Managing the Difficult Periodontal Patient

Samuel B. Low, DDS, MS, MEd

Periodontal patients may come in 2 forms that continue to challenge the practitioner. The first type of patient has compliance issues, such as marginal oral hygiene and inconsistent frequency of recare in resolving their disease state (Figure 1; Figure 2; Figure 3). The second type of patient is the one who is significantly more susceptible to periodontitis (Figure 4 and Figure 5).

The American Academy of Periodontology suggests that there are 2 categories of periodontitis.¹ The first category is chronic and generally includes adult periodontitis with rapid or slow progression that exhibits periods of exacerbation and remission. The second category is aggressive periodontits and includes the following: (1) generalized or localized juvenile periodontitis; (2) prepubescent periodontitis; (3) rapidly advancing periodontitis; and (4) refractory periodontitis (Figure 6).

REFRACTORY VS RECURRENT PERIODONTITIS

Refractory periodontitis generally implies cases that are hard to manage, are obstinate, and are not yielding to treatment.We are very aware that refractory periodontitis exists and even early studies by Hirschfield suggested that 17% of periodontal patients were in the “downhill to extreme downhill” category.² While such factors as oral hygiene and recare compliance, treatment technique, and local factors could contribute to a refractory stage, it is now thought that the microbial flora and the immunologic response to the periodontal pathogens are more the etiology.³ What confuses the practitioner is the discrimination between the recurrent and the refractory patient. The recurrent periodontal patient has had conventional periodontal care but continues to have progressive periodontits. These patients are recurrent generally because of marginal oral hygiene compliance and inconsistency with suggested frequency of recare appointments.

It is suggested that aggressive periodontis has a level of genetic predisposition to the disease process and is modified by risk factors. Three primary risk factors are: nicotine ingestion with an odds ratio of 5.3 for periodontal disease;⁴ diabetes mellitus with an odds ratio of 2.8 for periodontal disease;⁵ and occlusal abnormalities.

While some clinicians would not consider occlusion as a component in progressive periodontis, it is interesting that in a study by McGuire in 1996, mobility and crown root ratio were considered significant factors in predicting periodontal prognosis (Figure 7 and Figure 8).⁶

In determining a periodontal diagnosis, it is imperative that the data colletion being performed includes traditional parameters such as periodontal probing and radiographs. However, the initial data collection is not as critical for the difficult periodontal patient as data collection over a time period and comparing that data to a baseline (Figure 9 and Figure 10).

USING A PATIENT INTERVIEW

Obtaining a dental history through a patient interview is also a critical component of data collection by the clinician. The patient interview should include the following questions in each category:

Previous Dental History

1. Has any dentist ever suggested that you may have gum disease? At what age? How was it treated?
2. Do you have any symptoms of gum disease, such as bleeding, swelling, loose teeth, and bad breath?
3. When was your last cleaning and how many times a year do you have your teeth cleaned?
4. The last time you had your teeth cleaned, what kind of cleaning did you have?
5. Has a dental professional introduced you to plaque control and, if so, what plaque control devices do you use on a daily basis?

Familial History

1. Does anyone in your family, primarily your parents and siblings, have a history of gum diseases? If anyone in your family has had teeth removed, what were the reasons?
2. Does your spouse have a history of gum disease?

Nicotine Use

1. Do you currently use, or have you used in the past, tobacco products? What kind and at what frequency?

Systemic Implications

1. Does anyone in your immediate family have diabetes?
2. Do you have diabetes? If so, what type and are you under diabetic control?
3. What medications, if any, do you take?
4. Do you currently have, or have a history of, chronic illnesses?

Occlusion

1. Has a dentist ever suggested that you may have a bite problem?
2. Do you think you grind or clench your teeth?
3. Have you ever worn an appliance for your bite?

CONSIDERING RISK ASSESSMENT

In addition to conventional data collection, recent advances have suggested that risk assessment can be introduced to complement periodontal data collection systems. Several systems have been introduced and range from intuitive to genetic testing.

Intuitive
If the clinician observes a patient who is over the age of 35 and has significant local factors as plaque and calculus on initial presentation but has minimal periodontitis, then one may classify the patient as resistant to future tooth loss from periodontitis. However, patients having the opposite conditions, such as younger age, few local factors and a moderate to severe periodontal diagnosis, the individual would be considered susceptible. A graph can be used in data collection (Figure 11).

Genetic Testing
The Periodontal Susceptibility Test (PST) is a genetic test that measures the interleukin-1 genotype for severe periodontal disease using DNA in a patient’s cheek cells. Interleukin-1 is a cytokine involved in the local inflammatory response to bacteria and is an important modulator of bone resorption. Patients who are susceptible have an exaggerated inflammatory response to a bacterial challenge. Patients who test positive for PST generally have severe periodontits.

