Article Type: Supplement Article

Accepted Article
Primary and Secondary Prevention of Periodontal and Peri-Implant Diseases

Introduction to, and Objectives of the Consensus from the 11th European Workshop on
Periodontology

Maurizio S. Tonetti§, Iain L. C. Chapple§, Søren Jepsen§, Mariano Sanz§

§European Workshop on Periodontology Committee, European Federation of

Periodontology.

Correspondence: Prof. Dr. Mariano Sanz

Chair, European Workshop on Periodontology Committee
c/o Dept. Periodontology, Faculty of Odontology
Plaza Ramon y Cahal s/n
Madrid, Spain
marianosanz@mac.com

Running title: 11th European Workshop: Prevention

Conflict of interest and source of funding

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.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jcpe.12382
This article is protected by copyright. All rights reserved.
 Abstract
Accepted Article Background: Periodontitis prevalence remains high. Peri-implantitis is an emerging public
health issue. Such a high burden of disease and its social, oral and systemic consequences
are compelling reasons for increased attention towards prevention for individuals,
professionals and public-health officials. Methods: 16 systematic reviews and meta-reviews
formed the basis for workshop discussions. Deliberations resulted in 4 consensus reports.
Results: This workshop calls for renewed emphasis on the prevention of periodontitis and
peri-implantitis. A critical element is the recognition that prevention needs to be tailored to
the individual needs through diagnosis and risk profiling. Discussions identified critical
aspects that may help in the large-scale implementation of preventive programs: i) a need
to communicate to the public the critical importance of gingival bleeding as an early sign of
disease, ii) the need for universal implementation of periodontal screening by the oral
health care team, iii) the role of the oral health team in health promotion and primary and
secondary prevention, iv) understanding the limitations of self-medication with oral health
care products without a diagnosis of the underlying condition, and v) access to appropriate
and effective professional preventive care. Conclusions: The workshop provided specific
recommendations for individuals, the oral health team and public health officials. Their
implementation in different countries requires adaptation to respective specific national
oral health care models.

Keywords: periodontitis, peri-implantis, gingivitis, gingival bleeding, peri-implant mucositis,

prevention, public health, health policy, consensus conference, evidence based medicine,
clinical recommendations.

Clinical Relevance
Scientific Rationale: Persistence of a high burden of disease related to periodontitis and the
emerging issue of peri-implantitis in many industrialized countries with access to care
necessitates renewed professional efforts towards prevention.
Principal Findings: The 11th European Workshop on Periodontology systematically
addressed the scientific basis of primary and secondary prevention. An important finding is
the emphasis on gingival (mucosal) inflammation as the key risk factor for periodontitis

This article is protected by copyright. All rights reserved.

 onset. Recognition of gingival bleeding as a sign of disease and key component of self-
diagnosis at the population level is emphasized. Prevention requires an informed individual,
Accepted Article
a prepared oral health team, the use of appropriate screening and diagnostic approaches,
and effective oral care health care aids to assist in mechanical and chemical plaque control.
Practical Implications: The results of this workshop provide new insights and opportunities
to re-organize preventive services and enhance their effectiveness in a variety of health care
settings.

Introduction
Periodontal health across the human lifespan is a key component of oral health and an
important component of general health and well being for individuals and the population as
a whole. It encompasses healthy gingivae and periodontal attachment in the natural
dentition and also the health of their equivalent structures around dental implants: the peri-
implant mucosa and the peri-implant alveolar bone. The vast majority of periodontal and
peri-implant diseases are initiated by the accumulation of microbial biofilms on hard, non-
shedding surfaces, i.e. teeth or dental implants. These cause local inflammatory reactions in
the marginal soft tissues (gingivae and peri-implant mucosa). If the biofilms are not regularly
dispersed or disrupted by self-performed oral hygiene measures, they become dysbiotic as
local conditions favour the emergence of pathogenic species that lead to chronicity of soft-
tissue inflammation (gingivitis and peri-implant mucositis). In susceptible individuals, the
persistence of gingivitis and peri-implant mucositis leads to the development of
periodontitis and peri-implantitis respectively.

Periodontitis affects more than 50% of the adult population and its severe forms affect 11%
of adults, making severe periodontitis the 6th most prevalent disease of mankind. The
increased use of dental implants for replacement of missing teeth has created a new disease
burden in the form of peri-implant diseases, with contemporary research estimating a 43%
prevalence of peri-implant mucositis and a 22% prevalence of peri-implantitis. Such a high
burden of disease and its social, oral and systemic consequences are compelling reasons for
increased attention from individuals, professionals and public-health officials.

The objective of this Workshop was to discuss the available scientific evidence from
systematic evaluation of the research base, and to provide a consensus on preventive

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 efforts with an emphasis on patient-delivered, as well as professional interventions by the
oral health care team.
Accepted Article
Prevention rather than repair

Traditional models of oral healthcare provision have involved the repair and restoration of
tissues, following disease onset. Thus, diagnoses were formulated with invasive therapeutic
interventions in mind, consistent with a surgical philosophy to oral care. A preventive
approach to care requires diagnosis, education and motivation towards behaviour change,
with patients taking greater responsibility for their own health under guidance of, and with
support from the oral care team.

