ARE WE PRACTICING ACCORDING TO THE EVIDENCE?

The Effect of Patient-Centered

Plaque Control and Periodontal Maintenance
Therapy on Adverse Outcomes of Periodontitis
Julie Pastagia, DMD, Pamela Nicoara, DDS,
Paul B. Robertson, DDS, MS
From the Department of Periodontics, School of Dentistry, University of Washington, Seattle, WA

The purpose of this study was to evaluate systematic reviews that addressed
the effectiveness of periodontal maintenance therapy for the management of
patients with periodontitis. Recent surveys of dental care patterns suggest a
marked increase in preventive and maintenance periodontal care in
populations that retain the dentition for an increasingly longer lifetime. A
considerable body of clinical investigation concludes that a multitherapy
periodontal maintenance approach is effective in improving periodontal
outcomes in patients treated for periodontitis. Individual components of such
maintenance therapy were assessed, including the effects of an oral
examination, personal oral hygiene instructions, supragingival scaling and
polishing, subgingival scaling and root planing, adjunctive procedures, and
maintenance frequency.
There is much controversy about improvement in oral health that may
accrue from the placebo effect of an examination and the maintenance ritual.
Improved plaque control by the patient in anticipation of a forthcoming
examination alone might be reflected in decreased measurements for plaque
accumulation and gingival inflammation but the role of placebo effects on
periodontitis remains unclear. There are insufficient randomized controlled
trials to reach conclusions regarding the individual beneficial effects of repeated
oral hygiene instructions or routine scaling/polishing on the recurrence of
periodontitis. While subgingival root planing seems an effective component of
periodontal maintenance, neither clinical investigations nor randomly con-
trolled trial evidence have established an ideal maintenance frequency based on
individual patient risk for periodontitis. The adjunctive beneficial effects of both
locally and systemically administered antimicrobial agents were statistically
significant for some formulations, and may be particularly useful clinically in
patients who are resistant to mechanical therapy.
We conclude that few clinical or randomized controlled studies have
evaluated the individual benefit or required frequency of the periodontal
maintenance ritual for patients who are relatively resistant or susceptible to
periodontitis.

J Evid Base Dent Pract 2006;6:25-32

1532-3382/$35.00
Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jebdp.2005.12.009

