The Prevention of Periodontitis

Oral hygiene practices

The importance of optimal plaque control and oral hygiene practices is universally accepted. Facilitating effective self-performed oral hygiene practices can be challenging. For those patients who are engaged, it is important that our recommendations on the appropriate oral hygiene tools are evidence-based.

When considering manual toothbrushes, the evidence suggests that a single exercise of manual brushing leads to reductions in plaque scores of approximately 42% from pre-brushing scores. Whilst there are no data derived from meta-analyses on the impact of manual brushing upon gingival inflammation, there is evidence from individual studies that conscientious manual brushing does reduce inflammation. Reductions in plaque scores from baseline are reported as 24–47% for flat-trim bristle designs, 33–54% for multi-level bristles and 39–61% for criss-cross designs. However, meta-analyses did not report on inter-design differences in effectiveness.⁴ The size of the head should also be checked. Many of the current designs can be too large to accommodate comfortably in all parts of the mouth. If a manual toothbrush is used by the patient, he/she needs to be instructed specifically on its use.

Power brushes are more effective than manual and so should be recommended over manual brushes where possible (Figure 3). Power brushing is associated with 46% reductions in plaque scores following a single exercise of tooth brushing. In controlled studies, power brushes produce statistically significant greater short-term and long-term reductions in plaque indices compared to manual brushes. The same findings are observed for reductions in gingival inflammation. Greater reductions in plaque scores are achieved with rechargeable power brushes than battery-operated, so the former should be promoted. Short-term (1–3 months) data support greater plaque reductions for oscillating-rotating power brushes than those employing a side-to-side action. However, differences are small, and their clinical importance is unclear.⁴ For this reason, it is difficult to make direct comparisons of individual designs and brands.

Other advantages of many rechargeable power toothbrushes include the fact that they have a timer function. This makes it more likely that brushing is completed for a sufficient length of time. Often, a pressure sensor is present, which indicates that an optimal amount of pressure is being applied. Finally, connection with an app provides real-time feedback on coverage, helps motivate the patient and allows for long-term monitoring.

Interdental cleaning is essential in order to maintain interproximal gingival health, in particular for secondary prevention. A number of devices can be used for interdental cleaning, including floss, interdental brushes, wood sticks or oral irrigators. Evidence suggests that interdental cleaning using interdental brushes is the most effective method for interproximal plaque removal and so should be the first choice of device.⁴ If these do not fit, or would cause trauma, then floss is also an option. Whilst irrigators and air-based methods have been heavily marketed for use in interdental cleaning, there is limited evidence for their effectiveness. If patients are keen to include these as part of their regimen, then their use should be adjunctive to the aforementioned methods.

With regards to adjunctive chemotherapeutics (antiseptics), the guidance is that these might be considered for specific patients during the initial treatment phase or for supportive periodontal therapy, but benefits for long-term dental health are unclear and the decision to recommend these should account for the economic cost and adverse effects (eg staining) of long-term use.^5,6

With toothbrushing and interdental cleaning, professional instruction is vital for achieving optimal effectiveness and to avoid trauma. Reinforcement of instructions is also essential to provide additional benefits.

Achieving behavioural change

Although it is clear that self-performed oral hygiene is the key component in preventing periodontal disease, the general population does not consistently achieve an appropriate level of plaque control.⁷ There is a key behavioural component to achieving optimal plaque control and techniques that engage patients and help achieve the changes needed ought to be adopted.

A recent systematic review on psychological approaches to behavioural change for improved plaque control in periodontitis patients indicated that change in oral hygiene behaviour is related to patient perception of the harmful consequences, their own susceptibility to the condition, as well as their benefits from change.⁸ Motivational interviewing can help highlight these points for a patient and may drive behavioural change.

The European Federation of Periodontology Prevention Workshop consensus guidelines suggest using the Goal setting, Planning and Self-monitoring (GPS) approach to help motivate and achieve behavioural change when delivering oral hygiene instructions (Table 1).³ The importance of self-monitoring should not be underestimated. Even if disclosing tablets are not used within the appointment due to time constraints, these can be useful to give away to patients to help them better assess their level of plaque control and modify their habits, as needed (Figure 4).

