Risk Management in Clinical Practice. Part 10. Periodontology

Home , Mouth assessment, Periodontology

Risk management in clinical in brief • Failure to diagnose or treat periodontal disease is the fastest growing area of p practice. Part 10. Periodontology litigation in dentistry. ractice • Record keeping is the most essential part of managing periodontal disease. P. Baker1 and I. Needleman2 • Radiographs are a necessary part of assessing periodontal disease and its progress. • Patients must be made aware of factors that influence the outcome of periodontal disease treatment.

A sizeable proportion of patients in clinical practice will have some form of periodontal disease and most of these patients can be well managed in primary care. Unfortunately, dento-legal claims regarding inappropriate periodontal care are increasing rapidly and are now one of the most common reasons for litigation in dentistry. In this paper we will look at aspects of contemporary management of periodontal disease in clinical practice and offer guidance for examination, management and referral.

Periodontitis – Diagnosis a silent disease tooth loss, many people will be unaware that they have had periodontal disease for As with any disease, proper management Up to 90% of the population will expe- some years. As a result, irreversible dam- starts with a correct diagnosis. Patients rience some attachment loss during their age will have occurred which could have attending a dental check-up have a life. Of these, approximately 25% will lose been predictably prevented or treated if right to expect that they are receiving one or more teeth as a result of periodonti- identified at an early stage. a thorough examination of the mouth, tis. Unfortunately, until the point of facing The aggressive forms of periodontal dis- teeth and supporting structures, not just ease may result in significant amounts of dental decay. Figure 1 shows periapical RISK MANAGEMENT attachment loss occurring at a young age radiographs of a 55-year-old patient who IN CLINICAL PRACTICE or in a relatively short timeframe. In such reports being a regular dental attender cases, early diagnosis and proper manage- throughout his adult life. He presents 1. Introduction ment are essential. with advanced horizontal bone loss and 2. Getting to ‘yes’ – the matter of consent Periodontal dento-legal claims fre- in areas the bone loss is approaching the 3. Crowns and bridges quently involve a failure to diagnose the apices of teeth. There is general mobility 4. Endodontics disease, or a failure to adequately treat it. and teeth have been recently removed 5. Ethical considerations for dental enhancement procedures In this article we will set out guidance to because of this. His dentist had never 6a. Identifying and avoiding medico-legal help develop systems for effective screen- informed him of his periodontal disease. risks in complete denture prosthetics ing, planning of periodontal prevention Unfortunately this is not an uncom- 6b. Identifying and avoiding medico-legal and treatment. However, this is not a text- mon picture in patients being referred risks in removable dentures book on periodontology and more detailed for specialist treatment within the UK. 7. Dento-legal aspects of orthodontic practice aspects will be found in textbooks such as Nothing can justify such a lack of Palmer & Floyd.1 basic care. 8. Temporomandibular disorders 9. Dental implants 10. Periodontology 11. Oral surgery

1*Specialist in Periodontics, PerioLondon, 4 Queen Anne Street, London, W1G 9ZF; 2Specialist in Periodontics, Perio London, 4 Queen Anne Street, London, W1G 9ZF/ Professor of Restorative Dentistry and Evidence-Based Healthcare, Unit of Periodontology, UCL Eastman Den- tal Institute, 256 Gray’s Inn Road, London, WC1X 8LD *Correspondence to: Dr Paul Baker Email: [email protected]

Refereed Paper Accepted 20 October 2009 DOI: 10.1038/sj.bdj.2010.1084 ©British Dental Journal 2010; 209: 557–565 Fig. 1 Periapical radiograph set of a 55-year-old patient, showing advanced horizontal bone loss british dental journal VOLUME 209 NO. 11 DEC 11 2010 557

