ISP good clinical practice recommendations for gum care

Abstract

Oral health is vital for the general well-being, overall body health and the quality of life throughout our lifetime. Most of the oral diseases and conditions are largely related to the maintenance of oral hygiene, lacking that people suffer from diverse oral diseases at different times in their life. With greater life expectancy, the individuals have teeth involved with periodontal diseases that would not only require professional care but also home gum care for them to last a lifetime. Indian Society of Periodontology (ISP) has recognized the need for systematic documents to update everyday clinical practice of general dental practitioners and have provided evidence-based consensus documents, namely good clinical practice recommendations from time to time to raise the oral health-related awareness and standards of oral healthcare delivery across the country. The current set of clinical practice recommendations focused to “Gum Care for All”, is aimed at emphasizing and enhancing the awareness regarding oral health promotion, maintenance, and disease prevention. Twenty-five subject matter experts from across the nation, prepared these recommendations after a thorough literature review and group discussions. The document has been prepared in three distinct sections, namely pretherapeutic, therapeutic, and post therapeutic, to provide guidance during the respective phases of patient management and may serve as a quick and concise reference to the readers. The guidelines shall provide the distinct definitions, signs and symptoms, treatment required; recall visit specifications for plausible clinical case situations, home care advice regarding maintenance of oral hygiene including information on brushing technique, care and change of brush, use of interdental aids, and mouthwashes, etc. The document should advocate and guide the combined efforts of general dentists, and the population at large toward an empowered, evidence based, integrated, and comprehensive oral health care, which shall enhance the healthful functioning and longevity of the dentition and general health of the individual.

INTRODUCTION

For the past 30 years, the combined prevalence of major oral disease conditions, i.e., dental caries and periodontal disease has remained unchanged and ranked higher than any other noncommunicable diseases (NCD) worldwide. This puts the significance of oral health in much higher perspective from the stand point that, it may have a significant bearing on the population at large. The consequences of poor gum health include not only physical and functional limitations for the individual but also on the social well-being, daily productivity, and economic burden at the national level. Most of the oral diseases and conditions are largely related to the maintenance of oral hygiene, lacking that people suffer from diverse oral diseases at different times in their life. In most of the developing countries including India, where there is limited oral health literacy and access to dental care, people suffer from periodontal disease in a high prevalence, particularly certain specific population groups, namely aged, poor, rural, people with disabilities, etc. In general, with life expectancy increasing to more than 70 years, the individuals have teeth involved with periodontal diseases that would not only require professional care but also home gum care for them to last life time. There remains a huge unmet need for provision of dedicated oral health care and the only ray of hope seems in the preventive approach and maintenance of oral hygiene and health at the individual level.

Indian Society of Periodontology (ISP) is the only Indian society for the subject specialty “Periodontology,” which has recognized the need of systematic documents to update the knowledge regarding the various aspects of periodontology for everyday clinical practice of the general dental practitioners. The society has contributed immensely to provide evidence-based background information from time to time, to time to raise the oral health-related awareness and standards of oral health care delivery across the country. This consensus guidelines paper provides the evidence-based good clinical practice recommendations for achieving and maintaining gum health for all by emphasizing, educating, and equipping every individual including oral health care professionals and the population, responsible for oral health promotion, maintenance and disease prevention. It shall outline how our general dentists can serve as an effective resource in actualizing the changes and trends in oral health care and become a productive member of oral healthcare force contributing towards better national oral health.

SECTION I: PRETHERAPEUTIC/DIAGNOSTIC PHASE

What are the current practices of oral health in India at population level and access to health care in India at individual level?

Oral health is an integral part of general health. Dental caries, oral cancers, and periodontal diseases are the areas of national oral health concern. A few nationwide attempts to understand the oral health practices have been conducted from time to time, namely Dental Council of India (DCI) National Survey in 2003, Commission on Macro-economics and Health report in 2005, Multicentric study in 2007 by Ministry of Health and Family Welfare (MoHFW), Government of India.[1–3] Since then, only sporadic reports from the various parts of India have been made public. A high prevalence of periodontal disease was observed in the 35-44 years (65.2%) and 65-74 years (90.4%) age group.[4] In the studied population, periodontal disease was found to be quite prevalent (42.3%). Age, smoking, chewing of paan, decaying, missing, and filled teeth, oral hygiene index(OHI), and periodontal inflamed surface area scores were all found to be substantially linked with periodontitis in the urban participants.[5]

Very recently, National Oral Health Programme, MoHFW, Government of India, in 2021 identified that periodontitis in India among adults ranged from 15.3% to 77.9% and in the elderly was between 19.9% and 96.1%.[6] A variety of oral hygiene practices at the population level in urban and rural areas included brushing of teeth only once a day (42%) with toothbrush and toothpaste as the preferred cleaning aid (68%). Dental floss and interdental cleaning aids as modalities of maintaining oral health were opted by a limited segment of population (<30%) and >70% visited the dentist only in case of emergency.[7–10] Use of finger, chewsticks, and dentifrices such as tobacco-based tooth powder and herbal preparations were preferred among the elderly and in the rural population.[8,9]

Regarding access to oral health care at the individual level, it is important to understand that in India, the dentists-to-population ratio is now 1:10,000, down from 1:3,000,000 in the 1960s. Rural areas have a dentist to population ratio of 1:250,000. A ratio of 1:7500 is the recommended dentist-to-population ratio by the World Health Organization (WHO). Financial accessibility also poses a barrier to the care of the less fortunate because dental practitioners are disproportionately concentrated in the private sector in contrast to a public sector that offers subsidized services.[11] According to the National Oral Health Program, MoHFW, Government of India 2021, private practices provide the great majority of oral healthcare services in our nation.[6] Other institutions offering oral health services include the Central Government Health Scheme, Employee’s State Insurance Corporation, Railways, the Armed Forces, and paramilitary groups. These institutions are in addition to the District Hospital, Sub District Hospital, and Community Health Center levels.[6]

Studies show that utilization of the dental services among individuals was very low. It has been noticed that majority of individuals (>60%) in India prefer to visit the dentist only in case of emergency.[8] The reasons for not seeking dental services unless there is pain were that the respondents felt dental care is not needed unless having pain (>60%), dental diseases are less serious (50%), fear of dental procedures (49%), lack of time (45%), costs involved with dental procedures (30%), and nonavailability of dentist in the neighborhood (26%).[12–16] Low dental awareness is a significant contributor to the underuse of dental treatments.[12]

What is the existing level of oral health-related knowledge, attitudes, and practices in Indian population?

A limited number of investigations, to provide an insight in the existing level of oral health related knowledge, attitudes and practices have been conducted at the national level in the Indian population.[1–3] According to the DCI study from 2004, more respondents, regardless of age or sex, in the rural areas reported oral health problems such as dental decay, followed by gum disease and foul breath both nationally and in each state and union territory. Nearly two-thirds of respondents in all survey locations, regardless of age or gender, blame eating sweet foods, and skipping brushing sessions for oral health problems. This percentage is higher in metropolitan regions. Regardless of age, across both sexes, especially so in urban areas, roughly 45% of respondents specified a preventive intervention like regular dental cleaning. In the country, 23-24% of men reported smoking tobacco across all age categories. The smoking rate was greater than the national average in nearly 50% of the states and union territories. Men smoked 40-45% more than women did across all age groups. Across all age groups, the habit of smoking cigarettes was more prevalent among men and in the metropolitan areas. In the country as well as in states and union territories, between 76% and 86% of smokers, mostly women, reported smoking fewer than ten cigarettes per day. Across all age groups, about 9% of people reported chewing pan or pan masala with tobacco in the nation, with more men and more in rural areas.[1] The second initiative, i.e., multicentric study in 2007 mentioned an objective “To evaluate the knowledge, attitude, and practice regarding oral health in the same population.” However, it could not provide clear findings in this regards as variations in geography, culture, and eating habits existed significantly among various states, and the results from the study cannot be extrapolated to the whole country.[3]

Apart from these nationwide reports, independent investigations from Indian dentists/dental institutions have been carried out for specific populations, for example, primary health care workers, nurses, students, rather in the general population as a whole.[17–21] Individuals in the rural population rely on the untested traditional methods as cheap and effective way of getting treatment instead of visiting a dentist.[22,23] The widespread presence of quacks in the rural setting, along with the widespread misconceptions and false beliefs about oral diseases and their treatment is a common notion in the rural population.[22] In general, vast majority of the population both urban, rural, and semi urban perceive dental treatment to be painful.[24] There is a lack of education on oral health-related information and identification of conditions such as oral cancers at an early stage.[22] The patient visits the dental practice as a last resort due to expensive costs of dental treatment in our country.[8,12] Maximum number of patients (>50%) prefer self-medication (pain killer/clove/clove oil) as a primary approach to dental problems.[23]

Is there a need for increasing awareness of risk factor reduction? How can we help educate people regarding lifestyle modifications for better oral/periodontal health?

Even though oral disease is one of the most prevalent public health problems and a significant global health burden, it is typically disregarded in public health strategy and policy. Periodontal disease is just one of the several dental illnesses and ailments that have a large socioeconomic influence on healthcare costs, people’s everyday lives, overall health, and self-esteem. A significant association of periodontal disease with major NCDs, for example cardiovascular diseases (CVDs), diabetes mellitus (DM) and adverse pregnancy outcomes, and many other systemic diseases have been documented.[25] According to current knowledge of the etiopathogenic processes of major NCDs, a number of common risk factors and biological plausibility have been proposed to support the oral-systemic relationship.[25–28]

Risk factors are very important for a person’s response to periodontal infection, healing after treatment, and maintenance phase. By identifying these risk factors, it is possible to target patients for prevention and specialized therapy, with risk factor reduction being essential for the management of periodontal disease. Lifestyle variables, such as smoking and alcohol use, DM, obesity, metabolic syndrome, osteoporosis, and low dietary calcium and Vitamin D levels are among these independent but modifiable risk factors for periodontal disease. The control of these risk factors by appropriate patient education is a key aspect of the care given to many periodontal patients today. Periodontal disease is also influenced by genetic variables, which makes it possible to target certain people for the early identification and prevention.[29] Hence, risk factor awareness, identification, modification, and management have become a critical component in the standard of care treatment for periodontal patients in contemporary periodontal best practice settings, promoting optimal health and general well-being.[28] A two-pronged strategy is needed to improve the nation’s overall oral health i) Promoting oral health awareness and disease prevention (ii) enhancing the provision of oral health care. Use of print, electronic and social media, such as picture posters and brochures, has been encouraged to raise community knowledge of oral health.[3]

PERIODONTAL HEALTH

What is the current definition of periodontal health?

