Clinical FAQs

The BSP regularly receive questions and queries from professional colleagues in relation to various aspects of periodontics and periodontal management. We hope to post anonymised copies of what may be especially frequently asked or helpful queries and responses. We hope that you find these useful.

Members Frequently Asked Questions

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Q: I would like to ask for some guidance on how soon I can treat a periodontal patient after a hip replacement. However, I cannot find any guidance about it. I would really appreciate any scientific clearance about it or any guidance you have from Orthopaedic departments. Thank you.

A: There are no consistent UK guidelines in place suggesting that special measures are necessary  in these situations. You should write to the patient’s surgeon to confirm how  they wish to proceed.

Ideally, oral health should be achieved  before  this surgery is considered. It may be wise to then delay further interventions for some time, as many surgeons do worry about involvement of healing tissues as a consequence of bacteraemia (although this is controversial and not clearly proven).

Q: Just after some advice, I’m trying to set up a protocol for implants but dentists would like proof about recalls for maintenance, what is the time frame is it 3/12 or dependant on individual patients? Many thanks.

A: Obviously, we are not able to give precise advice on a patient by patient basis and this would be driven by your judgement or that of the practitioner prescribing care. Frequency for supportive/maintenance therapy is determined based on an individualised risk assessment for the patient taking into account local as well as systemic factors and of course a history of previous periodontitis. The papers below would tend to reflect the current consensus view that this would ideally be between 3 and 5 or 6 months to maintain peri-implant health, most likely influenced by the factors mentioned above, as well as the potential impact of peri-implant disease on the surrounding tissue, need for and consequences of treatment and outlook for any prostheses.

Implant Disease Risk Assessment IDRA–a tool for preventing peri-implant disease (Lisa J. A. Heitz-Mayfield | Fritz Heitz | Niklaus P. Lang)

Impact of Maintenance Therapy for the Prevention of Peri-implant Diseases: A Systematic Review and Meta-analysis (A. Monje, L. Aranda , K.T. Diaz , M.A. Alarcón , R.A. Bagramian , H.L. Wang , and A. Catena)

Q: I would like clarity and/or confirmation regarding recall periods following Initial Therapy of a new patient displaying BPE code 3. At University, we were informed 2/3 month recall. However, recently a colleague of mine has brought to my attention she was informed 1 month maximum.
Please could you advise the best recall that I should be advising my patients?

A: We would normally suggest that you would wish to reassess fully the patient’s response to treatment after a three month period, as this allows adequate time for good soft tissue responses and healing with resolution of inflammation. However, in addition to this, it is often helpful to contact a patient and/or see them after a month or so, in order to reinforce oral hygiene methods (which may need to change as tissues resolve) and other risk factors control, such as smoking cessation or diabetes control. Once in supportive/maintenance care, a three month review period is often suitable.

Q: I am enjoying the new series of webinars and have been implementing the new classification using the BSP flowchart since its inception. I am trying to develop some local treatment management protocols and I am just wondering whether the advice is still to use BPE codes to determine how you lead into the stepwise management of patients? 

A: Yes, the plan is to keep using BPE as a means to diagnosis and classification. The steps will fit into pathways accordingly. This will all hopefully become clearer once we release our new management flowchart in the next week or so, so it might be worth waiting until that is out before you go too far further.

Q: I am currently a GDP in practice and I have been following your latest series of webinars regarding the new S3 guidelines with interest. I have a couple of questions regarding the current BSP guidance that have cropped up through daily practice:

1. The current BSP Flowchart states that if BPE3 recorded then appropriate radiographs should be recorded then sites reviewed after 3/12 and following this if bone loss is evident then proceed to code 4 pathway. If bone loss is evident on radiographs should the clinician immediately proceed to code 4 pathway or still wait 3/12? I ask this as I am often taking bitewings on patients with posterior BPE3s for caries/restorative reasons and identify incidental loss of interdental crestal bone also. Should I be immediately taking PAs of sextants/ proceeding to 6ppc (ie code 4 pathway) or should I still be waiting 3/12 after OHE to carry out 6ppc and PAs as appropriate based off pocket chart measurements?

2. When encountering BPE3 should a differential diagnosis be made in the interim?

A: BPE guidelines state: “Radiographs should be available for all Code 3 and Code 4 sextants. The type of radiograph used is a matter of clinical judgement but crestal bone levels should be visible. Many clinicians would regard periapical views as essential for Code 4 sextants to allow assessment of bone loss as a percentage of root length and visualisation of the periapical tissues”.

