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Ch. 22 Periodontal Maintenance Therapy By : Sandy Rosales DHG220…
Ch. 22 Periodontal Maintenance Therapy By : Sandy Rosales
DHG220 Periodontology
Ms. McHuen
Refractory/ Recurrent Periodontal Disease
Refractory:
patients who fail to respond to periodontal treatment including maintenance therapy.
recurrent :
patients who previously responded well to periodontal therapy but later show signs of disease reactivation. Can also occur in pt's that show meticulous biofilm control and on a regular maintenance program.
Objectives of Perioontal Maintenance:
1. to prevent or minimize the occurs of periodontal disease by controlling risk factors. 2. to prevent or reduce the incidence of tooth or implant loss. by monitoring dentition and prosthetic replacement of natural teeth. 3. to increase the probability of locating and treating other conditions or disease found in the mouth. 4. to preserve the health, comfort, and function of teeth. 5. consider the oral-systemic link
Indications for Periodontal Maintenance
3 type of patients
: 1. Healthy patients who have never had a periodontal disease (preventative care)
Primary Prevention
2. patients who respond well to perio therapy to prevent or minimize recurrence and progression of perio disease and tooth loss
Secondary prevention
3. patients who continue with poor OH and are not candidate for perio surgery
Components of Perio Maintenance visit
Monitoring and Therapy
findings should be compared to base line findings that are established at the initial exam and following active therapy.
Perio maintenance design to eliminate or reduce primary and secondary risk factors,
Primary Risk Factor for inflammatory perio disease:
dental biofilm.
Secondary RIsk Factor:
Biofilm retentive areas.
Medical and Dental update:
ask pt about any changed to their health since last visit, notated chief complaint and any degree of discomfort, pt and dentist should sign the updated form. Pt should be counseled on risk factors including smoking cessation
EO/IO:
to check for enlarged lymph nodes or salivary glands and red, white, or pigmented lesions
Dental Exam:
examine the status of restorations, missing teeth, and implant care.
Gingival and Perio Assessment
Gingival assessment :
check color, contour, consistency, texture
Periodontal assessment:
probing debths, recession, CAL, furcation involvement, tooth mobility, and suppuration.
Recession:
location of gingival margin in relation to CEJ.
Disease stability : Probing depth and clinical Attachment level:
2-3 mm increase in attachment loss indicates disease progression.
Bleeding on Probing meaning:
1. laceration ( pressing too hard) 2. ulceration ( inflmmation) .
Bleeding from stroking the sides of the gingiva crevice indicates early gingival inflammation or gingivitis
:star: Didn't realize there was such a difference in the bleeding. I will be more observant next time I do perio assessment.
smokers may not have BOP
Tooth mobility:
should be recorded as Grade I, II , III, IV. and if fremitus is present.
:star: Before perio class I did not realized that something else could be behind the cause of periodontal disease .
Treatment: Recurrent Periodontal Disease versus a well-maintained periodontium
recurrent occlusal problems include increasing tooth mobility and fremitus.
When BOP or presence of suppuration is seen 4-8 weeks after perio maintenance appointment re-treatment is acceptable
re treatment can also happen if 1-2 mm or more of probing depth or attachment loss.
if re- treatment is not successful eval of systemic disease should be evaluated.
pts with implants should be asked if they have any discomfort, difficulty chewing, and any difficulty in oral care.
subgingival instrumentation of shallow pockets can result in attachment loss.
Radiographic Review
shows past bone destruction not active
for recall pts, clinical judgement is used to eval the need to take or type of radiograph needed.
Areas that have had bone grafting or guided tissue regeneration should be eval 6 months after surgery.
vertical bitewing views are ideal for patients with periodontal disease.
:star: never knew about vertical bwx until I arrived to Fortis.
oral hygiene evaluation and Briofilm control Regiment
scoring of biofilm at a periodontal maintenance appointment may not be accurate because most patients tend to brush very well before they come in for cleanings.
The patients oral hygiene practices are reviewed by asking the patient to brush and use inter-dental devices while the DH watches.
It is important to determine the level of patient motivation to perform daily biofilm removal.
:star:After showing my patient their plaque index score and having them look in the mirror, that itself was a wake up call for her.
Dental implants
if inflammation is present around an implant, probing depth and bleeding must be noted including any signs of suppuration.
Calculus is not able to firmly attach to implant due to nonporous surfaces.
All prosthesis are checked for occlusal wear.
To determine height of bone around an implant, a radiograph can be taken at 6 months to 1 year intervals.
Probing depth depends on how the implant was placed
Accepted standard for a stable endosseous implant 1 year after placement is vertical bone loss less than 0.2 mm per year.
a failing implant shows a varying amount of alveolar bone loss. Mobility will occur with the failed implant.
:star: I have been taking better care of my implant since I started reading the book
Chemotherapeutics
irrigating with water or medications can remove unattached biofilm
periodontitis is a subgingival disease rinsing with an agent will not work
systemic antibiotics are not recommended routinely during perio maintenance due to possible bacterial resistance. ( may be beneficial in aggressive and refractory periodontitis cases)
helps prevent re-population of gram-negative pathogens between pariodontal maintenance appointments.
Arestin, periochip , atridox
: may be placed in recurrent 5mm + pockets with bleeding
Desensitizing agents:
can be placed at periodontal maintenance visit to reduce or eliminate dentin hypersensitivity in patients with recession.
:star: I never really thought about the negative effects of taking antibiotics and periodontitist.
Frequency of visits
12 month recall may be acceptable to those with a very low susceptibility rate.
pt. returns 4-8 weeks after periodontal debridement for further observations.
3 month or less visits are recommended for those susceptible patients.
Any During a periodontal maintenance program a pt may go back to active therapy.
Depends on re-population time of periodontal pathogens after the last cleaning.
Periodontal maintenance visits are usually scheduled for one hour
it has to be customized to patient, not everyone should be recommended the same.
:star: I feel that one year without a cleaning is too long.
General Dentist- Periodontist Relationship
Perio maintenance can be alternated between general dentist and periodontist.
Gingivitis or mild chronic periodontitis
pt can receive total care and chronic periodontal maintenance by
General dentist.
Periodontal patients can be monitored by both general dentist and periodontist. But should be seen by periodontist at least 1xyear.
Moderate chronic periodontitis
patients should alternate once active treatment is completed.
Severe chronic Periodontitis
should be seen primary by periodontitist with 1x year appointment with general dentist
Refactory and agressive periodontitis
pt should be seen only by peridontist for active perio treatment
:star: Unfortunately some general dentist fail to work with a periodontist fearing a loss of money and they do not think about the patient.
Patient Adherence
Positive reinforcement is needed
main reason pt does not comply is expense.
better communication is necessary
Motivational Strategies:
1. giving pt printed self-care instructions after every perio maintenance visit. 2. making a note of their next visit on the print out. 3. counseling patient on benefit- to -risk on having perio condition and maintenance . 4. addressing pt concerns. 5. sending reminders or calling pt.
pts tend not to comply when they don't feel their condition is not life threatening.
:star: I believe expense will continue to be a struggle for patients whom do not have dental insurance.