Perio Tribune UK No. 1, 2014

Management of plaque related periodontal conditions / Perio meets implant dentistry / Beauty and health in one simple - state of the art - system

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Table of contents

Perio Tribune
Perio Tribune

Perio Tribune

Plaque-related perio management

Beauty and health

Perio meets implant dentistry

A clinical audit of general dental practice

Rachel Kendrick looks at Acteon’s Air-n-Go system

Rainer Buchmann looks at integrated dentistry

pages 11-14

pages 17-18

pages 15-16

Management of plaque
related periodontal conditions
A clinical studying the assessment and management of plaque-related
periodontal conditions of patients by the practitioners at a general dental
practice in Hertfoldrshire in 2013

bstract:
Undiagnosed and unmanaged periodontal
conditions are fast becoming one of the biggest areas
of litigation and complaints
within the dental field. Thorough periodontal assessment
is vital for diagnosis, treatment planning and monitoring
the progression of periodontal
disease. This is a report of a
clinical audit that studied the
periodontal assessment carried out at a general dental
practice in Stevenage, Herts.
This audit was conducted over
a seven month period, analysing 50 patients for each audit
cycle. A new protocol for periodontal assessment using the
guidelines of the British Society of Periodontology was introduced. The results demonstrate a marked improvement
in assessing the periodontal
condition of patients in this
general dental practice.
Clinical relevance:
Regular periodontal assessment is required to aid diagnosis, treatment planning and
monitoring of disease. Without
such assessment, it is possible
to misdiagnose, develop incorrect treatment plans and prevent objective assessment of
disease progression. With the
periodontium being the scaffolding for all other restorative
techniques performed by dentists, this is an essential area
which must not be overlooked

or under managed.
Null Hypotheses:
The five dental practitioners
being audited would not exceed the expected percentage
of 50 per cent of patients being provided with Gold Standard treatment with regards to
periodontal monitoring and
management.
The five dental practitioners being audited would exceed the expected percentage of less than 10 per cent of
patients being provided with
Unacceptable treatment with
regards to periodontal monitoring and management.
Aim:
The aim of this audit is to assess periodontal screening and
subsequent non-surgical periodontal treatment for patients
with plaque-related periodontal conditions at the practice
compared to that suggested in
guidance documents.
The main objective for
the audit is to investigate the
standard of screening and
treatment patients are receiving with regards to their periodontal condition. This will
be achieved by ensuring that
the number of ‘Unacceptable’
treatments provided is minimal, meaning the majority of
patients seen at the practice
receive at least an ‘Acceptable’
level of treatment, if not the

‘Gold Standard’ level. In this
way, the audit aims to disprove
the first null hypothesis.
A secondary objective is
that, as long as the first objective is achieved, the majority of the patients receive the
‘Gold Standard’ of screening
and treatment with regard to

surgical periodontal therapy.
Specific risk factors for patients were not included, such
as smoking status and medical
conditions. Ten patients were
chosen at random from each
of the GDP’s day lists. These
patients had been seen within
four weeks of 17th December
2012; the start date for the au-

‘The aim of this audit is to assess periodontal screening and subsequent non-surgical
periodontal treatment for patients with
plaque-related periodontal conditions at
the practice compared to that suggested in
guidance documents’
their periodontal condition. In
this way, the audit aims to disprove the second null hypothesis.
Description:
This audit examined sets of
patient’s notes kept by the five
dental practitioners (GDP’s)
working at the practice with
regards to their periodontal
screening process and any
follow up treatment based on
this. The type of treatment
investigated was the initial
treatment phase of plaquerelated periodontal conditions
which concerned patient’s oral
hygiene habits, and any professional and patient-based
cleaning of their teeth i.e. non-

dit. This gave an overall sample size of 50 patients, which
was deemed a decent sample
size for the audit. A four week
period prior to the date of the
audit was chosen meaning
that any periodontal treatment

suggested for the patient at the
time of their exam was likely
to have been carried out or at
least started by the start date
of the audit. Notes before this
were not investigated as this
may not represent the most
current practice of the practitioners being audited.
Inclusion criteria for the patients were as follows:
• The patient must have been
seen for an exam within the
four weeks prior to the audit start date. This ruled out
the possibility that the patient
had attended for an emergency appointment in the last
four weeks, where a full exam
including
a
periodontal
screening may not have been
carried out.
• The patients must have been
over 18 at the time of their
most recent exam and any
edentulous patients were excluded. This meant that an
exam must
DT page 12

Ref 1.0 Flowchart constructed in order to grade patients notes
with regards to their periodontal screening and management

