Prevention of periodontal diseases

This presentation includes various levels of preventive and strategies to be adopted based on the current scientific evidence

1. Newer strategies in prevention of periodontal disease Dr. Lakkireddy Vasavi reddy

2. Contents:

3. Introduction: Periodontal health across the human lifespan is a key component of oral health and an important component of general health and well-being for individuals and the population as a whole. Periodontitis affects more than 50% of the adult population and its severe forms affect 11% of adults, making severe periodontitis the 6th most prevalent disease of mankind. Such a high burden of disease and its social, oral and systemic consequences are compelling reasons for increased attention from individuals, professionals and public health officials.

4. Prevention: Prevention of periodontal disease encompasses a set of various actions which ultimately aim at preventing or controlling the disease. It may apply to any point of the disease process.

5. Objectives of prevention: To promote optimum health of periodontium To prevent initial lesions To intercept hard and soft tissue lesions already in progress in order to restore health and prevent further damage

6. Traditional approach:

7. Today’s approach:

8. Prevention in practice – forming a bridge to the patient: The strategy for the prevention at the patient level has to be global and comprehensive. Preventive interventions should be oriented towards influencing patient behavior.

9. Motivational interviewing: Motivational interviewing may be a useful tool for the clinician to assist the patient to adopt proper health behaviors (primary prevention) or to modify lifestyle and inappropriate behaviors (secondary and tertiary prevention). Motivational interviewing has been defined as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”. Motivational interviewing is designed as a brief, nonconfrontational, counseling method.

10. Preventive strategies :

11. Levels of prevention:

12. Levels of prevention:

13. Primary prevention

14. Health promotion: It is process of enabling people to increase control over and to improve health. It is not directed against any particular disease, but is intended to strengthen host through a variety of approaches like- a. Health education b. Nutritional intervention c. Environmental modification d. Lifestyle and behavior changes

15. Health education: Health education is fundamentally a learning process, which aims at favorable changing attitudes and influencing behavior with respect for health practices. Health education is vital for prevention. It is the channel for reaching the people and alerting them to the doctor’s services and to all other community health resources. True health education is an active process that involves changed behaviour. It can help to increase knowledge and to reinforce desired behaviour patterns

16. Educational aids:

17. Methods of health communication: Individual: Personal contact Home visits Personal letters Group: Lectures Demonstrations Discussions Mass approach: radio, television, posters, internet, printed material, direct mailing, posters, health museums and exhibition s and folk methods

18. Trends in mass approach: It is suggested to use current trending social media like twitter and Instagram with hashtags ( for e.g. #my healthy gums#) and develop a campaign to motivate and educate the public.

19. Specific protection: To avoid disease altogether is the ideal but this possible only in a limited number of cases. The following are some of the currently available intervention aimed at specific protection – a. Immunization b. Chemoprophylaxis c. Protection against occupational hazards d. Use of specific nutrients

20. Disclosing agents: Disclosing agents can be used in oral health prevention programs, both for more effective guidance on the use of oral hygiene tools and for their evaluation. Nepale et al. studied the role of disclosing agents in asseing patient compliance through a prospective study and concluded that it improves the quality of daily oral hygiene practice and home care study by lee et al in 2018 concluded that the correlations between the plaque indices measured for each tooth surface area using QLF-D and the clinical indices assessed were significantly high, and it allowed objective determination of the gingival status

21. Primary Prevention : Patient level: Oral hygiene practices. Habits Diet Dentist level: Professional mechanical plaque removal Patient education and motivation.

22. Mechanical plaque removal: Natural cleaning of dentition is virtually non-existent, to be controlled, plaque must be removed frequently by active methods. Hence, the dental community continues to encourage proper oral hygiene and more effective use of mechanical cleaning devices

23. Tooth brush: During the past 50 years, oral hygiene has improved, and, in industrialized countries, 80–90% of the population brushes their teeth once or twice a day . Today, numerous manual toothbrush types are available. However, there is still insufficient evidence that one specific toothbrush design is superior to another. Modern toothbrushes have bristle patterns that are designed to enhance plaque removal from hard-to-reach areas of the dentition, particularly proximal areas.

24. Powered tooth brush:

25. Ultrasonic tooth brush Emident is the first ultrasonic toothbrush generating ultrasound with its patented ultrasonic microchip embedded inside brush head. Chip creates up to 96 million ultrasonic impulses per min transmitted via bristles, together with nano bubble toothpaste into gums and teeth. It can be used effectively in individuals undergoing orthodontic treatment. Also, it is gentle enough to use immediately after oral surgery including implants, avoiding damage to teeth and gums and is painless on sensitive teeth and gums.

