Classic Literature Review 2018.06.

27

Maintenance/Compliance
Periodontal maintenance
Review
1. Manresa, C., et al., Supportive periodontal therapy (SPT) for maintaining the
dentition in adults treated for periodontitis. Cochrane Database Syst Rev
2018:1:CD009376.

2. Cohen, Robert E. Position paper: periodontal maintenance. J Periodontol

2003;74:1395-401.

3. Parameter on periodontal maintenance. American Academy of

Periodontology. J Periodontol 2000;71 (Suppl. 5):849-50.

4. Tan, A. E. Periodontal maintenance. Aust Dent J 2009;54(Suppl 1):S110-7.

Maintenance interval
5. Farooqi, O.A., et al., Appropriate Recall Interval for Periodontal Maintenance: A
Systematic Review. J Evid Based Dent Pract 2015:15:171-81.
- Shorter PM intervals (3-6 M) favored more teeth retention but also statistically
insignificant differences between regular compliers & irregular compliers, or
converse findings are also found.

- In the 2 studies reporting mean recall interval in groups, significant tooth loss
differences were noted as the interval neared the 12 M limit.

6. Ramfjord SP, Morrison EC, Burgett FG, et al. Oral hygiene and maintenance of
periodontal support. J Periodontol 1982;53:26-30.

- Every 3M recall for 8Y

- PD↓& CAL↑ can be maintained

7. Lindhe J, Nyman S. Long-term maintenance of patients treated for advanced

periodontal disease. J Clin Periodontol 1984;11:504-14.

- Every 3-6 M recall for 14Y

- PD/CAL/bone height did not vary significantly in well-maintained pts.

8. Axelsson P, Nystrom B, Lindhe J. The long-term effect of a plaque control
program on tooth mortality, caries and periodontal disease in adults. Results
after 30 years of maintenance. J Clin Periodontol 2004;31:749-57.

- Every 2M in the first 2Y, then every 3-12 M recall for 3-30 Y

- Low incidence of caries and periodontal disease & tooth mortality in carefully
monitored subjects.

9. Rosling, B., et al., Longitudinal periodontal tissue alterations during supportive

therapy. Findings from subjects with normal and high susceptibility to periodontal
disease. J Clin Periodontol 2001:28: 241-9.

- Post nonsurgical Tx, every 3M recall for 12Y

- 80% of highly susceptible subjects maintained attachment & bone levels.

Compliance
10. 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 2015:94:777-86.

- Regular-compliance group had significantly lower tooth loss rate than erratic-
compliance group (weighted mean difference of tooth loss rate: -0.12).

11. Axelsson P, Lindhe J. The significance of maintenance care in the

treatment of periodontal disease. J Clin Periodontol 1981;8:281-94.

- Every 2-3 M recall for 6Y

- Recall group: 0.2 mm CAL↑ over 6Y

(17% gain ≥1 mm, 10% loss ≥1 mm, others no alterations)

- Non-recall group: 1.3 mm CAL↓ over 3Y and additional 0.5 mm over 6Y (44%
loss ≤1 mm, 55% loss 2-5 mm, 1% loss ≥6 mm)

12. Becker W, Becker BE, Berg LE. Periodontal treatment without

maintenance. A retrospective study in 44 patients. J Periodontol 1984;55:505-
9.

- Without maintenance after 5.25Y in average

- Mean annual adjusted tooth loss rate= 0.22

13. Becker W, Berg L, Becker BE. The long-term evaluation of periodontal
treatment and maintenance in 95 patients. Int J Periodontics Restorative Dent
1984;4:54-71.

- With maintenance, every 3-4 M recall for 3 -11 Y (6.5Y in average)

- Mean annual tooth loss rate= 0.11

14. Loe H, Anerud A, Boysen H, Morrison E. Natural history of periodontal

disease in man. Rapid, moderate and no loss of attachment in Sri Lankan
laborers 14 to 46 years of age. J Clin Periodontol 1986;13(5):431-45.
- After 15Y f/u, 8% with rapid progression of periodontal disease (RP), 81% with
moderate progression (MP), and 11% exhibited no progression beyond gingivitis
(NP).

Loss of attachment RP MP NP

35 y/o 9 mm 4 mm 1 mm

(0.1-1 mm/Y) (0.05-0.5 mm/Y) (0.05-0.09 mm/Y)

45 y/o 13 mm 7 mm -

- Tooth in RP group: started in 20 y/o, loss of 12 teeth in 35 y/o, loss of 20 teeth

in 40 y/o, loss of all in 45 y/o.

15. Goldman MJ, Ross IF, Goteiner D. Effect of periodontal therapy on patients
maintained for 15 years or longer. A retrospective study. J Periodontol
1986;57:347-53.

- Every 3-6 M recall for 15-34 Y (22Y in average)

- The most prone to loss: maxillary molars; the most resistant: mandibular
canines

- Loss of teeth with furcation involvement: well-maintained 16.9%, downhill

66%, extreme downhill 99%

16. Fardal O, Linden GJ. Re-treatment profiles during long-term maintenance

therapy in a periodontal practice in Norway. J Clin Periodontol 2005;32:744-9.

