133. Effects of Therapy:

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a. Supportive Periodontal Therapy (Maintenance)

b. Re-treatment

c. Refractory Periodontitis

Why is maintenance therapy necessary? What is performed at these visits?

  1. Schallhorn RG, Snider LE. Periodontal maintenance therapy. JADA 101:227-231, 1981.

  1. Ramfjord SP. Maintenance care for treated periodontitis patients. J Clin Periodontol 14:433- 437, 1987.

  1. Echeverria JJ, Manau GC, Guerrero A. Supportive care after active periodontal treatment. A review. J Clin Periodontol 23:898-905, 1996. (Review)

  1. Tonetti MS, Steffen P, et al. Initial extractions and tooth loss during supportive care in a periodontal population seeking comprehensive care. J Clin Periodontol 27:824-831, 2000.

  1. Ramfjord SP, et al. Oral hygiene and maintenance of periodontal support. J Periodontol 53:26-30, 1982.

  1. Becker W, Berg L, Becker B. The long-term evaluation of periodontal treatment and maintenance in 95 patients. Int J Perio Rest Dent 4(2):54-71, 1984.

  1. Lindhe J, Nyman S : Long-term maintenance of patients treated for advanced periodontal disease. J. Clin. Periodontol. 11:504-514, 1984.

  1. Rosling B, Serino G, et al. Longitudinal periodontal tissue alterations during supportive therapy. J Clin Periodontol 2001; 28:241-249.

  1. Teles RP, Patel M, Socransky SS, Haffajee AD. Disease progression in periodontally healthy and maintenance subjects. J Periodontol. 2008 May;79(5):784-94.

  1. Muzzi L, Nieri M, Cattabriga M, Rotundo R, Cairo F, Pini Prato GP. The potential prognostic value of some periodontal factors for tooth loss: a retrospective multilevel analysis on periodontal patients treated and maintained over 10 years. J Periodontol. 2006 Dec;77(12):2084-9.

  1. Listgarten MA, et al: Clinical and microbiological characteristics of treated periodontitis patients on maintenance care. J. Periodontol. 60:452-459, 1989.

  1. Pontoriero R, et al : The angular bony defect in the maintenance of the periodontal patient. J. Clin. Periodontol. 15:200-204, 1988.

  1. Lindhe J, et al: Long-term effect of surgical/non-surgical treatment of periodontal disease. J. Clin. Periodontol. 11:448-458, 1984.

  1. Slots J, Jorgensen MG. Efficient antimicrobial treatment in periodontal maintenance care. JADA 131:1293-1304, 2000.

  1. Matuliene G, Pjetursson BE, Salvi GE, Schmidlin K, Brägger U, Zwahlen M, Lang NP.Influence of residual pockets on progression of periodontitis and tooth loss: results after 11 years of maintenance. J Clin Periodontol. 2008 Aug;35(8):685-95

  1. Position Paper: Supportive Periodontal Therapy (SPT). J Periodontol 69:502-506, 1998. (Review)

Discuss the reported level of patient compliance with maintenance recommendations and its implications for periodontal practice? How important is compliance for prognosis of teeth?

  1. Wilson TG, Glover ME, Schoen J, Baus C, Jacobs. Compliance with maintenance therapy in a private periodontal practice. J. Periodontol. 55:468-473, 1984.

  1. Wilson Jr. T, Hale S, Temple R. The results of efforts to improve compliance with supportive periodontal treatment in a private practice. J Periodontol 1993; 64: 311-314.

  1. Novaes A, Novaes A Jr, Moraes N, Campos G, Grisi M. Compliance with supportive periodontal therapy. J Periodontol 1996; 67: 478-485.

  1. Miyamoto T, Kumagai T, Jones JA, Van Dyke TE, Nunn ME. Compliance as a prognostic indicator: retrospective study of 505 patients treated and maintained for 15 years. J Periodontol. Feb;77(2):223-32. 2006.

  1. Miyamoto T, Kumagai T, Lang MS, Nunn ME. Compliance as a prognostic indicator. II. Impact of patient’s compliance to the individual tooth survival.J Periodontol. 2010 Sep;81(9):1280-8

  1. König J, Plagmann HC, Rühling A, Kocher T.Tooth loss and pocket probing depths in compliant periodontally treated patients: a retrospective analysis.J Clin Periodontol. 2002 Dec;29(12):1092-100.

What are the effects of maintenance therapy on wound healing?

  1. Yumet JA, Polson AM. Gingival wound healing in the presence of plaque induced inflammation. J. Periodontol. 56:107-119, 1985.

  1. Westfelt E, Nyman S, Socransky S, Lindhe J. Significance of frequency of professional tooth cleaning for healing following periodontal surgery. J. Clin. Periodontol. 10:148-156, 1983.

What happens if treated patients are not maintained?

  1. Becker W, Becker B, Berg L. Periodontal treatment without maintenance – A retrospective study in 44 patients. J Periodontol 55:505-509, 1984.

