Antimicrobial Host Response Therapy in Periodontics: A Modern Way to Manage Disease, Part 2

Interest in conservative management of periodontal disease has increased rapidly in the past year in private, academic, and commercial sectors. This renewed interest results from clinical research being done showing possible connections between cardiovascular disease and other serious medical conditions and gingivitis and periodontitis. Since we can provide predictable and successful long-term stabilization of our patients’ periodontal condition, and even prevent the condition from occurring by providing private management in the dental office, periodontal treatment can be included, as needed, as an active part of the physician’s management of cardiac disease.

PERIODONTITIS AND CORONARY HEART DISEASE (CHD)

Cardiovascular diseases still represent the major cause of death in industrialized countries.¹ Although the traditional risk factor concept has been well-established, it does not fully account for all the risk factors of cardiovascular disease.² Since periodontal disease has been described as an inflammatory process,³ it has been thought to be a trigger of chronic inflammation, which is associated with CHD. In 2006 Spahr, et al¹ found that periodontal pathogens may be a significant risk factor for CHD. They found a statistically significant association between the periodontal pathogen burden (total sum of all pathogens) and the presence of CHD.¹ There are also studies to support the specific correlation of periodontal infection and atherosclerosis. These include a recent study by Pussinen,⁴ demonstrating that high P. gingivalis antibody levels have been shown to predict myocardial infarct (MI), independent of classical cardiovascular risk factors. In 2005 Cueto, et al⁵ found an association between periodontal health and acute MI, which persisted after controlling for the classic cardiovascular risk factors (sex, age, tobacco habit, hypertension, diabetes, hypercholesterolemia, and lack of regular exercise). The study involved 149 patients, 72 with acute MI and 77 controls. Out of the total group, 15 (10%) were free of periodontitis, 66 (44.3%) presented mild periodontitis, 32 (21.4%) presented moderate periodontitis, and 36 (24.3%) presented severe periodontitis. Prior studies⁶ found no significant relationship between coronary disease and the presence of periodontitis when the latter was analyzed as a single entity. In this study, moderate-to-severe degrees of periodontitis were compared with absent-to-mild periodontitis. According to the authors, advanced periodontitis probably implies a sufficiently long evolution of the disease for it to become a risk factor for coronary disease. They found that the association between periodontal health and acute MI persisted after controlling for the classic cardiovascular risk factors. If the association is causal, a better control of periodontal disease is called for. If for some reason this may not be causal, then the demonstration that acute MI and periodontal disease cluster in the same sections of the population still raises an important public health issue.
In 1999 Ross⁷ listed the possible causes (risks) of the endothelial dysfunction leading to atherosclerosis to be elevated and modified low-density lipoprotein (LPL), free radicals caused by cigarette smoking, hypertension, diabetes, genetic alterations, and elevated plasma homocysteine concentrations. With the evidence now available, this could be joined by periodontal disease.
Once physicians become aware of this connection, they will be able to question those patients who are suffering from or at risk for cardiac disease about their periodontal health. In the International Consensus Statement from an International Panel, sponsored by Colgate-Palm-olive,⁸ the panel recommended that physicians and other healthcare providers be made aware of the relationship between oral and systemic disease and use specific questions added to the health questionnaire to identify patients who may be at risk of periodontal disease. The panel also recommended referral of these patients for appropriate dental care.
Dentists and dental hygienists must be aware of the connection between periodontal and cardiac/systemic disease. They can intelligently discuss with their patients the need for routine periodontal examination and treatment, where required, based in part on the need to reduce this potential serious risk. They should be able to share this information with physicians and integrate treatment with them based upon the patient’s condition.
Dr. Sheila Riggs, president and CEO of Delta Dental Plan of Minnesota, commented in the recent Procter and Gamble Oral and Whole Body Health supplement to Scientific American⁹ that insurance companies and employers are speeding the time it takes for new research on healthcare practices to become everyday patient treatment, using financial incentives. She felt these incentives must be injected with a healthy dose of dentistry, which would reconfigure programs to include gum disease as a preventable risk factor for several common health problems. She indicates that “pay for performance” programs, now beginning with large employers, where the focus is on improving patients’ physical health, could include tooth cleaning (ie, periodontal care). The anticipated result would be to save healthcare dollars with improved health.
Therefore, when a patient presents who is not aware of his or her own periodontal health, the physician should now feel comfortable to ask him or her  to have an evaluation and the appropriate treatment to manage the condition by a dentist experienced in providing conservative periodontal care. The anticipated goal would be overall improved health.

