Prevention and treatment of periodontal diseases in primary care.

SCOPE AND PURPOSE: The aim of this guidance is to support the dental team to; manage patients with periodontal diseases in primary care appropriately; improve the quality of decision making for referral to secondary care; improve the overall oral health of the population. It focuses on the prevention and non-surgical treatment of periodontal diseases and implant diseases in primary care. The surgical treatment of periodontal and implant diseases and the management of patients by periodontal specialists or in a secondary care setting are outwith the scope of this guidance and are not discussed in detail. The guidance is based on existing guidelines, including those from the British Society of Periodontology, relevant systematic reviews, research evidence and the opinion of experts and experienced practitioners.

METHODOLOGY: The methodological approach is based on the international standards set out by the Appraisal of Guidelines Research and Evaluation (AGREE) Collaboration (www.agreetrust.org). The guiding principle for developing guidance within SDCEP is to first source existing guidelines, policy documents, legislation or other recommendations. Similarly, relevant systematic reviews are also initially identified. These documents are appraised for their quality of development, evidence base and applicability to the remit of the guidance under development. In the absence of these documents or when supplementary information is required, other published literature and unpublished work may be sought.Review and updating. The guidance will be reviewed in three years and updated accordingly.

RECOMMENDATIONS: Recommendations are provided for assessment and diagnosis; changing patient behaviour; treatment of gingival conditions; periodontal conditions; long term maintenance; management of patients with dental implants; referral and record keeping. The key recommendations highlighted are: Assess and explain risk factors for periodontal diseases to patients. Screen all patients for periodontal diseases at every routine examination. Carry out a full periodontal examination for patients with BPE scores 3, 4 and (*)Use the Oral Hygiene TIPPS (talk, instruct, practise, plan, support) behaviour change strategy to address inadequate plaque removal. Raise the issue of smoking cessation where appropriate. Encourage patients to modify other lifestyle factors that may impact on their oral health. Ensure the patient is able to perform optimal plaque removal. Remove supra-gingival plaque, calculus and stain and sub-gingival deposits. Ensure that local plaque retentive factors are corrected. Remove supra-gingival plaque, calculus and stain and correct any local plaque retentive factors. Carry out root surface instrumentation at sites ≥ 4 mm probing depth where sub-gingival deposits are present or which bleed on probing. Do not use antimicrobial medication to treat chronic periodontitis. Remove supra-gingival plaque, calculus and stain and sub-gingival deposits and ensure that local plaque retentive factors are corrected. Assign an individual's risk level based on the patient's medical history and oral health status and schedule recall appointments accordingly. Ensure the patient is able to perform optimal plaque removal around the dental implant(s)Examine the peri-implant tissues for signs of inflammation and bleeding on probing and/or suppuration and remove supra- and sub- mucosal plaque and calculus deposits and excess residual cement. Perform radiographic examination only where clinically indicated. Consult any locally produced referral guidelines and the BSP 'Referral Policy and Parameters of Care' to determine if the patient is a suitable candidate for referral. Carry out initial therapy to address inadequate plaque removal, smoking status (if applicable) and to remove supra- and sub-gingival deposits. Provide supportive periodontal therapy and monitoring for patients who have been discharged from secondary care. Record the results of the periodontal examinations (basic and/or full) carried out and the current standard of oral hygiene. Record the diagnosis, suggested treatment plan and details of costs. Document any discussions you have with the patient, for example, treatment options, risks and benefits of treatment, oral hygiene advice, smoking cessation, alcohol consumption and/or other lifestyle factors.

RESEARCH RECOMMENDATIONS: There is a need for high-quality research carried out within an appropriate governance framework to improve the evidence base in the following areas: barriers and facilitators to the delivery of oral hygiene interventions in primary care;behaviour change interventions to improve inadequate oral hygiene;optimal timescales for provision of routine supra-gingival debridement (dental prophylaxis) and supportive periodontal therapy;effectiveness of supportive periodontal therapy regimens;effectiveness of supportive therapy regimens to maintain peri-implant tissues;effectiveness of interventions to treat peri-implant mucositis and peri-implantitis.Consensus is urgently required on the importance and validity of surrogate periodontal outcomes (eg bleeding on probing, changes in clinical probing depth and clinical attachment level and bone levels) and their relationship to true outcomes (eg tooth loss and patient-centred outcomes) so that consistency can be achieved across studies. There is also a need for independent research into the effectiveness of oral hygiene tools such as toothbrushes, interdental aids, toothpastes and mouthwashes and gels containing antibacterial agents.