Improving Periodontal Health

INTRODUCTION

Antimicrobial therapies play key roles in preventing and treating periodontal diseases. Hours of meticulous periodontal therapy alone cannot achieve the oral health goals we set for our patients. Self-care and the use of chemotherapeutics are critical components of maintenance therapy. This article provides a current review of the scientific evidence exploring benefits and limitations of nonsurgical periodontal therapy, the use of chemotherapeutics and adjunctive therapies, and the rationale for periodontal maintenance. The Colgate-Palmolive Company is delighted to have provided an unrestricted educational grant to support “Improving Periodontal Health” in collaboration with the American Academy of Periodontology.

— Matilde Hernandez, DDS, MS, MBA
Scientific Affairs Manager
Professional Oral Care
Colgate Oral Pharmaceuticals

 

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FROM THE AMERICAN ACADEMY OF PERIODONTOLOGY

With professional care and expertise, a patient can regain health, function, and esthetics after a bout with periodontal disease. But the key to maintaining what was once at risk is often out of the specialist’s hands, and hinges on the patient’s daily at-home habits. As such, the periodontist’s and dental hygienist’s job is about more than treating and arresting disease—it’s also about educating patients on what they can do to keep future infection at bay and motivating them to take action. Here, educator Maria L. Geisinger, DDS, MS, offers insights on how anti-infective treatment—when coupled with proper at-home maintenance and regular office visits—is essential to long-term patient health. The American Academy of Periodontology—which advises patients to brush twice a day, floss daily, and receive a comprehensive periodontal evaluation annually— is proud to work with Dimensions of Dental Hygiene and Colgate-Palmolive to bring you information that can aid in keeping your patients’ gums and smiles healthy for a lifetime.

— Wayne Aldredge, DMD
President, American Academy of Periodontology

 

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Periodontal diseases affect approximately 47% of adults in the United States.¹ The primary etiology of periodontal diseases is bacterial plaque, or biofilm.^2,3 Therefore, the effective and regular removal of biofilm and plaque-retentive factors is critical to achieving optimal periodontal health.⁴ The success of periodontal therapy depends on removing biofilm from tooth surfaces, periodontal tissues, mucosal surfaces, the tongue, and other niches within the oral cavity and keeping subsequent biofilms under control.⁵

Nonsurgical periodontal therapy aims to produce root surfaces that are biologically acceptable so that healthy epithelial attachments can be established and maintained.⁶ It typically includes oral hygiene education, improved self-care, professional debridement of tooth surfaces, and sometimes the use of adjunctive antimicrobial agents. Establishing and maintaining optimal oral hygiene is critical to the long-term success of both nonsurgical and surgical periodontal therapies.

Microbial plaque control is an effective method of preventing and treating gingivitis² and it plays a critical role in the treatment and prevention of periodontitis.⁷ Microbial biofilm begins to form almost immediately after cessation of oral hygiene measures and must be removed, on average, at least once every 48 hours to prevent inflammation in periodontally healthy patients.⁸ The American Dental Association (ADA) recommends that patients brush at least twice per day to effectively remove microbial biofilm and prevent gingivitis.⁹ While toothbrushing can remove some microbial biofilm, it is often inadequate in interproximal areas. Thus, the use of interdental cleaning aids, such as dental floss and interdental brushes, is often essential to remove plaque effectively in interproximal areas.^10,11 Finally, dentifrices and mouthrinses, as well as patient-delivered topical medications may contain chemicals that inhibit plaque microbes for some time after use. Topical medications can also be important adjuncts to manual plaque removal.¹²

Educating and motivating patients to perform adequate oral hygiene is challenging. Patients have been shown to overestimate their brushing times¹³ and often to fail to adequately remove microbial biofilm, even following demonstrations of optimal methods.¹⁴ Social/esthetic factors, such as fresh breath, an attractive smile, and avoiding disease, are typically the most significant motivators for performing oral hygiene measures.¹⁵ Repeated assessment and professionally guided modification of self oral hygiene measures are critical to the successful prevention and treatment of caries and periodontitis.⁴