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12 Perio Tribune

United Kingdom Edition

March 2014

ß DT page 11

include a full periodontal
screening, which may not have
been done for children and adolescents, or patients without
their natural teeth remaining.
A flow-chart was constructed which was followed during
the auditing process in order
to score each set of notes based
on whether sufficient periodontal screening had been
carried out and whether the
correct subsequent non-surgical management was recommended or carried out based
on the results of the screening.
Each of the sets of notes
were studied and the flowchart
followed in order to grade the
overall process of the monitoring and managing plaque-related periodontal disease. The
flowchart is shown in Ref 1.0.
By following the flowchart,
each patient’s screening and
management was given a
score according to the number
of correct steps completed. If
any step had not been correctly completed this was reflected
in the scoring system and lead
to a lower overall score for the
patient’s treatment.
A standard BPE was accepted as an appropriate screening
of periodontal health during a
patient’s exam.
If a patient had been offered
the correct treatment (i.e. it
was recommended) according
to the findings of their screening, but had refused to accept
or failed to attend for treatment suggested by the GDP,
the practitioner was scored according the steps taken up to
that point in the management
of the patient. This was considered acceptable treatment
delivered by the GDP as it was
the patient’s choice not to undergo suggested procedures.
Eight patients included in the
first cycle and one patient in
the second cycle of audit declined treatment which was
recommended to them. Two
patients in the first cycle were
found to be edentulous when
examining the notes and so
were re-selected; none were
found to be edentulous in the
second cycle.
Since the default recall
time for patients attending
this practice is six monthly,
this was accepted as the intended follow-up time for a
patient where no specific recall period was stated in the
notes. If the patient needed
to be seen before this time, it
should be written in the patients notes e.g. ‘Follow-up 3-4
months’, or modified on the
computer system, which was
also checked at time of audit.
This would be appropriate for

Table 1.0
Sources:
Clerehugh, V., Tugnait, A., and Genco, R. J., 2009. Periodontology at a Glance. West Sussex: Wiley-Blackwell
The Royal College of Surgeons of England, 2003. Faculty of Dental Surgery: Clinical guideline summaries - Second edition [Online] The
Royal College of Surgeons of England. Available at:
[Accessed 04.02.2013]
British Society Of Periodontology, 2012. Young Practitioners Guide to Periodontology [Online] British Society Of Periodontology. Available at: [Accessed 04.02.2013]
any patients with a BPE of 3, 4,
* or with pockets ≥ 4mm, who
had undergone plaque-related
periodontal treatment for this,
in order to monitor healing
and observe where further
treatment may be necessary.
Therefore if, for these patients,
a recall period was not stated
in their notes or modified on
the computer system following
treatment, this was seen as inappropriate follow-up.
The type of follow-up treatment was not included as part
of this audit. This was due to
the fact that not enough time
would have passed between
the start date of the audit and
the allocated four week period
prior to this, from which patients were chosen, in order
for the follow-up treatments to
have been carried out.
‘Appropriate’ management
of the periodontal condition
included further investigations and treatment based on
the BPE and was decided upon
by amalgamating information
from three different sources.
A chart was drawn up which
indicates the correct management for each particular
finding of the BPE screening.
This is shown in Table 1.0; the
sources are also quoted below
the table.
This audit included whether a diagnosis was made relating to the periodontal condition. The accuracy of diagnosis
in relation to the BPE findings
was not investigated as this is
outside the scope of the audit.
Each grading which was
given to a patients periodontal treatment according to the

Table 1.1

Table 1.1
(*Where Gold Standard and Unacceptable treatments are within the stated expected values)

Table 1.2

flowchart was then put into
one of three categories: Gold
Standard, Acceptable and Unacceptable.
This
reflected
the standard of treatment delivered to each patient. The
scores included in each category and explanations are as
follows:
Unacceptable= 0-2
Represents
patients
who
hadn’t received an appropriate screening at examination,
had had no diagnosis made
or treatment recommended
and hadn’t received correct
management for their plaquerelated periodontal condition
indicated by the screening
process. This was deemed an
unacceptable level of treatment.
Acceptable= 3-4
Represents patients who had
an appropriate screening carried out during their exam
and the correct treatment was
delivered according to this
screening. The ‘Gold Standard’
level was not given to these as
some steps along the flowchart
had not been followed e.g. diagnosis or follow-up wasn’t
included. However this was

not deemed as neglectful on
behalf of the GDP as screening and appropriate treatment
was still carried out for the patient, and the ultimate goal of
diagnosing and managing the
patient’s plaque-related periodontal condition was reached.
Gold Standard= 5
Represents the patients who

received completely correct
screening and management
from their GDP according to
the flowchart.
The percentage of the overall sample each category made
up was then calculated and
this was compared to the expected percentages set out at
the start of the audit.

