Ep. 35: Periodontal Disease: Everything A Patient Should Know

Part 10:00

This is Beyond the Arches, where full-arch dentistry meets real talk. Let's get into it. Hello and welcome back to Beyond the Arches. Today, I am going to be your host, Erica, and I am joined by Dr. Blake Hauer. Hi. Hello. How are you? Good. So let's go ahead and get started. Basically, today's podcast, what it's going to entail is periodontal disease, including just some risk factors for implant complications, medications, kind of some things that we take a look for, that we alert our doctors, especially myself, starting off in the consultations, just some things that we kind of see and we're like, hey, doc, you want to take a look into this? So we just kind of are here to educate

▶some people today. Hey, doc, so I have a question for you. What is periodontal disease? Do you want to give us kind of a basic rundown why this is something that alerts us when we see patients with it? What do we do about it? Some possible treatments for them? Um, totally. So just to give you a little bit of background. So Dr. Dan and I are both periodontists. So we did specialized training outside of dental school that was specific to treating periodontal disease, everything involving teeth and also implants. So when we talk about periodontitis, it's so critical to full arch because it's one of the main reasons why you have tooth loss. And in addition to that, periodontitis can lead to changes in your oral biofilm.

And changes in the profile of plaque and bacteria. So at the simplest, periodontal disease is a dysbiosis of your oral ecosystem, which leads to breakdown of bone, leads to inflammation, and eventually tooth loss. It's a very slow process. And the reason it's so relevant to full arch is because when there's teeth that are missing over time, sometimes patients get in a situation where they're full arch candidates. And over time, with more and more teeth, they're missing teeth and more tooth loss. It can complicate things. And it makes us think about what are risk factors for our patients and what can we control to either make patients better full arch candidates or maybe have full arch avoided in the first place.

So just kind of as a basic person, just getting started, just thinking that they might have periodontal disease, what is the first sign that somebody should kind of be aware of or, you know, what would alert a regular everyday? So before you have periodontal disease, you have gingivitis. So gingivitis can develop into periodontitis. So early on, you'll have red inflamed gums, bleeding gums, and you'll have tartar and calculus buildup that can accumulate around the teeth. Over time, if you have bone loss, in addition to the symptoms of gingivitis, that's where you have breakdown. So it's common to have feelings such as bleeding, as I talked about, even abscesses around teeth. And sometimes when hygiene is poor and cavities develop, you have periodontitis that can happen at the same time as endodontic problems like root canals and that and such.

Okay. What are the steps of somebody being diagnosed with periodontal disease? What would that look like in them sitting in a dental chair, sitting in a dental office, you know,

Part 23:25

thinking that something is not quite right right now? Are there like specific exams? Specific tests that can be performed to confirm this diagnosis? Sure. So the American Academy of Periodontology is the, you know, the soundboard for anyone that wants to diagnose and classify patients that have periodontal disease. So what it has is a staging grading system. So patients that have bone loss and inflammation essentially can be anywhere from stage one to stage four. And there's also a grading system from grade A to grade C. And the reason why patients that have periodontal disease, they're looked at differently if it's initial or if it's late and aggressive. And the patients that have a late and aggressive, which is more of a stage three and stage four, as we classify it, we're more likely to be in a full arch situation because of drastic tooth loss, flaring of teeth, collapsed bite, you name it. But one thing that's interesting that is actually used by the AAP is that when they classify patients, so there's a stage, as we talked about, and a grading. So grade A could be a healthy patient.

And grade C is unhealthy. But they use the two most common things are the aggressive nature of the periodontal disease. So the amount of bone loss over time. They talk about the level of control of diabetes and also smoking habits. So we know just from the Academy of Perio that patients that have aggressive perio, that are smokers and that are diabetics, these are factors that are looked at. And based on the progression and the use of these, you know, different things, patients can be, you know, in a situation where you have more bone loss over time, slower bone loss. And these are things we can sort of look at in our console, which is why we bring this up.

Is periodontal disease something that can be avoidable? Like you mentioned, it started out with gingivitis. Are you able to reverse it once it kind of starts those first signs, those first steps of it coming on? So once you're a perio patient, you always technically have periodontitis. But if you can control... Excuse me. The inflammation and the bleeding, but you have bone loss, then you're a controlled perio patient. So that's really the end point of treatment in a private practice office that doesn't do full arch.

