Diagnosis and management of chronic and aggressive periodontitis part 2: periodontal management

Periodontal treatment

What are the stages of periodontal treatment?

Following the clinical assessment and the establishment of the diagnosis of periodontitis, periodontal management should involve delivery of a phased treatment with steps as follows:

Periodontal indices and charts;

Behavioural change;

Non-surgical periodontal treatment;

Antibiotics and non-surgical periodontal therapy;

Adjuncts to non-surgical periodontal treatment;

Review following non-surgical periodontal treatment;

Surgical periodontal treatment;

Periodontal maintenance.

Periodontal indices and charts

Recording of plaque and gingival bleeding indices will indicate the level of oral hygiene and patient controllable inflammation.^2,3 These are essential baseline and sequential indicators of both the clinician‧s role and the patient‧s compliance in embarking on treatments and their outcomes. These baseline recordings are also noted for reference should a look back be required.

Recording of a detailed 6-point pocket chart based on the BPE scores is essential for the baseline record, and to monitor the progress of treatment.^2,3 Code 3 requires recording in that sextant only (post subgingival debridement) and code 4 requires recording for the entire dentition (pre- and post-subgingival debridement).² The presence of bleeding on probing should be recorded and indicates the likely presence of disease activity.²

Behavioural change

Establishing effective oral hygiene is central to the elimination of periodontal pathogens and promoting healthy colonization, and is essential in resolving gingivitis and preventing progression of periodontal disease and caries.⁴ Oral hygiene techniques must be demonstrated in the patient‧s mouth, including the Bass toothbrushing technique with emphasis on interdental cleaning aids, including the use of brushes designed to access into periodontal pocketing (Figure 1).^1,2 At this stage, the patient‧s motivation and compliance with oral hygiene requirements are critical for success of treatment and for long-term maintenance, since only a small number of patients have been shown to comply with recommended maintenance schedules.⁵

Smoking cessation is an essential step in periodontal disease management. Greater probing depth reduction and reduced bleeding on probing, with significantly greater gain of clinical attachment, is achievable following non-surgical and surgical treatments in non-smokers compared to smokers, with nicotine-derived products contributing to reduced inflammatory response and increased periodontal tissue destruction.^6,7

Non-surgical Periodontal Treatment

When plaque scores indicate a good level of oral hygiene (below 20%) supragingival cleaning followed by subgingival debridement in all pockets ≥5 mm should be carried out under local anaesthetic.¹ Local anaesthesia is essential to allow thorough instrument debridement to the full depth of the pocket, without causing discomfort to the patient.¹ Instrumentation needs to access all aspects of root surfaces with use of site-specific curettes and ultrasonic powered tips. Confirmation of removal of calculus deposits should be verified using explorer instruments, eg ODU explorer or the ball end of the WHO probe.

Antibiotics and non-surgical periodontal therapy

The global crisis of antimicrobial resistance continues and antimicrobial use needs to be appropriate and evidence based. Chronic periodontal disease should be managed by controlling bacterial plaque with hygiene measures and debridement of pocket root surfaces. Systemic antimicrobial use will be ineffective in microbial elimination within plaque biofilm and will not contribute in any way to the condition of the root surface required for pocket healing. Where there is likely tissue invasion of microbes, as in aggressive periodontitis, the appropriate use of antimicrobials is indicated as an adjunct to treatment, and should follow evidence-based protocols. Current recommended regimens include amoxicillin (500 mg tds 7 days) combined with metronidazole (400 mg tds 7 days) or, alternatively, if allergy is present, a regimen of doxycycline (100 mg OD for 21 days, with a 200 mg ‘loading dose’ on the first day)^2,8

These systemic antibiotics should commence on the day of completion of the root surface debridement.⁹ The debridement should ensure thoroughly clean root surfaces and be completed within a short time of less than one week to optimize the results.¹⁰ Patients who receive adjunctive systemic antibiotics for aggressive disease at initial therapy show statistically more significant improvement in pocket depth reduction than patients who receive antibiotics at re-treatment.¹¹

Adjuncts to non-surgical periodontal treatment

Other adjunctive treatments that have been combined with non-surgical periodontal treatment of chronic disease include, local delivery antimicrobials and laser photodynamic therapy. However, the literature on this remains equivocal and there is no firm indication that these treatment modalities will offer additional benefit to the outcomes of non-surgical periodontal treatment.¹, ¹² It is the quality of root surface debridement that is the critical factor and the adjuncts will not substitute for effective root cleaning.^13,14

Review following non-surgical periodontal treatment

Following non-surgical periodontal treatment a review should be undertaken at 3 months to include recording of plaque and gingival bleeding indices alongside a detailed pocket and bleeding on probing chart.^1,2 Healing will be more complete at 3 months following non-surgical treatment and earlier probing may damage healing sites.^13,14 BPE scores cannot be used to review treatment outcome as information about site specific change is not recorded. For some patients oral hygiene check appointments during the healing phase may be beneficial.

