Medical Forum / General / Dentistry / July 2006
gum surgery versus laser
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gummybear - 15 Jul 2006 01:24 GMT I have been diagnosed with advanced periodontitis on two quads an need flap surgery however i read laser is an option--i was wonderin if the laser would kill the bacteria where deep cleaning and roo planing could not get to (had that done versus the surgery two year ago) some say that was option A but to me there is no option excep surgery after two years of researching and hearing what second third, fourth perios have to say--i think i still need surgery so an thoughts or responses would be appreciated before heading for th scalpel YIKES!!! ( i am definitely dentistphopia) due to childhoo experience three front teeth with NO ANESTHESIA OR NOVaCAIN
Joel344 - 15 Jul 2006 02:29 GMT Six dozen of one .... half of the other .... its marketing hype!
Show me someone who has been cured of periodontitis and I will show you .. well you get the idea
-- Joel34
gummybear - 15 Jul 2006 09:14 GMT so are you saying neither will help
Joel344 - 15 Jul 2006 13:13 GMT Well, if you have gingivitis, and / or periodontitis (INFLAMMATION o the supporting structures), then a thorough prophylaxis or toot cleaning, complete with ultrasonic Cavitron debridement will reduc inflammation.
Home care is essential.
Now some dentists call this exact procedure SRP, scaling and roo planing at $600 a pop, others call it anything else and toss i irrigation at $40 a quadrant, but all in all, periodontal concerns ar best addressed through prevention and home care.
Now the APA (Periodontists' Association ~ PERIODONTISTS!) dream u classifications, treatment modalities, everything but please remembe this is a chronic disease. What this means is that 5 years or 10 year goes by and its impossible to say "THIS HELPED," or "That DID NO help."
The studies themselves are flawed as I elaborated in hundreds of post right here. More about PerioChip, Periostat, and Arestin later, if yo have lots of stamina to read my posts!
Some of them that is. I hear there are around 46,000 of them!
Joel
-- Joel34
ckouza@eudoramail.com - 16 Jul 2006 03:21 GMT Joel,
My hygienist doesn't use the ultrasonic scaler ... Can you think of a case(s) where scraping is preferred. (My old hygienist uses the ultrasonic scaler, though.) Could it be a funding issue? ... my current hygienist and dentist are members of a faculty group practice at USC.
Also, were you serious about being willing to look at x-rays from posters?
gummybear - 16 Jul 2006 02:06 GMT hi tks for your replies but i'm still not understanding you are yo saying to skip surgery then? i had the Deep root planing scaling and went to see another perio for his consultation and h recommend me to do surgery and bone grafting :shock: tk
Alexander Vasserman DDS - 16 Jul 2006 05:41 GMT > hi tks for your replies but i'm still not understanding you are you > saying to skip surgery then? i had the Deep root planing & > scaling and went to see another perio for his consultation and he > recommend me to do surgery and bone grafting :shock: tks Your engine block is still worn despite you cleaning all the parts and getting 4 consults on a very typical problem. Don't you think you should address the resurfacing issue (bone grafting and surgery) to get better performance and longer engine life???
george1234 - 25 Jul 2006 20:56 GMT >hi tks for your replies but i'm still not understanding you are you >saying to skip surgery then? i had the Deep root planing & >scaling and went to see another perio for his consultation and he >recommend me to do surgery and bone grafting :shock: tks FWIIW... I went to two periodontists shortly after after SRP and they both suggested surgery. I then went to the local dental school (Forsythe institute) and they said there was no periodontal disease.
If you are unsure of the opinion you are receiving, I'd recommend you go to a local dental school. The financial incentive in favor of recommending surgery is less there. I'm not saying don't get treatment, I'm saying go to a place where you can better trust the opinion offered.
Alexander Vasserman DDS - 16 Jul 2006 05:35 GMT > I have been diagnosed with advanced periodontitis on two quads and need flap surgery however i read laser is an option--i was wondering
> if the laser would kill the bacteria where deep cleaning and root > planing could not get to (had that done versus the surgery two years [quoted text clipped - 4 lines] > scalpel YIKES!!! ( i am definitely dentistphopia) due to childhood > experience three front teeth with NO ANESTHESIA OR NOVaCAINE Translation analogy of what you are asking us.
