This article was first published in the April 2021 issue of RDH magazine with the title, "Looking at clinical disease management through the long lens of time."
Dental professionals spend a lot of time in the sulcus. It’s a place that few people see, much less appreciate. We know that life in the sulcus is dynamic. We also know that oral inflammation can have a profound impact on the entire body and the microbes that fuel the inflammatory response are implicated in a wide range of systemic health conditions.1-3 We’re dealing with wounds that are hard to see, and we’re charged with fighting an army of microbes.
Our professional goals today have a dual focus: biofilm disruption and creating a new subgingival ecosystem where healthy commensal microbes outcompete disease-causing pathogens.1,2 Analogous to the dual focus, there are two teams in this fight: the patient and the dental professional. In order to win, the treatment plan must be organized, customized, based on an accurate diagnosis, actionable, and measurable. In other words, a cookie-cutter approach simply will not do. However, this is where the fun begins. When we’re able to create a custom plan that works, everyone wins!
The challenge is further complicated by a number of factors, many of which are simply difficult to quantify, much less control. Each one of these factors can have a profound impact on the course of the disease and health outcomes:4
- Is there an accurate diagnosis based on the unique microbial mix in the pathogenetic biofilm?
- Do you have the right equipment for the battle?
- Is there enough time allotted during the appointment for adequate treatment?
- Does the patient’s overall health status contribute to their oral inflammation?
- Are you treating an acute infection or an ongoing disease?
- Is the disease reversible?
- Is the patient’s immune system compromising the healing process?
- Is the patient capable of or willing to deal with the microbes on a daily basis?
- Are there financial barriers?
- Is the treatment plan driven by reimbursement or by actual health outcomes?
- Has there been irreversible damage?
- What are the patient’s priorities?
- What are the patient’s expectations?
Data is useful, but does not provide a complete picture
For decades clinicians have relied on information that falls short of what is actually going on in the sulcus. We’ve been lulled into thinking that traditional radiographs and a periodontal chart that records pocket depths, attachment loss, and mobility provide an accurate diagnosis.5 In reality, this information provides a historical picture, not a lesson in current events. This data does not provide a diagnosis, but in most cases, it is a requirement for third-party reimbursement groups to process a claim based on a procedure.
While knowing the location of an 8 mm pocket is important, the data does not indicate if there is active disease in this area or any other part of the mouth. Bleeding and pus are far better indicators of active disease, but still fall short. It is now possible to gain a far more robust picture of the microbial challenge using salivary testing that includes a high-level genomic evaluation. New generation tests can include both a PCR list of specific microbes and genetic sequencing, based on DNA profiles. The result is a rich diagnostic data set.6,7 The lab report includes the proportion of each species found in the sample, and if there are any antimicrobial-resistant strains.
The 2018 staging and grading framework created by the American Academy of Periodontology is another component of disease risk classification. The system is an organized patient-based medical model. It takes into account the complexity of periodontal disease, now recognized as multifactorial, where age, severity, and progression impact the clinical presentation.8,9 While it might seem like extra work to learn this new system, it is worth the time to consider a more comprehensive and multidimensional approach to patient classification.
Putting knowledge into action
Based on what we now understand about complex polymicrobial communities, it is time to look for opportunities that go beyond the traditional approach. There are a number of tools, therapies, and protocols that can be used solo or in combination that will either alter the micro-environment, reduce the bioburden, or decrease the impact of the inflammatory mediators produced in response to the pathogens.
There is a constant tug of war between what the research indicates are best practices and what clinicians actually observe. High-quality, double-blind clinical trials are expensive and typically lengthy, but when well designed, they create a strong basis for clinical practice. In many cases the research about dental treatment outcomes, protocols, or chemistries is scanty or decades old. On the other end of the spectrum, we treat real people with complex immune systems and lifestyles. Our judgments and treatment decisions are often formed by blending these two different perspectives.
The importance of quality tools and instruments
Success is dependent on equipment that actually works. There are significant limitations to hand scaling. It requires a sharp blade to have actual physical contact with the microbes. This is a problem when a hand scaler or a curette is worn out or dull, or simply too large to access an area. An instrument past its prime can’t be expected to provide optimal physical disruption of soft plaque biofilm or hard deposits. The same applies to worn-out ultrasonic scaler tips.