Ref 1.1

Ref 1.1 Graph showing expected ranges of each category and actual percentages for first cycle

[3] =>

United Kingdom Edition

Ref 1.2

Perio Tribune 13

March 2014

this level of treatment, this
meant that the Gold Standard
level of treatment was delivered to less than 50 per cent of
patients.
The results from the first
cycle of audit prove both null
hypotheses correct, and thus
the aims of the audit to disprove these are not met during
this cycle. Therefore changes
must be implemented at the
practice in order to improve
the levels of treatments be-

ing provided to patients at the
practice with regards to their
periodontal condition and disprove the hypotheses.
In order to improve these
results, the Gold Standard level of treatment provided must
be increased and the Unacceptable level of treatment provided must be decreased.
When examining the raw
data collected during cycle one
of the audit, there are some

obvious areas which needed
to be improved in order to increase the level of Gold Standard treatment and decrease
the level of Unacceptable
treatment provided. Where
treatment was Unacceptable,
this was mainly because a BPE
had not been performed at any
examinations within the last
year. Another point to note was
that the majority of treatments
provided within the Acceptable
à DT page 14

Ref 1.2 Sticker implemented to improve
monitoring and management of periodontal disease at the practice

Results Cycle 1:
The expected and actual percentages of each category
found during the first cycle of
the audit are shown below.
It was expected that Gold
Standard screening and treatment for plaque-related periodontal conditions should make
up more than 50 per cent of
the results and that Unacceptable periodontal screening
and treatment should make up
less than 10 per cent. If both
of these criteria are satisfied,
Acceptable treatments would
represent anything from 0 per

‘It was found during the second cycle
of audit that where
the stickers were
used in the patient’s notes, Gold
Standard treatment
was delivered or
planned’

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cent to 50 per cent, which is
why the expected percentage
for Acceptable treatments is
stated as less than or equal to
50 per cent where Gold Standard and Unacceptable treatments are within the stated
expected values. Where Gold
Standard treatments do not
make up more than 50 per
cent, but Unacceptable treatments make up less than 10
per cent, the Acceptable treatment percentage will rise
above 50 per cent.
As shown by the graph
(Ref 1.1), the percentage of
all treatment standards found
in the first cycle of audit were
outside the expected values.
The Acceptable level of treatment was delivered to 56 per
cent of patients included in
the audit, which is above the
expected 50 per cent. Due to
the Unacceptable treatment
being above the expected 10
per cent of patients provided

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14 Perio Tribune

United Kingdom Edition

March 2014

ß DT page 13

category, were not deemed as
Gold Standard due to the fact
that either a diagnosis had been
omitted, a follow-up time period
had not been recommended, or
both. These are the areas which
must be looked at in order to improve results at the next cycle of
audit. There was no specific pattern of scores for each individual
practitioner.
Changes implemented to improve overall standard of treatment provided:
As there was no specific pattern
shown from the scores for the
different practitioners, it was not
deemed appropriate to speak
to each individually to improve
the results, but to implement a
method which would improve
the practice’s score as a whole
for
periodontal
diagnoses,
management and follow up.
With this in mind, a sticker
was designed and produced,
which was to be stuck in each
patients notes who was attending for a regular check-up, and
which outlined the key parts
of diagnosis, treatment and
follow-up for periodontal conditions. The sticker designed is
shown in Ref 1.2.
Using this, each practitioner
would be able to concisely and
quickly record information regarding a patient’s periodontal
condition at their exam, and
would be less likely to forget to
include aspects such as a diagnosis and suggested follow-up
period. The sticker is designed
to give the practitioner a ‘tick
system’ for the management of
the patient’s periodontal condition. The treatment recommended for the BPE scores
found are shown in the brackets
next to the treatment options,
making it easy for the GDP to
tick which treatment they recommend the patient should receive according to the BPE score
and diagnosis recorded above.
There is also an option to circle
whether the GDP will carry out
the treatment or whether it is to
be carried out by the hygienist
working at the practice.
These stickers were distributed between the four surgeries and some were also given
to the receptionists. Staff, including the GDP’s, nurses and
receptionists, were instructed
to put a sticker in a patients
notes if they were attending
for a check-up only so that this
could be completed at their
appointment.
Following
implementation of these stickers into the
patients’ notes, the five GDP’s
were re-audited four weeks
later by again choosing and examining 10 patient’s notes from
each GDPs list at random who
had attended for an exam and

Ref 1.3

Ref 1.4

Ref 1.3 Graph showing expected ranges of each category and actual percentages for second cycle Ref 1.4 Results from Cycle 1 and 2 represented in pie charts

recording the score.
As shown by the table (1.2)
and the graph below (Ref 1.3),
the results from the second
cycle of the audit were found
to be within the expected values set out at the beginning of
the audit, therefore disproving
both the null hypotheses. The
audit has therefore achieved
its aim by improving the overall standard of monitoring
and management of patient’s
periodontal conditions at the
practice. It was found during
the second cycle of audit that
where the stickers were used in
the patient’s notes, Gold Standard treatment was delivered or
planned, resulting in the significant improvement in the findings during the second cycle.

