The Periodontal War: How Not to Lose

You're listening to the Phil Klein Dental Podcast As dentists, we're dealing with a never-ending war, and it's between the host and the invading bacteria. Can the host ever win? Our guest, Dr. Steven Milman, a periodontist, will help us answer this question. Dr. Milman received his dental degree from Baylor College of Dentistry in Dallas, Texas. He completed his periodontal residency at the University of Texas Health Science Center in San Antonio. He was a researcher in periodontal microbiology, and was a full-time periodontist in his private practice in Round Rock and Austin, Texas for 36 years. Recently retired. Congratulations, Dr. Milman, on your retirement. Thank you, Phil. It's great to be retired. It's gratifying to have been a dentist. Yeah, absolutely. We're very happy to have you on the show. We're going to be having quite a discussion with Dr. Milman today, but first... 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Tell us what's going on in the mouth and why this is important for general dentists to fully understand. The most important part of this is to understand there's a war going on between bacteria trying to invade under the gum and destroy bone because that's going to let them live and grow. And the host has available a lot of good stuff, nutrition, warm. environment. Meanwhile, the host doesn't want that to happen, so the host has an immune system that's going to defend and attack back against the invading army. The way bacteria get an advantage is they create a biofilm. A biofilm is a gooey mix of bacteria, calculus, dead cells. The most important way to think about it is as a headquarters for the bacteria. If that biofilm is successfully removed by the host, the bacteria are going to lose. So that means the host has to do things like go to the dentist, brush their teeth well, use devices like flosser and proximal brushes. If the host does not do that, the biofilm matures and then... what we call dysbiotic. There's an environment there that is not normal to the host. It's dangerous to the host. If it sits there longer, then what are called keystone pathogens arise. These are, let's say, the best weapons that their army has. These are the weapons that can actually cause bone destruction. So once they're locked and loaded with... their keystone pathogens, now you have potential for bone loss, periodontal disease, loss of teeth. So periodontal disease is a constant war between the host immune system and the invasion of bacteria. Would you say home compliance is the most important thing to keep that cycle from getting to the stage where those keystone bacteria start really doing damage? Yes, I think one patient we could talk about is someone who is middle-aged and has gone to the dentist, has flossed their teeth, have done everything right, and as a result, they have zero bone loss and they have clean teeth. Those folks, if they continue those behaviors, go to the dentist, floss their teeth, brush their teeth well, the chance of them losing any teeth to periodontal disease is very, very low. You know, they'd have to get some autoimmune or some disease during life that changed that dramatically. But short of that, they're going to keep their teeth. When I was in dental school at Penn back in the day, the first year in our first lecture in Perio, we had Dr. Jay Siebert, who was a fantastic periodontist. He was, yeah. You probably know him. Fantastic guy. He died an untimely death, unfortunately. What a nice guy. He passed around a skull of a patient of his. This woman was 97 years old when she died. She was his patient. And he said, would you mind donating your skull to the dental school so we can actually show what an amazing job you've done maintaining your teeth for your entire life. So for almost 100 years, I looked at the skull when I was a freshman dental student, not really understanding what I was looking at, but it looked like perfect. I didn't know what dental disease was in my first week of dental school. But it was an amazing thing. And he said that this is proof that if you have a patient that takes care of their teeth, this woman flossed every single day. She brushed and flossed every single day since she said, I think she said since her 20s. So it went on for over 75 years. And her bone level was like that of a 17-year-old kid. So the bottom line is you talked about the keystone bacteria. get the patient, in addition to home care compliance, what can the general dentist do to try to prevent that keystone bacteria from actually showing up? Preventing it from showing up is, like I said, starting with a patient who's healthy and keeping them healthy. A different category is a patient that comes into the dental office and hasn't been to the dentist in five years, and now they're not healthy. So they have below the gum line. pockets that have calculus below the gum line, potentially some bone loss. This is now reversing damage. It's not preventing future damage. Right, but we're still not at that critical point, or are we? The keystone bacteria is already working. When you start to see any bone loss at all? I would say yes. What that means is you have to have a mature enough biofilm. Another way of saying it is enough neglect to get to the point. that those keystone bacteria show up at all. So if you have a relatively good amount of gingival health and you acquire the patient at that point, and then you tell them, you educate them that you can keep your teeth until you're 90-some years old if you do this, this, and this, and they do this, this, and this, then you will not have a problem with periodontal disease in that patient. You mentioned to me offline about taking x-rays. So when you evaluate a patient, obviously as dentists, we all take x-rays. Talk about the level of the bone based on the age of the patient and how that should affect us as far as our treatment planning and our course forward. The thinking now is that we need to look at each patient as different. difference that people have is age. So if you have a patient that's 65 years old in your practice, and maybe they've been hit or miss, maybe they come once a year for cleanings. And as a result of this at age 65, they have some five millimeter pockets and they have 20, 25, 30% bone