INTRODUCTION
Periodontal diseases comprise a diverse group of inflamma-
tory conditions that adversely affect the surrounding and
supporting structures of the teeth. Prevention and treatment
of the periodontal diseases have historically depended on
improving personal oral hygiene and establishing oral
conditions that are cleansable by the patient. A critical
principle underlying this treatment approach is a regularly
scheduled professional maintenance regimen. For patients
without signs of periodontitis, this regimen is termed a dental
prophylaxis and is usually composed of an examination and
review of the patient’s plaque-control efficiency; application
of topical fluoride; and scaling and polishing procedures to
remove coronal plaque, calculus, and stains from the crowns
of teeth. For patients who have completed surgical or
nonsurgical treatment for periodontitis, the regimen is
commonly termed periodontal maintenance or supportive
periodontal therapy. The procedure includes an examination
and review of plaque control, scaling and polishing of the
teeth, and removal of the bacterial flora from crevicular and
pocket areas of tooth root surfaces. If new or recurring
periodontal disease is identified, additional diagnostic and
adjunctive treatment procedures may be considered. Typi-
cally, an interval of 3 to 6 months between maintenance
appointments is recommended.1-3
The components of such regimens and most outcome
measurements are based primarily on preventive studies of
gingivitis. The effectiveness of present maintenance therapy
procedures for the management of periodontitis is less clear.
Figure 1. Reductions in probing depth throughout phases of periodontal treatment.
26 Pastagia et al.
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
This review will address systematic reviews of periodontal
maintenance regimens in patients treated for periodontitis.
The primary question focuses on the individual effects of oral
examination, personal oral hygiene instructions (OHI),
supragingival scaling and polishing, scaling/root planing
(S/RP), adjunctive procedures, and treatment frequency
compared to the absence or widely divergent frequency of
each individual component on measures of periodontitis.
TREATMENT OF PERIODONTITIS
The various forms of periodontitis result in destruction of
connective tissues that attach the teeth to the jaw, with
ensuing tooth mobility and eventual tooth loss. Microbial
infection is necessary but insufficient for the initiation of
periodontitis, a process that appears highly dependent on
individual host factors including immune status and concur-
rent systemic diseases affecting other organ systems.4,5 The
destructive inflammatory process can be resolved by
nonsurgical and surgical treatment, but healing occurs
primarily by repair with a net loss of periodontal connective
attachment. Figure 1 illustrates the treatment outcome in
patients with periodontitis throughout the examination and
infection control phase, nonsurgical or surgical phase, and
maintenance phase of periodontal therapy. Disease resolution
was derived from summary mean probing depths initially
greater than 4 mm obtained from prospective studies of
periodontal nonsurgical6,7 and surgical8-12 therapy, and
retrospective studies of maintenance therapy13,14 for patients
with periodontitis. For most patients, initial infection-control
March 2006
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
procedures and surgical or nonsurgical therapy are effective
in reducing probing depths. During the maintenance period,
the majority of patients show relatively stable periodontal
health while about 10% to 20% of patients exhibit disease
recurrence.
Long-term clinical investigations15-17 suggest that this
treatment outcome pattern demonstrates the necessity of
frequent and regimented periodontal maintenance care.
Indeed, several studies suggest that patients not retained in
a maintenance program after surgical therapy show substan-
tial disease progression beyond baseline, with a rate of
attachment loss 3 to 5 times higher than what has been
documented for natural progression of disease in a high
disease susceptibility group.9,14,15,18,19
Conversely, other clinical studies show that even under
routine maintenance regimens, there is a small proportion of
patients (10% to 20%) who will continue to suffer from
occasional episodes of recurrent periodontal reinfec-
tion.13,14,20 It has been suggested that different patients are
at different risks for disease progression and that the
determination of these risks would enable the development
of an appropriate maintenance schedule for each patient.21
PERIODONTAL MAINTENANCE THERAPY
Prophylaxis and periodontal maintenance therapy are among
the most frequent dental procedures performed by the dental
office team. Table 1 summarizes data derived from about
1.25 million patients who were members of the Washington
Dental Service during 1993 and 1999, and who were treated
in about 3500 general and specialty dental offices.22
Procedure rates per 1000 patients for prophylaxis and
periodontal maintenance therapy increased dramatically
during the study period while surgical and nonsurgical
periodontal therapy declined. These findings are similar to
declining prevalence estimates for periodontitis23 as well as
surveys of practicing dentists,24 and suggest a marked
increase in preventive and maintenance periodontal care in
populations that retain the dentition for an increasingly
longer lifetime.
There is substantial observational, clinical, and controlled
trial evidence that periodontal maintenance therapy, com-
posed of oral hygiene instructions, coronal debridement, and
subgingival scaling and root planing is effective in resolving
Table 1. Changes in periodontal procedure rate per
1000 Washington Dental Service patients
1993 1999 % Change
Prophylaxis 1220.5 1350.6 +10.7
Periodontal maintenance 110.0 161.3 +46.6
therapy
Nonsurgical periodontal 159.1 141.7 j10.9
therapy
Surgical periodontal 10.9 6.8 j38.4
therapy
Volume 6, Number 1
gingival inflammation and improving periodontal probing
depth measurements. A summary of systematic reviews that
examine the relative benefits of individual components of
periodontal maintenance therapy is given in Table 2.
Placebo Effects of the
Periodontal Maintenance Therapy Ritual
There is much disagreement about beneficial effects that may
accrue from placebo effects that have no inherent power to
improve health outcomes.25-27 An example of such effects in
patients with periodontitis was described in studies of clinical
and microbiological measures that predicted the outcome of
periodontal treatment.28 Subjects with a history of period-
ontitis agreed to participate in a study of the efficacy of oral
hygiene instructions and scaling and root planing for the
management of their disease. Each subject received a
screening examination, which included measurement of
plaque accumulation, bleeding on probing, probing pocket
depth, and probing attachment loss. The subjects were
informed that they qualified for the study, which would begin
in approximately 3 months. The investigators did not
comment on the subject’s oral condition, suggest changes in
oral hygiene practices, or render any treatment. Each subject
was given an appointment and a clinic number to call if they
required any oral care in the interim period. Three months
after the screening examination, an identical pretherapy oral
examination was repeated and all subjects then received a
detailed explanation of their periodontal condition, individu-
alized oral hygiene instructions, and full-mouth scaling and
root planing with local anesthesia performed during a period
of 2 weeks. A post-therapy examination was conducted 3
months after the completion of scaling and root planning. The
results are shown in Table 3. Taken collectively, considerable
improvement in clinical measurements occurred after the
subjects were accepted into the study but before they received
oral hygiene instructions and scaling and root planing.
One explanation for the improvement that occurred before
active treatment is placebo or context effects that result from
patient expectations and conditioning, and the empathy and
reassurance that accompanies the health therapist-patient
interaction.29-31 Systematic reviews have concluded that a
patient’s positive expectations for care and a warm manner
on the part of the therapist was associated with improved
health outcomes.32 Beyond classical conditioning and con-
scious expectancies, unintended behavioral changes have
been demonstrated in a broad range of chronic condi-
tions.33-36 Improved plaque control by the patient in
anticipation of the forthcoming examination alone might be
reflected in decreased measurements for plaque accumula-
tion, gingival bleeding, and gingival fluid volumes.
In contrast, 2 systemic reviews with combined analyses of
156 trials found no evidence of a generally large effect of
placebo interventions.37,38 Moreover, a possible small effect
on patient-reported continuous outcomes could not be clearly
distinguished from bias. The authors suggest that many
published placebo effects are related to absence of true
Pastagia et al. 27
 JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE

Table 2. Summary of systematic reviews using different treatment modalities in the management of periodontal diseases
Primary
Outcome
Study Population Intervention Comparator Measures Summary
Watt 2005 Variable Oral health No oral health Plaque levels,
Reductions in plaque and
promotion promotion gingival bleeding
gingival bleeding in
short-term; questionable
long-term significance.
Hujoel 2005 Chronic Personal Usual care Tooth loss, CAL, No statistically significant
periodontitis OHI PD, RBL difference
Beirne 2005 Fully erupted Scaling & No scale & Tooth loss, PI, CI, Insufficient evidence-
permanent polishing polish; scale GI, BI, PD, CAL based studies to reach
dentition & polish only conclusions regarding
if signs of beneficial and adverse
perio disease effects of routine scale &
polish, or regarding
effects of providing this
intervention at different
intervals.
Van der Weijden Chronic SGD + SPC SPC alone BOP, PD, CAL SGD + SPC 9 SPC alone.
2002 periodontitis -Mean D PD: 0.59mm and
1.18mm and -Mean DCAL:
0.37mm and 0.64mm
for SPC and SGD,
respectively.
Heasman 2002 Chronic SGD SP PD, CAL No statistically significant
periodontitis difference
Hanes 2003 Chronic Local CRA S/RP alone PD and/or CAL Statistically significant PD
periodontitis + S/RP reduction or CAL gain
compared to control.
-DPD: 0.06-0.51mm,
DCAL: j0.04-0.39mm
Local CRA S/RP alone PD and/or CAL No statistically significant
alone difference
A Irrigant S/RP alone PD and/or CAL No statistically significant
+ S/RP difference
Haffajee 2003 Chronic SAB alone Placebo CAL Statistically significant
periodontitis SAB + S/RP S/RP +/j Placebo CAL CAL gain compared to
SAB + S/RP S/RP + Placebo CAL control.
+ Surgery + Surgery -Mean 0.45mm CAL
gain regardless of
intervention.
Herrera 2002 Chronic or SAB + S/RP S/RP alone CAL, PD Statistically significant
aggressive PD reduction or CAL gain
periodontitis compared to control.
PI indicates plaque index; GI, gingival index; BOP, bleeding on probing; PD, probing depth; CAL, clinical attachment level; S/RP, scaling and root
planing; OHI, oral hygiene instruction; RBL, radiographic alveolar bone loss; BI, bleeding indices; CI, calculus indices; SGD, subgingival debridement;
SPC, supragingival plaque control; SP, supragingival prophylaxis; CRA, controlled-release antimicrobial; A, antimicrobial; SAB, systemic antibiotics.

28 Pastagia et al. March 2006

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE

Table 3. Changes in periodontal measurements after examination only, initial therapy, and scaling/root planing
Examination 1 Examination 2 Examination 3
Mean SD Mean SD % 1-2 Mean SD % 1-3
Plaque index 1.7 (0.3) 1.4 (0.4) 17.6 0.6 (0.3) 64.7
Gingival bleeding 1.9 (0.5) 1.7 (0.4) 10.5 0.8 (0.4) 57.8
Gingival fluid 75.8 (22.6) 65.3 (29.6) 13.9 31.0 (20.9) 59.1
Pocket depth 4.5 (0.8) 4.2 (0.8) 6.7 3.4 (0.7) 24.4
Attachment loss 5.3 (0.9) 5.0 (0.9) 5.7 4.1 (1.0) 22.6