to make the results of the audit
more reliable.
The presence, or otherwise,
of risk factors for periodontal
disease was not accounted for
in this audit. The aim of the
audit was to determine whether the correct non-surgical
plaque-related treatment was
being carried out for each patient according to the screening
results, regardless of the risk
factors, e.g. medical conditions,
medications and smoking status. It was assumed that these
risk factors were observed by
the GDP and discussed or investigated accordingly. Also,
the precise diagnosis arrived at
for each patient was not investigated. The audit only looked
at the basic principles of man-

‘Periodontal disease is becoming increasingly prevalent amongst today’s population due to, amongst other factors, people
living for longer and maintaining their
natural teeth later into life’
The next step to improve the
results further would be to ensure that all dentists are using
the stickers during every adult
patient exam, as where this
wasn’t being done, some elements were still being omitted
resulting in treatment which
was less than Gold Standard. In
the future the monitoring and
management of periodontal
condition will need to be re-audited to ensure these standards
are maintained and improved
on where possible. The results
from both cycles can be seen
represented in the pie charts in
Ref 1.4.
Limitations and Improvements to the Audit:
There are many limitations
to this audit and possible improvements which could be
made to refine the results and
give a much broader and more
accurate representative of periodontal screening and treatment at the practice. Firstly,
a very small sample size was
considered. According to the
number of patients recorded on
the practice system, 50 patients
make up about 0.36 per cent
of the total patient population
of the practice. A much larger
sample size would be needed

agement of plaque-related periodontal condition according
to the findings of the BPE and
the diagnosis given, assuming
this diagnosis was correct. If a
patient suffered from any condition other than plaque-induced generalised gingivitis/
periodontitis, this was not accounted for.
Radiographs were not included in the ‘further investigations’ section as it was assumed
these were taken at the time
of examination and they were
appropriate to the periodontal
condition. This would be another area to expand the scope
of the audit.
To improve the audit and
make the results more valid,
the extent of treatment provided should be further scrutinised
to include whether the diagnosis made was correct according
to the findings of the screening,
and whether treatment took
into account associated risk
factors as well as oral hygiene
factors alone. The difficulty
with investigating a practitioner’s diagnoses is that these can
be very subjective and can vary
from dentist to dentist.

It would be hard to judge
whether a practitioner had
made the correct diagnosis
based on retrospective investigation of a patients notes alone
and without examining the patient. It is likely that more than
one investigator would need to
carry out the audit and interand intra-examiner calibration
would need to be done in order
for this to be reliable and valid.
This is another improvement which could be picked up
on with the current audit; only
one examiner carried out the
audit. This person may have
had different judgements on
whether the notes displayed
‘correct’ or ‘appropriate treatment’ according to the chart and
flowchart which were followed
when carrying out the audit.
Again, it would be improved by
having a second examiner present when auditing the patient’s
notes, giving the opportunity for
discussion and in order that a
more rounded decision is made
if there is any query over the
treatment provided.
For the patients who refused to accept or commence
appropriate treatment based
on their BPE score, it was assumed that the practitioner explained the risks of not having
the treatment suggested to the
patient, and that this was sufficient enough for the patient to
understand. For completeness,
this aspect should be checked
from the notes taken on the day
to ensure these patients were
able to make an informed decision on the treatment they had
chosen to opt out of.
It was noted by members
of staff at the practice that the
stickers used to improve the results were a costly way of doing
so, due to the expense of purchasing the stickers and then
printing the design onto them.
Following a successful trial period of the stickers use in patients’ notes at the practice, it
may be more cost-effective to
create a stamp which includes
the information on the sticker,
and use this to create the same
template in patients’ notes instead. With this method, staff
and GDP’s at the practice would
be able to use the stamp multiple times, with only the initial
expense of the stamp itself and

occasional cost of ink pads.
Conclusion:
Periodontal disease is becoming
increasingly prevalent amongst
today’s population due to,
amongst other factors, people
living for longer and maintaining their natural teeth later into
life. For this reason it is essential
to identify and manage any periodontal conditions as early as
possible in the disease process
in order to delay the deleterious effects of the condition and
prevent it progressing further.
In order to do this, we as dental
professionals must have simple
and effective methods of recording periodontal screenings
and diagnoses so that we may
recommend and deliver appropriate treatment to patients for
these periodontal conditions.
As demonstrated by the
implementation of a simple
pro-forma during a patient examination, in this case in the
form of a sticker, periodontal
screening and management
can be greatly improved. This
template quickly and effectively allows the practitioner to
cover all relevant areas of periodontal screening and management and means it is less likely
that any essential components
will be omitted from the process. With a reliable and reproducible procedure such as
this in place, the periodontal
condition of patients attending the practice is more likely
to remain healthier for longer.
This will subsequently improve
the prognosis of all other dental procedures delivered by the
GDP, giving the patients a better quality of care overall. DT

