Date of Web Publication 16-May-2016
Objective: Periodontal diseases are treated using nonsurgical treatment methods and surgical treatment methods. There is a paucity of information on surgical periodontal treatment in Nigerian periodontal healthcare settings. The objective of the study was to determine the indications and pattern of surgical periodontal treatment in the University of Benin Teaching Hospital, Benin City, Nigeria.
Materials and Methods: This retrospective review of patients that had surgical periodontal treatment at University of Benin Teaching Hospital, Benin City, Nigeria, over a 37 month period (January 2013–2016) was done using a self developed proforma as the data collection tool. A total of 52 patients out of the 5111 patients treated within the period had surgical periodontal treatment and were subsequently analyzed using SPSS version 20.0.
Results: The patients aged between 16 and 81 years with a mean age of 44.15 ± 18.99 years and a median age of 45 years had surgical periodontal treatments. The majority of the patients were older adults (57.7%) (middle-age adults [34.6%] and elderly [23.1%]) and females (75.0%). The indications for the surgical periodontal treatment were mainly periodontal abscess and gingival enlargement. The gingival enlargement was majorly pyogenic granuloma in 41.2% (7/17) and fibrous epulis in 23.5% (4/17). Incision and drainage and gingivectomy constituted the main surgical periodontal treatments among the patients in this study. Age and gender were found to be significantly associated with the indications for surgical periodontal treatment and the pattern of surgical periodontal treatment among the patients.
Conclusion: Periodontal abscess and gingival enlargement constituted the main indications for surgical periodontal treatment while incision and drainage and gingivectomy were the main surgical periodontal treatments in this study.
Keywords: Periodontal disease, surgery, treatment
Azodo CC, Ojehanon PI. Pattern of surgical periodontal treatment in a Nigerian Teaching Hospital: A 37 month review. J Oral Res Rev 2016;8:16-9
Azodo CC, Ojehanon PI. Pattern of surgical periodontal treatment in a Nigerian Teaching Hospital: A 37 month review. J Oral Res Rev [serial online] 2016 [cited 2022 Jan 20];8:16-9. Available from: https://www.jorr.org/text.asp?2016/8/1/16/182492
Periodontal disease, which is the disease of the supporting structures of the teeth, can affect any dentate individual irrespective of age, gender, race, ethnicity, religion, and socio-economic status. Periodontal disease can be treated using nonsurgical treatment and surgical treatment methods, and the goals of these treatment methods are to preserve the natural dentition, periodontium and peri-implant tissues and to maintain and improve periodontal and peri-implant health, comfort, esthetics, and function.[1]
The surgical periodontal treatment is usually rendered as a definitive treatment to patients after the preliminary nonsurgical periodontal treatment. The American Academy of Periodontology treatment guidelines considers the nonsurgical periodontal treatment as the least invasive and most cost-effective approach to periodontal health. The nonsurgical periodontal treatment helps to motivate patients with good oral hygiene practices and also reduces the effects of inflammation on the condition marked for surgery. This reduction of inflammation leads to reduced bleeding during surgery and also reduces friable tissues that could make surgical margins difficult, leading to poor and unesthetic outcomes.
Surgical periodontal treatment is usually scheduled based on the outcome of nonsurgical periodontal treatment, helps to further eradicate the persistent periodontal pockets and inflammation, creates a healthy environment, and stimulates regenerative potential of periodontium. It offers the advantage of visibility of site of disease and improves access to cleaning and debridement of the diseased sites.[2] Miremadi et >al.[3] reported that surgical periodontal treatment is ultimately associated with a significantly lower need for re-treatment during supportive care over the 3-year period in comparison with nonsurgical periodontal treatment. However, it has been stated that the critical determinant in periodontal treatment is not in the treatment method (surgical or nonsurgical) used for the elimination of the subgingival infection, but on the quality of the debridement of the root surface.[4] The objectives of surgical periodontal treatment are to eliminate periodontal pockets, regenerate attachment, and to restore normal periodontal form, function, and esthetics, while the goal is to provide an environment more conducive to oral hygiene and maintenance care with consequent increase in the longevity of the dentition.
