S3 BSP (2023) Guidelines on Management of Periodontal Disease

Question 1

Describe Step 1 treatment.

Answer 1

1. Explain disease, risk factors, treatment options and risks vs. benefits of treating and not treating condition.
2. Explain importance of OH and risk factor management.
3. Give patient-specific oral hygiene advice including ID brushing, +/- adjunctive mouthwash/toothpaste.
4. Carry out supra and sub gingival PMPR of clinical crown.
5. Reduce risk factors i.e. smoking cessation, diabetes control, removal of plaque retentive factors.
6. Agree recall period.

Question 2

What is the step 1 recall period ?

Answer 2

3 months.

Question 3

At step 1 3 month recall, patient engagement should be assessed using what special investigation ?

Answer 3

MPBS

Question 4

At step 1 3 month recall, patient engagement should be assessed, define an engaging patient ?

Answer 4

<20% plaque and <30% BoP score OR
>50% reduction in both plaque and BoP score OR
Patient has met personal self-care plan targets set out at first appointment by clinician.

Question 5

At step 1 recall, your patient is not engaging, how would you continue to treat this patient ?

Answer 5

Repeat step 1 treatment.

Question 6

At step 1 recall, your patient is engaging, how would you continue to treat this patient ?

Answer 6

Move to step 2 treatment.

Question 7

Describe step 2 treatment.

Answer 7

SUBGINGIVAL SCALING (RSD)
Reinforce OH, risk factor control and support behaviour change.
Can use ultrasonic or hand scaling +/- systemic antimicrobial adjuncts.
Set recall period.

Question 8

What is the step 2 recall period ?

Answer 8

3 months.

Question 9

At step 2 3 month recall, what do you assess ?

Answer 9

Periodontal condition stability.

Question 10

How would you assess stability of periodontal condition at step 2 recall ?

Answer 10

Using BPE probe around all teeth (like taking a BPE).

Question 11

Describe a stable (responding) periodontal condition (step 2 recall).

Answer 11

<10% BoP.
<4mm PPD.
No BoP at 4mm sites.

Question 12

Describe a periodontal condition in remission (step 2 recall).

Answer 12

> 10% BoP.
<4mm PPD.
No BoP at 4mm sites.

Question 13

Describe an unstable (non-responding) periodontal condition (step 2 recall).

Answer 13

=/>5mm PPD.
>4mm sites BoP.

Question 14

Describe step 3 treatment.

Answer 14

Re-instrumentation of 4-5mm PPD.
>5mm PPD - consider referral for other treatment (if not possible re-instrument the entire mouth).

Question 15

At step 2 3 month recall, your patient has stabilised their periodontal condition, how would you continue to treat this patient ?

Answer 15

Move to Step 4 treatment.

Question 16

At step 2 3 month recall, your patient still has persisting pockets of =/> 5mm which are not responding to step 2 non-surgical treatment, how would you continue to treat this patient ?

Answer 16

Move to Step 3 treatment.

Question 17

What methods might a tier 2 and tier 3 clinician in secondary care use to treat non-responding pockets =/> 5mm ?

Answer 17

Re-instrumentation of full mouth using systemic/local adjuncts.
Periodontal surgery - access flap, regenerative, resective surgery.

Question 18

What patient holistic factors might cause sites to fail to respond to step 2 non-surgical instrumentation ?

Answer 18

Poor patient engagement.
Smokers.
Uncontrolled diabetes.

Question 19

What patient specific oral factors might cause sites to fail to respond to step 2 non-surgical instrumentation ?

Answer 19

Deep vertical bone defects.
Mid-buccal or mid-palatal pockets.
1 sided vertical bony defects.
Endo-perio lesions.
Anatomical factors - enamel pearls, groove in roots, furcations.

Question 20

What type of local adjuncts can be used as part of step 3 treatment by a specialist ?

Answer 20

Disinfectants (Periochip).
Antimicrobials (Dentinomycin).
Host immune modulation therapy (Periostat).

Question 21

What systemic antimicrobial adjunct can be used as part of step 2/3 treatment by specialist ?

Answer 21

400mg 3x daily for 7 days Metronidazole.
Start immediately after full mouth sub-gingival scaling.

Question 22

What is the aim of access flap periodontal surgery ?

Answer 22

Direct access to root surface for debridement by lifting periosteal flap and removal of bone.

Question 23

What is the aim of resective periodontal surgery ?

Answer 23

Removal of overgrown soft tissue to make pockets more manageable for a patient to clean - gingivectomy.

Question 24

What is the aim of regenerative periodontal surgery ?

Answer 24

Improve clinical attachment, reduce probing depths, ridge augmentation.

Question 25

What are some medical contraindications to periodontal surgery ?

Answer 25

Smoker.
Unstable CVD or MI/stroke in last 6 months.
Poorly controlled diabetes.
Immunosuppressed.
Anticoagulants.

Question 26

What are the indications for periodontal surgery ?

Answer 26

Pockets >6mm.
No medical contraindications.
Teeth of reasonable prognosis.
Good OH - <20% plaque, <10% bleeding on probing.

Question 27

Describe step 4 treatment.

Answer 27

MAINTAINENCE
1. Reinforce OH, risk factor control, behaviour change.
2. Regular targeted PMPR to limit tooth loss.
3. Consider evidence based adjunctive toothpaste and/or mouthwash to control gingival inflammation.
4. Set recall period.

Question 28

What should the recall period for a patient in step 4 treatment be ?

Answer 28

3-6 months.

Question 29

How can an oral health educator help in managing your patients ?

Answer 29

Give OHI.
Direction for risk factor management - smoking cessation.
ID brushing - mouth map.

Question 30

How long does a prescription to a dental hygienist for treatment for a patient last ?

Answer 30

12 months.

Question 31

Does the hygienist need a separate LA prescription ?

Answer 31

Yes.
It should include preparation, dose, sites to be used.

Question 32

If making a referral to secondary care, what should the referral letter include ?

Answer 32

Diagnosis and classification.
Treatment already completed.
What treatment you think they could require.
Reason for referral.
SH.
FH.
MH.
DH - engagement, worst sites.
Radiographs and clinical images - including reports.

Question 33

Describe a level 2 complexity patient.

Answer 33

Periodontitis stage II or III and residual true pocketing of =/> 6mm.

Question 34

What treatment should a GDP carry out for level 2 and 3 complexity patients prior to making secondary care referral ?

Answer 34

Non-surgical treatment step 1 and 2.

Question 35

Describe a level 3 complexity patient.

Answer 35

Patient with stage IV or grade C periodontitis and true pocketing =/> 6mm.

Question 36

What other patients might you consider secondary care referral for ?

Answer 36

Very young patients. Complex medical histories. Require surgical intervention. Peri-implantitis.