133. Effects of Therapy:

Rapid Search Topics

the necessity of supportive periodontal therapy
prevalence of tooth loss during maintenance
attachment loss during maintenance therapy
the importance of plaque control during maintenance
patient compliance during maintenance therapy
the effect of maintenance on wound healing
the results of periodontal treatment when patients are not maintained
treatment results when maintenance id done at general dentists offices
the ideal maintenance frequency after periodontal treatment
treatment failure and the need to retreat
refractory periodontitis and it’s management

Study Questions:

Why is maintenance therapy necessary?
What is performed at a maintenance visit?
Discuss the reported level of patient compliance with maintenance recommendations and its implications for periodontal practice?
How important is compliance for prognosis of teeth?
What are the effects of maintenance therapy on wound healing?
What happens if treated patients are not maintained?
Is there a difference in treatment results if maintenance is done in general dentists offices?
What is the ideal maintenance frequency after periodontal treatment?
What causes failure of treatment?
When would you consider re-treatment for a patient?
How often do we need to retreat patients for periodontitis?
What is “Refractory Periodontitis” and how can it be managed?

References:

(References without links have not been added yet)

SPT (Periodontal Maintenance) . Residents- some of your references from this section in your 2020 LR will be found further down in the section “Maintenance done in general dental offices.” I preserved that important sub-section.

Trombelli, L., G. Franceschetti, and R. Farina, Effect of professional mechanical plaque removal performed on a long-term, routine basis in the secondary prevention of periodontitis: a systematic review. J Clin Periodontol, 2015. 42 Suppl 16: p. S221-36.
Dannewitz, B., et al., Loss of molars in periodontally treated patients: results 10 years and more after active periodontal therapy. J Clin Periodontol, 2016. 43(1): p. 53-62.
Schallhorn RG, Snider LE. Periodontal maintenance therapy. JADA 101:227-231, 1981.
Ramfjord SP. Maintenance care for treated periodontitis patients. J Clin Periodontol 14:433- 437, 1987.
Echeverria JJ, Manau GC, Guerrero A. Supportive care after active periodontal treatment. A review. J Clin Periodontol 23:898-905, 1996. (Review)
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.
Ramfjord SP, et al. Oral hygiene and maintenance of periodontal support. J Periodontol 53:26-30, 1982.
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.
Lindhe J, Nyman S : Long-term maintenance of patients treated for advanced periodontal disease. J. Clin. Periodontol. 11:504-514, 1984.
Rosling B, Serino G, et al. Longitudinal periodontal tissue alterations during supportive therapy. J Clin Periodontol 2001; 28:241-249.
Teles RP, Patel M, Socransky SS, Haffajee AD. Disease progression in periodontally healthy and maintenance subjects. J Periodontol. 2008 May;79(5):784-94.
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.
Listgarten MA, et al: Clinical and microbiological characteristics of treated periodontitis patients on maintenance care. J. Periodontol. 60:452-459, 1989.
Pontoriero R, et al : The angular bony defect in the maintenance of the periodontal patient. J. Clin. Periodontol. 15:200-204, 1988.
Lindhe J, et al: Long-term effect of surgical/non-surgical treatment of periodontal disease. J. Clin. Periodontol. 11:448-458, 1984.
Slots J, Jorgensen MG. Efficient antimicrobial treatment in periodontal maintenance care. JADA 131:1293-1304, 2000.
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
Position Paper: Supportive Periodontal Therapy (SPT). J Periodontol 69:502-506, 1998. (Review).
Leavy PG, Robertson DP. Periodontal maintenance following active specialist treatment: Should patients stay put or return to primary dental care for continuing care? A comparison of outcomes based on the literature. Int J Dent Hyg. 2018 Feb;16(1):68-77.

Patient Compliance

Wilson TG, Glover ME, Schoen J, Baus C, Jacobs. Compliance with maintenance therapy in a private periodontal practice. J. Periodontol. 55:468-473, 1984.
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.
Novaes A, Novaes A Jr, Moraes N, Campos G, Grisi M. Compliance with supportive periodontal therapy. J Periodontol 1996; 67: 478-485..
Novaes A B Jr , Novaes A B. Compliance With Supportive Periodontal Therapy. Part 1. Risk of Non-Compliance in the First 5-year Period J Periodontol 1999 Jun;70(6):679-82.
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.
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.
Fardal Ø. Interviews and assessments of returning non-compliant periodontal maintenance patients. J Clin Periodontol. 2006 Mar;33(3):216-20.
Lee, C.T., et al., Impact of Patient Compliance on Tooth Loss during Supportive Periodontal Therapy: A Systematic Review and Meta-analysis. J Dent Res, 2015. 94(6): p. 777-86.
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.

Effects of Maintenance on Healing

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

Treated patients – not maintained

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

Maintenance done in general dental offices

Axelsson P, Lindhe J. The significance of maintenance care in the treatment of periodontal disease. J. Clin. Periodontol. 8:281-294, 1981.
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.
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..
Nibali L, Sun C, Akcalı A, Meng X, Tu YK, Donos N. A retrospective study on periodontal disease progression in private practice. J Clin Periodontol. 2017 Mar;44(3):290-297. doi: 10.1111/jcpe.12653. Epub 2016 Dec 27.
Fardal Ø, Grytten J, Martin J, Houlihan C, Heasman P. Using prognostic factors from case series and cohort studies to identify individuals with poor long-term outcomes during periodontal maintenance. J Clin Periodontol. 2016 Sep;43(9):789-96. doi: 10.1111/jcpe.12573. Epub 2016 Jul 15.

Frequency of Maintenance

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.
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.
Listgarten MA, et al: Comparative longitudinal study of two methods of scheduling maintenance visits; 4-year data. J. Clin. Periodontol. 16:105-115, 1989.
Rosen B, Olavi G, et al. Effect of different frequencies of preventive maintenance treatment on periodontal conditions. J Clin Periodontol 26:225-233, 1999.
Shiloah J, Patters MR. Repopulation of periodontal pockets by microbial pathogens in the absence of supportive therapy. J Periodontol 1995; 67: 130-139..
Caton J, Proye, M. Polson A., Maintenance of Healed Periodontal Pockets After a Single Episode of Root Planing. J Periodontol 1982 Jul;53(7):420-4.

Treatment Failure and Retreatment.

Kerr NW. Treatment of chronic periodontitis- 45% failure rate after 5 years. Brit Dent J 150:222-224, 1981.
Chace R. Retreatment in periodontal practice. J Periodontol 48:410, 1977. (Review)
Rateitschak KH.Failure of periodontal treatment. Quintessence Int. 1994 Jul;25(7):449-57.
Fardal and Linden. Re-treatment profiles during long-term maintenance therapy in a periodontal practice in Norway.J Clin Perio 2005; 32:744-749.
Morrison EC, Ramfjord SP, et al: The significance of gingivitis during the maintenance phase of periodontal therapy. J Periodontol 53:31-34, 1982.

“Refractory Periodontitis”

Magnusson, C B Walker Refractory Periodontitis or Recurrence of Disease Review. J Clin Periodontol 1996 Mar;23(3 Pt 2):289-92.
Jenkins WM, Said SH, Radvar M, Kinane DF. Effect of subgingival scaling during supportive therapy. J Clin Periodontol 27:590-596, 2000.
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.

Abstracts:

SPT (Periodontal Maintenance)

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

Topic: Maintenance

Authors: Trombelli, L., G. Franceschetti, and R. Farina

Title: Effect of professional mechanical plaque removal performed on a long-term, routine basis in the secondary prevention of periodontitis: a systematic review.

Source: J Clin Periodontol, 2015. 42 Suppl 16: p. S221-36

Type: Systematic Review

Keywords: dental plaque; dental scaling; periodontal attachment loss; periodontitis; tooth loss

Purpose: To systematically review the evidence evaluating the efficacy of long-term, routine, professional mechanical plaque removal (PMPR) in the prevention of periodontitis progression.

