SCIENCE & TECH
Why should a dental office provide
By identifying the cause of periodontal disease, namely
the specific periodontal pathogens harbored in a patient’s
mouth, treatment planning and risk assessment are facilitated using hard data, rather than a subjective assessment
protocol. Other risk elements including genetics, diabetes,
smoking, xerostomia, poor oral hygiene, stress, immuno-compromise, hormonal variations, or connective tissue
diseases, among others, are important to identify and mitigate as much as possible, but they are all contributing
factors, not causative. Strange as it may seem, poor oral
hygiene on its own cannot cause periodontal disease—nor
can smoking, diabetes, xerostomia, etc. Of course, all of
these factors increase the likelihood of periodontal disease
development, severity, speed of onset, etc., but they are not
Our current understanding of the development of periodontal disease requires specific oral bacteria plus the patient’s immuno-inflammatory response in a genetically
susceptible individual, period. What is the evidence for this?
One piece was provided by the researchers who originally
identified the periodontal pathogens. The late Anne Haffajee,
DDS, and the late Sigmund (Sig) S. Socransky, DDS, stated,
“The ultimate risk factor for an infectious disease is the
causative agent of that disease. Without that agent, no disease
will take place no matter what [their emphasis] other risk
factors the subject may possess.” 1 The causative agents in
the case of periodontal disease are the specific bacteria.
The current standard for nonsurgical in-office periodontal
therapy includes periodontal evaluation and charting, radiographs, and scaling and root planing with or without the
use of various types of antimicrobials. This is the same way
we have approached periodontitis for more than 30 years.
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
Richard H. Nagelberg, DDS
GP PERIO: THE ORAL-SYSTEMIC CONNECTION
This protocol isn’t obsolete; it’s just not sufficient at this
point because we are leaving too much to chance. Without
identifying the specific bacteria that we are attempting to
control, we are simply guessing and practicing blindly.
Let’s say the salivary test reveals the presence of several
high-risk, highly pathogenic bacteria such as Porphyromonas
gingivalis (Pg), Tannerella forsythia (Tf), and Treponema
denticola (Td). These are highly toxic bugs associated with
aggressive forms of periodontal disease. The salivary test
report will specifically state which antibiotics are indicated
for each bacterial profile. Now, we can develop a treatment
plan for the individual patient, rather than providing a one-size-fits-all approach. With highly pathogenic, toxic bacteria,
we can anticipate that some areas will not respond to initial
therapy. But we can use the powerful information we gain
from the salivary testing to decide how to address nonre-sponding sites should they occur. This may include the use
of antioxidants, probiotics, additional biofilm control devices, or other adjunctive therapies.
Similarly, the presence of these high-risk bacteria in a
periodontally healthy individual or someone with gingivitis
would represent an elevated level of risk for periodontal
disease development, especially in the presence of a medical
history or a family history of periodontitis. This constitutes
a hard data-driven risk assessment. A thorough evaluation
and modification of the patient’s home-care regimen, if
necessary, would be warranted, followed by annual salivary
Another scenario includes patients whose bacterial tests
reveal the presence of Fusobacterium nucleatum (Fn), P.
gingivalis (Pg), and/or Aggregatibacter actinomycetemcomitans
(Aa), in addition to T. forsythia and T. denticola, because
these bacteria have been identified as directly causative for
atherosclerosis development. 2
So, are we treating mouths, pocket numbers, swelling
and BOP, or people? We work between the chin and the
nose, but the effect of the therapy we provide or ignore is
felt between the bottom of the feet and the top of the head.
Figure out what is holding you back from doing the best
you can for your patients, get past it, and reach your full
potential as a clinician.
WHEN ADVANCEMENTS ARE DEVELOPED that simply and affordably enable
clinicians to significantly improve the specificity of their treatment plans for
patients, and, by extension, the therapeutic outcome, we would reasonably expect
them to be accepted and implemented wholeheartedly by the profession. This is
the case with salivary identification of periodontal pathogens. Perhaps more
importantly, the same technology allows us to assess the risk for the development
of periodontal disease for a patient who may have a clinical condition prior to
periodontitis; in other words, the patient is periodontally healthy or has gingivitis.
1. Socransky SS, Haffajee
AD. Evidence of
bacterial etiology: a
2. Bale BF, Doneen AL,
Vigerust DJ. High-risk
contribute to the
Postgrad Med J. 2016.
[Epub ahead of print].