Polymicrobial synergy and dysbiosis: Impact on clinicians and patients
We know that the new model of periodontal disease is called polymicrobial synergy and dysbiosis. We also know some of the details of the mechanism of periodontal disease development and progression, but what does this mean on a clinical level? In his DentistryIQ blog, “Making the Oral-Systemic Connection,” Richard H. Nagelberg, DDS, explains how we can enhance the level of care we give to our patients—i.e., who should be tested for periodontal disease, how they should be tested, and what types of recommendations we should be making to our patients. He also discusses how we should modify our approach to exploit the research conclusions we’ve gained from the new model of periodontal disease.
So now we know that the new model of periodontal disease is called polymicrobial synergy and dysbiosis (PSD). We also know some of the details of the mechanism of periodontal disease development and progression, but what does this mean on a clinical level? How should we modify our approach to the disease to exploit the research conclusions and, as always, enhance the level of care we provide for our patients?
The big kahuna is Porphyromonas gingivalis (P. gingivalis), so if we are going to identify and control the initiator of periodontal disease, we need to demonstrate and knock down this bacterium whenever possible. This can most easily and accurately be done with salivary diagnostics. Who do we test? All patients with gingivitis or periodontitis should be tested for periodontal disease. We should also test patients who have a family history of periodontal disease. The presence of P. gingivalis should be a huge warning sign . . . any level of P. gingivalis. The current model of periodontal disease indicates that a significant quantity of the bacteria is necessary to cause disease. We now know that a small quantity of P. gingivalis is all it takes. It brings to mind the old Brylcreem hair cream commercial: “A little dab’ll do ya!”
What other recommendations should we be making? First and foremost, a power toothbrush. There is no comparison between the bacterial reduction achieved by a power versus a manual toothbrush. (1, 2, 3) Further, interdental brushes (IDB) are far more effective than dental floss, according to 2015 research. (4) IDBs should be used wherever they fit into our patients’ care regimens. Have patients use floss only where the contacts are too tight for IDBs. Make sure your patients have tongue cleaner and antibacterial rinses for daily use. We must be making all of these home-care recommendations with considerable urgency, since we are battling all of the bugs in the mouth—not just a select few.
My next blog post will offer further thoughts and recommendations for the brave new world of periodontal disease.
1. Ward M, Argosino K, Jenkins W, et al. Comparison of gingivitis and plaque reduction over time by Philips Sonicare FlexCare Platinum and a manual toothbrush. Philips Oral Healthcare website. https://www.usa.philips.com/c-dam/b2c/category-pages/personal-care/POHC/resource-library-docs/Comparison-of-gingivitis-and-plaque-reduction-over-time-by-Philips-Sonicare-FlexCare-Platinum-and-a-manual-toothbrush.pdf. Published 2012. Updated 2015. Accessed May 17, 2016.
2. Yaacob M, Worthington HV, Deacon SA, et al. Powered versus manual toothbrushing for oral health. Cochrane Database of Systematic Reviews. 2014;6:CD002281. doi: 10.1002/14651858.CD002281.pub3.
3. Kurtz B, et al. A randomized clinical trial comparing plaque removal efficacy of an oscillating-rotating power toothbrush to a manual toothbrush by multiple examiners. Int J Dent Hyg. 2016;5. doi: 10.1111/idh.12225. [Epub ahead of print].
4. Chapple IL, Van der Weijden F, Doerfer C, Herrera D, Shapira L, Polak D, et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol. 2015;42 Suppl 16:S71–6. doi: 10.1111/jcpe.12366.
Richard H. Nagelberg, DDS, has practiced general dentistry in suburban Philadelphia for more than 30 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact Dr. Nagelberg at firstname.lastname@example.org.