NONSURGICAL TREATMENT OF GUM DISEASE: An Update
Interview with Dr. Thomas E. Rams
Healthfacts, August, 1988

Five years have gone by since the nonsurgical approach to periodontal disease received a considerable amount of attention in the health media. Pioneered by microbiologist Paul Keyes, D.D.S. during his 27 years at the National Institute of Dental Research, the technique involves a combination of professional and home care (see HealthFacts, April 1986). What made the so-called Keyes technique so controversial was its open challenge to the necessity for gum surgery as the ultimate treatment for periodontal disease, a cause of tooth loss. In the intervening years, research has supported this challenge, specifically for pocket elimination surgery which removes the inflamed gum tissue from the base of the tooth. Surgery offers no advantage over nonsurgical techniques concluded Sigurd P. Ramfjord, D.D.S., Professor Emeritus of Periodontics at the University of Michigan School of Dentistry, Ann Arbor, after conducting a five-year study and reviewing all other studies designed to assess its efficacy.

In a 1987 interview, Dr. Ramfjord told HEALTHFACTS that surgery is seldom warranted, except in the rare circumstance of extremely advanced disease. Such cases can benefit from flap surgery in which the gum tissue is not removed but placed aside for deep scaling and then stitched back into place. Harald Loe, D.D.S., the current director of the National Institute of Dental Research and a world renowned periodontist, also reviewed the subject and wrote in the Danish dental journal Tandlaegebladet, “Whether the competent clinician treats the advanced [periodontal] lesion surgically or nonsurgically really makes no difference.”

For an update on professional acceptance of non-surgical techniques, HEALTHFACTS interviewed Thomas E. Rams, D.D.S., a former co-investigator with Dr. Keyes at the National Institute for Dental Research and now a clinical assistant professor in postgraduate periodontics at the University of Pennsylvania School of Dental Medicine, and a practicing periodontist in Washington, D.C.

When is additional treatment appropriate?
Dr. Rams: Some people do not respond to root planing alone and continue to have bleeding and inflammation. For these people, a course of oral antibiotics can usually clear up the infection; if not, gum surgery is needed. In a small number of cases, however, the disease remains unresponsive causing some people to go from dentist to dentist seeking relief. These people would likely benefit from the newly available sophisticated bacterial culturing procedures I just mentioned. Some people have unusual types of periodontal infection that require special treatment. Taking a culture is expensive, and it must be sent to laboratories with a special background in identifying periodontal bacteria. At present, two of these labs exist: at the University of Pennsylvania and at Emory University. The dentist must not only be knowledgeable about sampling and culturing techniques but also trained in interpreting the lab results.

Can we expect the average periodontist, let alone general dentist, to be knowledgeable about these culturing techniques?

Dr. Rams: There is a tremendous gap between research understanding and what is used in private practice. Most dentists need to be updated on these research breakthroughs. However, it is fortunate that most patients respond well to nonsurgical periodontal treatment and do not require this extensive bacterial analysis.

How would this small minority with periodontal disease–unresponsive to broad spectrum antibiotics–find a dentist trained in culturing techniques and knowledgeable enough to choose the drug appropriate to the lab findings?

Dr. Rams: This is a difficult question. Some, but not all, of the newly-trained periodontists coming out of dental schools today have these skills. People have to ask the dentist about his or her training. I would also ask whether the dentist sends cultures to the lab either at Emory or at the University of Pennsylvania. [2010 update: Three labs today do this work---they are at the Temple University, University of Southern California and the University of North Carolina dental schools. See their respective websites.]

HealthFacts, COPYRIGHT 1988 Center for Medical Consumers, Inc.