PERIODONTAL DISEASE

David J. Ahearn
J Am Dent Assoc 2002;133;809-

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L E T T E R S
LETTERS
ADA welcomes letters from
J readers on topics of current
interest in dentistry. The
Journal reserves the right to
edit all communications and re-
quires that all letters be signed.
The views expressed are those
of the letter writer and do not
necessarily reflect the opinion
or official policy of the Associa-
tion. Brevity is appreciated.
ORAL CANCER CAMPAIGN
I must express my deep concern
related to the March JADA let-
ter to the editor by Dr. Tyler
Potter and colleagues about the
ADA’s oral cancer awareness
campaign. The misinformation
and opinions expressed may re-
sult in many general dentists in
this country missing opportuni-
ties to save lives and improve
the quality of life for anyone
who may be unfortunate enough
to develop oral cancer. The key
to survival and, just as impor-
tant, I think, to having a rea-
sonable quality of life after the
diagnosis and treatment of oral
cancer is early detection.
I am using Oral CDx in my
practice, and my patients are
very pleased that I am. I have
multitudes of patients present-
ing with leukoplakias and other
benign-looking areas in the oral
cavity. I have seen them every
six months, some for even 25
years now. I did not recommend
surgical biopsy of these areas at
every recall appointment. First,
after one or two biopsies, they
would most surely have ignored
my advice thereafter. Second,
since the overwhelming major-
ity of these lesions are benign,
surgical excision of every one of
808 JADA, Vol. 133, July 2002
Copyright ©2002 American Dental Association. All rights reserved.
these lesions is impractical and
unwarranted.
A prudent course has been to
watch them, dare I say, maybe
even the standard of care. So
why now is it not acceptable to
monitor these lesions at the
cellular level and properly
guide patients for treatment at
the appropriate time and in an
accepting frame of mind to fol-
low your instructions for their
care?
My experience with this sys-
tem and the company is such
that I have volunteered to pre-
sent information related to
using this system to fellow den-
tists. I have made presentations
to over 100 dentists in the cen-
tral Pennsylvania area at my
own expense—no honorariums,
no travel expense reimburse-
ment and with the provision of
support materials only from
OralScan Laboratories. I hope
and am confident that every
general dentist is wise enough
to see for himself or herself that
this system makes sense and,
above all, that it’s the right
thing to do!
OralCDx is an excellent tool
for early cancer detection and
its use must be encouraged
often and openly by all dental
professionals.
Steven M. Parrett, D.D.S.,
F.A.G.D.
Chambersburg, Pa.
HIV AND ‘DIRECT THREAT’
Mr. Peter Sfikas’ March JADA
article, “HIV and Discrimi-
nation,” is interesting on many
levels. First, it illustrates the
lack of commonality with the
courts and juries. Second, it re-
veals that terms like “direct
threat” and “significant risk”
are undefinable even though
courts have tried. Third, that
scientific information is never
an obstacle to poor decisions.
And fourth, that patients are
presumed to have more rights
than medical/dental practi-
tioners.
While this situation is sad
and regrettable, what’s more
disturbing is the ADA’s position
coming down on the side of lim-
iting its members’ decision-
making ability. Listen to some
of the absurd rulings emanating
from courts, rulings supported
by our organization.
To quote Mr. Sfikas’ article,
“courts have held that because
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there is no ‘direct threat,’
providers have a legal duty to
treat infected patients” and
“courts perceived virtually no
HIV-transmission risk” in rou-
tine dental care. Evidently scal-
ing and root planing are not
routine since the court ruled
against Waddell. How inept
does this make us look!
All of this reinforces my be-
lief that clinical judgments need
to be made at the source, not in
Washington or the courts.
Peter M. Muehleis, D.D.S.
Sheboygan, Wis.
Author’s response: Dr.
Muehleis certainly points out a
number of issues that can arise
when courts engage in inter-
preting scientific information. I
am pleased that the article clar-
ified for him that the courts
have applied a double standard
when it comes to “direct threat,”
depending on whether it is the
patient or provider who is in-
fected. That is a key reason
why, since my article was pub-
lished, the ADA filed a brief
supporting Spencer Waddell’s
petition for the U.S. Supreme
Court to hear his case.
I must respectfully take issue
with Dr. Muehleis, however, re-
garding his view that the ADA

supports limiting dentists’ deci-
sion-making ability. Protecting
the dentist’s right to exercise
professional judgment within
the context of generally accept-
ed scientific knowledge is at the
core of our policies. We fight
vigorously in a variety of
arenas—HIV, amalgam, our
parameters of care, to name a
few—to protect that right.
