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Periodontal pockets and attachment levels
L
e tte r s to
the
E
d it o r
U nfortunately, insurance com panies are u n w illin g to include a factual statem ent on their “ E x p la n atio n of B enefit” forms, w hich w ould explain to the p atien t that the difference between the fee charged and the benefit paid is the result of the lim ita tions co n tained in the dental benefit p lan itself. T h e C ouncil on D ental Care Program s is stu d y ing this m atter and w ill be recom m ending guidelines for calculating fees. U n til th at tim e, however, the council has d ev elo p ed a p a tie n t le tte r fo r use by members. By educating p atients about this rath er unsavory insurance com pany prac tice, the council hopes to prevent un n ec essary h arm to the d o c to r/p a tie n t rela tionship. A copy of this letter is available from the council. MAR YE C. FELDM AN SECRETA RY C O U N C IL O N D E N T A L CARE PR O G R A M S
C y to x in s and d en tal a n o m a lies □ D rs. P a tr ic ia E. V an S to ry -L ew is, M ichael Roberts, an d J o h n K lippel are to be com m ended on their interesting case report, “ O ral effects of steroid therapy in a p atien t w ith systemic lu p u s erythem ato sus” (July). In this report, the authors concluded that the observed anom alies in dental developm ent were the result of the ad m in istratio n of systemic steroids. W hat the authors failed to discuss was the role oth er pharm acologic agents m ig h t have co ntributed to these observations. T h e p atien t was reported receiving the cytoxins—cyclophospham ide and azathiop rin e—at ab o u t the same tim e steroid therapy was initiated. T h e early histom orphological effect of a single dose of cyclophospham ide on rat incisors was described by K oppang1 and A datia.2 K oppang suggested that the p re odontoblasts an d their precursors were the cells m ost affected; A datia found th a t the m ost susceptible cells were the undiffer entiated m esenchym al cells in the pro lif e r a tin g zone of th e p u lp . N o rd lin e r 3 show ed th a t the effects of cyclophospha m ide in new born rats were dose depen dent an d that the effects produced a range of grow th m alform ations, including n o n eru p tio n of the incisors. V ahlsing and 388 ■ JADA, Vol. 115, September 1987
others4 described the long-term effects of a single dose of cyclophospham ide on rats as being “broken incisors,” elongation of teeth, m issing teeth, an d supernum erary teeth. T h e study by Reade and Roberts5 recon firm ed these findings. T hey explained the broken teeth observed by V ah lsin g as being caused by the calcific rep air that occurred between the pre- an d postcyclo phospham ide adm inistration of the tooth structure. T h is callous form ation predis posed these teeth to fracture w hen sub jected to n o rm al m asticatory stresses. Absence of teeth was the result of com plete cessation of tooth form ation or the form ation of an abnorm al toothlike mass that did n o t em erge in to the m o u th an d could be detected only radiographically. E longation of incisors occurred when the norm al functional relatio n sh ip between the opp o sin g incisors was lost because of a distortion of their form, thus interfering w ith norm al wear. Studies by o u r g ro u p and by Rosenberg an d others6 of children receiving chem o th erap y alo n e for acute ly m p h o b lastic leukem ia confirm th a t these agents can adversely affect d en tal d ev elo p m en t in hum ans. T hese anom alies include short ened roots, deform ed roots an d crowns, and arrested tooth development.
tion is not justifiable (“ Surgical p eriodon tal pocket elim in atio n : still a justifiable objective?” January). T h e two lo n g ju n c tio n a l ep ith eliu m an im al studies in question served to add som e in terestin g histological su p p o rt to the sim ilar conclusions of h u m an clinical studies. T h e best argum ents against su r gical pocket elim in atio n are the collective fin d in g s of q u a lity lo n g -te rm c lin ic a l studies, several of w hich are referenced in Dr. R am fjo rd ’s article. T hese studies con clude th a t in itia l choice of surgical treat m ent m odality does n ot ap p ear to be a significant factor in long-term m ain te nance of attach m en t levels. A long ju n c tional ep ith elial adhesion, know n to form consistently after treatm ent of h u m an and an im al root surfaces, was found in these clinical studies to be adequate for the p ro tective task of preventing further attach m ent loss. T h e difficulty of d u p licatin g the “p ro gressive n a tu re ” of periodontal disease in an im al studies was m entioned as a p ro b lem. Also, m any questions are still u n answered concern in g the epidem iology and the progressive nature of periodontal diseases in hum ans. T h e chronic lesions of ad u lt p erio d o n titis may n o t necessarily be “progressive,” and may n ot even be a m ajor cause of to o th loss.1 W ith o u t a great or im m ediate threat of tooth loss in A N D REW L. SO N IS, DMD T H E C H IL D R E N 'S H O S P IT A L m any cases from chronic ad u lt p erio d o n B O STO N titis, and w ith the availability of a variety of successful conservative surgical and 1. K oppang, H.S. H istom o rp h o lo g ical investiga n o nsurgical alternatives having regenera tio n s o n the effect of cyclophospham ide o n d e n tin o genesis o f the ra t incisor. Scand J D ent Res 81:383, tive p o ten tial, intervention w ith extensive 1973. resective pocket elim ination surgery seems 2. A datia, A.K. T h e effects of cyclophospham ide on even m ore