Periodontal Care in General Practice

Home , Occlusal trauma, Overeruption, Tooth mobility

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

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 periodontal 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 radiographs 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 considered. If occlusal adjustments are indicated to help latter is preferable whenever possible as it Grade C disease, antibiotics may be required. correct occlusal disharmonies, these must allows some independent tooth movement, In general practice, this will only be for a very be carried out carefully in order to preserve thus stimulating the periodontal ligament and limited number of patients as patients with centric stops. alveolar bone, preventing atrophy. Te use of Grade C disease are likely to be referred for fbre-reinforced composite resin produces a specialist care. Other less common examples 3: When might permanent splinting more rigid splint that can result in alveolar include those with necrotising periodontitis. in periodontitis patients be consid- bone atrophy and ultimately the need to If antibiotics are considered, these should ered? extract the tooth. be systemic as the evidence-base for local Te key indications for permanent splinting antibiotics employed at multiple sites is are: 4: When should I consider using an- limited. Studies for local antibiotics show that To immobilise mobile teeth that are causing tibiotics when treating periodontitis probing depth reductions following repeat discomfort or afecting function patients? root surface debridement alone are equal To immobilise teeth where there is With antimicrobial resistance on the increase, to or better than that achieved with local progressive increase in mobility; and the prescription of antibiotics for the antimicrobials.10,11,12 Systemic antimicrobials To prevent further movement of teeth, treatment of periodontitis should be carefully should be used as an adjunct to root surface including drifing, overeruption, or relapse of considered and if possible avoided. Antibiotics debridement and not as a monotherapy as orthodontically treated teeth.9 should only be prescribed when the amount there is a need to disturb the bioflm frst. of disease is clearly not consistent with Te antibiotics should be taken following the Prior to splinting, it is imperative that the existing aetiological factors or if the response fnal session of root surface debridement and periodontitis has been addressed as a splint to standard non-surgical treatment has been all debridement completed in 7–14 days.13,14 will make plaque control around teeth more unusual – this will ofen be in the previously Tere is no optimal protocol for antimicrobial difcult. A range of diferent materials have called ‘aggressive periodontitis’ patients. Te type or regime, however empirical evidence been described for splinting. One of the most term ‘Grade C’ periodontitis is now used in and practicality are usually taken into common is using composite resin. However, the 2017 classifcation system, and where the account. For example, in a penicillin-allergic composite resin alone is weak and brittle, rate of destruction of periodontal attachment patient 100 mg doxycycline might be so will fracture easily. Fibreglass-reinforced is not consistent with local factors (for benefcial. Tose with a signifcant amount of composite or archwire and composite would example, the patient has good oral hygiene infection may beneft from a combination of be more appropriate options (Fig. 2). Te and does not have sub-gingival calculus) in metronidazole and amoxicillin. Azithromycin

is popular as compliance is easy with only implantitis. Cement may also act as a foreign retaining periodontally involved teeth for one tablet per day for 3 days. Table 1 provides body and provoke an infammatory response as long as possible, before replacement with a summary of common antibiotic regimes that might result in peri-implantitis. implants, as a general principle. used in the treatment of periodontitis. D. Removable options 6: Why is it important to formally risk 5: What are the key factors to be It may not always be necessary to provide a assess my patients with periodontal aware of when considering dental fxed restoration. Overdentures are ofen a disease? implants for periodontitis patients? more cleansable and safer long-term solution Risk assessment uses the current evidence base for some patients. A removable prosthesis to identify patients who have a higher likelihood A. Risk of peri-implant disease replaces both hard and sof tissue, which of developing a specifc disease and provides Patients with existing periodontitis have a might provide a better aesthetic outcome as them with enhanced preventive care pathways.23 greater risk of developing peri-implantitis.15 well as allowing better access to the peri- Periodontitis is a complex condition Moreover, patients with a history of implant tissues for plaque control. in that it involves a series of interactions periodontitis, over a long term exhibit: greater probing depths and bone loss around implants, a higher incidence of peri- implantitis16 and higher overall failure rates.17 Implants placed in periodontally susceptible patients have been shown to experience signifcantly higher amounts of bone loss compared to periodontally healthy patients irrespective of the implant type chosen.18 For this reason, it is imperative to treat the periodontitis frst and aim to eliminate any deep periodontal probing depths before implant placement. Individuals with a history of periodontitis should be warned from the outset and as part of the informed consent process that they are at a higher risk of complications. Fig. 3 DEPPA print out for periodontal risk

