Periodontitis and the importance of oral hygieneNews
Posted by: The Probe 21st April 2020
Despite dental clinicians’ concerted efforts, just 17% of British adults have completely healthy periodontal tissues, with around 9% exhibiting pocketing of 6mm or more.[i] Early indicators and symptoms of periodontal disease can be very mild and easy to miss. If allowed to progress, it can lead to destruction of alveolar bone, resulting in tooth mobility, drift and eventual loss.[ii] Periodontal disease is the consequence of complex interactions between the subgingival microbiota, the host’s immune and inflammatory responses, and environmental factors.[iii]
While the threat of tooth loss is serious by itself, periodontal disease has implications for patient health that extend far beyond the oral cavity. As with other inflammatory conditions, periodontal disease increases the risk of acquiring further inflammatory diseases and health problems.[iv] Moreover, periodontitis is believed to increase the risk of cardiovascular disease by 19%, rising to 44% for individuals aged 65 years and above. Patients with type 2 diabetes and severe cases of periodontal disease have more than 3 times the mortality risk of those with mild periodontitis.[v] Some types of cancer have also been linked to periodontal disease, including oral, oesophageal, gastric, pancreatic, breast and prostate cancer.[vi]
Modifiable risk factors
Of the modifiable risk factors for periodontitis, poor oral hygiene represents the most substantial, yet is likely the most easily changed. Fair to poor oral health results in two- to five-fold increase in the risk of developing periodontitis respectively.[vii] The main risk factor coinciding with what by rights should be the least challenging intervention is unusually good fortune. However, as the data shows, we are still very far from eliminating periodontal disease, so we must carefully consider how to further improve patient’s oral hygiene.
Smoking is widely understood to carry a wide array of health risks, and affects both the immune system and circulatory system. It is therefore unsurprising that smoking is a risk factor for both gingivitis and periodontitis. Interestingly, smokers may exhibit less gingival bleeding than non-smokers with lower plaque indexes. This may be a reflection of the damage and disruption smoking does to the blood vessels in the gingival tissues. Bleeding on probing (BOP) is generally a good predictor of future periodontitis, but because smoking can interfere with this presentation, it is important to be aware if your patient smokes in order to properly diagnose them.[viii], [ix]
Stress can have wide-ranging effects on people, and that includes predisposing them to periodontitis and exacerbating the condition.[x] The extent to which stress is meaningfully modifiable depends on the individual and their circumstances. Studies have shown that shift work and long-working hours are associated with a significant increase in periodontitis prevalence, as is socio-economic status.[xi], [xii]
Non-modifiable risk factors
Aging has a deleterious effect on the immune system and the body’s ability to repair itself.[xiii] The risk of periodontitis increases with age, though it should not be considered an inevitability.[xiv] Aging also increases the likelihood of acquiring a condition that is comorbid with periodontitis.
Some individuals are more predisposed to developing periodontitis than others due to their genetic background.[xv] Gingivitis, probing depths, attachment loss, and plaque scores have all been shown to be influenced by genetic factors. However, the relationship between genetics and periodontitis is controversial and far from conclusive.[xvi]
Various mental health conditions appear to increase the risk and severity of periodontal disease, and can influence treatment outcomes. Psychological distress can place a great deal of stress on an individual, and an individual’s psychological state can affect their immune system and inflammatory response. Some psychological disorders, such as depression, can inhibit an individual’s self-care, including practising routine oral hygiene. As with stress, psychological distress can also lead to patients adopting unhealthy coping strategies, such as self-medicating with alcohol and nicotine, or comfort eating.[xvii] While many psychological disorders are generally regarded as incurable, they can be treated and managed, reducing the impact they have on patients’ lives, and therefore could be considered a modifiable factor to some extent.