Based on these measurements, the options will be to repeat the non-surgical periodontal treatment, to perform surgical periodontal treatment or for the patient to enter the maintenance phase³ (Figures 2 and 3).³

Surgical periodontal treatment

Review of non-surgical treatment should be critical of the quality of root surface debridement, and if deposit is detected when probing into a non-responsive site with bleeding on probing then further non-surgical periodontal treatment is indicated, in the compliant patient.^1,2 Where root surfaces feel smooth, then surgical treatment with open flap debridement may be required for improved access and visualization of root surface sites and where anatomy, eg furcation involvement, may have prevented effective debridement (Figure 4).¹⁵ Pockets of 7 mm or greater show improved pocket depth reduction and clinical attachment gain compared to moderate or shallow pockets after surgical periodontal treatment.¹⁶ Surgery is not indicated in smokers as healing will be compromised.^6,7

Where all pockets have resolved, or there are localized maintainable pockets of 5 mm without bleeding on probing, the patient should enter a maintenance phase.¹

Surgical and non-surgical treatment of aggressive periodontitis offers similar outcomes regarding probing pocket depth reduction, probing attachment gain and bone fill.¹⁷ Teeth treated for aggressive periodontitis that previously would have been deemed of questionable or hopeless prognosis can be maintained in the long-term provided that comprehensive mechanical debridement and antimicrobial therapy has been carried out with continued maintenance thereafter.^18,19,20

Periodontal maintenance

Maintenance is the most important element of periodontal management, with repeated reinforcement and monitoring of oral hygiene technique having a similar effect as regular professional mechanical debridement.²¹ A patient-tailored recall programme can help maintain excellent standards of oral hygiene and unaltered attachment levels. Without maintenance, recurrence of disease is likely.²²

An effective maintenance programme should include:

Regular review appointments every 3 months;

Recording of a detailed 6-point pocket chart at least annually to identify recurrence of disease;

Reinforcement of oral hygiene and supra- and subgingival scaling, as necessary.

Factors affecting prognosis of periodontally involved teeth

There are a number of factors that affect prognosis, with position in arch affecting likelihood of tooth loss, risk being greatest for maxillary second molars and least for mandibular canines (Table 1).^23,24 Teeth with increased probing depth, mobility, furcation involvement, unsatisfactory crown-to-root ratio, malposition and those used as fixed abutments have worse initial prognosis.²⁵ Prognosis can change over time, with good oral hygiene being a critical positive factor, and mobility decreasing likelihood for improvement. Continued smoking doubles the likelihood of a worsening prognosis.²⁵ During maintenance, phase sites with bleeding on probing have three times higher risk of attachment loss compared to non-bleeding sites.²⁶ Documented monitoring with indices is required to alert to early intervention, as presence of plaque deposits and bleeding on probing adversely affects prognosis, with 16% or more BOP sites reported as likely to lose further clinical attachment.²⁶

The incidence of caries and periodontal disease in treated and maintained periodontal patients is very small; Axelsson and Lindhe reported 0.4–1.8 tooth loss incidence over a 30-year maintenance period.²² Furthermore, progression of periodontal disease as assessed by radiographic bone loss, in treated and maintained patients, is minimal, with mean annual rate of bone loss of 0.037 mm.²⁷ Therefore, although periodontal management can be challenging, requiring behavioural changes and patient motivation, when successfully treated and maintained, the natural dentition can be retained well beyond previous expectations.

Summary

The first paper of this three-part series reviewed periodontal disease pathogenesis, periodontal clinical assessment and diagnosis of chronic and aggressive periodontitis. This second paper has focused on the aim of periodontal treatment, the management of chronic and aggressive periodontitis and the prognosis of periodontally involved teeth. Finally, the third part of the series will discuss the scientific evidence regarding diagnosis and management of chronic and aggressive periodontitis using two clinical examples.