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Probing periodontal pockets
J A D A L E T T E R S
TO
THE
E D I T O R <
J A D A devotes this 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 ed it all c o m m u n ic atio n s to fit a vailable space an d req u ires th a t all letters be typed, double-spaced, a n d signed. N o m ore th a n ten references should be given w ith each letter. P rin te d c o m m u n icatio n s do n o t necessarily reflect the o p in io n or official p olicy of the A ssociation. Y our p a rtic ip a tio n in this section is invited.
R e d u c in g to o th extraction s □ Dr. H ow ard B ailit and others, authors of the Perspectives article in the Ja n u a ry issue, ask an im p o rta n t q uestion about the search for ways to reduce the rate of tooth extractions. I agree w ith their conclusion th at the m ajor reason for tooth loss is car ies, b u t n o t caries per se. As they p o in t out, “ W ith perhaps a few exceptions, caries is an associated but n ondeterm ining factor in the ex traction of teeth: th a t is, m ost carious teeth can be restored.” W hy, then, were n o t these carious teeth restored and saved, the authors ask. E xclud in g th ird m olars an d prosthetic construc tion, they nam ed the “values of low er socio econom ic g roups an d their reduced fin a n cial access to dental services.” Here I dis agree. A lth o u g h they p o in t o u t correctly th a t “ to o th loss is clearly related to social class,” the values and financial status of the u p p er ranges of the lower class are likewise associated b u t nond eterm in in g factors in the extraction of teeth: th a t is, a m otivated d en tist can induce the m ajority of such p eople to save their teeth. My 40 years of experience w ith a “m in o r ity an d low er socioeconom ic class p o p u la tio n ” has show n me th a t given a fig h tin g chance, such people w ant to and do save their teeth w hen given proper education and a reasonable paym ent p lan (when a third-party p lan is unavailable). . . . Invari ably such people have told me th a t dentists extracted casually, offering no alternatives. T h u s the problem lies w ith not ju st the low er class status of the p atien t b ut also in 434 ■ JADA, Vol. 114, A pril 1987
the attitudes of the dentists they typically see. My questions are: sh o u ld a d en tist be judgm entally extraction-oriented because such patients seek h im o u t w ith toothaches or other emergencies? H ow can dentists recognize their advice is n o t a p t to be heeded, w hen they do n ot give it? Should this make a difference in treatment? Patients w ith toothaches in im p o rta n t a n d salvage able teeth could be offered palliative treat m ent sho u ld they refuse endodontic th er apy or a large p erm an en t restoration. T he only duty of a doctor is to offer relief from p ain and infection. W hether such patients return for m ore p erm an en t care is and should be none of the dentist’s concern. . . . It has been my experience that such patients often return, once the em ergency is past, to have conservative care. P eople do n o t value their teeth if victimized by den tists’ selffu lfillin g prophesies: dentists educate such patients by perform ance of expedient ex-, tractions. A lthough it is true th at remedies for the rate of extractions should include preven tion, reducing out-of-pocket costs for ser vices, an d education of the p ublic, Dr. B ailit and co-authors seem to view dentists as passive salespeople at the mercy of an extraction-oriented class of people. T hey do not seem to com prehend, or w an t to adm it th a t dentists can be at fault. (O nly once do they hint: “T h e fact th at large num bers of these teeth were extracted a p pears to be a fu nction of values a n d beliefs of certain groups of patients and, possibly, dentists.”)
O th er professions have long ago made this ad m issio n :. . . I, therefore, believe that dentists should be educated or otherw ise induced to upgrade their ow n values, beliefs, an d ethics first if they are to reduce the rate of tooth extractions.
