“We must always remember that a tooth wants to live” 

Dr Raúl Caffesse, D.D.S. from the Universidad de Buenos Aires, has collaborated in recent years as a visiting professor of the Master’s in Periodontology at the Universidad Complutense of Madrid. He holds a Master of Science in Periodontics from the University of Michigan, USA and has received five honoris causa degrees from various universities in Argentina. This eminence in dentistry currently resides with his family in Houston, Texas, and collaborates in various research projects, in addition to giving courses and conferences by invitation in many countries. 

You participated in a recent epidemiological study on peri-implant diseases in Spain. What is your impression of the results? 

In the first place, it was a great pleasure for me to participate with an excellent group of Spanish colleagues and friends in the planning and development of this study, and a great honour that the officers of the Spanish Society of Periodontology and Osseointegration (SEPA) should select me for this. 

Implants have “flooded” dentistry, modifying the usual classical therapeutic approach. They represent the best choice for the replacement of missing teeth, but unfortunately many teeth that could be maintained succumb to metal replacements. There is currently a great deal of evidence that this replacement is not permanent or free of complications and that peri-implant tissues may be as gravely affected as, or even more than, peridental tissues. 

The conclusions of this epidemiological study reveal that implants placed in Spain can be affected as greatly as that shown in other areas of the world. The samples of 474 implants in 275 patients from 49 different dental clinics representing the different regions of the country show that 51% of patients suffer from peri-implant disease; 27% from mucositis, and 24% from peri-implantitis. Overall, 47% of implants were affected. These are substantial figures that dentists must consider very carefully before extracting, and above all, they should always remember that “a tooth wants to live.” 

After all these years doing research in periodontics, what issues do you think will get most attention in the near future? 

All my research has been linked to the periodontal treatment of patients, and practically all my studies have had clinical applications. I believe that in the future we will continue to delve into basic periodontal knowledge with the aim of clarifying and understanding the bio-pathological mechanisms that trigger periodontal lesions. 

We know that there is no single treatment applicable to all patients. Thus, the more we come to appreciate the myriad of risk factors that may affect patients and modify our therapeutic approach, the more we will be able to maintain their dentition in form and function. In the face of a multifactorial chronic disease, we will in due course undoubtedly arrive at personalised treatment for each patient, and the area of periodontal medicine will continue to develop. We must recognise that, as a chronic inflammatory disease, periodontitis will be systemically connected with many other disorders. 

You have likewise carried out extensive research into periodontal regeneration. What remains to be discovered in this area? 

I have lived a golden age in the development of regenerative techniques in periodontics, and we have made significant progress in the last 40 years. 

But there is no doubt that the journey will continue, and active and fruitful development of research into this field still lies ahead. The future will doubtlessly hold remarkable advances in the areas of growth factors, stem cells, tissue engineering and gene therapy, as well as in the development of tissue substitutes, both soft and hard, not only for replacement, but also as vehicles for the application of inductive therapies. 

But I think it is appropriate to emphasise that conventional periodontal therapy has been so successful that all these innovative and effective methods should be considered from a cost-benefit standpoint when evaluating their overall application and relegated to the treatment of very specific cases. The conventional approach is still a successful and effective method to control most periodontal disorders. 

Plaque control and motivation to perform oral hygiene is an unresolved issue in many clinics. How can we improve this? 

There is no doubt that from a preventive perspective this issue is fundamental to oral health and of paramount importance for the success of at-home periodontal treatment. But we must recognise that through oral hygiene instruction, we are changing habits that patients have had ingrained for a long time. These habits are very difficult to change, and the motivational cycle must be maintained. 

The whole medical team—dentists, hygienists, and assistants—must be trained to repeat and emphasise the same message. Patients must receive reinforcement of the same instruction every time they are examined and be told why a change in their habits is so important. 

Unfortunately, in periodontics we do not have a magic potion that ensures the maintenance of the results achieved; we only have the patient's collaboration, a decisive factor in determining the maintenance of the recommended routine in proper oral hygiene. Every effort must therefore be made by using all the educational means available in order to accomplish individual patient motivation. 

Another key facet in the management of periodontal patients is the maintenance done at the clinic. How can this be improved? 

Periodontal maintenance represents the most important phase of the treatment, since without it, it is impossible to ensure stable long-term results. Frequency should be determined according to the reassessment made at each visit. Hygienists and dentists must work together in the evaluation process. The areas showing inflammation during maintenance should be identified mainly according to the degree of bleeding on probing. These are the areas to be worked on during support therapy, while the rest of the mouth needs only to receive prophylaxis with supragingival scaling and polishing with a prophy cup, and of course, reinforcement of oral hygiene. 

The fundamental problem arises when maintenance is shared between two practices, that of the specialist and that of the general dentist. Patients maintained exclusively by a general dentist after periodontal treatment tend to lose clinical attachment over time. Periodontists must clearly and precisely train their general dentists of referral in the approach to follow during maintenance of the periodontal patients treated by them, both in terms of the evaluation and the treatment to be received. 

As a world-renowned expert in periodontics, what do you think the industry’s role should be in this exciting field? 

The role of industry in the development of different kinds of products to be employed at different stages of treatment, periodontal in our case, is of utmost importance. The industry, universities and other research centres must keep up close cooperation in every way. The industry must be nourished by the experience and observations of researchers, from whom the ideas and hypotheses that need to be developed and corroborated arise; but in turn, the industry should as a rule support the research centres and cover the costs of their projects. 

In the US, the National Institute of Dental Research has been the source of the most substantial subsidies for research, but this is fundamentally basic research, rarely clinical. In the years I served as a member of the grants committee, very few clinical trials were approved. As far as they are concerned, researchers depend on private funds from companies linked to the dental industry. 

Several countries have official funds which different projects can draw upon. Spain is not one of these. So financial support for the research centres from the dental industry is even more important. Symbiosis between industry and researcher is essential for the benefit of both, and for the progress of the profession.