Periodontology 2000, Vol.

29, 2002, 235–246 Copyright C Blackwell Munksgaard 2002

Printed in Denmark. All rights reserved PERIODONTOLOGY 2000
ISSN 0906-6713

Prevention and control of

periodontal diseases in
developing and industrialized
nations
P A, J M. A & T E. R

Setting up effective programs for the prevention and In 1965, Löe & coworkers (31) demonstrated that
control of periodontal diseases in both developing subjects with healthy gingiva developed clinical
and industrialized nations requires a thorough signs of gingivitis within two to three weeks of re-
understanding of the various etiological factors con- fraining from all oral hygiene practices due to undis-
tributing to the initiation and progression of these turbed accumulation of dental plaque. On resump-
diseases. Colonization of tooth surfaces by bacteria tion of adequate oral hygiene, the gingival tissue in-
is recognized as the key etiologic factor in dental flammation subsided within a week. It has been
caries, gingivitis and periodontitis. This explains why established that an initial gingival lesion develops
combinations of different nonspecific plaque control within about four days of undisturbed plaque growth
programs have been so effective in the control of (36), and subclinical signs of gingival inflammation
these diseases (6, 7). Although dental plaque biofilm appear in the form of an exudate from the gingival
is the main etiological factor of gingivitis and peri- sulcus (19). In a 6-week study in students, Lang &
odontitis, other modifying and risk factors are also coworkers (25) showed that no clinical signs of gingi-
important. Hence, although recognizing that dental val inflammation appeared when plaque was thor-
plaque control is the key factor in the prevention and oughly removed at least every second day, whereas
control of periodontal diseases, the elimination and/ gingivitis developed if plaque removal was accom-
or control of other etiological modifying risk factors plished only every third or fourth day. Bosman &
should also be incorporated in periodontal disease Powell (16) induced experimental gingivitis in a
prevention programs. group of students, and found that gingival inflam-
mation persisted when dental plaque was removed
only every third or fifth day, whereas the inflam-
Dental plaque mation resolved within 7–10 days in subjects who
cleaned their teeth at least every second day.
According to Dawes et al. (18), dental plaque is ‘the These studies provide evidence that prevention of
soft tenacious material found on tooth surfaces gingivitis should be based on control of the dental
which is not readily removed by rinsing with water’. plaque growing along the gingival margins of teeth.
It is estimated that 1 mm3 of dental plaque, weighing In addition, these studies show that thorough mech-
about 1 mg, contain more than 200 million bacterial anical cleaning of all tooth surfaces every second day
cells (41, 42). Other microorganisms, such as myco- is more effective than daily cosmetic brushing of
plasma, yeasts and protozoa, also occur in mature only the buccal and lingual surfaces, as these latter
plaque; sticky polysaccharides and other products surfaces are at lower risk of developing gingivitis
form the so-called plaque matrix, which comprises than the approximal surfaces. However, such non-
10% to 40% by volume of the supragingival plaque specific mechanical plaque control by self-care may
(41). be supplemented by Professional Mechanical Tooth-

