Periodontal disease is a pathologic process that affects the supporting soft tissue and bone of the tooth. It is an inflammatory disease that results primarily from bacterial infection. Although other factors may affect the supporting periodontium, the primary cause is microorganisms that collect on the tooth surface above and below the gingival margin. Prevention of the disease and/or prevention of the loss of supporting periodontium (tissue and bone) and teeth can be best achieved mechanically through the combined effort of the patient and doctor, after the correct diagnosis is made.
Education and early intervention are always key to successful treatment. With the development of new drug applications to aid in the nonsurgical management of the disease, the affected patients can also be motivated to prevent recurrence of the problem. They will learn that the proper preventive procedures performed at home can now make it easier for them personally to control this disease with only minimum supervision by the dentist at regular periodontal follow-up/re-care visits. Knowing that they can avoid surgery will motivate them to do what has to be done minimally to help control the disease and maintain their health.
THE TRIANGLE OF CARE
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| Figure 1. The triangle of patient care. |
The triangle of care for the patient (Figure 1)—prevention, diagnosis, and nonsurgical treatment—must remain intact to achieve the goal of oral health. The dentist/hygienist is the key to establishing “total oral health” for the patient, making a correct diagnosis, and providing the necessary nonsurgical care. They must also guide patients in their prevention at home, making it as simple as possible for patients to remove, and control the effect of, the bacterial plaque in their mouths.
Periodontal disease, in most cases, can now be treated successfully, restoring the supporting diseased tissue to health. The obvious goal for both the patient and the dentist is to maintain teeth for a lifetime. Treatment is based on a correct diagnosis of the condition, and permits the patient to effectively participate in his or her own care.
Inflammation, the first sign of periodontal disease, must be controlled. Gingivitis is an inflammation of the gingival tissues where we often see redness of the gingival collar, swelling, bleeding on probing, and possible changes in the form and shape of the tissue. The key to controlling this inflammation is to reduce or change the activity of the bacteria residing in the periodontal pocket with the newer concepts of nonsurgical management.1 Using site-specific anti-infectives and systemic enzyme suppression, elimination of the deeper periodontal pockets surgically is not always necessary. Many times these pockets can be reduced with the use of these drugs.
ETIOLOGY OF PERIODONTAL DISEASE
There has been an evolution in theories of periodontal disease etiology. In 1965, Loe et al2 wrote their classic paper on “Experimental Gingivitis in Man.” This nonspecific plaque theory proposed that the quantity of plaque was the primary disease determinant. Plaque causes gingivitis and, if left untreated, will lead to periodontitis. It was felt that all individuals were equally susceptible. Plaque control was necessary for treatment.
By 1976, a specific plaque hypothesis had developed. The quality, not the quantity, of plaque was felt to be responsible for disease progression. Page and Schroeder3 described the pathogenesis of inflammatory periodontal disease, breaking it down into four different stages: initial, early, established, and advanced lesion. Many specific bacteria were identified. This gave rise to the beginning of soft tissue management programs, and the Keyes technique was developed as a possible nonsurgical option.
In 1984, Genco and Slots4 described the host-bacteria interrelationship. They found antibodies to various periodontal pathogens in the gingival crevicular fluid of patients with periodontal disease. While bacteria induce gingivitis and periodontitis, these host factors, although capable of inhibiting bacterial growth and invasion, are also capable of causing damage to the periodontal tissue. Much of the damage in inflamed periodontal tissue can now be attributed to the biologic activities of this host response defense. This has led to the current nonsurgical management techniques, using enzyme suppression to reduce the host response. The enzymes produced, specifically collagenase, can injure and destroy the host cells and periodontal tissues. Subclinical dosages of doxycycline (Periostat) may be used to suppress this enzyme production, preventing this destruction.5
Additionally, the toxins produced by the bacteria can be reduced by placement of site-specific anti-infectives such as Actisite, PerioChip, Atridox, and most recently, Arestin, below the gingival margin in the pocket. Ease of placement and complete resorption has made Arestin easier to use than the prior products.
DIAGNOSIS
Understanding that evidence has shown that the accumulation of supragingival plaque at the free gingival margin is associated with the development of gingivitis, removal of the plaque is a basic step in the prevention of the disease. However, before this is attempted and treatment considered, a correct diagnosis must be made.
