Dr. Richard Nagelberg challenges us with more concepts about how we and the bacteria that reside in and on our bodies are inextricably linked, relying on each other for survival. Be prepared to stop for a minute and think—or rethink—about what you know about periodontal disease and bacteria, as well as how you can help your patients achieve oral health.
PERIODICALLY, IT IS WORTHWHILE to examine some of the things we take for granted as we go through our day at the chair in our respective dental offices. For example, we now know that the bacteria that live in and on our bodies are not just something we tolerate; we have co-evolved over millions of years. There are at least as many bacteria that reside in and around our bodies as there are cells that make us who we are. We are inextricably linked partners relying on each other for survival.
We also know that when periodontitis develops, among the clinical manifestations is ulceration of the gingival epithelium in the periodontal pocket. It is through these ulcerations that bacteria gain entry to the circulation and travel all over the body. Do we ever think about how those ulcerations got there? Destruction of the underlying connective tissue by the inflammatory mediators, including the enzyme collagenase, result in the ulcerations of the gingival epithelium. In other words, it occurs from the bottom up.
Does periodontitis start supragingivally or subgingivally? The disease is initiated when bacteria accumulates on the surfaces of the teeth supragingivally. If not adequately disrupted primarily by the patient at home, the bacteria migrate apically between the tooth and gums, and a pocket forms. The fact that the order or sequence of events starts supragingivally gives each person the ability to stop it in its tracks, before the apical migration and pocket formation.
So, what is the primary goal of periodontal therapy? Is pocket reduction what we are trying to achieve? Well, yes and no. Providing any type of periodontal therapy in and of itself does not achieve pocket depth reduction, with the exception of resective surgery. The objective of treatment is adequate disruption of the pathologic etiology from supra- and subgingival root surfaces. Since bacteria are the causative agents in periodontal disease, reducing the population of the bacteria will ultimately result in pocket depth reduction. The primary goal of periodontal treatment is bacterial reduction.
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We can only remove the plaque and calculus we can see or feel with our instruments. It is vitally important to keep in mind that bacteria are microscopic in size. They are hiding in every nook and cranny available to them around the CEJ—in dentinal tubules and in the gingival epithelial cells. We do not have the instruments to access these areas presently. We do, however, have chemotherapeutic agents in the form of locally applied and systemic antimicrobials and antimicrobial rinses that extend the reach of our instruments, knocking out more bacteria than we can achieve mechanically.
Just some things to think about...