Nonsurgical periodontal treatments are performed at primary, secondary, and tertiary oral healthcare settings in Nigeria whereas the surgical periodontal treatments are performed in periodontology clinics in few teaching hospitals in Nigeria. There exists a paucity of information on the profile of surgical periodontal treatments in Nigeria. Previous study on the pattern of periodontal treatments in a teaching hospital in Nigeria revealed that nonsurgical treatment constituted the bulk of the treatment with surgical treatment constituting only 0.7%.[5] Hence, the objective of this study was to determine the indications and pattern of surgical periodontal treatment in the University of Benin Teaching Hospital, Benin City, Nigeria.
Study design/setting
This was a retrospective review of all patients who received surgical periodontal treatment at the University of Benin Teaching Hospital, Benin City, Nigeria, over a 37-month period (January 2013–2016).
Protocol of the diagnosis and treatment in the specialist clinic
After diagnosis, treatment is formulated, informed consent was obtained from the patients, nonsurgical treatment was performed and evaluated, after which the surgical periodontal treatment can be performed. The treatments are usually performed under local anesthesia by the trainee periodontologists under appropriate supervision, but may be performed by the periodontologist. Where indicated, suturing is done preferably with silk sutures and noneugenol periodontal dressing placed after surgery. Instruction in relation to periodontal treatment, medication, and oral hygiene instruction with special emphasis on cleaning of the surgical area are usually given after surgery. Patients are discharged after having been booked for recall appointment.
Data collection tool/procedure
Fifty-two patients who had surgical periodontal treatment were retrieved from the clinic log book. The self-developed pro forma was used to obtain age, gender, indication, and type of surgical treatment rendered to the patients.
The data obtained were subjected to univariate analysis using SPSS version 20.0 (Chicago, IL, USA). and reported as frequencies and percentages. The age of the patients were grouped into clinical age category as young adults (18–40 years), middle-age adults (40–64 years), and elderly (≥65 years). Test for significance was done using Chi-square statistics and Fisher's exact test. Statistical significance was set at P < 0.05.
A total of 52 patients out of the 5111 patients treated within the period had surgical periodontal treatment giving a prevalence of 1.0%. The patients aged between 16 and 81 years with a mean age of 44.15 ± 18.99 years and a median age of 45 years had surgical periodontal treatments. The majority were older adults (57.7%) (middle-age adults 18 [34.6%] and elderly 12 [23.1%]) and females (75.0%). The mean age of males was 49.08 ± 21.46 years while the mean age of females was 42.51 ± 18.09 [Table 1]. The indications for the surgical periodontal treatment were mainly periodontal abscess and gingival enlargement. The gingival enlargement was majorly pyogenic granuloma in 41.2% (7/17) and fibrous epulis in 23.5% (4/17). Age and gender were significantly associated with the indications for surgical periodontal treatment among the patients [Table 2]. The incision and drainage and gingivectomy constituted the main surgical periodontal treatments among the patients in this study. Age and gender were significantly associated with the pattern of surgical periodontal treatment among the patients [Table 3].
Table 1: Age and gender distribution of the patients
Table 2: Indications for surgical periodontal treatment among the patients
Table 3: Pattern of surgical periodontal treatment among the patients
This study was set to determine the indications and pattern of surgical periodontal treatment in a Nigerian Teaching Hospital and found that the treated patients were of wide age range because of the age range of different periodontal conditions that were definitively treated with surgery in this study. The higher proportion of older adults (middle-age adults and elderly) among the patients and the mean age of patients falling into the middle-age adulthood can be explained by a high prevalence of periodontal abscess which is a complication of chronic periodontitis, a condition whose prevalence increases with aging.[6] This is confirmed in the relationship between aging and periodontal abscess as an indication for surgical periodontal treatment where young adults had 50%, middle-age adults had 66.7%, and elderly had 75% of periodontal abscess treated with surgery [Table 2].
