European workshop on periodontology consensus conference. J Clin Periodontol ... Results: This workshop calls for renewed emphasis on the prevention of.
J Clin Periodontol 2015; 42 (Suppl. 16): S1–S4 doi: 10.1111/jcpe.12382
Primary and secondary prevention of periodontal and peri-implant diseases
Maurizio S. Tonetti1, Iain L. C. Chapple2, Søren Jepsen3 and Mariano Sanz4 1
European Research Group on Periodontology, Genova, Italy; 2Periodontal Research Group & MRC Centre for Immune Regulation Birmingham Dental School, Birmingham, UK; 3Department of Periodontology, Operative and Preventive Dentistry, University of Bonn, Germany; 4 Faculty of Odontology, University Complutense of Madrid, Spain
Introduction to, and objectives of the 11th European Workshop on Periodontology consensus conference Tonetti MS, Chapple ILC, Jepsen S, Sanz M. Primary and secondary prevention of periodontal and peri-implant diseases–Introduction to, and objectives of the 11th European workshop on periodontology consensus conference. J Clin Periodontol 2015; 42 (Suppl. 16): S1–S4. doi: 10.1111/jcpe.12382.
Abstract Background: Periodontitis prevalence remains high. Peri-implantitis is an emerging public health issue. Such a high burden of disease and its social, oral and systemic consequences are compelling reasons for increased attention towards prevention for individuals, professionals and public health officials. Methods: Sixteen systematic reviews and meta-reviews formed the basis for workshop discussions. Deliberations resulted in four consensus reports. Results: This workshop calls for renewed emphasis on the prevention of periodontitis and peri-implantitis. A critical element is the recognition that prevention needs to be tailored to the individual’s needs through diagnosis and risk profiling. Discussions identified critical aspects that may help in the largescale implementation of preventive programs: (i) a need to communicate to the public the critical importance of gingival bleeding as an early sign of disease, (ii) the need for universal implementation of periodontal screening by the oral health care team, (iii) the role of the oral health team in health promotion and primary
Key words: clinical recommendations; consensus conference; evidence based medicine; gingival bleeding; gingivitis; health policy; peri-implant mucositis; peri-implantitis; periodontitis; prevention; public health Accepted for publication 31 December 2014
Conflict of interest and source of funding statement Workshop participants filed detailed disclosure of potential conflict of interest relevant to the workshop topics and these are kept on file. Declared potential dual commitments included having received research funding, consultant fees and speakers fee from: Colgate-Palmolive, Procter & Gamble, Johnson & Johnson, Sunstar, Unilever, Philips, Dentaid, Ivoclar-Vivadent, Heraeus-Kulzer, Straumann. Funds for this workshop were provided by the European Federation of Periodontology in part through unrestricted educational grants from Johnson & Johnson and Procter & Gamble. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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and secondary prevention, (iv) understanding the limitations of self-medication with oral health care products without a diagnosis of the underlying condition, and (v) access to appropriate and effective professional preventive care. Conclusions: The workshop provided specific recommendations for individuals, the oral health team and public health officials. Their implementation in different countries requires adaptation to respective specific national oral health care models.
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. It encompasses healthy gingivae and periodontal attachment in the natural dentition and also the health of their equivalent structures around dental implants: the periimplant mucosa and the peri-implant alveolar bone. The vast majority of periodontal and peri-implant diseases are initiated by the accumulation of microbial biofilms on hard, nonshedding surfaces, that is teeth or dental implants. These cause local inflammatory reactions in the marginal soft tissues (gingivae and periimplant mucosa). If the biofilms are not regularly dispersed or disrupted by self-performed oral hygiene measures, they become dysbiotic as local conditions favour the emergence of pathogenic species that lead to chronicity of soft-tissue inflammation (gingivitis and peri-implant mucositis). In susceptible individuals, the persistence of gingivitis and periimplant mucositis leads to the development of periodontitis and peri-implantitis respectively. 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. The increased use of dental implants for replacement of missing teeth has created a new disease burden in the form of peri-implant diseases, with contemporary research estimating a 43% prevalence of peri-implant mucositis and a 22% prevalence of periimplantitis. 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.
The objective of this Workshop was to discuss the available scientific evidence from systematic evaluation of the research base, and to provide a consensus on preventive efforts with an emphasis on patient delivered, as well as professional interventions by the oral health care team.
