BDS6003 Strategies to

lessen the risk of

periodontal disease

Date : 15/10/2017
Strategies to reduce the risk of periodontal
disease
Aims:
The educational aims of this lecture are:
To provide a very brief revision of the local and systemic risk factors of periodontal disease (as
already outlined earlier in ADS 2)
To provide a very brief overview of the local methods to lessen the risk of periodontal disease
(these will be considered in detail in lectures within the periodontology section of module 2. 5)
To provide a review of current local, national and/or international guidelines to reduce the risk of
periodontal disease

Objectives:
On completion of this lecture, the student should have:
An understanding of the principle local and systemic methods of reducing the risk of periodontal
disease
An understanding of local, national and/or international programmes/guidelines to reduce the
burden of periodontal disease
What causes Periodontal Disease?
DENTAL PLAQUE
Non mineralized, bacterial aggregation on the teeth
and other solid structures in the mouth
bacterial cells (70%) protein
extracellular polysaccharides
epithelial cells
white blood cells

 Dental Calculus?
Calculus is the result of mineralization within plaque
(70-90% inorganic content)

Not in itself causative of periodontal disease

provides a rough PLAQUE retaining surface
allows greater bacterial proliferation within the gingival
crevice
 Local and systemic factors causing
periodontal disease
A) Local factors: B) Systemic factors
Factors which increase plaque accumulation Factors which modify periodontal
1. Dental Plaque & Calculus (bad oral disease
hygiene) 1.Nutrition
2. Faulty Dentistry (Iatrogenic factors) 2.Vitamins
3. Abnormal habits 3.Protein deficiency
4. Food impaction/retention 4.Blood Dyscrasias
5. Anatomical variation 5.Endocraniological disorders
6. Malocclusion. 6.Pituitary disorders
7. Hypofunction. 7.Allergies
8. Chemical & thermal irradiation 8.Drug idiosyncrasies
9.Radiation
10.Psychogenic
factors
 Risk factors in periodontal disease
A) Non-modifiable risk B) Modifiable risk factor
factor Risk determinants
1. Dental plaque
1. Age: 2. Smoking
-Periodontal disease has always been associated with 3. Diabetes
older age groups.
4. Obesity and metabolic syndrome
--Increased age as a risk factor for periodontitis could be
5. Osteoporosis, dietary calcium, and vitamin D
due to an increased opportunity for exposure to disease. 6. Stress
7. Medication/drugs
2. Gender: 8. Education
The males have a higher prevalence and severity of
Prevalence is inversely related to increasing level of education
periodontal disease than females. 7. Degree of urbanization
High incidence of Aggressive periodontitis has been Prevalence of periodontal disease are slightly higher in rural
found in females areas than in urban areas
8. Diet/Nutrition
3. Race ethnicity Prevalence is more evident among vegetarians as they tend to
The severity among spanish- americans appear to be consume more CHO containing sticky foods & in areas where
higher than that of white and blacks. protein malnutrition and vitamin A deficiency are common.
9.Socio-economic status
4. Genetic factors Periodontal disease is inversely related to increasing level of
IL-1 Genetic polymorphism income & more prevalent in lower socio-economic group.
 Why prevention is important?
1. Prevalence and severity of PD increases with age
2. Important cause of tooth loss

3. Time-consuming and difficult to treat

4. Potential source of systemic bacteraemia

1. Infective Endocarditis, coronary heart disease
2. Stroke
3. Low-birth weight preterm infants
4. Diabetes
 Prevention of periodontal disease
Gingivitis & Periodontitis can be prevented by adequate plaque
control.

Chronic gingivitis is reversible by effective plaque control.

Oral hygiene practices involve thorough daily removal of dental plaque

& other debris by tooth brushing.

Regular and thorough professional plaque removal by dentist

can successfully control periodontal disease.

Awareness of the destructive nature and prevention of periodontal

disease is achieved through interaction between oral health providers
& community decision makers & changes in the educational programs.