Risk factors: smoking cessation

Smoking is a key risk factor for the development and progression of periodontitis. It increases the risk of developing periodontitis by approximately five-fold and has been argued as being the most important modifiable risk factor. A recent systematic review identified strong evidence that brief interventions in the dental setting increase smoking cessation rates.⁹ While the reported quit rate was in the range of 10–20% at 12 months¹⁰, the magnitude of the effect seen in these studies was comparable to that described in similar studies in general healthcare settings¹¹. Six of the eight studies in the systematic review that supported the effectiveness of brief interventions to quit smoking in the dental setting were performed in a practice setting. Evidence demonstrates that patients also welcome and expect involvement of oral health professionals in smoking cessation.

Brief intervention is generally considered as a short conversation (up to 5 minutes), which provides advice and includes a degree of counselling on smoking. The structure of this brief intervention can be guided by the Ask, Advise and Refer (AAR) approach (Table 2).³

Using smoking cessation services has been shown to triple a person's chances of stopping and that is always worth mentioning to the patient. The NHS's Smokefree website has a cost calculator (www.nhs.uk/smokefree/why-quit/cost-calculator), where patients or healthcare providers can input data on the cost of a pack of cigarettes and the number of cigarettes smoked a day. This gives an output in terms of the amount of money saved per day/week/year if the patient were to stop smoking. On average, this works out to be around £128 per month. This can also be a great motivational tool.^12,13,14

There is much controversy regarding e-cigarettes, but they can be a useful tool to help achieve smoking cessation. However, it is wise to also encourage vaping cessation once smoking cessation has been achieved.

Risk factors: diabetes

Patients with poor diabetic control are more likely to have periodontitis and this is likely to be more severe/rapidly progressing compared to people without diabetes.¹⁵ In fact, patients with poorly controlled diabetes (type II) have a three-fold increase in the risk of periodontitis.¹⁶ As with smoking, patients with poor diabetic control are less likely to respond to treatment in the absence of an improvement in their diabetic control. Reassuringly, the role of diabetes has also now been recognized formally nationally within the publication of guidance by NHS England.¹⁷

The promotion of diabetes control is important both in primary and secondary prevention. Clinicians are encouraged to compile a careful history from their patients who have diabetes, including their level of control. The most objective way of ascertaining this is by requesting a copy of their most recent HbA1C results. Interventions should consist of patient education as well as brief dietary counselling and, in situations of hyperglycaemia, the patient's referral for glycaemic control. Recent guidance considering the latest systematic reviews emphasizes the importance of this in daily practice.^6,18

Risk factors: stress

Management of stress and coping with negative life events are key in the primary and secondary prevention of periodontitis. Simply asking patients how they are and what their stress levels are like is important. The effects of stress on the periodontal health of individuals is well established for certain conditions, such as necrotizing periodontal diseases, but it is also there for other forms of periodontal disease.¹⁹ The mechanisms by which stress may impact the periodontium are complex. It is understandable that, when patients are stressed, oral hygiene becomes less of a priority, patients may start to brux or start/increase smoking, all of which will have a negative impact. Furthermore, the unfavourable change in the immune system may predispose the patient to periodontitis or allow it to worsen. As with smoking and diabetes, patients who are stressed are not only more likely to develop periodontitis, but are also less likely to respond to periodontal therapy.^20,21 If the patient is suffering from high stress, suggestions for management strategies and referral may be considered.

Risk factors: nutrition

Dietary intake can be divided into macro- or micronutrients. Deficiencies in micronutrients can predispose patients to periodontitis. An example of this is the scurvy seen in vitamin C deficiency. This manifests as painful, swollen, bleeding gums and increased periodontal breakdown resulting in tooth loss. This is caused by defects of collagen production resulting from a deficiency in vitamin C, which has a critical role in the production of collagen. Defects in collagen production lead to defects in the connective tissues of the periodontium, making them more vulnerable to breakdown. In assessing the diet of patients with periodontitis, it is important to ascertain the consumption of food high in antioxidants, such as fresh fruit and vegetables. Antioxidants may protect against the development and progression of periodontitis. Similarly, diets high in saturated fats, refined sugars and carbohydrates will increase the oxidative stress burden in patients and may predispose to periodontal breakdown. At present, there is little evidence to support the need for dietary supplementation to improve the periodontal health of patients. Furthermore, the impact of specific dietary counselling is unclear. However, especially when patients ask about diet, promoting a balanced diet rich in micronutrients would seem sensible.^6,14

