Preventing recurrent disease and maintaining oral health are of fundamental importance for the success of periodontal therapy. Chronic gingival inflammation can resolve if the local etiologic factors are removed during the active phase of periodontal treatment. However, the long-term stability of results and the prevention of recurring disease require regular supervision in an effective periodontal maintenance program. Periodontal maintenance is “the continuing periodic assessment and prophylactic treatment of the periodontal structures that permit early detection and treatment of new or recurring abnormalities or disease,”1 commonly referred to as recall, periodontal maintenance therapy, supportive periodontal therapy, or the maintenance phase of periodontal treatment.
The overall goal of dentistry is to attain and maintain healthy and functional dentitions and oral tissues for a lifetime. Within this context, the primary objective of periodontal maintenance is to preserve the stable state achieved during the active phase of periodontal therapy. This chapter focuses on issues that are relevant to maintenance, including the following:
Providing preventive, educational, and therapeutic services for maintenance care is a challenging task. As a primary care provider in the treatment of periodontal disease, the dental hygienist retains significant responsibility for maintenance after the patient has completed active periodontal treatment. Periodontal maintenance emphasizes the important link between preventive oral health care and dental hygiene care aimed at achieving optimum oral health. As the public becomes increasingly aware of the importance of oral health, the role of the dental hygienist in providing maintenance care and patient education continues to grow.
The initial phase consists of individualized oral hygiene instruction and supragingival and subgingival debridement of bacterial plaque biofilm and calculus. During the reevaluation, a second assessment of the periodontal condition is performed to determine the results of initial therapy and whether additional periodontal intervention is required. The maintenance program is initiated immediately after reevaluation to ensure the stability of results attained in the initial phase. During this period, corrective surgical and restorative procedures are performed as indicated. The aim of the surgical phase is to provide reconstructive or surgical therapy to improve the periodontal condition further and increase the ability of the patient to perform adequate daily oral hygiene.
The major objective of periodontal therapy is to arrest the progression of periodontal disease by eliminating or reducing the local microbial etiologic factors—that is, removal of the pathogens that illicit the inflammatory response in the host. Overwhelming evidence shows the effectiveness of periodontal therapy in preventing disease, slowing the progression of disease, and minimizing tooth loss caused by the periodontal disease process. Many longitudinal studies show that periodontal therapy is effective in maintaining teeth in a state of health, function, and comfort for many years.2 In contrast, untreated periodontal disease progresses, with a continual loss of the periodontium over time.3 Ultimately, this chronic destruction is responsible for tooth mortality. Furthermore, the stability of results obtained through active periodontal therapy requires a regular maintenance program.
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.
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.
Research has verified the effect of periodontal therapies on clinical parameters such as bleeding on probing, loss of clinical attachment, and changes in gingival color and form. For example, two longitudinal studies evaluated the effects of four types of periodontal therapy—coronal scaling, root planing, modified Widman surgery (flap surgery to provide access for scaling and root planing), and flap surgery with osseous resection—on the prevalence of bleeding on probing and suppuration.11,12 Both studies confirmed that all four therapies, followed by maintenance care at 3-month intervals, reduced the prevalence of these disease indicators. However, coronal scaling alone was less effective in sites with greater than 5-mm pocket depths. It may be that areas with increased probing depths continued to exhibit greater inflammation because adequate debridement was more difficult without surgical intervention. Maintenance care at 3-month intervals promoted the long-term results of all therapies.
Nonsurgical periodontal therapy, also called Phase I therapy, or the hygienic phase, is recognized as an effective treatment to arrest or retard the progression of early periodontal disease. The American Academy of Periodontology defines nonsurgical periodontal treatment as the phase of periodontal therapy that includes plaque biofilm control, plaque biofilm removal, supragingival and subgingival scaling, root planing, and the use of chemical adjuncts.13 Several longitudinal studies confirmed the effectiveness of nonsurgical periodontal therapy for early intervention of periodontal disease when it is followed by regular maintenance visits.6 Research conducted in a patient group with moderate to advanced periodontal disease treated with oral hygiene instruction, scaling and root planing, and elimination of plaque biofilm retentive factors demonstrated the short-term effects of initial periodontal therapy. When examined 3 to 5 months after therapy, patients had reduced probing pocket depths and improved probing attachment levels.9
Regular periodontal maintenance is critical to the lasting success of both nonsurgical and surgical periodontal therapy. Numerous long-term studies have established the effectiveness of frequent maintenance care to halt or significantly reduce the rate of disease progression. Studies comparing patients who received maintenance care three to six times per year with patients who received maintenance care only once per year clearly showed the arrest of disease progression with frequent recall visits. Patients who underwent maintenance care visits only once per year showed gradual worsening of plaque biofilm and gingival indices, probing depths, and clinical attachment loss.14-16 Clearly, the benefits achieved by active periodontal therapy must be maintained by frequent maintenance care to prevent further deterioration of the periodontium.
Many long-term studies have shown the effectiveness of periodontal therapy and maintenance care in reducing the number of teeth extracted because of end-stage periodontal destruction. Several researchers have documented tooth loss in longitudinal studies of individuals either receiving or not receiving periodontal treatment, including maintenance therapy.17,18 Tooth mortality rates in treated individuals ranged from 0.6 to 2.2 teeth lost over 10 years. By comparison, individuals with untreated periodontitis lost five to six teeth over 10 years.19 For more detailed information regarding prognosis, see Chapter 18.
