Next-Generation Periodontics

Tim Donley, DDS | Gregg A. Helvey, DDS, MAGD, CDT | Betsy Reynolds, RDH, MS

The Roundtable is a new forum for debate on key topics, trends, and techniques in dentistry. Every other month, a panel of experts will take on a subject to help expand your knowledge and boost your practice. This month, our panel of experts discusses occlusion, a selection of which is presented here. Watch the whole conversation here.

About Our Panel

Tim Donley, DDS, is a leading expert in the treatment of gum disease and dental implants who is a sought-after international speaker and teacher. He coauthored the first textbook used in dental schools throughout the world on modern ultrasonic treatment for gum disease. He is in private practice in Bowling Green, Kentucky.

Gregg A. Helvey, DDS, MAGD, CDT, is an adjunct associate professor at the Virginia Commonwealth University School of Dentistry. He also teaches cosmetic dentistry in the AEGD residency program and maintains a private practice in Middleburg, Virginia. He is the Restorative Section Editor and a member of the Editorial Advisory Board for Inside Dentistry.

Betsy Reynolds, RDH, MS, is a dental hygienist and oral biologist. She presents dental and dental hygiene continuing education programs on a variety of topics involving the biologic basis for oral and systemic disease prevention, immunologic aspects of oral disease, and scientific developments affecting oral health care delivery.

By middle age, 50% of the population will have some form of periodontal disease. In this edition of the Roundtable, our panel examines how clinicians can assist in the prevention of the disease and what treatment options are available for patients.

Inside Dentistry (ID): Scaling and root planing are perhaps the most conservative treatments for gingivitis and periodontal disease. What do you recommend as a treatment beyond these procedures?

Dr. Tim Donley: That is a great question. I might add one point of clarification. Really, instead of root planing, maybe a better term is periodontal debridement. We now know that while periodontal disease is initiated by the bacterial biofilm, there is a very complex host response that occurs in response to that bacterial initiation. It is that host response that results not only in periodontal destruction but also has potential to lead to other more potentially serious systemic problems. As a result, some inflammatory and host modification concerns should be part of periodontal therapy. I think any discussion about periodontal therapy has to begin with consistently adequate and effective interruption of the biofilm that is actually initiating the host response.

Dr. Gregg A. Helvey: Yes, I agree with that. Instead of focusing on bacteria, thinking in terms of inflammatory response is a better way of looking at it. The things that we can do that are anti-inflammatory will contribute to the success of the perio program that we instigate in the office. The other risk factors—tobacco use, drug abuse, controlling diabetes, and weight control need to be addressed. These are areas that we still need to bring into the whole picture of the treatment plan.

Betsy Reynolds: I do believe it goes beyond bacterial control, and we are actually looking at an inflammatory response as part of the immune system. People with autoimmune disorders, especially women, are disproportionately affected. Combine that with hormonal influences, especially with progesterone affecting the vascular supply as well as estrogen deficiencies affecting bone loss potential, and I think we are looking at an era when we better understand the immune system and its role in inflammation.

I think many of my colleagues consider “immunocompromised” to be a hypo‑functioning immune system. I caution anybody that I am presenting to that ‘immunocompromised’ also means a hyper-functioning immune system such as is the case with autoimmune disorders.

ID: Are there specific demographics or age groups that are more likely to develop periodontal disease?

Reynolds: Yes, and I suppose this is what is troubling as a clinician. We have dramatically underestimated the proportion of the population that is experiencing periodontal diseases by up to 50%. So, the statistic of over half or almost half of Americans under the age of 65 experiencing periodontal disease is troubling enough, but sadly, over the age of 65, 70% of Americans have some type of periodontal disease. I think that it is troubling that low socioeconomic status remains one of the prime indicators of whether or not somebody is disease-free. I think that is a tragic comment on where we are. I do believe as age increases, the ability to adequately clean teeth in a timely and thorough way can be undermined by such things as arthritis in the hands and difficulty maneuvering floss and toothbrushes. That is why I am quite a fan of electronic devices that allow patients to implement flossing techniques without actually using floss and using electric toothbrushes to get to areas that they might not be able to access.

Donley: As patients get older, they are already at increased risk for developing the typical chronic serious diseases of aging. We know without question that if periodontal disease is inadequately treated over the lifespan of a patient, it only increases the amount of systemic inflammation. I think it is really critical to have patients partner with a dental professional so that over their lifespan, we can make sure if there is any evidence of oral inflammation that we provide the necessary therapy to maximally get that inflammation to resolve. That is going to pay dividends not only to their oral heath but their overall health as well.

Helvey: I am a very big proponent of the anti-inflammatory aspect, and one of the things that I have my patients do is start them on the low-dose aspirin to get some anti-inflammatory effects, but I also get them on omega-3 fatty acids. The aspirin not only provides the anti-inflammatory effect, but it also prolongs the half-life of the omega-3s and omega-6s in the bloodstream, and these have shown to have a counteractive effect on inflammation.

ID: What general health risks are associated with periodontal disease?

Donley: There remains uncertainty as to what we can say for sure as to the link between oral and overall health. It is admittedly difficult to quantify the level of inflammation that the oral cavity contributes when periodontal disease is not adequately controlled, and as a result, it is tough to quantify the impact that periodontal disease can have. But there is no question about the fact that inflammation itself is the root cause of chronic diseases of aging like cardiovascular disease, rheumatoid arthritis, Alzheimer’s disease, and diabetes. If oral inflammation contributes to systemic inflammation and systemic inflammation is linked to these other diseases, I think keeping gum disease at bay has to be on the list of health-promoting behaviors, and I think that is good news for all of us that are interested in caring for our patients.

Helvey: I agree totally. In fact, there are studies that have shown men who have periodontal disease are 49% more likely to develop kidney, pancreatic, and blood cancers. So, the relationship of the inflammatory autoimmune process is quite evident.

ID: Are there new treatment options that are showing promise in curing this disease?

Donley: I think with the emphasis on the inflammatory component, the answer is yes. Certainly diet/nutrition plays a role. While it has not really enjoyed widespread clinical use, the research on low-dose doxycycline is solid in terms of it actually modulating the host response. Omega-3 fatty acids actually promote the resolution of inflammation, and researchers aim to duplicate some of the beneficial parts of those chemicals and in essence supercharge them, even using a nanotechnology to get these beneficial anti-inflammatory agents right to the cells where they are needed.

Reynolds: One of the other things that I like about doxycycline is its anti-collagenase effect, which prevents collagenase enzymes from breaking down the collagen of the periodontal ligament. I think in the future we are going to be looking at modulating the bad perio pathogens and promoting a more symbiotic population of bacteria that does not lead to an inflammatory state. I do believe we are on the precipice of really turning these disease rates around, and I am excited to be a part of it.

Helvey: There is also such a correlation with the drugs that people with autoimmune disease, like rheumatoid arthritis and Crohn’s disease, are taking. These types of drugs are really helping the autoimmune-compromised patients and I think they are going down the right avenue as far as treating periodontal disease.

ID: Dr. Donley, you get the last word.

Donley: I think what we are all really saying is we are in the age of serious dental medicine. The fact of the matter is we all have to be doing more than just cleaning teeth. If you think about it, inflammation is the problem. Inflammation is the issue for systemic disease for oral disease. A lot of the things that lead to this inflammation—tobacco use, hypertension, stress, nutritional changes, sleep, and oral inflammation—we in dentistry can a play a role in affecting a lot of those. I think the bottom line is the old checkup and cleaning visit has to become less of a beauty visit and more of a health visit. I think tomorrow’s dentistry is about wellness, and I am excited to continue going along for the ride.