A Pathway To Healthier Gums

Developing ‘Healthy gums do matter’

In November 2014, following a piloting process, the HGDM toolkit was launched in the Greater Manchester area. Over the years, work has continued on the toolkit to refine its usefulness, so that, in 2019, lead author Saleem was able to report: ‘The evaluation showed encouraging results, with positive changes reported in patient self-care behaviour, improvements observed in clinical measures and an overall increase in periodontal health. The toolkit and care pathways were reported as valued by practitioners as an achievable way of implementing existing evidence-based best practice.’¹

When considering the potential effectiveness of different stages of periodontal therapy, it was reported: ‘Our challenge has been to try and recognise at what stage patients should move onto more extensive non-surgical and surgical periodontal therapy when they are still struggling with maintaining adequate oral hygiene and plaque control. The […] single largest significant impact on the stabilisation of periodontal disease is adequate plaque control and home care. Hence the value of formal non-surgical and surgical therapy without adequate plaque control will result in a poorer outcome post-therapy compared with therapy performed with good plaque control. In fact, most of these diseased sites would have stabilised with adequate plaque control and initial simple therapy.’¹

The toolkit continues: ‘The pathways produced reflect this and therefore a patient will move to formal non-surgical therapy once adequate plaque control is achieved. As a result, the stage at which formal therapy is started is when management is at tooth and site level. This in turn reduces the amount of treatment the patient has to undergo, and allows better-targeted periodontal therapy for the most favourable outcomes.’¹

Reflecting the new classification

At the World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions in 2017, experts reviewed the scientific evidence and subsequently created a new classification scheme for periodontal and peri-implant diseases and conditions, updating the 1999 classification.^3,4

For example, periodontal health was characterised,⁵ which may help to support dental professionals in their endeavours to offer preventive advice to patients at the first sign of gingivitis.

As stated in HGDM, ‘This is crucial for a number of reasons, one the of the most important being to determine a healthy or stable patient and the endpoint of treatment and where periodontal maintenance takes over. The new classification system now differentiates between an intact periodontium and a reduced periodontium, recognising the importance that a patient with a previous history of periodontitis remains a periodontitis patient for life and therefore requires closer monitoring and surveillance in the future as they have a greater risk of moving from a state of periodontal stability into recurrent disease (unstable).’¹

The role of the BPE

The British Society of Periodontology (BSP) then updated its BPE (basic periodontal examination) guidance in 2019.⁶

The BPE remains important because, as stated by Dietrich and colleagues (2019), it: ‘…is a screening tool employed to rapidly guide clinicians to arrive at a provisional diagnosis of periodontal health, gingivitis or periodontitis, irrespective of historical attachment loss and bone loss (that is, irrespective of staging and grading). As such, the BPE guides the need for further diagnostic measures before establishing a definitive periodontal diagnosis and appropriate treatment planning.’⁷

It is, however, important to note that the BPE is of limited value in patients who have already been diagnosed with periodontitis, as it is not able to identify historical problems that are resolved at the time of the patient presenting.⁷

Therefore, as stated by Holland (2019), ‘A periodontal assessment should begin with a comprehensive history. If the patient has no evidence of a history of periodontitis, then a BPE screening should be performed.’⁸

A detailed infographic showing how to use the BPE in relation to the new classification system is available at https://www.bsperio.org.uk/publications.⁶

Patient communication and education

HGDM states: ‘Oral health education and patient behaviour change are of the greatest importance when both treating periodontal diseases as well as during maintenance. If there is a lack of engagement and behaviour change from the patient, periodontal treatment will ultimately fail to achieve stability which will ultimately lead to further deterioration and destruction of periodontal tissues.’¹

To help the dental team in these endeavours, two documents were produced:¹

• 1. The patient agreement
• 2. The patient periodontal information leaflet & consent form.