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cleaning (PMTC) and the use of antimicrobial agents O The salivary secretion rate and other properties of
against specific periopathogens in individuals with saliva
progressive and/or aggressive periodontitis. O The intake of fermentable carbohydrates
Experimental animal studies have shown that un- O The mobility of the tongue and lips
treated, plaque-induced gingivitis can over time pro- O The exposure to chewing forces and abrasion
gress to periodontitis (27, 40). However, although from foods
gingivitis is very common in humans, only a minor- O The degree of gingival inflammation and volume
ity of individuals and sites develop aggressive and of gingival exudate
severe forms of periodontitis. Hence, it is reasonable O The individual’s oral hygiene habits
to conclude that presence of gingival plaque by itself O The use of fluorides and other preventive prod-
may not be invariably sufficient to induce peri- ucts such as chemical plaque control agents
odontal tissue breakdown and development of peri-
odontitis. These factors will affect the rate of plaque formation
Several risk factors other than dental plaque on tooth surfaces. The pattern of plaque re-growth
growth have been associated with the development will also be influenced by the same factors but may
of periodontitis. Some of these factors are localized differ somewhat on tooth surfaces exposed to
within the oral cavity, whereas others have a more chewing forces; abrasion from foods; and friction
systemic affect on the host (8). Proper assessment from the dorsum of the tongue, lips and cheeks; and
and control of these risk factors should be included on less accessible areas, such as approximal sites,
in periodontal diseases prevention programs. along the gingival margin, and in irregularities such
At the 1st European Workshop on Periodontology as occlusal fissures. These areas are often designated
(26), consensus was reached that periodontitis is al- stagnation areas for plaque.
ways preceded by gingivitis. Prevention of gingivitis In studies of de novo plaque growth after pro-
should therefore also prevent periodontitis. Longi- fessional mechanical tooth cleaning on tooth sur-
tudinal studies in humans have shown a close re- faces in a large group of 14-year-olds in Sweden (4,
lationship between the standard of oral hygiene, gin- 5), plaque growth was greatest on the mandibular
givitis and loss of periodontal support (20). mesiolingual and distolingual surfaces (33%), par-
A person’s standard of oral hygiene is strongly cor- ticularly on the molars (about 80%), followed by the
related to their educational level and dental care re- mesiobuccal and distobuccal surfaces on both
sources (particularly the number of dental personnel maxillary and mandibular teeth, particularly the mo-
focused on preventive dentistry such as dental hy- lars (about 60%). There was almost no plaque growth
gienists and prophylaxis dental assistants) (8). This (3%) on the lingual surfaces of the maxillary teeth,
probably accounts for the high prevalence of gingi- likely due to frictional forces from the rough dorsum
vitis and untreated forms of slight to moderate peri- of the tongue. It should be noted that the pattern of
odontitis in developing countries compared to in- dental caries and gingivitis in young adults is almost
dustrialized countries (8, 22, 30, 33, 37). identical to these patterns of plaque growth.
According to Listgarten (29), undisturbed dental
plaque is about 5 times thicker after 3 days than
Rate and pattern of plaque formation plaque growth after 2 days. This may account for the
development of gingivitis in student study subjects
The quantity of plaque that forms on clean tooth sur-
cleaning only every third or fourth day, but not in
faces during a given time represents the net result of
those who cleaned their teeth at least every second
the interactions between etiologic factors, many
day (25).
internal and external risk indicators and risk factors,
as well as host protective mechanisms. These include:
Plaque Formation Rate Index (PFRI)
O The total number of oral bacterial population An understanding of the importance of factors con-
O The types of bacteria constituting the oral bac- trolling the formation of dental plaque has been the
terial microbiota rationale for the construction of the Plaque Forma-
O The anatomy, surface morphology, and alignment tion Rate Index (PFRI) (4, 5). The index assesses the
of the dentition rate of plaque formation on all tooth surfaces, ex-
O The wettability and surface tension of the tooth cluding the occlusal surface, and is based on the
surfaces amount of plaque that grows in the 24 h period after

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 Prevention and control of periodontal diseases

professional mechanical tooth cleaning, during countries. In adults, the limited dental care resources
which time the subjects refrain from all oral hygiene. in developing countries should focus on oral health
In a pilot study in 50 adult subjects, adherent education and needs-related supplementary subgin-
plaque was found on 5% to 65% of the total number gival debridement and PMTC according to the non-
of tooth surfaces 24 h after professional tooth specific and ecological plaque hypotheses.
cleaning (4). Based on findings from this study, a In general, in populations with low levels of oral
five-point scale was constructed for the PFRI accord- hygiene and dental care, it is reasonable to im-
ing to the percentage of tooth surfaces having dental plement a whole population strategy to reduce the
plaque growth: periodontal treatment needs in the general popula-
tion. In comparison, in populations with moderate
Score 1 (very low): 1–10% surfaces or high standards of oral hygiene and well-organized
Score 2 (low): 11–20% surfaces oral health care services it is more cost-effective to
Score 3 (moderate): 21–30% surfaces implement a high risk strategy specifically targeting
Score 4 (high): 31–40% surfaces risk groups, and risk individuals, as well as key risk
Score 5 (very high): ⬎40% surfaces teeth and surfaces. This may be the strategy most
applicable to industrialized nations where the stan-
Axelsson (4, 5) assessed the plaque formation rate dard of oral hygiene and dental care resources are
in a group of 667 14-year-old-schoolchildren in the high.
city of Karlstad, Sweden, with a very low prevalence
of dental caries as well as gingivitis and peri-
odontitis, and found that the majority of the children
were either low (score 2: 48%) or moderate (score 3: Preventive materials and methods
27%) plaque formers. It has been shown that young
subjects with high PFRI scores develop more gingi- Among the presently available preventive methods
vitis than those with low scores (4, 38). There is also of periodontal diseases, dental plaque control is
a strong correlation between the rate of plaque for- regarded as the first choice because it is directed
mation and the occurrence of gingivitis at the sur- towards the elimination of the etiologic factors of
face level (38). gingivitis and periodontitis, namely, the pathogenic
Proper appreciation of the patterns and rates of microflora that colonizes the tooth surfaces.
plaque formation in a population is important for Studies in humans have shown that high-quality
establishing successful strategies for primary as well plaque control can prevent and control gingivitis
as secondary prevention and control of gingivitis and periodontitis in children as well as in adults
and other periodontal diseases. The plaque forma- (6, 7).
tion rate (PFRI) may be used as a guideline for how Plaque control can be achieved using mechanical
frequent the teeth have to be cleaned. The pattern of or chemical methods by self-care, or professionally
plaque re-growth shows where needs-related tooth by dentists or dental hygienists. Plaque control pro-
cleaning has to be focused. grams based on needs-related combinations of these
methods are, to date, the most successful means for
prevention and control of gingivitis and peri-
odontitis.
Periodontal diseases in developing
vs. industrialized countries
There is little evidence to suggest that the principal Mechanical plaque control methods
etiological factors of periodontal diseases are differ-
Mechanical plaque control by self-care
ent in industrialized and developing countries. Be-
cause of the lower standard of oral hygiene in devel- The effectiveness of a self-care mechanical plaque
oping countries, a higher prevalence of gingivitis in control depends on motivation, knowledge, pro-
children and slight to moderate periodontitis in vision of oral hygiene instructions, type of oral hy-
adults is generally found compared to industrialized giene aids used and manual dexterity. A huge assort-
countries (8). Improved mechanical toothcleaning ment of oral hygiene aids is available; the clinician
by self-care according to the nonspecific plaque hy- should assess the individual needs of the patient and
pothesis should thus be most relevant in developing recommend appropriate aids.