practice

Consequences of failure to diagnose Table 1 BPE codes recorded for each sextant

The chronic periodontal conditions are Code Clinical features Represents Management mostly asymptomatic until they reach the later stages of the disease. Symptoms No pockets exceeding 3 mm Code 0 No plaque retentive factors Health None of periodontal disease that may cause a No bleeding after gentle probing patient to seek advice from a dentist, such No pockets exceeding 3 mm as mobility of the teeth, drifting or pain Code 1 No plaque retentive factors Gingivitis Oral hygiene instruction from a periodontal abscess, are all associ- Bleeding after gentle probing ated with advanced bone loss. Treatment at No pockets exceeding 3 mm Gingivitis with sec- Removal of local factors this stage is usually complex, and indeed Code 2 Plaque retentive factors present (such ondary local factor Oral hygiene instruction extraction may be the only option. In con- as calculus or overhanging margins) trast, the management of early periodontitis Periodontal probing is relatively straightforward and predict- Periodontal probing of 4‑5 mm (black depths recorded for the Early chronic Code 3 band of WHO probe partially visible) on affected sextants able. It should therefore be obvious that periodontitis one or more sites Appropriate level of early diagnosis is extremely important in periodontal treatment the management of periodontal disease. Full periodontal Periodontal probing of 6 mm or more Moderate to assessment Relevant dental and Code 4 (black band of WHO probe disappears advanced chronic Appropriate level of into pocket) on one or more site periodontitis medical history periodontal treatment As with all diagnosis, the initial present- Moderate to Full periodontal ing complaint and concerns of the patient Attachment loss (probing depth plus advanced chronic assessment Code * recession) of 7 mm or more, or if a periodontitis or a site should be ascertained. This may give the Appropriate level of furcation can be probed requiring complex periodontal treatment clinician the first hint of what to expect periodontal treatment when it comes to the diagnosis. As already mentioned, patient symptoms tend to occur late in the progression of periodontal dis- achieved will help to select the appropriate reduced the number of patients to whom ease, so the absence of symptoms is no direction for treatment and avoid patient this applies.2 excuse for failure to screen for periodontal dissatisfaction later. disease. The patient’s concerns should also Questions regarding the previous den- Requirements for screening, recommended frequency be taken into account when formulating tal history should be asked, and, where the treatment plan. Figure 2, for example, it is thought to be relevant, these should As we have already stated, a routine dental shows a patient whose presenting com- include any previous periodontal treat- examination should include an examina- plaint is the drifted and over-erupted upper ment. While assumptions cannot be made tion of the periodontal tissues. The BPE left central incisor. This is a result of undi- about a lack of response to treatment in (Basic Periodontal Examination) is an effi- agnosed and untreated periodontal disease. the past, treatment planning decisions may cient way of doing this and Table 1 shows Treatment of the active periodontal dis- be altered in the context of success or fail- the codes that are recorded for each sex- ease alone will not correct this, indeed the ure of previous treatment. A family history tant.3 The ‘*’ category recognises complex associated recession may increase the aes- of periodontal disease or early tooth loss clinical situations, namely the involvement thetic concern for the patient. Achieving may also be relevant and indicate a patient of a furcation or where recession and prob- periodontal health might be fundamental with a higher risk of susceptibility. ing depth give an attachment loss level of to addressing the problem, or alternative A comprehensive medical history should 7 mm or more. treatment, such as extraction and replace- be taken for all patients and be kept up- The findings of the BPE should be com- ment, may better suit the patient. Defining to-date. Of particular interest to the peri- municated to the patient, documented and treatment aims and clarifying what can be odontist is the smoking history, both past acted upon. Other than a score of 0, each and present. There is also an increased score represents a level of disease that susceptibility to periodontal attachment should be treated. A score of ‘1’ is recorded loss in patients with poorly controlled where there is no pocketing greater than diabetes. Since Type II diabetes has a 3 mm, but where there is bleeding on prob- genetic link, enquiring about a fam- ing. This represents gingivitis, and the ily history may be helpful in identifying patient should be offered appropriate oral borderline cases. Periodontal procedures hygiene instruction. A code of ‘2’ is gingi- that involve subgingival instrumentation, vitis in the presence of local factors such as including periodontal probing, require calculus or a poor restoration margin. The Fig. 2 Drifted and over-erupted upper left antibiotic prophylaxis in patients who are local factor should be addressed and oral central incisor as a result of undiagnosed and at risk of infective endocarditis. Recent hygiene instruction offered. The manage- untreated periodontal disease changes in the guidelines have significantly ment of the problem highlighted by the

