Periodontal disease: causes, risk factors and prevention

Periodontal disease: causes, risk factors and preventions

Johnson & Johnson Ltd. is delighted to bring you this article, with the aim of supporting the ongoing Enhanced 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 [email protected]

Learning Outcomes: A | B | C | D

Aims & Objectives

The aim of this article is to consider the current evidence base in relation to periodontal disease, as well as exploring when to intervene, how to share the information with patients to best effect, and how progress can be monitored for improved outcomes.

On completing this Enhanced CPD session, the reader will:

  1. Understand the main cause of periodontal disease and how it may progress from gingivitis to periodontitis
  2. Understand that plaque biofilm disruption is an effective way to treat and prevent periodontal disease
  3. Understand the limitations of mechanical cleaning (brushing and interdental cleaning) in some patients in specific circumstances and how to bridge that gap
  4. Understand the role of the Basic Periodontal Examination (BPE) and how to use it properly
  5. Understand the importance of giving patients the information they need, in a way that they can understand, to enable them to make informed decisions about their oral health.

This article considers the current evidence base in relation to periodontal disease, as well as exploring when to intervene, how to share the information with patients to best effect, and how progress can be monitored for improved outcomes.

Intro page image

Plaque is a major cause of periodontal disease, with Page and Kornman (1997)stating that: ‘Experts agree that human periodontitis is initiated and perpetuated by a small group of predominantly gram-negative, anaerobic or microaerophilic bacteria that colonize the subgingival area. '1

In 2016, Scully added to the evidence base, writing, ‘It is estimated that 80% of the periodontal tissue damage is due to an inappropriate host response to pathogenic bacteria. '2

It is also important to note that although gingivitis and periodontitis are a continuum of the same inflammatory disease,3 gingivitis will not always progress to periodontitis.4

Plaque biofilm is present on all surfaces in the oral cavity,5 however oral plaque biofilm disruption is an effective way to treat and prevent periodontal disease.3

Recognising this preventive opportunity, Chapple and colleagues (2015) stated, ‘…management of gingivitis is both a primary prevention strategy for periodontitis and a secondary prevention strategy for recurrent periodontitis.'4

Using the BPE

In 2019, Dietrich and colleagues considered periodontal diagnosis in the context of the 2017 classification system of periodontal diseases and conditions and its implementation in clinical practice.6

Offering an overview of the implementation process, they wrote: ‘Comprehensive oral health assessment of any patient includes a periodontal assessment. This will typically commence by screening for periodontal diseases using a system like the Basic Periodontal Examination (BPE) and, if applicable, a full diagnostic workup/periodontal assessment.'6

According to the British Society of Periodontology (BSP) BPE guidelines, ‘The BPE is a simple and rapid screening tool that is used to indicate the level of further examination needed and provide basic guidance on treatment needed. These BPE guidelines are not prescriptive but represent a minimum standard of care for initial periodontal assessment. BPE should be used for screening only and should not be used for diagnosis.’7

The BSP further indicates, ‘The clinician should use their skill, knowledge and judgment when interpreting BPE scores, taking into account factors that may be unique to each patient. Deviation from these guidelines may be appropriate in individual cases, for example where there is a lack of patient engagement. […] The BPE scores should be considered together with other factors when making decisions about referral….’7

The BSP guidelines also offer practical help in relation to using the BPE, stating that it requires a WHO periodontal probe, which has a ball-shaped tip 0.5mm in diameter and a narrow shaft marked with black a line between 3.5mm and 5.5mm from the tip.7

Recording the BPE in adults is as follows:7

  1. The teeth are divided into six sextants – upper right, upper anterior, upper left, lower right, lower anterior and lower left
  2. All teeth in each sextant are examined, except for 3rd molars (unless the 1st and / or 2nd molar(s) is / are missing). For a sextant to qualify for examination, at least two natural teeth must be present.
  3. The probe is ‘walked’ around the pockets / sulcus in all qualifying sextants, with the clinician recording the highest score in each. A light probing force of 20-25g should be used.


Where a score of 4 is recorded, all areas in the sextant should be examined, to ensure furcation involvements are not overlooked and to gain a better understanding of the patient’s periodontal health.7

In terms of scoring, the BSP’s guidance indicates offers a simple system:7

  1. 0 – pockets <3.5mm, no calculus/overhangs, no bleeding on probing (black band entirely visible)
  2. 1 – pockets <3.5mm, no calculus/overhangs, bleeding on probing (black band entirely visible)
  3. 2 – pockets <3.5mm, supra or subgingival calculus/overhangs (black band entirely visible)
  4. 3 – probing depth 3.5mm to 5.5mm, black band partially visible, indicating pocket of 4-5mm
  5. 4 – probing depth >5.5mm, black band disappears, indicating a pocket of 6mm or more.
  6. * – furcation involvement.


When it comes to translating these scores into real-world care, the guidance suggests:7

  1. Code 0 – no need for periodontal treatment
  2. Code 1 – provide oral hygiene instruction
  3. Code 2 – provide oral hygiene instruction and remove plaque retentive factors, including both supragingival and subgingival calculus
  4. Code 3 – provide oral hygiene instruction, remove plaque retentive factors (including both supragingival and subgingival calculus), and perform root surface debridement if appropriate
  5. Code 4 – provide oral hygiene instruction and perform root surface debridement where required. In addition, assess the need for more involved treatment, for which referral to a specialist may be appropriate.
  6. * – Treat in line with BPE codes 0 to 4, as well as assessing the need to perform more complex dentistry, perhaps via a referral.

