Refractory periodontitis

From: Colleen Rutledge, RDH Sent: Friday, March 25, 2005 1:54 PM To: periotherapist group Subject: Re: [periotherapist] AAP term for refractory What is the term that replaced "REFRACTORY" the 1999 AAP Classification System ? - Colleen "Refractory" as a distinct 'type' of disease was discarded entirely. It was not replaced with anything as it never really existed in the first place. However, the word, as used in the article, is correct. It's used in the adjectival sense, not as a noun. It doesn't refer to particular form of periodontal disease, but to any treatment that does not produce the desired result - Bill I think that one has to distinguish between a diagnosis of refractory periodontitis (rare) and an advancing disease state that is due to inappropriate treatment, supervised neglect and, or, untimely referral. Many cases that were referred to me diagnosed as "refractory" by the general dentist were actually just the advancing stage of periodontal disease. The patients received necessary care in my office, and the majority were eventually pronounced disease free without surgical or medicinal intervention. These cases were not refractory as they responded to care and remained in a state of wellness over a long period of time. Specialized care, especially surgery, may have been avoided with a more timely referral. You can stop a speeding train, but once it is wrecked there is a hell of a lot more salvage work to do. You state that for refractory perio, "The proper care is to ratchet up the anti-infective therapy adding more and greater anti-infective measures both at home and in the office." But what if it is not a refractory case? What if more treatment, nonsurgical or surgical, eventually necessitates the referral to a periodontist regardless of how much more care is provided? This is precious time that could be a factor in a more beneficial outcome. Another consideration for the patient is the financial aspect of repetitive treatment with the result being referral for additional care. Who would appreciate being charged over and over for engine treatment by a gas station mechanic when the problem was actually clutch trouble, eventually repaired by a transmission specialist at even more expense? You state, "I know it is a common perception that non-surgical therapy is a nice compromise treatment, but if the patient can afford it and really wants to get better, the real thing (surgery) is indicated. Well that's just not true, especially with Refractory Periodontitis. If a patient is treated non-surgically and is left with RP, surgery is not indicated. Surgery under those circumstances would not be within the standard of care as we understand it today." You are correct. Surgery under those circumstances would not be advisable. But with the apparent confusion in properly diagnosing a refractory case, should one risk deterioration of the periodontium because of a misdiagnosis and an untimely referral? I have a concern with this article (abstract) from Socransky et al. you have attached in regard to treatment of "refractory" cases. I am glad to see that you came to the realization of the absurdity of this article as you stated in a PS in recent post. This is obviously an illustration of inadequate treatment by the initial practitioners. As you point out, the cases labeled as "refractory" were ultimately successfully treated (by the authors?). If the authors had seen these patients at the onset, the assumption is that their treatment would have been successful initially. If the original practitioners utilized the exact treatment as the authors, they would have succeeded originally. And if so, this is not a case of refractory periodontitis but arguably, inadequate treatment by the initial practitioners. I agree with Bill who stated "Refractory" as a distinct 'type' of disease was discarded entirely. It was not replaced with anything as it never really existed in the first place. To imply, as you did, that "medical additional treatment" is the meat of advanced therapy is ridiculous! These were not cases of a resistant infection. It was the original infection that was never properly treated. Who is to say that traditional perio scaling and root planing would not have achieved the same results? I rarely utilized medicinal treatment during initial therapy in my practice and had outstanding results. Medicinal treatment, similar to surgical care, should be considered as a last resort only after traditional therapy has not produced the desired positive results. I never personally liked taking antibiotics and found most patients did not either. Usually they understood that conservative treatment would be successful and if not, we could always consider antibiotics or other medicinals at a reevaluation visit. I would be curious to know how these patients in the study would have responded with scaling and root planing by an accomplished practitioner. Never mind, I think I know. Perhaps, instead of "ratcheting up the treatment of a case that does not respond" as you suggest Larry, a practitioner should consider evaluating for the timely referral to a periodontist who in most cases, after 3 years of additional specialized education, is probably more suited to successfully treat the progressing "refractory" cases. If my physician can't heal what ails me, I think it's best he refer me to a specialist rather than "ratchet up the treatment." As Mike would say, get a periodontist on your team. I will add....before the train wreck! Yours, Steve Ury