For most of the 20th century, extractions seemed to be the standard, or even perhaps the preferred, treatment option for patients presenting with periodontal problems.
Many older individuals recount that it was fairly ’routine’ to have teeth extracted at 20 or 30 years of age and be fitted with dentures. Even today, some patients seem to think that having teeth extracted and replaced with prosthetic restorations (preferably implant-retained) seems to be a better option than maintaining one’s own dentition.
What advice do we give our patients? Do we adequately emphasise the importance of maintaining the natural dentition? How good are we at stressing the importance of preventive periodontics?
The presence of bacteria in the oral cavity was established many centuries ago by the Dutch scientist Antonie van Leuwenhoek (17th century). He is mostly renowned for the development of lenses with increased magnification (the microscope) under which he examined accretions, “a little white matter” as he described it, from around his own teeth and those of others.
Leuwenhoek found “an unbelievably great company of living animalcules… in such enormous numbers”. This was the first sighting of dental plaque (oral biofilm) as we know it today.
Pierre Fauchard in the 18th century advised that “teeth should be periodically cleaned by the dentist”. In spite of these discoveries and the fact that toothbrushes have been around since 3500 BC, most dental treatment, until fairly recently, consisted of extraction of the offending tooth or teeth.
The importance of oral hygiene in reducing or eliminating periodontal diseases started to come to light in the early 1960s. A Norwegian study set out to improve the periodontal status of a large cohort of patients by improving their oral hygiene techniques. This was accomplished through meticulous instruction in oral hygiene and interdental cleaning together with supra and subgingival scaling 1.
The results of the study showed that gingival conditions improved by 60 per cent and the loss of teeth was only 50 per cent of the estimated tooth mortality.
It was not until the mid-1960s, however, that the seminal work of Harald Löe 2 provided an evidence-based approach between the association of oral bacteria and periodontal diseases. Löe asked a group of dental students to refrain from brushing their teeth for three weeks. He recorded plaque and oral hygiene indices throughout the experimental period.
During this time, the students developed clinical signs of gingivitis, which resolved following commencement of oral hygiene measures.
This classical experiment not only provided sound evidence of the causative link between bacteria and periodontal disease, but it also demonstrated that removal of dental plaque led to resolution of gingivitis.
The following years saw a cascade of papers 3,4,5,6,7,8 that led to changes in treatment concepts, emphasising the crucial importance of plaque control not only during the active phase of treatment, but also during supportive periodontal maintenance.
Active phase of treatment
The majority of patients own a toothbrush and claim to use it on daily basis; whether it is used effectively is another matter. Patients who are registered with a dentist will receive a dental check-up and a scale and polish routinely. While this is beneficial, it might impart the notion that the responsibility for oral and dental health resides with the treating clinician rather than with the patient.
Removal of the dental biofilm remains the cornerstone of preventive dentistry and of non-surgical periodontal therapy9. Good patient supragingival plaque control can influence the microflora in pockets up to 4mm, thereby reducing the build-up of periodontal pathogens subgingivally10,11.
The removal of the supragingival bacterial deposits is the patient’s responsibility. It depends on the patient’s desire to improve their oral health, on manual dexterity and also the patient’s knowledge of oral and dental anatomy imparted by the treating dentist, dental hygienist or dental therapist.
This is even more important when the periodontal architecture has been altered as a consequence of disease, such as reversed gingival contour, gingival recession and exposed furcation defects (Fig 1).
These areas are more difficult to maintain and the patient will need to be more attentive during daily hygiene routines. The demonstration of the effective use of a toothbrush and interdental tooth cleaning aides, at the labial/buccal or lingual/palatal tooth-gingiva junction is paramount if the patient is to perform effective plaque removal (Fig 2). This is important in all patients, particularly so in those who are susceptible to periodontitis.
It is the author’s experience that a significant number of patients with periodontitis are not shown how to achieve and maintain a high standard of self-performed plaque control; they are, however, often enrolled for a three-monthly scaling and polishing.