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Axelsson et al.

larly suitable oral hygiene aid for approximal tooth-

Toothbrushing and other oral hygiene aids
cleaning in adults with accessible interdental spaces.
Toothbrushing is the most widely used mechanical The best time to apply the cleaning power of
means of personal plaque control throughout the toothpaste as a fluoride vehicle is just as the gingival
world. More than 80% in Sweden and Denmark papilla is depressed. In individuals with advanced
brush their teeth more than once per day compared periodontal disease, with wide interdental spaces
to only 34% in Finland, Lithuania and Russia (24). and partially exposed root surfaces, interdental
Enthusiastic use of the toothbrush is not, however, brushes are recommended. Unfortunately, most
synonymous with a high standard of oral hygiene. interdental brushes are circular in cross-section.
The toothbrush has very limited access to the wide Their effectiveness would probably be enhanced if
approximal surfaces of the molars and premolars. the brush shape was triangular instead of circular
Clinical, visual assessment of plaque removal by (3). Other special supplementary oral hygiene aids
toothbrushing does not mean that the bacteria have include interspace toothbrushes for tipped or ro-
been removed completely from the tooth surfaces. tated teeth, Superfloss (Oral-B) for cleaning around
To systematize the toothbrushing procedure, dif- fixed partial denture pontics, and tongue scrapers.
ferent methods have been recommended. At least
during the last decades, the Bass method (15) has
been the most frequently recommended. It has been
Establishment of needs-related oral hygiene habits
shown that proper use of the Bass method 3 times
per week can prevent the formation of supragingival A fundamental principle of any preventive effort is
plaque on buccal surfaces accessible to the tooth- that the maximum positive effect is where the risk
brush and that dental plaque can be removed at for disease is greatest. The patient has the greatest
least 1 mm subgingivally (44). chance of being able to see positive results in his or
However, studies comparing the plaque-removing her oral hygiene efforts if the person concentrates
effect of different toothbrushing methods have initially on key-risk teeth and key-risk surfaces. For
shown that, with all methods, the effect on the ap- example, in a toothbrushing population, the maxi-
proximal tooth surfaces is very limited, particularly mum effect may be seen at the approximal surfaces
in the molar and premolar regions (21). Therefore, of the molars and premolars. However, interdental
the toothbrushing procedure has to be supple- cleaning is practically nonexistent and not an estab-
mented with special interproximal toothcleaning lished habit in most countries, and particularly in
aids, such as dental floss or tape, toothpicks and developing countries. Thus, in toothbrushing popu-
interdental brushes. Electric tooth brushes also have lations, needs-related toothcleaning is currently not
been shown to be very effective plaque control aids, practiced. The adult patient today tends to disrupt
and particularly in patients with low dexterity, the dental plaque principally from those tooth surfaces
handicapped and young children (45). least susceptible to disease (i.e. facial and lingual
On the approximal surfaces of molars and pre- surfaces)
molars, use of a flat, fluoridated dental tape com- The first condition for success in attempting to es-
bined with a fluoride toothpaste is recommended for tablish needs-related toothcleaning habits is a well-
children and young adults. By applying the so-called motivated, well-informed, and well-instructed pa-
rubbing-technique, either holding the tape by hand tient. Motivation is defined as readiness to act or the
or in a special holder, it is possible to remove plaque driving force behind a person’s actions. Greater re-
2 mm subgingivally on the approximal surfaces of sponsibility has been described as the motivating
the molars (43). factor of longest duration. People’s actions are also
It has been shown in vivo that a pointed, triangu- governed by the needs they feel they have. Therefore,
lar toothpick inserted interproximally can maintain training the patient in self-diagnosis is of great im-
a plaque-free region 2–3 mm subgingivally (34). The portance.
resilience of the gingival papilla allows plaque re- In this context, risk profiles and a toothcleaning
moval apical to the subgingival margins of restora- chart are useful tools. On the basis of the joint (pa-
tions (i.e., risk surfaces for recurrent caries). Subgin- tient-professional) observations of disease factors
gival removal of interproximal dental plaque is likely outlined on the risk profile and the toothcleaning
to be more decisive than supragingival plaque con- chart, the Plaque Formation Rate Index (PFRI), and
trol for prevention of periodontitis. Therefore, a flu- the location of plaque in the patient’s mouth, the pa-
oridated, pointed, triangular toothpick is a particu- tient should be encouraged to make suggestions as

