DOI: 10.1111/prd.
12330
REVIEW ARTICLE
The prevention of periodontal disease—An overview
Frank A. Scannapieco1,2 | Eva Gershovich2
1
Department of Oral Biology, University at Buffalo, The State University of New York, Buffalo, NY
2
School of Dental Medicine, University at Buffalo, The State University of New York, Buffalo, NY
Correspondence
Frank A. Scannapieco, Department of Oral Biology, University at Buffalo, The State University of New York, Foster Hall, Buffalo, NY 14214, USA.
Email: fas1@buffalo.edu
1 |  I NTRO D U C TI O N
It is widely accepted that the most common and important diseases
of the oral cavity (gingivitis and periodontitis, dental caries, and oral
cancer) are preventable. Based on a large body of scientific evidence,
a number of preventive strategies exist, that, if routinely implemented,
will prevent these diseases in most individuals. Unfortunately, while
most preventive strategies are theoretically simple to understand, they
are often difficult to employ in practice at individual and public health
levels. There are many complex reasons that may help explain why
prevention of oral diseases is difficult, especially in certain vulnerable
populations. It is the purpose of this volume of Periodontology 2000 to
review a variety of concepts, both old and new, on periodontal disease
prevention to allow the reader to understand more clearly the complex-
ities that impede the implementation of preventive strategies for the
individual patient and at the public health level. It is our hope that after
reading this volume, the practitioner will have improved their under-
standing of periodontal disease prevention in order to better educate
their patients and incorporate evidence-based preventive strategies
in their practice to help prevent these costly and impactful diseases.
Such action will save patients not only pain and suffering, but also their
hard-earned assets! It is also our hope to educate the scientific commu-
nity about those remaining critical questions that need to be answered
through new research efforts to provide a clearer understanding of the
etiology of periodontal disease, from the molecular pathways that lead
to disease, to cutting edge and novel strategies that will prevent the
initiation and progression of periodontal diseases in most individuals.
2 |  E TI O LO G Y O F PE R I O D O NTA L D I S E A S E
Before we discuss preventive approaches for periodontal diseases,
we first must briefly summarize the present understanding of the
© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Periodontology 2000. 2020;84:9–13. 
etiology of periodontal disease, a subject that has evolved over the
past decades. While a complete description of this topic is beyond
the scope of the present article, an excellent summary is provided
in this volume of Periodontology 2000.1 Briefly, there is no doubt
that most cases of periodontal disease are driven by exposure of
the host periodontal tissues to the microflora that adheres to teeth
in the form of a biofilm, long referred to as dental plaque. Bacteria
(and probably other microbes, including viruses, fungi, and parasites)
interact with each other and with the host. With time, a resulting
dysbiotic microbiome, together with dysregulated host inflamma-
tion, fosters the growth of selected microbes within the biofilm to
produce substances that exacerbate inflammation, which in some
subjects results in tissue destruction and tooth loss. Based on this
understanding, prevention of periodontal diseases is predicated
primarily on removing and preventing the formation of biofilm, and
secondarily on tempering inflammation.
Although there is no question that specific groups of oral bacteria
that populate dental plaque play a causative role in the development
of periodontitis, it is now thought that once the disease has been trig-
gered, other factors play an equal, and possibly more important, role
in the progression of periodontitis, particularly in severe periodon-
titis or in cases of periodontitis that prove difficult to treat. Once
exposed to oral periodontal pathogenic bacteria, the host mounts a
defense response mediated largely through the innate immune sys-
tem. 2,3 A critical cell type in the host response, polymorphonuclear
neutrophils, can upregulate the production of pro-inflammatory
cytokines, matrix metalloproteinases, and reactive oxygen species,
all of which contribute to increased oxidative stress and the tissue
damage that occurs in periodontitis. An article in this volume of
Periodontology 2000 discusses the characteristics of oxidative stress
and its effects on the periodontium and examines approaches that
attenuate the effects of reactive oxygen species, thereby potentially
preventing the initiation of progression of periodontal disease.3 For
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10       SCANNAPIECO and GERSHOVICH

example, resveratrol (3,5,4′-trihydroxy-trans-stilbene), a natural phe-
nol phytoalexin derived from a variety of plants in response to injury,
may serve as an antioxidant to prevent disease.
