Strategies for prevention
The problem with inflammatory periodontal disease is that it is often detected too late and treatment made more complex as a result. As in the rest of the world of medicine a deeper understanding of the causes of periodontal disease and the disease progression is allowing the development of new strategies and concepts in disease prevention. So lets consider a few.
Plaque is now viewed in a different way. It is considered to be a biofilm, a highly structured bacterial community that allows the bacteria to live in a protected environment reducing their susceptibility to antimicrobial agents. In addition the bacteria in a biofilm can function in a different way to free floating organisms.
The way a bacterium’s genes are expressed can alter in a biofilm, potentially making it more pathogenic, and bacteria can also work together through communication systems, with the same result. By understanding this we understand the significance of the bacterial biofilm and the significance of its disruption during therapy.
Transmission of pathogenic periodontal organisms has been documented between spouses particularly for Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis. There is limited evidence that cohabitation with a periodontitis patient can influence the periodontal status of the spouse and more research is needed, but it may be worthwhile setting up a cost effective screening process within practice.
I have observed a number of spouses both suffering from advanced disease and, on occasions, of a similar disease presentation. A swallow does not make a summer but it is food for thought.
We now understand that periodontal disease involves microbial challenge in conjunction with host susceptibility and response. How can we modify the host response? We can control risk factors such as smoking, diabetes, plaque biofilm and so on.
However newer therapies are looking at controlling the immune and inflammatory response but as yet the problems with this have not been fully overcome. There is evidence to suggest that non-surgical therapy with sub-antimicrobial dose doxycycline twice daily for nine months is beneficial in the management of chronic periodontitis over twelve months (through its anti-collagenase effects) although more research is apparently needed in high risk patients.
With regard to the use of anti-inflammatory COX-2 inhibitors and systemic biphosphonates, to inhibit alveolar bone loss, I feel the jury is still out.
There are still issues regarding genetic susceptibility testing and its significance and also in the development of a vaccine against periodontal pathogens. So at this stage the well-tried and tested methods of periodontal disease prevention and treatment still hold up and it is a case of watch this space.
1. Examine the spouses of those presenting with peridontal disease symptoms for symptoms too as they can have the pathogens responsible passed on to them.
2. Alert patients to the fact that smoking, diabetes and plaque biofilms can contribute to the development of the disease.
3. Evidence has shown that a sub-antimicrobial dose doxycycline twice daily for nine months can help with the management of chronic periodontitis.
4. The use of anti-inflammatory COX-2 inhibitors and systemic biphosphonates as treatments are still under review.