Probing considerations in relation to susceptibility to periodontal breakdown

Local Drug Delivery Based Treatment Approaches for Effective Management of Periodontitis

Background:

Periodontal disease is an immuno-inflammatory condition of tissues that surround and hold the teeth. It is the disease which succeeds in all races, groups and both genders. Almost 10 to15% of the global population gets suffered from severe periodontitis as per WHO reports. Periodontal disease may likely cause other systemic diseases such as cardiovascular disease and pre-term low birth weight infants. Mechanical removal of plaques and calculus deposits from supra and subgingival environment is the backbone of periodontal treatment till date whereas complete elimination of these deleterious agents is quite unrealistic as the pocket depth increases.

Recent Approaches:

Recently controlled local drug delivery application is more encouraging in comparison to systemic approach as it mainly targets to enhance the therapeutic efficacy by maintaining site-specificity, avoiding first pass metabolism, reduction in gastrointestinal (GI) side effects and decreasing the dose. Several drugs such as antiseptics and antibiotics alongwith various carriers are being formulated as local drug delivery systems for effective management of the disease. Various local delivery systems reported are fibers, films, strips, compacts, injectables, microparticles, vesicular carriers, gels and nanoparticles. These local carriers provide effective prolonged treatment at the site of infection at reduced doses. This review enlightens detailed pathophysiology and various phases of periodontitis, challenges in treatment of disease and various antimicrobial agents (along with their marketed formulations) used. The main emphasis of the review is to cover all carrier systems developed so far for local delivery application in the effective management of periodontitis, as a patient compliant drug therapy.

Periodontal diseases

The periodontal diseases are highly prevalent and can affect up to 90% of the worldwide population. Gingivitis, the mildest form of periodontal disease, is caused by the bacterial biofilm (dental plaque) that accumulates on teeth adjacent to the gingiva (gums). However, gingivitis does not affect the underlying supporting structures of the teeth and is reversible. Periodontitis results in loss of connective tissue and bone support and is a major cause of tooth loss in adults. In addition to pathogenic microorganisms in the biofilm, genetic and environmental factors, especially tobacco use, contribute to the cause of these diseases. Genetic, dermatological, haematological, granulomatous, immunosuppressive, and neoplastic disorders can also have periodontal manifestations. Common forms of periodontal disease have been associated with adverse pregnancy outcomes, cardiovascular disease, stroke, pulmonary disease, and diabetes, but the causal relations have not been established. Prevention and treatment are aimed at controlling the bacterial biofilm and other risk factors, arresting progressive disease, and restoring lost tooth support.

Levels of parotid and submandibular/sublingual salivary immunoglobulin A in response to experimental gingivitis in humans

Salivary secretory IgA (s-IgA) is considered to act as an important first line of defense mechanism in the oral cavity. It has therefore been suggested that an increased antigenic load would induce an increase in salivary IgA production. This study investigated the pure glandular levels of salivary IgA in parotid and submandibular/sublingual (SM/SL) saliva during plaque accumulation leading to experimental gingivitis. Starting from regular oral hygiene, 14 healthy, nonsmoking men refrained from all oral hygiene measures for 12 days. On days -2, 0, 3, 6, and 12 a plaque index, a bleeding index, and unstimulated and stimulated saliva from the parotid and the SM/SL glands were measured. Salivary IgA was quantified using a sandwich ELISA. All subjects developed gingivitis as measured by a bleeding index. Compared to baseline the salivary flow rate was increased on day 12. Regarding the secretion rate of IgA there was a statistically significant increase in stimulated parotid saliva but not SM/SL saliva compared to baseline after 6 and 12 days without oral hygiene. No significant changes were observed for the concentration of IgA during the trial. Thus, in healthy subjects with regular oral hygiene the development of plaque induced gingivitis is associated with increased salivary gland output and increased total IgA output levels in stimulated parotid saliva but not in SM/SL saliva.

Levels of salivary IgA antibodies reactive with bacteria from dental plaque are associated with susceptibility to experimental gingivitis

Serum IgG, IgA and IgM and salivary IgA antibody levels reactive with extracts from Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Eubacterium saburreum and Streptococcus mutans, were measured by enzyme-linked immunosorbent assay in samples from 12 persons before, during and after experimental gingivitis. The participants refrained from cleaning their teeth until 50% of their gingival units showed bleeding after gentle probing, but not longer than 15 days. Samples were taken from serum and saliva, before and during the period of experimental gingivitis, and up to 8 weeks after the start of the experiment. A pattern with minor fluctuations in specific serum and salivary antibody activities was consistently found in all patients. This indicates that immunoregulatory mechanisms succeed in maintaining unchanged antibody levels when plaque load increases. A subgroup of participants with low mean numbers of bleeding gingival units after plaque accumulation, showed significantly higher salivary IgA antibody levels reactive with S. mutans, A. actinomycetemcomitans and E. saburreum, as compared with the subgroup reaching high bleeding after probing scores (p < 0.05). When 1 person with outlying values (p < 0.05) for P. gingivalis was excluded from the tests, the former group also showed statistically significant higher salivary antibody levels to this bacterial species. High levels of salivary IgA directed against bacteria in dental plaque might thus protect against the development of gingivitis.

Periodontal probe use in general practice in Florida

Use of the periodontal probe in 134 Florida dental practices was studied. Results indicated that 62% of the practices performed a complete recorded periodontal probing for new patients. Recall patients received a complete recorded periodontal probing in 57% of the practices at a mean frequency of 12.7 months. Selected site probing was performed in 22% of the offices as part of the new patient examination, and in 34% of the offices as part of the recall examination. In the examinations in 57% of the practices, changes in pocket depths were detected that could suggest changes in connective tissue levels.

The bleeding/plaque ratio in the treatment of periodontal disease

The bleeding/plaque ratio has been suggested as a means of assessing susceptibility to periodontal disease, and as a prognosticator of periodontal breakdown. In this study, 100 males and 131 females were evaluated by means of the bleeding/plaque ratio to make a prognosis of the outcome of periodontal therapy. Initial plaque and gingival bleeding scores were used to calculate the bleeding/plaque of the subjects, and these ratios were compared with the resolution in the clinical parameters of plaque, gingival bleeding and severe and moderate pocketing. The subjects were divided into those showing higher bleeding incidence and lower bleeding incidence as assessed by post-treatment gingival bleeding. The bleeding/plaque ratios for the 2 groups were not significantly different, and therefore could not be used clinically for assessment of susceptibility to, or for prognostication of periodontal breakdown. 4 subjects were randomly selected from these 2 groups, and their data used to illustrate the limitations of the bleeding/plaque ratio. The bleeding/plaque ratios bore no relationship to the response to treatment in these 8 individuals, when evaluated in terms of reduction in plaque levels, gingival bleeding or pocketing. It is therefore concluded that the bleeding/plaque ratio in its present form is not of clinical value for making a prognosis of the likely outcome of treatment, and some suggestions as to how it may be improved are made.