Optimal Clinical Practice for Treating Patients With Periodontal Disease

Establish an oral hygiene regimen that supports “wellness”

The prevalence of periodontal disease in the United States is estimated to be 47%, affecting approximately 64.7 million adults aged 30 years or older. Data also exists on the severity and extent of periodontal disease: severity estimates are 8.7% for mild, 30% for moderate, and 8.5% for severe disease states. Analysis also revealed that periodontal disease was highest in men, Mexican Americans, adults without a high-school education, those below 100% federal poverty levels (FPL), and current smokers.¹

Understandably, those who do not receive or have access to regular dental care are at higher risk for dental disease. However, why people who have the means and access to care still present with periodontal disease is a perplexing issue. To begin to resolve this issue means starting with assessment and evaluation so that appropriate diagnosis and treatment can be delivered.

The proper assessment of periodontal status and delivery of preventive care, where appropriate, is a team effort. Each member plays a role in helping patients maintain their dentition for a lifetime. When problems occur, it is best to identify them early and provide the least invasive treatment possible. At times, patients present with severe periodontal disease, and referral to a specialist may be in the best interest of the patient.

This article is designed to support clinicians in their quest for optimal decision-making and best practices for diagnosis, treatment, and referral of patients for periodontal treatment that matches their disease level. It will review the current evidence and definitions for diagnosis, nonsurgical therapy, maintenance, and recare.

Diagnosis

Periodontal disease diagnosis is based primarily on clinical assessment² (Figure 1 through Figure 3). This cannot be accomplished without a comprehensive periodontal examination that includes probing depth(s), presence or absence of clinical signs of inflammation (eg, bleeding, edema, and redness), extent and pattern of attachment loss, and mobility (Figure 4). Documentation of patient complaints (eg, pain, bad breath, or taste) add another dimension to the extent and distribution of plaque and calculus, gingival ulceration, and exudate.

Periodontal disease is currently classified into seven categories.³ This classification is not the same as the case types that are used for third-party payment (Table 1). These classifications were developed in 1999 to better reflect the extent and severity of the disease state (Figure 5 and Figure 6). Additionally, chronic periodontitis replaced adult periodontitis, and aggressive periodontitis replaced early-onset periodontitis (Table 2).

The American Academy of Periodontology (AAP) commissioned a Task Force to address concerns by the AAP membership, education community, and practitioners who voiced challenges with the current classification. The Task Force will commence in 2017 and will focus on three specific areas: attachment level, chronic versus aggressive periodontitis, and localized versus generalized periodontitis.⁴

Nonsurgical Therapy

According to the AAP, periodontal health should be attained in the least invasive and most cost-effective way.⁵ This approach puts prevention at the “top of the list” and makes nonsurgical periodontal therapy the first line of defense for professional intervention.

A systematic review found insufficient data to definitively conclude that scaling and polishing can prevent periodontal disease in adults.⁶ There is some evidence that scaling and polishing, with oral hygiene instruction, is better than no treatment in adults.⁶ In addition, there is moderate evidence that thorough and periodic oral hygiene instruction (OHI) is just as good as scaling and polishing for improving plaque and gingival bleeding measurements.⁶ Therefore, the key to prevention is OHI. Adequate time and attention is, therefore, required at the “hygiene” appointment.

Nonsurgical therapy consists of many facets, including scaling and root planing (SRP), SRP with antimicrobial adjuncts, and laser therapy (with or without the addition of systemic antibiotics). The American Dental Association recently released evidence-based clinical practice guidelines on the nonsurgical treatment of chronic periodontitis.⁷ The systematic review evaluated studies that were at least 6 months in duration, published in English, and used clinical attachment level (CAL) as a measurement outcome because it is a more stable indicator of periodontal improvement compared to probing depth (PD) or bleeding; it also accounts for approximately 50% of PD reduction. The authors concluded that for patients with chronic periodontitis, SRP should be considered as the initial treatment. Figure 7 through Figure 12 demonstrate a patient with mild-to-moderate periodontitis responding well to SRP.

The addition of systemic subantimicrobial-dose doxycycline may be considered for patients with moderate-to-severe chronic periodontitis. Incorporating 20 mg twice a day for 3 to 9 months, in addition to SRP, resulted in a statistically significant though clinically limited net benefit.⁷ The research for using systemic antibiotics or locally delivered antimicrobials was weak in studies that fit this criteria.⁷ The expert opinion of the authors was that the use of chlorhexidine chips or minocycline microspheres may be considered, but the benefit or efficacy is uncertain. Research outcomes on SRP with adjunctive nonsurgical use of lasers, including diode, Nd:YAG, and erbium lasers, were weak, and the authors did not recommend this approach.

The delivery of SRP has also been studied by comparing the traditional method of a series of appointments, at least a week apart, to a full-mouth scaling (FMS) and root planing within a 24-hour period, or a full-mouth disinfection (FMD) (addition of antimicrobial agent) within a 24-hour period.⁸ The clinical rationale of a FMS or FMD was to prevent the likelihood of re-infection in previously treated areas. The practical rationale is reduced time and office visits for the patient. Based on this systematic review, there is no evidence to support the benefit of FMS or FMD over SRP. Adverse events, most notably an increase in body temperature, were reported in 8 of the 12 studies reviewed. Scheduling SRP appointments is a decision that warrants patient and practitioner considerations.

