Most general practitioners have many patients with moderate to advanced periodontal disease who refuse to have surgical treatment. The author, a periodontist, his brother a general practitioner and their father a periodontist developed, tested and used a nonsurgical approach on such patients that was very effective. About two years ago the author, at the urging of these patients, published a book describing the approach in detail. A small number of dentists who had seen the results achieved on their own patients purchased the book. The opinion of those who made a serious effort to learn and apply the methods described appears to vary from quite satisfied to enthusiastic.
This article was written at the encouragement of these dentists who felt the approach could be of great benefit to many patients. They like the approach because it is safe, very easy to learn and do, effective, and is well accepted by most patients. In addition they found that much of the work could be done by their hygienists after being trained by them in the use of the procedures involved.
Patients are happy with the procedure because as one said, “It works, it’s painless, no needles are needed and the gums don’t have to be cut.” Many favour it because they see it as a treatment that works with the body and does not employ exotic substances such as antibiotics. Hygienists like it, when they have mastered the techniques, because they can clearly see and easily get at the deposits on the roots of the teeth with deep pockets and furcations. This enables them to scale faster, more effectively and know when the teeth are clean.
The approach, which was developed over a period of many years (40 to 50 years), is based on two things. First, the use of a new form of displacement dressing that eliminates infection in pockets as well as opening them enough to make thorough scaling easy. Routine treatment of pockets of up to eight to 10 mm. deep is possible. Second, methods of home care based on exercise physiology that promote healing and the creation and maintenance of a gingiva with a heightened resistance to bacterial assault as well as plaque removal.
The displacement dressing used is a lineal descendant of one devised by Dr. W. J. Linghorne, Dr. Harold Box, a former head of periodontal at the University of Toronto Dental School and their associates during World War II. It was called Box’s Pack and was a thick sticky plasticine-like substance made of materials commonly used in dentistry.
The active ingredients were eugenol (oil of cloves), thymol and tannic acid. Properly placed and kept in pockets up to about 6 mm. deep for several days it killed bacteria in the pocket. When removed the clinician would find the pocket wall displaced several mm. away from the tooth and signs of inflammation and infection absent. The pocket would remain open for about fifteen minutes enabling a skilled operator to clean the root without traumatizing the wall of the pocket.
At a time when antibiotics were not available and dental abcesses could and did kill patients, the dressing was a real breakthrough. Dentists in the Canadian Dental Corps. and students at the University of Toronto Dental School were soon being trained in its use and it began to be employed in many places across Canada.
The dressing while very effective was extremely difficult to use. Many dentists were not able to master it. (Imagine trying to place plasticine in a pocket of a molar.) Therefore, when surgical techniques began to appear in the 1950s most were glad to drop displacement dressing in favour of surgery. Today few younger dentists have even heard about it.
In 1959, the author graduated as a general practitioner and was soon sharing an office with his father W. J. Linghorne and his brother Dr. Robert Linghorne. Dr. W. J Linghorne and those of his confreres who had mastered the use of displacement dressing approached periodontal treatment completely differently than the majority of the profession. Surgery was used only where treatment with displacement dressing was not feasible or possible. This approach greatly reduced the amount of surgery that patients needed to undergo.
Some of them, being aware of the limitations and difficulties associated with its use were actively experimenting in an effort to improve it. The author found his father and many of these dentists using modified forms of the original dressing manufactured by a drug company in Morrisburg Ontario and a number of different treatment methods. As one of Dr. W. J. Linghorne’s sons the author was expected to learn and adopt these methods when he began to treat patients referred for periodontal treatment.
NATURE OF EXPERIMENTATION WITH DISPLACEMENT DRESSING
By the time the author and his brother began to practice, the dressing had been used for almost 20 years on thousands of patients in hundreds of offices apparently without serious side effects. Having no way of assessing the effects and pharmacological action of the drugs used we did not change the chemical composition of the dressing except to eliminate two ingredients. Asbestos was eliminated when it became of public concern even though the form used in the dressing was not the harmful type. Thymol, which acts in many ways similar to eugenol, was also dropped, though, the author cannot remember why. He strongly suspects it was dropped when it was discovered the dressing without thymol appeared to work just as well.
