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Infection management and periodontists
LETTERS
TO
THE
EDITOR
J A D A devotes th is section to co m m en t by readers o n topics of c u rre n t interest to dentistry. T h e editor reserves th e rig h t to e d it all c o m m u n ic atio n s to fit available space an d requires th a t all letters be typed, double-spaced, an d signed. N o m ore th a n ten references sh o u ld be given w ith each letter. P rin ted c om m u n icatio n s do n o t necessarily reflect the o p in io n o r official policy o f the A ssociation. Y our p a rtic ip a tio n in this section is invited.
Infection managem ent and periodontists □ T h e Emphasis article on “N onsurgical an tib acterial ap p ro a ch es to p erio d o n tal tre a tm e n t” (January) o ffe re d an excellent discussion. T h e m essage th a t these afflic tions re p re se n t infectious diseases is clear. T h e q u estio n o f th e m ost a p p ro p ria te tre a tm e n t m ust, o f necessity, rest with the individual case. T ra d itio n an d prevailing practices lag considerably b eh in d basic a n d even clini cal research. R eluctance to translate new er know ledge into everyday practice is a p re vailing b u rd e n to be overcom e with tim e. I d a re say th a t conventional train in g in periodontics, as in all fields o f clinical care, p erp e tu ate s h alf-tru th s and even m yths w ith o u t critical assessm ent o f m any o f th eir everyday practices in the light o f c u r r e n t research . . . . T h e question is n o t “how m any angels can d an ce on th e head o f a p in ”; ra th e r, how can we apply w h at is broadly know n ab o u t infectious diseases to problem s o f th e m outh? Does it m ake sense to tre a t the gingiva w hen active infection exists 7 mm below th e surface? Does it m ake sense to blam e th e patien ts’ lack o f effective hom e care fo r a chronic progressive infection th a t can n o t be to u ch ed by the m ost consci en tio u s b ru sh in g a n d flossing? Does it m ake sense to tre a t one q u a d ra n t o f the m o u th w hen th e ecosystem o f th e m outh is a unit? Does it m ake sense to plane away at th e cem entum w hen th e organism s and th e ir noxious p ro d u c ts a re superficial, w ater soluble, an d not deeply em b ed d ed in th e ro o t surface? 310 ■ JADA, Vol. 116, March 1988
“Scaling an d ro o t plan in g ” has becom e the shibboleth o f th e p erio d o n tal w arrior, arm e d w ith s h a rp scalers. M o d e rn r e search shows th a t th e toxins are superficial and that rem oval o f cem en tu m is d estru c tive. It prejudices reg e n eratio n o f connec tive tissue attac h m e n t an d b one re g e n e ra tion. A lm ost w ithout challenge, “scaling and root p lan in g ” has been carried along as an essential elem e n t o f treatm en t. Be cause if serves to d is ru p t an d dim inish b ac te ria l co lo n iz a tio n , it is h e lp fu l in treatm ent. T o the ex ten t th a t it results in the rem oval o f all cem en tu m , it is d estru c tive. Connective tissues will n ot readily a t tach to den tin (even w hen p re p a re d with citric acid). A ggressively p lan in g th e root surface strips th e th in layer o f cem entum in far less tim e th a n th e q u o ted “30 m in utes o f ro o t p re p a ra tio n .” D uring th e past 10 years, I have applied general principles o f infection m an ag e m ent to periodontitis. I am sorry to say th a t my m a n a g e m e n t d isco m fits p e r i odontists, yet results in elim ination o f in fection, regro w th o f bone to co rrect verti cal defects, m inim izes tre a tm e n t tim e, avoids excision o f gingiva, avoids d elib er ate ro o t plan in g in a one-stage d eb rid e m ent with th e aid o f systemic antim icrobial m edications effective against anaerobes, an d results in lo n g -term h ealth an d to o th salvage. I apologize fo r discom fiting th e “estab lish m en t” b u t I w o u ld invite o th e rs to evaluate these p ro ce d u re s objectively. I m ust also acknow ledge that being a d e n tist, an o ral an d maxillofacial su rg eo n , an d a physician, I am n o t a card-carrying p eri o d ontist. My p relim in ary resu lts o f 30 cases w ere p ublished in 1982.1 O th e r p rac titioners have su b stan tiated these findings an d 1 have c o n tin u ed to derive g reat satis faction from teach in g dentists an d tre a t ing patients w ith these concepts to th e a d v a n ta g e o f b o th g r o u p s . S o m e tim e s , leeches an d b loodletting are n o t th e best therapy, alth o u g h th ey may be en d o rsed by the highest au th o rity as the stan d ard o f
m edical (dental) practice. N O R M A N T R IE G E R , DM D, MD B R O N X , NY
1. T rieger, N., and Chomenko, A. New con cepts in the treatm ent o f periodontitis. J Oral Maxillofac Surg 40:701-708, 1982.
