1. “What does a successful outcome look like?”

• From a clinician’s perspective, a successful outcome would consist of shallow pockets (4 mm or less), low levels of bleeding on probing (10% or less), minimal visible inflammation and low levels of plaque (15% or less).
• However, it’s important to remember that for a patient, it is much more than that. A good outcome provides the patient with the best chance of stability/keeping teeth. There is also evidence to suggest an improved quality of life with better periodontal health.

2. “Why are you poking at my gums and what does it all mean?”

• It’s helpful to explain to patients that periodontal probing is key for assessing levels of disease.
• If you have a 5 mm pocket compared to a shallow pocket you have an 8 times increased chance of losing that tooth. If the pocket is 6 mm, the risk increases to 11. When the pocket is over 6 mm, there is a steep increase to 64 times! (Matuliene 2008)
• Shallow pockets are a good predictor for keeping teeth so this is what we are trying to achieve with treatment. Treatment aims to achieve ‘pocket closure’ i.e. pocket depths less than 5 mm.

3. “What will non-surgical therapy do?”

• Non-surgical periodontal therapy works remarkably well. With continuous non-surgical therapy over 3 years, evidence suggests a 60% reduction in tooth loss. Even with intermittent non-surgical therapy there is a 48% reduction in tooth loss (Hujoel et al 2000).
• With pocket depths of 4-6 mm we would expect a 1 mm reduction. With deeper pockets of 7 mm and more, we would expect a 2 mm reduction (Cobb et al 1996). So one course of non-surgical debridement may not be enough for the deep pockets.

4. “What are the possible unwanted consequences of treatment?”

• At least 50% with suffer from sensitivity but this is usually short-term.
• Aesthetics may be compromised with recession and formation of ‘black triangles’.
• It’s not uncommon to have increased food packing between the teeth.
• Bleeding may initially increase before improving.

5. ” What if I don’t have active non-surgical therapy?”

• Not all patients will want/be ready for a definitive active course of therapy. This is fine so long as they are aware of the situation and their expectations are managed.
• Patients need to understand their periodontal health would be compromised and a palliative approach would be taken.

6. “Are there any factors which will mean I won’t have an optimal response?”

• Key causes of lack of response are well characterised. Potential causes can and should be identified at the initial examination. Identifying limitations early helps forecasting and appropriate forecasting promotes motivation and adherence to successful treatment.
• Consider local factors (deep pockets, infrabony defects, furcations/root grooves) as well as patient factors (level of oral hygiene, compliance, tobacco use, diabetes).

7. “How will smoking and smoking cessation affect my periodontal health?”

• Smokers will have less pocket depth reductions following both non-surgical and surgical therapy (Needleman et al 2007, Labriola, Needleman & Moles 2005).
• The health message is QUIT. Cutting down has little benefit. Smoking exposure may be similar for 30 cigarettes and 15 cigarettes as individuals who cut down may smoke more heavily on the fewer cigarettes (Jarvis et al 1997, Russell et al 1980). It may also be harder to completely quit when cutting down to a few cigarettes a day.
• Once a patient has quit, within 12 months they will have better clinical improvements than those who carry on smoking (Rosa et al 2011).
• Direct patients to the NHS quit smoking services (www.nhs.uk/smokefree).
• E-cigarettes are much better than smoking in terms of general health but risks to oral health are unknown. Consider it as a way of helping quit smoking rather than as an alterative.

8. “How will diabetes impact on periodontal therapy?”

• Poor/unstable glycaemic control reduces the benefit of periodontal therapy. The best way of measuring control is through the HbA1c level. Good control: <6.5% HbA1c, <48 mmol/mol (write to the physician, don’t rely on the patient).
• Non-surgical treatment can still achieve good improvements but it is unpredictable.
• A referral can be offered if severe disease or unresponsive.

9. “What happens if you can’t get control of the disease?”

• The BSP has provided guidance on referring for specialist care. If appropriate, offer referral to your patient.
• For aggressive periodontitis patients, offer referral after initial preventative advice. For chronic periodontitis patients, provide initial treatment in general practice and then if this is unsuccessful referral may be indicated. When referred, initial non-surgical periodontal therapy should still be commenced within general practice as part of the dental team’s duty of care. Furthermore, it’s important to treat any primary dental disease e.g. caries, endodontic lesions, prior to referring.

10. “Are there any resources/videos I can watch of patients who have undergone a similar journey?”

• Patient videos – The Sound of Periodontitis: http://www.bsperio.org.uk/periodontal-disease/sound-of-periodontitis.html
• The above videos are free to download and share.

*If you haven’t booked yourself onto the BSP annual conference, please do join us whether you’re a student, dentist, therapist or hygienist: http://www.bsperio.org.uk/events/info/bsp-conference-2017/*

Periodontology