Professional preventive measures need to be personalised to the individual patient, based

upon clinical findings and lifestyle factors. This requires diagnosis to stratify subjects into: i)
periodontally healthy; ii) gingivitis (peri-implant mucositis); and iii) periodontitis (peri-
implantitis) as well as risk assessment for future status. Validated periodontal screening
methods are now a fundamental requirement for all patients, given the high prevalence of
periodontal and peri-implant conditions and should be applied universally.

Specific recommendations

• An appropriate periodontal diagnosis alongside assessment of patient-level factors

(risk factors and attitudes) should determine the selection of the most appropriate
type of professional preventive care.
• Professional mechanical plaque removal as the sole element of professional
preventive care is inappropriate since education and behaviour change are
fundamental to sustained improvements in health status.
• Professional preventive care alone is inappropriate in subjects with a clinical
diagnosis of periodontitis or peri-implantitis, as they require treatment for their
condition.

This article is protected by copyright. All rights reserved.

 Article Type: Supplement Article
Accepted Article
Primary and Secondary Prevention of Periodontal and Peri-Implant Diseases

Introduction to, and Objectives of the Consensus from the 11th European Workshop on
Periodontology

Maurizio S. Tonetti§, Iain L. C. Chapple§, Søren Jepsen§, Mariano Sanz§

§European Workshop on Periodontology Committee, European Federation of

Periodontology.

Correspondence: Prof. Dr. Mariano Sanz

Chair, European Workshop on Periodontology Committee
c/o Dept. Periodontology, Faculty of Odontology
Plaza Ramon y Cahal s/n
Madrid, Spain
marianosanz@mac.com

Running title: 11th European Workshop: Prevention

Conflict of interest and source of funding

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.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jcpe.12382
This article is protected by copyright. All rights reserved.
 Chemical Plaque Control
The use of adjunctive chemical approaches to biofilm control may be considered in support
Accepted Article
of mechanical plaque removal protocols, but it is not a suitable substitute for the latter, or a
more time efficient method for effective biofilm control. When considering adjunctive
chemical agents for controlling plaque and/or gingival inflammation it is important that the
clinician is aware of the evidence base for such agents, their side effects and any
environmental impact.

Specific recommendation

• The public should be aware that self-medication with effective chemical plaque
control agents may mask more serious underlying periodontal disease and should seek
professional advice following periodontal examination.

Secondary Prevention of Periodontitis

Secondary prevention of periodontitis aims at preventing disease recurrence in patients

previously treated for periodontitis and hence, secondary prevention programs are targeted
to a high-risk group as evidenced by a previous diagnosis of periodontitis (peri-implantitis).
Patients should enter a secondary prevention program once they have completed the active
phase of therapy and the endpoints of therapy have been reached. These patients must
follow a specific supportive periodontal care regimen. It is recognized that secondary
prevention of peri-implantitis poses unique challenges that may only be partially addressed
by routine supportive periodontal care programs.

Specific recommendations

• Long-term success of periodontal therapy requires participation in a secondary

prevention program specifically designed to meet the needs of these individuals at
higher risk of disease recurrence.
• For optimal long-term tooth retention, patients participating in secondary
prevention programs require completion of an active phase of periodontal therapy
that achieves individually set treatment goals.

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 Management of Gingival Recession, Non-carious Cervical Lesions and Dentine
Accepted Article Hypersensitivity in the Context of Secondary Prevention

After successful treatment of periodontitis a degree of recession of the gingival margin

frequently occurs. The resulting exposure of a portion of the root-surface poses challenges
for long-term management and secondary preventive efforts and may lead to plaque
accumulation and gingival inflammation. Moreover, the loss of hard tissue from the cervical
region of a tooth that is not related to caries, may lead to dentine hypersensitivity that may
complicate secondary prevention.

Following professional diagnosis of dentine hypersensitivity, potential aetiological factors

should be addressed, including a dietary record and medical history questionnaire to assess
frequency of exposure to acid. Appropriate advice should be given and referral may be
required.

Specific recommendation

• Before implementing any specific treatment for dentine hypersensitivity, the dentist
should first confirm the diagnosis of dentine hypersensitivity.

Management of Oral Malodour

Oral healthcare professionals (within their scope of practice as dictated by the professional
legal authority) should be aware of the fundamental basis of halitosis and that they have the
primary responsibility for its diagnosis and management. Only a limited number of patients
with extra-oral halitosis and halitophobia (<10% together) will require referral to an
appropriate health professional. Diagnosis should include a proper medical history
questionnaire, periodontal examination and inspection of the coating of the tongue and an
organoleptic description.

Specific recommendation

• Before implementing measures for the management of oral malodour, the dentist,
within the limits of their professional competence, should establish whether there is
an intraoral source for the malodour.

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 Conclusions
The detailed results and specific recommendations of the 11th European workshop on
Accepted Article
Periodontology are reported in four consensus reports (Tonetti et al 2015, Chapple et al
2015, Jepsen et al 2015, Sanz et al. 2015) on the principles of prevention of periodontal and
peri-implant diseases, both primary and secondary, and the complications of periodontitis.
The reports are based upon 16 systematic reviews of the relevant literature and meta-
reviews of the former and provide guidance for practitioners, patients and the public. They
represent the expert view in Europe, endorsed by representatives of the American Academy
of Periodontology.

References
Chapple et al 2015

Jepsen et al 2015

Sanz et al. 2015

Tonetti et al 2015

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