3 |  I NTE RV E NTI O N S PROV E N TO
PR E V E NT G I N G I V ITI S A N D PE R I O D O NTITI S
When contemplating writing this article, we began by posing a very
simple question to ourselves, namely “What preventive modalities
have been unequivocally scientifically proven to prevent the initia-
tion (primary prevention) and progression (secondary prevention) of
gingivitis and periodontitis?” To answer this question, we conducted
a scoping review to identify published systematic reviews and meta-
analyses that address the efficacy of strategies claimed as effective
in preventing periodontal disease. The search was limited to sys-
tematic reviews of human adult patients with gingivitis (a definitive
manuscript describing details of our search strategy and results is
now in preparation). Table 1 shows a simplified summary of many of
the chemical and mechanical interventions that have been investi-
gated, over the years, for preventing periodontal diseases, and the
relevant clinical outcome terms (plaque index, gingival inflammation,
bleeding score, and pocket depth). Multiple systematic reviews of
clinical trials demonstrate that topical chlorhexidine gluconate 4,5
and adjunctive interdental brushing6,7 show the strongest capability,
of all interventions tested, to reduce periodontal probing depth and
signs of gingivitis. The evidence also suggests that cetylpyridinium
8 9-11
chloride, essential oil mouthwash, and powered toothbrushing
TA B L E 1   Essential findings of chemical and mechanical
interventions
Strength of
Intervention PI GI BS PD evidence
CHX + + + + Strong
CPC + + 0 0 Strong
are also effective in reducing gingivitis, but to a lesser extent than
interdental cleaning and chlorhexidine. Similarly, strong evidence is
not yet available in support of other interventions, including flossing,
probiotics, nonsteroidal anti-inflammatory agents, and nutritional
supplements. Of course, while other interventions could indeed
prove to be effective for preventing periodontal diseases, sufficient
evidence must be provided by conducting well-powered clinical
trials.
Human tooth cleaning has been a common practice for millennia.
However, until 100 years ago or so, people were probably motivated
to clean their teeth to mitigate unpleasant discomfort in the form
of bad breath (halitosis) and/or esthetic concerns, with a focus on
the removal of food debris. Not until it was clearly understood that
dental caries and periodontal diseases were a direct result of expo-
sure of the host tissues to microorganisms within dental plaque did
biologically based preventive strategies become apparent and rou-
tine for most people by daily mechanical removal of plaque. The task
became easier for patients with the development of the nylon tooth-
brush13 (which is more sanitary and comfortable to use than brushes
made of natural materials), along with floss and widely available and
inexpensive dentifrices. More recent innovations include interdental
brushes to remove interproximal biofilms, topical rinses with anti-
microbial properties, and the electric toothbrush, to name a few.
Together, these tools have made effective tooth cleaning possible
for most people. The strong evidence in support of contemporary
practices for mechanical oral hygiene to prevent periodontal disease
is well summarized in this volume of Periodontology 2000.14 In addi-
12
tion, several other articles are included that review newer chemical
or pharmacologic approaches that were developed with the purpose
of preventing periodontal inflammation or the formation of dental
plaque biofilm; these approaches include the use of natural prod-
ucts,14 the sustained release of soluble agents within the oral cav-
ity,15 and probiotics16.
Despite the availability of so much information on how to pre-
vent periodontal diseases, many people still struggle to maintain oral

EOMW + + + 0 Strong hygiene at a level sufficient to prevent such diseases. Patients’ lack
of knowledge or skill with the proper use of an oral hygiene device, a
Powered brushing + + 0 0 Strong
lack of appreciation of the time needed to perform thorough clean-
Zinc/citrate dentifrice + + + 0 Weak
ing, and in some cases downright apathy and no oral hygiene at all, as
Interdental cleaning + + + + Strong
well as the lack of knowledge or ambivalence of providers to recom-
Woodsticks 0 0 + 0 Moderate
mend evidence-based (yet affordable) oral hygiene aids to patients,
Irrigators 0 + + + Moderate
all contribute to the persistence of these preventable diseases in a
Magnesium 0 + 0 + Weak substantial proportion of the population.
