tonetti et al-2015-journal of clinical periodontology

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Principles in prevention ofperiodontal diseases

Consensus report of group 1 ofthe 11th European Workshop on

Periodontology on effectiveprevention of periodontal andperi-implant diseases

Tonetti MS, Eickholz P, Loos BG, Papapanou P, van der Velden U, Armitage G,

Bouchard P, Deinzer R, Dietrich T, Hughes F, Kocher T, Lang NP, Lopez R,

Needleman I, Newton T, Nibali L , Pretzl B, Ramseier C, Sanz-Sanchez I,

Schlagenhauf U, Suvan JE, Fabrikant E, Fundak A. Principles in prevention of periodontal diseases–Consensus report of group 1 of the 11th European workshop

on periodontology on effective prevention of periodontal and peri-implant diseases.

J Clin Periodontol 2015; 42 (Suppl. 16): S5 – S11. doi: 10.1111/jcpe.12368.

Abstract

Aims: In spite of the remarkable success of current preventive efforts, periodonti-

tis remains one of the most prevalent diseases of mankind. The objective of this

workshop was to review critical scientific evidence and develop recommendations

to improve: (i) plaque control at the individual and population level (oral

hygiene), (ii) control of risk factors, and (iii) delivery of preventive professional

interventions.

Methods: Discussions were informed by four systematic reviews covering aspects

of professional mechanical plaque control, behavioural change interventions to

improve self-performed oral hygiene and to control risk factors, and assessment

of the risk profile of the individual patient. Recommendations were developed

and graded using a modification of the GRADE system using evidence from the

systematic reviews and expert opinion.

Maurizio S. Tonetti1, Peter Eickholz2,

Bruno G. Loos3, Panos Papapanou4,

Ubele van der Velden3, Gary

Armitage5, Philippe Bouchard5,

Renate Deinzer5, Thomas Dietrich5,

Frances Hughes5, Thomas Kocher5,

Niklaus P. Lang5, Rodrigo Lopez5,

Ian Needleman5, Tim Newton5, Luigi

Nibali5, Bernadette Pretzl5, Christoph

Ramseier5, Ignacio Sanz-Sanchez5,

Ulrich Schlagenhauf5 and Jean E.

Suvan5

1European Research Group on

Periodontology (ERGOPerio), Genova, Italy;2Department of Periodontology, Johann

Wolfgang Goethe-University, Frankfurt,

Germany; 3Department of Periodontology,

Academic Centre for Dentistry Amsterdam

(ACTA), University of Amsterdam and Free

University Amsterdam, Amsterdam, The

Netherlands; 4Department of Periodontology,

Columbia University, New York, NY, USA;5Member of working Group 1 of the 11 th

European Workshop on Periodontology

Industry representative in working Group 1 of

the 11th European Workshop on Periodontology:

Angela Fundak and Ekaterini Fabrikant

Key words: behavioural changes; gingivitis;

oral hygiene; periodontal diseases;

periodontitis; prevention; prophylaxis; risk

assessment; risk factors; scaling; smokingcessation

Accepted for publication 31 December 2014

Conflict of interest and source of funding statement

Funds for this workshop were provided by the European Federation of Periodontology in part through unrestricted educational

grants from Johnson & Johnson and Procter & Gamble. 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.

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd S5

J Clin Periodontol 2015; 42 (Suppl. 16): S5–S11 doi: 10.1111/jcpe.12368



Results: Key messages included: (i) an appropriate periodontal diagnosis is

needed before submission of individuals to professional preventive measures and

determines the selection of the type of preventive care; (ii) preventive measures

are not sufficient for treatment of periodontitis; (iii) repeated and individualized

oral hygiene instruction and professional mechanical plaque (and calculus)

removal are important components of preventive programs; (iv) behavioural

interventions to improve individual oral hygiene need to set specific Goals, incor-

porate Planning and Self monitoring (GPS approach); (v) brief interventions forrisk factor control are key components of primary and secondary periodontal

prevention; (vi) the Ask, Advise, Refer (AAR) approach is the minimum standard

to be used in dental settings for all subjects consuming tobacco; (vii) validated

periodontal risk assessment tools stratify patients in terms of risk of disease pro-

gression and tooth loss.