In contrast to simply being free from illness or disability, “health is a state of total physical, mental, and social well- being.” According to the WHO’s definition, periodontal health may have been described as the absence of inflammatory periodontal disease, which enables a person to lead a normal life without experiencing any negative effects from a previous illness (either mental or physical). Although the fact that this definition is entirely patient-outcome driven, despite appearing holistic and comprehensive, it is actually impracticable and restricted for the goal of managing periodontal diseases clinically. Therefore, a more suitable and practical definition of periodontal health would be a state free from inflammatory periodontal disease. This, in turn, means that the absence of inflammation associated with gingivitis or periodontitis, as assessed clinically, is an essential prerequisite for defining periodontal health.[30] It is proposed that for the purpose of clinical assessment, there can be two levels of periodontal health, depending on the state of the periodontium (structural and clinical) and the relative treatment outcomes:

1. Pristine periodontal health, with a structurally sound and uninflamed periodontium. However, this may be hypothetical since such a condition may occur only in gnotobiotic (germ free) animals

2. Well-maintained clinical periodontal health with a structurally and clinically sound (intact) periodontium. With proper periodontal care, this situation is very much achievable as it remains the goal of all periodontal therapies.

The lack of bleeding upon probing, erythema, edema, associated patient symptoms, clinical attachment, and bone loss define clinical gingival health. Physiological bone levels range 1-3 mm apical from the cemento-enamel junction. For adding an objectivity to the definition for clinical assessment and contain the spectrum of periodontal health, a well-accepted threshold of <10% bleeding sites with probing depths (PD) ≤3.5 mm, as measured by the WHO probe with colored band completely visible, has been adopted as the indicator of gingival health.[31,32]

To create desirable and acceptable therapeutic end points for periodontal therapies, classify gingival and periodontal disease prevalence in communities, and assess individual risk for future disease development, it is essential to have a definition of periodontal health and wellness.[31]

What disrupts the periodontal health?

The prime reason for the disruption of periodontal health is the accumulation of dental plaque, which is a tenacious deposit formed on the tooth surfaces composed of a complex microbial community. It is the etiological agent for major dental diseases such as dental caries and periodontal disease. At the outset, dental plaque is composed predominantly of Gram-positive commensal organisms that are in harmony (homeostasis) with the host, which in the absence of oral hygiene progressively keeps on maturing and harbours gram-negative anaerobic bacteria capable of causing inflammation of periodontal tissues.[33] Periodontal health is regarded as the absence of clinically detectable inflammation. Even during the phase of clinical health, there is the presence of neutrophils in gingiva as the part of immune surveillance.[34] Failure to disrupt plaque accumulation at the gingival margin leads to the development of gingivitis. Gingivitis is a proportionate inflammatory response to plaque and is reversible upon reinstitution of proper plaque control. Gingivitis is associated with sustained overgrowth of nonspecific microorganisms within biofilm leading to swelling of gingival tissue, altered contour, and pocket formation.[35] If unchecked, it leads to establishment of a subgingival environment favorable for the growth and development of a dysbiotic microbiome dominated by Gram-negative anaerobic species. A disproportionate host response is initiated with subsequent destruction of connective tissue attachment and bone leading to the establishment of periodontitis.[36,37] Periodontitis is characterized by irreversible loss of periodontal attachment and alveolar bone. Micro-organisms are the principal cause of gingivitis, but it is the host response that drives the tissue destruction leading to periodontitis.[38]

What are the risk factors of periodontal disease?

It is now understood that periodontal disease is site specific and several longitudinal studies have shown that sites that progress to periodontitis are associated with persistently more inflammation than those sites that do not advance to the next level.[39,40] Hence, gingivitis is regarded as a necessary prerequisite for destructive periodontal disease. Individuals vary in their susceptibility to periodontal disease and certain sites are more vulnerable for tissue destruction even in the nonsusceptible person. The risk factors for periodontitis can be grouped as local risk (predisposing) factors and systemic risk factors.

Local risk factors

• Plaque retentive factors that either prevent routine plaque removal or favor its accumulation, for example, proximal overhangs, subgingival restorative margins, poorly contoured prosthetic crowns, untreated caries lesions, etc.,

• Oral dryness could be due to xerostomia, mouth breathing, or lip incompetence. Various medications or combination of medicines can contribute to dry mouth.[41]

Systemic risk factors

These are factors that negatively modify the individual’s immune-inflammatory response to plaque microbiota.

• Smoking exerts a local effect on the gingival tissues as well as systemic effect on inflammatory response and vasculature. The effect of smoking is dose dependent, with greater impact in those who smoke more. Smokers exhibit less clinical inflammation like bleeding from gums despite profound inflammatory changes in the underlying tissues[42]

• Hyperglycemia and diabetes

• Nutritional deficiencies

• Drugs that cause gingival enlargement, for example phenytoin, calcium channel blockers, and cyclosporine

• Sex hormones, for example, puberty and pregnancy

• Systemic diseases such as leukemia

• Emotional stress.

Assessing patient’s risk of developing periodontal disease has a significant impact on clinical decision making and nowadays, many freely accessible online tools have been developed for the objective evaluation of the individual risk profile for both clinicians and the patients.[43]

Can we list some common pointers/alarming symptoms of a potential periodontal disease?

Few common clinical signs and symptoms of the patients which can help identifying periodontal disease in general clinical practice. These are generally omitted as, they do not really present as a major discomfort to the patient, yet can surely contribute towards early diagnosis and management of impending or otherwise silent periodontal disease condition.

Deposits on teeth

Hard deposits on the teeth commonly known as tartar, i.e., dental calculus is a serious concern because it serves like a fixed surface for dental plaque (biofilm) to grow leading to build up of bacterial toxins and becomes difficult to be removed, making it challenging for the patient to practice good dental hygiene. Despite maintaining effective plaque control, some people have an innate propensity to develop calculus due to host-related variables such bacteria, nutrition, and biochemical factors (expressed as saliva or crevicular fluid). These patient categories namely heavy or light calculus formers, rapid or slow calculus formers need to be identified for appropriate management. Once a mineralized hard calculus is deposited, it initiates inflammation in the adjacent periodontal tissues. Much of classic periodontal literature have pointed on the etiologic significance of calculus in periodontal diseases.[44–47] With the advancements in the technology, recent focus on analysis of predisposing factors for rapid dental calculus formation has been laid down for identifying these specific population.[48]

Bleeding gums

Gum/gingival bleeding is a common sign of gingival inflammation, which indicates the presence of periodontal diseases.[49–51] It is a clinical sign which is very clear, objective, and often perceived by the patient. Bleeding on probing (BOP) may be used for discriminating between a healthy and gingivitis patient and classifying a case of Gingivitis to localized or generalized based on distribution of gingival inflammation.

BOP assessment is quite inexpensive and requires little to no technology. General dentists can attain and maintain the high levels of intra-examiner consistency in diagnosing bleeding with the right training. The bleeding score can be used to measure the effectiveness of preventive and therapeutic strategies aimed at controlling periodontal diseases as well as to educate and inspire patients.

In contrast to measuring the severity of the inflammatory condition, the BOP score is a simple, rapid way to gauge how much gingival inflammation is present. However, while measuring the periodontal inflammatory conditions generally and for identifying gingivitis particularly, the presence of patient factors like smoking, using anticoagulants, etc., that are known to alter the BOP response should be taken into consideration. It might help the clinician in daily practice that BOP present even on a single site irrespective of the state of periodontium calls for a professional intervention and therefore, should be considered as a significant pointer of disease.[45]

Bad breath

Halitosis, or bad breath, is a significant social issue. 90% of the time, the root cause of halitosis can be identified in the mouth cavity. The phrase “oral malodor” so applies. The microbial degradation of sulfur-and nonsulfur-containing amino acids into volatile, foul-smelling gases is the main contributor to oral malodor. The same species of anaerobic Gram-negative bacteria that have been associated to periodontal illnesses, Porphyromonas Gingivalis, Treponema denticola, and Tannerella forsythia, are particularly active in this process, which explains why doctors frequently link oral malodor with periodontitis.[52–56] Halitosis most frequently starts in bacterial niches, such as those present in the posterior tongue dorsum and periodontal tissue sites (including the gingival sulcus, pathological pockets, and interdental gaps).[52]

Halitosis is thought to have several key etiological elements, an important one of which is periodontitis. Previous research showed that when compared to healthy individuals, periodontal sufferers experience a much higher incidence of oral malodor. In addition, they claimed that sites having pockets of 5 mm or more were positively correlated with oral malodor.[57] In addition, they found that gingival inflammation leads to the degree of oral malodor. In participants with PDs more than 3 mm, the association between periodontitis, oral malador and volatile sulfur compounds level was considerably higher. Halitosis and oral microflora are associated with periodontal disease significantly, according to research on tongue coatings.[58] The aggregated findings of population-based observational research revealed a strong correlation between periodontitis and halitosis.[59] Multiple factors can cause halitosis, but most of the etiology is intra-oral. Simple self-evaluation methods for patients such as lick test should be suggested to detect halitosis; however, a careful comprehensive clinical periodontal examination should be undertaken in all patients with bad breath to identify the cause.

Spacing in the teeth

Periodontal disease affects the tissues that support the teeth, and over time, the loss of these tissues results in the development of spaces between the teeth or the enhancement of the existing ones. Pathologic migration is the name given to change in position of the teeth, due to disruption of the balance of forces holding teeth in their respective positions.[60] Periodontal disease also results in tooth mobility owing to the exaggerated and imbalance in occlusal forces.[61] The change typically occurs gradually and at first is barely noticeable. However, gaps in the back teeth are more detrimental to the dentition as a whole; however, these spaces will be more visible and obvious to the patient, when occur in front teeth. Patients may express concerns about food becoming stuck in places where it never did before or about the gaps between their teeth appearing wider in older photos. Between 30.03% and 55.8% of patients with periodontal disease had pathologic tooth migration.[62–64] Tooth migration and eventual tooth loss in some patients by their mid-twenties are not unusual in some circumstances where the periodontal disease is particularly severe and advances very quickly. Regular periodontal examinations by a dentist will aid in the early detection of these diseases.

Food lodgment

Food impaction results from the occlusal force that pushes food firmly into the periodontium. It could happen next to the lingual or facial tooth surfaces or it might happen interproximally.[65] Food impaction, a prevalent cause of periodontal disease, may be brought on by proximal tooth open contacts also.[66–68]

Getting food stuck between teeth may point to an improper contact or spacing in between the teeth which may cause periodontal breakdown of the bone and the gums also can cause teeth/root decay. Food impaction can set up inflammation in the gum tissue possibly resulting in periodontal disease and bone loss. Most food can get stuck between teeth, due to pathologic migration. Periodontal therapy conducted in the area has an unsatisfactory outcome if dietary impaction is not identified and eliminated. It is separate from food lodgments, which are later reduced to simple food particles that wash away even with routine mouthwashing.[65]

Suppuration in gums

An abscess is a pus-filled swelling that has a variety of spherical shapes. It may have one or more, and it normally continues to grow until it reaches a particular size before developing an aperture through which pus leaks. These abscesses are quite common in people with gum disease, thus looking for their existence or history is crucial for identifying the underlying periodontal issue. This abscess may or may not be painful depending on where it is (gingiva or periodontium) and the drainage that it is able to establish.

