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Decades ago, I recall reading about the epidemiological surveys conducted by the World Health Organization on periodontal disease in Asia, Africa and other parts of the world. It became clear that gingivitis could develop into periodontitis from about the age of 15.1 That information stuck with me and continues to be confirmed. Not all patients with gingivitis develop periodontitis, but we know that managing gingivitis is a primary prevention strategy for periodontitis and a secondary prevention strategy for recurrent periodontitis.2
We have at our disposal an array of mechanical and adjunctive agents for successful periodontal disease management, but I sometimes think we’re doing only a fair job of recommending them, especially in children and adolescents who present with generalized bleeding on probing and heavy plaque/biofilm. Why do we get a poor grade in private practice when it comes to the prevention of gingivitis in patients before they reach the age of 15? For me, I’ve noticed that I stopped disclosing and scoring plaque and inflammation and oftentimes parents aren’t included in the prevention efforts. I keep the two-tone disclosing solution on the counter, but I don’t pick it up as often as I should. I need to do better and score the teen’s plaque and gingival health with the appropriate index. Time with my patients is always an issue and sometimes 50-minute recare intervals for teens become 30 minutes and I make my displeasure known to the front desk. Parents are usually too busy to accompany teens to the appointment, but when they do, it makes me happy and I invite them into my operatory.
Teens are a group of patients I find most challenging. Recently, one in particular sat waiting for me in the reception room and I cringe to see her name on the schedule. Arriving with purple/green unwashed hair with nasal and mouth piercings, I cringe when asking her to “open wide,” fearing her teeth will be the same color and consistency as her hair.
This patient always presents with moderate chronic gingivitis and generalized early demineralization. To avoid “yes” and “no” answers, I asked her how she was using the prescription fluoride toothpaste and powered toothbrush we negotiated on during the last recare visit, and all she said was that she was using the same toothpaste her mother uses. I’m well aware that she drinks Coke on a regular basis and we’ve tried to implement CAMBRA, but she isn’t interested. This teen patient loves to shut me down during the beginning of her visit, but I’ve found another way to reach her. After dismissing her this time, I talked to the receptionist up front and she revealed that the patient has finally opened up to her, so she’s going to follow up from now on and I’ll just keep my mouth zipped. Sometimes a comprising approach is the only way so that the receptionist and I can work up a suitable plan. Tough love in dentistry is just as hard as it is in our personal lives.
RDHs already understand the importance of daily biofilm disruption, and we know that consistent recare debridement and polish are important to preventing bacteria from anchoring themselves more permanently. We know that within 24 hours of discontinuing oral hygiene self-care (i.e., toothbrushing), biofilm begins to form and within 10 to 21 days, gingivitis develops.3
Once the bacteria undergo a phenotypical change, they coalesce and secrete the extracellular polymeric substance called plaque/biofilm. Plaque/biofilm forms a barrier around the bacterial community, making it very hard for the body’s protective cells (white blood cells and even antibiotics and oxygen) to penetrate. Biofilm is a tough competitor against our body’s immune system, and it makes the biofilm community up to 1,000 times more resistant to antiseptics and antibiotics.4
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Using metaphors when trying to grab a teen’s attention is one way to make a point when it comes to the prevention of chronic gingivitis. Using Spider-Man’s web-shooters to explain the biofilm phenomenon is my latest attempt to persuade teenagers to tackle biofilms that are growing happily in their mouths. Spider-Man’s web-shooters come from his wrists and they shoot thin strands of special “web fluid” at high pressure. It’s a nylon-like substance that forms an extremely tough, flexible fiber with tremendous adhesive properties with exposure to air5.
Most teens aren’t paying attention to self-care. Just take a whiff when they sit down in your operatory chair and you’ll already know that oral biofilm will be rampant. There’s no way these patients will clean proximal areas unless they have a pro wrestler dad who will hover over the sink in the bathroom. Teens may benefit most from adjunctive agents for the prevention of periodontitis.
What do data support for these teenagers as adjuncts to prevent the onset of periodontitis? Rechargeable power toothbrushes offer a small, statistically significant benefit in gingival inflammation and plaque levels2. Interdental brushes (IDBs) would be nice, but I know from experience that they sit in the bathroom drawer untouched. IDBs are the interproximal device of choice for interproximal biofilm removal2. Brushing for two minutes with a fluoridated dentifrice is strongly recommended, but expert opinion suggests that two minutes is likely to be insufficient, especially because interdental cleaning devices are also needed2.
I am now recommending parodontax™ to teens with gingivitis, and our dental office also dispenses Enamelon®. Both products contain stannous fluoride to help prevent caries and gingivitis and I haven’t noticed any extrinsic staining. When compared to conventional sodium fluoride toothpastes, the use of stannous dentifrices results in gingivitis and plaque reduction6.
Recommend a mouthwash that possesses antibacterial and anti-inflammatory properties like Listerine® and give the teen a small sample. I find that if I tell them which color or brand mouthwash to purchase, they’re more likely to try it. I always make these recommendations known to parents, too, if possible.
Not all teens with poor oral hygiene will develop periodontitis, and researchers concur that lifestyle factors, including smoking, Type 2 diabetes, nutrition and psychological stress, along with genetic predisposition, are important risk factors2.
1. S P Ramfjord, R D Emslie, J C Greene, A J Held, and J Waerhaug. Epidemiological studies of periodontal diseases. Am J Public Health Nations Health. 1968 Sep; 58(9): 1713–1722.
2. Chapple ILC, Van der Weijden F, Doerfer C, Herrera D, Shapira L, Polak D, Madianos P, Louropoulou A, Machtei E, Donos N, Greenwell H, Van Winkelhoff AJ, Eren Kuru B, Arweiler N, Teughels W, Aimetti M, Molina A, Montero E, Graziani F. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol 2015; 42 (Suppl. 16): S71–S76
3. Mancl KA1, Kirsner RS, Ajdic D. Wound biofilms: lessons learned from oral biofilms. Wound Repair Regen. 2013 May-Jun;21(3):352-62. doi: 10.1111/wrr.12034. Epub 2013 Apr
6. Paraskevas S1, van der Weijden GA. A review of the effects of stannous fluoride on gingivitis. J Clin Periodontol. 2006 Jan;33(1):1-13.