Key points

  • Discusses the transition from UK undergraduate training in periodontology to treatment in NHS general practice.

  • Provides young practitioners' opinions on managing periodontal disease in NHS general practice.

  • Suggests clarity and change are needed to improve periodontal care in NHS general practice.

Introduction

Periodontal disease is one of the most common diseases in man and is mostly preventable.1 The majority of patients encountered in general practice are likely to have some form of the disease and it is often the first oral disease that is taught at dental school. However, the management of this condition in general practice appears to vary greatly between practitioners.

Knowledge of the periodontal structures and diseases forms a key part of undergraduate training as without a periodontally sound foundation, further restorative treatment is destined to fail. A study that questioned educational providers across 14 UK dental schools found that there is considerable uniformity with respect to periodontology teaching provided across UK institutes.2 This likely reflects the standardised GDC requirements3 and the comprehensive guidance set out by The European Federation of Periodontology.4 Unfortunately, the study lacks information on student experience in terms of case-load, case-mix and treatment experience. Discussion among recent graduates from different dental schools reveals varied clinical experience in both the number and type of patient cases seen during undergraduate training. However, newly qualified dentists leave dental school with the same academic grounding regarding the management of periodontal disease, even if they haven't had the same clinical experience.

The authors of this article, Louise Griffith and Jessica Naylor, are young dental associates working in mixed general practices in the South West of England and pursuing postgraduate research degrees at the University of Bristol. They both graduated in 2016, Louise from Newcastle University and Jessica from the University of Leeds and in this Q&A article they outline their experience of managing periodontal disease in NHS general practice.

Do you think your undergraduate teaching prepared you to treat periodontal patients in general practice?

Undergraduate training is comprehensive, both clinically and academically, and we emerge newly qualified with our heads full of facts, figures and best practice - all the things needed to pass finals. So yes, the knowledge and clinical skills should be adequate to prepare us for managing the disease in practice. What we soon came to realise, however, was how sheltered the walls of the dental hospital were compared to a busy NHS general practice. Seeing 30 patients a day compared to the maximum of three we would see in a university session is daunting. Couple this with suddenly having to get to grips with the NHS bands of treatment and then we didn't feel quite so prepared.

Talking to other recent graduates about their hands-on periodontal experience is eye-opening due to the wide variety of clinical experience between graduates from different schools. Some dental schools require all students to manage cases of severe periodontitis or to shadow surgical procedures for the students to meet their clinical quotas. In other schools, however, this kind of treatment is saved for specialists and is only addressed in lectures.

How different is your experience of periodontal treatment in practice compared to dental school?

We were taught that the management of periodontal disease involves several appointments as one course of periodontal treatment at dental school. As a student dentist, the first appointment with a new patient includes oral hygiene instruction, disclosing and plaque scores, bleeding on probing scores and simple scaling. Baseline pocket charting is carried out at the subsequent appointment along with reinforcement of oral hygiene. Oral hygiene thresholds are applied and the patient must have a plaque score below a target percentage before they can continue for non-surgical root surface debridement, which is carried out over multiple appointments.

Graduating from dental school into practice, the speed of diagnosis and any subsequent treatment must increase to achieve the same desired outcomes. How this is achieved varies greatly among practitioners. The first hurdle recent graduates must negotiate is to clarify what constitutes an NHS course of treatment.

Initially, the NHS banding system left us uncertain on what is involved in a single course of treatment when treating periodontal disease as we were taught in dental school that periodontal disease requires regular maintenance. There was also the worry about being accused of 'splitting' treatments up if we believed a patient needed to be stabilised before providing more complex treatment. The guidance from NHS Business Services Authority states that: 'Periodontal treatment, both surgical and non-surgical, including root-planing, deep scaling, irrigation of periodontal pockets, subgingival curettage is always Band 2, regardless of the number of visits that the treatment would require'. The number of visits required is left to the dentist's clinical judgement, on a case-by-case basis.5

In 2016, we both attended a post-graduate study day held at Bristol Dental School during which Dr Shazad Saleem outlined the 'Healthy Gums DO Matter' toolkit, an evidence-based care pathway approach for managing periodontal disease in NHS Dental practice. This teaching was invaluable and provided us with guidance on setting oral hygiene thresholds for NHS periodontal treatment in a familiar way, similar to how we provided treatment at dental school. By tailoring our treatment plan to the patient's needs, considering their current risk levels and ensuring appropriate record keeping and discussions with the patient, it is possible to improve a patient's oral health whilst being remunerated fairly for the time spent with the patient. We would recommend similar post-graduate study days on how to provide appropriate and ethical dentistry under the NHS system for all dental practitioners, especially those who are newly qualified and just getting to grips with the NHS banding system.