Method: A literature search was conducted to identify prospective studies evaluating the effect of PMPR in periodontitis patients undergoing active periodontal therapy and enrolled in a maintenance program including PMPR for at least 3 years.

Results: No RCTs evaluating the efficacy of the intervention when compared with no treatment during maintenance were found. Nineteen prospective studies assessing the effect of PMPR as part of the supportive therapy were included. In general, studies reported no to low incidence of tooth loss during follow-up. The weighted mean yearly rate of tooth loss was 0.15 ± 0.14 and 0.09 ± 0.08 for follow-up of 5 years or 12-14 years, respectively, with no significant differences between groups. Mean clinical attachment loss was <1 mm at follow-up ranging from 5 to 12 years.

Conclusion: Patients treated for periodontitis can maintain their dentition with limited variations in periodontal parameters when regularly complying with a SPT regimen based on routine PMPR. On the basis of the existing evidence, however, the true magnitude of the impact of PMPR on long-term tooth survival and stability of periodontal parameters has still to be assessed.

Topic: Tooth loss

Author: Dannewitz, B., et al.,

Title: Loss of molars in periodontally treated patients: results 10 years and more after active periodontal therapy

Source: J Clin Periodontol, 2016. 43(1): p. 53-62.

Type: Retrospective study

Keywords: Furcation involvement, loss of molar teeth, tooth loss, risk factors

Purpose: To identify risk factors for loss of molars during supportive periodontal therapy (SPT).

Materials and Methods: A total of 136 subjects with 1015 molars at baseline were examined retrospectively. Patients had undergone active periodontal therapy (APF, GTR, OFD, etc) between 1990 and 2002 (12 years). After which, patients were put into a SPT program based on each patient’s individual risk The association of risk factors with loss of molars was assessed using a regression analysis. Furcation involvement (FI) was assessed clinically at start of periodontal therapy and assigned according to Hamp.

Results: 50 molars were extracted during active periodontal therapy and 154 molars over the average SPT period of 13.2 +/- 2.8 years. FI degree III, baseline bone loss (BL) > 60%, residual mean probing pocket depth, and endodontic treatment were identified as relevant tooth-related factors for loss of molars during SPT. However, mean survival time for molars with FI III or BL > 60% were 11.8 and 14.4 years, respectively. Among the patient data, age, female gender, smoking. and diabetes mellitus were significant predictors for loss of molars.

Conclusion: Overall, periodontal therapy results in a good prognosis of molars.

Degree III FI, progressive BL, endodontic treatment, residual PPD, age, female gender, smoking, and diabetes mellitus strongly influence the prognosis for molars after active perio treatment.

Schallhorn 1981

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

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

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.

Echeverria 1996

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 OH in the overall context of supportive care.

Disc: Periodontal diseases are infections with a high potential for recurrence, progressive Aloss and eventually, tooth loss. Current treatments for 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 small number 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 OH 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 OH becomes a key factor in the long-term preservation of periodontal support.

Tonneti 2000

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 3^rd 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

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

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 3^rd 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.

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

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 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 unchanged during 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

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

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

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.

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.

Pontoriero 1988

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.

Lindhe(2) 1984 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

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

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.

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

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.

Position Paper: Supportive Perio Therapy 1998

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

Topic: Specialist vs primary dental care outcomes

Author: Leavy PG, Robertson DP.

Title: Periodontal maintenance following active specialist treatment: Should patients stay put or return to primary dental care for continuing care? A comparison of outcomes based on the literature.

Source: Int J Dent Hyg. 2018 Feb;16(1):68-77.

DOI: 10.1111/idh.12288

Type: Review

Keywords: Specialist care, periodontal maintenance, primary dental care, scaling and root planing

Purpose: To review the evidence for the efficacy of periodontal maintenance (PM) carried out in primary dental care (PDC) compared to the specialist setting for patients previously treated in a specialist setting for chronic (ChP) or aggressive (AgP) periodontitis.

Methods:

P: patients who have received specialist treatment for periodontitis
I: periodontal maintenance in primary dental care (PDC)
C: periodontal maintenance in specialist setting
O: disease progression and recurrence (Parameters: CAL, tooth loss, pocket probing depths, gingival inflammation/BOP)

Randomized clinical trials and observational studies were included. MEDLINE, EMBASE, Web of Science, and Cochrane were searched up to and including April 2015.

Results: A total of 56 articles were selected from an initial yield of 1149. Active periodontal therapy varied widely across the studies and included OHI, SRP, open flap debridement, GTR, and surgical pocket elimination. There were many differences in compliance, number of visits, and recall length.

Clinical attachment level:
mean change was significantly better in hospital PM (range: -0.10 – -0.42 mm) than PDC PM (-0.56 – -0.076 mm)
Mean change better for specialist (-0.1 – + 0.2 mm) versus PDC PM (-2.2 – -0.13 mm)
PD:
mean change was significantly better in hospital PM (range: -0.18 mm – +0.32 mm) than PDC PM (+0.20 – +0.69 mm)
Mean change better for specialist (-1.8 – + 0.8 mm) versus PDC PM (-0.59 – +1.1 mm)
Changes in CAL and PD were not statistically significant in all studies
GI/Aggressive periodontitis: juvenile and post-juvenile periodontitis inflamed sites dropped from a high of 21% to a low of 4% (across studies) after hospital APT but increased 22-38% after 5 years of primary dental care perio maintenance.
Tooth loss: least reported, statistically insignificant

Conclusion: Periodontal maintenance in a specialist environment is more effective in sustaining periodontal stability, especially for patients maintained for more than 12 months. The study could not say whether PDC provides the same level of care regarding periodontal maintenance. Further studies are needed especially in patients who have previously had severe periodontitis.

Compliance

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

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

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

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.

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 1^st year of therapy.

Topic: Maintenance Therapy

Author: Novaes A.B., Novaes A.B.

Title: Compliance with supportive periodontal therapy. Part 1. Risk of Non-Compliance in the first 5-year period.

Source: J Periodontol 1999 Jun;70(6):679-82

DOI: 10.1902/jop.1999.70.6.679

Type: Retrospective Study

Keywords: patient compliance, periodontal diseases/therapy, risk factors

Purpose: Develop a profile for patients who initiated but abandoned supportive periodontal therapy (SPT) by analyzing patient factors.

Methods: 874 patients in a private practice who completed active treatment 5 years earlier and began SPT were analyzed. SPT period was broken up into 5 year periods for up to 20 years. Recall visits were scheduled 3-4 months intervals, patients who initiated SPT but abandoned during the next 5 years were considered non-compliant. Profiles of non-compliant patients were analyzed to form a profile.

Results: After 5 years, 648 had surgical treatment and 226 had non-surgical treatment. After 5 years 45.5% of surgical and 50.4% of non-surgical patients were non-compliant. Age is a risk factor for non-compliance, especially with younger groups. Combining type of therapy, gender, and age together showed a risk factor for non-compliance. <20 yo 80% of non-surgical males and 62.5% of females were noncompliant. In the 21-30 age group, 73.3% and 55.9% were non-compliant. 31-40 age group, non-compliance decreased for 46.2 and 40% for males and females. Little change in 41-50 group, and for the >51 group non-compliance for females stabilized at 33.5% and increased for males at 50%. For the surgical group, <20 yo had high non-compliance with little difference between gender (77%). Both groups decreased in 21-30 group to 60 and 50.7%, decreases continued with difference between male and female remaining stable.

Discussion: Extra encouragement for males less than 40yo that underwent non-surgical treatment.

Miyamoto 2006

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

> 3mm compared to erratic, whereas complete compliers in compliance 1 had same likelihood of reduction in periodontal pockets compared to erratic compliers.

Under both compliance schemes complete compliers were more likely to exhibit tooth loss than erratic compliers with greatest tooth loss in Compliance 1 classification.

