DOI: 10.1111/prd.
12228
REVIEW ARTICLE
A public health perspective on personalized periodontics
Ellie T. Knight | W. Murray Thomson
Sir John Walsh Research Institute, Department of Oral Sciences, School of Dentistry, The University of Otago, Dunedin, New Zealand
Correspondence
Ellie T. Knight.
Email: ellie.knight@otago.ac.nz
In this paper, we consider personalized periodontics from the public
health perspective. At the heart of the public health approach is
creating and sustaining conditions and circumstances in which
everyone can be healthy, regardless of whether or not they are
patients within a health-care system. Periodontitis is a moderately
prevalent condition and the second most frequent cause of tooth
loss,1 for which the notion of universal susceptibility has long been
discredited.2-4 While the presence of plaque is necessary, exactly
which individuals will develop periodontitis is unknown.5 The mech-
anisms that contribute to this process are not well understood. The
current understanding is that periodontitis is the body’s immune
response to plaque,6 involving a complex combination of plaque
composition, genetic make-up, general health, and lifestyle and
7-9
social influences. Despite its complex pathogenesis and progres-
sion, periodontitis may be prevented simply by plaque removal,6,10
yet severe periodontitis is the sixth most common chronic inflam-
matory disease globally.1 As periodontitis is usually painless, many
11
who have it are unaware of it. When left untreated, it can lead
to significant morbidity and financial burden.12 Periodontitis is an
under-acknowledged and important public health problem.13
There has long been interest in the discovery of a ‘magic marker’
that would identify individuals at high risk of developing periodonti-
tis. Widely cited retrospective cohort studies by Hirschfeld &
Wasserman2 and a series of studies by McGuire & Nunn14-18 have
demonstrated the impossibility of predicting teeth or sites that will
deteriorate periodontally, even in individuals who respond sustain-
ably to clinicians’ exhortations for good plaque control and regular
maintenance visits.
Other attempts at developing a risk-assessment profile have
proved to be limited in their application. Most well-known, the Peri-
odontal Risk Assessment was developed to group patients based on
their average risk levels in order to aid resource allocation and deter-
mine recall intervals.19 However, the adoption of this tool in the clin-
ical setting has been limited because its additional benefits for
20
patient management and treatment remain unclear. By and large,
the current susceptibility/risk-assessment tools in periodontology are
in their early stages of development.
Periodontology 2000. 2018;78:195–200. wileyonlinelibrary.com/journal/prd
In this regard, the most cutting-edge research to determine those
at risk of developing and progressing periodontitis is occurring in the
field of personalized periodontics. Simply put, it involves utilizing
biomarkers to predict periodontal disease susceptibility, determine
optimal management and enhance treatment outcomes.21 Such an
approach is based on the medical model, the dominant orthodoxy in
health care, whereby the focus is on biological (pathological) expla-
nations for bodily aberrations,22 with the underlying assumption that
people are able to stay healthy only through remaining in the ‘pa-
tient role’ and submitting willingly to the diagnostic and therapeutic
ministrations of the various health practitioners. This ‘personalized
medicine’ approach is also known as stratified, individualized and/or
precision medicine.23,24 The term was first coined in the context of
genetics but it now broadly encompasses other personalized infor-
mation, such as the molecular or cellular components of health and
disease.
