the global strategy and teamwork for periodontal health and overall health - soren jepsen

The Global Strategy and Teamwork for Periodontal Health and Overall

Health

Prevention of periodontal and peri-implant diseases is it possible?

Søren Jepsen

Dept. of Periodontology, Operative and Preventive DentistryUniversity of Bonn, Germany

1.Periodontitis2. Periimplantitis

Prevention

Periodontal Health during Lifetime: Risk Factors and Prevention

• Background

• Primary Prevention

• Treatment and Secondary Prevention

• Effects of Treatment on General Health

• Conclusions

• Background

• Conclusions

• Background

• Epidemiology

• Aetiopathogenesis

• Risk Factors

Global Prevalence of Severe Periodontitis

Severe periodontitis:

6th most prevalent disease in the world

ca. 11% of population affected

• Tooth loss• Edentulism• Masticatory

Dysfunction

Consequencs of Severe Periodontitis

• Tooth loss• Edentulism• Masticatory

Dysfunctionaffecting: • Nutrition• Quality of Life• Self-Esteem• General Health• Healthcare Costs

Consequencs of Severe Periodontitis

• Background

• Epidemiology

• Risk Factors

Aetiopathogenesis of Periodontitis

microbial microbial attackattack

immuno-immuno-inflammatoryinflammatory

host host responseresponse

Connective Connective tissuetissueBoneBone

metabolismmetabolism PeriodontitisPeriodontitis

PMNsABs

AGsLPS

CytokinesProstanoids

Proteases(MMPs)

Aetiopathogenesis of Periodontitis

Microbial Microbial attackattack

immuno-immuno-inflammatoryinflammatory

host host responseresponse

Connective Connective tissuetissueBoneBone

metabolismmetabolism PeriodontitisPeriodontitis

PMNsABs

AGsLPS

CytokinesProstanoids

Proteases(MMPs)

Environmental- und Lifestyle Environmental- und Lifestyle Risk FactorsRisk Factors

Genetic Risk FactorsGenetic Risk Factors Page & Kornman 1997

CC- & CXC-Chemokines

(CCL20)

Symbiotic Biofilm

Dysbiotic Biofilm

DCsTh1 BTreg

AMPsMMPsROS

Complement SystemImmune System

Systemic Diseases„Keystone“-Bacteria

Gingivitis

Periodontitis

Aetiopathogenesis of PeriodontitisHajishengallis 2014 & Barthold & vanDyke 2013 (Jepsen & Dommisch 2014, adapted)

Microflora

variations inoral microbiome

Life Style

variations in oral hygiene, smoking, nutrition, stress etc.

GeneticSusceptibility

variations in immune defense & metabolism

Systemic Diseases

variations ingeneral health (i.e. diabetes)

E PI G

E N E T I CS

Different forms of Periodontitis

Periodontitis

•a complex, multifactorial, (multicausal?) disease

Periodontitis

•a complex, multifactorial, (multicausal?) disease

•initiation, progression and response to treatment determined by individual risk factors

Practical consequences?

Risk-oriented Prevention

• Background

• Epidemiology

• Risk Factors

ContinuousRisk-assessment („Multi-level Risk Assessment“)on

Patient-Level: • Genetics • Smoking• Diabetes

Diabetes Prevalence 2010 and 2030

20302010PrevalenceDiabetes

(20 -79 years)

Diabetes: A global emergency

Risk Factor Modification

Patient-Level: • Genetics not modifiable• Smoking modifiable• Diabetes modifiable

Continuous Multi-level Risk-Assessment at:

• Site-level: site risk assessment• Tooth-level: tooth risk assessment• Patient-level: subject risk assessment

Extraoraler Befund

Local risk factorEnamel projections

Blanchard SB, Derderian GM, Averitt TR, John V, Newell DH. Cervical Enamel Projections and Associated Pouch-Like Opening in Mandibular Furcations. Journal of Periodontology. 2012 Feb.;83(2):198–203 .