Certainly, the removal of calculus facilitates the patient’s endeavours to keep plaque at bay. However, more important is the patient’s education and efforts in plaque control which can then be followed by root surface debridement, i.e. removal of the subgingival biofilm.
This is key to successful periodontal treatment provided that it is targeted at sites which warrant it (i.e. limited only to periodontal pockets) and provided the patient maintains effective supragingival plaque control.
Clinical studies have shown that recolonisation of periodontal pockets to pre-treatment levels occurs within a few weeks following professional instrumentation if supra-gingival plaque control is not performed effectively, rendering previous therapy ineffective12. It is important to appreciate that sites that are healthy should not be instrumented, as this will induce loss of attachment13.
Supportive periodontal maintenance
Once the active phase of periodontal treatment is complete and periodontal pocket elimination has been achieved (whether by non-surgical or surgical means), the patient then enters a periodontal maintenance phase known as supportive periodontal therapy (SPT). SPT is defined as “the essential need for therapeutic measures to support the patient’s own efforts to control periodontal infections and to avoid recontamination” 14. SPT has two integral components:
1. Regular visits by the patient; these should yield positive feedback, encouraging the patient to maintain as plaque-free a dentition as possible.
2. Continuous diagnostic monitoring of the patient by the clinician in order to intercept with adequate therapy at the optimal time.
During these visits, the patient’s plaque control needs to be routinely monitored and its importance re-emphasised. The periodontal assessment performed at the beginning of the maintenance phase includes a periodontal risk assessment (PRA15). Based on the clinical findings at the end of the active phase of treatment, the PRA determines the patient’s risk of disease recurrence and also suggests the frequency of recall.
Thus, the SPT programme should be based on the patient’s risk susceptibility and should be tailored to the patient’s needs accordingly. High-risk patients should be seen every three to four months, while for low-risk patients, an annual visit will suffice.
Long-term follow-up studies have confirmed that periodontitis can, in most cases, be treated provided the patient is enrolled in a maintenance care programme, maintains a high standard of plaque control16,17,18 and refrains from smoking19.
The importance of SPT (which is different from the routine scale and polish) cannot be ov
eremphasised. Periodontal therapy will be far less effective in the presence of poor plaque control and inadequate supportive periodontal therapy16,20,21,22,23.
Benefits of preventive periodontics
Teeth will last for life unless they are affected by dental diseases or inadvertent trauma. Teeth surrounded by healthy periodontal tissues have a long life expectancy of up to 99.5 per cent over 50 years24.
Even if teeth are periodontally compromised but treated and
maintained regularly, their survival rate is very high – about 92-93 per cent25.
Several long-term studies spanning 1526, 2227 and even 30 years28 provide evidence that patients who received periodontal treatment, who are enrolled on a supportive maintenance care programme and who are motivated in maintaining a high standard of plaque control show very high survival rates for teeth.
Such patients were constantly encouraged to recognise and enjoy the benefits of maintaining a high standard of oral hygiene; this was seen to give them a sense of wellbeing. This is not to say that a small number of teeth are not lost due to periodontitis in the highly susceptible periodontal group.
Implants might be an alternative treatment option which the patient might choose to replace missing teeth. Implants should not be used to replace premature removal of teeth.
The 10-year success rate for implants is about 98 per cent29 in the non-periodontal patient, while that in the periodontally susceptible patient it is about 90 per cent30. Implant maintenance is as important and as intensive as periodontal maintenance31.
Furthermore, implants are not problem-free and it is estimated that up to 43 per cent can develop peri-implantitis if not well maintained32. Peri-implantitis is very challenging to treat (certainly in the author’s experience) and is a less reliable treatment option when compared to periodontal treatment.
The importance of practising preventive periodontics cannot be overemphasised and should be the mainstay of each and every treatment plan.
About the author
Dr Marilou Ciantar is a specialist periodontist and oral surgeon at Blackhills Specialist Referral Clinic, Aberuthven, Perthshire. She welcomes referrals for periodontal treatment, implant surgery and oral surgery, including treatment under sedation for anxious patients. Marilou is also senior clinical teaching fellow in oral surgery at Aberdeen Dental School.
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