Phase 3 Therapy Periodontal Maintenance Therapy—Recall Dental Hygienists Rule!

10.1055/b-0034-56527

Phase 3 Therapy Periodontal Maintenance Therapy—Recall Dental Hygienists Rule!

The long-term success of periodontal therapy depends less on the manner in which the case was actively treated (Phase 1 and 2) than on rigorous follow-up of the wound healing process immediately after therapy and on how well the case is maintained in subsequent recall (Rosling et al. 1976, Nyman et al. 1977, Knowles et al. 1979, Ramfjord et al. 1982, Wilson 1996; Axelsson 2002, AAP 2003).

Clinical research by Axelsson & Lindhe (1981, Axelsson et al. 1991) demonstrated dramatically the effects of preventive measures during recall (Fig. 698). This truly classic clinical study, which is ongoing even today (!), continues to demonstrate that regular and short-interval (2–3 months) prophylaxis by the dental hygienist (!) results in virtually no new caries and not the slightest periodontal attachment loss. This landmark clinical study, originally planned for 6 years duration, casts some serious doubts about “classical” reparative dentistry!

698 Axelsson Study: Caries and Attachment Loss with and without Recall Left: Patients who received neither homecare motivation nor preventive measures during one dental visit per year had 14 new caries and progressive attachment loss over the 6-year period. Right: Similar patients who received intensive professional prophylaxis every 2–3 months developed essentially no new carious lesions and actually exhibited some attachment gain!

The primary goals of maintenance therapy include:

  • Maintenance of oral health (including cancer screening)

  • Maintenance of chewing function, phonetics and esthetics

  • Prevention of new infection (gingivitis, periodontitis)

  • Prevention of re-infection of inactive residual pockets (periodontitis)

  • Prevention of dental caries

These goals can be achieved through:

  • Re-examination and re-evaluation

  • Re-motivation and new information for the patient

  • Re-instruction in oral hygiene and update of oral hygiene informative materials

  • Supragingival plaque and calculus removal

  • Subgingival debridement of pockets and root surfaces in areas exhibiting disease activity

  • Topical fluoride application

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!

699 Recall Effect I—Patients with a High Initial Plaque Index (PI = 70%)—Schematic With Phase 1 (blue curve) and Phase 2 therapy (red), healthy periodontal tissues result. The plaque index is now below the 20% mark; however, without re-motivation at recall appointments (R1, R2, R3) the PI rapidly sinks to the initial, poor level. With the relatively short recall interval of every 3 months, the periodontal therapeutic treatment result can be maintained over years.
700 Recall Effect II—Patients with a Lower Initial Plaque Index (PI = 40%)—Schematic For patients with less severe periodontitis (only Phase 1 therapy) and better initial oral hygiene, a “motivation kick” 3 months after completion of active therapy (R1) and then every 6 months (R2, R3) was sufficient to eliminate any risk of disease recurrence. Modified from M. Leu 1977

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:

  • At the patient level

  • At the level of the individual tooth

  • At the level of each surface of each tooth (“site”)

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.

701 Risk Assessment at Subsequent Recall Appointments The “red area”—the graphically represented total risk of the patient—becomes less and less in this model case. Unalterable risk factors (e.g., genetics) and the never-to-be-recovered bone loss leaves the depicted patient in a situation where he can no longer achieve the lowest level of risk.

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.

702 The “Recall Hour” The diagram portrays a rough approximation of a typical 1-hour recall visit. Rationalization of the instrumentarium (ultrasonic instruments) may compensate for the “lost time” required today for the thorough disinfection of the operatory. The fact is that the dental hygienist really has only about 50 minutes per patient. The division of the “prophy hour” is in four most important segments, depicted on page 313: 1 Patient history, clinical data collection (ca. 15 minutes*) 2 Patient instruction, instrumentation (ca. 25 minutes*) 3 Treatment of active sites (ca. 5 minutes *) 4 Polishing, fluoride application (ca. 5 minutes*) Continous motivation * The times required will vary from case to case.

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)!

703 Data Collection, Re-Evaluation, Diagnosis The current status of the patient is evaluated. The patient’s personal and even family difficulties are discussed as well as a follow-up of the general systemic health. Changes in medications are particularly important with older patients (stress?). Have any other risk factors changed (smoking)? Note: Five minutes of attentive listening is much more important than dental instrumentation, even when time is of the essence.
704 Motivation, Re-Instruction, Instrumentation The latest scientific findings show us the way: Perform scaling only where calculus is present, and remove microbial biofilm using the most gentle of instruments. Evaluate new developments! For example, the Vector ultrasonic device (pictured here); water-powder spray devices with minimally abrasive powder (EMS-Handy 2; p. 282) etc.
705 Treatment of Active Sites (Re-infected or Newly Infected) Individual active pockets can often be treated during the recall appointment (scaling; topical irrigation, e.g., betadine or controlled-release drugs). Pictured is an Atridox application into a “refractory pocket” (cf. p. 293). Multiple active sites or true recurrence of periodontitis will require separate appointments for treatment (scaling or surgery, supported by medicaments, p.r.n).
706 Polishing, Fluoridation, Scheduling the Next Appointment … Recall Interval Before applying fluoride, all teeth are polished with the rubber cup and a fluoride-containing prophy paste. Determination of the recall interval is made on the basis of risk assessment (type and severity of periodontitis, systemic and local risk factors, plaque control and patient compliance etc).
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Jul 2, 2020 | Posted by in Dental Hygiene | Comments Off on Phase 3 Therapy Periodontal Maintenance Therapy—Recall Dental Hygienists Rule!
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