Future Treatment Implications

Researchers have sought to develop diagnostic tests such as chairside microbial samplings as well as salivary testing, for detection and treatments designed to target periodontal pathogens. Treatments targeting biofilms include systemic and topical agents, including host modulators. Systemic antibiotics such as metronidazole, clindamycin, doxycycline, ciprofloxacin, azithromycin alone or in combination have been used.³² Local delivery of antimicrobials (tetracycline fibers, metronidazole and minocycline gels, chlorhexidine chips, and doxycycline polymer) have also been introduced.³⁶ Host modulation focuses on changing how the body responds to the bacterial challenge rather than solely reducing the bacterial challenge of the plaque biofilm. While these approaches have enhanced our ability to manage periodontal diseases to some extent, they have still failed to provide uniform success.

Viewing plaque as a polymicrobial biofilm that includes both commensal or beneficial species that are essential to health, along with other species that have the potential to become pathological (pathobionts), may be an explanation as to why these older approaches have not been as successful as hoped. If all microbes, including the commensal ones, are totally wiped out by antibiotics for example, that could seriously have an impact on the innate immune system that may no longer be able to control disease progression as well as having a negative effect on other necessary physiological functions.

With the new knowledge about the critical role of these commensal microorganisms, found in biofilm, it is becoming clear that maintenance of symbiosis must be the goal of plaque control, rather than total destruction of all species. This presents a major paradigm shift to older beliefs where all plaque was thought to be bad, and treatment approaches were targeted to eliminate all plaque microorganisms. We can no longer condone treatments that propose to eliminate or kill 99% of all microbes.^3,14