It could be argued that the medical and dental professions have
always practiced personalized medicine because practitioners will
routinely consider factors such as age, sex, family history, lifestyle
and psychosocial (and even economic circumstances) to make a diag-
nosis, tailor treatment and obtain a prognosis for a patient. However,
this traditional method of diagnosing and treating patients is, at best,
empirical by contemporary standards. Although based on some evi-
dence, it is still a “one-sizefits-all” approach. For example, a common
first-line treatment for bacterial infection is the use of broad-spec-
trum systemic antibiotics. This is not the most optimal drug regimen
in terms of effectiveness or safety (for reasons such as drug resis-
tance or adverse patient reactions). Personalized medicine would
enable patients to receive the most effective and safe therapeutic
agent as their first line of treatment, based on individual biomarkers
(immunological, genetic or epigenetic). The benefit of such an
approach could maximize clinical outcomes, cost-effectiveness and
patient satisfaction by accurately identifying a bespoke strategy for
each particular patient.25,26 Research, development and clinical
implementation are time consuming and costly, but there are already
many examples of personalized medicine currently being utilized. For
example, the use of a monoclonal antibody drug, Herceptinâ
© 2018 John Wiley & Sons A/S. | 195
Published by John Wiley & Sons Ltd
196 | KNIGHT
(trastuzumab), is reserved for those positive for the human epidermal
growth factor receptor-2 gene in the treatment of metastatic breast
cancer.27
An emerging parallel concept in periodontology is personalized
periodontics, which is aimed at real-time evaluation of disease activ-
ity and predicting therapeutic outcome and post-treatment stabil-
ity.21,28-31 In this concept, rather than requiring a change of more
than 2 mm of attachment loss before a given site may be considered
to have progressed,32,33 clinicians could target patients before the
onset of disease. Therefore, instead of using nonsurgical debride-
ment as the first line of management, patients could have a chair-
side test to determine whether (for example) the use of antibiotics
or a regenerative approach is the optimal initial approach. It is a field
fraught with costs, ethical and legal challenges and potential social
issues, including insurance and data ownership. Personalized peri-
odontics is still in its infancy but its use is increasingly becoming
realistic.34 The next decade should see it become part of routine
periodontal practice.
At the population level, however, personalized periodontics is
not an effective way of improving periodontal health because it
would target only those who seek help. There are well-recognized
differences in dental-care utilization by socio-economic position, eth-
nicity and even sex.9 Plaque removal and smoking abstinence are
the key to maintaining periodontal health5,35-37 and any able-bodied
person should be able to perform effective brushing and interproxi-
mal cleaning. Professional oral care is also a key component of the
long-term maintenance of periodontal health.38 Unequivocal data
demonstrate the effectiveness of repeated professional dental visits
and excellent home care in achieving periodontal stability and long-
35,36,39
evity of teeth among periodontally susceptible patient groups.
However, a major caveat of those findings is their lack of generaliz-
ability; the cherry-picked participants – highly motivated and receiv-
ing state-of-the-art care – were following a prescribed strict recall
regimen and maintained immaculate oral hygiene. In the real world,
even high-fee-paying specialist practice patients often do not follow
professional advice; the reported long-term retention of patients on
maintenance programs in private periodontal practice is low (40% in
the first year with an attrition rate of 10% every year thereafter).40
Most of the general population does not consistently achieve appro-
priate and sustained plaque control, and the longer-term oral health
consequences of that failure can be severe.41
Periodontitis is one of the major oral health burdens worldwide,
with its severe form generally affecting 5%-20% of adult popula-
1,13,42
tions. It has been implicated in the occurrence of a number of
systemic conditions – some convincingly, others less so – and
remains the second most frequent cause of incremental tooth loss
among adults.43-46 With a growing world population, increasing life
expectancy and decreasing edentulism, the burden of periodontal
disease is expanding.
Moreover, the occurrence of periodontitis in populations is
socially patterned, with those of higher socio-economic position hav-
ing better periodontal health.9,47-49 The pervasive impact of social
stratification on oral health has been repeatedly demonstrated.41,49-64
AND THOMSON
Periodontal examples include the Study of Health in Pomerania
(n = 2566), which showed that having low education and low income
increased the likelihood of increasing mean attachment loss by
0.27 mm (95% confidence interval: 0.40 to 0.14 mm) and
0.11 mm (95% confidence interval: 0.22 to 0.00), respectively, after
adjusting for age, education, income, marital status, smoking, body
mass index and C-reactive protein.52 Shin et al63 examined the Kor-
ean adult population (n = 5770) and found strong associations
between periodontitis and socio-economic position. As pointed out in
a recent review, periodontitis is a chronic condition which is largely
irreversible and cumulative; its chronic, cumulative nature (together
with that of its risk factors) means that the important detrimental and
beneficial exposures accumulate gradually and differentially in socially
patterned ways.9 Accordingly, periodontal differences observed
among individuals at a given time are the outcome of sustained and
differential contact with those exposures. Important adverse expo-
sures might be: dental plaque, through poor and unsystematic oral
self-care; chronic tobacco smoking; poorer access to professionally
provided preventive care; or even prolonged, severe psychological
stress. Interpersonal differences in the accumulation of such advan-
tages or disadvantages through a range of biological events and social
experiences can be very subtle and incremental, yet they result, over
time, in marked differences in periodontitis experience which
continue to widen with age.9 Most of those exposures are socially
patterned.