BL: Complete compliers in both classification groups showed a reduction in plaque and bleeding over time. Decision for tooth extraction made at maintenance visits may result in greater tooth loss. No difference based on these classification systems b/w Complete compliers and erratic compliers when it came to decreasing sites with PD>3mm.

Miyamoto 2010

P: To evaluate the impact of compliance (complete vs erratic) on alveolar bone loss and tooth survival in a long-term observation period (15-23 years).

M+M: A retrospective study of 295 patients over an observation period of 15-23 years (minimum 15 years of maintenance) in a general practitioner’s private practice. 3^rd M not included in the analysis. Teeth were divided into non-molar (5,585 teeth) and molar categories (1,917 teeth). All pts were diagnosed, treated, and maintained accordingly under the supervision of one clinician and the same private practice for the course of this study. The bone loss analysis was measured on both M and D aspect of the tooth, and the site of greater bone loss was used. Standard Pas were used. Maintenance was 3-6 months with 30-60min appts based on the perio condition of each pt. Any pt with a PD of 4mm was placed on 3-month maintenance, otherwise, they were on the 6-month interval period. Regression analysis performed.

R: 98 pts were complete compliers (failed % of appts) and 197 were erratic. NSSD in gender and smoking at initial, re-eval and final visits between compliers and erratic pts. Molar teeth had approximately 30% reduction in the risk of tooth loss for complete compliance. In contrast, there was NSSD in reduction of teeth loss among non-molars, although the trend was similar to that of molars. Complete compliance resulted in 27-31% less bone loss among molars, although this did not reach SS. In non-molar teeth, complete compliers were found to have over 50% reduction in risk of alveolar bone loss.

D: The perio condition of the pts in this study may be better than in other studies that are conducted in the private practices of periodontists.

BL: Complete compliers with increased frequency of perio maintenance is important for improved dental prognosis through reduction of tooth loss among molars and minimization of bone loss among non-molars.

Topic: Prognosis

Author: Fardal Ø, Grytten J, Martin J, Houlihan C, Heasman P

Title: Using prognostic factors from case series and cohort studies to identify individuals with poor long-term outcomes during periodontal maintenance.

Source: J Clin Periodontol. 2016 Sep;43(9):789-96. doi: 10.1111/jcpe.12573. Epub 2016 Jul 15.

Type: Retrospective study

Keywords: healing, plaque, gingival inflammation, post-surgical healing

Purpose: To apply prognostic factors from several outcome studies and to identify prognostically relavent factors.

Methods and Materials: A total of 1251 patients who received initial periodontal treatment and were compliant with periodontal maintenance between 1986 and 1998 in a private specialist practice in Norway. Factors to be assessed were: (1) patients who lost a tooth/teeth during periodontal maintenance; (2) patients who were non-responding to treatment; (3) patients needing re-treatment during periodontal maintenance. In addition, tooth loss was examined by initial prognosis and it was determined which of the prognostic factors were also risk factors. Chi squared analysis was carried out for the outcomes of patients with-, and without prognostic factors. Significance level was set at p ≤ 0.05. Sensitivity and specificity was calculated for patients with and without prognostic factors.

Results: The prognostic factors only identified a small proportion of patients who lost teeth (34–38%). Combining prognostic factors resulted in a lower accuracy. A higher proportion of patients with no prognostic factors lost teeth (53.8–96.2%). The chance of identifying a non-responding patient based on family history was 5.9%, for stress 32.4%, and for heavy smoking 8.7%. Combining prognostic factors identified 5–22% out of a total of 40% of patients needing re-treatment. six out of nine (67%) teeth with an initial hopeless prognosis were lost, 10/109 (9%) teeth with a poor prognosis were lost, 11/346 (3%) teeth with a moderate prognosis were lost and 9/1972 (0.46%) of teeth with a good prognosis were lost. None of the prognostic factors was found also to be a risk factor for developing periodontal diseases.

Conclusion: Based on the scope of this study, it was difficult to determine risk factors individually and in combination that can be reliably used for accurate prognostication of teeth.

Topic: Compliance

Author: Lee, C.T., et al.

Title: Impact of Patient Compliance on Tooth Loss during Supportive Periodontal Therapy: A Systematic Review and Meta-analysis

Source: J Dent Res, 2015. 94(6): p. 777-86.

Type: Systematic review

Keywords: Periodontitis, evidence-based dentistry, risk, treatment outcome, review literature as topic, root planing

Purpose: To analyze the effect of appointment compliance during supportive periodontal therapy (SPT) on tooth loss and to investigate the potential parameters affecting the association between compliance and tooth loss.

Methods: PRISMA guidelines were followed for this study. The focused question was, “does a patient’s degree of compliance with appointments affect the risk of tooth loss during supportive periodontal therapy?” Medical data bases were searched by two authors independently. Quality of the selected articles was assessed. Risk ratio of tooth loss was the primary outcome investigated.

Results: 11 studies met the inclusion criteria, and 8 are included in this review. Teeth in the regular compliance group had significantly less risk of being lost during SPT that did the teeth in the erratic compliance group. Based on risk difference, to prevent 1 tooth from being extracted, 20 teeth have to be maintained in patients regularly compliant with SPT during longer than a 5- year follow up period. Tooth loss was significantly lower for regularly compliant patients during SPT. One study showed that regular patients lost on average one tooth less than erratic patients over and 8-year follow up.

Discussion: A patient’s regular compliance with appointments during SPT can reduce the risk of having tooth loss. The degree of compliance is negatively related to the risk of tooth loss, though there was considerable data heterogeneity in the study.

Konig 2002

Purpose: To evaluate treatment outcome of compliant patients treated for moderate to advanced periodontitis in terms of PD changes and tooth loss during active treatment and supportive periodontal therapy.

Materials and methods: Longitudinal retrospective study based on tooth status and PD of compliant patients treated for moderate to advanced periodontitis at the Department of Periodontology University of Kiel, Germany. They had received active treatment and SPT and were followed for a period of at least 10 years. Active treatment included SRP and access flap surgery (no pocket elimination, osseous resections, regenerative procedures or occlusal analysis were performed). PD and plaque index values were recorded annually during the maintenance phase. Pt’s information was obtained from their file and comprised age, gender, number of teeth, PD, mobility, furc involvement, time of tooth loss and plaque index.

Results: Baseline data

Pt entered the maintenance phase with a mean number of 22 teeth. Mean PD started at 2.9mm after active treatment and was 3.6mm by year 8 of SPT. 2/3 of patients had good oral hygiene with a PI of 30% or less.

Overall 266 teeth (total 3353 teeth at baseline) were extracted during the observation period.167 during active treatment and 99 during SPT. More teeth had to be removed in the maxilla than in the mandible (10.3 vs 6.6%), mainly due to the higher extraction rate of maxillary 1^st premolars (13.1%) and 1^st and 2^nd molars (19.3%). In the mandible, higher extraction rates were observed at the molars (12.8%). Mandibular 1^st molars were the only teeth with higher extraction rate during SPT (6.3%) that during active treatment (2.1%). During active treatment 82% were extracted for periodontal reasons. During SPT 48% of the teeth were extracted for periodontal reasons, 30% for endodontic reasons and 14% as a consequence of further prosthodontic treatment.

Single rooted teeth had between survival prognosis. Molars without furcation involvement had survival rates similar to those of non-molar teeth. Increased furc involvement reduced survival rate. Increasing mobility also worsened the prognosis of the tooth.

45% of patients lost no teeth during observation period, 37% received extractions during either active treatment or SPT and 18% in both phases. Mean tooth loss per patient during SPT was 0.07 teeth/year and patients who received extraction during SPT lost on average 1.9 teeth/subject. Smoking and antibiotic therapy were statistically significantly associated with tooth loss.

