Periodontitis
Managing patients with a diagnosis of periodontitis
Periodontitis is defined in the 2018 Classification of Periodontal Diseases as interdental clinical attachment loss detected at ≥2 nonadjacent teeth and patients with periodontitis will typically present with pockets ≥4 mm and/or obvious evidence of interdental recession (see figure 6.2).8 Bone loss will be visible on radiographs.
Key recommendation
For patients with a diagnosis of periodontitis, carry out subgingival professional mechanical plaque removal (PMPR) in order to reduce probing pocket depth, gingival inflammation, bleeding on probing (from the base of the pocket) and the number of diseased sites.
(Strong recommendation; high certainty evidence)
The BSP implementation of European S3 - level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice (BSP-S3)6 guideline advocates a stepwise approach to periodontal therapy. It recommends supragingival professional mechanical plaque removal (PMPR) and control of retentive factors, as part of the first step of therapy for patients with a diagnosis of periodontitis. Interventions to address inadequate oral hygiene and other modifiable risk factors, such as smoking and diabetes, are also recommended.
The second step of therapy aims to address subgingival plaque biofilm, endotoxin and calculus. A recent review of the evidence confirmed the efficacy of subgingival instrumentation (subgingival PMPR) in the non-surgical treatment of periodontitis.42 The evidence is considered to be high certainty due to consistency of the findings across a substantial number of prospective studies. Accordingly, the BSP-S3 guideline recommends that subgingival periodontal instrumentation (subgingival PMPR) be employed to treat periodontitis to reduce gingival inflammation, the number of diseased sites and probing pocket depths.
Further details on the development of the recommendations in this guidance can be found in Methodology.
Step 1 of therapy
Explain to the patient the causes of periodontitis and the potential benefits of successful treatment: stabilisation of disease, increased oral comfort and reduced risk of tooth loss.
Explain to the patient their role in improving their periodontal health, emphasising that:
- periodontitis is a multifactorial condition and successful control is dependent on both self-care regimes and in-surgery interventions;
- management of the disease is a partnership between patient and clinician and requires a life-long commitment.
Provide personalised oral hygiene advice and instruction to assist and encourage the patient to improve their oral hygiene skills as well as their understanding of the value of good self-care routines (see Oral hygiene).
Where applicable, give smoking cessation advice and support (see Smoking cessation).
Give advice and support on the control of other modifiable systemic risk factors, for example control of diabetes (see Control of diabetes).
Remove supragingival plaque and calculus using an appropriate method.
Ensure that local plaque retentive factors are corrected – for example, remove overhanging restorations or alter denture design.
Assess the response to Step 1 of therapy, including the levels of engagement, oral hygiene and risk factor control, and consider whether it is appropriate to provide Step 2 of therapy.
Step 2 of therapy
Continue to encourage and support effective self-performed oral hygiene during this step of therapy (see Oral hygiene).
Where applicable, reinforce the importance of modifying personal risk factors such as smoking and diabetes (see Smoking cessation and Control of diabetes).
Assess the level of deposits, extent of disease along with patient preference and operator preference and skill to determine the number and length of appointments required for thorough subgingival PMPR.
Carry out subgingival PMPR at sites of ≥4 mm probing depth where subgingival deposits are present or which bleed on probing. Local anaesthesia may be required for this.
- Site specific instruments may be required to adequately instrument difficult to reach sites (e.g. furcations).
- Advise the patient that they may experience some discomfort and sensitivity immediately following treatment.
- Advise the patient that as periodontal pocketing and gingival swelling reduce when the disease stabilises, they may notice a degree of interdental (black triangles) or smooth surface recession.
Assess the response to Step 2 of therapy to decide whether further periodontal treatment is indicated.
Where residual disease is present after Steps 1 and 2 of therapy, discuss with the patient options for further treatment.
- Step 3 of therapy could involve further non-surgical or surgical treatment or onward referral for specialist care.
Once the active phase of treatment is complete, arrange and encourage regular maintenance care (Step 4 of therapy) to prevent and detect any areas of recurrent disease and to maintain stability.