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News feature: Managing periodontal disease and empowering patients
15th Mar 2010
The Johnson & Johnson UK National Advisory Panel from the left : Dr Stephen Hancocks, Professor Mike Lewis, Dr Mike Martin, Professor Monty Duggal, Sally Simpson, Professor Nairn Wilson, Professor Liz Kay. Front row – Dr Elaine Giedrys-Leeper, Professor Iain Chapple, Elaine Tilling, Dr Susie Sanderson
Periodontal disease is one of most challenging and problematic of clinical issues for a plethora of reasons: the diagnosis is often difficult, the treatment inadequately remunerated by the NHS and most patients are unaware of it. Yet the need to implement a preventive approach to periodontal disease has never been greater.
The possible associations between periodontal disease and systemic health have given impetus for a more preventive approach to the disease.
Another driver for prevention is that periodontal disease is one of the fastest growing and most costly areas of litigation in the dental field.
One third of all the highest value negligence claims relate to allegations of undiagnosed or untreated periodontal disease, with one recent claim in this country being settled for £94,0001.
So, this subject could not have been a more timely or apt topic for recent discussion by Johnson & Johnson's National Advisory Panel, consisting of 10 leading members of the dental profession, Professor Monty Duggal, Dr Elaine Giedrys-Leeper, Dr Stephen Hancocks, Professor Liz Kay, Professor Mike Lewis, Dr Mike Martin, Dr Susie Sanderson, Sally Simpson, Elaine Tilling and Professor Nairn Wilson (Chairman).
Also at the meeting was Iain Chapple, Professor and Head of Periodontology at Birmingham Dental School, who gave the panel a presentation illustrating the extent of periodontal disease and the consequent cost to society as well as an outline of research into the condition.
One of the first conclusions of the meeting was that it is misleading to refer to a 'link' between periodontal disease and systemic health.
Such terminology probably dates back to research from an era when there was no Cochrane Review and before evidence-based dentistry was in place.
Some of those present were happier to refer to an 'association' or even to refer simply to 'shared disease mechanisms'.
Nevertheless, it was pointed out that new research into people with cardiovascular disease found that their heart health improved if their perio condition was treated and the American Association of Cardiologists recommend that patients who have a periodontal condition get it treated prior to heart surgery2.
The key question of the day was how to encourage a more preventive approach to periodontal disease.
It is an aspect of dentistry which none of the different National Health Service contracts and systems have ever managed to cater for adequately. But hope lies on the horizon, the panel agreed, with the recommendations of the Steele Review and the possibility of outcomes being measured according to Key Performance Indicators. It was even suggested that high risk perio patients could be at the top of Steele's pyramid for advanced care.
Panel members agreed that the health gain of patients with periodontal disease could be measurable and this ought to be raised with commissioners of dental care.
It was stressed, however, that practitioners need to be paid properly to provide preventive care and encouraged to prioritise those patients at highest risk. One panel member suggested that CPD in periodontal diagnosis and treatment could be made a compulsory subject. Interestingly, this exact conclusion was subsequently made by the European Workshop on Periodontal Education, Segovia, Spain, November 20093.
A case was also made for the training of more hygienists to deliver the kind of intensive care that patients with periodontitis require.
But the lifestyle and behaviour of patients themselves is critical. The panel agreed the aim should be to help all members of the population achieve a high standard of plaque control involving appropriate use of toothbrushing, interdental cleaning and mouthwashes.
This led to a discussion about how patient behaviour can be changed.
Diabetic patients were quoted as an example of what is achievable. They are taught to take control of their condition through a combination of diet, exercise and medication. Dental patients with periodontal disease need to develop a similar kind of responsibility for their condition and an awareness that their diet and oral hygiene has a major impact on their dental health.
Professor Chapple advised the panel about Pre Viser, a new validated online risk assessment software.
Routinely collected information is input to the software which generates scores for the patient's future risk of periodontal disease and their current periodontal health status. Reports can then be printed for patients and their clinical records. The system has been shown to predict tooth loss with a high degree of accuracy4. Its motivational impact in stimulating patients to improve their periodontal health is due to be trialed in UK NHS practices in 2010.
At one UK dental hospital, the panel was told, patients are shown the bugs that are killed when plaque is exposed to Listerine, which is found to be a powerful oral health message. Another panel member found that patients' attitude to their oral health changed dramatically once they had invested in a cosmetic treatment, like bleaching. This motivated them to take better care of their mouths.
Another valuable consensus area among the panel members was the need for the medical and dental professions to work together to ensure that those with conditions which might make them more susceptible to dental disease got co-ordinated help and interventions.
This was particularly true for children who have survived cancer treatment but who have been immuno-suppressed as a result of chemotherapy. Transient bacteria are a threat to their health and they need to be seen by clinicians who are aware that they are more vulnerable than others of their age.
Delivering Better Oral Health, the Department of Health's evidence-based toolkit for prevention, was praised for its practical approach to reducing caries. What was needed, the panel agreed, was a toolkit for the management and treatment of periodontitis with a CPD element included. But it was also clear there should be a multi-pronged approach to achieving a new preventive strategy, resulting in more patients living into old age with their teeth.
The day was rewarding, partly because of the wealth of information to underpin the discussions and partly because of the shared commitment to a more preventive approach to periodontal disease.
The message for the future may be simple – a clean mouth is good for general health and wellbeing – but it's no mere slogan.
It is supported by some of the most influential people working in dentistry today who believe that commissioners, dentists and dental teams can start to turn back the tide of periodontal disease in this country.
The meeting concluded with agreement for the following consensus statements:
• The panel affirms that a clean and healthy mouth is good for general health and wellbeing as well as oral health
• The panel affirms the significant benefits of effective plaque control before clinical signs of inflammation
• The panel recommends that patients should achieve a high standard of plaque control involving appropriate use of toothbrushing, interdental cleaning and mouthwashes
• The panel recommends the development of an evidence based toolkit (with CPD) for management and treatment of periodontitis to update and enhance patients' and professionals' knowledge
• The panel strongly recommends the creation of a nationwide system within which periodontal care can be effectively delivered to those who need it most, and risk assessment underpins that assessment of need
• The panel recognises the need to understand the scientific basis for the relationship between periodontitis and other non-resolving inflammatory health conditions.
References
1. A presentation by Derrick Setchell, a former Vice Dean of the Eastman Dental Institute, to the 2009 Premier Symposium.
2. Friedewald VE, Kornman KS, Beck JD, Genco R, Goldfine A, Libby P, Offenbacher S, Ridker PM, Van Dyke TE, Roberts WC (2009). The American Journal of Cardiology and Journal of Periodontology Editors' Consensus: periodontitis and atherosclerotic cardiovascular disease. American Journal of Cardiology; Journal of Periodontology. Am J Cardiol; 104:59-68.
3. Sanz M, Chapple ILC (2010). 1st European Consensus Workshop in Periodontal Education – Overall Recommendation. Europ J Dent Edu (in press).
4. Martin JA, Page RC, Kaye EK, Hamed MT, Loeb CF (2009). Periodontitis severity plus risk as a tooth loss predictor. J Periodontol; 80:202-9.
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