Introduction

The European Federation of Periodontology (EFP) has recently launched a manifesto which promotes a fundamental shift in the role of dental healthcare professionals. The focus of the manifesto is upon prevention and engaging all other healthcare professionals in tackling the chronic inflammatory diseases of ageing. The thrust of the manifesto has been supported by a recent Houses of Parliament 'round table' event on oral health in relation to general health and wellbeing. The discussion at this event centred on 'strengthening public health initiatives and reducing pressure on the NHS; dentistry playing a greater role in the prevention and early intervention of chronic diseases and long-term conditions such as heart disease, diabetes, and cancer'. The group fully embraced the concept of dental practitioners playing a vital role in the identification of diabetes and cardiovascular risk, and actively engaging in the promotion of lifestyle changes, aimed at helping to reduce obesity and smoking, and at promoting healthy nutrition and exercise.

Encouragingly, the medical profession, NHS England, Public Health England, dental care professionals and opinion leaders in dentistry were completely aligned in this quest, which will expand the scope of dentistry to encompass roles and responsibilities in the control of chronic systemic diseases and other life-threatening conditions. But are the grass roots dental profession willing and ready to embrace this concept? It will require a paradigm shift in the thinking and behaviour of all members of the dental team, but the truth is that unless this happens dentistry may miss a unique, long sought after opportunity to realise the goal of being integral to general healthcare provision. So it seems that the EFP's manifesto, the first document of its kind in the global dental landscape, is both timely and vital for our patients, public health and the future of the profession.

The manifesto is available at http://perioworkshop.efp.org/efp-manifesto. We strongly recommend that you read it and consider signing it. Whether you are an individual member of the dental team, a student, a patient, or represent a group of dental healthcare professionals, a corporate, a member of the dental industry, or a regulatory body, it does not matter. By signing the manifesto, you will be contributing to the growing EFP mandate to lobby broadly and widely for a greater focus on the prevention and management of periodontitis – the most common chronic inflammatory disease of humankind – and periodontal health as a key element of oral health and genera health and wellbeing. The intention is to greatly increase awareness among members of the public, the media, government, regulatory and professional bodies, and other groups as appropriate of the importance of periodontal health and, in turn, the importance of oral health to general health and wellbeing throughout life, but, in particular, in old age.

Spreading the word

How many of the public would have any idea what 'perio' means or stands for? This realisation spurred the EFP into investing heavily in a media campaign aimed at promoting the EFP vision: 'Perio for a Better Life'. This campaign, running in parallel with the promotion of the manifesto, has a long way to go, but will gain momentum through your support for the manifesto.

The EFP is a federation of national periodontal societies with 24 full member countries, and a growing number of non-European associates. 'Perio for a Better Life' defines periodontology as 'the branch of dentistry which encompasses the art, science and practice of attaining and maintaining healthy tissues around and supporting teeth and implants to improve oral and general health and wellbeing'. The EFP, in working to this definition, has identified, within its strategic plan of 2012-2017, five strategic objectives centred around:

  • Improving health

  • Education and training

  • Policy

  • Research

  • Communication.

So what? And who cares? You may ask! Well the public and the press in other parts of the world care, as evidenced by front page articles in top newspapers in Spain, Germany, Italy and many other European countries, together with a recent feature article in 'Bloomberg' in the USA. In contrast, it would appear that the media and many members of the dental profession in the UK are yet to fully realise the impact of periodontitis upon general health. Why is that? Probably because the EFP has not yet managed to reach out to all members of the dental team in the UK, and has yet to impress on the British media the importance of the manifesto. The British Society of Periodontology (BSP) is well aware of this situation and has been galvanising into action to address the issue. The Society is fully signed up and committed to the EFP manifesto.

Part of the problem may be considered to have arisen through previous, premature 'over-hyping' of the importance and impact of periodontitis in certain quarters, based on epidemiological evidence of variable quality, linking periodontitis with almost every human condition, including, by way of example, male infertility! This quite naturally created an atmosphere of cynicism. Indeed the BSP, a society steeped in a strong history of being focused upon evidence-based practice, has been one of the strongest critics of many of the relevant studies. The BSP firmly believes in equipoise in reporting research evidence and is strongly opposed to scare-mongering and over stating the associations between periodontitis and general health. And rightly so, as such an approach not only disenfranchises the profession, but discredits potentially important knowledge before the evidence-base has had a chance to grow. However, even the BSP now accepts that there is real substance in the perio-systemic health story. What is intriguing about the BSP is that the majority of its members are enlightened general dental practitioners, rather than specialists and academics with special interests and expertise in periodontology.