My car has been diagnosed with advanced engine wear on 2 cylinders and I need to get it fixed by removing the engine however i read a power wrench is an option--i was wondering if the power wrench would resurface the breakdown in the engine where doing a thorough cleaning of the engine would not fix the problem (had that done versus the taking the engine apart two years ago) some say that was option A but to me there is no option except taking the engine apart after two years of researching and hearing what second, third, fourth mechanics have to say--i think i still need to take the engine apart so any thoughts or responses would be appreciated before heading for the traditional wrench YIKES!! (i am definitely mechanicphobic) due to childhood experience with my tricycle and no safety devices or Nike helmet.
george1234 - 25 Jul 2006 17:19 GMT >My car has been diagnosed with advanced engine wear on 2 cylinders and >...YIKES!! (i am >definitely mechanicphobic) due to childhood experience with my tricycle >and no safety devices or Nike helmet. You know, most people in need of help don't come to this forum with advanced degrees in medicine or dentistry, skilled in the art of succinct medic al history presentation. They pose their questions in a conversational manner, and some times meander about the point. You can choose to help by answering the underlying question, or to belittle the manner in which the question was posed
Alexander Vasserman DDS - 28 Jul 2006 07:40 GMT I did not mean to sound as if I was belittling just wanted to provide an analogy of what was being asked.
> >My car has been diagnosed with advanced engine wear on 2 cylinders and > >...YIKES!! (i am [quoted text clipped - 7 lines] > choose to help by answering the underlying question, or to belittle > the manner in which the question was posed george1234 - 25 Jul 2006 17:11 GMT >I have been diagnosed with advanced periodontitis on two quads and >need flap surgery however i read laser is an option--i was wondering >if the laser would kill the bacteria where deep cleaning and root >planing could not get to You can read the research (such as it is) on perio-lase here http://www.millenniumdental.com/research.html
The first article, IMO , gives the best overview http://www.millenniumdental.com/pdf/MDT-GD-Sept-Oct-2004.pdf pay attention to figure 2, for pocket depths up to 10 mm, SRP does almost as well as perio-lase. Figure 3 compares the different treatments, including flap surgery
As to treatment of periodontal disease, not all believe flap surgery is the best option. Loesche has done the most work on use of antibiotics. You can read his work here http://cmr.asm.org/cgi/content/full/14/4/727
or the summary of the debate here http://query.nytimes.com/gst/fullpage.html?sec=health&res=9F02E6DB1230F932A15752 C0A9659C8B63
Clinical trials in the use of antibiotics (metronidazole ) and cleaning as alternatives to surgery continue,e.g., at the Forsythe institute http://www.clinicaltrials.gov/ct/gui/show/NCT00066001?order=3
On a more personal note, I had a recommendation similar to yours, considered laser surgery as an alternative to flap surgery , and finally opted for SRP with better oral hygine. One year later no sign of deep pockets. I contacted Loesche by email ( he makes the offer of help somewhere on the net, I've lost the reference). He was very helpful in locating a local dentist that used antibiotic treatment as an alternative to surgery, though in my case it was not necessary.
Mark & Steven Bornfeld - 25 Jul 2006 18:07 GMT >>I have been diagnosed with advanced periodontitis on two quads and >>need flap surgery however i read laser is an option--i was wondering [quoted text clipped - 9 lines] > almost as well as perio-lase. Figure 3 compares the different > treatments, including flap surgery I have rarely if ever seen 10 mm pockets resolve with SRP. Yes, the tissue tone will improve and there may be some tissue shrinkage, but not pocket elimination to the extent that the remaining pocket (or sulcus, if you will) is sustainable by the patient. One other thing--the diagrams in this paper illustrate suprabony pockets. When you get over maybe 6-7 pockets most are infrabony. I can't say specifically whether grafting/guided tissue regeneration are used in combination with laser surgery (I wouldn't presume one way or another) but many of these infrabony lesions will require grafting and/or GTR, and possibly osseous recontouring for a good result. Therefore, I would be careful about making sweeping judgements about the suitability of laser surgery for individual patients whose situations may well be different from those in this paper.
