Changing Your Biology to Eliminate Caries and Periodontitis? Bioethical Considerations on the Topic of Discussion

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Oral illnesses such as dental caries (DC) and periodontitis (gum disease) are very common all over the globe. Biologically, it is normal for DC, periodontitis, and tooth loss (TL) to occur extensively in our species making it a statistical norm for the human species to live with these oral ‘diseases’ for the foreseeable future. TL is a syndrome that, once established, is strongly linked with systemic illnesses and may eventually develop to TL, which has a negative effect on both social and psychological health. Conditions such as DC and periodontitis are difficult to treat, and no treatment has yet been discovered for either of these conditions. Instead, contemporary therapies available in everyday practice for the management of DC, periodontitis, and its sequelae TL are either largely restorative in nature or focused at slowing the development of the illness. Dental professionals may also often suggest behavioral measures (such as flossing and brushing) that are intended to prevent the development of DC and periodontitis in the first place. However, as we will show further below, all of the currently available treatments have just a limited impact.

Technological advancements in dentistry are opening the door to the possibility of developing new methods for treating these diseases. DC and periodontitis will very certainly be the focus of new capacity-altering, biologically based treatments that seek to address direct biological risk factors in a broader context than just specific oral disease sites. In the meanwhile, the possibility of these new treatments raises ethical concerns regarding the appropriate scope of dentistry’s practice.

As a result of concerns of wellbeing and compliance with established dental procedures, we will propose in this article that dentistry should pursue the prevention and treatment of DC and periodontitis utilizing new, biological, capacity-altering therapies in order to prevent and cure the conditions. Dentures and oral structures damaged by DC and periodontitis become a lifelong burden, needing ongoing repair and extra care throughout one’s lifetime. Such treatments are not intended to cure, but rather to restore oral health functioning and cleanliness, thus assisting in the extension of the life of the dental organ(s). As a result, efforts to prevent/generate immunity against common oral diseases continue to be of critical significance for maintaining oral health.

However, while it has been shown that behavior modification is successful in substantially reducing the number of impacted teeth over time12 and 13, there are three important variables that influence the efficacy of that approach: First and foremost, regardless of socioeconomic status, the personal perceptions of a patient or the patient’s family on the importance of a behavioural change ultimately influence treatment adherence; second, manual dexterity; and third, genetic and epigenetic factors are all important factors to consider. Also noteworthy is the fact that some patients can develop DC and periodontitis even when following an optimal (behavioral) oral hygiene regime; for example, patients who have amelogenesis/dentinogenesis imperfecta, hereditary gingival fibromatosis, or who have periodontitis as a symptom of another disease may be at risk.

As a result, new treatments are required to prevent and/or cure DC and periodontitis at a more basic level, by addressing the biological mechanisms that underlie these illnesses and their progression. CRISPR-Cas9 gene-editing technologies, for example, have some promise in this area as well. There is presently no good genetic marker for DC or periodontitis, although a large number of candidate genes have been suggested as potential candidates. Furthermore, DC and periodontitis occur as a consequence of gene-environment interaction, indicating that gene editing, in addition to behavioural improvement methods, may provide a viable therapeutic route in dentistry. The use of CRISPR-Cas9 technology for dental problems has not received much attention, in part because the technology is still in its infancy outside of dentistry, and its safety and effectiveness have not been proven for more severe life-threatening illnesses such as cancer or diabetes. However, should the technique’s safety be shown in the future, such an approach may provide a possible route for changing host regulatory genes, which are critical in the battle against the infectious component of DC and periodontitis and are essential in the treatment of both diseases.

More to the point, somatic gene-editing treatments have the potential to have significant preventive benefits as well. First, somatic treatments might be used to alter the makeup of the native oral microbiome or the pathogenicity of the bacteria that cause DC and periodontitis. Second, somatic interventions could be used to alter the composition of the native oral microbiome29. If effective, such a strategy has the potential to reduce the amount of damage done to the oral organ and supporting tissues, thus avoiding the development of early disease stages. Alternatively, gene editing may be utilized to modify the tissues of oral organs and the supporting equipment that surrounds them. Such tissues are continuously exposed to pathogens as well as commensal bacteria, which may cause infection. Because of this, gene editing may be used to improve the capacity of local cell populations to react to environmental variables in their surroundings.

As previously mentioned, dentists are already attempting to prevent DC and periodontitis by encouraging patients to adopt healthier habits. The use of oral hygiene practices has been proven to be effective in the reduction of TL,12,13 despite the fact that such procedures were originally regarded with skepticism during the mid-twentieth century. One might well argue that there is a distinction between advocating for behavioral changes and implementing physiologically based treatments in a clinical setting. Using the example of bodily integrity, one might argue that the latter infringes on a right that the former does not. It is, however, somewhat moot whether or not there is a morally significant disanalogy between advocating for behavioral changes and performing biologically-based interventions because dentistry has already fought to universally implement and perform a biological intervention that is still widely used today – universal systemic water fluoridation – which is something that is somewhat moot. This intervention has been proven to be successful in lowering the prevalence of dental decay in children under the age of five. Furthermore, topical fluoride treatment to teeth in the dental office as well as fissure sealants are also utilized to prevent DC in the dental office. We believe that it is (and always has been) within the professional and ethical domain of dentistry to pursue novel biological preventative and curative strategies against DC, periodontitis, and TL, regardless of whether this is accomplished through behavioral modification or the use of biological interventions.

The ineffectiveness of current preventative methods for oral illnesses, rather than the strategy of prevention itself, is the actual issue with these interventions at this time. Even in high-income nations, DC is the most prevalent noncommunicable illness, accounting for 5-10 percent of total healthcare expenditures in industrialized countries. It is also one of the most common causes for hospitalization of children in several of these high-income countries. We believe that the treatment and prevention of DC and periodontitis via the use of new biological capacity-altering treatments is compatible with the historical and present pursuit of preventive strategies previously embraced in dentistry. As a result, the prospective use of new biological capacity-altering treatments in the future should be considered within the moral realm of dentistry.

Categories: Dental