FEATURE CPD: ONE HOUR Periodontal care in general practice: CPD 20 important FAQs – Part two Images Plus ©Santiago Iñiguez/EyeEm/Getty questions This article has four CPD 1 2 questions attached to it which Reena Wadia and Iain L. C. Chapple summarise answers will earn you one hour of to common periodontal care questions facing dental verifiable CPD. To access the free BDA CPD hub, go to professionals in general practice. The first part of this series https://cpd.bda.org/ login/index.php contains the first set of ten FAQs and is available at: https:// go.nature.com/2Opu20F. 1: How do I manage patients with drug-infuenced Te clinical appearance varies according to the causative drug, gingival enlargement? phenytoin giving rise to a largely fbrotic and pink enlargement, Drug-infuenced gingival enlargement is now classifed as whereas calcium channel blockers are associated with a more a form of plaque-induced gingivitis according to the 2017 vascular overgrowth. Te interdental papillae become swollen with World Workshop Classifcation of periodontal diseases and a granular, pebbly surface which may enlarge further to become conditions, recognising that certain drugs may modify the nodular and lobulated as the tissues coalesce to afect the marginal infammatory-immune response to plaque accumulation and attached gingiva.5 Enlarged tissues usually have two components: and that improved plaque control reduces the enlargement.1 a fbrosis component involving excess collagen deposition, and an Gingival enlargement, or ‘overgrowth’ as it has been referred infammatory one that is initiated by bacterial plaque accumulation. to, is an overarching clinical description that does not While the two components present in the enlarged gingivae are necessitate a diagnosis based upon the histologic composition likely to be a result of distinct pathogenic processes, they are almost of the afected gingival tissues. Moreover, it comprises a always observed in combination. Te role of bacterial plaque in the mixture of processes that include hyperplasia, hypertrophy of overall pathogenesis of drug-infuenced gingival enlargement is now several cell types, increased extracellular matrix production regarded as important, with the majority of studies indicating that and an infammatory component, hence justifying a non- plaque is a prerequisite for the gingival overgrowth to occur. specifc term like ‘enlargement’. Drug-infuenced gingival enlargement can be associated with calcium channel blockers (for example, amlodipine), immunosupressants (for example, ciclosporin) or anticonvulsants (for example, Author information phenytoin). Te frst signs of change are reported to arise 1RW Perio and King’s College Dental Hospital, London, UK; about 1–3 months following the start of dosing and there 2Department of Periodontology, The School of Dentistry, would appear to be minimal threshold plasma levels of the University of Birmingham, Birmingham, UK. drugs below which drug-related gingival overgrowth is *Correspondence to: Reena Wadia unlikely to occur.2,3,4 However, the evidence base is rather Email: [email protected] lacking and prevalence data varies signifcantly (for review see Heasman & Hughes 2014).5 26 BDJ Team www.nature.com/BDJTeam © 2020 British Dental Association. All rights reserved. FEATURE Steps for management in practice: 1. Ensure you have an up-to-date medical history for all your patients, including a drug history 2. Contact the patient’s general medical practitioner to fnd out if it would be feasible to replace the drug with an alternative. Tis might be carried out following initial therapy or at the start if the overgrowth is severe. It is important to emphasise that this decision rests with the prescribing medical practitioner and Fig. 1 (a) Phenytoin-related gingival enlargement; (b) Following non-surgical and surgical peri- odontal therapy. the dentist’s role is only to advise. Te decision to replace the drug will depend on the assessment of the potential benefts against the medical risks. However, it is also inappropriate to manage medical conditions/drug side efects surgically and therefore when alternative drugs exist, which is the case for ciclosporin (tacrolimus) and calcium channel blocking drugs (diuretics, beta-blockers, ACE-inhibitors etc), then the case for drug substitution is strong. In the case of epilepsy, this may be more challenging Fig. 2 (a) Severe periodontitis case with archwire and composite splint; (b) Pre-operative radio- graphs in patients who have been stable taking phenytoin for many years, as sufering a ft if it is substituted may impact upon their ability to drive. Drug substitution has been ‘Effective home care is important reported to result in spontaneous resolution of drug-infuenced gingival enlargement6 