Oral hygiene and communication
While periodontal disease is multifactorial, with a great variety of factors influencing the development and progression of the disease, the keystone for patients is the practice of good oral hygiene. Dental plaque is the primary aetiological factor in the development of the disease.[xviii]
Around a quarter of Britons fail to brush their teeth twice a day and view bleeding gums as trivial or even normal.[xix] While alarm should be avoided, some patients clearly need a firmer message. You are ultimately the best judge of what phrasing will work for your patients, but try not to shy away from impressing on them the seriousness of periodontal disease. Focus on simple, clear, memorable statements that will stay with the patient long after their appointment. Patients need to understand that gum disease is an infection and that it causes permanent damage to their bone – once that damage gets to a certain point, their teeth will be at risk of moving and falling out. While its important that patients understand that the damage to the bone is irreversible, with treatment and their own efforts to improve their oral hygiene, further harm can be avoided and their oral condition will improve (with observable benefits such as fresher breath). Patients appreciate clarity and will be much happier in the long-term for receiving a firm warning and clear guidance, rather than continually live at high risk of tooth loss.[xx]
Many patients neglect their interdental spaces by relying solely on toothbrushes that are inadequate for cleaning these difficult to reach areas. Given that plaque formation is the key instigating factor for gingivitis, ensuring these areas are kept plaque free is as important as any other area of the teeth. The NHS recommends that people use interdental brushes or floss daily in addition to regular toothbrushing from the age of 12.[xxi] Patients can be put off by a little blood at first, but it is important to remind them that this should diminish as their gums become healthier – though they should contact your practice if this does not improve. Brushes should be adequately small and patients should not force them into their interdental spaces.[xxii]
As specialists in oral healthcare, Curaprox offers a range of products that are designed to help patients optimise and maintain good oral hygiene. To get the most out of brushing, toothbrushes themselves should be excellent quality and in good condition. The CS5460 is an ultra-soft toothbrush with 5,460 CUREN® filaments. These ultra-fine filaments are gentle but effective at removing plaque, and can be recommended to help patients with sensitive teeth and gums brush thoroughly. In addition, Curaprox offers the CPS Prime interdental brush, featuring a reusable handle and replaceable brush head to help patients minimise their plastic waste. The fine, conical brush head design of the CPS Prime also makes it easier for patients to clean otherwise difficult to maintain interdental spaces.
It needs to be clear to patients why they need to take better care of their teeth and how to do it. If a patient has never learned proper technique (for instance, they neglect to brush the palatal surfaces of their teeth or the back of the molars), simply telling them to brush their teeth better will likely not result in significant improvement without further clarity. While not all patients will heed advice, longitudinal studies have demonstrated that oral hygiene instruction by a professional results in a small but statistically significant reduction in plaque and gingivitis.[xxiii]
Author: Richard Thomas CEO Curaprox UK LTD
[i] White D., Tsakos G., Pitts N., Fuller E., Douglas G., Murray J., Steele J. Adult dental health survey 2009: common oral health conditions and their impact on the population. British Dental Journal. 2012; 213: 567-572. https://www.nature.com/articles/sj.bdj.2012.1088 November 15, 2019.
[ii] Könönen E., Gursoy M., Gursoy U. Periodontitis: a multifaced disease of tooth-supporting tissues. Journal of Clinical Medicine. 2019; 8(8): 1135. https://doi.org/10.3390/jcm8081135 November 15, 2019.
[iii] Lang N., Bartold P. Periodontal health. Journal of Clinical Periodontology. 2018; 45(suppl 20). https://onlinelibrary.wiley.com/doi/full/10.1111/jcpe.12936 November 8, 2019.
[iv] Hoare A., Soto C., Rojas-Celis V., Bravo D. Chronic inflammation as a link between periodontitis and carcinogenesis. Mediators of Inflammation. 2019; 2019: 1029857. https://www.hindawi.com/journals/mi/2019/1029857/ November 15, 2019.
[v] Nazir M. Prevalence of periodontal disease, its association with systemic diseases and prevention. International Journal of Health Sciences. 2017; 11(2): 72-80. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5426403/ November 8, 2019.
[vi] Hoare A., Soto C., Rojas-Celis V., Bravo D. Chronic inflammation as a link between periodontitis and carcinogenesis. Mediators of Inflammation. 2019; 2019: 1029857. https://www.hindawi.com/journals/mi/2019/1029857/ November 15, 2019.
