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Aspects ref nl_5_june1
to the Aspects Referral Care newsletter. Thanks to those who continue to support our
The lifeblood of our practice is your referrals, so I really appreciate any new patients that you
feel may benefit from the specialist services available at Aspects. Please remember we can helpyou out with periodontics, endodontics, implants, prosthodontics, aesthetic dentistry and oral
I appreciate any feedback that you can give me, so I can continue to shape the practice to
your needs. It is always a pleasure when we meet up at the postgraduate meetings.
I hope you enjoy this special periodontal issue, I have tried to compile some cases sent to me
at Aspects to show how we can work together to effectively treat our patients.
The Periodontal Issue
We all know that the periodontal diseases are a complex interaction between bacterial plaqueand host factors. Familial history, genetic factors, systemic disease and smoking are all factorsthat play an important role in the aetiology and rate of progression of the disease.
Our role as clinicians is to make patients aware of their gum disease and the factors that aresignificant. We need to give advice regarding the oral health risks of smoking and by advisingand encouraging the patient to achieve high standards of oral hygiene.
My role as Periodontal Specialist is to support my referring dentist or hygienist. I spend a lotof time explaining to patients the aetiology of the disease. I think it is important that thepatient understands their role in helping to control their periodontal disease and how factorsoutside our control contribute to their periodontal disease.
Rob WardBDS (London) LDS RCS (Eng)MSc (periodontic) (London)
the 1999 classification ofperiodontal diseases and
The present periodontal diagnostic categories of periodontal diseases have evolved fromthe original 1977 classification. The early classification only recognised two disease entities
(Chronic Marginal Gingivitis and Juvenile Periodontitis).
1n 1986, Juvenile Periodontitis was recognised as two disease entities (localised and
generalised). Chronic Marginalised Periodontitis became Adult Periodontitis. Necrotising
Ulcerative Gingivo-Periodontitis and Refractory Periodontitis were recognised as distinct
The 1989 World Workshop, added the Pre Pubetal Periodontitis category (localised and
generalised) and recognised that systemic diseases have an impact on periodontal tissues.
A. LocalisedB. Generalised (>30% of sites
In 1999 the classification listed on the left was accepted. There were important changes
A gingival disease category was included. This was subdivided into diseases caused by plaque
and those gingival diseases that are not caused by plaque.
A. LocalisedB. Generalised (>30% of sites
The Pre Pubertal category was dropped. It was understood that a lot of the diseasespreviously recognised in this category were in fact systemic diseases with periodontal
Adult Periodontitis was recognised as Chronic Periodontitis. This was in recognition of the
non age related manifestation of the disease. There was a general and local sub division.
The Early onset classification was grouped together as Aggressive Periodontitis. The diseaseswere categorised by rapid tissue destruction, the presence of Aa and Pg and a strong genetic
component. Whilst most patients are under 35 years, it was accepted that age was no longer
diagnostic of this category. There is a localised and generalised sub classification.
The Refractory Periodontitis category was removed, it was accepted that this was morelikely to be disease reoccurrence rather than a separate disease.
The Necrotising Ulcerative disease category was added. This was divided into Gingivitis and
Periodontitis. Both diseases are due to a diminished resistance to bacteria. The Peridontitisdisease is likely to be an extension of gingivitis into the deeper tissues.
Endodontic lesionsA. Combined periodontic-
Periodontal Abscesses were given there own category, as recognition of the different
In conclusion, classification of Periodontal disease has changed as the understanding of
periodontal diseases has increased. The value of accurate diagnosis allows accurate
plaque-induced gingival diseases/periodontitis
His practitioner, noted the excessive bone lossand deep pocketing given his age. As maybe
typical with patients, he had excellent oralhygiene.
80% of cases fall into the bracket of chronicinflammatory periodontal disease. This disease
often ticks along controlled easily enough by our
hygienists and all of sudden there is a burst of
activity and there can be some quite dramatic
changes in bone levels. Sometimes these bursts ofactivity are related to life changes in patients’ lives
(death in the family, loss of job). Other factors like
smoking, stress and type 1 diabetes can increase
attachment losses in chronic periodontitis cases.
treatment and others thathave been a challenge.
