This presentation includes various levels of preventive and strategies to be adopted based on the current scientific evidence

1. Newer
strategies in
prevention of
periodontal
disease
Dr. Lakkireddy Vasavi reddy

2. Contents:
Introduction
Prevention
Change in approaches
Prevention in practice – forming a bridge to the patient
Levels of prevention
Preventive strategies and evidence
conclusion

3. Introduction:
• Periodontal health across the human
lifespan is a key component of oral health
and an important component of general
health and well-being for individuals and
the population as a whole.
• Periodontitis affects more than 50% of the
adult population and its severe forms
affect 11% of adults, making severe
periodontitis the 6th most prevalent
disease of mankind.
• Such a high burden of disease and its
social, oral and systemic consequences are
compelling reasons for increased attention
from individuals, professionals and public
health officials.

4. Prevention:
• Prevention of periodontal
disease encompasses a set
of various actions which
ultimately aim at preventing
or controlling the disease. It
may apply to any point of
the disease process.

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

6. Traditional
approach:
A consensus statement from a European Workshop in 1998
on mechanical plaque control reads “...effective removal of
dental plaque is essential to dental and periodontal health
throughout life”.
The traditional approach still relies on education, teaching
the patient proper oral hygiene.
Patient education imparts specific information on the cause
of periodontal disease, e.g. dental plaque, and technical skills
on how to control the cause, e.g. oral hygiene.
The basic problem of traditional educational intervention is
that it does not integrate the socioeconomic and behavioral
dimensions of the patient.

7. Today’s
approach:
Today, preventive interventions are evolving to more
complex educational programs involving
psychological and behavior change strategies
“Patient empowerment”, which implies that patients
play an active role in the management of their own
conditions and share responsibility for the outcomes.
Self-management is defined as “the individual’s
ability to manage the symptoms, treatment, physical
and psychosocial consequences and lifestyle changes
inherent in living with a long term disorder”.

8. Prevention in practice
– forming a bridge to
the patient:
• The strategy for the
prevention at the patient
level has to be global and
comprehensive.
• Preventive interventions
should be oriented towards
influencing patient behavior.

9. Motivational
interviewing:
• Motivational interviewing may be a useful tool for
the clinician to assist the patient to adopt proper
health behaviors (primary prevention) or to modify
lifestyle and inappropriate behaviors (secondary and
tertiary prevention).
• Motivational interviewing has been defined as “a
client-centered, directive method for enhancing
intrinsic motivation to change by exploring and
resolving ambivalence”.
• Motivational interviewing is designed as a brief,
nonconfrontational, counseling method.

10. Preventive
strategies :
Prevention is related to making the
occurrence or progression of a disease
process unlikely or impossible,
strategies can be developed to prevent
the disease or its progression.
preventive strategies play an
important role throughout all aspects
of periodontal treatment and new
strategies aimed at primary or
secondary prevention.

11. Levels of prevention:
Primary
Strategies designed to ensure that
the disease or process fails to
become clinically evident
secondary
Involves early recognition and
treatment of the disease processes
tertiary
Involves disability limitation and
rehabilitation. Supportive
periodontal treatment could be
considered a part of it

12. Levels of
prevention:

13. Primary prevention

14. Health
promotion:
• It is process of enabling people to
increase control over and to improve
health. It is not directed against any
particular disease, but is intended to
strengthen host through a variety of
approaches like-
a. Health education
b. Nutritional intervention
c. Environmental modification
d. Lifestyle and behavior changes

15. Health education:
• Health education is fundamentally a learning process, which aims at favorable changing
attitudes and influencing behavior with respect for health practices.
• Health education is vital for prevention.
• It is the channel for reaching the people and alerting them to the doctor’s services and to
all other community health resources.
• True health education is an active process that involves changed behaviour. It can help to
increase knowledge and to reinforce desired behaviour patterns

16. Educational aids:
AUDITORY VISUAL AUDIO-VISUAL AIDS

17. Methods of
health
communication:
• Individual: Personal contact
Home visits
Personal letters
• Group: Lectures
Demonstrations
Discussions
• Mass approach: radio, television,
posters, internet, printed material,
direct mailing, posters, health
museums and exhibitions and folk
methods

18. Trends in mass
approach:
It is suggested to use current trending
social media like twitter and Instagram
with hashtags ( for e.g. #my healthy
gums#) and develop a campaign to
motivate and educate the public.