Preventive strategy should be customized for each individual due to

variation in susceptibility
 Epidemiologic data form the basis for selection of
strategies to prevent and treat periodontal diseases

Three broad strategies:

A) Population strategy:
Uses a community-wide approach where health education is
introduced in the community and unfavorable behaviors are
changed.
B) Secondary prevention strategy:
Detecting and treating individuals with destructive periodontal
diseases.
Dental health education is an integral part of this strategy to improve
the oral hygiene of the individual patient
C) Identification of high risk groups for periodontitis:

The early detection of active disease and identification of

subjects who are at risk to develop periodontal diseases in
the future are important elements of dental care systems
planning.
Methods of prevention of periodontal disease
A) Mechanical plaque control
1. Self Care B) Chemical plaque control
a) Tooth brushing
1. Dentifrices.
b) Interdental cleaning
2. Antiseptic mouth washes.
2. Professional
a) Scaling/Root planing
b) Polishing
 A) Mechanical Plaque Control
1) Tooth brushing
A) Manual toothbrushes
1.Handle & head size appropriate to the users age.
2.Hard brushes should never be recommended.
3.Lacerate the gingiva, gingival recession and tooth abrasion.
nDiameter is too large to enter the gingival crevice.

4.Twice daily brushing with 2 - 3 minute duration is recommended.

5.Splaying of the toothbrush is the most obvious sign of toothbrush wear.
6.Renewal is usually recommended after 3 months use.
Brushing Techniques
1. Vertical
2. Horizontal
3. Roll Technique
4. Vibrating (Bass, Stillman, Charter)
5. Circular
6. Scrub
Bass technique most recommended by dentists.
Brush held at 45 to the axis of the teeth so that the end pointing into
the gingival crevice.
B) Powered toothbrushes
1.Oscillating, rotating or counter-rotational movements

2.Electric toothbrushes remove more plaque than manual

toothbrushes

3.Electric toothbrush is recommended for individuals who are unable

to maintain effective plaque control
1. Physical or learning disability
2. Fixed orthodontic appliances
3. Institutionalized patients depend upon care providers

4.A manual toothbrush is appropriate for most people

 B) Interproximal Cleaning
Periodontal conditions are worst in interdental areas.
Interproximal cleaners include :

1. Dental floss

2. Interspace brush

3. Interdental brush

4. Wood points (toothpicks)

5. Irrigation devices
 Evidence-based Periodontology
EBP is a tool for decision making.

Patients
Clinician
preference
s skills s
EBP

Best
evidence
available

Needelman et al. Evidence-based periodontology, systematic reviews & research quality. Periodontol 2000 2005;37:12-
28.
 Evidence regarding methods for prevention of
Periodontal disease
Current evidence suggest that mechanical oral hygiene plays an important part
in the prevention and treatment of periodontal disease.

A single oral hygiene instruction has a small positive effect that will last 6
months or more.

Using a manual toothbrush is effective in reduction of the plaque by

approximately half.

Additional efficacy can be obtained using powered toothbrush.

 A dentifrice is usually used in combination with tooth brushing
with abrasive ingredients to enhance the mechanical action of
the toothbrush.

Data on stannous fluoride and triclosan support use of these

products in the prevention of gingival inflammation.
 Interdental brushes should be the first choice in patients
with open interdental spaces.

Evidence showed that interdental brush removes plaque

better than floss.

Dental floss should not be the first tool recommended for

cleaning open interdental spaces & should be used only when
the interdental space allow the penetration of a string of
dental floss.

Dental professionals should realize that proper instruction &

sufficient motivation of the patient are necessary to make the
flossing effort worthwhile.
 WHO and the prevention of periodontal disease
WHO plays a major role in assuring a strong base for public health action.

The WHO helps countries to develop disease prevention programs.

Based on the common risk factors, improvements in periodontal health may be

achieved by countries along with a better control of diabetes mellitus, tobacco
cessation and unhealthy diet.

The WHO Global Oral Health Program supports the relationships between oral
and systemic health.
WHO Global Oral Health Program
Focuses on controlling risk factors by supporting the relationships between oral and
systemic health.

Helps national health authorities incorporate oral health in general health programs.

Help countries to incorporate periodontal disease prevention in national health programs

on prevention of diabetes and tobacco control.

Develops tools for assessment of the effect of diabetes & tobacco control on periodontal
health.

According to the WHO, national health authorities should ensure that prevention of
periodontal disease is made an integral part of the prevention of diabetes and tobacco
control.
 Smoking cessation
Previous epidemiological data strongly support the benefits of smoking
cessation in periodontal treatment.

Recent systematic reviews concluded that:

1.The current limited evidence is consistent to suggest that smoking
compromises non-surgical and surgical periodontal therapy.

2.However, it is enough to supports the benefits of smoking cessation in

periodontal treatment outcomes.