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to the choice of oral hygiene aids and, above all, the posterior teeth based on establishment of needs-re-
order of priorities for cleaning. lated plaque control methods should also result in
Thereafter, it is extremely important that the less future gingivitis and periodontal disease on the
sharing of responsibilities be discussed. The primary ‘key risk’ surfaces (1, 2, 9). The cost effectiveness of
responsibility of the patient is the daily care of his/ a large-scale implementation of the experiences
her teeth. The necessary oral hygiene methods from this low-cost, low-technology study based on
should be specified. When the sharing of responsib- self-care would be enormous and could be im-
ilities is complete, a ‘contract’ could be drawn up plemented world-wide in industrialized as well as
and signed by the parties involved. The responsi- developing countries.
bility ensuing from an agreement that an individual Oral hygiene training based on self-diagnosis and
has put his or her name to is more binding than a the linking method has also been implemented in a
hasty verbal affirmative. However, there is a high risk 15-year longitudinal study in adults. The strategy
that these habits will not become firmly established. was so effective that the intervals between PMTC
When new oral hygiene habits are established, they treatments could successively be extended, while an
should be linked firmly to pre-established habits. optimal to suboptimal effect on gingivitis, peri-
The new habit should always be carried out immedi- odontitis and dental caries was recorded (13).
ately prior to the established habit, as the risk that
the latter habit will not be performed is minimal.
Traditional oral hygiene methods in the
These principles of behavioral science are called
developing countries
the linking method and have been described in a
dental context (46). If the patient has irregular oral In many developing countries, traditional methods
hygiene habits, an interview should reveal already- of oral hygiene have been an integral part of re-
established habits that, in terms of frequency and ligious and/or traditional beliefs, and because of this
point in time during the day, happen to coincide well and other reasons, such as their availability and low
with the proposed oral hygiene routine. According to cost, these traditions have been practiced by these
the linking method, oral hygiene should be ‘slotted cultures for decades. For instance, in certain coun-
in’ immediately prior to the patient’s daily routine. tries in Asia and Africa, chewing sticks prepared from
For example, needs-related toothcleaning in patients certain plants have been used as oral hygiene tools
with well-established daily toothbrushing habits akin to the use of a common toothbrush.
should start with interproximal cleaning in the molar A variety of plant species have been used for the
and premolar regions immediately before they use preparation of chewing sticks in different parts of the
the toothbrush. world. Normally, a stick is cut from the twigs, stems
These principles for establishment of needs-re- or roots of the plant, then chewed or tapered at one
lated oral hygiene habits were implemented in a 3- end until it becomes frayed into a brush-like tool.
year longitudinal study (1, 9). Children in test group This is then used to brush the facial aspects of teeth
I (self-identify inflamed gingival and white spot and gingiva and the tongue. Some individuals may
lesions and focus oral hygiene on specific areas) had also leave this tool in the mouth for an extended
reduced gingival inflammation and developed 60% period of time after brushing, thereby stimulating
and 75% fewer new approximal carious lesions in salivation and enhancing their cleansing effects. In
dentin per individual on the molars and premolars, addition, extracts which normally leach out of these
respectively, compared to subjects in test group II sticks into the user’s mouth are believed to have bio-
(nonspecific focus of oral hygiene activities) and the logical properties including potential antibacterial
control group (1, 2, 9). The conclusions from the effects.
study were: i) in a toothbrushing population using It has been suggested that these plants contain
fluoride toothpaste and fluoridated drinking water, a antimicrobial substances that naturally protect them
highly significant reduction in the incidence of ap- against invading microorganisms or other parasites,
proximal caries and gingival inflammation will be and that these substances may then exert their effect
achieved by an oral hygiene training program based in protecting the host against cariogenic and peri-
on self-diagnosis and the linking method; and ii) in odontopathic bacteria. Wu et al. (49) concluded that
such a population, frequent repetition of meticulous extracts from these plants may possess varying anti-
oral hygiene training is almost redundant, and iii) microbial activities against diverse oral microorgan-
the successful prevention of plaque retentive carious isms including periodontal pathogens, and selected
lesions and fillings on the approximal surfaces of the clinical studies have shown that chewing sticks,