PreViser
PreViser (PreViser, Mount Vernon, WA) is a Web-based risk assessment tool that uses a disease score 0 to 100 plus a risk score of 0 to 5 based on such variables as age, previous dental care, smoking, and diabetes. The scores assist the clinician in determining the risk of periodontal disease for the future and adjusting therapies to the risk assessment. Printouts and screen viewing assist the clinician in educating patients about periodontitis (Figure 12). PreViser has also introduced a risk assessment for oral cancer, caries, and fractures.⁷

Florida Probe
Florida Probe (Florida Probe Corp., Gainesville, FL) uses a computer-based examination with such clinical parameters derived from the existing data collection as depth, bleeding, furcation, and mobility with such risk data as systemic conditions, smoking, medication use, and dental history. This data can be converted to a Lang/Tonetti spider graph (Figure 13). The data is not consolidated to a single score but assists the clinician in making clinical decisions and, moreover, educating the patient about the disease state and future therapy options.

Florida Probe collects periodontal probing data and places it in a computer memory for future comparisons. Each probing site is compared from the present exam to previous patient encounters (Figure 9 and Figure 10). This allows the clinician to determine whether there are progressively increasing pocket depths that would suggest progressive periodontitis and a poorer respective prognosis.

PROVIDING THERAPY FOR THE DIFFICULT PERIODONTAL PATIENT

How to treat the difficult periodontal patient depends on whether the patient is in a recurrent or refractory state of disease. Behavior practice management systems are used more often in recurrent patients. However, attempting to decrease the periodontal pathogens and adjusting host modulation is generally implemented for the refractory patient.

Managing the Recurrent Periodontitis Patient
Patients who are noncompliant with oral hygiene. Increasing the frequency of recare may help by disrupting the colonization of the microbial biofilm. It is suggested to increase the frequency of recare because of inadequate oral hygiene, increasing pocket depth, radiographic bone loss, and furcation involvement, as well as in complex restorative cases.

From a behavioral viewpoint, the recommendation for encouraging oral hygiene compliance is to place gentle emphasis on oral hygiene but to not challenge the patient. Consider stressing technique over motivation. Considering power toothbrushes minimizes behavior concerns and focuses on dexterity. Power toothbrushes have been shown to enhance effectiveness and acceptance up to 81%.⁸ Timers incorporated into power toothbrush technology have been a milestone in compliance issues.

While the data is inconsistent, some clinicians suggest using mouthrinses for patients after debridements at recare appointments. The rationale is that periodontal pathogens are found in the saliva and on the tongue, gingiva, and tonsilar pillars. Substantive mouthrinses may be considered most effective and would be those products containing stannous and sodium fluoride and chlorohexidine.

Local delivery antimicrobials (LDA) placed in site-specific areas may also be adjunctive to routine periodontal debridments at the time of maintenance appointments. Key requirements in choosing a LDA are that it stays in place; requires no removal; enhances the effect of the debridment; and is user-friendly. However, placement can be difficult in some sites because of access, the physical properties of the LDAs, and the devices necessary for delivery of the medicaments.

Patients who are inconsistent with recare maintained appointments. It is important to document cancellations and no-shows not only for liability reasons but also to educate patients about their dental history. This information may assist the clinician in establishing the nature of the recurrence of the disease. Some practices reappoint returning patients for periodontal maintenance after a lapse of time to 2 separate appointments 1 week apart. This allows the hygienist adequate time to perform procedures in a competent manner.

Managing the Refractory Periodontitis Patient
Using systemic antibiotics. Many known periodontal pathogens demonstrate susceptibility to available antibiotics. Some antibiotics, such as amoxicillin, show comparable concentrations in gingival crevicular fluid as in blood samples after oral ingestion. However, there does exist a level of susceptibility and resistance to antibiotics.⁹ Culture and sensitivity tests can be performed on available subgingival microbial biofilms with chairside collection techniques. One must appreciate that collection techniques can affect the sample and thus cause concerns about the validity of the results. Because of the generalized nature of refractory disease and multiple sites incurred, systemic antibiotic therapy may be indicated in aggressive periodontitis (Figure 14 and Figure 15).

Host modulation. With genetic predisposition and interplay of risk factors being significant features in refractory disease, an attempt to control risk factors becomes a key element in management. Therefore, nicotine cessation programs, diabetic control systems, and even nutritional supplementation are adjunctive to care.

Several studies have demonstrated the validity of using oral systemic doxcycline as an antiproteinase on a regiment of 20 mg twice daily to affect the host by decreasing endogenous collagenase activity and thus being a host-enzyme-suppressing process.¹⁰ Difficulty in compliance can occur because of the daily regimen for a mostly asymptomatic disease process. However, indications do include individuals at high risk for periodontis because they smoke, have diabetes, or have an aggressive periodontitis diagnosis.

