Non-surgical periodontal therapy (NSPT) underpins all other restorative treatment which takes place in the mouth. Therefore a thorough understanding of the process of delivery of effective NSPT and long-term maintenance of periodontal health is essential for every dental practitioner. This article covers the steps involved and discusses the benefits and challenges which may be encountered.
CPD/Clinical Relevance: This article highlights the benefits and challenges of non-surgical management of periodontal disease and the key role that the patient plays in achieving and maintaining periodontal health.
Article
Imogen Midwood
Gingivitis and periodontitis are prevalent conditions,1 which have been found to impact negatively on a patient's quality of life2 and have the potential to influence systemic health.3
Non-surgical periodontal therapy (NSPT) encompasses every non-surgical aspect of managing a patient who presents with any form of plaque-induced periodontal disease.4 NSPT includes motivating patients to engage with positive behavioural changes, such as improvements in daily plaque removal practices or smoking cessation. It also includes communicating with other healthcare professionals to manage any medical issues a patient may have which could impact on periodontal health.
Effective NSPT can play a huge role in improving and maintaining oral and general health at both an individual and a population level.5 The aim of treatment is ultimately to improve tooth longevity by preventing soft and hard tissue damage of the supporting periodontium. This is achieved by control of modifiable risk factors, including daily disruption of the supragingival bacterial biofilm by the patient and periodic removal of the subgingival bacterial biofilm by the dentist, dental therapist or dental hygienist.6 These, in turn, reduce the inflammation and active disease in the periodontal tissues,6 and enable healing. There are both benefits and challenges of NSPT (Tables 1 and 2 and Figure 1).
To the Patient
Improved tooth longevity
Improved mastication, nutrition, speech and self-esteem
Improved quality of life
Less bleeding when brushing, fresher breath, teeth may feel firmer and gums less tender when brushing and eating
Enables restorative treatment to be performed more effectively
Potential improvements in systemic health
To the Dentist
Encourages a holistic approach to treatment
When performed well the results are effective and rewarding
Opportunity to build a rapport with patients through effective behaviour change
Enables restorative treatment to be performed more easily
Better periodontal health allows greater predictability and longevity of restorations and dental implants
To the Patient
Time consuming to perform effective plaque removal daily and undergo treatment
root surface sensitivity from the exposed root surfaces;
increased risk of root caries.
Failure to respond to treatment, requiring a need for further treatment
To the Dentist
Managing patients' expectations
Motivating patients to be compliant at home
Time consuming to provide effective treatment
Failure to respond to treatment, which requires further treatment
Defects such as furcations or infrabony defects or areas with extensive bone loss may not respond to non-surgical therapy
Future recurrence of disease
Figure 1. Clinical images of a 29-year-old female patient who presented with Generalized periodontitis; Stage IV; Grade C; currently unstable. The patient had a family history of periodontitis and an unrestorable fracture of LR6. This tooth was extracted. The images were taken before and after two courses of NSPT.
Management
After carrying out the necessary special investigations and diagnosing either gingivitis or periodontitis, the clinician should explain to the patient the causes and progression of the disease, including the various treatment options and the sequelae of no treatment. When communicating with the patient, a visual aid is helpful and, following the explanation, a patient information leaflet can be provided to reinforce the message (Figures 2 and 3).
Figure 2. Visual aid to show the stages of periodontal disease from health to gingivitis to periodontitis available to download from the Scottish Dental Clinical Effectiveness Programme (SDCEP): http://www.sdcep.org.uk/wp-content/uploads/2015/01/SDCEP+OH+TIPPS+Visual+Aid.pdfFigure 3. Patient information leaflet available to order or download from the British Society of Periodontology (BSP): https://www.bsperio.org.uk/publications/downloads/95_105645_bsperio-patient-information.pdf
If a patient wishes to improve his/her periodontal health, the clinician can follow the basic flow chart of patient management outlined, however, the management should be tailored to the individual.
It is critical to explain to the patient that treatment of periodontal disease is:
A partnership between the patient and the clinicians who care for the patient. Effective daily plaque removal at home is of equal importance to the treatment carried out in the clinic.