239
Axelsson et al.

when properly used, can have an effect comparable started from the lingual aspect of the mandibular
to that of toothbrushes in removing dental plaque teeth. This is a rational means of applying the fluor-
(49). ide prophylaxis paste to all approximal surfaces.
With paste already applied to the surfaces requiring
maximum attention, mechanical cleaning can be
Professional mechanical plaque control
carried out very quickly.
Professional mechanical toothcleaning (PMTC) is The specially designed prophylaxis contra-angle
the selective removal of plaque – not only supragin- handpiece with reciprocating V-shaped flexible tips
givally but also 1–3 mm subgingivally – from all tooth or triangular pointed tips is used for interproximal
surfaces, using mechanically driven instruments and PMTC. The tips are self-steering and reciprocating
fluoride prophylaxis paste. It is performed by spe- with 1.0- to 1.5-mm strokes. When entering the in-
cially trained personnel including a prophylaxis den- terproximal space, the tip will have a 10-degree co-
tal nurse, dental hygienist or dentist. In essence, the ronal angle until the papilla is pressed down. The
term professional gingival plaque removal (control) resilience of the papillae will result in an expected
may more accurately describe this procedure. It is cleaning effect 2–3 mm subgingivally. A suitable
emphasized that the buccal, lingual and occlusal speed for the contra-angle handpiece is approxi-
surfaces of teeth are generally at low-risk or nonrisk mately 7000 r.p.m. (i.e. 14 000 strokes per minute or
for the development of destructive periodontal dis- 300 strokes per second). The direction of the tip
eases. Hence, prophylaxis or polishing with a rotat- should continually be adjusted vertically and hori-
ing rubber-cup and prophylaxis paste which is pri- zontally so as to reach the entire approximal surface.
marily aimed at these surfaces should not be re- At the same time, fluoride polishing paste is applied
garded as professional mechanical toothcleaning. If to all instrumented surfaces.
calculus and deep subgingival plaque biofilms are The PMTC should always commence from the lin-
also removed, the procedure is usually referred to as gual surface of the mandibular molars, according to
scaling or debridement. the linking method. When the approximal surfaces
Axelsson & Lindhe (10–12) described the use of have been carefully instrumented from the more
PMTC in children and adults and recommended easily accessible lingual side, they are then instru-
using the following materials when performing these mented from the buccal direction, followed by the
procedures: maxillary interproximal surfaces, lingual em-
brasures, and buccal surfaces. A regular prophylaxis
O Plaque-disclosing pellets or tablets contra-angle handpiece and rotating rubber cup,
O A Profin contra-angle handpiece (a modification combined with the application of the same prophy-
of the EVA prophylaxis contra-angle handpiece; laxis paste, are recommended for PMTC on lingual
Dentatus) and reciprocating tips and buccal surfaces. Hand instruments, such as cu-
O A prophylaxis contra-angle handpiece and rotat- rettes, may also be used to remove partly mineral-
ing rubber cup ized plaque in the gingival sulcus as well as more
O A fluoride-containing prophylaxis paste (medium deeply located subgingival plaque biofilms.
abrasive) The frequency of PMTC should be based on indi-
O A syringe for injecting the prophylaxis paste inter- vidual needs to maximize its cost-effectiveness.
proximally
Efficacy of professional mechanical
As PMTC must be directed to the tooth surfaces
toothcleaning and plaque control on
normally neglected by the patient, disclosing the
periodontitis
dental plaque accumulations is the first step in this
technique. Significant plaque growth is often found PMTC alone also has favorable effects on peri-
in the mandibular lingual embrasures of the molars odontitis particularly in patients with moderately
and premolars. Plaque is almost always present in deep pockets (4–6 mm). A number of studies have
the interproximal spaces if continuous visible plaque shown that frequent PMTC sessions with no prior
is found in the line angles and this can easily be veri- subgingival scaling can lead to a reduction in the
fied by probing. pocket depth and a gradual decrease in the total
A disposable syringe facilitates the application of number of subgingival bacteria at the treated sites
fluoride polishing paste into the interproximal together with a shift from a periopathogenic to a less
spaces. Approximal application should always be pathogenic microflora (17, 23, 32). These favorable