Figure 1. Voice recognition dictation probing record.

Figure 2. EagleSoft perio charting, with areas requiring treatment highlighted in red.

Figure 3. Colorvue must be placed down to the dentogingival seal.

Figure 4. Waterpik Dental Water Jet.

Figure 5. Porter nitrous oxide flowmeter assembly.

Figure 6. Oraqix cannula dispenser (141 US).

Figure 7. Oraqix applicator tip is placed in gingival sulcus.

Figure 8. BIDENT unit.

Figure 9. BIDENT tip.

ORAL SITE-SPECIFIC CLINICAL MANAGEMENT OF PERIODONTAL DISEASE

To provide clinical periodontal management and achieve the anticipated stabilization of the patient’s periodontal condition, it is suggested that a system employing automation for data gathering, recording, organizing, and presenting be employed. Such systems now available are efficient and simple to use. They accurately record the patient’s clinical data as it is serially collected over time. Such systematic documentation of clinical parameters on a periodic basis is mandatory to achieve accurate monitoring and assessment of the patient’s ongoing periodontal health status. With accurate serial documentation over time, a temporal profile of the periodontal health status is simply and efficiently achieved, coinciding with the contemporary standard of care.
Computerized clinical documentation systems, including the Stat-Ck,¹⁰ available on Patterson Dental EagleSoft Version 13.00, not only permit accurate recording of periodontal health assessment parameters, but they also allow graphic and data printouts that can be effective educational and motivational demonstrations for the patient. The patients’ visual and auditory interaction with the collection and visualization of the data during the clinical experience encourages their participation in the data collection process and inspires interest and curiosity about their own periodontal health status.
Such automation reduces the time required for a traditionally tedious and demanding exercise associated with clinical periodontal documentation, and it allows presentation of data in a predetermined format that can be most effectively employed to illustrate educational and motivational objectives.
In addition to computerized organization and presentation of data, the data collection process can be facilitated with high-tech devices such as voice recognition dictation (Figure 1), computerized chartings with areas requiring treatment highlighted in red (Figure 2), automated periodontal probes, and color-coded, easily viewed manual probes (Figure 3), user friendly to all dental professionals.
The “war” against inflammation can be won by reducing biomarkers, using a sensible and realistic systematic approach with proven principles of diagnosis, treatment, and practice management. The data collection systems can help motivate the patient to undertake the necessary periodontal treatment.
No longer should there be any frustration with periodontal disease in the general dental practice. While diagnostic probing, required to identify the disease, can be monotonous, it is now much more exciting to the patient who understands the information it provides, and thus easier for the practitioner to accomplish. Diagnostic probing is a prerequisite to using any management system and provides guidance for successful treatment. Standard 6-point measurements are taken for each tooth. These probing procedures can be standardized, utilizing the same style probe each time. An easily viewable probe, eg, the Colorvue made by Hu-Friedy (Figure 3), can be used. The readings should be taken from the dentogingival seal. The black/yellow colors make it easier to read the depths, and the patient should see representative areas probed. They can see the bleeding on probing, establishing to them the need for treatment. The automated computer printouts highlight in red the areas probing above 4 mm. The patient is advised that these red areas represent teeth that require special attention and periodontal treatment. This can be an excellent patient experience, and patient confidence in our ability to diagnose and treat can be significantly enhanced by using this technology.
In order to provide the anticipated predictable and successful long-term stabilization of the patient’s periodontal condition, it is suggested that site-specific treatment be utilized to manage the disease. This includes the use of the following:

• antimicrobial toothpastes
• antimicrobial mouthwashes
• hygiene devices, including power brushes
• irrigation
• ultrasonics and hand instrumentation (painless treatment)
• placement of time-released, locally applied anti-microbial drugs below the gingival margin into periodontal pockets
• site management of the medically compromised patient.

