Periodontal Management: Time to Go Beyond Reduced Probing Depths

Periodontitis results from a microbial infection, which induces a host-mediated generation of inflammatory mediators that cause clinically significant connective tissue and bone destruction.² In the typical periodontal lesion, destruction of connective tissue leads to ulceration of the lining epithelium. Bacterial, bacterial byproducts, and mediators of inflammation released in response to the bacterial challenge can find their way through the ulcerated epithelium and spill into the systemic circulation.³ Medicine has long been focused on the role systemic inflammation plays in the development and progression of several serious systemic diseases.⁴ Not surprisingly, inadequately managed periodontal disease has been identified as a potential risk factor for many of the chronic diseases of aging.⁵ Maintaining an oral cavity free of inflammation reduces the systemic burden of inflammation and can lower the risk for the potentially affected systemic diseases.⁶

Periodic removal of etiology to prevent recurrence of periodontal disease has long been recognized as being an important part of maintaining periodontal health once it has been achieved. Reduction of probing depths is desirable not only because this bodes well for the anatomic stability of most periodontal sites over time and suggests that inflammation has been mitigated, but also because it enhances patient and therapist access for the maintenance of periodontal health. However, now that there is an awareness that helping patients achieve and maintain an oral cavity relatively free of chronic inflammation can potentially improve oral and overall health, it seems prudent to redefine the goal of periodontal therapy for all patients. The goal of periodontal management should be expanded beyond the reduction of probing depths to include eliminating oral inflammation and then keeping it at bay.

Therapy should be aimed at interrupting the etiology from tooth surfaces and creating an environment that minimizes the re-accumulation of pathologic biofilm and enhances maintainability by the patient and therapist. Once a dental therapist has sufficiently interrupted the subgingival etiology, the patient must be provided with the appropriate oral hygiene devices to enable sufficient daily interruption of etiology to prevent disease relapse. While the importance of effective subgingival debridement cannot be overstated, patient efforts are essential to maintaining oral health after it has been established.

Periodontal disease is a systemic disease with site-specific presentations. Yet, too often daily hygiene techniques are recommended in a full-mouth context. "Brushing and flossing" has long been the cornerstone of dental therapist recommendations. Flossing has long been an unofficial benchmark of one's dedication to his or her oral health. Dental professionals often begin their assessment of patients' ability to maintain their oral health by questioning whether the patient flosses regularly. In America the percentage of people who use floss on a regular basis is dismal.⁷ Even though few people do it, flossing remains the most commonly recommended method for interproximal daily hygiene. Even more disconcerting is the lack of evidence supporting the use of dental floss. The conclusion from a systematic review suggested, "The dental professional should determine, on an individual patient basis, whether high-quality flossing is an achievable goal. In light of the results of this comprehensive literature search and critical analysis, it is concluded that a routine instruction to use floss is not supported by scientific evidence."⁸

Floss interrupts periodontal and caries pathogens via mechanical dislodgement only when the threads of the floss contact the tooth surface. Against flat or convex interproximal surfaces floss, used properly, may be able to effectively interrupt the pathogenic bacterial biofilm. However, recession of the gingival margin, especially posteriorly, can expose a root surface that has a morphology that does not lend itself to contact with floss. Patients who are faithful with regular flossing and even use an ideal technique will have no effect on the potential biofilm on the concave portions that comprise most interproximal tooth surfaces (Figure 1).

An ideal patient hygiene device should be user friendly, have no deleterious soft-tissue or hard-tissue effects, and interrupt biofilm effectively over the entire intended surface.⁹ Also, the topography of the surface to be debrided must influence the selection of the specific oral hygiene device and technique. Rather than a general recommendation to "brush and floss," the dental therapist must determine the contours of the patient's tooth surfaces and then recommend potential hygiene devices that maximize the ability to contact those surfaces; only then can the patient be expected to sufficiently and fully interrupt etiology on a routine basis.

For maximum effectiveness, the patient must use the recommended daily hygiene device in the proper manner. For instance, due to tooth arrangement, in some patients simply placing a toothbrush against the teeth may not maximize contact between the bristles and the adjacent tooth surfaces. Alterations in technique or recommended device may be needed to achieve thorough biofilm interruption (Figure 2).

Refinement in technique or use of alternative methods may be necessary to achieve consistently adequate debridement. Power toothbrushes, which optimally control the amplitude and frequency to create a strong enough fluid dynamic effect, have been shown to dislodge and remove biofilm beyond the reach of the bristle tip.¹⁰ This can only increase the likelihood that the patient will adequately interrupt biofilm from as much tooth surface as possible.

The question from dental professionals then should not be limited to, "Do you brush and floss?" Rather, the questions by dental professionals when addressing patient-driven daily hygiene should be two-fold and include: What are the surface contours that are in need of debridement, on an individual patient basis? What will give that patient the optimal chance to consistently debride those surfaces?

Then, the dental professional should periodically assess for the presence of reformation of visible etiology and the persistence of any gingival inflammation. At sites that have not responded to previously recommended hygiene protocols, the therapist should consider if the patient is using the most appropriate hygiene method for the involved surface and further verify that the patient is employing the method properly.

Dental therapists must interrupt clinically detectible etiology (plaque and calculus) and as much microscopic biofilm as possible to allow periodontal inflammation to resolve. Then, to prevent relapse, patients must use hygiene devices that maximize the chance of interrupting as much etiology as possible from as much of the tooth surface as possible. Tooth surface contour dictates when hygiene aid will maximize the chance that the etiology will continue to be controlled daily. Eliminating periodontal inflammation and then equipping patients with the devices and knowledge to keep inflammation at bay will improve oral and overall health, oral function, comfort, and appearance.

Timothy Donley, DDS, MSD
Private Practice, Bowling Green, Kentucky