Recently, DentistryIQ interviewed Stuart J. Froum, DDS, whose private practice is limited to periodontics and implant dentistry in New York City. Dr. Froum, a diplomate of the American Board of Periodontology, is currently a clinical professor in the Department of Periodontology and Implant Dentistry at the New York University Krieser Dental Center, as well as the director of clinical research in the Department of Periodontology and Implant Dentistry at the New York University Dental Center. He is the past president of the Northeast Society of Periodontics and is on both the Research Committee and the Continuing Education Oversight Committee of the Academy of Osseointegration. Dr. Froum is a trustee of the American Academy of Periodontology and the recipient of several awards: Hirschfeld Award from the Society of Periodontologists, the Clinical Research Award for 2004 and 2005, and the William J. Gies Award for 2006. You may contact Dr. Froum by e-mail at [email protected].
DentistryIQ: With an increasing number of general dental practitioners performing more periodontal treatment in their offices and a greater number of dentists placing implants, do you see a decreased need for the periodontal specialist?
Dr. Froum: On the contrary, with more services and treatment options being offered to patients today, I feel that for predictable successful outcomes, the periodontist must be an essential member of any treatment team. Whether a patient presents for treatment of a single tooth or full-mouth restoration, the diagnosis and treatment decisions should be interdisciplinary. For example, the decision to save or extract single or multiple teeth is one that requires the knowledge and expertise of both the restorative dentist and periodontist. I call this concept the “Partnership in Treatment.”
The decision to treat a furcated molar, a tooth with subgingival caries, a chipped or fractured crown, one with both periodontal and endodontic involvement, or a tooth with moderate to severe periodontal pathology requires collaboration between the periodontist and restorative dentist, and where indicated, an endodontist. A decision to retain a questionable tooth or extract it and place an implant again should be made in consultation with a periodontist.
I think that increased public awareness and earlier intervention has reduced the prevalence of periodontal disease in the United States, yet more and more patients are seeking dental care after years of neglect. Moreover, the fact that Americans are living longer and demanding more esthetic restorations has brought new and oftentimes more complex dental situations into the dental office.
Many of these cases present more risk for successful results, especially for patients with higher expectations. The partnership in treatment is the best means of assessing the risks and obtaining successful treatment outcomes with less chance of untoward results or complications.
DentistryIQ: Can you give us some examples of an interdisciplinary approach that you speak about?
Dr. Froum: There are many — for example, a patient presenting with a number of questionable teeth requesting restorative therapy to improve his or her smile. The decision to treat these teeth and place conventional crowns or fixed bridges or remove select teeth and replace them with implant-supported restorations is one that requires consultation, treatment planning, and proper coordinated treatment from both the periodontist and restorative dentist. Without an accurate treatment plan, regardless of the dentist’s skill, the case is doomed to failure.
Even if many teeth are hopeless and must be extracted, planning a fixed provisional, treating salvageable teeth, and placement and restoration of the implants should be a collaborative effort.
DentistryIQ: You mentioned esthetics. Is there a role for the periodontist in the case of a patient presenting for a better-looking smile?
Dr. Froum: Again, treatment in the esthetic zone usually requires an interdisciplinary approach. Patients look at both the “red and white” (as a teacher of mine used to say) in determining what is esthetic to them. This certainly is true of patients with a high smile line (one that shows teeth and gingiva), but it is also true in patients with a low smile line, who, as a friend of mine says, are “lip lifters.” For these patients, good esthetics (many say “cosmetics”) requires harmonious gingival levels and teeth that have the proper proportions. This often requires crown lengthening, gingival plasty procedures, and/or soft-tissue root coverage prior to placement of veneers or crowns. This planning and treatment require cooperation between the periodontist and restorative dentist. I usually work with restorative dentists who can create virtual esthetics on the computer to guide me, as a periodontist, to the procedures needed to obtain the desired results.
DentistryIQ: Getting back to implants, with more non-periodontists placing implants, do you see a decreased role for the periodontal specialist?
Dr. Froum: As a clinical professor who teaches implant treatment to postgraduates and periodontists in the Department of Periodontics and Implant Dentistry at NYU Dental College, I think that is a good question. NYU is one of the dental schools that teaches implant therapy to undergraduates. In the program, patients are carefully screened and only those with no systemic diseases and partial or fully edentulous areas with adequate height and width of bone (very favorable implant sites) are selected. Our periodontal or implant residents place the implants under faculty supervision. The dental student then assists with the restoration under faculty guidance. The success of these implant restorations is very high.
However, the implants are placed in pristine sites. These are areas of high predictability for dentists to place and restore implants. Unfortunately, in areas of deficient bone, or in areas that require implants in the esthetic zone, much more experience and skill is required. These areas often require bone or soft-tissue grafts prior to or in conjunction with implant placement. In these cases, periodontists are usually the go-to specialists to prepare the sites and place the implants, which — in conjunction with the restorative dentist — can yield a successful result and a satisfied patient. Often, patients require additional bone in the posterior areas and need sinus or ridge augmentation as part of the overall implant/restorative plan. Again, the periodontist is an essential part of providing these services.
DentistryIQ: What about maintenance of implant restorations? In whose area of responsibility does that fall?
Dr. Froum: Implants, like natural teeth, require maintenance and monitoring. This should be performed as team effort with both the periodontist and restorative dentist seeing a patient intermittently for recall. Porcelain chipping, screw loosening, or any mechanical complication should be monitored and treated by the restorative dentist at the earliest detection of a problem. Mucositis or peri-implantitis should be detected early, and it’s up to the periodontist to institute treatment to prevent further breakdown or loss of an implant. Post-restoration implant loss is usually related to occlusal overload (often caused by bruxism or clenching) or microbial infiltration leading to peri-implantitis or soft-tissue recession. In many cases, implant complications can be avoided with proper collaborative diagnosis and treatment planning by the restorative dentist and periodontists. Risk assessment should be an integral part of this planning. Systemic as well as local factors must be considered in planning an implant-supported restoration before the treatment begins. Moreover, if there is a mixed dentition (teeth and implants), any disease related to these teeth must be treated and the periodontal tissues kept healthy throughout and following restorative therapy to ensure a lasting outcome.
DentistryIQ: When you speak about a team approach, do you mean the periodontist and restorative dentist?
Dr. Froum: No, the team should be composed of the restorative dentist/periodontist/lab technician and, when required, an orthodontist and endodontist. Moreover, the key part in decision-making must include the patient. The patient’s systemic condition, risk profile, and expectations must be considered prior to initiating any treatment. Patients with unrealistic expectations must be made aware of the limits of what can be delivered. Risk assessment includes both systemic problems and local evaluation. Americans are aging and with an older patient comes more risk of systemic diseases and the necessity to know the impact of any medications that the patient is taking on treatment decisions and procedures. Anticoagulants, blood pressure medication, medications for depression or anxiety, and more recently the bisphosphonates for osteoporosis may affect treatment complications and outcomes. Local evaluation of tooth proximities, occlusal scheme, available bone, and anatomic structures (i.e., inferior alveolar nerve, sinus proximity, etc.) must all be evaluated in the planning phase. An ideal wax up, radiographic, surgical guides, and cone beam or computer axial tomographic scans are essential in any restorative plan with either teeth or implants.
Interdisciplinary therapy is the best way to consider all factors for a successful outcome and avoid complications and an unhappy patient. I have found that this approach not only increases predictability, saves time and money, and avoids litigation, but it also increases patient referrals.
DentistryIQ: Dr. Froum, thank you for your time.
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