Periodontal treatment

The overall goal of modern periodontal treatment is to achieve and then maintain acceptable gum health without the long-term need for specialist therapy (which often in the past involved surgery, but is now according to the Scientific Evidence-Base carried out as a phased non-surgical programme).

After initial stabilisation of the condition has been achieved, the aim is for the patient to be able to control their predisposition to disease through a life-long home-care programme with regular monitoring and maintenance at their dental practice.

What conditions are treated by the dental hygienist and the periodontist?

• Gingivitis (treated by the dental hygienist)
• Periodontitis (treated by the periodontist)

What are these conditions and who is at risk from them?

Gingivitis

The majority of people suffer from a mild form of gum disease (gingivitis) that can lead to bleeding gums and often the plaque causing it will harden on the teeth forming a calcified deposit of “tartar” (calculus).  Routine appointments with a dental hygienist are aimed at the treatment and ongoing prevention of these reversible problems, which are caused by plaque which is totally accessible to cleaning at home.

Symptoms may not appear until an advanced stage of the disease. However, warning signs of gum disease include the following:

• Red, swollen or tender gums or other pain in your mouth
• Bleeding while brushing, flossing, or eating hard food
• Gums that are receding or pulling away from the teeth, causing the teeth to look longer than before
• Loose or separating teeth
• Pus between your gums and teeth
• Persistent bad breath
• A change in the way your teeth fit together when you bite
• A change in the fit of partial dentures

Periodontitis

A small proportion of the population (10-20%) are genetically more susceptible to the effects of plaque and irreversible damage may be caused to the attachment between the gum and the roots of the teeth (periodontitis).
This can result in the formation of gaps between the gums and the teeth (pockets) in which more plaque can collect and thus continue the disease process. As these pockets deepen, the plaque under the gums becomes more inaccessible to cleaning, more extensive and more toxic.
This leads to increasing damage to the supporting bone around the roots of the teeth. The bone is gradually destroyed and in the worst cases the teeth may eventually become loose and even be lost.

Increased risk factors for periodontitis

Existing susceptibility to periodontal attachment loss can be modified by secondary and environmental risk factors such as:

• Smoking
• Type I and Type II diabetes (particularly type II when inadequately controlled)
• Conditions and/or medication which interfere with a patient’s ability to perform acceptable plaque control or reduce their body defences against infection.
• Psychosocial factors and the presence of certain putative periodontal pathogens in periodontal pockets.
• Stress
• Excessive biting forces

Age is not in itself a risk factor, and as suggested by the most recent classification of periodontal diseases it should only be considered in concert with the clinical characteristics of the individual patient's periodontal condition.

Why it is imperative to stabilise periodontitis before considering teeth implants?

In the UK in April 2008, the General Dental Council published a Statement supporting the Training Standards in Implant Dentistry for General Dental Practitioners first published by the Faculty of General Dental Practice (UK) in 2004. These standards highlight the requirement to eliminate any pre-existing dental pathology and where possible secondary risk factors prior to dental implant treatment planning.
Late failure of dental implant osseointegration can follow periods of immediate postplacement stability. These late failures are associated with overloading and not a Periodontitis-like pathology.

Why giving up smoking will significantly improve the outcome of the patient's treatment and recovery time

Smokers do not respond to treatment as well as those who have never smoked, or who cease smoking as part of their treatment.
Individuals who stop smoking can respond as well to periodontal treatment as non-smokers.  Within a few months of quitting smoking the appearance and health of the gums improve with treatment.

Evidence shows that smokers

• Have more severe gum disease than non-smokers, with deeper periodontal pockets and more loss of gum and bone support
• Have greater tooth loss
• Respond less well to all types of periodontal treatment
• Are more likely to suffer a return of periodontal problems
  

What proportion of the population may be at risk of multiple tooth loss due to periodontal breakdown?

A definitive review of the natural history of periodontal disease and its prevalence in populations suggests that around the world there may be up to 20% of adults in this group.
In the UK, the 1998 Adult Dental Health Survey (ADHS) suggested that at the time of the survey (1998) overall 8% (potentially more that 3 million patients) of those who were dentate and over 16 years of age had at least one site with 6mm or more of periodontal attachment loss and 5% had at least one pocket which was 6mm or deeper.
A commentary on the 1998 UK ADHS concluded “the continued high prevalence of disease needs to be seen in the context of the far larger number of people who are now potentially at some risk, particularly in the older age groups, because of improvements in tooth retention. However, the cumulative effects of disease means that control of the periodontal diseases, even mild and slowly progressing disease, will be a key issue if large numbers of teeth are to be retained into old age”. This statement was supported by the prevalence of advanced attachment loss in the 65 years of age and older group in the ADHS being 15%.