Professional mechanical plaque removal

Professional mechanical plaque removal (PMPR) should be a part of the overall prevention strategy in combination with tailored oral hygiene instructions and risk factor control. Professional mechanical plaque removal and control of retentive factors is recommended as part of the first step of therapy.⁶ Removal, both supra-gingivally and sub-marginally, as deep as necessary to remove all soft and hard deposits, is required to allow good self-performed oral hygiene. This can be performed with hand and/or powered instruments.

There is little value in providing professional mechanical plaque removal without oral hygiene instructions to reduce gingivitis.²² A single episode of PMPR followed by repeat OHI is as effective as repeated PMPR in reducing gingivitis followed up to 3 years.

Professional mechanical plaque removal, as part of secondary prevention, ie preventing disease recurrence in patients previously treated for periodontitis, will form a part of supportive periodontal therapy.

Supportive periodontal therapy

The ideal endpoints of active periodontal therapy in the management of periodontitis are the reduction of signs of inflammation, as defined by full mouth bleeding on probing scored (≤15%), the elimination of deep pockets (PD ≥5 mm) and the absence of signs of active infection as defined by the presence of suppuration. Whenever possible, these endpoints should be reached prior to the patient starting supportive periodontal therapy in order to optimize the secondary prevention.²³

Professional mechanical plaque removal in the context of secondary prevention is the routine professional mechanical removal of supragingival plaque and calculus with subgingival debridement to the depth of the sulcus/pocket. The appointment should also include the evaluation of oral hygiene performance, motivation and reinstruction in oral hygiene practices and, when appropriate, other risk factor control. As part of this, a periodontal examination must be conducted with the aim of early detection of any relapsed pockets, which should undergo active periodontal therapy.

Supportive periodontal therapy is integral for all patients with periodontitis. It is imperative that the patient understands the chronic nature of the condition and emphasis should be placed on the condition being ‘controllable’ rather than ‘curable’. The evidence base clearly demonstrates that supportive periodontal therapy is effective. Patients undergoing supportive periodontal therapy, including professional mechanical plaque removal, showed mean tooth-loss rates of 0.15±0.14 teeth/year for 5 year follow-up and 0.09±0.08 teeth/year (corresponding to a mean number of teeth lost ranging from 1.1 to 1.3) for 12–14-year follow-up.²⁴ More than half of the patients did not lose teeth and only a minority were responsible for the majority of tooth lost during supportive periodontal therapy.²⁵ Recall intervals should be based on risk profiles to optimize long-term tooth retention.

Risk-assessment tools

As different individuals demonstrate varying susceptibility to the onset and progression of periodontitis,²⁶ the application of uniform prevention protocols may not meet the needs of all individuals. Prediction tools based on risk factors allow the grouping of patients into various levels of risk. The provision of patient care guided by the assessment of patient-level risk for the progression of periodontitis may be an advantageous approach for the individual patient.²⁷

The risk factors for periodontitis carry different weights and interactions. For this reason, periodontal risk assessment is not a simple process. A recent consensus meeting by the European Federation of Periodontology, which analysed the latest systematic reviews in this area, supported two systems: PreViser (also provided through DEPPA, the Denplan PreViser Patient Assessment in the UK) (Figure 5)²⁸ and the Periodontal Risk Assessment (PRA) tool (Figure 6).²⁹ The validity and predictive ability of these systems has been demonstrated in a number of studies.^30,31

The key aim of risk assessment is to identify patients who are at risk before irreversible damage occurs. The clinician is able to determine the high-risk patient's care plan in terms of recall periods, reduction of risk factors, intensity of treatment and referral to specialists more effectively. In the same way, risk-based prevention also helps to prevent over-treatment. In addition, quantifying risk and disease by means of scores allows the success of care plans to be objectively measured. This would be valuable on an individual, practice and population level. Perhaps most importantly, personalized risk communication to patients appears effective in stimulating behaviour change and has important medico-legal implications regarding the engagement of patients in their own health behaviours.