*
JU L IA N M. FIR E S T O N E , DDS NEW YORK
P r o b in g p erio d o n ta l p o ck ets □ Dr. S igurd R am fjo rd ’s article “ Surgical 1 p eriodontal pocket elim in atio n : still a ju s tifiable objective?” (January) questioned the need for pocket-reduction procedures. T h e efficacy of root p la n in g was well stated; nevertheless, an o th er perspective indicates m in im al p ro b in g depths are de- ^ sirable. Studies cited in the article docum ented th a t ro o t curettem ent m a in tain ed attach m ent levels as well as surgical procedures in patients treated for periodontitis. H ow ever, m any papers indicated th a t it took 3 to 8 h ours for root p la n in g d entitions. T h is • fact is n o t stated to d ow nplay the effective ness of root p lan in g , b u t rath er to u n d er score the com m itm ent req u ired to treat patients w ith deep pockets. L im ited conclusions should be draw n from in v e stig a tio n s referred to by Dr. R am fjord for several reasons. T h e profes sion sh o u ld acknow ledge th a t studies co n ducted by periodontists in a university set tin g do n ot reflect the stan d ard of care provided by the average clin ician . P racti tioners have different skill levels, an d root curettem ent is one of the m ost d em anding
procedures in dentistry. M ost of the studies assessed the efficacy of different therapies only on single-rooted teeth. Statistical a n a l yses frequently included all teeth in the studies an d p ro b in g m easurem ents were reported as means. T h is can have a “ w ash in g -o u t effect,” regarding the efficacy of surgery a t deep pockets, because large changes at a sm all num ber of sites may not be reflected in the data. C urrently, it is advocated th a t researchers provide fre quency d istrib u tio n s of changes and in clude analyses to seek large alterations at a few sites to preclude m issing significant findings. M any authors dem onstrated that root curettem ent of pockets greater than 5 m m resulted in incom plete rem oval of plaque an d calculus. In contrast, surgical access facilitates definitive root debridement, there by p ro v id in g cleaner and sm oother root surfaces. At sites w ith deep pockets, surgi cal procedures also result in a greater gain of new clinical attachm ent and osseous rep air th an n onsurgical treatm ent. W hen access is achieved to o b ta in these results, it is advantageous to “shallow o u t” pockets to ensure easier m aintenance. No one is suggesting m u tila tin g gingival topogra phy, b u t several m illim eters of recession can also occur after nonsurgical therapy. It was suggested th a t deep pockets do not w orsen faster th a n shallow crevices. T he au th o r q u o ted L in d h e and o thers1to illu s trate th at all sites are equally susceptible to perio d o n tal breakdow n, regardless of past destruction. However, data were based on statistical assessments th a t assumed in d i vidual to o th surfaces could be judged as indep en d ent observations. T h is premise may lead to w rong conclusions as discussed by C h ilto n .2 Furtherm ore, the concept that p erio d o n tal diseases are episodic and occur random ly also has been challenged, and some of the data su p p o rtin g this hypothe sis may be explained as experim ental error.3 E pidem iologic data indicate that certain teeth are susceptible to periodontitis, regard less of w hether the disease process is con tin u o u s or episodic. Sites w ith deep pockets are disease-prone areas, as evidenced by their previous breakdown. O ther investiga tors noted th a t these areas tend to deterio 436 ■ JADA, Vol. 114, A pril 1987
rate faster than shallow sulci.4 6 P o ck etin g correlates fairly w ell w ith param eters used to evaluate periodontal disease. Bleeding d u rin g pro b in g occurs m ore frequently in deep sites th an shallow ones.4'7 W hereas bleeding does n o t reflect attachm ent loss, it does indicate the pres ence of an inflam m atory lesion in the co n nective tissue. Furtherm ore, deep pockets usually co n tain m ore bacteria an d a higher percentage of spirochetes an d m otile forms than crevices.8Sim ilarly, other overt p ath o gens (A ctinobacillus actinom ycetem com itans and Bacteroides gingivalis) tend to be garnered from the base of deep lesions. T hese sites app ear to provide an anaerobic niche an d lower redox p otentials facili tatin g proliferatio n of microbes. Conven tional hygienic efforts by p atients do n ot affect the flora in pockets greater th an 5 m m 9; therefore, surgical procedures w hich create shallow sulci can help patients pre vent rep o p u la tio n of subgingival p ath o gens. Dr. R am fjord’s rem arks should n ot be m isinterpreted an d used to rationalize per fu nctory m an ag em en t of deep pockets. T reatm en t of these sites takes tim e, skill, patience, an d they m ust be continuously m onitored to avoid overlooking progres sive loss of clinical attachm ent. R oot curet tage sh o u ld be used repeatedly as long as satisfactory results are obtained, b u t other types of surgical therapy should be consid ered w hen root p la n in g an d personal hy giene fail to resolve inflam m ation, enhance tissue tonus, an d decrease pocket depths. GARY G R E E N S T E IN , DDS, MS FREEHOLD, NJ
