VITAL GUIDE

VITAL GUIDE SERIES Vital guide to 15

● Which affect the periodontal tissues?

● How can periodontal diseases be treated?

● Is the wider dental team involved? VITAL GUIDE TO Periodontology

Geoff Sharpe* explains why dental professionals should strive to promote excellent periodontal health for all patients.

Introduction Periodontal diseases affect a signifi cant pro- portion of the population. The most prevalent periodontal is , although it should be remembered that this condition is only one of a number of diseases that can affect the periodontal tissues (Table 1).1 Chronic periodontitis is a plaque-induced infl ammatory disease resulting from interac- tions between plaque and the immune Fig. 1 Chronic periodontitis case showing system. These interactions result in loss of plaque accumulation, marked gingival and bleeding after probing attachment to the root surface and pocket for- mation, allowing more bacteria to accumulate beneath the . If left untreated, disease.3 Although a causal link has not been loss of supporting alveolar occurs, which proven, the common risk factors between the Fig. 2 A WHO used to can lead to increased mobility and loss.2 two conditions are now well established and carry out a Basic This process may be exacerbated by various are subject to ongoing research activity. Some (BPE). All sites (excluding third molars) are examined and each sextant given a code systemic factors such as , and of this discussion has been published in the depending on the worst site in that sextant some rare disorders of the . news media and many patients are becoming (as described in Table 2) Common signs and symptoms of periodon- concerned over the possible link between peri- titis include bleeding , halitosis, receding odontitis and their overall general health. gums, tooth sensitivity and (Fig. 1). Unfortunately, periodontal diseases Diagnosis of periodontal diseases often don’t cause obvious symptoms until Since periodontitis is often asymptomatic, it is the teeth begin to move or feel loose. Many essential to screen all patients for periodontal patients think that it’s perfectly normal to have diseases to allow early diagnosis and treat- bleeding gums when brushing! ment. A simple and effective way of screening There is emerging evidence of a signifi - patients in general dental practice is to carry cant association between periodontitis and out a Basic Periodontal Examination (Table other diseases, most notably cardiovascular 2) using a WHO periodontal probe (Fig. 2). Patients who have signs of signifi cant peri- * Specialist in Periodontics, odontitis will require a more comprehensive The Cosmetic Dental Clinic, examination including pocket charting, bleed- 2 Old Eldon Square, ing scores and radiographs in order to assess Newcastle-upon-Tyne, NE1 7JG Fig. 3 Radiograph showing advanced bone the extent of the disease and periodontal bone loss resulting from severe chronic periodontitis Email: [email protected] levels (Fig. 3).4 www.nature.com/vital vital 15 VITAL GUIDE

Table 1 1999 International Workshop Classification of Periodontal Diseases

I Gingival diseases

II Chronic periodontitis

III

IV Periodontitis as a manifestation of systemic diseases Fig. 4 Chronic periodontitis case before initial periodontal therapy V Necrotising periodontal diseases

VI Abscesses of the

VII Periodontitis associated with endodontic lesions

VIII Developmental or acquired deformities and conditions

Table 2 The Basic Periodontal Examination (BPE)

Given to the sextant if there are no pockets exceeding 3 mm in depth Fig. 5 Chronic periodontitis case (seen in Fig. Code 0 (coloured area remains totally visible), no or overhangs of fi llings 4) after initial periodontal therapy and no bleeding after gentle probing.

Given to the sextant if there are no pockets exceeding 3 mm in depth control, most periodontal patients will require Code 1 (coloured area remains totally visible) and no calculus or overhangs of supportive periodontal treatment at regular fi llings but bleeding occurs after gentle probing. intervals in order to monitor their , remove any deposits and re-instrument any Given to the sextant if there are no pockets exceeding 3 mm in depth residual sites that the patient is unable to access.7 (coloured area remains totally visible) but dental calculus or other Code 2 Much of this treatment may be carried out by a plaque retention factors are seen at, or recognised underneath, the or therapist working under the gingival margin. guidance of a or periodontist. Various types of locally delivered antimi- Given to the sextant if the colour coded area of the probe remains Code 3 crobials are available to place into periodontal partially visible when inserted into the deepest pocket. pockets and these can be useful to manage non- responding sites or areas of disease recurrence. Given to the sextant if at one or more teeth the colour coded area of the are rarely indicated in the manage- Code 4 WHO probe disappears into the infl amed pocket indicating pocket depth ment of periodontitis except in exceptional of 6 mm or more. circumstances, such as in cases of aggressive periodontitis.