558 british dental journal VOLUME 209 NO. 11 DEC 11 2010

practice

susceptible may require infrequent exam- may be originating from the depth of the inations. Unfortunately the patient’s pocket, indicating residual inflammation at susceptibility can often only be judged the base of the pocket. This is considered retrospectively. There are occasions where to be a risk factor for disease progression periodontal attachment loss can occur and such bleeding may be an indication for in a relatively short timeframe. In some further treatment. patients, risk factors might be present that Probing depths will need to be recorded, help to predict such a breakdown, includ- as these indicate sites that require treatment ing poorly controlled diabetes or smoking. and also allow long-term comparisons for There is a small group of the population monitoring disease progression. Where susceptible to the aggressive forms of peri- there is gingival recession, this should also Fig. 3 Advanced periodontal bone loss in a odontal disease, both localised and gener- be recorded to give an indication of the 15-year-old boy alised. Figure 3 presents the radiographs of actual amount of attachment loss (Fig. 4). a 15-year-old boy with localised aggressive Patients who have thin tissues may develop periodontitis. These patients can undergo recession rather than pocketing as their extensive bone loss in a very short period periodontal disease progresses. In such of time. cases, the probing depth may remain shal- low and constant in the presence of con- Detailed Periodontal tinued attachment loss. Such situations will Examination only be obvious to the clinician where the Once significant periodontal attachment increasing recession can be monitored. loss has been diagnosed, the clinician Individual tooth mobility scores should should perform a full periodontal exami- be recorded. Mobility may reflect the nation. The full periodontal examination extent of alveolar bone loss, but mobility Fig. 4 Probing depth will be recorded as records a baseline clinical picture for the may also be a reflection of occlusal forces 4 mm. This underestimates the actual level of attachment loss patient. This is essential for assessing (including parafunction and interferences). the response to treatment, and also for The occlusion should be examined for any long-term comparison in the assessment such interferences and a record made. This of future periodontal breakdown. The can then be reviewed with radiographs to full dental and periodontal examination, build up a picture of the processes lead- along with radiographic examination, will ing to the increased mobility. Other aspects give the clinician the information required of occlusion that are important include to treatment plan cases of moderate to assessing the risk of teeth drifting, such advanced disease, or where there are also as the position of the lower lip in relation significant restorative problems. to the upper incisors, parafunction and loss The full periodontal assessment should of posterior support. include a review of the oral hygiene. At this Furcation involvements will have a sig- Fig. 5 A furcation probe in situ stage in treatment, a detailed plaque chart nificant influence on the periodontal prog- is not necessarily required, rather a view of nosis of a tooth. Furcation involvements BPE should be documented in the notes. the patient’s need for oral hygiene instruc- should be recorded and where it is possible, When scores of ‘3’, ‘4’ or ‘*’ are recorded, tion and their response to it. Later stages horizontal measurements of involvement these indicate attachment loss and a fur- in treatment may well require a detailed (in mm) can help in monitoring progres- ther detailed periodontal examination is objective assessment of the oral hygiene sion (Fig. 5). Recognition of these limita- required, in the involved sextant in the in order that the clinician can decide on tions to treatment response helps to predict case of a ‘3’ and of the full mouth in the what treatment options are likely to suc- outcomes and to achieve realistic expecta- case of a ‘4’ or ‘*’. Since the BPE, once ceed. Surgery, for example, is unlikely to tions from treatment. practised, is a quick examination, it should succeed in all but the short-term when be incorporated as part of the routine den- performed on a patient without adequate Special tests tal examination. It must be stressed that plaque control. Following the detailed periodontal exam- the BPE is designed for screening and must Bleeding scores have become an essential ination, the clinician is in a position to be acted upon. It does not give sufficient part of the periodontal examination. At the decide what special tests are required. information to make a diagnosis or to initial stage, the bleeding following probing allow longitudinal monitoring of disease may well be from the superficial tissues as a Radiographs progression or the response to treatment. result of marginal inflammation (gingivitis). The decision of what radiographs to take The interval between periodontal exami- Following a well performed course of non- will depend on the extent and distribu- nations depends very much on patient surgical therapy and where the patient has tion of the periodontal disease from the needs.4 A patient who is not periodontally a good level of plaque control, the bleeding clinical examination. Overall, intraoral british dental journal VOLUME 209 NO. 11 DEC 11 2010 559