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| Figure 2. The Hu-Friedy Colorvue probe. |
Periodontal probing is the most common screening process for measuring gingival pocket depth. Taking these measurements allows the dentist to make conclusions about any disease that is present. A probe that enhances visibility should be used, such as the new Hu-Friedy Colorvue probe (Figure 2). The probe, with yellow and black markings, provides superior contrast to gingival tissue when measuring pocket depth. Recession can be easily assessed as a result of contrast between the probe and exposed root surface. The probes must have optimal flexibility and rounded tips so patient comfort during this sometimes painful procedure can be maintained. It is very important to hold the probe as close to the tooth as possible and against the contact points when taking measurements, to ensure accuracy in recording pocket depths.
Once the correct diagnosis has been made, these probings can be used as a baseline for long-term monitoring of the patient”™s periodontal condition, and should be repeated at least one time per year at the periodontal follow-up/re-care visit. Abbreviated probings, in each sextant of the mouth, can be used for screening for renewed disease activity and to determine if additional periodontal probing assessments are necessary.
The Importance of Prevention
Regardless of the stage of the disease, preventive measures must be taken to achieve the lowest plaque levels possible. Plaque control prevents the potential destructive effects of the bacteria on the periodontal supporting structures. The goal of treatment must be to prevent the progression or recurrence of the disease, as well as to prevent the disease from occurring in unaffected areas.
The primary method of removing plaque, in attempting to achieve good oral hygiene, is using a toothbrush. While there are many other plaque removal tools available, much depends on the ability of the patient to manipulate the toothbrush to remove the bacterial plaque and the patient”™s motivation to prevent the disease from occurring.
When a patient is informed and positively reinforced, and when barriers to treatment are reduced, the patient will be more compliant. If there is a lack of compliance, it is usually due to lack of pertinent information, fear, economics, and the patient”™s perception of the lack of compassion on the part of the dental therapist.6 Once patients understand how painless and predictable nonsurgical care for their condition can be, and see the interest and concern of the dentist/hygienist, they are much more likely to be compliant in their efforts to prevent/control their own disease.
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| Figure 3. Power versus manual brushing in interproximal areas. |
While effective brushing is difficult for many patients, it can be made much easier with the use of a power toothbrush. Manual toothbrushes have been shown to remove an average of less than 50% of the plaque from the smooth area of the tooth and less from the interproximal areas.7 Studies have shown a significant reduction in plaque levels when using a power brush when compared with manual brushing in interproximal areas8,9 (Figure 3). The power toothbrush studies have also shown these brushes to be superior to a manual brush in removing tooth stain.10 There are a number of power brushes now available, including among others Sonicare, Braun Oral B, Rotadent, and the Colgate Actibrush.
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| Figure 4. Diagram of electronically driven brushing action. |
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| Figure 5. Photomicrograph of plaque removal beyond the reach of bristles. |
Advances in technology have led to the development of an electronically driven sonic toothbrush (Sonicare), which has demonstrated improved oral hygiene performance over manual toothbrushes.11 The Sonicare toothbrush is unique among power brushes. It disrupts plaque with a mechanical action as well as with a dynamic fluid activity generated by a low-frequency acoustic energy (Figure 4). With bristle vibration at 31,000 strokes/minute, causing cavitation and streaming in the fluid surrounding the teeth, it disrupts adherent plaque at distances up to 3 mm beyond the physical reach of the bristles12 (Figure 5). When patients are informed of this and the ease of plaque removal using this device, they are much more likely to use such a powered brush. Most patients want to maintain their health, and if such devices make periodontal health easier to achieve, they will want to use it.
Mouthrinses can also be effective in preventing the progress and recurrence of periodontal disease. They can further help by increasing patient compliance and improving the desired result. If the patient understands and is informed how these rinses, if used regularly, can reduce the cost of treatment by helping to maintain periodontal health, he/she will use them. While rinses such as chlorhexidine and the essential oil rinses with alcohol (Listerine) have also been helpful, many patients want to avoid the staining that occurs with chlorhexidine, and many want to use an alcohol-free rinse. The stabilized chlorine dioxide rinses do not stain, are alcohol-free, and can also be therapeutic.
