Prevention—Prophylaxis: Dentistry: Caries, Gingivitis, Periodontitis

Maintenance of Health and Prevention of Disease …

… are the noblest goals of modern medicine! For the patient, prevention is more comfortable, simpler to perform and, last but not least, less costly than treatment. The cost “explosion” in all disciplines of diagnostic and therapeutic medicine is enormous. It is scarcely possible to finance such costs regardless of whether socialized medicine or private insurance or direct payment by patients are invoked. Ethical, social and scientific facts demand that we move to-ward prevention.

Dentistry

Prevention of the ubiquitous inflammatory periodontal diseases should benefit every socioeconomic segment of society and every age group. Children, young persons and young adults in particular should be exposed to preventive measures. At the same time, they must be educated concerning the importance of their own responsibility in personal health care. Long-term preventive awareness and behavior demand insight, will and persistence from the patient (compliance). This can only be expected if the dental team, dental educators etc. continually make known the possibilities and the enormous importance of prevention, and thereby motivate the patient toward maintenance of health. This demands especially that the dentist not only possess current knowledge of new developments in periodontal diagnosis and treatment possibilities, the dentist must also recognize and keep abreast of systemic medical relationships, and communicate these to all patients.

Definition: Prevention—Prophylaxis

Prevention: Medical and dental measures to inhibit disease initiation

• Primary prevention: “Strengthening” health—inhibition of a disease, e.g., through vaccination; in dentistry, e.g., patient information, oral hygiene instruction, prophylactic measures

• Secondary prevention: Early detection and treatment of diseases, e.g., comprehensive diagnosis of the disease, and anti-infectious therapy

• Tertiary prevention: Stopping and preventing the recurrence of an already treated/healed disease, e.g., through regular recall

  (SPC—“supportive periodontal care”)

Prophylaxis: Prevention of diseases (individual and collective)

• Oral prophylaxis: Mechanical removal of deposits, plaque and calculus

• Antibiotic prophylaxis

Prevention of Gingivitis and Periodontitis

In recent years it has been demonstrated in well-documented studies that prevention of periodontitis can be successful if performed consistently and appropriately (Axelsson & Lindhe 1977, 1981a, b; Axelsson 1982, 1998, 2002).

The primary etiologic agent for gingivitis and periodontitis is the microbial biofilm. In the absence of biofilm, marginal inflammation will not develop. Therefore, prevention and prophylaxis involves, as always, the elimination of plaque and calculus, and motivation of the patient toward adequate oral hygiene.

From a somewhat broader prospective, prevention of periodontal disease encompasses several additional measures that are also targeted toward elimination of plaque, but indirectly. This is termed anti-infectious therapy, and includes the elimination of natural plaque-retentive areas (crowding, etc.) and above all the elimination of iatrogenic irritants. An overhanging restoration or a poorly adapted crown margin make oral hygiene in the interdental area impossible. Dental floss is ineffective in such cases; it tears and becomes lodged in the defective restoration. The possibility for satisfactory hygiene in each individual patient must be created by the dentist and the auxiliary dental personnel. Finally, the margins of restorations and reconstructions must be placed supragingivally whenever this is esthetically feasible in order to enhance prevention of gingival inflammation.

Total freedom from plaque is only a utopic goal. The reality is that, for each patient, an individual optimum hygiene level (plaque index) must be achieved, one which can be maintained consistently over the years, dependent upon the patient’s own degree of motivation and above all the recall interval. It has been demonstrated again and again that the gingival and periodontal conditions, even in large groups of patients, do not deteriorate if an appropriate recall interval is established and maintained for the individual patient (Ramfjord et al. 1975, 1982; Rosling et al. 1976a; Axelsson & Lindhe 1981a, b; Axelsson 1982, 1998, 2002; Manser & Rateitschak 1997).

In the absence of microorganisms, there will be no gingivitis or periodontitis; on the other hand, the existence of plaque bacteria alone does not in every case lead to periodontitis. The susceptibility of the patient, her/his immune status, the existence of non-alterable (usually genetically-determined) and alterable risk factors, and the host’s response to the infection are what determine the initiation and progression of periodontitis.

“Prevention,” then, extends beyond elimination of the infection—as far as this is possible—and to influencing the host itself. Any strengthening of the immune system has, heretofore, been possible only in minute measure, and true gene manipulation stands far in the future. Most likely, the future will hold the possibility to suppress pro-inflammatory mediators or, on the other hand, to stimulate anti-inflammatory mediators. Possible already today is the effort to influence and therefore reduce alterable risk factors. Systemic diseases that enhance or even elicit periodontitis must be appropriately treated; e.g., diabetes must be optimally controlled. Most especially, smokers must eliminate the high risk of tobacco use. The goal is a generally healthy lifestyle, with a minimum of stress.

Dental/oral prevention cannot simply be a casual endeavor. It demands time—considerable time—from both the patient and the practitioner. This is usually underestimated, and the consequences may render treatment success problematic.

The practical performance of prevention for gingivitis and periodontitis is for the most part identical to the measures described in the chapter “Initial and Phase-1 Therapy” (pp. 211–252), and will not be further discussed in this brief treatise on “Prevention.”