Stepping up in 2023: Periodontics is breaking new ground
This article was first published in the ADA's News Bulletin, February 2023
The statistics regarding periodontology, if nothing else, are always guaranteed to give pause. Roughly a fifth of the world’s adult population, according to the FDI World Dental Federation, is affected by severe periodontal disease – this represents more than 1 billion cases globally. The links between oral disease and whole-body health are now strengthened by new study reports seemingly every time we open a journal or industry publication, and the FDI’s Vision 2030 advocacy program, launched in early 2021, has particularly focused on better integrated, whole-person healthcare to prevent and manage oral diseases as they affect well-being on not only a personal but community and even global scale.
Yet, despite these widely known and accepted numbers, and the now quite universally acknowledged link between poor periodontal health and serious systemic health challenges – diabetes, chronic kidney disease, Alzheimer’s disease, cardiovascular disease, respiratory ailments and more – the funding for improvements in this field has lagged significantly behind. So can increased advocacy help address this lag?
Starting from the bottom
“It’s a very timely question,” begins Professor Sašo Ivanovski, Head of School and Professor of Periodontology at the University of Queensland School of Dentistry, and a key leader of ongoing joint ADA-FDI periodontics resources projects. “Over the last few years, oral health has indeed suffered in terms of the allocation of research funding by competitive research funding bodies in Australia. In fact, we’ve just recently published a paper with a few other dental schools – University of Queensland together with University of Melbourne, and the University of Sydney – looking at the amount of funding that’s allocated to dental research in relation to the global burden of oral disease.
“This global burden of oral diseases is very large, and the burden within Australia is correspondingly large. It’s one of, if not the major, burden in terms of non-communicable diseases. Now if we look at the table of all the different diseases in the healthcare world receiving funding to improve outcomes, it’s absolutely dead bottom. Perhaps 0.1% of funding in Australia goes to oral health, while the disease burden is easily within the top 10 in the country, so it’s a huge disparity.
We’ve highlighted that in this recent paper, and we hope this can galvanise the profession as a whole to lobby the relevant authorities, which will then result in more funding for oral health.”
Even through the pandemic and its necessary distractions in the healthcare sphere, developments in both the classification of disease, and advocacy for global health coverage, has positively affected the public face of periodontology.
Most recently, toward the end of last year, the World Health Organization’s publication of its Global oral health status report: towards universal health coverage for oral health by 2030 in November was a significant step forward. It is now quantifiably clear that there is a large prevalence of oral health issues, with the range going beyond simply caries. “Periodontics is not particularly sexy,” says Prof. Ivanovski, “so it’s always a little bit of a struggle to increase the visibility of periodontics. Hopefully this will assist.”
The study has called public attention to the all-important fact that, sometimes, disease affects not just the teeth themselves, but also the surrounding tissues. Furthermore, this widespread prevalence calls into prominence the idea that prevention alone is not enough; confident diagnosis and appropriate management must be embraced by every practitioner.
An inflamed issue
“While dental caries and decay is very prevalent, it tends to be more localised to the tooth, though of course it can affect the pulp and pulpal tissues,” says Prof. Ivanovski. “However because periodontal disease is in the gums, in the bone and in the surrounding tissues, it can also influence the general health of patients as well. That’s why it does get a lot of attention in this context, and so it should.
“The public and certainly the profession is aware of all the links between oral health and systemic disease, but we need a more nuanced approach as far as the implications for practice, starting from the very commencement of the relationship with the patient.
“We may understand the patient’s general attitude towards oral health and towards oral hygiene, but sometimes where we fall down is in screening for the disease. I think it’s very important to understand the mechanism of the interaction between oral diseases and systemic health.
“It really comes down to this very important concept of inflammation. Most of the systemic conditions that are associated with periodontal diseases are chronic inflammatory diseases. Cardiovascular diseases, atherosclerosis, diabetes, obesity – they all add to the overall inflammatory burden in the patient. In an inflammatory disease, a lot of inflammation is considered to be very unhealthy long term, because of the burden on the ability of your body to function properly. Periodontal disease also acts exactly like a chronic inflammatory disease.
“Dentists obviously play a key role in recognising and identifying this, and screening for periodontal disease is probably not done as well as it possibly can be. It’s not a painful disease. Patients are not aware of it and they don’t seek treatment for it; sometimes, dentists don’t necessarily see immediate value in looking for it and managing it.”
Prof. Ivanovski emphasises that, above all, we as dental professionals need to communicate to patients the importance of managing that inflammation. “That’s where screening is so vital,” he says. “It’s not this thing called gum disease per se that we treat; patients need to know that what we’re really treating is the inflammation in those tissues, which can impact your oral health and the longevity of the teeth, which is a very important thing to focus on.
“A lot of people go to the dentist because they don’t want to lose their teeth, and this systemic disease interaction awareness can sometimes help getting the message to the patient. The dentist must still remember that we are there to offer help, make sure that we are keeping teeth healthy, but we are also maintaining overall health within the mouth.
“That means real management of inflammation. If it’s on your skin or somewhere else, of course, you go to the doctor and they manage this redness and ulcerations. When it’s in your mouth, it’s also red – it’s inflamed tissue, but it’s less visible. So understanding that is actually the real problem, not this mythical thing called ‘gum disease’ that people might disconnect a little bit with.”
