Best Practice                                                                                   

November 2013

Current guidelines for GDP's considering orthodontics for patients.

The first in a series of three current "best practice" guides in the field of Orthodontics
compiled by
Dr Avani Patel our Specialist in Orthodontics at 42 and Specialist Clinical Lecturer
(The Royal London Dental Institute).
(Source:"Managing the Developing Occlusion" from the British Orthodontic Society)

We hope you find the following guidance useful.

Part 1:  Spotting problems early in the young patient

An early orthodontic assessment, around the period of eruption of the permanent incisors, is a useful exercise as a number of simple interceptive measures are available to the orthodontist, which could significantly reduce the later complexity of many developing malocclusions.

A radiographic examination should be considered if the occlusion appears not to be developing normally.

Early orthodontic assessment is used to monitor the following:

a) Normal eruption of permanent incisors and first permanent molars

     plus investigating possible causes of failure of eruption.
    A tooth will normally erupt within six months of its contra-lateral number.

b) Presence of malocclusion

i) Crowding of incisors
ii) Significant displacement of incisors labially or lingually (incisors inside the bite)
iii) Posterior crossbites
iv) Coincidence of upper and lower centre lines
v) Severe skeletal discrepancies – especially Class II cases as these patients may be suitable for early intervention by means of a functional appliance therapy in the late mixed or early permanent dentition.

c) The long term prognosis of first permanent molars

d) Trauma to permanent incisors

e) Persistent thumb or finger sucking habits

During the mixed dentition the occlusion is in a dynamic state. Premature loss of deciduous teeth may cause shifts of centre lines and molar relationships, which are responsible for the development of many localised problems in the permanent dentition.
The plasticity of the occlusion can, however, be used to our advantage. For example, centre line shifts, caused by deciduous tooth loss, can be corrected by the extraction of the contra-lateral deciduous tooth.

The aim at this stage of dental development, around the age of 8 ½ years, is to achieve the complete eruption of upper and lower permanent incisors, in reasonable alignment, with coincident centre lines.

Further details on the management of unerupted upper incisors are available in the form of published national clinical guidelines on the Faculty of Dental Surgery (Eng.) website at:

Interceptive treatment:

Interceptive treatment is defined as the first stage of a more complex treatment plan. The aim is to aid the development of an ideal occlusion and minimise any deviation from normal. However, inappropriate intervention may complicate matters, especially if excessive space loss has been allowed to occur.

Thus, if in any doubt, always seek further advice from a Specialist Orthodontist.

Some possible measures include:
1. Extract deciduous teeth displacing their permanent successors.
2. Balance the loss of one deciduous canine with the extraction of the contra-lateral tooth to prevent the centre line shifting to the side of the missing tooth.
3. Observe the effects on centre lines of the loss of first deciduous molars. Consider extracting the contra-lateral first deciduous molar if this occurs.
4. Appliances to discourage thumb sucking at this stage are found to be less valuable than gentle dissuasion, encouragement and advice.

Possible Orthodontic treatment measures:

1. Surgical removal of supernumerary teeth related to unerrupted incisors.
(If in doubt you can refer to an orthodontist for assessment of eruption sequence and space availability).
2. Removable appliance therapy to correct:
i) one or multiple incisors in crossbite
ii) unilateral buccal crossbite causing displacement
iii) to recreate space for unerupted incisors.
3. Space maintainers at this stage are seldom indicated. The best space maintainer is the patient’s own deciduous dentition! Upper second deciduous molars should be preserved, whenever possible, to prevent mesial movement of the upper first permanent molars andloss of arch length.