practice

films are best for periodontal diagnosis will require radiographic examination and caries. However, a balance needs to to aid diagnosis. be struck between diagnostic value and When treating periodontal disease, the radiation exposure. The FGDP guidelines initial changes in probing depth follow- are helpful in this respect.5 Well aligned ing conventional treatment, both surgi- bitewing radiographs will allow assess- cally and non-surgically, are mostly due ment of early levels of bone loss affecting to changes in the soft tissues. Obviously, the posterior teeth, and vertical bitewings further radiographs are unlikely to show allow assessment of early to moderate significant changes from baseline and levels of bone loss. Periapical radiographs cannot be justified for at least a year, Fig. 6 An endodontic sinus draining along the periodontal ligament may mimic a will show advanced levels of attachment unless major changes occur. Small clinical periodontal pocket loss, as well as other features, such as the changes of 1 mm may represent probing root anatomy, possible furcation involve- error rather than actual deterioration, and ments, apical radiolucencies and widened radiographic examination is unlikely to be ligaments. These will help in the diagnosis of diagnostic benefit. of the pathological and physiological processes that are influencing the clinical pic- Vitality testing ture and will all influence the periodontal Endodontic lesions can, on occasion, mimic prognosis of an individual tooth. Further periodontal lesions. Periapical abscesses to this, the clinician must also consider can drain along the periodontal liga- the endodontic and restorative status of ment and present as a periodontal pocket the tooth to ascertain the overall prognosis probing to the apex (Fig. 6). Therefore, of the tooth. vitality testing is recommended for the Good quality panoramic radiographs following situations: have the advantage of showing the entire 1. Attachment loss approaching the root mouth. The nature of panoramic radiog- apex raphy may result in a lack of fine detail 2. Deep sites unresponsive to non- that is useful in the assessment and moni- surgical treatment toring of periodontal disease. The infor- 3. Periodontal pockets associated with mation shown represents a focal trough deep furcation involvements and information outside this will not be 4. Periodontal pockets associated with shown in detail and there is also a degree heavily restored teeth. of magnification. The decision on which areas to radio- Perio-endo lesions can be difficult to graph will depend on the clinical exami- diagnose, as can situations where there are nation. Periapical radiographs should be vertical fractures (Fig. 7). Correct treatment taken with a film-holder and paralleling will depend on the correct diagnosis, and Fig. 7 Rapid periodontal breakdown occurred on the distal root and into the furcation. technique since bisected angle radiographs, therefore it is essential that the clinician Surgical exploration revealed the vertical however well taken, distort the image. This gathers all possible information to help fracture on the distal root gives a picture that is very close to actual with said diagnosis. Where there is still size, and also improves the reproducibil- doubt over the underlying cause, the least prognosis may be patient-based, or done ity. A degree of reproducibility in position invasive treatment option should be con- for each tooth individually, or both. and angulation of radiographs is extremely sidered first, as a failure to respond may The prognosis for the patient will take useful in the long-term monitoring of peri- aid diagnosis. into account systemic risk factors such odontal disease. as smoking or susceptibility. The suscep- Follow-up radiographs may be taken Prognosis tibility of the patient can be considered in the long-term depending on clinical When all the appropriate data has been as the severity of the disease in the con- need. For instance, these might be needed gathered, the first step is to make a diag- text of how old the patient is. The long- to assess stability of the bone levels and nosis. The diagnosis should be relayed to term outcome is also highly reliant on look for areas of continued bone loss. the patient with an indication of its sig- the patient’s motivation, their ability to Such radiographs should follow a peri- nificance. The diagnosis may also help perform an adequate level of oral hygiene odontal examination and be based on a with the decision making and treatment and their willingness to maintain this in perceived need for the additional informa- planning. For example, a diagnosis of an the long-term. These factors cannot usu- tion that the radiograph will yield. Acute aggressive form of the disease may mean ally be judged early on in treatment, and problems, such as periodontal abscesses, that adjunctive systemic antibiotics will the patient prognosis may be adjusted rapid development of deep probing benefit the patient during non-surgical later on when such factors become sites or sudden increases in mobility treatment.6 For periodontal disease, the more apparent.

560 british dental journal VOLUME 209 NO. 11 DEC 11 2010

practice

A tooth-by-tooth prognosis is extremely an appropriate level of patient-centred important when dealing with cases that plaque control. Systemic antibiotics may 8 involve more than one branch of dentistry. useful in the management of acute peri- Where teeth need to be extracted and odontal conditions or in aggressive dis- replaced, or where teeth have endodontic ease where they are used as an adjunct to or restorative issues, treatment planning non-surgical treatment. There is no evi- can become a complex and confusing dence of benefit in using systemic antibi- process. To approach this logically, a deci- otics in the management of early-moderate sion needs to be taken as to whether or not chronic periodontitis.6 individual teeth are likely to survive in the One key issue with the treatment of 9 short-, medium- and long-term. Obviously moderate to advanced periodontal disease a patient will not be happy if their new is the relative uncertainty of the outcome bridge fails after a short period because of treatment. Initial treatment will almost the abutments had untreatable periodon- invariably start with a course of non- tal disease or endodontic complications. surgical therapy. This may be undertaken Sometimes it is appropriate to use compro- with the knowledge that surgery is likely. mised teeth, for instance as part of a tran- However, the decision to proceed with sitional treatment plan or if the prognosis surgery can only be taken at the reas- is reasonably favourable but not yet clear. sessment stage, based on the need still In this situation, the patient must be fully being present and on several factors aware of the risks of failure and agree to being favourable, such as an appropri- accept the compromise after an explana- ate level of oral hygiene. Patients should Figs 8 and 9 Poorly fitting veneers with tion of why such a plan is being consid- be informed of this and the reasons for subgingival margins leading to marginal inflammation. Over-preparation has also led ered, and what the options are. This does initial uncertainty about the treatment to a loss of vitality of 12 and 21 not give the dentist the right to undertake needs explained. inappropriate treatment, just because a The initial uncertainty about teeth with patient has agreed to it. a questionable periodontal prognosis may also affect treatment planning. Teeth with Treatment planning such a prognosis may also have signifi- Treatment planning may be a relatively cant restorative requirements. However, simple process or it may be complex, the medium- to long-term prognosis may depending on the degree of the periodon- be uncertain until after periodontal treat- tal attachment loss and the extent of other ment. In such cases primary disease such restorative dental problems that need to be as caries or apical pathology should be considered. Obviously the more problems addressed, with the deferment of complex that need to be addressed, the more pos- and potentially expensive treatments until sible options there are to be considered. after a favourable response to periodontal Fig. 10 Subgingival veneer margin in thin tissues may lead to gingival recession The nature of the treatment plan may be treatment has been seen. The provision of influenced by the patient’s presenting a provisional bridge, for example, where complaints and their specific requirements. one or more of the abutment teeth has a inflammation and attachment loss (Figs 8 That said, patients must be made aware of questionable periodontal prognosis will and 9). Wherever possible, margins should all reasonable options and the advantages reduce the initial cost to a paying patient. be properly finished and supragingival. and disadvantages involved. The patient is less likely to be dissatisfied Invasion of the biologic width will result There are a number of adjunctive anti- should the supporting teeth prove peri- in an apical shift in the attachment appa- biotic and antiseptic devices that are odontally untreatable in a relatively short ratus. Where this is associated with thick commercially available for use in the time. If the periodontal prognosis of the gingival tissues, there will be an associated treatment of periodontal disease. The abutment teeth looks favourable follow- increase in probing depth. This may pre- decision to use such products lies with the ing the periodontal treatment, then the dispose to a progressive attachment loss in clinician, within the context of informed permanent bridge can be made with more the susceptible patient. Where the tissues are consent. What should be stressed is that confidence about its longevity. thin, the patient is likely to develop localised these products are designed to be used gingival recession. While this is unlikely to as adjuncts to properly performed non- Restorative dentistry progress, it might result in exposure of the surgical periodontal treatment. They Restorations can contribute to perio- restoration margin, which may be unac- are unlikely to be of any benefit to the dontal disease where they act as plaque ceptable to a patient in the aesthetic zone patient in all but the short-term in retentive factors. Subgingival margins (Fig. 10). Recession might also occur where the absence of adequate supragingi- and overhanging or deficient margins localised inflammation is not resolved before val and subgingival debridement and in particular may contribute to localised placement of the restoration. Placement of british dental journal VOLUME 209 NO. 11 DEC 11 2010 561