▶But these patients that can't be controlled or they're controlled for so many years and the teeth are mobile and they want to look better, that's where full arch can occur and be a good solution. One thing that's really important to know as well about perio is that even if you are missing teeth, it's still a risk factor for complications with implants. And the reason why is because periodontal disease has a large amount of dysbiotic biofilm, meaning bacteria and plaque, which are not favorable to a normal ecosystem in the mouth. This plaque and bacteria, it goes away when you have teeth that are removed, but not totally. So just because that you have a history of perio and all your teeth are removed doesn't mean you don't have consequences. And we'll talk about it in a bit, but...

We'll bring up some literature today that talks about some of the risk factors that go into implant complications. And one of them is periodontal disease, which is very important. And what are some consequences of having periodontal disease with the bone loss, tooth loss, and so forth? Sure. So most patients that get diagnosed with period disease are probably older. And the consequence here is that if it goes uncontrolled, it's likely that you're going to

Part 36:59

have periosteum. Aggressive bone loss, loss of teeth, flaring of teeth, aesthetics, which is unfavorable. You can develop black triangles, which means you're going to have spaces in between the teeth and loss of gum tissue. You're going to have bad breath, all kinds of issues, problems with your bite, bite collapse. So periodontal disease, when it is controlled, is great. But when it's not controlled, it really leads us to thinking about full arch scenarios. And why is full arch a good suggestion?

Is it a good suggestion for somebody who is struggling with periodontal disease? Is it the only solution? Is it the best solution? Is it just a solution? So it depends. Every office, of course, has different philosophies. And the reality is on a younger patient, if you can control periodontal disease for a number of years with a lot of bone loss, let's say your classic 30-year-old who has a familial pattern, that over time when you're probably in your 60s or 70s, you're going to have a lot of bone loss. And so if you're you're going to have flared teeth, you're going to have a smile that doesn't look great. You're going to have black triangles. It's not really something that you want to have. So over time, these patients, they get to a point where they're not happy with the aesthetics. And this is where we sort of draw the line and say, okay, maybe helping you with implants is the way to go.

But also, people that have periodontal disease, they just lose teeth. And when it goes uncontrolled, we think about implants. What is the most common age that you see periodontal disease kind of onsetting? It's most common in patients probably 40 and older. But the patients that have it at a young age that are in 20s or 30s have a very aggressive pattern. So it really depends on the person. And it's all about the level of control. Okay. And then what is the difference of periodontal disease versus peri-implantitis? Yeah. So I think the reason we wanted to tell everyone about, you know, gum disease, periodontal disease is because we have a foundation in our office on understanding how to treat teeth, but treating implants is a lot different. And if you understand those differences, you know, and we know, or we want to avoid risk factors for implant problems.

So the difference between implants is that they have something called peri-implantitis if they develop bone loss and inflammation, whereas teeth have periodontal disease. So peri-implantitis is a similar pattern of bone loss, bleeding, inflammation. But the difference here is that the tissue attachment around teeth is a lot different and stronger than around implants. So once implants start to have ailing issues, it can exacerbate and be a lot worse. So that's why having, you know, frequent checks, maintenance, and really getting to know our patients is so critical in full arch because once problems can occur, if we don't catch them, it can lead to more issues quicker than implants or quicker than actual natural teeth.

▶Got it. Do you see like different treatments for periodontitis versus periodontal disease?

Is it like, what would, what's the biggest difference besides it being an implant? Is it a different smell? Is it a different odor? Is it a different effect of the patient? Do they feel like any different signs? Yeah. So patients that have periodontitis, typically you're going to have a lot of mobility on teeth. Okay. With an implant, it's either integrated or it's not. So if an ailing implant is still in your mouth, it's very unlikely that it's going to be mobile. But I think the main difference here to understand is that implants are more aggressive with their bone loss pattern than teeth.

And when implants have problems, you want to catch it early. And the whole idea here is that implants have a tissue attachment, which is not as stable as around teeth. Implants don't have cementum. They don't have a periodontal ligament. They lack a lot of the structures that teeth have. So if I had one teeth, I would have a periodontal ligament. I would have a periodontal ligament. I take home from this episode, it would be implants are more likely to have problems once there's a problem than teeth. So maintenance is really critical. And I think any patient that thinks, oh, I'm going to have my teeth removed, I'll have implants and no need for maintenance. That's not true. The teeth have to be maintained. The implants have to be maintained totally.