  1. Becker BC, Karp CL, Becker W, Berg L. Personality differences and stressful life events. Differences between treated periodontal patients with and without maintenance. J. Clin. Periodontol. 15:49-52, 1988.

Is there a difference in treatment results if maintenance is done in general dentists offices?

  1. Axelsson P, Lindhe J. The significance of maintenance care in the treatment of periodontal disease. J. Clin. Periodontol. 8:281-294, 1981.

  1. Johansson LA, Oster R, Hamp SE. Evaluation of cause-related periodontal therapy and compliance with maintenance care recommendations. J Clin Periodontol 11:689-699, 1984.

  1. Kerr NW. Treatment of chronic periodontitis- 45% failure rate after 5 years. Brit Dent J 150:222-224, 1981.

  1. McFall WT, Bader JD, Rozier RG, et al. Clinical periodontal status of regularly attending patients in general dental practices. J. Periodontol. 60:145-150, 1989.

  1. Fardal Ø. Interviews and assessments of returning non-compliant periodontal maintenance patients. J Clin Periodontol. 2006 Mar;33(3):216-20.

What is the ideal MT frequency after periodontal treatment ?

  1. Mousques T, Listgarten MA, Phillips R. Effect of scaling and root planing on the composition of the human subgingival microbial flora. J Perio Res 15:144-151,1980.

  1. Sbordone L, Ramaglia L, Gulletta E, Iacono V. Recolonization of the subgingival microflora after scaling and root planing in human periodontitis. J Periodontol. 1990 Sep;61(9):579-84.

  1. Listgarten MA, et al: Comparative longitudinal study of two methods of scheduling maintenance visits; 4-year data. J. Clin. Periodontol. 16:105-115, 1989.

  1. Rosen B, Olavi G, et al. Effect of different frequencies of preventive maintenance treatment on periodontal conditions. J Clin Periodontol 26:225-233, 1999.

  1. Shiloah J, Patters MR. Repopulation of periodontal pockets by microbial pathogens in the absence of supportive therapy. J Periodontol 1995; 67: 130-139

What causes failure of treatment? When would you consider retreatment for a patient? How often do we need to retreat patients for periodontitis?

  1. Chace R. Retreatment in periodontal practice. J Periodontol 48:410, 1977. (Review)

  1. Rateitschak KH.Failure of periodontal treatment. Quintessence Int. 1994 Jul;25(7):449-57.

  1. Fardal and Linden. Re-treatment profiles during long-term maintenance therapy in a periodontal practice in Norway.J Clin Perio 2005; 32:744-749

  1. Morrison EC, Ramfjord SP, et al: The significance of gingivitis during the maintenance phase of periodontal therapy. J Periodontol 53:31-34, 1982.

What is “Refractory Periodontitis” and how can it be managed?

  1. Jenkins WM, Said SH, Radvar M, Kinane DF. Effect of subgingival scaling during supportive therapy. J Clin Periodontol 27:590-596, 2000.

  1. Haffajee AD, Uzel NG, Arguello EI, Torresyap G, Guerrero DM, Socransky SS. Clinical and microbiological changes associated with the use of combined antimicrobial therapies to treat “refractory” periodontitis.J Clin Periodontol. 2004 Oct;31(10):869-77.

Why is maintenance therapy necessary? What is performed at these visits?

Schallhorn 1981                NO ARTICLE

P: To discuss the different aspects of prevention programs and to give the time frame of a typical maintenance visit.

D:PREVENTATIVE PERIODONTAL MAINTENANCE prevents inception of periodontal disease in individuals without periodontal disease.

TRIAL PERIODONTAL MAINTENANCE maintains borderline cases.

COMPROMISE PERIODONTAL MAINTENANCE is designed to slow the progression of periodontal disease in individuals who for what ever reason do not undergo surgical or nonsurgical therapy.

POSTTREATMENT PERIODONTAL MAINTENANCE to prevent re occurrence of periodontal disease in patients that have undergone active therapy.

Maintenance intervals should be individualized.

Factors: nature and extent of periodontal problem, type of therapy performed, effectiveness and frequency of plaque control, rate of calculus formation, systemic health, BOP.

The article outlines the components of an average maintenance appointment as performed by the dental hygienist (total under 1 hour). Greeting and health/dental history 8.5 minutes, Dental screening (extraoral and intraoral exam) 1.12 min., Periodontal assessment (BOP, PD, REC, fremitus, color/ architecture of gingiva),3.25 min., Plaque index 3.0 min., Oral hygiene inst. 4.20 min., Polish/Floss 10.9 min., SC/RP 10.9 min., Ultrasonics 6.83 min., Caries assessment 1.0 min., Chemical therapy (irrigation with antimicrobial agents) 1.50 min., Fluoride 1.0 min, Dismissal 1.0 min.

