Quo vadis: what is the future of periodontics? How will we get there?

Approximately 40 years ago periodontists began systematically developing the evidence to treat predictably and prevent gingivitis and periodontitis. More recently, periodontists have been among a small group of skilled dental‐implant surgeons leading that revolution in dentistry. Today, much of the mild/localized moderate periodontitis is not treated by periodontists, and an increasing number of implants are placed by dentists with limited surgical training. The current field of periodontics includes a broad range of surgical skills and technologies to regenerate predictably destroyed tissues and manage complex interdisciplinary treatment that may, in some way, involve the tissues that support teeth and implants. In addition, periodontal researchers have shown that moderate‐to‐severe periodontitis increases the systemic inflammatory burden and transient bacteremias that result in a significant independent role for periodontitis in multiple systemic diseases. Although many periodontists have very advanced practices that incorporate certain aspects of the current and near‐future dimensions of periodontics, the innovations and technologies have not yet fully integrated throughout the specialty. It is an appropriate time to ask the question: Quo vadis? Which paths have the potential to deliver great value to our patients and to the health‐care system? And who will be our patients in the near future? We propose some key capabilities, knowledge and clinical applications. Perhaps most importantly, we propose new partnerships. Much of the vision centers around the application of special diagnostic technologies and surgical skills to help our dental colleagues better manage complex dental and periodontal cases and to deliver on the promise of reducing systemic inflammation sufficiently to enhance medical management of certain chronic diseases and reduce preterm births. The specialty has always been about retaining teeth in good health and in recent years has focused on controlling oral inflammation to enhance systemic health. We already have several of the key principles, concepts and technologies that are likely to define the role of periodontics in the evolving health‐care delivery system. Perhaps it is time to define the mission and start moving toward the future periodontics.     

Stress,allostatic load,and periodontal diseases

Psychosocial stress plays an important role in periodontal disease through biological and behavioral pathways. In this paper we review studies that examine the relationship between stress and periodontal diseases, and discuss the different measures used to assess stress. Self‐reported measures, such as the Perceived Stress Scale and the Stress Appraisal Measure, have traditionally been used to assess stress. Frequent and repeated exposure to stressor(s) leads to wear and tear of the body's systems, resulting in what is known as allostatic load. In recent years, few studies examining the relationship between stress and periodontal diseases have used an aggregate variable, including primary and secondary markers of allostatic load, as a biological marker of stress. While research on the relationship between allostatic load and periodontal disease is still developing, as most of the studies used cross‐sectional data, this line of research presents a good opportunity for establishing a composite biological indicator as a risk factor for periodontal disease. Such an indicator is also potentially beneficial for personalized periodontics as it will help to target intervention to specific levels of risk and will help in integrating oral and general health promotion policies.     

Periodontal health through public health - the case for oral health promotion

Periodontal diseases are highly prevalent, particularly amongst socially disadvantaged populations, impact on quality of life and are costly to treat. Clinical treatments and chairside preventive approaches alone will never adequately address this problem. Indeed in many parts of the developing world clinical care and chairside prevention are both unaffordable and inappropriate for the control of periodontal diseases. A paradigm shift away from the individualized treatment approach to a population public health model is needed to promote periodontal health and, in particular to address social inequalities in periodontal status. Public health measures need to focus on the underlying determinants of periodontal diseases. Poor hygiene, tobacco use, psychosocial factors and related systemic diseases are the main risk factors for periodontal diseases. Public health interventions need to tackle these factors but also must recognize and act upon the distal underlying influences that determine and pattern these identified risks. Recognition also needs to be placed on the interlinking and common risk factors shared by periodontal diseases and other chronic conditions. A complementary range of public health policies acting at local, regional, national and international levels need to be implemented to achieve sustainable improvements in oral health. To be effective these policies need to link across the broader public health agenda and require public engagement and support. Clinicians, public health practitioners, commercial organizations and professional groups all have an important role to play in promoting periodontal health.     