What does the maintenance look like for a single implant versus the full arch that we do? Anything there? So with singles, you're going to clean your mouth pretty, similar. Patients use floss. They use toothbrushes. You have your maintenance appointments with your hygienist, but with full arch, you actually have to remove an entire prosthetic. So the prosthetic has a outside surface and an inside surface. The inside

▶surface is called the intaglio. So the intaglio surface is the surface that's always in contact with your gums. That surface is easy to clean at home with a water pick, but it doesn't mean that everything will be clean all the time. So the intaglio surface is the surface that's always in contact with your gums. So with that inherent challenge, you need to come to the dentist at least once a year to have that cleaned. And, you know, it needs to be maintained well. And if you don't have, you know, your full arch prosthetic cleaned, then you'll have possible issues down the road. It's very critical. It's just harder to maintain. And also there's no floss. So water picking is critical. And our patients have great maintenance, but I think the difference here is that you need to have a full arch center that will actually remove this for you at least once a year that it's very critical. That's a good idea. That's actually a very controversial topic that we hear about in our consultations sometimes too. When we hear patients who have had some outside sources, outside opinions other than done in one, which we love and we encourage, they're sometimes they, the patients have been to these centers where they do not want to remove the actual full arch. So maybe you can go into a little bit about why we actually take it out versus some other places that just say it's okay to remove it. So I think that's a good idea.

Yeah. I think, you know, we're kind of quoting a previous episode actually I did with Dr. Dan when we talked about the ACP, American Academy of Prosthodontics and their statement. And what it really says is that they don't believe in removing the prosthetic. I think that that can work, but it's not how we believe just because we see the challenges in older patients actually cleaning under the prosthetic. And also, you know, I think that's a good idea. I think that's a good idea. And also we want to catch problems early. Sometimes the x-ray isn't totally diagnostic with scatter and removing the prosthetic once a year, we found is the perfect amount. We're not over-torquing the screws. We're not causing problems and we can actually see what's going on and be in our patient's team. So that's our philosophy. I think other offices work differently and that's fine, but for us, that's how it works. And we can see everything that's going on and

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doing it more than once a year is definitely overkill. Gotcha. Okay. So, and you, fairly recently started doing some consultations as well. What are some big health risk factors that you kind of take a look at when you come into these consultations or meeting the patients for the very first time? Is there any specific points that kind of alert you outside of periodontal disease and outside of peri-implantitis? So there's definitely risk factors that alert me to educate the patient and also factors that may necessitate a medical consultation.

So patients that come in that need a medical consultation, patients that are on blood thinners, patients that have a history of chemo, radiation, bisphosphonates. So these situations will actually communicate with your doctor to find the best regimen to control you, whether it's risk of problems with your bone healing, such as with bisphosphonates or with bleeding issues. So that's a different scenario. But for us, the really important thing is what are the factors we can control and the factors we can't.

And what I wanted to get into here is that perio disease is something that at this point, if you're getting full arch, we can't control. If you have perio in the past, you have a history of perio and you have those pathogens. Removing teeth will definitely help. We can educate you on hygiene, but there are certain factors that we can help you and you can actually improve to have a better prognosis long-term. And two of those I wanted to talk about were diabetes and smoking.

Mm-hmm. There's a body of a disease that's not a disease that's not a disease that's not a disease that's not a disease that's not a disease that's not a disease. There's a body of evidence from the AAP, from literature. I have an article here from the Clinical Oral Implant Research paper. And what we know is that patients that have diabetes and patients that are smokers, it's not just black or white. If you're a diabetic and you're controlled, it's a big different situation than if you're a diabetic with an A1C level that's not controlled.

So to kind of take a step back, many patients either have diabetes that are controlled or not controlled. You may ask, okay, well, I know my number, but I'm not really sure what it means. So typically, a diabetic is anywhere above 6.5 for an A1C value. So your physician, typically an endocrinologist, will look at this value as a three-month measure of your glycemic control. And the reason we care about this is because if you have imbalances in your blood sugar, you can have essentially inflammation that goes on and you can have problems with the entire cascade of osseointegration and what we call a blood sugar imbalance.

▶So if a patient has a diabetic level of their A1C, let's say 9, that's important at the consultation because instead of rushing you into surgery, we're probably going to speak with your doctor, adjust your medication, adjust some lifestyle changes, and have you in a better situation. But the good thing about this is it's actually something we can control. So that's one major factor on diabetes.

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And another example of that is implants. So having a history of smoking, whether you smoke a cigarette a day or two packs a day is a lot different. And when the American Academy of Perio looked at all of these factors, what they found was that patients that smoke greater than a half pack a day have a lot different of a situation than less than a half pack a day. Interesting. I actually did my research when I was in residency.