Steve
> As to treatment of periodontal disease, not all believe flap surgery > is the best option. Loesche has done the most work on use of [quoted text clipped - 16 lines] > helpful in locating a local dentist that used antibiotic treatment as > an alternative to surgery, though in my case it was not necessary.
 Signature Mark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001
george1234 - 25 Jul 2006 19:19 GMT >> You can read the research (such as it is) on perio-lase here >> http://www.millenniumdental.com/research.html
> I have rarely if ever seen 10 mm pockets resolve with SRP. Yes, the >tissue tone will improve and there may be some tissue shrinkage, but not [quoted text clipped - 6 lines] >another) but many of these infrabony lesions will require grafting >and/or GTR, and possibly osseous recontouring for a good result. I agree SRP is not the answer to all, the severity of the disease influences the selection of treatment. The conclusion the perio-lase author does reach is "It is evident from this comparison that pocket depth reductions from LANAP are similar to those obtained from ffalp and osseous resection and modified Widman flap surgical procedures"
>Therefore, I would be careful about making sweeping judgements about the >suitability of laser surgery for individual patients whose situations >may well be different from those in this paper. Again we agree. My goal was to answer the question about laser surgery, and to cover alternatives to surgery. My intent was to point out alternatives that have an outcome similar to surgery, so that such alternatives could be explored. There are, of course, gradations in severity of the disease which requre different treatments.
Leaving perio lase behind.... Then there is Loesch's opinion that the disease is caused by specific pathogens that can be treated with specific antibiotics. He also gives the reason why traditional treatment recommendations have not changed: in 8 of 10 cases traditional methods work.
" If dental decay was a specific infection, why could periodontal diseasenot also be a specific infection resulting from the selection of bacteria that can grow in the stagnant pocket environment, using nutrients which leak into the pocket in the GCF as the result of the microbes' production of proinflammatory molecules? In the past 25 years, over 200 studies have compared the flora of disease-associated plaques with the flora found in plaques associated with periodontal health. The results have generally shown a limited number of bacterial species mainly gram-negative anaerobes, to be significantly associated with periodontal disease.These findings have not changed the prevailing treatment philosophy in periodontal disease, because of the powerful legacy of the nonspecific plaque hypothesis in dictating treatment protocols that have become the standard of care in clinical dentistry. It is difficult to change a treatment approach whose 80% level of effectiveness is accepted by the clinician (111, 189, 190) and which provides the economic infrastructure of clinical periodontology. "
>Steve Mark & Steven Bornfeld - 25 Jul 2006 19:52 GMT >>>You can read the research (such as it is) on perio-lase here >>>http://www.millenniumdental.com/research.html [quoted text clipped - 31 lines] > treatment recommendations have not changed: in 8 of 10 cases > traditional methods work. Yes they "work", but patients hear these words and equate them with "cure". Many chronic periodontal conditions are refractory because patients think they have been cured.
> " If dental decay was a specific infection, why could periodontal > diseasenot also be a specific infection resulting from the selection [quoted text clipped - 13 lines] > and which provides the economic infrastructure of clinical > periodontology. " The basic premise here is actually pretty well-known. The more interesting part is why these specific bacteria colonize some patients and are difficult to impossible to eliminate long-term, while other patients are resistant to these same strains establishing themselves in the first place (even in the absence of oral hygiene).
Steve
>>Steve
 Signature Mark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001
george1234 - 25 Jul 2006 20:19 GMT >> Leaving perio lase behind.... Then there is Loesch's opinion that the >> disease is caused by specific pathogens ... > > Yes they "work", but patients hear these words and equate them with >"cure". Loesch posits that specific anerobes are responsible for AP. He finds
" a combination of metronidazole and doxycycline, followed if necessary by local delivery of antimicrobial agents to the pocket in an ethylcellulose film, resulted in an 80% reduction in the need for surgery and extraction (153). These results have been sustained for 5 years or more "
That is as much of a cure as traditional treatments
>Many chronic periodontal conditions are refractory because >patients think they have been cured. It's pretty clear that re-infection will take place regardless of the method of dis-infection ( debridement, surgery, or antibiotic). There is no "cure", It is a more or less chronic condition, not a strict division into the sick and the well
But I defer to your clinical experience here.
