Periodontal Referrals

When to refer

The basic periodontal examination (BPE) forms the basis for assessing the need for a periodontal referral.

BPE scores and findings

0 - No bleeding or pockets detected
1 - Bleeding on probing - no pocketing > 3.5mm
2 - Plaque retentive factors present – no probing >3.5mm
3 - Pockets >3.5mm but <5.5 mm in depth
4 - Pockets >5.5 mm in depth

Additional furcation involvements and muco-gingival problems, generalised or localised, should be marked with a * in addition to the BPE score of the respective sextant (e.g. a sextant with bleeding on probing, no probing depth >3.5mm but furcation involvement would be scored as 1*).

According to the British Society of Periodontology referral policy guidelines, patients can be categorised into the following complexity degrees:

• Complexity 1: BPE 1-3
• Complexity 2: BPE 4
• Complexity 3: BPE 4, and additional complicating factors such as smoking habit, age (<35 years), medical history, root morphology, rapid breakdown; additional need for dental implant therapy and/or augmentation/bone removal)

Patients with a complexity grade 2 or 3, furcation involvements or muco-gingival problems may require advanced periodontal therapy (e.g. surgical periodontal procedures or adjunctive therapies) and should therefore be referred to a Periodontist.

Periodontal therapy

Periodontal therapy is best carried out in defined treatment phases which require a systematic approach to treatment planning. At the initial consultation the extent and severity of the problem as well as underlying modifying factors will be assessed.

We will take into account the patient’s expectations and wishes and patients will receive detailed information regarding the cause of periodontal disease and what they can do to get actively involved in the treatment.

A 6-point pocket chart with a computerised constant-force probe (Florida probe) and radiographs will be taken as required (usually full mouth status). Following this we will be able to provide a detailed written report, proposed treatment plan and estimate detailing the timescale and cost of treatment. In advanced cases that may require perio-prostho planning patients will attend further planning appointments that may include study casts, face bow registration etc. before a definitive treatment plan can be provided.

We adopt the tooth by tooth prognosis system. After collection of the relevant data, teeth will be categorised according to those that are irrational to treat and therefore should be extracted, teeth that are questionable and require appropriate treatment and teeth that are secure. Using this as a base to formulate the patient’s treatment needs a treatment plan will evolve.

The Cause-related (Hygienic) Phase of Therapy

The initial cause-related phase of therapy is aimed at bringing caries and gingivitis under control as well as arresting periodontal disease progression. The main key points of this phase of therapy are:

• Patient motivation: The patient should understand dental disease and get actively involved in the treatment process.

• Information and instruction in self-performed plaque control methods.

•Root surface debridement: Removal of all supra- and sub-gingival plaque.

•Removal of additional retention factors: Removal of overhanging fillings, ill-fitting restoration margins etc.

• Extraction of teeth that are irrational to treat and provision of temporary replacement/restoration.

At Flint and Flint Dental Surgeons we use state-of-the art piezon-electronic equipment with specially shaped periodontal inserts that allow a non-traumatic access to root surfaces even in deep periodontal pockets and into furcations. Nowadays it is well established that it is not required to remove cementum from the root surface in order to achieve successful treatment outcomes.

We therefore limit the use of hand instrumentation to specific areas and use small dimension Gracey curettes to minimise trauma to the soft and hard tissues. This approach should help reduce post operative discomfort and the occurrence of tooth sensitivity after periodontal therapy.

The Corrective Phase of Therapy

This phase of therapy aims at restoring function and aesthetics. The decision regarding what type of further periodontal therapy may be needed and on how many sites should be made after the effect of the initial cause-related phase of therapy has been evaluated. The time laps between termination of the initial cause-related phase of therapy and this evaluation may vary from 1-6 months.

This allows for marked reduction in gingival inflammation and improvement in tissue texture as well as for a proper assessment of the prognosis. The effectiveness of the patient’s home care is of decisive importance for the long-term prognosis and can be evaluated over this time period.

Several treatment strategies are available for correction of residual problem areas.

Periodontal surgery

Over the years, several different techniques have been described and used in periodontal therapy. Nowadays, various flap procedures are commonly used such as the access flap, modified Widman flap, apically positioned flap, papilla preservation flap and distal wedge procedures.

Regenerative periodontal therapy

In cases of advanced periodontal disease, non-surgical or surgical periodontal therapy may lead to poor aesthetics in the anterior regions of the dentition. This may be avoided by applying regenerative periodontal procedures by which the lost periodontal attachment in the bone defects can be restored.