About the authors
Catherine Turner BChD (Leeds)
DF Trainee Bedford Scheme (Health
Education East of England)
Victor Gehani
BDS. MFDS RCS (Eng). MFGDP(UK).
DPDS (Bristol). PG Cert (Med and Den
Ed).
FHEA. FICOI. MSc Implant Dentistry
(Warwick). FIADFE. PG Cert Rest
Dent (UCL).
DF Trainer Bedford Scheme (Health
Education East of England)
Patch Associate Dental Dean (North
Central London)
Health Education England, London
Dental Education and Training.
Sabina Wadhwani
BDS (U.Lond). MFGDP(UK). PG Cert
(Med and Den Ed). FHEA. PG Cert
(Mentoring).
DF Trainer Bedford Scheme (Health
Education East of England)

[5] =>

United Kingdom Edition

Perio Tribune 15

March 2014

Perio meets implant dentistry
Author_Rainer Buchmann

he preservation of the natural dentition is the prerequisite in daily patient
care. In advanced periodontal
disease, the successful realisation of implant therapy requires
knowledge in patient expectations, clinical diagnostics, proper
surgical skills and delegation of
basic services to dental hygienists. Implant treatment in severe
periodontitis demands a two-step,
time-tested approach, evaluating
the outcomes of basic periodontal therapy before implant placement.

• Long-term missing bridgeworks
or prosthesis, edentulous mandible
• Advanced endodontic damage
• Trauma (tooth fracture)
• Oral cancer surgery
Periodontal diseases represent
can-indications. Treatment plan-

ning is running more complex.
The decision- making comprises
a time-tested therapeutic approach. In advanced periodontal
settings of more than 50 per cent
bone loss with furcation involvement level III, patients suffer
from oral discomfort. The tooth
prognosis becomes less positive,
the frequencies of follow-up visits increase (Fig 1). Periodontal

therapy ‘before’ implant planning
is aimed at saving doubtful (not
hopeless) teeth with a grace period of at least three to six months to
evaluate for periodontal treatment
outcomes. Thorough scaling and
root planing frequently results in
a mid-term improvement (two
years) up to a long-term stabilisation (five years) of preliminary affected teeth.

£3,300

The decision to maintain the
periodontally compromised dentition undergoes the following criteria (Fig 2):
• Patients with no preferences to
comfort, aesthetics and costs
• Patients willing to accept enhanced tooth mobility, occasional
à DT page 16

inc.

Integrated dentistry: Success
The successful positioning of
dental partnerships in the fastgrowing health market implicates
predictable treatment strategies
to save permanent teeth. According to orthopaedic, cardiac or
vascular medicine, an on-time
decision-making protocol for implant therapy is recommended to
counterbalance functional and
aesthetic discomfort in advanced
endodontic
and
periodontal
breakdown settings. Patient’s current and future expectations drive
our practices into the necessity to
provide synergistic periodontal
and implant treatment solutions.
The advantages are:
• Optimising implant success
by proceeding with periodontal
therapy
• Enhanced economic profit due
to by-effects from delegated scaling and root planing
• Promotion of oral and body
health of both dental patients and
staff members
The need to preserve healthy
teeth and gums, the ever-expanding influences of web, TV and
magazines and an increase in
low-cost implant treatment render implant dentistry internationally attractive. The transition of
dental practices into the implant
market is reasonable, especially
for growing dental partnerships.
The capital investment and running costs for a surgical implant
setting are redeemed by more
than 30 implants a year. Because
of the economic commitment, a
careful financial strategy is needed not to neglect challenges and
developing concepts preserving
and salvaging compromised teeth
from conservative and periodontal dentistry.

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Decision-making
Classical implant therapy protocols comprise must-indications
resulting in an immediate treatment plan. According to patient
preferences, clinical settings and
insurance plans, these must-indications with an ad-hoc implant
placement recommendation are,
in order of precedence:

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[6] =>

16 Perio Tribune

United Kingdom Edition

March 2014

ß DT page 15

food impaction and frequent professional tooth cleaning
• Individuals with chronic diseases and autoimmune disorders
The recommendation to replace affected teeth with implants is indicated in the following
clinical situations and should be
planned on-time after completion
of periodontal therapy (three to
six months):
• Patients running a demanding
business striving for fixed teeth
• Enhanced masticatory and
cleaning comfort
•Long-termrehabilitationwithlow
input in time, effort and expenses

Fig. 1 Treatment of advanced periodontal disease with implants replacing the natural
dentition is recommended “time-tested” 3-6 months following periodontal therapy (SRP).

