This article is an overview to update the practicing general dental practitioner about clinically relevant evidence-based topics published in the recent past in the diagnosis, etiopathogenesis, and management of gingivitis and periodontitis.
Dysbiosis between microbes and the host immune system altered with environmental and genetic factors is the current understanding of etiopathogenesis of chronic periodontitis.
Management of periodontitis should involve an individualized risk assessment and treatment plan that include appropriate risk factor mitigation, such as control of diabetes, smoking cessation, among others.
Prevention of gingivitis and consequently periodontitis involves maintaining meticulous oral hygiene by tooth brushing twice daily with preferably powered toothbrushes and fluoridated tooth paste, flossing, use of interdental brushes, and essential oil mouth rinses.
Professional management of periodontitis include scaling and root planing with beneficial effects noted using adjuncts in specific situations.
Persistent periodontitis after nonsurgical therapy will necessitate surgical periodontal therapy. Resective or regenerative periodontal therapies will aid in the elimination of remaining periodontitis and, hence, in retention of teeth.
Periodontal disease: definition
Periodontal disease comprises all diseases that affect the periodontium: gingiva, periodontal ligament, cementum, and alveolar bone. These diseases range from gingivitis to viral infections to tumors. Hence, the cause ranges from a simple, unifactorial agent, such as herpes simplex virus, to complex, multifactorial bacteria-host immune system–mediated dysbiosis.
Update in diagnosis classification
In 2015, the American Academy of Periodontology (AAP), published a focused update to the AAP’s 1999 classification of periodontal diseases on 3 issues regarding the diagnosis of periodontitis. They include further clarifications on the differences between chronic and aggressive periodontitis, guidelines on determining the severity of periodontitis, and, localized versus generalized periodontitis. More recently, in June 2018, the AAP in collaboration with the European Federation of Periodontology published a series of review and consensus articles by experts around the world in periodontics and implant dentistry to update the periodontal disease classification. Several major updates have been proposed through this series. One of the major changes in this update is the proposal of combining chronic and aggressive periodontitis as a single-entity periodontitis exhibiting different phenotypes. For the sake of familiarity by dental practitioners and the relatively recent release of the updated classification, this review focuses on the review of gingivitis (dental-biofilm–induced gingivitis), chronic periodontitis (slow to moderate rates of disease progression), and aggressive periodontitis (rapid rate of disease progression). The readers are recommended to the cited references for further understanding of the updated 2017 classification.
Chronic and Aggressive Periodontitis
In general, chronic periodontitis affects adults and corresponds to the amount of local factors, mainly plaque/calculus. It tends to progress slowly with periods of exacerbation. Systemic diseases, such as diabetes, and environmental risk factors, such as smoking, impact the severity of chronic periodontitis ( Fig. 1 ). In contrast, aggressive periodontitis affects younger individuals (<25 years of age) with familial aggregation and the striking feature being rapid destruction of attachment and bone with little or no microbial deposits. Most patients with aggressive periodontitis are otherwise healthy systemically ( Fig. 2 ). According to the updated 2017 classification, both cases in Figs. 1 and 2 would be called periodontitis but will have different stages and grades.
Periodontal disease: prevalence and burden of tooth loss
The prevalence of periodontal disease in the United States was estimated using the National Health and Nutrition Examination Survey data. Full-mouth periodontal examination was done in this population measuring periodontal pockets and gingival recession (distance between free gingival margin to cementoenamel junction) in 6 sites for all teeth except the third molars. The prevalence of periodontitis in the United States was estimated to be 45.9% during the period of 2009 to 2012 with severe periodontitis attributed to 8.9% of the American people. Severe periodontitis affects about 11.2% globally. It is unfortunate that significant gaps in knowledge exist among the public regarding periodontal disease.
Systemic disease connection
Numerous studies over the last few decades have studied associations between periodontitis and systemic diseases as risk factors. Although there is an established association between certain diseases, such as diabetes, obesity, and cardiovascular diseases, most associations are not very strong. It is important to realize that managing periodontal disease for its own right is important because of the poor quality of life associated with tooth loss. Association with systemic diseases, although very important to study to reduce the overall morbidity associated with both periodontitis and systemic diseases, should not distract the focus on managing periodontal disease for its own sake as the second most common oral disease after dental caries. Insufficient or low-quality evidence makes it difficult to understand whether periodontal treatment has any positive effects on improving diabetes or reducing low birth weight, preterm weight, or adverse obstetric outcomes. Tooth loss is associated with significant reductions in quality of life.