Patients vary with respect to number of teeth present, PDs, amount of calculus and staining and other considerations influencing the time required for therapy. Appointments should be individualized for the patient with either shorter or longer time allocations as appropriate for adequate therapy.

If the patient’s condition is stable with lack of inflammation, minimal calculus deposits and optimal plaque control, the interval can be extended between maintenance visits. If there are adverse findings the interval should be shortened until the optimal recall time for the patient is determined.

Ramfjord 1987                ARTICLE

P:Review of current literature with clinical observations to evaluate maintenance care

D:

  • Caton 1982 showed that initial gross clinical results of therapeutic procedures are established 4-6 wks after completion of therapy, although changes can be observed 6-9 months after completion of treatment.

  • Maintenance appointments should include prophylaxis of all teeth, OHI and fluoride. Maintenance should be scheduled every 3-4 months(although post surgical, recommend professional plaque removal once/wk for first month then 3 month maintenance).

  • Pts with better plaque control will have better surgical results, but once they have healed, maintenance results are similar regardless of OH (Ramfjord 1982) as long as pts have professional tooth cleaning every 3 months.

  • Pocket depth after treatment may not be the most critical determinant for prognosis.

  • Retreatment is often necessary to remove residual accretion of calculus and the treatment of new active lesions (bleeding or suppuration). These areas should be re-evaluated after 2-3 weeks to retest and decide if more SRP or surgery is needed.

  • Maintenance visits should also be used to monitor sensitivity, caries, pulpal status, evaluate old restorations and check occlusion.

BL: Maintenance should be completed every 3 months.

Echeverria1996                ARTICLE

P: This review addresses the most significant questions regarding supportive (maintenance) care after active periodontal treatment: the effectiveness and ideal frequency of maintenance appointments, the adequacy of the supportive therapy according to pt needs, the possible alternatives to currently accepted protocols, and the relative value of personal in the overall context of supportive care.

Disc: Periodontal diseases are infections with a high potential for recurrence, progressive loss and eventually, tooth loss. Current treatmentsfor periodontal diseases are highly predictable in arresting disease activity. Supportive periodontal care has been shown to be very effective in maintaining support when adapted to each particular case. Nevertheless, current maintenance therapies may be unsuccessful in preventing further ALoss in a smallnumber of sites for some patients. Tests aiming at bacterial identification and the subgingival application of antimicrobials may be helpful in the management of such cases, however the practical value in a specific setting is not known. There is growing evidence of the fundamental role of personal in supportive periodontal care. Careful consideration of the pt’s personal risk factors relating to the development of further disease is essential in the long-term management of the periodontal pt after the completion of active tx.

BL: In cases with rapid and severe periodontal destruction and where local and/or systemic risk factors are present, personal becomes a key factor in the long-term preservation of periodontal support.

Tonneti 2000                ARTICLE

Purpose: To describe 1) the prevalence of tooth loss and 2) the dental pathologies associated with extraction during active periodontal therapy and in the subsequent supportive periodontal care (SPC) period in a periodontal population who received comprehensive care at a University clinic and was maintained in an individualized recall program.

Materials and methods:Retrospective longitudinal survey of tooth extraction during active periodontal therapy tooth loss during the following SPC interval at University of Bern. Number of teeth present was determined at three time points: the initial consultation, the first SPC apt following active treatment and the latest clinical session of SPC. Clinical diagnosis according to ADA case type was retrospectively performed. Consecutive patients presenting for SPC between January and April 1995 were invited to participate in the study. 270 patients, 58% females between 16-1 years of age were included. The had completed active periodontal therapy 6 months previously, the did not have a contributory medical history and the clinical records were available. Whenever surgery was performed it did not include osseous recontouring. Each tooth that was extracted was classified as having one of the following pathologies: periodontal disease, caries, endodontic problems, technical failures (e.g. root fractures) or unknown. If teeth were used as abutments or had furc involvement was also recorded. Smoking status and radiographic bone loss were also assessed.

Results: Patients remained in an SPC program for 67+/- 46 months. 39.6% were current smokers and 27.8% previous smokers. 6.2% had gingivitis, 20.5% mild, 48.4% moderate and 24.9% severe periodontitis. Average frequency of the recall visits was 4.4+/- 1.5 apts/year.

Pts presented with 6503 teeth at their initial examination and 5929 at the recall. 574 were extracted totally, 311 (4.8% of total teeth, 1.1 extractions/patient but performed in 46% of patients) during the initial phase of treatment and 263 (4.2% of teeth present after completion of active treatment) during the recall period. 15.7% were 3rd molars and 1.9% retained primary teeth.

299 were maxillary teeth (106 molars, 47 multi-rooted upper premolars) and 175 mandibular (79 molars).

Pathologies associated with tooth extraction:

In the initial phase extractions that were associated with periodontal disease only were 63% and during recall 50%.

The teeth extracted with periodontal disease as the only pathology had an average radiographic bone loss of 56%. 62% in single rooted teeth and 49% in multi rooted teeth.

