Reena Wadia and Iain L. C. Chapple summarise answers to common periodontal care questions facing dental professionals in general practice.
1: Does periodontitis affect quality of life?
Periodontitis is a common, chronic, multifactorial, inflammatory condition affecting the supporting tissues of the teeth. It leads to the progressive destruction of the tooth supporting apparatus and eventual tooth loss. There is now overwhelming evidence that periodontitis has a negative impact on oral health-related quality of life.1,2,3,4,5 Significant impacts have been shown in the functional, physical, social and psychological domains. Severe periodontitis appears to have a greater impact than mild to moderate periodontitis.6,7,8
It is important to be aware of this impact when assessing patients in practice. Discussions might include psychological concerns, halitosis, pain, and poor aesthetics. The periodontal treatment plan should be based on both the needs diagnosed by the clinician but also those perceived by the patient.
The latest 'Global burden of diseases, injuries and risk factors' study demonstrated that, from 354 diseases/injuries measured across 195 countries, the greatest age-standardised prevalence of 'years lived with disease' in both 1990 and 2017 were oral disorders, headache disorders, and tuberculosis including latent tuberculosis.9 The periodontal data were true for both males and females and, unlike caries where age-standardised percentage rates had decreased, in periodontal diseases rates had increased between 2007 and 2017.9
2: What's the latest on the role of diabetes in periodontitis?
Diabetes mellitus is a long-term condition characterised by an inability to control blood glucose levels due to an absolute or relative lack of the hormone insulin or a lack of cell responsivity to insulin (insulin resistance).10 The majority of people with diabetes can be classified as having type 1 or type 2, with type 2 diabetes being eight to nine times more common than type 1. In the UK, there are at least 3.2 million people who have been diagnosed with diabetes. By 2025, it is estimated that five million people will have diabetes in the UK.11 Perhaps more importantly, there are approximately one million undiagnosed cases of diabetes in the UK and 17 million across Europe. These people regularly attend dental practices, providing an opportunity for the oral healthcare team to engage in prevention strategies and early detection.12
Diabetes is a significant risk factor for periodontitis, if sub-optimally controlled.13 Patients with hyperglycaemia (diabetes) are three times more likely to develop periodontitis. Indeed, even glycaemia in people with no diabetes is associated with severe periodontitis.14 Diabetes also increases the severity of periodontitis; that is, patients have greater clinical attachment loss and probing pocket depths.15,16 Diabetes is considered as a modifiable risk factor for periodontitis because, although it cannot be cured, it can be controlled.
“Diabetes is a significant risk factor for periodontitis, if sub-optimally controlled. Patients with hyperglycaemia (diabetes) are three times more likely to develop periodontitis”
Dentists are encouraged to compile a careful history from their patients who have diabetes, including their level of control. The most objective way of ascertaining this is by requesting a copy of their most recent HbA1C results. Diabetes patients without periodontitis should be placed on a preventive care regime and monitored regularly, while those with periodontitis should be treated accordingly, ensuring that the importance of good glycaemic control is also emphasised. Dental patients without diabetes but with risk factors for type 2 diabetes should be informed of their risk and, if appropriate, referred to their general practitioner for screening.17
Recently, the European Federation of Periodontology and the International Diabetes Federation joined forces to publish a report and consensus guidelines for physicians, oral healthcare professionals and patients to improve early diagnosis, prevention and management of people with diabetes and periodontitis. This includes encouraging physicians to refer people with diabetes for a periodontal examination.18 Conversely, a recent study has demonstrated that the public, patients and the profession are strongly supportive of formally risk assessing for diabetes in the dental practice and potentially testing HbA1C levels as part of the risk assessment (rather than formal diagnosis).19
3: What do I need to bear in mind when treating smokers and vapers?
The literature unanimously demonstrates that smoking increases susceptibility, severity and rate of progression of periodontitis.20 In the NHANES III study, which was designed to assess the health and nutritional status of adults and children in the United States, approximately half of periodontitis cases were attributable to either current or former smoking. After adjusting for age, race, ethnicity, income and educational level, smokers were four times as likely to have periodontitis when compared to non-smokers.21 The effect of smoking has been shown to be dose-dependent and particularly marked in younger individuals.22 The evidence further demonstrates that smokers lose more teeth and have a less favourable response to periodontal therapy than non-smokers. Smokers are also more likely to suffer disease recurrence following treatment of their periodontitis. Although it is well established that smoking significantly impacts on the onset, progression and outcome of periodontitis, the mechanisms involved remain unclear.
