Controversies in Periodontics - Rapid review

Controversies in
Periodontics
Dr. Abhay Kolte
Professor & Head, Department of Periodontics & Implantology
VSPM Dental College & Research Centre, Nagpur.
Dr. Amit Agrawal
Professor & PG Guide
Department of Periodontics & Implantology
MGV’s KBH Dental College and Hospital,
Nashik.
Under the guidance of:

No great advancement has ever been
made in science, politics, or religion,
without controversy.
-Lyman Beecher

• Classification
• Pathogenesis
• Diagnosis
• Prognosis
• Mobility
• Curettage
• Full-mouth disinfection
Index
(Controversies related to)

• Systemic antimicrobials
• Postsurgical antimicrobial
• Non-surgical versus surgical
• Periodontal pack
• Periodontal-endodontic relationship
• Implant therapy
• Conclusion

Why do we have controversies ?
 Lack of complete knowledge & understanding.
 Over dependence on historical data.
 Lack of well controlled, high standard clinical
trials
 Lack of critical meta analyses.
 Innate refusal to change our ideas with the
progress of time.

Classification of periodontal diseases
Controversies Related To

 Should we follow 1999 classification or recent 2017
classification?
 Is it practically possible to use 2017 classification so
widely or so easily even by general practitioners ?
 Why there is no separate category of aggressive
periodontitis in AAP 2017 classification?
 Gingival inflammation on reduced periodontium
(postop or recessed gingiva) should be diagnosed as
periodontitis?
Controversy :

• One of the interesting historical features of classification
systems is the often intense resistance to their
modification.
• Classification systems should be viewed as dynamic
works-in-progress that need to be periodically modified
based on current thinking and new knowledge.
• Unfortunately, it seems that once people learn and accept
a given classification, no matter how flawed it may be,
they are extremely reluctant to accept revisions to their
favourite system of nomenclature.

The staging and grading of periodontitis is descriptive of
not only the extent and severity of the disease, it is also
provide complexity of:
 treating the case,
 disease progression and the patient's systemtic status,
which helps to assess the prognosis and
 risk assessment of the patient.
Classification of periodontal diseases 2017 classification

There is no clear cut demarcation between chronic and
aggressive periodontitis
But the limitations are application of this classification for
epidemiological surveys (due to the extensive nature of the
classification) and also implementation into dental practice (as
most of the clinicians are general dentists.)
Classification of periodontal diseases 2017 classification

Periodontal Pathogenesis

In the 20th century, one or a group of specific
microorganisms were identified as the pathogen of
periodontitis by isolation and culture studies.
So the role of “red complex” was believed as the most
representative theory of periodontitis pathogenesis in
the late 1980s to 1990s. (Holtz et al 1988, Socransky et al 1998)

However, with deeper immunological research, the
important role of the local host immune response in the
pathogenesis of periodontitis was revealed. (Darveau et al
2010)

In addition, new data obtained from meta’genomic and
meta’transcript’omic studies suggested that a more
complicated microbial community is involved in the
pathogenesis of periodontitis rather than one or several
specific pathogenic bacteria. (Jiao et al 2013, Abusleme et al 2013)

Many studies have found that single nucleoid polymorphisms in
cytokines and associated receptor-encoding genes are related to
the risk and severity of periodontitis, which indicates that the
disordered regulation of cytokines initiates or accelerates
periodontitis. (Ding et al 2014, Li et al 2014)

Diagnosis of Periodontal Diseases

Diagnosis of periodontal diseases
 How good are the conventional diagnostic methods?
 Are the indices employed useful in clinical practice?
 Can the etiological factors be established consistently?
Controversy :

 The current diagnostic methods does rely too much on
historical/past events. (CAL/PPD/BONE LOSS)
 With the current diagnostic methods factors cannot
always be established
 In many situations such as trauma from occlusion,
environmental risk factors, the effect can not be
established accurately.
Facts:

At present we do not have a predictable
methods to evaluate disease activity.
 Diseases susceptibility is again difficult to
determine.
Borderline cases continue to pose problem.
Position:

Evidence:

Prognosis of periodontal diseases

With the current understanding of disease
process, can periodontal disease prognosis be
determined accurately?
Do we have an evidence based model to
determine prognosis?
Should prognosis be determined in initial
examination?
Controversy :

 The complexity of periodontal pathology and the
incomplete understanding of the same precludes the
clinician in determining the prognosis accurately.
 Few systematic reviews & meta analysis lead us to
believe that prognosis prediction is accurate only when
extremities are considered viz very good, or hopeless
 At present we do not have an evidence based model to
assist in the determination of prognosis.
Facts:

 Conflicting data reported in various studies precludes the
clinician in making an accurate determination of
prognosis except in well-defined cases.
 Prognosis determination should not be rigid & should be
reviewed following successive stages of treatment.
Position:

Evidence:

Tooth mobility & splinting

 Does tooth mobility indicate poor prognosis?
 Are mobile teeth more prone for periodontal
breakdown?
 Should all mobile teeth be splinted?
 Is the therapeutic outcome different between mobile &
non mobile teeth?
Controversy :

