Prevention of Disease

Successful prevention of gingivitis and periodontitis begins with good personal oral hygiene and periodic professional maintenance care to minimize or eliminate the etiologic factors that lead to the pathogenic state. As an oral health educator and clinician, the dental hygienist is an essential provider of preventive services in the initial phase of periodontal therapy and during periodontal maintenance care. Hence, the dental hygienist must recognize the benefits of periodontal therapy, maintenance care, and effective plaque biofilm control in order to select appropriate treatment modalities and effectively educate patients about the prevention of gingival and periodontal diseases.

Epidemiologic and clinical studies have provided strong evidence to correlate poor personal oral hygiene care and the presence of gingivitis. A landmark study by Löe and colleagues⁴ and Theilade and associates⁵ described heavy plaque biofilm accumulation and generalized mild gingivitis in patients with a normally healthy periodontium after 9 to 21 days without any personal oral hygiene. The observed experimental gingivitis was reversed when daily plaque biofilm control procedures were reinstituted. These results provide the foundation on which plaque biofilm control is based. To encourage and support the patient in maintaining a clean and healthy oral environment, the dental hygienist should emphasize the significance of personal oral hygiene and review appropriate plaque biofilm control techniques during each maintenance visit.

Gingivitis is associated with the occurrence of periodontal disease. Both human and laboratory animal studies have shown that gingivitis does not always proceed to periodontitis; however, periodontitis is always preceded by gingivitis.³ Therefore, the recognition and treatment of gingivitis are vital to the goals of maintenance therapy.

Both effective personal oral hygiene and professional maintenance therapy are critical to the prevention of periodontal disease. Despite their benefit in resolving gingivitis, daily oral hygiene procedures alone have limited effects on periodontal disease. Evidence suggests that supragingival plaque biofilm control alone can reduce inflammation associated with gingivitis; however, improvement in probing depths and clinical attachment from plaque biofilm control alone is minimal in patients with periodontitis.⁶ This limited clinical improvement may be a result of the unpredictable effect of supragingival plaque biofilm control in altering the subgingival microbiota in pocket depths greater than 5 mm. However, scaling and root planing have a significant effect on subgingival biota and probing depths.^7–10 This observation reinforces the importance of professional subgingival mechanical instrumentation at regular intervals in conjunction with personal oral hygiene to maintain periodontal health.

Prevention of Disease Progression

The periodontal response after effective nonsurgical and surgical therapy favors the reestablishment and maintenance of periodontal health. Numerous studies have shown that removing supragingival and subgingival bacterial deposits can resolve inflammation and halt disease progression.⁶ In addition, significant advances in understanding the complex causes of periodontal disease and a wider selection of therapeutic modalities have contributed to successful periodontal treatment.

Commonly, several forms of therapy are combined to disrupt the pathogenesis of periodontal disease. Current periodontal therapies and the clinical benefits provided are shown in Table 17-1.

Determinants of Successful Periodontal Maintenance

The success of periodontal treatment relies on surgical and nonsurgical procedures for thorough root debridement and long-term maintenance through periodic professional therapy and daily personal oral hygiene. There are several integrated factors that contribute to the success of periodontal maintenance, as listed in Table 17-2.

Preservation of Clinical Attachment Levels

Monitoring the gain or loss of clinical attachment levels and probing depths is necessary to assess periodontal health. A gain of clinical attachment and improved probe depth measurements are common findings after active periodontal therapy. However, long-term results are highly dependent on patient compliance with maintenance care and the frequency of maintenance visits. For poorly maintained patients with insufficient plaque biofilm control, clinical inflammatory parameters soon resemble those observed before treatment and deeper probe depths, indicating the continued loss of attachment and alveolar bone, are common.¹⁷

Reductions in probe depths after periodontal therapy result from healing at the epithelial attachment and reduction of gingival swelling.⁸ Therefore, increasing probe depths are the most valuable and practical measurements to predict clinical attachment loss during maintenance therapy. They are more predictable than increased plaque biofilm scores, bleeding sites, or amount of suppuration.²³

Evaluation of the stability of periodontal health requires thorough documentation of probe depths and clinical attachment levels. These measurements are essential for monitoring patient periodontal status during the maintenance phase. However, there are no national guidelines recommending the frequency of these comprehensive evaluations. Suggestions include evaluation at annual or biannual intervals or at every maintenance visit.²⁴ Despite this lack of standardization of the comprehensive evaluation, every recall appointment must include a periodontal evaluation, regardless of whether it is a comprehensive or a monitoring assessment. The monitoring examination has been described as a “directed” assessment in which all sites are evaluated for inflammatory changes, with problem sites recorded. Thus, comparisons with baseline data can be made and significant changes identified.