Thus, health-related behaviors are important in periodontitis
occurrence and are closely associated with socio-economic posi-
tion,65,66 with smoking arguably the strongest risk factor for peri-
odontitis.67 Smoking is believed to be the primary driver of the
periodontitis epidemic68-70 and is estimated to account for up to
75% of cases of periodontitis.71 Smoking is prevalent globally, some
22% of adults being daily smokers.72 While smoking is declining in
most countries, a very low quit rate is reported in low- or
middle-income countries (where approximately 80% of the world’s
smokers live).73-78
In developed countries, smoking prevalence has been steadily
declining, from 36% to 16% between 1976 and 2014/2015 in New
Zealand79,80 and from 34% to 18% between 1978 and 2013 in the
USA.81,82 Alarmingly, there has been a substantial widening of socio-
economic differentials in smoking prevalence, as smoking rates have
mainly declined among the most affluent.77,80,81,83 Similarly, quit
rates are greater in high socio-economic position groups, while little
or no change is seen in low socio-economic position groups.77,80,83
As a result, those living in the most deprived neighborhoods in New
Zealand have the highest prevalence of current smokers (28%), while
those living in the least deprived areas have the lowest prevalence
(8%)80. These differences are reflected in the occurrence of peri-
odontitis in that country.77
Significant associations were also observed with other dental
health-related behaviors, such as self-care. A 40-year birth cohort
study (n = 1037) in New Zealand characterized longitudinal patterns
in plaque control, identifying three distinct trajectories of plaque
control. Some 12% of people had high plaque levels that steadily
KNIGHT AND THOMSON
worsened as they aged; the plaque levels of half of the cohort
showed no improvement; and only 39% had plaque levels which
improved steadily with age, and that group not only had far superior
periodontal and dental health by age 32, but were more likely to be
routine visitors for dental care in adulthood.41 This phenomenon is
not limited to New Zealand’s somewhat ‘Darwinian’ system of dental
care for adults, under which routine dental care is not supported by
84
the State once people reach 18 years of age. Data from the 2004-
2005 Swedish National Survey of Public Health (n = 37 399)
showed that those of lower socio-economic position were far less
likely to seek professional dental care than their higher socio-eco-
85
nomic position counterparts.
In considering these findings, it is important to acknowledge
that the poorer oral health of disadvantaged people is not a result
of their personal neglect. In fact, in that Swedish study, the only
reason associated with lack of access to dental treatment was
financial limitation (others, such as fear of the dentist, or disap-
pearance of pain, were not).85 Other studies have shown that
social disparities in oral health are not explained by personal
neglect in lower socio-economic position groups.62,86 In a repre-
sentative sample of 3678 Australian dentate adults, the socio-eco-
nomic gradient in oral health was not explained by dental
attendance or self-care behaviors.62 Missing teeth were signifi-
cantly associated with socio-economic position, but that associa-
tion did not attenuate after adjusting for dental behavioral
variables (routine check-ups, episodic visits, brushing and flossing).
Data from the third US National Health and Nutrition Examination
Survey 1988-1994 showed the same findings. Even after adjusting
for all indicators of health-related behaviors (smoking, dental visits,
fruit and vegetable consumption), those of lowest socio-economic
position were almost five times more likely to have periodontitis
than their higher socio-economic position counterparts.86 Similar
associations were observed for other oral characteristics, such as
gingival bleeding and perceived oral health. Income and education
remained significant determinants of almost all oral health indica-
tors, even after adjusting for all behaviors, suggesting that an
association between oral health and socio-economic position is
independent of health behaviors.