Given to a sextant if there is total attachment loss at any site of 7 mm or Surgical treatment Code * more, or if a furcation can be probed. Further treatment may occasionally be necessary to deal with residual pockets or diffi cult ana- tomical features. This can involve periodontal Initial periodontal therapy greater focus on subgingival decontamination surgery to allow better access to the root surface, Maintaining excellent oral hygiene on a daily and disruption of the subgingival biofi lm, usu- eliminate periodontal pockets and re-shape the basis is critical for successful treatment. This is ally with ultrasonic instrumentation and often periodontal tissues to aid oral hygiene proce- an excellent opportunity to involve the whole over fewer appointments. In the presence of dures by the patient.8 In certain circumstances, it dental team in providing educational materials adequate supragingival plaque control, this ini- is possible to regenerate some of the periodon- and oral hygiene advice. tial therapy allows resolution of infl ammation tal tissues that have been lost due to destructive The conventional approach to periodontal and a reduction in probing pocket depths (Figs periodontal diseases by using specialist tech- treatment is to remove bacterial deposits from 4-5).5 Full- treatment protocols typically niques and biomaterials.9 the teeth and root surfaces by scaling and root involve instrumentation within a very short planing. This traditionally involves thorough timescale (usually within 24 hours) and often Rehabilitation of the periodontally subgingival to remove all plaque require signifi cant adjunctive compromised dentition and calculus using a combination of hand application. The concept of ‘full-mouth disin- Periodontitis is a major cause of and and ultrasonic instruments over a series fection’ has been very popular in recent times, many patients will require replacement of miss- of appointments. although new research suggests that conven- ing teeth due to the effects of periodontitis. This Contemporary treatment places less emphasis tional staged treatment may be just as effective.6 requires careful treatment planning and often on mechanical scaling of the root surface and a Once the disease has been brought under requires multi-disciplinary management with

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ensure maintenance of the biologic width and maintenance care in the treatment of peri- a stable outcome. This technique can also be odontal disease. J Clin Periodontol 1981; 4: helpful when restoring posterior teeth with 281-294. subgingival restoration margins or when insuf- 8. Heitz-Mayfi eld L J A, Trombelli L, Heitz F, fi cient coronal tissue remains to provide a Needleman I, Moles D. A systematic review satisfactory restoration. of the effect of surgical debridement vs. can be treated with soft non-surgical debridement for the treatment tissue surgery using locally repositioned fl aps of chronic periodontitis. J Clin Periodontol

Fig. 6 Gingival asymmetry case prior to or soft tissue grafts taken from elsewhere in the 2002; 29 (Suppl 3): 92-102. cosmetic treatment mouth to cover recession defects.13 Soft tissue 9. American Academy of Periodontology grafting may also be necessary to recreate a Academy Report. Position Paper. Periodon- better soft tissue profi le beneath pontics tal Regeneration. J Periodontol 2005; 76: or adjacent to implant fi xtures to improve the 1601-1622. aesthetic outcome. 10. Wennström J L, Ekestubbe A, Gröndahl K, Karlsson S, Lindhe J. Oral rehabilitation Conclusions with implant-supported fi xed partial den- Periodontology has evolved over the years to tures in periodontitis-susceptible subjects. A address not only the treatment of periodontitis, 5-year prospective study. J Clin Periodontol but also the functional and cosmetic rehabilita- 2004; 31: 713-724. tion of patients who have suffered periodontal 11. Berglundh T, Persson L, Klinge B. A system-