Maintenance of Alveolar Bone Height

Periodontal disease is characterized by the progression of gingival inflammation into deeper periodontal structures, resulting in the loss of alveolar bone support for the teeth. Periodic radiographic examinations are required to compare bone changes over time. Radiographs provide important data that can be used to evaluate the long-term stability of alveolar bone height during maintenance therapy. However, radiographic image records of alveolar crestal height reflect only historical bone loss, not active bone destruction; therefore, they are a necessary record of therapy but not a substitute for monitoring clinical parameters.

Control of Inflammation

Maintenance of satisfactory periodontal health requires control of inflammation and prevention of recurrent disease. Toward this end, personal oral hygiene is one of the most important aspects of periodontal maintenance. Studies of supervised maintenance programs that focused on refinement of personal oral hygiene skills showed that improved gingival and periodontal conditions were achieved in compliant subjects.²⁵ In contrast, Lindhe and colleagues²⁶ showed that maintenance patients with imperfect plaque biofilm control continued to exhibit loss of periodontal attachment. Other studies have shown that patients with imperfect plaque biofilm control could maintain clinical attachment levels as long as regular, professional, subgingival instrumentation was performed.²⁷ Poor oral hygiene alone, resulting in marginal gingival inflammation in maintenance patients, may not lead to increased periodontal destruction. Evidence-based review confirms that routine professional care, including disruption of the subgingival microbial biofilm ecosystem, plays a vital role in conjunction with daily oral home care in maintaining a stable periodontium.

Evaluation and Reinforcement of Personal Oral Hygiene

Daily personal oral hygiene, in conjunction with professional maintenance care, is the foundation of preventive periodontics. Each maintenance visit must include an evaluation of the patient’s oral home care and personalized instruction on proper plaque biofilm control techniques, as indicated by current assessments. It has been shown that in patients who had 2 years of professionally monitored plaque biofilm control emphasizing meticulous oral hygiene, the subgingival microbiota changed to one associated with health.²⁶ Although perfect supragingival plaque biofilm control is an unrealistic goal for most patients, the amount of plaque biofilm can be reduced to levels tolerated by the body. This change can prevent the reestablishment of gingivitis or reinfection by opportunistic periodontal pathogens. Using behavioral modification and motivational techniques, the dental hygienist plays a role in plaque biofilm control education that is equally as important and demanding as the more technical aspects of maintenance therapy.

Maintenance of Optimal Oral Health

An essential component of the maintenance program is the evaluation of the overall health of each patient. Updating the patient’s medical record is imperative to identify any systemic conditions that may complicate or contraindicate dental and dental hygiene care. In addition to the periodontal examination, assessment of oral soft tissues, restorations, caries, sensitive teeth, occlusion, and dental prostheses must be performed each time the patient is seen for a maintenance visit. All these assessments are essential elements of the preventive and therapeutic services provided by the dental hygienist during maintenance therapy, and each contributes to helping patients achieve optimal oral health.

Compliance with Recommended Maintenance Intervals

Numerous studies verify that periodontal health is maintained in individuals who comply with suggested maintenance intervals, regardless of the type of surgical or nonsurgical therapy received.⁶ In contrast, patients who do not comply or who comply erratically have increased periodontal deterioration. Typically, patients who comply erratically show an increased loss of periodontal attachment,²⁸ require more corrective surgical procedures,²⁹ and tend to lose more teeth.¹⁸

Large variations are seen in studies describing patient compliance with recommended maintenance therapy. In private periodontal practices, 16% to 95% of patients complied with 3-month maintenance intervals.29,30 University-based studies reported relatively low percentages of maintenance schedule compliance, ranging from 11% to 45%.^31,32 These discrepancies, like compliance, may have many causes and are not easily explained. However, it appears that obtaining patient cooperation is a major challenge for dental hygienists.

The reasons patients do not comply with maintenance schedules are complex, because each individual has different needs and experiences. Some of these reasons are detailed in Box 17-1. In general, noncompliance is seen more commonly in patients who do not perceive chronic diseases to be life-threatening.³² It is the dental hygienist who must take the time to identify the factors that will be personally motivating for each patient and individualize instruction.

Compliance with Recommended Oral Hygiene Regimens

Bacterial plaque biofilm is the primary etiologic agent of gingivitis and periodontal disease, and it is well established that meticulous oral hygiene can prevent both dental caries and periodontal disease. Adequate plaque biofilm control is a major determinant of successful periodontal therapy. Daily mechanical plaque biofilm control with a variety of cleaning aids is the responsibility of the patient. However, the dental hygienist is responsible for educating patients and motivating them to perform these tasks.

Reported rates of compliance with suggested oral hygiene procedures vary, but they are often disappointing. A survey of patients in a private dental practice showed approximately equal proportions of patients claiming to be highly, moderately, and poorly compliant.³³ Other findings suggest that at most, 51% of patients claim high compliance, 38% report moderate compliance, and 11% are noncompliant 30 days after oral hygiene instruction.³⁴ Patient compliance with the use of interproximal cleaning devices appears no better, with less than 50% compliance.³⁵

Periodontal patients report that oral hygiene procedures are cumbersome and time-consuming. Improved plaque biofilm control may be achieved in these patients by introducing an electric toothbrush, which they perceive as faster and simpler than manual brushing.³⁶ Compliance with suggested oral hygiene regimens may also be directly related to the number of cleaning aids recommended at the maintenance visit. When more oral hygiene aids are recommended, decreased compliance is observed.³⁷ The dental hygienist should therefore avoid giving instruction for every possible aid at one time and instead create a plan for implementation of recommended tools over time.

