**2. Periodontal office as a hub for interdisciplinary approach**

## **2.1 Periodontics and referral in general medicine**

The separation of medicine and dentistry is a peculiar historical artefact resulting in medicine being preoccupied with various systems of the body and dentistry being focused on disease and injury of the teeth and its supporting and surrounding structures, jaw and mouth. The professional boundaries are dutifully respected but the distinction has resulted in a poverty of cooperation, greatly inhibiting the synergistic potential. There are numerous diseases that produce both medical and dental complications like chronic kidney disease, cardiovascular disease, endocrine disorders and peripheral vascular disease. These chronic diseases capitulate a huge financial and social burden that necessitate medicine and dentistry to coordinate for achieving a more substantial delivery of care.

Poor oral health affects morbidity more than mortality [5]. Unfortunately, oral health has been a disregarded area of global health and has been registered as low on the sight of National policy makers. Link between oral/periodontal health and systemic health is an established fact now. Despite the awareness regarding the impact of oral health and the increasing attention within public policy, there are barriers preventing access to both basic & specialist dental care. The affordability of dental care and the economic hardships associated with its use presents one of the main barriers to care. The insurance system also determines the frequency with which individuals access dental care. Age is strongly associated with the interval between visits to dentists, despite having increased risk of periodontitis [6].

**Figure 2.** *Periodontitis and its relation to systemic condition.*

The impact of periodontal health and the release of inflammatory mediators are not restricted to the cardiovascular and cerebrovascular systems. Periodontal infections influence the initiation and progression of chronic obstructive pulmonary disease and respiratory infections such as pneumonia [7]. Periodontal disease also have been associated with preterm birth and low birth weight baby [8]. Patients with periodontitis have been found to be at increased risk of being in dysmetabolic state,characterised by decreased serum level of high density lipoprotein and mild insulin resistance [9] (**Figure 2**).

There are various common risk factors that explains the link between periodontal diseases and systemic diseases such as age, gender, socio economic status, income, smoking, ethnicity. Therefore, physicians should be well aware of this fact and should identify these risk factors and refer accordingly. These facts should be strengthened in continuing medical education programmes for surgical & physician trainees as well as be put into action into the medical and dental student curriculum. Before referral, the doctor and the dentist should inform the patient why there is reason to be concerned and the importance of managing risk factors. The doctor and dentist should provide a letter of referral for the patient outlining the medical and dental history respectively. The dentist should outline the list of procedures carried out, their impression of prognosis as well as whether there is a requirement for follow-up appointments. Most medical departments should hold regular multidisciplinary team meetings and one possible suggestion would be to include a periodontist.

#### **2.2 The connection between periodontics and oral pathology**

The periodontium in health and biofilm induced periodontal infections are very familiar to all oral health professionals including general practitioners and periodontists. The gingiva and buccal mucosa are associated with numerous local and systemic diseases. There are certain rare pathologies that may manifest in soft or hard tissue components of periodontium can be deliberated by by periodontists

#### *Interdisciplinary Periodontics DOI: http://dx.doi.org/10.5772/intechopen.99265*

with oral pathologists and they should act cohesively in aconvenient way so that these pathological conditions are perfectly diagnosed and treated. Not all possible disease processes that affect the gum can be included but it will facilitate a structure to steer the investigations and treatment plan if something abnormal identified.

These are the list of some abnormal lesions of gingiva that can be diagnosed & managed in a timely manner if interdisciplinary approach is followed between periodontist and oral pathologists [1]:

1.Gingival lesions of developmental/ genetic origin

	- Peripheral giant cell lesions
	- Brown tumours of hyperparathyroidism
	- Herpes simplex virus infection
	- HIV infection
	- Lichen planus
	- Mucous membrane pemphigoid
	- Pemphigus vulgaris
	- Orofacial granulomatosis
	- Langerhans cell histiocytosis
	- Drug induced gingival enlargement
	- Drug induced xerostomia
	- Odontogenic cysts and neoplasms
	- Leukoplakia
	- Squamous cell carcinoma

Lesions of the periodontium may be of a simple local nature or may be an indication of severe local or systemic disease. These patients with such lesions will be referred to periodontists, who will need to have a structured plan to follow when signs and symptoms of gingival pathology persists.

## **2.3 The interdisciplinary relationship between periodontics and oral and maxillofacial surgery**

Oral and maxillofacial surgery and Periodontics are two surgically oriented specialities of dentistry. The education and practice is very contrasting in many countries where an oral and maxillofacial surgeon requires both dental and medical qualification. If restorative procedures limited to the dental hard tissues are excluded, the surgical procedures of the oral cavity include those performed on the oral mucosa, attached gingiva and bone are common to both specialities. The purpose of interdisciplinary approach between these two surgical branches is to highlight some areas of dentistry where patient management could be performed by either speciality and to present some examples where periodontists and oral and maxillofacial surgeons can work closely together to achieve the best possible outcome for the patient.