Caries, endodontic, and technical problems represented the leading pathology associated with gingivitis and mild periodontitis patients. Severe periodontal disease alone or in combination with other problems was present in 76-94% of initial extractions in moderate and severe periodontitis cases respectively.

During recall the incidence tooth loss/year was 0.17+/-0.31 teeth. During this period 41% of subjects had extractions, number of teeth that was extracted amounted to 2.35+/- 1.9 teeth/patient in this population and 0.4+/-0.37 teeth/year. The % of teeth that were extracted because of technical problems increased from 14% during initial phase to 27% during recall visits. During maintenance visits, 45% of patients presenting with moderate periodontitis at baseline had extractions and 48% of patients that had severe periodontitis had extractions. 86% of extraction in severe periodontitis patients were extracted because of periodontal reasons alone or in combination with other etiologies. In moderate periodontitis teeth extracted for this reason were 60%.

Conclusion: 8.8% of teeth present at baseline were extracted either during active therapy or in the subsequent SPC period. 4.2% of teeth were extracted during SPC and this suggests that initial extractions should be taken into account to compare the overall impact of comprehensive therapy on tooth loss.

Advanced periodontitis was associated with the majority of teeth that were extracted and was the only obvious pathology in 57% of the cases.

Tooth extractions were experienced by specific sub-populations and a minority of cases accounted for the majority of extractions.

Ramjford 1982                 ARTICLE

Purpose: To evaluate if PD and AL gained by therapy can be maintained despite variations in levels of OH while on 3 months maintenance.

Materials and methods:

  • 78 patients previously treated and on 3 month recall over 8 years.

  • PD and AL related to plaque scores above and below the median were assessed. 25% of sample having lowest plaque score was compared with 25% of sample with the highest plaque score over 6-8 years of maintenance.

  • All pts were given repeated instruction and motivation to improve their OH.

Results:

  • Plaque score was not critical for maintenance of posttreatment PD and AL in patients with professional prophylaxis every 3 months.

  • Initially OH had an effect (the better the OH, the better the results for 4-5 years) on PD and AL, but their effect did not hold long term.

  • Although initial post-tx gain of AL appears highly related to the degree of OH, the long-term results were not dependent on plaque scores.

BL: AL and PD 1 year after therapy can be maintained over 6-8 years with maintenance every 3 months, regardless of unavoidable variations in the effectiveness of the patient’s plaque control.

Becker 1984                ARTICLE

P: A retrospective study to evaluate the clinical results of periodontal therapy and maintenance.

M&M: 95 diagnosed, treated and maintained perio patients (ages 25-74) in a private practice (average length of tx was 6.5 yrs). Each patient had minimum of 2 exams, excluding 3rd molars. Clinical exam included PD, GM, furcations, and FMX. On the basis of clinical and radiographic findings, teeth were given a questionable prognosis (bone loss 50% of root length, PD 6-8mm, Class II Furcation) or hopeless prognosis (bone loss over 75%, PD 8-10mm or more, Class III furcation). All teeth not questionable or hopeless were given a good prognosis. Bone scores were determined using the Bjorn bone score. Tx included OHI, 1-3 sessions of SRP, occlusal adjustment, and pocket reduction surgery. All pts were placed on 3-4month recall.

R:

  • 6.21% of the total teeth were lost (150/2414) or 0.24 teeth per pt. per year(w/o hopeless teeth corrected to 0.11).

  • The maxillary second molars lost most often. Canines and mandibular incisors were lost least often.

  • Mortality based on prognosis, 87 of 102 (85%) given a hopeless prognosis were lost, thus 87/150 (58%) of the lost teeth were hopeless teeth.

  • Only 1.7% of teeth w/ good prognosis were lost.

  • 22% of molars with no furcations had furcations by the last exam.

  • 55% of the pockets 4-6mm at the first exam were in the 1-3mm range at the second exam

  • Over 50% had no changes in bone score.

  • Maintenance interval average was 5.2 mos. They had a 22% drop out rate.

BL:Perio Tx and maintenance are successful in reducing mod to deep pockets with minimal long term bone loss.

Lindhe 1984                ARTICLE

PURPOSE: To evaluate the perio condition of pts who had undergone treatment for advanced periodontitis and were well maintained for 14 years.

M&M: 61 of the 75 original patients treated in 1969 for advanced perio dz. All patients had received treatment consisting of OHI, SRP, Sx (pocket elimination) and then 3-6 month recall interval. Once a year plaque, GI, PD, AL and alveolar bone height were examined. This was evaluated at 1, 3, 5, 8, 10, 12, and 14 years after the completion of active therapy.