It has been proposed by Fine and Mandel13 that the hydrogen sulfide generated by causative bacteria in periodontal disease may be an indicator for initiation or progression of periodontal disease. Untreated patients were studied and showed significantly higher hydrogen sulfide levels than maintenance patients who had prior periodontal treatment. These sulfide levels have been shown by Morita and Wang14 to be significantly higher in patients with periodontal disease and a higher percentage of bleeding on probing positive sites. Using a stabilized chlorine dioxide rinse, Goultschin et al15 showed significantly reduced dental plaque scores without any change in the number of salivary bacteria. Stabilized chlorine dioxide rinses such as Oxyfresh are available for direct purchase by the dentist to dispense to the patient in the office.
CONCLUSION
With the correct diagnosis made, the newer technologies of nonsurgical periodontal care can be used to treat periodontal disease more conservatively, often without surgery. If patient compliance is an important criterion in prevention of disease and/or progression of a disease condition, then knowledge of the condition and the ability to have it treated successfully by an interested dental therapist who cares about the patient will make the outcome of care more successful.
With the patient motivated to use a power brush and a preventive rinse, a correct diagnosis, and nonsurgical care provided, the triangle of care is closed. Patients can now expect to have a healthy mouth that will allow them to keep their teeth for a lifetime.
References
1. Gottehrer N, Donley T. A current protocol for nonsurgical periodontal therapy. Dent Today. 2001;20:76-81.
2. Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontol. 1965;36:177-187.
3. Page RC, Schroeder HE. Pathogenesis of chronic inflammatory periodontal disease: a summary of current work. Lab Invest. 1976;33:235-240.
4. Genco RJ, Slots J. Host response in periodontal disease. J Dental Res. 1984;63:441-451.
5. Caton J, Ciancio SB, Bliedent TM, et al. Treatment with subantimicrobial dose doxycycline improves the efficacy of scaling and root planing in patients with adult periodontitis. J Periodontol. 2000;7:521-532.
6. Wilson TG. Compliance and its role in periodontal therapy. Periodontol. 2000,1996;12:16-23.
7. Boyd RL. Clinical and laboratory evaluation of powered electric toothbrushes: review of the literature. J Clin Dent. 1997;8:67-71
8. Saxer UP, Yankell SL. Impact of improved toothbrushes on dental diseases. Quintessence Int. 1997;28: 573-593.
9. Tritten CB, Armitage G. Comparison of a sonic and a manual toothbrush for efficacy in supragingival plaque removal and reduction of gingivitis. J Clin Periodontol. 1996;23:641-648.
10. Moran JM, Addy M. A comparative study of stain removal with two electric toothbrushes and a manual brush. J Clin Dent. 1995;6:188-193.
11. O’Bierne GO, Johnson RH, Persson G. Efficacy of a Sonic toothbrush on inflammation and probing depth in adult periodontitis. J Periodontol. 1996;67:900-908.
12. Stanford DM, Srikantha R, Wu CD. Efficacy of the Sonicare toothbrush fluid dynamic action on removal of human supragingival plaque. J Clin Dent. 1997;8:10-14.
13. Fine DH, Mandel ID. Indicators of periodontal disease activity: an evaluation. J Clin Periodontol. 1986;13: 533-546.
14. Morita M, Wang HL. Relationship of sulcular sulfide level to severity of periodontal disease and bana test. J Periodontol. 2001;72:74-78.
15. Goultschin J, Green J, Machtel E, et al. Use of a metastabilized chlorous acid/chlorine dioxide formulation as a mouthwash for plaque reduction. Isr J Dent Sci. 1989;2:142-147.
Dr. Gottehrer has maintained a private practice in aesthetics, periodontics, and implant dentistry in Havertown and Abington, Pa, since 1975. He is a board certified diplomate of the American Academy of Periodontology, and he is a former assistant clinical professor of oral medicine at the New York University College of Dentistry. He can be reached at (610) 449-9500 or drneilg@dentalife.com.
Dr. Light received postgraduate training in the Periodontics Department at the Temple University Dental School. He owned and operated a large multispecialty group practice with significant focus on periodontics and implants. He is CEO of Healthcare Management Services, a national dental/medical consulting firm specializing in practice achievement and profitability.
