Stopping periodontal disease (and caries) in its tracks

August 31st, 2010

PreViser quantifies a patient’s risk of perio disease on a scale of 1-5 and their current disease level on a scale of 1-100.  But this is only useful if we can act on the information.

 The landmark 30 year  longitudinal study which demonstrated just what is achievable was reported by Axelsson et al.  In 1971 over 550 patients were recruited, 375 to a test group and 180 to a control group.  This paper reports on the results of the first 15 years and this link gives the abstract of the 2004 paper at 30 years. 

In summary:

  • For the first 6 years the test group were given intensive instruction and training in oral hygiene and frequent hygiene appointments
  • Controls from the same age cohort received standard dental care
  • After 6 years
    • New and recurrent caries were reduced by >98%
    • Frequency of periodontitis was reduced by >95%
    • Attachment loss was arrested; had attachment gain
    • The control group was discontinued for ethical reasons
  • Participants were retained in the preventive program with the number of hygiene appointments reassessed based on risk.  The test group was re-examined after 30 years when it was found:
    • Few teeth were lost during the 30 years of maintenance; 0.4-1.8 in different age cohorts.
    • The main reason for tooth loss was root fracture; only 21 teeth were lost because of progressive periodontitis or caries.
    • The mean number of new caries lesions was 1.2, 1.7 and 2.1 in the three groups.About 80% of the lesions were classified as recurrent caries.
    • Most sites, buccal sites being the exception, exhibited no sign of attachment loss. Further, on approximal surfaces there was some gain of attachment between 1972 and 2002 in all age groups.

The key?  Risk based preventive treatment and patients who were educated and motivated in home care.  Learn more at www.previser.co.uk.

Posted in About PreViser, About risk assessment | No Comments »

Do your patients know?

August 25th, 2010

Perio disease is the cause of 50-60% of tooth loss in adults. That is bad enough. But do your patients know it is not just their teeth that they putting at risk?  Prof Iain Chapple highlights below findings from some recent research on the evidence for links between periodontal disease and other chronic inflammatory conditions:

  • Diabetes – periodontal disease is an independent predictor of incident diabetes (Demmer et al Diabetes Care 2008) and periodontal therapy improves glycaemic control (Stewart et al J Clin Perio 2001)
  • CVD – men <65 yrs of age with periodontal bone loss have an increased hazard ratio of incident coronary heart disease of 2.12 (Dietrich et al, Circulation 2008)
  • Rheumatoid arthritis patients are 82% more likely to have periodontitis and seropositive RA patients are 120% more likely (dePablo et al, J Rheumatol 2008)
  • Stroke – periodontal bone loss is associated with an increased hazard ratio of stroke of 3.52 and 5.81 in under 65 yr-olds (Jimenez et al, Stroke, 2009)

    • For links to the relevant articles please scroll down the page here. 

    Are your patients at risk (see www.previser.co.uk).  And do they know the wider implications?

    Posted in Perio-systemic links | No Comments »

    Friday video

    July 22nd, 2010

    An old favourite. Short and sweet, with a splash of risk but no perio

    Posted in Risk Videos | No Comments »

    All patients are not created equal

    July 19th, 2010

    In the past it was thought that every patient would get periodontitis.   Why then bother to define a patient by their risk level?  Knowledge has moved on.  We know that patients exhibit a wide spectrum of risk which changes over time.  We now have a clearer understanding of systemic and local periodontal risk factors, and we have a systematic way (PreViser) of assessing their complex interactions to enable us to predict future bone and tooth loss (Page et al 2003). 

    Patient immune to periodontitis

    We know that about 10% of patients are disease resistant (Löe et al 1986).  Take this 45 year old gentleman, who never brushes his teeth and who has marginal gingivitis but no periodontal pocketing or bone loss. He will probably never lose teeth through periodontitis, despite his lack of oral hygiene. 

    19 year old high risk patientAnd at the other end of the spectrum you have patients such as this 19 year old girl who has good oral hygiene, apparently minimal inflammation but 9mm pockets.  She is clearly very high risk.  But knowing this before the onset / progression of disease enables us to adopt appropriate preventive measures.

    Given recent developments in our understanding together with the research which proves that periodontal disease is preventable (subject of future post), it is no longer acceptable to simply treat all patients as equal and repair the disease as it presents.  Risk assessment should form the basis of our treatment plans, and our patients have to be made aware of where they stand.  They need to know what actions they can take to reduce the risk both of losing their teeth, and also the other systemic diseases that are known to be associated with perio disease.

    The American Academy of Periodontology has stated that risk assessment should be a component of every dental and periodontal examination (see here).  The conclusions from the Steele report were that every new patient should be assessed for periodontal (and caries and oral cancer) risk.   

    Do you have a protocol in place?  Do your patients know?

    Posted in About PreViser | No Comments »

    Simply put: laser application in non-surgical periodontal therapy

    July 13th, 2010

    PreViser’s personalised reports optionally give you treatment guidance based on your patient’s presentation. We thought it would be helpful to back this up with a short summary of certain aspects of current best practice in perio.

    The European Academy of Periodontology draw experts in perio from across Europe to both research and education workshops every 3 years to search and critically assess the literature on a range of topics which are strategically important for patient care and clinical outcomes. The results are published in the Journal of Clinical Perio.

