Periodontal Diagnosis and Treatment: Lasers, Chemotherapeutics, and Guided Tissue Regeneration

Periodontal Diagnosis and Treatment: Lasers, Chemotherapeutics, and Guided Tissue Regeneration

A diagnostic full mouth series of radiographs (either a 20 or 21 series FMX). The 20 or 21 series employs the small number 1 film being used in the anterior sextant.  Once you get used to these small films in front, you will never go back to the number 2 films in front.  The improvement in diagnostic quality is tremendous!  Today we also have digital films which can allow you to reverse image, change densities, etc., all which help in diagnosis.  There are still arguments that traditional analog films still may yield better diagnostic quality than digital radiography. 

Full mouth diagnostic probing scores with a periodontal probe. This is such an easy thing to do and unbelievably this is not done in so many offices as part of the complete oral examination. Not doing this would be like going to the physician and not getting your blood pressure taken.  Probing scores obviously tell you the extent of probing depths, they help in establishing the clinical topography and hence the degree of disease.  Bleeding and purulent drainages can be further established from probings.  Probing further allows one to look for open furcation areas.  Attachment loss and the degree of recession clinically seen are also measured. 

Mobility testing is important to establish the stability of teeth and looking at the occlusion cannot be overemphasized.  An intra and extra oral examination and a TMJ examination are further done to complete the data gathering.

The art and science of periodontics are currently undergoing many exciting changes. Advances in biology, technology, procedures and materials have dramatically impacted the way periodontal diseases are diagnosed and treated. It has been well established that periodontal diseases are chronic destructive oral infections, with a wide range of manifestations in different individuals.

Spurring much of the innovation in the field of periodontics is the ever-growing body of evidence linking periodontal health with a broad array of other conditions, from stroke and diabetes to pre-term low-birth-weight babies. One of the most recent discussions on the perio/systemic link was a January 2009 meeting of the editorial boards of the Journal of Periodontology and the American Journal of Cardiology, published in spring 2009 issues of both journals.

As this summary demonstrates, this topic typically generates more questions than answers. While there’s general consensus on the link and on the need for dental and medical communities to partner in their efforts, there are no hard-and-fast answers on causality, predictiveness, and recommendations for everyday diagnosis and therapy. So the quest continues for definitive answers and periodontal protocol continues to evolve.

Dr. Robert Pick and Dr. Peter Shatz, both in-the-trenches practitioners as well as noted educators, shared their observations and experiences about this ever-changing discipline

Diagnosis

Current standards for risk assessment and disease detection combine tried-and-true techniques (like manual probing) along with an array of advanced tests (like bacterial and genetic assays) and high-tech imaging.   
"Bacterial culturing and inflammation studies--i.e. the biomarkers of inflammation which indicate disease sensitivity-have made a dramatic difference in our ability to not only diagnose and accurately define the severity of periodontal disease, but also reliably assess a patient's risk," noted Dr. Shatz.

"As we diagnose today differently than we did 20 years ago, we will diagnose again differently 20 years from now.  However, some things remain constant with the diagnosis of periodontal disease. The amalgamation of certain traditional clinical data still yields the best information in making a correct diagnosis and henceforth then treating the case correctly," said Dr. Pick. "From this data and by using all of the wonderful procedures we have today, periodontal diseases can be treated effectively and in many instances new tissues regenerated!"  

Treatment

“We currently have an incredible range of treatment options that didn’t exist just a few years ago: localized delivery of chemotherapeutics (antibiotics, chlorhexidne), lasers for soft-tissue management, lasers for surgery, guided tissue regeneration barriers, platelet rich plasma, recombinant growth hormones (r-BMP, rh-PDGF), and more,” Dr. Shatz observed. “Bacterial management is key to control of early disease progression. Any adjunctive treatment to mechanical plaque and calculus control ultimately may improve clinical outcomes.”

Dr. Pick agreed, and added, "I feel the specialty of periodontics has seen the greatest advancements in treatment of any field of dentistry. Today in individuals with gingival recession with no open gingival embrasure spaces, no matter what the extent of the recession, using the powerful Subepithelial Connective Tissue Graft (see before and after images below), we can completely cover the exposed recessed root with close to perfect tissue blends. It can be very difficult to tell afterwards where the grafting was done. Further, the wound on the palate is very minimally invasive especially when compared to the old free soft tissue graft that left a wound that healed by secondary intention wound healing.

BEFORE

BEFORE

AFTER

AFTER

“Another fabulous diagnostic aid and then treatment is the use of CAT scans and 3D imaging in the treatment planning and placement of dental implants. All cases are different and require different diagnostic factors, but in general the patient is sent for a CT scan and the scan is then uploaded into your computer and using powerful software such as DentaScan for SIMPLANT, the dentist can actually do a “virtual surgery” on the computer on the x-rays. Once the appropriate manufacturer’s fixtures are placed into the jaw correctly, the images can be saved and sent in order to get back a surgical guide or stent which allows you to perfectly place the implants into the jaw mimicking exactly what was done in the planning phase,” Dr. Pick said.

