Prevention of Periodontal Disease

Introduction:
Periodontal disease is the affection of the periodontium or the supporting
tissues of teeth. It may range in the same mouth from mild inflammation of the
gingival margin (marginal gingivitis) to a severe destruction of the periodontal
ligaments and the supporting alveolar bone. Epidemiological surveys and clinical
studies demonstrate a direct association between the prevalence of and severity of
periodontal disease and the accumulation of bacterial plaque and debris.
It is well known that untreated or unsuccessfully treated periodontal disease
is a significant cause of tooth loss. Periodontal disease once established, is often
time-consuming and costly to treat, studies suggest that it may often have its onset
during adolescence and early adulthood. Furthermore, gingivitis, which always
precedes periodontitis, is widely prevalent in children. So, Preventive strategies
which are targeted at children, adolescents, and young adults may therefore,
reduce the need for the complicated and expensive treatments of the established
disease.
Normal gingiva has been defined as pink, firm, stippled, with well formed
papillae and gingival sulci (crevices) shallow in depth and without exudate.
Clinically, the probing depth with a blunt probe of the healthy gingival crevice
reaches about 2mm. three areas are distinguished clinically in the gingiva, namely
the interdental papillae, the gingival margin which forms the soft tissue wall of the
gingival crevice (free gingiva), and the attached gingiva which is firmly bound down
to the underlying cementum and alveolar bone.

Fig 1: The structure of a normal healthy gingiva

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 When the gingiva is inflamed, there is increased hyperemia, which shows as
deepening of the normal pink color to red, this is usually associated with bleeding
either on brushing or spontaneously. The gingival margin and the interdental
papillae are usually swollen and edematous. This results in a shiny appearance of
the surface with loss of stippling. Mild gingivitis is very prevalent among children,
often merely being limited to loss of stippling, swelling and slight redness. In more
advanced cases, however, marked redness with frequent bleeding may occur
accompanied sometimes by soreness and etching, where inflammation has been
present for a long period of time there may be an overgrowth of connective tissue
specially in the anterior region where the gingivae become rough and irregularly
enlarged. In more severe cases, destruction of the periodontal ligaments will occur,
this may be accompanied by resorption of the alveolar bone, pocket formation,
loosening and tooth migration.
At puberty there is sometimes a pronounced gingivitis showing more swelling and
discoloration than usual but after a time this may tend to improve although
frequently treatment is also required.

Causes of periodontal disease:

Dental plaque occupies the central role as the major etiological factor in the
pathogenesis of periodontal disease. It is, however, recognized that a number of
factors which may predispose to the plaque accumulation, or which modify the
host’s response, also play a significant role in disease initiation and progression.

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 ➢ Dental plaque:
It is well established that, for gingivitis to occur and periodontitis to be initiated,
plaque must be present. Dental plaque is the non-mineralized, bacterial
aggregation on the teeth and other solid structures in the mouth , which is so
tenaciously adherent to the surface that it resists removal by salivary flow or a
gentle spray of water across its surface.
70% of the volume of plaque is composed of bacterial cells. The remainder
comprises protein, extracellular polysaccharides and epithelial cells. these bacteria
can provoke an inflammatory response and cause tissue damage.
➢ Dental calculus:
Mineralization within plaque results in calculus formation. The surface texture
of the calculus promotes more and more plaque accumulation.
The rate of calculus formation between individuals is very variable, and children
form less calculus than adults. The upper labial segment, which is one of the
commonest sites for gingivitis in children, is rarely affected by calculus.

Factors predisposing to plaque accumulation:

a) Local Factors:

1. The consistency of the diet:

The consistency of the diet is considered important on the basis of functional
stimulation derived from mastication which is an essential requirement for
the normal metabolic activity of the gingiva and underlying tissues. Soft foods
are detrimental to the periodontium, first because they do not afford
functional stimulation, and second, the faster accumulation of irritating food
debris at the gingival margin. Bacterial activity in the food debris around the
teeth and gums can cause damage to the underlying gingival tissues and
initiate gingivitis.