Fish oil 0 + 0 + Weak
Probiotics 0 + + 0 Weak
NSAIDs 0 + + + Weak 4 | PR E V E NTI O N O F PE R I - I M PL A NT
Note: Strength of evidence was determined using Preferred Reporting DISEASES
Items for Systematic Reviews and Meta-Analyses (PRISMA).
Abbreviations: 0, no significant difference between groups, +, Like teeth, dental implants can suffer from progressive loss of sup-
significance in favor of intervention, −, significance in favor of porting tissues as a result of exposure to dental plaque microor-
control; BS, bleeding score; CHX, chlorhexidine; CPC, cetylpyridinium
ganisms that adhere to the implant surface. Indeed, a considerable
chloride; EOMW, essential oil mouthwash; GI, gingival index; NSAIDs,
nonsteroidal anti-inflammatory drugs; PD, pocket depth; PI, plaque proportion of implants placed will experience peri-implantitis over
index. their lifespan. While not as well studied as periodontitis, approaches
SCANNAPIECO and GERSHOVICH
used to prevent peri-implantitis probably mirror those used to pre-
vent destruction of the periodontal tissues that support natural
teeth. Wang and colleagues provide an excellent overview on the
prevention of peri-implantitis.17 They conclude that, like teeth,
dental implants must be cleansed daily, using toothbrushes and
interdental aids, to remove biofilm. In addition, professional me-
chanical debridement must be performed at regular intervals (every
3 months) to reduce the submucosal microbial load. It is also sug-
gested that a healthy lifestyle, including maintenance of good gly-
cemic control and avoiding smoking, will help ensure long-term
retention of implants.
5 | TO BACCO C E S SATI O N TO PR E V E NT
PE R I O D O NTA L D I S E A S E
Tobacco smoking, especially in the form of cigarettes, has been con-
vincingly demonstrated to serve as an important risk factor for peri-
odontitis.18 Tobacco smoke probably exacerbates the pathogenesis
of disease though impacting both the human immuno-inflammatory
system and oral microbial communities. The most common-sense
approach to reduce this risk is never to smoke, or to quit smok-
ing. The dentist can play an important role in encouraging patients
not to smoke, or to convince present smokers to quit. The review
by Kumar19 in this volume of Periodontology 2000 expands this
idea to consider prevention of periodontal diseases in individuals
engaged in multiple forms of substance abuse. The point is made
that all substances with abusive potential (such as tobacco, alcohol,
and/or narcotics) affect the host response and the microbiome to
influence the pathogenesis of periodontal diseases. Promotion of
tobacco cessation through counselling continues to be an important
tool that dentists need to utilize to help their patients quit smoking.
Of course, the new habit of vaping presents an as-yet mostly unex-
plored environmental risk factor that can also negatively impact the
periodontium.
6 | W H AT I S TH E O P TI M A L I NTE RVA L
N EC E S SA RY FO R S U CC E S S FU L
PE R I O D O NTA L M A I NTE N A N C E ?
Prevention and management of periodontal disease not only re-
quires the removal of biofilm from teeth at the time when the patient
presents to the dentist for treatment, but also the establishment of
lifelong daily habits by the patient to prevent biofilm formation on
their teeth. It is clear that maintenance of effective biofilm control is
essential for preventing the progression of periodontitis in afflicted
patients. Periodic recall visits are required to support patients to
maintain good oral hygiene to prevent disease progression. Thus,
supportive periodontal therapy is a mainstay of proper periodontal
practice. The accompanying article by Trombelli et al20 reviews the
existing evidence to support if, and to what extent, a predefined
frequency of periodontal recall will prevent periodontal disease
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activity. They conclude that there is enough evidence supporting
primary and secondary preventive protocols to preserve a periodon-
tally healthy dentition and prevent tooth loss. In patients affected
by moderate-to-advanced periodontitis, the long-held belief that a
proper supportive periodontal therapy interval is 2-4 months con-
tinues to be reasonable.
