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Emails from Patients

These emails were selected because they illustrate several issues that have come up repeatedly with patients. Remember that most dentists/periodontists have not received any training in the antimicrobial management of periodontal infections/disease because this subject is rarely, if at all, covered in the dental curriculum. (One should ask why? Curricula changes are slow in all disciplines, and the dental curriculum is more tradition bound than most). Insurance plans do not readily allow for reimbursements for antimicrobial treatments, and most patients seem happy with their dentists and the treatment that they receive. It is a situation in which no one, except certain patients, are complaining, so why change?

E-mail Message from Ann Arbor.

"Is there some one in private practice (in Ann Arbor or vicinity) who could evaluate me for anti-microbial treatment for advanced periodontal disease? Recently, a few days before turning 50, I was told by a periodontist to have 8 teeth extracted and then (to) go on Periostat. I spent 5 years in orthodontic braces and have subsequently seen dentists/periodontists every 3 months for most of my life. Outside of root planing and deep scaling, I have been offered no other treatment possibilities.

Searching desperately for anyone who might offer a different approach, I came on your paper, "Diagnosis and Treatment of Anaerobic Periodontal Infections," and it gives me some bit of hope that there is another school of thought out there”.

WL response. This patient was referred to Dr. James Giordano in Dearborn MI. No teeth have been extracted after 2 years, and the prognosis for 6 of the teeth is good.

This patient’s experience shows that a conscientious patient can go progressively downhill, if a periodontal infection is not diagnosed and treated. She did all that she was told to do in terms of seeing the dentist/periodontist regularly, and yet at age 50 she was told that 8 teeth needed to be extracted. Periodontal disease does not happen suddenly, so that the anaerobic infection about her teeth had not been diagnosed over a period of years by her clinicians.

This situation reflects a growing concern among ethically conscious dentists that teeth are being extracted, or in this case being recommended for extraction, prematurely without efforts to treat them. Part of this rush to eliminate problem teeth reflects the availability of an attractive treatment alternative for the clinician, namely dental implants. The success of dental implants has provided some clinicians with the excuse that the patient would be better served to do away with the infected/diseased teeth and to immediately receive dental implants. Dental implants are expensive to the patient and profitable for the clinician.

E-mail Message from Pittsburgh.

“Could you please provide me with some information regarding your study, Nonsurgical treatment of patients with periodontal disease. Oral Surg, Oral Med, Oral Path, 81(5):533-43, 1996 May. My fiancée is scheduled for osseous surgery this Friday. She specifically asked her periodontist about antibiotic therapy--his response was it is only effective during dosing and that there are no long term benefits--is this true--your report mentions several years of follow-ups.

We cannot help wondering if her periodontist is just not up to speed on the latest techniques. I would appreciate discussing this with you--i will call you later today”.

“Thank you for your response. Its amazing that two periodontists that my fiancee has visited would not entertain any options besides osseous surgery. Even after presenting your work to them. More amazing it that yesterday afternoon I took her to see a periodontist at the University of Pittsburgh's school of dental medicine. His conclusion is that her condition is so mild that several cleanings and better oral hygiene should remedy her problem. I have to wonder, considering chemotherapy and non-surgical methods--how many unnecessary osseous surgeries are performed”.

WL response. This woman was fortunate in that she found a periodontist who provided the minimal treatment that apparently was all that she needed. This example shows how important it is to obtain a second opinion, and perhaps to avail yourself of the opinion of clinicians at an academic institution, if one is in your city.

This case also illustrates a common theme among some clinicians; that they automatically dismiss the use of antimicrobial agents, in this case using the perceived lack of follow-up. Our studies always provided some follow-up results, which the writer of the email presented to the periodontist. We published in 2002 in the Journal of the American Dental Association five-year follow-up data which shows that patients treated with antimicrobial agents do very well over time. A graph showing the five year results is shown in Figure 1 below. In the summer of 2005 a 6.4 year follow-up report will be published in the Journal of General Dentistry. This report suggests that the use of metronidazole for one week each year may provide additional benefits.

E-mail Message from Oklahoma.

"One year ago, I contacted you, about my husband's periodontal disease. You may recall that he had pockets up to 12mm, and it had been recommended by a periodontist that at least two teeth be pulled. I was interested in your study recommending debridement plus the use of metronidazole. When I mentioned this study to the periodontist, he completely dismissed it and scheduled my husband for extraction.

However, we called back later and said we would like to pursue a plan of action based upon your findings. Last January 24, my husband had SRP and took metronidazole for two weeks or so. He also embarked upon an extensive home maintenance program, based upon findings I came across on the Internet, using a Hydrofloss machine, frequent brushing and flossing.