in those who have developed drug- 3. Oral hygiene reinforcement – efective home care is important in those who have developed drug-infuenced gingival infuenced gingival enlargement, but enlargement, but also for those who are at risk of developing it. Highlight the importance of this to patients and show also for those at risk of developing it’ the patient how they can achieve this. Modifcation of brushing technique with particular attention to angulation overgrowth and interference with speech, occlusal force resulting in injury of the teeth into the gingival sulcus area and use of function or aesthetics persists, surgery may and/or the periodontal attachment apparatus.8 interproximal cleaning aids would be be indicated. Even if complete resolution is Occlusal trauma is a term used to describe important. Single-tufed brushes might be unlikely without surgery, the non-surgical the injury to the periodontal attachment helpful around large areas of overgrowth approach should be attempted in the frst apparatus A clinical diagnosis of occlusal where the use of interdental brushes is not instance to reduce infammation and risk trauma may be made in the presence of one physically possible of recurrence post-operatively. Referral or more of the following: progressive tooth 4. Complete a BPE and six-point pocket to a specialist may be required. Surgery mobility, adaptive tooth mobility (fremitus), chart if indicated. Radiographic for these cases is of a resective nature, radiographically widened periodontal examination is essential to determine which aims to make the gingival tissues ligament space, tooth migration, discomfort/ the extent and severity of any bone loss, more amenable to plaque control (Fig. 1). pain on chewing, and root resorption. given that probing measures are likely to However, patients should be aware that Primary occlusal trauma has been defned be confounded by the enlargement and long-term recurrence will occur in around as injury resulting in tissue changes from thus inaccurate as measures of gingival 40% of cases if there is no change in the traumatic occlusal forces applied to a tooth attachment drug treatment7 or teeth with normal periodontal support. 5. Carry out supragingival debridement and 7. Regular periodontal supportive therapy/ Tis manifests itself clinically with adaptive root surface debridement as necessary. maintenance would be important to mobility and is not progressive. Secondary Ensure any plaque retentive factors, such minimise the risk of recurrence. occlusal trauma has been defned as injury as overhanging restorations, have been resulting in tissue changes from normal or corrected 2: What is occlusal trauma, and traumatic occlusal forces applied to a tooth 6. Where cause-related therapy has failed does it impact on periodontitis? or teeth with reduced support,8 ie in patients to bring adequate resolution of gingival Traumatic occlusal force is defned as any with periodontitis. Teeth with progressive www.nature.com/BDJTeam BDJ Team 27 © 2020 British Dental Association. All rights reserved. FEATURE Table 1 Common antibiotic regimes used in the treatment of periodontitis Mechanism of Drug(s) Bacteria targeted Dosage Avoid action Should not be taken with warfarin, try Bacteriostatic, Broad spectrum, many gram- Tetracycline Doxycyline 200 mg to avoid antacids or consume diary anti- positive and gram-negative (oxytetracycline, (loading dose), products, (they reduce absorption of inflammatory, bacteria including anaerobes, minocycline, 100 mg OD for tetracyclines) oral contraceptives less anti- rickettsia, mycoplasma and doxycycline) 14 days effective, should not be taken by those collagenolytic some protozoa with renal dysfunction 400 mg TDS for up Patients should not consume alcohol, Metronidazole Bactericidal Obligate anaerobes to 5 days may increase effect of warfarin Metronidazole as Should not be consumed with alcohol, Amoxicillin and above, amoxcillin Bactericidal Broad spectrum may increase effect of warfarin, can metronidazole 500mg TDS for up to render contraceptive pills less effective 5 days May increase effect of warfarin, Gram-positive bacteria, 500 mg OD for Azithromycin Bacteriostatic contraindicated in patients with severe mycoplasma, legionella 3 days liver problems mobility may also exhibit migration and pain on function. ‘Prior to splinting it is imperative that Occlusal trauma is a co-factor that can increase the rate of progression of periodontitis. When treating patients with the periodontitis has been addressed as secondary occlusal trauma, the treatment of the periodontitis itself should remain the primary focus. In addition to this, if the it will make plaque control diffcult’ patient has parafunctional habits, provision of an occlusal splint should be