control groups, natural fluctuations of chronic diseases over
time, regression to the mean value of physical measurements,
and lack or loss of blinding among patients and investiga-
tors.39 All of these conditions would also explain a reduction
in signs of periodontitis. While resolution of gingival
inflammation as a function of improved oral hygiene may
decrease periodontal probe penetration40 in measurements of
pocket depth and attachment loss, the role of the placebo
effect on the progression of periodontitis remains unclear.
Personal Oral Hygiene Instructions
Personal oral hygiene is considered to be essential in the
maintenance of patients diagnosed with periodontitis.41
Experimental gingivitis models, in which oral hygiene alone
was shown to resolve plaque-induced gingivitis, have lent
credence to this concept for periodontitis.42 One systematic
review43 showed short- term reductions in plaque and
gingival bleeding by means of oral health education
interventions. The clinical and public health significance of
these changes were not clear. Another systematic review44
questioned whether the frequency or the extent of personal
oral hygiene alone is related to the incidence or progression
of chronic periodontitis. The oral hygiene procedures
examined in the included studies consisted of flossing and
brushing instructions given by a dental practitioner, and
self-diagnosis of plaque and gingival inflammation. The
reviewers concluded that there was no randomized con-
trolled trial evidence indicating that repeated oral hygiene
instructions prevent or control periodontitis. The authors
discuss the possibilities of a direct relationship and contra-
dictory lack of association between personal oral hygiene and
periodontitis. In the absence of sufficient randomly con-
trolled studies, the authors further question whether dental
practitioners are placing an unsubstantiated emphasis on
patient oral hygiene and its impact on their long-term
periodontal health, particularly for those who are resistant to
conventional periodontal therapy.
Supragingival Scaling and Polishing
A systematic review was conducted in order to determine the
beneficial and harmful effects of routine scaling and polishing
for periodontal health.45 Only randomized clinical trials with
at least 6 months of follow-up were included in the review.
The authors concluded that there is insufficient evidence to
allow confident statements to be made regarding the
Volume 6, Number 1
beneficial and harmful effects of routine scaling and polishing
for periodontal health. In addition, no conclusions could be
made regarding the frequency with which this intervention
should be provided.
Supragingival Scaling
and Subgingival Root Planing
A systematic review7 assessed the effect of supragingival
scaling versus subgingival root planing on clinical outcomes
in patients at least 35 years of age with chronic periodontitis
and with no recent history of systemic antibiotic agent or
anti-inflammatory agent use within preceding 6 months. The
weighted mean attachment gain in pockets initially 5 mm or
more was 0.64 mm for subgingival root planing as compared
to 0.37 mm for supragingival scaling. Reduction of pocket
depth was 1.18 mm for subgingival root planing and
0.59 mm for supragingival scaling. The results of the review
suggest that subgingival S/RP in conjunction with supragingi-
val scaling in patients with chronic periodontitis was more
effective in reducing PD and improving CAL, compared to
that of supragingival scaling alone.
However, another systematic review46 concluded that it
was not possible to make any firm recommendations
regarding the superiority of supragingival scaling versus
subgingival root planing because of the limited amount of
evidence-based data available. The authors did suggest that
the best available evidence indicates that both treatment
modalities are comparable with respect to probing depth
measurements 12 months after nonsurgical treatment.
Both reviews emphasize the need for more evidence-based
studies on the effectiveness of supragingival and subgingival
debridement.
Local Antimicrobial Agents
Locally delivered anti-infective pharmacological agents have
been proposed as either an adjunct or alternative to
traditional mechanical debridement for treatment of period-
ontitis. A recent systematic review6 addressed 3 approaches
to local antimicrobial therapy. The first was the effect of local
controlled release anti-infective agents combined with scaling
and root planing compared to scaling and root planing alone.
Controlled-release anti-infective agents included chlorhexi-
dine gluconate, minocycline, doxycycline, metronidazole,
and tetracycline. The results of meta-analysis showed that
some sustained-release antimicrobial agents combined with
Pastagia et al. 29