1. L in d h e, J.; H affajee, A.D.; a n d Socransky, S.S. Progression of p e rio d o n ta l disease in the absence of p e rio d o n ta l therapy. J C lin Periodontol 10:433-442, 1983. 2. C h ilto n , N .W ., ed. Conference on clinical trials in p erio d o n tal disease. J C lin Periodontol 13:335, 1986. 3. R alls, S.A., a n d C ohen, M.E. Problem s identify in g bursts of p erio d o n tal a ttachm ent loss. J P eriodon tol 57:746, 1986. 4. B adersten, A., an d others. Effect of nonsurgical perio d o n tal therapy. Bleeding, s u p p u ra tio n an d p ro b in g d ep th in sites w ith p ro b in g a tta ch m e n t loss. J C lin P erio d o n to l 12(6):432-439, 1985. 5. Buckley, L.A., a n d Crowley, M .J. A lo n g itu d in al study of u ntreated pe rio d o n ta l disease. J C lin P eriodon tol 11:523, 1984. 6. L istgarten, M .A., a n d Levin, S. Positive correla tio n betw een the p ro p o rtio n s of subgingival sp iro chetes a n d m o tile bacteria an d susceptibility of h um an subjects to p e rio d o n ta l deterioration. J C lin P e riodon tol 8(2): 122-138, 1981. 7. L an g , N .P ., an d others. B leeding o n probing. A p re d ic to r for th e p rogression of pe rio d o n ta l disease. J C lin P erio d o n to l 13:590, 1986. 8. Savitt, E.D., a n d Socransky, S.S. D istrib u tio n of certain sub g in g iv al m icrobial species in selected p eri o d o n ta l con d itio ns. J P eriodont Res 19(2):115-123, 1984.
9. K ho, P., a n d others. T h e effect of supragingival p la q u e co n tro l o n the subgingival m icroflora. J C lin Periodontol 12:676, 1985.
□ . . . . Please, Dr. R am fjord, ease u p on your trigger. D O N A LD E. JA N O F F, DDS N O R T H A M P T O N , MA
E th ics— a tw o -w a y street □ T h e A ssociation rep o rt on ethics, self regulation, an d q u ality assurance (Febru ary) makes an im p o rta n t p o in t regarding the in terrelatio n sh ip of cost an d q uality and the fact th a t there may be m u ltip le levels of acceptable service at differing costs. O bvious exam ples include fixed ver sus rem ovable prosthetic appliances or cast versus p o rcelain crowns. It is rightly p o in t ed o u t th a t the p a tie n t w ill have a role in selecting betw een various acceptable ser vices. However, the p atien t’s role goes beyond th at an d the A ssociation w ill be m ak in g an error if the full extent of th at role is n ot explored in discussions regarding quality, especially w ith governm ent agencies. In the absence of absolute perfection, any d efin itio n of an acceptable level of q uality w ill be unacceptable to some. W hat m aybe d eterm ined to be adequate m argins on a crow n may in fact be a m ajor problem in a cariesprone patient. O ther aspects of den tistry have sim ilar problem s, an d so the q uestion becomes one of d eterm ining w hat a m o u n t of failure is acceptable. In ad d itio n , the p a tie n t’s ability to coop erate d u rin g treatm en t affects the level of q u ality the doctor can provide, as anyone w ho has ever carved a th ird m olar am algam on som eone w ith lim ited o p en in g w ill attest. O nly standards that recognize the dual resp o n sib ility can be fair to b oth parties and, in fact, absolute standards of q u ality may be im possible to define. GARY R. T E M P L E M A N , DDS C LO V ER D A LE, CA
□ C o n g ratu latio n s on a well th o u g h t o ut an d w ritten article th at I believe has id en ti fied several of the critical areas th at are h aving an im p act on dentistry. H ow we in dentistry respond to the challenges facing us is very im p o rtan t. T h e way we respond w ill determ ine w hether dentistry continues to be a profession or w hether it reverts to a trade. I agree w ith you th at the relationship betw een the dentist an d his o r her p atien t or clien t is the keystone to dentistry’s suc cess in reta in in g its ability to be self-
TO
THE
E D I T O R <
J A D A devotes this 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 ed it all c o m m u n ic atio n s to fit a vailable space an d req u ires th a t all letters be typed, double-spaced, a n d signed. N o m ore th a n ten references should be given w ith each letter. P rin te d c o m m u n icatio n s do n o t necessarily reflect the o p in io n or official p olicy of the A ssociation. Y our p a rtic ip a tio n in this section is invited.