This 44 year old female was referred to Aspectsafter her dentist noted swelling related to LL6
Angular defects and bone loss typical of aggressive
and pocketing mesially and at the furcation.
LL6 mesial bone loss
and at the furcation
I tend to throw the kitchen sink at these patients.
Typically, I start with rigorous non surgical therapy.
Classic studies in the 1980s revealed that non-
surgical therapy is equally as effective as
conventional periodontal flap debridement
surgery. I use a technique called full mouth
carried out a course root debridement with
disinfection (all the root debridement is carried
adjunctive topical antibiotics. Secondly, Norman
out on one day, to prevent reinfection of clean
Gluckman, our endodontist, root treated the
Which cases can I
and infected sites). I tend to use adjunctive
systemic antibiotics, typically doxycycline.
help you with?
Post op radiograph
The Surgical Phase
The holy grail of all periodontists is to regenerate
all the tissues destroyed as a result of the disease.
These days I tend to use Emdogain. This is anenamel metalloprotein of porcine origin. Under
carefully controlled situations following surgery,
it is possible to regenerate bone, periodontal
surgery with aim of regenerating the lost bone
Pre op, angular bone
I usually recommend at least annual
loss mesial LR7
monitoring of all cases of chronic periodontal
disease. Some of my most prudent referrers
send me patients with BPE scores of 3 and 4
and when there has been sudden loss of
attachment, more than 0.2mm per year.
Post op, after 1 year
bone infill LR7
will use surgical therapy to either further reducepocketing or regenerate bone.
10-15% of the population suffer from aggressiveperiodontal disease. The disease often has early
onset before the age of 40 years. It may be
My advice is to REFER, REFER, REFER
localised to a few teeth usually the centrals and
aggressive periodontitis cases.
first permanent molars (previously known aslocalised juvenile periodontitis) or moregeneralised (previously known as rapidlyprogessive periodontitis).
These patients are at risk of losing their teethearly in life. This patient was referred to Aspectsabout 6 months ago. He is a 45 year old male,who was a good regular attendee at the dentist.
Bleeding elicited after gentle probing without calculus or pocketing being present
The whole of the coloured band of the probe is visible but supra or subgingival
calculus or the defective margin of a filling or crown are detected – shallow pockets
The probe penetrates a pocket so that only part of the coloured band is visible –
indicating a pocket between 3.5mm and 5.5mm.
root resections, apicallyrepositioned flaps can all be less
The probe penetrates a pocket so that the whole of the coloured band disappears –
replacement with either an implantretained denture or implant
Periodontal control index (debris and bleeding)
have to be evaluated carefullyagainst success rates with
less than two thirds of the tooth surface
Diabetes, smoking, (stress), pain, mobility,oral medicine problem (e.g. lichen planus),
immunosuppression, periodontalsuppuration and any other relevant
Hygienist management, no referral required
Periodontist directed management required
often asked by my restorativecolleagues to stabilise things, prior
Periodontal risk categories and management protocol
to restorative creations. I am happyto work side by side with you in
Age over 40
Age under 40
Maintenance is important in
up to 4mm but usually have little lossof attachment and pocketing.
Bitewing or panoramic radiograph.
Dentist examination required.
Hygienist recall 3-6 month intervals.
ongoing job is to maintain thelower teeth so that he can retain
BPE scores 4 anywhere in of periodontal disease, including
BPE scores 4 anywhere in deteriorate despite good plaque
bacterial and genotype testing.
Panoramic and parallel techniqueperiapical radiographs required.
Hygienist recall 3-6 month intervals
Agency for Healthcare Medical Expenditure Panel Survey Research and Quality December 2004 Top 10 Outpatient Prescription Highlights Medicines Ranked by Utilization and Expenditures for the U.S. Community medicines reported as purchased by respondents in the Population, 2002 U.S. community population totaled $150.6 billion in 2002, an increase of 12.3 per
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