The Board of Trustees (AAP) was recently asked by Samuel Low to comment on a recent “roundtable discussion” published in the March 2010 issue of “Inside Dentistry” held by Robert Levine, DDS, Michael Rethman, DDS and Francis Serio DMD, MS, MBA. My comments are as follows:
I find the replies in “Inside Dentistry” of all 3 panelists to the question “Whatever happened to treating periodontal disease?”, interesting. For the most part, I agree with all 3 in their assessment of the goals of periodontal treatment. The one I think is closest to the mark regarding actions that our Board may consider is Dr. Serio.
But taking it one at a time and looking at the questions through our “Strategic Plan” (SP) glasses, I would say the following:
(1) All agree that bleeding on probing (BOP) is our best clinical tool to assess inflammation. However, as we all know when clinically measured (BOP) can be subjective. I’ve seen charts of patients that GPs did not refer but presented to my office on their own or on the advice of a friend or family member and there is no indication of any BOP and the probing depths (PD) were much more shallow than my examination indicated.
I agree with Dr. Levine about the systemic link but feel that the success and limitations of scaling and root planning (SRP) PDs > 5mm has been well documented (see Waerhaug, Stambaugh, etc.). However, even patients with these inaccessible PDs > 5mm are not being referred to periodontists today. I feel risk assessment must be stressed in our SP and we must start the Diabetes-Periodontal Study asap. The results of that study has the potential to bring in a good number of new patients and referrals to our membership (best evidence our SP is working). Personally, I feel the local use of antibiotics (Atridox/Arestin) is very limited (see Greenstein JP) and we should not jump on that bandwagon. Oftentimes, these local antibiotics act as a “profit center” (both for the company manufacturing the product and GP) and do little to alter the disease progression. Shotgun approaches to full mouth disinfection are good but we ought to be careful with repeated doses of systemic antibiotics (resistant strains, host tolerance, etc.). I would save this approach for aggressive forms of periodontitis (again the need for Risk Assessment and Proper Diagnosis). I think our SP should include an individualized approach to the diseases based on risk assessment, type of disease, patient compliance, the ability to access the biofilms, plus the need for regenerative or auxillary procedures (ie orthodontics, endodontics, etc.).
As for Dr. Rethman’s comments, I feel he is correct in his observations on the attractiveness of implants for “Patients seeking a problem-free, fully functional, attractive, and pain-free oral complex.” But we should stress in our (SP) that implants are certainly not problem free and carry their own set of risks. How many periodontal procedures result in partial or full paresthesia compared to these which include implant placement? Dr. Rethman’s discussion of OPT and PTMPs assumes control of the key factor – Patient Compliance. And as Wilson and others have shown, we are fortunate when that percentage approaches the 19% mark. I think we must come out strongly against “Miracle Therapies”. Unfortunately, the “Keyes Technique”, “Perio Protect” and other types of miracle treatments take years to prove lack of effectiveness compared to time tested evidence based approaches, and during those years our membership suffers from a decrease in patients seeking proven care. When our specialty criticizes these “simplified miracle treatments”, we are labeled as self serving. So we have to confront that conundrum. Minimally invasive surgery using the microscope maybe the way of the future but to date has not been proven in long term RCT. Those who have tried the endoscope (and I have) find that the instruments and skills required are rarely as attainable as is the microscope.
As I stated previously, I think Dr. Serio is on the right track in his identifying the problems facing the AAP and our SP. Many dentists see “Soft tissue management” programs as revenue centers and will go no further to monitor their results which is what is necessary for the OPT that Dr. Rethman writes about. Moreover, using soft tissue management as an endpoint without monitoring does not result in patient referrals. It is here where our “Outreach Program” and PR efforts will be tested. I have several ideas that may be effective in breaking through but I think the entire board has to share their thoughts with each other and the PR firm representing us. Our “Guidelines” for referral frightened many GPs, especially the AGD. I feel a more educated and informational approach might have better results. Our PR firm must stress the systemic perio link, risk assessment, the limits of soft tissue management programs and treatment tailored to the needs of the patient. Again, none of the 3 dentists interviewed touched on the necessity of the GP and restorative dentist to accurately access the need for referral. Moreover, some of our most valuable services (soft tissue grafting, bone grafting, and other regenerative procedures) were not even mentioned. There’s a very large gap between SRP (soft tissue management) and extraction and implants. Unfortunately, allowing periodontal disease to progress from the SRP phase performed by the GP to extraction/implantation present our membership with little chance to perform the treatments Drs. Levine and Rethman write about. I feel that all of these items should be discussed at our next AAP Board of Trustees meeting relative to strategic planning with the public relations firm that the Board has employing.