scaling and root planing provided a statistically significant
but clinically small reduction in PD or gain in CAL
compared to scaling and root planing alone.
The second approach considered the effects of subgingival
sustained-release antimicrobials alone compared to scaling and
root planing alone. The review found no statistically or
clinically significant differences in probing depth measurement
between sites treated with antimicrobial agents alone or scaling
and root planing alone. The authors suggest that controlle-
d-release anti-microbial agents employed without subgingival
debridement may be most important for patients with high
disease recurrence, and that the clinical use of these agents is a
matter of therapeutic judgment and patient susceptibility.
The third approach examined therapist-delivered chlor-
hexidine irrigation during subgingival scaling and root
planing. Chlorhexidine irrigation showed no adjunctive
beneficial effects on bleeding and probing depth measure-
ments and was not considered a useful adjunctive procedure.
Systemic Antimicrobial Agents
Two systematic reviews47,48 evaluated the use of systemic
antibiotics alone or as an adjunct to surgical and nonsurgical
periodontal therapy. In general, systemically administered
antibiotic therapy showed statistically significant improve-
ments in clinical attachment levels compared to a systemi-
cally administered placebo with and without surgical and
nonsurgical therapy. The adjunctive benefit was greatest in
patients with aggressive periodontitis. However, like locally
administered antimicrobial agents, the clinical effect was
relatively small and the use of adjunctive systemic antibiotics
in the treatment of periodontitis for most patients remains
unclear.
Treatment Frequency
The preponderance of clinical studies have shown that some
form of maintenance treatment is necessary for overall
periodontal health but the exact frequency of such mainte-
nance appears to be a matter of clinical opinion. A recent
systematic review45 addressed the frequency of periodontal
maintenance. Studies that met their inclusion criteria49,50
compared a control group that received regular periodontal
prophylaxis with an experimental group that received
maintenance based on the results of differential darkfield
microscopic tests. The interval for maintenance was gradu-
ally extended from 1 to 24 months for patients with negative
microscopic results. In both studies, there were no statisti-
cally significant differences in plaque scores, gingivitis
measurements, and probing depths between the regularly
scheduled and microbial-test scheduled groups. Moreover,
there was no relationship between the monthly frequency
and periodontal outcome measurements.
Other studies included in the systematic review had
variable results for the effect of recall intervals on differences
in plaque, gingival inflammation, probing depths, and
attachment levels. Of note, 2 studies compared professional
tooth cleaning every 2 weeks versus 6- to 12-month
30 Pastagia et al.
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
maintenance after periodontal surgery for advanced period-
ontitis.51,52 In both studies, the 2 weekly maintained patient
group remained periodontally stable while the control
maintenance group showed a gradual recurrence of deep
pockets and continuous loss of attachment.
Due to the small number of studies that met the inclusion
criteria and the lack of well-designed randomized controlled
clinical trials, the authors of the systematic review concluded
that there were insufficient data to make any definite
conclusions regarding the effects of providing maintenance
treatment at different time intervals.
PLAQUE CONTROL: HAS ANYTHING
REALLY CHANGED THE WAY WE PRACTICE?
Periodontal maintenance therapy is performed as a package
of treatments that usually includes an examination, oral
hygiene instructions, coronal debridement, and, when
indicated, subgingival root planing scaling plus other
adjunctive procedures. In general, these procedures evolved
primarily for prevention of caries and gingivitis. Prevention
of gingivitis was deemed critical to preventing subsequent
periodontitis. Accordingly, assessment measurements in
clinical practice for periodontal maintenance therapy are
based either on signs of gingivitis (redness, swelling,
bleeding) or are affected by levels of gingival inflammation
(probing pocket depths, attachment loss, and mobility).
Clinical evidence demonstrates that this package of mainte-
nance procedures is effective in controlling gingival inflam-
mation and decreasing periodontal probing depths.
The past 5 decades have seen a marked decrease in caries,
severe gingival inflammation, and generalized periodontitis in
many populations. At the same time, dental care for these
patients is progressively more preventive and directed to
maintaining an intact dentition for an increasingly longer
lifetime. Under such conditions, the progression of gingivitis
to periodontitis appears to depend primarily on individual
host susceptibility, and surrogate measurements of plaque
accumulation or gingival inflammation are less predictive of
future periodontal destruction. Moreover, the relative
therapeutic benefits of individual components that comprise
preventive periodontal care in these populations are also
unclear.
The Proceedings of the Fourth European Workshop on
Periodontology53 concluded that there were no randomly
controlled trials that addressed the effectiveness of combined
periodontal maintenance therapy for periodontitis. The panel
recommended that such trials be initiated, and that present
care of patients with periodontitis should be based on
cause-related therapy established in clinical studies. We
agree, and conclude that few clinical or randomized
controlled studies have evaluated the benefit or required
frequency of individual components of the maintenance
ritual, including repeated oral hygiene instructions, supra-
gingival scaling and polishing, subgingival root planning, and
March 2006
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
adjunctive procedures for patients who are relatively resistant
or susceptible to periodontitis.
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