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When a patient presents to our office with any pathological condition, we identify the cause of the pathology, address the cause and monitor resolution. Even something as simple as a denture adjustment is a case in point. Do we just apply a topical anesthetic or prescribe pain meds for an ulcer from an ill-fitting denture? No, we identify where it is rubbing and adjust the denture to remove the cause of the ulcer.

 

When a patient has periodontitis a comprehensive clinical and radiographic evaluation is provided. The periodontal evaluation; however, is nothing more than a damage report of a disease process that happened sometime in the past. It is merely a snapshot of one moment in time, specifically, when the evaluation was provided. The disease process however, is like a video, something that happens over time. Evaluations and radiographs tell us nothing about what caused each case of gum disease in the first place and they provide no insight into what will happen in the future.

The specific aim of periodontal treatment is pocket depth reduction, cessation of redness, bleeding and swelling and improvement in all the clinical and radiographic parameters of gum disease that we measured in the first place……NOT!

 

When we provide gum treatment with an aim of pocket depth reduction we are treating pocket numbers rather than the disease itself. The pocket numbers are just manifestations of the disease process. It would be akin to treating the signs and symptoms of diabetes rather than the diabetes itself, e.g., prescribing medication for incontinence due to the frequent urination which afflicts poorly controlled diabetic individuals rather than addressing their glycemic control.

 

The aim of perio disease treatment is bacterial reduction.  Improvement in the clinical signs of the disease will always follow.

 

What is the evidence for this viewpoint? The researchers who originally identified the perio pathogens, Dr. Anne Haffajee and the late Dr. Sig Socransky, stated that; “The ultimate risk factor for an infectious disease is the causative agent of that disease. Without that agent, no disease will take place no matter what other risk factors the subject may possess.” (Their emphasis) The causative agent is the specific bacteria causing each patient’s case of periodontal disease. Drs. Haffajee and Socransky further stated, “The most appropriate control of these diseases is through the control of the microorganisms that cause them.  Nevertheless, those of us who are clinicians often treat periodontal diseases in a fashion that is minimally influenced by the microbial agents that caused the problem.” “Rarely do we focus on the real culprit, the organisms that caused the disease in the first place!!!” (Again, their emphasis)

The 11th edition of Carranza’s Clinical Periodontology states in the chapter titled Rationale for Periodontal Treatment, “The removal of plaque and all the factors that favor its accumulation is the primary goal of local therapy.” Pocket numbers, BOP, swelling, redness and bone loss are not plaque nor are they factors that lead to plaque accumulation. They are the clinical manifestations, the evidence, the observable and measurable results of periodontal disease, rather than the primary goal of treatment (My emphasis).

 

So next time you have a patient in your chair, remember, pocket numbers are important, but they are not what we should be treating.