Periodontal Referrals

When to refer

The basic periodontal examination (BPE) forms the basis for assessing the need for a periodontal referral.

BPE scores and findings

0 No bleeding or pockets detected
1 Bleeding on probing - no pocketing > 3.5mm
2 Plaque retentive factors present – no probing >3.5mm
3 Pockets >3.5mm but <5.5 mm in depth
4 Pockets >5.5 mm in depth

Additional furcation involvements and muco-gingival problems, generalised or localised, should be marked with a * in addition to the BPE score of the respective sextant (e.g. a sextant with bleeding on probing, no probing depth >3.5mm but furcation involvement would be scored as 1*).

According to the British Society of Periodontology referral policy guidelines, patients can be categorised into the following complexity degrees:

Complexity 1: BPE 1-3
Complexity 2: BPE 4
Complexity 3: BPE 4, and additional complicating factors such as smoking habit, age (<35 years), medical history, root morphology, rapid breakdown; additional need for dental implant therapy and/or augmentation/bone removal)

Patients with a complexity grade 2 or 3, furcation involvements or muco-gingival problems may require advanced periodontal therapy (e.g. surgical periodontal procedures or adjunctive therapies) and should therefore be referred to a Periodontist.

Periodontal therapy

Periodontal therapy is best carried out in defined treatment phases which require a systematic approach to treatment planning. At the initial consultation the extent and severity of the problem as well as underlying modifying factors will be assessed. We will take into account the patient’s expectations and wishes and patients will receive detailed information regarding the cause of periodontal disease and what they can do to get actively involved in the treatment.

A 6-point pocket chart with a computerised constant-force probe (Florida probe) and radiographs will be taken as required (usually full mouth status). Following this we will be able to provide a detailed written report, proposed treatment plan and estimate detailing the timescale and cost of treatment. In advanced cases that may require perio-prostho planning patients will attend further planning appointments that may include study casts, face bow registration etc. before a definitive treatment plan can be provided.

We adopt the tooth by tooth prognosis system. After collection of the relevant data, teeth will be categorised according to those that are irrational to treat and therefore should be extracted, teeth that are questionable and require appropriate treatment and teeth that are secure. Using this as a base to formulate the patient’s treatment needs a treatment plan will evolve.

The Cause-related (Hygienic) Phase of Therapy

The initial cause-related phase of therapy is aimed at bringing caries and gingivitis under control as well as arresting periodontal disease progression. The main key points of this phase of therapy are:
Patient motivation: The patient should understand dental disease and get actively involved in the treatment process.
Information and instruction in self-performed plaque control methods.
Root surface debridement: Removal of all supra- and sub-gingival plaque.
Removal of additional retention factors: Removal of overhanging fillings, ill-fitting restoration margins etc.
Extraction of teeth that are irrational to treat and provision of temporary replacement/restoration.

At Flint and Flint Dental Surgeons we use state-of-the art piezon-electronic equipment with specially shaped periodontal inserts that allow a non-traumatic access to root surfaces even in deep periodontal pockets and into furcations. Nowadays it is well established that it is not required to remove cementum from the root surface in order to achieve successful treatment outcomes.

We therefore limit the use of hand instrumentation to specific areas and use small dimension Gracey curettes to minimise trauma to the soft and hard tissues. This approach should help reduce post operative discomfort and the occurrence of tooth sensitivity after periodontal therapy.

The Corrective Phase of Therapy

This phase of therapy aims at restoring function and aesthetics. The decision regarding what type of further periodontal therapy may be needed and on how many sites should be made after the effect of the initial cause-related phase of therapy has been evaluated. The time laps between termination of the initial cause-related phase of therapy and this evaluation may vary from 1-6 months.

This allows for marked reduction in gingival inflammation and improvement in tissue texture as well as for a proper assessment of the prognosis. The effectiveness of the patient’s home care is of decisive importance for the long-term prognosis and can be evaluated over this time period.

Several treatment strategies are available for correction of residual problem areas:

Periodontal surgery

Over the years, several different techniques have been

described and used in periodontal therapy. Nowadays, various flap procedures are commonly used such as the access flap, modified Widman flap, apically positioned flap, papilla preservation flap and distal wedge procedures.