Maintenance

The key to disease prevention is appropriate OHI and patient adherence to therapist recommendations. While this is an important factor in patient treatment, it may not receive the level of attention necessary in daily clinical practice. Providing proper OHI is also not easy. Select skills are needed to elicit and support behavioral change. Research shows that OHI should be repeated periodically, and tailored to each individual’s needs to improve outcomes.⁹ Prac­titioners and patients both have a responsibility: clinicians provide an environment that can be maintained, and patients perform effective plaque removal techniques.

Supragingival Biofilm Control

Research reveals that either a manual or powered toothbrush can be recommended to control supragingival biofilm. A single brushing with a manual toothbrush provides an average plaque reduction of 42%, versus 46% with a powered toothbrush.¹⁰ The difference in bristle design for manual toothbrushes produces some variation in the extent of plaque removal: flat-trim, 24% to 47% plaque removal; multi-level, 33% to 54%; and criss-cross, 39% to 61%. Following a systematic review, no single toothbrush design was found to be superior, relative to its impact on gingival inflammation and management of gingivitis.¹⁰

Rechargeable power toothbrushes tend to perform better than replaceable-battery toothbrushes on plaque removal, and oscillating-rotating power design toothbrushes have shown a slight advantage over side-to-side action but the differences most likely are not clinically significant.¹¹ Power toothbrushes have a slight edge over manual toothbrushes in reducing inflammation, but not enough to have a clinical impact. Patient preference and skill will guide recommendation.

Interdental Biofilm Control

Most people need to clean interdentally. However, it could be argued that in a healthy mouth, it may not be necessary if there is no bleeding, loss of attachment, and/or identifiable risk factors. This is usually not the case, and most practitioners start with the ubiquitous brushing and flossing instructions. This is not patient-centered care, and with the availability of systematic reviews, it is not scientifically supported.¹²

Systematic reviews of interdental cleaning devices for managing gingivitis found there is often limited data to help make a clinical decision. Interdental brushes proved more effective for cleaning interproximal spaces in periodontal patients who have sufficient space to insert the brush without causing trauma.¹⁰ This is helpful information to a point, as the studies evaluated only those areas where the brush could access. What to use for the other interdental areas was not addressed. The addition of a triangular wood wedge to tooth brushing was systematically reviewed and was found to be better than brushing alone for reducing bleeding, but there was no benefit seen for plaque removal or gingival inflammation.¹³

Other devices have either limited data or have not been systematically reviewed. A pulsating water flosser, also known as an oral irrigator or dental water jet, has been compared to dental floss in several studies, but this information has not been systematically reviewed. The studies demonstrated that a pulsating water flosser is more effective at removing plaque and reducing gingival bleeding and inflammation compared to dental floss.^14-17 The differences ranged from 29% for plaque removal,¹⁴ 52% for reducing gingivitis around natural teeth,¹⁵ 145% for reducing bleeding around implants,¹⁶ and 26% for reducing bleeding in adolescents with orthodontic appliances.¹⁷ These differences are also clinically significant. Water flossing is also set apart from other interdental aids by the ability to clean pockets up to 6 mm in depth.¹⁸

Devices such as rubber-tip stimulators, end-tuft or single-tuft brushes, tufted dental floss, and floss holders are available along with many other products that are sold in retail stores and online. A decision to use these should be based on expert opinion because the research is insufficient to make a scientific recommendation.

Recare Interval

The semiannual hygiene visit is based on tradition and expert opinion but not science. There is no evidence that shows the ideal interval between recare visits to prevent periodontal disease or maintain resolution of infection.¹⁹ The recare interval is a clinical judgment by the dentist and periodontist based on a risk analysis and the patient’s ability to perform and adhere to oral hygiene recommendations.

Referral

Deciding when to refer a patient to a periodontist for care can be difficult. “Guidelines for the management of patients with periodontal disease” (Table 3), a report published by the AAP, is intended to help clinicians provide early interventions to improve the periodontal health of all patients.²⁰ This includes identifying those individuals who have an increased or higher risk of developing periodontal disease, and incorporating changes early to prevent or minimize the effects.

Sometimes dentists may hesitate to refer to a periodontist for fear of losing the patient. This reticence may also be due to economic reasons, since periodontal therapy can be the most productive procedure for hygienists. However, the patient’s well-being must be the primary concern.

Some patients may simply refuse treatment or to see a periodontist. If so, this must be reflected in the dental record, which must be signed by the patient. This is called “informed refusal” and can be scanned into the electronic record or placed in the patient’s chart.

To achieve a best-case scenario, collaboration is essential. It includes good communication with the patient and periodontist. It is also important to have a treatment plan that reflects resolution of the periodontal condition and the restorative and recare needs. This all hinges on patient acceptance and compliance. Providing elective restorative treatment or cosmetic dentistry to a patient who refuses periodontal treatment is a poor decision, setting everyone up for failure.

