Recall in the Dental Practice—Recall Effect

Recall—maintenance therapy—in every dental practice can only be accomplished using competent auxiliary personnel: Enter the highly skilled dental hygienist! In particular, every treated periodontal patient must remain in recall “for life,” and be re-treated as necessary.

It is of course true that even the best recall system managed by competent practice personnel and supported by appropriate infrastructure will not be effective for all patients; there will always be patients who are poorly motivated, who do not accept personal responsibility for their oral health or who simply do not accept the recall schedule. Such patients, exhibiting non-compliance or “erratic” compliance (Wilson 1996) must be recognized before any systematic, active periodontal therapy is initiated.

But even patients who are highly motivated initially often, over the course of time, become less so. These individuals must be re-motivated during each and every recall appointment, and this is the highest calling for a truly prevention-oriented dental practice; the dental hygienist is the key person!

Recall Effect—Successful Prevention

The positive results of “prevention” have been demonstrated without exception for more than 20 years. Preventive dental medicine helps the patient not only to maintain healthy teeth in a healthy periodontium, but also inhibits the numerous potential negative effects of chronic inflammatory periodontitis on general systemic health (cardiovascular disease, diabetes, pulmonary problems) and pregnancy (risk of premature birth, low birth weight); such risks are greatly increased in the absence of periodontal therapy and without periodontal recall (Becker et al. 1984, Beck et al. 1996).

The recall interval will be different for each patient, depending upon her/his degree of motivation/compliance and manual dexterity. Depending upon the patient’s success in personal oral hygiene and personal daily “antimicrobial” homecare, the recall interval may be established between 2 and 12 months.

The time necessary for a recall appointment seems always to be underestimated. The recall appointment is not just a brief “scraping” of the calculus in the mandibular anterior segment! The comprehensive diagnostic, prophylactic, and possibly also therapeutic procedures may require one hour or more, depending upon the case (p. 311).

Recall—Continuous Risk Management

In the dental specialty of periodontology, the term “prevention” includes all measures targeted toward identifying the occurrence, progression or re-emergence of all forms of periodontitis—to prevent them or to identify them early in order to prevent further progression.

The very purpose of a recall appointment includes, in addition to purely clinical treatment, the obligation for risk-co-ordination in the sense of documentation of any changes that have occurred since the comprehensive initial diagnostic findings (cf. p. 193).

Early on it was recognized that the general patient history and clinical findings must be based upon a multilevel assessment of risks at three levels:

The general systemic medical history is without a doubt the most important (What is new since the last appointment? Cardiovascular problems? Metabolic disease/diabetes? Anticoagulant medication? Other medications?). These aspects of each patient must be updated at each recall appointment. Generally, every appointment begins with “How are you”?!

According to the Berne model (Lang & Tonetti 1996, p. 193), the individual risk profile for any given patient is determined by six risk parameters: Two are related to tooth surfaces (BOP and probing depths), and two are tooth-related (tooth loss and bone loss related to patient age); both of these patient-related factors determine the overall risk (alterable: smoking, life style; unalterable: systemic and genetic diseases).

What is missing, logically enough, is the participation of causal factors of periodontitis: The dental plaque “biofilm.” However, it is important to understand the reaction/response of the susceptible host organism to the microbial colonization of the periodontal pocket. This is what determines the initiation, progression and course of disease.

For the dentist and above all the dental hygienist, who is in every case responsible for maintenance therapy, the previously depicted model simplifies each individual case both diagnostically and prognostically.

The primary purpose of the schedule of recall appointments is to consistently follow the long-term health status of each patient’s periodontal condition.

Levels of Risk Assessment

Patient-related:

• Systemic diseases

• Environmental factors (smoking!)

• Compliance (oral hygiene)

• Attachment loss in relation to age

• Plaque accumulation in the oral cavity

• Percentage BOP on all tooth surfaces

• Number of pockets deeper than 4 mm

Dental arch relationships:

• Tooth tipping

• Tooth morphology (grooves, ridges)

• Tooth mobility

• Iatrogenic factors

• Remaining tooth support

• Furcation involvement

“Site” involvement:

• BOP

• Probing pocket depth

• Attachment loss

• Suppuration, pocket activity

The “Recall Hour”—Practical Periodontal Maintenance Therapy

Clinical Findings

• At every recall appointment:

  • Gingival condition (BOP or PBI)

  • Plaque accumulation (PI/PCR or API; disclosing solution)

  • Activity of residual pockets

• Additionally, every 6–24 months:

  • Pocket probing depths, radiographs (?)

  • Occlusion, reconstructions (tooth vitality), caries

• Additionally, every 3–4 years:

  • Panoramic radiograph and individual PA films, p.r.n.

Clinical Procedures

Depending upon the findings, the following procedures should be performed:

• At every recall appointment(e.g., every 2–6 months):

  • Medical history up-date

  • OHI and re-instruction

  • Re-motivation of patient compliance

  • Plaque and calculus removal where indicated!

  • Treatment of disease recurrence, p.r.n: debridement, topical meds (p. 291); additional appointments.

See also the 10-point program plus X, below.

Checklist: 10-Point Program Plus X

1. Medical history update ….. new systemic risks

2. Mucosal examination …… oral cancer prevention

3. Evaluation of inflammation. motivation

4. Pocket probing depths …… activity?

5. OHI…………………… compliance

6. Oral hygiene …………… re-instruction

7. Calculus removal ……….. targeted!

8. Biofilm removal ………… mild instrumentation

9. Polishing restorations ……. minimal abrasiveness

10. Fluoridation of the teeth …. information about its effectiveness

11. Extra measures …………. radiographs, vitality, sensitivity, surgery etc.

Recall—“As Fine as Possible”

Of top priority at recall appointment is the instrumentation of root surfaces and any exposed dentin surfaces. Just as we advise patients to not use any abrasive dentifrice when cleaning interdental areas, the dental hygienist is also well advised to use only the gentlest machines and hand instruments as well as the least abrasive prophy pastes as she/he cleans and polishes tooth surfaces.

Goal: Clean, but not abrasive/destructive! Even after 100 re-call appointments (20–40 years), there should be no gross evidence of excessive “scraping” on the teeth (cf. Fig. 713)!