Currently, the items above are
effective at implant placements
within the local bone, minor
lateral hard and soft tissue deficiencies, following sinus floor elevation, in settings with sufficient
implant abutment distances of
3mm and after periodontal therapy. Extended surgical protocols
enhance treatment time (Fig 3),
render the case prognosis uncertain and may aggravate long-term
success.
Implant therapy in advanced
periodontal disease
The survival rates of teeth with
severe periodontal damage published in evidence-based studies are rarely valid for patients
inquiring treatment in dental offices (Fig 4). Shortcomings in oral
hygiene, lack in supportive care,
oral dysfunctions, stress, smoking
and general disorders abbreviate
the function times of periodontally
compromised teeth sustainably.
The advice to replace affected
teeth with implants in advanced
periodontal settings within the
maxilla implicates on-time patient information of the second
and third molar removal: implant
placement and prosthetic bridgeworks are scheduled in the functional masticatory area until to the
first molar. In the mandible, the
second molars can be preserved
due to their beneficial root anatomy. They should be restored,
but not included in implant planning. Following the removal of
the first molar in the maxilla, implant therapy is often preceded (if
the supporting bone is less than
4mm) or accompanied by a simultaneous sinus lift. The implant
treatment plan in periodontally
compromised patients results in a
reduced dentition (Fig 5):
• Fixed bridgeworks in the maxilla
and mandible up to the first molar
• Maxilla: preservation of premolars and first molars, tooth removal and implant therapy with
sinus floor elevation at furcation involvement level III (Fig 6)
• Mandible: preservation of second molars, restoration, no inclusion into bridgeworks
• Volume thickening with free autogenous gingival grafts in initial
thin biotype settings (Fig 7)

Fig. 3 Implant therapy should be performed with minimal augmentation. Extended
surgical therapy prolongs treatment time, renders case prognosis unsafe and may aggravate long-term success.

Fig. 8 Short implants are advised in
critical anatomic situations when the
alveolar bone width is sufficient. Functionally, they represent no alternative to
classical augmentation protocols. (Photo:
Kochhan)

Fig. 2 Exclusion criteria for implants with continuation of saving natural teeth after
comprehensive periodontal therapy.

Fig. 4 Unexpected life-events half cut the
survival rates of teeth with advanced
periodontal bone loss in daily practice
down to 5–7 years.

Fig. 5 Guidelines to a safe implant treatment protocol in advanced periodontal
disease.

Fig. 6 The piezosurgical access to the lateral sinus is the best approach to promote
implant supported bone in the maxilla.
plants are not advocated, internal lifts
technique-sensitive.

Fig. 7 Volume thickening with a free gingival graft in an initial thin tissue with
buccal perforation.

Fig. 9 Insertion of short implants close to
the alveolar nerve in the mandible with
sufficient alveolar bone width. (Photo:
Kochhan)

Fig. 10 Implants require a comprehensive maintenance care. Peri-implant inflammations display foreign body infections that are more harmful for the body health than
periodontal diseases.

Fig. 11 Periodontal therapy lowers the inflammatory burden and promotes health while
optimizing body metabolism with stimulating effects onto the vascular system.

• Short implants in both aesthetically and functionally less demanding situations as an alternative
to surgical augmentation (Fig 8).
Low bone quality (D3/D4),
lateral hard-tissue deficiencies
and increased mechanical loading are contraindications for short
implants. According to conventional implant rehabilitation, the
horizontal width of the alveolar
bone crest is the fundament for
functional stabilisation, vascularisation and nutrition, thus for implant survival and clinical success
(Fig 9).
Inflammation and hygiene
Clinical healthy and stable implants are completely covered
within the alveolar bone by os-

seointegration. They also are attached to the peri-implant gingiva
and thereby become functionally
included into the body’s metabolism. This explains the high overall survival rates of oral implants
between eight and more than 15
years. The combination of
• A thin biotype gingiva with lack
of soft tissue protection
• Functional overload due to
stress, habits or a missing frontcanine equilibration
• Loss of biofilm protection by
periodontal diseases often causes
mid-term damages (two years
after functional loading) of the
implant-to-bone interface. Like
periodontally affected teeth with
lack of hygiene access and enhanced biofilm accumulation,

implants develop a potential risk
of inflammation when bacteria
enter the implant-to-bone interface (Fig 10). If the close hard
and soft tissue sealing disappears
irreversibly, foreign-body infections occur within the oral cavity,
which are more harmful for the
implant-supporting bone and the
body health than periodontal diseases. The best protection against
peri-implant inflammation is not
avoiding implants: a careful implant placement strategy with
concomitant thickening of the
surrounding tissues and relief
from functional overload preceded by comprehensive periodontal
therapy (hygiene) are the best
therapeutic helpers for implant
survival and oral health (Fig 11).

evaluate the affected dentition for
periodontal treatment outcomes.
If patients anticipate immediately
fixed and aesthetic restorations,
on-time implant therapy with
minimal augmentative solutions
is recommended. Preservation of
periodontally compromised natural teeth is advised when patients
display no preference for further
comfort and aesthetics. Periodontal therapy is continued, supplemented with surgery in advanced
intra-bony settings where oral hygiene is impaired. The long-term
success for the natural dentition
and implants similarly depends
on patient’s medical and local risk
factors that cannot be forecasted
with any genetic or susceptibility
test for sale. DT

Summary
In advanced periodontal diseases, the network between medical progress and ever-expanding
patient’s expectations requires a
time-tested schedule with a grace
period of three to six months to

About the author
Prof Dr Rainer Buchmann
Practice limited to Periodontics
Königsallee 12, 40212 Düsseldorf,
Germany
Tel.: +49 211 8629120
E-Mail: info@rainer-buchmann.de
www.rainer-buchmann.com

[7] =>

United Kingdom Edition

Perio Tribune 17

March 2014

Beauty and health in one simple,
state of the art, system
Rachel Kendrick looks at Acteon’s Air-n-Go
A system that’s going to
particularly appeal to hygienists is Acteon’s Air-n-Go.

