Introduction

Periodontal health is the foundation of good oral health. However, periodontal diseases are prevalent in a large proportion of the UK population, with epidemiological studies suggesting that around half of dentate UK adults have evidence of current or historical periodontitis (periodontal pocketing ≥4 mm).² Similar levels of disease are observed globally,³ the prevalence of severe disease is increasing⁴ and periodontitis is acknowledged as one of the most common chronic inflammatory diseases. 

Primary prevention of periodontal diseases (gingivitis and periodontitis) focuses on interventions to prevent disease occurring in those who are susceptible and includes control of plaque biofilm as well as other risk factors, such as tobacco use. In addition, secondary and tertiary prevention of disease in patients with a diagnosis of gingivitis or periodontitis relies on early detection and management of disease progression by providing appropriate treatment, controlling risk factors and supporting those patients at higher risk.

Members of the dental team play a vital role in detecting disease, carrying out dental treatments to manage and prevent disease, supporting patients to develop effective oral hygiene self-care routines to control dental plaque biofilm and addressing other relevant risk factors, such as tobacco use or sub-optimally controlled diabetes. 

Although most periodontal diseases can be, and are, managed in primary care, interviews with dental professionals suggest that some lack the confidence to treat more advanced periodontal diseases in this setting.⁵ Recognising the need for accessible guidance in this area, the Scottish Dental Clinical Effectiveness Programme first published clinical guidance on the Prevention and Treatment of Periodontal Diseases in Primary Care in 2014. The guidance aimed to encourage a consistent approach to delivering preventive care and, where necessary treating periodontal diseases in primary care by providing recommendations and advice based on research evidence and expert opinion.

In this second edition, the guidance has been updated following a full review of the 2014 first edition, with a focus on aligning with the British Society of Periodontology and Implant Dentistry’s BSP implementation of European S-3 level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice (BSP-S3)⁶ and the Delivering Better Oral Health (DBOH) toolkit (originally published by Public Health England).⁷ The recommendations in the first edition of the guidance have been updated in line with current evidence and several new recommendations have been included. Information on classification and treatment has been brought together in one resource, with further advice on practical implementation of the recommendations in primary care dental practice.

Although this guidance has been developed to support improvements in oral health care in Scotland, these recommendations are likely to be relevant in other countries, taking local differences in the organisation of dental services into consideration.

The main changes in this edition are inclusion of: 

• new advice on the assessment of risk;
• updated information on diagnosis of periodontal diseases to reflect the 2018 Classification of Periodontal Diseases;⁸
• information on planning treatment that reflects the stepwise approach to periodontal therapy⁶ and consideration of tooth prognosis;
• expanded advice on the management of risk factors and assessing the response to periodontal treatment;
• advice on the specific management of patients with furcation involvement and the management of patients with systemic conditions linked to periodontal disease;
• expanded advice on the management of patients considering dental implants;
• updates to the evidence and basis for the key recommendations; 
• updates to the supporting tools.

There is a significant volume of research evidence to inform the prevention and treatment of periodontal diseases. Consequently, the Key Recommendations in this guidance are based on research evidence, including guidelines developed by specialist societies, and agreed by the Guidance Development Group via a consensus process. Where evidence is lacking, the recommendations reflect the consensus view of expert and experienced practitioners. If the prevention and treatment strategies presented in this guidance are followed by the dental team, patients at risk of developing periodontal diseases who attend for dental care are more likely to be recognised early and appropriate care (both preventive and treatment-based) can be provided to improve their oral, and some cases general, health.

The second edition of the Prevention and Treatment of Periodontal Diseases in Primary Care guidance aims to assist and support the dental team to:

• identify and manage patients at risk of and with periodontal diseases in primary care;
• improve the understanding of periodontal diagnoses based on the 2018 Classification of Periodontal Diseases;⁸ 
• improve the quality of decision making in treatment planning;
• improve the overall oral health of the population. 

The guidance focuses on the screening and management of risk factors, support for patients at risk of disease to control these risk factors, and non-surgical management of periodontal diseases in primary care. The guidance adopts the Stepwise approach to periodontal therapy advocated by the European Federation of Periodontology and the British Society of Periodontology and Implant Dentistry. Information on diagnosis has been updated to reflect the 2018 Classification of Periodontal Diseases.⁸ There is also advice on the management of patients with dental implants, including advice on periodontal aspects of pre-implant placement assessment and the prevention and treatment of peri-implant diseases. Advice on appropriate referral and record keeping is included. The surgical treatment of periodontal and implant diseases and the management of patients by periodontal specialists or in a secondary care setting are beyond the scope of this guidance and are not discussed in detail.