19. Specific protection:
• To avoid disease altogether is the ideal but this possible only in a
limited number of cases. The following are some of the currently
available intervention aimed at specific protection –
a. Immunization
b. Chemoprophylaxis
c. Protection against occupational hazards
d. Use of specific nutrients

20. Disclosing agents:
• Disclosing agents can be used in
oral health prevention programs,
both for more effective guidance
on the use of oral hygiene tools
and for their evaluation.
• Nepale et al. studied the role of
disclosing agents in asseing patient
compliance through a prospective
study and concluded that it
improves the quality of daily oral
hygiene practice and home care
study by lee et al in 2018 concluded that the correlations between the
plaque indices measured for each tooth surface area using QLF-D and the
clinical indices assessed were significantly high, and it allowed objective
determination of the gingival status

21. Primary
Prevention :
Patient level:
• Oral hygiene practices.
• Habits
• Diet
Dentist level:
• Professional mechanical plaque removal
• Patient education and motivation.

22. Mechanical plaque removal:
• Natural cleaning of dentition
is virtually non-existent, to
be controlled, plaque must
be removed frequently by
active methods.
• Hence, the dental
community continues to
encourage proper oral
hygiene and more effective
use of mechanical cleaning
devices

23. Tooth brush:
• During the past 50 years, oral hygiene has improved, and, in
industrialized countries, 80–90% of the population brushes their
teeth once or twice a day .
• Today, numerous manual toothbrush types are available.
However, there is still insufficient evidence that one specific
toothbrush design is superior to another.
• Modern toothbrushes have bristle patterns that are designed to
enhance plaque removal from hard-to-reach areas of the
dentition, particularly proximal areas.

24. Powered tooth brush:
4th European Workshop on Periodontology in 2001, Sicilia et al. reviewed the available literature to
evaluate the effectiveness of power-driven toothbrushes compared with manual toothbrushes in terms
of gingival bleeding or inflammation resolution in the treatment of patients with gingivitis or chronic
periodontitis, concluded that limited evidence exists for the higher efficacy of electric toothbrushes
relative to manual brushes in reducing gingival bleeding or inflammation. This advantage appears to be
related to the ability of the electric toothbrushes to remove dental plaque.
Systematic review by Derry in 2004 concluded that, in general, there was no evidence of a statistically
significant difference between powered and manual brushes (38). However, rotation ⁄ oscillation-
powered brushes (see Fig. 2) significantly reduced both short- and long-term plaque and gingivitis.

25. Ultrasonic tooth brush
• Emident is the first ultrasonic toothbrush generating
ultrasound with its patented ultrasonic microchip
embedded inside brush head.
• Chip creates up to 96 million ultrasonic impulses per
min transmitted via bristles, together with nano
bubble toothpaste into gums and teeth.
• It can be used effectively in individuals undergoing
orthodontic treatment. Also, it is gentle enough to
use immediately after oral surgery including
implants, avoiding damage to teeth and gums and is
painless on sensitive teeth and gums.

27. Ionic tooth
brush:
ionic toothbrush works on the principle of polarity that every
element in nature has a positive or a negative charge.
Deshmukh et al. in 2006 conducted a clinical study to evaluate the
effectiveness of an ionic toothbrush on oral hygiene status. There
was a significant reduction in plaque index and gingival index
scores as well as there was no soft-tissue trauma following the use
of ionic toothbrushes.
Singh et al. in 2011 conducted a study to clinically assess and
compare the efficacy of the sonic and ionic toothbrushes among
22 individuals. From their study, it was concluded that though the
sonic toothbrush was insignificantly superior to the ionic
toothbrush, both the toothbrushes are clinically effective in
removing plaque and improving the gingival conditions

28. Super brush:
• It is a triple headed manual tooth brush in which
three brush heads are combined together. It is
designed such that when placed on the chewing
surface, all the three surfaces of tooth are cleaned
simultaneously.
• Dogan M chem, et al. concluded in his study that
triple headed super brush could be an effective and
cheaper alternative for use in children including
disabled individuals.