Motivational interviewing can be used to emphasize the importance of plaque control in oral health.¹⁶ It is a person-centered, goal-directed method that fosters a patient’s intrinsic motivations for positive change.¹⁷ Motivational interviewing is based on the use of open-ended questions, affirmations, reflections, and summary (Table 1). Open-ended questions are used to elicit information from patients and typically begin with an interrogative such as “how,” “what,” or requesting a description, such as, “Tell me about…” Affirmations are used to encourage positive health behaviors that patients already practice. Reflections serve to prompt further discussion to better clarify a patient’s intentions. Summary demonstrates that the interviewer is an active listener and sets the stage for change.¹⁸ Motivational interviewing may induce change in patients’ health behaviors, including improved oral hygiene. Even a single session of motivational interviewing has been shown to improve gingival bleeding scores and plaque index.^19,20

THE USE OF CHEMOTHERAPEUTICS

The use of adjunctive chemotherapeutics delivered in dentifrices may offer additional benefits. For example, stannous fluoride provides antimicrobial properties.²¹ Dentifrices containing stannous fluoride, however, may cause temporary staining of teeth.²² Dentifrices containing pyrophosphates may interfere with the crystal formation in calculus, thus reducing the formation of supragingival calculus by more than 30%.²³ They do not affect subgingival calculus formation.

The anti-gingivitis agent triclosan has antimicrobial properties and may reduce gingivitis when compared with control dentifrice.²⁴ Questions have arisen regarding the safety of triclosan.²⁵ However, many regulatory agencies, including the US Food and Drug Administration, Health Canada, and the Scientific Committee on Consumer Safety of the European Commission, have reviewed the data surrounding triclosan’s safety and effectiveness in products and cosmetics and deemed the ingredient safe for use where a health benefit has been demonstrated.²⁶

Numerous studies have suggested that systemic statin medications may reduce clinical signs of gingival inflammation and periodontal disease progression.²⁷ The mechanism of this action is likely a reduction in the expression of lipopolysaccharide-induced matrix metalloproteinases (MMPs).²⁸ Several randomized controlled trials have demonstrated decreased signs of gingival inflammation following topical application of a simvastatin or atorvastatin gels as compared with placebos.^29–31 Other investigations are underway to determine long-term effectiveness.

Dentifrice with edathamil has shown promise in reducing gingivitis levels and decreasing plaque formation.³² Edathamil is thought to help prevent the attraction of bacteria to the dental pellicle. Multicenter trials are now underway to better elucidate edathamil’s mechanism of action and to determine its effect on inflammation and the subgingival microbiome.

Mouthrinses have been shown to be effective adjuncts that reduce plaque and gingival inflammation.^33,34 Bisguanide antiseptics (including chlorhexidine gluconate) provide broad spectrum antimicrobial effects while demonstrating high substantivity.³⁵ Long-term use, however, is associated with tooth staining and alterations in taste, which may make compliance challenging. Moreover, beneficial oral microflora may be adversely affected by the long-term use of antiseptic oral mouthrinses.^36,37 Other mouthrinses, including those containing propolis, oxygenating agents, amine alcohols, metal ions, triclosan, probiotics, and salicylamide, offer antimicrobial properties.^35–38 A propolis-containing mouthrinse demonstrated a reduction in papillary bleeding greater than chlorhexidine mouthrinse or placebo after 28 days of use.³⁶ A salicylamide-containing rinse has demonstrated antimicrobial activity against a wide spectrum of bacterial species.³⁹ Additionally, the use of a probiotic mouthrinse to promote beneficial bacteria and eliminate pathogenic bacteria has also ­compared favorably with the use of a broad spectrum antimicrobial mouth­­rinse.⁴⁰ As technologies permit more detailed evaluations, the development of new mouthrinses with increased effectiveness and decreased side effects may be possible.⁴¹

SCALING AND ROOT PLANING

Debridement of tooth surfaces to remove local etiologic factors is the primary goal of mechanical periodontal therapy.⁴² Scaling and root planing is often the first treatment recommended for periodontitis cases^6,43 and has produced beneficial effects for sites with deep probing depths (Table 2).⁴³ The probing depth reduction seen after scaling and root planing is caused by reduced edema, repair of junctional epithelium, and greater tissue resistance to probe penetration at the base of sulci.⁴⁴ A decrease in subgingival microbes, including a reduction of pathogens, also occurs.^43,44 Maintaining these clinical improvements, however, depends on sustained plaque removal by the patient at home.