B. Implant position Implants should not be positioned too close together as this may impair access for ‘Incorrect bucco-lingual implant adequate plaque control. It is advisable to aim to maintain 3 mm spacing between implants where this is possible. Prior to implant placement can lead to restorations placement, historical loss of hard and sof tissues may result in the inability to place an implant in the correct three-dimensional with uncleansable overhangs.’ position. Incorrect bucco-lingual implant placement can lead to restorations with uncleansable overhangs. Deep placement may E. Supportive therapy between the host’s infammatory-immune create deep probing depths and an extensive Longitudinal studies have shown that a lack responses, which are infuenced by genetic, subgingival environment impairing optimal of supportive therapy is associated with environmental and lifestyle factors and plaque control. It is important to be aware of a higher frequency of peri-implantitis.20 the plaque bioflm. Te risk factors for these complications during the planning stage For this reason, supportive periodontal periodontitis carry diferent weights and and consider bone and/or sof tissue grafing therapy is integral in minimising risks. interactions. For this reason, periodontal if indicated. Recall intervals should be tailored according risk assessment is not a simple process. A to previous periodontal therapy, location recent consensus meeting by the European C. Screw vs cement of the sof tissues, implant location and Federation of Periodontology, which analysed Screw-retained restorations are preferable prosthesis design. the latest systematic reviews in this area, where possible. Caution is required if using supported two systems: PreViser (also cemented restorations due to the risk of the F. Extracting teeth to replace with provided through DEPPA, the Denplan extrusion of excess cement into the peri- implants PreViser Patient Assessment in the UK)24 and implant sulcus when seating the restoration. Tere is now a growing body of evidence the Periodontal Risk Assessment (PRA) tool.25 Te amount of excess cement is generally to suggest that maintaining periodontally Te validity and predictive ability of these greater with deeper crown margins.19 Cement involved teeth can provide better survival systems has been demonstrated in a number remnants may provide a rough surface outcomes and can also be more cost-efective of studies.26,27 for microorganisms to colonise leading to than placing implant-retained crowns.21,22 PreViser/DEPPA technology is commonly peri-implant mucositis and possibly peri- Tus there is a gradual move towards used in general dental practice (Fig. 3). www.nature.com/BDJTeam BDJ Team 29 © 2020 British Dental Association. All rights reserved. FEATURE

BOP % = 22% 7: Can periodontitis be stabilised for life so my patients can retain their teeth? PD ≥5 mm Tere is now overwhelming evidence that well Envir. performed periodontal therapy in an engaged patient works well. Successful treatment can mean patients retain their teeth for life. Even with an improved periodontal outcome that is not absolutely optimal, the lifespan of the teeth will be improved. Te key to maintaining improvements and preventing Tooth loss Syst./Gen. tooth loss is optimal oral hygiene and regular supportive periodontal therapy.31,32 Figure 5 illustrates a case where only non-surgical BL/Age = 0 periodontal therapy was carried out. Most might consider extracting this tooth but Fig. 4 PRA spider diagram through efective non-surgical periodontal therapy the probing depths have reduced signifcantly and there is also evidence of bony infll when examining the radiographs.

