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BDJ Team volume 9, pages 18–20 (2022)
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Ashleigh Tibbs, Frazer Gregory and Ewen McColl discuss the management of a patient presenting with necrotising periodontitis by student dentists and dental therapists.
Necrotising periodontal diseases are a severe form of dental disease that can be accompanied by systemic illness and may involve the destruction of periodontal tissue and connective tissue. They range in extent and severity, with manifestations ranging from minor loss of papillary architecture to the extensive destruction caused by Noma. Whilst description and classification of these diseases has ranged from trench mouth to acute necrotising ulcerative gingivitis, this has relatively recently been reclassified to emphasise the range and progression of this condition.
In 2017, a new classification system was developed in the World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.1 The new periodontal classifications led to a shift in the way clinicians classify and diagnose periodontal diseases. In the previous 1999 classification2 necrotising periodontal diseases (NPD) were classified as ‘necrotising ulcerative gingivitis’ and ‘necrotising ulcerative periodontitis’. In the 2017 classification system, necrotising periodontal diseases are defined as: necrotising gingivitis (NG), necrotising periodontitis (NP), necrotising stomatitis (NS), noma.3 Clinically it can be challenging to differentiate between NG and NP as often the transition is difficult to distinguish as the disease advances. Studies suggest that NG, NP, NS and Noma are different stages of the same disease as they share some clinical characteristics and, to some extent, treatment.4
Many of the bacteria involved in NPD are opportunistic pathogens commonly present in healthy patients which highlights the importance of predisposing risk factors and their impact on host susceptibility. The bacterial dysbiosis is classically described as a fuso spirochaetal complex indicating the prevalent bacteria types.
Multiple predisposing factors are significantly influential in the pathogenesis of necrotising periodontal diseases. The most common risk factors relate to oral hygiene, smoking, stress, and young age, very much as seen in First World War trenches – hence the previous description of trench mouth. Pre-existing gingivitis, being immunocompromised, malnutrition and a history of necrotising periodontal disease are also thought to be important and may be linked to the normal gingival architecture being compromised due to previous disease episodes and patients not improving their oral hygiene or the gingival architecture making this difficult to clean.
In this paper we discuss the management of a patient presenting with necrotising periodontitis on student clinics at Peninsula Dental School, University of Plymouth. In the final year clinics third year dental therapy students work alongside final year BDS students. The integration of the Dental Therapy and Bachelor of Dental Surgery courses5 ensures team members are fully cognisant of other team members’ scope,6 with students encouraged to share care in order to optimise outcomes for patients. This improves the outcome for patients and also reduces the time frames to completion by working as a team. Similar utilisation would have similar outcomes in primary care practice.
Seeing the patient in acute pain was upsetting for all. Empathy for social circumstances was essential at a personal and clinical level.
The recent publication of Health Education England’s (HEE) Advancing Dental Care Review highlighted the underutilisation of dental therapists in general dental practice:7
‘They frequently find themselves unable to exploit their full Scope of Practice – often for historic or contractual reasons. The potential for dentists – particularly in primary care – to share workload with DCPs in line with their Scope of Practice and experience is greatly under-utilised. This opens opportunities for securing an adaptive workforce, particularly in rural and coastal areas, where dental access is a challenge.’
In this paper we hope to highlight team working and utilisation of individual scope to optimise outcomes as discussed above.
A patient in their early twenties attended Peninsula Dental School, University of Plymouth as a new patient emergency and was seen by the BDS students under supervision. On presentation the patient complained of pain from all quadrants of the dentition which they felt had been present for three months and had worsened recently, with the patient now rating the pain as ten out of ten. The patient noted their gums bled excessively on brushing and that they woke in the morning to find blood on the pillow. They felt that the pain was now worsening in the anterior region specifically and reported irregular tooth brushing habits and not using interdental aids with the pain on brushing reducing this further. Additionally, the patient reported four sugar hits per day.
Medically the patient was taking sertraline for depression.
The patient gave a complex social history and was very emotional and agitated on first presentation. They described being homeless and had been sleeping on friends’ sofas for three months. Self-reported stress levels were described as being ‘incredibly high’ due to their housing situation. They smoked 30/40 cigarettes per day until recently, which had now reduced to 20.
Examination revealed submandibular lymphadenopathy, a temperature of 38.8 degrees centigrade and extremely painful gingiva which showed spontaneous bleeding (Figs 1 and 2 on presentation), and foetor oris. There was generalised loss of papillary architecture, punched out papilla, grey sloughing on lingual and buccal aspects of anterior teeth with spontaneous bleeding on probing.
Necrotising periodontitis on initial presentation
Necrotising periodontitis on initial presentation
A diagnosis of necrotising periodontitis was made. The treatment plan was based around the following phases of treatment planning.
Visit 1. Pain relief – local debridement, new toothbrush given, oral hygiene instruction (OHI) given lymphadenopathy, pain, and temperature of 38.7C. Metronidazole 400 mg TDS with review at three days was prescribed. Prescription by BDS under registrant, local debridement and tailored oral hygiene plan provided by the dental therapist student under registrant. Written consent to treatment and use of images.