Conventionally, gingival abscesses don’t directly harm the neighboring tooth/teeth. A localised buildup of pus within the gingival wall of a periodontal pocket is known as a periodontal abscess (PA).[69] Patients with prior periodontal pockets are more likely to have it. It develops quickly, causing the destruction of periodontal tissues and exhibiting obvious signs.[70] Periodontitis-related abscesses typically develop during periodontal therapy or when the untreated periodontal disease worsens.[69] The majority of PA are caused by a periodontal pocket becoming blocked or obstructed.[71] Several factors, including calculus buildup, dislodged calculus driven into the soft tissues during debridement, or an impaction of a foreign substance like dental floss or a piece of toothpick, could be to blame for this.[72]

The accumulation of bacteria and food debris in areas where gingival pockets have formed as well as regions where angular bone loss has taken place causes abscesses. It is important to take an abscess seriously because it might appear rather early in the course of the illness. Multiple abscesses could be an indication of a medical condition that is left untreated, such as diabetes mellitus.

Mobile teeth

Tooth mobility is a very common and salient indicator of gum disease. Diseases of the tooth-supporting structures inevitably affect the degree of tooth mobility or the strength of anchoring. One of the main symptoms that should cause concern to a physician and prompt an evaluation of the periodontium is increased mobility or loosening of the teeth. The loss of alveolar bone due to periodontal disease and increased occlusal force from occlusion, i.e., trauma from occlusion (TFO) are the two main causes of tooth movement. By reducing the excessive force, tooth mobility brought on by TFO can be treated, but it is more difficult to treat tooth movement brought on by alveolar bone loss. The presence of signs of tooth movement typically indicates that the localized periodontal disease is fairly advanced. Sometimes, tooth mobility is accompanied with tooth migration also, which may impede the regular maintenance of oral hygiene in the area, thus further enhances the susceptibility of periodontal disease and many also lead to the exaggeration of the existing disease.

Studies suggest that tooth mobility is associated with periodontitis and is an important physical feature of the disease.[73–76] It has been discovered that higher periodontal damage is proportional to less root surface area with connective tissue attachment, consequently leading to increased tooth mobility.[77] In addition, periodontal disorders can harm the supporting soft tissues and result in bone resorption. The teeth become movable as a result of the loss of the supporting structure that keeps them secure in place.[78] In addition, it has been noted that elderly individuals with teeth that were more mobile were more likely to notice a difference in their quality of life.[79]

Some physiologic situations cause temporary mobility; however, this mobility is quite moderate in nature and does not persist for very long. These conditions include things like the hormonal changes that occur in women during pregnancy and menstruation. The time should be set aside as soon as possible for a thorough periodontal examination, nevertheless, if the mobility in a particular tooth or a group of teeth is persistent and getting worse with time.

PERIODONTAL DISEASE

What are the predominant clinically prevalent periodontal disease conditions?

The members of the expert panel were of the opinion that the present classification as proposed in the literature is quite complex and at times difficult to comprehend and follow, more so to incorporate into the general practice. Due to the complexities of such a classification, it is quite obvious that a general dentist may overlap the diagnosis, hence compromising the results. The members felt that there is a need to highlight those components of the big classification table of gingival and periodontal diseases, which are most commonly encountered in routine dental practices. Moreover, the risk factors including the systemic risk factors which have an impact on the periodontal disease and treatment should also be highlighted in a simple conceptual form.[80] For simplicity and comprehensibility, the members suggested that the periodontal diseases be better understood in two main categories:

Gingivitis

Gingivitis or gingival disease is the reversible inflammation of the gingiva, without the involvement of deeper periodontal tissues. The main features of gingivitis are: Erythema (redness), edema (swelling) and BOP on brushing, sometimes pain (soreness) of gums and bad breath also. For the ease of clinical assessment of gingivitis, presence of ≥10% bleeding sites with PDs ≤3.5 mm in the oral cavity has been adopted as an objective criteria. Gingivitis is primarily a clinical diagnosis, and radiographs have no role in diagnosing a case of gingivitis, as there is no involvement of alveolar bone. Persistent gingivitis, however, can lead to periodontitis.[31,32,81]

Periodontitis

Periodontitis is an irreversible disease, sometimes difficult to treat and is characterized by deep pocket depths and clinical attachment loss (CAL), i.e., the base of the pocket moves apical to the cementoenamel junction, gingival recession, increased mobility, and furcation involvement.[32,81] Periodontitis can be further considered into three categories based on clinical features: Mild, moderate, and severe [Figure 1 and Table 1].

Figure 1.

Type and classes (predominant clinically prevalent)

Table 1.

Expert consensus on guidelines for determining severity of periodontitis based on clinical examination

	Slight (Mild)	Moderate#	Severe (Advanced)##
Probing Depths	>3 & <5 mm	>5 & <7mm	>7mm
Bleeding on Probing	Yes	Yes	Yes
Radiographic bone loss	Up to 15% of root length or > 2mm &< 3mm	16% to 30% or>3mm & < 5mm	>30% or>5mm
Clinical attachment loss	1 to 3mm	3 to 5mm	More than 5mm

PD: Pocket depth, BoP: Bleeding on Probing, CAL: Clinical attachment loss *Localized disease is defined as ≤30% of sites are involved; Generalized disease infers >30% of sites are involved ^#referral to specialist may be indicated for additional treatment after initial therapy ^##referral to specialist should be considered

Distinguishing periodontitis (clinical signs and symptoms)

Loss of periodontal tissue support due to inflammation is the primary feature of periodontitis. Periodontitis is characterized by the presence of CAL around teeth, either manifested as deep periodontal pockets and/or gingival recession. Clinicians typically confirm the presence of interproximal tissue loss through radiographic assessments of bone loss in case of periodontitis.[31,32,81] Clinically, meaningful descriptions of periodontitis should be based upon the presence of sites that bleed on probing, and PD over certain thresholds given.[31,32,81,82] The expert panel summarized the case criteria and classification of periodontitis in Table 1, based on the severity of involvement in the individual scenario.

Pocket depth

It is the recording of the distance between the gingival margin and base of pocket. The probe should be walked around the tooth and the deepest recording should be noted.

Clinical attachment loss (CAL)

It is to be measured as the vertical distance from cementoenamel junction (a fixed reference point) to the base of the periodontal pocket. Because the bone level in health is approximately 2 mm apical to the cementoenamel junction, clinical attachment levels provide a more reliable indication of the extent of bone support for a tooth.

Significance of clinical attachment loss

The CAL reveals the approximate extent of the root surface that is devoid of the periodontal ligament.

A clear distinction should be made of the “true pocket (apical deepening of the sulcus)” and “false pocket (caused by enlargement of the gingiva)” since the treatment plan for both is quite distinct.

Bone loss

An overall impression of the bone loss can be evaluated with the help of an orthopantomograph (OPG)and/or intraoral periapical (IOPA) X-rays.

Mobility

Mobility of tooth should be recorded with the back ends of mouth mirror. The fingers should not be used to evaluate mobility.

Other conditions of interest for a practitioner

Muco-gingival defects: (a) Frenal attachments, (b) inadequate keratinized gingiva, and (c) gingival recession (all gingival recessions may not be related to periodontal disease and may have diverse etiologies such as faulty tooth brushing etc). Clinicians should look for validated symptoms of periodontal disease rather than considering standalone gingival recession as a sign and symptom of existing periodontal disease. A note of other conditions such as “Malodor,” “dentinal Hypersensitivity,”[83] should also be made at the time of diagnosing the case.

Incisor molar involvement (aggressive or early-onset periodontitis)

Incisor molar involvement pattern signifies the indirect evidence toward a greater rate of progression and more susceptibility to future bone loss in these patients thus needs a careful and rigorous supervised customized oral care. Although recent studies have provided with no evidence to suggest that such forms of periodontitis have a unique pathophysiology, yet attention to detail with these patients presenting with early onset incisor molar pattern of bone loss is vital.[82,84] A careful comprehensive periodontal examination even in the absence of plaque is vital, as the usual presentation of gingival inflammation corroborating with the amount of plaque is missing in these scenarios.[84]

Endo-perio lesions

Endo-periodontal lesions (EPL) are clinical conditions that can damage the pulp and periodontal tissues in both acute and chronic forms. When symptoms are related to a recent traumatic or iatrogenic incident, an abscess and discomfort are the most common ones (such as a root fracture or perforation). However, in people with periodontitis, EPL typically advances slowly, constantly, and without obvious signs. The most common symptoms of a tooth affected by an EPL include deep periodontal pockets that extend to or are very close to the tooth’s apex and a negative or inconsistent response to pulp vitality tests. The following signs and symptoms have also been noted, in the decreasing order of frequency: Tooth mobility, sinus tract, purulent discharge, spontaneous discomfort, pain on touch and percussion, bone resorption in the apical or furcation region, and gingival color changes.[84]

Periodontal abscesses

A periodontal abscess (PA) is a localized pus collection that develops in the gingival wall of the periodontal pocket or sulcus and causes serious tissue damage. The chief observable symptoms and indicators of a PA may include bleeding upon probing and ovoid elevation in the gingiva along the lateral section of the root. In addition, discomfort, suppuration upon probing, a deep periodontal pocket, and greater tooth movement may be seen. PA can appear in either a periodontal pocket that already exists (such as in patients with periodontitis) or one that doesn’t (such as in healthy individuals). In individuals with untreated periodontitis, for example, or after scaling and root planing or systemic antibiotic therapy, a PA may form in an already-existing periodontal pocket.

PA are significant because they are frequent dental emergencies needing prompt treatment and can cause the periodontium to be rapidly destroyed, which has a detrimental effect on the prognosis of the affected tooth. PA may cause serious systemic effects under some conditions. A history of impaction or bad practices is frequently linked to a PA that develops at a previously healthy region. The patient’s medical history may also be important, particularly in cases of abscesses connected to previous treatments (such as scaling and root planing, periodontal surgery, the use of systemic antibiotics, or the use of other medications like nifedipine and endodontic therapy), or in cases of abscesses caused by foreign body impaction.[84]

How to perform basic clinical assessment of periodontal disease?

The experts firmly agreed that the objective screening protocols in dental clinics are currently nonexistent in India and that there is a need to develop a simple and consistent means of screening and consequent charting for patients which should be user friendly [Tables 2, 3 and Box 1].

Table 2.

Expert consensus on initial screening for adults

Code	Probing depth (By WHO Probe)	Observations |
0	Pockets < 3.5mm	First black band completely visible Healthy periodontal tissues No calculus/overhangs No bleeding on probing
1	Pockets < 3.5mm	First black band completely visible Bleeding on probing No calculus/overhangs
2	Pockets < 3.5mm	First black band completely visible Supra and subgingival calculus or plaque retention factor (overhangs etc)
3	Probing depth (3.5-5.5mm)	First black band partially visible, indicating pocket of 4-5 mm)
4	Probing depth >5.5mm	First black band entirely within the pocket, indicating pocket of 6mm or more
	Furcation involvement, mobility, JXUJCogjngiyal problems or recession (indicating 3.5 mm or greater )#	Detection of a furcation, mobility, recession and any mucogmgiYal problem

Table 3.

