Ch. 22
Periodontal Maintenance Therapy

Patient Adherence:

  • Most patients do not comply with long-term behavioral changes, especially for conditions that are not life threatening
  • 3 types of compliers:
    1. full compliers
    2. irregular compliers
    3. noncompliers (less-successful surgical outcomes over time)
  • Better communication may contribute to more successful outcomes
  • Provide patient reinforcement and attempting to better accommodate patient needs
  • The severity of the periodontal problem should be stressed because the more threatening a patient perceives a disease, the higher is the adherence
  • Patient dropout rate rate was highest in the first year
  • Common reasons for patient non adherence with office visits (expense, belief by patients that they no longer require treatment because they no longer have any signs of disease , fear of dental trx, or lifestyle changes
  • Patients who receive therapy maintain their teeth longer than those who do not
  • Give patients printed self-care instructions at every perio maintenance visit
  • Note the next periodontal maintenance appt on the instructions
  • Conseling patients about their condition and the benefit-to-risk ratio of having periodontal maintenance
  • Seeking out patient concerns and responding to them
  • Send out reminders or call patient about their next periodontal maintenance visit.

Refractory Periodontal Diseases/Recurrent Periodontal Diseases:

  • Refractory periodontal disease- occurs in treated periodontal pts who fail to respond to periodontal treatment (including maintenance therapy)
  • Refractory because of inadequate trx, presence of systemic disease, deficient immune response, or persistence in periodontal pathogens
  • Refractory TRX: antibiotics, and referral
  • Recurrent periodontal disease - patients who responded well to therapy but later showed signs of disease reactivation
  • Recurrent disease sites also occur in patients demonstrating meticulous biofilm control and on a regular maintenance program
  • Recurrent TRX: scaling/root planing, surgery, good biofilm control and maintenance

Chemotherapeutics:
-may be beneficial in certain patients as adjunct to standard oral hygiene procedures

  • does not replace brushing and flossing
  • Helps to prevent repopulation of potential gram (-) periodontal pathogens , help medically compromised patients and those exhibiting poor oral hygiene
  • rinsing with an agent is ineffective
  • oral irritation (water or medicament) is helpful and detoxifies and removed unattached dental biofilm
  • Systemic antibiotics are not recommended because of bacterial resistance
  • Controlled-release drugs such as Arresting, Periochip or Atridox may be used in selected recurrent pockets of 5mm or greater that bleed
  • Desensitizing agents may be applied a maintenance visit to reduce or eliminate dentinal hypersensitivity in patients whom gingival recession is present

Objectives of Periodontal Maintenance:

  1. Prevent or minimize the recurrence of periodontal diseases in patients by controlling risk factors known to contribute to the disease process
  2. prevent or reduce the incidence of tooth or implant loss by monitoring the dentition and prosthetic replacements of the natural teeth
  3. increase the probability of locating and treating other conditions or diseases found in the mouth
  4. preserve the health, comfort, and function of teeth

General Dentist-Periodontist Relationship:

  • Monitored by both their general dentist and their periodontist, but they should be seen by tier periodontist at least once a year for a thorough periodontal evaluation
  • Periodontal maintenance can be performed by general dentist and the periodontist
  • Gingivitis and mild chronic = dentist
  • moderate chronic perio patients should alternate between general dentist and periodontist once active treatment is completed
    -Severe chronic periodontitis patients = seen primarily by a periodontitis, with annual appointments with the general dentist for general care
  • Refractory and Aggressive periodontitis = seen exclusively by the periodontist for all active periodontal trx

Frequency of Intervals:

  • determined on an individual basis according to severity, type of trx performed, adequacy of oral hygiene self care, presence of ortho and prosthetic appliances, systemic health and patient adherence and cooperation
  • Time-interval frame is based on the repopulation time of periodontal pathogens after the last perio debridement
  • Maintenance intervals of 3 months or less are indicated for continued suppression of potentially pathogenic microorganisms in susceptible patients
  • 12-month recall interval may be acceptable for patients with limited susceptibility to periodontitis
  • Determined on a patient-by-patient basis
  • Patients can return 4-8 weeks after perio debridement for further observations
  • Anytime during a periodontal maintenance program, a patient may temporarily go back into active therapy
  • Time required depends on number of teeth, disease severity, amount of biofilm, calculus and stains, instrumentation access, presence of extensive prosthetic crowns and bridges, ortho appliances, depths of pockets, and patient cooperation.
  • Perio maintenance visits are usually scheduled for 1 hour, but the amount of time should be individualized

