Chapter 2 Periodontal disease
There is no doubt that screening patients, diagnosing periodontal disease and then effectively treating the disease is an essential part of restorative treatment. It is crucial that successful periodontal management, demonstrated over a period of time, precedes provision of complex fixed and removable prosthodontics and implants. One analogy of this would be to consider the construction of a new building. It would make no sense to begin building walls or choosing the lighting if the foundations were not sound.
It is clear from many studies that there is considerable variation in individual susceptibility to periodontal disease. This information has shown that a relatively small percentage of the population (probably less than 15%) suffer from severe or advanced disease and are highly susceptible. A similar percentage appears to be disease resistant and have a very low susceptibility, while the remaining 70% show some susceptibility demonstrated by moderate disease progression.
It is essential to have some understanding of an individual patient’s susceptibility to periodontal disease as several things flow from this. If a patient has a high susceptibility their periodontal treatment may need to be protracted and complex if stability is to be achieved, their recall times will have to be shorter and their periodontal prognosis is reduced. For highly susceptible patients, complex fixed and removable prosthodontics can be undertaken, but only when both periodontal stability and adequate plaque control have been demonstrated over time – usually at least a few months. Conversely, for patients with low susceptibility, the treatment needs are usually simple, the recall times can be longer and the periodontal prognosis is good. In these patients, the decision to provide complex fixed and removable prosthodontics is much more straightforward.
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.
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.
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.
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:
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.
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.
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 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.
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’.
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.
• It is a screening system which detects individuals requiring a more detailed periodontal assessment