ANTIMICROBIAL TOOTHPASTES AND MOUTHWASHES

Predictability in periodontal therapy is no longer simply achieving a biologically acceptable root surface. While root preparation is a critical element of active and supportive periodontal therapy, it is only as good as the patient’s oral hygiene. One of the first questions the dentist/hygienist should ask the new patient as they review his or her medical history is what type of toothpaste and mouthwash is currently being used. This is the simplest way to introduce the periodontal exam and begin a discussion about oral health and the need to use antimicrobial toothpastes and mouthwashes. It allows the dentist to begin the important discussion about self-care and how the patient can help create a healthy mouth and maintain his or her dental health.
Douglas¹¹ has recently commented that patient self- care is an integral part of disease management and should include a 3-step daily oral care regimen of brushing, flossing, and rinsing to help control plaque biofilm. Lamster¹² has stated that limiting the accumulation of dental plaque has an important role in controlling the development and progression of periodontal disease. He feels that by adhering to a daily oral hygiene routine, patients may play an essential role in disease management by controlling this accumulation of plaque.
Thomas has written that it is critical to use antibacterial toothpastes and mouthwashes to reduce the bacterial burden and maintain a normal flora via oral hygiene including toothbrushing, flossing, and rinsing with the antimicrobial mouthwash.¹³ He describes dental plaque biofilms, the microbial “Trojan horse” that attacks tissue, as an adhesive mass with viscoelastic properties and significant inflammatory disease potential that cannot be eliminated. He feels that the pathogenic nature of the biofilm can be decreased in the mouth by reducing the bacterial burden and maintaining a normal flora via oral hygiene, including toothbrushing, flossing, and rinsing using an antimicrobial mouthrinse.
Two antimicrobial over-the-counter (OTC) toothpastes are now available, Crest Pro-Health (Procter & Gamble) and Colgate Total (Colgate-Palmolive). Colgate Total contains a triclosan/copolymer, which has been documented¹⁴ to significantly reduce microorganisms from the tongue, plaque, and saliva, and produce sustained effects on these oral bacteria for 12 hours. In the Consensus Statement sponsored by Colgate-Palmolive,⁸ Dr. Foti Panagakos summarized the body of research performed for Total, which shows it to deliver significant oral benefits, including plaque and gingivitis control, calculus and oral malodor control, and caries prevention. He states that Colgate Total also provides benefits in preventing and controlling periodontal disease, information regarding the use of Total that has not been approved by the US Food and Drug Administration.
Crest Pro-Health contains a new group of technologically developed ingredients that are collectively called the Polyfluorite System. The stabilized stannous fluoride offers significant decreases in gingival bleeding with a sustained antibacterial action.¹⁵ It also decreases dentinal sensitivity¹⁶ and contains sodium hexametaphosphate, which inhibits calculus formation¹⁷ and resists stain deposition while it whitens the teeth by extrinsic stain removal.¹⁸
Two OTC mouthwashes  are currently available that have been documented to have antimicrobial activity. They are Listerine (Pfizer) and Crest Pro-Health Rinse (Procter & Gamble). Thomas13 states that an oral hygiene regimen that includes rinsing with an antimicrobial mouth-rinse is a practical approach to the prevention and management of periodontal disease, which may have wider benefits when the link between periodontal disease and certain systemic diseases is considered. Fine¹⁹ studied the effects of rinsing with Listerine (essential oil mouth-rinse). He found that it can have long-lasting effects in reducing anaerobic bacteria overall as well as Gramnegative anaerobes and VSC-producing bacteria in dental plaque and on the dorsum of the tongue. He found it effective in reducing supragingival plaque as well as controlling intrinsic oral malodor over prolonged periods. Listerine is the only major brand name OTC (antimicrobial) mouthwash to receive the ADA Seal of Acceptance from the Council on Scientific Affairs, based on its finding that the product is effective in helping to prevent or reduce gingivitis and plaque above the gumline when used as directed.
Crest Pro-Health Rinse (cetylpyridinium chloride mouthrinse [CPC]), an alcohol-free preparation, has been studied by Mankodi,²⁰ who observed its effects on gingivitis and plaque and found significant reductions in gingival inflammation, gingival bleeding, and plaque, relative to a placebo group. Results were similar at 3 and 6 months. CPC, the active ingredient in Crest Pro-Health Rinse, derives its bactericidal and bacteriostatic effects from co-solubilization of the ingredients into the lipophilic (hydrophobic) portions of the bacterial cell walls. The long chain lipophilic alkyl portion of the CPC molecular structure can lyse bacterial membranes, producing cidal activity.
Barnett²² summarized the rationale for the daily use of an antimicrobial mouth-rinse. He felt there was a 2-fold rationale. First, given the inadequacy of mechanical plaque control by the majority of people, it is an additional component for control and prevention of periodontal disease. It delivers antimicrobial agents to mucosal sites throughout the mouth that harbor pathogenic bacteria capable of recolonizing supra-and subgingival tooth surfaces, providing a complementary mechanism of plaque control. He felt that the daily use of an effective antiplaque/antigingivitis (antimicrobial) mouthrinse is well-supported by scientific rationale and can be a valuable component of an oral hygiene regimen, controlling the plaque bio-film and related periodontal disease.
Listerine began a new print advertisement in August 2006. It depicts a Listerine bottle donning a stethoscope, with the heading, “If you think it’s just for your mouth, think bigger.” The ad goes on to say that “big news about oral care may change the way you think about rinsing with Listerine. Emerging science suggests that there may be a link between the health of your mouth and the health of your body…One thing everyone agrees on is that a healthy mouth can only lead to good things…Do it for your Mouth. Do it for Life.”
Dr. Madeline Monaco, director of oral care professional relations and a member of Listerine’s research and development team, has said that there is an association between the health of the mouth and the health of the body (Monaco M. personal communication, November 15, 2006). While there is a strong association, no cause-and-effect studies have been conducted to show if gingivitis or advanced gum disease can cause health problems such as heart disease or diabetes. Her statements reflect the state of the science after having discussions with the ADA, the American Heart Association, and the American Medical Association.
With the preponderance of evidence present for the effectiveness of antimicrobial toothpastes and rinses in reducing inflammation and managing gingivitis, there can be no substitution for use of these products when the patient is being treated for oral disease. Patients must be told of this and advised that these are the products they are to use if they are concerned about their health!