Strategies to Improve Patient Compliance

Strategies to increase compliance start with increasing the patient’s knowledge. The importance of periodontal maintenance, the benefits of preventive therapy, an appreciation of improved oral health, and the dental hygienist’s commitment to maintaining a caring attitude and providing the highest quality professional services should be emphasized. Recommendations to improve compliance are listed in Table 17-3.³²

Research suggests that the highest patient dropout rate occurs during the first year of maintenance therapy. Up to 35% of patients who received periodontal therapy thought that treatment was complete after the initial phase, before maintenance even began.³⁸ Therefore, special attention should be given to patients at the initiation of treatment and again at the commencement of periodontal maintenance to emphasize the importance of compliance and establish a positive long-term relationship.

Economic considerations are a common source of concern about suggested maintenance intervals. Socioeconomic status, educational level, and perception of oral health may affect a patient’s attitude toward purchasing oral health care services. The cost of maintenance appointments is often a primary determinant of patient compliance. A survey of noncompliant maintenance patients in a private periodontal practice showed that many were concerned about the long-term expense of treatment.³² This concern may reflect a lack of appreciation for the cost-effectiveness of maintenance care. Because chronic periodontal disease is often asymptomatic, disease progression goes unnoticed. Subsequent re-treatment can be much more expensive than maintenance in terms of financial cost and tooth loss. The dental hygienist can correct these misconceptions and help patients understand the preventive and cost-effective aspects of maintenance care.

The popularity of healthy lifestyles and physical fitness has skyrocketed and health concerns have become a part of mainstream American life. The promotion of physical and mental health and well-being focuses on prevention. This requires individuals to make decisions leading to healthier lifestyles. The promotion of oral health is a part of this trend. The media, federal and state governments, employers, health professionals, family, and friends greatly influence an individual’s attitude toward health. Because oral health is often a reflection of systemic health, the dental hygienist is in an excellent position to encourage patients to maintain both their oral and physical health. As evidence continues to emerge suggesting a link between periodontal and systemic diseases, patients’ awareness of oral health as an essential component of overall well-being will increase. Moreover, evidence suggests that health-related behavior, including compliance, is often dictated by the individual’s beliefs about health.³⁸ Hence, an appreciation of oral health is likely to improve compliance and ultimately help achieve success in periodontal maintenance.

As a health professional, the dental hygienist is obligated to educate and motivate patients continually to comply with recommendations for good oral health. The establishment of a partnership between the patient and the dental hygienist is essential to facilitate this learning relationship. Dental hygienists have sometimes been perceived as indifferent to patient concerns.³² Maintaining a caring attitude and good rapport encourages patients to ask questions and express their fears and concerns regarding therapy. Dental hygienists should take advantage of opportunities to teach and provide a better understanding of maintenance therapy; this understanding, in turn, promotes patient compliance.

Oral and Dental Examination

A thorough extraoral and intraoral examination of the soft tissues to detect pathologic conditions is a routine component of each maintenance visit. If an abnormality is identified, the dental hygienist is responsible for providing detailed documentation and obtaining an evaluation by the dentist.

A complete dental examination that includes caries detection, restorative assessment, and prosthesis evaluation is performed during each maintenance appointment. Recognition of conditions that may be detrimental to the patient’s periodontal health is an indispensable skill and an important responsibility of the dental hygienist. Factors that may cause adverse periodontal conditions include defective restorations, overhanging margins, open contacts, overcontoured crowns, and poorly fitting removable prostheses. All oral conditions that appear to deviate from normal should be brought to the attention of both the patient and the dentist. In addition, even excellent restorations and prostheses may cause plaque biofilm retention and problems with oral hygiene. These special problems can be identified and the patient can be taught techniques to clean such areas.

Periodontal Evaluation

Before any therapy is performed, assessment of the patient’s current periodontal status is mandatory. The clinical parameters that are evaluated include the following:

Gingival Recession

Gingival recession is apparent when the root surface is clinically exposed as a result of apical migration of the junctional epithelium and loss of marginal gingiva, as illustrated in Figure 17-2. It represents increased attachment loss, but it is not equivalent to the measurement of loss of attachment. Recession is measured from the cementoenamel junction to the gingival margin, and when added to probing depths in the area, it provides an estimate of total clinical attachment loss. The exposed root surfaces in the areas of recession are of special concern because of the increased risk for dentin sensitivity or hypersensitivity and carious lesions. The dental hygienist must carefully assess all areas of recession for these conditions.