How assessment for a referral for periodontal treatment is made by the dental professional at Clinic 95

The Matrix assessment will be used to record the results of the periodontal (gum) examination (where the dental professional uses the ball ended probe to assess the depth of pockets -the area between the tooth and the gum - sulcus).
The dental professional will guide patients to their position on the periodontal matrix to inform them of their optimum treatment decisions and goals. This approach of careful measurement and team care, offers patients the best management of their gum health.
The periodontal assessment matrix is designed to help the dental professional decide the most appropriate form of dental hygiene treatment and to give the patient a ‘benchmark’ to help them understand the severity of any problems they may have.

Following the assessment with the Matrix, the dental professional and patient will discuss the Matrix results and what the recommended next steps might be. The patient will receive a copy  of their assessment.
If a referral is made to see the Periodontist they will receive an information pack and offered a consultation appointment.

See the Matrix guide here.

What it means to be in each of the Matrix zones:

Green Zone
Ideally everyone should aspire to be at the top of the green zone and this is the aim of all dental hygiene regimes. The dental hygienist will remove tartar (calculus) which can harbor bacterial plaque and recommend appropriate home-care techniques to help prevent plaque accumulation. Once the teeth have been professionally cleaned it is essential that home-care plaque removal regimes are followed daily.

Amber Zone
For those patients initially in the amber zone a series of more intensive sessions with their dental hygienist and a concerted effort to improve plaque-control, should allow most patients to move towards and into the green zone*.
Once this has been achieved, regular professional dental hygiene support initially on a three monthly basis will be necessary. However, if home maintenance and plaque removal is successful, but there is no improvement in underlying gum disease, then referral to a periodontist is indicated at this stage.

Red Zone
For those patients initially in the red zone it is important to seek specialist care with a periodontist in the first instance and referral will be advised straight away.

How the periodontal treatment programme works and the benefits of a non-surgical approach

Periodontitis is treated with a phased non-surgical programme.  It has been demonstrated that surgical approaches have less value in the treatment of the majority of sites with periodontal disease than non-surgical treatment.
Evidence for the optimal treatment-outcomes, (compared to those produced by traditional surgical protocols), achieved by non-surgical approaches to therapeutic treatment continues to mount.
All the specialist periodontal (gum-treatment) programmes conform to the latest evidence-based clinical specialist protocols.
The overall goal of modern periodontal treatment is to achieve and then maintain acceptable gum health without the long-term need for specialist therapy (which often in the past involved surgery, but is now ideally carried out as a phased non-surgical programme).
After initial stabilisation of the condition has been achieved, the aim is for the patient to be able to control their predisposition to disease through a life-long home-care programme with regular monitoring and maintenance at their dental practice.

The initial periodontal consultation - what to expect

This will involve a very detailed analysis of the patient's gum problems looking at each individual tooth, the extent of the disease, the long term prognosis and treatment required (no treatment will be carried out at the consultation visit).

Following the consultation

PHASE 1, The hygiene phase

Periodontal disease can in most cases be controlled to avoid further loss of bone around the roots of the teeth – but there is no cure and lost bone usually cannot be replaced. Since nothing can be done to change the patient's susceptibility to periodontal disease, control of the disease process is achieved by reducing the amount of plaque in the mouth. In this respect the patient's own plaque-control at home is of fundamental importance and their ability to clean consistently well on a daily basis (particularly between their teeth and under their gums into the pockets) will have a very strong influence on the outcome of their treatment.

For this reason in Phase 1 of treatment (“The Hygiene Phase”) the emphasis will be on helping the patient develop effective plaque-control techniques. These will be monitored closely throughout treatment, because the patient cannot proceed to the next stage if they are unable to consistently perform plaque-control with the home-care techniques they will have been trained to use.

It should be possible for the patient to learn to clean thoroughly up to 2mm into their pockets. The home-care will be optimally supplemented during this phase by a carefully structured professional cleaning programme for tooth surfaces above and below their gum margins.

*Note: The treatment appointments recommend for the Phase 1 programme are spaced at monthly intervals. This provides an optimal period for the patient to achieve the standards of plaque-control required and to receive the necessary professional support, plus allowing time for the soft tissues to respond. The treatment at these visits will always be carried out by a periodontist.

Re-Assessment:
Once the patient’s plaque-control has reached a sufficiently high standard and the necessary professional root-surface cleaning has been completed during Phase 1, the periodontist will re-assess the response of the patient’s gums to this treatment. The depths of the patient’s pockets will be re-measured and any residual deep-bleeding recorded (pocketing and inflammation should have reduced since the initial consultation).

PHASE 2, The debridement phase (this will not be required if the patient achieves optimal healing in phase 1)

A further specialist treatment plan will be formulated for the treatment of pockets where plaque still remains inaccessible to the patient (4mm pockets which are still inflamed or deeper pockets). This is Phase 2 of specialist treatment (“The Debridement Phase”).

