Periodontal Health – It is clear that regular maintenance visits are a key component to successful periodontal therapy. There is a demonstrated 70% reduction in lost teeth comparing untreated patients to those who received treatment and followed through with regular maintenance. There is a 50% improvement in tooth retention when comparing treated patients without maintenance therapy to those who were both treated and well maintained. Some studies suggest that with a regular 3-month maintenance interval, attachment levels may be maintained even in the face of a patients poor oral hygiene.
What Are the Components of the Periodontal Health Visit?
The basic periodontal health maintenance appointment should have the following components:
- Update and review the medical history – This aspect is particularly important related to the onset of Type 2 diabetes mellitus in adult patients, and changes in patient medications, both prescribed and self-administered. Queries to the patient must take more than one form, for simply asking the question; Has anything related to your health changed since your last visit with us? this may not garner the necessary information. Asking patients to list their current medications, whether or not they are continuing to take previously reported medications, and inquiring about recent visits to the physician may all elicit more meaningful answers.
- Update the dental history – This review may seem unnecessary for the patient being treated solely in one office. Unfortunately, for whatever reason, some recommended treatment may not have been completed and a periodic review of patient treatment will uncover any incomplete treatment needs. The patient who sees both a generalist and a specialist or specialists must update his/her dental history to acknowledge the following, or decide not to follow treatment recommendations for good periodontal health.
- Extraoral and intraoral hard and soft tissue examinations – This step will uncover any clinically evident hard and soft tissue lesions that may require some follow-up attention.
- Dental examination – This step will reveal clinically evident decay and/or restorations that have outlived their usefulness.
- Periodontal evaluation – This step includes review of oral hygiene effectiveness (best accomplished before plaque and calculus is removed), marginal inflammatory control as demonstrated by bleeding on gentle skimming, and reduction or maintenance of probe depths. Use of the Periodontal Screening and Recording (PSR) system may simplify documentation of this review.
- Radiographic review – Review of existing radiographs can corroborate clinical findings and the decision for new radiographs may be made. Vertical bitewing films should be exposed for patients with posterior interproximal bone loss.
- Removal of supra- and subgingival plaque
- Scaling and root planning where indicated
- Polishing the teeth – Selective polishing, using a rubber cup and abrasive prophylaxis paste only where plaque and stain are evident, has been advocated to maintain tooth structure, particularly the fluoride-rich layer of enamel on the surface of the crown. An air abrasive type of polishing unit may be used as long as the abrasive stream is not directed onto root surfaces or composite resin restorations.
- Topical fluoride application – This step helps to restore the fluoride-rich surface that may have been removed during the polishing step.
- Final oral hygiene instructions and the dispensing of appropriate personal hygiene implements
How Is the Patient’s Periodontal Health Maintenance Interval Determined?
The Periodontal Health maintenance interval should be determined on an individual basis. Among the factors to be considered are the initial level of disease, the aggressiveness of the attachment loss, the patient is response to therapy, the patient is ability to perform effective plaque control, and the post-treatment stability of gingival inflammation and attachment levels. Maintenance intervals may be as short as 1-2 months, up to about 6 months between appointments. Patients who have already demonstrated a susceptibility for attachment loss should be seen no less often than every 4 months.
How Compliant Is the Average Periodontal Patient?
One study suggests that only about 16% of patients receiving periodontal therapy comply with recommended periodontal health maintenance intervals. Other studies have demonstrated a similar lack of compliance. Behavior modification is difficult even when the patient is faced with a life-threatening disease. There are many factors contributing to a lack of compliance including:
• Denial and negligent attitude towards own health
• Acknowledging the problem means the patient must participate in his own care
• Many patients want the dental profession to take responsibility for and fix their problems
• Compliance decreases as treatment time or the complexity of the required behavioral change increases
Several steps to improve patient compliance have been proposed:
• Simplify behavioral change
• Accommodate the patient
• Remind patients of appointments
• Keep compliance records
• Inform the patient about the necessity for and consistency of keeping maintenance appointments
• Provide positive reinforcement
• Ensure the dentists involvement
What Type of Biological Modulation May Be Used to Control Recurrent Periodontal Disease in the periodontal health Maintenance Patient?
Maintaining stable post-treatment attachment levels may be difficult. There are several approaches to treating new areas of attachment loss or to prevent new attachment loss. In situations where the attachment loss is localized, local delivery of antibiotics or antimicrobial agents such as doxycyline, minocycline, or chlorhexidine is possible. For situations where new attachment loss may be more widespread, the use of systemic antibiotic therapy may be warranted.
Systemic administration of a subantimicrobial dose of doxycycline (SDD) has been advocated to help prevent attachment loss. SDD has been shown to stabilize the activity of collagenase and other matrix metalloproteinases and therefore slow down the destructive inflammatory process. Initial clinical studies to receive U.S. Food and Drug Administration approval were of 9 months duration. There is minimal evidence of the effect of SDD over longer time periods, It has been suggested that SDD they be effective in controlling other collagenase-based inflammatory disorders.
When Should a Patient Be Comprehensively Retreated for Recurring Periodontal Disease?
There are no clear-cut guidelines as to when a patient should re-enter comprehensive periodontal treatment. Fortunately, in most cases, only localized sites remain a problem. One rule of thumb would be that if the patients recurrent problems cannot be addressed in 2-3 appointments, consideration should be given toward a new round of comprehensive therapy. In addition, a patient who has recently completed surgical therapy but continues to have difficulty should be treated with alternative therapies, such as antibiotics, and further control of risk factors, with additional surgical therapy held in abeyance.
When Should a Patient Be Referred for Specialty periodontal health Care?
The decision on when to refer a patient for specialty care must be made between the general practitioner and patient, with the periodontist available to provide the necessary treatment. In general, most periodontists prefer to treat the patient from the beginning of initial therapy through advanced therapy. In certain situations, particularly when the general practitioners office can provide high quality initial therapy or when there is a questionable need for referral, the patient may be referred for specialty care after the results of initial therapy have been evaluated.
This arrangement should be worked out in advance as it is uncomfortable for both the patient and periodontist if additional initial therapy is recommended by the specialist. In most cases, third party carriers will not provide benefits for this additional treatment. This situation also begs the question in the patients mind as to the quality of the care received in the generalists office. Effective communication between the general dentist and periodontist is paramount to a clear understanding of the overall course of the patients treatment.
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