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2. Inadequate oral hygiene:
One of the most powerful factors indicated by many studies that directly
influence the plaque accumulation on tooth surface.

3. Occlusal abnormalities:
Occlusal abnormalities e.g. crowding of teeth, open bite, proclined maxillary
incisors, and incompetent lips, are common causes of gingivitis by interfering
with normal function and allowing food stagnation. Early extraction of a first
permanent molar will prevent the normal cleansing effect of mastication and
allow food stagnation around the tooth opposite the space.

4. Untreated caries:
Untreated caries, especially in cases of interproximal and cervical caries due
to increased impaction or lodgment of food debris, is also a cause of
periodontal disease.

5. Overhanging restorations:
Overhanging restorations and rough surface restorations can act as retention
sites for dental plaque, also subgingival restoration margins which lead to
greater plaque accumulation, and result in poorer gingival health than do
restoration margin that are in level with or remain above the gingival crest.

6. Prosthetics and ortho appliances:

Prosthetic and orthodontic appliances constitute a significant local irritating
factor particularly when they are poorly fitted or incorrectly designed.

7. The process of shedding of deciduous teeth and eruption of permanent

teeth:
These processes are probably responsible for much of the gingivitis seen
during the mixed dentition period. The child will avoid chewing on. a loose or
painful tooth allowing deposits to be left on and around the affected site.

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b) Systemic factors:
When planning preventive measures, it is desirable to consider systemic factors.
The systemic background conditions the gingival tissue response to the local
irritating factors.

1. Endocrinal disorders: Diabetes often permits an increased inflammatory

gingival response, particularly if there is neglected oral hygiene. At puberty
there are often hormonal changes and temporary upset in the gingival
condition characterized by a rather swollen hemorrhagic appearance.

2. Drugs: The administration of certain drugs on long term basis may give rise
to gingival alterations. The anticonvulsant drug 'Dilantin" causes
characteristic gingival hyperplasia starting at the interdental papillae and
spreading over other areas too, occasionally completely covering the teeth.
In some cases, the gum is rather firm and shows little tendency to bleed, in
others superadded gingivitis is present as well.

3. During acute fevers: Such as typhoid and measles, deterioration of the

gingiva may occur due to the concomitant poor oral hygiene, but an
improvement should be shown on recovery from the fever.

4. Blood dyscrasias: Such as agranulocytosis, leukaemia and purpura often

exhibit gingival changes and these may even be the first symptoms
experienced by the patient.

5. Avitaminosis: may affect the gingiva, particularly the lack of vitamin C which
gives rise to scurvy but nicotinic acid deficiency also may precipitate gingival
lesions too.

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Objectives of prevention:
• To promote optimum health of periodontium.
• To prevent initial lesions.
• To intercept hard and soft tissue lesions already in progress in order to
restore health and prevent further damage.

Preventive Measures:
Prevention of periodontal disease encompasses a set of various actions which
ultimately aim at preventing or controlling the disease. It may apply to any point of
the disease process.
Preventive measures of periodontal disease can be achieved in the following
steps:
I. Plaque control
II. Modification of predisposing/risk factors

I. Plaque control:
As gingivitis is caused by supragingival plaque accumulation and as gingivitis is
prerequisite for the development of periodontitis, both diseases can be prevented
by an adequate standard plaque control.
Plaque control can either be mechanical or chemical.

➢ Mechanical plaque control can be of two types:

1. Professional
2. Self- care
1. Professional plaque control comprises of:
a. Dental health education.
The stressing from an early age on the importance of good oral hygiene in
assisting the natural cleansing action of the mouth is valuable; in addition, it
should be recommended that children eat some hard fibrous and fresh foods

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 in addition to the rather soft diet prevalent today. It must be stressed also
that the toothbrush is really a mouth brush, and the care of the gingivae is
just as important as that of the teeth.

b. Scaling and root planning. (Dental prophylaxis).