Peter M. Sfikas, J.D.
ADA Chief Counsel
Chicago
PERIODONTAL DISEASE
Thank you for publishing the
results of Dr. Loesche and col-
leagues’ landmark study (“The
Nonsurgical Treatment of
Patients With Periodontal
Disease: Results After Five
Years,” March JADA). As prac-
titioners, it is our obligation to
do not simply what we are good
at, but rather that which is good
for our patients.
The advances in conservative
periodontal therapy clearly indi-
cated by this work will in no
way threaten the specialized
practice of periodontics, but in-
stead will allow for a great ele-
vation of the science in the
same way that medical cardiol-
ogy has broadened and elevated
that field.
Congratulations to JADA for
taking the challenge of publish-
ing what some might consider
controversial works. Our future
lies in our willingness to accept
and encourage growth and im-
provement. Only by participat-
ing in the medical treatment of
oral disease will we earn the
right to continue our role as
doctors rather than become rel-
egated to technician status.
The choice is ours. Let’s
choose our future.
David J. Ahearn, D.D.S.
Westport, Mass.
Copyright ©2002 American Dental Association. All rights reserved.
CONSISTENT RESULTS
I commend Dr. Loesche and col-
leagues for their article, “The
Nonsurgical Treatment of
Patients With Periodontal
Disease: Results After Five
Years” (March JADA).
The results of this study are
certainly consistent with what
we currently understand to be
the therapeutic endpoints of
nonsurgical periodontal thera-
py.1,2 The inclusion of the sys-
temic antimicrobials metronida-
zole or doxycycline further
enhanced this success as noted
by the authors. Though I am
aware that surgical therapy was
considered and potentially rec-
ommended by one examiner, my
particular concern is the obser-
vation of the authors categoriz-
ing surgical therapy into a sin-
gle “traditional” grouping.
This simplification of surgery
as an either/or choice is not a
service to the dental profession.
The authors state “[our] results
would indicate that patients
have a choice in treatment op-
tions: either the traditional ap-
proach of surgery or extraction
of hopeless teeth, or an ap-
proach based on an antimicro-
bial strategy.” The 2001
Glossary of Periodontal Terms
defines periodontal surgery as
“any surgical procedure used to
treat periodontal disease or to
modify the morphology of the
periodontium.”3
This surgical modification in
morphology can entail many dif-
ferent techniques with varied
goals. These techniques can in-
clude replaced flap surgery, re-
sective flap surgery or regenera-
tive flap surgery. These
procedures, correctly planned
and expertly performed, can re-
sult in a form and function of
periodontal support that is
L E T T E R S
more conducive to routine main-
tenance. The resulting reduc-
tion in probing depths and the
gain in clinical attachment lev-
els that results from such cor-
rective periodontal surgical
treatment(s) is a therapeutic
endpoint oftentimes unachiev-
able by a sole nonsurgical
approach.4
Successful therapeutic inter-
vention, whether it be nonsurgi-
cal or surgical in nature, needs
to be evidence-based. “The evi-
dence-based medicine method of
answering clinical questions in-
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volves searching the literature
for relevant studies, assessing
study quality, interpreting the
findings and applying them in
light of patients’ preferences
and societal values.”5
I appreciate and applaud the
study in question adding to our
evidence-based body of knowl-
edge. However, the dental pro-
fession needs to be wary of that
old adage, “If all you have is a
hammer, the whole world looks
like a nail!”
Col. Mike Cuenin, D.M.D.
Director, U.S. Army
Periodontic Residency
Program
and Consultant to
The Surgeon General
in Periodontology
Fort Gordon, Ga.
1. Cobb CM. Non-surgical pocket therapy:
mechanical. Ann Periodontol 1996;1(1):443-
90.
2. Drisko CH. Non-surgical pocket therapy:
pharmacotherapeutics. Ann Periodontol
1996;1(1):491-566.
3. American Academy of Periodontology.
Glossary of periodontal terms. 4th ed.
Chicago: American Academy of Periodon-
tology;2001.
4. Harrel SK, Nunn ME. Longitudinal com-
parison of the periodontal status of patients
with moderate to severe periodontal disease
receiving no treatment, non-surgical treat-
ment, and surgical treatment utilizing indi-
vidual sites for analysis. J Periodontol
2001;72(11):1509-19.