loss. This is what you would expect from their behavior, from their age. A different patient that, say, is 30 years old, and they're the same hit or miss, they're the same level of oral hygiene, but at 30 years old, they have 30% bone loss and damage to the bone. This is not normal. There's something about that patient that's abnormal, probably in their immune system. Possibly they have other inflammatory diseases. That one needs to red flag. And this is somebody different. This is someone who has potential to lose their teeth. We need to put them in a whole different category, whether that in your practice means referring to a specialist or at least note that they need a lot more treatment than the next guy. We'll be getting back to Dr. Millman in a second. But first, we all know that to achieve healthy, beautiful smiles, we sometimes need to align the teeth. and to do so, aligner therapy is a great option. So why not set your practice apart with 3M Clarity Aligners Flex? Designed for comfort, Clarity Aligners Flex feature a thin, flexible design, yet they deliver excellent force persistence over a two-week period. Plus, they resist scratching and stains, and they're backed by a dedicated clinician team providing support every step of the way. With a variety of affordable case type options, single or dual arch, Clarity Aligners Flex offer a great value to your patients and practice. To learn more, visit 3m.com slash clarity dash aligners dash flex. All right, so you have these two patients, one's 30, one's 65. They both have about 30% bone loss in areas. You don't send them through the same hygiene protocol where they have identical treatment, right? You have to assess them. and put them in categories that are different. And that should also affect the way they travel through your department of perio, your hygiene and what follows hygiene. Is that right? The thing you would think about at that moment with a 30-year-old with a third bone loss is, do I want to take on a difficult case or do I want to put that in the specialist's hands? Do I feel comfortable? Knowing, based on that presentation, that this is going to be hard to do over the next lifetime, 50 years, 60 years. Do you want somebody who's got more training and more experience with that case? As far as treating it, if you want to treat it yourself, normally you're going to start everything with scaling and root planning. So you would. and you'd see what happens. You would take that patient, do the scaling and replanting. When they come back for reevaluation, they would present a certain way. If they look healthy at that point, then eureka, you did a good job. If they don't, it's puzzling. It's how do they not look healthy? What bleeding do you see on probing? Are there bacteria there? What if their oral hygiene is perfect? And you feel like your hygienist did a great scaling and root planing and there's no response. How do you make sense out of that? And what do you do about it? What's the point where you think that scaling and root planing and reevaluation is kind of a moot point? It's kind of a waste of time and you're just letting this patient drag on for treatment in your office and you're not going to accomplish anything. Is it determined by the reevaluation, looking at the bleeding index? Give us an example of something that you would say I would refer that out. We're not talking about that GP who does all the perio themselves and they're very skilled in periodontal work. We're talking about the general dentist who does dentures and crowns and direct restoratives and he has a hygiene department, but he's not interested in doing sophisticated periodontal therapy. When would you say it's time to send that out based on bleeding index, pocket depth? and so forth. If we want to throw it at an easy answer, seven millimeter pockets. Want a harder answer? I'll go back to what I just said. You need to distinguish what your skill set allows you to do. Do you like to treat diabetic patients that have gum disease? They're hard to treat. Smokers, rheumatoid arthritis, young people that already have gum disease. All these should I think, get thrown in a different bucket. And either that bucket is, I have a great periodontal skill set, I treat them, or those are oddities, I better send them to the periodontist. Yeah, no, that makes total sense. So to wrap up this episode of this podcast, and it's been very good, Dr. Milman, summarize for us what a GP, the most important thing a GP should understand when onboarding a new patient that has some form of periodontal disease. Do they go through the typical? hygiene department protocol and their re-eval, or do they go into a different bucket and you talk to the patient and say, listen, I've just assessed everything. You need some restorative work. You need this, you need that. But before we get started, we need to make sure that your periodontal health is under control because there's absolutely no way we're going to go into restorative dentistry unless it's an emergency situation before you get your periodontal health in control. What recommendation would you make to make sure that GPs are following this correctly? started with a patient, just figure out whether this looks normal and will respond normally, or this looks weird and it might not. So, you know, let's go to something in the middle. We got a 50-year-old patient, hasn't seen the dentist in five years, has a lot of calculus, but some bone loss, but minimal. Okay, he's got the calculus because he didn't see the dentist for five years. You clean it off, he's going to get better. That's your patient. You've got a 50-year -old that comes in and has seen the dentist for cleanings three times a year and has flossed every day, and you probe that patient. They got 5, 6, 7-millimeter bleeding pockets. I would say that's weird. That may not respond well. Maybe we need somebody who's done a lot of those to look at it. Thank you, Dr. Milman. We appreciate your insight, and we look forward to having you on future episodes. Thank you, Phil. If you're enjoying this podcast, please leave a review or follow us on your favorite podcast platform. It's a great way to support our program and spread the word to others. Thanks so much for listening. See you in the next episode.