What to advise patients?

'Well that's helpful' you may say, but 'what can we genuinely believe today?' and 'what are we supposed to say to our patients?' These questions were the reason why the EFP dedicated its ninth European Workshop to the relationship between periodontitis and systemic diseases. The American Academy of Periodontology (AAP) were joint partners making the event the first ever EFP/AAP transatlantic workshop, which attracted representatives from as far away as the Asia-Pacific rim. Eleven exhaustive, systematic reviews, involving 24 world experts as reviewers, were commissioned to look at the relationship between periodontitis and cardiovascular disease, diabetes, adverse pregnancy outcomes and 'other' systemic diseases.

The chairmen and reviewers were joined by 45 experts from across the globe. The group spent three days dissecting the evidence and preparing authoritative, consensus reports, alongside a supplemental report and guidance for dental and medical practitioners, patients and the public. What was clear was that the associations between periodontitis and the selected conditions did not seem spurious but genuine, with the common factor being inflammation. Periodontitis increases systemic inflammation, by means of bacteria entering the circulation during speech, eating and tooth brushing. These bacteria activate an acute-phase response by the liver and activate immune cells, such as neutrophils, to generate 'oxidative stress' in the circulation. It appears that it is not the bugs, but the inflammatory response to the bugs that causes the mayhem. The reaction to the bugs ticks over at a slow, low-grade, but relentless pace over many years, and in doing so contributes to the overall 'inflammatory burden' that drives many of the inflammatory diseases of ageing.

Freely available online (at http://onlinelibrary.wiley.com/doi/10.1111/jcpe.2013.40.issue-s14/issuetoc), the consensus reports and papers are worth reading. For those of you who prefer the 'headlines', then check out http://perioworkshop.efp.org where you will find the same information provided in more accessible short video clips and summary articles.

Based on the outcomes of the workshop the EFP manifesto calls upon all dental and health professionals to act in the prevention, early diagnosis and effective treatment of periodontal disease in order to combat the devastating oral and general health effects for the individual and society. It provides the rigorous scientific analysis of the current evidence base for links between periodontitis and systemic diseases and calls to action interested parties who care about oral health and its impact upon the public and our patients. Below are key extracts taken directly from the manifesto:

Periodontitis

Periodontitis is a chronic multifactorial inflammatory disease initiated by bacterial microorganisms and characterised by a severe chronic inflammation that leads to progressive destruction of the tooth supporting apparatus, tooth loss and eventually to masticatory dysfunction. Periodontitis:

  • Is common

  • Reduces chewing function

  • Impairs aesthetics

  • Causes tooth loss

  • Causes disability

  • Leads to social inequality

  • Reduces quality of life

  • Has a significant impact upon escalating public health costs.

In addition, periodontitis is a chronic inflammatory disease with potentially negative consequences for general health. Cross-sectional and prospective epidemiological studies have shown that periodontitis increases the risk of poor glycaemic control in patients with diabetes mellitus as well as diabetes complications and associated morbidity. Successful periodontal interventions also improve glycaemic control in type 2 diabetes patients. Periodontitis is also independently associated with cardio-vascular diseases and adverse pregnancy outcomes in some populations. Additional emerging evidence also appears to link periodontitis with nosocomial pulmonary infections, certain types of cancer and rheumatoid arthritis.

Periodontitis and diabetes

The evidence for an association between diabetes and periodontitis is as follows:

  • Plausibility – type-2 diabetes is preceded by systemic inflammation, leading to reduced pancreatic β-cell function, apoptosis and insulin resistance. Increasing evidence supports elevated systemic inflammation (acute-phase and oxidative stress biomarkers), resulting from the entry of periodontal organisms and their virulence factors into the circulation, thus providing biologically plausible mechanisms underpinning the adverse impact of periodontitis upon diabetes and its complications

  • Epidemiological data – consistent and robust evidence is available which demonstrates that severe periodontitis adversely affects glycaemic control in diabetes and glycaemia in non-diabetes patients. In addition, in patients with diabetes, there is a direct and dose-dependent relationship between periodontitis severity and diabetes complications. Emerging evidence indicates an increased risk for diabetes onset in patients with severe periodontitis

  • Intervention studies – randomised clinical trials consistently demonstrate that mechanical periodontal therapy associates with approximately a 0.4% reduction in HbA1C at three months, a clinical impact equivalent to adding a second drug to a pharmacological regime for diabetes.