After active treatment % of teeth with PD more than 6mm dropped form 21.8% to 0.1%. After 8 years of SPT it was below 2.7%. % of teeth with PD less than 4mm increased from 17% to 83.7% and reached 64.4% after 8 years of SPT. PD 4-6mm increased from 16.2 to 33% during SPT. The deeper the initial PD, the more pronounced the decrease after active treatment. Sites with initially shallow PDs showed minimal change. Multi rooted teeth had significantly deeper PDs at baseline and after active treatment. During 8 years of SPT mean PD values increased for all categories.

Significant differences in PD were observed at baseline between loose and firm teeth and at the end of SPT between smokers and non-smokers. Numbers of maintenance visits/year (positively) and number of teeth at initial examination (negatively) were correlated SSD with PD changes in SPT.

Conclusion: Periodontal surgery without resective osseous recontouring in combination with regular supportive therapy can achieve stable results during an observation period of 11.7 years, irrespective of a minor increase in mean PD during maintenance.

A minority of the patients possess the greatest proportion of teeth with furcation involvement and mobile teeth, that are responsible for the majority of tooth extractions during active treatment and SPT.

Effects of Maintenance on Healing

What are the effects of maintenance therapy on wound healing?

Yumet and Polson 1985

Purpose: to evaluate histologically the healing of incisional wounds in the gingival supracrestal region in the presence and absence of bacterially induced inflammation

Materials and methods:

4 squirrel monkeys. In the experimental group, marginal inflammation was induced w. silk ligature, OH was stopped and 10 wks later, sulcular incisions were made to the crest on the F & L, but not at the IP. Pressure was applied for 30 sec w/o suturing. Control group: Similar wound were created on normal gingiva. Histology evaluated at 1,3,7,21 d.

Results:

Control:
- Areas bled less than experimental when the incision was made and the experimental sites showed clinical signs of inflammation up to 3 days.
- In the control group, epithelium was continiously present over the wound and at day 7 morphologically appeared the same as normal epithelium.
- At day 3, The CT fibers were discontinious and a fibrin clot was present.
- At day 7 fibrin was absent and had been replaced cell and reticulin fibers that were perpendicular to the incised ends of CT fibers.
- At 21 days the healing was complete and tissues showed normal morphology.
Exp group:
- There was early establishment of epithelium continuity across the wound with marked penetration of epithelium into incision, that was sig higher than the control group.
- Also, there was a 2^nd migration of epi between 7-21 d (possibly due to collagenolytic activity from the CT rather than from bact).
- This migration extended through the major portion of the supracrestal area and terminated near the cementum surface.

Discussion:

Inflammation of CT may increase the mitotic activity of basal cell layer.
The mechanism responsible for the rapid proliferation of epithelium may relate to fibrinolysis (sources- plasma, bact products, leucocytes, endothelial cells, proteases, epithelium cells associated w/inflamed CT).
So, in plaque-induced healing, a combination of bacterial, cell & tissue factors, would facilitate degradation of newly synthesized collagen.

BL: It is possible that in inflammed tissue, that the marked epithelium coverage into the supracrestal wound may predispose to an accelerated loss of CTA. Minimal epithelium coverage seems to provide basis for performing perio sx in absence of inflammation.

Westfelt 1983

P: To further evaluate the relative importance of the plaque control program maintained immediately following periodontal surgery for healing results.

M+M: 24 patients. Baseline exam of OH, GI, PD, AL and OHI. Pts had modified widman flap, then randomly divided into 3 groups. Group 1: maintenance every 2 weeks, Group 2: maintenance every 4 weeks, Group 3: maintenance every 12 weeks, including disclosing & OHI every time. This initial phase lasted for 6 months. During the subsequent 18 months, all patients were seen on 3-month recall.

R: During the initial 6 months, Group 1 showed decreased BOP and PD. The other groups had more BOP and PD > 3mm. Sites exhibiting AL > 1mm was closely related to the frequency of maintenance care, patients in Group 3 had 3x the number of sites with attachment loss >1 mm as compared to Group 1.

D: Frequent recall appointments resulted in higher frequency of plaque free tooth surfaces (78%). Also, patients with infrequent recall appointments also maintained a large number of plaque free surfaces (56%). When the critical PD was calculated for plaque free tooth surfaces in Groups 1 and 3, these values did not vary between the groups. This clearly demonstrates that it is not the frequent recall per se, but the high standard of oral hygiene obtained that influences the value of the critical probing depth.

BL: Patients who maintain optimal plaque control are most likely to establish ideal conditions for healing. It is not the frequency of recall, but the high standard of OH that influences the value of critical PD.

Treated patients- Not maintained.

What happens if treated patients are not maintained?

Becker(2) 1984

P: To report findings on 44 patients who were treated for periodontal disease but for various reasons elected not to participate in the maintenance phase of therapy.

M&M: 44 patients, mean age of 44 years participated in the study. Initial exam: PD, REC, furcation involvement, full mouth radiographic series were taken for 33/44 patients (parallel technique, no fixed holding devices), prognosis was determined. Interproximal bone levels were determined on 33/44 patients.

Treatment: sc/rp, OHI, most of the patients received osseous surgery. Upon completion of active therapy, each patient was given a post-treatment consultation at which time the importance of the maintenance therapy was stressed. All patients were called 3 times but none of them responded to recall reminders. The patients returned to the office because of an acute situation or were referred back by their dentists. The average time interval between examinations was 5.25 years. Clinical parameters were evaluated, full mouth x-rays were taken, prognosis, bone loss and tooth loss were determined.

R: 6% of teeth were lost between examinations. This represents a mean annual tooth loss of 0.29 tooth/year. Maxillary second molars presented the highest percentage of tooth loss. Mandibular cuspids and second premolars were lost least frequently. Of the 1117 teeth available at first examination, 90% were given a favorable prognosis. 3% of these were missing at the second examination. 37% of questionable teeth and 33% of hopeless teeth were missing at the second examination. 84 teeth had furcation involvement at first examination, of these 77% were unchanged and 22% had worsened by the second examination. There were no significant changes in PD between the two examinations. Bone level scores were significantly worse at the second examination.

C: Treatment without maintenance revealed a high incidence of tooth loss, worsening of furcation involvement, no reduction of mean PD between examinations, and significant bone loss. Periodontal therapy without maintenance is of little value in restoring periodontal health.

Becker 1988

P: To determine whether personality differences exist between pts who have had perio therapy and continued in maintenance compared to those who have had perio therapy and did not receive maintenance.

M&M: 34 pts who had undergone maintenance following perio therapy (group I) and 49 pts who had not had maintenance following perio therapy (group II) received a survey by mail. The survey was anonymous and consisted of grouping 300 commonly used adjectives (adjective check list) to determine personality traits.

R: Group I pts: were more outstanding in pursuit of socially recognized significance, more confident, better adjusted personally, stronger sense of personal worth, more creative, greater leadership characteristics involving self-discipline and good judgment, more independent, objective, and industrious.

Group II: more aggressive behavior, more skeptic and conformist.

The personality differences were NSS

BL: The unmaintained group had higher incidences of stressful life events, less stable personal relationships and higher negative aggression scores. This finding was not SS.

Maintenance done in general dental offices

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

Axelsson & Lindhe 1981

P: To assess the efficacy of a maintenance program to prevent disease recurrence in patients with advanced periodontitis and to monitor a group of patients referred back to a GP following active therapy for maintenance care.

M&M: 90 patients referred for specialist treatment of advanced periodontitis received exam, initial therapy and individual treatment plans. Most patients received MWF. Following surgery, patients were seen every 2 weeks for 2 months, then reexamined for baseline data and every third patient (non-Recall) was referred back to GP with specific instructions for maintenance. The other two patients (Recall) were seen in carefully controlled maintenance program at university clinic involving recalls every 2-3 months. All patients were re-examined at 3 and 6 years after baseline.