HYGIENE DEVICES

At the first office visit, new patients (and existing patients, if not previously discussed) should be asked about the hygiene devices they are currently using at home. Asking about this immediately establishes for the patient the high priority for oral hygiene. Many patients are still using manual brushes, and many practices still dispense them complimentary at every supportive periodontal therapy (SPT) follow-up visit. However, more attention is being given to the home use of powered toothbrushes for the removal of plaque. Multiple brands are now available, including Pulse Plus (Butler), Sonicare (Philips), and Oral-B (Procter & Gamble).
The Cochran review (November 2002) compared manual and powered toothbrushes in relation to the removal of plaque, the health of the gingivae, staining and calculus, dependability, adverse effects, and costs.²³ Twenty-nine trials involving 2,547 participants were conducted. The study concluded that brushes that worked with a rotation oscillation action removed more plaque and reduced gingivitis more effectively than manual brushes in the short and long term. In 2004 Williams,²⁴ in conjunction with Procter & Gamble, studied a new, dual-head powerbrush, battery operated with a powered, oscillating round head and a second powered head that translates back and forth. When compared to a manual brush, the powered brush had an average 42.1% and 49.6% greater plaque removal scores after l minute and 3 minutes of brushing. Plaque removal scores were about 50% higher after 3 minutes of brushing.
Based upon the results of these clinical studies, the patient who wants to achieve optimal hygiene with removal of bacterial plaque from the gum, should use a power brush. With the cost of power brushes relatively low, they can be dispensed at the recare visit. The patient can supplement the use of a manual brush with a power brush where needed. By suggesting the use of and dispensing the powered brush, the absolute importance of effective plaque removal for optimal oral health is established for the patient.

IRRIGATION

A major site-specific hygiene procedure is oral irrigation. In 1995 the American Academy of Periodontology described in a position paper the role of supragingival oral irrigation in periodontal therapy.²⁵ It is to flush away any bacteria in the gingival crevice, thereby diminishing the potential for developing gingivitis or decreasing gingival inflammation.
In 1988 Cobb²⁶ demonstrated that the Waterpik Dental Water Jet cleansed deep between teeth and below the gumline to remove bacteria associated with gum disease. He suggested that pulsating oral irrigation produced a qualitative change in subgingival plaque, with the remaining dental plaque after water irrigation being less pathogenic. In 2000 Cutler²⁷ demonstrated that oral irrigation with water for 14 days had an improved therapeutic benefit for adult periodontitis over that of routine oral hygiene alone, and this improvement was accompanied by a down-modulation of the pro-inflammatory cytokine profile in gingival crevicular fluid.
In 2005 Barnes²⁸ assessed the efficacy of the addition of daily oral irrigation to both power and manual toothbrushing compared to a traditional regime of manual toothbrushing and flossing, to determine which regimen had the greatest effect on the reduction of gingival bleeding, gingivitis, and supragingival plaque. At the conclusion of the study a manual toothbrush, plus a Waterpik Dental Water Jet, was 93% better in reducing facial bleeding and 52% better at reducing facial gingivitis than manual brushing and flossing. A powered toothbrush plus the Waterpik was 92% better at reducing facial plaque than manual brushing and flossing.
The results of this clinical trial were very significant. They indicated that when combined with manual or power toothbrushing, oral irrigation with a Waterpik, with the new models now available (Figure 4), is an effective alternative to manual toothbrushing and dental floss for reducing bleeding, gingival inflammation, and plaque removal. This study gives hope for successful oral hygiene to the patient who cannot floss effectively. It shows the Waterpik to be a viable alternative to achieve desired hygiene outcomes, and use of a power toothbrush with the Waterpik to allow even further improvements in oral health. This can make it simpler for patients to establish optimal levels of oral hygiene/health and possibly help to reduce their risk for developing significant systemic disease.

