DTUS1410

Opinion Feedback DENTAL TRIBUNE | May 20106A ing natural teeth, when treated with traditional periodontal surgery, have excellent long-term prognoses (Lindhe and Nyman, J Clin Perio 1984). The fact that implant surfaces and designs are changing so rap- idly makes it difficult to find any comparable long-term statistics for implants currently being placed. Moreover, currently used implants, like natural teeth, can and do develop bone loss (peri-implantitis), which has been documented to be more prevalent than formerly believed. In fact, in a recent consensus report and literature review authored by Lindhe and Meyle and published in the Journal of Clinical Peri- odontology 2008, they cite two cross-sectional studies documenting that peri-implant mucositis occurred in 80 percent of the subjects and in 50 percent of the implant sites. Peri-implantitis was identified in 28 percent and greater than 56 percent of subjects and in 12 percent and 43 percent of implant sites, respectively. This was corroborated by a more recent study (Koldstand, J Perio 2010) that documented a prevalence of peri-implantitis of 11.3 to 47.1 percent. This, combined with the results of two long-term stud- ies — Pjetursson (2004), who reported that 38.7 percent of patients had complications in the first five years after implantation; and Lang (2004), who reported that biological and technical complications with implant-supported restorations occurred in about 50 percent of the cases after 10 years in function — should dispel any beliefs that implants are a trouble-free panacea when compared to retention of teeth that require periodontal treatment. As for your contention that new procedures, i.e., wavelength opti- mized periodontal therapy (WPT) and the LANAP procedure using a Nd:YAG (neodymium: yttrium aluminum garnet) laser present mini- mally invasive alternatives for patients who want to keep their teeth without “heavily invasive periodontal surgery,” I again refer to the dental profession’s reliance on evidence-based data before recom- mending new treatment modalities. I ask you: Where’s the proof that these modalities are as or more effective than what has been proven through evidence? Before using any new modality, any dentist should have histologi- cal, clinical and long-term proof that these procedures are effective. Many therapies are “minimally invasive” but useless for effective periodontal treatment. Dr. Malcmacher, I’ve been performing and teaching periodontal therapy for over 35 years and have seen trendy, minimally invasive and “easy” therapies fall by the wayside when clinically tested in ran- domized controlled studies. The Keyes technique, many time released local antibiotics (i.e., chlorhexidine in a gelatin chip, tetracycline fibers, doxycycline hyclate in a polymer carrier or minocycline micro- spheres) and even lasers were tested scientifically and found to yield little, if any, improvement over traditional scaling and root planning (without surgical therapy). Utilizing ineffective therapies to avoid traditionally effective ones oftentimes results in progression of the disease around teeth that, when finally referred to a periodontist, are truly hopeless and have no other option but extraction. However, the proper use of surgical regenerative procedures, with a variety of grafts and membrane barriers, have shown that bone and soft tissue that had been lost due to periodontal disease can be regen- erated and questionable teeth saved. This has been well documented over the last 30 years. New products, i.e., tissue healing modulators, growth factors (BMP- 2) and even stem cells, are promising additions to currently proven materials and techniques but require evidence-based research, which in many cases is currently being performed before being recommend- ed as replacement materials. I feel that general practitioners and periodontal specialists should be co-therapists in patient treatment. The decision to extract or attempt to save a tooth should be made by the dental team, not by one quarterback. I feel the periodontal specialist is in the best posi- tion to advise the referring dentist of the risks, options and treatment required to save a tooth or teeth. I don’t see many patients who come to my office or the New York University Dental Center clinic who would rather have an implant than a healthy functioning tooth. That’s why I advocate saving teeth, and periodontists are trained to save teeth. There certainly are circumstances where extraction and implant placement is indicated and, here too, periodontists should be part of the team involved in these decisions and procedures. Periodontists have always been involved with soft- and hard-tissue esthetics around teeth and implants, and certainly have the experience and expertise in both areas. It would be best for the patient and treating team to be on the same page when it comes to knowing the options, risks, benefits, anticipated results and potential complications before any implant treatment option is considered. You concluded with the statement: “You are the dental clinician, so it is for you, the periodontist and the patient to decide.” I couldn’t agree more, but the decision should be based on sound evidence- based data that is currently available rather than promises or hype from any company with minimal scientific long-term data to back up their claims. So again, to answer your question, “Where did all the periodontists go?” “We’re here and available for a team approach to predictable dentistry.” I urge you and your readers to attend the Joint Periodontal-Restor- ative Dentist Conference that will be held in Chicago in April 2011 to see first hand how this collaboration can work. I also direct you to a book I edited, “Dental Implant Complications — Etiology, Pre- vention and Treatment,” that will be published by Wiley-Blackwell within the next two months (www.wiley.com/WileyCDA/WileyTitle/ productCd-0813808413.html). The latter is a comprehensive textbook discussing potential implant complications and how to avoid them. This should be of interest to all dental practitioners be they general dentists or specialists. The book emphasizes the team approach to avoiding unwanted complications and results. If you have any questions or comments, please do not hesitate to contact me. Best Regards, Stuart J. Froum, DDS, PC • Diplomate of the American Board of Periodontology • Diplomate of the International Congress of Oral Implantology, Periodontics and Implant Dentistry • Clinical Professor and Director of Clinical Research Dept. of Periodontology and Implant Dentistry at New York University College of Dentistry New York, N.Y. 10019-5404 Tel. (212) 586-4209 www.drstuartfroum.com f DT page 5A Subject: RE: Where did all the periodontists go? | Dental Tribune International Date: Mon, 10 May 2010 From: Louis Malcmacher To: Dr. Stuart J. Froum CC: r.goodman@dental-tribune.com Hi Dr. Froum, Thanks for your detailed response. I agree with most of what you say. My article was clearly just an observation, I did not make any judgments or arguments whether the periodontists who prefer implants over natu- ral teeth or vice versa were correct or incorrect, that was not the issue and indeed it is up to every dental and periodontal clinician to decide for themselves. My objective was to get the conversation going about critically think- ing through these clinical decisions, offering options to patients based on their needs and desires, and cause the dental community to realize that there is a change going on and to be proactive rather than reactive to treatment decision making. Based on your excellent response and the many others I received from dentists and periodontists on both sides of the “implant vs. teeth” controversy, I feel that the article has succeeded in bringing the discus- sion to the forefront. Thanks and have a great day! Louis Malcmacher DDS, MAGD Tell us what you think! Do you have general comments or criticism you would like to share? Is there a particular topic you would like to see more articles about? Let us know by e-mailing us at feedback@dental-tribune.com. If you would like to make any change to your subscription (name, address or to opt out) please send us an e-mail at database@dental-tribune.com and be sure to include which publication you are referring to. Also, please note that subscription changes can take up to 6 weeks to process.