A lifelong commitment. Periodontitis is a chronic disease which needs to be managed. The patient may never be cured of the disease. The aim of treatment is to stabilize and slow the progression of the disease. Regular visits to a dentist or hygienist for remotivation with regard to plaque removal and, when required, scaling both supra and subgingivally will be necessary for life, following initial intensive NSPT.
Diagnosis
Gingivitis – Follow Steps 1-4 and 7
Periodontitis – Follow Steps 1 to 7
Long-term maintenance
Gingivitis patients
At each routine check-up carry out a BPE and, based on the findings, prescribe appropriate assessment and treatment which may include:
Plaque and gingivitis charting;
Behaviour change and risk factor intervention;
Supra- and subgingival scaling, as required.
Periodontitis patients
For periodontal status of patients with periodontitis following initial NSPT please see Table 3.
Currently Stable
≤10% of sites BOP
PPD of ≤4 mm
No 4 mm sites BOP
Currently in Remission
≥10% of sites BOP
PPD of ≤4 mm
No 4 mm sites BOP
Currently Unstable
PPD ≥5 mm or
PPD ≥4 mm and BOP
Supportive periodontal therapy (SPT) with the dentist or hygienist at 3 monthly intervals for the first year including:
Plaque and gingivitis charting;
Targeted plaque removal intervention;
Supra- and subgingival scaling as required.
Repeat 6-point pocket chart after 12 months and decide on future SPT intervals or another course of NSPT based on findings.
Carry out plaque score:
Above 20%, focus on reducing plaque score to less than 20% before another course of NSPT;
Below 20%, complete another course of targeted NSPT.
Consider:
Patient factors;
Operator factors;
Site specific factors.
Modify as necessary, before considering another course of NSPT or referral to a specialist.
Challenging situations
Tooth sensitivity
Tooth sensitivity can occur as a sequela of root surface exposure, and is common following NSPT.11 The longevity of tooth sensitivity ranges from one up to a few weeks and depends on the individual and disease severity.11 Patients should be advised to use a toothpaste targeted toward managing tooth sensitivity, and use a technique of spitting and not rinsing the excess toothpaste from the mouth after toothbrushing.
Furcations
Patients should be informed about the presence of a furcation. It can be useful to convey what a furcation is on a radiograph or tooth model and explain that furcation involvement worsens the prognosis for a tooth.12 All furcations can be managed initially with NSPT, however, a referral for specialist treatment may be required for some furcation lesions which are challenging for the patient and clinician to manage (Figure 7).
Figure 4. A plaque disclosed mouth showing plaque present interproximally and at the gingival marginFigure 5. Oral Hygiene TIPPS behaviour change circle http://www.sdcep.org.uk/published-guidance/periodontal-management/oral-hygiene-tipps-video/Figure 6. Radiograph to show subgingival calculus present: UR7, UR6d and overhanging restorations: UR6m and UR5d with associated bone loss.Figure 7. Grade 3 furcation and mesial vertical bone defect on LL6.
Vertical defects
Vertical defects may experience bony infill with effective non-surgical treatment (Figure 8).13 However, these sites are challenging to manage. If periodontal pockets ≥5 mm, or ≥4 mm with bleeding on probing persist after an initial course of NSPT, the area can be re-treated to ensure that all the subgingival deposits have been removed. If the pocket does not heal following this, the patient can be referred to a specialist periodontist for therapy, which may include surgical periodontal treatment options.
Figure 8. (a-d) Bony infill on the mesial surfaces of the lower first molar teeth before (a, b) and after (c, d) NSPT.
Medications associated with drug-induced gingival overgrowth (Figure 9)
Drug-induced gingival overgrowth (DIGO) is seen in patients taking calcium channel blockers such as nifedipine, anti-epileptics such as phenytoin, or immunosuppressive medications, such as ciclosporin. There is no official guidance for the management of drug-induced gingival overgrowth (DIGO), however, it is recommended to start with effective and supportive NSPT.14 If DIGO persists, communicate with the patient's general medical practitioner to ask if the medication can be changed and explain that DIGO is a recognized side-effect of the particular medication. If this is not possible, the patient may be referred to a specialist periodontist who is able to perform a surgical resection of the bulk of gingivae (gingivectomy). Effective plaque control on the part of the patient will resolve much of the gingival inflammation, making the surgical resection less prone to bleeding. Patients should be warned that, in the absence of good oral hygiene and possibly a change in the medication, DIGO may recur, even after surgical treatment.