The types of problems that specialists would prefer to see early:
 (i.e. at 7-9 years of age)
1. Delayed eruption of permanent incisors, whether or not related to supernumerary teeth. Always refer to an orthodontic professional.
2. Supplemental incisors – especially if you are unsure which tooth to extract.
3. Developmental (congenital) absence: commonly affects lower central and upper lateral incisors and second premolars. Consideration must be given to the eventual position of the upper canines, if lateral incisors are absent.
4. One or more upper incisors in crossbite. This may indicate a developing Class III jaw relationship which would benefit from early orthopaedic treatment.
5. Impaction or failure of complete eruption of one or more first permanent molars.
6. Severe crowding.
7. Severe skeletal discrepancies - especially Class II (small lower jaw) and Class III (small upper jaw) children.

If you are ever in doubt you can always contact Dr Avani Patel at our practice. She'd be delighted to help you.

September 2013

This update has been put together by Dr Shekha Bhuva, Specialist in Periodontics at 42

Recommendations for GDP'S in the management of diabetic and cardiovascular patients relating to periodontal health.
As you are probably aware, over the past few years there has been a growing body of evidence linking periodontal health to overall health. At present it is seen as a major health issue which has wide reaching effects for the individual as well as society.  

We hope you find the following guidance useful.
Recently the European Federation of Periodontology released a manifesto to ‘call upon all dental and health professionals to act in the prevention, early diagnosis and effective treatment of periodontal disease’. This was after intense and rigorous scrutiny of the ever growing evidence base.
It was agreed by experts that dental and medical professionals should be provided relevant treatment guidelines to help clinicians treat patients in a timely and correct manner.
We have summarised the findings of this meeting and outlined their recommendations and guidelines for your convenience. Please follow the link to read the in depth report:
Periodontal disease is a chronic inflammatory disease with potentially negative consequences for general health.
Cross sectional and prospective epidemiological studies have shown patients with diabetes are at a higher risk of suffering with periodontitis. A poor glycaemic control is likely to increase the severity of their periodontitis. A 2 way association has been discovered, in that poor glyaemic control increases the risk of periodontitis and uncontrolled periodontitis increases the risk of poor glycaemic control.
Periodontitis has also been independently linked with cardiovascular diseases and adverse pregnancy outcomes. However, although plausible links to adverse pregnancy outcomes have been stated, the evidence of a link is still under scrutiny.

Below we have summarised some specific recommendations:

The management of DIABETIC and CARDIOVASCULAR DISEASE patients
• Patients with diabetes should be told that periodontal risk is increased by poorly controlled diabetes.
They should be advised that if they suffer with periodontal disease their glycaemic control may be more difficult to manage and they are at higher risk for diabetic complications such as cardiovascular and kidney disease.
• As part of their initial evaluations patients with Type 1 Type 2 and gestational diabetes should receive a thorough oral and periodontal examination
• For all newly diagnosed diabetics, annual periodontal examinations must occur as part of ongoing management of their diabetes (even if no periodontal disease is initially picked up).
• Any overt signs of periodontitis : loose teeth, suppuration, drifting or deepening pockets MUST require prompt appropriate treatment. (Strongly consider referral of these cases).
• Diabetic patients who have extensive tooth loss through periodontitis should be encouraged to have restoration of gaps to ensure proper nutrition.
• Any patients who present without a diabetes diagnosis but with obvious risk factors and signs of periodontitis should be referred ASAP to their GP for diabetic screening.
• Periodontitis is a risk factor for developing atherosclerotic cardiovascular disease. Advise patients of the risk of periodontal inflammation to general as well as oral health.
• Periodontitis patients with other risk factors for atherosclerotic plaques such as hypertension, obesity, smoking etc who have not seen their GP within the last year should be referred for a medical examination.
• Modifiable lifestyle associated risk factors for periodontitis (and atherosclerotic cardiovascular disease) should be addressed in the dental surgery and within context of comprehensive periodontal treatment, ie smoking cessation programs, diet and exercise
• Regular periodontal screening of patients with risk factors or a history of CVD.
We hope you find this information useful. Dr Shekha Bhuva (Our Specialist in Periodontics) would be very happy to discuss any aspect of this with you in more detail.

If you have particular patients that you feel may be affected by any of the points covered She would be very happy to assist you in their periodontal management.