Summary
Guidance summary
This page summarises the key recommendations and clinical practice advice from the full guidance.
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.
For a full appreciation of the key recommendations, the basis for them and further advice on following them, refer to the relevant sections of the full guidance using the links provided below.
Periodontal assessment
A thorough periodontal assessment involves an evaluation of risk factors and appropriate clinical examination.
- Screen all patients for periodontal diseases at every routine examination.
- Take a patient history
- Assess risk factors
- Examine tissues for signs of disease
- Carry out BPE screening for all dentate patients
- Carry out more detailed assessment in patients with signs of periodontitis (BPE 3 or 4)
- Perform appropriate radiographic assessment
- Assign a risk level to inform future treatment and recall interval
- When carrying out a risk assessment, use a structured approach to assess the patient’s medical, dental and social history, any relevant risk factors and the outcome of the clinical examination, to inform future treatment and recall.
- For patients who are at increased risk of periodontitis, provide information about their periodontal risk, how it affects them and the ways that they can reduce this risk (e.g. provide oral hygiene instruction or advice on smoking cessation) as part of a strategy to encourage behaviour change.
Making a diagnosis
Making a diagnosis is fundamental to provision of individualised periodontal care.
- Establish a periodontal diagnosis for all patients and record the diagnostic statement in the clinical record.
- For patients with a diagnosis of periodontitis, ensure that the diagnostic statement includes the disease type, extent, stage, grade, current periodontal status and a risk factor profile.
Planning periodontal treatment
Planning periodontal treatment incorporates a structured, Stepwise approach to periodontal therapy.
- Identify potential treatment needs
- Assess tooth prognosis
- Use the Stepwise approach to plan the periodontal therapy required by the patient
- For patients with a diagnosis of periodontitis, perform professional mechanical plaque removal (PMPR) using either a full mouth or quadrant approach, taking into account patient factors and preferences and clinician skills, experience and preferences
Components of periodontal treatment
Periodontal treatment comprises controlling modifiable systemic risk factors and local risk factors, and providing PMPR, when required.
Managing risk factors
- Give advice regarding modifiable systemic risk factors for disease (e.g smoking, diabetes)
- Control local risk factors for disease
- Provide support for effective oral hygiene and behaviour change
- Advise patients (and their carers, where appropriate) to regularly remove plaque biofilm using a toothbrush, and interdental aids where required, as an effective regime to prevent and facilitate management of plaque-induced gingivitis and periodontitis.
- Use behaviour change methods when providing oral hygiene instruction for patients who have sub-optimal oral hygiene.
- Advise patients to regularly clean their teeth and gums, using either a manual or rechargeable powered toothbrush, and that an effective technique should be employed.
- Advise patients with a diagnosis of periodontitis to clean interdentally every day, using appropriately sized interdental brushes where the interdental space allows, and floss in interdental spaces too small to allow interdental brush use.
- Advise patients without a diagnosis of periodontitis but who have gingival inflammation to clean interdentally as required to control their inflammation. The method and frequency of cleaning should be tailored to individual patients.
- Advise all patients to use a toothpaste containing 1350-1500 ppm fluoride to prevent dental caries.
PMPR and principles of periodontal instrumentation
- Remove plaque biofilm from crown and root surfaces using an appropriate technique.
- During routine care:
- Do not use systemic antibiotics.
- Adjunctive agents (local antimicrobials, host modulation therapy) are not recommended.
- Assess the response to treatment to inform ongoing management.
- For patients with a diagnosis of periodontitis, use either powered instruments, manual instruments, or a combination of both, to carry out subgingival professional mechanical plaque removal (PMPR) to a high standard; base the choice of instrument on clinician and patient preferences, the clinical situation and the goal of treatment.
- Local antimicrobials are not recommended for the routine care and management of patients with a diagnosis of periodontitis.
- Do not use adjunctive systemic antibiotic therapy for the routine care and management of patients with a diagnosis of periodontitis.
- Consider referral to a specialist or advanced care practitioner for those patients who may benefit from adjunctive systemic antibiotic therapy, such as those whose level of disease suggests a high susceptibility (e.g. younger patients with Grade C periodontitis and who show little or no improvement after non-surgical treatment).
- The use of host modulation therapy is not recommended for the routine care and management of patients with a diagnosis of periodontitis.
- For patients who experience post-PMPR dentine sensitivity, consider the use of a desensitising agent.
- At-home treatments (e.g. desensitising toothpaste) should be tried initially, with professionally-applied desensitising agents used for persistent sensitivity.
Management of plaque-induced periodontal diseases
Management of patients diagnosed with periodontal health, gingivitis or periodontitis should be individualised to each patient’s needs.
- Provide personalised oral hygiene instruction where required.
- Give advice about control of other risk factors (e.g. smoking, diabetes).