R e d u c in g to o th extraction s □ Dr. H ow ard B ailit and others, authors of the Perspectives article in the Ja n u a ry issue, ask an im p o rta n t q uestion about the search for ways to reduce the rate of tooth extractions. I agree w ith their conclusion th at the m ajor reason for tooth loss is car ies, b u t n o t caries per se. As they p o in t out, “ W ith perhaps a few exceptions, caries is an associated but n ondeterm ining factor in the ex traction of teeth: th a t is, m ost carious teeth can be restored.” W hy, then, were n o t these carious teeth restored and saved, the authors ask. E xclud in g th ird m olars an d prosthetic construc tion, they nam ed the “values of low er socio econom ic g roups an d their reduced fin a n cial access to dental services.” Here I dis agree. A lth o u g h they p o in t o u t correctly th a t “ to o th loss is clearly related to social class,” the values and financial status of the u p p er ranges of the lower class are likewise associated b u t nond eterm in in g factors in the extraction of teeth: th a t is, a m otivated d en tist can induce the m ajority of such p eople to save their teeth. My 40 years of experience w ith a “m in o r ity an d low er socioeconom ic class p o p u la tio n ” has show n me th a t given a fig h tin g chance, such people w ant to and do save their teeth w hen given proper education and a reasonable paym ent p lan (when a third-party p lan is unavailable). . . . Invari ably such people have told me th a t dentists extracted casually, offering no alternatives. T h u s the problem lies w ith not ju st the low er class status of the p atien t b ut also in 434 ■ JADA, Vol. 114, A pril 1987
the attitudes of the dentists they typically see. My questions are: sh o u ld a d en tist be judgm entally extraction-oriented because such patients seek h im o u t w ith toothaches or other emergencies? H ow can dentists recognize their advice is n o t a p t to be heeded, w hen they do n ot give it? Should this make a difference in treatment? Patients w ith toothaches in im p o rta n t a n d salvage able teeth could be offered palliative treat m ent sho u ld they refuse endodontic th er apy or a large p erm an en t restoration. T he only duty of a doctor is to offer relief from p ain and infection. W hether such patients return for m ore p erm an en t care is and should be none of the dentist’s concern. . . . It has been my experience that such patients often return, once the em ergency is past, to have conservative care. P eople do n o t value their teeth if victimized by den tists’ selffu lfillin g prophesies: dentists educate such patients by perform ance of expedient ex-, tractions. A lthough it is true th at remedies for the rate of extractions should include preven tion, reducing out-of-pocket costs for ser vices, an d education of the p ublic, Dr. B ailit and co-authors seem to view dentists as passive salespeople at the mercy of an extraction-oriented class of people. T hey do not seem to com prehend, or w an t to adm it th a t dentists can be at fault. (O nly once do they hint: “T h e fact th at large num bers of these teeth were extracted a p pears to be a fu nction of values a n d beliefs of certain groups of patients and, possibly, dentists.”)
O th er professions have long ago made this ad m issio n :. . . I, therefore, believe that dentists should be educated or otherw ise induced to upgrade their ow n values, beliefs, an d ethics first if they are to reduce the rate of tooth extractions.