Conclusions: Consensus was reached on specific recommendations for the public,

individual dental patients and oral health care professionals with regard to best

action to improve efficacy of primary and secondary preventive measures. Some

have implications for public health officials, payers and educators.

Gingivitis and periodontitis areinflammatory conditions caused bythe formation and persistence of microbial biofilms on the hard, non-shedding surfaces of teeth. Gingivi-tis is the first manifestation of theinflammatory response to the biofilm.It is reversible (i.e. if the biofilm is dis-rupted gingivitis resolves), but if biofilms persist gingivitis becomeschronic. In some subjects, chronicgingivitis progresses to periodonti-

tis. Besides the presence of a disease-associated biofilm, these subjects areexposed to additional risk factorsincluding smoking and systemiccomorbidities. Periodontitis is char-acterized by non-reversible tissuedestruction resulting in progressiveloss of attachment eventually leadingto tooth loss. Severe periodontitis isthe 6th most prevalent disease of mankind (Kassebaum et al. 2014), itis associated with reduced quality of life, masticatory dysfunction, and it is

a major factor in the increase in costsof oral health care. It is a publichealth problem since it is highlyprevalent and causes disability andsocial inequality (Baehni & Tonetti2010).

In the context of prevention, gingi-vitis and periodontitis are best viewedas a continuum of a chronic inflam-matory disease entity with periodon-titis representing a perturbation of host-microbial homeostasis in sus-

ceptible individuals that leads to irre-versible tissue destruction. Regulardisruption and periodic removal of accumulating bacterial deposits atand below the gingival margin is akey component of the prevention of plaque-induced periodontal diseases.Given that individuals are oftenunable to accomplish this, profes-sional intervention is required.

Prevention of gingivitis refers toinhibition of the development of clinically detectable gingival inflam-

mation or its recurrence. It iscurrently unknown whether low levelsof gingival inflammation are compat-ible with maintenance of oral healthor should also be considered a riskfor development of periodontitis insusceptible individuals. Primary pre-vention of gingivitis aims to avoidthe development of more severe andwidespread forms of gingivitis thatmay ultimately convert to periodontitis.

Prevention of periodontitis may be

primary or secondary. Primary pre-vention of periodontitis refers to pre-venting the inflammatory processfrom destroying the periodontalattachment; it consists of treating gin-givitis through the disruption/removal of the bacterial biofilm andthe consequent resolution of inflam-mation. In addition, adjunctive inter-ventions including pharmacologicalmodification of the disease-associatedbiofilm and host modulation havebeen explored.

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

S6 Tonetti et al.



Secondary prevention of periodon-titis refers to preventing recurrence of gingival inflammation, which maylead to additional attachment loss insuccessfully treated periodontitis.

Both at the population and at theindividual subject level, prevention

(and treatment) of gingivitis is a crit-ical component for the prevention of periodontitis. Furthermore, the control/management of risk factors forperiodontitis such as smoking anddiabetes form an important part of prevention of periodontitis.

Prevention of periodontal diseaseconsists of patient-performed controlof the dental biofilm and profes-sional interventions. In developedcountries, the above approaches havebeen used for several decades. Theirapplication at the population levelhas been associated with an overallimprovement in the levels of oralcleanliness, a decrease in gingivalinflammation and in the prevalenceof mild to moderate periodontitis(Eke et al. 2012). In the majority of these countries, however, the preva-lence of severe periodontitis has notdecreased.

Similar to approaches adopted inthe prevention of other commonchronic diseases, effective preventionof periodontitis requires the com-bined involvement of policy makers,health professionals and empowered

individuals.It is noted that the oral health

care team comprises different profes-sional figures in different countries.These should participate in theprofessional delivery of preventionas determined by the competent gov-erning laws.