Summary

Assessing a patient’s periodontal status must be done in a thorough manner. Even if the patient presents with a healthy oral environment all readings should be documented as a baseline for future comparison. Evidence shows that SRP is effective in reducing inflammation, but recare interval is based on expert opinion and experience. Periodontal infections are dynamic, and assessment updates allow for early intervention and, perhaps most importantly, time for OHI. Establishing an oral hygiene program that addresses the challenges of behavior change can positively impact a patient’s oral health.

Periodontal diseases are preventable for most people. It starts with patient-centered care using available evidence and clinical judgment. A patient cannot be expected to keep 4-mm to 5-mm–deep pockets clean by brushing and dental flossing. Dental professionals must provide patients the information and tools necessary for success.

Acknowledgments

Figure 1 through Figure 3 and Figure 7 through Figure 12 were provided courtesy of Dr. Jolkovsky. Figure 4 was provided courtesy of Praktika Online Dental Software, Glen Waverley, Australia. Figure 5 and Figure 6 were provided courtesy of Dr. White.

References

1. Eke PI, Dye BA, Wei L, et al. Update on prevalence of periodontitis in adults in the United States: NHANES 2009 to 2012. J Periodontol. 2015;86 (5):611-622.

2. Armitage GC, Research, Science and Therapy Committee of the American Academy of Periodontology. Diagnosis of periodontal diseases. J Periodontol. 2003;74(8):1237-1247.

3. Parameter on comprehensive periodontal examination. American Academy of Periodontology. J Periodontol. 2000;71(5 suppl):847-848.

4. American Academy of Periodontology Task Force Report on the Update to the 1999 Classification of Periodontal Diseases and Conditions. J Periodontol. 2015;86(7):835-838.

5. Non-surgical periodontal treatment. American Academy of Periodontology website. Patient resources. https://www.perio.org/consumer/non-surgical. Accessed February 2, 2016.

6. Needleman I, Nibali L, Di Iorio A. Professional mechanical plaque removal for prevention of periodontal diseases in adults—systematic review update. J Clin Periodontol. 2015;42 suppl 16:S12-S35.

7. Smiley CJ, Tracy SL, Abt E, et al. Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. J Am Dent Assoc. 2015;146 (7):525-535.

8. Eberhard J, Jepsen S, Jervoe-Storm PM, et al. Full-mouth treatment modalities (within 24 hours) for chronic periodontitis in adults. Cochrane Database Syst Rev. 2015;(4):CD004622.

9. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305-312.

10. Chapple IL, Van der Weijden F, Doerfer C, et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol. 2015;42 suppl 16:S71-S76.

11. Van der Weijden FA, Slot DE. Efficacy of homecare regimens for mechanical plaque removal in managing gingivitis a meta review. J Clin Periodontol. 2015;42 suppl 16:S77-S91.

12. Sambunjak D, Nickerson JW, Poklepovic T, et al. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev. 2011;(12):CD008829.

13. Hoenderdos NL, Slot DE, Paraskevas S, Van der Weijden GA. The efficacy of woodsticks on plaque and gingival inflammation: a systematic review. Int J Dent Hyg. 2008;6(4):280-289.

14. Goyal CR, Lyle DM, Qaqish JG, Schuller R. Evaluation of the plaque removal efficacy of a water flosser compared to string floss in adults after a single use. J Clin Dent. 2013;24(2):37-42.

15. Barnes CM, Russell CM, Reinhardt RA, et al. Comparison of irrigation to floss as an adjunct to tooth brushing: effect on bleeding, gingivitis, and supragingival plaque. J Clin Dent. 2005;16(3):71-77.

16. Magnuson B, Harsono M, Stark PC, et al. Comparison of the effect of two interdental cleaning devices around implants on the reduction of bleeding: a 30-day randomized clinical trial. Compend Contin Educ Dent. 2013;34 spec no 8:2-7.

17. Sharma NC, Lyle DM, Qaqish JG, et al. Effect of a dental water jet with orthodontic tip on plaque and bleeding in adolescent patients with fixed orthodontic appliances. Am J Orthod Dentofacial Orthop. 2008;133(4):565-571.

18. Cobb CM, Rodgers RL, Killoy WJ. Ultrastructural examination of human periodontal pockets following the use of an oral irrigation device in vivo. J Periodontol. 1988;59(3):155-163.

19. Riley P, Worthington HV, Clarkson JE, Beirne PV. Recall intervals for oral health in primary care patients. Cochrane Database Syst Rev. 2013; (12):CD004346.

20. Krebs KA, Clem DS 3rd, American Academy of Periodontology. Guidelines for the management of patients with periodontal diseases. J Periodontol. 2006;77(9):1607-1611.

About the Authors

Cecil White, Jr., DMD, MSD
Board Certified Periodontist
Private Practice
Atlantic Beach, Florida

David L. Jolkovsky, DMD, MS
Lecturer, UCLA School of Dentistry
Los Angeles, California
Board Certified Periodontist
Private Practice
Davis, California

Deborah M. Lyle, RDH, BS, MS
Director of Professional & Clinical Affairs
Water Pik, Inc.
Fort Collins, Colorado