Lasers

Both doctors see the value of dental lasers in periodontal care when applied appropriately, and both acknowledge that these instruments do have limitations and may be over-marketed by vendors.
"Lasers kill bacteria and cut tissue, but also offer other beneficial side effects, such as hemostasis," said Dr. Shatz. "Ultimately, lasers are just another tool, like hand instruments, rotary instrumentation, ultrasonics, piezoelectrics and chemotherapeutics. Standard of care is by definition the degree of prudence and caution required of an individual who is under a duty of care.  Standard of care is outcome- and performance-based, and not based upon which instrument was used to obtain that outcome."

"The topic of dental lasers is dear to me, as I co-wrote the text Lasers in Dentistry, published by Quintessence," Dr. Pick noted. "I think lasers still have a long way to go – I hate to admit this, but there is still a lot of mis-marketing out there.  When lasers, however, are used for what they do well, there is simply no better surgical tool out there! 
"As an example, for a maxillary midline frenum that needs to be removed, the laser does it better than any other surgical modality that exists.  There is never any bleeding during and after surgery, no swelling, no stitches used, no scarring and no pain after surgery.  Those advantages cannot be beat," said Dr. Pick. "We have recently seen some evidence of lasers being used for guided tissue regeneration.  The initial results may show promise but much more research is needed with larger sample sizes. I have always postulated that in the future, lasers will be common place." 

Perio in General Practice

General dentists are increasingly offering soft-tissue and periodontal services that have historically been the exclusive domain of the specialist. While typically referring out more complex and surgical cases (especially implant placement), today's GP has a growing caseload of simpler periodontal therapy and maintenance. So what's the impact on patient care?
Dr Shatz’s opinion is that periodontal therapy in the general dentist's offices leads to "better care for our patients, better diagnosis and better treatment. Increased periodontal awareness in the general practice environment may also lead to more referrals to periodontists for the treatment of advanced disease and more complex cases. The only caveat is that general dentists must also include a reassessment of response to soft-tissue management and recommendation of advanced therapy, if indicated."

Again, Dr. Pick agrees. "There is a double edged sword here--although GP's are becoming more aware of periodontics, but many times, by the time the periodontist sees the case, it is actually at the reevaluation phase," he said. "So technically you have never really seen the patient from the start of treatment and you sometimes are not aware of how hygiene has been and most importantly what the patient looked like at the initial examination before scaling and root planing. I personally have never been too bothered by this as I now see more referrals than ever before.  With good interoffice communication and digital photography, this can easily be overcome.  I have always felt that one of the keys to a great specialty practice is great communication.  Besides, my really good referring practices are so busy doing restorative dentistry, it is really not a problem."

The future is now

What's in the pipeline for periodontal care?
"Phototherapy," said Dr. Shatz, "where a dye is used to target tissue, and then light used to activate a therapeutic agent.  This system, now used in Europe and coming to North America, can reduce bacterial load with a non-invasive, highly targeted agent. Stay tuned."
"As we unravel embryonic development of the periodontium, I believe that we'll see this and genetic engineering not only prevent and cure periodontal disease, but we'll see periodontal tissue regeneration like we've never seen it before!" Dr. Pick noted. " We will also see tests that look for one's risk of getting periodontal disease--and if one does get the disease, we will know exactly what the etiology is, the actual bugs that are responsible for the disease." 

And on Dr. Pick's wish list...
"The specialty of periodontics will genetically place a tooth bud in area where a tooth was lost (instead of placing a dental implant), the bud will be stimulated, the ortho-restorative dentist will guide the tooth in and if need be, the restorative dentist veneer or repair any deficiencies." Again... stay tuned.


Peter C. Shatz, DDS

Dr. Shatz is an Assistant Clinical Professor of Periodontics at the Medical College of Georgia in Augusta, Georgia.  Dr. Shatz lectures both Nationally and Internationally on the topics of Periodontal Plastic Surgery, Dental Implantology, Hard and Soft Tissue Regenerative Surgical Techniques. Dr. Shatz has contributed extensively to the Literature with numerous scientific articles published in refereed journals, and having been a contributor to several textbooks. Dr. Shatz is a Consultant to the Georgia Board of Dentistry and is active in the Northwest District Dental Society of the Georgia Dental Association.  Dr. Shatz has been granted a Fellowship in the Pierre Fauchard Academy. Dr. Shatz is an author of the text book entitled "Principles of Soft Tissue Surgery: A Complete Step by Step Procedural Guide" This textbook has been Peer reviewed and has the ADA "CERP" certification. 

Dr. Robert Pick

Dr. Pick received his Dental Degree (1980), Certificate of Residency in Periodontics (1982) and his Master of Science Degree (1982) all from Northwestern University Dental School.  At graduation he was awarded the Outstanding Student in Periodontics from the American Academy of Periodontology. Dr. Pick is currently engaged in full time private practice of Periodontics and Implants in Chicago.  He is also a member of the attending staff of Northwestern Memorial Hospital and a Clinical Associate Professor of Surgery at Northwestern University Medical School.  Dr. Pick is a Fellow in both the American and International College of Dentists. Dr. Pick presents programs both nationally and internationally on practice management/motivation and periodontics and implant dentistry.  He has published numerous articles in the scientific literature, has authored and co-authored numerous chapters on periodontics, implants and lasers for various textbooks, manuscripts and co-edited and wrote the text, "Lasers in Dentistry." He is an official spokesperson for the American Dental Association on implants, periodontics and lasers.  Dr. Pick has frequently been featured in the broadcast and print media throughout the U.S. and abroad

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