Dr. Edward F. Gonsky, Jr. D.M.D, M.S.D. Periodontist

Effective Periodontal Treatment - The Scientific Basis

Effective Periodontal Treatment evolved from conservatively oriented philosophies originating in schools and among practitioners in New York, Indiana, and especially Michigan.

The Michigan philosophy remains valid and compelling to this day:

“In general terms we are philosophically committed to a search for methods of prevention and treatment in which maximum benefits may be gained by minimum patient discomfort as well as expenditure of time and money. Our search is for simple procedures and for minimal removal of the patient’s hard and soft tissues, as well as minimal insertion of prosthetic appliances. However, beyond all we are committed to doing everything within our power to maintain the natural dentition in health and comfortable function throughout the lifetime of the individual.”

Our practice supports these goals. We advocate precise treatment that maximizes our patient’s healing abilities. Our patient heals. We can only assist. It’s a treatment partnership. Research studies support these conservatively oriented philosophies. The following ideas have been drawn from respected scientific literature:

Looking at the patient...

The aim of periodontal therapy is to make the tooth biologically acceptable to the surrounding periodontal tissues. Since there is no one-time cure for most periodontal diseases, long-term favorable results are determined by mutual cooperation between patients and professional personnel that goes beyond mere technical skill.

The average clinician is usually far too pessimistic regarding the prognosis for teeth with periodontal disease...It also appears that the potential for healing and maintenance of health and function of teeth with very deep periodontal pockets is much better than previously assumed.

Although many aspects of periodontal inflammation appear to be self-destructive, characterized by collagenolysis and fiber degeneration, the inflammatory process is protective in an attempt to contain the injurious agents, and the inflamed tissues do not have to be surgically removed for improved healing.

Most of the pathogenic organisms live on the tooth surface and in the crevice or pocket, but some may also be present within the tissues of the pocket wall. However, there is ample evidence that the elimination of the surface organisms, without any specific antimicrobial therapy will lead to healing of the periodontal lesion.

When confronted with a biological phenomenon (such as a periodontal pocket), try to envision it as an adaptation. An adaptation is some sort of biological machinery or process shaped by natural selection to help solve one or more problems faced by the organism. Infection is not a happenstance encounter with another organism, but an arms race between host and parasite, with extraordinary elaborations of weapons, strategies, defenses and counterdefenses...a contest between two organisms with divergent interests. Natural selection has shaped the body’s response to invading microbes. Standard disease treatments may interfere with these defenses.

Looking at debris on the tooth...

Elimination of bacterial plaque and accretions is vital to the success of all periodontal therapy, and in fact constitutes the basic therapy for all patients with periodontal disease.

For today and for the future, calculus within the pocket must always be removed...the critical factor in comparing surgical and non-surgical therapy is complete debridement of the root surface, and not the technique by which it is achieved.

All of the teeth lost (because of periodontal reasons) had residual old calculus and/or inaccessible furcations. Both professional and personal oral hygiene proved inadequate to stop the progress of periodontitis when residual infection was left on the root surfaces. The common cause of loss of teeth after treatment is residual calculus and plaque associated with furcations.

Any systemic or local disorder that may impair normal body responses to irritants should also be recognized and corrected, if possible. Fortunately, with rigid control of bacterial irritation, periodontal disease can be treated successfully even if unfavorable systemic factors persist.

The great challenge in periodontal therapy is to eliminate the surface irritants and to correct the conditioning factors that may allow the opportunistic infections to return.

In favor of conservative treatment...

Although the prognosis is fairly similar following various modalities of periodontal therapy, the better postoperative attachment levels, esthetics, and comfort following conservative surgery... favor selection of those modalities over the more radical surgical pocket elimination procedures.

Periodontal pockets from 4 to 12 mm deep will, on average, respond favorably to periodontal therapy. The prognosis is as good for deep as for shallow pockets, provided the teeth have adequate support for function.

The ultimate long-term prognosis is poor for teeth with deep furcation involvement. However, such teeth may be asymptomatic and maintained in good function for an indeterminable number of years, provided that the root surfaces in the furcation can be instrumented properly. If all teeth with advanced periodontitis or furcation involvement are extracted prior to the periodontal treatment, the prognosis for the remaining teeth is usually good, with or without treatment.

While some therapists can meticulously root plane teeth despite deep pockets, it needs to be emphasized that root planing is one of the most demanding disciplines in dentistry.

The case against aggressive surgery...

In the past, the main objectives of periodontal surgery were: 1) to eliminate pockets deeper than 3 mm, and 2) to provide optimal contour of the alveolar process and the gingiva. These two objectives have proven to be of no value for the future maintenance of the teeth in health and normal function. They complicate periodontal treatment with unfavorable root exposure and discomfort, and should not be considered as viable objectives anymore. Periodontal surgery in itself is valueless unless it is followed by adequate plaque control.

Surgical pocket elimination is not essential for a good prognosis of periodontal treatment.

Induced gingival recession following gingivectomy and apically positioned flaps does not have a favorable effect on the maintenance of attachment for the teeth.

The case against antibiotics...

Bacterial pathogens may complete a million cycles of fission within the lifetime of one human host, and there may be more pathogens in one individual than the earth’s human population. Even in one host, a pathogen can be expected to produce highly improbable mutatons many times and to evolve significantly in response to even minute selection forces...some bacteria rapidly acquire high levels of antibiotic resistance. Resistant strains can locally replace susceptible ones in a few weeks.

Many infectious diseases, once curable by antibiotics, are reappearing in forms that are difficult...and sometimes impossible...to treat with conventional drugs...The emergence of drug-resistant microbes is epidemic. If measures are not taken now to slow their spread, the day of untreatable common infections may return. Each time a microbe is exposed to an antibiotic, there’s a chance a resistant strain will emerge. Physicians need to break the habit of routinely prescribing antibiotics, and especially broad-spectrum versions, when they’re not needed.

In support of professional maintenance...

Frequency of recall for professional cleaning of the teeth may have a decisive effect on the prognosis, and apparently is much more important then the modality of initial surgical treatment. In general, in patients with advanced periodontitis, good results have been reported for recall intervals of from 2 weeks to 3 months, and poor results for 6 to 12 month intervals. The pockets will be significantly reduced in depth initially and, with prophylaxis at least every 3 months, remain reduced over a long period of time.

Regeneration and interfering with healing...

Ability to regenerate varies according to the normal likelihood of the usefulness of such capabilities. The risk of cancer must also limit the capacity for tissue regeneration, if increased ability to regenerate makes cell division less controllable. Mechanisms for the restraint of maladaptive growth confine regeneration to those tissues where they are most needed.

Medical intervention directed against the pathogen’s adaptations will usually be helpful, while those that disrupt the host’s defenses should be more cautiously applied.