Sociobehavioral aspects of periodontal disease

As one of the most common chronic diseases suffered by adults, periodontitis affects sufferers' day-to-day lives and is a threat to the integrity of the dentition. An important part in the condition's occurrence is played by sociobehavioural factors, the understanding of which is facilitated by using a number of largely complementary theoretical frameworks. Differences among individuals with respect to their periodontal status at any particular point in their life-course (and particularly once they are into early middle-age and beyond) are likely to have resulted from prolonged and differential exposure to the various protective and risk factors that determine their periodontal status. Thus, a sound understanding of the psychosocial pathways of the behaviors that are strongly linked to periodontal disease - and how such psychological factors affect the response of the periodontal tissues to pathogens - is essential for improving periodontal health, whether at the personal level or at the population level. Controlling periodontitis in populations therefore requires a number of complementary strategies. The current state of knowledge of its risk factors means that there is sufficient information to enable control of the disease, and public health officials should include it alongside their efforts to control dental caries. Controlling periodontitis has three strategies: (i) a population strategy for altering life practices, particularly those determining smoking behavior and oral self-care (plaque removal) in the community; (ii) a secondary prevention strategy to detect and treat people with destructive periodontal disease; and (iii) a high-risk strategy for treating existing disease and preventing further disease in those at special risk. The Common Risk Factor Approach and the health promotion approach are key aspects of these strategies.     

The global burden of periodontal disease: towards integration with chronic disease prevention and control

Chronic diseases are accelerating globally, advancing across all regions and pervading all socioeconomic classes. Unhealthy diet and poor nutrition, physical inactivity, tobacco use, excessive use of alcohol and psychosocial stress are the most important risk factors. Periodontal disease is a component of the global burden of chronic disease, and chronic disease and periodontal disease have the same essential risk factors. In addition, severe periodontal disease is related to poor oral hygiene and to poor general health (e.g. the presence of diabetes mellitus and other systemic diseases). The present report highlights the global burden of periodontal disease: the ultimate burden of periodontal disease (tooth loss), as well as signs of periodontal disease, are described from World Health Organization (WHO) epidemiological data. High prevalence rates of complete tooth loss are found in upper middle‐income countries, whereas the tooth‐loss rates, at the time of writing, are modest for low‐income countries. In high‐income countries somewhat lower rates for edentulism are found when compared with upper middle‐income countries. Around the world, social inequality in tooth loss is profound within countries. The Community Periodontal Index was introduced by the WHO in 1987 for countries to produce periodontal health profiles and to assist countries in the planning and evaluation of intervention programs. Globally, gingival bleeding is the most prevalent sign of disease, whereas the presence of deep periodontal pockets (≥6 mm) varies from 10% to 15% in adult populations. Intercountry and intracountry variations are found in the prevalence of periodontal disease, and these variations relate to socio‐environmental conditions, behavioral risk factors, general health status of people (e.g. diabetes and HIV status) and oral health systems. National public health initiatives for the control and prevention of periodontal disease should include oral health promotion and integrated disease‐prevention strategies based on common risk‐factor approaches. Capacity building of oral health systems must consider the establishment of a financially fair service in periodontal care. Health systems research is needed for the evaluation of population‐oriented oral health programs.     

An educational model for preparing dental hygiene students in the treatment of periodontal diseases

Inflammatory periodontal disease is the leading cause of tooth loss. Experts agree that prevention is crucial, with frequent and through plaque removal being the simplest and most effective method for preventing inflammatory periodontal disease. Since it is often the dental hygienist who plays the major role in providing such care, it is imperative that dental hygiene programs educate students in the prevention and treatment of periodontal diseases and provide necessary breadth and depth in theory and clinical experience in the curriculum. The purpose of this paper is to describe an educational model designed to enhance the treatment phase of the periodontal component of the curriculum for dental hygiene students. Both the didactic and clinical components of the periodontics courses are built upon a program-planning model: students assess, plan, implement, and evaluate the periodontal needs of all patients. Case presentations permit students to assimilate and analyze clinical data while internalizing the importance of comprehensive care and adequate follow-up. In general, the program-planning model in periodontics incorporates the application of theory to practice and enhances clinical decision-making skills needed for graduates to meet the complexity of periodontal health needs.     

