FOCUS: Journal of Clinical Periodontology publishes Perio Workshop 2016 consensus findings on caries and periodontal diseases

The consensus findings of Perio Workshop 2016, which explored the boundaries between caries and periodontal diseases, have been published in an open-access supplement of the EFP’s scientific publication the Journal of Clinical Periodontology.

The workshop, organised by the EFP in conjunction with the European Organisation for Caries Research (ORCA), was held in November last year in La Granja de San Ildefonso, near Segovia in Spain. It was sponsored by Colgate.

Among the key findings of the workshop were the fact that both caries and periodontal diseases share common genetic, aetiological, and environmental factors, although they follow different trajectories.

The 75 invited experts from the two organisations who took part in the workshop also found that similar preventive approaches, based around routinely performed oral hygiene with a fluoride toothpaste, are effective with both diseases.

The JCP supplement, guest-edited by Mariano Sanz, chair of the EFP’s workshop committee, comprises the consensus reports of the workshop’s four working groups, which explored different areas concerning the relationship between caries and periodontal diseases.

Working Group 1, chaired by Mariano Sanz (EFP) and David Beighton (ORCA), considered the question of the role of microbial biofilms in the maintenance of oral health and in the development of dental caries and periodontal diseases.

The JCP supplement includes the consensus report of this working group plus related articles on Dental biofilm: ecological interactions in health and disease and Role of microbial communities in the pathogenesis of periodontal diseases and caries.

The results and conclusions of this working group were:

• A health-associated biofilm includes genera such as Neisseria, Streptococcus, Actinomyces, Veillonella, and Granulicatella.
• Microorganisms associated with both caries and periodontal diseases are metabolically highly specialised and organised as multispecies microbial biofilms.
• Progression of these diseases involves multiple microbial interactions driven by different stressors. In caries, the exposure of dental biofilms to dietary sugars and their fermentation to organic acids results in increasing proportions of acidogenic and aciduric species. In gingivitis, plaque accumulation at the gingival margin leads to inflammation and increasing proportions of proteolytic and often obligately anaerobic species.
• The natural mucosal barriers and saliva are the main innate defence mechanisms against soft-tissue bacterial invasion. Similarly, enamel and dentin are important hard-tissue barriers to the caries process.
• Given that the present state of knowledge suggests that the aetiologies of caries and periodontal diseases are mutually independent, the elements of innate immunity that appear to contribute to resistance to both are somewhat coincidental.

Working Group 2, chaired by Iain Chapple (EFP) and Andreas Schulte (ORCA), explored the interaction of lifestyle, behaviour, and systemic diseases with oral health, dental caries, and periodontal diseases.

The results and conclusions of this working group were:

• There is moderately strong evidence for a genetic contribution to periodontal diseases and caries susceptibility, with an attributable risk estimated to be up to 50%.
• The genetics literature for periodontal disease is more substantial than for caries and the genes associated with chronic periodontitis are the vitamin D receptor (VDR), Fc gamma receptor IIA (Fc-γRIIA), and Interleukin 10 (IL10) genes.
• For caries, genes involved in enamel formation (AMELX, AMBN, ENAM, TUFT, MMP20, andKLK4), salivary characteristics (AQP5), immune regulation, and dietary preferences had the largest impact.
• No common genetic variants were found.
• Fermentable carbohydrates (sugars and starches) were the most relevant common dietary risk factor for both diseases, but associated mechanisms differed. In caries, the fermentation process leads to acid production and the generation of biofilm components such as Glucans. In periodontitis, glycaemia drives oxidative stress and advanced glycation end-products may also trigger a hyper inflammatory state.
• Micronutrient deficiencies – such as vitamin C, vitamin D, or vitamin B12 – may be related to the onset and progression of both diseases.
• Functional foods or probiotics could be helpful in caries prevention and periodontal disease management, although evidence is limited and biological mechanisms are not fully elucidated.
• Hyposalivation, rheumatoid arthritis, smoking/tobacco use, undiagnosed or sub-optimally controlled diabetes, and obesity are common acquired risk factors for both caries and periodontal diseases.

The JCP supplement also includes the related review papers considered by this group: Host genetics role in the pathogenesis of periodontal disease and caries and Nutrition, dental caries, and periodontal disease: a narrative review.