practice

restorations under such circumstances is they must understand why the treatment is through a lack of interest or ability, more likely to result in inadequate margins structured in the way that it is. Definitive then the relevance of this must be explained due to moisture contamination during the treatment planning may not be possible at clearly to the patient and the conversation impression taking or bonding. If the patient the outset. The prognosis of certain teeth documented in the notes. Such patients may does manage to control the gingivitis, then and the patient in general may only become benefit from regular periodontal mainte- the subsequent gingival shrinkage may apparent after the response to the stages of nance where regular professional plaque result in exposure of the margins. Margins treatment can be assessed. In such a case, control may, in part, compensate for the should be finished supragingivally or just it is important that the patient understands patient’s inadequate level of oral hygiene. within the sulcus to allow adequate cleaning this at the outset. Patients who are unaware when aesthetics is critical. of this may be unpleasantly surprised after a Smoking course of invasive treatment, if they are only There is an established link between smok- Implant dentistry told then that they need further treatment. ing and chronic periodontitis. Smokers The exact nature of the interaction experience increased amounts of attach- between periodontal disease and dental Oral hygiene ment loss and respond less well to treat- implants is not clear, although current Effective patient oral hygiene is one of ment. True ‘refractory periodontitis’, that is best evidence suggests that in patients suc- the key factors in the successful treatment chronic periodontitis that does not respond cessfully treated for periodontitis, there is of chronic periodontitis. The long-term to well performed conventional therapy, is an increased risk of implant failure and success of periodontal treatment, and in rare. The majority of patients who do not biological complications.7 In view of the particular patients who are overtly suscep- respond to treatment in the long-term, in evidence, patients should be warned about tible, relies very much on them achieving spite of adequate professional and home- the risk. It is clearly unacceptable to place and maintaining high standards of oral care, are smokers. implants into a mouth that has untreated or hygiene in the long-term. Periodontal patients should be informed inadequately treated periodontal disease. Effective oral hygiene is the responsibility of the implications of their smoking habit of the patient. However, the dental team’s and the effect that it will have on treatment Alternatives – longevity and cost role is to provide appropriate advice and and prognosis. Smoking cessation advice When formulating a treatment plan for an training throughout the period of care. This should be given. Current best practice is advanced periodontal case or a complex responsibility includes assessment of: to refer patients interested in quitting for restorative case, there may be many alter- 1. Effectiveness of existing oral hygiene specialist advice such as NHS stop smok- native approaches. As we have mentioned 2. The need for coaching and advice ing clinics unless the dental team possesses before, a patient must be aware of all rea- 3. The provision of appropriate advice these specialist skills.8 sonable alternatives and options before and coaching including teaching of accepting a treatment plan and consenting techniques and selection of aids. Non-surgical treatment to treatment. The various pros and cons, As with any clinical procedure, the cli- risks and benefits, cost and long-term con- Careful documentation will facilitate nician must be competent and suit- sequences should be explained. ongoing care by ensuring that all members ably equipped for the job in hand. Sickle of the dental team are informed about the scalers are not designed for subgingival Periodontal Prevention patient’s care (and choices) to date. The use as by definition they have a pointed and Treatment patient’s reaction to such advice should end which can damage the gingival Education also be recorded. Similarly, the patient tissues. Periodontal curettes have a rounded should be advised of the level of their oral end and are therefore suitable for subgingival It would seem obvious that once a patient hygiene and also be educated as to why use. No single curette can access all sites in has been diagnosed with a condition, they their homecare is such an essential part of a quadrant due to the design of the working should be informed of the nature and effective periodontal treatment. ends. The clinician should have the appro- significance of that condition. In the case priate instruments to be able to adequately of chronic periodontal disease, successful Patients who have inadequate oral access all the involved root surfaces. hygiene, despite adequate advice treatment relies very heavily on patient and coaching Before non-surgical therapy, patients motivation and adherence to self-care. should be warned of likely side effects. Susceptible patients will be expected to Complex treatment such as periodontal sur- The most common include: spend a significant time each day under- gery is contra-indicated in the presence of • Recession (particularly the taking a thorough cleaning regime. It is inadequate plaque control. Before embark- development of black triangles) unreasonable to expect the patient to ing on such treatment, patients should have • Dentine sensitivity which is usually perform such tasks without understanding proven to be motivated and able in their mild and responsive to fluoride its importance. cleaning. Ideally this should be assessed and toothpastes and mouthrinses Periodontal treatment plans can be recorded by means of an objective measure • Food packing between teeth. expensive and involve many appointments, such as a percentage plaque score. some of which may be relatively invasive. Where patients fail to achieve an Furthermore, it might be helpful to warn For patients to agree to such treatment, adequate level of oral hygiene, either patients of a possible increase in bleeding