Given the strong social patterning of periodontitis and dental
behaviors, it is entirely unsurprising that targeted health promo-
tion, aimed at encouraging behavioral change in high-risk individu-
als, has been unsuccessful. Indeed, the effectiveness of such
strategies has been questioned by the medical83,87,88 and den-
tal62,89-91 communities. Prevention efforts largely target high-risk
individuals, and this requires identification by screening.91 Once
identified (because they already have disease), people are then
offered preventive support to change their behavior (and, in
future, this is likely to include personalized periodontics). The most
important limitation of high-risk-group interventions (whether clini-
cal and/or educational) has been that they did not result in sus-
tainable improvements or reduce oral health disparities because
the conditions creating disease were not altered.90,92-99 There is
the potential for inequalities actually to worsen as a result
| 197
because people with more resources would have a greater ability
to access the recommended interventions.100
By contrast, a population-level intervention aims to address the
underlying causes of disease across the whole population by alter-
ing environmental, psychosocial, economic and political systems.91
A variation – geographic targeting or the directed population
approach – involves focusing on groups, communities or subpopula-
tions at high risk. Screening is not required, but instead epidemio-
logical and/or sociodemographic data are used to define risk
groups.91 Currently, the international evidence suggests that a com-
bination of population-based and high-risk approaches is the most
effective.91,96,97,101,102
Indeed, a recent study demonstrated that institutional ‘classism’ is
ingrained in health care, and that treatment of dental caries was signif-
icantly dependent upon socio-economic position. Using Australian
National Survey of Adult Oral Health 2004-2006 data, Mejia et al103
found that, while there was a modest socio-economic position differ-
ence in overall disease experience (reflected in mean decayed, missing
and filled teeth [DMFT] scores), a clear social gradient was apparent
when the individual DMFT index components were scrutinized. A dis-
proportionately greater proportion of decayed teeth was found in the
lowest income group than in the highest (34.5% vs 13.9%), more teeth
were ‘missing’ in the lowest income group than in the highest (83% vs
66%) and fewer teeth had been filled in the lowest income group than
in the highest (7.7% and 9.7%, respectively). The largest disparities
were found for untreated decay, for which lower income groups had
the greatest burden of untreated disease and need for treatment.
While they did not investigate periodontal treatment in that study, it is
likely that the findings would have been similar.
The very notion of personalized periodontics is predicated upon
the assumption that people will present in a timely and appropriate
manner for some form of screening, followed by diagnosis and then
the allocation of an appropriately targeted intervention which is
most likely to be able to restore them to periodontal health. Our
major criticism of this approach is that, in most health systems in
the world, this is likely to be accessible only to the social strata for
whom it is affordable, and those with the greatest need for such
intervention will remain the least likely to be able to get it. Thus,
personalized periodontics is likely to be a niche service for a small
proportion of the adult population, much like the situation with den-
tal care for adults in countries such as New Zealand.
In summary, personalized periodontics could revolutionize the
way that we understand, research and practice periodontology.
There have been promising early developments in diagnostic and
prognostic tests using noninvasive samples, such as saliva and gingi-
val fluid.34,104,105 These could help determine exactly who with gin-
givitis will go on to develop periodontitis. Paradoxically, those who
are most likely to develop periodontitis are least able to afford
expensive clinical interventions. High-cost, cutting-edge scientific
advances in periodontics are absolutely necessary and essential but,
on the other hand, periodontal health can be achieved simply by
effective daily personal plaque control and avoiding smoking. Since
the World Health Organization finally integrated oral health formally
198 | KNIGHT
into its chronic disease prevention program in 2003,106 focused
strategies have been developed to improve oral health and reduce
disparities; these include supporting a global health governance
framework, promoting a healthy lifestyle, promoting oral health for
those most vulnerable in the community (such as schoolchildren and
older people), water fluoridation and oral health research.97,107-109
The major challenge will be to translate novel technologies, such as
personalized periodontics, into public-health-relevant resources and
to make them accessible to all.
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How to cite this article: Knight ET, Thomson WM. A public
health perspective on personalized periodontics. Periodontol
2000. 2018;78:195–200.
https://doi.org/10.1111/prd.12228