I think what it means is a pack is 20 cigarettes. I'm not 100% sure. I'm not a smoker.

▶But that means that if you smoke more than 10 cigarettes a day, that you have a higher risk. And if we can have our patients smoke less, have control of their diabetes, even if they have a history of perio, that's something that's positive. How does smoking and vaping, having diabetes, how does that all kind of come into the healing of having the procedure? We talked about kind of getting over the bridge, having the procedure done. Does someone who does have diabetes versus, does not have diabetes, how does that first initial week after the procedure look?

Yeah, totally. I hope we're not too technical for our listeners. But anyways, we'll give you the details. So diabetes, essentially, if I were to give you the true spark notes, it's going to affect your blood flow and angiogenesis. So if you have, it's a microvascular disease. So if you have uncontrolled diabetes, you're not going to have the proper blood flow to your implant. Mm-hmm. Mm-hmm. Mm-hmm. Mm-hmm. Mm-hmm. Mm-hmm. ▶So if you have improper blood flow, your bone isn't really as vascular as it can be around the implant, and you can have problems and leading to maybe bone loss, not osseointegrating around the implant.

So that's a problem there. And also physical signs at all, like bruising? Somewhat, but I think it's more about the blood flow to the implant site. Okay. And with smoking, patients that are smokers, you have, you know, it's a vasoconstrictor. There's going to be less bleeding at the time of surgery. And then smoking has carcinogens. So if you're smoking and inhaling that vapor around a healing implant site, it's just not good for soft tissue healing. And it's known to be a risk factor for us and our health of our implants.

Mm-hmm. How come we typically avoid giving our diabetic patients our steroid dexamethasone? Got it. Got it. Yeah. So what you're quoting is that typically patients that are diabetics, you want to control their inflammation and swelling, but we don't give them a steroid. Correct. Typically, we're going to avoid that by having our patients taking Advil and Tylenol. And normally that does the trick. But definitely we don't want to have elevated blood sugar levels with our patients that are diabetics.

That's the reason we don't give a steroid. So the steroid elevates blood sugar levels. Definitely, yeah. And that's one of the main reasons that we don't want to lead to a patient who's smoking. Because they're working so hard with their diabetic control and then giving them a steroid and leading to some problems there. Got it. Especially because eating during that 90-day soft food diet

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can kind of be a challenge in itself, finding things that work for you. Totally. Yeah. So just to kind of circle back is that what I'm referring to is an article from the Clinical Oral Implant Research. And this is a pretty well-quoted article for peri-implantitis, so diseases around implants. And what this group did is they looked at over 900 implants and they said, okay, what are the factors that go into patients' health and which ones are actually significant?

So they looked at systemic conditions like heart disorders, hypertension, smoking, alcohol, period disease, everything you can think of that can have problems. And also they looked at some of the issues around teeth, such as wherephysets, grinding, bruxism, all of that. And what they found is that periodontal disease led to a 2.2 times risk higher for implant problems. And 3.6 times risk for cemented restorations. And they also found that cemented prosthesis and wherephysets were issues here. So what I'm getting at is that controllable things such as diabetes and smoking we have, there's also factors that can affect implants that are done by the surgeon.

▶So if you have a poor bite scheme, if you have cement that you're using to retain the teeth that is extruded, those are factors that can affect implants. Those are biological issues that can lead to complications. So the whole idea here is that us as surgeons and our prosthetic team needs to hone in on what we can't control, which is going to be everything on the teeth, and also your medical history, which is modifiable. And the parts we can't control, we just can't control.

We want to talk about all of these factors so we know as a candidate, are you at risk for having problems as a full-arch patient? And the reality is implants, implants and full-arch do very well. We don't see a lot of high complications, but the patients that have uncontrolled diabetes, that are uncontrolled smokers, that don't follow our soft diet, that have poor biting habits during our 90 days, that are not compliant, that's probably where we see the most problems.

Okay. Do you have any advice to share with someone who does currently smoke and is interested in having a full-arch procedure done? I know this is kind of random and off topic, but... Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Good question. It's not like if you're a smoker, we're going to tell you, hey, you never can have this procedure. We can't help you. But I would say at least a month or two before, if you're preparing to have this surgery, try something such as edibles, try something such as patches.

