The Global Strategy and Teamwork for Periodontal Health and Overall Health
Feb 17, 2017
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
Periodontal Health during Lifetime: Risk Factors and Prevention
• Background
• Primary Prevention
• Treatment and Secondary Prevention
• Effects of Treatment on General Health
• Conclusions
Periodontal Health during Lifetime: Risk Factors and Prevention
• 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
Periodontal Health during Lifetime: Risk Factors and Prevention
• Background
• Epidemiology
• Aetiopathogenesis
• 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
RANKL
IL-17
CC- & CXC-Chemokines
(CCL20)
Th17
PMN
Blood
OCs
HGFs
GECs
Symbiotic Biofilm
Dysbiotic Biofilm
DCsTh1 BTreg
AMPsMMPsROS
G-CSF
Complement SystemImmune System
Systemic Diseases„Keystone“-Bacteria
etc.
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
AP CP
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
Periodontal Health during Lifetime: Risk Factors and Prevention
• Background
• Epidemiology
• Aetiopathogenesis
• Risk Factors
ContinuousRisk-assessment („Multi-level Risk Assessment“)on
Patient-Level: • Genetics • Smoking• Diabetes
Diabetes Prevalence 2010 and 2030
2010
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 .
PUS
Regenerative Surgery
EDTA
Periodontal Health during Lifetime: Risk Factors and Prevention
• Background
• Primary Prevention
• Treatment and Secondary Prevention
• 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
Prevention guidelines
prevention.efp.org
www.efp.org
Periodontal Health during Lifetime: Risk Factors and Prevention
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
to severe Periodontitis
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
to severe Periodontitis
High Riskfor future moderate
to severe Periodontitis
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
Periodontal Health during Lifetime: Risk Factors and Prevention
• Background
• Primary Prevention
• Treatment and Secondary Prevention
• Effects of treatment on general Health
• Conclusions
Periodontal Health during Lifetime: Risk Factors and Prevention
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
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 guidelines
prevention.efp.org
Periodontal Health during Lifetime: Risk Factors and Prevention
• Background
• Primary Prevention
• Treatment and Secondary Prevention
• Effects of Treatment on General Health
• Conclusions
Positive effects of periodontal therapy on quality of life
Periodontal Health during Lifetime: Risk Factors and Prevention
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
Periodontal Health during Lifetime: Risk Factors and Prevention
• Background
• Primary Prevention
• Treatment and Secondary Prevention
• Effects of Treatment on General Health
• Conclusions
Periodontal Workshops Prevention 2014, Perio-Systemic 2012
Periodontal Health during Lifetime: Risk Factors and PreventionConclusions
•Prevention of periodontitis is possible
Periodontal Health during Lifetime: Risk Factors and PreventionConclusions
•Prevention of periodontitis is possible •Periodontitis can be easily detected,
successfully treated and controlled in the long-term
Periodontal Health during Lifetime: Risk Factors and PreventionConclusions
•Prevention of periodontitis is possible •Periodontitis can be easily detected,
successfully treated and controlled in the long-term •If left untreated, periodontitis in its severe form may affect general health
Periodontal Health during Lifetime: Risk Factors and PreventionConclusions
•Prevention of periodontitis is possible •Periodontitis can be easily detected,
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
Source: IDZ for BZÄK and KZBV
Periodontitis in young seniors65 – 74 years
Prognosticated perio tx needs due to demographic changes
Source: IDZ for BZÄK and KZBV
Source: IDZ for BZÄK and KZBV
Oral disease load has moved to higher age group (75 – 100 years)
Improved home care?
Source: IDZ for BZÄK and KZBV
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
113
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.
115
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
122
Baseline
Reevaluation
Reevaluation
Corrective Surgery
6 months postoperative
6 months postoperative
6 months postoperative
Renvert & Giovannoli 2012
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
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?
Bleeding on Probing
• Peri-implant Probing Light force (0.25N)
Wolf u. Rateitschak
Renvert & Giovannoli 2012
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?
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
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?
Patient risk factor: Smoking
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?
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
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?
Professional plaque control
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
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?
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.
Recommendations for Dental Professionals
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.
Recommendations for Dental Professionals
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.
Recommendations for Dental Professionals
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.
Recommendations for Dental Professionals
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
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