7 | W H AT A R E S O M E O F TH E PR E V E NTI V E
S TR ATEG I E S O N TH E H O R IZO N TH AT A R E
PRO M I S I N G B U T N OT Y E T PROV E N?
There is much interest in whether natural or herbal-based health-
care products can prevent diseases such as periodontal disease. For
example, the ability of aloe vera, green tea, and triphala to prevent
oral diseases has been studied. 21 Results to date suggest that natural
products have a positive impact on periodontal health, with many
studies showing inhibition of dental plaque accumulation and im-
proved gingival health. Less is known about how natural products
directly impact the periodontium. Additional well-powered rand-
omized clinical trials, along with basic mechanistic studies, are re-
quired to understand how these products work and to formulate
clinical guidelines for use in practice.
8 | B I O LO G I C A L S TR ATAG I E S FO R
PR E V E NTI O N : PRO B I OTI C S A N D VACC I N E S
Probiotics have received considerable attention recently as a po-
tential approach to prevent periodontal disease. Probiotics are
defined by the Food and Agricultural Organization/World Health
Organization as “live micro-organisms which, when administered
in adequate amounts,” confer a health benefit on the host. A num-
ber of mechanisms have been suggested to explain the benefits
associated with probiotic bacteria. The accompanying review ex-
plores the potential mechanisms and clinical evidence concerning
the use of probiotics to prevent periodontal disease.16 Probiotic
bacteria may reverse damage to epithelia, caused by inflammation,
through stimulating the upregulation of structural proteins. These
bacteria may also colonize and proliferate sufficiently to deprive
pathogenic bacteria of nutrients and thus inhibit their growth.
Probiotic bacteria have also been reported to produce antimicro-
bial products, such as acetic acid and lactic acid, that inhibit gram-
negative bacteria. Moreover, probiotics may influence the host
to downregulate pathways that might damage host tissues, while
simultaneously upregulate other pathways that inhibit the growth
or virulence of pathogens.
Another biological strategy considered to prevent periodontal
disease revolves around the development of a vaccine. Vaccines, “an
inactivated or attenuated pathogen or a component of a pathogen
(nucleic acid, protein) that when administered to the host stimulates
a protective response of cells in the immune system”, have been
long in use in medicine as an effective public health intervention to
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12       SCANNAPIECO and GERSHOVICH
prevent diseases. Periodontal vaccines, which have been a subject
of research starting in the 1970s, are a proposed preventive mo-
dality for periodontal disease based on its polymicrobial etiology. A
number of research groups have reported a periodontal vaccine in
development which targets antigens of specific oral gram-negative
anaerobic pathogens that have been implicated in the pathogenesis
of this disease. The accompanying article also summarizes the pres-
ent status of the development of probiotics and vaccines to prevent
periodontal disease.16
9 |  PR E V E NTI O N O F PE R I O D O NTA L
D I S E A S E S I N O LD E R A D U LT S
It is well accepted that the world's population is ageing, especially in
developing countries. The increased proportion of older adults in the
population will place serious demands on the health-care system, in-
cluding dental services. The connections between oral diseases and
other chronic diseases impose further burdens on the delivery of
health care to the elderly. 22 The dental needs of elders often include
treatment for periodontitis and root caries. The accompanying arti-
23
cle by Al-Nasser and Lamster addresses the role of prevention of
oral diseases in the elderly population in the context of overall health
and the present status of health-care delivery for this segment of the
population.
10 | B E H AV I O R A L A S PEC T S O F
PR E V E NTI O N
Why is it that for some patients, adherence to an effective oral
hygiene regimen seems impossible, no matter how often they are
reminded by the dentist or hygienist? The paper by Jönsson and
24
Abrahamsson provides insight into how behavioral obstacles that
interfere with self-performed oral hygiene can be overcome using a
person-centered care approach and behavioral change techniques
through education. Further research is needed to document the ef-
fectiveness of the use of different behavioral change techniques in
different patient groups and when delivered in general dental prac-
tice. In addition, dental professionals’ experiences of delivering such
an intervention, and patients’ experiences of taking more responsi-
bility in planning and making decisions on their oral self-care, needs
further study.