It has been long known that dental plaque and calculus initiate gingival inflammation (gingivitis) and that given sustained presence of this gingival inflammation can eventually, in many cases, progress to destruction of underlying connective tissue and alveolar bone (periodontitis). The interesting observation has been that not all gingivitis progressed in the same manner despite identical local factors. Individual variability in the host response to local factors plays a crucial role in this difference. Today, it is known that the balance between host and bacteria determines the state of health, and the loss of this balance leads to what is termed dysbiosis and state of disease (referred to as polymicrobial synergy and dysbiosis model). Certain keystone pathogens, such as Porphyromonas gingivalis , even in low abundance, has been shown to lead to dysbiosis. Herpes viruses have been implicated in the cause of periodontitis. A recent meta-analysis using 12 case-control studies found herpes simplex virus type 1 and human cytomegalovirus to be significantly associated with aggressive periodontitis. The investigators caution against the heterogeneity among the studies while interpreting these findings. Also, the association between Epstein-Barr virus (EBV) and herpes simplex virus type 2 was inconclusive because of insufficient evidence and publication bias. According to another meta-analysis, EBV was frequently detected in periodontal pockets of 5 mm or greater. Besides the microbial-host interactions in disease onset and progression, genetics, epigenetics, diabetes, and smoking (a major lifestyle risk factor) have all been shown to have a major impact on disease onset and progression.
Using personalized risk assessment tools, such as the periodontal risk assessment and the periodontal risk calculator (PRC), may lead to better risk assessment and counseling of patients for better periodontal health. The PRC takes the following information into consideration to calculate periodontal disease progression: ‘ patient age ; smoking history; diabetes diagnosis; history of periodontal surgery; pocket depth; bleeding on probing; restorations below the gingival margin; root calculus; radiographic bone height; furcation involvements; and vertical bone lesions .’ For example, a recent systematic review clearly showed that teeth with furcal involvement had a higher risk of tooth loss. However, the same study showed that periodontal therapy on furcal involved teeth reduced the loss of teeth. Smoking counseling and dietary interventions to improve periodontal outcomes has been shown to be effective, and dental practitioners should include this as part of discussion from the initial visit and through periodontal maintenance. Genetic risk assessment, such as interleukin-1 genetic tests, have been attempted in the past and have not been shown to be clinically useful yet.
Prevention and management
Tooth brushing reduces dental plaque. Powered toothbrushes, especially the oscillating-rotating type, have been shown to improve plaque levels and gingivitis. Similar findings were also observed with gingival index and gingival bleeding in patients undergoing orthodontic treatment. Nine randomized controlled trials were included in a meta-analysis for this finding. For removal of plaque from interdental areas, using interdental brushes has been shown to be very effective. Water-jets have also been shown to be effective recently in a meta-analysis along with interdental brushing. Essential oil containing mouthwashes and chlorhexidine mouth rinses have been shown to be effective in reducing gingivitis and plaque levels. For patients with oral malodor, mouth rinses containing a combination of chlorhexidine, cetylpyridinium chloride, and zinc or a combination of cetylpyridinium chloride and zinc chloride have been found helpful. Probiotics used as an adjunct to scaling and root planing (SRP) have been shown to have a short-term benefit in the management of chronic periodontitis. Much of the evidence has been shown in the probiotic Lactobacillus reuteri ( L reuteri ).
The 11th European Workshop on Periodontology published recommendations on the prevention of periodontal and peri-implant diseases in 2015 as a consensus report, which was also endorsed by the AAP. These recommendations were developed from 16 systematic reviews and meta-reviews of the same.
For the management of gingivitis
Brushing twice daily for 2 minutes with powered toothbrushes using a fluoridated toothpaste
Flossing in teeth with tighter contacts around healthy gingival tissue
Using interproximal brushing especially around inflamed gingival tissue where flossing may cause trauma
Using chemical plaque control agents like mouth rinses
American Dental Association’s Clinical Practice Guideline
The American Dental Association (ADA) has recently published a systematic review and meta-analysis on the nonsurgical management of chronic periodontitis. This review aided in the development of clinical practice guidelines that outline recommendations based on the best available evidence on various nonsurgical modalities and expert opinion when evidence was unavailable or unclear. The clinical recommendations can be obtained from the ADA Web site. The investigators looked at the net benefit for all nonsurgical treatment modalities balancing the benefits versus potential harms. The clinical relevance was estimated based on the clinical attachment level (CAL) improvement. The clinical effect was judged as zero, small, moderate, and substantial if the CAL were 0 to 0.2 mm, greater than 0.2 to 0.4, greater than 0.4 to 0.6, and greater than 0.6, respectively. It must be noted that the average CAL improvement noted for all recommended treatments ranged between 0.24 mm to 0.64 mm. The clinical recommendations were in favor of SRP without any adjuncts as well as SRP with systemic subantimicrobial-dose doxycycline. The specific dosage recommended for moderate to severe chronic periodontitis was doxycycline 20 mg twice a day for 3 to 9 months. Other adjuncts that were recommended with weak strength of evidence were SRP with systemic antimicrobials, locally delivered antimicrobials (chlorhexidine chips), and photodynamic therapy (PDT) using diode lasers. Expert opinion recommendations included SRP with locally delivered antimicrobials, namely, doxycycline hyclate gel and minocycline microspheres. It should be noted that this guideline concluded that there was no net benefit from using diode (non-PDT), Nd:YAG, and erbium lasers. Another systematic review has concluded that the evidence is insufficient for the use of lasers as an adjunct in periodontal resective or regenerative surgeries.
