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Early intervention for gum health – Dentistry Online

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Alison Edisbury explains the links between gingivitis and periodontitis and how effective interdental cleaning is essential.

This article is brought to you by Johnson & Johnson, the makers of Listerine(R). The content is the authors own, but their time has been compensated by Johnson & Johnson.

Periodontal disease is an inflammatory disease caused by the formation and persistence of bacterial biofilm.

It affects approximately 50% of the world’s adult population. Severe periodontitis is the sixth most prevalent human disease according to the 2010 global burden of diseases study (Chapple et al, 2015).

Not only is periodontal disease a major cause of tooth loss, it also has a negative impact on quality of life and overall wellbeing. It is linked to a number of systemic diseases.

However, periodontal disease is preventable with early intervention.

Gingivitis and periodontitis links

Gingivitis and periodontitis are a continuum of the same chronic inflammatory disease. Whilst not all patients with gingivitis will progress to periodontitis, there is a weight of evidence indicating that prevention of gingivitis prevents periodontitis (Kinane and Attström, 2005).

Gingivitis is the first manifestation of the body’s inflammatory response to bacterial plaque biofilm. It is also reversible if the patient disrupts the biofilm.

However, if biofilm persists gingivitis can become chronic. In susceptible individuals the persistent challenge of the biofilm produces a chronic inflammatory response to protect the host and limit the effect of the biofilm. But this results in some tissue destruction, progressing gingivitis to periodontitis (Kinane and Attström, 2005).

Periodontitis is non-reversible and results in loss of attachment and can lead to tooth loss.

Periodontitis

The extent and severity of periodontitis varies among individuals. It is the result of the host response to the biofilm. This is dependent on a number of risk factors including poor oral hygiene, genetics, poor nutrition, smoking, diabetes and also stress.

Research suggests plaque biofilm causes 20% of periodontitis. And other modifying factors such as the host response cause 80% of cases (Lang and Bartold, 2018).

Periodontitis is a major cause of tooth loss, which can affect speech, nutrition and confidence. But it has also been long established that there is a link to a number of systemic diseases.

We do not yet know if there is a causal link between periodontitis and systemic disease, or other risk factors.

Research shows links with cardiovascular disease, diabetes and adverse pregnancy outcomes. With emerging associations for rheumatoid arthritis, chronic kidney disease, cognitive decline and osteoporosis.

Interdental cleaning

As biofilm initiates periodontal disease, effective and consistent biofilm disruption is vital in the prevention of both gingivitis and periodontitis.

By preventing gingivitis, the aim is to avoid the progression to periodontitis in susceptible individuals. We can achieve this by motivating patients in the disruption of supragingival dental biofilm and risk factor control such as smoking cessation, improved diabetes control, and optimal plaque removal.

Mechanical plaque removal performed on a daily basis by the patient remains the gold standard.

Effective tooth brushing and interdental cleaning achieves this. However, achieving and maintaining optimal self-performed oral hygiene is complex. It relies heavily on manual dexterity and the patient’s motivation for behaviour change.

Patients with reduced manual dexterity and those with malpositioned teeth, crown and bridge work or orthodontic appliances may find effective brushing and interdental cleaning particularly difficult.

Despite the patient’s best efforts, bacteria is likely left behind. This is where chemotherapeutic agents may play a key role in controlling plaque bacteria as an adjunct to mechanical cleaning methods.

Disrupting biofilm

A recent systematic review concluded that antiseptic chemotherapeutics have a clinical benefit for the patient in reducing plaque when used alongside mechanical plaque removal. And that mouth rinse was more effective in reducing plaque compared to dentifrices formulations (Figuero et al, 2020).

This was because mouth rinse is likely to access more sites within the oral cavity such as proximal surfaces of teeth, inter-proximal papillae and the oral soft tissues as well as those areas that are harder to reach through mechanical cleaning methods (Figuero et al, 2020).

The daily addition of a mouth rinse containing essential oils to use adjunctively alongside mechanical cleaning practices significantly increases the chances of having a cleaner mouth (Araujo et al, 2015).

Effective and consistent biofilm disruption on a daily basis by the patient is essential. Not only due to the oral health implications, but also due to the possible links with systemic diseases such as cardiovascular disease and diabetes.

Whilst mechanical plaque removal remains the gold standard, for some individuals this is not possible or sufficient. Therefore adjunctive use of antiseptic chemotherapeutics such as essential oils in mouth rinses is beneficial.

Clinicians can consider these as part of the patient’s daily oral hygiene routine.

References

Araujo M, Charles C, Weinstein R, McGuire J, Parikh-Das A, Du Q, Zhang J, Berlin J and Gunsolley J (2015) Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. J Am Dent Assoc 146 (8): 610-22

Chapple ILC, Van der Weijden F, Doerfer C, Herrera D, Shapira L, Polak D, Madianos P, Louropoulou A, Machtei E, Donos N, Greenwell H, Van Winkelhoff A, Kuru BE, Arweiler N, Teughels W, Aimetti M, Molina A, Montero E and Graziani F (2015) Primary prevention of periodontitis: managing gingivitis. J Clin Periodontal 42 (Suppl 16): S71-6

Figuero E, Roldán S, Serrano J, Escribano M, Martín C and Preshaw P (2020) Efficacy of adjunctive therapies in patients with gingival inflammation. A systematic review and meta-analysis. J Clin Periodontol 47 (Suppl 22): 125-43

Kinane DF and Attström R (2005) Advances in the pathogenesis of periodontitis. Group B consensus report of the fifth European Workshop in Periodontology. J Clin Periodontol 32 (Suppl 6): 130-1

Lang NP and Bartold PM (2018) Periodontal health. J Clin Periodontol 45 (Suppl 20): S9-S16

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