>> " If dental decay was a specific infection, why could periodontal >> diseasenot also be a specific infection resulting from the selection >> of bacteria
> The basic premise here is actually pretty well-known. The more >interesting part is why these specific bacteria colonize some patients >and are difficult to impossible to eliminate long-term, while other >patients are resistant to these same strains establishing themselves in >the first place (even in the absence of oral hygiene). Well, yes that is interesting. not to put to fine a point on it, I think periodontists have only begun to scratch the surface (groan) The advance from non specific theory of infection infection to the identification of 4 to 10 anerobic species specifically associated with the disease is a recent result..
--G
Steven Bornfeld - 26 Jul 2006 00:52 GMT >>>Leaving perio lase behind.... Then there is Loesch's opinion that the >>>disease is caused by specific pathogens ... [quoted text clipped - 11 lines] > > That is as much of a cure as traditional treatments "Need for surgery" is a very, very fungible concept. Need for extraction is somewhat less fuzzy. ;-) I can tell you that there is nothing new in use of metronidazole, docycycline, or intrasulcular medications. I can also tell you that in the real world (experience of the periodontists I refer to), the results have been underwhelming. Certainly the fact that these men and women are surgeons could be seen as a potential bias. ;-) Call me gullible; I believe them.
>>Many chronic periodontal conditions are refractory because >>patients think they have been cured. [quoted text clipped - 22 lines] > identification of 4 to 10 anerobic species specifically associated > with the disease is a recent result.. I am not up on the latest research, I'm afraid (I hang my head). However, implication of specific anaerobes (as well as specific host factors) was already being discussed during my dental school days (I graduated in 1976), if not before. I don't doubt that the list of implicated pathogens is longer now than it was then.
Steve
> --G george1234 - 26 Jul 2006 20:11 GMT > I am not up on the latest research, I'm afraid (I hang my head). >However, implication of specific anaerobes (as well as specific host >factors) was already being discussed during my dental school days (I >graduated in 1976), if not before. I don't doubt that the list of >implicated pathogens is longer now than it was then. The paper is a survey paper and he does summarize the work of others. I'm not schooled enough in the art to identify Loesche's unique contirbution.
I found the list of pathogens studied suprisingly small. At one point he cites more thatn 400 species in the plaque. When he summarizes earlier studies in table 2 and 5 he concentrates on 10. In his conclusion he callls out only 3 (P. gingivalis, B. forsythus, and T. denticola)
Bacterial species that were monitored listed in tables 2 and 5
Micro-aerophilic Aa, A. actinomycetemcomitans; Cr, C. rectus; Ec, E. corrodens;
Anerobic Pg, P. gingivalis; Bf, B. forsythus; Td, T. denticola; Pi/Pn, P. intermedia/nigrenscens; Fn, F. nucleatum; Eub. Sp. = Eubacterium species; Spir, spirochetes; Tv, T. vincentii.
BTW... I hope my summaries have not mis represented Loesche's view. I'll let him speak for himself in the conclusion to his survey paper
"The evidence presented in this review indicates that most, if not all, forms of periodontal disease are specific, albeit chronic, infections. Regardless of whether the host is genetically predisposed to periodontal disease, as in Papillon-LeFevre syndrome or Down syndrome, or if the host is compromised by leukocyte defects as in LJP or diabetes, or is a smoker, or has poor oral hygiene, or has simply aged, the clinical symptoms are almost always significantly associated with the overgrowth of a finite number of anaerobic species, such as P. gingivalis, B. forsythus, and T. denticola in the subgingival plaque. This overgrowth can be periodically suppressed by mechanical debridement over a lifetime, the current treatment paradigm, or the flora can be altered by the judicious short-term usage of antimicrobial agents targeted against the specific anaerobes. This latter approach, while supported by several double-blind clinical studies (147), goes contrary to centuries of dental teaching which states that periodontal disease results from the overgrowth of plaque on the tooth surfaces, i.e., a "dirty mouth." The challenge lies not in proving that periodontal disease is an infection but in implementing treatment procedures based on the fact that it is an infection. The antimicrobial treatment of periodontal infections will benefit from studies suggesting that periodontal disease may be a risk factor for cardiovascular disease and stroke. If an antimicrobial approach is as effective as a surgical approach in the restoration and maintenance of a periodontally healthy dentition (147, 153), this would give a cardiac or stroke patient and his or her physician a choice in the implementation of treatment seeking to improve the patient's periodontal condition so as to reduce and/or delay future cardiovascular events.