Experimentation was confined to form, techniques of usage, preparation, storage etc. This in time produced a steady flow of new insights and improved techniques. A major breakthrough occurred when Dr. W. J. Linghorne began to use a particular modified form of dressing. The dressing was mixed to a consistency of toothpaste, which was then used to impregnate small thin strands of sterile surgical cotton. These were drawn into the pockets using a modified diagnostic instrument shaped like a periodontal probe. When the pocket was full of strands it was covered with a thick, firm mix of the dressing with the consistency of plasticine in a manner similar to that used with surgical dressing. This innovation made placing the dressing fast and VERY EASY to do. It also made it easy to place it to the bottom of deep pockets so it reached all the bacteria present. When properly placed and kept in the pockets for a number of days all signs of inflammation and infection disappeared.
A second innovation was the use of successive multiple applications of the dressing enabling us to open pockets up to eight to ten mm. in depth. A third innovation, was the use of an intra oral diagnostic light to enable us to better see the deposits on the roots of the teeth with open pockets. Over the years many were tried and used. About twelve years ago the author found a small dental manufacturer in Texas willing to make a light to our specification.
At last we were able to get an intra oral diagnostic light made to suit our needs for scaling. With this light, we learned the most effective way to use it was to transilluminate the tooth and the open pockets. This enabled us to see the most minute deposits on the roots clearly and to tell if inflammation was or was not present.
One of our major treatment objectives then became to refine dressing usage to eliminate all haemorrhage as much as possible to facilitate scaling. Patients of course, preferred this because when the pocket wall was not disturbed they experienced no pain, and very little or no bleeding.
It was around this time that the author began to be really aware of and study the soft tissue response to the dressing and different methods of usage. A small amount of tissue sluffing occurs when the dressing is used to exert pressure on the pocketwall to displace it, to open the pocket. This sluffing had been noticed from the very first when displacement dressing began to be employed in the early nineteen-forties. It was ignored because it appeared to be of no importance. Dr. W. J. Linghorne had used pressure from the dressing to eliminate soft tissue instead of doing surgery in certain circumstances.
The author and his brother however, had never used it in this way because it was usually accompanied by considerable discomfort or pain and other side effects and one of our objectives was to eliminate pain and any other side effects. In time, it became apparent that a moderate amount of pressure could be used to painlessly eliminate granulation tissue in the pocket, most of the interproximal soft tissue and cause of the removal a great deal of connective tissue fibre in the pocket wall without causing any untoward clinical side effects.
We gradually came to realize that the dressing could be used to eliminate much of the scar tissue that tended to build up over time in pocket walls and to control gingival hyperplasia. This made curretage rarely necessary. We began to use the dressing to eliminate excess soft tissue and fibre, preparing the gingiva for the home care exercises to follow.
A NEW APPROACH TO HOME CARE
The second thing the approach is built on is a totally new paradigm of home care based on the application of exercise physiology. A brief outline of the paradigm follows; interested readers can find full discussion of the facts and observations supporting it in the authors’ book.
The primary objective of the home care procedures is to build and maintain a strong fibrous gingiva with a high resistance to the attack of the bacteria in the mouth. Plaque removal is a secondary major objective. The gingiva as part of a living machine has the ability to respond and adapt to the stresses placed upon it. The gingival structure, as we see it, is, just like the periodontal membrane, largely a manifestation of the body’s response and adaption to the forces placed upon it during eating etc.
To put it another way, the gingival structure we observe is to a large degree due to the exercising action of food that occurs during eating. The author found that exercises can be designed and used so they become a primary determinant of gingival form, height and structure overpowering to a large degree the tissue response to food. Many soft tissue pockets can be reduced in size or eliminated.
A strong healthy gingiva highly resistant to bacterial attack can be built and maintained where the exercising action of food is poor or absent (often after surgery) or provokes an undesirable response like hyperplasia. We discovered that following treatment with displacement dressing, healing and repair can be frequently guided to ensure the formation of healthy structures more resistant to bacterial attack. The shape of these structures can be and is often quite different from those created by the action of food on the gum.
Assuming that the author has convinced the reader that it should be possible to use home care with an exercise component to promote gingival health the next logical step is to discuss what happens when the gums are exercised by food. This will give us some insight into what the exercises we design must do.
THE ROLE OF EXERCISE
When structures are subjected to stress they tend to deform. Engineers study and measure this deformation which they call strain. The nature of the deformation or strain that occurs when the gingiva is exercised by food as it passes down over it during eating is of great interest to us. Study shows that a gentle rubbing action occurs that deforms the gingiva in a way that both compresses and tends to pull it away from the tooth.