Guidance tool on interpretation of codes

Interpretatio n of codes	Guidance	Special investigations	Periodontal reassessment
0	No need for periodontal treatment	None indicated	Repeat coding at next appointment
1	Oral hygiene instruction (OHI)	Plaque and bleeding charts	Repeat coding at next checkup appointment
2	As for code 1, plus removal of plaque retentive factors, including all supra and subgingival calculus	Plaque and bleeding charts	Repeat coding at next checkup appointment
3	As for code 2 and OHI, root surface debridement(RSD) if required	Plaque and bleeding charts Radiographs must be considered (in order to establish if there is bone loss)	Periodontal charting of sextant scoring 3, after initial therapy
4	OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated	Plaque and bleeding charts Radiographs should be taken	Full periodontal charting before and after treatment
*	Treat according to codes (0-4). Assess the need for more complex treatment; referral to a specialist maybe indicated	Plaque and bleeding charts Radiographs should be considered	Full periodontal charting before and after treatment

Box 1.

Expert consensus on charting (for each sextant)

Efforts should be made to disseminate the importance of an early and objective assessment during screening for proper diagnosis and treatment plan of the patient.[81] In the general clinical care situation, WHO probe offers

• A simple screening method for determining the level of intervention required

• Easier to read with colored bands at distinct depths

• Rapid detection of threshold pocket depths, important for defining treatment options

• Avoids confusion and quick decision making

• Also as a tool for the longitudinal monitoring of disease changes.

The use of WHO probe shall help the clinician to easily, accurately, and quickly detect the presence of areas of gingival health and disease. Further, the screening will help identify the areas of potential concern, requiring a comprehensive periodontal examination and needful management at an early stage. The experts were of the opinion that the general dental practitioner should take cognizance of key clinical features, which along with proper screening and charting (wherever required) should help them reach a proper diagnosis and subsequently a viable treatment plan as well.[85,86]

Diagnosis and need for involving specialists in patient care

The experts opined that major clinical features which distinguish periodontal diseases should be the key to diagnosis after the initial screening and charting is performed. Based on this an age group, specific clinical feature list was agreed upon, which should be known to the general dental practitioner at a basic level since they may be indicative of either an existent or impending periodontal disease [Table 4].

Table 4.

Age group specific clinical feature list

Age Group	Important C/F 1
Children <15 years	BOP
Young adults (15- 30 years)	BOP Mobility Deep Pockets
Older adults (>30 years)	BOP Mobility Unexplained tooth loss Increased space between teeth Thermal sensitivity in absence of caries Interdental itching Pain on chewing Food lodgment

Specialist intervention

There is evidence that more patients would benefit from receiving periodontal specialized care. There has undoubtedly been some unclarity regarding periodontal therapy, continued reviews of its efficacy, and when a periodontist should be consulted as a member of the patient’s treatment team. The entire dental team can benefit from guidelines to quickly identify patients with periodontal disorders and those who need specialized care.[81,87] The experts strongly felt that specialist interventions at the right time can greatly improve patient outcomes. However, there is a dearth of protocols on referrals in the Indian scenario. The panel discussed and suggested the best time for collaborative care and follow ups during the treatment process [Box 2]. Another tool, which helps the general dentist to decide regarding the specialist intervention, on the basis of clinical features, was also suggested [Table 4].

Box 2.

Clinical features at the time of diagnosis for a “YES,” “NO,” or “MAY BE” decision for specialist intervention

How can we define peri-implant health and disease?

The tissues that are present around osseointegrated dental implants are referred to as peri-implant tissues. They are separated into two distinct portions, or compartments for soft and hard tissue. The “peri-implant mucosa,” which is referred to as the soft-tissue compartment, develops as a result of the wound healing process that occurs after the placement of the implant or abutment.[88] To provide implant stability, the hard tissue compartment touches the implant surface.[89] The peri-implant tissues perform two primary purposes as a result of their anatomical and histologic characteristics: The mucosa protects the underlying bone, and the bone supports the implant. Indeed, the loss of peri-implant tissues can compromise the implant’s success and survival,[90] and the disease can be identified by studying the traits of healthy peri-implant tissues.

The absence of peri-implant signs of soft-tissue inflammation, the absence of bleeding or suppuration upon gentle probing, a decrease in PD from previous visits, and the absence of radiographic bone loss (RBL) above the crestal bone level changes brought on by initial bone remodelling following implant placement are all considered indicators of good peri-implant health.[91–93] The presence of bleeding and/or suppuration with mild probing, with or without increased PD compared to prior examinations, as well as the absence of subsequent RBL alterations that occurred after the first remodelling of the bone, are characteristics of peri-implant mucositis.[91,93,94]

Whether or not a patient’s prior records are present affects how peri-implantitis is defined. Peri-implantitis is characterized by the presence of peri-implant symptoms of bleeding and/or suppuration with mild probing, increased PD compared to earlier examinations, and presence of RBL beyond crestal bone level changes after initial bone remodelling, which should not be >2 mm. The symptoms of peri-implantitis, however, include the presence of bleeding and/or suppuration with gentle probing, PD 6 mm, and RBL 3 mm apical to the most coronal section of the intraosseous portion of the implant, in the absence of prior radiography records.[91,93,95]

In addition, there are a number of soft and hard tissue shortcomings in regard to implants. The 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions attempted to categorize and describe the etiology of these hard and soft tissue deficiencies, including but not limited to recession, lack of keratinized tissue, and insufficient mucosal thickness.[96]

SECTION II-THERAPEUTIC PHASE/TREATMENT PHASE PERIODONTAL HEALTH

What are the measures which would ensure maintenance of existing periodontal health and prevent the onset of periodontal disease?

In case of periodontally healthy condition with no active disease an assessment needs to be done regarding presence or absence of plaque and calculus. In the absence of external deposits with no clinical signs of inflammation, reinforcing oral hygiene practices should suffice. No evidence exists regarding additional benefit of professional oral prophylaxis in individuals with clinically healthy periodontium. Good oral hygiene is the gold standard in maintenance of periodontal health and patients need to be educated about the correct technique, frequency and force of brushing, frequent replacement of the toothbrush and indicated usage of interdental aids.[1] Oral prophylaxis with professional scaling and root planing is recommended in patients with presence of plaque and calculus, even though there are no clinical signs of inflammation. The rationale for treatment is that plaque/calculus deposition would be initiator of disease progression and should be removed for health maintenance.[2,3]

Plaque and calculus as risk factors accounts for only 20% chances of developing periodontitis. Remaining 80% risk of disease progression is dependent on other predisposing and modifying risk factors which directly or indirectly contribute in periodontal breakdown.[4]

All local risk factors such as overhanging margins, enamel pearls, malpositioned teeth, and open contacts should be removed or corrected for the maintenance of periodontal health. Counselling and physician collaboration should be done for risk factors such as diabetes and smoking. In case of any suspected systemic disorders, a comprehensive evaluation in collaboration with other medical specialists is important. In addition, the patients’ should be advised to eat healthier food so as to incorporate adequate quantities of vitamins and nutrients in their diet and also to include exercise in their daily routine in order to keep his/her weight within the normal limits to reduce psychological stress and enhance immune system. Furthermore, the patients should be educated and motivated to control/quit, if possible, any deleterious habits, such as smoking. Continuous monitoring should be done to control the development of unfavorable changes predominantly those associated with uncontrolled risk factors.

Is there a requirement of any intervention for periodontally healthy individuals?

An important consideration in defining periodontal health and its maintenance is recognition of controllable or noncontrollable disease determinants and modifiers. Predisposing disease determinants are those elements that encourage the buildup of dental plaque (like tooth anatomy, tooth position, restorations, etc.,). Modifying factors are those elements that change how a person reacts to the buildup of subgingival plaque (like, smoking, systemic conditions, and medications).[5] Treatment outcomes would depend on the ratio of these controllable elements (like removing overhangs) to uncontrollable aspects (like hereditary predisposition).

The new classification system has defined a periodontally healthy condition as the absence of any active disease in an intact periodontium or in a reduced periodontium (a condition with the presence of disease activity that has reverted to a state of health/absence of active inflammation after periodontal treatment).[6] In both of these diseases, variant treatment objectives would be used to maintain periodontal health.

The results of treatment depend on whether or not those who have periodontal disease in the form of gingivitis return to a state of clinical health after full periodontal restoration. Individuals with periodontitis revert to clinical health in a state of reduced periodontium. Both these kinds of health restoration require meticulous maintenance of periodontal health through regular supportive periodontal therapy (SPT).

Risk assessment needs to be done and examined for the presence of plaque and calculus. If plaque and/or calculus are present, patient needs to undergo scaling and polishing along with removal of any etiology leading to deposition of plaque and calculus, and if there are no deposits, then professional intervention is not needed with regular home care complying with the oral hygiene instructions given being sufficient.

Clinical health in reduced periodontium has recently been defined as <10% bleeding sites, PDs ≤4 mm and optimal improvement in other clinical parameters with arrest of progressive periodontal destruction.^[7] However, as the panel has advocated the use of WHO probe for ease in periodontal examination, clinical health in reduced periodontium may also be defined as <10% bleeding sites, with PDs ≤3.5 mm (colored band completely visible), along with optimal improvement in other clinical parameters and arrest of progressive periodontal destruction. Such patients yet remain at increased risk of future disease events, need periodic monitoring and maintenance therapy (MT).

Role of scaling in a patient with periodontal health

Plaque and calculus are deposits that are removed from tooth surfaces during scaling. Regularly removing these deposits as a preventive approach may eventually lessen gingivitis and stop it from developing into periodontitis.

Even if individuals have a minimal risk of acquiring gingival disease, many dentists use scaling as their primary form of treatment for the majority of their patients on a regular basis. The effectiveness of scaling and the ideal time between treatments are most contested topics. Scaling is an invasive technique associated to a number of unfavorable side effects, for example, tooth sensitivity and tooth surface damage and therefore should be done only in the presence of plaque and calculus and not as a preemptive measure to prevent formation of plaque and calculus.

GINGIVITIS

What is the treatment of gingivitis?/How would you treat a case of gingivitis?

Although not all patients with gingivitis will progress to periodontitis, treating gingivitis acts as a primary preventive step for periodontitis as well as a secondary preventive step for recurrent periodontitis.[8] Gingivitis and periodontitis are both manifestations of the same inflammatory disease.

Numerous gingivitis patients have calculus or other local factors that make it difficult to remove plaque and practice good oral hygiene, such as malocclusion, inadequate dental restorations, developing grooves, etc. To achieve good outcomes in these patients, personal plaque control approaches are combined with in-office plaque, calculus, and other local contributing component removal.[9,10] Lowering subgingival bacteria is the major goal of plaque and calculus removal to prevent clinical inflammation. Dental calculus can be removed with the aid of manual, sonic, or ultrasonic tools. As in the cases of gingivitis, there is no loss of attachment and therefore, root cementum is not affected, supragingival and subgingival scaling is typically the only procedure used to remove plaque and calculus in gingivitis. In cases of gingivitis with reduced periodontium (cases which have undergone treatment periodontitis in past), root planing may be necessary. The evaluation of the condition of tissues after the treatment and during the maintenance phase of therapy will determine the effectiveness of the instrumentation.[11]

To effectively prevent the development of gingivitis and inter-dental caries, teeth brushing should be accompanied with the elimination of inter-dental plaque once every 24 h.[12,13]

Guidelines for treatment

Explaining the diagnosis to the patient, etiology, risk factors, treatment options and alternatives, anticipated risk, and benefits of the treatment are a crucial prerequisite for periodontal therapy. A unique care strategy should be part of the therapy approach. On the basis of patient preferences, clinical findings, and benefits for general health, the plan may be amended over the course of the treatment. Gingivitis is generally treated in Step 1 of Phase I therapy (Phase I has Step 1 and Step 2) followed by SPT after the inflammation is resolved.