In terms of their practical use: ‘Both documents are designed to be completed and personalised to individual patients and should be fully explained to ensure the correct understanding as well as ensuring the patient remains aware of their disease throughout the pathways. The documents are then signed by both patient and clinician. The detailed pathway journey later in the toolkit will outline which pathways the two documents are used in, although the patient agreement can be used for all patients.’¹

As for patient education, ‘The success of managing periodontal disease is dependent to a large extent on the patient’s ability to maintain immaculate plaque control. Behaviour change lies at the heart of this. The dental team has to change their approach from the traditional delivery of oral hygiene instruction alone.’¹

HGDM continues: ‘…current research shows that brief behaviour change interventions can improve plaque control more than the traditional oral hygiene instruction alone. These approaches encourage the patient to understand how oral hygiene might be beneficial to them, to develop confidence in their oral hygiene abilities, to set targets for change that they feel able to achieve and to challenge their perceived barriers to performance and encourage them to find their own motivation for change. Some of these methods address common barriers to the development of an effective oral hygiene routine, which may not otherwise be addressed during traditional oral hygiene instruction.’¹

The pathway process

HGDM created five pathways:¹

• 1. Periodontal health pathway
• 2. Periodontal risk pathway
• 3. Periodontal disease pathway
• 4. Advanced periodontal disease pathway
• 5. Grade C rapidly progressing periodontal disease pathway.

Offering an overview of these pathways, it is written: ‘In the health and risk pathways, the increased risk of recurrent disease on a patient with a reduced periodontium due to periodontitis has been reflected by reducing the recall interval for these patients and developing a separate pathway for them. It should be noted that once a patient has been classified as having a reduced periodontium due to periodontitis, even though they may be in the health or risk pathways, they will always remain a periodontitis patient (for life) who is diagnosed as either stable, in remission or unstable. Staging and grading should be carried out on these patients and they should have detailed pocket charting (6-point pocket chart) carried out annually whilst they are in the maintenance phase of care and there are no pockets 4mm or greater with bleeding.’¹

HGDM continues: ‘In the disease and advanced disease pathways, the therapeutic end points for therapy and entry into maintenance phase of care have been changed to reflect the agreement that pockets 4mm or greater WITH bleeding on probing are unstable sites and pockets that are 4mm or less and do NOT bleed on probing are seen as stable.’¹

Offering a further point, it is stated: ‘In addition to this entry points into the pathway for recall patients has been suggested to begin at the 3-month recall level. However, all prevention, education and investigations including the patient agreement, the patient leaflet and consent form and radiographs should be carried out here if they have not already been done.’¹

Another significant change relates to aggressive periodontitis, since the new classification system does not differentiate between aggressive and chronic periodontitis. Nonetheless, it is still acknowledged that how periodontal disease progresses varies on an individual basis.¹

In relation to this, HGDM offers the following guidance: ‘… the aggressive disease pathway has been replaced by patients who present under the new classification system with stages 3 or 4 and a grade C, rapid rate of progression, who have oral hygiene inconsistent with the level of destruction seen [and] no associated systemic risk factors.’¹

A framework for managing disease

Providing an overview of the need to help periodontally-involved patients, Saleem (2019) wrote: ‘The heart and soul of achieving periodontal health in practice lies in oral health education and changing and influencing the behaviour of patients, so that they achieve and maintain adequate plaque control and oral hygiene.’²

He added: ‘It is important to understand and recognise that this is not an easy task to undertake and time is limited. Success requires building a trusting relationship with the patient in order for them to believe what they are being advised and to appreciate the benefits of changing their behaviour.’²

In conclusion, offering further insight into the value of HGDM, Saleem (2019) stated: ‘The HGDM toolkit provides a framework for managing periodontal diseases to support dental teams with the broad spectrum of patients they see and raise the standards of care in primary dental care. Achieving periodontal health in practice is challenging, but the toolkit has been developed to provide a more pragmatic approach to delivering care. While guidelines are fairly straightforward for engaging patients, the challenge has always been when and how guidelines can be departed from, with little guidance on when it is appropriate to use clinical discretion. The most recent revision of the BPE guidance by the BSP recognises that all patients are not the same and allows for deviation from the guidance. The HGDM framework is one approach on how to practically implement this in practice.’²