I work as a full time periodontist in specialist practice, so it was a pleasure to see Prof Peter Heasman and Prof Val Clerehugh speak recently at a Procter & Gamble (Oral-B) sponsored seminar on periodontology. Their lectures were respectively entitled, Emerging from the recession without the need for cuts and Maintaining periodontal health – what matters?
The master of ceremonies for the evening was Stephen Hancocks, editor of the BDJ and editor in chief of the International Dental Journal. Stephen began with his own entertaining style and introduced both speakers. This was a particularly fitting moment for me as I had been taught by Prof Clerehugh some time ago whilst training as an undergraduate at Manchester Dental Hospital. The fact that I am now working as a specialist in perio is testament to the teaching provided at the school during my stint as an undergraduate.
Prof Heasman (Newcastle School of Dental Sciences) began by defining recession, namely that it occurred due to the apical migration of the gingival margin past the CEJ. He divided the aetiology into two main causes, those caused by periodontal disease and those by non-inflammatory tissue loss. He reminded us periodontal disease was a chronic inflammatory process which resulted in the breakdown of the supporting structures of teeth. Non-inflammatory loss of gingival tissue can be a result of many factors, though is more commonly associated with local anatomy, tooth position, orthodontic tooth movement and finally, mechanical trauma. He went on to talk about the different types of recession and suggested patients with a high standard of oral hygiene tended to have predominantly buccal gingival recessions and those with low standards had predominantly lingual recessions. The aetiology and pathogenesis of periodontal disease was touched upon and its role in the formation of gingival recessions highlighted.
The effect of toothbrushes in recessions was discussed and factors such as bristle hardness, brushing technique, brushing time and toothpaste were shown to be possibly involved in this process. Other forms of non-inflammatory recession included tooth alignment such as crowding, local alignment including frenal attachments and gingival biotype (Allis and Melsen 2003). The impact of traumatic overbite was also discussed.
He then explored the management of such cases. He suggested the main problems that arise as a result of gingival recession are dental hypersensitivity, root caries, progression of attachment loss, further recession and poor aesthetics. Prof Heasman highlighted the merits of a more conservative approach when dealing with these matters. He also looked at the surgical management of cases and was able to illustrate a few examples. In conclusion, he stressed the importance of identifying the aetiology of the condition, followed by a hygiene phase, as well as addressing the causes of related problems associated with the recession. A specialist referral for advice regarding surgical options would be the next step.
Prof Clerehugh’s (Leeds Dental Institute) lecture looked at the importance of maintaining periodontal health and the various impacting factors. She started by discussing the role of supportive periodontal therapy (otherwise called maintenance therapy) and referred to a definition in the 2003 position paper of the American Academy of Periodontology which stated: ‘periodontal maintenance is instituted following periodontal and implant therapy and continues at varying intervals for the life of the dentition or its implant replacements’. She stressed the importance of this phase of periodontal care and highlighted the fact the British Society of Periodontology had included this in its paramenters of care document.
She then went on to discuss the biological basis of SPT and emphasised the objective was to bring about a balance between the host defence mechanism and the microbial challenge. It was the offsetting of
this balance which caused a reduction in periodontal health leading to further disease. It was highlighted that Lang et al 2009 had recently suggested gingival inflammation could be a precursor for periodontitis and that clinically healthy gingivae were a prognostic indicator of tooth longevity.
The concept of an hour for an SPT visit was also discussed. This would involve an examination of 10-15 minutes with motivation and reinstruction/instrumentation for 30-40 minutes. Polishing teeth and fluoride application would take up the rest of the time. The mechanical removal of plaque still remained the main objective of SPT and the merits of oscillating-rotating power brushes compared with manual toothbrushes were highlighted based on the Cochrane systematic review in 2003 and subsequent publications. The importance of interdental cleaning in periodontal cases using interdental brushes was also considered. Prof Clerehugh suggested the patient may need to return for a subsequent treatment for re-infected sites and that there was good evidence three to six monthly visits were effective in such cases.
Systemic factors can also affect the outcome of SPT and the two main risk factors affecting the success of SPT are smoking and poorly controlled diabetes. The effects of smoking on oral health are well documented, and the role of a dentist in helping patients to quit was emphasised. The role of diabetes control measured using the glycated haemoglobin HBA C value against periodontal disease relationship was considered, and there is significant evidence suggesting patients with well controlled diabetes have better control over their periodontal health status. The debate on the link between periodontal disease and cardio vascular disease was briefly touched upon, and Prof Clerehugh concluded that, based on the recent consensus report by the editors of the Journal of Periodontology, there was insufficient evidence of a direct link and that more robust prospective research studies need to be carried out.
In conclusion, she suggested supportive periodontal therapy was integral to maintaining periodontal health and the absence of inflammation was conducive to tooth longevity.
An interesting discussion took place at the end of the lecture, looking at the role of the NHS in providing SPT in practice. This provided a nice way of ending the evening, having heard two excellent speakers.
Prof Trevor Burke and Dr Julian Satterthwaite are lecturing for P&G in London, (June 10), Manchester, (June 24), and Bristol, (June 29). The events take place in the evening (6-9.30pm) and are free of charge to dental professionals.
For more information call 0208 399 6730 or email michelle@ab-communications.com