The long-term success of periodontal and maintenance therapy has been documented in both prospective and retrospective studies.6 These studies demonstrated that surgical and nonsurgical periodontal therapies were effective in halting the destructive disease if routine professional maintenance was followed. Maintenance care must begin soon after active therapy and must occur at 3- to 4-month intervals. Conversely, periodontal therapy without comprehensive maintenance care resulted in higher rates of loss of attachment than expected without treatment.20 In fact, alveolar bone loss and tooth mortality rates in unmaintained individuals have been reported to be twice those observed in patients receiving maintenance therapy.21 Furthermore, regular effective plaque biofilm control by the patient, in addition to proper maintenance care by the clinician, is necessary to maintain the results of periodontal therapy.17 Poor oral hygiene permits an environment for opportunistic reinfection by pathogenic microbes, possibly resulting in disease progression.
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.
|•Collaboration among periodontist, dentist, and dental hygienist is established.||•This ensures that all oral care providers understand the patient’s goals, the treatment plan, and case prognosis.|
|•Partnership between patient and oral health care team is created.||•This facilitates a positive relationship and favorable outcome.|
|•Patient accepts responsibility for oral health.||•Success relies on the patient’s commitment to achieve and maintain oral health.|
|•Maintenance of periodontal health is influenced by patient’s overall condition.||•Factors to be considered include the nature and severity of periodontal disease, systemic health, mental health, and host response to therapy.|
The overall objective of periodontal maintenance is to prevent the development of new or recurrent periodontal disease through supervised care and to preserve a functional and comfortable dentition for life. Specifically, there are five underlying objectives22:
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.
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.
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.
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.
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.
The overall success of periodontal therapy depends significantly on patient compliance with recommended recall schedules and personal oral hygiene regimens. Many studies show that patients who comply with maintenance recommendations have better periodontal health and overall prognoses than patients who forgo maintenance care.27 Periodontal patients must be made aware that continued maintenance care and personal plaque biofilm control are essential elements of successful treatment. Failure to comply with these regimens can lead to further periodontal destruction and possibly to tooth loss. In essence, periodontal disease can be arrested and controlled, but not cured. Compliance requirements seem demanding, but for most individuals, the benefits of compliance far outweigh the risks of periodontal disease and tooth loss.
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.
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 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
|1. Simplify||Speaking at the patient’s level of understanding enhances communication efforts; patients tend to remember what is told to them first; the simpler the required behavior, the more likely it is that the patient will comply.|
|2. Accommodate||Recommendations should be tailored to the patient’s needs and lifestyle; satisfied patients tend to comply more than dissatisfied patients.|
|3. Remind patients of appointments||Patients must recognize the importance of frequent recall appointments to maintain periodontal health.|
|4. Keep records of compliance||Noting the patient’s history of compliance with recommended maintenance schedules and plaque control regimens provides legal documentation as well as a guideline for behavior modification.|
|5. Inform||Written specifications of the recommended regimens can be reminders for patients.|
|6. Provide positive reinforcement||Positive feedback enhances compliance more than a negative approach.|
|7. Identify||If noncompliance is suspected in a patient, the consequences of failure to comply should be discussed before therapy is initiated.|
(From Wilson TG. Compliance: a review of the literature with possible applications to periodontics. J Periodontol. 1987;58:709.)
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.
To achieve these objectives, the maintenance visit consists of a medical history update, a complete periodontal and dental examination, a radiographic examination if needed, a review of personal oral hygiene, and removal of supragingival and subgingival plaque biofilm and calculus. The maintenance visit is outlined in Box 17-2. On average, the maintenance appointment lasts 1 hour and generally provides sufficient time for thorough and proper care.39 However, the length of the appointment can be adjusted depending on the needs of the patient. The next section describes the components of a periodontal maintenance appointment, commonly referred to as a maintenance visit or periodontal recall.
Before seeing the patient, the dental hygienist should review the patient’s chart to determine the patient’s medical history, dental history, need for antibiotic premedication, record of compliance, and any special circumstances that may affect the dental hygiene care plan. The time necessary for this review is brief, but it is important to be familiar with each patient’s background and needs.
The periodontal maintenance appointment must begin with a verbal and written update of the patient’s medical history, dental history, current medications, and vital signs. Changes in health conditions may also require modifications of the dental hygiene care plan. In addition, a review of the patient’s dental history and specific dental concerns may alert the dental hygienist to conditions that require special attention.
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 probing is a valuable tool for the assessment of periodontal health. Evaluation of probing depths serves to complement the initial visual assessment of the gingival tissues. The periodontal probe is used to measure the normal sulcus and periodontal pocket depths from the base of the sulcus to the gingival margin. Six measurements are taken for each tooth on the distobuccal, buccal, mesiobuccal, distolingual, lingual, and mesiolingual surfaces. To permit changes to be monitored over time, a complete periodontal charting is performed at least once a year. Measurements obtained at maintenance intervals that deviate from this baseline must be documented in the patient’s chart.
Research shows that changes in clinical attachment are more accurately represented in measurements of attachment loss than by probing depths.40 Determination of attachment loss is made from a fixed reference point on the tooth surface, such as the cementoenamel junction or the margin of a restoration to the base of the pocket. For a complete discussion of measuring attachment loss, see Chapter 8. This procedure is time-consuming but important to include in practice.
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.
Specific sites that elicit bleeding on gentle probing during the examination should be noted. Bleeding on probing is a reliable indicator of pocket inflammation and is a good, but not perfect, predictor of active disease.41 In contrast, the absence of bleeding on probing />