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Interview: How plaque biofilm can be managed

Dr Fotinos S. Panagakos is director of clinical research relations and strategy in the Research and Development division of Colgate-Palmolive Co.
Fred Michmershuizen, DTA

Fred Michmershuizen, DTA

Mon. 7 June 2010

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The plaque biofilm is the cause of the two most common oral diseases — caries and periodontal disease. In an interview with Dental Tribune, Dr Fotinos S. Panagakos, director of clinical research relations and strategy within the Research and Development division of Colgate-Palmolive Co., discusses how plaque biofilm affects the surrounding soft tissue, as well how it can be managed.

You have an upcoming course on the management of biofilm and gingival management. Would you please tell our readers why this topic is important?
Periodontal diseases are a set of poly-microbial diseases characterized as dental-plaque/biofilm–induced gingival inflammation that without treatment can result in the loss of periodontal support tissues, bone loss and, ultimately, tooth loss. For the past several decades, significant clinical and basic research has established the complex microbiology and pathology of periodontal diseases and, specifically, that they involve a combination of bacterial infection, host immune reaction and bone metabolism, as well as genetic and environmental risk factors.

The importance of bacterial plaque to the onset and progression of periodontal diseases is well accepted. While more than 400 species of bacteria can be detected in the oral cavity, only selective pathogenic species produce products harmful to gingival tissues. Microbial products of specific pathogens, such as lipopolysaccharide (LPS) and proteolytic enzymes, directly or indirectly trigger a host tissue response by inducing inflammatory protein (cytokine) production, increasing the levels of inflammatory mediators, which leads to inflammation and tissue destruction. Without intervention or treatment, supporting tissues will be destroyed, clinical pockets will form, bone resorption will occur, and, ultimately, the tooth will be lost (Fig. 1).

How does plaque biofilm affect the surrounding soft tissue?
The plaque biofilm, if not removed, will trigger a chronic inflammatory disease of the gingiva and periodontium. This will result in the destruction of gingival connective tissue, periodontal ligament and alveolar bone (Fig. 2). The periodontium responds to the tooth-borne biofilm by the process of inflammation. The dental biofilm is composed of numerous bacteria, which tenaciously adhere to the tooth surface. Scientists are now beginning to understand the complex molecular interactions that occur, for example, between the bacteria and salivary pellicle that coats the tooth, and between gram-positive cocci of early plaque and gram-negative filamentous bacteria that populate the tooth as plaque matures. Recent work has identified a set of complex signaling pathways (referred to as quorum sensing) between bacteria, mediated by soluble chemicals produced by the bacteria.

Clinically, inflammation is seen as redness, swelling and bleeding upon probing. However, at molecular and cellular levels, the inflammatory process is defined by cellular infiltrates and the release of a variety of cytokines. The main provoking factor that induces inflammation of gingival tissue is the presence of bacterial biofilm on the teeth/gingival interfaces. The products of biofilm bacteria are known to initiate a chain of reactions in the tissue leading to host response as well as the destructive process.

How can patients better manage plaque biofilm at home? Are there certain techniques or over-the-counter products that are especially beneficial?
Control of the biofilm/plaque begins with daily oral hygiene. Mechanical cleaning of the teeth and associated gingival tissue removes the bulk of biofilm that has developed in the time since the last oral hygiene session. Within a few hours of meticulous tooth cleaning, bacteria colonize the tooth surface primarily around the gingival margin and inter-dental spaces. The developing biofilm releases a variety of biologically active products, including lipopolysaccharides (endotoxins), chemotactic peptides, protein toxins and organic acids. These molecules diffuse into the gingival epithelium to initiate the host response that eventually results in gingivitis and, in some circumstances, inflammatory periodontal diseases. Clinically, gingivitis is characterized by a change in color—from normal pink to red—with swelling and, often, sensitivity and tenderness. Gentle probing of the gingival margin typically elicits bleeding when gingivitis is present. Because gingivitis is often not painful, it may remain untreated for many years. Lack of management at this stage may result in disease progression. This is why periodontal disease is often depicted as a spectrum of severity (Figs. 2a, 2b).

Given the complexity of periodontal diseases and the importance of oral health, one of the critical questions is how to best prevent and treat periodontal infection. Clinical procedures like scaling and root planing provide immediate and universal benefits, whereas effective routine oral care can help maintain a healthy oral environment and decrease the occurrence of oral disease. It is interesting to speculate that a therapeutic agent that combines antibacterial and anti-inflammatory efficacy may provide a unique and beneficial approach to the prevention of periodontal diseases via daily oral-care procedures, not only for high-risk individuals but also for the general population.

The current therapeutic strategy to control periodontal infections involves mechanical removal of deposits, both supra- and subgingival. This also could involve the use of topical and systemic antimicrobial agents. Can topical antimicrobials applied via an oral delivery system (toothpaste, rinse, or gels) help with the management of dental biofilm? A unique triclosan/copolymer/fluoride dentifrice technology, found in Colgate Total (Fig. 3), has been developed and clinically proven to enhance conventional oral care procedures. This technology uses a patented system consisting of a broad-spectrum antibacterial agent, triclosan and a polyvinylmethylether/ maleic acid (PVM/MA) copolymer to deliver sustained antibacterial activity in the oral cavity, thereby controlling dental plaque and preventing and treating gingival inflammation. Triclosan is a broad-spectrum antibacterial agent that has been shown to kill oral pathogens and clinically effective concentrations of triclosan are present up to 12 hours post-brushing, providing an anti-bacterial benefit between brushings.