[vii] Lertpimonchai A., Rattanasiri S., Vallibhakara S., Attia J., Thakkinstian A. The association between oral hygiene and periodontitis: a systematic review and meta-analysis. International Dental Journal. 2017; 67: 332-343. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5724709/ November 8, 2019.
[viii] Mehta A. Risk factors associated with periodontal diseases and their clinical considerations. International Journal of Contemporary Dental and Medical Reviews. 2015; 2015: 1-15. http://www.ijcdmr.com/index.php/ijcdmr/article/view/74 November 8, 2019.
[ix] Zimmermann H., Hagenfeld D., Diercke K., El-Sayed N., Fricke J., Greiser K., Kühnisch J., Linseisen J., Meisinger C., Pischon N., Pischon T., Samietz S., Schmitter M., Steinbrecher A., Kim T., Becher H. Pocket depth and bleeding on probing and their associations with dental, lifestyle, socioeconomic and blood variables: a cross-sectional, multicentre feasibility study of the German National Cohort. BMC Oral Health. 2015; 15(7). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324664/
November 8, 2019.
[x] Nazir M. Prevalence of periodontal disease, its association with systemic diseases and prevention. International Journal of Health Sciences. 2017; 11(2): 72-80. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5426403/ November 8, 2019.
[xi] Lee W., Lim S., Kim B., Won J., Roh J., Yoon J. Relationship between long working hours and periodontitis among the Korean workers. Scientific Reports. 2017; 7: 7967. https://www.nature.com/articles/s41598-017-08034-6 November 15, 2019.
[xii] White D., Tsakos G., Pitts N., Fuller E., Douglas G., Murray J., Steele J. Adult dental health survey 2009: common oral health conditions and their impact on the population. British Dental Journal. 2012; 213: 567-572. https://www.nature.com/articles/sj.bdj.2012.1088 November 15, 2019.
[xiii] Leng J., Goldstein D. Impact of aging on viral infections. Microbes and Infection. 2010; 12(14-15): 1120-1124. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998572/ November 8, 2019.
[xiv] Nazir M. Prevalence of periodontal disease, its association with systemic diseases and prevention. International Journal of Health Sciences. 2017; 11(2): 72-80. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5426403/ November 8, 2019.
[xv] Nazir M. Prevalence of periodontal disease, its association with systemic diseases and prevention. International Journal of Health Sciences. 2017; 11(2): 72-80. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5426403/ November 8, 2019.
[xvii] Halawany H., Abraham N., Jacob V., Al Amri M., Patil S., Anil S. Is psychological stress a possible risk factor for periodontal disease? A systematic review. Journal of Psychiatry. 2015; 18(1). http://dx.doi.org/10.4172/1994-8220.1000217 November 15, 2019.
[xviii] Johnson T., Worthington H., Clarkson J., Pericic T., Sambunjak D., Imai P. Mechanical interdental cleaning for preventing and controlling periodontal diseases and dental caries. Cochrane Library. 2015; 12: CD012018. https://doi.org/10.1002/14651858.CD012018 November 15, 2019.
[xix] NHS. Adult dental health survey 2009 – summary report and thematic series. NHS Digital. 2011. https://digital.nhs.uk/data-and-information/publications/statistical/adult-dental-health-survey/adult-dental-health-survey-2009-summary-report-and-thematic-series November 15, 2019.
[xxi] NHS. Why should I use dental floss. NHS. 2017. https://www.nhs.uk/common-health-questions/dental-health/why-should-i-use-dental-floss/ November 15, 2019.
[xxii] NHS. Why should I use interdental brushes? NHS. 2018. https://www.nhs.uk/common-health-questions/dental-health/why-should-i-use-interdental-brushes/ November 15, 2019.
[xxiii] Chapple I., Van der Weijden F., Doerfer C., Herrera D., Shapira L., Polak D., Madianos P., Louropoulou A., Machtei E., Donos N., Greenwell H., Van Winkelhoff A., Kuru B., Arweiler N., Teughels W., Aimetti M., Molina A., Montero E., Graziani F. Primary prevention of periodontitis: managing gingivitis. Journal of Clinical Periodontology. 2015; 42(S16): 71-76. https://onlinelibrary.wiley.com/doi/full/10.1111/jcpe.12366 November 15, 2019.
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