Regenerative Surgery

• Background

• Effects of treatment on general Health

• Conclusions

EFP Prevention Workshop 2014

Tonetti MS, Chapple ILC, Jepsen S, Sanz M. Primary and secondary prevention of periodontal and periimplant diseases. Introduction to, and objectives of the 11th European Workshop on Periodontology consensus conference. Journal of Clinical Periodontology 2015; 42 (Supp. 16): S1-S4.

www.efp.org

Prevention guidelines

prevention.efp.org

www.efp.org

Prevention of Periodontitis is possible by managing gingivitis and promotion of a healthy

lifestyle

Critical importance of

• Bleeding• Universal screening• Early targeted diagnostics• Individual risk assessment (i.e. oral hygiene, smoking,

diabetes) • Professional care and health education

Bleeding (on probing)

• Bleeding• Recession• Halitosis

Early stages

Clinical Signs of Periodontitis

• Mobility• Migration• Tooth loss

Late stages

Screening

www.dgparo.de

Screening

Examination, DiagnosisFor stratification:

•Health

•Gingivitis

•Periodontitis

Examination, DiagnosisConsequence:

•Health • Prophylaxis

•Gingivitis• Prophylaxis

•Periodontitis • Active Perio Therapy, SPT

prevention.efp.org

Risk factor modification

Primary PreventionManaging gingivitis

Screening Diagnosis Anti-infective tx Corrective Phase Supportive Care

Risk-Stratification of patients for more effective Prevention?(primary prevention of periodontitis)

Adults with no prior prognosis of periodontitis, who see the dentist regularly for preventive care

Low Riskfor future moderate

to severe Periodontitis

High Riskfor future moderate

Positive for 1 or more Risk factors

Smoking; Diabetes; IL-1 Genotype

Negative for 3 Risk factors

Risk-Stratification of patients for a more effective prevention of periodontitis

Retrospective Cohort Study

Data base of insurance company

Non-periodontitis patients (with low or high Risk)

Question:Are 2x preventive visits/year better than 1x preventive visit/year with regard to long-term tooth loss?

MethodsPatient recruitment

Risk-Classification„Low Risk“ (LoR):Non smoker (≥ 10 years)No DiabetesIL-1 Genotype negative

„High Risk“ (HiR):≥ 1 of 3 risk factors

4 patient groupsHiR-P1, HiR-P2, LoR-P1, LoR-P2

ResultsInfluence of risk status and frequency of preventive visits on tooth loss events

Significant differenceonlyin high-Risk group

ResultsFrequency of tooth loss events relative to the number of risk factors

ResultsSummary

A personalized medicine approach combining gene biomarkers with conventional risk factors to stratify populationsmay be useful in resource allocation for preventive dentistry

Adults with no prior prognosis of periodontitis, who see the dentist regularly for preventive care

Low Riskfor future moderate

High Riskfor future moderate

Positive for 1 or more Risk factors

Smoking; Diabetes; IL-1 Genotype

Determine frequency of preventive visits based on risk factors and history of periodontitis

Negative for 3 Risk factors

Risk-Stratification of patients for a more effective prevention of periodontitis

Risk-oriented Prevention

Personalize, Predict, Prevent

• Background

• Effects of treatment on general Health

• Conclusions

Periodontitis can be successfully treated

Critical importance of

1) Active therapy with defined endpoint*2) Supportive therapy based on individual risk

*PPD < 5mm, no BOP

(Early) Treatment Secondary Prevention

Screening Diagnosis Anti-infective tx Corrective Phase Supportive Care Active Therapy

Periodontal Risk Assessment (PRA)

Lang & Tonetti (2003) Periodontal Risk assessment (PRA) for patients in supportive periodontal therapy (SPT) Oral Health Prev Dent 1: 7-16.

perio-tools.com

Periodontal Risk Assessment (PRA)Lang & Tonetti 2003 Risikobeurteilung

Predictive Value for Periodontitis-Progression and/or Tooth Loss shown by 5 longitudinal Studies:Matuliene et al. 2010, Leininger et al. 2010, Meyer-Bäumer et al. 2012, Costa et al. 2012, Lu et al. 2013

Periodontal Risk Assessment (PRA)in the prevention of periodontitis progression(secondary prevention):

•Validated in longitudinal studies for predictionof periodontis-progression/tooth loss

Tonetti, M. S., Eickholz, P., Loos, B. G., Papapanou, P., van der Velden, U., Armitage, G., Bouchard, P., Deinzer, R., Dietrich, T., Hughes, F., Kocher, T., Lang, N. P., Lopez, R., Needleman, I., Newton, T., Nibali, L., Pretzl, B., Ramseier, C., Sanz-Sanchez, I., Schlagenhauf, U. & Suvan, J. E. (2015) Principles in prevention of periodontal diseases.

