Low-cost periodontal therapy

Periodontitis is a common and often lifelong infectious disease that is defined by loss of periodontal ligament and alveolar bone (81). The disease proceeds with periods of exacerbation and remission. Some types of periodontitis arrest spontaneously within a relatively short period of time, while other disease types undergo a prolonged course of tissue destruction that may lead to excess tooth mobility and edentulism (22). Periodontitis can also affect and be affected by the systemic health (33, 298). Periodontitis occurs with increased frequency in immunocompromised and low-income individuals (8, 40, 66, 79, 327), and the disease may be associated with specific genetic variants (167, 172, 204, 327, 386) and is particularly severe in patients with various Mendelian (monogenic) diseases that primarily affect nonoral tissues (122, 125). Periodontitis is associated with and probably caused by a combination of virulent bacteria, mammalian viruses and proinflammatory host responses (303). The most prominent putative periodontal pathogens are gram-negative anaerobic rods and herpesviruses (303). Virtually all cases of aggressive periodontitis involve an active herpesvirus infection, which has the potential to impair periodontal host defenses and induce an overgrowth of pathogenic bacteria (304). Slowly progressing or stable types of periodontitis may occur in subjects who demonstrate plaque accumulation of low-grade pathogenic bacteria, or who possess protective immunity against the major periodontal pathogens. The key to combating periodontitis is easy-to-follow preventive guidelines and early disease intervention with effective and safe antimicrobial therapy that is implemented cooperatively by the dental professional and the patient (29). Lack of patient compliance with disease-preventive measures can undermine an otherwise successful treatment by the dental professional (165). Basic periodontal treatment includes removal of dental biofilms and biofilm-retentive calculus by mechanical means and by antimicrobial medication. However, the ability of mechanical treatment alone (scaling and root planing, periodontal surgery) to resolve destructive periodontal disease was probably overestimated in the past. The chemotherapeutic option became increasingly important after the recognition of the microbial specificity of periodontitis, and the use of topical and systemic antimicrobial agents is now the rule rather than the exception in the treatment of severe periodontitis. Proper management of periodontal disease must also consider follow-up treatment after initial therapeutic success, and contemplate alternative modes of intervention in the event of therapeutic failure. This article reviews current periodontal therapeutic intervention, with emphases on the treatment needs of low-income individuals, putative periodontal pathogens and their antibiotic-susceptibility profiles, professional mechanical and chemotherapeutic options, and affordable patient self-care. The article concludes with proposing a multifaceted approach to periodontal treatment that possesses high efficacy and tolerability and can be implemented in virtually all parts of the world using low-cost local resources.