Visit 2. Review at three days – pain much reduced. Smoking cessation and further dietary advice. Full mouth gross scale – local anaesthetic required. Full mouth biofilm disruption but limited due to pain – continued with metronidazole for two days.
OHI measures:
Brush with soft tooth brush, massage gums @ 45-degree angle
Dip TePe brushes into Corsodyl, gently use 1 x day, demo given, samples given after appropriate sizing
Importance of keeping bacterial load as low as possible stressed.
Visit 3.
BPE:
3/3/3
3/2/2
BW radiographs (Fig. 3) taken to assess bone levels/caries
Bitewing radiographs
Horizontal bone loss on both LHS/RHS
Difflam Benydamine Hydrochloride MW 600 ml prescribed (can use before meals if eating difficult)
Smoking cessation advice given, pt declined and will quit independently when ready.
Visit 4.
Patient reports marked reduction in bleeding and pain now able to carry out recommended oral hygiene regime
Supra/sub gingival professional mechanical plaque removal (PMPR) upper arch and LLQ (time restraints – did not complete FM) under LA
Cavitron/hand instruments used in aerosol generating procedure – air controlled pod
Patient struggled throughout.
Visit 5.
Supra/sub gingival PMPR LRQ under LA
USS + hand instruments in aerosol generating procedure – air controlled pod
Smoothed sharp cusp UR3 LL1 LR2.
Visit 6.
Teeth 17 and 27 fissure biopsy
11(L) enamel deficit – composite fill
37 Fissure sealed.
Visit 7.
16(O) and 42(B) restorations
Whilst further appointments would have been arranged for maintenance (essential phase of treatment) the patient advised that they were leaving the country so emphasis was placed on maintaining oral hygiene and regular follow up of the condition in addition to reinforcing dietary advice and smoking cessation advice.
This was a challenging case given not only the patient presenting with pyrexia, lymphadenopathy, and severe pain but complicated by the patient’s social circumstances and their emotional state in the early treatment sessions. The dental therapy student’s reflections on this case were as follows:
‘The patient found the treatment uncomfortable due to the acute nature of necrotising periodontitis, so I had to perform it in an intermittent manner allowing plenty of intra appointment recovery time.
‘Seeing the patient in acute pain was upsetting for all. I believe showing patience and empathy towards the patient, although the patient was in severe pain, made the experience more manageable for the patient. Empathy for social circumstances was essential at a personal and clinical level.’
Whilst this case was completed under supervision, it illustrates the advantages of a shared care approach in managing such complex patients in order to optimise outcomes (Fig. 4).
Gingival condition at completion of treatment (note improved papillary architecture)
Dental therapists have a wide skill set often underutilised in practice.7 Dental therapists working to their full scope will not only complement the work of other team members but optimise outcomes for patients, whilst ensuring dentists are free to focus on areas unique to their scope.
American Academy of Periodontology. 2017 Classification of Periodontal and Peri-implant Diseases and Conditions. 2017. Available at: https://www.perio.org/2017wwdc (accessed June 2022).
1999 International Workshop for a Classification of Periodontal Diseases and Conditions. Papers. Oak Brook, Illinois, October 30- November 2, 1999. Ann Periodontol 1999; doi: 10.1902/annals.1999.4.1.i.
Papapanou P, Sanz M, Buduneli N et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol 2018; doi: 10.1002/JPER.17-0721.
Rowland R W. Necrotising ulcerative gingivitis. Ann Periodontol 1999; 4: 65-73.
McIlwaine C, Brookes Z L S, Zahra D et al. A novel, integrated curriculum for dental hygiene-therapists and dentists. Br Dent J 2019; 226: 67-72.
General Dental Council. Scope of practice. London: General Dental Council, 2013.
NHS Health Education England. HEE’s Advancing Dental Care Review: Final Report. September 2021. Available at: https://www.hee.nhs.uk/sites/default/files/documents/Advancing%20Dental%20Care%20Report%20Sept%2021.pdf (accessed 1 May 2022).
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The authors have no conflict of interest. Ewen McColl (Director of Clinical Dentistry/Specialist Periodontist) conceived the idea to write the paper. Ashleigh Tibbs (Year 3 Dental Therapy student), Frazer Gregory (Year 5 BDS student) were the treating clinicians. Sincere thanks to the Clinic Leads Dr William Beare and Jo Power and all Clinical Supervisors involved in supervision of this case.
University of Plymouth, Peninsula Dental School, Plymouth, UK
Ashleigh Tibbs & Frazer Gregory
University of Plymouth, Plymouth, UK
Ewen McColl
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Tibbs, A., Gregory, F. & McColl, E. Necrotising periodontal disease – A shared care approach to management. BDJ Team 9, 18–20 (2022). https://doi.org/10.1038/s41407-022-0957-0
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