How effective do you think the current NHS dental contract is in allowing patients to receive adequate treatment for periodontal disease?

The current NHS system has limitations with the focus of remuneration being for courses of treatment. Ultimately, carrying out treatment on an unmotivated patient who is failing to perform adequate oral hygiene measures is unlikely to improve their periodontal or oral health status. Bringing about behaviour change is arguably most important, although delivery of effective oral hygiene instruction is often overlooked by practitioners. It is difficult to encourage and engage patients to take responsibility for maintaining and improving their own oral health, meaning practitioners need more effective ways to deliver the important messages within the limited appointment times they have. One research study we are involved in looks at how dentists can bring about changes to patient behaviour using motivational techniques, something which is not taught in dental schools but could be utilised in NHS general practice to help dental professionals improve their patients' oral health. As periodontal patients require ongoing maintenance and many practitioners are uncertain when the course of treatment should be considered complete, clearer guidance is needed on the management of periodontal disease on the NHS.

Another issue is undertreatment and failure to diagnose or adequately treat periodontal disease, which has led to a rapidly rising number of dento-legal claims.6 There have also been suggestions that practitioners might under-record the BPE to avoid carrying out a 6-point pocket chart in that sextant.7 The current system doesn't make treating more severe forms of periodontal disease straightforward for dentists. These issues together could be demotivating dentists as it is difficult to apply the principles of periodontology learnt at dental school into NHS general practice.

Two years post-qualification, what have you learnt? Do you have any advice for young dentists starting out in NHS practice?

Although it is hard to find your feet initially, coming up with a periodontal treatment strategy that feels worthwhile for both you and the patient is important to manage periodontal diseases effectively and to maintain morale by seeing the positive improvements in your patients.

Both of us feel we have adapted our management of periodontal disease to allow us to follow the principles we learnt at dental school in the prescriptive NHS system. We use techniques designed to encourage and support patients to make life-long changes to their oral hygiene regime, which we both implement in everyday general practice. This starts with setting out an agreement with the patient of their commitment to improving their oral health and performing effective oral hygiene before we progress with any further periodontal treatment. The patient is made aware at the initial appointment that they may require more than one course of treatment.

We recommend that during your foundation year you discuss any issues you are facing at study days and with your educational supervisor. Talking to more experienced colleagues about how they manage periodontal disease on the NHS is helpful as it is surprising how many dental practitioners have different approaches but share the same difficulties.

Stick to your academic grounding even as you increase your speed - bleeding on probing is essential to record to see whether the disease is stabilising and a useful tool to motivate your patient, if you set realistic goals with them. If you are not seeing changes in your patients' behaviour then you may need to adapt your method of delivering oral hygiene advice to get them on board. Engaging them and ensuring they take responsibility for their disease is the biggest hurdle in improving their oral health.

What do you think needs to change to make the management of periodontal disease more straightforward in NHS general practice?

The band charges for NHS treatment are unclear for both dentists and patients. A simpler system which separates periodontal treatment from other types of treatment and based on the severity of the disease would allow dentists to give more specific and tailored treatment relevant to individual patients.

There needs to be a shift in what is important in managing periodontal disease, concerns about whether pocket charting is required to claim a Band 2 course of treatment means bleeding on probing is often overlooked, indicating disparity on what is important to monitor the disease. The focus in NHS general practice seems to be on what needs to be done to claim three UDAs, rather than what is needed to improve the oral health of the patient. Practitioners prescribing this 'one size fits all' periodontal treatment that focuses on scaling and pocket depths are in danger of forgetting the importance of the patient's role in their treatment.

Patients need to be made aware that management of their periodontal disease requires life-long commitment and what this really means for them. Education and motivation of patients is important for the stabilisation of periodontal disease and there are under-utilised resources out there to help NHS dentists such as the 'Healthy gums DO matter' toolkit.8

There is a gap which needs to be bridged when it comes to applying the principles of periodontology learnt at dental school into NHS general practice but there are campaigns and work currently being undertaken to arm dentists with strategies to manage this disease more effectively in NHS general practice.