The Prevention of Periodontal Disease-An Overview: Frank A. Scannapieco - Eva Gershovich
The Prevention of Periodontal Disease-An Overview: Frank A. Scannapieco - Eva Gershovich
The Prevention of Periodontal Disease-An Overview: Frank A. Scannapieco - Eva Gershovich
12330
REVIEW ARTICLE
Correspondence
Frank A. Scannapieco, Department of Oral Biology, University at Buffalo, The State University of New York, Foster Hall, Buffalo, NY 14214, USA.
Email: fas1@buffalo.edu
1 | I NTRO D U C TI O N etiology of periodontal disease, a subject that has evolved over the
past decades. While a complete description of this topic is beyond
It is widely accepted that the most common and important diseases the scope of the present article, an excellent summary is provided
of the oral cavity (gingivitis and periodontitis, dental caries, and oral in this volume of Periodontology 2000.1 Briefly, there is no doubt
cancer) are preventable. Based on a large body of scientific evidence, that most cases of periodontal disease are driven by exposure of
a number of preventive strategies exist, that, if routinely implemented, the host periodontal tissues to the microflora that adheres to teeth
will prevent these diseases in most individuals. Unfortunately, while in the form of a biofilm, long referred to as dental plaque. Bacteria
most preventive strategies are theoretically simple to understand, they (and probably other microbes, including viruses, fungi, and parasites)
are often difficult to employ in practice at individual and public health interact with each other and with the host. With time, a resulting
levels. There are many complex reasons that may help explain why dysbiotic microbiome, together with dysregulated host inflamma-
prevention of oral diseases is difficult, especially in certain vulnerable tion, fosters the growth of selected microbes within the biofilm to
populations. It is the purpose of this volume of Periodontology 2000 to produce substances that exacerbate inflammation, which in some
review a variety of concepts, both old and new, on periodontal disease subjects results in tissue destruction and tooth loss. Based on this
prevention to allow the reader to understand more clearly the complex- understanding, prevention of periodontal diseases is predicated
ities that impede the implementation of preventive strategies for the primarily on removing and preventing the formation of biofilm, and
individual patient and at the public health level. It is our hope that after secondarily on tempering inflammation.
reading this volume, the practitioner will have improved their under- Although there is no question that specific groups of oral bacteria
standing of periodontal disease prevention in order to better educate that populate dental plaque play a causative role in the development
their patients and incorporate evidence-based preventive strategies of periodontitis, it is now thought that once the disease has been trig-
in their practice to help prevent these costly and impactful diseases. gered, other factors play an equal, and possibly more important, role
Such action will save patients not only pain and suffering, but also their in the progression of periodontitis, particularly in severe periodon-
hard-earned assets! It is also our hope to educate the scientific commu- titis or in cases of periodontitis that prove difficult to treat. Once
nity about those remaining critical questions that need to be answered exposed to oral periodontal pathogenic bacteria, the host mounts a
through new research efforts to provide a clearer understanding of the defense response mediated largely through the innate immune sys-
etiology of periodontal disease, from the molecular pathways that lead tem. 2,3 A critical cell type in the host response, polymorphonuclear
to disease, to cutting edge and novel strategies that will prevent the neutrophils, can upregulate the production of pro-inflammatory
initiation and progression of periodontal diseases in most individuals. cytokines, matrix metalloproteinases, and reactive oxygen species,
all of which contribute to increased oxidative stress and the tissue
damage that occurs in periodontitis. An article in this volume of
2 | E TI O LO G Y O F PE R I O D O NTA L D I S E A S E Periodontology 2000 discusses the characteristics of oxidative stress
and its effects on the periodontium and examines approaches that
Before we discuss preventive approaches for periodontal diseases, attenuate the effects of reactive oxygen species, thereby potentially
we first must briefly summarize the present understanding of the preventing the initiation of progression of periodontal disease.3 For
© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
example, resveratrol (3,5,4′-trihydroxy-trans-stilbene), a natural phe- are also effective in reducing gingivitis, but to a lesser extent than
nol phytoalexin derived from a variety of plants in response to injury, interdental cleaning and chlorhexidine. Similarly, strong evidence is
may serve as an antioxidant to prevent disease. not yet available in support of other interventions, including flossing,
probiotics, nonsteroidal anti-inflammatory agents, and nutritional
supplements. Of course, while other interventions could indeed
3 | I NTE RV E NTI O N S PROV E N TO prove to be effective for preventing periodontal diseases, sufficient
PR E V E NT G I N G I V ITI S A N D PE R I O D O NTITI S evidence must be provided by conducting well-powered clinical
trials.
