Diagnostic And Therapeutic
Strategies For The Management
Of The Diabetic Patient

The pathway to periodontal disease

Understanding the pathway to periodontitis is essential because it enables clinicians, researchers, and patients to consider the possible mechanisms by which oral–systemic connections occur (Figure 1).1 It is a microbial challenge to the host or person with poor oral hygiene that initiates the cascade of events that can result in periodontal breakdown. The presence of bacterial endotoxins, antigens, and other virulence factors stimulate the host immuno-inflammatory response. Neutrophils are recruited to the site of the infection to address the pathogenic microbes, which then invoke an antibody response. In more resistant individuals, these events lead to the development of localized reversible inflammation, known as gingivitis. In more susceptible individuals, very high levels of pro-inflammatory mediators–known as cytokines, prostanoids, and matrix metalloproteinases–will be produced by the host, leading to connective tissue breakdown and bone metabolism changes associated with the bone loss that is pathognomonic to periodontitis. In the clinical setting, this cascade of events presents as the signs of disease: increases in probing depth, loss of clinical attachment, and radiographic evidence of bone loss. So the question becomes, "Who are these susceptible individuals?"

Genetics plays a significant role in who may be susceptible. Studies have shown that at least 50% of all cases of periodontal disease have some genetic component.2 In addition, there are a number of environmental and acquired risk factors that put patients at greater risk (Table 1). Risk assessment is important because it has been recognized that the more risk factors a patient has, the more likely he or she is to develop the disease. There is often more than an additive effect, there is a synergistic effect between these risk factors.

Identification and consideration of these risk factors is critical to successful periodontal treatment because they can affect the onset, the rate of progression, and the severity of periodontal disease. In addition, these risk factors may determine treatment strategies and explain variability in the therapeutic responses of patients. Risk factor assessments can alter the way patients are viewed by the practitioner, leading to a decision process based on risk. The primary goal of the practitioner would be risk reduction. A simple example of this would be improvements in oral hygiene since it has long been known that poor oral hygiene increases the risk of disease. A clinician may proceed with caution if a patient presents with multiple risk factors. In addition, patients begin to be viewed in terms of risk when considering how treatment should proceed. Depending on the type of risk (eg, the presence of a systemic condition such as diabetes), the clinician will interact more with our medical colleagues in an attempt to reduce the risk.

Ultimately, as part of a risk assessment,risk reduction for periodontal disease needs to be considered. Risk reduction strategies are listed in Table 2. Obviously, the more risk factors a patient has, the more frequent his or her dental visits should be, including more intensive periodontal therapy and follow-up maintenance. Certain risk factors can be modified while others cannot (eg, heredity). Once this is determined, the appropriate therapeutic regimens can be utilized, including the use of adjunctive medications that may be administered to the patients that have been referred to as "perioceutics" in the past.3 Locally applied or systemically delivered antimicrobials may be one choice; host modulatory agents are another,which may be ideal for patients who cannot reduce their risk (such as patients who have a genetic predisposition). For smokers, smoking cessation is the obvious first step, but what if the patient will not stop smoking? Cutting back on tobacco use may help, but other strategies would need to be considered in those patients who cannot or will not stop smoking. In diabetic patients, the patient's physician should be consulted to help the patient achieve better metabolic control of his or her diabetes to facilitate an optimal response to periodontal therapy. Patients who are unable to control their diabetes will be much more difficult for the oral health care provider to manage and may require the use of adjuncts to traditional mechanical therapy, such as antimicrobials and host modulatory therapy as part of their treatment regimen.

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