Steven Bornfeld - 26 Jul 2006 23:41 GMT >> I am not up on the latest research, I'm afraid (I hang my head). >>However, implication of specific anaerobes (as well as specific host [quoted text clipped - 60 lines] > patient's periodontal condition so as to reduce and/or delay future > cardiovascular events. I remember the A. actinomycetemcomitans and Eichenella sp. as the ones they harped on the most. Does "Micro-aerophilic" equal facultative anaerobe? I'm unfamiliar with the term.
Steve
george1234 - 27 Jul 2006 17:04 GMT >Micro-aerophilic Steve,
These days wikipedia is my source for technical terms I don't know
http://en.wikipedia.org/wiki/Microaerophilic
"Microaerophilic organisms are a specific type of organism that requires oxygen to survive, but requires or can tolerate environments containing lower levels of oxygen than are present in the atmosphere (~20% concentration)."
george1234 - 25 Jul 2006 20:27 GMT > The basic premise here is actually pretty well-known. The more >interesting part is why these specific bacteria colonize some patients >and are difficult to impossible to eliminate long-term, while other >patients are resistant to these same strains establishing themselves in >the first place (even in the absence of oral hygiene). I'm slowly making my way through the Loesch paper quoted, but a partial explanation is offered
However, the tooth surfaces cannot be completely "cleaned" of plaque species by these procedures, even when surgery to get access to the root surfaces is performed (318). If these residual organisms are enriched per"`centage-wise for the periodontopathic species, then the plaque community that returns could be as proinflammatory as the plaque that had just been suppressed. This would be especially true if there is an enrichment of the plaque flora by bacteria that are left behind on the root surface or that have invaded the dentinal tubules (2). Large numbers of bacteria invade these tubules and have been shown by electron microscopic examination to repopulate the root surfaces (3). This selection for periodontopathic species as a result of debridement, as well as the difficulty in controlling a biofilm such as dental plaque, might explain the failure rate of about 20% observed in clinical practice (111, 189).
Steven Bornfeld - 26 Jul 2006 01:01 GMT >> The basic premise here is actually pretty well-known. The more >>interesting part is why these specific bacteria colonize some patients [quoted text clipped - 19 lines] > such as dental plaque, might explain the failure rate of about 20% > observed in clinical practice (111, 189). Why would the residual bacteria be enriched percentage-wise for specifically pathologic species? In fact, most of the studies we've heard over the years followed an experimental biofilm beginning with thorough debridement. Forgive, for my memory is quite hazy. The first precipitant on the root surface is a proteinaceous "salivary pellicle", which is itself non-bacterial but provides an excellent medium for bacterial growth. The maturation of plaque from this point on has been studied--the primary organisms to populate the plaque are primarily gram-positive rods and cocci. These are generally considered normal resident organisms. Only if the plaque is left undisturbed for a longer period do you start seeing the gram-negative bacteria, including the bulk of the usual suspects in pathogenesis (in our day the professors always spoke of "spirochetes", which I assume some of them are--for all I know maybe some treponema were implicated at one time). In any case, it certainly is believable that residual bacteria in the sulcus, or even in the dentinal tubules could repopulate the plaque. BTW, I consider a failure rate (again, what are the criteria for failure) of 20% as exceptionally LOW.
Steve
george1234 - 26 Jul 2006 19:56 GMT > Why would the residual bacteria be enriched percentage-wise for >specifically pathologic species? I'm not sure.. I have not read the refeerences he cites. It may be that the electron microscope observation is that the the anerobic pathogens preferentially occupy the tubules, and that when you scrape the general population away when you debride, you leave the pathogens. However.. that does not conform to my undestanding of the symbiotic/ecological relation among the species. By that I mean the anaerobes don't show up until the aerobes have created the proper ecological niche.
