“Refractory periodontal disease”

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PRIORITY NO.2556
New endodontics research:
Pin-pointing the oversized foramen
February 2008
“Refractory periodontal disease”
What exactly does that mean?
by Larry Burnett, DDS
Portland, OR
I recently received a nice note from Dr. J.
Fernandez asking my opinion concerning the
theory that bacteria associated with periodontal
disease can penetrate soft tissue and thereby
escape treatment.
Figure 1: When the foramen is abnormally large, an
electronic apex locator will be more accurate if you
connect it to a larger file.
by Nelson Gendusa, DDS
Director - Research
Some research suggests that electronic
apex locators tend to give short readings when
the foramen is unusually wide.
Researchers at the Tokyo Medical and
Dental University recently investigated four
different apex locators to see if they all shared
this limitation. They sorted 36 extracted teeth
into 4 groups according to the diameter of their
apical foramen. … ranging from 0.8 mm to
1.5mm in diameter. 1
The devices they tested were …
The Root ZX (J. Morita - $862)
The Apex NRG (Clinician’s Choice - $649)
The Apit 7 (Osada - $??) …
The Foramatron D-10 (Parkell - $499).
In teeth with relatively small apices, all the
devices performed admirably. But sure
enough, as the canals got wider and the foramina larger, there was a clear tendency for the
locators to make larger errors.
“I’ve found studies that seem to show this.
Then I find others that suggest this phenomenon hasn’t been confirmed. What are your
thoughts?”
Great question!
But before we discuss soft tissue invasion,
I’d like talk a little about refractory periodontitis. We’ve all had cases where the patient fails
to respond to treatment. We do everything we
can think of to stop the attachment loss, yet at
each recall, the probe slides a little further into
the pockets and the radiographs look bleaker.
Some treat the term “refractory periodontitis” as if it were a type of disease. Others use
it to mean “untreatable”. In fact, “refractory”
simply refers to any stubborn disease that has
not responded to conventional treatment.
In this little article I’d like to suggest that
calling a periodontal condition “refractory”
simply means we haven’t yet reached the
pathogens that are triggering the tissue loss.
Take juvenile periodontitis, for example
Figure 1: We’ve all seen cases where despite our best efforts,
the patients periodontal condition seems to spiral downhill at
each recall, as attachment continues to be lost. At what point
should we call cases like these “refractory”?
90% of juvenile periodontitis suffers. This
antigen was in virtually 0% of the tissue of
healthy patients or patients suffering conventional periodontitis.
It’s rare that a single periodontal disease is
so closely identified with a single pathogen.
But it gets even more interesting …
Occasionally, antigens to A.a would be discovered in a healthy patient. But when this
occurred, it was always in the plaque - never in
the tissue itself.1 So apparently juvenile periodontitis wasn’t just associated with a specific
pathogen (A.a) but with a specific pathogen in
a specific location.
Until the 1980’s juvenile periodontitis was
a mysterious, untreatable disease that defied
scaling, root planing and periodontal surgery.
Despite all the recognized therapies, the disease seemed destined to run its course.
This suddenly changed when researchers
discovered antigens to a single bacillus,
Actinobacillus
actinomycentumcomitans
(A.a), in the periodontal tissue of more than
It’s a shame all studies aren’t as definitive
as these, because this work lead to one of the
few true “Eureka!-moments” in dental science.
An incisal registration won’t help the
cosmetics of your case if it arrives at the
laboratory in pieces. Here’s an easy way to
ensure your bite-stick assembly survives the
trek.
By Uwe Mohr, MDT
Toronto, ON
Once upon a time the so-called “bitestick registration” was used only by cosmetic dentists who wanted to control orientation
of the patient’s incisal line without all the
fuss of a facebow.
With cosmetic dentistry now a major part
of most practices, stick registrations are frequently submitted with the models we
receive. They’re not as comprehensive as a
facebow registration, but they’re a lot easier
to take, and they can easily identify such
things as midline angle and incisal plane
cant.