In gingivitis patients, Step 1 which includes patient motivation, risk factor control and Professional mechanical plaque removal (PMPR) are generally sufficient to control the disease.

By clearing the supragingival dental biofilm effectively and reducing risk factors, the first step in therapy is to encourage the patient to maintain their oral hygiene on their own. Supragingival dental biofilms can be managed using mechanical and auxiliary chemical techniques.

Plaque elimination with mechanical means still mostly involves brushing your teeth. The additional mechanical plaque control techniques include using dental floss, interdental brushes, oral irrigators, wood sticks, or powered toothbrushes as an additional tool for cleaning in between the teeth. As a supplement to mechanical plaque reduction, antiseptic compounds that can be used in a number of ways, including as dentifrices and mouthwashes, have been proposed.

The XI European Workshop in Periodontology (2014)[14] and the systematic review on oral hygiene practises for the prevention and treatment of gingivitis[15] provided evidence for interventions needed to maintain oral hygiene and other prophylactic measures for gingivitis:

• Oral hygiene instructions from a professional to prevent plaque accumulation and gingivitis, are required. Re-enforcing oral hygiene instructions might have additional benefits

• Brushing the teeth with either manual or electric brash remains the primary method of plaque removal and reduction in gingivitis. The advantages offered by brushing are far more than any risks caused by it

• Interdental cleaning is essential, not only as it cleans the area where plaque builds up first but also because it is a hard-to-keep area. When gingival inflammation is present, patients should be given a professional demonstration of interdental cleaning, ideally utilizing interdental brushes (IDBs). Clinicians may suggest different inter-dental cleaning methods or instruments when the usage of IDBs is unsuitable.

The management of gingivitis includes:[14]

1. Utilizing fluoride toothpaste and powered toothbrushes to brush twice a day for 2 min: According to evidence, power brushes result in 46% lower plaque scores after just one tooth-brushing session. Rechargeable power brushes resulted in greater plaque score reductions than brushes with replaceable batteries.[16] In controlled investigations, power toothbrushes outperform manual brushes in terms of both short- and long-term reductions in plaque indices (28 days to 3 months; 11%) and (3 months; 21%) and in reduction of gingival inflammation.(6% in short-term trials; 11% in long-term studies)

2. Flossing around healthy gingival tissue in teeth with tighter contacts

3. Although a Cochrane study[17] showed that flossing in addition to brushing had a statistically significant advantage over brushing alone in terms of lowering gingival inflammation, nevertheless, the evidence was of very low quality. It means that there is little evidence that flossing decreases gingivitis and that there is doubtful evidence that flossing lessens plaque[18]

4. Interproximal brushing should be used, especially in areas with inflamed gingival tissue where flossing could cause trauma. Inter-dental brushes work well as adjuncts to tooth brushing to remove plaque in adult patients.[19] Since using interdental brushes in addition to tooth brushing helps to reduce dental plaque, the evidence from this research supports that dentists’ advice their patients to use interdental brushes.[20]

Controlling the calculus and subgingival biofilm is the goal of the treatment. The removal of supragingival dental biofilm and calculus, also referred to as PMPR, is regarded as an essential step in the primary[6] and secondary[21] prevention of periodontitis as well as in the fundamental management of plaque-induced periodontal diseases.[22] Retentive factors, whether brought on by the tooth’s architecture or, more frequently, by insufficient restorative margins, should be eradicated to reduce their detrimental effects on periodontal health. They frequently induce gingival inflammation and/or the loss of periodontal attachments. Subgingival instrumentation removes hard and soft deposits from the tooth surface in an effort to reduce soft-tissue inflammation.

It is therefore recommended using either manual or powered (sonic/ultrasonic) tools, either separately or in combination, for subgingival periodontal instrumentation. A traditional quadrant-wise or complete mouth delivery of subgingival periodontal instrumentation can be accomplished within 24 h.

Use of adjunctives

Use of lasers, photodynamic therapy (PDT), probiotics, or systemic sub-antimicrobial dose doxycycline (SDD) in addition to subgingival instrumentation is not indicated.[22]

Using mouthwashes and other chemical means of controlling plaque

Many people find it challenging to maintain a sufficient degree of plaque control, making adequate clearance of the microbial biofilm using mechanical treatments alone difficult.^[23-28] In these persons, the level of plaque control reached by regular mechanical cleaning alone might not be sufficient to prevent the emergence or recurrence of periodontal disorders.[29] Therefore, the supplementary use of chemical plaque control techniques in addition to the mechanical removal of the microbial biofilm has been recommended in some instances or as a replacement altogether. Topical antibacterial medications that help lessen bacterial plaque may be beneficial for the treatment and prevention of gingivitis.[30,31]

The American Dental Association Seal of acceptance has been given to three medications for the treatment of gingivitis. These medications are tri-closan, chlorhexidine digluconate (CHX) or a combination of thymol, menthol, eucalyptol, and methyl salicylate as active components.[30]

Mouth rinses containing chlorhexidine are typically used as a supplement to routine mechanical oral hygiene and are widely recognized as the gold standard by which other antiplaque treatments are evaluated.[32,33] In some situations, adjunctive antiseptics, particularly chlorhexidine mouthwashes for a brief length of time, may be recommended in addition to mechanical debridement regimen.

Along with interdental brushing, water jets have recently been demonstrated to be helpful in a meta-analysis.[34] Mouthwashes containing chlorhexidine and essential oils are beneficial in lowering gingivitis and plaque levels[35,36,37]

Is there a need for an adjunct drug?

No evidence related to need for an adjunct drug for gingivitis unless medically compromised.

Are any pretreatment investigations required?

No evidence related to pretreatment investigations for gingivitis unless medically compromised.

What are the endpoints of treatment?

The endpoints for the treatment of gingivitis are:

Reduction in the pocket depth, which is indicated by a probing pocket depth (PPD) of ≤3.5 mm (colored band completely visible) and BOP in <10% of sites.[38,39]

After the achievement of end-point, the patient is shifted to SPT phase.

Are there any associated posttreatment adverse effects/complications?

Numerous studies have documented certain unfavorable effects of periodontal treatment.[17,18,40] Some of the most frequent adverse drug reactions (ADRs) of CHX mouthwash and gel included xerostomia, hypogeusia, and darkening of the tongue in addition to calculus and extrinsic tooth staining with continued use.[41,42] Oral paraesthesia glossodynia, oral mucosal desquamation, and parotid gland enlargement are less common ADRs. However, individuals who use chlorhexidine most frequently report tooth discolouration as an adverse reaction.[41] An anti-staining chlorhexidine has been developed and is available in the markets.

The most frequent and reversible side effect of using dental floss was soft tissue/gingival damage. The majority of patients would refrain from flossing in the damaged areas, and the wounds would heal. The advantages of flossing in preventing gingivitis appear to exceed the risks.

What is the necessity and benefit of intervention?

As it removes microbial plaque and prevents it from accumulating on teeth and gingivae, regular oral hygiene is essential for preserving oral health.[43] On the whole, it makes sense to state that eliminating interdental plaque at least once per 24 h and achieving adequate plaque control by brushing are enough to prevent gingivitis and interdental caries from developing.[12,13]

Gingivitis associated with systemic disease

(This section of the current paper entails the most widely prevalent systemic conditions, i.e., DM and CVD).

What investigations are necessary?

Investigation with regard to DM, random blood sugar, fasting blood sugar, postprandial sugar, and glycated hemoglobin levels is generally recommended. With regard to CVD, the history, medical clearance, and blood picture may be required.

• Role of medications

• Antibiotic coverage may depend on the status of disease

In cardiovascular diseases

Dental procedures and infective endocarditis

According to American Heart Association[44] prior to some dental operations, antibiotics may be provided (Infective Endocarditis [IE] prophylaxis) to patients who are most at risk for adverse outcomes from IE to lower their risk of contracting it. These include procedures that manipulate the gum tissue, the periapical region of the teeth, or perforate the oral mucosa.

Any of the above-mentioned dental procedures to be performed in patients with heart valve disease who have any of the following conditions, prophylactic antibiotic coverage is necessary:

1. Patients with prosthetic cardiac valves, such as homografts and transcatheter prostheses.

2. The prosthetic material used to repair heart valves, such as clips, rings, or chords for annuloplasty

3. Previous history of IE

4. Unrepaired cyanotic congenital heart defects with residual shunts or valvular regurgitation at the location next to a prosthetic patch or prosthetic device (birth defects with oxygen levels below normal)

5. A structurally deficient valve in a cardiac transplant causing valve regurgitation

6. Antibiotic prophylaxis before dental operations is not advised for any other types of congenital heart disease outside the categories mentioned above.

Maintenance of good oral health through regular professional dental care and using manual or powered toothbrushes, adjunctive mechanical plaque control devices such as dental floss, for removing plaque, can reduce the risk of developing IE.

The dentist can ask the patient to consult a cardiologist and prescribe recommended dose of antibiotic for IE prophylaxis. The dose for children will depend on their weight. Always take care if patient is allergic to any antibiotics or other medications.[44]

Diabetes

Implementation of nonsurgical periodontal therapy (NSPT) in all diabetic patients with periodontal disease, regardless of the glycemic level to actively reduce inflammation is indicated.^[45-47] Further evidence suggests that periodontal therapy combined with efficient at-home care is both safe and beneficial in patients with diabetes.[48] Even in patients with poorly controlled diabetes, clinical periodontal metrics and local inflammatory markers improve after routine nonsurgical therapy.[45,46,49]

The joint guidelines of ISP and Research Society for the Study of Diabetes in India, recommended for the management of diabetic patients:[46]

1. NSPT must be implemented as part of active inflammation control at the time of the visit in all diabetics with periodontal disease, regardless of glycemic level

2. Before any dental surgical procedure, patients with diabetes must use a mandatory preprocedural mouth rinse containing chlorhexidine (non-alcohol based) 0.12% (15 mL) or 0.2% (10 mL) for 1 min. This will reduce the microbial burden in their mouths and the risk of developing transient bacteremia

3. It is not recommended to routinely administer preoperative antibiotic prophylaxis to diabetic individuals undergoing dental treatments to prevent bacteremia

4. Preoperative antibiotic prophylaxis for diabetic patients undergoing dental treatments should be decided on a case-by-case basis, taking into account the patient’s systemic condition and worries about the evolution of antibiotic resistance through indiscriminate antibiotic usage.

PERIODONTITIS

Guidelines for treatment of periodontitis

The patient must be informed of the diagnosis, conditions’ etiology, risk factors, and available treatments, alternatives to those treatments, and anticipated risks and benefits prior to beginning periodontal therapy. Preestablished step wise therapy is advised for the treatment of periodontitis patient. A customised care plan should be used for the treatment protocol. The strategy may need to be adjusted based on the course of the treatment, patient preferences, clinical findings, and the advantages for general health. A flowchart summarizing the guidelines for gum care has been provided [Figure 2].

Figure 2.