This is the first dual purpose – supra and perio – air
polisher. No other polisher
better exemplifies the possi-

bilities of combining the beauty and health of your patients’
teeth. It speeds up treatment,
maximising your time, while

giving your patients the most
gentle, yet powerful cleaning
experience they’ve ever encountered.
à DT page 18

A

dvancements in dental
technology offer better solutions for traditional oral health problems
than ever before. Technology
makes dentistry as comfortable, durable, efficient and
natural-looking for the patient
as possible. Patient and dentist benefit from newer techniques that are less invasive
and more dependable than
ever before. Procedures that
formerly took multiple trips to
the dentist or required multiple health care providers can
now often be performed in the
comfort of one surgery by one
qualified provider.
Technology increases efficiency significantly. With
the latest generation of dental equipment, patients see

‘Technology
increases efficiency
significantly With
the latest generation of dental
equipment,
patients see exactly what you see’

exactly what you see. This
creates trust and empowers them to make decisions
about their own care, and not
rely purely on the first advice
they’re given.
Technology
also
helps
with patient education and
case acceptance. If someone
is missing a tooth, the team
can virtually place an implant
and crown with 3D scans and
show them exactly where the
tooth will go. Patients can see
digital X-rays and photos of
their teeth blown up on flat
screen monitors right in front
of or above their dental chair.
Showing patients what’s
going on in their mouth, versus just trying to explain it,
leads to quicker understanding and fewer questions, making both dental practitioner
and hygienist’s job easier.

BEAUTY

HEALTH

The supra and perio double effect

THE FIRST
DUAL PURPOSE
AIR POLISHER
Supra version
The Beauty: for perfect cosmetic
results thanks to a fast, effective
and painless polishing that is both
gentle to the gingiva and teeth.

Perio version
The Health: for a simple and
efficient way to treat periodontal
diseases and peri-implantitis
sub-gingivally.

buy an

now

receive an

kit

free of charge
* offer ends 31st May 2014
Please contact Acteon UK for a free demonstration

tel: +44 (0) 1480 477307 • email: info@acteongroup.co.uk
• www.acteongroup.co.uk •

[8] =>

18 Perio Tribune

United Kingdom Edition

ß DT page 15

based ‘Perio’ powder, the Airn-Go is used for sub-gingival
pockets of between 4-10mm,
in addition to initial therapy.
It provides remarkable therapeutic results, with a considerable reduction of inflammation and pocket during the
phase of initial periodontal
treatment. And the nozzle
comes with 3-6-9mm depth
markings to allow rapid assessment of the health of a
patient during sub-gingival
treatments. The use of this device eliminates bacteria in the
pocket and prevents recurrence of the disease.

Air-n-Go is extremely versatile. The device is made up
of a convertible handpiece,
available in supra and perio
versions, that are compatible
with high performance powders, unique in that they are
made from all natural components and taste great. Treatments are very gentle, which
results in a significant reduction in bleeding and pain. A
winning combination for patient choice.
The reason for Air-n-Go’s
versatility is its convertible
handpiece. This increases
options for supra-gingival
and sub-gingival treatments.
In Supra mode, it helps you
achieve perfect cosmetic results with fast, effective, painless polishing that is gentle to
both the gingiva and teeth. In
Perio mode, it transforms into
a simple and efficient device
to treat periodontal disease
and
peri-implantitis
subgingivally. Just 20 seconds
of maintenance is enough to
treat periodontitis or peri-implantitis effectively.
The ergonomic handpiece
The handpiece has been
designed to create better
working conditions for whoever handles it. It is fine, lightweight, well balanced, easy to
manipulate and has 360º rotation, resulting in less stress
and less manual fatigue. It
enables smooth, fast move-

The 20º angle of the perio
nozzle means that all sides of
the tooth or implant may be
treated without changing instruments. It also means that
treating periodontitis or periimplantitis in just 20 seconds
is now possible.
And it’s worth noting here
that ‘Perio’ powder can also
be used in supra mode for the
prevention and control of periodontitis and peri-implantitis.
By pressing the ‘stop powder’ button, at the back of the
tank, you cut off the powder
flow, which transforms the air
polisher into an air and water syringe. This feature allows you not only to clean the
treated area, but also to rinse
out the interior of the device.
Switching
from
supra
mode to perio couldn’t be sim-