I am overjoyed to tell you that when he went back to the periodontist in March for a checkup, there was absolutely no sign of infection!! They had a hard time admitting how much better his mouth was. He has continued to have his teeth cleaned by our home dentist every three months, and each time, they cannot believe there is no infection.

My husband's mouth is, today, free of infection, and no loose teeth. You may put our experience in your book of success stories, that, according to the dental establishment, should never have happened!"

WL response. This is a success story, and shows the importance of the patient insisting on a course of action that has scientific evidence behind it, namely that most forms of periodontal disease are treatable anaerobic infections. Also the patient took control of his infection by improving his home care procedures. The periodontists deserves some credit for prescribing the metronidazole, but it is disappointing that he seems not to be able to acknowledge the success of his usage of the antimicrobial treatment. This is a common experience that I hear from patients, namely that the dentist/periodontist is amazed at the improvement, but s/he will not change their treatment paradigm.

E-mail Message from New Haven CT.

My high classmate was told that she would need to have a repeat of her periodontal surgery. I told her about our metronidazole studies.

“Hi, Walter, this morning was my usual six-month cleaning and the dentist gave me a prescription for metronidazole, 500 mg, twice a day for one week so we're finally getting to try your recommendation. Any other information that I should know about while I'm doing this?”

6 months later.

“Had to have a tooth filled today and the dentist asked if I was through taking the medication, probed my gums, and after my saying that my gums haven't been this tight in years, smiled and said someday, he "might have to call Dr. Loesche.".

WL response:

This dentist has yet to call after 4 years.

The infection was not eliminated by the treatment, so that it simmered on. Infected teeth need to be monitored for resolution of the infection, which is something that is rarely done by the dental profession. Their training stresses only the dirty mouth approach and when cleaning doesn’t work, the tooth is recommended for extraction. Some teeth require a second and possibly a third course of antimicrobial agents combined with use of irrigating devices and local application of antimicrobial agents. The extent and duration of treatment should be monitored bacteriologically, either with a microscope, with the BANA test, or with some other bacteriological detection system.

After several years the dentist recommended that she have the tooth extracted and replaced with a dental implant. Even though she requested another course of metronidazole, he would not write a prescription for metronidazole, nor would two periodontists whom she subsequently saw. All three were aware of our metronidazole studies, but our successes with metronidazole would not change their treatment recommendations.

E-mail Message from Vienna, Austria

I showed my GP (physician) some of your articles, a print-out of the website bibliography and the University of Michigan School of Dentistry "Our People" page. He agreed immediately that my plan was a good one and gave me the prescription for the metronidazole. He said, "after all, who knows, perhaps in a few years, medical research will find a good way to stimulate bone growth around a tooth like that."

Three or four days after I started the metronidazole I could already tell a dramatic difference. Now, ten days later, the mushy lesions around that tooth are nearly completely healed, and the gum is beginning to adhere to the root again. There is no bleeding, and the gum is a lovely light pink rather than the angry red it had been for weeks, despite frequent, intense cleaning and chlorhexidine twice daily. And I feel like a spring chicken again. The bursitis in my shoulder and my other aches and pains are also gone.

I am really looking forward to seeing the surprised look on my dentists' faces when they see how well this has healed. Of course, I will continue the stepped up hygiene from now on. I certainly don't want a relapse!

Wl response:

This email is of interest because it showed the immediate acceptance of the metronidazole treatment by a physician, who prescribed the medication. He had no problems with using an antibiotic to treat a periodontal infection, and even speculated that “medical research” will find a way to grow bone. Quite a different response from the comments or behavior of the dentists in the previous emails. Note also how the patient is looking forward to the “surprised look on my dentists’ faces.

E-mail Message from Boulder CO.

Patient had one or two deep pockets and surgery was recommended. I sent her to a periodontist in Boulder, who had taken my course about 25 years ago, when he was a grad student in periodontology at the University of Michigan. After her treatment she sent me the following email.

“I just wanted you to know that I finally saw Dr. X today and he took an x-ray that showed that the bone loss in tooth #25 HAD grown back to a degree that he said would have made you proud. So thank you for your pioneering work with antimicrobials. So often it seems that it takes the world 50 to 100 years to catch up to the leading edge and so often the pioneers are ridiculed in their time. But, your work has impacted me and I appreciate it deeply and hope to impact others. May the dental profession awaken to all the possibilities of healing that are out there and hopefully people will begin to understand that there mouth is connected to their whole body and how to take care of their teeth to keep them their whole life.

Wl response:

There are periodontists and dentists out in the real world that do use antimicrobials to treat periodontal infections. I try to send patients to them when I know of someone in their area. I included this response, not only because of the kind words s/he had for our research, but because the fact that the “mouth is connected” to the body is getting increased attention in today’s scientific literature and in the press. This is the next subject that will be addressed.