When contemplating writing this article, we began by posing a very Human tooth cleaning has been a common practice for millennia.
simple question to ourselves, namely “What preventive modalities However, until 100 years ago or so, people were probably motivated
have been unequivocally scientifically proven to prevent the initia- to clean their teeth to mitigate unpleasant discomfort in the form
tion (primary prevention) and progression (secondary prevention) of of bad breath (halitosis) and/or esthetic concerns, with a focus on
gingivitis and periodontitis?” To answer this question, we conducted the removal of food debris. Not until it was clearly understood that
a scoping review to identify published systematic reviews and meta- dental caries and periodontal diseases were a direct result of expo-
analyses that address the efficacy of strategies claimed as effective sure of the host tissues to microorganisms within dental plaque did
in preventing periodontal disease. The search was limited to sys- biologically based preventive strategies become apparent and rou-
tematic reviews of human adult patients with gingivitis (a definitive tine for most people by daily mechanical removal of plaque. The task
manuscript describing details of our search strategy and results is became easier for patients with the development of the nylon tooth-
now in preparation). Table 1 shows a simplified summary of many of brush13 (which is more sanitary and comfortable to use than brushes
the chemical and mechanical interventions that have been investi- made of natural materials), along with floss and widely available and
gated, over the years, for preventing periodontal diseases, and the inexpensive dentifrices. More recent innovations include interdental
relevant clinical outcome terms (plaque index, gingival inflammation, brushes to remove interproximal biofilms, topical rinses with anti-
bleeding score, and pocket depth). Multiple systematic reviews of microbial properties, and the electric toothbrush, to name a few.
clinical trials demonstrate that topical chlorhexidine gluconate 4,5 Together, these tools have made effective tooth cleaning possible
and adjunctive interdental brushing6,7 show the strongest capability, for most people. The strong evidence in support of contemporary
of all interventions tested, to reduce periodontal probing depth and practices for mechanical oral hygiene to prevent periodontal disease
signs of gingivitis. The evidence also suggests that cetylpyridinium is well summarized in this volume of Periodontology 2000.14 In addi-
8 9-11 12
chloride, essential oil mouthwash, and powered toothbrushing tion, several other articles are included that review newer chemical
or pharmacologic approaches that were developed with the purpose
TA B L E 1 Essential findings of chemical and mechanical of preventing periodontal inflammation or the formation of dental
interventions
plaque biofilm; these approaches include the use of natural prod-
Strength of ucts,14 the sustained release of soluble agents within the oral cav-
Intervention PI GI BS PD evidence ity,15 and probiotics16.
CHX + + + + Strong Despite the availability of so much information on how to pre-
CPC + + 0 0 Strong vent periodontal diseases, many people still struggle to maintain oral
EOMW + + + 0 Strong hygiene at a level sufficient to prevent such diseases. Patients’ lack
of knowledge or skill with the proper use of an oral hygiene device, a
Powered brushing + + 0 0 Strong
lack of appreciation of the time needed to perform thorough clean-
Zinc/citrate dentifrice + + + 0 Weak
ing, and in some cases downright apathy and no oral hygiene at all, as
Interdental cleaning + + + + Strong
well as the lack of knowledge or ambivalence of providers to recom-
Woodsticks 0 0 + 0 Moderate
mend evidence-based (yet affordable) oral hygiene aids to patients,
Irrigators 0 + + + Moderate
all contribute to the persistence of these preventable diseases in a
Magnesium 0 + 0 + Weak substantial proportion of the population.
Fish oil 0 + 0 + Weak
Probiotics 0 + + 0 Weak
NSAIDs 0 + + + Weak 4 | PR E V E NTI O N O F PE R I - I M PL A NT
Note: Strength of evidence was determined using Preferred Reporting DISEASES
Items for Systematic Reviews and Meta-Analyses (PRISMA).