    One panel of experts addressed the question of how the clinical effect of lasers compares to mechanical debridement in non-surgical periodontal therapy in patients with chronic periodontitis.  Their conclusions were as follows:

  • although the evidence is weak, the Er:YAG laser appears the most suitable for non surgical treatment of chronic periodontitis.  Its safety and effects appear to be within the range reported for conventional mechanical debridement both in the short and long term (up to 24 months)
  • there is insufficient evidence to support the use of CO2, Nd:YAG, Nd:YAP or different diode laser wavelengths.  This is because studies have used these as adjuncts to mechanical debridement and have not demonstrated a signicant added clinical value.
  • There is limited information on the safety of different laser therapies, but a potential thermal injury to adjacent periodontal tissues must be prevented by using proper radiation parameters, conditions and techniques.

    • A further paper in the Journal of Periodontology in 2009: The Effect of a Pulsed Nd:YAG Laser in Non-Surgical Periodontal Therapy by Slot et al. reviewed the literature on the use of the Nd:YAG laser both as monotherapy and as an adjunct to non-surgical periodontal treatment.  Efficacy was determined by the extent of plaque removal and the reduction of periodontal inflammation. This paper also concluded that there is no evidence to support the superiority of the Nd:YAG laser over traditional modalities of periodontal therapy.

    Posted in Best practice in Perio | No Comments »

    TGIF Video

    July 2nd, 2010

    A touch of risk but absolutely no perio

    Posted in Risk Videos | No Comments »

    How long would you spend on this perio patient?

    June 27th, 2010

     How long would you be able to spend treating this patient in your practice?

    Perio radiographs

    This was a question asked in a study conducted by the University of Birmingham.  Questionnaires were sent out to 865 NHS GDPs and 59 specialist practitioners with a 64% and 88% response rate respectively.  The results are a startling reflection of the lack of time available to properly address periodontal disease in general practice……

    This is how much time they estimated they would spend

    Graph of time spent

    And this is the amount of time they felt they should spend in an ideal preventive world

    Graph of how much time dentists would spend in an ideal world

    Most studies report 45 – 60 mins per quadrant or 4 hours for a one stage full mouth therapy (Quirynen et al 1995, Apatzidou et al 2004).

    Time is limited and resources must be focused where they are most needed.  Visit www.previser.co.uk to find out how.

    Posted in Best practice in Perio | No Comments »

    PreViser now integrated with Kodak R4

    June 22nd, 2010

    We are delighted to announce that we are now integrated with Kodak R4. This means that you can launch PreViser from the charting page of your practice management software, thus making it even easier to perform your on-line risk assessment. The instructions are very simple:

    Go to:

    1. Any patient’s chart.
    2. Tools
    3. Options
    4. Xray programs
    5. Tick the “other” box
    6. Put the path to the executable file in the box (to find out where this is, simply right click the PreViser icon on your desktop and view properties).

    To save the PreViser reports to your patient notes, just print to pdf using a free software such as cutepdf.com.

    Any questions, please let us know on 07725125291 or call your Practiceworks helpdesk.

    Posted in About PreViser | No Comments »

    That Friday feeling…….

    June 17th, 2010

    Our Friday ‘risk’ video to brighten your day.

    Posted in Risk Videos | No Comments »

    Simply put: Full Mouth Debridement

    June 16th, 2010

    PreViser’s personalized reports optionally give you treatment guidance based on your patient’s presentation. We thought it would be helpful to back this up with a short summary of certain aspects of current best practice in perio.

    The European Academy of Periodontology draw experts in perio from across Europe to both research and education workshops every 3 years to search and critically assess the literature on a range of topics which are strategically important for patient care and clinical outcomes. The results are published in the Journal of Clinical Perio.

    One panel of experts addressed the question of how the outcomes of Full Mouth Debridement and Conventional Staged Debridement compared after a follow up period of at least 6 months.

    Three concepts were compared:

    1. Full Mouth Debridement (FMD) : Disinfection of entire oral cavity in <24 hours; rinsing with chlorhexidine for 1 min 2x per day for 2 weeks to deplete subgingival plaque deposits and prevent biofilm formation;  tongue scraping and spraying of tonsillar region with chlorhexidine, and subgingival irrigation of all pockets 3 x within 10 mins with 1% chlorhexidine gel:  This was repeated after 8 days.
    2. Full Mouth Scaling and Root Planing (FMSRP): Derived from the above, this is full mouth scaling and root planing without use of antiseptics
    3. Conventional Staged Debridement (CSD): Quadrant or sextant instrumentation at 1-2 week intervals

    Conclusions

  • In the cause related stages of perio therapy with moderate to advanced perio, CSD has been shown to produce PPD reduction of ≈1mm in sites with initial PPD of 5-6mm and PPD reduction of 2.2mm in deeper pockets (>7mm).  In the light of these outcomes, the adjunctive effects of FMD or FMSRP are modest and do not justify a claim of superiority over CSD.
  • All 3 treatment approaches may therefore be recommended without preference
  • Performance of optimal oral hygiene should be observed with any protocol of mechanical debridement.

    • Posted in Best practice in Perio | No Comments »

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