240
 Prevention and control of periodontal diseases

results may be brought about by the repeated 2–3 or surgical treatment of periodontitis. In a study by
mm subgingival plaque removal approximally ac- Rosling et al. (39), patients with a high prevalence of
complished by the PMTC. In contrast, supragingival intrabony pockets were randomly divided into a test
plaque control by self care conceivably has little ef- or a control group. After initial scaling and root plan-
fect on the subgingival microflora of deep peri- ing using open flap surgery, the test group received
odontal pockets. PMTC every second week for 2 years. At re-examina-
Recently, Ximenez-Fyvie et al. (50) showed that tion, the gingival status was excellent and about 95%
frequent PMTC during a 3-month period after one of the intrabony pockets had healed.
single subgingival debridement resulted in a subgin- Nyman et al. (35) studied two groups of advanced
gival microbial profile comparable to that observed periodontitis patients and treated both groups with
in periodontal health. This profile was still main- similar treatment including periodontal surgery.
tained at the final examination 9 months after com- Subsequently, the test group received thorough
pletion of therapy. PMTC and oral hygiene training every 2 weeks,
In a selected group of patients with advanced peri- whereas the control group was recalled once for de-
odontitis, Badersten et al. (14) compared the effect bridement and scaling 6 months postoperatively,
of one session of subgingival scaling and root plan- with no other attempts to maintain gingival plaque
ing with three sessions, at one month intervals, in a control. At the end of the 2-year period, the test
24-month split-mouth study. After the initial instru- group showed a stable periodontal status with no
mentation of single-rooted teeth, the patients were further loss of clinical attachment and the pocket
recalled for repeated oral hygiene training and depths were maintained at the immediate post-
PMTC, at intervals based on individual need. The operative level. The patients in the control group,
initial pocket depth varied from 2.5 to 11 mm. The however, exhibited on average 2 mm of clinical
results were evaluated by recording plaque scores, attachment loss, and the probing depths were ap-
bleeding on probing, probing pocket depths and proximately the same as before surgery. This rapid
probing attachment levels. During the initial 9 periodontal destruction in the control group sug-
months of the study, there was a gradual marked im- gests that, in the absence of adequate plaque control
provement of periodontal status. During the remain- and maintenance program, periodontal treatment
ing 15 months of the 24-month experimental period, may be of little value.
no further changes of the recorded variable were Lindhe et al. (28) used a split-mouth design to
noted. No differences in results could be observed compare the efficacy of surgical and nonsurgical
between the effects of single vs. repeated instrumen- periodontal treatment methods, and they demon-
tation. Thus, it appears that deep periodontal strated excellent resolution of the defects and main-
pockets in incisors, cuspids and premolars may be tenance of periodontal health during a 2-year period
successfully treated by a single initial session of irrespective of the type of treatment method when
meticulous instrumentation together with adequate periodontal therapy was followed by regular and fre-
gingival plaque control. The results also suggest that quent PMTC. Similarly, Wennström et al. (47) com-
recurrence of disease due to subgingival recoloniza- pared the efficacy of surgical and nonsurgical
tion by microorganisms during the healing phase methods in the treatment of aggressive (early onset)
may not be a major clinical problem if high-quality periodontitis and reported no recurrence of the dis-
plaque control is established. ease over a 5-year period when treatment was fol-
Thus, after one single session of meticulous scal- lowed by frequent PMTC during the first 2 years
ing, root planing and debridement, avoiding aggres- postoperatively.
sive removal of the root-cementum, the health of the Westfelt et al. (48) compared the use of 0.2% chlor-
periodontal tissues can be maintained by excellent hexidine digluconate mouthrinse with regular mech-
gingival plaque control which includes self-care anical plaque control during healing after peri-
supplemented by PMTC at needs-related intervals. odontal surgery. Following treatment, half of the pa-
The need for repeated subgingival scaling should be tients rinsed with chlorhexidine for 2 min, twice a
regarded as an unfavorable response to treatment. day for 6 months postoperatively, whereas the re-
maining patients were enrolled in a strict gingival
plaque control program with PMTC once every 2
Periodontal maintenance programs
weeks during the same period. Following a 6-months
Frequent PMTC has also been successfully used in postoperative examination, both groups were placed
maintenance programs, following initial nonsurgical on a maintenance care program consisting of recall