29. Chewable brush:
• It is a miniature plastic moulded toothbrush which can
be used when no water is available.
• Myoken et al. in 2005 investigated the effectiveness of
the chewable toothbrush in a care-dependent elderly
populationand concluded that chewing the brush
results in the removal of a significant amount of plaque.
• Bezgin et al. in 2015 also conducted a pilot study on the
effectiveness of chewable brush in removing plaque in
children and concluded that chewable brush may be an
appropriate oral hygiene adjunct for school children,
including children with disabilities.

30. • Laser tooth brush: . Ko et al. in 2014 and Yaghini et al. in
2015 tested the efficacy and the safety of a low-level
laser-emitting toothbrush on the management of
dentinal hypersensitivity and concluded that the use of
the low-level laser-emitting toothbrush is a safe and
effective treatment option for the management of
dentinal hypersensitivity.
• Beam brush: Beam brush can collect up to 3 weeks
brushing data & upload it wirelessly on android mobile
that can be sent or shared with the dentist or can be
recorded for subjects own regular check purpose.
• Along with tracking record for oral health it use all
active two-minute brushing with quadrant indicator
which is helpful in oral health information

31. • Foam brush: Foam brushes resemble
a disposable soft sponge soaked in
chlorhexidine on a stick.
• They are used in particular for oral
care in medically compromised and
immunocompromised patients to
reduce the risk of oral and systemic
infection
• Towelettes: Finger brushes are
mounted on the index finger of the
brushing hand, and the agility and
sensitivity of the finger are used to
clean the teeth.

32. Pre brushing rinse:
• Binney et al. examined the effectiveness of
rinsing before brushing on plaque removal.
• Water served as a negative control and was
used as a both a pre-brushing rinse and
while toothbrushing.
• Rinsing with water and then brushing with
water removed more plaque than any
other combination of pre brushing mouth
rinse and dentifrice.

33. Brushing
techniques:
The ideal brushing technique is the one that
allows for complete plaque removal in the
least possible time, without causing any
damage to tissues (Hansen & Gjermo 1971).
The most common technique used by
uninstructed individuals is typically a
horizontal scrub technique that engages the
occlusal and free surfaces (Loe 2000).
The most common method recommended
was the (Modified) Bass technique.

34. Filament design:
• Manual toothbrushes with cut filament ends
resulted in significantly greater gingival lesions than
rounded ends (Breitenmoser et al. 1979).
• Non-end-rounded filament turn out to be about
twice as abrasive to soft tissues as rounded filament
tips (Alexander et al. 1977).
• Shory, et al. found the Collis curved brush, with two
short middle rows and curved outer rows. Williams
and Schuman[19] had found that handicapped
children were able to remove more lingual plaque
with this curved brush.

35. Brushing time, frequency, force:
There is no standard recommendation for how many times per day persons should brush their teeth.
Kressin et al. (2003) evaluated the effect of oral hygiene practices on tooth retention in a longitudinal study with 26 years of follow-
up. They observed that consistent brushing (at least once per day) resulted in a 49% reduction of the risk of tooth loss, compared
to a lack of consistent oral hygiene habits
The American Dental Association advocates to brush twice a day (ADA 2014a).
The recommended brushing duration often is 2 min (Van der Weijden et al. 1993)
Force: An increase in efficacy was observed with raising brushing force from 1.0 N to 3.0 N (Van der Weijden et al. 1996).

36. Tongue cleaner:
• Tongue cleansing reduces the number of organisms,
thereby controlling oral malodor (Van der Sleen et al.
2010).
• Combining tooth brushing with tongue cleaning
significantly reduced tongue coating; however, there
appeared to be insufficient evidence to recommend
frequency, duration, or delivery method of tongue cleaning
(Kuo et al. 2013).

37. Interdental aids:
A fundamental principle of
prevention is that the effect is
greatest where the risk of
disease is greatest.

38. Floss:
More recently, Sambunjak et al.
(2011) in their Cochrane review
found that in terms of reducing
gingival inflammation, flossing plus
toothbrushing showed a
statistically significant benefit
compared to toothbrushing alone.
Evidence on flossing to effectively
reduce gingivitis is very low and
the evidence to suggest that
flossing reduces plaque is
unreliable (Matthews 2012).

