Richard H. Nagelberg, DDS
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Adhering to a periodontal protocol allows us to provide comprehensive perio care for most patients. The typical perio protocol has a flow chart with columns into which patients fall, depending on the severity of their disease. We are currently at the point, however, in which we can provide truly personalized perio care, since we can now identify the specific perio pathogens that cause an individual patient's disease. Enhanced treatment outcomes and long-term disease stabilization are the norm when practicing this way.
Identifying perio pathogens is not new. Culturing oral bacteria has been available for a long time, but the procedure is very technique-sensitive and time-consuming since live bacteria must be sent to a lab for testing. Now, salivary bacterial DNA testing is changing our profession. The test is easy to administer, the salivary sample does not have special handling requirements, and the results are available in a few days. The primary reason why identification of the bacterial etiology of disease is so important is because it tells us which microorganisms are activating an individual's immuno-inflammatory response, manifesting as the perio disease we see clinically.
Consider a common scenario: Two patients present with identical clinical characteristics: 5 mm to 6 mm pockets in all four quadrants, bone loss, gingival redness, swelling, and BOP. Nonsurgical treatment planning for each patient will likely consist of scaling and root planing, irrigation with an antimicrobial agent, locally applied antibiotics, and systemic antibiotics.
One patient improves significantly and the other does not. Why is there no improvement in one case, and how do we proceed with that nonresponding patient? Do we repeat treatment, prescribe low-dose doxycycline to address the host response, change the systemic antibiotics?
If we had examined each patient's risk factors, we may have discovered that one had a strong family history of perio disease, was prediabetic, and had an acceptable home-care regimen. The other patient with the same clinical presentation had no risk factors, but poor home care. Identifying the biological processes underlying the clinical presentation is critical to treatment planning, including how nonresponding sites will be addressed.
We need to keep in mind that bacteria are necessary, but not capable of producing perio disease on their own. The interplay of the bacteria and the patient's immune response determines the level of disease we see clinically. Without knowledge of the specific perio pathogens that are igniting the immune system, we are essentially guessing at the best course of treatment.
In addition to locally applied antimicrobials such as Arestin, commonly prescribed systemic antibiotics include amoxicillin and metronidazole; however, these turn out to be the systemic antibiotics of choice less than a third of the time. Without post-treatment bacterial testing, we have no idea if we have reduced the bacterial load, despite clinical improvement.
Addressing nonresponding patients depends on the reason for the less-than-ideal treatment outcome. For example, if the bacterial load has been reduced and clinical resolution is inadequate, it may be necessary to prescribe low-dose doxycycline to address the host response. Referring a prediabetic individual to their physician for an updated HbA1c test to determine glycemic control may be indicated. Every patient is different.
Providing individualized patient care entails identifying and managing risk factors. We must examine the medical, dental, and family histories to understand the contribution of factors such as smoking, immunocompromise, diabetes, hormonal status, xerostomia, systemic diseases, medications, diet, home-care habits, family history of periodontal disease, cardiovascular diseases, diabetes, autoimmune conditions, etc.
Pre-treatment bacterial DNA testing is necessary to understand the number and virulence of the bacterial species causing the perio disease, and to determine the antibiotics that are effective against those particular pathogens. Post-treatment testing will indicate if we have reduced the bacterial load and achieved the therapeutic endpoint.
Providing individualized perio care requires more time and consideration, but the rewards are tremendous for the patient and clinician. The primary reason to provide personalized perio treatment is to increase disease resolution, because the oral contribution to the total inflammatory burden has significant impact on the patient's overall health. We are caring for the entire person, not just the oral cavity.
Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 27 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on many topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].
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