Fig. 7 Gingival asymmetry case (seen in Fig. diseases. Our approach to treating periodontitis atic review on the incidence of biological 6) after lengthening surgery to improve has also changed to refl ect a greater understand- and technical complications in implant den- gingival contours and provision of anterior ing of the disease process and the response tistry reported in prospective longitudinal veneers (restorations by Dr Darren Cannell) to therapy. studies of at least 5 years. J Clin Periodontol The whole dental team can play an important 2002; 29 (Suppl 3): 197-212. role in managing periodontitis by becoming 12. Garber D A, Salama M A. The aesthetic input from periodontists, prosthodontists and involved with patient education, providing oral smile: diagnosis and treatment. Periodontol dental technicians. Dental implants are becom- hygiene advice, co-ordinating treatment and 2000 1996; 11: 18-28. ing more widely available to replace missing carrying out some of the initial non-surgical 13. Zucchelli G, Cesari C, Amore C, Mon- teeth and are often the treatment of choice in therapy. Most periodontal diseases are prevent- tebugnoli L, De Sanctis M. Bilaminar the rehabilitation of the periodontally compro- able with good oral hygiene and we should techniques for the treatment of recession mised dentition.10 Since periodontitis results in therefore strive to promote excellent periodontal type defects. A comparative clinical study. J the loss of alveolar bone, placement of implant health for all of our patients. Clin Periodontol 2003; 30: 862-870. fi xtures in patients who have suffered periodon- titis may be quite complex, sometimes requiring 1. Armitage G. Development of a classifi cation Further reading bone grafts or augmentation to provide suffi - system for periodontal diseases and condi- Lindhe J, Lang P L, Karring T. Clinical cient bone for implant placement. tions. Ann Periodontol 1999; 4: 1-6. periodontology and implant , 5th ed. Peri-implant disease (peri-implantitis) is 2. Offenbacher S. Periodontal diseases: patho- Blackwell Munksgaard, 2008. also becoming an increasing problem and can genesis. Ann Periodontol 1996; 1: 821-78. be diffi cult to manage.11 It is very important to 3. Friedewald V E, Kornman K S, Beck J D, Test yourself thoroughly treat any existing Genco R et al. The American Journal of prior to implant treatment and arrange frequent Cardiology and Journal of Periodontol- 1. Bone loss from chronic periodontitis review appointments to carry out any necessary ogy Editors’ Consensus: Periodontitis and may be exacerbated by: supportive periodontal treatment. atherosclerotic . J Peri- A. smoking odontol 2009; 80: 1021-1032. B. alcohol intake Cosmetic periodontal treatment 4. The British Society of Periodontology. Peri- 2. All patients should be screened for There has been a signifi cant growth in the odontology in general dental practice in the periodontal diseases by carrying out: market for cosmetic dental treatment in recent United Kingdom. A Policy Statement. 2001. A. a full mouth years. Many patients are requesting ‘smile make- http://www.bsperio.org.uk/members/policy. B. a Basic Periodontal Examination overs’ involving , pdf (BPE) or the provision of porcelain crowns or veneers. 5. Cobb C M. Clinical signifi cance of 3. Supportive periodontal treatment may It is important that the soft tissue aesthetics are non-surgical periodontal therapy: an evi- be carried out by: not overlooked when planning and discussing dence-based perspective of scaling and root A. dental hygienists or therapists cosmetic dental treatment. Common problems planing. J Clin Periodontol 2002; 29 (Suppl B. registered only include gingival asymmetry, excess gingival dis- 2): 6-16. play and recession.12 6. Eberhard J, Jepsen S, Jervøe-Storm P M, 4. Most periodontal diseases: Excess gingival display can be treated using Needleman I, Worthington H V. Full-mouth A. are preventable with good crown-lengthening surgery to reduce the disinfection for the treatment of adult oral hygiene

amount of soft tissue around the teeth and chronic periodontitis. Cochrane Database of B. do not require treatment

1A, 2B, 3A, 4A. 3A, 2B, 1A, recreate a more natural gum line (Figs 6-7). Syst Rev 2008; 1: 1-71. Answers: Osseous recontouring is usually required to 7. Axelsson P, Lindhe J. The signifi cance of www.nature.com/vital vital 17