R: After active therapy, both groups had essentially the same % plaque, gingivitis and PDs. Patients with advanced periodontitis that were treated in an advanced maintenance program (Recall) had clinically healthy gingiva and shallow pockets and were able to maintain excellent OH standard and unaltered attachment levels. The non-Recall patients showed obvious signs of recurrent periodontitis at follow up exams (increased PD, BOP, CAL, and decreased OH), most evident in the molar regions.

BL: Adequate maintenance is critical in maintaining periodontal health following active therapy.

Johansson 1984

P: To study the long-term clinical effects of an intense period of cause related treatment provided by hygiene students and to evaluate compliance with maintenance care .

M&M: 44 patients with moderately advanced periodontitis, treated by 8 dental hygiene students. Non-surgical therapy, OHI, no more than 2 OH aids were introduced at each training session. SRP, adjustments to ill-fitting restorations and prophylaxis were performed. Caries preventive measures included rinsing with .05% NaFL rinse at each appointment. This study lasted an average of 8.8 visits. The patients were returned to the general dentist for maintenance. 3 years post treatment, students reexamined the patients for PI, PD, and BOP. At the re-examination, each patient answered, 8 questions concerning their periodontal maintenance care during the 3-year period. In addition, the patients were asked to provide written answers to 4 questions about the cause and prevention of dental caries and periodontal disease.

R: Majority of patients did not continue to use additional aids. After 3 years, approximately half of the patients complied with the recommendations concerning daily use of toothpicks; the remaining patients made only occasional or no use at all. Less than half of the patients who had been recommended the daily use of interproximal brushes followed the recommendation; the majority of the remaining patients did not use this aid. Likewise, the use of dental floss was reduced, while the single-tufted interspace brush had been almost completely abandoned by the patients.

73% only visited dentist 1 time/year, 20% twice/year. The majority (66%) had a prevalence of BOP <20% regardless of the frequency of the visits. Less than one third of the patients gave fully correct answers to the questions about the cause of dental caries, and the beneficial effect of proper preventive habits in these aspects. The questions about the etiology and prevention of periodontal disease were correctly answered by almost 2/3 of the patients.

	PI %	BI %	PD (buc/ling >3mm)	PD (proximal > 4mm)
Initial visit	50.9	50.5	13	21.7
After SRP	12.8	15.0	5.8	8.7
Exam at 3 years	32.6	17.6	3.6	9.3

BL: 3 years after non-surgical treatment, the periodontal status of patients showed no further deterioration with considerably less personal and professional effort than traditionally recommended.

McFall 1989

P: To assess the effectiveness of continuing professional education in altering provider behavior and pt periodontal health.

M+M: Clinically examined 1092 pts (mean age=48) in the offices of 36 general practitioners. The mean number of missing teeth was 4 teeth (3^rd molars excluded). 63% were females. Pts were regular attending patients (6 month recall) and were selected at random. Exams were done on facial and mesio-facial surfaces of Ramfjord teeth (#3, 9, 12, 19, 25, 28) and included PI, GI, Calculus Index (0=absence; 1=supragingival; 2=supra and/or subgingival), PD, and AL.

R: BOP at > 1 site occurred in 52% of the pts and 95% had AL of 2mm. 4% had AL of > 4mm. Males and nonwhites had the highest PI scores along with greatest PD and AL. Mean AL was 1.6mm. Deepest PD was equal to or greater than 4mm in 9% of pts. Calculus present in 62% of pts.

BL: Pts in this study, with regular professional care, still exhibited risk factors for periodontal disease.

Topic: Disease progression in private practice

Author: Nibali L, Sun C, Akcalı A, Meng X, Tu YK, Donos N

Title: A retrospective study on periodontal disease progression in private practice

Source: J Clin Periodontol. 2017 Mar;44(3):290-297. doi: 10.1111/jcpe.12653. Epub 2016 Dec 27

Type: Restrospective

Purpose: To assess tooth loss in a cohort of chronic periodontitis patients undergoing maintenance care in a private practice.

Methods: 100 patients with a t least 5 years of maintenance were included. Patients must have been diagnosed with chronic periodontitis with inter-proximal attachment loss ≥ 3mm in at least 2 non-adjacent teeth. At least 2 sites with more than 5mm probing depths and radiographic evidence of bone loss of more than 20% of root length at the first visit, treated with non-surgical treatment with or without subsequent surgeries. Assessed at least once a year during maintenance care and reassessed at least 5 years after completion of initial therapy. Full mouth plaque scores, probing depth, recession, bleeding on probing, mobility, furcation involvement, and clinical attachment level. Teeth which were deemed to have unfavorable/hopeless prognosis were extracted.

Results:

93% Caucasian population, with an average age of 53
58% were non-smokers, 22% were former smokers, and 20% current smokers at baseline. 6 patients gave up smoking during the study
Most common medical condition was hypertension 13%
Average observation period was 79.1 ± 18.0 months. Average annual visits were 2 with a hygienist.
Average PPD, average CAL, percentage of PPD 5– 6 mm and percentage PPD >5 mm, FMPS and FMBS – all significantly decreased between baseline and visit 2
Excluding third molars, the number of teeth extracted during active treatment was 45 (37 for periodontal, seven for endodontic reasons and one for oral hygiene access reasons).
During maintenance a total of 34 teeth were extracted excluding third molars. ( 11 for periodontal, 9 for fractures, and 3 for root caries. Overall tooth loss during maintenance was .06 teeth/patient/year
age at baseline and baseline average CAL were associated with higher risk of incidence of tooth loss at baseline.
Age, CAL, FI, prognosis, and endodontic treatment at visit 2 were associated with a higher risk of incidence of tooth loss.

Conclusion: Patients with moderate to severe chronic periodontitis under SPT undergo a low risk of tooth loss, suggests the use of combined patient-based and tooth-based prognoses systems, and also reiterates the need for prospective studies in periodontitis patients in maintenance.

Fardal 2006

Purpose: To identify, interview and make profiles of returning non-compliant periodontal patients from a specialist periodontal practice.

Materials and methods: Patients with chronic slight, moderate or severe periodontitis from a periodontal practice in Norway were included in the study. Patients received similar non-surgical and surgical periodontal therapy. Based on the initial diagnosis and the response to treatment, patients were designated the prognosis of good, uncertain or poor. All patients were seen for 2-4 times/years for maintenance visits alternating between the periodontists and the general dentists. Based on the tooth loss, re-treatment response and stability during maintenance phase, patients were categorized as stable or downhill. They were interviewed to determine the reasons for not complying with maintenance therapy the reasons for returning to the specialist practice and ether the patient was compliant with their own dentist while not compliant with the specialist practice.

Results: 61 patients were included in the study (18 males, 43 females, 36-83 years old). 60/61 pts had received surgical therapy as part of the initial treatment. 17 pts were given a good overall prognosis, 38 an uncertain and 6 a poor overall prognosis. Average time they attended the periodontal practice for maintenance visits was 3.4 years (0-11 years). 38 pts were fully compliant, 9 erratic compliers and 14 did not attend for any maintenance therapy. Average time of non-compliance before returning to the specialist office was 5.5 years. During this time they lost 1.6 teeth on average.

The main reason for non-compliance was that they chose to visit only their own dentist for maintenance care. Other reasons included ill-health and lack of motivation.

36 patients were re-referred from their dentist, 13 changed dentist and were referred by the new dentist and 12 patients contacted the office directly requesting care.

53 patients claimed to have been fully compliant with their own dentist-s maintenance schedule while not compliant with the specialist office.

Conclusion: The main reason for non-compliance given by patients returning for treatment to the periodontal specialist was found to be their understanding that the general dentist could carry out adequate maintenance therapy.

Frequency of Maintenance

What is the ideal maintenance frequency after periodontal treatment ?

Mosques 1980

Purpose: To determine how long it takes for the microbial population to return to baseline following a single session of SRP.

