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Prevention and periodontal disease

Johnson & Johnson is delighted to bring you this article, with the aim of supporting the ongoing CPD needs of dental healthcare professionals in improving and maintaining the oral health of their patients.

This article is equivalent to one hour of Enhanced CPD. To provide feedback on this article, please contact dentalcpd@its.jnj.com

Learning outcomes

A,B,C,D

Aims and objectives

The aim of this article is to present the current evidence base for what may constitute best at-home practice for patients with periodontal disease, bearing in mind the consensus statement by Working Group 2 of the 11th European Workshop in Periodontology that, for patients with periodontitis, the universal recommendation to brush twice daily for at least two minutes with a fluoridated toothpaste is likely to be insufficient.1

On completing this CPD session, the reader will:

• Understand why plaque control is at the heart of tackling the periodontal disease challenge

• Understand the significance of patients with periodontal disease taking responsibility for their oral health between appointments

• Understand why brushing the teeth with a fluoridated toothpaste is insufficient to prevent periodontal disease, and what can be done to bridge this gap

• Understand that effective oral hygiene instruction is key to achieving and maintaining oral health

Prevention and periodontal disease

This article presents the current evidence base for what may constitute best at-home practice for patients with periodontal disease.

In 2015, Working Group 2 of the 11th European Workshop in Periodontology shared that, for patients with periodontitis, the universal recommendation to brush twice daily for at least two minutes with a fluoridated toothpaste is likely to be insufficient.1

Whilst this statement refers to periodontitis, gingivitis is also a challenge that needs to be considered in terms of helping patients to adopt an effective at-home oral care regimen, since it has been demonstrated that gingivitis and periodontitis are a continuum of the same inflammatory disease.2

It is also worth noting, however, that it does not follow that gingivitis will always progress to periodontitis.2 Rather, it is considered that: ‘The weight of the evidence indicates that the prevention of gingival inflammation prevents periodontitis’.2

With this in mind, what assistance may the dental team be able to offer patients with periodontal disease, to help improve and maintain their gingival tissue health?

Plaque control

Plaque control is at the heart of tackling the periodontal disease challenge: ‘[…] the most important risk factor for periodontitis is the accumulation of a plaque biofilm at and below the gingival margin, within which dysbiosis develops and is associated with an inappropriate and destructive host inflammatory immune response. Plaque removal and/or control is therefore fundamentally important in the prevention of periodontal diseases.’1

Practically speaking, tooth brushing is recommended in terms of reducing plaque. Where improvements are needed, to achieve better plaque control it may be prudent to recommend a patient uses a power tooth brush as opposed to a manual one. This is because, in controlled studies, the former has been shown to produce significantly better reductions in plaque bacteria over both the short- and long-term, when compared to the latter.1

However, the FDI’s 2018 ‘White Paper on Prevention and Management of Periodontal Diseases for Oral Health and General Health’ states that brushing the teeth with a fluoridated toothpaste is insufficient to prevent periodontal disease: ‘The additional use of flosses and/or interdental brushes is essential for removal of interdental plaque. In addition, according to the Guidelines for Effective Prevention of Periodontal Diseases produced by the EFP (2015), some specific mouth rinses offer benefit in the management and prevention of gingivitis, as do certain chemical agents in dentifrices as an adjunct to mechanical plaque removal.’3

Interdental cleaning, therefore, is another crucial tool in the patient’s at-home armamentarium, considered, ‘[…] essential in order to maintain interproximal gingival health, in particular for secondary prevention […]’.1

In terms of whether to use interdental brushes (IDBs), floss, oral irrigators or wooden sticks, the current view tends towards the use of brushes: ‘Evidence suggests that inter-dental cleaning with IDBs is the most effective method for interproximal plaque removal. IDBs were consistently associated with higher levels of plaque removal when compared to flossing and the use of wood sticks. No comparisons are available from meta-analyses evaluating oral irrigators and information pertaining to reductions in gingival inflammation is limited. The superiority of IDBs is related to the higher efficacy in plaque removal and to the high level of acceptance by patients, who perceive it as their preferred method.’1

Whichever interdental tool is chosen, it is imperative that the patient receives hygiene instruction as to their use, to avoid causing trauma to the gingival tissues.1

The use of a mouthwash as an adjunct the brushing and interdental cleaning may also help patients struggling to maintain a satisfactory level of oral health. Indeed, Chapple and colleagues (2015) wrote: ‘For the treatment of gingivitis and where improvements in plaque control are required, adjunctive use of antiplaque chemical agents may be considered.1

In 2015, Araujo and colleagues’ (2015) meta-analysis demonstrated the clinically-relevant benefits of an essential oil-containing mouthrinse in site-specific areas of the mouth, when used as an adjunct to mechanical cleaning over a six-month period.4

In addition, in 2016 Haas and colleagues investigated the effect of essential oil mouthwash on plaque, concluding: ‘Mouthwashes containing essential oils should be considered the first choice for daily use as adjuvants to self-performed mechanical plaque control.’5

Key elements to success

Offering one of the most recently published insights into the prevention of periodontal disease, the FDI’s white paper (2018) suggests: ‘Repeated and individualized OHI [oral hygiene instruction] are the key elements to achieve and maintain oral/periodontal health. Therefore, oral/periodontal health education should start early in the pre-school period. Proactive behaviour change is essential to achieve sustained improvements in periodontal health status. Patients should have access to regular professional care in order to get feedback on the efficiency of their daily oral hygiene measures.’3

QUESTIONS: 

References

  1. Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol 2015; 42 (Suppl. 16): S71-S76

  2. Kinane DF, Attström R. Advances in the pathogenesis of periodontitis. Group B consensus report of the fifth European Workshop in Periodontology. J Clin Periodontol 2005; 32(Suppl. 6): 130-1

  3. White Paper on Prevention and Management of Periodontal Diseases for Oral Health and General Health. FDI World Dental Federation 2018

  4. Araujo MWB et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. JADA 2015; 146(8): 610-622

  5. Haas AN. Essential oils-containing mouthwashes for gingivitis and plaque: Meta-analyses and meta-regression. Journal of Dentistry 2016; 55: 7-15