnerable sites with random opportunistic behavior. These sites are the "pockets" that are measured to record and map the disease. This occurs daily.
GIVE ME ANTIBIOTICS TOO?
Antibiotics will work against the gum disease bacteria for awhile, then it can lose its effectiveness (immunity) or you develop other problems associated with killing of necessary bacteria in other parts of your body. (diarrhea, nausea, etc.) Antibiotics are very bug specific and there are extensive types of bugs involved with the disease. Pills dilute the antibiotic over your entire bloodstream and would only allow a small dose to actually reach the needy "pocket" of concern.
WHO SAID INFECTION?
Traditionally we have described gum disease as a slow infection with occasional abscesses or flare-ups. Gingivitis is when the surface of the gums gets swollen and sore from bacterial contact. Remove the plaque and gingivitis disappears. Periodontal disease is when the attachment of the tooth to the bone is destroyed. Once it is destroyed, removing the plaque does not restore the permanent damage. It is not reversible. Pockets remain and are available to re-collect bacteria. It is not simply the presence of the various bacteria types that cause the disease, it is the organization they undergo when they form the disease engine or biofilm. The "biofilm" forms in the "pocket" between the teeth near the bone protected by overlying swollen gum tissue. It takes 90 days to become dangerous if left alone to mature. Toxins by the bacteria are produced that irritate the body and stimulate our immune system to protect us….just like a bee sting. The first few stings and nothing happens other than redness, swelling and soreness. But after chronic exposure to the biofilm, our body can launch an inflammatory counter attack that is self-destructive. Our own body launches an over zealous reaction to the bone and gums that is like the life threatening bee sting that causes anaphylactic in the unlucky victim. At the point that gingivitis becomes periodontal disease, infectious disease has converted to an inflammatory disease. Your body's response is now independent to the number of bacteria (as opposed to an infection). One stimulation is all that is required to pull the trigger and get the same destructive response.
WHY CAN'T I REVERSE PERIODONTAL DISEASE
The more occurrences of biofilms forming in your "periodontal pockets" the more likely your body is to form "memory cells". The memory cells that develop in your jaws will trigger your body's over-reaction to the biofilm if exposed again. Some people are more sensitive than others in the immune reactions based on their genetic background. Over 50% of the factors relating to the periodontal disease are related to how the genetics of your immune system responds to the assaults of the biofilm mediated by he memory cells. We cannot regenerate gum, bone, and tooth attachment that are lost. We can only treat the biofilm.
YOU CAN REVERSE GINGIVITIS!
Gum infections (gingivitis) on the surface start after 3 days of poor oral hygiene. Three days after a professional cleaning, the disease is back if you don't remove the plaque on the tooth surfaces at home. Poor oral hygiene means that if you schedule care every 6 months, you are exposed to biofilms for 117 days in the zones that you have "missed". The exposure sensitizes your body to create the deeper periodontal disease. Minimizing your exposure is the name of the game. You can't win if you don't understand the objectives. "Gingivitis progresses to "periodontitis".
THE HYGIENIST IS YOUR COACH
Some patients seek exams yearly because they have a "self protective heredity" for decay or gum disease. Some patients seek care every 6 months because they have "decay issues". Patients with gum disease are "retreated" every 3 months to monitor their oral hygiene effectiveness and disrupt biofilms they can't access at home. Our Hygienist and Doctor will provide you with a plan to address your personal health issues. Your hygiene coach will help you perfect and implement your strategy and self-reliance. You need to understand the "play book".
WHERE'S THE SCOREBOARD?
Strategy changes with every play in a game. You need to know the score to help you decide on each move… and the success of each previous move. Probing is measuring "the pockets in the bone" to assess attacking disease. Know your pocket depths in "your risk areas" to apply a defense. Plaque scores let you rank how well you are doing at each visit. We will be glad to give you our opinion to your predisposition of future gum problems based on your "risk factors". Age, medical history, and social history including smoking are going to change your odds. "Scoring" helps you manage your problem efficiently and minimize your healthcare expenses.
YOU DON'T WIN WITH LUCK ALONE!
Skill is a paramount in daily plaque control. Some got it…and some don't. The hygiene coach helps with your oral hygiene but she does more. Scaling and root planing "disrupts" the biofilms. We flag all the active diseased pockets, then direct our energy at disrupting the developing biofilms within. This is called "re-care", not a cosmetic cleaning. Each pocket gets a red flag and needs to have the biofilm disrupted every 90 days. Holes in the bone around the teeth need care like "fillings" that repair the holes from decay. Know their locations. We will give you a map! Focus your talent on your needs.
IF PROBLEMS CAN'T BE CONTROLLED WHAT WILL I DO?
It's time for "bump up the defense" if the disease cannot be beaten with oral hygiene and simple biofilm control techniques. The doctor may refer you to a periodontist for surgery. Less involved strategies can be undertaken in our office. Localized antibiotic applications and minor pocket elimination are additional levels of care if you control the biofilm and your risk factors. We can't change your susceptibility because we can't change your genetics. But we can give you a strong defense.
WHY DO YOU DO THAT?
Scaling and Root Planning:
- It breaks up the biofilms while we smooth the root. It makes daily cleaning easier if we remove any roughness or deposits. We do it every 3 months because it takes biofilms 90 days to form and become active.
Curettage:
- We remove diseased tissue that harbors biofilms removing memory cells that are in the active site.
Surgery:
- We improve your daily access for preventing biofims at home. We remove the active disease sites and the memory cells in the active and surrounding tissue.
GIVE ME TREATMENT OR GIVE ME DEATH!
Treatment can take many forms but to be successful it must be patient focused. The patient that is motivated and informed always has a better prognosis. Our approach is to provide evidence-based care that is cost effective and minimally invasive. Aggressive surgical care will relapse if not supported by basic oral hygiene and non-surgical procedures. So we'll keep it simple. Do it for yourself, not because you are told to. Know the rational first. Then follow the protocol to full compliance. Full compliance allows us to match individual progress with scientific studies. Non-compliance is a waste of your healthcare dollar. So just tell us what you want in a note and we promise no lecture. If we can work together, we will offer more options or refer you to a specialist if necessary or desirable. Care can be provided to the teeth on many levels but it is important to your general health as well.
WHERE DO WE START?
Measuring pockets with a probe and recording their depths is essentially a map of your gum disease. Unfortunately, it is a measure of destruction and not current activity. Bleeding or puss are signs that pockets are active disease sites, but only on the day they are observed. Pockets that do not bleed can be thought of as inactive "scars" but may convert into sites for new biofilms to reform in the future. We need to map the disease initially, then each year re-map and re-evaluate how we have managed the periodontal problem.