The guidance is largely based on existing guidelines, including those from the British Society of Periodontology and Implant Dentistry,⁶ the European Federation of Periodontology,^{9, 10} and Public Health England.⁷ Additionally, relevant systematic reviews, research evidence and the opinion of experts and experienced practitioners have informed several of the recommendations and advice within this guidance.

The guidance is applicable to patients of all ages in all population groups in primary care.

The guidance is primarily directed at all clinicians who are involved in the detection, prevention and management of periodontal diseases in primary care. These include dentists, dental therapists, dental hygienists and oral health educators in general dental practice, and the public dental service. The guidance is also of relevance to the hospital dental service, those involved in dental education and undergraduate trainees. General medical practitioners and medical specialists will also find parts of the guidance relevant. Patients and carers may also refer to the guidance and use the accompanying patient information.

The recommendations presented in this guidance were developed by a multidisciplinary guidance development group that included dental practitioners and specialists along with a patient representative. The group considered the available evidence, clinical experience, balance of benefits and risks, patient and practitioner perspectives, and the acceptability and feasibility of treatment options. Further details about the updating of this guidance are given in Methodology. Details of these considered judgements are provided in Methodology.

Key recommendations in the guidance are indicated by a key symbol (see below).

The strength of each key recommendation is stated directly after the recommendation with a rating of the certainty of the evidence,* following the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach (www.gradeworkinggroup.org). 

A strong recommendation is one where it is considered, based on all the available information and weighing up the balance of benefits versus risk, that almost all individuals would choose this option. A conditional recommendation is one where there is a finer balance between the options, and it is likely that the majority, but not all, would choose the recommended option. In the case of a conditional recommendation, the dental practitioner should expect to spend more time discussing the treatment management options so that the patient can make an informed decision.

The basis for each recommendation, including a brief overview of the evidence, is provided in the accompanying text. Further details can be found in Methodology and at www.sdcep.org.uk.

Other clinical practice advice in this guidance is based on consensus, expert opinion and best practice as identified in the accompanying text. These advice points are indicated with molar bullet points (see below).

Key recommendation and molar bullet symbols

Note that the FDI World Dental Federation tooth notation is used throughout this guidance.¹¹

* Previously referred to as evidence quality.

Tools to support the implementation of the guidance are provided and include:

• advice on monitoring plaque and bleeding levels;
• a tool to facilitate risk assessment;
• advice on treatment prescriptions for referral to dental hygienists and therapists; 
• advice on raising the issue of smoking cessation and alcohol consumption with patients;
• information for other healthcare professionals (e.g. General Medical Practitioners, diabetologists and diabetic nurses) on the most common medical conditions and medications associated with the development of periodontal diseases;
• the updated Oral Hygiene TIPPS behaviour change strategy;
• patient information.

Climate change, caused by the accumulation of greenhouse gases in the atmosphere, represents a major threat to both human health and the health of our planet.  It is now widely recognised that we should all strive to minimise the impact we have on the environment.

National Health Services in the UK are committed to reduce greenhouse gases and their environmental impact.^12-14 SDCEP aims to contribute to this ambition, promoting more sustainable oral healthcare through the provision of clinical guidance.

The overarching principles set out in the second edition of the Prevention and Treatment of Periodontal Diseases in Primary Care guidance align with efforts to reduce the environmental impact of oral healthcare. Specifically, this guidance: 

• promotes the prevention of periodontal diseases and encourages the early identification and treatment of disease. Prevention is widely recognised as a fundamental pillar of sustainable healthcare, as it avoids the need for more complex care, which has associated environmental and health costs.  Similarly, early intervention aims to minimise the need for more complex treatment. 
• provides strategies for the dental team to encourage and empower patients to take an active role in maintaining their own oral health, which is crucial for periodontal health. 
• advocates a risk-based approach to periodontal care that underpins planning of appointments at intervals tailored to clinical need, thereby avoiding unnecessary travel to attend and unnecessary use of resources.
• gives practical advice on how to efficiently deliver care that is effective in maintaining and improving patients’ periodontal health. 
• recommends against interventions that are not supported by evidence, thereby avoiding unnecessary, and therefore wasteful, care.

Following the recommendations and clinical advice in this guidance is one means by which dental professionals can contribute to reducing their carbon footprint. For more general advice on other strategies the dental team can follow towards achieving more sustainable healthcare, refer to the SDCEP Practice Support Manual.¹⁵

This guidance is based on careful consideration of the available evidence, expert opinion and other resources and has been developed with the direct involvement of experts, end-users and patients (see Guidance development). As guidance, the information presented does not override the healthcare professional’s right, and duty, to make decisions appropriate to each patient, with the patient’s valid consent. However, it is advised that significant departures from this guidance, and the reasons for this, are fully documented in the patient’s clinical record.