The success of debridement depends on the severity of the initial defect, operator skill, time expended, and the design of instru­ments.^7,45,46 While studies suggest that similar results can be achieved using manual, sonic, or ultrasonic scalers, the time ex­pended during debridement with manual instruments alone can range up to 50% longer when compared with the combined use of manual and powered scalers.^47,48

Various protocols for the delivery of mechanical subgingival debridement have been proposed. Two systematic reviews have indicated slightly greater probing depth reduction at sites with deep probing depths (pocket depth > 6 mm) after full-mouth scaling and root planing performed in one appointment or over a brief interval when compared with quadrant scaling and root planing provided over longer intervals.^49,50 These protocols may be particularly effective in patients with aggressive periodontitis and/or patients who have significant underlying systemic illnesses that impair healing.^49,50

ADJUNCTIVE THERAPIES

Two protocols using laser technologies—laser-assisted new attachment procedure (LANAP) and photodynamic therapy—have been evaluated as adjuncts that may help increase the effectiveness of scaling and root planing. LANAP, which uses an Nd:YAG laser in conjunction with meticulous scaling and root planing and occlusal adjustment, has demonstrated a reduction of pocket depths (PD) and in clinical attachment levels (CAL) and limited evidence of periodontal re-attachment that includes new connective tissue.^51,52 No studies have compared the LANAP procedure to a control procedure, such as scaling and root planing and occlusal adjustment, so as to better assess the additive effects, if any, associated with laser use. Nevertheless, the US Food and Drug Administration recently accepted the LANAP protocol as a regenerative approach that may result in the growth of new bone, cementum, and periodontal ligament on a previously diseased root surface.

Photodynamic therapy has demonstrated destruction of putative periodontal pathogens in vivo and improvement in PD and CAL at 3 months, but not 6 months after therapy when compared with scaling and root planing alone.^53,54 The long-term benefits of either LANAP or photodynamic therapy are not yet known, but they may be effective in some cases.

A dental endoscope was developed and introduced in 1999 to provide magnified imaging below the marginal gingiva for diagnosis and as an aid in the treatment of periodontitis. Root deposits and caries were identified in situ using the dental endoscope and confirmed with direct visualization after extraction.⁵⁵ Furthermore, calculus removal on single-rooted teeth was more effective following scaling and root planing with the use of the endoscope than without.⁵⁶ However, there were no statistically significant outcome differences reported on multirooted teeth that received nonsurgical periodontal therapy with or without the endoscope.⁵⁷ Clinical results have also varied with regard to probing depth reductions and residual levels of cytokines in gingival crevicular fluid.^55,58

Local antimicrobial delivery in the treatment of periodontal diseases has been shown to be effective in the reduction of PD and CAL gain when applied after scaling and root planing.^7,59 Patients with chronic periodontitis and isolated recurrent pockets ? 5mm with bleeding on probing are most frequently prescribed this type of therapy.^7,60,61 A review of current evidence suggests that the use of chlorhexidine chips, locally delivered doxycycline, and locally delivered minocycline microspheres may provide benefit in patients with chronic periodontitis when used as an adjunct to mechanical debridement.⁶² Current literature suggests similar adjunctive CAL gains and improvements in clinical parameters between doxycycline and minocycline therapies for initial probing depths of 4 mm to 6 mm.⁶³ The data on the efficacy of the chlorhexidine chip is variable, but those studies that report positive results have similar effect magnitudes as the other adjunctive treatments discussed.⁶⁴ The use of any of these adjuncts should be tailored to individual patient needs and considered in terms of cost-effectiveness.

Subantimicrobial dose doxycline (SDD) is prescribed 20 mg twice daily and has been shown to be an effective adjunct in the reduction of PD and CAL gain over 3 months to 9 months.^65,66 SDD’s mechanism of action involves the local downregulation of MMPs and the upregulation of tissue inhibitors of matrix metalloproteinases^67,68 and may also demonstrate reductions in prostaglandin and pro-inflammatory cytokine levels.^67,68 Patients’ overall health may impact the effectiveness of this treatment. A modest benefit has also been reported when systemic antibiotics are used as adjuncts to scaling and root planing in chronic periodontitis patients. Even more robust benefits are reported in patients with aggressive periodontitis.⁶⁶ A meta-analysis did not report differences in effectiveness based on the types of systemic antibiotics administered.⁶⁶ Therefore, systemic antibiotics may be considered based on the clinical presentation and overall risk profile.

