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Preventing the progression of gingivitis

This article explores the concept that gingivitis and periodontitis are a continuum of the same inflammatory disease, and the implications for everyday preventive care.

Periodontal disease is one of the most prevalent diseases in the world, and can affect up to 90% of the population across the globe.1 For over 200 years, the search has been on to identify the causes of periodontal disease.1 Today, it is considered that the main sources of periodontal disease are microbial in nature, adhering to, and growing on, teeth to form dental plaque.1 According to the Group B consensus report of the fifth European Workshop in Periodontology, gingivitis and periodontitis are a continuum of the same inflammatory disease; however, it does not follow that gingivitis will always progress to periodontitis.2 Rather, it is considered that, ‘The weight of the evidence indicates that the prevention of gingival inflammation prevents periodontitis’.2

Group B participants further suggested that interrupting the plaque colonisation process may well offer the most appropriate approach in helping to prevent the progression of periodontal disease.2

Disrupting plaque biofilm

It is widely accepted that twice-daily brushing and interdental cleaning are essential in achieving and maintaining good levels of oral hygiene,3 serving to disrupt the plaque bacteria that can contribute to the development of periodontal disease.4 However, it is also known that, for a variety of reasons, brushing and interdental cleaning alone can fail, ‘[…] to maintain an adequate level of plaque control […] in many people.’ Because of this, it has been suggested that an adjunct in the form of an effective antimicrobial measure may help such patients dislodge and disrupt plaque bacteria to an adequate level.4

To this end, Working Group 2 of the 11th European Workshop in Periodontology on the primary prevention of periodontitis considered the value of adjunctive chemotherapeutic intervention.5 They reached a consensus supporting: ‘[…] the almost universal recommendations that all people should brush their teeth twice a day for at least 2 min. with fluoridated dentifrice. Expert opinion is that for periodontitis patients 2 min. is likely to be insufficient, especially when considering the need for additional use of inter-dental cleaning devices. In patients with gingivitis once daily inter-dental cleaning is recommended and the adjunctive use of chemical plaque control agents offers advantages in this group.’5

A probiotic approach

In addition to this, probiotics appear to offer a promising new area of research in the treatment of periodontal disease.6 Bhatia and Sidhu (2014) suggested that: ‘Probiotic bacteria, generally regarded as safe, may favor periodontal health if able to establish themselves in oral biofilm and inhibit pathogen growth and metabolism.’6

They go on to write: ‘Probiotics lower the pH so that plaque bacteria cannot form dental plaque and calculus that causes the periodontal disease. They make an excellent maintenance product because they produce antioxidants. Antioxidants prevent plaque formation by neutralizing the free electrons that are needed for the mineral formation.’6

Adding to this concept, Morales and colleagues (2017) wrote: ‘Considering the beneficial effects of probiotics, this therapy could serve as a useful adjunct or alternative to periodontal treatment. The use of probiotics in oral care applications is gaining momentum. There is increasing evidence that the use of existing probiotic strains can deliver oral health benefits. Therefore, proposing a treatment involving the non-surgical treatment plus probiotic intake may result in better regulation of bacterial plaque and thus contribute to a successful periodontal treatment […].’7

It is early days in establishing the true efficacy of probiotics in relation to periodontal disease but, so far, the results appear encouraging, making it a subject seemingly worth further investigation.6,8 As Chapple and colleagues (2017) wrote just this year: ‘[…] probiotics could be helpful in […] periodontal disease management, although evidence is limited and biological mechanisms not fully elucidated.’8

Best practice

As researchers continue to explore the possible benefits of adjuvants other than a mouthrinse, such as probiotics, the evidence base may change. For now, however, the best evidence available supports the use of a three-step preventive home-care regimen of brushing, interdental cleaning and rinsing in those for whom mechanical cleaning alone may be insufficient to control plaque biofilm, which may then contribute to the development of periodontal disease.5

 

References

  1. Khan SA et al. Periodontal diseases: bug induced, host promoted. PLOS Pathogens 2015; 11(7): e1004952. doi:10.1371/journal.ppat.1004952
  2. Kinane DF, Attström R. Advances in the pathogenesis of periodontitis. Group B consensus report of the fifth European Workshop in Periodontology. J Clin Periodontol 2005; 32(Suppl. 6): 130-1
  3. Sharma N et al. Adjunctive benefit of essential oil-containing mouthrinse in reducing plaque and gingivitis in patients who brush and floss regularly: a six-month study. JADA 2004; 135: 496-504
  4. Barnett ML. The rationale for the daily use of an antimicrobial mouthrinse. JADA 2006; 137: 16S-21S
  5. Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol 2015; 42 (Suppl. 16): S71-S76
  6. Bhatia V, Sidhu GK. Probiotics and periodontal disease – an update. Journal of Advanced Medical and Dental Sciences Research 2014; 2(3): 91-96
  7. Morales A et al. Probiotics and periodontal diseases. Insights into Various Aspects of Oral Health. InTech Open 2017; Chapter 5: 73-96
  8. Chapple ILC et al. Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases: consensus report of group 2 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol 2017; 44 (Suppl. 18): S39-S51