Dr Paul Renton-Harper discusses the provision of personalised periodontal treatment, and the importance of staging and grading disease according to measurable risk factors. Paul presented this topic in a session supported by Curaden at the Oral Health Conference in November 2024.
Periodontal disease is often thought of as an infection caused by the introduction of bacteria. However, it is in fact an inflammatory disease where the majority of the destruction is inflicted by the genetically-determined immune response to bacteria. The initiation, presentation, progression, and response to treatment are also influenced by a number of risk factors. These risk factors can be assessed using up-to-date methods in order to enable clinicians to provide the best possible treatment to patients.
Personalised periodontal medicine
The current European Federation of Periodontology (EFP) Classification[i] places importance on providing patients with personalised treatment, and is designed to enable the provision of an individualised treatment approach. As such, periodontal treatment should take into account the severity, extent, progression rates, and systemic complicating factors in each case.[ii]
Personalised treatment identifies the unique risk factors and hyperinflammatory responses of each patient and adapts treatment to their needs. In order to provide personalised care, it is important to assess the severity of disease and complexity of treatment when the patient first presents to the practice (staging), and measure the rate of progression and factors affecting response to treatment over time (grading). This measured approach will provide initial parameters against which to accurately plan any future care.
Identifying and measuring risk factors
Identifying and measuring risk factorsThere are a number of key measurable factors that should be taken into account to inform the best course of treatment for each individual. Firstly, active matrix metalloproteinase-8 (aMMP-8) is an enzyme that can be used as part of point of care tests to identify periodontal disease.[iii] By measuring the level of this enzyme, clinicians are able, with other factors, to establish an initial grade and use it throughout treatment and maintenance to measure the rate of progression and changes in grading.
Diabetes is a huge risk factor, presenting a well-established bi-directional link with periodontal disease. There are relatively inexpensive kits available to measure a patient’s HbA1c, and this can contribute to the grading in the full classification. Many patients now wear a continuous blood glucose monitor which can produce a calculated HbA1c level. If the patient’s diabetes is poorly controlled, the periodontal disease will be more difficult to treat, however if treatment is successful their control can improve.[iv]
Whilst systemic conditions, such as diabetes, impact a patient’s risk of developing periodontal disease, behavioural factors can also play a role. Smoking, for example, is widely accepted to increase a patient’s risk of periodontal disease. As such, cessation advice should be given to patients who smoke, and equipment is widely accessible to clinicians which assesses CO levels and monitors their attempt to cease. However, it should be noted that this equipment is not suitable for assessing patients who vape.
Vision for the future of periodontal care
The treatment and monitoring of periodontitis patients will be hugely impacted by our growing ability to measure data points and base our decision making on these results. Prior to now, we relied far more on clinical experience to make judgements. However, whilst this is still important, we must support our clinical judgement with measurable factors. Further to this, once treatment has been provided and the patient is stabilised, modern assessment techniques enable us to more accurately understand their response to treatment and measure how stable they are in the maintenance phase.
As microbiology continues to evolve in the future, we can also expect to more effectively identify, measure and control the bacterial species that cause the disease. One would hope that, in the future genetic testing may become available that allow us to more accurately risk-assess patients in terms of their inflammatory response. The steps we continue to take now in terms of personalised treatment and clinical testing will help to inform the direction of periodontal care for the future.
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Author Bio:
Dr Paul Renton-Harper undertook his specialist training at the University of Bristol and won the FDI Prize for his work on the use of lasers in Periodontal Treatment. Holding the Braun research lectureship at Bristol, he contributed extensively to research and publications on mechanical aids to patient home care. He has taught periodontics to both undergraduates and postgraduates and been an examiner at the University of Bristol. He lectures to both national and international audiences on periodontal care and treatment and runs a specialist referral practice in Bristol seeing patients from across the South of England and further afield.
[i] EFP. Perio classification. Accessed Dec 24. https://www.efp.org/education/continuing-education/perio-classification/
[ii] BSP. BSP UK Version of the S3 Treatment Guidelines for Periodontitis. Accessed Dec 24. https://www.bsperio.org.uk/professionals/bsp-uk-clinical-practice-guidelines-for-the-treatment-of-periodontitis
[iii] Sorsa T, Sahni V, Buduneli N, Gupta S, Räisänen IT, Golub LM, Lee HM, Pätilä T, Bostanci N, Meurman J, Pärnänen P, Nwhator SO, Singla M, Gauba K. Active matrix metalloproteinase-8 (aMMP-8) point-of-care test (POCT) in the COVID-19 pandemic. Expert Rev Proteomics. 2021 Aug;18(8):707-717. doi: 10.1080/14789450.2021.1976151. Epub 2021 Sep 11. PMID: 34468272; PMCID: PMC8442753.
[iv] Prof. Tonetti (modified by the University of Helsinki, Prof. T. Sorsa). EFP Grading parameters. Accessed Dec 24. https://www.dentognostics.de/wp-content/uploads/2019/01/02_Tonetti-Chart_dentoversion2.pdf
