Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made.  (Formerly, these situations were captured under a "C Recommendation".)  This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade.  For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Prevention of Periodontal Disease

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings, 2 to 3 times per year from January 1993 to June 1993. Consensus was reached on final recommendations.

Benefits, Harms, and Costs
Unless otherwise specified, results are from RCTs.

Good evidence shows that supragingival plaque causes gingivitis and effective plaque removal every 48 hours is associated with gingival health. A 2-week clinical trial involving adults found that brushing twice a day was associated with a 35% reduction in gingival bleeding, and that brushing plus flossing resulted in a 67% reduction. A clinical trial involving school children found brushing to be as effective as brushing plus flossing (p422).

No consistent evidence exists regarding the superiority of electric toothbrushes over manual toothbrushes (422-23).

One RCT found that adults benefited from receiving 11 professional prophylaxes over a 3 year period. This finding has limited generalizability because of the intensity of care provided. Other RCTs reported that annual scaling was as effective as more frequent care (p423).

Unsupervised use of chlorhexidine oral rinse for 6 months reduced supragingival plaque and gingivitis more effectively than sanguinarine or Listerine ®. Adverse effects included increased calculus formation, bad taste and staining of teeth (p423). Listerine ® was effective in preventing gingivitis when compared with placebo over 6 to 9 month periods. Adverse effects were poor taste and a burning sensation in the mouth. No long term studies of the effectiveness of unsupervised use of other over-the-counter oral rinses exist (p424).

No studies of the effect of antibiotic prophylaxis have been conducted because of potential side effects, and the potential development of resistant bacterial strains and patient hypersensitivity (p424).

Anticalculus (anti-tartar) toothpastes prevent calcification of plaque. Supragingival calculus was reduced by 32% to 35%. Potential adverse effects are cheilitis and mucosal erythema; long term effects are unknown.

Cross-sectional and longitudinal studies confirm the association between cigarette smoking and periodontitis. Smokeless tobacco is not associated with severe periodontal destruction (421)

No studies exist on the effectiveness of physician counselling (p422) or screening for periodontal disease.

Recommendations
Recommendation grade [A, B, C, D, E]  and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

• There is fair evidence to recommend toothbrushing in adults and children [B, I, III] and good evidence to recommend flossing in adults [A, I] to prevent gingivitis. There is poor evidence to include or exclude flossing in children, but flossing is recommended to develop flossing skills and habits [C, I]. Based on poor evidence, supervised toothbrushing and flossing are recommended for patients with malocclusion, diabetes or HIV infection [C, II-2].
• There is fair evidence not to recommend electric toothbrush use for the general population [D, I]. Based on poor evidence, use is recommended for patients with limited dexterity [C, II-2].
• There is fair evidence to recommend professional scaling and prophylaxis depending on a patient’s periodontal disease status [B, I].
• There is good evidence to recommend rinsing with 0.12% chlorhexidine twice daily for patients who have difficulty cleaning their teeth (e.g., patients with disability, cancer) [A, I].
• There is fair evidence to recommend use of Listerine ® oral rinse for patients with severe gingivitis [B, I]. There is fair evidence not to use other over-the-counter oral rinses [D, no studies available].
• There is good evidence not to recommend prophylactic antibiotic use [E, no studies available].
• There is no evidence to recommend anticalculus toothpaste use for the general population [C, I], and good evidence to recommend its use for patients at high risk for calculus formation [B, I].
• There is fair evidence to recommend smoking cessation [B, II-2].
• There is insufficient evidence to evaluate screening for periodontal disease by physicians, but screening is recommended in regions with no available dental services [C, no studies].

Source Document
Ismail, A.I., Lewis, D.W., Dingle, J.L. Prevention of periodontal disease. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 420-431.