RESULTS: Prior to txt, 76% of sites examined had PD>4 mm, with 47% having PD >6 mm. Initial therapy reduced GI and improved plaque control, which was maintained over the life of this study. 92-99% of sites remained <4mm over 14 yrs. <1% developed PD >6 mm over 14 yr period. Individual mean values describing PD, AL and bone heights did not significantly vary over the 14 years; however, a small number of sites in a few pts lost substantial attachment. 0.8% of sites lost >2 mm of attachment over 14 yrs. During the entire treatment course, 30 teeth were lost out of 1330 (2.3%) from all 61 pts. Looking at individual data, 16 teeth were lost from 7 pts.

BL:Tx of advanced forms of periodontal disease can be maintained over a period of 14 years. Recurrent disease in well-maintained pts is a site-specific disorder which evidently develops and progresses in a few unpredictable sites and is not a generalized phenomenon

Rosling 2001                ARTICLE       attachment loss

P:To evaluate disease progression in “normal” susceptibility patients (NSG) and “high” susceptibility patients (HSG) to periodontitis during SPT.

M&M: HSG : 109 patients, NSG: 232 patients. All received 4-6 one hr sessions of S/RP, followed by 3-4x/year recalls. If BOP or PD>5mm noted at recall, site was re-treated. Teeth that presented with abscess or unresolved mob were extracted. The following clinical parameters measured at baseline (1 year after S/RP) and 12 years: # of teeth, PPD, PAL, RA bone level (standardized).

R:NSG: most subjects maintained their perio condition unchangedduring the MT period; only a few subjects experienced small amount of bone and ALoss (0.5 mm and 0.3 mm respectively). HSG: patients lost significant amounts of bone and attachment during the 12 years of SPT. Thus, in this group of subjects, the mean overall PAL loss amounted to 0.8 mm (0.06 mm/tooth surface/year). In the NSG, the overall ALoss was significantly smaller: 0.5 mm (0.04 mm/tooth surface/year). The subjects in the NG lost 0.3 teeth during the 12 years interval while the corresponding loss in the HSG was 1.9 (0.8 non-molar and 1.1 molar teeth). 20% of the HSG patients and 3% in the NG were exited of the study after 3-5y of SPT due disease progression.

BL:In patients with a high susceptibility for perio disease it is possible to maintain bone and Attach Levels at a reasonably stable level over a 12-year period after no-sx therapy. SPT in pts with normal susceptibility to perio disease, prevented almost entirely major tooth, bone and attach loss. Some patients and sites could be identified that responded poorly to therapy despite good plaque control and regular recall appointments.

Teles 2008                ARTICLE

P:To determine whether the rate of attachment loss in periodontally healthy subjects in a prevention regimen would differ from the rate of disease progression in periodontitis subjects in a maintenance program.

M&M:55 periodontally healthy patients and 57 periodontitis patients were clinically and microbiologically monitored at baseline and at 1, 2, and 3 years. Parameters measured included BOP, plaque, PD, and AL. Periodontally healthy and maintenance groups received SPT every 6 and 3-6 months respectively. Subgingival plaque samples were taken from the MB aspect of every tooth and were measured by checkerboard DNA/DNA hybridization. No subgingival treatment was carried out within 3 months prior to the annual examinations.

R:Clinical parameters for both groups improved over time. 4% of the sites in the periodontitis patients lost ≥2 mm of attachment. Only 1% of the healthy periodontal patients lost ≥2 mm of attachment. Maintenance group lost 0.12 teeth/subject/year, whereas the prophylaxis group lost 0.02 teeth/subject/year over 3 years of study. At baseline, the maintenance subjects showed SS higher levels of red complex species compared to prophylaxis subjects. By year 2, both groups demonstrated reductions in the mean levels of most species.

BL:Treated periodontitis patients under maintenance displayed more rapid attachment loss than periodontally healthy subjects in a preventive regimen. This may be related to an elevated exposure to periodontal pathogens in the red complex.

Muzzi 2006                ARTICLE

P:To evaluate the value of some clinical, genetic, and radiographic variables in predicting tooth loss in periodontal patients treated and maintained for 10 years.

M&M:retrospective analysis, 60 (29M/31F) healthy, mean age 46.77 years, non-smoking patients, all 40-60 years of age and of white heritage (study from Italy) with moderate to severe periodontitis, treated in private practice with SRP and surgery per need (MWF or Osseous), and all received maintenance for 10 years. Probing depths, number of teeth, prosthetic restorations recorded. CEJ- to root apex, CEJ- to bottom of defect, CEJ- to bone crest, bone crest to bottom of defect, and bottom of defect to root apex (residual supporting bone) all were measured from radiographs. IL-1 genotypes were recorded.

R:two-level variance analysis for both patient level prognostic variables and tooth level prognostic variables.

SS prognostic relationship was found for molar teeth (positive correlation). Molar teeth were found more prone to loss. Bottom of defect to root apex distance was associated with tooth loss. The lower the amount of residual supporting bone, the greater the probability of losing the tooth. Bone crest to bottom of the defect distance was associated with tooth loss (negative correlation). The greater the distance the lower the probability of losing the tooth. Deep infrabony defects tend to respond better to regenerative procedures. Tooth mobility, PDs, presence or restorations and CEJ-bottom of defect were not found predictive for tooth loss.