26. Ionic tooth brush:

27. Super brush: It is a triple headed manual tooth brush in which three brush heads are combined together. It is designed such that when placed on the chewing surface, all the three surfaces of tooth are cleaned simultaneously. Dogan M chem, et al. concluded in his study that triple headed super brush could be an effective and cheaper alternative for use in children including disabled individuals.

28. Chewable brush: It is a miniature plastic moulded toothbrush which can be used when no water is available. Myoken et al. in 2005 investigated the effectiveness of the chewable toothbrush in a care-dependent elderly populationand concluded that chewing the brush results in the removal of a significant amount of plaque. Bezgin et al. in 2015 also conducted a pilot study on the effectiveness of chewable brush in removing plaque in children and concluded that chewable brush may be an appropriate oral hygiene adjunct for school children, including children with disabilities.

29. Laser tooth brush: . Ko et al. in 2014 and Yaghini et al. in 2015 tested the efficacy and the safety of a low-level laser-emitting toothbrush on the management of dentinal hypersensitivity and concluded that the use of the low-level laser-emitting toothbrush is a safe and effective treatment option for the management of dentinal hypersensitivity. Beam brush: Beam brush can collect up to 3 weeks brushing data & upload it wirelessly on android mobile that can be sent or shared with the dentist or can be recorded for subjects own regular check purpose. Along with tracking record for oral health it use all active two-minute brushing with quadrant indicator which is helpful in oral health information

30. Foam brush: Foam brushes resemble a disposable soft sponge soaked in chlorhexidine on a stick. They are used in particular for oral care in medically compromised and immunocompromised patients to reduce the risk of oral and systemic infection Towelettes: Finger brushes are mounted on the index finger of the brushing hand, and the agility and sensitivity of the finger are used to clean the teeth.

31. Pre brushing rinse: Binney et al. examined the effectiveness of rinsing before brushing on plaque removal. Water served as a negative control and was used as a both a pre-brushing rinse and while toothbrushing. Rinsing with water and then brushing with water removed more plaque than any other combination of pre brushing mouth rinse and dentifrice.

32. Brushing techniques:

33. Filament design: Manual toothbrushes with cut filament ends resulted in significantly greater gingival lesions than rounded ends (Breitenmoser et al. 1979). Non-end-rounded filament turn out to be about twice as abrasive to soft tissues as rounded filament tips (Alexander et al. 1977). Shory, et al. found the Collis curved brush, with two short middle rows and curved outer rows. Williams and Schuman[19] had found that handicapped children were able to remove more lingual plaque with this curved brush.

34. Brushing time, frequency, force:

35. Tongue cleaner: Tongue cleansing reduces the number of organisms, thereby controlling oral malodor (Van der Sleen et al. 2010). Combining tooth brushing with tongue cleaning significantly reduced tongue coating; however, there appeared to be insufficient evidence to recommend frequency, duration, or delivery method of tongue cleaning (Kuo et al. 2013).

36. Interdental aids: A fundamental principle of prevention is that the effect is greatest where the risk of disease is greatest.

37. Floss:

38. Wooden tips:

39. Interdental brush: The systematic review by Slot et al. (2008) highlights the effectiveness of inter-dental brushes as an adjunct to toothbrushing for plaque removal in adult patients. The evidence derived from this review supports recommendations by dental care professionals for their patients to use inter-dental brushes in addition to toothbrushing since it reduces dental plaque (Rasines 2009). Moderate evidence was available for the efficacy of interdental brushes in addition to toothbrushing as compared with toothbrushing alone.

40. Oral irrigator:

41. Newer aids: New inter-dental cleaning products have become available since the systematic reviews reported in this meta-review were conducted. They comprise new developments in oral irrigation devices with respect to the characteristics of the spray and the design of the nozzles (Sharma et al. 2012), as well as an inter-dental device constructed of a plastic core with soft elastomeric fingers protruding perpendicularly (Yost et al. 2006, Abouassi et al. 2014).

42. Chemical plaque control:

43. Dentifrice: The addition of abrasives supposedly facilitated plaque and stain removal. Study by Jayakumar et al. (2010), a 9% difference in plaque removal, in favour of the non-dentifrice group, was observed. The results of a recent study by Rosema et al. (2013) showed a difference in plaque removal of 2% in favour of the nondentifrice group. American DentalAssociation (ADA) Division of Science (ADA 2001), accepts that “plaque removal is minimally associated with abrasives.” The effectiveness of plaque removal during tooth brushing with dentifrice appears to be essentially a function of the access of brush filaments, rather than dentifrice abrasives (Creeth et al. 2009). Dentifrice is, however, able to carry a multitude of different chemotherapeutic ingredients. Fluoride toothpaste is the most widespread and significant form of fluoride used globally and the most rigorously evaluated vehicle for fluoride use (Benzian et al. 2012).

