By Richard H. Nagelberg, DDS
Current approaches to the management of periodontal disease are focused on two primary strategies. One strategy is to provide the proper balance of bacteria in the oral cavity that favors periodontal health. This approach starts with identifying the existing bacteria and making home-care and treatment recommendations intended to reduce the population of pathogenic bacteria. The other strategy addresses the contribution of the host response to gum tissue destruction.
One of the frustrations with currently available modalities of treatment is the extremely complex nature of periodontal disease. Patients can have minimal amounts of periodontally associated bacteria identified by salivary diagnostics and significant, generalized periodontitis clinically. The contribution of risk elements such as stress, family history, xerostomia, and systemic disease, among others, is difficult or impossible to quantify at this time. Addressing these risk elements, determining the extent to which they contribute to an individual's disease, and the efficacy of risk element modification are also difficult or impossible to measure. As clinicians, we are responsible for addressing our patients' needs using existing information and technology.
Oral probiotics have been available to dental professionals and patients for years; however, it appears as if they are not widely utilized. There is a larger body of research investigating the impact of gastrointestinal probiotics than oral probiotics. Different species of bacteria are used in different oral probiotic products. Commonly utilized bacteria include a variety of Lactobacilli and Streptococcus species. In the oral cavity, probiotics primarily compete for nutrients and binding sites on teeth and gingiva and other soft-tissue surfaces. Gingivitis and periodontitis can only develop from bacteria that are in direct contact with the gingival epithelium. Biofilm accumulation starts supragingivally, so it is important to control the total population of pathogenic bacteria in the oral cavity.
Additional articles by Dr. Nagelberg
Research has demonstrated that GI probiotics favorably alter the balance of proinflammatory and anti-inflammatory cytokines secreted by intestinal epithelial cells; however, this has not been demonstrated in the oral cavity at present. There is a potential in the future for therapeutic applications of probiotics to address periodontal disease, but at this time their role is confined to maintenance and prevention. The impact of probiotics on clinical parameters of periodontal disease is currently inconclusive. Some studies have demonstrated improvement in bleeding and pocket depth. Others have shown bacterial reduction without clinical improvement. The complex, multifactorial nature of periodontal disease may account for some of these conclusions. Currently completed studies have had small numbers of subjects and limited control of confounding factors. On the other hand, the safety of oral probiotics has been recognized with no significant side effects reported.
Deciding which products and technologies we bring on board in our offices is a daily concern in clinical practice for all the diseases and conditions we encounter, including periodontitis and gingivitis. A long view of oral and general health should be undertaken. Rather than attempting to manage the patient's health for the next three to six months, the goal should be lifetime health. For those patients who demonstrate excellent oral health year after year, emphasis should be placed on ensuring that it continues. Recommendations for these patients are focused on monitoring and maintenance of the healthy status they enjoy. For patients with less-than-ideal periodontal health, utilization of bacteria-reducing strategies and biofilm control products should include the use of probiotics, especially since the side effect profile is very favorable. The evidence is sufficiently compelling to recommend probiotics for patients with a high caries rate. Other indications include healthy individuals, those with refractory disease, and patients with physical challenges which prevent adequate biofilm control. Patients with xerostomia can also benefit from probiotic usage since there is concentration of bacteria in the lower salivary volume. Periodontal patients with significant amounts of pathogenic bacteria demonstrated by salivary DNA testing may also benefit from probiotic usage. They should also be considered for patients with a family history of periodontal disease, even if the patient is currently healthy.
Oral probiotics have the potential to make a worthwhile contribution to the health of many of our patients by modifying the balance of favorable and harmful bacteria. Bringing different strategies to bear for our patients struggling with periodontal disease and caries can pay off for the patient.
Richard Nagelberg, DDS, has practiced general dentistry in suburban Philadelphia for more than 30 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations, and he lectures on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at email@example.com.
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