 Mobile teeth shows increased bone loss over a period of 10
years
 Poorer healing response after periodontal treatment
compared to firm teeth
 Control of tooth mobility with splinting after osseous
surgery did not reduce mobility of the individual teeth.
(Kegel et al. 1979)
 Mobility can be controlled and managed with splinting and
will improve periodontal prognosis. (Pollack 1999)
Facts:

 Non-progressive tooth mobility not always indicate
poor prognosis.
 Better to have firm teeth while planning regenerative
procedures.
 Provisional splinting to facilitate instrumentation.
Position:

Evidence:

Gingival curettage

Gingival curettage
 Should gingival curettage be considered as a
separate procedure in treatment plan?
 Does it have any advantage over SRP?
 Can the results of curettage be maintained over a
period of time?
Controversy :

 Gingival curettage provides no additional benefit
when compared to SRP alone in terms of PD
reduction, CAL gain or inflammation reduction
 Also, it is a blind procedure does not afford the
improved root surface access and visibility gained
with flap surgery that is mandatory to achieve
complete mechanical removal of biofilm and
accretions.
Facts:
The American Academy of Periodontology statement regarding gingival curettage. J
Periodontol 2002; 73: 1229-1230.
Gingival curettage

 SRP alone produces results that are clinically
equivalent to curettage + SRP
 ADA has deleted the code from the fourth edition of
Current Dental Terminology (CDT-4)
 AAP Guidelines for Periodontal Therapy, did not
include gingival curettage as a method of treatment
Position:
Gingival curettage

One stage full-mouth disinfection versus
quadrant SRP

One stage full-mouth disinfection versus quadrant SRP
 Is full mouth disinfection significantly superior to
the standard quadrant SRP?
Controversy :

 FMDT reduced number of treatment visits.
 FMDT reduced cost of therapy.
 FMDT improved clinical and microbiological results.
 When FMDT was compared to quadrant SRP, the
largest PD reductions and gains in CAL occurred at ≥ 7
mm deep pockets (Quirynen et al. 1995)
Facts:

 Lack of convincing evidence to support that FMDT
approach superior to traditional quadrant-wise
therapy.
 Less time-consuming, yet equally efficacious
clinically as the standard quadrant SRP. (Koshy et al.
2005, Wennstrom et al. 2005)
 Determine time availability, clinical workload &
patient preference while selecting Rx modality.
Position:

Evidence:

Systemic antimicrobials in periodontal
therapy

Systemic antimicrobials in periodontal therapy
 Which periodontal conditions require systemic
antimicrobials?
 How severe does the periodontal infection have to
be in order to justify the use of an antimicrobial
agent?
 Should they be given to all individuals? If not, then
who should receive these agents?
Controversy :

 Additional benefit of adjunctive antimicrobials over
SRP alone in terms of CAL gain & PD reduction,
particularly at initially deep periodontal pockets
(Herrera et al. 2002)
 Antibiotic provided significantly better CAL gain of
0.3–0.4 mm at 6 months post-therapy than the
comparison groups not receiving antibiotic. (Haffajee et
al. 2003)
 Valuable in the treatment of aggressive periodontitis
in adolescents, especially cases predominated by A. a.
(Slots & Schonfeld 1991)
Facts:

 Systemic antimicrobials are indicated in patients
who show progressive attachment loss despite
mechanical therapy.
 Aggressive periodontal conditions benefit from this
therapy.
Position:

Evidence:

Postsurgical antimicrobial medication

 Should antimicrobials be prescribed regularly in
every case after periodontal surgery?
 If antimicrobials are prescribed, then which
one/combination?
 Do regenerative procedures benefit by antimicrobial
medication?
Controversy :

 Reduced post operative complications when
antibiotics given before periodontal surgery &
continued for 4 to 7 days after surgery (Ariaudo 1969; Dal
Pra & Strahan 1972)
 Post operative infection rates following periodontal
surgery without antibiotics 1 - 4.4% for routine
periodontal surgery 4.5% following implant surgery
(Gynther et al. 1998; Checchi et al. 1992)
Facts:

 Not mandatory to prescribe antimicrobials in an
otherwise normal patient if proper aseptic &
infection control procedures have been followed
 Literature data – Routine use of PO antibiotic
medication, whether indicated or not.
Position:

Evidence:

Non-surgical therapy

 Are the results of non surgical & surgical
approaches comparable?
 Are the results obtained following surgery
maintainable?
 Does surgery actually prolong the life of the
dentition?
Controversy :

 SRP reduce the amount of bacterial plaque &
calculus attached to subgingival root surface.
 Total elimination of all bacteria & calculus from
subgingival tooth surface is not possible with any
instrumentation techniques . (Anderson et al. 1996 Caffesse
et al. 1986)
Facts:

PPD Results
≤ 3 mm OFD results in more CAL loss than SRP
4–6 mm OFD results in less CAL gain than SRP
> 6 mm OFD results in more CAL gain than SRP

Both SRP alone and SRP+flap procedure are proven
to be effective methods for the treatment of chronic
periodontitis in terms of attachment level gain and
reduction in gingival inflammation.
In the treatment of deep pockets open flap
debridement resulted in greater PPD reduction and
clinical attachment gain.
Position:

Evidence:

Periodontal pack

Periodontal pack
 Is it mandatory to use periodontal dressings after
periodontal surgery?
 Which type of periodontal dressings is most
commonly recommended?
 Are there any adverse effects to use of periodontal
dressings?
 Are periodontal dressings plaque retentive?
Controversy :

 Protection of wound from mechanical trauma, stability
of the surgical site during healing process (Ariaudo and
Tyrell et al)
 Patient comfort during healing, good adaptation to
underlying gingival and bony tissue, prevention of
postoperative haemorrhage or infection, decreasing
tooth sensitivity.
 Dressing accumulates plaque.(Stahl et al)
 Greater pain experience, plaque accumulation, microbial
invasion. (Kidd and Wade et al)
Facts:
Periodontal pack

 Not mandatory to pack surgical sites in all.
 Complete healing can take place even without a
dressing, provided the surgical area is kept clean.
 There is no difference in healing between dressed and
non-dressed wounds.
 The choice of use of a periodontal dressing is a matter
of individual preference and the judgment of the
operator.
Position:
Periodontal pack

Periodontal-endodontic relationship

 Does periodontal disease cause pulpal necrosis?
 Does periodontal therapy cause pulpal changes?
 Do severely periodontally involved teeth with normal
vitality response, still require RCT as a prophylactic
measure?
 What is the effect of pulpless teeth on periodontal
tissues?
 Do endodontically treated teeth respond differently to
periodontal therapeutic procedures?
 Can periodontal regenerative techniques be attempted on
endodontically treated teeth?
Controversy :

 Periodontal disease & treatments should be regarded as
potential causes of pulpitis and pulpal necrosis.(Wang HL
et al. 2002)
 Pulpless tooth with a periapical lesion promotes the
initiation of periodontal pocket formation, progression of
periodontal disease, and interferes with healing of a
periodontal lesion after periodontal treatment. (Jansson L
et al. 1993, Simon JH et al. 2002)
Facts:

 Periodontal disease has no effect on the pulp, unless it
extends all the way to the tooth apex. The dental pulp is
capable of surviving significant insults and that the effect
of periodontal disease as well as periodontal treatment on
the dental pulp is negligible. (Czarnecki RT et al. 1979)
Facts:

 Perio endo lesions are very complex in nature and can
have varied pathogenesis.
 Treatment decision making and prognosis depend
primarily on the diagnosis of the specific endodontic
and/or periodontal diseases.
 To achieve the best outcome for these lesion, a multi
disciplinary approach should be involved.
Position:

Evidence:

Trauma From Occlusion

 Is TFO an etiological factor or cofactor for the
occurrence of periodontal diseases?
 Does TFO causes gingival recession?
Controversy :

 TFO the involved in the pathogenesis of Infrabony
pockets. Waerhaug (1979)
 A periodontium remains healthy despite the persistent
forces that caused the drifting of the teeth and
significant changes in occlusion. Wolffe et al. (1991)
Facts:

 Occlusal forces do not initiate periodontitis, results
are inconclusive on the interactions between
occlusion and the progression of attachment loss
due to inflammatory periodontal disease.
 Occlusal forces may be a cofactor in the
progression of periodontal disease and the
treatment of occlusal discrepancies may be a
beneficial adjunct to routine periodontal therapy.
Position:

Evidence:

Implant therapy in periodontally
compromised patients

Implant therapy in periodontally compromised patients
 Does a history of periodontitis have an effect on
the long-term prognosis of implants?
Controversy :

 Implants placed in partially edentulous patients are more at
risk for colonization with periopathogens emerging from
periodontal pockets . (Rose LF, Mealey BL2004)
 Significantly higher bone loss after insertion of the final
abutment in GAP patients as compared to CP patients over 3
years
 Incidence of periimplantitis in Periodontitis patients is 28.6%
& in Healthy patients is 5.8% (Karoussis et al. 2003)
 Mean peri-implant bone loss of >2 mm 64% of periodontitis
patients 24% of healthy patients. ( Hardt et al. 2002)
Facts:

 No contraindications for implant treatment in periodontitis
susceptible patients.
 Higher incidence of peri-implantitis may jeopardize
longevity of implant treatment.
 High survival rates for implants in individuals with h/o
periodontitis-associated tooth loss.
Position:

Evidence:

Additional Controversies Related To
 Periodontal – Systemic disease link (Periodontal
medicine)
 How much width of attached gingiva is adequate?
 Is periodontitis is age related ?
 Granulation tissue to be removed completely or not?
 Root biomodification should be done or not?
 Frenectomy – during/at the end/after ortho Rx ?
 Implantoplasty really works ?

• Summarizing a controversial topic is a big controversy
in itself !
• Although there are so many controversial topics in
periodontics, the choice of the treatment should be
made based on the individual patients need i.e. what
according to us will benefit the particular patient the
most and the our (clinician`s) skill, experience and
expertise.
Conclusion

When a thing ceases to be a matter
of controversy,
it ceases to be a
matter of interest.
William Hazlitt (1778-1830)

Controversies in Periodontics - Rapid review

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