Continued on page 3
© 2008 Parkell, Inc.
Suddenly most cases of “refractory” juvenile periodontitis were no longer refractory.
Figure 2: Juvenile periodontitis was once considered a refractory disease. Then dentists discovered
where the pathogens were hiding. (Radiograph reprinted with the kind permission of Dr. Cameron Clokie and
the Journal of the Canadian Dental Association.)
The bite-stick registration
and how to get it safely to
your technician
Figure 1: The dentist usually wants the incisals
(horizontal stick) to line up with the patient’s eyes.
Because this dentist included a vertical stick, the
technician won’t have to guess where the midline
should be. (Clinical photos courtesy of Dr. Howard
Goldstein, Bethelhem, PA.)
It was a classic example of the “locus of
infection.” Even if you managed to get a pocket clean, the hidden beasts in the tissue would
immediately emerge to repopulate the crevicular area.
This model also suggested a potential treatment. Instead of attacking the A.a from the
outside with curettes, what if we attacked them
from the inside? At that time, systemic antibiotics were seldom used for treating periodontitis. But tetracycline was found to be effective.
Later Dr. Loesche and crew showed that
Amoxicillin combined with metronidazole is
even more effective in treating juvenile periodontitis.
It was the quintessential “refractory” periodontal disease.
Continued on page 3
et into the connective
tissue, they aren’t susceptible to mechanical debridement or root-planing. The tissue would even protect them
against antibacterial irrigants that would be
lethal against free-swimming beasts. (Not that
many were irrigating back then.) And since
they’d evolved an ability to suppress antigens,
the body’s natural defense against pathogens in
tissue was less effective.
The findings suggested a new model for
juvenile periodontitis, one that clearly
explained why it had been so resistant to conventional therapy. Other studies suggested that
A.a may actually have developed the ability to
suppress the body’s immune system, preventing the synthesis of antibodies.2
Once pathogens penetrate beyond the pock-
So in answer to your question, Dr.
Fernandez, Absolutely YES! Periodontal bacteria can penetrate the soft tissue. That’s now
the generally-accepted model for juvenile periodontitis.
And it’s probably not just A.a either
Treponema denticola is an anaerobic
spirochaete that in conjunction with
Treponema socranskii and Porphyromonas
gingivalis, is associated with a particularly
aggressive periodontitis.
About Dr. Burnett ...
Figure 2: When taken the traditional way bitesticks frequently break on the way the way to the lab.
A graduate of the Medical College of Virginia School of Dentistry,
Dr. Larry Burnett has authored numerous articles and lectured extensively on conservative periodontal therapy throughout the US and
Canada. A frequent speaker at the ADA annual scientific session,
Chicago Midwinter and AGD meetings, he is moderator of the internet Perio Discussion Board and author of the video-based study program “Advanced Ultrasonics in General Practice.”
He can be reached at [email protected]
Continued on page 22
The Bite-Stick Registration
(continued from page 1)
In a bite-stick registration, a blob of BluMousse® is expressed onto the handle of the
bite tray. The dentist then stands at arm’s
length, so he gets an observer’s view of the
patient’s face, and places a swab-stick into
the Blu-Mousse to establish the incisal line.
Most frequently, this means the stick is
aligned with the pupils of the eyes. Some
dentists use plastic BendaBrush™ sticks, but
plastic can bend in the heat of a UPS or
Alcan truck, so I suggest wooden swab
sticks. Though some dentists use just a single horizontal stick, I encourage them to add
a vertical stick to establish the midline.
As a technician I can strongly vouch that
when you’re requesting a diagnostic wax-up
or cosmetic temp, including a bite-stick registration with the order will help us get it
right the first time.
(And if you’re not
requesting one of these preliminary steps,
the registration may help avoid a complete
remake.)
Figure 3: To avoid breakage, simply coat the
sticks with a little Vaseline before seating them.
Figure 4: Then after the Blu-Mousse sets, twist
the sticks (one direction only!) as you gently pull
them out.
istrations frequently arrive at the lab in
pieces.