Abbreviations: 0, no significant difference between groups, +, Like teeth, dental implants can suffer from progressive loss of sup-
significance in favor of intervention, −, significance in favor of porting tissues as a result of exposure to dental plaque microor-
control; BS, bleeding score; CHX, chlorhexidine; CPC, cetylpyridinium
ganisms that adhere to the implant surface. Indeed, a considerable
chloride; EOMW, essential oil mouthwash; GI, gingival index; NSAIDs,
nonsteroidal anti-inflammatory drugs; PD, pocket depth; PI, plaque proportion of implants placed will experience peri-implantitis over
index. their lifespan. While not as well studied as periodontitis, approaches
SCANNAPIECO and GERSHOVICH |
11
used to prevent peri-implantitis probably mirror those used to pre- activity. They conclude that there is enough evidence supporting
vent destruction of the periodontal tissues that support natural primary and secondary preventive protocols to preserve a periodon-
teeth. Wang and colleagues provide an excellent overview on the tally healthy dentition and prevent tooth loss. In patients affected
prevention of peri-implantitis.17 They conclude that, like teeth, by moderate-to-advanced periodontitis, the long-held belief that a
dental implants must be cleansed daily, using toothbrushes and proper supportive periodontal therapy interval is 2-4 months con-
interdental aids, to remove biofilm. In addition, professional me- tinues to be reasonable.
chanical debridement must be performed at regular intervals (every
3 months) to reduce the submucosal microbial load. It is also sug-
gested that a healthy lifestyle, including maintenance of good gly- 7 | W H AT A R E S O M E O F TH E PR E V E NTI V E
cemic control and avoiding smoking, will help ensure long-term S TR ATEG I E S O N TH E H O R IZO N TH AT A R E
retention of implants. PRO M I S I N G B U T N OT Y E T PROV E N?
prevent diseases. Periodontal vaccines, which have been a subject of new ideas into practice. There are also health-care system-level
of research starting in the 1970s, are a proposed preventive mo- barriers that prevent facile adoption of new evidence and routine
dality for periodontal disease based on its polymicrobial etiology. A application in patient care. These obstacles led to the development
number of research groups have reported a periodontal vaccine in of a new branch of clinical research called implementation science,
development which targets antigens of specific oral gram-negative which studies the factors that hinder the promotion and adoption
anaerobic pathogens that have been implicated in the pathogenesis of evidence into practice. The accompanying article25 reviews the
of this disease. The accompanying article also summarizes the pres- history of implementation science and how it might be applied to
ent status of the development of probiotics and vaccines to prevent help practitioners adopt strategies to prevent periodontal diseases.
periodontal disease.16
or risk-assessment tools, should be conducted to establish the 10. Neely AL. Essential oil mouthwash (EOMW) may be equivalent to
chlorhexidine (CHX) for long-term control of gingival inflammation
recall frequency.
but CHX appears to perform better than EOMW in plaque control.
6. Conduct studies to document the effectiveness of behavioral- J Evid Based Dent Pract. 2012;12(3 Suppl):69-72.
change techniques in different patient groups in the general 11. Van Leeuwen MP, Slot DE, Van der Weijden GA. Essential oils
dental practice setting. compared to chlorhexidine with respect to plaque and parame-
ters of gingival inflammation: a systematic review. J Periodontol.
7. Long-term randomized controlled trials to test novel therapies
2011;82(2):174-194.
that increase the level of antioxidants and/or antioxidant activity 12. Robinson PG, Deacon SA, Deery C, et al. Manual versus pow-
to diminish oxidative stress within the periodontium. ered toothbrushing for oral health. Cochrane Database Syst Rev.
8. Develop a new generation of slow-release agents for local de- 2005;(2):CD002281.
livery to include novel components (such as quorum-sensing 13. Mandel ID. Why pick on teeth? J Am Dent Assoc. 1990;121(1):129-132.
14. Sälzer S, Graetz C, Dörfer CEP, Slot DE, Van der Weijden FA.
inhibitors) or nonantibacterial agents (such as anti-inflammatory
Contemporary practices for mechanical oral hygiene to prevent
or bone-regeneration agents). periodontal disease. Periodontol 2000. 2020;84(1):35-44.
9. Continue research to develop biological approaches, such as 15. Steinberg D, Friedman M. Sustained-release delivery of antimicro-
probiotics and vaccines, to prevent periodontal diseases. bial drugs for the treatment of periodontal diseases: fantasy or al-
ready reality? Periodontol 2000. 2020;84(1):176-187.
10. Consider new and facile approaches with promise for preventing
16. Myneni SRV, Wang HH. Brocavich K. Biological strategies for
periodontal diseases in ageing populations. the prevention of periodontal disease: probiotics and vaccines.