Journal of Clinical Periodontology 42 (Suppl 16): S5-S11

Periodontal Risk Assessment (PRA)in the prevention of periodontitis progression(secondary prevention):

•Validated in longitudinal studies for predictionof periodontis-progression/tooth loss

•No studies for risk-related stratification of patients with regard to Recall-interval and/or –

intensityTonetti, M. S., Eickholz, P., Loos, B. G., Papapanou, P., van der Velden, U., Armitage, G., Bouchard, P., Deinzer, R., Dietrich, T., Hughes, F., Kocher, T., Lang, N. P., Lopez, R., Needleman, I., Newton, T., Nibali, L., Pretzl, B., Ramseier, C., Sanz-Sanchez, I., Schlagenhauf, U. & Suvan, J. E. (2015) Principles in prevention of periodontal diseases.

Journal of Clinical Periodontology 42 (Suppl 16): S5-S11

Results of long-term secondary prevention

Annual tooth loss rates of 0.1 teeth/patient

Lifelong preservation of masticatory function

Improved quality of life

Baseline

After 5 years (active therapy and secondary prevention)

9.2.2012

prevention.efp.org

• Background

• Conclusions

Positive effects of periodontal therapy on quality of life

Periodontal therapy has positive effects on general health

• on glycemic control in diabetes

• on early stages of atherosclerosis (endothelial dysfunction)

Tonetti & Kornman 2013

Courtesy: QuintessenceAtherosclerosis Diabetes

www.efp.org

• Background

• Conclusions

Periodontal Workshops Prevention 2014, Perio-Systemic 2012

Periodontal Health during Lifetime: Risk Factors and PreventionConclusions

•Prevention of periodontitis is possible

•Prevention of periodontitis is possible •Periodontitis can be easily detected,

successfully treated and controlled in the long-term

successfully treated and controlled in the long-term •If left untreated, periodontitis in its severe form may affect general health

successfully treated and controlled in the long-term •If left untreated, periodontitis in its severe form may

affect general health•Periodontal treatment can have positive effects on

general health

German Oral Health Study V

Periodontitis in young adults35 – 44 years

Source: IDZ for BZÄK and KZBV

Periodontitis in young seniors65 – 74 years

Prognosticated perio tx needs due to demographic changes

Oral disease load has moved to higher age group (75 – 100 years)

Improved home care?

Periodontal Health during Lifetime: Risk Factors and PreventionHowever,

•High burden of periodontal disease in the population

•Lack of awareness of periodontal disease in the public

Key Messages• Periodontitis is widespread and a major cause of tooth loss affecting

nutrition, speech, self confidence and well-being.

• If left untreated periodontitis can affect general health.

• Periodontitis can be prevented and successfully treated and controlled in the long-term.

• Periodontal care can have positive effects on general health.

Future role for Dental Team in Prevention(i.e. Diabetes)

Patients see GP when ill, see GDP when well → opportunity for risk based screening

Screening for diabetes in dental setting = effective in identifying pre-diabetes & diabetes (Albert et al 2012)

If periodontitis included in decision making algorithm, diagnostic identification rates ↑ significantly

Perio Tx in diabetes → 40% saving -medical costs per pt. per year ($2840) (Jeffcoat et al 2014)

Dental team role in behaviour change: wt control; dietary counselling ↓ sugar consumption; exercise.

Adipositas

PhysicalInactivity

Diabetesmellitus

Hypertonia

Hyper-cholesterin-

emiaSmoking

GeneticsAge

„Common Risk Factor“ Modification

Atherosclerosis Periodontitis

Healthy Lifestyle• Stop smoking• Eat well• Exercise• Control weight• Oral health WHO

„Common Risk Factor Approach“

1.Periodontitis2. Periimplantitis

Prevention

Baseline

Reevaluation

Corrective Surgery

6 months postoperative

Renvert & Giovannoli 2012

Gingivitis

Peri-implantat Mucositis

Periodontitis

Peri-implantitis

„Peri-implant diseases: Consensus report of the sixth European Workshop on Periodontology.”Lindhe & Meyle: J Clin Periodontol 35 (Suppl. 8): 282-285 (2008)

Peri-implant mucositis and peri-implantitis are infectious diseases.

Peri-implant mucositis describes an inflammatory lesion that resides in the mucosa, Peri-implantitis also affects the supporting bone.

Consensus Report of the Sixth European Workshop on Periodontology

Peri-implant Diseases: Definition

EFP Prevention Workshop 2014

Primary prevention of peri-implantitis

Facts/Assumptions

1.Placement of dental implants has become a routine procedure for oral rehabilitation

2.Number of patients/implants affected by peri-implant diseases is increasing

3.At present no established and predictable concepts for the treatment of peri-implantitis

4.Management of peri-implant mucositis is a preventive measure for the onset of peri-implantitis

Questions

1.What is current prevalence, extent and severity of peri-implant health and disease?