Clinicians should strongly advise smokers to enrol in cessation programmes to improve overall periodontal outcome. Engagement with NHS stop-smoking services triples the odds of successfully quitting when compared to going alone or using over-the-counter products
Simple and brief advice on smoking cessation in general dental practice increases quit rates and personalised biofeedback adds further benefit
If the patient continues to smoke, they should be warned of the risk of less predictable and poorer outcomes as well as an increased rate of recurrence
The above should be discussed in detail with the patient and also recorded in their notes
If a patient is unwilling to stop, it is sensible to accept the level of disease following an appropriate level of active treatment, place them onto a regular supportive periodontal therapy regime, and accept that this is a palliative periodontal care programme, until they engage with cessation advice.
In recent years, electronic e-cigarettes have been gaining popularity, with over two million Britons now regularly vaping.25 E-cigarettes provide nicotine for inhalation in a vapour generated by heating a solution containing water, nicotine, propylene glycol and vegetable glycerine. Since e-cigarettes became available in the UK in 2007, their safety and use as a substitute for tobacco smoking have been surrounded by medical and public controversy. A report by the Royal College of Physicians concluded that e-cigarettes are likely to be much safer for general health than smoking. They have also been shown to help smokers quit.26 However, their effects on periodontal health have yet to be determined. In practice, it would be important to ask all patients about the use of e-cigarettes. It would be worth recording their vaping habits, including the nicotine concentrations of the solution that is being used, which usually ranges from 0-36 mg/ml. It would also seem sensible to include vaping cessation as part of the periodontal treatment plan.
4: What do I need to be aware of when treating pregnant patients?
In pregnancy, elevated hormone levels (oestrogen and progesterone) significantly increase vascular permeability in the gingival tissues and, in the presence of dental plaque, promote gingival inflammation. In those who already have gingivitis or periodontitis, the clinical situation normally worsens and can do so rapidly. Specific localised lesions (pregnancy/vascular epulides) and a more generalised pregnancy gingivitis are associated with pregnancy. Moreover, existing periodontal bone loss can deteriorate rapidly in certain patients when pregnant and a more intensive supportive care programme is recommended in such cases. The evidence base remains inconclusive when exploring whether periodontitis is related to adverse pregnancy outcomes, however it is safe to treat periodontitis during pregnancy.27
When treating pregnant patients in practice:28
Identify the stage of pregnancy and perform a comprehensive periodontal examination.
Pregnant women with a healthy periodontium should be provided with oral health education including detailed oral hygiene instructions
Emphasise to patients with gingivitis or periodontitis that non-surgical periodontal therapy during pregnancy is safe, effective and beneficial
Following treatment, reassess the periodontal status according to normal practice
Once treated, frequent monitoring of the periodontal condition should be maintained throughout pregnancy and, if there is a recurrence, a similar intervention should be provided
For a pregnancy epulis, surgical excision can be performed for large lesions that are impacting upon function or aesthetics. However, if lesions are small, excision can be delayed until postpartum and supportive measures (plaque removal demonstration and professional debridement) should be carried out during pregnancy. If possible, other forms of elective periodontal surgery should also be avoided during pregnancy.
5: What is the link between periodontitis and general health?
Periodontitis has potentially negative consequences on general health. Consistent and robust evidence is available which demonstrates that severe periodontitis is associated with premature mortality due to 'all causes' and due to cardiovascular disease.29,30 Furthermore, in patients with diabetes, there is a direct and dose-dependent relationship between periodontitis severity and diabetes complications. Emerging evidence indicates an increased risk for diabetes onset in patients with severe periodontitis. Randomised clinical trials consistently demonstrate that mechanical periodontal therapy is associated with an approximately 0.4% reduction in HbA1C at three months; this is a clinical impact equivalent to adding a second drug to a pharmacological regime for diabetes. Recently, a 0.5% HbA1C reduction at 12 months following intensive periodontal therapy has been reported.31 Periodontitis is also independently associated with cardiovascular diseases, and additional emerging evidence also appears to link periodontitis with a range of other conditions.32 In practice, it is important to increase awareness among patients about the importance of periodontal health for general health and wellbeing.
6: What were the key changes made to the BPE guidelines in 2016?