- 1-3 times/Y recall for 13.1Y

- Nearly half of the patients (50/101) who were initially treated for periodontal
disease and regularly maintained required re-treatment at least once over a 13-
year period. (Systemic antibiotics: 6, non-surgical tx: 5, surgery: 40)
17.Costa FO, Miranda Cota LO, Pereira Lages EJ, et al. Progression of
periodontitis in a sample of regular and irregular compliers under
maintenance therapy: a 3-year follow-up study. J Periodontol 2011;82:1279-
87.

- Every 3-4 M recall for 3Y

- Progression of periodontitis & tooth loss: erratic compliers (EC)> regular

compliers (RC)

- Smoking should be considered.

Smokers Non-smokers

EC (n=20) RC (n=20) EC (n=38) RC (n=38)

Progression of periodontitis 25.0% 20.0% 10.5% 2.6%

Lost teeth during the 3Y 3.49% 2.95% 3.33% 2.86%

18. Costa FO, Cota LO, Lages EJP, et al. Periodontal risk assessment model in a
sample of regular and irregular compliers under maintenance therapy: a 3-
year prospective study. J Periodontol 2012;83:292-300.

- Every 4M for 3Y

- Regular compliers have a lower recurrence rate (2.7% vs . 3.4%) and tooth loss
(0.65 vs. 0.78) than erratic compliers.

19. Miyamoto, T., et al., Compliance as a prognostic indicator. II. Impact of patient's
compliance to the individual tooth survival. J Periodontol 2010:81:1280-8.

- Molar teeth had an approximately 30% reduction in risk of tooth loss for complete
compliance (interval < 2 yrs. or miss recall < 30%)(SS.)

- Complete compliers (miss recall < 30%): > 50% reduction in the risk of alveolar bone
loss among non-molars (SS.)

20. Eickholz, P., et al., Tooth loss after active periodontal therapy. 1: patient-related
factors for risk, prognosis, and quality of outcome. J Clin Periodontol 2008:35:165-
74.
- mean plaque index during SPT, irregular attendance of SPT  tooth loss &
worse periodontal status 10 yrs after initiation of therapy (SS.)

21. Pretzl, B., et al., Tooth loss after active periodontal therapy. 2: tooth-related
factors. J Clin Periodontol 2008:35:175-82.
- High plaque scores, irregular attendance of SPT  tooth loss (SS.)
- P’ts with regular SPT: 93% of teeth with 60-80% bone loss survived 10 yrs.

22. Escribano, M., et al., Efficacy of a low-concentration chlorhexidine mouth rinse in

non-compliant periodontitis patients attending a supportive periodontal care
programme: a randomized clinical trial. J Clin Periodontol 2010:37:266-75.
- Moderate/severe chronic periodontitis under SPT, inadequate plaque control

- Post-3M plaque levels & BOP: ↑ placebo group vs. ↓test group (SS.)

- ↓Subgingival counts of F. nucleatum & P. intermedia, ↓total bacterial counts in

saliva (SS.)

Academic vs. private practice

23. Wilson TG Jr, Glover ME, Schoen J, Baus C, Jacobs T. Compliance with
maintenance therapy in a private periodontal practice. J Periodontol
1984;55:468-73.

- Private, every 3M recall for 8Y

- 16% compliance, 49% erratic compliance, 34% no compliance

24. Wilson TG Jr, Glover ME, Malik AK, Schoen JA, Dorsett D. Tooth loss in
maintenance patients in a private periodontal practice. J Periodontol
1987;58:231-5.

- Private, every 3M recall for 5Y

- Erratic compliance: 0.06 tooth loss per pt per year

25. Wilson TG Jr, Hale S, Temple R. The results of efforts to improve

compliance with supportive periodontal treatment in a private practice. J
Periodontol 1993;64:311-4.

- Private

- Compliance: 16% in 1984 vs. 32% in 1991

26. Novaes AB, Novaes AB Jr, Moraes N, Campos GM, Grisi MF. Compliance
with supportive periodontal therapy. J Periodontol 1996;67:213-6.

- Private, every 2-6 M recall for 20Y

- Compliance: surgical (40.5%) >non-surgical (38.9%), F (41%) > M (38.7%),

older >younger (<20Y: 18.7%, 21-40Y: 27.7%, 41-60Y: 41.8%, >60Y: 57.1%)
27. Novaes AB Jr, de Lima FR, Novaes AB. Compliance with supportive
periodontal therapy and its relation to the bleeding index. J Periodontol
1996;67:976-80.

- Private, every 3-6 M recall for 6Y

- BOP: regular SPT (8.04% 7.87%) < no SPT (5.84% 14.32%)

28. Novaes AB Jr, Novaes AB. Compliance with supportive periodontal

therapy. Part 1. Risk of non-compliance in the first 5-year period. J
Periodontol 1999;70:679-82.