> In fact, most of the studies we've heard over the years followed an >experimental biofilm beginning with thorough debridement. Forgive, for [quoted text clipped - 7 lines] >gram-negative bacteria, including the bulk of the usual suspects in >pathogenesis That's my general understanding too
>(in our day the professors always spoke of "spirochetes", >which I assume some of them are--for all I know maybe some treponema >were implicated at one time). Spirochetes are found in Acute necrotizing ulcerative gingivitis.(the trench mouth of ww1)as well as AP. Apparently the understanding of the "cause " shifted from the anerobic spirochetes to the microaerophilic A. actinomycetemcomitans and now back to the anerobes. Because their caracteristic structure is evident in a phase contrast microscope, Loesche suggests spirochetes be used as an indicator of AP. He says
"The older literature identified anaerobic organisms such as spirochetes and black-pigmented Bacteroides species (now classified as Porphyromonas and Prevotella species), as putative periodontal pathogens "
"With the identification of A. actinomycetemcomitans as a putative periodontal pathogen, emphasis shifted from anaerobes to this microaerophilic species. "
"The findings shown in Tables 2 through 4, involving large numbers of samples and using diverse methods, indicate that anaerobes, rather than A. actinomycetemcomitans or other microaerophilic species, are more likely to be present or to dominate in plaques associated with EOP and AP. This would suggest that treatment strategies and tactics should be designed to selectively target certain anaerobic members of the plaque flora."
> In any case, it certainly is believable that residual bacteria in the >sulcus, or even in the dentinal tubules could repopulate the plaque. > BTW, I consider a failure rate (again, what are the criteria for >failure) of 20% as exceptionally LOW. By failure he means preiodontitis
" 30% <of the gerneral poulation> have periodontitis as defined by the presence of three or more teeth with pockets of >= 4 mm ."
>Steve --George
Steven Bornfeld - 26 Jul 2006 23:36 GMT >> Why would the residual bacteria be enriched percentage-wise for >>specifically pathologic species? [quoted text clipped - 7 lines] > anaerobes don't show up until the aerobes have created the proper > ecological niche. It may just be that the intradentinal bacteria are in a relatively anaerobic environment. That would make sense.
>> In fact, most of the studies we've heard over the years followed an >>experimental biofilm beginning with thorough debridement. Forgive, for [quoted text clipped - 45 lines] > > By failure he means preiodontitis Most of the patients receiving (or who should receive) SRP already have periodontitis.
> " 30% <of the gerneral poulation> have periodontitis as defined by the > presence of three or more teeth with pockets of >= 4 mm ." If you select for a population over 35-40 years of age, every survey I've seen shows a far higher incidence. Certainly counting children in your statistics would make things more grim. Sadly, I would say the majority of my patients under the care of periodontists (GOOD periodontists!) show relapse at some point, or more or less acute exacerbations. This doesn't mean treatment is a failure, but success must be viewed in less absolute terms. Certainly this is a tough concept to sell to a patient--that losing your teeth in 20 years rather than 10 (obviously a presumption) is a worthy goal. Understandably patients aren't happy. Thanks for the info--this is an interesting article.
Steve
>>Steve > > --George george1234 - 27 Jul 2006 17:26 GMT > Thanks for the info--this is an interesting article. It's always a pleasuer to discus an issue with you, thank you.
Another researcher in antibiotics and bacterial infection is Anne Haffajee. She has an interesting interview in a NIDCR pub whre she points out that there are geographical differences in the relative distribution of bacterial species. She says there are ~40 species involved, that make up about 60% of the biofilm.
http://www.nidcr.nih.gov/NewsAndReports/Media/InsideScoop012005.htm
"Comparing the subgingival plaque obtained from patients with chronic periodontitis, we found marked variations in the microbial profiles from country to country. After adjusting for age, gender, smoking status, and other factors, these differences held up. "
The clinical implications are
"treatment responses with a given therapy might be different geographically. What we want to know now is: Which treatment works best for a given microbial profile?"
Not to say that she has actually worked out the different treatments.
I suspect in a few years we will see DNA profiles of the biofilm as an adjunct to asessing periodontal disease.
--george
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