8: What is the importance of supportive periodontal therapy? Supportive periodontal therapy or maintenance is an efective and integral component of managing periodontitis patients. Its importance should be emphasised to patients before commencing any active treatment. With supportive periodontal Fig. 5 Non-surgical periodontal therapy (a) Before; (b) Six months after therapy, periodontal health can be maintained in the majority of patients, even in advanced cases.33,34 Rosling and colleagues (2001) It involves an online assessment that representation of a patient’s risk based on six demonstrated that over a 12-year period of evaluates 11 factors: patient age, smoking, clinical, systemic and environmental factors, risk-directed periodontal maintenance, tooth diabetes, history of periodontal surgery, including: percentage bleeding on probing, loss could be minimised and the periodontal pocket depth, bleeding on probing, furcation number of residual periodontal pockets condition of high-risk individuals could be involvements, subgingival restorations, root ≥5 mm, number of lost teeth, alveolar bone maintained in a largely stable situation; in calculus, radiographic bone height and the loss in relation to patient age, systemic and/ low risk individuals, the periodontitis was presence of vertical bone lesions. A patient or genetic predispositions and environmental virtually eliminated.35 report is then designed as a biofeedback and factors such as tobacco use. Tis tool is Te aims of supportive periodontal therapy communication tool. Tis includes numeric designed to be used afer periodontal therapy would be to: and trafc light coded representations of has been completed. Monitor whether the condition is stable periodontal disease risk (scale of 1–5) and Te key aim of risk assessment is to identify and provide an opportunity to initiate severity (scale of 1–100). A graph is also patients who are at risk before irreversible treatment if progression is detected produced which tracks changes in comparison damage occurs. Te clinician is able to Remove aetiological factors before the to the previous assessment. Suggested determine the high-risk patient’s care plan disease progresses treatment options are provided depending on in terms of recall periods, reduction of risk Reinforce smoking cessation and organise the initial inputs. A randomised controlled factors, intensity of treatment and referral to referral if appropriate. trial (RCT) showed that this system improves specialists more efectively. In the same way, Recall intervals should be based on the psychological outcomes for the patient.28,29 risk-based prevention also helps to prevent patient’s risk profle but the default is usually 3 Te use of the system as a biofeedback tool over-treatment. In addition, quantifying months. However, evidence-based algorithms has also been shown in a RCT performed risk and disease by means of scores allows are being developed to direct recall intervals in the primary care sector to improve the success of care plans to be objectively in a more personalised approach.36 plaque scores, bleeding and self-reported measured. Tis would be valuable on an interdental cleaning. Tis is the frst time a individual, practice and population level. 9: What are the guidelines for refer- risk assessment tool has been demonstrated to Perhaps most importantly, personalised ring patients for specialist care? improve oral health.30 risk communication to patients appears It is important to minimise any delay in Te PRA is an online tool that has been efective in stimulating behaviour change referral for specialist care if indicated. It widely used in specialist teaching programmes and has important medico-legal implications is much easier for patients to allege, afer (Fig. 4). It is ofen referred to as the spider regarding the engagement of patients in their the ‘event’ (usually tooth loss), that they diagram. It produces a functional graphical own health behaviours. would have preferred a referral for specialist