39. Wooden tips:
Woodsticks depress the gingivae by up to 2 mm and,
therefore, clean parts of the subgingival area (Morch &
Waerhaug 1956).
Hoenderdos et al. performed a systematic review to evaluate
and summarize the available evidence on the effectiveness of
using triangular woodsticks in combination with
toothbrushing to reduce both plaque and clinical
inflammatory symptoms of gingival inflammation. None of the
studies that scored visible interdental plaque demonstrated
any significant advantage of using woodsticks as opposed to
alternative methods (toothbrushing only, dental floss or
interdental brushes) in patients with gingivitis.

40. Interdental brush:
• The systematic review by Slot et al. (2008) highlights
the effectiveness of inter-dental brushes as an
adjunct to toothbrushing for plaque removal in adult
patients.
• The evidence derived from this review supports
recommendations by dental care professionals for
their patients to use inter-dental brushes in addition
to toothbrushing since it reduces dental plaque
(Rasines 2009).
• Moderate evidence was available for the efficacy of
interdental brushes in addition to toothbrushing as
compared with toothbrushing alone.

41. Oral irrigator:
Oral irrigators are designed to disturb and remove plaque and soft debris
through the mechanical action of a stream of water.
Husseini et al. (2008) systematically reviewed the literature on the
adjunctive effect of the oral irrigator in addition to toothbrushing on
controlling plaque and bleeding index gingival inflammation and pocket
probing depth. oral irrigator, as an adjunct to toothbrushing, does improve
gingival health more than regular oral hygiene measures or toothbrushing
alone, although no evidence for a beneficial effect in reducing visible
plaque was retrieved.
More recently, a 4-week study indicated that when combined with manual
toothbrushing the daily use of an oral irrigator is significantly more
effective in reducing gingival bleeding scores than is the use of dental floss
(Rosema et al. 2011).

42. Newer aids:
• New inter-dental cleaning products have become available since the
systematic reviews reported in this meta-review were conducted.
• They comprise new developments in oral irrigation devices with
respect to the characteristics of the spray and the design of the
nozzles (Sharma et al. 2012), as well as an inter-dental device
constructed of a plastic core with soft elastomeric fingers protruding
perpendicularly (Yost et al. 2006, Abouassi et al. 2014).

43. Chemical plaque control:
CLASSIFICATION OF CHEMICAL PLAQUE CONTROL AGENTS
Capable of reducing plaque scores
by about 20-50%.
Exhibits poor retention within
mouth.Ex: antibiotics ; phenols ;
quaternary ammonium compounds
and sanguanarine.
Produce an overall plaque
reduction of around 70-90%
Are better retained by the oral
tissues
Exhibit slow release properties.
Ex: bisbiguanides [Chlorhexidine
(CHX)]
They block binding of m/o to tooth
or to each other.
Compared to CHX , they do not
exhibit good retentive properties.
Ex: delmopinol .

44. Dentifrice:
• The addition of abrasives supposedly facilitated plaque and stain removal.
• Study by Jayakumar et al. (2010), a 9% difference in plaque removal, in favour of
the non-dentifrice group, was observed.
• The results of a recent study by Rosema et al. (2013) showed a difference in
plaque removal of 2% in favour of the nondentifrice group.
• American DentalAssociation (ADA) Division of Science (ADA 2001), accepts that
“plaque removal is minimally associated with abrasives.” The effectiveness of
plaque removal during tooth brushing with dentifrice appears to be essentially a
function of the access of brush filaments, rather than dentifrice abrasives (Creeth
et al. 2009).
• Dentifrice is, however, able to carry a multitude of different chemotherapeutic
ingredients.
• Fluoride toothpaste is the most widespread and significant form of fluoride used
globally and the most rigorously evaluated vehicle for fluoride use (Benzian et al.
2012).

45. Plaque
disclosing
dentifrice:

46. Dentifrobots
• Nanorobotic dentifrice could patrol all supragingival
and subgingival surfaces, metabolizing trapped
organic matter into harmless, vapours and
performing continuous calculus debridement.
• 103-105 nanodevices per oral cavity crawl at 110
microns/sec. The invisible, inexpensive devices
would safely deactivate themselves if swallowed.
• They destroy only pathogenic bacteria allowing 500
harmless species to flourish in ecosystem.