Thanks for legal advice □ I w ant to th an k atto rn ey s Beverly L. Bailey (“M alpractice an d p erio d o n tal dis ease”) a n d M ary K. L ogan (“Legal im plica tions o f infectious disease in the dental office”) fo r th e ir d ental-legal c o n trib u tions in th e D ecem ber issue. Both au th o rs have ad d re ssed p ertin en t a n d tem poral legal issues a ffe c tin g d e n ta l ca re sta n d ard s. T h e d u e care th a t is legally m an d ated m ay n o t always be perceived by d e n tal caretak ers a n d this legal objectivity may be clouded by subjective an d paternalistic attitu d es o f w hat is p ro p e r an d acceptable care by “d o cto r knows best” testam ents. T h e A D A ’s legal w riters have consis tently a n d accu rately p ro ffe re d salient pap ers fo r o u r d en tal constituency, an d I tru st th a t the ta rg et re a d e r has g arn e re d th e im p o rt fro m these offerings. W e n eed a “fra tern ity ” interaction be tw een atto rn ey s an d h ealth providers to w ork o u t legal dilem m as from a p rev en tive o r risk -red u ctio n p o stu re. O u r society is so educationally sophisticated th a t it ex pects an d d em an d s n ot only p ro p er health care b u t w ants it duly te m p ered with legal protections a n d insulations. T his is a b u r d en th a t m u st be ad d ressed an d fully u n d ersto o d by all actors on the health team . R ath er th an dismiss th e legal co m m u nity as a “gadfly” in dustry, w hich is so fis cally self-serving th a t it acts unconsciona bly in th e h ealth aren a, the health v en d o r m ust be legally p re p a re d at all levels o f p atien t care interv en tio n , a n d if necessary, seek o u t legal in fo rm atio n from schools, m eetings, a n d ADA factions./A DA an d its legal w ritings o ffe r a good beginning, b ut
TO
THE
EDITOR
J A D A devotes th is section to co m m en t by readers o n topics of c u rre n t interest to dentistry. T h e editor reserves th e rig h t to e d it all c o m m u n ic atio n s to fit available space an d requires th a t all letters be typed, double-spaced, an d signed. N o m ore th a n ten references sh o u ld be given w ith each letter. P rin ted c om m u n icatio n s do n o t necessarily reflect the o p in io n o r official policy o f the A ssociation. Y our p a rtic ip a tio n in this section is invited.
Infection managem ent and periodontists □ T h e Emphasis article on “N onsurgical an tib acterial ap p ro a ch es to p erio d o n tal tre a tm e n t” (January) o ffe re d an excellent discussion. T h e m essage th a t these afflic tions re p re se n t infectious diseases is clear. T h e q u estio n o f th e m ost a p p ro p ria te tre a tm e n t m ust, o f necessity, rest with the individual case. T ra d itio n an d prevailing practices lag considerably b eh in d basic a n d even clini cal research. R eluctance to translate new er know ledge into everyday practice is a p re vailing b u rd e n to be overcom e with tim e. I d a re say th a t conventional train in g in periodontics, as in all fields o f clinical care, p erp e tu ate s h alf-tru th s and even m yths w ith o u t critical assessm ent o f m any o f th eir everyday practices in the light o f c u r r e n t research . . . . T h e question is n o t “how m any angels can d an ce on th e head o f a p in ”; ra th e r, how can we apply w h at is broadly know n ab o u t infectious diseases to problem s o f th e m outh? Does it m ake sense to tre a t the gingiva w hen active infection exists 7 mm below th e surface? Does it m ake sense to blam e th e patien ts’ lack o f effective hom e care fo r a chronic progressive infection th a t can n o t be to u ch ed by the m ost consci en tio u s b ru sh in g a n d flossing? Does it m ake sense to tre a t one q u a d ra n t o f the m o u th w hen th e ecosystem o f th e m outh is a unit? Does it m ake sense to plane away at th e cem entum w hen th e organism s and th e ir noxious p ro d u c ts a re superficial, w ater soluble, an d not deeply em b ed d ed in th e ro o t surface? 310 ■ JADA, Vol. 116, March 1988