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Prevention Rather than Repair
Traditional models of oral health care provision have involved the repair and restoration of tissues, following disease onset. Thus, diagnoses were formulated with invasive therapeutic interventions in mind, consistent with a surgical philosophy to oral care. A preventive approach to care requires diagnosis, education and motivation towards behaviour change, with patients taking greater responsibility for their own health under the guidance of and with support from the oral care team. Professional preventive measures need to be personalized to the individual patient, based upon clinical findings and lifestyle factors. This requires diagnosis to stratify subjects into: (i) periodontally healthy, (ii) gingivitis (peri-implant mucositis) and (iii) periodontitis (peri-implantitis) as well as risk assessment for future status. Validated periodontal screening methods are now a fundamental requirement for all patients, given the high prevalence of periodontal and peri-implant conditions and should be applied universally. Specific recommendations
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An appropriate periodontal diagnosis alongside assessment of patient-level factors (risk factors and attitudes) should determine the selection of the most appropriate type of professional preventive care.
Professional mechanical plaque removal as the sole element of professional preventive care is inappropriate since education and behaviour change are fundamental to sustained improvements in health status. Professional preventive care alone is inappropriate in subjects with a clinical diagnosis of periodontitis or peri-implantitis, as they require treatment for their condition.
Management of Gingival/Peri-Implant Inflammation
Chronic gingival inflammation in response to microbial biofilms is considered the key risk factor for the onset of periodontitis, or its progression in treated patients. Prevention and treatment of gingival inflammation are essential for the prevention of periodontitis. Peri-implant diseases are highly prevalent and it is imperative for the clinician to examine and evaluate patients who have been provided with implant-supported restorations on a regular basis. Control/management of risk factors for periodontitis (and periimplantitis) such as tobacco smoking and diabetes are an integral part of primary and secondary preventive approaches. Specific recommendation
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Gingival (peri-implant mucosa) bleeding is the main risk factor for the onset and progression of periodontitis (peri-implantitis) and the first sign of disease. Public health campaigns, professional information and labelling of oral health care products should highlight this and encourage professional diagnosis whenever
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
11th European Workshop on Periodontology gingival bleeding is present and persists.
Mechanical Plaque Control
Mechanical plaque removal remains the foundation stone of successful periodontal and peri-implant therapy. However, professional plaque removal is ineffective longer term without high standards of daily patient-delivered oral hygiene. The latter requires a patient-centred approach to education, motivation and sustained behaviour change, as well as good knowledge of the most effective methods of plaque removal from the marginal, sub-marginal and interproximal areas of teeth and implants. Specific recommendation
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Patient motivation alongside the choice of, and instruction in the use of mechanical plaque control aids is best performed by the oral health care team
Chemical Plaque Control
The use of adjunctive chemical approaches to biofilm control may be considered in support of mechanical plaque removal protocols, but it is not a suitable substitute for the latter, or a more time efficient method for effective biofilm control. When considering adjunctive chemical agents for controlling plaque and/or gingival inflammation it is important that the clinician is aware of the evidence base for such agents, their side effects and any environmental impact. Specific recommendation
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The public should be aware that self-medication with effective chemical plaque control agents may mask more serious underlying periodontal disease and should seek professional advice following periodontal examination.
Secondary Prevention of Periodontitis
Secondary prevention of periodontitis aims at preventing disease recurrence
in patients previously treated for periodontitis and hence, secondary prevention programs are targeted to a high-risk group as evidenced by a previous diagnosis of periodontitis (peri-implantitis). Patients should enter a secondary prevention program once they have completed the active phase of therapy and the endpoints of therapy have been reached. These patients must follow a specific supportive periodontal care regimen. It is recognized that secondary prevention of peri-implantitis poses unique challenges that may only be partially addressed by routine supportive periodontal care programs. Specific recommendations
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Long-term success of periodontal therapy requires participation in a secondary prevention program specifically designed to meet the needs of those individuals at higher risk of disease recurrence. For optimal long-term tooth retention, patients participating in secondary prevention programs require completion of an active phase of periodontal therapy that achieves individually set treatment goals.
Management of Gingival Recession, Non-carious Cervical Lesions and Dentine Hypersensitivity in the Context of Secondary Prevention
After successful treatment of periodontitis a degree of recession of the gingival margin frequently occurs. The resulting exposure of a portion of the root-surface poses challenges for long-term management and secondary preventive efforts and may lead to plaque accumulation and gingival inflammation. Moreover, the loss of hard tissue from the cervical region of a tooth that is not related to caries, may lead to dentine hypersensitivity that may complicate secondary prevention. Following professional diagnosis of dentine hypersensitivity, potential aetiological factors should be addressed, including a dietary record and medical history questionnaire to assess frequency of exposure to acid. Appropriate advice should be given and referral may be required.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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Specific recommendation
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Before implementing any specific treatment for dentine hypersensitivity, the dentist should first confirm the diagnosis of dentine hypersensitivity.
Management of Oral Malodour
Oral health care professionals (within their scope of practice as dictated by the professional legal authority) should be aware of the fundamental basis of halitosis and that they have the primary responsibility for its diagnosis and management. Only a limited number of patients with extra-oral halitosis and halitophobia (