Figure 9. Drug-induced gingival overgrowth due to (a) a calcium channel blocker and (b) phenytoin.
During pregnancy, there is an increased gingival response to plaque, thought to be due to the higher circulating levels of oestrogen and progesterone,15 hence a patient may experience gingival swelling and increased bleeding when brushing. It is safe for pregnant women to undergo NSPT during pregnancy and the best time to perform treatment is during the second trimester. Guidance and infographics are available on the BSP website on the relationship between oral health and pregnancy: https://www.bsperio.org.uk/professional/oralhealthandpregnancy/index.html
Figure 10. (a, b) Two patients with pregnancy gingivitis. (b) The patient has a localized pregnancy epulis in relation to the buccal surfaces of teeth UR2 and UR3.
Step 1. Assess: medical history, dental history and social history to determine any risk factors for gingivitis and/or periodontitis
Medical issues: Any medical issues which may affect periodontal health, such as diabetes and medications which may cause gingival overgrowth (see below), should be discussed with the patient. If a diabetes patient has signs of periodontal disease this should be communicated to the patient's doctor.7 A proforma letter is available on the BSP website at https://www.bsperio.org.uk/professional/periodontal-disease-and-diabetes/index.html together with other useful information for patients and healthcare professionals about the relationship between diabetes and periodontal disease.
Dental attendance: Have there been any visits to the dental hygienist or dental therapist for previous deep cleaning of teeth? If not, address the barriers – attendance for appointments due to work or domestic commitments, other priorities, lack of knowledge.
Smoking: Ask what, how much, and how long the patient has been smoking or did smoke in the past. For current smokers find out if the patient wants to quit. If so, direct to the NHS stop smoking services website for information about local smoking cessation services https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/#how-to-contact-a-stop-smoking-adviser
A holistic approach: Identify any factors which could influence periodontal health and give advice where possible. These include lifestyle factors such as stress, a poor diet, deficient in macro/micro nutrients and anti-oxidants, and lack of exercise.
Step 2. Review: plaque control
Ask the patient to bring current oral hygiene aids into the practice. In a non-judgemental way examine the condition of these and find out how often they are being used and replaced.
Advise that toothbrushes, interdental brushes and floss are more effective than chemical agents in mouthwashes and toothpastes at removing plaque; rechargeable rotation/oscillation power toothbrushes have been shown to be more effective than manual brushes at removing plaque8 and interdental brushes are more effective than floss for patients with gingival recession.9
Examine the patient's mouth and carry out a plaque and bleeding score. Disclosing tablets and solutions are useful for the clinician and patient to visualize where plaque is present on the tooth surfaces (Figure 4). A target plaque score of 20% or less is ideal.
Step 3. Behaviour change
A. Risk factor managment
When a modifiable risk factor is identified, such as smoking or poor diet, the patient should be informed about the effect of the risk factor on the periodontium and how it may negatively impact on response to treatment.
Offer advice and support on how to eliminate risk factors, for example offering a referral to a local NHS Stop Smoking Service.
B. Effective plaque removal
Explain to the patient that effective plaque removal requires practice (in the same way as learning to play a musical instrument or a sport). Although it is clear that the patient is cleaning his/her teeth he/she would benefit from coaching in order to acquire the skills for excellent plaque removal.
Obtain consent from the patient and demonstrate plaque removal in the patient's mouth.
Oral hygiene advice should be tailored to the individual patient.
Interdental cleaning should be introduced before toothbrushing. Demonstrate to the patient the correct use of either floss or, where recession is present, interdental brushes. The interdental brushes should be a snug fit without the wire rubbing on the tooth and should be moved back and forth in each space eight to ten times. Ask the patient to practise while you observe.
Ask the patient to clean his/her teeth using a toothbrush and modify the technique as required. Give the patient confidence that he/she can clean effectively.