We advise that if you already have bitewings showing the bone crests (even if reduced) you wait until completing the OHE as per the Step 1 of patient management, as was outlined in the webinar. The idea is that this then allows for resolution of inflammation and helps to determine better what is going on when you carry out your full assessment, as hopefully you will have eliminated some aspects of the false pocketing which may be present. Then your PAs are taken with more knowledge basis behind their selection, for instance if the tissues respond well and pockets are eliminated (eg by recession or other improvements), and the bone loss was not that great then there may be no justification for taking further radiographs to see root length involvement.

However, if your bitewings show bone loss and you are unable to see bone crests then it might be pragmatic to take PAs sooner, as you need to see where the bone levels and how long the roots are, and it’s likely that these areas may be less likely to respond well to OHE (although of course they are also more likely to be code 4 too).

Obviously, all of this is in the absence of any restorative issues… if there are restorative aspects then that might drive you to PAs sooner, especially for treatment planning where there are other problems.

Strictly speaking the pathway doesn’t have a diagnosis for this point…. However, you nee to use your judgement here, so if there is radiographic evidence of bone loss then it’s likely that there is active periodontitis, but if not then likely gingivitis. You can write that in the notes then make further notes at review. Obviously do not retrospectively change your records!

Q: I was wondering if you could clarify whether High Volume Aspiration is still required when carrying out a hand scale?  We have tried to search this information in Public Health Info as well as the updated NHS CDO but they have not specified.

A: BSP is not strictly in a position to issue formal guidance on these issues. People should be advised to refer to current guidance and make a risk-assessed decision.

The problem is that if one briefly reviews Sections 3.1, 3.2 and  4.1 and Table 3 of the SDCEP guidance (here Aerosol Generating Procedures in Dentistry - SDCEP), it (dated 25/09/20) is at odds with this High_Volume_suction_statement_NDNWPD_2020_7_14.pdf (bsperio.org.uk) dated 14/07/20 and the previous statement table from June...

“While the evidence supporting the use of high volume suction to reduce the risk associated with dental AGPs is very low certainty, the use of suction does have other benefits (e.g. saliva/debris removal, airway protection) and is standard practice in dentistry. ..... Therefore, an individual risk assessment to identify such patients may be necessary. High volume suction has a number of variables and is both equipment and operator sensitive. While suction is available in all dental practices, there may be practices where the existing ‘high volume suction’ does not meet the required standard and additional costs may be involved in upgrading facilities to meet these. There are also ongoing costs associated with assessing and calibrating the level of suction, and servicing of the suction equipment, although these costs are unlikely to be additional as use of suction is standard practice. Following consideration of these factors, the Working Group reached an agreed position:

The Working Group’s agreed position is that the use of high volume suction is recommended to reduce the potential risk of SARS-CoV-2 transmission associated with dental aerosol generating procedures. This agreed position is based on very low certainty, indirect evidence in favour of high volume suction, insignificant risk of harm, and as a standard current practice, high volume suction is known to be acceptable and feasible. “

However, this relates to AGPS, not to the issue in question, and reading in more detail and going to the Implementation points at the bottom of p13 you will find:

“Implementation Points

- Whenever possible, high volume suction should be used for dental procedures which will produce splatter, droplets or aerosol.

- High volume suction may not be suitable for certain dental procedures (e.g. biopsy) and some patients (e.g. those with a strong gag reflex).

- Use of high volume suction might contribute to a reduction in fallow time following a Group A dental procedure”.

And hand scaling can make splatter - therefore it is recommended, and this is in agreement with the BSP statement High_Volume_suction_statement_NDNWPD_2020_7_14.pdf (bsperio.org.uk):

“BSP would like to clarify that for non-surgical supra- and subgingival instrumentation, high

volume suction (HVS) should be used as and when needed during hand instrumentation to remove blood/debris/calculus and reduce the potential risk of splatter. According to risk assessment and the particular circumstances of each case/site, the clinician should judge if a wide or narrow tip can be used with HVS.”

There is also more information available here: COVID-19 latest guidance for England (gdc-uk.org)

Q: I am currently trying to get some firm guidance on the use of ETB intra-orally for OHI provided within our department. I am aware that the BSP guidance in the July 2020 classifies OHI given intra orally with Level 2 PPE is at moderate risk of aerosol. I assume this is with the use of high volume suction.
I have contacted our rep who states that the use of the ETB intra orally with high volume suction has been shown to only produce splatter. They appear to be a lot more reluctant to provide the research that supports this statement.
I wondered if there was anything on BSP’s stance/guidance on this point that I have missed?

A: It Is splatter and hence is Level 2. Aerosols need a much higher rpm from the device in question. Therefore, you may need to consider use of high volume suction in this situation.

Reference section 3.2.1 of SDCEP guidance from September attached and here Mitigation of Aerosol Generating Procedures in Dentistry - A Rapid Review (sdcep.org.uk)

Also might want keep an eye on here Aerosol generating procedures and their mitigation in international guidance documents | Cochrane Oral Health