The indication for regenerative periodontal therapy is therefore often based on aesthetic considerations or on the fact that it may improve the long-term prognosis of individual teeth. The following materials are commonly used for regenerative procedures: Emdogain Gel, synthetic membranes, porcine derived membranes, synthetic or bovine derived graft materials.

Treatment of furcation-involved teeth

Furcation involvement presents a challenge for periodontal therapy as it reduces the prognosis of the affected teeth. Treatment options to manage such situations include: furcation plasty, tunnel preparation, root separation and resection and regenerative periodontal surgery.

After the correction of residual periodontal problem areas, restorative therapy can be carried out as part of the corrective phase of treatment. This may include any type of definitive restoration. From a periodontal point of view, removable reconstructions should be avoided if at all possible since they lead to further plaque retention and an increased risk of periodontal disease recurrence.

Supportive Periodontal Therapy (SPT)

Excellent maintenance of post operative attachment levels were documented to be maintained over many years first at the University of Michigan, University of Gothenburg, Sweden and Universities of Minnesota, Nebraska and Loma Linda (Knowles 1973, Ramfjord et al. 1982). Many further studies support these findings.

The key to success is the attendance for recall visits at regular intervals (generally 3-4 months).

At these recall intervals a continuous multilevel risk assessment in conjunction with the appropriate therapy will be carried out. The following factors determine the patient’s risk assessment:

• Percentage of bleeding on probing
• Prevalence of residual pockets
• Number of teeth lost
• Loss of periodontal support in relation to the patient’s age
• Systemic and genetic conditions
• Environmental factors such as cigarette smoking

For this purpose a functional diagram has been constructed – the so call `spider web’ (Lang & Tonetti 2003)

Depending on the severity of the disease and the patient’s risk assessment we will offer SPT at Flint and Flint Dental Surgeons. However, we would like to encourage a `shared care’ approach whereby the maintenance treatment is carried out in conjunction with the referring General Dental Practitioner and Dental Hygienist respectively.

Orthodontics and Periodontics

Orthodontic treatment in periodontal patients can certainly contribute to further periodontal tissue breakdown. The combination of inflammation, orthodontic forces and occlusal trauma may produce a more rapid destruction than would occur with inflammation alone (Kessler 1976).

However, provided that periodontal diseases are controlled and supportive periodontal therapy is provided, studies (Nelson & Årtun 1997, Re et al. 2000) could show that:

• Pre-treatment evidence of periodontal tissue destruction is no contraindication for orthodontic therapy
• Orthodontic therapy improves the possibilities of saving and restoring a deteriorated dentition
• The risk of disease recurrence is not increased during appliance therapy.

We therefore feel very strongly about good collaboration with Specialist Orthodontists who may be seeing periodontal patients who need or would like orthodontic treatment.

Some patients undergoing orthodontic therapy including frontal movement of incisors and lateral movement of posterior teeth suffer gingival recession and loss of attachment. If tooth movement is required outside the envelope of the alveolar process, a careful examination of the dimensions of the tissues covering the facial aspect should precede any tooth movement. Thin gingival tissues may require some form of periodontal plastic surgery prior to orthodontic tooth movement.

Muco-gingival Therapy – Periodontal plastic surgery

Periodontal plastic surgery is best defined as “surgical procedures performed to prevent or correct anatomic, developmental, traumatic or disease induced defects of the gingiva, alveolar mucosa or bone” (Proceedings of the World Workshop in Periodontics 1996).

These procedures require good collaboration with the restorative dentist/specialist, thorough assessment and treatment planning, careful management of patient expectations and precise execution of the surgical procedure.

At Flint and Flint Dental Surgeons we take the time to understand the patient’s needs and expectations and explain on models and with the help of images, the possibilities of therapy. These delicate surgical procedures are usually carried out with micro-surgical instruments under magnification:

• Gingival augmentation: Grafting procedures (free gingival grafts, connective tissue grafts) in conjunction with full thickness flap, split thickness flap, apically positioned flap, sandwich technique.

• Root coverage: Pedicle soft tissue graft procedures (lateral sliding flap, double papilla flap, coronally advanced flap for single or multiple recession defects, semilunar coronally advanced flap, tunnel technique, envelope technique) and free soft tissue graft procedures (epithelialised or subepithelial connective tissue graft usually taken from the palate)

• Correction of mucosal defects at implants
• Interdental papilla reconstruction
• Crown lengthening procedures
• Gingival preservation at ectopic tooth eruption
• Removal of aberrant frenum
• Prevention of ridge collapse associated with tooth extraction
• The deformed edentulous ridge