“Scaling an d ro o t plan in g ” has becom e the shibboleth o f th e p erio d o n tal w arrior, arm e d w ith s h a rp scalers. M o d e rn r e search shows th a t th e toxins are superficial and that rem oval o f cem en tu m is d estru c tive. It prejudices reg e n eratio n o f connec tive tissue attac h m e n t an d b one re g e n e ra tion. A lm ost w ithout challenge, “scaling and root p lan in g ” has been carried along as an essential elem e n t o f treatm en t. Be cause if serves to d is ru p t an d dim inish b ac te ria l co lo n iz a tio n , it is h e lp fu l in treatm ent. T o the ex ten t th a t it results in the rem oval o f all cem en tu m , it is d estru c tive. Connective tissues will n ot readily a t tach to den tin (even w hen p re p a re d with citric acid). A ggressively p lan in g th e root surface strips th e th in layer o f cem entum in far less tim e th a n th e q u o ted “30 m in utes o f ro o t p re p a ra tio n .” D uring th e past 10 years, I have applied general principles o f infection m an ag e m ent to periodontitis. I am sorry to say th a t my m a n a g e m e n t d isco m fits p e r i odontists, yet results in elim ination o f in fection, regro w th o f bone to co rrect verti cal defects, m inim izes tre a tm e n t tim e, avoids excision o f gingiva, avoids d elib er ate ro o t plan in g in a one-stage d eb rid e m ent with th e aid o f systemic antim icrobial m edications effective against anaerobes, an d results in lo n g -term h ealth an d to o th salvage. I apologize fo r discom fiting th e “estab lish m en t” b u t I w o u ld invite o th e rs to evaluate these p ro ce d u re s objectively. I m ust also acknow ledge that being a d e n tist, an o ral an d maxillofacial su rg eo n , an d a physician, I am n o t a card-carrying p eri o d ontist. My p relim in ary resu lts o f 30 cases w ere p ublished in 1982.1 O th e r p rac titioners have su b stan tiated these findings an d 1 have c o n tin u ed to derive g reat satis faction from teach in g dentists an d tre a t ing patients w ith these concepts to th e a d v a n ta g e o f b o th g r o u p s . S o m e tim e s , leeches an d b loodletting are n o t th e best therapy, alth o u g h th ey may be en d o rsed by the highest au th o rity as the stan d ard o f
m edical (dental) practice. N O R M A N T R IE G E R , DM D, MD B R O N X , NY
1. T rieger, N., and Chomenko, A. New con cepts in the treatm ent o f periodontitis. J Oral Maxillofac Surg 40:701-708, 1982.
Thanks for legal advice □ I w ant to th an k atto rn ey s Beverly L. Bailey (“M alpractice an d p erio d o n tal dis ease”) a n d M ary K. L ogan (“Legal im plica tions o f infectious disease in the dental office”) fo r th e ir d ental-legal c o n trib u tions in th e D ecem ber issue. Both au th o rs have ad d re ssed p ertin en t a n d tem poral legal issues a ffe c tin g d e n ta l ca re sta n d ard s. T h e d u e care th a t is legally m an d ated m ay n o t always be perceived by d e n tal caretak ers a n d this legal objectivity may be clouded by subjective an d paternalistic attitu d es o f w hat is p ro p e r an d acceptable care by “d o cto r knows best” testam ents. T h e A D A ’s legal w riters have consis tently a n d accu rately p ro ffe re d salient pap ers fo r o u r d en tal constituency, an d I tru st th a t the ta rg et re a d e r has g arn e re d th e im p o rt fro m these offerings. W e n eed a “fra tern ity ” interaction be tw een atto rn ey s an d h ealth providers to w ork o u t legal dilem m as from a p rev en tive o r risk -red u ctio n p o stu re. O u r society is so educationally sophisticated th a t it ex pects an d d em an d s n ot only p ro p er health care b u t w ants it duly te m p ered with legal protections a n d insulations. T his is a b u r d en th a t m u st be ad d ressed an d fully u n d ersto o d by all actors on the health team . R ath er th an dismiss th e legal co m m u nity as a “gadfly” in dustry, w hich is so fis cally self-serving th a t it acts unconsciona bly in th e h ealth aren a, the health v en d o r m ust be legally p re p a re d at all levels o f p atien t care interv en tio n , a n d if necessary, seek o u t legal in fo rm atio n from schools, m eetings, a n d ADA factions./A DA an d its legal w ritings o ffe r a good beginning, b ut