Periodontitis and cardiovascular disease

The evidence for an association between cardiovascular diseases and periodontitis is as follows:

  • Plausibility – periodontitis leads to entry of bacteria into the blood stream. The bacteria activate the host's inflammatory-immune response by multiple mechanisms. Several animal models have demonstrated that the host's inflammatory response favours atheroma formation, maturation and exacerbation

  • Epidemiological data – there is consistent epidemiological evidence that periodontitis imparts increased risk for future cardiovascular disease, independently of other confounding factors

  • Intervention studies – there is moderate evidence that periodontal treatment reduces systemic inflammation as evidenced by reductions in C-reactive protein (CRP) and oxidative stress, and leads to improvements of surrogate clinical and biochemical measures of vascular endothelial function.

Periodontitis and adverse pregnancy outcomes

The evidence for an association between adverse pregnancy outcomes and periodontitis is as follows:

  • Plausibility – current evidence supports the idea that oral microorganisms and their products enter the blood circulation and travel directly to the foetal environment where they cause inflammatory and immune responses affecting the foeto-placental unit. These bacteria in the circulation may also circulate to the liver, where inflammatory agents are produced, which in turn then circulate to the developing foetus

  • Epidemiology – in clinical studies, low birth weight, pre-term birth and pre-eclampsia have all been associated with the presence of periodontitis in the mother, when all other risk factors have been accounted for. However, the strength of the connection found between periodontitis and these pregnancy outcomes varies between studies, and some show no association. The heterogeneity of data is likely due to differences in the study designs, study populations and different methods used for assessing and classifying periodontal disease

  • Intervention studies – results from clinical trials have shown that, in general, scaling and root debridement carried out during the second trimester of pregnancy, with or without antibiotic therapy, does not significantly improve adverse pregnancy outcomes, such as preterm birth and low birth weight. However, some clinical trials did report a favourable effect overall and it is possible that certain populations of pregnant women may benefit from periodontal therapy, even though others will not. One reason for negative study results may be that the interaction between periodontitis and pregnancy outcomes is more complex than our current understanding and the study results may have been affected by the type and timing of treatment employed and by the types of patients selected.

Periodontitis and other diseases

There is emerging evidence for associations between periodontal diseases and chronic obstructive airways disease, chronic kidney disease, rheumatoid arthritis, cognitive impairment, obesity, metabolic syndrome and some cancers. To date, the only evidence for causality is in relation to respiratory microorganisms that colonise the oral/periodontal biofilm and may subsequently cause a hospital-acquired pneumonia (nosocomial pneumonia) in ventilated patients.

  • Plausibility – respiratory pathogens arising from oral/periodontal biofilm reservoirs may be aspirated in certain risk patients within hospital environments and result in a nosocomial pneumonia

  • Epidemiological data – available data supports a role for the oral/periodontal biofilm acting as a reservoir for respiratory pathogens in patients with poor oral hygiene and periodontitis, which may cause nosocomial pneumonia

  • Intervention studies -randomised controlled trials strongly support a role for improving oral hygiene in the prevention of nosocomial pneumonias in acute care hospital environments and nursing homes.

Recommendations

The EFP manifesto calls for a fundamental change in the perception of dental professionals' responsibilities with regard to achieving the general health of patients and affirms that patients' needs will best be met through collaborative development between the dental and medical communities in applying multidisciplinary approaches and guidelines for patient care, independently of a patient's presenting location.

The recommendations that follow are extremely important to the dental and medical professions, as well as the public and patients. They are available at http://perioworkshop.efp.org/efp-manifesto. They deal specifically with:

  • Diabetes

  • Cardiovascular disease

  • Adverse pregnancy outcomes

  • Nosocomial pneumonia.

From the manifesto and its recommendations, it is clear that dental healthcare professionals and oral healthcare provision have a critical role to play in enhancing general health and well-being. All those concerned that dentistry and the dental profession plays its part in addressing the major oral/systemic disease health challenges to be faced nationally and internationally, let alone at the individual and local levels, are encouraged to follow the lead provided by the BDA in signing up to the EFP manifesto. This may be done by accessing the following link: http://perioworkshop.efp.org/efp-manifesto. Yes, we appreciate that this is signing up to yet more fundamental change, but the change, which we consider to be vital to the future role of dentistry and the dental profession, will have many far-reaching benefits for patients, populations and healthcare systems.