Attention to behaviors can also be considered at the population
level. It is well known that even the most scientifically well-sup-
ported breakthroughs to treat or prevent diseases are often not
immediately embraced by the clinical practice community. Indeed,
the creation of and access to scientific knowledge alone are not
sufficient to facilitate routine implementation in everyday practice.
There are numerous obstacles that prevent the adoption and routine
use of new evidence in patient care. These include difficulty in ed-
ucating practitioners about new knowledge, as well as the inherent
bias of individual practitioners that prevent immediate incorporation
of new ideas into practice. There are also health-care system-level
barriers that prevent facile adoption of new evidence and routine
application in patient care. These obstacles led to the development
of a new branch of clinical research called implementation science,
which studies the factors that hinder the promotion and adoption
of evidence into practice. The accompanying article25 reviews the
history of implementation science and how it might be applied to
help practitioners adopt strategies to prevent periodontal diseases.
11 | PU B LI C H E A LTH A PPROAC H E S TO
PR E V E NT PE R I O D O NTA L D I S E A S E S
There are many examples of public health initiatives that have
helped to drive down the prevalence of serious medical conditions.
For example, antismoking educational campaigns and, most impor-
tantly, no-smoking laws have greatly reduced the number of smokers
as well as the diseases that often result from smoking, such as lung
cancer. However, more action at the public health level is needed in
order to motivate behaviors that would prevent periodontal disease.
Indeed, most action in this regard has occurred at the individual,
patient-focused level. Currently, public health approaches for peri-
odontal disease prevention and control are essentially nonexistent.
The accompanying review26 presents a brief history of strategies for
preventing periodontal disease from an epidemiologic perspective,
and discusses ideas for novel public health approaches to prevent
periodontal disease at the population level.
12 | FU T U R E R E S E A RC H
The articles in this volume of Periodontology 2000 present a wide
array of information on the present status of periodontal disease
prevention. In addition, some of the ideas put forward in this volume,
for new avenues of research to prevent this prevalent and costly dis-
ease, include the following.
1. Continue research to provide a better understanding of
periodontal disease pathogenesis by unraveling the complex
mechanisms that result in tissue destruction.
2. Well-designed hypothesis-driven mechanistic studies, as well as
large-scale randomized controlled trials, to inform both practi-
tioners and public policy about the contribution of tobacco, al-
cohol, and narcotic abuse to periodontal disease initiation and
progression.
3. Definitive randomized, controlled trials to test the efficacy of
floss, woodsticks, or other interdental tools.
4. Long-term randomized controlled trials to determine clinical
guidelines for the use of natural products for promoting peri-
odontal health.
5. Long-term randomized controlled trials to validate the appropri-
ateness, risk-benefit, and cost-effectiveness of different recall
intervals. Investigations using residual diseased sites as an index,
SCANNAPIECO and GERSHOVICH
or risk-assessment tools, should be conducted to establish the
recall frequency.
6. Conduct studies to document the effectiveness of behavioral-
change techniques in different patient groups in the general
dental practice setting.
7. Long-term randomized controlled trials to test novel therapies
that increase the level of antioxidants and/or antioxidant activity
to diminish oxidative stress within the periodontium.
8. Develop a new generation of slow-release agents for local de-
livery to include novel components (such as quorum-sensing
inhibitors) or nonantibacterial agents (such as anti-inflammatory
or bone-regeneration agents).
9. Continue research to develop biological approaches, such as
probiotics and vaccines, to prevent periodontal diseases.
10. Consider new and facile approaches with promise for preventing
periodontal diseases in ageing populations.
11. Utilize public health informatics to define a strategy in areas of
surveillance, prevention, and health promotion to define peri-
odontal disease assessment that better informs decision making.
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How to cite this article: Scannapieco FA, Gershovich E. The
prevention of periodontal disease—An overview. Periodontol
2000. 2020;84:9-13. https://doi.org/10.1111/prd.12330