Periodontal surgery. If one considers that the anatomical environment of the sulcus depth precludes the host to the colonization of periodontal pathogens, then altering the depth via sulcular reduction is a viable therapeutic course.¹¹ Alteration can come in 2 forms: surgical reduction of the coronal aspect of the sulcus; and regeneration of new attachment from the apical area of the sulcus. Studies do demonstrate that a more significant pathogenic flora colonizes as the pocket depth increases.¹¹ Decreasing sulcular depth by either method affects the microbial flora, and enhances access by the patient, and, more importantly, by the clinician during periodontal maintenance. Sulcular alteration must be considered an integral part of treatment for the periodontitis patient.

While no therapy is exclusive for any diagnosis of periodontitis, selecting from a menu of appropriate therapies may provide the best result for the respective patient. Difficult periodontal patients can be a challenge to the general practitioner. Referral to a periodontist as part of the decision tree provides an effective team approach. Referral guidelines for consideration may include: probing depths ≥ 4 mm, especially when associated with angular radiographic osseous topography; probing depths that continue to deepen with attachment loss; increasing mobility; and atypical forms of periodontal disease.

CONCLUSION

Past dental history, risk assessment, and oral hygiene compliance are critical in establishing the differential diagnosis between chronic adult and aggressive periodontal disease. New patients with a history of previous periodontal surgery should be monitored for at least 1 year before additional surgery. Adjunctive local and/or systemic antibiotic therapy may be necessary in difficult periodontal patients. The frequency of recare and the competency of debridement are crucial to stabilization. Occlusal stability is a necessity.

DISCLOSURE

The author is a shareholder in Florida Probe Corporation.

References

1. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol. 1999;4(1):1-6.

2. Hirschfield L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J. Periodontol. 1978;49(5): 225-237.

3. Kornman KS. Refractory periodontitis: critical questions in clinical management. J Clin Periodontol. 1996;23(3 Pt 2):293-298.

4. Stoltenberg JL, Osborn JB, Pihlstrom BL, et al. Association between cigarette smoking, bacterial pathogens, and periodontal status. J Periodontol. 1993;64(12):1225-1230.

5. Emrich LJ, Schlossman M, Genco RJ. Periodontal disease in non-insulin-dependent diabetes mellitus. J Periodontol. 1991; 62(2): 123-131

6. McGuire MK, Nunn ME. Prognosis versus actual outcome. II. The effectiveness of clinical parameters in developing an accurate prognosis. J Periodontol. 1996;67(7):658-665.

7. Page RC, Krall EA, Martin J, et al. Validity and accuracy of a risk calculator in predicting periodontal disease. J Am Dent Assoc. 2002;133(5): 569-576.

8. Warren PR, Ray TS, Cugini M, Chater BV. A practice-based study of a power toothbrush: assessment of effectiveness and acceptance. J Am Dent Assoc. 2000;131(3):389-394.

9. Walker CB. The acquisition of antibiotic resistance in the periodontal microflora. Periodontol. 2000;1996;10:79-88.

10. Novak MJ, Johns LP, Miller RC, Bradshaw MH. Adjunctive benefits of subantimicrobial dose doxycycline in the management of severe, generalized, chronic periodontitis. J Periodontol. 2002;73(7):762-769

11. Levy RM, Giannobile WV, Feres F, et al. The effect of apically repositioned flap surgery on clinical parameters and the composition of the subgingival microbiota: 12-month data. Int J Perio Res Dent. 2002;22(3): 209-219.

Figure 1 Radiograph of patient presenting in 1975.		Figure 2 Radiograph 20 years later of patient with sporadic infrequent periodontal maintenance.
Figure 3 Clinical view of patient in Figure 1 revealing noncompliance in oral hygiene.		Figure 4 Intraoral view of a 20-year-old patient with aggressive juvenile periodontitis.
Figure 5 Radiograph of patient in Figure 4 demonstrating severe angular osseous resorption.		Figure 6 Clinical view of a 35-year-old male patient with aggressive rapidly advancing periodontitis.
Figure 7 Initial radiograph after placement of a fixed restoration in a periodontal patient.		Figure 8 Six-month follow-up of patient in Figure 7 demonstrating widened periodontal ligament as a result of occlusal trauma.
Figure 9 Initial charting of periodontal patient using electronic charting.		Figure 10 Patient in Figure 9 now returns for reevaluation. Note arrows on respective sites depicting up arrows for decreasing pocket depths.
Figure 11 Using formulas for resistance/susceptibility, the clinician can indicate such with userfriendly documentation.		Figure 12 A Web-based risk calculator by PreViser can provide both the clinician and the patient with adjunctive numerical information to help determine overall prognosis.
Figure 13 Data input including clinical parameters, medical and dental history, and additional risk factors are summarized in a visual graphic with Florida Probe software.
Figure 14 Initial intraoral view of a generalized aggressive periodontal patient.		Figure 15 One-year follow-up of patient in Figure 14 after periodontal therapy incorporating systemic antibiotics.
About the Author
Samuel B. Low, DDS, MS, MEd Associate Dean of Continuing Education and Faculty Practice University of Florida College of Dentistry Gainesville, Florida