The aim of this consensus was toidentify effective approaches toimprove: (i) plaque control at theindividual and population level (oralhygiene), (ii) control of risk factors,and (iii) preventive professional

interventions.The scope of this consensus is

to review the evidence supportingapproaches for the prevention of periodontal diseases in self-caringadults without disabilities and toprovide specific recommendations tothe public, oral health professionalsand policy makers. Specific recom-mendations were developed based onthe evidence and the expert opinionof the group participants. Each rec-ommendation for oral health care

professionals and the public/patientwas rated in terms of strength of therecommendation and in terms of thelevel of evidence underlying it. Thiswas accomplished with a modi-fication of the GRADE system asutilized in a previous workshop sup-

ported by the European Federationof Periodontology (Tonetti & Jepsen2014). The effectiveness of specificpreventive tools and technologies isdiscussed in the consensus of groupII (Chapple 2015), while adverseevents of prevention of periodontaldisease are discussed in the consen-sus of group IV of this workshop(Sanz 2015). Principles extendingprevention to dental implants arediscussed in the consensus of groupIII of this workshop (Jepsen 2015).

Professional Mechanical PlaqueRemoval for Primary Prevention of

Periodontal Diseases in Adults

One of the most commonly per-formed preventive measures in adultsin countries with organized dentalservices is professional mechanicalplaque removal (PMPR), with orwithout concomitant oral hygieneinstructions (OHI).

PMPR comprises supra-gingivaland sub-marginal plaque and calcu-lus removal using hand instruments(scalers, curettes), or powered instru-ments (sonic, ultrasonic, rotatingdevices, air polishing). The intention isto remove deposits from the toothsurface, extending into the gingivalsulcus. This is done to allow adequatepatient-performed oral hygiene.

The systematic review (Needlemanet al. 2015) on PMPR for preventionas defined above, resulted in thefollowing findings:

• There is little value in providingPMPR without OHI to reducegingivitis.

• A single episode of PMPR fol-lowed by repeated OHI is aseffective as repeated PMPR inreducing gingivitis at least up to3 years follow-up.

• There are no published random-ized controlled trials (RCTs) todirectly inform on the efficacy of PMPR for primary and second-ary prevention of periodontitis asopposed to the indirect evidencederived from gingivitis treatmentstudies

Recommendations

The available evidence and expertopinion led the working group tomake the following recommendations:

Oral health care professionals

• Repeated and individually tailoredOHI is the key element in achiev-

ing gingival health.Strength of recommendation: Mod-erate, Level of evidence 1.

• PMPR both supra-gingivally andsub-marginally as deep as neces-sary to remove all soft and harddeposits is required to allowgood self-performed oral hygiene.

Strength of recommendation: Goodpractice point.

• PMPR as the sole treatmentmodality is inappropriate in patientswith periodontitis.


• An appropriate periodontal diag-nosis should determine the selec-tion of the type of preventive care.


Patients

• Remove plaque effectively withthe methods prescribed and regu-larly checked by the dental teamto achieve and maintain gingival

health.Strength of recommendation: High,level of evidence 1.

• Seek professional supervision intailoring and monitoring oralhygiene and PMPR to remove alldeposits and allow good oralhygiene.

Strength of recommendation: High,level of evidence 1.

Public

• Consider proper oral hygiene aspart of a health conscious lifestyle.

• Recommend regular visits with anoral health professional for peri-odontal screening, check of oralhygiene and the need to receiveprofessional tooth cleaning.

Research

• There is urgent need for researchon the direct impact of PMPR andOHI on secondary prevention.

• The relative contribution of PMPR and OHI needs to be


Group 1 consensus S7



investigated, including frequency,types of interventions, patientreported outcome measures andhealth economics.

• There is a need to investigatewhether there is a threshold of gingival inflammation (in terms

of both severity and duration)which is compatible with long-term periodontal health.

Psychological Approaches to

Behavioural Change for Improved

Plaque Control in Periodontal

Management

Whilst it is recognized that self-performed oral hygiene is the keycomponent of prevention of peri-odontal disease and that long-termsuccessful outcomes of periodontaltherapy are contingent upon effective

and consistent oral hygiene practices,the general population does not con-sistently achieve appropriate plaquecontrol (Petersen & Ogawa 2005). Itis therefore necessary to facilitatebehavioural changes conducive toenhanced plaque control. The publicneed to acquire positive attitudestowards behavioural change and toachieve actual behavioural changeconducive to enhanced plaque control.