562 british dental journal VOLUME 209 NO. 11 DEC 11 2010

practice

sionals ensures that the patient receives but should also occur if the patient is not 11 proper treatment. responding as would be expected. When working with a hygienist, the A standard periodontal treatment plan, dentist should explain exactly what is be it for a course of non-surgical or surgi- required. The current curricula frameworks cal treatment, will end with a reassessment. produced by the General Dental Council Since the supervising dentist is ultimately as guidelines for the training of dental responsible for the patient’s well-being, it hygienists suggest that hygienists should, would seem appropriate that such a re- among other things, be able to: examination is performed by, or in discus- • Be competent at providing preventive sion with, the dentist. The next stage of oral care for the individual patient who patient care, be it further active treatment 12 presents with dental caries, periodontal or maintenance, will then be planned by disease and tooth wear the dentist. • Be competent at completing a The NICE guideline on dental recall4 is periodontal examination and charting specifically aimed at helping clinicians • Be competent at supragingival to decide on appropriate recall intervals and subgingival scaling and root between oral health reviews. It does not debridement, using both powered and give guidance on the intervals between manual instrumentation, and in stain examinations relating to ongoing courses removal and prophylaxis of treatment. This would include a course • Be competent in the use of of periodontal treatment. Figs 11 and 12 Soft tissue changes following appropriate antimicrobial therapy non-surgical periodontal treatment in the management of plaque Surgical treatment related diseases.9 Periodontal surgery plays a role in achieving the main aim of periodontal treatment, and tenderness at the commencement of When referring the patient to the hygi- which is long-term maintenance and pre- thorough oral hygiene and scaling. enist, the dentist must be clear what is vention of continued attachment loss. This Non-surgical therapy may result in a expected from the hygienist, what aspects is facilitated by access to the root surfaces period of dentine sensitivity following the of the periodontal treatment plan are to for visualised debridement, and by reshap- removal of root surface deposits and sub- be undertaken by the hygienist, and what ing the hard and soft tissues to facilitate sequent gingival recession. Patients should will be undertaken by the dentist. The role post-surgical maintenance, both profes- be warned of this and encouraged to re- of the hygienist must fall within the scope sional and by the patient. Periodontal sur- attend should this become problematic. of their competence. gery does not represent a magic bullet in Where patients have particularly inflamed Once the patient has been referred to the the treatment of chronic periodontitis. Its tissues, often associated with significant hygienist, the dentist can ask the hygienist success will rely on a number of factors. plaque retentive factors, then there is scope to set the recall intervals, defined as how Periodontal surgery is destined for for significant amounts of recession to often the patient should return to be seen failure in the absence of immaculate oral occur following non-surgical therapy. This by a member of the dental team. The den- hygiene by the patient and long-term may result in an aesthetic change, such as tist, however, should also set a reassess- periodontal maintenance. In almost all the creation of ‘black triangles’ between ment date, when the patient must return cases, periodontal surgery is only consid- the teeth due to loss of the papillae (Figs 11 to be seen by a dentist for a full-mouth ered following the completion of a course and 12). Patients should be warned of this examination and treatment plan. of thorough non-surgical treatment. One before embarking on treatment. The General Dental Council, in its docu- of the key factors in this is establishing ment ‘Principles of dental team working’,10 a proven level of patient homecare and Role of the dental states that ‘all members of the dental team a commitment to periodontal treatment. hygienist/therapist who have to register with us are individu- Sufficient time should also be allowed Any course of dental treatment should ally responsible and accountable for their following the active phase of treatment start with a full mouth assessment by a own actions and for the treatment proc- to allow the response to the non-surgi- dentist. This should result in a diagnosis esses which they carry out.’ However, the cal treatment to be assessed. Surgical and treatment plan. If the treatment plan dentist does take on overall responsibility treatment can then be considered for includes a referral to a dental hygienist (or for the care of the patient. While under sites that have not responded to the less therapist) then there is a shared respon- the care of a hygienist, the hygienist has a invasive therapy. The non-surgical treat- sibility for that patient. It is therefore responsibility to the patient to refer back to ment will also improve the health of the imperative that both dental profession- the dentist when it is appropriate and this superficial tissues, which facilitates the als understand their role in the manage- should be defined by the dentist, as well surgical phase, improving the soft tissue ment of that individual patient, and that as the procedure for doing this. This may handling and reducing the amount of communication between those profes- be at the end of a defined treatment plan, intra-operative bleeding. british dental journal VOLUME 209 NO. 11 DEC 11 2010 563