Guidelines for gum care flow chart

There are three phases in periodontal therapy:

1. Phase I therapy also called as nonsurgical therapy which is divided into Step1 and Step 2

   • In periodontitis patients, Step 1 which includes patient motivation, risk factor control, and PMPR

   • The second stage (Step 2) of treatment is indicted if the endpoint of the treatment is not achieved after step 1 of the Phase I therapy.

2. Phase II therapy also called as surgical therapy

3. Phase III is SPT.

Phase I therapy

Step1 in Phase I therapy

Controlling the supragingival biofilm is the primary goal. The most crucial factor in improving oral hygiene is patient behavior modification.[50] The mechanical and adjunctive methods described in the treatment of gingivitis are applicable in the Step 1 of Phase I therapy.

The removal of supragingival plaque and calculus as well as the rectification of plaque-retentive factors is all included in PMPR.[51] Periodontitis must be stopped in its tracks by controlling the risk factors including smoking and diabetes.[46,52] Subgingival instrumentation can be used with powered (sonic/ultrasonic) or hand-held instruments, either alone or in combination, to remove calculus and subgingival biofilm.[53] The goal is to lessen the number of diseased sites, gingival inflammation, and PPD. These procedures involve the traditional removal of plaque and calculus quadrant by quadrant or across the mouth within 24 h.[54]

Regardless of the disease stage, all patients should undergo the aforementioned Phase I therapy step. This procedure is continually reviewed to keep the patient motivated, build abilities for removing plaque biofilm, and adapt as necessary.

Incremental treatment interventions can be carried out depending upon the disease stages. After Step 1 of Phase I therapy, the residual PPD should be evaluated. The end point of the treatment is that the PPD should be ≤3.5 mm without any BOP.

The residual PD needs to be re-evaluated at the end of Step I of Phase I therapy. The residual pocket depth after Step 1 of Phase I therapy determines further line of treatment and shifting the step 2 of phase I therapy.

• If end-point of treatment is achieved, the patient is shifted to SPT (Phase III)

• If the PD is more than 3.5 mm with BOP, Step 2 of Phase I should be initiated.

Step 2 in phase I therapy

On re-evaluation, after Step 1 of Phase I therapy, the treatment options can be divided on the basis of residual pocket depth

• Residual pocket is 3.5-5.5 mm

• Residual pocket is more than 5.5 mm.

The treatment options in case with residual pocket depth is in between 3.5-5.5 mm.

Repetitive subgingival instrumentation in adjunct with short-term use of chemotherapeutics (antiseptics), notably chlorhexidine mouthwashes is indicated.[26,55] In order to overcome the adverse effects of chlorhexidine (staining), newer version of chlorhexidine which do not cause stains can be recommended. Adjunctive to subgingival instrumentation like use of lasers, PDT are not recommended.[26,56] Local administration of drugs such as statin gels (atorvastatin, simvastatin, and rosvastatin), probiotics, sub antimicrobial dose doxycycline (SDD), systemically or locally delivered bisphosphonates gel, omega-3–polyunsaturated fatty acid, systemic or local nonsteroidal anti-inflammatory drugs, metformin gel with subgingival instrumentation are also not recommended.[26,57] Due to the impact on public health, routine use of systemic antibiotics along with subgingival debridement is not advocated. Specific systemic antibiotics as an adjunctive may be considered for specific patient category for example generalized periodontitis in young adult patients.[58]

The treatment options in case with residual pocket depth is more than 5.5 mm.

These categories of patients are treated under Phase II therapy (surgical phase). In order to reduce the inflammation, patients with pocket depth of more than 5.5 mm may be subjected to Step 2 of Phase I therapy, as subgingival instrumentation may be used as presurgical procedure to reduce inflammation.

Surgical treatment, although indicated, may not be feasible due to uncontrolled diabetes or patients with CVS disorders, age factors, patient’s apprehensions, economic factors and post treatment recurrence. In such cases, shifting the patient to Phase II may not be possible. Such patients where surgery is indicated but cannot be undertaken, are maintained by implementing Step 2 of Phase I therapy by repeated use of subgingival instrumentation in adjunct with short-term use of chemotherapeutics (antiseptics), notably chlorhexidine mouthwashes.

Re-evaluation of Phase I therapy

The residual PD needs to be re-evaluated at the end of Phase I therapy. If the PD is more than 3.5 mm with BOP, Phase II (surgical phase) should be initiated.

In case of residual pocket is still 3.5-5.5 mm after repeated subgingival instrumentation and adjunctive use of chemotherapeutics but no BOP, then patient can be shifted to rigorous SPT (Phase III) and observed over a period of time.

Phase II therapy (surgical periodontal therapy)

The surgical phase of treatment to be considered when there is a residual pocket depth is ≥3.5 mm with BOP or deep periodontal pockets of >5.5 mm after Phase I therapy. The goal of surgical therapy is to gain further access to subgingival instrumentation or to manage periodontitis by regenerative or resective surgical procedures. Periodontal surgery is always complex depending on the many factors such as anatomical variations of the site, patient’s response to the treatment, medical conditions, and many more. Therefore, the periodontal surgical treatment requires special training in the procedures. Hence, the dentist should be trained to handle such cases or should positively involve the specialists (periodontist) in managing the periodontal surgeries.

Any periodontal residual pocket is more than 3 mm intra bony defect or deeper should be treated with regenerative surgery.[59] In regenerative procedures, the use of either barrier membrane, enamel matrix derivatives, bone-derived grafts is indicated.[59] The selection of the flap technique should consider maximum preservation of interdental soft tissues by utilizing the techniques such as papilla preservation flap and limited flap elevation for maintaining the wound stability.[59,60]

Management of furcation lesions

Furcation involvement may be one of the most complex periodontal pathological conditions but is no reason for extraction of teeth. The anatomical complexity of furcations makes periodontal surgery challenging. Regenerative surgery should be used to treat mandibular molars with class II furcation and residual pocket.[61] Nonsurgical instrumentation, open flap debridement (OFD), periodontal regeneration, root separation, or root excision are all options for treating Class II furcations in the maxilla.^[62-64] Nonsurgical instrumentation, OFD, tunnelling, root separation, or root excision may be taken into consideration when class III furcation involvement affects the maxilla and mandible.[62]

Successfully treated periodontitis patients generally have reduced periodontium after completing active periodontal therapy. Such patients have reduced but healthy periodontium.[6] Due to their increased risk of periodontitis development and recurrence, these patients need SPT for life that has been specifically created for them.

What are the endpoints of treatment?

Clinical health in reduced periodontium has been defined as <10% bleeding sites, PDs ≤3.5 mm measured by WHO probe (colored band completely visible) and optimal improvement in other clinical parameters with arrest of progressive periodontal destruction. These patients remain at increased risk of future disease events and need periodic monitoring and MT.

Management of peri-implant conditions

Peri-implant mucositis

Inflammation due to the accumulation of plaque around implants leads to the development of peri-implant mucositis, but the available evidence point out that resolution of inflammation generally occurs after treatment, taking into consideration certain risk factors such as surface characteristics of implant, residual cement remnants, oral hygiene maintenance, smoking, and others.

The majority of nonsurgical treatments for peri-implant mucositis involve professional debridement of plaque and calculus from the surface of the implant, abutment, and implant neck as well as the application of at-home maintenance techniques. Antimicrobials such as antiseptics or local or systemic antibiotics may be used adjuvantly, although this is controversial. In addition, it is ideal for patients to be motivated and to practice good oral hygiene to stop the rebuild of calculus and peri-implant biofilm.^[65-67]

Different implant curettes are available which can be used for debridement without damaging the titanium implant surface. Manual curettes such as titanium-coated curettes,[65] carbon-fiber curettes,[67] teflon curettes,[68] plastic curettes;[69] and ultrasonic curettes with carbon fiber, silicone, plastic and polyether-ether ketone-coated tips can be used to debride the implant surface.^[70-73] Vector^® system (Durr Dental, Bietigheim-Bissin-gen, Germany) is an ultrasonic system which converts horizontal vibration into vertical vibration using a resonating ring, causing the working tip to move parallel to the surface has shown good clinical results without damaging the implant surface.[71]

The studies on peri-implant mucositis highlighted that following 21 days of plaque buildup, inflammatory reaction was more as compared to the gingival[74] and 3 months of plaque buildup led to 3 times greater inflammatory infiltrate in peri-implant mucositis as compared to gingivitis,[75,76] indicating the requirement of anti-infective treatment for peri-implant mucositis so as to prevent its progression to peri-implantitis.[77] However, the current evidence proposes that similar significant reduction of peri-implant tissue inflammation was obtained after professional mechanical debridement with and without the use of adjunctive antimicrobials.[65] The usage of chlorhexidine as an adjunct to the treatment did not show any surplus benefits from the clinical point of view and is also not without unfavorable adverse effects. Conversely, it should be recommended to patients with the presence of systemic diseases and psychosocial conditions where the benefits outweigh the adverse effects.[67,69,70,78]As far as the usage of systemic antibiotics is concerned, the current evidence is insufficient for it to be used as an adjunct to treat peri-implant mucositis as there are no additional benefits observed with regards to clinical factors, and moreover, unfavorable effects such as antibiotic resistance and harmful gastrointestinal effects are observed.[66] Further benefit in relation to reduction of BOP and occasionally in decrease of the plaque scores is obtained with home care mechanical plaque control along with the use of an antiseptic.[65]

Hence, consistent peri-implant treatment with the removal of biofilm is an important prophylactic approach to prevent transformation of health to peri-implant mucositis and also to prevent progression of peri-implant mucositis to peri-implantitis.[79]

Peri-implantitis

In patients with peri-implantitis, clinical and radiographic evaluation is vital and presence of radiolucent line along the implant surface radiographically and tender on percussion and/or mobility clinically indicates the removal of implant. In case where retaining the implant is considered, a varied range of nonsurgical and surgical treatment options have been proposed for the treatment of peri-implantitis.[80]

Nonsurgical treatment is the first line of treatment with the aim of controlling the infection.[81] The evidence supports the use of instrumentation with manual and ultrasonic curettes with specific tips (similar to the ones mentioned in treatment of periimplant mucositis) in the treatment of peri-implantitis.^[71-73] Although the use of adjunctive treatments (air polishing, local antimicrobials, LASER, and PDT) is recommended to improvize clinical outcomes,[81,82] comparison of manual versus ultrasonic curettes led to nonsignificant differences regarding changes in PD while both exhibiting improvements in inflammatory parameters.^[71-73] Standard powdered air polishing systems should not be used on implant surfaces because of their abrasiveness.[83] Glycine air polishing system has shown good results though systematic reviews states that there is evidence of slight surface alterations in in-vitro studies, however the evidence in in-vivo studies is weak.[84,85] In vitro analysis has shown better cleaning of the implant surface with air-polishing, mainly in larger peri-implant defects, but the clinical significance of this procedure is yet to be established.[86] The literature also suggests that locally delivered antibiotics may provide an extra clinical benefit when compared with chlorhexidine, especially when repeated applications are administered.[65,87] Evaluation of studies on LASERs suggested that it offers short-term clinical improvements lasting up to 3 months in the nonsurgical treatment of peri-implantitis. However, expense of this therapy should be considered because of the similar results obtained with options involving lesser expenditure and were easier to use.[65]