Materials and methods:

14 pts with radiographic evidence of generalized bone loss and multiple pockets  4mm received a single session of full mouth SRP (lasting 3 hrs).
OHI were not given. Pocket sampling at one random site per pt and clinical exams to evaluate PlI, GI and PD were performed at 3, 7, 14, 21, 28, 35, 42, 49, 56, 70, and 90 days. Darkfield microscopy was used to distinguish microorganisms.

Results:

The PlI and GI tended to decrease during the first 2 wks returning to baseline after 3-4 wks.
They declined again at 5-6 wks and remounted to baseline values toward the end of the study. Mean PD decreased from 6.4 mm to 5.0 mm or less after 1 week and remained below baseline thereafter, with the exception of day 28.
Coccoid cells increased from 25% to 76% on day 3. Return to baseline occurred after 21 days.
Spirochetes decreased from 37% to 2% on day 7. Return to baseline occurred after 42 days.
Proportion of motile rods & other bacteria decreased at 3 days and returned to baseline after one week.
Coccoid cells are negatively correlated with GI & PlI, while spirochetes are positively correlated with GI & PlI, and PD.

BL: After a single session of SRP, proportion of cocci increased within 3 days while spirochetes proportion decreased dramatically at 7 days and returned to baseline after 42 days.

Sbordone 1990
P: To determine the recolonization patterns of the microflora of periodontal pockets after a single session of SRP using both morphological and cultural techniques.

M&M: 8 patients, mean age of 43.6, with PDs at least 5mm on any surface of at least 8 teeth, radiographic evidence of bone resorption and at least 17 natural teeth. 3 sites from each patient were selected which exhibited BOP and PD ≥ 5mm. The GI and PI were determined for each and subg microbial samples were collected by a Periodontist. Each subject received a single session of SRP (2hrs) by a second Periodontist under local. 7,21,and 60 days after tx, clinical indices were obtained again and microbial samples were collected in a manner that each of 3 test sites were only sampled once after tx. Microbial sampling was done with a sterile curette. Techniques were utilized to isolate the following species: Capnocytophaga spp, Fusobacterium nucleatum, Eikenella corrodens, Actinobacillus actinomycetemcomitans, Bacteroides spp, Veillonella spp, and Actinomyces spp.

R: PDs had a small but significant improvement up to 21 days after tx.

7 days after tx= relative increase in facultative cocci and decrease in anaerobic rods, while levels of anaerobic cocci and facultative rods remained the same.

After 21 days= the facultative microbes reached a steady state while the anaerobic rods were still below pretreatment levels.

A. viscosus, Capnocytophaga spp and Eikenella corrodens reached pretreatment levels only after 7 days.

At 21 days, Strep intermedius, Veillonella parvula, and Peptostreptococcus micros were the predominant anaerobic cocci. The most prevalent anaerobic rods prior to and 60 days after were Fusobacterium nucleatum, B. gingivalis, and B. intermedius.

Darkfield Microscopy= 7 days after SRP incease % of cocci and decrease in % of spirochetes. At 21 days this pattern continued. At 60 days the composition of the microflora was comparable to that observed before tx.

D: Clinical implications of the study include the usefulness of initial therapy- which was confirmed by the changes in the subgingival flora. However the effects of SRP are short lived, as evidenced by the recolonization of subgingival sites with potential periodontal pathogens 3 weeks after tx. This would support the need for frequent recall visits for pts who might be periodontally at risk.

BL: A single session of SRP is clearly insufficient to maintain a healthy subgingival microflora.

Listgarten (2) 1989

PURPOSE: To compare two methods for scheduling maintenance visits.

M&M: 116 patients followed longitudinally over 4 years with maintenance either q3 month (control group n=47) or based on the differential dark field microscopic count of different subgingival bacteria (test group n=33). Recurrent periodontitis was considered an increased PD of 3mm from baseline.

RESULTS: No significant difference in disease recurrence was noted between the two schedules (q3 months or avg q19.4 months). Yet, over 50% had at least one site of recurrent disease (an increases in PD from baseline of 3mm or more). Molars and maxillary premolars were the teeth most affected by disease recurrence. 81% in the interproximal and only 19% buccal/lingual were affected.

BL: Some patients may remain in good periodontal health without a strict q3 month recall schedule.

Rosen 1999

P: to evaluate the effects of the interval of supportive recall treatment, provided at q 3, 6, 12 and 18 month intervals.

M&M: The subjects for the study were recruited from pts attending a public, general dentistry clinic. Prior to baseline, 323 pts were given necessary dental treatments to provide a proper baseline for the study. 153 pts participated, 4 test grps: recalls q 3,6,12 and 18 most, each group having age stratification: 21-34 y, 35-49y and 50y. Baseline, intermittent and final recordings included PI, BOP, PD and PAL. Final exams were done after 54-66 months.

R: The maintenance visits took 0.5-1.0 hr apiece. The analyses showed some advantage to shorter recall intervals for plaque and bleeding scores (3 month recall tended to improve, 18 mo recall tended to rebound but NSD). Similarly, there was a trend that the 18-month group showed a higher percentage of B/L furcation sites with CALoss > 1.0 mm than the other groups. The majority of the subjects did show some disease progression. Apart from these trends, the analyses failed to demonstrate differences b/w the groups for either changes of PD or PAL.

BL: There is some benefit to a shorter recall interval with regards to plaque and bleeding. Even so, this trial supports that recall intervals up to 12 months might reduce perio dz progression in pts with a history of limited susceptibility to the disease.

Cr: Pts from general practice (may have had limited susceptibility to periodontal disease).

Shiloah 1995

P: To determine 1.the rate of repopulation of pockets by A.a., Pg, and Pi after SRP and 2. If intrapocket microbial irrigation slows the repopulation rate.

M&M: 6 pts w/ moderate to severe perio disease, 41 inflamed pockets of ≥ 5mm on non-adjacent teeth. Base line clinical exam paramenters were measured including: PI,GI,GCF,PD,CAL and microbial samples were taken with paper points and analyzed w/ DNA probe, followed by SRP. (4-7 hours of SRP) 1 to 2 tth per patient were randomly assigned to either: control grp with no irrigation or irrigation with either .85% saline, 5% tetracycline HCL, or Chlorhexidine. Subjects received no additional tx for 1 yr. Clin parameters & microbial analyses recorded again at 1 wk & 1,3,6,9, and 12 mos post SRP.

R: NSD found between the irrigation groups nor when all irrigation groups were combined and compared to non-irrigated in regard to repopulation of bacteria. Aa was detected in 34% of sites initially, then 14% (1wk,1mo,3mo), 21% (6mo), 28% (9mo), 50% (12mo). Pg was detected in 80% of sites initially, then to 18% (1wk), 15% (1mo), 3% (3mo), 15% (6mo), 18% (9mo), 36% (12mo).

Pi was detected in 90% of sites initially, then to 8% (1wk), 19% (1mo), 16% (3,6 mo), 30% (9,12 mo). 51% of sites were infected initially w/ 2 species vs. 22% & 27% for 1 & 3 species.

Tx resulted in reduction of infection below detectable levels by 3 target species in 78% of infected sites @3 mo, 68% @6mo, 58% @12mo. Half or fewer of the originally infected sites became reinfected at 12 months, in spite of no maintenance. Sites w/ Aa infection originally appear more susceptible to reinfection.

C: Thorough SRP had a lasting suppressive effect on these pathogens in chronic perio. A single session of irrigation did not affect the repopulation of pockets by Aa, Pg, Pi. Amount of GCF flow, pre-op PD, and composition of initial subgingival microflora were the significant factors shown to predict repopulation. Reinfection by Aa, Pg, and/or Pi may constitute a risk factor that diminishes the effect of therapy in the absence of SPT.

Treatment Failure and Retreatment

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

Kerr 1981

P: To perform a critical appraisal of the periodontal health of patients 5 years after extensive periodontal treatment and return to the care of their general dental practitioner.

