VITAL GUIDE VITAL GUIDE SERIES Vital guide to periodontology 15 ● Which diseases 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 disease is chronic periodontitis, 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 bacteria and the immune Fig. 1 Chronic periodontitis case showing system. These interactions result in loss of plaque accumulation, marked gingival inflammation and bleeding after probing attachment to the root surface and pocket for- mation, allowing more bacteria to accumulate beneath the gingival margin. If left untreated, disease.3 Although a causal link has not been loss of supporting alveolar bone occurs, which proven, the common risk factors between the Fig. 2 A WHO periodontal probe used to can lead to increased mobility and tooth loss.2 two conditions are now well established and carry out a Basic Periodontal Examination 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 smoking, diabetes and of this discussion has been published in the depending on the worst site in that sextant some rare disorders of the immune system. 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 gums, halitosis, receding odontitis and their overall general health. gums, tooth sensitivity and tooth mobility (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 Aggressive periodontitis 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 periodontium 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 calculus 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 oral hygiene, 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 dental hygienist or therapist working under the gingival margin. guidance of a dentist 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 Antibiotics 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-mouth 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 debridement to remove all plaque require signifi cant adjunctive chlorhexidine compromised dentition and calculus using a combination of hand application. The concept of ‘full-mouth disin- Periodontitis is a major cause of tooth loss 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 16 vital www.nature.com/vital VITAL GUIDE 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. Gingival recession 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 bridge 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