ULTRASONICS AND HAND INSTRUMENTATION: PAINLESS TREATMENT

Ultrasonics and hand instrumentation, and scaling and root planing are standard conservative periodontal care procedures. Using both ultrasonic and manual instrumentation is the most effective treatment protocol for periodontal patients.²⁹
Shaklee recommends a treatment protocol for chronic periodontitis to begin with ultrasonic instrumentation with standard size tips for removal of any supragingival deposit. This is then followed by subgingival debridement with thinner tips, at the lowest power that still allows the deposit to be removed. It is then recommended that the root surfaces be evaluated and debridement continued with hand scaling/root planing.
In an article by McCann, Low³⁰ suggests that the key tool for general dentists is the ultrasonic scaler, which has become the panacea for treating patients nonsurgically. The ultrasonics, he believes, have more magnitude in reducing periodontal disease nonsurgically in early periodontitis than any other therapeutic device available. Tips are now very thin and move deeper into the pocket and actually destroy bacteria. Acceptance of this treatment can be delayed if the patient has fear of the procedures to be done or has had significant pain when previous periodontal procedures were attempted. Conservative pain management techniques must be utilized where required to achieve the desired result and retain the patient for further necessary and/or elective dental treatment. Two of the more successful modalities are use of nitrous oxide analgesia and placement of locally applied, noninjectable anesthetics.
Doring³¹ indicates that it has been estimated that nitrous oxide, in its principal use as a mild sedative and analgesic to allay anxiety, has proven to be safe and effective. While it has been estimated that 15% of the US population declines dental treatment primarily because they fear oral injections, nitrous oxide/oxygen analgesia relaxes patients and reduces their perceptions of discomfort, allowing more of these patients to undergo treatment painlessly. If the patient is at risk medically for cardiac problems, possibly as a result of their poor oral health, analgesia must be used where required to allow the patient to complete the necessary care painlessly.
The ADA Council on Dental Materials³² recommends the use of a properly installed nitrous oxide delivery system with appropriate scavenging system that effectively eliminates any patient or practitioner danger, a readily visible flowmeter, and a vacuum pump with capacity of up to 45 L per minute per workstation, eg, the Conscious Sedation Flowmeter (Porter Instrument Company, Figure 5). Preferably, the nitrous unit used should have an automatic vacuum switch with double mask scavenger, and should be approved by the ADA Council to be sure that it is safely designed for use in the dental office.
The most recent innovation in analgesia that makes it possible to do conservative treatment most of the time, without injectable anesthesia, is a thermogel containing 2.5% lidocaine and 2.5% prilocaine (Oraqix/DENTSPLY Pharmaceutical). The thermogel is held in a cartridge carried to the sites to be applied with the unique Oraqix dispenser (Figure 6). The material works transmucosally by using a blunt cannula device to place the anesthetic directly into the pocket, where it will gel at body temperature (Figure 7). It takes approximately 30 seconds to create anesthesia, and can last for an average of 20 minutes. It has been found in 3 clinical studies to be effective in reducing pain during scaling/root planing.33 If use of these analgesic products permits the dentist/hygienist to complete the required conservative periodontal treatment, there is then the opportunity for patients to reduce their risk of serious illness possibly related to their periodontal condition. It is patient-preferred over injectable anesthesia.

PLACEMENT OF TIME- RELEASED LOCALLY APPLIED DRUGS

One of the major challenges of managing periodontal disease conservatively is control of the bacterial pathogens commonly found in dental plaque. Their chronic presence, with incomplete removal on a daily basis by the patient, or inability to completely remove with site-specific instrumentation with active or supportive periodontal care, perpetuates the diseased condition. Site-specific, locally delivered antimicrobials have been developed as adjunctive