Private practice of periodontics. Past patterns, future prospects

The private practice of periodontics has grown in a comparatively short time from a handful of clinicians to a significant factor in the overall practice of dentists. Periodontics has matured into a specialty that interfaces with every aspect of dentistry. Patient awareness demands it service. With the changes taking place in the health delivery system, there has emerged insurance and capitation programs that have influenced the private practice of periodontics. Along with these changes have come economic factors that have encouraged many periodontists to seek new avenues of revenue such as implantology. The dental awareness of the public and the continuance of the high standards of periodontics will prevail. If this is the case, then the future prospects of the private practice of periodontics is ensured.     

CONFERENCE PRESENTATION:Changing perceptions of oral health and its importance to general health: provider perceptions, public perceptions, policyma ker perceptions

He first ever Surgeon General's Report on Oral Health¹ emphasizes that oral health is essential to the general health and well‐being of all Americans, and that oral health can be achieved. But it will require that we think about and approach oral health activities in a different manner. If we desire to influence the mind‐set of health care providers, the public, policymakers, and institutions, how do we get from what we know about the relationship of oral health and general health to integrating the notion into everyday actions? The Surgeon General's Report on Oral Health has elevated this issue to the forefront of health care and provided us with an extraordinary opportunity. The challenge: Lead with action and catalyze integration into multiple forum‐public, private, and professional‐and engage in activities that will change how oral health is perceived broadly. Ultimately, geriatric oral health and the health of all access‐limited populations should benefit. To continue preserving the oral health of the millions of older individuals who now enjoy it and to ensure it for those who lack it will require change on multiple societal levels: the health care providers, the neighborhood, the community; Federal, state, and local governments; and the nation as a whole. It means addressing and overcoming multiple barriers to oral health care, which may include problems or disparities in: education, economics, the environment, cultural and social issues, and the health care system itself¹ To change perceptions, we must remove the barriers to care, educate the stakeholders who can influence or benefit from training programs, conduct broader, population‐based research, build public and private partnerships, develop a stronger health care infrastructure, and expand initiatives that target specific risks for declining oral health. In addition to seeking new answers to these problems, it is imperative that we apply what we already know.     

Treatment trends in periodontics

This volume of Periodontology 2000, entitled “Treatment Trends in Periodontics”, evaluates the importance of nonsurgical periodontal therapy and defines its role as the key etiologic treatment of the disease. The need for scaling and root planing is mandatory step during the initial phase of therapy, as is self‐care by the patient. Only after reevaluation of the outcome achieved by nonsurgical procedures should surgery be considered, and the concept of “critical probing depth” is emphasized. The chapters in this volume discuss different aspects of periodontal surgery, including regeneration and plastic periodontal procedures, and, looking toward the future, cell therapy in periodontics is explored. The impact of periodontal therapy on systemic diseases is reviewed, and the role of occlusion in periodontal disease is revisited and discussed. Topics on implants include their placement in fresh extraction sockets, socket healing with or without implant placement, and research on osseointegration. The important topic of maintenance care of teeth and implants for long‐term therapeutic success is thoroughly evaluated, as is the efficacy of dentifrices in oral hygiene. The editors convey a nutshell review of the concepts of what periodontal treatment should entail, based on scientific evidence generated during half‐a‐century of work in periodontics.     