3.Further observational studies are warranted to clarify the effects of smoking

cessation on the periodontium.
Chambrone et al. Effects of smoking cessation on the outcomes of non-surgical periodontal therapy: a systematic review and individual patient data
meta- analysis. J Clin Periodontol 2013; 40: 607615.
 Evidence-based recommendations
Dental practitioners are recommended to:
1. Consider smoking in a periodontal examination.
2. Counsel all of their patients to quit smoking.
3. Implement smoking cessation as a part of periodontal therapy.
4. Inform smoker patients preoperatively of the substantial reduction in clinical
outcomes compared with non-smokers.

1Chambrone et al. Effects of smoking cessation on the outcomes of non-surgical periodontal therapy: a systematic review and
individual patient data meta-analysis. J Clin Periodontol 2013; 40: 607615.
2Kotsakis et al. Impact of cigarette smoking on clinical outcomes of periodontal flap surgical procedures: a systematic review
and meta-analysis. J Periodontol 2015;86:254-263.
 Consensus report on Periodontitis and Systemic
Diseases
Given the current evidence, it is timely to provide guidelines for
periodontal care in diabetes patients for use in dental practice and
recommendations for patients/the public.

Chapple, Genco. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on
Periodontitis and Systemic Diseases. J Periodontol 2013 ;84,106-112.
 Guidelines for periodontal care in diabetes patients
1. Monitored regularly for any periodontal changes.

2. Glycemic control of periodontitis patients is difficult.

3. Annual screening for early signs of periodontitis should start at 6 years age.

4. Professional mechanical debridement with sustained effective home care.

5. Currently, there is insufficient evidence to suggest additional benefits for

adjunctive antibiotic therapy.

Chapple, Genco. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on
Periodontitis and Systemic Diseases. J Periodontol 2013 ;84,106-112.
Evidence-based recommendations

Dentists should be more proactive in working with medical

colleagues to identify unrecognized diabetes and pre-diabetes and
refer them to a physician.

This in turn will help to reduce periodontal disease and other

complications of diabetes.
 Cochrane Database of Systematic Reviews 2010, Issue 5. Art.No.:CD004714

There is some evidence of improvement in glycemic control in type 2

diabetic patients after treating periodontal disease.

Larger carefully conducted studies are needed to determine the optimal

periodontal treatment to sustain better glycemic control.
 A clear understanding of risk factors for periodontal disease is

essential for clinical practice.

It is essential that the clinician looks beyond the oral cavity for

systemic factors to help their patients in prevention of periodontal

disease & thereby possibly improve general health as well.

Periodontal disease can be prevented by adequate plaque control.

Proper oral hygiene involves self care removal of dental plaque by tooth
brushing & professional plaque & calculus removal by dentist.

Awareness and prevention of periodontal disease is achieved through oral

health educational programs.

Preventive strategy should be customized for each individual based on risk

factors.

According to the WHO prevention of periodontal disease may be achieved with

a better control of diabetes mellitus, tobacco cessation and unhealthy diet.
 Further readings
Needelman et al. Evidence-based periodontology, systematic reviews & research
quality. Periodontol 2000 2005;37:12-28.
Chambrone et al. Effects of smoking cessation on the outcomes of non-surgical
periodontal therapy: a systematic review and individual patient data meta-analysis. J
Clin Periodontol
2013; 40: 607615.
Kotsakis et al. Impact of cigarette smoking on clinical outcomes of periodontal flap
surgical procedures: a systematic review and meta-analysis. J Periodontol 2015;86:254-
263.
Chapple & Genco.Diabetes and periodontal diseases: consensus report of the Joint
EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013 ;84,106-
112.
Petersen and Ogawa. Strengthening the Prevention of Periodontal Disease: The
WHO Approach. J Periodontol 2005;76:2187-2193.
Genco & Borgnakke. Risk factors for periodontal disease. Periodontology 2000, Vol.
62, 2013, 5994 .
Strategies to reduce the risk of periodontal
disease
Aims:
The educational aims of this lecture are:
To provide a very brief revision of the local and systemic risk factors of periodontal disease (as
already outlined earlier in ADS 2)
To provide a very brief overview of the local methods to lessen the risk of periodontal disease
(these will be considered in detail in lectures within the periodontology section of module 2. 5)
To provide a review of current local, national and/or international guidelines to reduce the risk of
periodontal disease

Objectives:
On completion of this lecture, the student should have:
An understanding of the principle local and systemic methods of reducing the risk of periodontal
disease
An understanding of local, national and/or international programmes/guidelines to reduce the
burden of periodontal disease
Thank you