Make a plan with the patient as to how and when he/she will make cleaning a daily habit. Some patients benefit from written goal-setting and plaque removal diaries.10
Follow up at future visits and focus on any areas the patient is missing. The patient's gingivae may bleed more initially and the patient will need support and encouragement to keep cleaning. Changing behaviour is an ongoing process which can take months. Relapse is common and constant remotivation will be required as the stresses of daily life can impact on plaque removal.
The Oral Hygiene TIPPS behaviour change intervention developed by SDCEP can be helpful in bringing about behaviour change in patients (Figure 5).
Step 4. Supra and subgingival scaling
Remove any barriers impeding plaque control such as supra- or subgingival calculus (Figure 6).
Overhangs on restorations should also be removed or the restoration replaced.
Failure of NSPT
NSPT can fail for a number of reasons, including patient factors, operator factors or site-specific factors. It is possible that the patient's cleaning is inadequate, that a patient continues to smoke, or that subgingival plaque and calculus deposits remain on the root surfaces, all of which can influence the treatment outcome. Other reasons which can influence treatment outcome are an undiagnosed underlying condition, for example, uncontrolled diabetes, or a patient may have high susceptibility for periodontitis (2017 Classification Grade C). In these situations, it is recommended to consider liaising with the patient's general medical practitioner or to make a referral to a specialist periodontist.
Step 5. Root surface debridement
Treatment Aim:
Disruption of the bacterial biofilm on the tooth surfaces both above and below the gingival margin, by removing any plaque retentive calculus.
Method:
Depending on patient preference and localization of periodontal pocketing, treatment can be carried out over one or several days.
Warn the patient of post-operative discomfort, tooth sensitivity, gum recession and possible need for further treatment.
All teeth with probing pocket depth (PPD) ≥5 mm or ≥4 mm and bleeding on probing require treatment and should be anaesthetized as required for patient comfort.
Root surface debridement can be carried out with a combination of ultrasonic scalers and hand instruments to debride the root surfaces but care should be taken not to damage root surfaces.
The amount of time required to complete root surface debridement effectively will vary, depending on a number of factors. For example, more time will be needed to debride root surfaces at deep pockets which have large amounts of subgingival calculus deposits or where furcation involvement is present.
Aftercare advice: advise the patient to use pain relief as necessary, and try to clean the teeth as normal after treatment; it may be uncomfortable to use interdental cleaning aids until the following day. For patients who have full mouth treatment in one day, 2% chlorhexidine mouthwash (twice per day) may be prescribed until the patient can clean normally.
Step 6. Plaque removal review: Two to four weeks after root surface debridement
Follow up on goal setting and plaque removal diaries, if applicable.
Record plaque and bleeding scores and compare with the baseline scores and use if possible for patient motivation.
Demonstrate and practise plaque removal with the patient, where required. Due to recession, the sizes of interdental brushes may have to be increased.
Remove any supragingival calculus deposits.
Follow up again if necessary.
Step 7. Reassessment: three months after initial treatment to review periodontal status
Record any changes in how the patient feels about his/her gums.
Follow up on goal setting and plaque removal diaries, if applicable
Record plaque score and compare with the previous scores and use, if possible, for patient motivation.
Repeat 6-point pocket chart (including probing depths, bleeding, recession, furcations, suppuration, mobility): - for patients with initial BPE code 3s, this should be carried out in the involved sextants; - for patients with initial BPE code 4s, this should be carried out in all sextants.
Conclusions
Non-surgical periodontal therapy encompasses every aspect of managing gingivitis or periodontitis which does not include a surgical approach.
Successful NSPT is a mechanism for building rapport with a patient and improving his/her health and wellbeing. This can be very satisfying for a clinician and have a huge impact on a patient's quality of life.
Some patients may not respond to NSPT, depending on many factors. It is recommended that patients with good plaque removal and persistent pockets of 5 mm or more, which are bleeding on probing, are referred to a specialist periodontist for further management.
All patients following initial intensive NSPT will require regular effective supportive periodontal therapy for life.
Useful Links
The Good Practitioner's Guide to Periodontology https://www.bsperio.org.uk/publications/good_practitioners_guide_2016.pdf?v=3
SDCEP Guidance – Prevention and Treatment of Periodontal Diseases in Primary Care http://www.sdcep.org.uk/wp-content/uploads/2015/01/SDCEP+Periodontal+Disease+Full+Guidance.pdf
