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Are We Removing Too Many Teeth?

As dentists have gained confidence with the long-term success of implants, the use of these devices has increased.

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As dentists have gained confidence with the long-term success of implants, the use of these devices has increased. While this is often the treatment of choice for patients with severe periodontitis, it seems that, with increasing frequency, teeth with moderate bone loss are being removed and replaced. This has led to extractions of teeth that could have been successfully treated and maintained in health and function.

Recently, the pendulum has swung back to a more conservative approach. Practitioners are now retaining teeth with moderate or, in some cases, severe periodontal disease. This trend has been supported by new techniques and materials for treating teeth that previously would have been extracted.

Of course, the root of the issue is the lack of early diagnosis and appropriate treatment of periodontal disease. It is unfortunate, but true, that many clinicians do not routinely probe their patients. Treatment for the early stages of periodontal disease (3 mm to 4 mm pockets) should include behavior modification to encourage appropriate oral hygiene techniques, along with closed subgingival scaling and root planing. This should be followed by an evaluation of the efficacy of treatment before the use of antibiotics, antimicrobials, lasers and other advanced therapeutics.

A COMBINATION OF IMPROVED VISUALIZATION AND MATERIALS THAT ENCOURAGE REGENERATION HAS LED TO MORE PREDICTABLE OUTCOMES WHEN TREATING PATIENTS WITH MODERATE TO SEVERE PERIODONTITIS

The complete removal of calculus and biofilm in deep pockets is difficult, to say the least. Unfortunately, roots that have been insufficiently debrided allow disease to progress. This typically results in a slow, but inexorable, loss of bone. In many cases, by the time the patient learns of the problem, the severity of the defect requires tooth extraction or advanced periodontal therapy. The basic concepts and some of the techniques used to treat moderate to severe periodontitis were introduced about the same time as implants. This approach emphasizes the complete removal of calculus and biofilm, along with the use of materials and products (such as barrier membranes) designed to exclude epithelial down growth. The generic name for these techniques is guided tissue regeneration.

Newer treatments, which include enamel matrix derivatives and platelet-derived growth factor (among other approaches), have increased success rates. Recent advances in subgingival visualization, including dental endoscopes and videoscopes, allow practitioners to effectively remove calculus from affected root surfaces. A combination of improved visualization and materials that encourage regeneration has led to more predictable outcomes when treating patients with moderate to severe periodontitis. And, in fact, recent studies have shown good long-term success with these therapies.

We can keep more teeth with this five-step approach. (1) Probe early and often. (2) Encourage improved oral hygiene. (3) Perform adequate closed subgingival scaling and root planing in cases of mild periodontitis (3 mm to 4 mm pockets). (4) Monitor the results with periodic probing at maintenance visits. (5) In more advanced cases, make sure the patient has access to advanced therapies — either in your office or a specialist’s — when bone loss continues.

If more clinicians were to adopt these measures, we could keep the pendulum swung toward preserving periodontally involved teeth whenever possible.

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