Global experts urge control of gingivitis
Oral antiseptics and their role are highlighted as allies in the prevention of periodontal diseases
Prioritising the prevention and treatment of periodontal diseases and promoting periodontal health is essential for improving overall health outcomes, preserving natural teeth, reducing healthcare costs, enhancing quality of life and promoting public health.
This was highlighted at an International Summit of Experts held in Madrid at the headquarters of the Spanish Society of Periodontology (SEPA). The summit combined current knowledge and thoroughly analysed the scientific literature and prevailing international guidelines to clarify the role of certain mouthwashes in oral hygiene, gingivitis treatment and periodontitis prevention.
“Periodontal diseases are prevalent worldwide, affecting hundreds of millions of people,” said Dr Paula Matesanz, vice president of SEPA and the meeting coordinator. She said that “focusing on prevention and promoting periodontal treatment among the general public allows us to reduce the burden of this disease, improve equality in oral health, and promote overall public health. And to achieve this ambitious objective, there are effective and safe resources that are still currently underutilised”.
It is time for a paradigm shift: we must control gingivitis and not wait until periodontitis develops
Dr Iain Chapple
Oral antiseptics, generally antimicrobial mouthwashes or rinses, can play a key role in preventing periodontal diseases and their recurrence, given their ability to reduce dental biofilm formation. Depending on their active ingredients, as revealed by an analysis of the scientific literature, they can help reduce bacterial load, complement daily oral hygiene practices, reduce plaque and inflammation rates, or even be incorporated as additional resources in periodontal maintenance programmes, helping preserve periodontal health and supporting the long-term success of periodontal treatment.
Hence the need to make clinical practice guidelines, developed by the European Federation of Periodontology and adapted by SEPA, accessible to oral health professionals, physicians, pharmacists, patients and the general population. “So that scientific knowledge is more accessible and capable of improving health,” said Dr Matesanz.
Currently available scientific and clinical evidence, systematic reviews of studies, and reference guides for dental professionals support the effectiveness and value of antiseptics as complements to daily oral hygiene. Their use can be considered within the prevention and treatment procedures for periodontal diseases.
The Clinical Practice Guidelines for the treatment of periodontitis in stages I–III and the conclusions of the XI Periodontology Workshop of the European Federation of Periodontology provide recommendations and indications for the use of these resources. However, these recommendations may sometimes be complex for the oral health team, limiting their use.
Scientific information supporting the impact of certain mouthwashes and toothpastes with antiseptic formulations has been available for decades and is part of dental education. However, as Dr David Herrera, trustee of the SEPA Foundation and co-director of the Etiology and Therapeutics of Periodontal Diseases Research Group (ETEP) at the Complutense University of Madrid (UCM), points out: “Scientific information is often mixed with less reliable sources, inducing confusion among oral health professionals.”
The Clinical Practice Guidelines for the Treatment of Periodontitis in Stages I–III, developed by the European Federation of Periodontology and translated into numerous languages and adapted for use in many countries around the world, is one of the main sources of information and guidance on the prevention and management of periodontitis.
According to Dr Iain Chapple, professor of periodontology and head of research at the Institute of Clinical Sciences of the University of Birmingham, “the evidence from systematic reviews on the adjunctive use of oral antiseptics was strong, but due to cost implications, environmental factors and the presence of alcohol in many mouthwashes, the consensus was to reduce the recommendation from strongly favourable to an ‘open’ recommendation.”
This was an aspect that the meeting of experts sought to clarify and overcome through a soon-to-be-released report that is expected to be widely disseminated and implemented globally.
Primary and secondary prevention
Some antimicrobial mouthwashes have been shown to be effective in controlling dental biofilm and gingival inflammation in many studies, including numerous randomised clinical trials. However, it is essential to understand their impact on the primary prevention of periodontal diseases (preventing their appearance) and on secondary prevention (reducing the risk of recurrence after treatment of periodontitis).
A crucial aspect discussed by attendees at the summit was the need to focus attention on the prevention of periodontitis and, therefore, adequately treat gingivitis (a previous stage of the disease characterised by inflammation and bleeding of the gums without affecting the alveolar bone and periodontium tissues). Dr Chapple said: “It is time for a paradigm shift: we must control gingivitis and not wait until periodontitis develops.” Multiple economic and health factors point to this change. It has been determined that eliminating gingivitis, thus preventing the progression to periodontitis, would save considerable costs – tens of billions of pounds in the UK alone – over a 10-year period compared with “business as usual”.
Furthermore, recent research reveals that periodontitis has systemic effects on health.
The primary procedure for managing gingivitis and periodontitis is mechanical plaque removal. However, it may not be possible to remove 100% of the biofilm, and for some people at high risk for periodontal disease, their plaque accumulation threshold is extremely low. “Sometimes it is not realistic for high-risk individuals to remove enough plaque daily to remain periodontally healthy,” says Dr Chapple.
Dr Filippo Graziani, professor of periodontology at the University of Pisa (Italy) and honorary professor at University College London, commented: “There is no doubt that mechanical plaque control, through tooth brushing, is the cornerstone of oral health. However, it requires proper technique and consistent daily motivation. Lack of technique is a significant factor, which is why we recommend the complementary use of mouthwash.”
According to Professor Graziani: “Mouthwash is easier to use than brushing and can reach even the most difficult-to-access areas.” Thus, he concludes: “For those who lack manual dexterity or have lost it, mouthwashes can supplement oral hygiene routines.”
Over the past five years, the European Federation of Periodontology (EFP) has endorsed systematic reviews (Serrano et al., 2015; Figuero et al., 2020) showing that while mechanical plaque control by patients remains fundamental to successful periodontal treatment, antiseptic agents, including certain mouthwashes, may be more effective than toothpaste in plaque removal and reducing gingival inflammation.
Recently, Professor Graziani’s research group published the results of a large randomised clinical trial, revealing that the primary factor in resolving gingivitis is a high level of plaque control and the use of appropriate devices. Hence, according to him, “mouthwashes are not only effective for their antiplaque properties but also for their ability to modulate inflammation.”
The experts gathered in this forum also shared the possibilities of antiseptics in patients undergoing supportive periodontal care, meaning those who have received periodontal treatment and in whom secondary prevention aims to prevent the recurrence of periodontitis. “One of the main components of this prevention is the control of supragingival biofilm, based fundamentally on mechanical control,” said Dr Herrera, who indicates that “for those patients with more than 10% bleeding, additional measures can be considered, including the use of antiseptics.”
Growing impact of periodontal diseases
The current socioeconomic impact of periodontitis is enormous, and its prevalence and incidence are strongly related to health inequalities. “The most disadvantaged are the most exposed: a low level of education is associated with an 86 per cent higher risk of periodontitis,” said Dr Chapple.
This was highlighted in the 2021 Economist Impact White Paper Time to Take Gum Disease Seriously, which highlighted how periodontal care was simply unaffordable for many people and identified important problems with access to basic oral health resources. There are four million oral health professionals worldwide, of which about 2.5 million are dentists. Around 80 per cent of these dentists work in upper-or upper-middle-income countries, while only 1.4 per cent practice in low-income countries.
“Building a global strategic alliance that aims to create a synergy, ultimately, will benefit patients,” said Soha Dattani, Director and Head of Scientific Engagement at Listerine Oral Care, EMEA.
“Bringing together this group of global experts to analyse the scientific literature and guidelines, and share their extensive clinical and research experiences is of vital importance to address the existing challenges in periodontal care.
This collaboration represents an important step to educate and train oral health professionals so that they receive optimal support to help their patients on their journey towards periodontal health.”