44. Plaque disclosing dentifrice:

45. Dentifrobots Nanorobotic dentifrice could patrol all supragingival and subgingival surfaces, metabolizing trapped organic matter into harmless, vapours and performing continuous calculus debridement. 103-105 nanodevices per oral cavity crawl at 110 microns/sec. The invisible, inexpensive devices would safely deactivate themselves if swallowed. They destroy only pathogenic bacteria allowing 500 harmless species to flourish in ecosystem.

46. Petite Particle For Perfect Plaque Rapidly advancing “Nanodentistry” will make possible the maintenance of 'near- perfect Oral health' Innovation of 'Nano Hydroxyapatite crystals' a remineralising agent has shown strong propensity to adhere plaque bacteria in the oral cavity, facilitating easy removal. The remineralised zones also showed reduced plaque adherence and bacterial growth in vitro.

47. Nano drug delivery system : It is a novel method of targeted delivery system which is much researched in nanomedicine, recently striking the boundaries of dentistry. This could deliver the therapeutic agents in mouth rinses against specific pathogens. Marzeih et al in a study in 2013 used silver nano particles as active ingredient and concluded that it has high antinmicrobial properties even at low concentrations. Nurturing with Nature : Herbal and organic chemical plaque control is evidenced from chronicles. Essential oil extracts as a plaque control agent made gyration among the existing ones, where Listerine was the first to get its FDA approval. Time honoured ones are neem ( Azadirachta indica ), meswak ( Salvadora persica ), mango ( Mangifera indica ) extracts etc. Of late, in the queue are tea tree oil, aloe vera and propolis (bees wax), Green tea, Garlic (Allium sativum), onion (Allium cepa L), Triphala etc.

48. Biologic plaque control: Despite its important role in controlling gingival and periodontal disease, mechanical plaque control is not properly practiced by most individuals. Also, emergence of antimicrobial resistance is currently posing a major global challenge, with an increasing number of strains, including commensal and pathogenic oral bacteria, becoming resistant to commonly used antimicrobial agents. Therefore a newer approach for control of plaque has been suggested. Naoyuki Sugano in his review suggested Probiotics and Vaccines as two approaches for control of periodontal diseases.

49. Probiotics: It is an interesting new field of periodontology research that aims to achieve biological plaque control by eliminating pathogenic bacteria. Live micro-organisms which, when administered in aquate amounts, confer a health benefit on the host. Oral administration of lactobacillus species (LS1) has shown to prevent the colonization of periodontopathic bacteria like Actinomycetemcomitans , Porphyromonas gingivalis , Prevotella intermedia[

50. Periodontal vaccines: Various Virulence factors, one of which is cysteine proteinases (gingipains), have been reported to contribute to the pathogenicity of P. Gingivalis . Hence, Inhibition of gingipain by vaccination might reduce the periodontitis caused by P. gingivalis infection. In a study conducted by Yokoyama et al, Passive administration of Egg yolk antibody against gingipains ( IgY -GP) has shown significant reduction in amount of P.gingivilis . Application of this newer biological approach in children can be further studied.

51. No smoking strategies: Meta-analyses reported that the degree of success was related to the length of the intervention, with rates of 13.4% for brief intervention and 22.1% for intensive intervention

52. Diet recommendations of 2011 European workshop on Periodontology

53. Role of health care professional:

54. Professional mechanical plaque removal: One of the most commonly performed preventive measures in adults in countries with organized dental services is professional mechanical plaque removal (PMPR), with or without concomitant oral hygiene instructions (OHI). PMPR comprises supra-gingival and sub-marginal plaque and calculus removal using hand instruments (scalers, curettes), or powered instruments (sonic, ultrasonic, rotating devices, air polishing). The intention is to remove deposits from the tooth surface, extending into the gingival sulcus. This is done to allow adequate patient-performed oral hygiene

55. Correction of malaligned teeth: primary prevention also includes the correction of mal aligned teeth.

56. Role in education and motivation: The patients must be told and shown that the periodontal disease is insidious and usually asymptomatic. The precise status of his own periodontal health should be explained to him. The recommendations for plaque control instruction should include: Patient education. Patient motivation. Patient instructions. Encouragement and reinforcement.

