Paul J. Jacobs, DDS, D-ABDSM
Biofilm
The nature of biofilms makes them a very difficult target. As strains of pathogenic bacteria multiply and organize into a mature biofilm, they form a protective coating over their community called a glycocalyx. This glycocalyx walls off the biofilm and makes it impervious to attack by infection fighting cells and antibiotics. The most effective tool against pathogens in a biofilm is dental ultrasonics. Ultrasonic treatment breaks down the glycocalyx and renders the biofilm more susceptible.
Mechanically Resistant Bacteria
Some periodontal pathogens are mechanically resistant to treatment. That means that they don’t respond to brushing, flossing, or scaling and root planing. Specifically, those are: Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, Prevotella intermedia, and Peptostreptococcus micros. Knowledge of the presence of these bacteria, which is accomplished through oral microbiome DNA testing, allows the dentist or hygienist to employ more focused therapies for success.
Timing of Treatment
Bacterial loads can double every 5 hours. Traditional sequencing of periodontal therapies involves quadrant or half mouth appointments. The problem with these approaches is that they don’t allow for enough multiple appointment, sequential reduction in bacterial load. Research shows that successful treatment of biofilms includes full mouth disinfection within a 24 hour period. Also, when antibiotics are used in treatment, they must be administered within 2 hours of ultrasonic treatment.
pH Balancing
Periodontal pathogens thrive in an acid environment. Periodontal health is difficult to attain when there is no attention paid to improving the pH of the oral environment. Techniques must be employed such as reducing consumption of red meats and other pH reducers. Eating green leafy vegetables and avoiding frank dietary acids like soda or lemon water help to boost salivary pH. Prebiotics and probiotics must be considered in shifting from pathogenic to healthy microbiomes.
Use of Mouthwashes
Use of mouthwashes, especially those containing alcohol or wide spectrum disinfectants should be discouraged. The mouth and its healthy microbiome are essential to overall body health. Normal commensal bacteria are necessary gatekeepers to the mouth. They help reduce pathogenic bacteria by competing for nutrition and staving off undesirable bacteria and viruses, yeasts and fungi. When free floating (planktonic) bacteria are eliminated by mouthwashes, the remaining anaerobic subgingival pathogens are free to replicate unhindered.
Understanding the science and microbiology behind the cause of periodontal diseases is a necessary first step toward successful treatments. For too long, we as dentists and hygienists have treated all patients and all bacteria as if they respond identically to treatment. Once we encounter patients who are non responsive, we are quick to assume that we have done all that we can, and to incorrectly blame our patients for “not flossing enough.” New knowledge of the etiology of periodontal diseases should be employed in order to finally control this insidious, chronic infection.