Oral health professionals need toidentify and adopt effective tech-niques that help patients change oral

health behaviour, but there is consen-sus that, in general, oral health careproviders lack a structured, provenapproach to facilitate behaviouralchanges that improve plaque control.

The systematic review (Newton &Asimakopoulou 2015) on psychologi-cal approaches to behavioural changefor improved plaque control inperiodontitis patients indicates thatchange in oral hygiene behaviour is:

• Related to patient-perceptions of

○ harmful consequences,

○ their own susceptibility toperiodontitis and

○ their benefits from change,

• Facilitated by

○ goal setting (i.e., identifyingwith the patient the change to bemade),

○ planning (i.e., working with thepatient to decide when, whereand how they will undertakethe behaviour change)

○ self-monitoring (i.e., encourag-ing the patient to assess theirown behaviour in relation tothe goals)

Based on this evidence a reason-able approach to facilitate behaviour-

al change with oral hygiene practicesis the incorporation of Goal setting,Planning and Self-monitoring (GPS).

Recommendations

Oral health professionals

• Oral health professionals needto routinely adopt an effectiveindividual oral hygiene programfor their patients. This requiresincorporating behavioural changetechniques.

Strength of recommendation: High,

level of evidence 1.• Behaviour change for the delivery

of OHI can be based on the GPSapproach:

○ Goal setting (including instruc-tion in an appropriate tech-nique to achieve that goal),

○ Planning and○ Self-monitoring

Strength of recommendation: Mode-rate, Level of evidence 5 (expertopinion).

• Delivery of OHI includes assess-ing Patients’ perceptions regard-ing harmful consequences, theirown susceptibility, their benefitsof change and their self-efficacyin order to identify and addressperceptions which might hamperpatient’s motivation for behaviouralchange. Motivational interviewingmight be one appropriate method-ology for this.

Strength of recommendation: Mode-rate, Level of evidence 5 (expertopinion).

• The OHI should be based on thecareful selection of tools (type of

toothbrush and type of interden-tal kit) and techniques for usetailored to the needs and prefer-ences of the patient.


Policymakers

One possible barrier to the adoptionof current best practice in behaviourchange is the lack of an explicit

remuneration for such practices.Dental health policy makers shouldgive consideration to adopting suchremuneration for practitioners under-taking behavioural change approachesfor oral hygiene promotion in dentalservices.

Dental educators

Education of oral health profession-als should include methods of behavioural change approaches likeGPS. There is a need to developspecific educational and trainingmaterials for both the oral healthcare team (dental practitioners,specialists, hygienists, oral healthpromotion staff) and the entirehealthcare team.

Research

Additional research is needed todevelop validated methodologies thatcan be used as a structured approachto facilitate behavioural changeamongst (i) dental practitioners, and(ii) patients and the public.

Studies must adopt a standardizedand agreed taxonomy of behaviourchange methods and state explic-itly which approaches to behaviourchange have been used [e.g., provid-ing information on the link betweenbehaviour and health, goal setting,providing contingent rewards,prompt self-monitoring of behaviour;

Abraham & Michie 2008).Studies and practitioners must

clearly distinguish between enhancing(i) motivation, i.e., a positive attitudetowards engaging in a behaviour, and(ii) volition, i.e., strategies for imple-menting the change (Gollwitzer 1993).

Studies must include self-efficacyas a predictor of behaviour changeand a possible target for intervention.

Research is needed to assess thecost/benefit of an approach thatactively integrates health behaviourchange in dental practice.

Behaviour Change Counselling for

Tobacco Use Cessation in the Dental

Setting

As smoking is a risk factor sharedamong several of the most prevalentdiseases of mankind including perio-dontitis, avoiding tobacco consump-tion also contributes to periodontitisprevention.

