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 Dentistry
University of Bonn, Germany

1.Periodontitis
2. 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
• 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
Dysfunction
affecting:
• Nutrition
• Quality of Life
• Self-Esteem
• General Health
• Healthcare Costs
Consequencs of Severe Periodontitis

Aetiopathogenesis of Periodontitis
microbialmicrobial
attackattack
microbialmicrobial
attackattack
immuno-immuno-
inflammatoryinflammatory
hosthost
responseresponse
immuno-immuno-
hosthost
responseresponse
ConnectiveConnective
tissuetissue
BoneBone
metabolismmetabolism
tissuetissue
BoneBone
metabolismmetabolism PeriodontitisPeriodontitisPeriodontitisPeriodontitis
PMNs
ABs
AGs
LPS
Cytokines
Prostanoids
Proteases
(MMPs)

MicrobialMicrobial
attackattack
MicrobialMicrobial
attackattack
immuno-immuno-
hosthost
responseresponse
immuno-immuno-
hosthost
responseresponse
tissuetissue
BoneBone
metabolismmetabolism
tissuetissue
BoneBone
metabolismmetabolism PeriodontitisPeriodontitisPeriodontitisPeriodontitis
PMNs
ABs
AGs
LPS
Cytokines
Prostanoids
Proteases
(MMPs)
Environmental- und LifestyleEnvironmental- 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
DCs
Th1 BTreg
AMPs
MMPs
ROS
G-CSF
Complement System
Immune System
Systemic Diseases
„Keystone“-Bacteria
etc.
Gingivitis
Periodontitis
Hajishengallis 2014 & Barthold & vanDyke 2013 (Jepsen & Dommisch 2014, adapted)

Microflora
variations in
oral microbiome
Life Style
variations in
oral hygiene, smoking,
nutrition, stress etc.
Genetic
Susceptibility
variations in
immune defense &
metabolism
Systemic Diseases
variations in
general health
(i.e. diabetes)
EPIG
E N ET 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

Continuous
Risk-assessment („Multi-level Risk Assessment“)
on
Patient-Level:
• Genetics
• Smoking
• Diabetes

Diabetes Prevalence 2010 and 2030
2010
20302010
Prevalence
Diabetes
(20 -79 years)

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

Local risk factor
Enamel 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.

• Background
• Primary Prevention
• Treatment and Secondary Prevention
• Effects of treatment on general Health
• Conclusions

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.

Prevention guidelines
prevention.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
• Recession
• Halitosis
Early stages
Clinical Signs of Periodontitis
• Mobility
• Migration
• Tooth loss
Late stages

Examination, Diagnosis
For stratification:
•Health
•Gingivitis
•Periodontitis

Examination, Diagnosis
Consequence:
•Health
• Prophylaxis
•Gingivitis
• Prophylaxis
•Periodontitis
• Active Perio Therapy, SPT

Primary Prevention
Managing gingivitis
Screening Diagnosis Anti-infective tx Corrective Phase Supportive C

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 Risk
for future moderate
to severe Periodontitis
High Risk
for 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?

Methods
Patient recruitment
Risk-Classification
„Low Risk“ (LoR):
Non smoker (≥ 10 years)
No Diabetes
IL-1 Genotype negative
„High Risk“ (HiR):
≥ 1 of 3 risk factors
4 patient groups
HiR-P1, HiR-P2, LoR-P1, LoR-P2

Results
Influence of risk status and frequency of preventive visits on tooth loss events
Significant difference
only
in high-Risk group

Results
Frequency of tooth loss events relative to the number of risk factors

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

Adults with no prior prognosis of periodontitis,
who see the dentist regularly for preventive care
Low Risk
for future moderate
to severe Periodontitis
High Risk
for 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

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

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

in the prevention of periodontitis progression
(secondary prevention):
•Validated in longitudinal studies for prediction
of 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

in the prevention of periodontitis progression
(secondary prevention):
•Validated in longitudinal studies for prediction
of periodontis-progression/tooth loss
•No studies for risk-related stratification of
patients with regard to Recall-interval and/or –intensity
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

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

After 5 years (active therapy and secondary prevention)

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

Periodontal Workshops
Prevention 2014, Perio-Systemic 2012

Conclusions
•Prevention of periodontitis is possible

Conclusions
•Periodontitis can be easily detected,
successfully treated and controlled in the long-term

Conclusions
•If left untreated, periodontitis in its severe form may affect
general health

Conclusions
•If left untreated, periodontitis in its severe form may
affect general health
•Periodontal treatment can have positive effects on
general health

Periodontitis in young adults
35 – 44 years
Source: IDZ for BZÄK and KZBV

Periodontitis in young seniors
65 – 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?

However,
•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
Physical
Inactivity
Diabetes
mellitus
Hypertonia
Hyper-
cholesterin-
emia
Smoking
GeneticsAge
„Common Risk Factor“ Modification
Atherosclerosis Periodontitis

Healthy Lifestyle
• Stop smoking
• Eat well
• Exercise
• Control weight
• Oral health
WHO
„Common Risk Factor Approach“

„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

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-
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 mucositis
22% Peri-implantitis
2131 Patients
8893 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

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-
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
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
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
mucositis
1.What are effective ways of patient-performed plaque control in the
2.What are effective ways of professional plaque control
in the management of 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

Questions
mucositis
1.What are effective ways of patient-performed plaque control in the
2.What are effective ways of professional plaque control in the
3.What is the standard of care for patient- and
professionally administered plaque control for the

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.

Recommendations for Dental Professionals
Before implant placement
1. When implant treatment is considered, patients should be informed
on the risks for biological complications (peri-implant diseases) and
the 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 eliminate
                       Hence, treatment of periodontal disease aiming for elimination of
pockets with bleeding on probing and smoking cessation should prece
implant placement.

During reconstruction
The correct fit of implant components and the suprastructure has
to be ensured to avoid additional niches for biofilm adherence.
If cemented implant restorations have been selected, the restora
margins should be located at the mucosal margin to allow meticulous
removal of excess cement.
Clinicians have to be aware that implant placement at a submucosal
level (to hide crown margins) may carry a higher risk for periimplant
diseases.

Patient care
To facilitate personal oral hygiene, clinicians should consider
having keratinized attached and unmovable tissue surrounding
the 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-implant
diseases, patients have to be instructed on their personal oral
hygiene 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 examined
including probing assessments with special emphasis on bleeding on probing.

Prevention of Periimplantitis
Conclusions
1.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

Thank you very much for your attention!

The Global Strategy and Teamwork for Periodontal Health and Overall Health - Soren Jepsen

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