5. Guyatt GH, Rennie D. Users’ guides to
the medical literature. JAMA 1993;270(17):
2096-7.
JADA, Vol. 133, July 2002 809
L E T T E R S
Author’s response: I thank
Col. Cuenin for his kind com-
ments concerning our study. I
truly appreciate his remarks
testifying that our study is con-
sistent with the “therapeutic
endpoints of nonsurgical peri-
odontal therapy,” and that our
study adds “to our evidence-
based body of knowledge.”
However, he takes exception,
and properly so, with our “cate-
gorizing surgical therapy into a
single ‘traditional’ grouping.”
He notes that surgery consists
of that used to gain access to
the plaque and calculus-laden
tooth surfaces so as to treat
periodontal disease, and that
used to modify the morphology
of the periodontium. Our study
involved the use of access
surgery, and, while we thought
that it would be understood that
this is the only type of surgery
that is presented to a newly di-
agnosed periodontal patient, it
is appropriate that Col. Cuenin
calls on us to make this distinc-
tion between periodontal access
surgery and periodontal plastic
surgery.
Col. Cuenin expresses con-
cern when he states that “sim-
plification of surgery as an
either/or choice is not a service
to the dental profession.” We
stated that our “results would
indicate that patients have a
choice in treatment options: ei-
ther the traditional approach of
[access] surgery or extraction of
hopeless teeth, or an approach
based on an antimicrobial
strategy.”
Why giving patients a choice
“is not a service to the dental
profession” is not clear to me.
Many individuals who contact
me indicate that they are not
given a choice when they are
told that they have advanced
forms of periodontal disease,
810 JADA, Vol. 133, July 2002
Copyright ©2002 American Dental Association. All rights reserved.
but are only offered access sur-
gical therapy, which most of
these individuals decline. It
would seem to be a service to
the dental profession to be able
to offer these individuals with
advanced disease a treatment
option based on an antimicro-
bial approach.
I appreciate Col. Cuenin’s
comments and the opportunity
to clarify that the surgery that
we referred to in our report was
access surgery, and not those
forms of surgery that seek to re-
store form and function to the
periodontal tissues.
Walter J. Loesche, D.M.D.,
Ph.D.
Marcus Ward Professor
Emeritus of Dentistry,
School of Dentistry
Professor Emeritus of
Microbiology and
Immunology,
School of Medicine
University of Michigan
Ann Arbor
ANTIMICROBIAL APPROACH
I agree with the conclusion of
Dr. Walter Loesche and col-
leagues that patients now have
a choice in treatment options:
surgery or extraction, or treat-
ment based on an antimicrobial
approach (“The Nonsurgical
Treatment of Patients With
Periodontal Disease: Results
After Five Years,” March
JADA).
I have been treating patients
with moderate to advanced peri-
odontal disease since 1979 with
an antimicrobial approach, and
I know that teeth can be saved
without surgery. While metro-
nidazole and doxycycline are ex-
tremely useful toward this end,
a successful reduction of peri-
odontal pathogens can be ac-
complished without the use of
systemic or local antibiotics.
This is especially important
when private-practice patients
refuse antibiotics or cannot take
them.
Metronidazole, for example,
is contraindicated if a patient
uses alcohol or is taking lithium
or coumadin. Doxycycline is
contraindicated if a patient
takes digoxin, while antacids
and gastroesophageal reflux
disease medications may impair
doxycycline absorption. And
antibiotics, as we know, can
decrease the efficacy of oral
contraceptives.
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Periodontal microorganisms
can be reduced effectively with
preliminary pocket irrigation
using PVP-iodine,1 followed by
full-mouth (not quadrant) scal-
ing and root planing, or SRP,2,3
utilizing ultrasonics4,5 with an
antiseptic irrigant such as
chlorhexidine.6 The use of non-
steroidal anti-inflammatory
drugs, both topical and sys-
temic, also has been shown to
reduce the alveolar bone loss of
periodontal disease.7 As Dr.
Loesche indicated, during the
active periodontal treatment
phase, SRP should take place
several times over a period of
several months. I typically see
patients every two to three
weeks over a three-to four-
month period.8
Then, to maintain low levels
of bacteria commensurate with
periodontal health, supportive
periodontal treatments should
be scheduled every three
months. A rigorous but realistic
home care program including
pulsed oral irrigation9,10 is es-
sential. This nonsurgical proto-
col is extremely effective in
eliminating periodontal infec-
tion and inflammation and ar-
resting moderate to advanced
periodontitis without the use of
antibiotics.