47. Petite Particle
For Perfect
Plaque
• Rapidly advancing “Nanodentistry” will make
possible the maintenance of 'near- perfect Oral
health' Innovation of 'Nano Hydroxyapatite
crystals' a remineralising agent has shown
strong propensity to adhere plaque bacteria in
the oral cavity, facilitating easy removal.
• The remineralised zones also showed reduced
plaque adherence and bacterial growth in vitro.

48. • Nano drug delivery system: It is a novel method of
targeted delivery system which is much
researched in nanomedicine, recently striking the
boundaries of dentistry. This could deliver the
therapeutic agents in mouth rinses against specific
pathogens. Marzeih et al in a study in 2013 used
silver nano particles as active ingredient and
concluded that it has high antinmicrobial
properties even at low concentrations.
• Nurturing with Nature: Herbal and organic
chemical plaque control is evidenced from
chronicles. Essential oil extracts as a plaque
control agent made gyration among the existing
ones, where Listerine was the first to get its FDA
approval. Time honoured ones are neem
(Azadirachta indica), meswak (Salvadora persica),
mango (Mangifera indica) extracts etc. Of late, in
the queue are tea tree oil, aloe vera and propolis
(bees wax), Green tea, Garlic (Allium sativum),
onion (Allium cepa L), Triphala etc.

49. Biologic plaque control:
• Despite its important role in controlling gingival and periodontal
disease, mechanical plaque control is not properly practiced by most
individuals.
• Also, emergence of antimicrobial resistance is currently posing a
major global challenge, with an increasing number of strains,
including commensal and pathogenic oral bacteria, becoming
resistant to commonly used antimicrobial agents.
• Therefore a newer approach for control of plaque has been
suggested.
• Naoyuki Sugano in his review suggested Probiotics and Vaccines as
two approaches for control of periodontal diseases.

50. Probiotics:
• It is an interesting new field of periodontology research that aims to
achieve biological plaque control by eliminating pathogenic bacteria.
Live micro-organisms which, when administered in aquate amounts,
confer a health benefit on the host.
• Oral administration of lactobacillus species (LS1) has shown to
prevent the colonization of periodontopathic bacteria like
Actinomycetemcomitans, Porphyromonas gingivalis, Prevotella
intermedia[

51. Periodontal vaccines:
• Various Virulence factors, one of which is cysteine proteinases
(gingipains), have been reported to contribute to the pathogenicity of
P. Gingivalis. Hence, Inhibition of gingipain by vaccination might
reduce the periodontitis caused by P. gingivalis infection.
• In a study conducted by Yokoyama et al, Passive administration of Egg
yolk antibody against gingipains (IgY-GP) has shown significant
reduction in amount of P.gingivilis. Application of this newer
biological approach in children can be further studied.

52. No smoking strategies:
2nd European Workshop on
Tobacco Use Prevention and
Cessation for Oral Health
Professionals
(i) basic care: brief intervention
of only a few minutes to inquire
about tobacco habits and assess
patients readiness to quit;
(ii) intermediate care:
intervention of 5–10 min with
brief motivational interviewing
to build on readiness to quit and
provide support for changes;
and
(iii) advanced care: multiple
interventions of 20 min to
develop a detailed plan to quit
including cessation medications.
Meta-analyses reported that the degree of success was related to the length of the intervention, with rates of
13.4% for brief intervention and 22.1% for intensive intervention

53. Diet recommendations of 2011 European workshop on Periodontology

54. Role of health
care professional:

55. Professional mechanical
plaque removal:
• One of the most commonly performed preventive
measures in adults in countries with organized dental
services is professional mechanical plaque removal (PMPR),
with or without concomitant oral hygiene instructions
(OHI).
• PMPR comprises supra-gingival and sub-marginal plaque
and calculus removal using hand instruments (scalers,
curettes), or powered instruments (sonic, ultrasonic,
rotating devices, air polishing).
• The intention is to remove deposits from the tooth surface,
extending into the gingival sulcus. This is done to allow
adequate patient-performed oral hygiene

56. The systematic review
(Needleman et al. 2015) on
PMPR for prevention as
defined above, resulted in
the following findings:
• There is little value in
providing PMPR without
OHI to reduce gingivitis.
• A single episode of PMPR
followed by repeated OHI is
as effective as repeated
PMPR in reducing gingivitis
at least up to 3 years
follow-up.
• There are no published
randomized controlled
trials (RCTs) to directly
inform on the efficacy of
PMPR for primary and
secondary prevention of
periodontitis as opposed to
the indirect evidence
derived from gingivitis
treatment studies.

