Periodontics: Since I Began Practicing…

Since I began practicing, the biggest impact has come from technology and dental implants. With the success of implants, however, many dentists nowadays are often too quick to condemn periodontally involved teeth. Fifty years ago dentistry's comprehension of prognosis was based mainly on home care and preventive maintenance. With the publication of the Miller-McEntire Periodontal Prognostic Index in 2014, our understanding of periodontal prognosis took a quantum leap.¹ This index broke several barriers. It became the first index to quantitatively determine periodontal prognosis. It determined a systematic score for smoking and diabetes mellitus. And it provided patients concrete data to help them determine their long-term periodontal prognosis. The index gave patients a clearer understanding of what periodontal treatment could accomplish, allowing them to make better-educated decisions on whether to treat or extract their teeth.

By the time I began practicing, the gingivectomy technique of the 1950s had been replaced by flap-and-osseous surgery. Bone contouring and pocket elimination were in vogue. Surgical treatment continued to evolve with regenerative techniques such as guided tissue regeneration. Today the dental laser is having the greatest impact on periodontal surgery. Patients now are increasingly willing to accept in-depth treatment, and even retreatment, with the laser because of reduced discomfort.

With teeth now being saved for many years, the term "ideal probing depth" has taken on new meaning. For the sake of discussion, let's define ideal probing depth as less than 5 mm. A periodontal defect may be the result of the clinician's inability to achieve ideal pocket elimination with surgical techniques. These areas can remain stable and relatively healthy for many years, however, with proper preventive maintenance and good home care. By contrast, a periodontal pocket represents active disease and progressive attachment loss. Periodontal defects can be markedly stabilized with the use of a water irrigator (water flosser). For many years, the impact of water irrigation was downplayed because it did not physically remove bacterial plaque. It does, however, reduce inflammation by flushing out noxious products such as bacterial toxins. An even more positive impact can be achieved by adding disinfecting solutions to water irrigation. While commercial mouthrinses can have a positive effect, the most potent and effective disinfecting solution is one that incorporates a highly diluted solution of sodium hypochlorite, the active ingredient in household bleach. I guess some things haven't changed much.

Even simple changes-and many of them-in toothbrush design and texture have occurred since I began practice. No longer is it considered necessary to brush hard to "stimulate" the gum or use abrasive dentifrices such as salt and baking soda. These older home care techniques often created significant gingival recession and root abrasion. The advent of mechanical battery-operated electric toothbrushes has led to effective plaque removal with less risk of creating gingival recession. Automated toothbrushes require less dexterity yet allow patients to better remove plaque.

The scope of periodontal practice has increased with the utilization of a technique known as periodontal accelerated osteogenic orthodontics. By regenerating bone, periodontists can provide orthodontists with a technique that allows considerable expansion of a dental arch without pushing out the roots of the bone. This is particularly significant in adult orthodontic patients. Many cases originally treated by orthognathic surgery can now be treated with this simpler, less invasive surgical approach.

Finally, another momentous change over the years has been the cost of dental education and the related sizeable debt incurred by today's graduating dentists. This has markedly altered practice style, with the solo practice becoming less prevalent and corporate dentistry proliferating.

What originally attracted me to dentistry remains so today: the opportunity to make patients well. Although my clinical career, as well as my post-clinical academic experience, has ended, the passion remains. I repeatedly told my students I would start in dentistry again tomorrow on one condition: that the second time around would be even half as good as the first time.

P.D. Miller, DDS
Dr. Miller practiced 45 years before beginning his teaching career in 2008 at the Medical University of South Carolina where he recently retired as clinical professor. He introduced the concept of periodontal plastic surgery to periodontics as well as a new, universally accepted classification of recession.

1. Miller PD Jr, McEntire ML, Marlow NM, Gellin RG. An evidenced-based scoring index to determine the periodontal prognosis on molars. J Periodontol. 2014;85(2):214-225.