2.What is the best clinical measure to distinguish between peri-implant health and disease?

3.What is the risk of conversion from peri-implant mucositis to peri-implantitis?

Prevalence of Mucositis and Peri-implantitis

Subject level:43% Peri-implant mucositis22% Peri-implantitis

2131 Patients8893 Implants

Questions

Bleeding on Probing

• Peri-implant Probing Light force (0.25N)

Wolf u. Rateitschak

Renvert & Giovannoli 2012

Questions

Risk of Progression from Mucositis to Peri-implantitis

With Recall-Compliance:18% Peri-implantitis

Without Recall-Compliance:44% Peri-implantis

Questions

Identify risk indicators for peri-implant mucositis

1.What are systemic/patient-related risk indicators for the development of peri-implant mucositis?

2.What are the local risk indicators for the development of peri-implant mucositis?

Questions

Patient risk factor: Smoking

Questions

Local Risk-Factors: excess cement

Korsch et al. 2014

Questions

Assess the efficacy of measures to manage peri-implant mucositis

1.What are effective ways of patient-performed plaque control in the management of peri-implant mucositis?

2.What are effective ways of professional plaque control in the management of peri-implant mucositis?

Patient performed plaque control

Questions

Assess the efficacy of measures to manage peri-implant mucositis

Professional plaque control

Adjunctive measures (antiseptics, local and systemic antibiotics, air-abrasive devices) were not found to improve the efficacy of PAPR in reducing clinical signs of inflammation

A complete resolution of mucositis was not always possible

QuestionsAssess the efficacy of measures to manage peri-implant mucositis

3.What is the standard of care for patient- and professionally administered plaque control for the management of peri-implant mucositis?

What is the standard of care for patient- and professionally administered plaque control for the management of peri-implant mucositis?

1.Chemical plaque control either by oral rinses or a dentrifice tested to date had limited adjunctive effect.

2.Patient administered mechanical plaque control alone (with manual or powered toothbrush) should be considered the current standard of care.

3.Professionally administered plaque control procedures should include regular, individual, oral hygiene instructions and mechanical debridement employing different hand or powered instruments with or without polishing tools.

Prevention

Recommendations for Dental Professionals

Before implant placement

1. When implant treatment is considered, patients should be informedon the risks for biological complications (peri-implant diseases) andthe need for preventive care.

2.An individual risk assessment including systemic and local risk indicators should be performed and modifiable risk factors, such as residual increased probing pocket depth in the remaining dentition or smoking, should be eliminated. Hence, treatment of periodontal disease aiming for elimination of residual pockets with bleeding on probing and smoking cessation should precedeimplant placement.

During reconstruction

The correct fit of implant components and the suprastructure hasto be ensured to avoid additional niches for biofilm adherence. If cemented implant restorations have been selected, the restorationmargins should be located at the mucosal margin to allow meticulousremoval of excess cement.

Clinicians have to be aware that implant placement at a submucosallevel (to hide crown margins) may carry a higher risk for periimplantdiseases.

Patient care

To facilitate personal oral hygiene, clinicians should considerhaving keratinized attached and unmovable tissue surroundingthe transmucosal implant portion already during implant placement (for one-stage implant placement) or during abutment connection (for two-stage implant placement).

Since infection control is essential in the prevention of peri-implantdiseases, patients have to be instructed on their personal oralhygiene with regular monitoring and reinforcement.

Maintenance

Implant position should be selected and suprastructures should be designed in a way facilitating sufficient access for regular diagnosis by probing as well as for personal and professional oral hygiene measures.

Professional supportive care should be established according to the individual needs of the patient (e.g. 3-, 6- or 12-month recall intervals) and their compliance has to be confirmed.

Supportive care

Particularly in patients with a history of treated aggressive periodontitis indicating an increased susceptibility for periodontal and peri-implant diseases, shorter recall intervals should be considered.

During recall peri-implant tissues must be regularly examinedincluding probing assessments with special emphasis on bleeding on probing.

prevention.efp.org

dgparo.de

Prevention of PeriimplantitisConclusions1.Number of patients/implants affected by peri-implant diseases is rapidly increasing

2.At present no established and predictable concepts for the treatment of peri-implantitis

3.Management of peri-implant mucositis as a preventive measure for the onset of peri-implantitis is of uppermost importance

SAVE THE DATE

Thank you very much for your attention!

the global strategy and teamwork for periodontal health and overall health - soren jepsen

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