M+M: 56 pts had treatment divided into 3 phases (diagnosis, corrective and maintenance). Post surgery recall at periodontal office was 6-weekly visits expanded to every 3 months based on the patient’s home care. Once the patient demonstrated a consistently low PI they returned to their G.P. (this time varied from 9 months to 1.5 years). Patients were recalled after 5 years. Using the Periodontal Index (Russell) and Plaque Index (Silness & Loe). A Perio Index of more than 3 and a PI > 0.5 (range 0-1.9) were considered failure.

R: 44/56 patients responded to the recall. 27.7% of those treated were deemed to be successful in both criteria (perio index and plaque index), 27.7% for partial success (only fulfilled with perio index>3 requirement), leaving with 45% as failure.

BL: Within a 5-year period, approximately half of the patients showed signs of periodontal deterioration, according to the author’s definition of a failure. Results seemed to indicate that a periodontal patient must be reviewed at intervals of 3-4 months, certainly not more than 6 months, if periodontal health is to be maintained. Some of the 27% patients could be evaluated at longer intervals and be expected to maintain gingival health, but there is no way to identify this group in the short term. Older pts and females were more successful.

Chace 1977

P: A review of some reasons for treatment failure and to present his philosophy for their management.

Disc: All patients treated for periodontal disease require professional maintenance. The degree of professional care depends on the severity of the original involvement, the skill and motivation of the patient in oral hygiene procedures, and the susceptibility of the patient to periodontal disease. A typical preventive treatment consists of checking plaque control, careful sub-gingival curettage, and charting of the mouth by the hygienist. The role of the dentist includes examining the occlusion and the curettage of any deepened crevice. It is a rare patient, indeed, that does not have some area that needs special attention. Often one or more deep crevices exist immediately after the original treatment, usually because of incomplete pocket elimination. The decision as to whether or not retreatment is necessary should not be made at the preventive maintenance appointment, but should be postponed for 1 to 2 weeks. Often the mouth will look better at that time and crevicular depth will be less. The improvement is due to the resolution of any edema present and to the increased tone of the gingival unit.

CRITERIA FOR FAILURE: 1) BOP, 2) increasing PD, 3) increase in bone loss, 4) increased tooth mobility

The treated patient that has a recurrence of periodontal disease should ring a warning bell to the therapist. Before retreating, every effort must be made to discover what has gone wrong in the general handling of the patient.

REASONS: 1.) Maintenance is not frequent enough. 2) Poor home care. 3) Inadequate root preparation. 4) Improper surgical technique. 5) Systemic disease may alter periodontal disease progression. 6) Uncontrolled occlusal factors.

WHEN TO RETREAT: Postpone until the above factors can be assessed. Always get a careful history before re-treatment, because that case may be at its best as it is.

The psychological preparation of the patient who needs surgical retreatment is very important. No matter how smoothly the original procedure went, the patient will dread, and to a degree, resent additional surgical therapy. During the original treatment program, the therapist should prepare each patient for the possibility of additional treatment in the future. The patient should be informed that not only do we not know all of the etiological factors that produce periodontal disease, but that we cannot always eliminate the known factors.

CON: Periodontal disease has a greater or lesser tendency to recur. The therapist controls rather than cures the condition. Careful maintenance is as important as skillful original treatment if periodontal health is to be maintained. A t the time of the original treatment, every patient should be informed that retreatment of some type is occasionally necessary.

Patients with recurrence of disease should be treated as conservatively as possible and every effort should be made to find the cause of failure. Surgical retreatment should be done only after a reasonable effort has been made to improve the situation by other means. The deepened crevice that does not bleed when probed and is not accompanied by bone loss does not provide justification for surgical retreatment.

Rateitschak 1994

P: To analyze and discuss failure of periodontal treatment.

D: Defining tx success:

Bleeding (inflammation) stopped
Pockets eliminated
PD reduced
Gain of attachment
Stabilized tooth mobility

Defining tx failure:

BOP continued
Symptoms of activity in addition to BOP are seen in response to probing (like exudate or pus)
PD is not reduced or continues to increase
AL is progressive
Tooth mobility increased

Causes for failure:

Incorrect pt selection
Incomplete diagnostic procedures, improper diagnosis, or incorrect prognosis
Difficult or inappropriate tx
Unsupervised healing
Absence of maintenance therapy

Important points:

1. Only those patients prepared for long-term cooperation should be treated. Patients with certain serious

systemic diseases tend to have recurrences.

2. Time cannot be saved in diagnostic procedures. Only a careful, comprehensive examination leads to

a well-founded diagnosis and prognosis, and a precise treatment plan.

3. The limits of successful therapy must be recognized. Advanced periodontitis, Class III furcation involvement, and rapidly advancing diseases are difficult to control over the longer term.

4. Reinfection of the pockets must be prevented through supervision of the healing process by repeated

prophylaxis and checking of oral hygiene immediately following each active intervention (closed root planing or flap operation).

5. Long-term treatment success is possible only if the patient, once treated, is placed on a regular recall

schedule.

6. Consistent periodontal therapy requires a great deal of time. That time is usually underestimated. Informing the patient about the disease (case presentation), instruction in and repeated checking of oral

hygiene, supervision of the healing process and recall all are enormously time consuming. The actual surgical treatment is the smaller part of the total tx.

Fardal 2005

P: To quantify the type and extent of re-tx in a group of pts who had completed a definitive course of perio tx in a Norwegian specialist perio practice. The study also investigated factors associated with the provision of perio sx as a re-tx modality.

M&M: A consecutive group of pts who had comprehensive perio tx, including perio sx, and were maintained between 10 and 17yrs were studied retrospectively. The following were noted for each pt: dates of their initial exam, the completion of definitive tx and final review, age at review, gender, smoking status, medical hx, family hx of perio dz and compliance with prescribed maintenance (poor/erratic, good). Maintenance included scaling and polishing of tth, and if necessary, minor occlusal adjustments and OHI. The maintenance was divided between the periodontist and general practitioner, so that each pt was seen 2-4 times per year for maintenance. The interval period was lengthened or shortened as appropriate dependant upon the stabililty of the perio condition. Re-tx was defined as tx over and above prescribed maintenance and included the prescription of systemic atb, non-sx tx or surgical tx. All tooth loss was quantified with no attempt to determine if it was because of periodontal reasons or other reasons (root fracture, decay, etc). Re-tx was considered necessary in 2 situations: PD 7mm with BOP, or increases in PD 3mm with BOP at 3 consecutive maintenance visits. Sx procedures included GV, MWF, APF.

R: 101 pts included in the study with an average age of 59. Average length of the review period was 13 years. Only 2.9% of the teeth present after the initial baseline tx were lost during the review period, which equated to 0.06 teeth per pt per year. 50/101 pts had further re-tx during the observation period. 6 were tx’ed with systemic atbs and 4 with non-sx therapy in addition to the prescribed maintenance. The remaining 40 pts received perio sx. Sx was preceded by non-sx perio tx in 11 of these cases. In total, 12% of tth present after baseline had sx re-tx This was broken down into 31% incisors and canines, 29% PMs, and 40% molars. Of the 40pts that had re-tx, on average 7.7 teeth were involved. A little over half of the pts were in the good compliance group. After regression analysis was performed, family hx of perio dz was the most significant factor associated with re-tx. Less than ideal compliance as well as an uncertain or poor prognosis were also associated with the need for re-tx. Gender, smoking status, and tooth loss were NSS.

D: Early diagnosis may reduce the need for sx re-tx. Emphasis on pts coming to maintenance visits may reduce the need for sx re-tx.

BL: Considerable amounts of re-tx (40% of pts treated initially), including in many cases extensive non-sx tx or perio sx, were provided for pts who had previous sx perio tx and were subsequently maintained for at least 10 years in a specialist perio practice.