#### *2.3.1 Surgical exposure of an impacted canine for orthodontics*

Impacted maxillary canine can be successfully managed by periodontist as well as oral and maxillofacial surgeon. It mostly depends on the referral pattern of orthodontist and experience of surgeon. Irrespective of who does the treatment, follow up management of the patient is most important. A proper interdisciplinary approach and communication between referring dentist & orthodontist is vital in this. This follow up management for initial 2 to 3 months recall should be individually tailored to the patient.

#### *2.3.2 Removal of mandibular tori*

Mandibular lingual tori are common benign osseous growths that may require surgical removal when they are chronically traumatised, affect overall oral hygiene or for prosthodontic reasons. Mandibular tori have also been used as autogenous graft during dental implant surgery [10]. Many times surgeries involving structures close to the floor of the mouth are associated with the complications such as bleeding and airway obstruction [11]. Keeping in mind this complications which may require hospital admission,referral dentist may prefer an oral and maxillofacial surgeon rather than a periodontist.

#### *2.3.3 Autogenous block bone grafting for dental implants*

Stability of dental implant is always questionable where there is deficient bone quality and volume [12]. There are many methods of augmenting bone including autogenous onlay bone grafts. Intra oral donor sites for bone harvesting include mandibular ramus, symphysis, retromolar area and maxillary tuberosity. Oral

#### *Interdisciplinary Periodontics DOI: http://dx.doi.org/10.5772/intechopen.99265*

surgeons are more confident in dealing with open bony procedures of high complexity but some periodontists may still wish to continue with the implant treatment of their patient requiring a block bone graft.

Interdisciplinary referral between Periodontist and Oral and Maxillofacial surgeon may be influenced by availability of services in the area, patient preferences and the professional and personal relationships between clinicians. There are many instances where a proper interdisciplinary approach exists between oral and maxillofacial surgeon and periodontist. To identify and appreciate what other specialities have to offer is for the best interest of the patient.

Any patient planned for orthognathic surgery by oral surgeon should be referred to a periodontist for a detailed periodontal examination including assessment of width of keratinized gingiva and thickness of bone, otherwise there will be chances of gingival recession and there should be a close liaison between the restorative dentist and periodontist during the oral rehabilitation phase of any patient with dentofacial deformity.

Early removal of impacted mandibular third molars especially when angulated and in close proximity to the second molar is at increased risk of worsening probing depths and clinical attachment levels. To prevent periodontal defects following mandibular third molar surgery, oral surgeon should work with periodontists for immediate placement of bone graft with and without collagen membrane. When the patient is associated with significant medical problems, periodontist always wish to refer him/her to oral and maxillofacial surgeon. Because of increased risk of morbidity the patient may be best managed in a hospital setting by the oral and maxillofacial surgeon.

#### **2.4 Paediatric dentistry and periodontic interface**

It is evidence based that child oral health reflects overall health and also forecasts their condition of oral cavity in youth. Child oral health mostly emphasises on dental caries and is segregated from general health care. So, it has become very crucial to realise the condition of oral tissue and mainly the periodontium in health and disease to facilitate a long lasting oral health in youth.

According to American Academy of Paediatric dentistry, all adolescents and children should perform periodontal screening and recording during their regular dental check-up. It should include colour & shape of gingival margins, plaque visualisation with disclosing agent and height of interproximal bone on radiographs [13]. Regular screening (periodontal screening and recording) is adviced for child and young teens with deciduous and mixed dentition [14]. Such screening helps to find out prior signs and symptoms of destruction of periodontal tissue. With emerging branch of periodontal medicine and established evidence of link between general health and oral health, it has become more important for the physicians and paediatricians to use oral health screening tools, particularly those who do not wish to obtain oral health care facility. Paediatric dentistry and Periodontology should work cohesively to come up with proof, capability and endorsements to ensure that all health professionals will be able to recognise the oral health problems of children.

Periodontal conditions that integrate Pedodontics and Periodontics focus in children:

#### *2.4.1 Dental trauma*

The periodontal complex is always prone to be affected by occlusal trauma that can lead to ischemic changes in periodontium. Following periodontal ligament

destruction adjoining to alveolar bone, ligament regeneration can occur, and repairrelated resorption or resorption ankylosis have also been demonstrated. After occlusal/dental trauma in child and youth, it is important to assess the periodontal staus to have the proper diagnosis and treatment planning that will help to advise the children and their parents of the intended result [15].