Nonsteroidal anti-inflammatory drugs and bisphosphonate medications have demonstrated slowed progression of chronic periodontitis.⁶⁹ Recent investigations have evaluated the use of low-dose aspirin (81 mg to 325 mg, once daily)⁷⁰ accompanying polyunsaturated fatty acids.^70,71 Polyunsaturated fatty acids have been shown to produce anti-inflammatory effects⁷² and may also improve CAL gains after nonsurgical periodontal therapy.^73,74 The use of statin medications may improve periodontal health in conjunction with nonsurgical periodontal therapy.²⁹ Such results may be more pronounced in patients who have elevated levels of inflammatory mediators due to systemic diseases,^75–77 and indicate the need for individualized treatment planning based on each patient’s health status.

Repeated reevaluations of patients’ periodontal therapy and plaque control are essential to establishing and maintaining periodontal health. These reevaluations offer insight into the response to periodontal therapy and the patient’s overall prognosis. Such longitudinal information guides the need for additional interventions, including adjustments in patient’s self-care. Evaluations may occur perpetually, but are particularly useful 4 weeks to 6 weeks after completion of nonsurgical therapy, after surgical therapy if warranted, and at subsequent periodontal maintenance appointments, typically four times per year.^78,79 Signs of progressive periodontal disease activity may include progressive attachment loss,^80,81 presence of particular bacterial species,^82,83 and conversion from nonbleeding to bleeding gingiva.⁸⁴ While bleeding on probing itself is an inaccurate predictor of attachment loss,⁸⁵ the absence of bleeding on probing is a reliable predictor of health, making achieving and maintaining nonbleeding sites important therapeutic waypoints.⁸⁶ The consistent monitoring of periodontal disease activity and re-assessment of etiologic factors is critical to the long-term success of periodontal therapy.

PERIODONTAL MAINTENANCE

Because most periodontal diseases are chronic, following the completion of active periodontal therapy, a periodontal maintenance schedule should be established to maintain periodontal health. Studies have shown that tooth loss in periodontal patients is related to the frequency and quality of their maintenance care.^87,88 Patients who are seen at regular intervals experience less attachment loss, lose fewer teeth, and have overall lower oral health care costs than those who are seen more infrequently.⁸⁹ Intervals for periodontal maintenance should range between 2 months and 6 months depending on the patient’s disease presentation and history, risk factors for progression, treatment performed, new clinical findings, and the initial and changing prognoses for the teeth (based on periodic reevaluations). Shorter maintenance intervals may decrease the likelihood of subsequent disease progression.⁹⁰ Furthermore, consistent reevaluations that include surveillance of probing depths, bleeding on probing, and subgingival scaling and root planing when indicated result in better maintenance of attachment levels and are more effective than supragingival plaque/calculus control alone.⁹¹ Additionally, periodontal maintenance visits enable clinicians to reassess patients’ medical conditions, plaque control, and disease activity while providing the opportunity to motivate and encourage them to be co-practitioners with dental professionals in achieving periodontal health.

CONCLUSION

Anti-infective therapies are the cornerstone of periodontal treatment and critical to the prevention of gingivitis and periodontitis. They are also key to arresting periodontitis and maintaining periodontal health. Anti-infective treatments may include: patient-delivered plaque control; mechanical debridement that may be nonsurgical, surgical, or both; adjunctive antimicrobial/anti-inflammatory therapies; and periodontal maintenance. Understanding the current scientific evidence while incorporating patient needs and health status with clinical expertise are critical to providing excellent patient care.

ACKNOWLEDGEMENT

The author would like to thank Elizabeth Bolton and Maninder Kaur, BDS, MPH, MS, for their assistance with this manuscript.

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From Dimensions of Dental Hygiene. July 2016;14(07):53–58.