Clinical Success in Management of Advanced Periodontitis.

Clinical Success in Management of Advanced Periodontitis 

by Roger Detienville, DDS. Paris: Quintessence International; 2005.

110 pages. ISBN 2-912550-41-6

THIS VERY COLOURFUL SOFT-COVERED textbook has 110 easy-to-read pages that include numerous case descriptions of individuals with advanced periodontitis. Each case includes multiple coloured glossy intra-oral photographs and radiographs along with a description of the case, its treatment, and its outcome capturing the multi-factorial nature of periodontal disease. It also includes an excellent description of biofilms and bacterial complexes, i.e., red complex, orange complex, green and yellow complexes, along with a brief review of host-bacterial interactions. A review of the most current AAP classification (1999) of periodontal disease is presented. However, the author indicates that he has limited the cases and discussion in the text to just chronic and aggressive cases of periodontitis, excluding cases of periodontitis associated with systemic disease. Given that most cases of periodontitis associated with systemic disease are "advanced" cases of periodontitis, the exclusion of this category somewhat limits the effectiveness of the text. Inclusion of advanced cases of periodontitis, particularly those associated with uncontrolled diabetes and AIDS, would have been more inclusive of what is found in practice.

The author makes a global statement that periodontitis is a risk factor for a variety of systemic diseases such as cardiovascular disease, atherosclerosis, pulmonary diseases, and pre-term low birth weight babies. Although a substantial number of cohort and case control studies exist that demonstrate higher odds ratios for the occurrence of these systemic diseases in individuals with periodontal disease, no causal relationship has been established for any of these systemic conditions. Thus the use of periodontitis as a "risk factor" for these diseases is misleading.

The book includes both non-surgical and surgical treatment of advanced cases of periodontitis with excellent photographs of some select surgical cases. The treatment protocol for non-surgical cases suggested by the author is not referenced nor could it be found in the periodontal literature. He suggests four to six initial therapy appointments of scaling and root planing specifically without anesthesia with the rationale of not being too invasive, i.e., avoiding tissue damage. He also includes standard polishing at the end of this therapy. After re-evaluation, he suggests more aggressive therapy with the use of local anesthesia and the application of surgical dressings. The current standard of non-surgical periodontal therapy cited in the literature continues to include the use of local anesthesia at quadrant or sextant initial therapy appointments with the intent to remove all etiological factors to promote a good healing response. Furthermore, there is no substantial evidence in the literature to support the beneficial effects of routine polishing except for esthetic reasons. Most North American dental hygiene schools therefore teach "selective polishing" as opposed to routine polishing. The use of surgical dressings is also no longer supported in the scientific literature. Treatment options presented in textbooks should be supported by scientific studies.

One excellent non-surgical treatment option that is well documented in the periodontal literature is two-stage initial therapy performed within 48 hours. Unfortunately, this treatment option is not mentioned at all. Additionally, the use of locally delivered chemotherapeutic agents such as doxycyline, minocycline, or chlorhexidine as adjunctive treatment options was not included. Despite the fact that these local agents have been shown to be more effective in mild to moderate cases of chronic periodontitis rather than advanced cases, a discussion would have helped to clarify their lack of usefulness in advanced cases. A good discussion was included of the use of systemic antibiotics. However, there was no mention of low-dose enzyme suppressants such as doxycycline hyclate that have recently been documented in the literature demonstrating considerable efficacy.

Overall, perhaps the treatment methods discussed in this text reflect the differences in philosophies between North American and European treatment protocols. However, the American Academy of Periodontology represents world-wide periodontal literature and many excellent published trials are of European origin. I would not recommend this textbook for dental hygiene students as recommendations in the text conflict with the periodontal literature. However, for a practising dental hygienist who would like to review some good advanced cases, it could be very helpful and informative. Study clubs seeking good cases to discuss could also benefit from this very colourful and easy-to-read textbook.

--Salme Lavigne, RDH, BA, MS(DH)

Professor and Director

School of Dental Hygiene, University of Manitoba