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) Specialist Periodontist
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
after non-surgical
The Surgical Phase
periodontal therapy
The holy grail of all periodontists is to regenerate and endodontic
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 Referral
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 Referral
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
years, no
years, or
Category A
Category B
Maintenance is important in
complex cases
up to 4mm but usually have little lossof attachment and pocketing.
Category C
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 Category D
BPE scores 4 anywhere in of periodontal disease, including Category E
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


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