6. Butterworth C J, Chapple I L C. Drug- ‘There is now overwhelming evidence induced gingival overgrowth: a case of auto-correction of incisor drifting. Dent Update 2001; 28: 411–416. that well performed periodontal therapy 7. Ilgenli T, Atilla G, Baylas H. Efectiveness of peri-odontal therapy in patients with drug-induced gingival overgrowth. in an engaged patient works well. Long-term results. J Periodontol 1999; 70: 967–972. Successful treatment can mean patients 8. Jepsen S, Caton J G, Albandar J M et al. Periodontal manifestations of systemic diseases and developmental and acquired retain their teeth for life.’ conditions: consensus report of workgroup 3 of the 2017 World Workshop on the Classifcation of Periodontal and Peri- Implant Diseases and Conditions. J Clin care. Failure to refer at an appropriate time periodontal disease’ Periodontol 2018; 45(S20): S219–S229. is a common reason for litigation when ‘Patient warned of tooth mobility and 9. Hughes F J. Clinical problem solving in considering periodontal cases. tooth loss related to periodontal disease’ periodontology and implantology. 1st ed. Te British Society of Periodontology’s ‘Patient advised that they are at risk of Churchill Livingstone Elsevier, 2013. guidelines on specialist referral37 suggest developing periodontitis’ 10. Magnusson I, Lindhe J, Yoneyama complexity 3 cases should mostly be referred. ‘Patient informed on the risks of smoking T, Liljenberg B. Recolonization of a Tis includes a BPE score of 4 in any sextant in relation to periodontal disease – subgingival microbiota following scaling as well as one or more of the following discussed increased risk for the condition in deep pockets. J Clin Periodontol 1984; additional factors: and likely poorer response to therapy’ 11: 193–207. A medical factor that is afecting the ‘Patient advised that oral hygiene is not 11. Timmerman M F, van der Weijden G A, periodontal tissues, such as diabetes adequate to support formal periodontal van Steenbergen T J, Mantel M S, de Graaf Complicating root morphologies and therapy. Guided to improve plaque levels J, van der Velden U. Evaluation of the anatomical factors adversely afecting to support periodontal therapy’ long-term efcacy and safety of locally- prognosis ‘Patient shown how to use interdental applied minocycline in adult periodontitis Previous classifcation as ‘aggressive brushes and advised on the following patients. J Clin Periodontol 1996; 23: periodontitis’ sizes:...’ 707–716. No response to previous optimally carried ‘Discussed referral to periodontal 12. Garrett S, Adams DF, Bogle G et al. Te out treatment specialist.’ efect of locally delivered controlled- Patient’s requiring surgical procedures release doxycycline or scaling and root Medical history signifcantly afecting Declaration of interest: planing on periodontal maintenance clinical management (history of head/ Prof Chapple acts as an adviser to Oral Health patients over 9 months. J Periodontol 2000; neck radiotherapy or intravenous Innovations, who license PreViser sofware in 71: 22–30. bisphosphonate therapy) the UK and Ireland. 13. Herrera D, Sanz M, Jepsen S, Needleman I, Immunocompromised/ Roldán S. A systematic review on the efect immunosuppressed, signifcant bleeding References of systemic antimicrobials as an adjunct to disorder, potential drug interactions 1. Murakami S, Mealey B L, Mariotti scaling and root planing in periodontitis Regular tobacco smoking (10+ cigarettes/ A, Chapple I L C. Dental plaque-induced patients. J Clin Periodontol 2002; 29(S3): day) gingival conditions. J Clin Periodontol 136–159. Concurrent mucogingival disease such as 2018; 45 (Suppl 20): S17–S27. 14. Hafajee A D, Socransky S S, Gunsolley erosive lichen planus. 2. Tipton D A, Stricklin G P, Dabbous M K. J C. Systemic anti-infective periodontal Fibroblast heterogeneity of collagenolytic therapy. A systematic review. Ann If referring to a hospital rather than private response to cyclosporine. J Cell Biochem Periodontol 2003; 8: 115–181. practice, it is also important to be aware of the 1991; 46: 152–165. 15. Pjetursson B E, Helbling C, Weber H hospital’s guidelines and acceptance criteria. 3. Hallmon W W, R o s s m a n J A. The role P et al. Peri-implantitis susceptibility of drugs in the pathogenesis of gingival as it relates to periodontal therapy and 10. How can I minimise my chances overgrowth. A collective review of current supportive care. Clin Oral Implants of litigation through record keeping? concepts. Periodontol 2000 1999; 21: Res 2012; 23: 888–894. Specifc phrases in your record-keeping 176–196. 16. Sgolastra F, Petrucci A, Severino M, Gatto templates can help minimise chances of 4. Nishikawa S, Taha H, Hamasaki A et al. R, Monaco A. Periodontitis, implant loss missing important discussion points with Nifedipine-induced gingival hyperplasia: and peri-implantitis. A meta-analysis. Clin patients. It is important that the templates a clinical and in vitro study. J Periodontol Oral Implants Res 2015; 26: e8–e16. used are true, appropriate and tailored to each 1991; 62: 30–35. 17. Koldsland O C, Scheie A A, Aass A individual patient. Here are a few examples of 5. Heasman P A, Hughes F J. Drugs, M. Prevalence of implant loss and phrases that may be helpful: medications and periodontal disease. Br the infuence of associated factors. ‘Patient advised of mild/moderate/severe Dent J 2014; 217: 411–419. J Periodontol 2009; 80: 1069–1075. www.nature.com/BDJTeam BDJ Team 31 © 2020 British Dental Association. All rights reserved. FEATURE

