Every clinician has experience with patients who do not respond to periodontal therapy. Most commonly, there are sites that respond to therapy, and some holdouts that do not improve. Why is it that some sites do not heal while the adjacent site does? It’s difficult to know for sure; however, one possibility may be the bacterial and host processes occurring when periodontal disease is present, as explained by the polymicrobial synergy and dysbiosis (PSD) model.
The combination of the impaired gingival immune response and the hijacking of the genetic expression of the entire microbial community by Porphyromonas gingivalis (P. gingivalis) may provide some clues. Some combination of these factors may be operating in nonresponding sites. The reality that the entire microbial community is releasing virulence factors can be addressed by all of the biofilm-control items we recommend, such as the specific interdental devices each patient needs, a tongue cleaner, antimicrobial mouth rinse, and—most importantly—a power toothbrush. Perhaps we should be recommending several weeks of meticulous home care with the devices noted here prior to undertaking periodontal therapy. Periodontal disease cannot be brushed away, but treatment outcomes should improve when the bacterial challenge is reduced.
How do we address the impaired immune system that P. gingivalis is responsible for as a keystone pathogen? Benefit may be obtained by anything that supports immune system health, including the diet. Recommending a diet high in fruits, vegetables, and whole grains and low in saturated fat is sound advice for our patients. There are limitless volumes of information on nutrition. There may be benefit to the gingival immune system from the use of antioxidant gels that are applied directly to the gingiva, oral mucosa, and other soft tissues of the mouth.
The more we resist the inertia of doing things as we have always done and accepting less-than-ideal results without questioning why, the better off our patients will be. The primary focus of this blog is to spread the wealth of information already out there and that which is in the works. Tune in frequently to stay ahead of the bleeding edge!
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