Even if you're not smoking tobacco, but you're smoking anything else, just the vapor in the mouth, even front vapes is not beneficial to our early healing. So having anything that's an adjunct is definitely helpful. And avoiding things that can lead to surgical problems is key. Unfortunately, we can't hold everyone's hand and we can't tell you what to do, but we want to give you the tools to make the best decisions. Yeah. The best success. Absolutely. And my final probably close out question is going to be,

▶how long do we advise to hold off on smoking after the procedure? We talked about before, during, now after. Is it something that like if they, if the patient was healed, they waited the full 90 day period, then they started smoking again. Is it possible that they're then putting themselves at risk for, you know, those factors that we just discussed? It's kind of like you're saying, Hey, I'm on a diet, but how often a week can I have McDonald's?

Exactly. These are the questions that we receive. There's probably no good answer to that. So if I was on the spot as I am now, unfortunately, I would say no smoking at all is the best answer. But if you have to smoke, and it's something that patients want to do, then I would probably recommend you wait at least six to eight weeks. And the reason why is because that's a time to allow for soft tissue healing and having smoking going on and carcinogens with an open wound before all the soft tissue closes is definitely an issue.

Got it. Got it. Okay. And then just in your personal experience, are there preventable measures that patients can take to ensure that they have the best experience possible? If someone who does already have diabetes, someone who already does have periodontal disease, what kind of steps can they take just leading up to this procedure? You said maybe stop smoking a couple of months before. But is there anything that somebody who already does experience periodontal or peri-implantitis, is there anything they can do to themselves to just make sure that they have the best experience and the best possible outcome and having full arch?

Sure. So I think that's why I'm really supportive of the maintenance program. And what we do here at Dundon One, no matter who the patient is, if you're healthy, if you have risk factors, I think being maintained is probably one of the top three ways to avoid problems. So I would say as a patient, the most controllable thing is whether you go with us, whether you go for another group is having a center that isn't going to just

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do the surgery and say goodbye and go live on. You have to have someone that's going to watch what's going on. So that's number one is having someone that's going to maintain you, remove the teeth about once a year, no more, no less clean well and have the proper oral hygiene instructions. Number two is we talked about smoking. Yes. Limit smoking. I wouldn't smoke close to surgery or after surgery. And if you have to smoke, try to wait at least six to eight weeks.

Diabetes. I would ensure that if you're a diabetic, you see your endocrinologist, you have an updated a one C value, which is a three month level of your glycemic control. And if your range is anywhere from six to seven and it's controlled, that's pretty normal. If it's anywhere from eight and above, you may want to consider working with your doctor, having a better value than going to surgery. And then patients that have teeth already, you know, we talked about patients that you know, some risk factors can be cement.

I can be, uh, bruxism. It can be occlusion. Let's say you're already in a full arch and you're part of our warranty, which is a whole nother topic or a refresh program. Maybe the problem here is that you have a, uh, a bad occlusion and we can help you with having a better bite.

▶Maybe the problem here is that we'll give you a night guard at night and you're going to avoid bruxism. I mean, there's just so many ways to go about this. And I think there's no answer to how do I prevent complications? How do I make sure that I'm a hundred percent? A slam dunk full arch candidate. But I think if you have the right team, you have specialists and we can evaluate everything. That's the best solution into having a group of people that will look at you often and anywhere that just does the surgery and has no idea how to remove the prosthetic and maintain and clean probably isn't the way to go because you want to catch all of these problems.

And I think, um, I keep saying circling back, but totally circling back to early in the episode, we talked about how, how implants are different than teeth and implants have more of aggressive bone loss patterns. They have issues. So we can catch this early on. We can help you. And it's almost like if you have a knee replacement or hip replacement, would you want to see your doctor often just to make sure everything's okay? Totally. So there's no difference here and we're here to help.

So I think that's, that's the bottom line. Awesome. So I guess on a different note, um, we're getting close to the new year. So we're enjoying some of the, sunny Florida. It's, uh, maybe six to eight degrees. Beautiful outside. It's beautiful today. Any good plans coming up? Um, I actually don't have plans. New year's is tomorrow. Um, I don't know. I want to sit outside. I want to enjoy our weather. When New Year's is tomorrow. Yeah. Tomorrow's the 31st.

That's crazy. Yeah. I joined the group here a couple of months ago and it's crazy. Now we're going together into 2026. Amazing team. I love it. Dr. Dan, he's traveling now, but I'm sure we'll all be back together after the new year and join forces for

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another great episode. Yeah. Sounds like a plan. Well, I appreciate you joining me today and we had a lot of fun filming this. So, um, hopefully Dr. Dan is proud and we look forward to talking to you guys again soon. Thank you. Thanks. Happy holidays. Bye.