‘The flavours I was offered are amazing.
I wanted to try them all! In fact, I got
carried away and tried two: peppermint
and raspberry’

long and a short one, suit all
hand sizes
• Two tanks – supra and perio
– come with a ‘Clip-n’Go’ connector (bayonet type) and a
colour coding system for identification
• Specific powders for each
type of treatment: supra-gingival and sub-gingival applications
• Autoclavable (except for the
tank and its lid), all parts of
Air-n-Go can be cleaned, to
prevent the risk of clogging
and to ensure the best hygiene.
In Supra mode, the indications are:

ment, improved visibility and
excellent accessibility, even in
the difficult to reach posterior
areas. A non-slip silicone ring
on the front gives you a better
grip during treatment – even
with wet gloves. Manipulation
is precise to enable the practitioner to focus on the treatment area. Two exchangeable
heads – short and long to suit
all hand sizes – are autoclavable. The shorter ‘hygienist’
head is specially designed for
smaller hands and as it rests
perfectly in the hand, it ensures you exert less pressure
manipulating the handpiece
during treatment.

pler or quicker. You select the
nozzle, power and the tank –
depending on the treatment –
and then choose which mode
you want without any need to
change instrument.
This has the added benefit of needing only one direct
connection to the delivery system and other convenience
features include:
• Three nozzles cover a variety of applications, including
prophylaxis, periodontal and
implant maintenance
• Two exchangeable heads, a

• Polishing – to finish after scaling or to prepare for
bleaching
• Cleaning – interproximal
areas, fissures and troughs,
preparation of the tooth surface before etching and orthodontic brackets
• Removal – biofilm, plaque,
stains and remnants of temporary cementum
In Perio mode, the
indications are:
When combined with the action of ultra-fine glycine-

Powders
The well-being approach to
prophylaxis is a concept that
is perfectly matched to the
needs and wants of your patients. The Classic range of
Air-n-Go powders are indicated for maintenance, prevention of tooth decay and
improving the oral hygiene
of the patient. Their abrasive
properties cause no damage to
the enamel, the gingiva or the
root surface.
This range comes in a variety of flavours that each
patient chooses, according
to individual taste. There is
a choice of cola, raspberry,
neutral, peppermint or lemon.
The fine balance between flavour and sodium saccharin
concentration removes any
unpleasant taste and offers a
feeling of freshness.
In addition to Classic, there
is Pearl, a powder specifically
designed for supra mode and
Perio, exclusively for sub-gingival treatment.
Many patients think of a
polishing session as an unpleasant experience, so the
motivation to establish a maintenance plan fades quickly.
Most sodium bicarbone-based
powders are composed of layered particles, with angular
geometries which have an

March 2014

abrasive effect that is too aggressive on delicate tissues.
For this reason, Satalec’s
research and development
department studied these angles and grain size to come up
with a formula that is more
suitable. The new powder
formulation they developed
specifically reduces the sensation of pain and bleeding
caused by most of the others
on the market.
The
anti-clogging
and
controlled hydrophobic properties of these powders give
them a dual action effect:
• In contact with water, micro-particles shrink slightly:
the polishing effect is much
more efficient
• The powder dissolves gently,
which avoids trauma to the
delicate tissues and prevents
the risk of clogging.
So what do patients think? .
“I have a double problem: I’m
hooked on caffeine and cigarettes! So it’s not surprising my
smile was not very attractive,
with stained, dull teeth. The
results of this treatment are
really impressive and visible!
I no longer have the unsightly
stains on my teeth that used to
stop me from smiling normally.” Stephanie, 23.
“I love being able to choose
the flavor I want. For once, I
can have my say at the dentists!
I really liked the raspberry – it
was almost as if I was actually
eating some.” Maya, 31.
“Like many people, I’m
afraid of going to the dentist
and I hate having my teeth polished. You have to admit that it
hurts and isn’t pleasant at all.
But this time, it was quite the
opposite – completely different! During this session, I forgot my fear and felt no pain at
all, although I’m very sensitive
where my teeth are involved. It
made me want to come back to
my dentist.” Carlos, 31.
“The flavours I was offered
are amazing. I wanted to try
them all! In fact, I got carried away and tried two: peppermint and raspberry, and
I didn’t have to wait long because the tanks of powders had
already been prepared. I like
mint best, it’s so refreshing.”
Hugh, 34.
Air-n-Go is an ideal complement to Acteon’s Newtron
portfolio of piezo-ultrasonic
equipment too. DT

About the author
Rachel Kendrick
is
a
freelance
journalist with a
special interest in
the dental sector

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[cover] => Perio Tribune UK No. 1, 2014

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Table of contents

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Management of plaque related periodontal conditions / Perio meets implant dentistry / Beauty and health in one simple - state of the art - system

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