Periodontal disease represents one of the main causes of tooth loss in adulthood. According to the WHO, there is a clear discrepancy between the need for treatment and the therapies actually carried out. Approximately 60% of German citizens over the age of 40 have periodontal disease, which should be treated immediately. Periodontitis becomes the cause of tooth loss in adulthood more frequently than caries.
Obligate anaerobic bacteria cause periodontal disease
Periodontal disease is the irreversible inflammation of the periodontium that leads to the destruction of periodontal soft and bone tissue, as dentist Dr. med. dent. who specializes in periodontology explained to us. Martin Hoppe M.Sc. explained. This is primarily caused by obligate anaerobic bacteria, such as Porphyromonas gingivalis or Treponema denticola. Facultative anaerobic bacteria such as Aggregatibacter actinomycetem comitans cause periodontitis extremely rarely on their own. They are usually found in the gingival pockets, where they are kept alive as second colonizers by the metabolic products of aerobic bacteria. Facultative anaerobic bacteria consume oxygen in their metabolism, thus paving the way for obligate anaerobic bacteria, which require an oxygen-free zone to survive. Thus, the number of facultative anaerobic bacteria in the oral flora is also important. The more of them present, the better living conditions are created for the aggressive third colonizers, which release their toxins. The body’s response to this is the release of pro-inflammatory cytokines, which cause the inflammatory response of periodontitis. An oral flora in which the distribution of germs is in physiological balance is composed of 25% anaerobic germs and 75% aerobic germs. In periodontal disease, the composition is exactly the opposite. The personal composition of the oral flora is therefore decisive for the development of periodontal disease. With a strongly developed immune system, it is quite possible that the bacterial infection is fought in such a way that periodontopathy does not occur despite insufficient oral hygiene. The following infographic shows which bacteria make up the biofilm of periodontal patients:
The development of periodontal disease is determined by other factors as well, such as:
- Genetic predisposition,
- Smoking,
- Diabetes,
- Diseases which involve immunodeficiency,
- Malnutrition
When is a germ test useful?
Schematic representation of healthy gums, periodontal disease and gingivitis. Click to enlarge. How severely the oral cavity is infested with the disease-causing obligate anaerobic bacteria is shown by the probe test. On clinical inspection, high pocket depths and bleeding also stand out on the probe test. For a more precise determination, the Gram test and pathogen cultivation are available, the latter being used more frequently for reasons of precision. As the bacterial test is not a service specific to a health insurance fund, we only recommend it in our practice if it really makes sense, Dr. Hoppe told us. The following indications speak for a bacterial test in periodontitis:
- Therapy-resistant or aggressive disease progression.
- Children or adolescents as affected persons
- Gum pockets of more than 4 mm in depth
For the bacterial test, bacterial samples are taken from the deepest gingival pockets. For the Gram test, the samples are dried and by means of staining with basic dye the germs made visible. However, individual pathogens cannot be determined with this method. This process is carried out in special molecular biology laboratories by cultivating germs. After the lapse of 24 hours, the various periodontal germs can be determined individually.
Aggressive periodontal disease as an indicator of heart attacks?
Tooth loss is to be expected as the most frequent consequence of periodontitis. However, past research at the universities of Dresden, Kiel, Amsterdam and Bonn, among others, has demonstrated a link between aggressive periodontal disease and the occurrence of heart attacks. Apparently, a gene alteration on chromosome 9 in the gene ANRIL is causative. According to research, this gene encodes a regulatory RNA molecule.These molecules most likely have an influence on fundamental physiological processes. At the Institute of Molecular Biology at Kiel University, a clear match was found in the genetics of patients with aggressive periodontitis and patients with coronary artery disease. However, this genetic match is not the only indicator that periodontitis and myocardial infarction are linked. The main etiology for heart attacks in Germany is atheromatous plaques or thrombosis. In both cases, there is a lack of oxygen in the heart. According to studies, the pathogens of periodontitis migrate through the arterial system and cause inflammation at other sites as well. These reactions lead to swelling of the vessels, which results in reduced blood flow and can promote a heart attack. In particular, the bacterium Porphyromonas gingivalis has been detected in the platelets of heart attack patients, where it appears to have contributed to platelet clumping. In the course of bacterial infections, the liver produces C-reactive protein in the acute phase, and this is also the case in periodontal patients. As is known, this protein also increases the risk of cardiovascular disease.
Better quality of life through qualified periodontal treatment
Both to prevent tooth loss and because of its association with serious diseases, great importance is attached to the treatment of periodontitis in dentistry. The gold standard is considered to be minimally invasive closed root canal treatment, known as debridement or curettage. If this proves ineffective, minimally invasive periodontal surgery can be performed. For example, bone defects can also be filled. In order to detect bone resorption and bone defects, a 3D X-ray (DVT) is used in Dr. Hoppe’s practice. The spectrum of adjuvant therapy measures ranges from medicinal agents that bring about a reduction in inflammation to antibacterial photodynamic therapy. Antibacterial photodynamic therapy is proving helpful not only in the treatment of periodontal disease, but also in the therapy of:
- Peri-implantitis,
- Caries,
- Infections in the root canal,
- Oral fungal diseases,
- Lesions of the oral mucosa,
- Implantological procedures (e.g., immediate implants),
- Major surgical procedures (all on 4).
In aPDT, the biofilm of the affected areas is stained blue with a photosensitizer and activated with low-energy laser. The subsequent photodynamic reaction leads to the formation of singlet oxygen, which has a cytotoxic effect. This form of therapy is particularly effective because it is possible to treat areas that are difficult to reach mechanically. The patient does not need anesthesia, the cytotoxic reaction is completely painless. This method of treatment is also a suitable form of therapy for patients with anxiety. Another gentle treatment option that acts directly on the site of infection (in the gingival pocket) is the insertion of a periochip. The periochip is made of gelatin and contains chlorhexidine in a highly concentrated form; the membrane measures 4 x 5 mm. The chip dissolves completely in 7 to 10 days, but has already created a depot of active substance in the diseased tissue. The effectiveness is around 3 months. Where rinses and solutions do not reach the bacterial focus, the periochip can act locally against pathogenic germs. Side effects with chlorhexidine are virtually unknown.