practice

Periodontal maintenance/ The initial extent of attachment loss during the period that self-performed supportive periodontal treatment will, to a degree, dictate the end result. plaque control is not possible or diffi- Periodontal surgery may be aimed at cult. Professional care must assume this Chronic periodontal disease is not cured pocket elimination where this achiev- responsibility including plaque removal and treatment is aimed at control. The able, or access for debridement. The latter and modification of self-care methods. parameters used to monitor periodontal may be indicated where deep persistent disease are predominantly plaque control, pocketing or complex root anatomy lim- Regenerative materials probing depths and bleeding on probing. its non-surgical debridement. Where the Periodontal regenerative surgery utilises None of these are good predictors of sites extent of the bone loss is excessive, peri- various surgical adjunctive materials at risk of attachment loss; however they odontal surgery may be destined to fail with the aim of promoting regeneration are associated with an increased risk of and in such cases can lead to hastening of cementum, periodontal ligament and attachment loss occurring. the loss of the tooth. Obviously patients alveolar bone lost though periodontal dis- Patients entering maintenance following need to be aware of this before agreeing ease. The initial protocol for ‘guided tissue the treatment of chronic periodontitis are to undergo the discomfort and expense of regeneration’ utilised Gore-Tex membranes likely to fall into one of two categories. such a procedure. which were secured over periodontal The first are patients who have reached the Conventional periodontal surgery has bone defects beneath the mucoperiosteal end of active treatment and are considered a resective component, be it excision of flaps. More recently, other materials and ‘treated’. These patients must be monitored part of the soft tissue or bone reshaping approaches for periodontal regeneration and assisted in maintaining the post- by means of osteoplasty or ostectomy. This have been researched and are now avail- treatment result. They require regular oral can result in a dramatic apical shift of the able for use in dental practice. hygiene re-inforcement, regular suprag- dento-gingival tissues resulting in gingival Resorbable membranes have the advan- ingival and subgingival debridement, and recession. Surgically created recession in tage that, unlike the Gore-Tex membranes, close monitoring of the probing depths. the upper anterior region may be aestheti- they do not need to be removed. Many Recurrence of increased probing depths cally unacceptable to the patient. A patient resorbable membranes are made from will require further active treatment. should certainly be warned about such synthetic materials, however a signifi- The second group are patients who are recession before consenting to anterior cant proportion are derived from bovine deemed untreatable. These may be patients periodontal surgery. There is evidence that or porcine collagen. Bovine derived bone who consistently fail to achieve an ade- repeated courses of non-surgical treatment mineral derivatives are also commonly quate standard of oral hygiene, either may result in a similar end result, however used, as are enamel matrix proteins which because they will not or cannot clean this will occur over a relatively long time- are extracted from young pigs. All these properly. Other patients may not be pre- frame. Since the change occurs gradually, materials have been approved for medi- pared to complete treatment for financial the impact might be less dramatic cal use and should be considered safe. reasons or because they are not prepared to When undertaking periodontal sur- The decision, however, to insert any of undergo complex periodontal treatments gery, patients should be given appropriate these materials lies with the patient, such as surgery. Such patients will benefit pre-operative warnings for oral surgical and should be made by the patient with from regular maintenance, though this is procedures. Risks of prolonged bleeding enough information regarding the moral aimed at slowing disease progression. and infection are minimal with careful and medical implications. Regenerative The interval between maintenance technique and appropriate postoperative procedures are also technically chal- appointments should be tailored to the instructions. Nerve damage is a remote lenging and can be unpredictable with- patient’s need. Often after active treat- risk unless with injudicious surgery to out very careful case selection. Patients ment for chronic periodontitis, an initial the lingual of the lower second and third should be aware of this before agreeing three monthly recall interval is set. The re- molars and buccal to the lower premolars. to treatment. examination date should also be set. The Post-surgical pain is usually minimal, but maintenance interval may be increased will vary depending on the extent of the Consequences of treatment – after periods of stability have been aesthetic and functional surgery, the time that the mucoperiosteal observed. If patients show signs of dis- flaps are raised and the amount of exposed As we have mentioned previously, peri- ease recurrence or attachment loss during alveolar bone left after surgery. Patients odontal treatment can result in irrevers- maintenance, then they should be assessed should be warned of this and the appropri- ible changes that can inconvenience the and a new treatment plan formulated to ate analgesic advice given. A chlorhexi- patient. Gingival recession may create an address their problems. dine rinse should be given to compensate aesthetic issue for the patient, in particular for the inability to mechanically clean the the creation of ‘black triangles’ between When to refer surgical area in the immediate post-surgi- the teeth where the papillae have been lost. When a clinician accepts a patient, he cal phase. Patients should also be warned Gingival recession in combination with or she has a duty of care for that patient. about sutures and also periodontal dress- root surface instrumentation often leads The decision of whether to treat or whether ing if this is to be used. to dentine sensitivity. This can usually be to refer will depend on the clinician’s One essential component of postopera- controlled by local measures but on occa- ability, determined by their training and tive care will be professional plaque control sion can become persistent experience. If they undertake periodontal

