Coordinated risk reduction strategies
Reducing systemic inflammation requires reducing the pathogenic bacteria causing periodontal disease and the inflammation associated with infection. Therefore in order to protect the health of patients and to reduce the risks of periodontal disease, dental and medical professionals need to work closely together. Following are some of the key areas where jointly coordinating risk reduction strategies can reduce patient risk for oral and systemic inflammation.
• More frequent medical/dental checkups
• Treatment for dry mouth
• Smoking cessation therapy
• Weight management
• Addiction treatment
• Stress management therapy
• Nutritional consultation
• Consultation between physician and dentist/periodontist regarding:
° medical conditions
° menopause (potentially calcium, hormonal supplements or medication)
Proactive dental examination/patient communication
Today, dentists, dental hygienists and periodontists play an integral role in protecting the overall health of their patients. Knowing as we now do that periodontal disease has a major impact on systemic health, it's vital to proactively intervene to not only treat periodontal disease but to prevent or slow its progression.
Physicians understand that disease is multifactorial. Heart disease has a long list of contributing risk factors. So does diabetes. So do most degenerative diseases of the body.
The downward spiral of disease in dental hard and soft tissue is multifactorial as well. Therefore rather than "watching and waiting" and focusing on "minimally invasive" or "minimal intervention" dentistry, today dental professionals need to diagnose, assess risk, and proactively intervene before the situation requires more extensive treatment. The following are the key steps involved in delivering proactive dental examinations and patient communication.
Proactive dental examination
• Assess risk factors
• Take detailed medical history
• Conduct a thorough clinical examination/visual inspection of mouth/oral cancer examination
• Evaluate probing depths, presence and number of bleeding points and location of gingival margin (clinical attachment levels)
• Use disclosing dye to reveal biofilm
• Examine glands and lymph nodes for possible signs of inflammation
• Conduct radiographic examination, if indicated, to identify possible bone loss caused by periodontitis
• Consult with health care provider where patient has a condition that requires further evaluation related to treatment and outcomes
Proactive patient communication
• Review the oral-systemic link
• Discuss risk reduction strategies as indicated
• Show patient his/her oral tissues including any signs of active disease such as bleeding and pockets
• Discuss ways to improve oral hygiene practices and, if indicated, optional periodontal disease treatments
• Review need for re-evaluation appointment, if necessary
Brushing and interproximal cleaning is the ﬁrst-line approach to microbial reduction. We know that proper oral hygiene can eﬀectively reduce gingivitis and aid in the treatment of periodontal disease. We also know that floss, interproximal brushes, stimudents and other mechanical aids can reduce plaque levels. The unfortunate reality, however, is that many patients do not spend a suﬃcient amount of time brushing and interproximal cleaning, with the result that some 75% have or will have an oral infection.
Scaling and root planing – aggressive subgingival debridement, using manual instrumentation or sonic or ultrasonic scalers, is considered the ‘‘gold standard’’ nonsurgical treatment of periodontal disease. Multiple clinical studies demonstrate this technique eﬀectively reduces the microbial load, reduces bleeding on probing as well as probing depths and promotes gains in clinical attachment .
The use of a preprocedural rinse with chlorhexidine or cetylpyridinium chloride will reduce the risk of spreading infection from unhealthy to healthy sites.
The need for more eﬀective diagnosis and control of periodontal infections has led to demand for microbial evaluations and chemotherapeutic treatment that kills selective pathogens. For an antibiotic agent to be successful, the specific pathogens must be known and susceptible to the drug being introduced. Without knowing the specific bacteria causing the infection, there's only a one in 10 chance of selecting effective antibiotics.
This is why microbial analysis is an important tool for determining the risk, presence, type and numbers of pathogenic bacteria in order to successfully treat periodontal infections as well as prevent them from initially developing or from recurring. For these evaluations, the dental practitioner takes oral biofilm samples from the base and top of the tongue and between the teeth. At the microbiology lab, these samples can be Gram-stained or cultured depending on the method used to collect the samples.
Such fast and economical testing provides comprehensive information about specific sites of the oral microflora. The bacteria that are active in periodontal disease and halitosis are predominantly Gram-negative anaerobic bacteria. Bacteria that stain red are Gram-negative.