Into the future: precision periodontics
In 2019, changes in the reclassification guidelines for periodontitis and peri-implant disease were presented to that year’s ADA FDI World Dental Congress by Prof. Søren Jepsen, Chair of the department of periodontology, operative and preventive dentistry of the University of Bonn in Germany. He commented at the time that these new classifications, resulting from a collaborative international review by about 100 experts in this field, would facilitate precision medicine in dentistry. In the years since, says Prof. Ivanovski, this prediction on the trend of precision medicine as it pertains to periodontics has come true.
“Precision periodontics is quite exciting, and it is going to be important; it will probably change practice a fair bit over the next 10-15 years,” he says. “Having a better understanding of the interaction between the bacteria in the mouth, living in dental plaque, and the patient’s susceptibility to gum disease, is a lot like other chronic inflammatory diseases.
“We know that some people can develop diabetes or cardiovascular disease easier than others, for example. Some people can get away with all sorts of poor diets and activity levels and still be OK, while others are very susceptible. It’s exactly the same with gum disease. Some people can have a lot of plaque in their mouth and have fairly mild disease, or experience only low implications of disease in terms of losing bone, while others can be quite good with their oral hygiene but nevertheless end up with a lot of disease. We never really fully understood that, but now there’s a lot of research being done so we can identify bio markers and patterns of disease, and that results in much more individualised treatment plans for patients.
“Up till recently, we’ve been a little guilty of having a ‘one size fits all’ approach; everyone comes and gets their cleans every six months, which is convenient in some ways. But is it really the best use of resources or in the best interest of the patients?
Now we know some people might need management every two or three months, while for others, it might be once a year. The nature of the disease means that for some patients it might need to be much more, let’s say, proactive. So, we can identify risk markers, which then gives us an indication of who is susceptible to disease – either through the type of plaque they have, or if it is due to genetic make-up, or the environment in their mouth – and then we can be much more intensive in terms of preventing the infection. This personalised approach, precision periodontics, fits in with a trend that is now quite big in medicine. Precision medicine hadn’t really filtered through to dentistry so much, but since periodontics has to do with a medical, biological approach to management, it is well aligned with that precision medicine concept.”
Developments in precision medicine are directly linked to technological breakthroughs being effected in research labs. Although these are sometimes felt to be somewhat ephemeral, Prof. Ivanovski says that it won’t be long before they affect and improve everyday dentistry in a very real and practical way.
“Things like chairside tests, even off-the-shelf tests, are going to be important. In the near future, I think that the patient will probably play some role in monitoring, which is a big part of precision medicine and dentistry – active participation of the patients in their management. The idea is to develop tests or other devices that give feedback to patients about the nature of their oral status at any time, and aligning that also with chairside tests done by dentists, create a scenario where they can quickly get some indication of how susceptible they are at any particular point of time. It’s the job of research to provide tools to both the patient and the practitioner to be able to manage the disease in a more precise way.”
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The value of teeth: future trends and emerging strategies
The ADA and the FDI have enjoyed a fruitful collaboration in regards to periodontics, with the ADA only one of two international associations (along with the French Dental Association) invited to help the FDI put together a raft of new periodontal resources as part of its FDI Global Periodontal Health Project (GPHP).
Additionally, in September this year, as part of the upcoming FDI World Dental Congress 2023, Prof. Ivanovski will be convening a symposium on ‘Dental implants – risk management, maintenance and managing complications’, with seven expert speakers taking on some essential questions surrounding this subject that crosses over so often with periodontal issues.
“One key aspect that’s a big focus now for periodontics generally, is the value of teeth,” says Prof. Ivanovski. “Periodontics is in a unique situation. We periodontists do a lot of dental implants, and we have realised now that we may have overestimated what can be achieved with dental implants, and maybe haven’t fully appreciated the value of teeth that we’re replacing. It’s becoming very clear that the most important thing we can do as dentists is retain teeth, and replacements like dental implants are an absolute last resort.
“The reason for that is, their prognosis and performance is often not as good as teeth. In some cases it’s the only option, of course, so we provide the best treatment we possibly can. But nothing can replace the quality or function offered by teeth. That natural situation, with a ligament around the tooth and the full sensory perception of teeth in the mouth, is something implants can’t do.
“We also sometimes underestimate the longevity of teeth. Sometimes we may say, ‘Oh, this tooth will only last another five to 10 years, so maybe we take it out and put in an implant.’ Then, in five to 10 years, that implant is starting to develop problems. Five or 10 years for an implant seems to be a good outcome, but actually, the teeth often would have lasted for the same amount of time. Maybe we should give a tooth the opportunity to fulfil its full life. A tooth has been in there for 40, 50, 60 years already. Implants are not likely to last that long – perhaps 10 or 15 years. I think we underestimate the value of our teeth, so it’s a good time to revisit the subject of implant dentistry with that in mind.
“I think it’s fantastic that we have the opportunity to host the FDI Congress, in Australia,” he adds. “It’s going to be fantastic to have these world leaders here to tell us about the state of the art in all of the different disciplines, including periodontics. To have been chosen by the FDI as one of the associations rolling out these and other educational programmes in periodontics is very important and a real privilege. It gives us the opportunity to really have a world-class engagement in assisting practitioners to understand new and changing paradigms.”