Cr: We do not know if teeth that were lost were because of periodontal reasons. Does not specify exact difference between poor/erratic and good with respect to attending maintenance visits.

Morisson 1982

Purpose: To investigate whether the severity of the recurrent gingivitis has any influence on PD and AL in treated periodontal patients on recall for prophylaxis every 3 months.

Materials and methods: 78 patients were included in the study, they all had initial treatment, surgical therapy and were on 3 month maintenance recalls. Scorings were repeated annually.

Gingivitis scores 1-year post- treatment were used for comparison of PD and attachments responses to various categories of gingivitis during 7 years of maintenance therapy. The material was divided into higher and lower than the median gingivitis scores. Individuals with the upper 25% of gingivitis scores were compared with those having the lower 25% of scores.

Results: When pocket reduction for pockets 1-3mm was related to maintenance gingivitis scores, there was no difference 1 year after treatment and the gradually developing difference over time indicated more return of PD for the lower than for the higher gingivitis group. With regard to AL, there appears to be slightly less loss of attachment 2 years post-Tx for the groups with the lower gingivitis scores but from then on here was no difference until the end of the study.

For sites with initially PD of 4-6mm there was no difference between in PD response for the first 5 years post-treatment and after that PD reduction was better maintained in the groups with the higher gingivitis scores. Differences were NSSD. IN the same group there appeared to be a greater gain in attachment for the low gingivitis groups for the first 2-years but no difference from that time to the end of the experiment.

For PD 7mm or more there was more PD reduction for groups with less gingivitis than although differences were SSD for only 3-years. AL gain was also more favorable in patients with lower gingivitis scores. These differences appeared to be related to favorable initial response after Tx.

Significance: Gingivitis scores were based on scores for separate teeth so no specific correlation can be made based on the date between PD and AL changes and tooth sites. Differences between gingivitis scores were small, the index used was not ideal therefore the results have to be interpreted with some reservations and the possibility that real differences have been masked cannot be excluded.

Conclusion: Severity of recurrent gingivitis during maintenance therapy with prophylaxis every 3 months does not appear to have any significant impact on recurrence of PD or maintenance of clinical attachment levels.

“Refractory Periodontitis”

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

Topic: recurrence of disease

Author: Magnusson I, Walker CB

Title: Refractory periodontitis or recurrence of disease

Source: J Clin Periodontol 23:289-292, 1996

DOI: 10.1111/j.1600-051x.1996

Type: review

Keywords: refractory periodontal disease, recurrence of disease, microbiology of refractory disease

Purpose: to review refractory periodontal disease

Discussion:

– In 1986, the AAP defined “refractory periodontitis” as disease in multiple sites in patients that contitnue to demonstrate attachment loss after apparent appropriate therapy.

– At the time of this article, clinicians can only diagnose refractory periodontitis longitudinally by the careful monitoring of periodontal patients who fail to respond to therapy.

– Refractory periodontal disease is characterized by low plaque scores and low responsiveness to periodontal therapy.

– The patients often have a history of antibiotic therapy and as a result, have a high incidence of resistance in the subgingival microflora.

– Both aforementioned features are in contrast to adult chronic periodontitis and recurrence of disease.

Microbiological Aspects

– Studies attempting to describe the microflora associated with refractory periodontitis have arrived at different conclusions, due to difficulty in distinguishing between refractory periodontitis and recurrent disease

– The subgingival microflora of refractory disease may be either predominantly gram-positive with elevated levels of S. intermedius or may be gram-negative with elevated levels of the classical periodontal pathogens (P. gingivalis, P. intermedia, F. nucleatum, C. rectus)

– Deep active sites tend to be more gram-negative and have a greater tendency to contain black pigmented bacteria and other gram-negative anaerobic rods

– Shallow sites tend to be more gram-positive and contained S. intermedius, but sometimes they also contain black pigmented bacteria.

– One study showed that in refractory periodontitis patients, the percent of sites resistant to amoxicillin, erythromycin, tetracycline, and clindamycin are 25%, 66, 55, and 41%, respectively.

Immunological Aspects

– in some cases, serum IgG antibodies against P. gingivalis are elevated and tend to decrease during 24 months after therapy.

– Antibody responses to A. actinomycetemcomitans, P. intermedia, and E. corrodens did not change significantly after treatment

– Antibody responses to C. rectus also decreased significantly over the 24 months post treatment, but the actual changes in values are biologically unimpressive.

Smoking

– Smoking may be an important factor in refractory periodontal disease as well as adult chronic periodontal disease.

– Smoking has also been suggested to be associated with increased risk of subgingival infection and that smoking might modulate the periodontal flora.

BL: Treatment with directed antibiotic therapy as an adjunct to SRP delays the progression of disease for a limited time. However, further research are necessary since many questions are still unanswered

Jenkins 2000

Purpose: to investigate the role of root debridement at 3 month intervals for pts with periodontitis whose disease had persisted following completion of conventional perio tx.

Materials and methods:

39 SPT pts w/ at least 4 pockets > 4 mm were assigned to coronal scaling (CS) and subgingival scaling (SS) groups.
PD’s, BOP and attachment loss were recorded at all eligible sites at baseline and 3, 6, 9 and 12 months later.
Plaque index was recorded at the 12-month visit. At every visit following data collection, both groups received a CS and the SS group, in addition, received thorough subgingival debridement.
In the CS group, subgingival debridement was performed only for loser sites which exhibited attachment loss 2 mm relative to baseline values. Due to low compliance, only 31 pts completed the study. Thus, data analyses were carried out for 130 sites in 17 CS group pts and 146 sites in 14 SS group pts.

Results:

21 loser sites were identified in each group, but NSD in proportion of loser sites b/t groups.
Although there was a trend toward PD reduction in both groups, mean PD, attachment loss and BOP values were NSD from baseline values at any time point and between groups with respect to these variables.
Mean plaque scores measured at the 12-month visit revealed NSD b/t groups.

Conclusion:

These findings call into question the value of performing repeated subgingival scaling at 3-month intervals for patients with persistent disease.

Haffajee 2004

P: To examine the clinical and microbial changes after a combined aggressive antimicrobial therapy in subjects identified as refractory to conventional periodontal therapy.

M&M: 14 subjects were identified as refractory based on full-mouth mean attachment loss and/or >3 sites with attachment loss of > 3mm following scaling and root planning, periodontal surgery and systemic antibiotics. Subjects had complete clinical and microbiological data 24 months post-therapy. Baseline measurement included plaque accumulation, BOP, suppuration, PD, PAL. Subgingival samples were taken at each appointment from the mesial of the tooth (taken with sterile gracey curettes) and put through checkerboard DNA-DNA hybridization. Counts of 40 subgingival species were determined.

After baseline clinical and microbiological monitoring subjects received SRP (1 quad per week for one month), LDD (Tetracycline fiber, Actisite) for pockets > 4mm, systemic antibiotics (Amoxicillin 500 mg and Metronidazole 250 mg t.i.d. for 14 days starting at the first SRP session), and weekly maintenance for 3 months, then every 3 months for 2 years.

Results: On average, subjects showed significant improvements in all clinical parameters after therapy. Mean pocket depth reduction was 0.83 mm and AL gain was 0.44 mm over 24 months. The subjects were subset in 2 groups, good responders (n=8) and modest responders (n=6). Change in AL for the modest responders from baseline to 24mos was 0.0mm (range: “gain” of 0.13mm to a loss of 0.08mm). The change in the good responders was a mean “gain” of 0.77mm (range: 0.39-1.27)

Clinical improvement was accompanied by major reductions in multiple subgingival species during the first 3 months of active therapy that were maintained for most species to the last monitoring visit. Reductions occurred for 3 Actinomyces species, orange complex species, 3 Fusobacterium nucleatum subspecies, and 3 Streptococcus species.

BL: The combined antibacterial therapy was successful in controlling disease progression in 14 refractory periodontitis subjects for 2 years.