C:Molar teeth, infrabony component of the defect and residual supporting bone may be considered prognostic factors for tooth loss.

Listgarten 1989                ARTICLE

P:To determine whether the presence of Aa, Pg, Pi in selected periodontal sites can predict future disease recurrence.

M+M:98 adults (>25 years old) with moderate to advanced periodontal disease that had been treated surgically and in maintenance programs for at least 1 year (75% over 5 yrs) were evaluated for PI, GI, PD, AL and microbiological analysis with paper points from sites with greatest PD in each sextant. A site was considered infected and positive for Aa, Pg, or Pi, if the above mentioned microbes were found at levels of > 0.01% for Aa, 0.1% for Pg, and 2.5% for Pi.

R:

  • PI scores were higher for molars than the rest of the teeth.

  • GI was uniform throughout the dentition.

  • PD tended to be greater for the M/D than the B/L surfaces with a bilateral symmetrical pattern, PD increased from midline to posterior.

  • Sites positive for Aa, Pg, and Pi tended to have greater PD (mean: 4.14mm) than non-infected sites in the same pts (mean: 3.76).

BL:There was a positive correlation between Aa, Pg, Pi, Capnocytophaga and increased AL loss, as well as greater GI and PD.

CR:While it does somewhat correlate to disease activity, it is not enough to rationalize its routine use, especially in maintenance pts.

Pontoriero 1988                ARTICLE

P:To evaluate some long-term alterations of the alveolar bone level at sites with angular & horizontal bone loss.

M&M:48 patients were treated for advanced perio disease and then placed on SPT with recalls q 3-6 months for 5-16 years. 100 teeth with angular defects that could be detected after active treatment phase were included. A comparison was made between post-tx radiographs to current radiographs. Contralateral or neighboring teeth with horizontal bone loss used as controls. The following measurements were taken and measured with the Bjorn technique at 2x:

1.distance between base of defects & apex (B-A)

2.distance between alveolar crest & base of defect (C-B)

3.Distance between crest & apex on control teeth.

R: Current measurements (5-16 years post-active tx):

1.B-A distant remained unchanged.

2.The average C-B distance decrease from 1.41 bone scoring units (BSU) to 1.07 BSU. 12% of the sites showed ~ 0.7 to 2.0 mm apical shift in this distance (possibly downhill patients).

3.Distance from crest to apex remained almost unchanged in controls.

BL:The presence of angular bony defect after active treatment does not make a site more prone to additional bone loss in well-maintained patients. After perio treatment, most sites with angular or horizontal patterns of AB loss underwent none, or very little additional bone loss after 5-16 years of SPT.

Crit:Non-standardized radiographs. Authors do not describe what active perio tx included. Where there attempts to eliminate the defects that were unsuccessful (osseous, GTR)? The distance between bone crest-base of defect initially was 1.4, which is not a very deep bony defect…

This study does not apply to pts that present with deep verticals defects.

Lindhe(2) 1984                ARTICLE           plaque control

Purpose: 1) To further analyze the role played by the patients’ self performed plaque control in preventing recurrent periodontal disease and 2) TO assess the periodontal conditions of patients 5 years after completion of active treatment (SRP or SRP + MWF) with special emphasis on sites with initial PD>3mm.

Materials and methods:15 subjects 32-57 years old were selected. After baseline examination patients received SRP or SRP + MWF in a split mouth design and had follow-up for 24 months. After the 24-month examination, the recall appointments were extended to 4-6 months. Maintenance program was restricted to OHI and supra-g tooth cleaning (sub-g instrumentation was avoided) and at 26, 48 and 60 months after Tx the quality of patients’ plaque control was assessed. At 60 months a final examination was performed and included the same parameters as assessed at baseline. Data include 11/15 patients that took part in the entire 5-years study and represent baseline – 60-month changes as well as 24-60 months changes.

Results: Group I: patients that maintained an excellent standard of OH during the 5 -year period at each re-examination. Group II: patients who failed to maintain a proper standard of OH at each re-examination.

24-60 months: AL remained unchanged in 86-88% of the sites. 2% gained 2mm or more of attachment and 10-12% exhibited attachment loss of 2mm or more. Attachment loss was more prevalent in interproximal surfaces. In Group I 2-3% of sites had attachment loss and 95% of istes remained unchanged or gained attachment, in Group II no sites had attachment gain and 20% had attachment loss.

Baseline-60-months in sites with PD>3mm at baseline: 55-65% showed PD reduction. 1-2% showed increase in PD. 85% in of sites with 4mm or more PD in Group I were reduced in depth, in the majority more than 2mm. Such a reduction of the PD was less prevalent in Group II. In Group II 60% of sites remained unaltered.