The clinical trials support that the nonsurgical therapy of peri-implantitis alone may not be effective in completely resolving the disease due to inadequate decontamination of the implant surface exposed to biofilm, which might be because of the Gram-negative microorganisms found in peri-implantitis lesions similar to that of periodontitis lesions and also associated bone loss that occurs exposing the implant threads to the biofilm making the sites challenging to control with nonsurgical therapy unaided.[88,89] The investigations on the usefulness of nonsurgical procedures in controlled trials disclosed that improvement in BOP was more significant, whereas only a little effect in terms of the PD reduction was observed.[65]

Once the nonsurgical phase is completed, it should be analyzed that in cases where oral hygiene is not improving and nonsurgical therapy is not able to control the infection, implant removal should be considered as the only option. However, it is recommended to consider surgical treatment modality, when nonsurgical peri-implant treatment options are not able to control infection but oral hygiene maintenance is adequate.[80] The surgical approach for peri-implantitis justifies its role by facilitating adequate access for debridement/decontamination and for amendment of soft and hard peri-implant tissues to achieve re-osseointegration.[81]

For implant surface decontamination during peri-implant surgery–mechanical (manual/ultrasonic debridement), chemical (citric acid, hydrogen peroxide, chlorhexidine, and/or saline for disinfecting/decontaminating the implant surface) and LASER (for decontaminating the implant surface), treatments are the available options. The evidence suggests that all decontamination treatments have provided successful outcomes and none is superior to the other.[90,91]

Resolution of inflammation is one of the important objectives of peri-implantitis treatment; although, it is also essential to accomplish the regeneration of the lost bone. The evidence clearly mentions that surgical treatment should be considered for peri-implantitis, when the aim of treatment is PD and marginal bone loss reduction.[77]

The morphology of the peri-implant bony defect needs to be evaluated to select the most appropriate surgical approach. Many different approaches are available for the treatment of periimplantitis such as access flaps, resective surgery, and regenerative surgery along with implantoplasty, i.e., surface modification of the implant.[80] Regenerative surgeries have been recommended for improved outcomes in circumferential defects with intact bony walls and intrabony defects.[92] Uneven residual bony margins or defects are best accomplished using resective surgery with or without implantoplasty.[93] There is no evidence supporting the use of access flaps, but it provides aid in defects that are shallow or in esthetic regions where nonsurgical treatment was found to be ineffective, as it minimizes the risk of recession and is effective in reducing inflammation and PDs.[65,80]

There is no evidence suggesting the use of any particular regenerative material as all have shown similar improvements in terms of bone fill, although literature also found evidence that the use of barrier membranes does not provide any additional advantage over bone grafts in the treatment of peri-implantitis.[65,77,80,94] However, it also needs to be understood that direct bone-to-implant contact on a formerly contaminated implant surface has been recognized in preclinical models but has certainly not been confirmed in humans.[95,96]

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SUPPORTIVE PERIODONTAL THERAPY/MAINTENANCE THERAPY

Prior to the onset of periodontal disease, it is difficult to anticipate susceptibility, and treatment outcomes are likewise unexpected. Patients with a history of periodontitis are significantly more likely to experience further episodes of the disease, that most often affect the same areas. As a result, patients are usually carefully evaluated after receiving treatment for an active periodontal/peri-implant disease as part of a structured plan of SPT or maintenance therapy(MT).

The transition of the patient from an active treatment state to a maintenance program is a crucial stage in overall patient care that necessitates the clinician’s time and effort. Patients must be made aware of the maintenance program’s objective, and the practitioner must stress that MT is essential for tooth preservation. SPT provides an opportunity for professionals to maintain periodontal health and quickly determine and stop the progression or recurrence of periodontal disease.[1,2]

What is the rationale for a follow-up regimen such as SPT/MT?

The cornerstone of periodontal health has long been thought of as keeping good oral hygiene. It is typically accomplished by combining proper dental hygiene at home with regular professional care. Even after the completion of successful periodontal therapy, studies have proven that the progression of periodontal disease is possible. This may be due to the multifactorial nature of the disease, inadequate removal of periodontal pathogens, and relocation of the bacteria from the diseased sites.[3] There may also be differences in the disease pattern between patients (or even the sites within the same patient) as determined by local bacterial challenge, host response, and the modified effect of various risk factors.

Although the subgingival bacteria linked to periodontitis is diminished by pocket debridement[4], Within days or months, periodontal bacteria may regain baseline levels.[5] The relapse of the disease can be prevented or kept under control in most of patients essentially through rigid surveillance at regular recall appointments.[6] Numerous long-term, retrospective, epidemiological studies have revealed that, regardless of the clinical practice context, only upto five percent of teeth in patients previously treated for chronic periodontitis are lost over a five-to ten-year period, confirming the usefulness of follow-up.[7,8]Additionally, studies assessing SPT/MT have found that frequent-recall patients were able to maintain excellent oral hygiene standards and stable attachment levels.[9] Well-maintained patients experienced a reduced loss of periodontal support per annum and reductions in tooth loss over time.[10,11]

For the maintenance of dental implants, SPT/MT is useful for monitoring dental implants from the perspective of mechanical and biological aspects.[12] Sometimes in spite of best efforts of clinicians some individuals may have advanced periodontal disease and additional diagnostic information like microbial analysis and therapies that include antibiotic usage may be required.[13,14]

There is a high likelihood of tooth loss without SPT.[15] SPT and meticulous microbiological supervision have been shown to significantly reduce the need for tooth extractions in individuals with periodontally affected teeth.[16] This highlights the critical role that a correctly planned SPT plays in periodontal therapy success.

What should be the goal and the objectives of SPT/MT?

Clinicians should be aware that the primary purpose of SPT/MT is to avert the advancement and resurgence of periodontal disease in patients who have already had treatment for periodontal or peri-implant disease[17] and maintain it in the most stable condition.[18] Therefore, the objectives of SPT are to:[19]

• Prevent/minimize recurrence and progression of periodontal disease sites previously treated for gingivitis, periodontitis, or peri-implantitis

• Reduce the incidence of tooth loss by monitoring the dentition/dental prostheses

• Increase the probability of identifying and treating, in a timely manner, other oral diseases or conditions.

What do the SPT/MT encompass?

A typical maintenance appointment for patients with periodontal disease has been provided in Figure 3.[19]

Figure 3.

Components of SPT/MT

Scaling and root planing normally lasts no more than thirty to 40 min during an hour-long SPT/MT consultation.[20,21] However, the need for a somewhat longer course of therapy may result from the appearance of deep periodontal pockets and open furcations.

What is the role of home care in SPT/MT?

Home dental care plays a significant role in maintaining oral health and can help reduce the need for future expensive dental work. Clinicians should customize home oral care recommendations for individual patient focusing on a personalized approach to treatment and prevention.

Daily mechanical removal of dental plaque is regarded as crucial for maintaining oral health in addition to professionally administered plaque removal services, such as those offered by a dental professional. Figure 4 shows various modalities of patient performed home care measures.

Figure 4.

Patient performed maintenance care

General recommendations for daily oral care

Toothbrush and toothbrushing

For daily mechanical plaque control it is recommended to use a small brush head to access all teeth. The brush should have soft bristles to prevent injury to teeth and gums, and should have a comfortable handle for better grip and ease of use. Figure 5 provides the recommended sequence of brushing.

Figure 5.

Sequence of brushing (Adapted from Graetz et al, 2013[23])

There is adequate evidence to support the claim that twice-daily brushing was ideal for reducing the likelihood of caries, gingival recession, or periodontitis when compared to brushing less frequently. This conclusion is also supported by recommendations from governmental and professional associations.[22,23]

Dentifrices

Dentifrices assist in reducing plaque buildup, preventing teeth from caries, clearing stains, remove food debris, and leaving the mouth feeling fresh.[24] Although there are several dentifrices to choose from, one of the most important ingredient to have is fluoride. In addition, dentifrices with sodium bicarbonate formulation like Parodontax^©[25,26] provides a further antiplaque advantage by interrupting the sticky polysaccharide matrix when it penetrates the plaque layer, loosening the biofilm, and facilitating the physical removal of plaque.

Powered toothbrushes

When used properly, powered toothbrushes, similar to their manual counterparts, effectively remove dental plaque and reduce gingival inflammation.[22] Powered toothbrushes might be more convenient for certain patients to use. Starting with the maxillary molars, it is advised to move systematically to the opposite side molar (and repeat for the lower teeth) by going around and over each tooth.

Interdental cleaning devices (ICD)

Dental and peri-implant biofilm develop because the interdental spaces are not kept clean. The development of dental plaque and conditions like gingivitis and halitosis can all be prevented with the assistance of the Interdental cleaning devices (ICD). According to studies, adults who used ICD more regularly to clean in between their teeth had a lower risk of developing periodontitis.[27]

Advising patients they need to floss and expecting that it will become a regular part of their oral home care regimen may not be effective because of the impediments to interdental cleaning. Instead, by assessing their patients’ level of comprehension, learning about their motivation, and thereafter acting as a guide by communicating and encouraging daily cleaning between their teeth, clinicians may promote good home dental care. Types of available ICDs can be discussed with patients to assist them to understand their options and provide them with some of the skills needed to be effective.

One should gauge the interdental space while choosing an ICD. Currently, there are interdental space gauges, which help in determining the interdental spaces.[28] Interdental bleeding has been demonstrated to be reduced by 46% after a week and 72% after 3 months when using calibrated brushes.[29]

Choosing an interdental brush

• Good grip with an ergonomic design

• A comfortable, small head that makes it possible to access even the most difficult areas

• Soft bristles to prevent enamel or gums from being harmed.

Regular flossing is advised, at least once daily, preferably in the morning or just before bed. Take a piece of dental floss measuring around 12 and 18 inches in length, then loop both ends around your fingers for proper flossing. To remove plaque, bacteria, and food particles, carefully slide the floss up and down the sides of each tooth.

Water flossing

Often patients find it difficult to select the correct ICD and use it effectively. However, recent introduction of handy devices such as water flossers (subgingival irrigators) offers a more practical alternative to clean interdental spaces. Using a water flosser before or after brushing and flossing is an effective way to reduce the risk of periodontal infection.[30] People who use a water flosser as part of their regular self-care routine have greater results in reducing gingival bleeding and gingivitis than those who don’t.[31,32] Water flossers are easy to use for those with low manual dexterity. It is a gentle yet effective way to clean crowns, bridges, veneers, dental braces and dental implants.