Many clinicians use a combination of hand instrumentation and power-driven scaling.10 Ultrathin tips are now available for modern ultrasonic scalers. These thin perio tips can reach into deep, narrow, hard-to-access areas. They are designed to disrupt both hard and soft deposits, and the fluid irrigant helps flush out microbes. While there are frequent discussions about whether or not power scaling should be used at all, especially when there is no visible soft biofilm or hard detectible deposits, clinicians who routinely use power scaling for biofilm disruption report better outcomes over time.
Persisters and time
Despite our best efforts, it is still difficult to know how much we have actually accomplished. Experienced clinicians look for clues in how the soft tissue looks and responds. Red, puffy, bleeding gingiva is an indicator that microbes are still at work.11 This type of observation is also a sign that the person’s immune system is either overwhelmed or another systemic issue might be throwing a monkey wrench into everyone’s best efforts.
Research indicates that microbes known as persisters are responsible for recurrent biofilm-based infections.12,13 While it is disheartening to consider that it is impossible to remove 100% of the pathogens, it is important to remember that the patient’s immune system is generally capable of recovering when the bioburden is reduced significantly and frequently.
Time is another critical factor. The best equipment in the world is useless if there is not enough time to employ the tools properly during an appointment. It takes time and skill to disrupt biofilm communities.14 The time interval between professional appointments also deserves consideration. There is no consensus on the best interval.15-17 Microbes are not tied to a six-month interval; therefore, it is reasonable to consider a more frequent appointment schedule for those with complex health issues or who simply can’t care for themselves effectively.
A look at treatment methods
Through the years, a wide variety of chemical medicaments for subgingival irrigation after scaling have been tried.18,19 The list includes chlorhexidine, 0.25% diluted sodium hypochlorite, 10% povidone iodine,20 essential oil mouth rinses, and ozonated water. While these methods may appear to have efficacy, there is insufficient or inconclusive research to support these approaches. The gingival crevicular fluid flow rate increases in areas that are inflamed. Due to lack of substantivity, the flow flushes out any liquid irrigant in a short period of time.
Locally delivered antibiotics and antiseptics in the form of gels, fibers, chips, and microspheres have also been used for decades in conjunction with subgingival debridement.21,22 There is increasing concern in the scientific community regarding frequent use of antibiotics and the ability of microbes to become resistant over time, shifting the focus to antibiotic stewardship.24,25 A recent review concluded that local delivery was an appropriate methodology when combined with mechanical debridement, but no one drug provided superior results.25
For over a decade, clinicians in Europe have been disrupting subgingival biofilm using a targeted spray decontamination that utilizes glycine powder.26,27 The newest technique now incorporates erythritol powder.28 The goal is to remove soft biofilm deposits with minimal damage to valuable root structure. Additional research indicates that this decontamination protocol can have a negative effect on subgingival periodontal pathogens.29,30 European clinicians have used professionally applied chlorhexidine thymol varnish to reduce the microbial population.31
Bacterial decontamination using diode laser therapy is also gaining traction. Laser therapy is a decontamination protocol, capable of reducing periodontal pathogens imbedded on the tooth surface and in soft tissue lining of the sulcus. It can be used as a solo therapy or in conjunction with traditional debridement techniques.32-34
A handful of clinicians have access to a periodontal endoscope. Their view of the sulcus is far more advanced than what the rest of us can see. The endoscope gives clinicians a direct and magnified view of the root surface and inflamed endothelial lining of the sulcus. With endoscopy, clinicians can see hard deposits, anatomical irregularities, and root fractures that are not clinically detectible by traditional tactile examination.35,36
Simply making decisions based on what we have always done needs to stop. It is time to quit recommending or performing treatment based on what will be reimbursed or what we think a patient will accept. We need to take off the blinders, perform better and more thorough diagnostics, and prevent or treat disease based on individual needs.
Microbes are smart, but we can be smarter. While it is unlikely that all microbes will be removed with any one modality, simply reducing the subgingival bioburden allows the host’s immune system to begin the healing process. The science of wound healing supports using multiple modalities and regular and thorough debridement.
Our professional treatment begins the pathway to health, the next step is partnering with the patient and developing strategies for effective daily biofilm disruption. The final answer for how we deal with the clinical challenges is a simple formula: science + personal circumstances = the right decision.
