Periodontics

Abstract

It should be axiomatic that increasing understanding of a disease process should result in more rational and successful therapy. For the various forms of periodontitis this holds true only to a limited extent. Argument and both clinical and scientific uncertainty are the affliction of diagnosis for the various stages of periodontal disease. Nevertheless, some of the well-accepted clinical measurements, particularly those of bleeding on probing and measurements of loss of attachment, including pocket depth, are universally employed despite shortcomings. To be more positive such measurements have shown themselves sufficiently sensitive and accurate to allow some judgements to be made, for example, before and after programmes of active treatment in terms of well-recognized clinical improvement. Encouragement should be the order of the day, particularly in the area of general dental practice, as the periodontal probe and the practitioner's own skills in observation are all that are required, with perhaps the adjunctive use of simple radiographs. An additional boost may come in time from the use of commercially available kits designed to estimate more 'precisely' the stage of tissue destruction at a given time. Over the past few years general dental practitioners in the UK have been encouraged to employ simple periodontal screening of their patients and the further development of this approach and consequent treatment within the philosophy of the Self Assessment Manual and Standards (SAMS)1 is to be welcomed. The treatment of periodontal disease is traditionally protracted. Many studies carried out and published over the past 30 years have underlined the importance of plaque control, both on a patient self-care and professional basis. A traditional surgical therapy, particularly directed at treating advanced forms of disease, and generated primarily in the North American Schools, has now been superseded particularly in Europe by a more conservative approach. In 1978 Hirschfeld and Wasserman2 published their findings from monitoring the outcome over a protracted period of treatment performed within their own private practice. Amongst other issues this study highlighted the variable patient response to therapy and interestingly these findings have been reproduced almost identically in Australian periodontal practice.3 The essential message is that most disease in most patients will respond well to treatment. Whilst the argument as to whether treatment should be surgical or non-surgical persists the evidence overall is that this is not the crucial factor.4 Simple therapy, wellperformed by skilled operators and with appropriate equipment can produce considerable improvements in health status. Of particular relevance here is the work of dental hygienists and in long-term studies this conservative, non-surgical approach has been found to be particularly effective.5 As important as the treatment itself, is the follow-up including long-term monitoring and maintenance, which again may fall within the remit of the dental hygienist. This essential role of maintenance has been highlighted in studies following the outcome of surgical therapy where the results were disappointing. The author concluded that one of the principal reasons for treatment failure was inadequate and infrequent maintenance.6 If long-term therapy and maintenance can be carried out successfully using basic treatment techniques by both dental practitioners and ancillaries then it is tempting to assume that this treatment is both simple to perform and inexpensive. A pilot study within our own department, examining the treatment of adult patients with periodontitis, has shown that a mean of five visits is required to bring the disease under control. Often this is a minimum and, interestingly, for patients who smoke, the number of visits is likely to be 50% greater. In a cost-conscious environment objectives therefore have to be clearly defined and expectations as to treatment outcome realistic. Simplistically, we should be seeking to help patients preserve a functional and acceptable dentition. Specific problems may be addressed in different ways. For example, a Class II furcation affecting a lower molar may be treated as successfully by a simple furcationplasty as by a more advanced therapy such as guided tissue regeneration. It is now possible to build on the wealth of research data demonstrating the efficacy of various treatment modalities. These can be translated into routine clinical practice to good effect. Although we are some way from being precise in our definitions of destructive disease processes, ideal treatment and assessment of outcome, the scene is set for all these to be resolved.