A young patient with severe disease whose plaque control is good would be regarded as having a high susceptibility whilst an elderly patient with poor plaque control and little evidence of disease would be regarded as having a low susceptibility. Susceptibility is thus a very individual concept relating to each patient. It must be appreciated that a patient’s innate susceptibility cannot be changed as this is partly genetically determined. Recognition of this has led to the realization that risk recognition and control forms an essential part of periodontal management, particularly in patients with higher susceptibility.

The concept of risk

It is known that the presence of risk factors will increase the chance that periodontal disease will occur. Local risk factors are essentially plaque retentive features such as restoration overhangs. These factors must be corrected before commencing periodontal treatment. Systemic risk factors may be genetic (e.g. Down’s syndrome), haematological (e.g. cyclic neutropenia), behavioural (e.g. smoking, poor oral hygiene), environmental (e.g. effects of drugs, HIV), endocrine/metabolic (e.g. poorly controlled diabetes) or lifestyle (e.g. stress, poor nutrition). Factors such as smoking are modifiable whilst others, such as genetic predisposition, are not. In susceptible patients, recognition of the risks and control of the modifiable risk factors is essential if periodontal therapy is to be successful. This is particularly true if provision of more complex fixed and removable prosthodontics is envisaged.

Risk recognition begins at the stage of taking thorough histories from patients.

Taking histories from patients with periodontal disease

Taking thorough histories is an essential part of a patient’s oral health care and is particularly relevant to periodontal therapy. This takes time but should not be ignored or truncated as the information derived is essential if appropriate decisions regarding treatment planning, provision of periodontal therapy and maintenance are to be made. This again is particularly important when periodontal management precedes and is integrated into treatment plans that involve complex fixed and removable prosthodontics.

There are four main histories to be taken. These are Medical, Dental, Social and Family histories, and aspects of relevance to periodontal disease are highlighted here.

Medical history

This serves three main functions:

1. It may explain, at least in part, the severity and extent of periodontal disease encountered. An example would be the increased disease which may be seen in some patients with poorly controlled diabetes. If control is not improved, the chance of producing a successful periodontal treatment outcome is reduced, thus making the later provision of complex restorative work unlikely.

2. It may alert the clinician to precautions which should be taken to safeguard the patient. This may include provision of steroid cover or highlight the need for treatment in a specialist or hospital setting. These complications may also make the provision of complex restorative work less likely.

3. It may alert the clinician to potential risks posed by a patient to staff and subsequent patients in the surgery. Standard cross-infection procedures should be operated for all patients but it would be wrong, for example, to use an ultrasonic scaler in a patient carrying a known infective risk. Ultimately, however, provided periodontal stability has been achieved, there should be no reason not to proceed with complex restorative work if this was the desired outcome.

Dental history

It is clear that patients who attend the dentist irregularly are not candidates for advanced restorative treatment plans. In addition to the standard parts of a dental history, particular aspects that should be assessed in relation to periodontal health are as follows:

• Plaque control regime used. If there is active periodontal disease in the mouth, plaque control is, by definition, ‘inadequate’ and must be modified. It is usually very straightforward to recommend appropriate changes to the techniques and frequencies employed; however, it must also be recognized that plaque will potentially cause caries. This means that even if plaque control is sufficient to control the periodontal condition, it may not be sufficient to prevent damage to the teeth themselves. If plaque control is not subsequently improved, the provision of complex restorative treatment would not be indicated.

• Wearing a removable appliance. Use of an appliance such as a denture is relevant as numerous studies have shown that this increases plaque retention, which in turn may be sufficient to take the plaque levels above the patient’s individual disease threshold. Adequate denture hygiene and advice to remove the appliance at night are essential.

• A previous history of periodontal disease. This is the best indicator of future risk because the innate susceptibility has not changed. As stated previously, provided periodontal stability is demonstrated over time, and provided the plaque regime is adequate to control both caries and periodontal disease, provision of complex operative care should not be withheld. It must be recognized, however, that the patient is not ‘cured’ and it is worthwhile considering that the disease may reactivate.

• A history of previous periodontal treatment. This may indicate both the patient’s attitude to treatment and the degree of difficulty encountered in treating their previous disease. If it has proven difficult to stabilize the periodontal condition in the past (repeated root surface instrumentation, periodontal surgery, use of antimicrobials, etc.), this suggests a high susceptibility and increased chance of subsequent periodontal breakdown. If complex restorative work was being considered in such circumstances it would be wise to delay this until periodontal stability had been demonstrated over several months at least. Short recall times would also be needed for a substantial period after placement.