57. Secondary prevention

58. Secondary prevention: It includes early diagnosis and prompt treatment. Regular PMPR with respect to secondary prevention. Life-long individualized supportive periodontal care based through an efficient recall system may be necessary, in order to establish the prerequisites for secondary prevention. Risk assessment tools may help to group patients in different risk levels, and predict the probability of disease recurrence, yet until today their clinical benefits have not been proven at an individual level

59. Early diagnosis: The first two aspects of prevention, prevention of occurrence and prevention of progression, are closely linked. In order to evaluate the effectiveness of prevention or to determine the need for more aggressive measures, early recognition of disease patterns is necessary. Signs and symptoms of disease- One of the most reliable clinical signs of gingival inflammation remains the bleeding response of the gingiva following gentle probing. While bleeding on probing has approximately a 30% predictive power for future loss of attachment, the negative predictive power of 98% makes bleeding following probing a very useful tool

60. Diagnostic tools:

61. Periodontal screening and recording: Developed by American academy of periodontology. By following the recommendations of the Periodontal Screening and Recording system, the practitioner can focus on those areas that begin to present evidence of inflammation and follow the progress of therapy to completion.

62. PMPR Regular PMPR with respect to secondary prevention includes the same measures as in primary prevention accompanied by evaluation of oral hygiene, and if necessary reinforced OHI. It also encompasses subgingival debridement to the depth of periodontal pocket. Repeated periodontal examinations of residual pockets are necessary for the early detection of deepening pockets (probing depth ≥ 5 mm) that require active therapy. At each appointment, patients should be educated about a healthy lifestyle and smoking cessation45,46.

63. Risk assessment tools: Different individuals demonstrate varying susceptibility to onset and progression of periodontitis ( Loe et al. 1986). It is important to note that in general, prediction tools based on risk factors allow the grouping of patients according to different levels of average risk, they do not however allow the accurate prediction of individual patient outcomes (prognosis). Previous literature shows that risk factors and combinations thereof typically have poor performance for individual risk prediction (Wald et al. 1999, 2005). Nonetheless, 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 ( Rosling et al. 2001).

64. Tertiary prevention: It includes mainly disability limitation and rehabilitation . Supportive periodontal therapy can be a part of tertiary prevention. Disability limitation is mainly directed at reduction of infection, resolution of inflammation, reduction of tooth mobility and prevention of tooth loss. These measures include- Deep curettage. Root planing Splinting Mucogingival and periodontal surgery including crown lengthening procedures, gingivoplasty , osseous recountering , ostectomy and treatment of furcation involvement and root amputation. Cosmetic procedures such as ridge augmentation, subepithelial connective tissue or free gingival grafts and lateral repositioning or pedicle grafts. Regenerative therapies including osseous grafting, GTR growth factors, enamel matrix proteins, etc. Endodontic therapy Selective extractions.

65. Newer trends in treatment : 1. Extracorporeal shock wave therapy 2. Photodynamic therapy 3. Electrical stimulation on osteogenesis of alveolar bone 4. Ultrasonic vibrations 5. Biofilms and bioelectric effect 6. Control of subgingival biofilm with fine grain glycine powder polishing 7. Hyperbaric oxygen therapy 8. Topical and systemic administration of simvastatins. 9. Local and systemic use of bisphosphonates   10. Use of Teriparatide 11. Use of antibiotics as monotherapy 12. Use of herbs, fruits, flowers, foods to resolve inflammation and improve regeneration 13. Gene therapy 14. Use of stem cells 15. Nanotechnology 16. Use of newer molecules to resolve inflammation 17. Therapeutic approaches recently available to control inflammation and bone resorption.

66. Supportive periodontal therapy: Compliance with suggested supportive periodontal treatment schedules. The first study on the degree of compliance with supportive periodontal treatment was published in 1984 (Wilson et al). It reviewed all the patients whose progress could be followed after treatment for periodontitis in a private periodontal office of approximate 1000 patients followed for up to 8 years, only 16% complied with suggested SPT intervals, 34% never came back for maintenance, and the rest complied erratically. In a follow up study for 5 years, the tooth loss was surveyed (non-compliers were not included). Tooth loss frequency was zero teeth per year for complete compliers and 0.06 teeth per patient per year for erratic compliers.

67. Rehabilitation:

68. Compliance:

69. Compliance in periodontics: Strack et al. found that 51% of patients given oral hygiene instructions were in the “high compliant” group; 38% were “moderately compliant,” and 11% “noncompliant” 30 days after instruction. In some surveys the use of a disclosing agent erythrosin was found helpful in improving the efficacy of plaque removal. The use of mechanical toothbrushes has shown an increase of efficiency (decreased Plaque Index score) of 10% in one study. Other groups have suggested that the patients’ beliefs about their health significantly affect compliance or the lack thereof. Stressful life events may also reduce compliance.

70. Why do patients fail to comply?

71. Methods of improving compliance:

72. Conclusion:

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76. Thank you