The systematic review (Ramseier& Suvan 2015) identified strong


S8 Tonetti et al.



evidence that brief interventions inthe dental setting increase the smok-ing cessation rate. While the reportedquit rate was in the range of 10 – 20%at 12 months (Carr & Ebbert 2012),the magnitude of the effect seen inthese studies is comparable to that

described in similar studies in generalhealth care settings (Fiore et al.2008). Six of the eight studies in thereview that supported the effective-ness of brief interventions to quitsmoking in the dental setting wereperformed in the dental office.

Evidence demonstrates thatpatients welcome and expect involve-ment of oral health professionals insmoking cessation.

A limitation of the evidence is thelack of consistency of definition of specific interventions in the dentalsetting. However, a “brief intervention”in this context is generally a shortconversation with the patient of up to5 min., which provides advice andincludes a degree of counsellingregarding tobacco use.

Recommendations


• Oral health professionals shouldbe aware that brief interventionsin the dental setting increase thesmoking cessation rate. The

health benefit is both for oral(periodontal) health and for gen-eral health.


• Oral health professionals shouldadopt validated smoking cessationcounselling approaches in theirpractice.


• Oral health professionals shouldroutinely adopt, as a minimum, abrief intervention using the AAR

approach:

○ Ask (ask every patient abouttobacco use)

○ Advise (advise every tobaccouser to quit, provide informa-tion on 1. the effects of tobaccouse on oral health, 2. the bene-fits of stopping tobacco use, and3. available methods for quitting)

○ Refer (offer referral to special-ist smoking cessation services,if available)


Patients

• Patients need to be informed of the oral health benefits of avoid-

ing or quitting tobacco use andof its harmful oral health effects.


• Patients should be aware of therole of the dental team in sup-porting them to quit tobacco use.


Policymakers

Public health policy makers shouldbe aware of the role of the dental

team in supporting patients to quittobacco use. They should give con-sideration to adopting remunerationfor practitioners undertaking brief interventions for tobacco use in den-tal practice settings.

Education

Smoking cessation courses should bepart of undergraduate dental anddental hygienist curricula as agreedin European guidelines on profes-sional competencies (Cowpe et al.2010). As a minimum, oral health

professionals should be competent tocarry out “brief interventions” basedon the AAR approach.

Research

• To investigate the most effectiveway to encourage oral healthprofessionals to implement rou-tine brief intervention proceduresinto their practice.

• To investigate optimal techniquesfor smoking cessation counsellingsuch as motivational interviewing.

• To investigate the costs and ben-

efits of implementation of brief interventions for tobacco use indental settings.

Behaviour Change Counselling for

Promotion of Healthy Life Styles in

the Dental Setting

With regard to promotion of healthylifestyles in the dental setting, thesystematic review (Ramseier & Suvan2015) identified limited evidence that

brief interventions in the dentalsetting can have positive influenceson other healthy lifestyle behaviours,particularly enhancing fruit/vegetableconsumption.

Unlike the large body of evidencein the field of tobacco cessation, there

is very limited data available on otherlifestyle interventions; there is insuffi-cient evidence to interpret further thedata on these interventions and norecommendations can be made at thistime other than the need to furtherexplore the potential of such interven-tions in the context of clinical andpublic health research.

Risk Factor Assessment Tools for

the Prevention of Periodontitis

Different individuals demonstratevarying susceptibility to onset andprogression of periodontitis (L€oeet al. 1986). Consequently, the appli-cation of uniform preventive proto-cols will rarely meet the individualneeds resulting in under-provision of care to some individuals and over-provision to others. This can resultin increased burden of disease,unwanted side effects as well as sub-optimal allocation of resources. Thisis an important issue for both pri-mary and secondary prevention.

It is important to note that in gen-eral, prediction tools based on risk

factors allow the grouping of patientsaccording to different levels of aver-age risk, they do not however allowthe accurate prediction of individual patient outcomes (prognosis). Previ-ous literature shows that risk factorsand combinations thereof typicallyhave poor performance for individualrisk prediction (Wald et al. 1999,2005). Nonetheless, the provision of patient care guided by the assess-ment of patient level risk for theprogression of periodontitis may bean advantageous approach for the

individual patient (Rosling et al.2001).