During both the treatment
and the maintenance phase, Dr.
Loesche makes no mention of
any home care regimen or pa-
tient compliance. It has been
my observation that nonsurgical
periodontal treatment, either
with or without antibiotics, will
not be successful without a
structured, detailed and compli-
ant home care schedule that in-
cludes dietary recommendations
or supplements.11,12
Stephen Z. Wolner, D.D.S.
New York
1. Rosling B, Hellstrom MK, Ramberg P,
Socransky SS, Lindhe J. The use of PVP-
iodine as an adjunct to non-surgical treat-
ment of chronic periodontitis. J Clin
Periodontol 2001;28(11):1023-31.
2. Quirynen M, Bollen CM, Vandekerckhove
BN, Dekeyser C, Papaioannou W, Eyssen H.
Full- vs. partial-mouth disinfection in the
treatment of periodontal infections: short-
term clinical and microbiological observa-
tions. J Dent Res 1995;74(8):1459-67.
3. Mongardini C, van Steenberghe D,
Dekeyser C, Quirynen M. One stage full-
versus partial-mouth disinfection in the treat-
ment of chronic adult or generalized early-
onset periodontitis, I: long-term clinical obser-
vations. J Periodontol 1999;70(6):632-45.
4. Walsh TF, Waite IM. A comparison of
postsurgical healing following debridement by
ultrasonic or hand instruments. J Periodontol
1978;49(4):201-5.
5. Drisko CL, Cochran DL, Blieden T, et al.
Position paper: sonic and ultrasonic scalers in
periodontics. Research, Science and Therapy
Copyright ©2002 American Dental Association. All rights reserved.
Committee of the American Academy of
Periodontology. J Periodontol
2000;71(11):1792-801.
6. Reynolds MA, Lavigne CK, Minah GE,
Suzuki JB. Clinical effects of simultaneous
ultrasonic scaling and subgingival irrigation
with chlorhexidine: mediating influence of
periodontal probing depth. J Clin Periodontol
1992;19(8):595-600.
7. Jeffcoat MK, Reddy MS, Haigh S, et al. A
comparison of topical ketorolac, systemic flur-
biprofen, and placebo for the inhibition of
bone loss in adult periodontitis. J Periodontol
1995;
66(5):329-38.
8. Sbordone L, Ramaglia L, Gulletta E,
Iacono V. Recolonization of the subgingival
microflora after scaling and root planing in
human periodontitis. J Periodontol 1990;
61(9):579-84.
9. Walsh TF. Pulsed oral irrigation in the
management of inflammatory periodontal dis-
eases. Dent Update 1993;20(2):65, 67-8, 70-1.
10. Frascella JA, Fernandez P, Gilbert RD,
Cugini M. A randomized, clinical evaluation
of the safety and efficacy of a novel oral irriga-
tor. Am J Dent 2000;13(2):55-8.
11. Krall EA, Wehler C, Garcia RI, Harris
SS, Dawson-Hughes B. Calcium and vitamin
D supplements reduce tooth loss in the elder-
ly. Am J Med 2001;111(6):452-6.
12. Nishida M, Grossi SG, Dunford RG, Ho
AW, Trevisan M, Genco RJ. Calcium and the
risk for periodontal disease. J Periodontol
2000;71(7):1057-66.
ROOT TIPS
I enjoyed the creative and
nicely documented technique
for removing fractured root
tips in Dr. Kenneth Stoner’s
“Using a Hedström Endodontic
File to Retrieve a Root Tip”
L E T T E R S
(April JADA).
As an endodontist, I have two
comments. First, something im-
portant is missing from the
photograph of the successfully
removed root tip: a floss liga-
ture to prevent the file from
being swallowed or aspirated if
it should be dropped accidental-
ly in the retrieval attempt.
Second, although H-files are
more aggressive in their en-
gagement of the root, they are
well-known for their tendency
to separate under torsional
loads. It is possible that an op-
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erator less familiar with the in-
strument in this application
might be more “safe” using a
K-file of similar size.
Although I no longer extract
root tips, I’m sure there are
plenty of clinicians who will ap-
preciate Dr. Stoner’s technique.
Stephen M. Weeks, D.D.S.
Clinical Assistant
Professor
Department of
Endodontics
University of Illinois at
Chicago
College of Dentistry
JADA, Vol. 133, July 2002 811