The British Society of Periodontology (BSP) updated the BPE guidelines in 2016.33 The following six changes or key points were made:
If a code 4 is identified in a sextant, continue to examine all sites in the sextant. This will help to gain a fuller understanding of the periodontal condition and will make sure that furcation involvements are not missed
If a code 3 is detected, then perform initial therapy including self-care advice (oral hygiene instructions and risk factor control) first. Then after initial therapy, record a six-point pocket chart in that sextant only
The BPE should not be used around dental implants (four- or six-point pocket charting is recommended)
Radiographs should be taken for all code 3 and code 4 sextants. The type of radiograph used is a matter of clinical judgement but crestal bone levels should be visible. The periapical view is regarded as the gold standard
When a six-point pocket chart is indicated, it is only necessary to record sites of 4 mm and above (although six sites per tooth should be measured)
Bleeding on probing should always be recorded in conjunction with a six-point pocket chart.
7: Where can I find out more about the new classification?
The 2017 World Workshop Classification system for periodontal and peri-implant diseases and conditions was developed in order to accommodate advances in knowledge derived from both biological and clinical research, that have emerged since the 1999 International Classification of Periodontal Diseases. The new classification defines clinical health for the first time and distinguishes an intact and a reduced periodontium throughout. The term 'aggressive periodontitis' has been removed, creating a staging and grading system for periodontitis. The BSP convened an implementation group to develop guidance on how the new classification system should be implemented in clinical practice. The clinical implementation of the new classification system in the UK was recently published in the British Dental Journal,34 and has been followed by a case series to help illustrate its implementation. There are also webinars available on the BSP website related to the new classification.
“When explaining the benefits of periodontal treatment, it is important to translate clinical information into a language that the patient can understand and closely relate to.”
8: What language can I use with my patients to convince them of the importance of treating periodontitis?
When explaining the benefits of periodontal treatment, it is important to translate clinical information, such as improvements in probing pocket depths, into a language that the patient can understand and closely relate to. For example, you might prefer to explain that if the condition is treated and the patient adopts the requisite lifelong home care regime, then the patient may:
Not lose any teeth or will keep their teeth for longer, potentially for life
Not have bad breath
Have greater self-confidence, less oral discomfort as well as a better oral function and quality of life
Not have to wear dentures
Not have a bad taste in their mouth or suffer from bad breath
Not wake up with blood on their pillow.
The associations between periodontitis and general health should also be discussed to improve motivation. Phrases that can be used include:
The mouth is a gateway to the rest of the body and should not been seen in isolation
A healthy mouth is an important step to a healthy body.
9: How do I provide effective oral hygiene instructions in the limited time given?
Optimal plaque control is imperative for the prevention of periodontitis, its treatment and long-term stability. In practice, it is therefore important to identify steps to ensure your oral hygiene instructions are effective in the limited time available (Table 1).
10: When carrying out non-surgical periodontal therapy, is there one approach that is superior to another, specifically when considering number of visits and instruments/equipment used?
The ultimate goal of periodontal therapy is to preserve or maintain the dentition in a state of health and comfort throughout life. Non-surgical periodontal therapy is beneficial and effective in the treatment of periodontitis.39 It should be considered:
In highly motivated patients
For those with a high standard of supragingival and subgingival plaque control
For pockets with probing depths of >5 mm or 4 mm with bleeding on probing
Where there are subgingival deposits in a high risk patient despite an absence of overt clinical signs of inflammation.
We no longer vigorously remove cementum/root structure as endotoxins have been shown to be superficially attached.40,41,42 There is also no evidence that one technique or regime is superior to another.43 Generally, when it comes to deciding between quadrant, half-mouth or full-mouth debridement, this is dependent on:
Severity of disease
Need for anaesthesia
Level of plaque control
However, the systemic insult caused by full-mouth debridement may be significant and the quality of the debridement is more important than the technique.44,45 There is an incorrect perception that one-stage full-mouth therapy is beneficial,46 and its use should now be carefully considered given the above evidence. The expected reduction in probing depth through non-surgical periodontal therapy for moderate (4-6 mm) pockets is 1 mm and for deep pockets (7 mm +) it is 2 mm.47
In general, no significant difference has been shown between hand and powered instrumentation in deposit removal and improved clinical parameters,48,49 but in furcation grade II or III lesions, powered instruments are more effective due to the difference in tip size.50 There are specific benefits of both ultrasonic and hand scaling, and so the use of a blended approach is ideal for non-surgical periodontal therapy.47 The evidence from a recent review on the use of lasers in the treatment of periodontitis remains conflicted and insufficient to suggest that the integration of a laser in a periodontal treatment protocol will provide antimicrobial and healing outcomes superior to those achieved by traditional therapy.51
For further resources and reading material concerning periodontal care in general practice, see Box 1.