Scaling and root planning are done to remove the plaque and calculus
from enamel and root surface to achieve a favourable plaque free
environment and help in renewal of junctional epithelium and epithelial
attachment.
Also polishing can be done because plaque removal is obviously inhibited
by surface roughness, also Plaque is more difficult to get attached to Smooth
surfaces. Polishing Includes removal of extrinsic tooth stains.
Dental prophylaxis is more important in the control of periodontal disease
than it is in the control of caries. This is because deposits of calculus are highly
conductive to periodontal disease and cannot be removed by the patient in
the course of home care.
Patients with a tendency to gingivitis must be observed until it is known
in how many months the accumulation of hard deposits upon the teeth will
pass beyond the control of home care. Many periodontal patients must
receive dental prophylaxis every 3 months or every 4 months, in addition to
whatever more extensive treatment may be necessary at the hand of the
dentist Posterior bite-wing X-ray films should be taken at annual intervals and
studied for any alveolar bone loss.
If calculus forms in a child's mouth a thorough prophylaxis should be
carried out and repeated at intervals; in addition, the child's brushing habits
should be checked to try to prevent any recurrence.

2. Self-care:
Includes all dental hygiene methods the patient can practice at home.
a. Tooth brushing:
It is the most commonly recommended measure for the removal of
food debris and plaque from the teeth mechanically. On the basis of the

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 motion, methods of brushing are different, from vertical, horizontal, roll,
circular to scrub method. None of them has been shown to be superior to
others. The thoroughness of plaque and debris removal depends upon the
careful and correct application of any brushing method rather than the
applied methods itself. The roll technique mentioned before can be
suggested, other techniques are beneficial particularly when periodontal
disease is existing; these are:

▪ Charter's method:
The ends of the bristles are placed in contact with the enamel of the
tooth surface and the gingival tissue with the bristles pointing occlusally at
an angle of 45. Much lateral and downward pressure is then placed upon the
brush and the brush is vibrated gently back and forth a millimeter or so. This
gentle vibratory procedure forces the ends of the bristles between the teeth
and cleans the interproximal tooth surfaces very well. This technique also
massages the interdental tissues as well.
▪ Stiliman's method:
The brush is placed in approximately the same position as required for
the beginning stroke of the roll method, except that it is nearer the crowns
of the teeth. The handle is vibrated gently in a rapid but slight mesiodistal
movement. This technique forces the bristles into the interproximal spaces
and handles the teeth in that area very well. It also adequately massages the
gingival tissues. As a final step of brushing, it is recommended to brush the
dorsum of the tongue with the brush. This will increase its circulation and
remove bacteria and waste products that can cause fetid oris.

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 b. Devices for entering individual crevices:
It is well established that periodontal conditions are worst in interdental areas
where standard toothbrushes are less effective at removing proximal surface
plaque. Furthermore, bacterial deposits that remain after brushing will promote the
regrowth of fresh plaque. The need for effective interdental cleaning has led to the
manufacture of various devices like Dental floss, toothpicks, rubber tips etc. Which
are sometimes recommended according to the individual dexterity and dental
anatomy for cleaning areas inaccessible to the toothbrush. They are beneficial in
massaging the gingival tissues and cleaning the interproximal spaces. (The uses of
these devices are discussed before).
Self-care effectiveness depend on:
• Motivation
• Knowledge
• Oral hygiene instructions
• Manual dexterity
• Oral hygiene aids

➢ Chemical plaque control:

A large number of chemical agents have been tested for their ability to
reduce plaque accumulation. Various delivery vehicles are used for delivery of these
chemicals such as mouth rinses, gels, toothpastes, chewing gums and lozenges,
irrigants and varnishes.
Chemical plaque control should always be regarded as needs related
supplement to and not a substitute for mechanical plaque control. Therefore, based
on individual’s patient’s predicted risk for oral disease, the choice of agent and
frequency of use should be decided.
By far the most efficient plaque control programmes are those combining
mechanical and chemical methods, for example the toothpaste used can contain
not only an abrasive agent but also antiplaque or antimicrobial agent such as
stannous fluoride, triclosan or any other chemical plaque control agent.