Working towards periodontal health

At the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions, working group 1 concluded that there are four levels of periodontal health:8

  1. Pristine periodontal health, defined as a total absence of clinical inflammation and physiological immune surveillance on a periodontium with normal support (no attachment or bone loss). Pristine periodontal health is not likely to be observed clinically
  2. Clinical periodontal health, characterized by an absence or minimal levels of clinical inflammation in a periodontium with normal support
  3. Periodontal disease stability in a reduced periodontium
  4. Periodontal disease remission / control in a reduced periodontium


In seeking improvement in relation to periodontal health, Chapple and colleagues (2015) words are significant, in that, ‘Plaque removal and/or control is […] fundamentally important in the prevention of periodontal diseases.’4

However, brushing the teeth with a fluoridated toothpaste alone may be insufficient to prevent periodontal disease in some patients. This shortfall may be bridged by using interdental brushes or floss to remove interdental plaque, according to the FDI’s White Paper on Prevention and Management of Periodontal Diseases for Oral Health and General Health (2018).9

In addtion, the FDI’s 2018 paper went on to suggest, ‘…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.’9

Patient communication

The General Dental Council (GDC) requires dental professionals to, ‘Communicate effectively with patients – listen to them, give them time to consider information and take their individual views and communication needs into account.’10

They must also give patients the information they need, in a way that they can understand, to enable them to make informed decisions about their oral health.10

This may seem easier said than done, however one effective communication tool for use in dentistry is that of CLASS – Context, Listening, Acknowledgement, Strategy and Summary.11

Together they can help to elicit information from the patient in an effective way:

  1. Context – the structure for discussion between parties, which may involve providing an empathetic setting, maintaining eye contact, and making deliberate use of positive body language.11
  2. Listening – this involves making a ‘…concerted effort to listen to the way the words are said, to recognise the feelings underlying the spoken word and to be aware of what the patient has left out of their narrative.’11
  3. Acknowledgment – of both the clinician’s and patient’s feelings and thoughts. An important element of this involves concentrating on how the dental professional reacts to what the patient has shared, as it has been shown that the clinician’s behaviour can influence care / treatment outcomes. In addtion, connecting with patients by means of empathy, for instance, has been show to ‘pay dividends’.11,12
  4. Strategy – this clarifies what the patient has expressed both verbally and non-verbally, taking into account, for example, their hopes and emotions about dental treatment, to help create a satisfactory oral health care plan.11
  5. Summary – the dental professional sums up what is needed going forward, which may involve some oral health instruction.11

Intro page image

Preventing disease progress

In 2021, Forshaw and Taylor wrote: ‘If left to progress untreated, periodontal disease can have serious effects on a patient’s quality of life. With a rapidly growing body of evidence linking poor periodontal health to several systemic conditions, [it is] essential that this globally prevalent disease is managed effectively.’13

They continued: ‘To halt the progression of periodontal disease, accurate diagnosis is essential. The Basic Periodontal Examination (BPE) is a quick, effective screening tool, and while it should not be used for diagnosis, [it] is useful both in providing direction for treatment, and indicating whether additional investigation is appropriate.’13

As for communicating effectively with patients, to help them with their oral health endeavours at home, according to Jönsson and Abrahamsson (2020), ‘…it is possible to support patients to overcome behavioural obstacles in the establishment of proper self‐performed periodontal infection control by applying a person‐centred care approach and by using behavioural change techniques in oral health education.’14

Reinforcing this idea, Newton and Asimakopoulou (2018) wrote: ‘It is widely acknowledged that the maintenance of periodontal health is critically dependent upon the behaviour of the patient, both in terms of the practice of good oral hygiene and in treatment seeking when disease exists. It is therefore incumbent on those dental healthcare professionals working with patients susceptible to periodontal disease to provide evidence-based advice regarding the actions patients should take to maintain their oral health, within a communication framework that maximises the likelihood that patients will follow those recommendations.’15



  1. Page RC, Kornman KS. The pathogenesis of human periodontitis: an introduction. Periodontology 2000 1997; 14: 9-11

  2. Scully C. Churchill's Pocketbooks. Clinical Dentistry. Churchill Livingstone, 4th edition, 2016; 465

  3. 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): 130-131

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

  5. Sanz M et al. Role of microbial biofilms in the maintenance of oral health and in the development of dental caries and periodontal diseases. Consensus report of group 1 of the Joint EFP/ORCA workshop on the boundaries between caries and periodontal disease. J Clin Periodontol 2017; 44 (Suppl 18): S5-S11

  6. Dietrich T et al. Periodontal diagnosis in the context of the 2017 classification system of periodontal diseases and conditions – implementation in clinical practice. BDJ 2019; 226(1): 16-22

  7. Basic Periodontal Examination (BPE). British Society of Periodontology 2019. Accessed 17 February 2021

  8. Lang NP, Bartold PM. Periodontal health. J Clin Periodontol 2018; 45(Suppl 20): S9-S16

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

  10. Standards for the dental team. General Dental Council 2016; Standard 2.1. Accessed 17 February 2021

  11. Freeman R. Communicating effectively: some practical suggestions. BDJ 1999; 187(5): 240-244

  12. Frankel RM, Sherman HB. The secret of the care of the patient is in knowing and applying the evidence about effective clinical communication. Oral Diseases 2015; 21: 919-926

  13. Forshaw E, Taylor J-A. The understanding of the basic periodontal examination amongst final year undergraduate students: a survey. BDJ Team 2021; 8: 40-45.

  14. Jönsson B, Abrahamsson KH. vercoming behavioral obstacles to prevent periodontal disease: behavioural change techniques and self‐performed periodontal infection control. Periodontology 2000 2020; 84:134–144. Doi: 10.1111/prd.12334

  15. Newton JT, Asimakopoulou K. Behavioural models for periodontal health and disease. Periodontology 2000 2018; 78: 201-211. Doi: 10.1111/prd.12236