Here’s how –
Think about it. You have a thin 6” stick
surrounded by maybe an inch of hard BluMousse. It doesn’t take much for that stick
to break ... just a little jostling in the box,
Before taking the stick bite, coat the center of the swab-stick (the part that will be
seated in the Blu-Mousse) with a thin coat of
Vaseline (fig. 3).
So I suggest to my customers that they
remove the swab-stick before sending the
case.
Take the bite as usual. Let the BluMousse set.
However, I can also tell you that the reg-
Figure 5: The technician easily re-assembles the
registration when it gets to the lab.
Before packaging the case, remove the
sticks by twisting them in one direction only
(fig. 4). Continue twisting it as you pull
them out.
Send both the swab sticks and the registration with no fear of breakage.
When we receive the case at the lab, all
we have to do is re-insert the sticks and
we’re good to go (figs 5/6).
To learn more about Blu-Mousse, see
page 16.
About the author
Uwe Mohr, MDT is owner of Smart Ceramics Dental Art Studio in
Toronto, Canada. A graduate of Germany’s rigorous Master Dental
Technician program with more than 30 years at the bench, he specializes
in aesthetic and prosthodontic cases. He serves an international clientele
with customers in the USA and Europe as well as Canada. He is an
active member of the DentalTown community. He can be reached at 888
264 0787 or [email protected]
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The oversized Foramen
(continued from page 1)
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However, not all locators were equally vulnerable
Two devices were significantly more accurate in those roots with monster apices –
In their words “The Root ZX and Foramatron
D10 showed significantly better
scores than the other two EALs
(Electronic Apex Locators) and may
be more reliable to determine the
working length of teeth with a wide
apical foramen if a tight-fit file is
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For best results reading these abnormal
canals, use a file that fits the canal snugly. No
matter what apex locator you use, you don’t
want to connect it to a #15 file in order to read
the working length of a monster apex.
To be honest, we’re not really sure how
practical this technique is for immature roots
with wide open apices. These can be rather
fragile, so it seems to us probing a molar with
a monster #150 file might be something better
done in vitro than in vivo.
Nevertheless, several years ago endodontists at the Semmelweis University in Budapest
conducted an in vivo comparison of electronic
locators in mature roots – and got similar
results. 2 An endodontist first determined the
working lengths of the canals scheduled for
RCT using the “Ingle technique” (radiographs,
file and tactile sensitivity.) Then the canals
were read using four “all-fluids” locators:
Morita Root ZX,
Parkell Foramatron D-10,
Analytic’s Apex Finder AFA 7005
Dentsply’s Propex.
The Foramatron and Root ZX agreed with
the endodontist 100% of the time. The Apex
Finder agreed with the endodontist 70% of the
time. And the Dentsply’s apex locator agreed
with the endodontist just 50% of the time.
The teeth weren’t subsequently extracted
and examined, so the precise working lengths
of the canals can’t be known for certain. The
authors assumed that an experienced endodontist was likely to determine a valid working
length, and therefore the Foramatron and Root
ZX were judge to have performed best.
Regardless of the clinical significance of
these studies, taken together they do seem to
support what dentists who own both the
Formatron D-10 ($499) and the Root ZX
($862) consistently tell us: In their practice
they see no discernible difference in their performance .
By the way, Parkell had nothing to do with
either the Tokyo University or Semmelweis
studies. In fact, we didn’t even know about
them till someone sent us the papers.
1 Ebrahim AK, et al. Ex vivo evaluation of the ability of four different electronic apex locators to determine the working length in teeth with
various foramen diameters. Aust Dent Jour, 51:3, p258-262, 2006
2 Gyorfi A et al. An “in vivo” comparison of different apex locators
during endodontic treatment. Hungarian Society of Endodontology and
Dento-Maxillo-Facial-Radiological Section of the Hungarian Dental
Association. June 04
To learn more apex location, see pge 7.
3