Translating Science to Practice

As often occurs, research provides many answers and drives more questions. Despite the knowledge obtained through science, it is incumbent upon clinical practitioners to translate the evidence into practical use. What does the above information mean for clinical practice? Does it offer opportunities for changing dental hygiene interventions? How can we use this information to answer patients’ questions when they inquire about CRP levels, or ask if their periodontal condition will give them heart disease? Are we better prepared to address their question when they say they read two conflicting articles about oral and systemic health in the same issue of Reader’s Digest, Prevention magazine, or Every Woman and wonder which one is accurate?

Understanding the association between oral health and systemic health does provide opportunities for oral hygiene clinicians to reframe their protocols. The process begins by practicing oral medicine. First, comprehensive medical assessment is needed for each patient. A review of systems and vital signs evaluation should be part of that assessment process. During these assessments, identifying risk factors for specific systemic diseases is important, including age (over 40 years), hypertension, dyslipidemia, smoking, obesity/overweight, CVD, diabetes or symptoms of diabetes and women who are pregnant and have poor oral hygiene.

Comprehensive oral assessment is equally important. This may include thorough head and neck examination, radiographs (if clinically indicated), periodontal probing, bacterial monitoring of periodontal and carious pathogens, genetic testing for periodontal disease or other diagnostic tools that seem appropriate to each individual need.

As these assessments are being performed, risk factors for oral and systemic diseases are being noted and explained to the patient. It is essential that the patient understand that the purpose of these assessments is to prevent problems from occurring or treat them as readily as possible. Patients are well acquainted with the idea that physicians prefer to treat a stroke or a heart attack before it occurs by identifying possible risk factors and trying to reduce them. They are used to attending a medical appointment and having certain assessments performed. They are even used to requesting certain tests or procedures based on their own education and experience. Thus, it is time that we incorporate these approaches into dental and dental hygiene practice. Our patients need to become accustomed to the same comprehensive assessment process. Clinicians can then put together a picture for the patient that incorporates oral and systemic risk factor findings, and discuss how their chronic gingivitis or periodontitis condition may place them at risk for CVD, poor glycemic control or an adverse pregnancy outcome.

Once risks have been identified, those that can be modified are incorporated into the dental hygiene treatment plan and patient education process. Just as a physician will recommend a patient lose weight or prescribe an antihypertensive agent, the dental hygiene therapist may make recommendations for the patient to begin a smoking cessation program, use specific preventive oral care products, monitor their blood sugar regularly or complete a nutrition counseling program, in addition to having debridement of plaque biofilm and calculus. Certainly, patients will view the dental hygiene appointment as more than a “cleaning” if greater emphasis is placed on the patient’s total health, risk factor assessment and risk factor modification.

In addition, once risk factors have been identified and appropriate treatment planned, it is important to be prepared to answer questions about medications and products that have anti-inflammatory and/or antibacterial properties. For example, in the past decade, several engineered therapeutic proteins and antibodies have been generated and are either currently in use or in the late stages of clinical trials. Patients may be familiar with:

• Etanercept (Embrel®), which binds TNF-α and prevents it from engaging its inflammatory functions
• Recombinant Protein C, which helps the body dissolve small clots triggered during inflammation
• Infliximab (Remicade), a monoclonal antibody that binds to TNF-α, and has been used to treat autoimmune inflammatory diseases such as rheumatoid arthritis and Crohn’s disease

While these drugs are being used to treat systemic diseases, it is possible that they could be used to treat inflammation related to gingivitis and periodontal disease. Other engineered proteins under development may also be used to treat these oral infections.43

Another anti-inflammatory medication that has been shown to be effective for the treatment of periodontitis is low-dose doxycycline hyclate (Periostat). Periostat inhibits the collagenase activity by neutrophils, thus preventing the degradation of connective tissue and bone loss. Therefore, it is beneficial as part of host modulation therapy. It is administered twice daily at a dosage of 20 mg. Periostat is an antibiotic; however, the dose is too low to produce antibacterial effects. Studies have demonstrated that Periostat improves the effectiveness of routine scaling and root planing and that the progression of periodontitis is decreased.43

Optimal preventive education programs should include discussion of twice-daily brushing, flossing and use of a chemotherapeutic mouth rinse to reduce bacterial plaque and susceptibility to gingivitis.44 Products recommended should be those that have been well-researched and demonstrated safety and efficacy. For example, Peridex® and Listerine® Antiseptic Mouthrinse are the only two chemotherapeutic mouth rinses that have been approved by the American Dental Association Council on Scientific Affairs. Their effectiveness has been well established. Similarly, a dentifrice containing triclosan/copolymer (Colgate Total® Toothpaste) has been shown to be effective in reducing plaque and gingivitis, controlling bacterial infection and preventing or slowing the progression of periodontal disease.45 In addition, triclosan has been shown to possess potent anti-inflammatory properties. In vitro studies have demonstrated that triclosan has inhibited IL-1 stimulated prostaglandin production in human gingival fibroblast cells, inhibited the production of IL-1 by fibroblasts stimulated with TNF-α and has inhibited the production of collagenases by human bone cells and fibroblasts stimulated with IL-1 and TNF-α.46,47 The antibacterial and anti-inflammatory properties of triclosan are reasons to recommend Colgate Total® toothpaste both for patients with periodontal diseases as well as for those whose systemic health has been compromised.