Wolfe’s Law tells us that connective tissue can respond in certain circumstances to stress that tends to deform it by laying down fibre along the lines of stress to control the amount and nature of deformation or strain. This means that if we wish to promote the strengthening of or formation of a particular ligament we must apply an appropriate stress to cause the type of tissue deformation or strain that will induce the cells to lay down fibre where we want it. We also know that the amount, method of application, frequency, etc. of stress application will affect the nature of a body’s response. Inappropriately applied stress can cause damage or fail to produce the results we wish.
This understanding leads to a number of very interesting conclusions. One, is that if we wish to build and maintain strong ligaments to hold the gingiva to the tooth we must use exercises that stress it in a way that TENDS to pull it away from the tooth.
Consideration and clinical study of the effect of the intermittent gentle compression of the gingiva that occurs during eating also leads to a number of interesting conclusions. The intermittent pressure appears to facilitate the passage tissue fluid through the ground substance. When connective tissue is compressed, tissue fluid is squeezed out of the ground substance into the venous capillaries and lymphatics where blood pressure is minimal and lower than the arterial system. When the pressure on the tissue is removed, the ground substance being unsaturated will suck up fresh tissue fluid rich in oxygen and nutrients from the arterial system. Fluid in the venous and lymphatic system is prevented from backing up by the one way valves in these systems. In this way circulation is facilitated in the dense connective tissue of the gingiva.
Clinical observations and clinical experiments easily performed by any dentist that are described in the book convinced the author that repeated appropriate compression of the gingiva a number of times a day is absolutely necessary if a densely fibrous healthy gingiva is to be maintained. This means, the clinician must learn to study the gingiva of each patient around each tooth to see if it is being appropriately stressed and compressed by food during eating. Where this does not occur changes in the mouth should be made where feasible to facilitate the exercising action of food and/or exercises devised to provide the needed stimuli.
What can be achieved when a patient is treated long term with displacement dressing and uses a home care program based on the exercise physiology as well as plaque removal?
In most cases almost any tooth that can be periodically properly packed and scaled will last indefinitely, probably for the rest of the patient’s life if enough supporting bone remains to handle chewing loads. This includes molars with involved furations when very large pockets are present. Interestingly, these are often easier to treat that single rooted teeth because the pockets open better for scaling.
Pockets up to about six mm. deep on single rooted teeth will usually gradually heal over a period of a few years if the occlusion is not a contributing factor to the disease. Identifying such teeth is discussed in some detail in the book.
On many furcation involved molars sufficient pocket depth reduction occurs to make it economically feasible to maintain them since most will with periodic treatment with a single application of displacement dressing, last indefinitely.
The results that can be obtained by using this approach have convinced the author it is a safe, practical effective way to treat patients with moderate to advanced periodontal disease who refuse to have surgery.
SOME FINAL THOUGHTS
The approach has a number of other uses that space does not allow the author to discuss. Two are the nonsurgical management of periodontal abcesses and the facilitation of the construction complex restorations like crowns and bridges.
The actual techniques and devices used are not discussed in the paper because to produce the results outlined without problems the clinician must know a great deal more than has been presented.
In time, periodontists as they better understand the role of function in gingival health will probably alter their surgery to facilitate the exercising action of food and to make it easier for patients to use commonly available devises like tooth brushes to provide the needed exercise to build and maintain a strong, healthy gingiva with a heightened resistance to bacterial attack.
New home care devises and methods of usage will probably be developed.
The information provided in NO way diminishes the importance of plaque control.
The book contains a reprint of a 1959 paper in the Canadian Dental Journal written by Dr. W.J. Linghorne and an associate that contains much useful information. Interested readers can access further articles in the dental literature published in the nineteen forties and fifties. There are also probably still copies of a small book discussing displacement dressing in the Toronto Dental library that was used as a text by dental students.
Several copies of the author’s book are in the Toronto Dental Library.
The author is aware that he is just a clinician and not an authority. Therefore, in the book he has attempted to provide the interested reader with enough information to enable them to verify the validity of the approach and to try it if interested. He is also quite ready to discuss it with any dentist who wishes to begin using it.
Finally, it is the author’s fervent hope that teachers in positions of authority in dental schools will investigate the approach and in time teach it as a regular part of the curriculum.OH
Dentists & hygienists interested in learning more about the approach may contact Dr. Linghorne at 55 Anglesey Blvd., Etobicoke, ON M9A 3B8.
Oral Health welcomes this original article.