Public Health Implications of Recent Research in Periodontal Diseases

Knowledge of the epidemiology, natural history, and bacterial etiology of the periodontal diseases has advanced considerably as a result of research conducted through the 1980s. Prevention and control of these conditions, however, remains mechanical, cumbersome, and often impractical, based as it is on bacterially nonspecific plaque removal for an indeterminate period. This research has not yet changed the content of public health programs, but it does affect the way the programs are applied. Because sever, generalized disease seems to be less prevalent than previously thought, the need of regular, routine professional care for everybody is questioned. Professional care in a public health context is likely to be more efficient when targeted toward those with severe disease. Dental health education for personal oral hygiene is still supported by scientific studies, though a targeted approach and careful assessment of educational content is needed. Until predictive screening methods for identifying susceptible individuals are developed, selection of priority groups for education and treatment should be guided by epidemiologic data.     

Association Between Periodontal Disease and Kidney Function Decline in African Americans: The Jackson Heart Study

Background: Chronic kidney disease (CKD) remains a prevalent public health problem that disproportionately affects African Americans, despite intense efforts targeting traditional risk factors. Periodontal disease, a chronic bacterial infection of the oral cavity, is both common and modifiable and has been implicated as a novel potential CKD risk factor. The authors seek to examine to what extent periodontal disease is associated with kidney function decline. Methods: This retrospective cohort study examines 699 African American participants with preserved kidney function (defined by estimated glomerular filtration rate (eGFR) >60 mL/minute/1.73m² at baseline) who underwent complete dental examinations as part of the Dental‐Atherosclerosis Risk in Communities study (1996 to 1998) and subsequently enrolled in the Jackson Heart Study (2000 to 2004). Using multivariable Poisson regression, the authors examined the association of periodontal disease (severe versus non‐severe) with incident CKD, defined as incident eGFR <60 mL/minute/1.73m² and rapid (5% annualized) eGFR decline at follow‐up among those with preserved eGFR at baseline. Results: Mean (± SD) age at baseline was 65.4 (± 5.2) years, and 16.3% (n = 114) had severe periodontal disease. There were 21 cases (3.0%) of incident CKD after a mean follow‐up of 4.8 (± 0.6) years. Compared with participants with non‐severe periodontal disease, those with severe periodontal disease had a four‐fold greater rate of incident CKD (adjusted incidence rate ratio 4.18 [95% confidence interval 1.68 to 10.39], P = 0.002). Conclusions: Severe periodontal disease is prevalent among a population at high risk for CKD and is associated with clinically significant kidney function decline. Further research is needed to determine if periodontal disease treatment alters the trajectory of renal deterioration.     

Prevalence of systemic diseases in Brisbane general and periodontal practice patients

BACKGROUND: Periodontitis has been associated with a number of systemic diseases such as atherosclerosis, coronary heart diseases, and respiratory diseases. This study aimed to determine whether there is a significant difference in the prevalence of systemic diseases (a) in patients referred for periodontal care compared to the general practice population, (b) in patients attending a public hospital and private practices, (c) in patients attending public and private periodontal practices, and (d) among patients with periodontitis of varying severity. METHODS: Charts of 1000 adult patients were selected from four clinics (University of Queensland (UQ) School of Dentistry Admissions Clinic, UQ School of Dentistry Periodontics Clinic, Private Periodontal Practice, and Private General Dental Practice). The prevalence of medical conditions was evaluated using validated self-reported health questionnaires. The periodontal condition was assessed from the most recent relevant radiographs in the files. RESULTS: Periodontal patients had a higher prevalence of systemic diseases compared to the general practice population. Public patients had a greater prevalence of systemic diseases compared to patients in private practice for both general practice and periodontal patients. In patients with advanced periodontitis, bronchitis, hepatitis and rheumatoid arthritis were most prevalent. Patients with periodontitis also took more medications and were more likely to suffer from multiple conditions compared to the general dental population. CONCLUSIONS: Patients attending public dental facilities have an increased prevalence of systemic disease compared to those attending private practices. Furthermore periodontal patients have a greater prevalence of diseases compared to general practice patients. Patients with moderate or advanced periodontitis show an increase in the prevalence of some systemic diseases previously reported to be risk factors for periodontal disease.     