difficult for the p atien t and o dontogenesis in the rat. A rch O ral Biol 20:141, 1975. dentist to justify w hen long-term m ain te 3. N o rd lin er, H . M alform ations in new born rats nance of the d en titio n is the goal. treated w ith a single dose of cyclophospham ide. Acta Soc Med U ps 76:97, 1971. T h e treatm en t of chronic ad u lt p eri 4. V ah lsin g , H .L ., and others. D ental a b n o rm a li od o n titis has been influenced by m uch of ties in rats after a single large dose of c yclophospha the research literature referenced in Dr. mide. C ancer Res 35:199, 1975. R am fjo rd ’s article. Periodontics has p ro 5. Reade, P.C ., an d R oberts, M .L. Som e long-term effects of cy clophospham ide o n the grow th of rat gressed from an era characterized by m ost incisor teeth. A rch O ral Biol 23:1001, 1978. ly resective pocket elim ination techniques 6. R osenberg, S., a n d others. A ltered dental ro o t (such as gingivectomy and osteotomy) into developm ent in long-term survivors of pediatric acute an era where pocket reduction techniques, lym phocytic leukem ia. C ancer 9:1640, 1987. designed to conserve an d regenerate p e ri P erio d o n ta l p ock ets and od o n tal tissues, are com m onplace. Some attach m en t levels p ro m is in g regenerative tech n iq u es use various g raftin g m aterials, chem otherapy, □ In reference to the letter to the editor, an d ep ith elial exclusion methods, am ong “ D isputed pocket e lim in a tio n ” from Drs. others, to com plem ent the fundam ental M ark T h o m a s a n d W illia m M o rg a n treatm ent of tho ro u g h root debridem ent (July), it is en couraging to see the im p o r and reg u lar p laq u e control. tant issue of surgical pocket elim in atio n R O B E R T H. B EA U M O N T , DMD, MSD G O L D SB O R O , N C continue to be presented and debated. It is interesting th a t the au th o rs of the letter 1. B ailit, H .L ., an d others. Is pe rio d o n ta l disease “strongly d isp u te” Dr. S igurd R am fjord’s the prim ary cause o f tooth extraction in adults? JADA conclusion th a t surgical pocket elim in a 114(l):40-45, 1987.
e tte r s to
the
E
d it o r
U nfortunately, insurance com panies are u n w illin g to include a factual statem ent on their “ E x p la n atio n of B enefit” forms, w hich w ould explain to the p atien t that the difference between the fee charged and the benefit paid is the result of the lim ita tions co n tained in the dental benefit p lan itself. T h e C ouncil on D ental Care Program s is stu d y ing this m atter and w ill be recom m ending guidelines for calculating fees. U n til th at tim e, however, the council has d ev elo p ed a p a tie n t le tte r fo r use by members. By educating p atients about this rath er unsavory insurance com pany prac tice, the council hopes to prevent un n ec essary h arm to the d o c to r/p a tie n t rela tionship. A copy of this letter is available from the council. MAR YE C. FELDM AN SECRETA RY C O U N C IL O N D E N T A L CARE PR O G R A M S
C y to x in s and d en tal a n o m a lies □ D rs. P a tr ic ia E. V an S to ry -L ew is, M ichael Roberts, an d J o h n K lippel are to be com m ended on their interesting case report, “ O ral effects of steroid therapy in a p atien t w ith systemic lu p u s erythem ato sus” (July). In this report, the authors concluded that the observed anom alies in dental developm ent were the result of the ad m in istratio n of systemic steroids. W hat the authors failed to discuss was the role oth er pharm acologic agents m ig h t have co ntributed to these observations. T h e p atien t was reported receiving the cytoxins—cyclophospham ide and azathiop rin e—at ab o u t the same tim e steroid therapy was initiated. T h e early histom orphological effect of a single dose of cyclophospham ide on rat incisors was described by K oppang1 and A datia.2 K oppang suggested that the p re odontoblasts an d their precursors were the cells m ost affected; A datia found th a t the m ost susceptible cells were the undiffer entiated m esenchym al cells in the pro lif e r a tin g zone of th e p u lp . N o rd lin e r 3 show ed th a t the effects of cyclophospha m ide in new born rats were dose depen dent an d that the effects produced a range of grow th m alform ations, including n o n eru p tio n of the incisors. V ahlsing and 388 ■ JADA, Vol. 115, September 1987
others4 described the long-term effects of a single dose of cyclophospham ide on rats as being “broken incisors,” elongation of teeth, m issing teeth, an d supernum erary teeth. T h e study by Reade and Roberts5 recon firm ed these findings. T hey explained the broken teeth observed by V ah lsin g as being caused by the calcific rep air that occurred between the pre- an d postcyclo phospham ide adm inistration of the tooth structure. T h is callous form ation predis posed these teeth to fracture w hen sub jected to n o rm al m asticatory stresses. Absence of teeth was the result of com plete cessation of tooth form ation or the form ation of an abnorm al toothlike mass that did n o t em erge in to the m o u th an d could be detected only radiographically. E longation of incisors occurred when the norm al functional relatio n sh ip between the opp o sin g incisors was lost because of a distortion of their form, thus interfering w ith norm al wear. Studies by o u r g ro u p and by Rosenberg an d others6 of children receiving chem o th erap y alo n e for acute ly m p h o b lastic leukem ia confirm th a t these agents can adversely affect d en tal d ev elo p m en t in hum ans. T hese anom alies include short ened roots, deform ed roots an d crowns, and arrested tooth development.