57. • Correction of malaligned teeth: primary prevention also includes the
correction of mal aligned teeth.

58. Role in
education and
motivation:
The patients must be told and shown that the
periodontal disease is insidious and usually
asymptomatic. The precise status of his own
periodontal health should be explained to him.
The recommendations for plaque control
instruction should include:
• Patient education.
• Patient motivation.
• Patient instructions.
• Encouragement and reinforcement.

59. Secondary
prevention

60. Secondary prevention:
• It includes early diagnosis and prompt treatment.
• Regular PMPR with respect to secondary prevention.
• Life-long individualized supportive periodontal care based through an
efficient recall system may be necessary, in order to establish the
prerequisites for secondary prevention.
• Risk assessment tools may help to group patients in different risk
levels, and predict the probability of disease recurrence, yet until
today their clinical benefits have not been proven at an individual
level

61. Early diagnosis:
• The first two aspects of prevention, prevention of occurrence and
prevention of progression, are closely linked.
• In order to evaluate the effectiveness of prevention or to determine the
need for more aggressive measures, early recognition of disease patterns is
necessary.
Signs and symptoms of disease-
• One of the most reliable clinical signs of gingival inflammation remains the
bleeding response of the gingiva following gentle probing.
• While bleeding on probing has approximately a 30% predictive power for
future loss of attachment, the negative predictive power of 98% makes
bleeding following probing a very useful tool

62. Diagnostic tools:

63. Periodontal
screening and
recording:
• Developed by American academy of
periodontology.
• By following the recommendations of
the Periodontal Screening and
Recording system, the practitioner can
focus on those areas that begin to
present evidence of inflammation and
follow the progress of therapy to
completion.

64. PMPR
• Regular PMPR with respect to secondary prevention includes the
same measures as in primary prevention accompanied by evaluation
of oral hygiene, and if necessary reinforced OHI.
• It also encompasses subgingival debridement to the depth of
periodontal pocket. Repeated periodontal examinations of residual
pockets are necessary for the early detection of deepening pockets
(probing depth ≥ 5 mm) that require active therapy. At each
appointment, patients should be educated about a healthy lifestyle
and smoking cessation45,46.

65. Risk assessment
tools:
• Different individuals demonstrate varying susceptibility to
onset and progression of periodontitis (Loe et al. 1986).
• It is important to note that in general, prediction tools
based on risk factors allow the grouping of patients
according to different levels of average risk, they do not
however allow the accurate prediction of individual patient
outcomes (prognosis).
• Previous literature shows that risk factors and combinations
thereof typically have poor performance for individual risk
prediction (Wald et al. 1999, 2005).
• Nonetheless, the provision of patient care guided by the
assessment of patient level risk for the progression of
periodontitis may be an advantageous approach for the
individual patient (Rosling et al. 2001).

66. The systematic review (Lang et al. 2015)
reached the following conclusions:
• Five different risk assessment tools have been described. These tools consist of various
combinations of patient level factors.
• Three of these were evaluated on longitudinal data demonstrating an association between
the risk score and disease progression (PRC, PRA, and DRS).
• One of the tools (PRA) has been externally validated in multiple supportive periodontal care
(SPC) populations in several countries. Data showed an association between the risk
categories and the outcome (AL/tooth loss).
• The review could not identify any study investigating whether the application of the tools
would result in clinical benefits for the individual patient.

67. It includes also the
corrective
restorations and
occlusal services.
Also manages the
non carious cervical
lesions and dentinal
hypersensitivity.

68. Tertiary prevention:
• It includes mainly disability limitation and rehabilitation. Supportive periodontal therapy can be a
part of tertiary prevention.
Disability limitation is mainly directed at reduction of infection, resolution of inflammation,
reduction of tooth mobility and prevention of tooth loss. These measures include-
• Deep curettage.
• Root planing
• Splinting
• Mucogingival and periodontal surgery including crown lengthening procedures, gingivoplasty,
osseous recountering, ostectomy and treatment of furcation involvement and root amputation.
Cosmetic procedures such as ridge augmentation, subepithelial connective tissue or free gingival
grafts and lateral repositioning or pedicle grafts.
• Regenerative therapies including osseous grafting, GTR growth factors, enamel matrix proteins,
etc.
• Endodontic therapy
• Selective extractions.

