The philosophy of periodontic care

The vast majority of dental professionals have historically approached their professional responsibilities with an impressive desire to do what is best for their patients.

Patients, in essence, partner with their dentist and hygienist with an implicit expectation that this partnership will assist the patient in successfully managing their oral health.

Unfortunately, the focus in the clinical management of periodontal disease has rarely ventured beyond what is best for a specific tooth – in a particular clinical situation, at one given point in time. The inflammatory basis of periodontal diseases has long been known. A now well-accepted awareness of the importance of inflammatory mechanisms in the development of most of the chronic diseases of ageing means that it certainly is time for the focus of dental hygiene to be squarely on what is best for the patient not just what is best for the patient’s teeth.

Due to the chronic nature of periodontal disease, it is the sum total of all of the treatments that have been provided at the numerous recall/maintenance/re-care visits that will ultimately be used to determine if the provided care has, indeed, been what is best for the patient over their lifespan.

The emergence of strong data linking oral and overall health has led to an urgent and significant need to reassess the value of varying treatment philosophies. More simply put, evidence strongly suggests that a preferred treatment philosophy can lead to benefits far beyond maximising the functional life of one’s natural dentition.

Despite the long-overdue acknowledgement of the need for dental care providers to use an evidence-based approach when making treatment decisions, most dental hygiene visits continue to consist of little more than prophylaxis, some degree of scaling and oral hygiene instruction.

Interpretations of the inherent value of the various periodontal diagnostic routines and therapeutic protocols are almost as varied as the practitioners themselves. Rather than being outcome based, the actual routine that is followed during a maintenance visit after active periodontal therapy is typically based on that particular practitioner’s personal (and often passionate) belief in the value of a particular periodontal diagnostic approach or therapeutic option.

Some practices consider periodontal therapy only when pocket depth exceeds a subjective threshold. Some are true believers in hand instrumentation and never use ultrasonic instrumentation. Many apparently put great stock in prophylaxis and devote the bulk of the time allotted for the typical maintenance visit to providing little more than this service. 

Varying methods
Methods used to evaluate the success of reaching a desired periodontal endpoint (in addition to the actual endpoints themselves) are also quite varied. Removing all calculus that can be seen or felt is traditionally thought to be an impressive and highly desirable endpoint.

However, with the potential links between oral and overall health in mind, it is imperative for periodontal therapy providers to reassess which aspects of the maintenance visit protocol will have the most profound impact in their effort to do what is best for their patients. That reassessment has to begin with a clear vision of the preferred endpoint in the life-long management of a patient’s oral health. Inflammatory mediators appear to be critical factors in the development and progression of many of the chronic diseases of ageing. There is now unmistakable evidence that the mouth is a significant source of these inflammatory mediators when periodontal disease is present.

So, while reducing pocket depths continues to be important, the major emphasis of periodontal
intervention must be on eliminating oral inflammation and then maintaining an oral cavity that is chronically as inflammation-free as possible.

Continuing to foundationally base our maintenance/visit/treatment philosophies on simply cleaning teeth is clearly no longer doing what is best for the patient. Evidence is abundantly clear that the most significant factor in the development of periodontal disease is the development ­ and then chronic persistence ­ of a pathogenic subgingival biofilm.

So, to stave off the adverse effects of periodontal destruction and, even more importantly, to reduce any oral contributions to the overall inflammatory burden of the host, diagnostic and therapeutic protocols must change. Simply cleaning teeth is no longer enough.



Tim Donley is presenting his seminar Profitable periodontics on Friday 5 March 2010 in London. To book your places, call 0800 371 652 or visit


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