Novel and Emerging Strategies
Innovative diagnostic technologies have the potential to usher in a new era in the evaluation and management of periodontal disease. Biomolecules found in saliva and in gum crevices can now be measured to gauge inflammation and bone remodeling, and guide more effective screening and treatment. This technology has the potential to allow convenient in-office analysis that can lead to individualized treatment (Taylor 2014; Ram 2015). Tests for additional biomolecules that impact periodontal disease are being investigated; these may allow a sensitive analysis of bacterial, genetic, immunological, and stress-related factors (Patil, Patil 2011). Currently available salivary tests that measure bacterial and human DNA give insight into genetic susceptibility to periodontal disease even before symptoms occur. These tests allow for earlier and more accurate diagnosis and treatment (Nabors 2010). Ongoing research continues to identify unique genetic patterns associated with increased periodontal disease risk (Shaffer 2014).
Minimally invasive dentistry. Conventional dental care often involves aggressive mechanical treatment of even minor caries, colloquially termed the “drill and fill” approach. But emerging evidence suggests this aged practice—it has permeated dental dogma for over a century—may be unnecessarily invasive in many cases. Also, dental fillings, or restorations, may deteriorate over time necessitating replacement, which entails additional drilling that further undermines the structural integrity of the tooth (Borges 2011; Stahl 2007).
It turns out that progression of mild caries can often be halted, or even reversed, through the use of remineralizing agents and protective resins and sealants. In these procedures, gentle etching of affected tooth surfaces followed by application of a remineralizing agent and sealant facilitates tooth remineralization and prevents further erosion of tooth enamel. One of the newer widely studied remineralizing agents is casein phosphopeptide-amorphous calcium phosphate, or CPP-ACP (Borges 2011; Stahl 2007).
In the modern era, invasive “drill and fill” dentistry is beginning to fall out of favor, with more preference being given to minimally invasive clinical treatments coupled with at-home use of remineralizing agents such as fluoride- and CPP-ACP-containing mouthwashes and gums along with xylitol, a sugar alcohol that helps displace pathogenic oral bacteria (Emamieh 2015; Borges 2011; Stahl 2007; Milgrom 2006).
Laser. Dental lasers, due to their antibacterial effects and ability to access hard-to-reach sites while minimizing damage to tooth surfaces, can improve the efficacy of traditional periodontal treatments (Zhao 2014). Although one literature review found laser treatment to be as effective as scaling and root planing in improving periodontal health, another review found lasers ineffective for calculus removal, suggesting the role of lasers in conventional treatment of periodontitis requires further investigation (Zhao 2014; Kamath 2014). However, emerging evidence suggests laser treatment plus conventional scaling and root planing may be more effective than scaling and root planing alone (Cheng 2015; Roncati 2014).
Photodynamic therapy. In photodynamic therapy, a special photosensitizing chemical that specifically binds to bacteria is used. A laser, or visible light of a particular wavelength, is then directed at the area to which the photosensitizer has been applied. In the presence of oxygen, the light reacts with the photosensitizer and produces reactive oxygen species that kill bacteria without damaging surrounding tissue (Vohra 2015; Mielczarek-Badora 2013). Antimicrobial photodynamic therapy may help remove biofilm in deep root pockets, increasing the efficiency of scaling and root planing and potentially avoiding post-treatment hypersensitivity (Mielczarek-Badora 2013; Mang 2012). Photodynamic therapy may also be considered as an alternative to antibiotics due to its instantaneous antibacterial effects, reduced likelihood of resistance, absence of toxicity to periodontal tissue, and no known effects in other parts of the body (Vohra 2015). Several reviews have concluded that the addition of antimicrobial photodynamic therapy to conventional scaling and planing more effectively treats periodontal disease compared with scaling and planing alone (Vohra 2015; Smiley 2015; Mielczarek-Badora 2013).
Tissue engineering. Tissue engineering is a technologically advanced method of regenerating or reconstructing healthy periodontal tissue and supporting bone that has been lost to periodontal disease. These innovative techniques may eventually help activate the body’s own restorative self-repair mechanisms, modulating immune activity, promoting new bone growth, and inhibiting loss of existing bone structure. Tissue engineering uses new specialized materials, genetic modification, stem cell therapies, or biomolecules called growth factors (Sood 2012; Rios 2011; Racz 2014). Tissue engineering is a rapidly growing field of research and has great potential to offer a new approach to chronic and aggressive periodontitis treatment; however, only some of these methods have been incorporated into current periodontal treatment (Chen 2010; Sood 2012; Rios 2011).
Metformin and atorvastatin (Lipitor) are two widely-used medications that treat diabetes and cardiovascular disease, conditions associated with periodontal disease. These drugs have shown promise for their beneficial effects on periodontal health.
Metformin. Metformin is generally considered to be the first-line drug treatment for type 2 diabetes (Rena 2013). But metformin has a remarkably wide range of therapeutic indications beyond diabetes: there is strong evidence that it reduces the risk of multiple types of cancer, improves response to cancer treatment, increases likelihood of survival in some forms of cancer, and mimics some of the anti-aging benefits of caloric restriction (Zhang 2011; Lee 2012; Wang 2014; Zhang 2012; Wang 2013; Yu 2014; Kasznicki 2014; Col 2012; Song 2012; Skinner 2013; Noto 2012; Storozhuk 2013; Anisimov 2013; Stein 2012; Fontana 2004; Pryor 2015).
Now, emerging evidence indicates metformin’s benefits may extend to periodontal disease as well. In two controlled clinical trials, topical metformin was applied directly to affected periodontal tissues in people being treated for chronic periodontitis with scaling and root planing. After six months of treatment, subjects treated with metformin had reduced periodontal pocket depth, better gingival attachment, and improvements in bony defects compared with those receiving placebo (Pradeep, Rao 2013; Pradeep 2015). Similar results were seen in a trial involving smokers with chronic periodontitis (Rao 2013).
Atorvastatin. Atorvastatin, widely used to treat high cholesterol and reduce cardiovascular risk (AHA 2014), appears to reduce periodontal inflammation as well. In one study, 71 participants with suspected or known atherosclerosis were treated with either 10 or 80 mg per day of atorvastatin. After 12 weeks, those on the higher dose had significantly reduced levels of periodontal inflammation, which was accompanied by an improvement in vascular inflammation (Subramanian 2013). In another trial, 60 subjects with periodontitis were treated with scaling and root planing plus either topical atorvastatin or placebo for nine months; subjects receiving topical atorvastatin had greater reductions in periodontal pocket depths and better gingival attachment compared with placebo (Pradeep, Kumari 2013).