11. Utilize public health informatics to define a strategy in areas of Periodontol 2000. 2020;84(1):161-175.
surveillance, prevention, and health promotion to define peri- 17. Fu JH, Wang H. Breaking the wave of peri-implantitis. Periodontol
2000. 2020;84(1):161-175.
odontal disease assessment that better informs decision making.
18. Leite FRM, Nascimento GG, Scheutz F, López R. Effect of smoking
on periodontitis: a systematic review and meta-regression. Am J
REFERENCES Prev Med. 2018;54(6):831-841.
1. Hajishengallis G, Chavakis T, Lambris JD. Current understanding of 19. Kumar P. Interventions to prevent periodontal disease in to-
periodontal disease pathogenesis and targets for host-modulation bacco, alcohol and drug dependent individuals. Periodontol 2000.
therapy. Periodontol 2000. 2020;84(1):14-34. 2020;84(1):84-101.
2. Khan SA, Kong EF, Meiller TF, Jabra-Rizk MA. Periodontal diseases: 20. Trombelli L, Simonelli A, Franceschetti G, Maietti E, Farina R. What
bug induced, host promoted. PLoS Pathog. 2015;11(7):e1004952. periodontal recall interval is supported by evidence? Periodontol
3. Sczepanik FSC, Grossi ML, Casati M, et al. Periodontitis is an in- 2000. 2020;84(1):124-133.
flammatory disease of oxidative stress: we should treat it that way. 21. Laleman I, Teughels W. Novel natural product based oral topical
Periodontol 2000. 2020;84(1):45-68. rinses and toothpastes to prevent periodontal diseases. Periodontol
4. Supranoto SC, Slot DE, Addy M, Van der Weijden GA. The effect 2000. 2020;84(1):102-123.
of chlorhexidine dentifrice or gel versus chlorhexidine mouthwash 22. Scannapieco FA, Cantos A. Oral inflammation and infection, and
on plaque, gingivitis, bleeding and tooth discoloration: a systematic chronic medical diseases: implications for the elderly. Periodontol
review. Int J Dental Hygiene. 2015;13(2):83-92. 2000. 2016;72(1):153-175.
5. James P, Worthington HV, Parnell C, et al. Chlorhexidine mouth- 23. Al-Nasser L, Lamster IB. Prevention and management of periodon-
rinse as an adjunctive treatment for gingival health. Cochrane tal diseases and dental caries in the older adults. Periodontol 2000.
Database Syst Rev. 2017;(3):CD008676. 2020;84(1):69-83.
6. Slot DE, Dorfer CE, Van der Weijden GA. The efficacy of interdental 24. Jönsson B, Abrahamsson KH. Overcoming behavioral obstacles
brushes on plaque and parameters of periodontal inflammation: a to prevent periodontal disease. Behavioral change techniques and
systematic review. Int J Dental Hygiene. 2008;6(4):253-264. self-performed periodontal infection control. Periodontol 2000.
7. Worthington HV, MacDonald L, Poklepovic Pericic T, et al. Home 2020;84(1):134-144.
use of interdental cleaning devices, in addition to toothbrushing, for 25. Frantsve-Hawley J, Kumar SS, Rindal DB, Weyant RJ.
preventing and controlling periodontal diseases and dental caries. Implementation science and periodontal practice: translation of ev-
Cochrane Database Syst Rev. 2019;(4):CD012018. idence into periodontology. Periodontol 2000. 2020;84:188-201.
8. Haps S, Slot DE, Berchier CE, Van der Weijden GA. The effect of 26. Janakiram C, Dye BA. A public health approach for prevention of
cetylpyridinium chloride-containing mouth rinses as adjuncts to periodontal disease. Periodontol 2000. 2020;84(1):202-214.
toothbrushing on plaque and parameters of gingival inflammation:
a systematic review. Int J Dental Hygiene. 2008;6(4):290-303.
9. Haas AN, Pannuti CM, Andrade AK, et al. Mouthwashes for the How to cite this article: Scannapieco FA, Gershovich E. The
control of supragingival biofilm and gingivitis in orthodontic pa-
prevention of periodontal disease—An overview. Periodontol
tients: evidence-based recommendations for clinicians. Braz Oral
Res. 2014;28(spe):1-8. 2000. 2020;84:9-13. https://doi.org/10.1111/prd.12330