Systemic antibiotics have been shown to be helpful in the management of chronic periodontitis as an adjunct to SRP. The combination of amoxicillin and metronidazole used short-term along with SRP especially in patients with a periodontal pocket depth of 6 mm or more has been clinically significant. The same combination has also been shown to be useful in the management of aggressive periodontitis. Azithromycin has been also shown to improve the clinical outcomes when used as an adjunct to SRP. In addition, azithromycin has been shown to be very effective in the management of cyclosporine-induced gingival overgrowth. Full-mouth disinfection including the use of antibiotics/antiseptics or full-mouth scaling within 24 hours have been studied extensively as an alternate to quadrant-wise SRP. A recent systematic review has not found a significant difference in these modalities. Host modulation therapy using antiinflammatory medications, such as nonsteroidal antiinflammatory drugs, have been shown to reduce gingivitis but are not recommended in clinical practice because of the limited quality of evidence and known side effects.
Periodontal Surgical Therapy
When initial nonsurgical therapy using SRP and other adjuncts fail to resolve periodontitis during reevaluation, periodontal surgical therapy is indicated. Surgical therapy has been shown to be beneficial at an average probing depth of 5.4 mm. Osseous surgery has been shown to improve CAL gain compared with SRP in deeper periodontal pockets of 7 mm or greater. In certain scenarios, such as intrabony periodontal defects with well-contained osseous walls, regenerative periodontal therapy can be beneficial.
Supportive Periodontal Therapy
Supportive periodontal therapy to maintain the improved periodontal health after active periodontal therapy has been shown to reduce the risk of tooth loss. Oral hygiene instructions for patients is usually effective among motivated patients. Behavioral interventions, such as motivational interviewing, have been shown to be very effective in improving periodontal outcomes. Motivational interviewing involves personalizing the oral hygiene needs and communicating in a way that brings out the intrinsic motivation among patients.
Several factors discussed thus far, such as dysbiosis, genetic, environmental, and behavioral risk factors, among others, lead to interindividual and intraindividual variability in periodontal disease onset, progression pattern, and response to therapy. Prognostication of periodontally compromised teeth becomes challenging due to the multifactorial and complex nature of risk factors. Prognostication scoring systems, such as the Miller-McEntire scoring system for molars, may be useful for assessing prognosis. Hence, personalized maintenance protocols based on risk factors should be established. Dental practitioners must become comfortable with general health risk assessments with interprofessional collaboration to improve not only periodontal health but also general health, such as by participating in smoking cessation and dietary modifications for weight control, among others. Specific recall intervals, such as every 3 to 6 months, do not have strong support of evidence.
Chronic periodontitis is a chronic inflammatory disease initiated by microbial biofilm and mediated by dysbiosis between the microbial biofilm and host inflammatory response.
Aggressive periodontitis can be differentiated from chronic periodontitis by the rapid destruction of periodontium in a relatively short time in a relatively younger individuals (<25 years of age) with minimal presence or at times absence of calculus. Familial aggregation is common in aggressive periodontitis.
Severe periodontitis affects about 11% of the world’s population.
Certain systemic diseases, such as diabetes, have a strong established bidirectional relationship with periodontitis.
Management of periodontitis should be focused on for its consequences of tooth loss and related loss of quality of life rather than merely its association with a plethora of systemic diseases and their consequences.
Dysbiosis between microbes and the host immune system altered with environmental and genetic factors is the current understanding of etiopathogenesis of chronic periodontitis. This process is complex and multifactorial. Hence, prediction of disease progression and response to treatment can vary tremendously within individuals and within the same individual.
Management of periodontitis should involve an individualized risk assessment and treatment plan that include appropriate risk factor mitigation, such as control of diabetes and smoking cessation, among others.
Prevention of gingivitis and consequently periodontitis involves maintaining meticulous oral hygiene by tooth brushing twice daily preferably with powered toothbrushes and fluoridated tooth paste, flossing, use of interdental brushes, and essential oil mouth rinses.
Professional management of periodontitis includes SRP with beneficial effects noted using adjuncts in specific situations. Adjuncts include systemic antibiotics, systemic subantimicrobial-dose doxycycline, locally delivered antimicrobials (chlorhexidine chips, doxycycline hyclate gel, and minocycline microspheres), and PDT using diode lasers.
Disclosure Statement: The author has nothing to disclose.