241
Axelsson et al.

visits once every 3 months until the final examina- surfaces (11). For ethical reasons, and following the
tion at 24 months. At the end of the healing phase first 6 years of the study, the control group was also
there was a higher frequency of pockets ⬎ 4 mm in offered a needs-related preventive program which
the chlorhexidine group, and less gain of attachment many of the subjects accepted.
in pockets initially ⬍ 4 mm, than in the PMTC group. The second phase of this 15 year longitudinal
This suggests that the PMTC program when pro- study (13) consisted of a nine year individualized
vided every second week is more efficient than daily secondary preventive program given to all subjects
chemical plaque control twice a day during the post- of the test group and administered by the same den-
operative healing period. tal hygienist. To maximize the cost-effectiveness of
Based on the findings of these studies, it is evident the program, the intervals, as well as the preventive
that a very cost-effective course for treatment and measures used, were based entirely on individual
control of periodontal diseases would include an ini- needs. Hence, the frequency of visits increased with
tial, comprehensive, ‘nonaggressive’ subgingival the increase in the estimated risk of developing peri-
scaling and root planing, followed by a maintenance odontal diseases. and according to this program, ap-
program based on excellent control of gingival proximately 65%, 30% and 5% of the subjects visited
plaque by a combination of self-care and PMTC at the dental hygienist only once a year, twice a year,
needs-related intervals. and three to six times a year, respectively.
Remarkably, the results showed that only 0.23
teeth were lost per individual during the 15 years
Long-term effect of PMTC and self-care plaque
study period. Comparably, it has been estimated that
control
a similar population of adults in Sweden not re-
The use of PMTC with patient plaque control was ceiving the same prevention program would have
tested in a 15-year longitudinal study in adults (13). lost on average 2–3 teeth per individual during 15
Two groups of subjects from one geographic area years, or ⱖ 10 times more tooth loss than subjects re-
participated in the study and included a test group ceiving the program. Indeed, based on these find-
comprising 375 subjects and a control group of 180 ings, one may postulate that a 50-year-old-subject
subjects. The subjects were stratified into three age receiving a similar preventive program may have a
groups: 20–35, 36–50 and 51–70 years. Subjects in the very low risk of losing any teeth during the following
test group were given an initial session of nonaggres- 50 years of his/her life.
sive scaling, root planing and debridement, and were At the end of the study period, almost all subjects in
seen once every other month for the first 2 years, and the test group showed healthy periodontal tissue
then once every third months for the following 4 (CPITN score 0). Furthermore, the subjects had a
years. During these visits, the subjects were individu- mean gain of periodontal attachment of 0.3 mm per
ally educated in correct oral hygiene technique individual and had developed less than one new cari-
based on self-diagnosis, and also received PMTC ous tooth surface per individual, regardless of age.
supplemented by nonaggressive debridement, where The caries incidence and periodontal attachment
necessary, by a dental hygienist. Subjects in the con- gain were similar in the 36–50 years as the 66–85 years
trol group, however, were seen annually during the olds. In addition, it was estimated that the annual cost
first 6 years of the study and were given conventional of dental care in the test group was only about 50% of
dental care only. Re-examinations of both groups the average annual cost for Swedish adults (13).
were carried out at the end of the third and sixth
years of the study.
The role of plaque retentive factors
On average, the control group lost 1.2 mm of peri-
odontal attachment per individual during the 6 For optimal mechanical plaque control, through
years, whereas the test group showed no further loss self-care or PMTC, plaque-retentive factors must be
of periodontal attachment. Notably, however, in the eliminated or at least minimized. Plaque-retentive
control group most of the periodontal attachment may be present supragingivally and/or subgingivally.
loss was limited to a few subjects who showed sig- Supragingival plaque retention is most commonly
nificant deterioration of their periodontal status. Al- the result of the following conditions:
though most of the subjects in the control group did
not lose any periodontal attachment, the condition O Supragingival dental calculus
of some subjects deteriorated badly, with continued O Carious lesions
attachment loss and development of new carious O Restoration overhangs and defective margins

242
 Prevention and control of periodontal diseases

O Unpolished restorations late or pointed double-knife-edged instruments are

O Resin composite restorations even more useful for removing overhangs, recon-
O Ill-fitting crown and inlay margins touring, and finishing restorations because they can
O Excess resin cement be used subgingivally between the papillae and the
O Open proximal contact and other anatomical tooth surface. Both diamond-coated and tungsten-
flaws of restorations coated tips are available in sizes from 15 to 150 mm.
O Exposed, unplaned root surfaces Tungsten-coated tips are regarded risk-free when
O Furcation involvements used on tooth enamel, root surfaces, and porcelain
and glass-ceramic restorations, and are therefore
The following subgingival factors can predispose suitable for final finishing of restorations and re-
to plaque retention and may complicate subgingival moval of excess resin cement. Overhangs of approxi-
plaque control: mal amalgam restorations can easily be removed
using the Profin contra-angle and a 50-mm diamond-
O Subgingival dental calculus coated reciprocating tip.
O Deep, narrow bony defects
O Root surface grooves
Summary
O Rough, unplaned cementum surface
O Cementum hypoplasia
O Needs-related oral hygiene habits can be estab-
O Root resorption defects
lished by self-diagnosis, the linking method, edu-
O Iatrogenic effects of subgingival scaling, such as
cation and training
grooves and exposed dentinal tubules on the root
O High-quality mechanical plaque control through
surfaces
self-care and frequent PMTC will remove plaque
O Restoration overhangs, defective and ill-fitting
biofilms not only supragingivally but also 1–3 mm
crown margins, excess resin and other cement,
subgingivally, and successfully prevent regrowth
and unpolished restorations
of subgingival plaque biofilms, i.e. provide gingi-
O Recurrent caries and root caries
val plaque control
O Furcation involvements
O Even in diseased, untreated periodontal pockets,
frequent PMTC can cause a reduction in pocket
Overhangs of restorations are often located on the
depth and in the amount of subgingival micro-
approximal surfaces of teeth, and mostly subgingi-
flora and may also lead to a shift in the compo-
vally. Several studies have shown a close relationship
sition of the microflora by reducing the number
between the size of restoration overhangs and local
of pathogenic microorganisms
loss of periodontal support as a result of plaque re-
O Meticulous PMTC is not the same as the regularly
tention (6).
practiced prophylaxis and polishing of tooth sur-
To prevent and control periodontitis through
faces
mechanical gingival plaque control, it is imperative
O To allow optimal mechanical plaque control,
that subgingival approximal restorations be optim-
plaque-retentive factors must be minimized or
ally finished and repeatedly polished. Indeed, this
eliminated
task should be given a higher priority than finishing
O High-quality mechanical plaque control, based on
occlusal, buccal and lingual restorations. Rotating
individual needs, can efficiently prevent the initia-
instruments have traditionally been used to finish
tion (primary prevention) as well as the recur-
and polish restorations and remove overhangs. How-
rence (secondary prevention) of gingivitis, peri-
ever, in narrow, triangular interproximal spaces, the
odontitis and dental caries because the method is
subgingival area is almost inaccessible to rotating in-
directed toward the cause of these diseases
struments. Many subgingival approximal restora-
tions are therefore poorly finished and have persist-
ent overhangs.
Chemical plaque control methods
Reciprocating triangular or v-shaped pointed in-
struments are more appropriate for narrow triangu- Chemical plaque control can also be achieved
lar interproximal spaces than are rotating instru- through self-care or professionally. By far the most
ments. The resilience of the papillae means that efficient plaque control programs are those combin-
such reciprocating instruments can access 2–3 mm ing mechanical and chemical methods: self-care,
of the subgingival area. Reciprocating, thin, spatu- supplemented by needs-related PMTC and Pro-