- Private, every 3-4 M recall for 5Y

- Non-compliance rate= 46.8%; age↑, compliance↑(gender, therapy: n.s.)

- The most unstable in ≤20 y/o & male & nonsurgical group, non-compliance
rate= 80%

29. Novaes AB Jr, Novaes AB, Bustamanti A, Villavicencio JJ, Muller E, Pulido J.
Supportive periodontal therapy in South America. A retrospective multi-
practice study on compliance. J Periodontol 1999;70:301-6.

- Private, every 3-4 M recall during 20Y

- Peak of abandonment: 5Y

30. 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 2006;77:223-32.

- Private, every 3-6 M recall for 15Y

- Erratic compliance complete compliance: BI↓, PI↓, DMFT↓

- The decision for tooth extraction at maintenance visits may result in greater
tooth loss.

31. Costa FO, Santuchi CC, Lages EJP, et al. Prospective study in periodontal
maintenance therapy: comparative analysis between academic and private
practices. J Periodontol 2012;83:301-11.

- Every 3M recall for 12M

- Private clinic (OR=3.6) showed lower progression and tooth loss than public
academic environment (OR=5.01).

32. Stadler, A.F., et al., Tooth Loss in Patients under Periodontal Maintenance in a
Private Practice: A Retrospective Study. Braz Dent J 2017:28:440-6.
- Compliers in a private practice lose fewer teeth than non-compliers (SS.)

- Compliers: periodontal disease progression  not the main cause of tooth loss

Factors associated with maintenance results

33. Martinez-Canut, P., A. Llobell, and A. Romero, Predictors of long-term outcomes in
patients undergoing periodontal maintenance. J Clin Periodontol 2017:44: 620-31.
- 174 pts with moderate-severe periodontitis
- Smoking & bruxism  ↑ rate of tooth loss due to periodontal disease (SS.)
- Bruxism  Vertical & circumferential bone defects (SS.), abfractions (SS.)
- Smoking  Furcation defects (SS.), fewer radio-opaque subgingival calculus (SS.),
lower mean Gingival index (SS.), increased mean recessions >1.5 mm (SS.)

 Angular bony defect

34. Pontoriero R, Nyman S, Lindhe J. The angular bony defect in the

maintenance of the periodontal patient. J Clin Periodontol 1988;15:200-4.

- Every 3-6 M recall for 5-16 Y

- Only minor bone level alteration.

- Horizontal vs. angular pattern in well-maintained gr: no additional bone loss

 Age

35. Albandar JM. A 6-year study on the pattern of periodontal disease

progression. J Clin Periodontol 1990;17:467-71.

- Without maintenance over 6Y

- Rate of tooth loss: molars> premolars> incisors; >57 y/o> 46-57 y/o> 34-45
y/o> 18-33 y/o

 Age & Smoking

36. Chambrone LA, Chambrone L. Tooth loss in well-maintained patients with
chronic periodontitis during long-term supportive therapy in Brazil. J Clin
Periodontol 2006;33:759-64.

- Every 6-12 M recall for ≥10Y

- Rate of tooth loss: ≤60 y/o (35.7%) vs. >60 y/o (7.5%); non-smokers (8.0%) vs.
smokers (65.0%)

 Smoking

37. Lorentz, T.C., et al., Tooth loss in individuals under periodontal maintenance
therapy: prospective study. Braz Oral Res 2010:24: 231-7.
- 150 P’ts: chronic moderate-advanced periodontitis s/p Tx, SPT over 12M period.
- 130 P’ts (86.7%): stable periodontal status
- 20 P’ts (13.3%): periodontitis progression
- 28 P’ts (18.66%): tooth loss  47 lost teeth (1.38%)
- Smoking  greater progression of periodontitis (OR=2.7, SS.)

 Furca

38. Salvi, G.E., et al., Risk factors associated with the longevity of multi-rooted teeth.
Long-term outcomes after active and supportive periodontal therapy. J Clin
Periodontol 2014:41:701-7.
- Grade II/II furcation invovlement, smoking & lack of compliance with regular
SPT risk factors for the loss of multi-rooted teeth in subjects treated for
periodontitis

39. Dannewitz, B., et al., Loss of molars in periodontally treated patients: a

retrospective analysis five years or more after active periodontal treatment. J Clin
Periodontol 2006:33:53-61.
- 5 yrs. of SPT
- Smoking, baseline bone loss, number of molars left, and degree III FI as risk factors
influencing the retention time of molars.

40. Nibali, L., et al., Tooth loss in molars with and without furcation involvement - a
systematic review and meta-analysis. J Clin Periodontol 2016:43: 156-66.
- 21 studies
- The relative risk of tooth loss during SPT attributable to FI: 2.21 (SS.) for studies with a
F/U of 10-15 yrs
- Most molars, even with grade III FI respond well to periodontal therapy