Building a stairway of care – Iain Chapple puts the spotlight on periodontitis, behavioural change, and risk management

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In a well-attended live EFP Perio Sessions webinar on January 28, Iain Chapple gave a clear presentation on Step 1 of the EFP’s S3-level clinical practice guideline for the treatment of stage I-III periodontitis, focusing on behavioural change, risk factors and their management, and professional mechanical plaque removal (PMPR).

Prof Chapple, professor of periodontology at the University of Birmingham in the UK and former secretary general of the EFP, outlined a “stairway of care” using the acronym PRICE (Public health, Risk, Intervention, Checkpoint, Exit) and emphasising that “there is a price to pay if we get this wrong”.

He emphasised that Step 1 “gives us our biggest improvement in oral healthcare gain and in periodontal healthcare gain” and that “everything else performed in periodontal therapy depends upon it.”

Divided into two parts, Step 1 has two components: the education phase and PMPR. According to Prof Chapple, “The education phase is really important. It is about engaging the patient in personal risk-factor control and plaque control and it’s the most important step. If we get this wrong, no matter what we do after, no matter how clever or complex it is, it’s going to fail long term. So, we have to get this step right.”

Personalised approach

Advocating a personalised approach, he emphasised the importance of “knowing our patient, identifying the risk factors, and tailoring our behaviour change and our care plan for that patient to deal with those risk factors.”

He explained that the key to Step 1 was explaining the disease process and the risk factors to the patient, trying to engage them in behaviour change to improve their oral hygiene and their plaque control, and to make lifestyle changes.

He identified six key risk factors:

Genetics
Age
Nutrition
Smoking
Diabetes
Stress

Smoking and diabetes were the key areas to focus on, he said. “These are really very critical, but we can also look at physical activity, weight loss, and lifestyle, although these don’t have such a strong recommendation in the guideline.”

He discussed the interaction of genetic predisposition, environmental, and behavioural risk factors, highlighting that “genetic predisposition doesn’t always translate into clinical disease. We can modify our genetic make-up. Through behaviour change we can reduce our risk and we can reduce the likelihood of the translation of the genetic predisposition (risk) of periodontitis into actual disease.”

Prof Chapple’s presentation involved accounts of his own personalised approach to a particular patient (a neurosurgeon) with almost total bone loss around the lower incisors and significant bone loss around the upper ones, who, after a difficult start, “has meticulous plaque control and, in his case the behaviour change message was one that was focused around his practice and his professionalism. And it worked for him.”

He explained the Guideline’s recommendations on powered toothbrushes versus manual brushes, interdental brushes versus flossing, and the use of antiseptic mouth rinses.

Prof Chapple’s presentation was followed by a lively question-and-answer session, moderated by Spyros Vassilopoulos, which explored topics including patient motivation, advice on diet and exercise, air-polishing, flossing, and the use of online risk-assessment tools.

Note: Some of Iain Chapple’s comments have been edited for clarity and concision.

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