Working Group 3, chaired by Søren Jepsen (EFP) and Vita Machiulskiene (ORCA), tackled the prevention and control of dental caries and periodontal diseases at the individual and the population level.

The group’s consensus report included the findings and conclusions that:

• The prevalence and experience of dental caries has decreased in many regions in all age groups over the last three decades; however, not all societal groups have benefitted equally from this decline.
• Although some studies have indicated a possible decline in periodontitis prevalence, there is insufficient evidence to conclude that prevalence has changed over recent decades.
• Because of global population growth and increased tooth retention, the number of people affected by dental caries and periodontitis has grown substantially, increasing the total burden of these diseases globally (by an estimated 37% for untreated caries and 67% for severe periodontitis between 1990 and 2013), with a high global economic impact.
• There is robust evidence for an association of low socio-economic status with a higher risk of having dental caries and with a higher prevalence of periodontitis.
• The most important behavioural factor, affecting both dental caries and periodontal diseases, is routinely performed oral hygiene with fluoride.
• Population-based interventions address behavioural factors to control dental caries and periodontitis through legislation (anti-smoking, reduced sugar content in foods and drinks), restrictions (taxes on sugar and tobacco), guidelines, and campaigns; however, their efficacy remains to be evaluated.
• Psychological approaches aimed at changing behaviour may improve the effectiveness of oral-health education.
• Different preventive strategies have proven to be effective.
• Management of both dental caries and gingivitis relies heavily on efficient self-performed oral hygiene – tooth-brushing with a fluoride-containing toothpaste and interdental cleaning.
• Professional tooth cleaning, oral-hygiene instruction and motivation, dietary advice, and fluoride application are effective in managing dental caries and gingivitis.
• The prevention and control of dental caries and periodontal diseases and the prevention of ultimate tooth loss is a lifelong commitment employing population- and individual-based interventions.

The JCP supplement includes the three systematic reviews considered by the group: (1) Global epidemiology of dental caries and severe periodontitis: a comprehensive review, (2) Socio-behavioural aspects in the prevention and control of dental caries and periodontal diseases at an individual and population level, (3) Mechanical and chemical plaque control in the simultaneous management of gingivitis and dental caries: a systematic review.

Working Group 4, chaired by Maurizio Tonetti (EFP) and Sebastian Paris (ORCA), considered age-related effects on oral health, dental caries, and periodontal diseases. Its consensus report is a “call to action to protect and enhance oral health and well-being as an essential component of healthy ageing.”

The group’s findings included:

• The ageing population, trends in risk factors, and improve tooth retention point towards an expected increase in the total burden of disease posed by caries and periodontal diseases in the older population.
• Specific surveillance is required to monitor changes in oral health in the older population.
• Senescence impacts oral health, including periodontitis and possibly caries susceptibility.
• Evidence indicates that caries and periodontal diseases can be prevented and treated also in older adults.
• Oral health and functional tooth retention later in life provide benefits both in terms quality of life – both oral and general – and in preventing physical decline and dependency by fostering a healthy diet.
• Oral-healthcare professionals and individuals should not base decisions impacting tooth retention on chronological age but on the level of dependency, life expectancy, frailty, comfort, and quality of life.
• Health policy should remove barriers to oral healthcare for vulnerable elders.

Working Group 4 also reached consensus on certain actionable priorities for public-health officials, oral-healthcare professionals, educators and workforce planners, caregivers and relatives, and for the public and ageing patients.

The group said that “some priorities have major implications for policymakers” because health systems will need to adapt to the challenges by introducing “system-wide changes” that enable tooth retention later in life and the “management of deteriorating oral health in increasingly dependent elders.”

The JCP supplement includes the three reviews considered by this working group: (1) Ageing, dental caries, and periodontal diseases, (2) Age-related changes in immune function (immune senescence) in caries and periodontal diseases: a systematic review, (3) Gingival recession and root caries in the ageing population: a critical evaluation of treatments.

Mariano Sanz, chair of the EFP’s workshop committee and guest editor of the JCP supplement on Perio Workshop 2016, said: “These disease processes have been historically analysed under very different optics and the cultures of analysing the scientific evidence by the cariologists and the periodontists was clearly well apart.

“This workshop has allowed us to identify the areas of convergence between these diseases and also the aspects in prevention and therapy which are key to both disease processes.”