18. Matarasso S, Rasperini G, Iorio Siciliano 30. Asimakopoulou K, Nolan M, McCarthy V, Salvi G E, Lang NP, Aglietta M. A 10- C, Newton J T. Te efect of risk year retrospective analysis of radiographic communication on periodontal treatment bone-level changes of implants supporting outcomes: A randomised controlled trial. single-unit crowns in periodontally J Periodontol 2019; 90: 948–956. compromised vs. periodontally healthy 31. Axelsson P, Lindhe J. Te signifcance patients. Clin Oral Implants Res 2010; 21: of maintenance care in the treatment of 898–903. periodontal disease. J Clin Periodontol 19. Linkevicius T, Vindasiute E, Puisys 1981; 8: 281–294. A, Linkeviciene L, Maslova N, Puriene A. 32. Ramford S P, Morrison E C, Burgett F Te infuence of the cementation margin G et al. Oral hygiene and maintenance of position on the amount of undetected periodontal support. J Periodontol 1982; cement. A prospective clinical study. Clin 53: 26–30. Oral Implants Res 2013; 24: 71–76. 33. Axelsson P, Nyström B, Lindhe J. Te long- 20. Roccuzzo M, Bonino L, Dalmasso P, term efect of a plaque control programme Aglietta M. Long-term results of a three on tooth mortality, caries and periodontal arms prospective cohort study on implants disease in adults. Results afer 30 years of in periodontally compromised patients: maintenance. J Clin Periodontol 2004; 31: 10-year data around sandblasted and acid- 749–757. etched (SLA) surface. Clin Oral Implants 34. Nyman S, Lindhe J. A longitudinal study Res 2014; 25: 1105–1112. of combined periodontal and prosthetic 21. Levin L, Halperin-Sternfeld M. Tooth treatment of patients with advanced preservation or implant placement: a periodontal disease. J Periodontol 1979; 50: systematic review of long-term tooth and 163–169. implant survival rates. J Am Dent Assoc 35. Rosling B, Serino G, Hellström M K, 2013; 144: 1119–1133. Socransky S S, Lindhe J. Longitudinal 22. Schwendicke F, Stolpe M, Müller F. periodontal tissue alterations during Professional oral health care for preventing supportive therapy. J Clin Periodontol 2001; nursing home-acquired pneumonia: A 28: 241–249. cost-efectiveness and value of information 36. Ramseier C A, Nydegger M, Walter C analysis. J Clin Periodontol 2017; 44: et al. Time between recall visits and 1236–1244. residual probing depths predict long-term 23. Chapple L, Chapple I. Risk assessment in stability in patients enrolled in supportive periodontal disease. Dent Update 2018; 45: periodontal therapy. J Clin Periodontol 920–926. 2019; 46: 218–230. 24. Genco R J, Borgnakke W. Risk factors for 37. British Society of Periodontology. Referral periodontal disease. Periodontol 2000 2013; policy and parameters of care. Available 62: 59–94. online at https://www.bsperio.org.uk/ 25. Lang N P, Tonetti M S. Periodontal publications/downloads/28_143801_ risk assessment (PRA) for patients in parameters_of_care.pdf (accessed 4 April supportive periodontal therapy (SPT). 2019). Oral Health Prev Dent 2003; 1: 7–16. 26. Page R C, Martin J, Krall E A, Mancl L, Tis article was originally published in the BDJ Garcia R. Longitudinal validation of a risk as Periodontal care in general practice: 20 calculator for periodontal disease. J Clin important FAQs - Part two (Br Dent J 2019; Periodontol 2003; 30: 819–827. 227: 875-880). 27. Matuliene G, Studer R, Lang N P et al. Signifcance of periodontal risk assessment in the recurrence of periodontitis and tooth loss. J Clin Periodontol 2010; 37: 191–199. CPD questions 28. Asimakopoulou K, Newton J T, Daly B, Kutzer Y, Ide M. Te efects of providing This article has four CPD questions periodontal disease risk information on attached to it which will earn you one psychological outcomes – a randomized hour of verifiable CPD. To access the controlled trial. J Clin Periodontol 2015; free BDA CPD hub, go to 42: 350–355. https://cpd.bda.org/login/index.php. 29. Sharma P, Busby M, Chapple L, Matthews R, Chapple I. Te relationship between general health and lifestyle factors and oral health outcomes. Br Dent J 2016; 221: 65–69. https://doi.org/10.1038/s41407-019-0208-1