Social history

There are three particular aspects of the social history that are relevant to periodontal disease. The single most important factor is a history of smoking. Recent research suggests that smoking accounts for up to 50% of cases of chronic periodontitis and it has been established that the incidence and severity of periodontal disease increase with increasing tobacco exposure. Tobacco exposure should be quantified as ‘pack years’ and this is calculated as the number of packs of 20 cigarettes smoked per day multiplied by the number of years for which the patient has smoked. For example, smoking 20 cigarettes per day for 10 years would equate to 10 pack years. This provides a better indicator of total nicotine exposure than knowing that someone smokes 20 cigarettes per day but without knowing for how long they have had the habit. Some patients do not smoke standard cigarettes and for them it is possible to convert to ‘pack years’ by assuming that 1 g of pipe tobacco is equivalent to one cigarette, one small cigar is equivalent to 3 cigarettes and 1 standard cigar is equivalent to 5 cigarettes. The impact of ‘pack years’ is also relevant to implant assessment as it is widely accepted that smoking reduces the success of osseointegration.

The other two factors that are thought to influence periodontal disease, but to a lesser extent, are alcohol consumption and stress. Several sources, including the Third National Health and Nutrition Examination Survey (NHANES), United States, have found a moderate but consistent dose-dependent relationship between alcohol consumption and periodontal disease. The recommended maximum number of units of alcohol per week for a woman is 14 and for a man it is 21. In times of stress, amongst other things, a patient’s oral hygiene and oral health care may deteriorate, their nutrition may suffer, their salivary flow decreases, immune function is depressed, and plaque becomes stickier and thicker. Stress is not easy to measure, however, and although regarded as a risk factor, its single impact on dental care is difficult to determine.

Family history

The genetic links associated with aggressive periodontitis (AgP) are much stronger than with chronic periodontitis. It is important to know if there is a family history of periodontal disease, particularly involving early loss of teeth, as this may be significant in making the periodontal diagnosis. AgP, as the name suggests, is characterized by a very rapid loss of periodontal support and referral to a specialist periodontist is often indicated. Clearly, there should be no provision of complex restorative work until the periodontal condition is stabilized. Fortunately, many AgP cases ‘burn out’ and when stability is subsequently demonstrated over time, advanced restorative care can be considered.

It should also be noted that siblings or children of AgP patients should be regularly screened for the disease.

Assessment of periodontal disease

A clinical examination and where necessary sensitivity testing, will inform the clinician as to whether radiographic examination is required and if so which views are required in order to produce a diagnosis and treatment plan.

The clinical assessment

The basic periodontal examination (BPE)

The BPE (Table 2.1) is a screening tool to enable practitioners to determine whether or not their patient has significant periodontal disease. This examination should be used to screen:

• all new patients

• all those patients who have not had a periodontal examination of any kind in the past year.

Table 2.1 BPE codes, together with the description, a clinical example and appropriate management

The BPE can only be performed using a WHO probe and the probing force applied should be 20–25 g. There are two common variants of the WHO probe in use: the WHO-E (epidemiological) type probe and the WHO-C (clinical) type probe (Figure 2.1). The key elements to note on each are a ball-shaped probe tip of diameter 0.5 mm and a coloured band extending from 3.5 to 5.5 mm. The WHO-C probe has, in addition, a second coloured band extending from 8.5 to 11.5 mm.

Figure 2.1 WHO-E (epidemiological) type probe (left) and the WHO-C (clinical) type probe (right).

To carry out a BPE, the dentition is divided into sextants (first premolar to second molar and canine to canine). The probe tip is gently placed in the base of the gingival crevice/pocket and ‘walked’ around all the teeth in the entire sextant. One code is assigned per sextant and this is the highest encountered anywhere within it. Table 2.1 shows the criteria used for assigning the BPE codes and the corresponding management for each sextant.

Third molars are not included in the BPE and at least two teeth must be present in a sextant for it to be coded. If there is only one tooth in a sextant this is included in the adjacent sextant and if there are no teeth present in a sextant this is denoted on the completed chart as ‘X’.

An example of a completed BPE chart is shown below:

X	4	3
*	1	2

Should significant disease be found (BPE Codes 3, 4 or *), a more detailed periodontal, clinical and possibly radiographic examination is required (see later).

As with any system, the BPE has both advantages and disadvantages (Table 2.2) and the reader should be aware of these if the system is to be correctly applied and interpreted.

Table 2.2 Advantages and disadvantages of the BPE

Advantages	Disadvantages
• It is a screening system which detects individuals requiring a more detailed periodontal assessment • It is recognized internationally • It is quick and easy to carry out and the required equipment is inexpensive • It encourages examination of the periodontium in general dental practice • It summarizes the periodontium in a readily communicable form • It gives an indication of treatment requirements and who should treat the patient – should the patient be referred to a specialist?

Advantages

Disadvantages

• It is a screening system which detects individuals requiring a more detailed periodontal assessment

• It is recognized internationally

• It is quick and easy to carry out and the required equipment is inexpensive

• It encourages examination of the periodontium in general dental practice

• It summarizes the periodontium in a readily communicable form

• It gives an indication of treatment requirements and who should treat the patient – should the patient be referred to a specialist?

•

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