Periodontal disease and its impact on general health in Latin America: LAOHA Consensus Meeting Report.

Periodontal diseases are considered a worldwide public health problem, owing to their high prevalence in developed and developing countries. Periodontitis may lead to tooth loss, which can impact oral health-related quality of life. Gingivitis and periodontitis have been extensively studied regarding their etiopathogenesis, epidemiology, prevention and treatment outcomes. However, most of these aspects are studied and discussed globally, which may hamper a clear interpretation of the findings and the design of effective plans of action for specific regions or populations. For example, in Latin America, epidemiological data about the distribution of periodontal diseases is still scarce, mainly when it comes to nationwide representative samples. This Consensus aimed to address the following topics related to periodontal diseases in Latin America: a) The impact of the global burden of periodontal diseases on health: a global reality; b) Periodontal diseases in Latin America; c) Strategies for the prevention of periodontal diseases in Latin America; d) Problems associated with diagnosis of periodontal conditions and possible solutions for Latin America; e) Treatment of Periodontitis. This consensus will help to increase awareness about diagnosis, prevention and treatment of periodontal diseases, in the context of Latin American countries.


Introduction
The Meeting coordinated by the Latin American Oral Health Association (LAOHA) was held on January 30, 2019, in São Paulo, Brazil. "Periodontal disease and its impact on general health in Latin America -Consensus Meeting" was the theme of this event that aimed to examine the main oral health problems in Latin America and to propose individual and collective recommendations to address these problems.
Sixty Five speakers each prepared a scientific paper on their specific topic of expertise, which was peer reviewed by the moderator of each session. The topics of the papers were as follows: (i & ii) two introductory presentations on the impact of the global burden of periodontal diseases on health in the world and Latin America, (iii) prevention, (iv) diagnosis and (v) periodontal treatment. The presentations were based on the content of each paper and followed by discussions including the guests and presenters. A final session presenting general conclusions of all topics presented during the meeting was conducted by Mariano Sanz (University Complutense of Madrid, Madrid, Spain). Closing remarks were made by Maria Ryan and Giuseppe Alexandre Romito. LAOHA appreciates the support received from its members and students. This meeting was sponsored by LAOHA and the Colgate Palmolive Company (Piscataway, NY, USA). The key messages of the papers and the general recommendations sections are presented below.

Key messages
Periodontitis is a chronic non-communicable disease (NCD) that impacts on quality of life and represents a major public health problem around the world. Oral diseases (caries and periodontal diseases, such as gingivitis and periodontitis) are now recognized as being both an epidemic and one of the most important public health problems in the world. In 2015, 3,500 million people were suffering from untreated dental conditions; 2,500 million people with untreated decay in permanent teeth; 573 million children with untreated decay in temporary teeth; 538 million people with severe periodontitis; and 276 million people with total loss of teeth. Moreover, the number of people affected by periodontal diseases will increase even further, and their prevalence will be concentrated on the most vulnerable groups, thus becoming a significant source of social inequality. Periodontal treatment and traditional actions of promotion and prevention carried out in the dental unit are not enough to control the onset of periodontal diseases and access to health care systems is unfair, which reinforces health inequities and maintains the current situation of oral diseases around the world. Therefore the epidemiological indicators will only be modified by the implementation of public policies focused on health equity and comprehensive care.

Session 2. Periodontal diseases in Latin America
(male), education/schooling, socio-economic status, smoking and obesity. Periodontitis is not homogenously distributed among the Latin American populations but establishing the actual prevalence and distribution of this disease is not a simple task, especially because there is a lack of a standardized "case definition system" to be used in epidemiological studies. The development of such a tool would help to generate reliable data regarding periodontitis in the region. Gingivitis and periodontitis are prevalent in subjects of all ages, including children and adolescents. However, epidemiological data are scarce in Latin America, particularly with respect to nationwide representative studies. On an average, gingivitis affects 34.7% of young Latin American individuals. In the Latin American adult population the prevalence of gingival inflammation reached 96.5% to 100%. In Latin American adolescents from 15 to 18 years of age, the prevalence of CAL ≥ 3 mm is 32.6%, and the prevalence of the probing pocket depth ≥ 4 mm is 59.3%. In addition, the prevalence of severe periodontitis in adults reached 7.8% to 25.9% from middle age to seniors, respectively. Raising awareness of the prevalence and consequences of periodontal diseases is still low in Latin America; thus, the use of social media and networks were suggested as an effective strategy to increase awareness about periodontal diseases in the population. Therefore, the implementation of a periodontal screening procedure during Primary Care is now being recommended, so that those who present clinical signs and symptoms of periodontal disease can be referred to specialists (periodontists) for complete periodontal examination and periodontal treatment, if necessary. This strategy would improve to the diagnosis of periodontal diseases in their early stages, and consequently improve the prognosis. Moreover, interlocutions between oral health associations and Academia were proposed in order to address topics related to diagnosis and prevention of periodontitis in undergraduate programs, specialist training and post-graduate programs in comprehensive care context.