Oral irrigators work mechanically by a combination of pulsation and pressure. The gingival tissue is compressed and decompressed in stages as a result, supragingival plaque is removed, and subgingival bacteria and other debris are flushed out.[33]An impact zone is formed when the solution meets the gingival margin, and a flushing zone is formed when the irrigant reaches subgingivally.[34]

Additionally useful for maintaining implants, oral irrigators greatly reduce bleeding when compared to floss while cleaning the area around implants.[35]

Mouthwashes

Mouthwashes/mouthrinses have found their place in plaque control as an adjunct to regular toothbrushing for maintenance of oral hygiene. Several studies and systematic reviews have demonstrated an additional advantage of mouthrinse use in lowering plaque and gingival inflammation in people who brush and floss regularly in addition.^[36-38] The antiseptic/antimicrobial ingredients of the mouthwashes help reduce the periodontopathogens andcariogenic bacteria by various mechanisms.[39] Among them, Chlorhexidine gluconate, is one of the most widely used antiplaque and antimicrobial agent in mouthwashes, 0.12% and 0.2% concentrations. It has been a reliable antiplaque agent owing to its long substantivity. However, the associated side-effects of chlorhexidine have often proved to be an impediment for its regular use, resulting in a quest for alternatives.[40] Newer antimicrobial cationic surfactant compound, such as Octenidine dihydrochloride[41] and those containing Hyaluronic acid have been shown to be effective alternatives.[42]

Desensitizing agents

Depending on the type of periodontal intervention, the incidence of post-therapeutic dentinal hypersensitivity has been reported to be in the range of 23% - 80.4%,[43] therefore it must be addressed to in the maintenance phase. For the treatment of post-intervention dentinal hypersensitivity, there is enough research to advocate the use of potassium, stannous fluoride, calcium sodium phosphosilicate, and arginine-containing desensitizing toothpastes.[44]

When should the SPT/MT be initiated and what should be its frequency?

SPT/MT begins once patients are deemed periodontally stable, which is determined six to eight weeks after completion of active treatment.[45]

SPT/MT involves reevaluating the periodontal and peri-implant conditions of the patient and determining the recall frequency. Patients who have had definitive periodontal therapy but still have recurrent gingivitis without further attachment loss can be adequately managed with semi-annual SPT/MT.[46] SPT/MT should, however, be conducted more frequently for patients with a history of periodontitis at least four times annually and at intervals of fewer than 6 months.[9] Nevertheless, the intervals for SPT/MT might be customized to each patient’s needs, allowing for personalized SPT/MT frequency. If oral hygiene is not properly maintained, microbial recolonization in periodontal pockets that have already undergone treatment happens swiftly. In such conditions, intervals of 3-4 months for MT has been recommended.[2]

SPT/MT can last anywhere between 6 months and 12 months for patients who have responded well to periodontal intervention, adhere to the home care regimen, and have no new systemic or behavioral risk factors. An SPT/MT interim of 2 months is suggested for patients who exhibit poor response to treatment and are at higher risk due to systemic disease or smoking habits until periodontal stability has been reached. The recall visit interval may alter as risk factors vary. If oral hygiene maintenance improves and attachment levels stay consistent, a patient who is currently on a 3-month recall may be put on a 6-month recall instead. On the other hand, the recall period must be shortened to every 4 months if the patient’s home care practices deteriorate and more sites bleed on probing. It is quite understandable that a more complicated case would require a more frequent SPT/MT interval. If recurrence is discovered, SPT/MT may be temporarily terminated and surgical or non-surgical therapy may be resumed. Every successful supportive periodontal/implant therapy program should place a strong emphasis on rigorous oral hygiene practices, thorough peri-implant inspection, careful consideration of risk factors, and routine clearance of microbiological deposits.

Although Merrin’s classification[47] for patients on SPT/MT is one of the most commonly referred for determination of recall interval among periodontists, an easy-to-understand and practical reference guide have been presented in Table 5 for all clinicians taking into account multiple factors such as case type, plaque control, smoking status, and diabetic status.

Table 5.

Supportive periodontal therapy/maintenance therapy interval

Periodontal Health		Home Care & 6 Months -1 Year
		First Year	Subsequent Visits
			Plaque Control*		Smoker	HbAlc> 6.5
			Good with less than 10% BOP	Poor with more than 10% BOP
Gingivitis		6 months	6 Months - 1 Year	6 Months	less 1 Month	less 1 Month
Periodontitis	PD <3.5 mm	3 months	6 months	3-4 months
	PD 3.5-5.5 mm	3 months	4-6 months	3 months

*Good Plaque Control = No visible plaque and Calculus >10% becomes a case of gingivitis. BOP-Bleeding on probing, HbAlc-Glycated hemoglobin, PD-probing depth

How can the general dental practitioner and the periodontist work together in SPT?

While SPT/MT is well within the domain of the general practitioner and can well handle this phase of the therapy, in cases they feel the need for an expert opinion/intervention, the periodontist may provide that support. The periodontal condition at the end of active therapy will determine whether to allocate SPT/MT to the general practitioner, the periodontist, or both.[48] The general practitioner should provide regular checkups for patients who have gingivitis or mild to moderate periodontitis, with shallow PDs. The general practitioner and the periodontist may interchangeably attend patients with moderate residual PDs, aberrant gingival architecture, and unsatisfactory plaque control.[2,49]

General dental practitioners play a significant role in routinely alerting patients to follow oral hygiene instructions and educating them on the value of compliance, endorsing the fact that patients who follow the SPT schedule experience better results. This is in addition to evaluating and updating the risk profile by the general dental practitioners.[14]

Can there be recurrence of gingivitis/periodontitis in the maintenance phase?

Periodontal lesions can occasionally return, which is frequently the result of the patient not controlling their plaque/biofilm well enough or not following the advised SPT regimens. Surgery should not be undertaken unless the patient participates in disease prevention and demonstrates proficiency in plaque/biofilm control.

Figure 6 lists (a) important causes of recurrence and (b) indicators of failing cases. In an eventuality of recurrence/failure, re-initiation of active therapy would be required.

Figure 6.

(a) Causes of recurrence and (b) indicators of failing cases

What are the barriers to SPT/MT and how can we overcome them?

One of the most important barriers for the success periodontal therapy is dependent on the adherence of SPT/MT by the patient. non-compliant patients would be those who did not show up for SPT/MT, whereas compliant patients are those that regularly attended the prescribed recall session.[50] Also, there are those who continued to attend the SPT/MT, but quite irregularly. Compliance to SPT/MT has generally been seen to be poor.^[50-52] Various social, behavioral, cultural, economic, and personality variables have been found to be predictors of periodontal maintenance compliance patterns.[50,53]A schematic of factors related to patient compliance to therapy has been provided for reference in Figure 7.[54]

Figure 7.

Factors related to compliance. Adapted from Jin et al 2008[54]

The effectiveness of periodontal treatment and, consequently, the patient’s periodontal health would be enhanced by early detection of likely non-compliant patients and the implementation of strategies to ensure their return.[52] To improve compliance, patients must be made to acquire an active role in the management of their periodontal disease. Clinicians must ensure that patient understand the disease and their status, as well as the rationale of the recommended treatment. This increases their autonomy and their capacity for self-care.[55]

Pointers for improving adherence to SPT/MT

• Communicating through simplification of procedure

• Accommodation and understanding of the patient’s need

• Patients who are happy with their treatment tend to follow the recommended therapy more consistently

• Reminding of appointments

• Compliance recording and follow-up

• Positive reinforcement and constructive guidance.

Peri-implant maintenance

What should be the maintenance protocol in terms of follow-up intervals and home care adjuvants in patients with peri-implantitis?

The focus for an implant’s long-term success has been modified throughout time from the surgical stage of treatment to osseointegration and more recently, to the continued maintenance of the hard and soft tissues surrounding the implant. The maintenance of proper home care by the patient and the execution of skilled prophylaxis procedures by the dental team in the dental office are crucial for the lasting effectiveness of implants.[56,57] In light of this, patients are seen as co-therapists in MT, and their input is essential, particularly for the long-term success of dental implants.

Maintenance protocol for post-therapeutic peri-implantitis or supportive implant therapy (may be addressed through assessment of the implant and peri-implant tissues and initiation of care through the hygiene phase.

Assessment phase

1. Dental plaque:[58]

2. Peri-implant marginal mucosa:[59]

3. Peri-implant BOP:[60]

4. Peri-implant PD:[57]

5. Width of peri-implant keratinized mucosa:

6. Suppuration:[61]

7. Food impaction around implants:[62]

8. Implant mobility:[63] Either by the conventional method using two rigid instruments or using the automated devices [Periotest® (Siemens AG, Bensheim, Germany) OsstellTM (Integration Diagnostices Ltd., Goteborgsvagen, Sweden)]

9. Occlusal evaluation: Evaluation of any deflective or premature contacts, parafunctional habits

10. Crestal bone loss and radiographic evaluation:[64,65]

Hygiene phase

Clinician performed implant maintenance

The instruments chosen for implant maintenance should be lightweight, disposable or sterilizable, efficient at plaque control without scratching the implant surface, affordable, simple to operate, and adjustable in the implant sulcus.

Scaling

It is recommended to avoid using metallic devices at the implant-abutment interface because they can scrape, taint, or cause galvanic responses. In case, the implant prostheses make it difficult to use manual scalers, sonic or ultrasonic scalers with nylon or plastic tips reinforced with graphite may be used alternatively. To avoid unintentional harming the peri-implant tissues, brief strokes with light pressure should be employed, depending on the sites of deposits.

Polishing

Polishing should be done with nonabrasive polishing pastes such aluminum oxide, tin oxide, suitable prophy paste, and low abrasive dentifrice. Air polishing and coarse abrasive polishing pastes should not be used on implant components.

Patient performed implant care

Patients with dental implants have demonstrated poor home care resulting in a state of edentulousness. This might be as a result of postsurgical fear of causing harm or overzealous self-care in an effort to remain completely plaque-free. Either of these scenarios may have negative effects.[66] Consequently, oral hygiene instructions should involve thorough verbal counselling visual demonstration, and evaluation of the patient’s oral hygiene methods and tools.

It is crucial to use and advocate for home care products that won’t change the implant abutment surface and are also secure and efficient for routine use.[67] The patient must begin the implant care regimen as soon as possible following surgical insertion with a one-stage system, after the implant site has been exposed with a two-stage system, and in the event that the implant healing abutment has been prematurely exposed.[68]

Brushing

The use of a soft toothbrush or an extremely delicate power brush is recommended to clean implants twice a day.[27] In addition, a power toothbrush can be used with a tapered brush to reach connection bars’ undersides or to help with interdental cleaning.[69] Instructing patients to use small, soft-bristled brushes in a circular motion is important. Smaller diameter toothbrush heads like end-tufted brushes or narrow rotary brushes may be useful in hard-to-reach places.[57] An end-tufted brush is particularly helpful in posterior places where a traditional toothbrush might not be able to reach and can be adjusted under hot water to fit the contour of the prosthesis.

Interproximal/circumferential cleaning

Floss

Various floss varieties can be applied. It needs to be used like a “shoe-shine rag.” For efficient debridement, all surfaces should be cleansed using a looping approach. In addition, it can be utilized to regularly provide antiseptic chemicals to the implants.

Interproximal cleansers

Depending on how big the interproximal area is, different interproximal cleansers can be used, including foam tips, brushes, and disposable wooden picks. The peri-implant soft tissue and the surface of the abutment are both susceptible to harm if the interproximal brush has an exposed metal tip. In such circumstances, they should be used with caution.

Water flosser/irrigation

In order to avoid damaging the peri-implant tissue, the water stream should be directed horizontally and inter-proximally between implants.

Financial support and sponsorship

The project was supported by an unrestricted educational grant from GlaxoSmithKline Consumer Healthcare Ltd.

Conflicts of interest

There are no conflicts of interest.

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