- Costalonga M, Herzberg MC. The oral microbiome and the immunobiology of periodontal disease and caries. Immunol Lett. 2014;162(2 Pt A):22-38. doi:10.1016/j.imlet.2014.08.017
- Fischer RG, Lira Junior R, Retamal-Valdes B, et al. Periodontal disease and its impact on general health in Latin America. Section V: Treatment of periodontitis. Braz Oral Res. 2020;34(supp1 1):e026. doi:10.1590/1807-3107bor-2020.vol34.0026
- Slots J. Focal infection of periodontal origin. Periodontol 2000. 2019;79(1):233-235. doi:10.1111/prd.12258
- Murakami S, Mealey BL, Mariotti A, Chapple ILC. Dental plaque-induced gingival conditions. J Clin Periodontol. 2018;45(Suppl 20):S17-S27. doi:10.1111/jcpe.12937
- Slots J. Periodontitis: facts, fallacies and the future. Periodontol 2000. 2017;75(1):7-23. doi:10.1111/prd.12221
- Polymerase chain reaction (PCR) fact sheet. National Human Genome Research Institute. Updated August 17, 2020. Accessed January 25, 2021. https://www.genome.gov/about-genomics/fact-sheets/Polymerase-Chain-Reaction-Fact-Sheet
- Heng NCK, Stanton JL. Next-generation DNA sequencing of oral microbes at the Sir John Walsh Research Institute: technologies, tools and achievements. J R Soc N Z. 2020;50(1):91-107. doi:10.1080/03036758.2019.1687530
- Staging and grading periodontitis. The American Academy of Periodontology. Accessed January 27, 2021. https://sites.perio.org/wp-content/uploads/2019/08/Staging-and-Grading-Periodontitis.pdf
- AAP Periodontal Disease Classification Animation – Sponsored by J&J. December 16, 2020. Accessed January 27, 2021. https://www.youtube.com/watch?v=RUz1LJpTpeI&feature=youtu.be
- Apatzidou DA. Modern approaches to non-surgical biofilm management. Front Oral Biol. 2012;15:99-116. doi:10.1159/000329674
- Bosshardt DD. The periodontal pocket: pathogenesis, histopathology and consequences. Periodontol 2000. 2018;76(1):43-50. doi:10.1111/prd.12153
- Del Pozo JL. Biofilm-related disease. Expert Rev Anti Infect Ther. 2018;16(1):51-65. doi:10.1080/14787210.2018.1417036
- Lewis K. Persister cells, dormancy and infectious disease. Nat Rev Microbiol. 2007;5(1):48-56. doi:10.1038/nrmicro1557
- Aimetti M. Nonsurgical periodontal treatment. Int J Esthet Dent. 2014;9(2):251-267.
- Manresa C, Sanz-Miralles EC, Twigg J, Bravo M. Supportive periodontal therapy (SPT) for maintaining the dentition in adults treated for periodontitis. Cochrane Database Syst Rev. 2018;1(1):CD009376. doi:10.1002/14651858.CD009376.pub2
- Farooqi OA, Wehler CJ, Gibson G, Jurasic MM, Jones JA. Appropriate recall interval for periodontal maintenance: A systematic review [published correction appears in J Evid Based Dent Pract. 2016 Mar;16(1):79]. J Evid Based Dent Pract. 2015;15(4):171-181. doi:10.1016/j.jebdp.2015.10.001
- Haukka A, Heikkinen AM, Haukka J, Kaila M. Oral health indices predict individualised recall interval. Clin Exp Dent Res. 2020;6(6):585-595. doi:10.1002/cre2.319
- Nagarakanti S, Gunupati S, Chava VK, Reddy BV. Effectiveness of subgingival irrigation as an adjunct to scaling and root planing in the treatment of chronic periodontitis: A systematic review. J Clin Diagn Res. 2015;9(7):ZE06-ZE9. doi:10.7860/JCDR/2015/13862.6210
- Ramanauskaite E, Machiulskiene V. Antiseptics as adjuncts to scaling and root planing in the treatment of periodontitis: a systematic literature review. BMC Oral Health. 2020;20(1):143. doi:10.1186/s12903-020-01127-1
- Leonhardt A, Bergström C, Krok L, Cardaropoli G. Microbiological effect of the use of an ultrasonic device and iodine irrigation in patients with severe chronic periodontal disease: a randomized controlled clinical study. Acta Odontol Scand. 2007;65(1):52-59. doi:10.1080/00016350600973078
