Avoiding perio pitfalls

PRACTITIONERS often struggle with periodontics in general practice. Good disease control depends largely on patient buy-in, as well as having sufficient time to treat. Achieving these can be challenging but risks can be minimised through careful diagnosis, treatment and, crucially, good communication and record keeping.

Clear advice about basic standards of diagnosis, referral, treatment and follow-up can be found in both the Scottish Dental Clinical Effectiveness Programme (SDCEP) guidelines and documents produced by the British Society of Periodontology.

Diagnosis

Failure to make one. Follow-up by the clinician of either reported clinical symptoms or BPE scores of 4 is crucial. Major causes of under-diagnosis of periodontitis include failure to:

• recognise symptoms of disease until the late stages
• carry out comprehensive assessment when BPE scores of 4 are recorded
• report incidental findings of periodontal bone loss on radiographs.

Failure to document the diagnosis. Accurately recording conversations relating to periodontal problems and findings of full chartings or radiographs is essential. Good clinical records can help support a practitioner who has discussed periodontal problems and offered treatment or referral, even if that was not taken up.

Failure to advise the patient of the situation. In many cases the practitioner recognises that there are periodontal problems, however the patient either hasn’t been told or can’t remember being told that is the case. If we accept that periodontitis is a chronic, debilitating, multifactorial condition with a strong basis in disordered immune and inflammatory mechanisms, like diabetes or rheumatoid arthritis, then it becomes easier to explain to patients why they are at risk and why they have developed the disease. Periodontitis is not anyone’s fault and diagnosing it does not imply blame or failure, rather it is a complex disease for which timely diagnosis and management present an opportunity to improve not only the patient’s dental prognosis but their general health.

Failure to refer. Specialists now expect to save teeth which in the past would have been removed. Together with their teams they can help maintain teeth for many years, and this is especially true if referral is done at an early stage. Despite the challenges of long waiting times and limited access to NHS specialist periodontists, referral should at least be discussed as an option and followed up if the patient accepts it. Guidelines for when to consider referral can be used to make a case for access to specialist level treatment.

Treatment

Treatment schedules. Periodontal disease requires periodontal treatment, rather than periodontal maintenance. Initial treatment involves control of risk factors for disease progression, followed by in-surgery management of the tooth and periodontal tissues, oral hygiene instruction, scaling, root debridement and subsequent follow-up. All of those aspects comprise treatment and depend on each other for successful ongoing management. Providing routine three-monthly scaling may control tissues where there is minimal disease but won’t correct problems in those with established or more severe conditions.

Controlling risks. In patients who cannot be encouraged to reduce their general systemic risk (e.g. by stopping smoking) or who cannot be encouraged to clean their mouth at home, disease control will always be problematic. It is this stage of disease management that requires the dentist or hygienist to communicate convincingly. Documenting conversations about risk and risk reduction along with understanding objective measures of patient risk are important in helping both practitioner and patient understand what is likely to happen in the long term. Examples of this include: markers for diabetes control, patients’ smoking habits and sequential plaque indices. Such conversations also provide feedback to patients about where they are on a continuum of disease control.

Providing good quality treatment. In an ideal world, practitioners have sufficient time and skill to remove calculus and plaque from teeth and root surfaces. Only a small cohort of patients have disease which does not respond to simple non-surgical treatment; a good maxim to follow is “if the patient isn’t responding... look again". Break down the process of management into its constituent parts and think about what is happening. Does the patient understand they have disease? Do they understand how to control that disease and what their role is? Is oral hygiene good enough and, if not, which aspect of home cleaning is inadequate? Has the message you delivered about risk control and oral hygiene got through and if not, then is your delivery good enough? Have scaling and root debridement been carried out to leave teeth and roots clean, or is calculus still present, especially subgingivally?

Antiseptics and antibiotics. Often reliance is placed on either systemic or local antimicrobials in the form of mouthwashes, locallydelivered agents or courses of oral systemic antibiotics. These adjuncts do not have evidence supporting their effectiveness in disease management in the absence of good tooth cleaning. These agents may control symptoms in acute phases but do little in the long term.

Follow-up after initial treatment. In all cases where a course of treatment is needed and has been provided, it is essential that the outcome of management is assessed after that treatment. This can only be done by again recording the indicators used to diagnose disease. For patients with complicated disease, BPE is not adequate for monitoring. The BPE index outlines treatment need and is not sensitive to probing pocket depth changes or recession, especially in deeper pockets. For monitoring of patients who have had more severe disease, full pocket chartings, including probing depths, measurements of bleeding, recession and mobility carried out after treatment are needed. These charts should then be used to monitor on an ongoing basis and should be discussed with the patient.

Provision of complex treatment

Patients are increasingly presenting at the dental surgery requesting sophisticated and expensive dental treatments. The success of many of these treatments depends on a sound periodontal foundation. When complex treatment is planned, periodontal examination is paramount as part of the treatment planning phase.

Where periodontitis exists, patients should be informed. Ideally periodontal treatment should be provided and completed before final prosthodontic or orthodontic planning. The identification and management of periodontitis not only stabilises the dentition prior to complex treatment but also allows a degree of understanding of long-term tooth prognosis during planning and prepares the patient for maintenance challenges in the future.

Key points

In a busy general practice, managing patients with periodontitis is not easy. The key is to make sure that those identified as having signs of disease and those who are at risk are informed, and that the treating practitioner follows up the diagnosis with treatment and then closes the circle to check for a good response to treatment by review. If the patient fails to respond to simple treatment then referral to a specialist should be considered and offered. At all points, good record keeping and following of guidelines provide support for the dentist or hygienist if challenges to care arise later.

Dr Madeleine Murray is a specialist in restorative dentistry, limiting her practice to periodontics