69. Newer
trends in
treatment :
1. Extracorporeal shock wave therapy
2. Photodynamic therapy
3. Electrical stimulation on
osteogenesis of alveolar bone
4. Ultrasonic vibrations
5. Biofilms and bioelectric effect
6. Control of subgingival biofilm with
fine grain glycine powder polishing
7. Hyperbaric oxygen therapy
8. Topical and systemic administration
of simvastatins.
9. Local and systemic use of
bisphosphonates
10. Use of Teriparatide
11. Use of antibiotics as
monotherapy
12. Use of herbs, fruits, flowers,
foods to resolve inflammation and
improve regeneration
13. Gene therapy
14. Use of stem cells
15. Nanotechnology
16. Use of newer molecules to
resolve inflammation
17. Therapeutic approaches recently
available to control inflammation
and bone resorption.

70. Supportive periodontal therapy:
• Compliance with suggested supportive periodontal treatment schedules.
The first study on the degree of compliance with supportive periodontal treatment
was published in 1984 (Wilson et al). It reviewed all the patients whose progress could be
followed after treatment for periodontitis in a private periodontal office of approximate 1000
patients followed for up to 8 years, only 16% complied with suggested SPT intervals, 34%
never came back for maintenance, and the rest complied erratically. In a follow up study for 5
years, the tooth loss was surveyed (non-compliers were not included). Tooth loss frequency
was zero teeth per year for complete compliers and 0.06 teeth per patient per year for erratic
compliers.

71. Rehabilitation:
Dental restorations and periodontal health are inseparably
interrelated.
The adaptations of margins, the contour of the restoration,
the proximal relationship and the surface smoothness have a
critical biological impact on the gingiva and the supporting
periodontal tissues. Dental restorations therefore play a
significant role in maintaining the periodontal health.
In addition to cosmetic enhancement fixed and removable
prosthesis serve many purposes including the improvement
of the masticatory efficiency and speech, the prevention of
food impaction, tilting and extrusion of teeth with resultant
disruption of the occlusion.

72. Compliance:
Compliance (also called adherence and therapeutic alliance) has been
defined as “the extent to which a person’s behaviour coincides with
medical or health advice”.
• Non-compliance - Patient does not comply at all.
• Erratic compliance -Patient complies occasionally.
• Complete compliance - Patient complies 75% of
the time
Types of compliance:
Boyer’75

73. Compliance in periodontics:
• Strack et al. found that 51% of patients given oral hygiene instructions
were in the “high compliant” group; 38% were “moderately
compliant,” and 11% “noncompliant” 30 days after instruction.
• In some surveys the use of a disclosing agent erythrosin was found
helpful in improving the efficacy of plaque removal.
• The use of mechanical toothbrushes has shown an increase of
efficiency (decreased Plaque Index score) of 10% in one study.
• Other groups have suggested that the patients’ beliefs about their
health significantly affect compliance or the lack thereof. Stressful life
events may also reduce compliance.

74. Why do
patients fail to
comply?
DENIAL AND NEGLIGENT
ATTITUDES TOWARD
THEIR ILLNESS
FEAR OF DENTAL
TREATMENT
THE SOCIOECONOMIC
STATUS

75. Methods of
improving
compliance:
Simplify
Accommodate
Remind patients of appointments
Keep records of compliance
Inform
Provide positive reinforcement
Identify potential non-compliers
Ensure the dentist’s involvement

76. Conclusion:
The onset and progression of periodontal disease is linked to local,
systemic and environmental factors. Most of these factors are
related to health behavior and lifestyle.
In chronic periodontitis, as in other chronic diseases, patients are
expected to take an active part and apply self-care preventive
measures. Thus,the role of the oral health professional cannot be
limited to delivering technical acts.
The oral care provider should be able to assist the patient to acquire
the necessary preventive and therapeutic skills to control the
problem and to guide the patient in the management of the
condition. This requires the clinician to be patient-centered and to
have very good communication skills. Changing health behaviors is a
challenge for both the patient and the care-provider.

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80. Thank
you