Epidemiology of periodontal diseases in adults from Latin America

A decade has passed since we first reviewed the epidemiology of periodontal diseases in Latin America. At that time, lack of population‐based studies was the norm and our conclusions were based on very limited evidence. The aim of the present comprehensive review was to update and expand our previous work by providing a broad overview of Latin America and its current social, economic and demographic status and by focusing on the epidemiology of periodontal diseases in Latin American adults published in the last 15 years. The amount of periodontal epidemiological data available has increased but is still restricted to a few countries only. The scope of the literature available has also broadened to include oral health‐related quality of life and systemic interactions; however, most studies had methodological limitations that might have biased their results. In general, periodontitis was very prevalent, but severe periodontal destruction was localized. Besides being associated with well‐established risk factors, periodontitis was associated with demographics and socio‐economic factors in Latin American populations. To advance epidemiological knowledge, population‐based cross‐sectional and longitudinal studies, using appropriate methodologies, should be the future focus of the research agenda of researchers and public health planners in Latin American countries.     

Geriatric oral health issues in Germany

A review of the oral health issues for the elderly in Germany is presented. The percentage of aged and very old people in the total population of Germany is increasing rapidly, as is the percentage of the dentate population due to the high standard of dental care. The percentage of the edentulous population has therefore decreased. It has become necessary for all who care for the elderly, to adjust to caring for the dentate patient and to begin to work together and communicate about the patient's needs. Physicians in particular need to be given training in the detection of caries, periodontal diseases and denture problems. They should feel comfortable working with the dentist and dental team as partners in rehabilitation treatment. The dental treatment needs of the German population aged 70 years and older are not yet adequately met although the social insurance of the elderly includes dental treatment. Provision of oral health care for the dependent elderly, especially those who are homebound or in nursing homes, is not effectively organised and has to be completely reconsidered. The social health insurance and the social long‐term care insurance must adjust their insurance coverage to the dental needs of the frail elderly. The development and further improvement of age‐adjusted dental care is of crucial importance with respect to future demographic changes.     

Personalized medicine: an update of salivary biomarkers for periodontal diseases

This article provides an up‐to‐date review of the more robust salivary biomarkers, as well as of panels of combinatorial markers and periodontal pathogens, that reveal high sensitivity and specificity for enhancing clinical decision‐making in periodontal disease progression, risk and diagnosis. Periodontal diseases are complex and require an inflammatory response to bacterial pathogens in a susceptible host to stimulate tissue destruction. When used alone, traditional clinical assessments provide a diagnosis of periodontitis only after the biologic onset of the disease process, and are unable to substantiate disease activity or future risk. New technologies are becoming available that are capable of measuring combinations of inflammatory cytokines and proteinases for rapid chair‐side testing. Utilizing saliva to identify and measure specific phenotypes and host‐derived mediators will allow highly individualized diagnosis, prognosis and treatments for periodontal diseases. This personalized medicine approach will strengthen the power of the clinical oral examination and medical history assessments, providing patients with evidence‐based, targeted risk care.     

Can we successfully maintain risk patients?

The most fundamental premise in the current view of periodontal disease is that not all individuals are at equal risk for disease and disease progression. Studies reveal that about 5-20% of the population is at risk for severe disease progression. The purpose of this paper is to define at-risk patients, review risk factors and indicators of disease progression, and outline an evidence-based strategy that includes both self-care and professional care for maintaining periodontal health. Risk factors/risk indicators considered include history of previous disease, increased pocket depth and loss of clinical attachment, frequency of dental care, specific bacterial pathogens, and systemic/environmental host factors such as smoking, diabetes mellitus, genetics, and stress. Because host factors may have more influence on disease progression than periodontal pathogens, personal and professional maintenance care must include the role of the host in periodontal disease progression. By examining the evidence surrounding these complex issues, dentists and dental hygienists are able to determine the extent to which evidence supports available approaches to maintain periodontal health and control disease progression.     