*
JU L IA N M. FIR E S T O N E , DDS NEW YORK
P r o b in g p erio d o n ta l p o ck ets □ Dr. S igurd R am fjo rd ’s article “ Surgical 1 p eriodontal pocket elim in atio n : still a ju s tifiable objective?” (January) questioned the need for pocket-reduction procedures. T h e efficacy of root p la n in g was well stated; nevertheless, an o th er perspective indicates m in im al p ro b in g depths are de- ^ sirable. Studies cited in the article docum ented th a t ro o t curettem ent m a in tain ed attach m ent levels as well as surgical procedures in patients treated for periodontitis. H ow ever, m any papers indicated th a t it took 3 to 8 h ours for root p la n in g d entitions. T h is • fact is n o t stated to d ow nplay the effective ness of root p lan in g , b u t rath er to u n d er score the com m itm ent req u ired to treat patients w ith deep pockets. L im ited conclusions should be draw n from in v e stig a tio n s referred to by Dr. R am fjord for several reasons. T h e profes sion sh o u ld acknow ledge th a t studies co n ducted by periodontists in a university set tin g do n ot reflect the stan d ard of care provided by the average clin ician . P racti tioners have different skill levels, an d root curettem ent is one of the m ost d em anding
procedures in dentistry. M ost of the studies assessed the efficacy of different therapies only on single-rooted teeth. Statistical a n a l yses frequently included all teeth in the studies an d p ro b in g m easurem ents were reported as means. T h is can have a “ w ash in g -o u t effect,” regarding the efficacy of surgery a t deep pockets, because large changes at a sm all num ber of sites may not be reflected in the data. C urrently, it is advocated th a t researchers provide fre quency d istrib u tio n s of changes and in clude analyses to seek large alterations at a few sites to preclude m issing significant findings. M any authors dem onstrated that root curettem ent of pockets greater than 5 m m resulted in incom plete rem oval of plaque an d calculus. In contrast, surgical access facilitates definitive root debridement, there by p ro v id in g cleaner and sm oother root surfaces. At sites w ith deep pockets, surgi cal procedures also result in a greater gain of new clinical attachm ent and osseous rep air th an n onsurgical treatm ent. W hen access is achieved to o b ta in these results, it is advantageous to “shallow o u t” pockets to ensure easier m aintenance. No one is suggesting m u tila tin g gingival topogra phy, b u t several m illim eters of recession can also occur after nonsurgical therapy. It was suggested th a t deep pockets do not w orsen faster th a n shallow crevices. T he au th o r q u o ted L in d h e and o thers1to illu s trate th at all sites are equally susceptible to perio d o n tal breakdow n, regardless of past destruction. However, data were based on statistical assessments th a t assumed in d i vidual to o th surfaces could be judged as indep en d ent observations. T h is premise may lead to w rong conclusions as discussed by C h ilto n .2 Furtherm ore, the concept that p erio d o n tal diseases are episodic and occur random ly also has been challenged, and some of the data su p p o rtin g this hypothe sis may be explained as experim ental error.3 E pidem iologic data indicate that certain teeth are susceptible to periodontitis, regard less of w hether the disease process is con tin u o u s or episodic. Sites w ith deep pockets are disease-prone areas, as evidenced by their previous breakdown. O ther investiga tors noted th a t these areas tend to deterio 436 ■ JADA, Vol. 114, A pril 1987
rate faster than shallow sulci.4 6 P o ck etin g correlates fairly w ell w ith param eters used to evaluate periodontal disease. Bleeding d u rin g pro b in g occurs m ore frequently in deep sites th an shallow ones.4'7 W hereas bleeding does n o t reflect attachm ent loss, it does indicate the pres ence of an inflam m atory lesion in the co n nective tissue. Furtherm ore, deep pockets usually co n tain m ore bacteria an d a higher percentage of spirochetes an d m otile forms than crevices.8Sim ilarly, other overt p ath o gens (A ctinobacillus actinom ycetem com itans and Bacteroides gingivalis) tend to be garnered from the base of deep lesions. T hese sites app ear to provide an anaerobic niche an d lower redox p otentials facili tatin g proliferatio n of microbes. Conven tional hygienic efforts by p atients do n ot affect the flora in pockets greater th an 5 m m 9; therefore, surgical procedures w hich create shallow