243
Axelsson et al.

fessional Chemical Plaque Control (PCPC). For ex- Programs for prevention and
ample, in mechanical plaque control through self- control of periodontal diseases
care, the toothpaste used usually contains not only
an abrasive agent but also antiplaque or anti- Prevention programs may be primary, secondary
microbial agents, such as sodium lauryl sulfate, stan- or tertiary. The aim of primary prevention pro-
nous fluoride, triclosan plus zinc citrate, triclosan grams is to prevent the initiation and develop-
plus copolymers, triclosan plus pyrophosphate, or ment of periodontal diseases. Primary prevention
chlorhexidine digluconate. should be targeted towards populations of healthy
Antiplaque and/or antimicrobial preparations (ex- individuals, usually children and young adults,
cluding antibiotics) suitable for self-care are avail- and directed to the establishment of healthy peri-
able in a variety of vehicles, including toothpastes, odontal tissues promptly after the eruption of
mouthrinses, irrigants, gels and chewing gums. For primary and permanent teeth. Secondary preven-
PCPC, several types of antiplaque and/or anti- tion is aimed at preventing the recurrence of dis-
microbial preparations are available, including ease after successful treatment, and is achieved
pocket irrigants, gels, slow-release agents (varnishes) through periodontal maintenance programs, sup-
and controlled slow-release agents. Chemical plaque portive care, and other means. Tertiary prevention
control should always be regarded as a needs-related is the elimination of disease through treatment,
supplementation to, and not a substitute for, mech- usually using nonsurgical or surgical treatment
anical plaque control. Therefore, the choice of agent methods.
and frequency of use for self-care and professional As periodontitis is considered always to be pre-
care should be related to the individual patient’s pre- ceded by gingivitis, the introduction of daily
dicted risk for oral disease. mechanical toothcleaning with a toothbrush and
fluoride toothpaste at a very early age performed
by parents is a very cost-effective primary pre-
Chemical plaque control by self-care vention program of periodontal diseases as well
as dental caries in both developing and industri-
alized countries. Oral hygiene training programs
O Agents are applied with high frequency – one to and supervised toothcleaning in preschool and el-
three times per day, regularly or intermittently ementary schools could also be a cost-effective
O Accessibility and efficacy are good supragingivally, primary prevention in developing as well as in-
but very limited subgingivally and interproximally dustrialized countries.
in the molar and premolar regions, particularly for In many developing countries there is a high
mouthrinsing prevalence of poor oral hygiene, particularly
O The method is compliance-dependent and rela- among children. This and the limited dental care
tively costly for regular daily use, unless the agent resources in these countries usually translate into
is uncorporated in toothpaste a high prevalence of gingivitis, and periodontitis.
Hence, a population-based secondary prevention
program performed by specially trained personnel
in preventive dentistry, which may include ‘non-
dentist’ personnel including dental hygienist, den-
Professional chemical plaque control
tal assistants and teachers specially trained in
and focused on self care education, should be
O The frequency should be needs-related and PCPC very cost-effective.
generally is more frequent during the initial inten- For underprivileged persons in industrialized
sive period to heal inflamed periodontal tissue as countries, prevention programs similar to those
soon as possible and thereby reduce the Plaque established for developing countries may be
Formation Rate Index (PFRI) needed, with certain modifications corresponding
O Accessibility is high because the agent is pro- to the availability of the expertise and personnel
fessionally applied needed. For the rest of the population, however,
O The duration of effect can be extended by using the most cost-effective strategy for the improve-
slow-release agents, such as chorhexidine-thymol ment of oral health status are needs-related self-
varnish and gels, and controlled slow-release care programs based on self-diagnosis, supple-
agents mented with professional mechanical tooth-

244
 Prevention and control of periodontal diseases

cleaning and topical application of fluoride vals, the effect of the maintenance program
agents at needs-related intervals. All new patients should be evaluated in terms of probing attach-
in such a ‘high risk strategy’ program should be ment level measurements, pocket depth measure-
introduced to a needs-related preventive program ment, radiographs, and other diagnostic means
(8).

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