For sites with PD of 4mm or more, more sites lost attachment in the patients in Group II (20% and 6% vs 7% and 2%). Gain of attachment occurred more frequently in the patients of subgroup I.

24-60 months for PD>3mm at 24 month re-eval: 75-85% of PDs and 85% of AL remained unchanged. Reduction in PD and AL gain occurred mainly in patients in Group I while further increase in PD was found mainly in patients in Group II.

It is likely that attachment level gain is the result of reduction of inflammatory infiltrate after treatment and increase in collagen.

Conclusion: Patients’ standard of OH had a decisive influence on the long – term result of treatment of periodontal disease.

Sites with an initial PD exceeding 3mm responded equally well to the non-surgical as to the surgical mode of treatment.

Slots 2000                ARTICLE

Purpose:To outline the current approaches to follow-up care after initial (“definitive”) perio tx and advance a suitable protocol for perio maintenance care.

Discussion:

  • Preventive periodontal therapy can be categorized as primary, secondary or tertiary. Primary prevention aims to reduce risk factors before clinical presentation of disease and can be accomplished by intervention strategies aimed at both the general public and special, high-risk populations.

  • The aim of secondary prevention is to intervene at early disease or precursor

  • Tertiary prevention seeks to limit the impact of established disease.

  • Perio exam should include full-mouth probing, with PD, BOP, AL, PI, plaque score. Calculus removal using hand instruments or ultrasonic. Recommend using 10% povidone-iodine diluted 1:9 with water for irrigant in the ultrasonic. After ultrasonic use air-polishing device on each tooth for 5 sec. OHI is given to the pt along with any necessary prescription or rinses like CHX.

  • Mechanical and chemical antimicrobial intervention is the mainstay of preventive periodontal therapy. Chemotherapeutics alone are unlikely to be effective in the presence of subgingival calculus, subgingival mechanical debridement is very important.

  • Toothbrushing and rinsing alone do not reach pathogens residing in periodontal pockets of increased depths, oral hygiene procedures should include subgingival treatment with home irrigators or other appropriate self-care remedies.

  • Recall every 3 months in pts with ongoing perio destruction and microbial sampling may be needed. Pts with stable perio diagnosis can be scheduled for maintenance every 4 months.

Matuliene 2008                ARTICLE

P:To investigate the influence of residual PPD 5mm and BOP after active periodontal therapy (APT) on the progression of periodontitis and tooth loss.

M&M:Retrospective longitudinal study, 172 patients (95F/77M), 14-69 years of age were included in the study. Complete clinical periodontal (PD, REC, CAL, BOP, MOB, FURC) and radiographic examinations were performed (full mouth x-rays) at baseline, at the end of the active therapy and at re-evaluation. At re-eval the full mouth x-rays were replaced by panoramic x-rays. Periodontal therapy consisted of OHI, SRP and periodontal surgery if indicated. Prosthetic therapy using dental implants or fixed prosthesis was performed. Following completion of comprehensive periodontal treatment, patients were enrolled in SPT program. Re-eval was performed after a mean of 11.34.9 years of age. Smoking habits, health status and frequency of recalls during SPT were assessed. A case was defined as being progressive if there were at least 2 teeth with 3mm attachment loss at the end of APT and re-eval.

R:

  • Number of residual PPD increased during SPT.

  • Increased PPD was associated with tooth loss. The increase by 1mm PPD increased the odds and therefore the probability of tooth loss in a statistically significant way.

  • Heavy smoking (, initial diagnosis (severe periodontitis), duration of SPT (>10years) and PD6mm were risk factors for disease progression.

  • PPD6mm and BOP 30% represented a risk for tooth loss.

C:Residual PPD 6mm after APT represented a risk factor for both progression of periodontitis and tooth loss during SPT.

Position Paper: Supportive Perio Therapy 1998               NO ARTICLE

P:To provide an overview of the role of SPT in the tx of perio dz

D:SPT includes an update of medical and dental hx, extraoral and intraoral soft tissue exam, dental exam, perio evaluation, rx review, removal of plaque and calculus from supra-g and sub-g regions, selective root planing if indicated, polishing of teeth, and a review of the pt’s plaque removal efficacy.

Tooth loss in some pts has been shown to be inversely proportional to the frequency of SPT. Ten years after perio therapy, pts who had received at least periodic SPT had SS decreased PD and tooth loss. Less CALoss has also been linked to frequency of SPT. Some individuals still may suffer CALoss despite maintaining a regular SPT schedule. Additional microbial analysis as well as anti-microbial therapy may be necessary for those individuals.

For pts without a history of periodontitis (simply gingivitis), SPT performed every 6 months is sufficient. Although there are several different opinions on how often perio pts should receive SPT, the data suggests that it should be performed at least every 3 months. Nevertheless, the frequency of SPT should be individualized. SPT may be performed by the dentist and/or periodontist depending on severity of the perio dz.