Debridement involves the further systematic but gentle removal of plaque from the affected deeper root surfaces of the patient’s teeth “Periodontal Debridement”. Pockets initially deeper than 6mm frequently require repetition of this treatment following reassessment, because of the difficulty in stabilising periodontal disease in these deep sites.
If the patient requires this phase of treatment, it will be carried out during one additional appointment.

Re-Assessment
Another specialist re-assessment will be carried out three months after completion of the Debridement Phase (if this phase has been necessary). This allows for an optimal further healing period.
Note: Further treatment may be required, but the patient would be informed of any additional costs as treatment proceeds.

PHASE 3, The supportive (“maintenance”) phase:

As for all patients with the same degree of susceptibility to periodontal disease, it is essential that the patient receives regular supportive care and continued monitoring, once health has first been achieved.  This is ideally carried out at three-monthly intervals, by a dental hygienist working to the periodontist's prescription. During Phase 3 (“The Maintenance Phase”), initially specialist re-assessment is required at approximately the eighteen-month point to check that no deterioration is occurring and to provide an ongoing treatment plan for the next stage of the patient’s Supportive Periodontal Therapy.

This process should continue indefinitely (but with specialist review intervals increasing up to a maximum of 3 years) in order to monitor and encourage the patient’s home-care plaque-control and provide for any necessary further treatment at the earliest indication of any relapse.

The patient’s home-care plaque-control will continue to be monitored during all phases of the patient’s active treatment and long-term supportive programme.

Treatment Outcomes

If successful resolution of the superficial swelling affecting the patient’s gums is achieved during the first phase of treatment, there will be some recession of the gum margins (which should in many cases not be detectable to the eye). Some recession can occur as pocket-depths shrink during treatment and the gum margins tightening to establish a more healthy position in a closer relationship to the patient’s reduced bone levels (this will be minimised if optimal healing is achieved).

Recession can result in a slightly lengthened appearance in affected teeth, with the exposed root surfaces more prone to sensitivity to some stimuli and to a lesser extent decay. The twice-daily use of an alcohol-free mouth-rinse containing fluoride, is part of a preventive programme to reduce any sensitivity and to improve the patient’s resistance to root surface decay generally.

Treatment summary

At the outset of treatment it is never possible to predict absolute success with certainty (due to variations in the rate of response between different patients) and it is important to understand that the long-term outcome very much depends on the patient’s own continual compliance with the treatment programme (particularly the detailed and specific Oral Hygiene Instruction (OHI) the patient will receive as an integral part of the prescription).

During the patient’s treatment for periodontal disease they should, of course, continue to attend their dentist at Clinic 95 for any emergency or current dental treatment plus their routine scheduled dental examinations.

OUTLINE FOR PHASE 1 TREATMENT (3 Treatment visits & review illustration)

Treatment Visit One (treatment visits spaced approximately monthly)

• Instigation of initial home-care programme
• Initial home-care target setting
• Initial specialist debridement (tooth and root surface cleaning)

Treatment Visit Two

• Evaluation of initial home-care progress
• Intermediate personalised home-care programme
• Further target setting
• Intermediate specialist debridement – deeper under gum margins

Treatment Visit Three

• Evaluation of success of intermediate home-care programme
• Setting of targets for definitive long-term home-care
• Optimal specialist debridement of all tooth surfaces –(particularly the root-surfaces)

Phase 1 Review Appointment
(Approximately two months following Treatment Visit Three)

• Full periodontal re-charting of measurements
• Re-evaluation of prognosis
• Prescription for next stage
• Supportive debridement

Periodontal treatment costs

A deposit of 50% is paid in advance of each treatment and review appointment, although for the initial periodontal consultation the full fee is payable at the time of booking.

Initial Periodontal Consultation:  £160
Detailed analysis of gum problems, examining each individual tooth, determining extent of the disease, long term prognosis and treatment required.
Please note: No treatment is carried out during the Initial Periodontal Consultation

Phase 1 (3 treatment and 1 review appointment) 

Treatment Appointment: One (all Phase 1 treatment visits are at monthly intervals)
Instigation of initial homecare programme
Target setting
Initial specialist cleaning
£140 (plus essential home-care equipment at each stage with additional cost)

Treatment Appointment: Two
Evaluation of initial homecare progress
Intermediate homecare training and target setting for next stage
Intermediate specialist cleaning deeper under gum margins
£140

Treatment Appointment: Three
Evaluation of success with intermediate homecare programme
Amended targets for definitive homecare programme
Optimum specialist cleaning of all exposed tooth surfaces-above and below gum margins
£140

Review Appointment: End of Phase 1 (Two months following Treatment Appointment: Three)
Full Periodontal re-charting of measurements
Amendment to programme as required with time-limited prescription for the dental hygienist
Supportive professional cleaning
£140

Dental Finance
Clinic 95 offer competitive dental finance deals, including 0% finance that can help with treatment plans that are £500+
Finance is available through Medenta - just ask us for details.