Evolution of periodontology

Periodontal disease has long plagued mankind since time immemorial. In the earlier days, treatment was based on less concrete scientific approaches.

However, careful methodical and scientific approaches began to emerge in the 20th century. Over the years, as dentists learnt more about the specific bacterial etiology of periodontal disease and the role of inflammation in tissue destruction, they were able to better tailor prevention and treatment strategies that focus on specific bacterial types and specific host destructive pathways. Moreover, in the past two decades, impressive advancements in dental technologies have improved the treatment process, especially in regenerative medicine and dentistry. With new scaffolds, growth factors, biologics and membranes, dentists are able to predictably rebuild structures such as alveolar bone lost as a result of periodontitis.¹

Yet, regardless of the improvement and extensive research in the field of periodontology, classification systems of periodontal diseases still remain a controversy. This is especially so when there is an attempt to group a range of periodontal diseases into a precise and universally accepted classification system, as opposed to recognising that each diagnosis is very different and complex. As a result, there is an imperative need for dentists and/or periodontists to take new knowledge and try to develop a more personalised approach to diagnosing each patient. Dental professionals are trying to move into “precision dentistry” in which all that they know about an individual patient will help define a specific diagnosis and approach to treatment. For instance, a 7mm pocket in a person who smokes and is a Type 2 diabetic will have a very different finding compared to a 7mm pocket in an otherwise healthy person (Figure 1a, Figure 1b and Figure 1c).

Periodontal disease and overall health symbiosis

There are different types of periodontal diseases, such as mild, moderate and severe gingivitis and periodontitis, be it localised or generalised. The disease may also be classified as chronic or aggressive. Symptoms of periodontal disease may be red saliva after brushing one’s teeth, mouth malodour and loosening of teeth. Pain is often mistaken as a symptom, however, it is not common. During a clinical exam, gingival redness, gingival recession, pocket probing depths greater than 4mm and tooth mobility would be revealed. Radiographs would also show the extent and severity of alveolar bone loss (Figure 2a, Figure 2b and Figure 2c).

Research has shown that periodontal diseases are often associated with several other diseases. For many years, bacterial infection was perceived to be the most common factor that links periodontal diseases with other types of diseases in the body. This is because periodontal disease is initiated by the presence of a bacterial biofilm on the teeth. However, while the presence of bacteria is necessary to explain the development of periodontal disease, it is not sufficient. Inflammation is equally important, since it is the response of the host (inflammation) that ultimately destroys the periodontal tissues. Bacteria in the periodontal pocket and inflammatory mediators in the periodontal tissues reach distant sites and organs via the bloodstream and can contribute to disease forming elsewhere in the body.

The relationship between periodontal disease and poor health remains a chicken and egg mystery, where dental professionals require more information for clarity. The presence of periodontal disease increases the risk for a subject to develop coronary heart disease, diabetes and for women to experience adverse pregnancy outcomes. For diabetes, there is a clear bi-directional involvement as people with diabetes are more susceptible to periodontal disease. In addition, periodontal disease can contribute to diabetes severity. This puts people with diabetes at increased risk for complications.

Treatment and management

Periodontal disease is very treatable and healthcare professionals, especially dentists and hygienists, are well-equipped in identifying patients with such diseases. On the other hand, physicians, need to be more educated on identifying patients with or at risk for periodontal disease. This may simply be done by adding a few questions to a health questionnaire, for example, “how often do you see a dentist”, “when did you last have your teeth cleaned”, etc.

Generally, dental practitioners are able to treat early stage periodontal disease such as gingivitis and pockets up to 4mm deep. A referral to a specialist should be done for patients with periodontitis. There are various treatment processes available; using anti-infective approaches such as scaling and root planting, pocket reduction surgery, locally delivered anti-microbials such as Arestin™ or oral antibiotics in aggressive cases. Dentists are also focusing on reducing the destructive inflammatory processes that destroy tissues as well as rebuilding bone back around teeth. From the patient’s perspective, careful daily home care including tooth brushing and flossing is important and going to the dentist for an exam and prophylaxis every four to six months.

Overall, there is a trend in moving towards adopting a multi-disciplinary approach to treating people with periodontal disease and increasing awareness in overall health. Dental professionals are reaching out to general practitioners and other healthcare providers in consulting each other in patient care and contributing to the overall health management of the patient.

References

1. Periodontitis, also known as pyorrhea, is a set of inflammatory diseases affecting the periodontium, i.e, the tissues that surround the support the teeth. http://www.mayoclinic.org/diseases-conditions/periodontitis/basics/definition/con-20021679.

About the author

Ray Williams is Adjunct Professor of Periodontology at the University of North Carolina School of Dentistry. He received his DMD (with honors) from the University of Alabama and his certificates in Periodontology and Oral Medicine from the Harvard School of Dental Medicine. Dr Williams was formerly Professor of Dental Medicine and Dean of the Stony Brook University School of Dental Medicine, New York. His major research interests are clinical and translational research in both pharmacological modification of the host response and in anti-infective approaches to treat periodontal disease. He has authored 140 papers and is co-editor of the textbook Periodontal Disease and Overall Health: A Clinician’s Guide.