Correlation between health‐care costs and salivary tests

The burden of health‐care costs relative to gross domestic product in Japan is increasing. A large percentage (7.6% in 2009) of the Japanese gross domestic product has been spent on health care, and this percentage has been increasing annually. Soaring health‐care costs have been recognised as a serious social problem. In this study, we attempted to estimate the relationship between periodontal disease and health‐care costs. Subjects consisted of teachers and staff members (35 men, 26 women; mean age, 45 ± 9 years) from two high schools. The salivary levels of lactate dehydrogenase and haemoglobin were adopted as biomarkers to assess periodontal disease. After salivary tests, data for the health‐care costs over the subsequent 6 months were provided by the mutual association of the public schools on an individual basis. Curve‐fit estimations were then performed where health‐care costs were used as a dependent variable and age or salivary levels of haemoglobin or lactate dehydrogenase were used as independent variables. However, no good fitness was obtained. Subsequently, multilayer perceptron neural networks were applied. With the neural networks, good fitness was obtained by using lactate dehydrogenase as an independent variable. The results of this study show that oral health, particularly periodontal disease, is correlated with total health‐care costs. The data presented in this study suggests that, from the perspective of both oral and systemic health, oral health can be a signpost in well‐being and health promotion.     

Periodontal complications of hyperglycemia/diabetes mellitus: Epidemiologic complexity and clinical challenge

This report provides a comprehensive overview of the adverse effects of hyperglycemia on the periodontium. It combines data from literature reviews of original data from two large, population‐based epidemiologic studies with comprehensive periodontal health assessment. Emphasis is placed on the exploration of hitherto sparsely reported effects of prediabetes and poorly controlled (uncontrolled) diabetes, in contrast to the umbrella term “diabetes.” This stems from the realization that it is not simply having a diagnosis of diabetes that may adversely affect periodontal health. Rather, it is the level (severity) of hyperglycemia that is the determining factor, not the case definition of the diagnosis of diabetes or the type of diabetes in question. Importantly, based on existing evidence this paper also attempts to estimate the improvements in periodontal probing depth and clinical attachment level that can be expected upon successful nonsurgical periodontal treatment in people with chronic periodontitis, with and without diabetes, respectively. This exploration includes the implentation of new systematic reviews and meta‐analyses that allow comparison of such intervention outcomes between hyperglycemic and normoglycemic subjects. Based on both existing literature and original analyses of population‐based studies, we try to answer questions such as: Is there a glycated hemoglobin concentration threshold for periodontitis risk? Does short‐term periodontal probing depth reduction and clinical attachment level gain after scaling and root planing depend on glycemic control in type 2 diabetes? Are short‐term scaling and root planing outcomes in people with hyperglycemia/diabetes inferior to those in people without diabetes? Do periodontitis patients with diabetes benefit more from the use of adjuvant antibiotics with nonsurgical periodontal treatment than people without diabetes? Does hyperglycemia lead to greater tooth loss in patients in long‐term post‐periodontal treatment maintenance programs? Throughout this review, we compare our new findings with previous data and report whether the results of these new analyses corroborate, or are in discord with, similar scientific reports in the literature. We also explore the potential role of dental health‐care professionals in helping patients control the risk factors that are identical for periodontitis and diabetes. Finally, we suggest various topics that still need exploration in future research.     

Oral health delivery systems for older adults and people with disabilities

This article describes new oral health care system models designed to meet the needs of a rapidly growing population of older adults and people with disabilities. These populations are not currently able to access traditional dental offices and clinics to the same degree that younger and much healthier population groups do. So new models proactively target specific community organizations where these high‐risk underserved population groups live, work, go to school, or obtain other health or social services. Collaborative on‐site and clinic‐based teams establish “Virtual Dental Homes” that provide ongoing, year‐round access to oral health services designed to prevent mouth infections, deliver evidence‐based preventive care, and restore infected individuals to stable and sustainable oral health. These new delivery models are beginning to demonstrate better health care delivery, better health outcomes, and the potential to drive down total health care costs for older adults and people with disabilities.