Discuss the reported level of patient compliance with maintenance recommendations and its implications for periodontal practice? How important is compliance for prognosis of teeth?

Wilson 1984                ARTICLE

P:To determine compliance of maintenance schedules recommended in a private periodontal practice.

M&M:961 patients with chronic periodontitis were divided based on the severity of disease. Procedure performed was either SC/RP, flap with osseous, or flap alone. During active therapy, the importance of recall was stressed to patients. After active therapy, all patients were placed on 3-month recall schedule and later modified as needed. 92% of the patients were on a 3- or 4-month recall interval. Compliance was classified as complete, erratic, or none based on the longest recall interval possible for each classification. Study period was 8 years.

R:Only 16% completely complied with recommended maintenance recall. Erratic compliance was found in 49% of patients, and 34% never reported for any maintenance therapy. Compliance decreased over time after active therapy. Patients who had periodontal surgery were in compliance slightly more often, and patients with mild disease kept their maintenance schedules the best. Patients with a poor prognosis had the worst record of all categories (higher proportion of non-compliant, and least completely compliant). The less often patients were required to return for maintenance, the better they complied.

BL:The vast majority of patients (84%) did not completely comply with maintenance recall. One third didn’t return after active therapy.

Wilson 1993                ARTICLE

Purpose:Comparison of a literature review on compliance improvement techniques and the results shown by implementing these techniques in a practice.

Methods: 604 patients were studied during the 5 yrs from which data were collected. Some patients were alternating maintenance with their general dentist office. Efforts to improve compliance included simplifying compliance, maintaining records of compliance, informing patients of the consequences of noncompliance, and attempting to identify non-compliers before active therapy was initiated. Also patients’ scheduling included accommodating patients’ schedules and post card reminders.

Results: Mean age 46 yrs (range 18-78). 32% were complete compliers. 48% were erratic. 20% were non-compliers. 44% were men. Noncompliance was highest in the 0-2 month group.

Conclusion: Non-compliance can be reduced if the problem is recognized and efforts are made to increase compliance.

Novaes 1996                ARTICLE

P:To present data from private periodontal practice records to analyze compliance according to age, sex, and type of therapy and to discuss about the need for an aggressive office routine to keep patients committed to supportive therapy.

M&M:Data was obtained from 1280 records of patients seen over a 20- year period in a private periodontal practice in Brazil. All patients had completed the proposed treatment including the procedures indicated. Cases were considered surgical if they received basic periodontal therapy followed by surgical intervention in at least 3 areas. Recall visits were scheduled with intervals 2-6 months. Those who fulfilled 2/3 of the appointments were considered regular (R) less than 2/3, irregular (I); and those who did not return for any appointments, noncompliant (N). Patients were classified according to age, sex, and type of therapy. The compliance and noncompliance groups were further subdivided according to age: <20, 21-40, 41-60, & > 60 years. The 854 patients who initially co-operated and then abandoned supportive periodontal therapy were analyzed according to sex and type of surgery.

R:

  • 25.2% were non-compliant and 74.8% returned for at least some appointments

  • Among those who returned, 40.1% returned regularly, 34.7% returned irregularly

  • Number of women who returned was greater than the number of men (76.5% vs 72.2%)

  • Patient ages 21-40 and 41-60 showed the greatest interest in supportive therapy

  • Proportion of surgical patients who returned for supportive therapy was significantly greater than non-surgical patients, however there was not SSD between surgical therapy and non-surgical therapy for regular compliance (40.5% vs 38.9%)

  • 854 patients begun but did not continue with SPT (66.7%), more females than males (59.5% vs 40.5%), greater among surgical cases than non-surgical

C:The vast majority of patients did not comply w/ the recommended recall periods. The authors recommended an intense program of education and motivation for the 1st year of therapy.

Miyamoto 2006                ARTICLE

P: To evaluate the impact of compliance (complete vs erratic) on common clinical parameters in a long term observation period (15-23 years).

M+M: A retrospective study of 505 patients over an observation period of 15-23 years. Patients were classified by two methods of classification:

Compliance 1 classification– pts attended at least 70% of all expected maintenance visits were considered complete compliers while those who failed >30% of maintenance visits were considered erratic

Compliance 2 classification– pts who attended most of their scheduled maintenance visits were considered complete compliers while those who failed to attend a maintenance visit for a minimum of 2 years were considered erratic

In both classification schemes, patients who did not respond to recommendations for maintenance therapy or disappeared completely during the active phase of treatment were designated as total non-compliers. Total non-compliers were excluded from this study.

The groups were evaluated for: Plaque index reduction vs. no reduction; bleeding index reduction vs no reduction; reduction in pockets >3 mm vs no reduction; no increase in DMFT vs increase; and no tooth loss vs tooth loss

R: Complete compliers tended to show a reduction in BOP and a reduction in plaque index compared to the other groups.

Complete compliers under compliance 2 were less likely to see a reduction in pockets

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