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“Periodontitis


is not anyone’s fault and diagnosing it does not imply blame or failure”


of patient risk are important in helping both practitioner and patient understand what is likely to happen in the long term. Examples of this include: markers for diabetes control, patients’ smoking habits and sequential plaque indices. They also provide feedback to patients about where they are on a continuum of disease control. Providing good quality treatment. In an ideal world, practitioners


have sufficient time and skill to remove calculus and plaque from teeth and root surfaces. Only a small cohort of patients have disease which does not respond to simple non-surgical treatment; a good maxim to follow is “if the patient isn’t responding... look again.” Break down the process of management into its constituent parts and think about what is happening. Does the patient understand they have disease? Do they understand how to control that disease and what their role is? Is oral hygiene good enough and, if not, which aspect of home cleaning is inadequate? Has the message you delivered about risk control and oral hygiene got through and if not, then is your delivery good enough? Have scaling and root debridement been carried out to leave teeth and roots clean, or is calculus still present, especially subgingivally? Antiseptics and antibiotics. Often reliance is placed on either


systemic or local antimicrobials in the form of mouthwashes, locally- delivered agents or courses of oral systemic antibiotics. These adjuncts do not have evidence supporting their effectiveness in disease management in the absence of good tooth cleaning. These agents may control symptoms in acute phases but do little in the long term. Follow-up after initial treatment. In all cases where a course of


treatment is needed and has been provided it is essential that the outcome of management is assessed after that treatment. This can only be done by again recording the indicators used to diagnose disease. For patients with complicated disease, BPE is not adequate for monitoring. The BPE index outlines treatment need and is not sensitive to probing pocket depth changes or recession, especially in deeper pockets. For monitoring of patients who have had more severe disease, full pocket


chartings, including probing depths, measurements of bleeding, recession and mobility carried out after treatment are needed. These charts should then be used to monitor on an ongoing basis and should be discussed with the patient.


Provision of complex treatment Patients are increasingly presenting at the dental surgery requesting sophisticated and expensive dental treatments. The success of many of these treatments depends on a sound periodontal foundation. When complex treatment is planned, periodontal examination is paramount as part of the treatment planning phase. Where periodontitis exists, patients should be informed. Ideally


periodontal treatment should be provided and completed before final prosthodontic or orthodontic planning. The identification and management of periodontitis not only stabilises the dentition prior to complex treatment but also allows a degree of understanding of long-term tooth prognosis during planning and prepares the patient for maintenance challenges in the future.


Key points In a busy general practice, managing patients with periodontitis is not easy. The key is to make sure that those identified as having signs of disease and those who are at risk are informed; and that the treating practitioner follows up the diagnosis with treatment and then closes the circle to check for a good response to treatment by review. If the patient fails to respond to simple treatment then referral to a specialist should be considered and offered. At all points, good record keeping and following of guidelines provide support for the dentist or hygienist if challenges to care arise later.


Dr Madeleine Murray is a specialist in restorative dentistry, limiting her practice to periodontics


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