In practice, this triclosan/copolymer/fluoride dentifrice has been proven to deliver statistically significant and clinically relevant benefits in the prevention of caries, the reduction of dental calculus buildup and oral malodor, as well as the control of dental plaque and treatment of gingivitis.1 Such a multi-benefit oral-care technology can significantly enhance routine oral care procedures and help to maintain a healthy oral environment. Control of the plaque biofilm through effective oral hygiene procedures, in combination with the use of a product such as Colgate Total, can provide most patients with an effective regimen to maintain good oral health between dental visits.

What about treatment in the dental office? Are there prescription-based therapies available?
As previously mentioned, professional removal of the dental biofilm and associated calculus is critical to maintaining optimum periodontal health. For the patient with gingivitis, regular visits, usually every six months, in combination with good home care, can achieve this goal for most if not all patients. For those patients with more advanced periodontal disease, a more aggressive in office approach must be taken by the dental professional to get the patient back to a state of health. These procedures include scaling and root planning, ultrasonic cleaning and possibly surgical procedures to correct any residual periodontal defects, such as deep pockets, which can not be maintained by the patient following treatment. Some clinicians also use locally applied antimicrobials to address periodontal pockets, which do not respond to traditional treatments, and in some cases, systemic antimicrobials are prescribed to patients as well.

Just as important as the professional treatment of advanced periodontal disease is the patient’s maintenance of the treatment results between professional visits. Excellent daily oral hygiene is even more critical for those who undergo treatment of advanced periodontal disease. The use of adjunctive products to assist in this process is often recommended and/or prescribed by the dental professional. These products could include the use of a prescription mouth rinse with chlorhexidine, the use of toothpaste and/or over the counter mouth rinses with anti-bacterial benefits, and specialized interproximal cleaning devices. In addition, patients who undergo treatment for advanced periodontal disease often have recession of the gingival tissue post-treatment, with exposure of the root surface. The exposed root surface is more susceptible to caries and dentin hypersensitivity. The dental professional may place fluoride varnish on the exposed root surfaces, and may also prescribe a 5000 ppm fluoride dentifrice for daily use to manage these problems. Colgate recently launched a new in office desensitizing polishing paste, Colgate Sensitive Pro-Relief, based on the Pro-Argin technology, which can be applied in office using a prophylaxis cup and slow speed hand piece, and has been shown to provide instant and lasting dentin hypersensitivity relief.

Is there anything you would like to add?
Management of the dental biofilm is critical to maintain periodontal health. It begins with excellent daily home care by the patient. However, we know that not every patient achieves this goal, no matter how much in office education we provide. Unfortunately, some patients will develop more advanced periodontal disease, which will require a more intensive course of professional treatment to treat and manage the disease, followed by more attentive home care. Dental professionals have a variety of professionally applied, prescribed and OTC products to choose from to help maintain the periodontal health following treatment. Research has demonstrated that the use of Colgate Total, an OTC toothpaste with anti-bacterial properties, can help patients control the build-up of dental biofilm between twice daily oral hygiene procedures, and help maintain periodontal health between visits to the dental office.

I ask the Dental Tribune readers to review the research literature published on Colgate Total and consider it as the daily toothpaste recommendation for their patients.

 

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Attend Dr Fotinos Panagakos’s CE-accredited webinar!

On 29 June, 2010 at 7 p.m. EST, Dr Fotinos Panagakos will offer a FREE one-hour webinar, Biofilm, Gingival Inflammation and its Management, followed by a live question-and-answer session with the online audience. The plaque biofilm is the cause of the two most common oral diseases — caries and periodontal disease. Understanding the biology of the biofilm and how it initiates disease is critical to managing this disease-causing entity effectively. In this course, participants will:

  • Understand the biology of the plaque biofilm.
  • Understand the inflammatory response triggered by the plaque biofilm in the surrounding soft tissue.
  • Understand the various OTC and Rx chemotherapeutic products that can be used to help manage the plaque biofilm.

Receive one ADA CERP C.E. credit. Registration is FREE and attendees require an online computer with audio capabilities. Please register under www.DTStudyClub.com > Online Courses.

About Fotinos S. Panagakos, DMD, PhD
Dr Fotinos S. Panagakos received his DMD from UMDNJ-New Jersey Dental School and his PhD in biochemistry and molecular biology from UMDNJ-Graduate School of Biomedical Sciences in June 1992. In May 1999, he received his masters in education from Seton Hall University, and in December 2007 he received his master’s in business administration from Lehigh University.

Panagakos served for 14 years as a faculty member at New Jersey Dental School. While at New Jersey Dental School, Panagakos served in a number of administrative positions, including group practice administrator, director of environmental safety and associate dean of academic affairs. Panagakos was active in both the undergraduate and graduate dental teaching programs at NJDS and had an active research program, examining the role of inflammatory proteins on connective tissue biology and function.

In June 2005, Panagakos joined the Colgate Palmolive Oral Care Clinical Research Department as an associate director. His responsibilities included clinical research and development support for the North American Oral Care division and Colgate Oral Pharmaceuticals. In January 2006, Panagakos was promoted to director of professional relations and scientific affairs — North America. In that role, Panagakos served as the primary liaison between Colgate and professional and academic communities in the United States, coordinated all professional education programs and served as the scientific affairs liaison to the professional community. Since April 2009, Panagakos is the director of clinical research relations and strategy within the Research and Development division of Colgate-Palmolive Co. His responsibilities include oversight of clinical studies, scientific communication strategy, and liaison with dental professional organizations.

1. J Clin Dent 16 (Supplement):S1–S20, 2005

*Colgate Total and Pro-Argin are trademarks of Colgate-Palmolive Co.

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