tion is not justifiable (“ Surgical p eriodon tal pocket elim in atio n : still a justifiable objective?” January). T h e two lo n g ju n c tio n a l ep ith eliu m an im al studies in question served to add som e in terestin g histological su p p o rt to the sim ilar conclusions of h u m an clinical studies. T h e best argum ents against su r gical pocket elim in atio n are the collective fin d in g s of q u a lity lo n g -te rm c lin ic a l studies, several of w hich are referenced in Dr. R am fjo rd ’s article. T hese studies con clude th a t in itia l choice of surgical treat m ent m odality does n ot ap p ear to be a significant factor in long-term m ain te nance of attach m en t levels. A long ju n c tional ep ith elial adhesion, know n to form consistently after treatm ent of h u m an and an im al root surfaces, was found in these clinical studies to be adequate for the p ro tective task of preventing further attach m ent loss. T h e difficulty of d u p licatin g the “p ro gressive n a tu re ” of periodontal disease in an im al studies was m entioned as a p ro b lem. Also, m any questions are still u n answered concern in g the epidem iology and the progressive nature of periodontal diseases in hum ans. T h e chronic lesions of ad u lt p erio d o n titis may n o t necessarily be “progressive,” and may n ot even be a m ajor cause of to o th loss.1 W ith o u t a great or im m ediate threat of tooth loss in A N D REW L. SO N IS, DMD T H E C H IL D R E N 'S H O S P IT A L m any cases from chronic ad u lt p erio d o n B O STO N titis, and w ith the availability of a variety of successful conservative surgical and 1. K oppang, H.S. H istom o rp h o lo g ical investiga n o nsurgical alternatives having regenera tio n s o n the effect of cyclophospham ide o n d e n tin o genesis o f the ra t incisor. Scand J D ent Res 81:383, tive p o ten tial, intervention w ith extensive 1973. resective pocket elim ination surgery seems 2. A datia, A.K. T h e effects of cyclophospham ide on even m ore difficult for the p atien t and o dontogenesis in the rat. A rch O ral Biol 20:141, 1975. dentist to justify w hen long-term m ain te 3. N o rd lin er, H . M alform ations in new born rats nance of the d en titio n is the goal. treated w ith a single dose of cyclophospham ide. Acta Soc Med U ps 76:97, 1971. T h e treatm en t of chronic ad u lt p eri 4. V ah lsin g , H .L ., and others. D ental a b n o rm a li od o n titis has been influenced by m uch of ties in rats after a single large dose of c yclophospha the research literature referenced in Dr. mide. C ancer Res 35:199, 1975. R am fjo rd ’s article. Periodontics has p ro 5. Reade, P.C ., an d R oberts, M .L. Som e long-term effects of cy clophospham ide o n the grow th of rat gressed from an era characterized by m ost incisor teeth. A rch O ral Biol 23:1001, 1978. ly resective pocket elim ination techniques 6. R osenberg, S., a n d others. A ltered dental ro o t (such as gingivectomy and osteotomy) into developm ent in long-term survivors of pediatric acute an era where pocket reduction techniques, lym phocytic leukem ia. C ancer 9:1640, 1987. designed to conserve an d regenerate p e ri P erio d o n ta l p ock ets and od o n tal tissues, are com m onplace. Some attach m en t levels p ro m is in g regenerative tech n iq u es use various g raftin g m aterials, chem otherapy, □ In reference to the letter to the editor, an d ep ith elial exclusion methods, am ong “ D isputed pocket e lim in a tio n ” from Drs. others, to com plem ent the fundam ental M ark T h o m a s a n d W illia m M o rg a n treatm ent of tho ro u g h root debridem ent (July), it is en couraging to see the im p o r and reg u lar p laq u e control. tant issue of surgical pocket elim in atio n R O B E R T H. B EA U M O N T , DMD, MSD G O L D SB O R O , N C continue to be presented and debated. It is interesting th a t the au th o rs of the letter 1. B ailit, H .L ., an d others. Is pe rio d o n ta l disease “strongly d isp u te” Dr. S igurd R am fjord’s the prim ary cause o f tooth extraction in adults? JADA conclusion th a t surgical pocket elim in a 114(l):40-45, 1987.