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Goals of chemical plaque control:
1. To prevent plaque formation.
2. To reduce, disrupt or remove existing plaque.
3. To alter the composition of plaque flora.
4. To exert bactericidal or bacteriostatic effect on microflora implicated in
periodontal disease.
5. To alter the surface energy of the tooth, in turn, affecting the plaque
adherence.

Factors influencing effects of chemical plaque control.

Substantivity: it is the ability of an agent to bind tissue surfaces and be released
overtime delivering an adequate dose of the active principal ingredient in the agent.
Penetrability: it is the efficiency of an agent in penetrating deeply into the formed
plaque matrix.
Selectivity: it is the ability of the agent to affect specific bacteria in a mixed
population.
Solubility: it is the property of the active agent to be soluble in its delivery vehicle
to allow rapid release into the oral environment.
Stability: the agent should not undergo chemical breakdown or modification
during storage

Chlorhexidine:
Chlorhexidine was developed in the 1940s and was first marketed in 1953 as
a general disinfectant for skin and mucous membrane, later the antiseptic was more
widely used in medicine and surgery.
Chlorhexidine has a broad spectrum of bactericidal activity against gram-
positive and gram-negative organisms. Streptococcus mutans seems to be
particularly sensitive to Chlorhexidine. Besides acting immediately on oral bacteria,
it is retained on the tooth surface to exert a prolonged bactericidal effect, and

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subsequently, as its concentration falls, a bacteriostatic effect for several hours.
Chlorhexidine may be administered as a mouth rinse, as a toothpaste, gel, in an oral
irrigator, or as a spray.
Side effects:
Chlorhexidine may possess the following side effects:

• Unpleasant taste and disturbances in taste sensation which may last for
several hours.
• Brown discoloration of teeth and fillings is common, both with mouthwash
and gel preparations. Brown staining of the dorsum of the tongue occurs with
the mouthwash but not with the toothpaste/gel.
• Desquamation and soreness of oral mucosa may occur in small number of
patients.

II. Modification of predisposing/risk factors

Disorders of occlusion: Early diagnosis of occlusal disorders and early treatment by

preventive or interceptive measures will save the gingiva, the deleterious
consequences of crowding, open bite, cross bite etc.
Mouth breathing: This should be treated either by clearing the air passages (oro-
nasal part) by surgical or medical specialists, or by orthodontic means as oral
screen. The effect of repeated drying on the gingival tissue will thus be eliminated.

Early -treatment of carious cavities: To avoid gingival inflammation, caries should

be treated as soon as a cavity is spotted. There is no urgent "big cavity" to cause
wary and non-urgent "little cavity" warrants no such interest. Caries is caries in both
conditions. Cervical cavities and interproximal cavities cause irritation of the
neighboring gingival tissue, whereas an open occlusal cavity causes decreased
function of the same side and results in the accumulation of debris.
The use of bite wing films in the early detection of interproximal lesions is advisable
because such early cavities may be missed on clinical examination only. New

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restorations should be carefully inserted, contoured and polished to avoid food
impaction and gingival damage. Old restorations should be checked for improper
contact, overhanging margins and defect at the tooth restoration junctional line.

In the presence of prosthetic, surgical or orthodontic appliances: the patients

must be aware of the role of such appliances in encouraging the stagnation of
debris and traumatizing oral soft tissues including the gingiva. It is necessary to
maintain good oral hygiene and clean the removable appliances thoroughly outside
the mouth. It is occasionally suggested to relief the oral tissues by leaving dentures
out at night.

Systemic diseases: such as blood dyscrasias, endocrine disorders and vitamin

deficiencies will need medical attention in addition to local treatment. Proper oral
hygiene will add to the health of oral and periodontal tissues.

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 prevention of
periodontal disease

modification of
plaque control
risk factors

early ttt of
mechanical chemical disorders of
occlusion

early ttt of
professional self care e.g.CHX caries/faulty
restorations

care in presence
dental health
tooth brushing of
education
ortho/appliances

extra care in
dental interdental
presence of
prophylaxis cleaning aids
systemic disease

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