564 british dental journal VOLUME 209 NO. 11 DEC 11 2010

practice

treatment, then they should be monitor- their ability or experience, then they have 1. Palmer R M, Floyd P D. A clinical guide to periodontology. 2nd ed. London: BDJ Books, 2003. ing the response and reacting accord- a duty of care to the patient to offer refer- 2. National Institute for Health and Clinical Excellence. ingly. If the patient does not respond in ral to someone who is suitably trained. The Prophylaxis against infective endocarditis. Clinical guideline 64. London: NICE, 2008. http://guidance. the expected manner, if they continue extent of the disease is not the only fac- nice.org.uk/CG64. to lose attachment for example, then tor that should be considered. Risk factors 3. British Society of Periodontology. Periodontology in general dental practice in the United Kingdom. the treatment plan should be adjusted should also be taken into account. Smokers A policy statement. Leeds: British Society of accordingly and this may include referral to may provide more challenges to treat- Periodontology, 2001. http://www.bsperio.org.uk/ members/policy.pdf. a more experienced practitioner or special- ment in the long-term and where there 4. National Institute for Health and Clinical Excellence. ist. The British Society of Periodontology is advanced disease, early referral may Dental recall. Recall interval between routine dental has drawn up guidelines on patient referral be appropriate. examinations. Clinical guideline 19. London: NICE, 2004. http://guidance.nice.org.uk/CG19. in their document titled ‘Referral policy Aggressive disease, and in particu- 5. Faculty of General Dental Practitioners (UK). and parameters of care’.11 lar where this presents in people under Selection criteria for dental radiography. London: Faculty of General Dental Practitioners (UK), 2004. A BPE score of 3 or less should be 35 years of age, may also benefit from 6. Herrera D, Alonso B, Leon R, Roldan S, Sanz M. treatable by means of relatively simple early referral. Such patients can lose bone Antimicrobial therapy in periodontitis: the use of systemic antimicrobials against the subgingival bio- periodontal therapy. It is reasonable to at relatively rapid rates and may benefit film. J Clin Periodontol 2008; 35(Suppl 8): 45–66. expect a properly trained dentist to be from the care of someone experienced in 7. Ong C T, Ivanovski S, Needleman I G et al. Systematic review of implant outcomes in treated able to manage such patients. That said, their management. Obviously, the sooner periodontitis subjects. J Clin Periodontol 2008; where there are aggravating factors or such patients can be brought under 35: 438–462. 8. National Institute for Health and Clinical Excellence. an unusual presentation, the involve- control, the more likely they are to retain Brief interventions and referral for smoking ces- ment of a specialist may aid diagnosis their teeth. sation in primary care and other settings. Public health intervention guidance no. 1. London: NICE, and management. Patients who present with periodontal 2006. http://guidance.nice.org.uk/PHI1/?c=296726. A BPE score of 4 implies moderate disease combined with significant levels of 9. General Dental Council. Developing the dental team. London: General Dental Council, 2004. to advanced disease. Whether or not to other dental disease can be demanding to 10. General Dental Council. Principles of dental team refer depends on the competence of the treatment plan. Involvement of a special- working. London: General Dental Council, 2009. 11. British Society of Periodontology. Referral policy practitioner in managing the presenting ist can help with formulating a suitable and parameters of care. http://www.bsperio.org.uk/ patient. If the level of disease is beyond treatment plan. members/referral.htm (accessed 31 March 2010).

british dental journal VOLUME 209 NO. 11 DEC 11 2010 565