- Carry out professional mechanical plaque removal (PMPR) where required.
- Provide appropriate periodontal treatment to patients with systemic conditions related to periodontitis (e.g. diabetes, pregnancy).
- For patients with a diagnosis of periodontal health, prioritise personalised oral hygiene instruction over professional mechanical plaque removal (PMPR) to encourage effective oral self-care.
- For patients with a diagnosis of gingivitis, provide personalised oral hygiene instruction. In addition, assess levels of plaque and calculus and deliver professional mechanical plaque removal (PMPR) at required sites, especially where inflammation is present, to enable and encourage oral hygiene self-care.
- 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.
- For teeth with Grade I furcation involvement, provide non-surgical treatment with the aim of achieving medium/long term retention of the tooth.
- For teeth with Grade II or III furcation involvement, especially those that are holistically assessed as being of ongoing value to the patient and their dentition, provide non-surgical treatment with the aim of achieving medium/long term retention of the tooth.
- Referral and/or surgical management might be appropriate for some patients.
- Furcation involvement alone is not an indication for extraction.
- For patients with diabetes and periodontitis, provide periodontal treatment, including oral hygiene instruction and supra- and subgingival professional mechanical plaque removal (PMPR), with the aim of reducing oral inflammation and improving diabetes control.
- For patients with periodontitis and with systemic conditions that may be related to periodontitis, provide periodontal treatment, including oral hygiene instruction and supra- and subgingival professional mechanical plaque removal (PMPR), with the aim of reducing oral inflammation.
Long-term periodontal care
Long-term periodontal care is essential for all patients.
- Provide long-term periodontal care for all patients,
- Base recall intervals on an assessment of the patient’s individual periodontal risk level.
- Assess risk factor control and the level of oral hygiene and provide additional support where required.
- Monitor the periodontal tissues for signs of inflammation and provide professional mechanical plaque removal (PMPR) where required.
- Where there are signs of disease recurrence, determine the cause of the deterioration and provide treatment to address this.
- For patients with a diagnosis of periodontitis who have completed active periodontal therapy, provide regular* supportive periodontal care to maintain stability of the patient’s disease status.
*Suitable recall intervals range from 3 to a maximum of 12 months, with the frequency determined by the patient’s clinical history, an assessment of their risk and the needs and wishes of the patient.
- For patients with a diagnosis of periodontitis who have completed active periodontal therapy, provide a comprehensive regime of supportive periodontal care that comprises updating patient histories, assessment of risk factor control, oral tissues and care needs, and treatment, where necessary.
Management of patients with dental implants
For patients with dental implants, effective self-performed oral hygiene and regular monitoring of the peri-implant tissues are key to the prevention of peri-implant disease.
- Address modifiable risk factors and stabilise any periodontal disease prior to the placement of dental implants.
- Provide supportive care to reduce the risk of peri-implant disease.
- Monitor the peri-implant tissues for signs of inflammation.
- Provide non-surgical periodontal treatment for patients with peri-implant diseases.
- For patients with a diagnosis of periodontitis who are considering dental implants, ensure they are aware that they are at increased risk of peri-implant disease.
- Prior to placing implants in patients with a diagnosis of periodontitis, stabilise any periodontal disease around teeth which are to be retained, address modifiable risk factors (e.g. inadequate oral hygiene, smoking, systemic disease) and explain the need for ongoing periodontal and implant maintenance care after placement to reduce the risk of peri-implant disease.
- For patients with dental implants, provide implant-specific maintenance care to reduce the risk of peri-implant disease.
- For patients with peri-implant mucositis, the routine use of adjunctive or alternative measures to professional mechanical plaque removal is not recommended.
- The routine use of local or systemic antibiotics for the treatment of peri-implant mucositis in primary care is not recommended.
- For patients with peri-implantitis, the routine use of adjunctive or alternative measures to professional mechanical plaque removal is not recommended.
- The routine use of local or systemic antibiotics for the treatment of peri-implantitis in primary care is not recommended.
Referral
Referral may be appropriate for some patients with severe disease or where the periodontal treatment required is complex or complicated by other factors.
- If considering referral for specialist/secondary care, consult local and national guidelines to determine if the patient is a suitable candidate
- Carry out initial therapy prior to referral.
- Give advice about control of systemic risk factors for disease (e.g smoking, diabetes);
- Provide support for effective oral hygiene and behaviour change;
- Remove plaque biofilm from crown and root surfaces using an appropriate technique.
- Provide supportive periodontal care and monitoring for patients who have been discharged from secondary care.
Record keeping
Good record keeping underpins the provision of quality patient care.
- Record the results of the periodontal examinations (basic and/or full) carried out and the current standard of oral hygiene.
- Record the diagnosis, suggested treatment plan and details of costs.
- Document any discussions you have with the patient, for example advice on controlling risk factors or improving oral hygiene.