This article was originally published in the BDJ as Periodontal care in general practice: 20 important FAQs - Part one (Br Dent J 2019; 226: 850-854).
Part 2 of this article will appear in a future issue.
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Chapple I L C. Bleeding gums: Sentinels of non-communicable diseases of ageing. 2018. Available at https://www.openaccessgovernment.org/bleeding-gums-non-communicable-diseases/55853/ (accessed May 2019).
Chapple I L C, Genco R, Working group 2 of joint EFP/AAP workshop. Diabetes and periodontal diseases: Consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Clin Periodontol 2013; 40 (Spec Iss): 106-112.
Graziani P, Gennai S, Solini A, Petrini M. A systematic review and meta-analysis of epidemiologic observational evidence on the effect of periodontal disease on diabetes: An update of the review of the EFP-AAP workshop. J Clin Periodontol 2018; 45: 167-187.
Khader Y S, Dauod A S, El-Qaderi S S, Alkafajei A, Batayha W Q. Periodontal status of diabetics compared with nondiabetics: a meta-analysis. J Diabetes Complications 2006; 20: 59-68.
D'Aiuto F, Gable D, Syed Z et al. Evidence summary: The relationship between oral diseases and diabetes. Br Dent J 2017; 222: 944-948.
European Federation of Periodontology. Recommendations for the oral-healthcare team. Available at https://www.efp.org/publications/projects/perioanddiabetes/recommendations/recommendations_01-oralteam.pdf (accessed May 2019).
Sanz M, Ceriello A, Buysschaert M et al. Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International Diabetes Federation and the European Federation of Periodontology. J Clin Periodontol 2018; 45: 138-149.
Yonel Z, Sharma P, Yahyouche A, Jalal Z, Dietrich T, Chapple I L. Patients' attendance patterns to different healthcare settings and perceptions of stakeholders regarding screening for chronic, non-communicable diseases in high street dental practices and community pharmacy: a cross-sectional study. BMJ Open 2018; 8: e024503.
Nociti F H Jr, Casati M Z, Duarte P M. Current perspective of the impact of smoking on the progression and treatment of periodontitis. Periodontol 2000 2015; 67: 187-210.
Tomar S L, Asma S. Smoking-attributable periodontitis in the United States: findings from NHANES III. National Health and Nutrition Examination Survey. J Periodontol 2000; 71: 743-751.
Tonetti M S. Cigarette smoking and periodontal diseases: aetiology and management of disease. Ann Periodontol 1998; 3: 88-101.
Stead L F, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev 2012; CD008286.
Barnfather K D P, Cope G F, Chapple I L C. Effect of incorporating a 10 minute point of care test for salivary nicotine metabolites into a general practice based smoking cessation programme: randomised controlled trial. BMJ 2005; 331: 999-1001.
Action on Smoking and Health. Over 2 million Britons now regularly use electronic cigarettes. 2014. Available at http://ash.org.uk/media-and-news/press-releases-media-and-news/over-2-million-britons-now-regularly-use-electronic-cigarettes/ (accessed May 2019).
Royal College of Physicians. Nicotine without smoke: Tobacco harm reduction. London: RCP, 2016. Available at https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0 (accessed May 2019).
Sanz M, Kornman K, working group 3 of the joint EFP/AAP workshop. Periodontitis and adverse pregnancy outcomes: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol 2013; 84 (Spec Iss): S164-S169.
European Federation of Periodontology. The relationship between oral health and pregnancy: guidelines for oral health professionals. Available at https://www.bsperio.org.uk/professional/oralhealthandpregnancy/EFP_OralB_GUIDELINE_01.pdf (accessed May 2019).
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Wadia, R., Chapple, I. Periodontal care in general practice: 20 important FAQs - Part one. BDJ Team 6, 15–20 (2019). https://doi.org/10.1038/s41407-019-0147-x
Should, must and risk - the three words at the heart of the decision whether a hygienist/therapist is assisted by a dental nurse
BDJ Team (2019)
Primary Dental Journal (2019)