The shape (rod, coccal or spiral) and size indicate the types oral microbia and the amount indicates whether this microflora is in balance. Samples are also assessed for the presence of amoeba, white blood cells and fungi, which can indicate the presence of infection.
The lab provides the dental or medical professional with a detailed report on the types and numbers of oral microbia found in the samples. This information provides comprehensive information to facilitate the selection of appropriate treatment.
Along with successfully treating gingivitis and mild to periodontal disease, microbial analysis can assist with halting the development of periodontal disease as well as preventing recurrence.
Antiseptic mouth rinses – These are most often used to complement mechanical therapy to aid in controlling plaque buildup.
• National brand mouthrinses can reduce plaque by 20% and gingivitis by 11%.
• Rinses with chlorhexidine gluconate can reduce plaque by 55% and gingivitis by 30% to 45%. While in the past chlorhexidine has sometimes stained teeth, new formulations do not.
• Rinses with cetylpyridinium chloride act similarly to those with chlorhexidine by disrupting the bacterial cell membrane in primarily Gram-positive biofilms.
• Rinses with sodium chlorite/chlorine dioxide reduce bacteria by interfering with protein breakdown. These rinses also target Gram-negative bacteria but can also reduce some types of Gram-positive bacteria. They also reduce sulphur compounds, resulting in fresher breath. The SmartMouth brand also releases Zinc ions, which block the ability of bacteria to ingest protein particles, thereby preventing the formation of volatile sulphur compounds that cause halitosis.
Locally applied antiseptics – Used as an adjunct to scaling and root planing, biodegradable chips with chlorhexidine gluconate, which is released into the periodontal pocket over a period of 7 to 10 days, can suppress oral pathogens for up to 11 weeks.
While scaling and root planing continues to be the most common treatment for removing dental plaque and calculus that cause gingival inflammation and disease, there is a high probability of reinfection, often within 60 days. Thus, where there is moderate to severe bleeding, antibiotics (rinses, oral dose or locally applied) should be considered for optimal results
Oral delivery –Traditional systemic antibiotic therapy can eradicate infections by subgingival pathogens and pathogenic bacteria that invade the deeper subepithelial periodontal tissues (pockets 6 mm and more) or colonize the deep crevices of the tongue or extradental areas. It can also suppress chronic reinfection.
However, systemic delivery of antibiotics has a number of disadvantages:
• insufficient concentration in saliva to effectively penetrate supragingival biofilms or tongue and throat biofilm;
• ineffective for mild to moderate gingivitis or breath odour control and;
• may lead to increased risk of antibiotic resistance and fungal infections.
Local delivery – Intensive, locally-applied antimicrobial treatment using targeted antibiotic agents are among the most effective treatments for oral biofilm infections. There are a couple of delivery methods.
- Subgingival/intrapocket: Since periodontal disease frequently appears in localized areas in the patient’s mouth antibiotic agents such as Arestin (in cream, chip, gel or powder formulations) may be applied directly to the pocket, thereby eliminating many of the adverse side effects associated with systemic delivery of antibiotics. This method also delivers antibiotics in a concentration not achievable with an oral dose. Sustained-release delivery maximizes the therapeutic effect of antimicrobials by maintaining a constant drug concentration for a prolonged period of time in a controlled manner.
- Mouthrinse: Low dose antibiotics in a colloidal suspensions delivered as a mouthrinse can impact pathogens with a concentration of antibiotic 4,000 times more concentrated than systemic antibiotics.
This is due to the antibiotic being delivered directly to the site of infection, resulting in 100% concentration. By comparison, delivering antibiotics systemically results in a substantially reduced concentration of antibiotic when it reaches the oral site.
Since infected gum tissue is typically swollen and may have pockets around the teeth, medicated rinses are able to enter the sulcus and are drawn into the depth of these pockets by a reduction in crevicular fluid pressure (the Venturi Effect). Particles dissolve over several hours; thus patients rinse three times a day for a two-week period.
Combining full scaling and root planing with an antibiotic rinse can result in substantial improvement in periodontal pockets. Typically, within a couple of weeks, harmful bacteria and fungi will be significantly reduced. The Oravital® System, for example, reduces pockets by up to 84% and bleeding points by 87%. Proper oral care can often control or prevent the return of disease.