The systematic review (Langet al. 2015) reached the followingconclusions:

• Five different risk assessmenttools have been described. Thesetools consist of various combina-tions of patient level factors.

• Three of these were evaluated onlongitudinal data demonstratingan association between the risk





score and disease progression(PRC, PRA, and DRS).

• One of the tools (PRA) has beenexternally validated in multiplesupportive periodontal care (SPC)populations in several countries.Data showed an association

between the risk categories andthe outcome (AL/tooth loss).

• The review could not identifyany study investigating whetherthe application of the toolswould result in clinical benefitsfor the individual patient.

The development, validation andevaluation of clinical predictionrules are a multistage process. Perio-dontal risk assessment tools are inthe early stages of this developmentprocess. While several tools havebeen proposed, the implications of patient stratification using these toolsin terms of clinical decision-makingare unclear, and their efficacy/effectiveness in terms of improvementof periodontal care and clinical out-comes has not been evaluated.

In the absence of evidence, clini-cians still need to make decisions onthe provision of both primary andsecondary prevention. The contextof primary and secondary preventiondiffers: secondary prevention isfocused on the segment of the popu-lation at higher risk (as demon-

strated by having had the disease).As recommended by the consensusreport of group 4 of this workshop,these patients should participate in alife-long professionally supervised,secondary prevention program. Thesesubjects still have a continuum of riskfor recurrence of periodontitis, displaydifferent severity of destruction, andare characterized by individual pre-ventive needs. These could either bemet providing maximum care toevery patient such as described inthe classic study by Axelsson &

Lindhe (1981, Axelsson et al. 1991),or by a more tailored approachinformed by the patient’s risk profileand disease history. Given thisdilemma, the consensus considersrisk assessment tools as a way tocapture the complexity of the patientprofile to inform clinical decision-making.

There was also consensus thatthese tools may be useful to commu-nicate risk to the patient and poten-tial preventative targets.

Recommendations


The application of validated riskassessment tools at baseline and/oreach SPC appointment by oral healthprofessionals may be useful to:

• facilitate patient communicationin terms of GPS (goal setting,planning, self-assessment) at eachSPC appointment.

Strength of the recommendation:Good practice point.

• stratify patients in terms of risk of disease progression and tooth loss

Strength of recommendation: High,Level of Evidence: 2

• facilitate clinical decision makingat initial consultation and/or dur-ing SPC.

Strength of recommendation: Low,

Level of Evidence: 5 (expert opinion).

Research

Further research on the developmentof clinical prediction rules for peri-odontal risk stratification is encour-aged. Systematic evaluation andoptimisation of different combina-tions of individual risk indicators isrecommended to improve the accu-racy of future tools.

There is a need for research onthe possible effects of risk assessmenton patient management, includingbut not limited to patient motiva-tion, clinical decision-making andallocation of resources.

Ultimately, the benefit of riskassessment tools on clinical andpatient outcomes should be assessed.This may include observational stud-ies, studies utilising decision analysismodels and/or prospective random-ized studies in different patient pop-ulations.

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Address:

Maurizio S. Tonetti

European Research Group on Periodontology

12th Floor, WTC Tower Genoa, Via deMarini 1

16149 Genova, Italy

E-mail: [email protected]

Clinical relevance

Scientific rationale: Prevention of biofilm associated periodontal dis-eases is a public health priority inthe majority of countries. In spite of improvement of oral cleanliness inthe population of developed coun-tries, prevalence of periodontitis

remains high. Efforts for the preven-tion of periodontal diseases require.

Practical implications: Professionalpreventive measures must be basedon appropriate periodontal diagno-sis, as mechanical plaque removalalone is inappropriate as treatmentof periodontitis. Prevention andtreatment of gingivitis is a criticalcomponent for the prevention of

periodontitis. Risk factors controland behavioural change approaches

should be incorporated in preven-tive efforts.Conclusions: The consensus devel-oped a series of recommendationsbased on scientific evidence andexpert opinion of group partici-pants. The oral health care teamand public health officials should

implement these at the populationand individual level.



tonetti et al-2015-journal of clinical periodontology

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