In this study, more females were treated which is in tandem with reports of more females than males attending periodontology clinics in Nigeria for treatment.[5],[7],[8] The higher receipt of surgical periodontal treatment in females than males has been linked to quest for esthetics as more female were treated at young and middle adulthood while more males were treated as elderly.[5],[7] The high combined prevalence periodontal abscess and pericoronitis which presents classical with pain may also explain the higher female attendance as males have higher capacity and tendencies to endure pain without treatment than females as it is culturally ingrained.[9]
The pattern of the surgical periodontal treatment varied reflecting the different indications for the treatment in this study. Incision and drainage for periodontal abscess constituted the majority of the surgical periodontal treatment. Elderly and males were the greatest recipients of incision and drainage, which is a reflection of aging and gender as the risk factors of chronic periodontitis that may be complicated by periodontal abscess. Gingivectomy, which is a resective periodontal surgical treatment for several forms of discrete and diffuse gingival enlargements, was the second most performed surgical periodontal treatment in this study, and young adults and females were the greatest recipients of this treatment. The role of resective surgery on esthetics may be the explanation why younger adults and females had more of this type of surgical periodontal treatment. The predominance of young adults and females in gingivectomy treatment can also be explained by the fact that the increase in the production of sex steroid hormones in women during puberty, ovulation, and pregnancy results in increased gingival inflammation, characterized by gingival enlargement which may not resolve with nonsurgical periodontal treatment only, hence the need for surgical periodontal treatment.[10] Operculectomy as a form of treatment in some cases of pericoronitis is controversial. Some authorities have rejected it as a treatment option because of frequent recurrence/growth of pericoronal flap after excision, but a few other permissive authorities still practice it, as it is beneficial in a few selected cases. In a previous study by some periodontologists, they argued in favor of operculectomy as against surgical disimpaction of the affected tooth and extraction of the opposing tooth and also recommended pericoronal flap gingivectomy as its new nomenclature.[7] In this study, this treatment was received mainly by younger adults and females who are dominantly affected by pericoronitis in Nigeria.[11]
Flap and regenerative surgeries offered as the treatment for gingival recession, periodontal pockets, and furcation involvements were in the minority of surgical periodontal treatment in this study. This is tandem with reports by Nwhator et >al.[7] and Umeizudike et >al.[5] in Lagos University Teaching Hospital, Nigeria, in 2006 and 2012, respectively. These surgeries are not commonly performed in periodontology clinic because not all patients will consent to having these surgical periodontal treatments when prescribed due to cost, fear of the surgery as a treatment, ignorance, and erroneous beliefs. The role of nonsurgical periodontal treatment in improving periodontal conditions and resulting in reasonably acceptable outcomes can also be an explanation for the few cases of flap and regenerative surgeries seen in this study.
Overall, the prevalence of surgical periodontal treatment is low which may be related to the low prevalence of severe periodontal disease in the form of periodontitis and deep periodontal pockets in Nigeria.[12],[13],[14] However, the training of periodontologists in Nigeria must emphasize surgical periodontal treatment to ensure complete periodontal healthcare delivery and successful outcome of the few cases of periodontal conditions indicated for surgery. The authors recommend dental awareness campaign to encourage patients to indulge in regular dental attendance to facilitate early detection and treatment of periodontal treatment instead of late and delayed presentation that commonly results in surgical periodontal treatment.
Periodontal abscess and gingival enlargement constituted the main indications for surgical periodontal treatment while incision and drainage and gingivectomy were the main surgical periodontal treatments in the studied teaching hospital.
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Akhionbare O, Ojehanon PI, Ufomata DO, Jeboda SO. Periodontal treatment needs of urban and rural populations in Edo State, Nigeria. Niger Dent J 2007;15:13-7.
Umoh AO, Azodo CC. Prevalence of gingivitis and periodontitis in an adult male population in Nigeria. Niger J Basic Clin Sci 2012;9:65-9.
Okeigbemen SA, Jeboda SO, Umweni AA. A preliminary assessment of the periodontal status of elderly pensioners in Benin City, Nigeria. Gerodontology 2012;29:e1244-8.
[Table 1], [Table 2], [Table 3]