Overeager periodontists are performing gum surgery on their patients, although a less invasive and costly alternative is usually just as effective, David D. Millen says.
Millen, a New Haven periodontist, has developed a reputation as a medical gadfly by insisting that many gum removal procedures are unnecessary.
Millen has made himself even less popular among periodontists by suggesting that their preference for surgery is profit-driven.
“Millen is in a very small minority that chooses to practice without surgery,” said Dr. John W. Dean III of New Haven, who is president of the Connecticut Society of Periodontists.
Millen, who considers himself a medical maverick, said that gum disease is emerging as a factor in several significant public health problems.
A cheaper treatment to clean and calm swollen, bacteria-ridden gums, could ultimately improve the country’s health, he said.
Studies are beginning to show a link between infected gums, and coronary artery disease, diabetes, and stroke.
“It’s a given now that gum disease is a risk factor in these other disorders. The biggest problem is that doctors and the public don’t know it,” Millen said.
The common factor in these disparate conditions is inflammation, he said.
A National Survey of Adult Oral Health showed that 77 percent of people 18 to 65 have gum disease. In the population over 65, a full 95 percent have some degree of periodontal detachment.
It all starts as a question of which bacteria are living in your mouth, Dean said.
One type, which depends on oxygen, consumes residual carbohydrates and forms a film on teeth and along the gumline. If this film is not removed within about 72 hours it hardens into tartar, of calculus. The cement-like material summons an immune response, which is why gums become swollen, and bleed easily. The medical name for this is gingivitis, or inflammation of the gums.
This is why brushing and flossing properly are so important, along with periodic professional cleaning. Once the tarter is scraped away, the gums get healthier.
If the tartar is neglected, what happens next is largely a matter of genetics.
The bad actor here is anaerobic bacteria that live below the gumline and cannot be reached with a toothbrush.
Some people are susceptible to these bacteria, while others aren’t.
These anaerobic bacteria, which do not require air, start to multiply in pockets below the gumline. They can reach the bone that supports teeth: periodontis.
If nothing is done, the “bad” bacteria thrive on proteins in the blood and release a toxin. The bacteria and the immune response they trigger eats at the bone until unsupported teeth fall out.
The body’s immune system does not sit idly by as pathogenic bacteria bore into your jaw.
The full arsenal of the immune response is actually responsible for most of the bone loss, Dean said.
Cytokines and other cells that fight invaders overzealously attack bone.
Immune cells also circulate through the blood stream, aggravating inflammation everywhere they go, said Millen (pictured).
Consequently, researchers at Columbia University, in in a study for Aetna, determined that treating periodontitis reduces the risk of — and payment for — diabetes, coronary artery disease and cerebrovascular disease.
Delta Dental recently sent doctors a fax describing research at the National Institutes of Health showing that periodontal disease interferes with treatment of patients with non-insulin dependent, or type 2, diabetes.
How do you get rid of the bad bacteria before your gums develop pockets of pus and your teeth get wobbly?
According to Millen, deep cleaning, or debridement, followed by a course of antibiotics is usually sufficient to banish troublesome bacteria.
Dean said that both surgical and non-surgical methods are necessary to treat periodontitis.
“Some pockets cannot be cleaned out because they’re too deep. I pull the gum out of the way to clean the roots out. Eighty percent of the time I peel back the gum, place in bone grafts (which resemble grains of salt), and close the gums back up. It’s very successful,” Dean said.
Some other periodontists remove the strip of gum, along with the infected pockets.
As times goes on, the problem recurs and more strips are removed, Millen said. At some point a bone and/or gum transplant becomes necessary, he said.
“Routinely, we don’t cut gums away,” Dean said. “Most people with garden variety periodontal disease respond well to deep cleaning, and a gum peel-back.”
To Millen, it all comes down to other people’s money and his reluctance to take it.
“I make one-third of what I used to make,” he said, when he performed gum-removal surgery.
“That’s why I’m a maverick.”