Key messages
Prevention of periodontal disease in Latin America has mainly been focused on oral hygiene instruction for reducing dental biofilm by means of motivational schemes, increasing patients' knowledge about the disease, patient empowerment, and providing adequate oral hygiene instruction. In this context, there are two main preventive approaches that could be used: (i) at the individual level -centered on patients, and (ii) the population/community level, which would require the proactive participation of the government in decisionmaking. The prevention of oral diseases is crucial in terms of public health and should not be concentrated on dentists only, but on interdisciplinary groups working together. In this context, the important role of dental hygienists should be highlighted; these professionals must participate proactively in this process as health coaches, going beyond their traditional role in Latin America, which has been passive and limited to primary prevention. In addition, there is emerging evidence of the lack of knowledge of some health professionals in Latin America about periodontal diseases and their oral and systemic consequences. Furthermore, health professionals should be part of healthy lifestyle initiatives, focusing on diabetes awareness, tobacco cessation, and cardiovascular prevention programs, among others. In addition, alliances between different associations, governmental and-non-governmental organizations (policymakers and stakeholders), and health systems should be encouraged in order to create a joint effort to replace Oral Health Programs by Oral Health Policies. It was suggested that such policies should emphasize the concept of "Full Mouth Health", focused on comprehensive care. Session 4. Problems associated with diagnosis of periodontal conditions and possible solutions for Latin America important issue concerning periodontal health/disease diagnosis is the divergence between parameters used in epidemiological studies and those used for individual patients. It should be emphasized that the gold standard strategy for periodontal diagnosis is full-mouth periodontal examination, and when this approach is adopted, there is little likelihood of periodontal disease being misdiagnosed. However, other simplified approaches have been proposed in an attempt to increase the number of dentists routinely performing periodontal examinations. A common an effective tool for use in epidemiological studies and screenings in Public Health services in Latin America should be established. However, it should be borne in mind that although screening is an effective way of evaluating a higher percentage of the population more rapidly, it is not a diagnostic tool. In 2018, the European Federation of Periodontology and the American Academy of Periodontology launched a new classification system for periodontal and peri-implant diseases and conditions. This new classification system was meant for individual diagnosis, not for epidemiological studies/screening initiatives. In Latin America, dental professionals should routinely perform individual periodontal clinical examination, and researchers should attempt to develop a standardized diagnostic test that could help the clinical periodontal screening (for epidemiological studies). In addition, dental professionals should be trained at undergraduate level to appropriately diagnose periodontal diseases at their early stages.

Key messages
In most patients, along with an oral hygiene maintenance program, Non-surgical (NSPT) and surgical periodontal treatment (SPT), good plaque control and regular maintenance programs are predictable procedures for treating periodontitis. However, NSPT and/or SPT alone may not be sufficient to re-establish periodontal health in patients with severe periodontitis or with associated risk factors. Therefore, other adjunct therapies, such as lasers, systemic antibiotics, host-modulators and probiotics have been suggested. Among these protocols, systemic metronidazole and amoxicillin is an adjunctive treatment backed by strong scientific evidence for its use in daily clinical practice. Periodontal diseases are associated with a negative impact on oral health-related quality of life (OHRQoL), especially on function and esthetics, and NSPT and SPT lead to a significant improvement in patients' OHRQoL. In addition, Pat ient-Reported Outcomes (PROs) used i n medicine have been proposed to assess the impact of periodontal treatment on patients' OHRQoL. The development of an effective instrument to assess PRO in periodontal treatment could contribute to fully assessing the benefits of different protocols. It would also be helpful to increase the participation of periodontists in the decision-making about tooth extraction, implant reconstruction, and management of advanced, complex periodontal cases. Dentists are trained to preserve teeth. Periodontitis has been associated with several systemic conditions, including adverse pregnancy outcome, cardiovascular disease, respiratory diseases, and diabetes mellitus (DM) and chronic renal disease. There is good evidence in the literature that periodontal treatment may improve glycemic control of patients with diabetes mellitus (DM). 1 Thus, the inclusion of periodontal assessment and treatment in clinical guidelines for the management of DM has been suggested. In addition, periodontists should establish stronger connections with nondental healthcare professionals, including physicians and nurses.

Final recommendations
In general, health authorities in Latin America have recognized that periodontitis is a non-communicable disease with severe impact in the quality of life and represents a major health problem around the world. The consensus group recognizes that periodontitis and gingivitis are socially determined diseases and that their effective combat, necessarily requires efforts and public policies to promote equity by reducing social inequalities. Prevention should be the main measure of oral health actions, policies and programs for maintaining oral health and avoiding periodontitis through the effective management of gingivitis and promotion of healthy lifestyles at both population and individual levels. The group identified the need for implementing the below mentioned actions in order to foster the awareness, prevention, diagnosis and treatment of periodontitis in Latin America: Awareness and prevention a. Increase the awareness of both dental and non-dental health professionals regarding the prevalence and consequences of periodontal diseases for patients' oral and systemic health, using social media and networks. b. Establish alliances between dental associations, governmental and non-governmental organizations (policymakers and stakeholders), and health systems to emphasize the replacement of Oral