- Matesanz-Pérez P, García-Gargallo M, Figuero E, Bascones-Martínez A, Sanz M, Herrera D. A systematic review on the effects of local antimicrobials as adjuncts to subgingival debridement, compared with subgingival debridement alone, in the treatment of chronic periodontitis. J Clin Periodontol. 2013;40(3):227-241. doi:10.1111/jcpe.12026
- Zhao H, Hu J, Zhao L. Adjunctive subgingival application of chlorhexidine gel in nonsurgical periodontal treatment for chronic periodontitis: a systematic review and meta-analysis. BMC Oral Health. 2020;20(1):34. doi:10.1186/s12903-020-1021-0
- Bowler P, Murphy C, Wolcott R. Biofilm exacerbates antibiotic resistance: Is this a current oversight in antimicrobial stewardship?. Antimicrob Resist Infect Control. 2020;9(1):162. doi:10.1186/s13756-020-00830-6
- Yan J, Bassler BL. Surviving as a community: Antibiotic tolerance and persistence in bacterial biofilms. Cell Host Microbe. 2019;26(1):15-21. doi:10.1016/j.chom.2019.06.002
- Sholapurkar A, Sharma D, Glass B, Miller C, Nimmo A, Jennings E. Professionally delivered local antimicrobials in the treatment of patients with periodontitis–A narrative review. Dent J (Basel). 2020;9(1):2. doi:10.3390/dj9010002
- Sculean A, Bastendorf KD, Becker C, et al. A paradigm shift in mechanical biofilm management? Subgingival air polishing: a new way to improve mechanical biofilm management in the dental practice. Quintessence Int. 2013;44(7):475-477. doi:10.3290/j.qi.a29615
- Flemmig TF, Hetzel M, Topoll H, Gerss J, Haeberlein I, Petersilka G. Subgingival debridement efficacy of glycine powder air polishing. J Periodontol. 2007;78(6):1002-1010. doi:10.1902/jop.2007.060420
- Hägi TT, Hofmänner P, Eick S, et al. The effects of erythritol air-polishing powder on microbiologic and clinical outcomes during supportive periodontal therapy: Six-month results of a randomized controlled clinical trial. Quintessence Int. 2015;46(1):31-41. doi:10.3290/j.qi.a32817
- Petersilka G, Koch R, Vomhof A, et al. Retrospective analysis of the long-term effect of subgingival air polishing in supportive periodontal therapy. J Clin Periodontol. 2021;48(2):263-271. doi:10.1111/jcpe.13392
- Tsang YC, Corbet EF, Jin LJ. Subgingival glycine powder air-polishing as an additional approach to nonsurgical periodontal therapy in subjects with untreated chronic periodontitis. J Periodontal Res. 2018;53(3):440-445. doi:10.1111/jre.12532
- Anand V, Govila V, Gulati M, Anand B, Jhingaran R, Rastogi P. Chlorhexidine-thymol varnish as an adjunct to scaling and root planing: A clinical observation. J Oral Biol Craniofac Res. 2012;2(2):83-89. doi:10.1016/j.jobcr.2012.05.006
- Mizutani K, Aoki A, Coluzzi D, et al. Lasers in minimally invasive periodontal and peri-implant therapy. Periodontol 2000. 2016;71(1):185-212. doi:10.1111/prd.12123
- Aoki A, Mizutani K, Schwarz F, et al. Periodontal and peri-implant wound healing following laser therapy. Periodontol 2000. 2015;68(1):217-269. doi:10.1111/prd.12080
- Gadzhula NG, Shinkaruk-Dykovytska MM, Cherepakha OL, Goray MA, Horlenko IM. Efficiency of using the diode laser in the treatment of periodontal inflammatory diseases. Wiad Lek. 2020;73(5):841-845.
- Shi JH, Xia JJ, Lei L, et al. Efficacy of periodontal endoscope-assisted non-surgical treatment for severe and generalized periodontitis. West China J Stomatol. 2020;38(4):393-397. doi:10.7518/hxkq.2020.04.007
- Zhang YH, Li HX, Yan FH, Tan BC. [Clinical effects of scaling and root planing with an adjunctive periodontal endoscope for residual pockets: a randomized controlled clinical study.] (Chinese) Hua Xi Kou Qiang Yi Xue Za Zhi. 2020;38(5):532-536. doi:10.7518/hxkq.2020.05.010
ANNE NUGENT GUIGNON, MPH, RDH, CSP, has received numerous accolades over four decades for mentoring, research, and guiding her profession. As an international speaker and prolific author, Guignon focuses on the oral microbiome, erosion, hypersensitivity, salivary dysfunction, ergonomics, and employee law issues. She may be contacted at [email protected].