Components of the Periodontal Maintenance Visit:

  • patient needs vary and are modified on an individual basis
  1. Medical and Dental Hx update
  2. EO/IO exam
  3. Dental exam and gingival and periodontal assessment
  4. Radiographic review
  5. Oral hygiene evaluation
  6. Review of patients biofilm-control efficacy
  7. Removal of the dental biofilm from the supra gingival and sub gingival areas, root debridement where indicated, teeth polishing, and adjunctive chemotherapy if necessary
  • Review patients chart for previous treatment before any current treatment is initiated
  • Two aspects emphasized and provided during perio maintenance (monitoring and therapy)
  • compare to baseline findings
  • reduce primary (dental biofilm) and secondary risk factors (biofilm-retentive areas like calculus, restorations with overhangs pr defective margins)

Indications for Periodontal Maintenance:
Three types of patients

  1. periodontally healthy patients who have never had periodontal disease as a preventive procedure
  2. patients who respond favorably after active perio therapy to prevent or minimize the recurrence and progression of periodontal disease and tooth loss
  3. medically compromised patients or patients who maintain poor oral hygiene and are not considered candidates for periodontal surgery.

Dental Exam:

  • caries assessment and documentation of the status of restorations
  • Note any defective restorations (open margins, etc)
  • Stability of bridges, removable partial dentures, and implants should be noted
  • Document tooth loss and cause
  • Count number of teeth present

Gingival and Periodontal Assessment

EO/IO Exam:

  • Detection of any abnormalities, including enlarged lymph nodes or salivary glands and red, white, and pigmented lesions
  • Dentist should be informed

Radiographic Review:

  • Radiographs show past bone destruction
  • Taken according to the ADA guidelines
  • Sites that have had bone grafting or guided tissue regeneration can be evaluated with radiographs at least 6 months after surgery
  • Vertical bitewing views are ideal for patients with perio disease because they show more alveolar bone than they fo horizontal bitewings

Medical and Dental Update:

  • patient asked if there have been any changes
  • Review current meds
  • Note changes in doses or instructions of use
  • Med consult may be needed by patient physican if new illnesses are recognized or if a previous condition has changed significantly
  • chief complaint should be noted

Periodontal Assessment:
Recording of probing depths, gingival recession, clinical attachment level, furcation involvement, suppuration (pus), and tooth mobility

Gingival Assessment:

  • visual exam of gingival tissues
  • color, contour, consistency, and surface texture
  • mucogingival involvement should be noted
  • etiological factors noted

Gingival Recession:

  • inappropriate toothbrushing technique
  • attachment loss
  • shrinkage of tissue after initial therapy

Disease Stability: Probing Depth and CAL:

  • monitoring CAL is the most reliable way to determine perio disease stability
  • six sites per tooth
    -2-3 mm increase = disease progression

BOP:

  • laceration or ulceration
  • absence of BOP is a better indicator of gingival health than its presence is of periodontal disease
  • BOP may not be evident in smokers
  • BOP is apparent 10 seconds after probing

Tooth Mobility:

  • tooth mobility for each tooth is noted on the chart (measured and recorded (Grade I, II, III, IV)
  • presence of fremitus should be recorded

OHE and Patient's Biofilm-Control Regimen:

  • Disclosing agent used for patient edu as a basis for recording a biofilm index
  • May be misleading because patients frequently brush very well just before coming to the appointment
  • Evaluate the patients compliance with oral hygiene self-care
  • Ask patients to brush and use interdental devices while the hygienist watches
  • Level of patient determination must be determined

Dental Implants:

  • Probing depths depend on how the implant was placed
  • Not as meaningful around implants as natural teeth
  • Prosthesis is checked for occlusal wear (loosened screws should be recorded)
  • Light short strokes should be used to prevent trauma to the peri-implant tissues
  • Essential to take radiographs periodically
    -PA films are indicated at a 6-month- 1-year interval to determine the height of bone around an implant
  • Accepted standard for a stable endosseus implant 1 year after placement is vertical bone loss less than 0.2 mm per year

REFLECTION:
I believe it is important to notify and educate your patients that as their maintenance cleanings progress, provided that their pocket depths are measuring smaller, they may be able to be moved to four-month or even six-month cleanings. This will also save them money