sulci can help patients pre vent rep o p u la tio n of subgingival p ath o gens. Dr. R am fjord’s rem arks should n ot be m isinterpreted an d used to rationalize per fu nctory m an ag em en t of deep pockets. T reatm en t of these sites takes tim e, skill, patience, an d they m ust be continuously m onitored to avoid overlooking progres sive loss of clinical attachm ent. R oot curet tage sh o u ld be used repeatedly as long as satisfactory results are obtained, b u t other types of surgical therapy should be consid ered w hen root p la n in g an d personal hy giene fail to resolve inflam m ation, enhance tissue tonus, an d decrease pocket depths. GARY G R E E N S T E IN , DDS, MS FREEHOLD, NJ
1. L in d h e, J.; H affajee, A.D.; a n d Socransky, S.S. Progression of p e rio d o n ta l disease in the absence of p e rio d o n ta l therapy. J C lin Periodontol 10:433-442, 1983. 2. C h ilto n , N .W ., ed. Conference on clinical trials in p erio d o n tal disease. J C lin Periodontol 13:335, 1986. 3. R alls, S.A., a n d C ohen, M.E. Problem s identify in g bursts of p erio d o n tal a ttachm ent loss. J P eriodon tol 57:746, 1986. 4. B adersten, A., an d others. Effect of nonsurgical perio d o n tal therapy. Bleeding, s u p p u ra tio n an d p ro b in g d ep th in sites w ith p ro b in g a tta ch m e n t loss. J C lin P erio d o n to l 12(6):432-439, 1985. 5. Buckley, L.A., a n d Crowley, M .J. A lo n g itu d in al study of u ntreated pe rio d o n ta l disease. J C lin P eriodon tol 11:523, 1984. 6. L istgarten, M .A., a n d Levin, S. Positive correla tio n betw een the p ro p o rtio n s of subgingival sp iro chetes a n d m o tile bacteria an d susceptibility of h um an subjects to p e rio d o n ta l deterioration. J C lin P e riodon tol 8(2): 122-138, 1981. 7. L an g , N .P ., an d others. B leeding o n probing. A p re d ic to r for th e p rogression of pe rio d o n ta l disease. J C lin P erio d o n to l 13:590, 1986. 8. Savitt, E.D., a n d Socransky, S.S. D istrib u tio n of certain sub g in g iv al m icrobial species in selected p eri o d o n ta l con d itio ns. J P eriodont Res 19(2):115-123, 1984.
9. K ho, P., a n d others. T h e effect of supragingival p la q u e co n tro l o n the subgingival m icroflora. J C lin Periodontol 12:676, 1985.
□ . . . . Please, Dr. R am fjord, ease u p on your trigger. D O N A LD E. JA N O F F, DDS N O R T H A M P T O N , MA
E th ics— a tw o -w a y street □ T h e A ssociation rep o rt on ethics, self regulation, an d q u ality assurance (Febru ary) makes an im p o rta n t p o in t regarding the in terrelatio n sh ip of cost an d q uality and the fact th a t there may be m u ltip le levels of acceptable service at differing costs. O bvious exam ples include fixed ver sus rem ovable prosthetic appliances or cast versus p o rcelain crowns. It is rightly p o in t ed o u t th a t the p a tie n t w ill have a role in selecting betw een various acceptable ser vices. However, the p atien t’s role goes beyond th at an d the A ssociation w ill be m ak in g an error if the full extent of th at role is n ot explored in discussions regarding quality, especially w ith governm ent agencies. In the absence of absolute perfection, any d efin itio n of an acceptable level of q uality w ill be unacceptable to some. W hat m aybe d eterm ined to be adequate m argins on a crow n may in fact be a m ajor problem in a cariesprone patient. O ther aspects of den tistry have sim ilar problem s, an d so the q uestion becomes one of d eterm ining w hat a m o u n t of failure is acceptable. In ad d itio n , the p a tie n t’s ability to coop erate d u rin g treatm en t affects the level of q u ality the doctor can provide, as anyone w ho has ever carved a th ird m olar am algam on som eone w ith lim ited o p en in g w ill attest. O nly standards that recognize the dual resp o n sib ility can be fair to b oth parties and, in fact, absolute standards of q u ality may be im possible to define. GARY R. T E M P L E M A N , DDS C LO V ER D A LE, CA
□ C o n g ratu latio n s on a well th o u g h t o ut an d w ritten article th at I believe has id en ti fied several of the critical areas th at are h aving an im p act on dentistry. H ow we in dentistry respond to the challenges facing us is very im p o rtan t. T h e way we respond w ill determ ine w hether dentistry continues to be a profession or w hether it reverts to a trade. I agree w ith you th at the relationship betw een the dentist an d his o r her p atien t or clien t is the keystone to dentistry’s suc cess in reta in in g its ability to be self-