MAINTENANCE PHASE OF PERIODONTAL CARE

The maintenance phase of periodontal therapy is defined as the maintenance of periodontal health following active treatment of periodontitis. Chronic periodontitis requires supervision and maintenance over a period of time after treatment in order to achieve long-term stability of results and to minimise recurrence. OBJECTIVES OF MAINTENANCE THERAPY The goal of maintenance therapy is to preserve the dentition for life, following periodontal treatment. In order to achieve this goal, maintenance therapy has the following objectives: 1. Preservation of alveolar bone support, by maintaining or even improving bone height after periodontal therapy 2. Maintenance of stable clinical attachment 3. The prevention of recession 4. Control of inflammation 5. Revaluation and reinforcement of effective plaque control by the patient 6. Maintenance of healthy and functional oral environment by monitoring any changes in the dentition and oral cavity Control of inflammation is important since low levels of gingival inflammation often correlate with gains in clinical attachment. However, increased inflammation does not necessarily lead to loss of clinical attachment. Although gingival inflammation is not a good indication of recurrent periodontitis, in an inflammation-free dentition, the recurrence of periodontitis is rare. THE MAINTENANCE VISIT The work performed during the maintenance visit should be adjusted to the needs of the individual patient. However, each visit should include the following practical routines, to make the work more efficient and to avoid omissions. 1. Examination and evaluation: Examination includes a brief review of medical and dental histories. A systematic oral examination is performed, including the oral mucosa, tooth and root surfaces, occlusion and oral hygiene. The periodontal examination is the most important component of maintenance therapy, as it determines the presence or absence of gingival inflammation and possible recurrences of disease. Evaluation of periodontal conditions may be obtained by an inspection of gingival tissues, assessing changes in colour, consistency and texture of the tissues. Periodontal probing is used to assess bleeding, suppuration, pocket depths, clinical attachment levels and presence of subgingival plaque and calculus. Bleeding on probing indicates inflammation. Increased pocket depths are assumed to indicate loss of periodontal attachment, although they may be partly due to inflammation. Loss of periodontal tissue support may also be assessed by the amount of gingival recession, tooth mobility and extent of radiographic bone loss. 2. Treatment provided at a maintenance visit(s): The supportive treatment of maintenance therapy includes:

provision of information and reinforcement of motivation instruction in plaque control removal of all supra- and subgingival plaque and calculus deposits

At each maintenance visit, patients should be informed about their dental conditions and effects of any aggravating factors such as poor oral hygiene, smoking and diet. Reinforcement of motivation and effective oral hygiene is essential, since patients tend to revert to their original behaviour. Scaling and root planing play an important role in the prevention of recurrence of periodontal disease. It is NOT enough to merely remove supragingival calculus and staining. The subgingival plaque needs to be removed as part of a maintenance visit, even if no active disease is detected. This can be done using fine tips in an ultrasonic device (if the patient does not have any problems with dentinal sensitivity). A gentler method is to use fine pcriodontal curettes to gently debride the subgingival root surfaces. 2. Treatment of recurrent disease: If active disease is detected, re-treatment is undertaken during the maintenance therapy over a series of appointments, in effect, returning the patient to a phase of active periodontal treatment. In cases of recurrences due to poor oral hygiene, surgical intervention should be postponed. Scaling and root planing should be the first re-treatment attempted. Periodontal flap surgery may be indicated when the accessibility of the lesion is difficult, or when recontouring of the gingival tissues is necessary so that the patient can clean a particular area. Antibiotic therapy may be indicated if there has been recurrent periodontal abscesses in spite of periodontal therapy. MAINTENANCE RECALL INTERVAL In the first year following active periodontal therapy, it is important to assess the patient's periodontal tissues and provide maintenance therapy every three months. For some patients, this interval of scheduling maintenance visits will continue throughout the rest of their lives. However, for 'stable periodontal patients - those who have excellent oral hygiene, no inflammation of the periodontal tissues and only shallow pockets remaining, then the recall interval may be extended. In essence, the frequency of recall visits must be adjusted to patients' individual needs. Factors that influence the length of` the recall intervals include: patient's plaque control individual tendency to form calculus severity of initial disease whether the patient is a smoker degree of` control of inflammation achieved by the periodontal treatment host response to bacterial infection presence of some systemic conditions that may disrupt the host-bacterial response age of the patient

TO TOP PROBLEMS ASSOCIATED WITH MAINTENANCE THERAPY 1. Patient motivation

Patient motivation is of great importance since it affects compliance and home care of a patient. Not enough reinforcement and emphasis on the importance of maintenance therapy will result in decreased motivation of the patient. Inadequate knowledge of` the nature of periodontal problems, and the need for on-going therapy, may effect the patient's motivation. Many patients envisage that the active phase of periodontal treatment is a 'cure', and express surprise at the need for further treatment of recurrent disease, or the need to attend 3-monthly for maintenance therapy. This may be caused by a lack of communication between the dentist and the patient at the start of treatment. Problems with communication may arise from language difficulties, as well as from different patterns of reasoning. Patients often operate on their beliefs, that may not correlate with the facts on which dentists base their work. Personal crises of patients may at any time create problems with motivation. 2. Patients' oral hygiene Due to poor manual dexterity or simply lack of effort, patients may not be able to effectively control their plaque accumulations. Inadequate and irregular toothbrushing produces generalised inflammation, and patients may avoid brushing near the inflamed tissues due to the bleeding it produces. This cycle of thinking must be challenged if periodontal treatment is to succeed. Patients may develop a habit of missing certain areas of their dentition during teeth cleaning, which may correlate with localised recurrences of periodontal lesions. Selection of a smaller toothbrush, such as an end-tufted brush or an interproximal brush may help the patient overcome such localised cleaning problems. Some undesirable habits during brushing may result in selfinflicted trauma to the dentition and the gingival tissues. This may produce areas of recession, and toothbrush abrasion lesions. Plaque retentive factors within the dentition include furrows and concavities in crown and root surfaces, poorly contoured restorations, subgingival margins, crowding of` teeth, and exposed narrow furcation openings. All of these factors make oral hygiene challenging, and also increase the complexity of the maintenance therapy. 3. Dentinal sensitivity Patients suffering dentinal hypersensitivity following periodontal therapy can pose a problem at the maintenance phase. Ideally, maintenance therapy should be carried out without the use of local anaesthetic, as it involves only lightly cleaning the root surfaces. However, some patients may resist even the lightest touch of a curette against the root surface, and the use of ultrasonic cleaners would be definitely contra-indicated. Therefore, in order to prevent these problems arising, it is important to treat dentinal hypersensitivity as it occurs during periodontal treatment. The professionally applied oxalatebased desensitising solutions eg, Protect or Sensodyne Sealant are extremely effective in minimising dentinal sensitivity. The adjunctive use of desensitising agent at home by the patient eg, Colgate Gel-Kam further minimises the problems. 4. Root caries One of the unfortunate things that may follow periodontal therapy is root caries lesions on the exposed root surfaces. The appearance of root caries may correlate with a change in the patient's medical status (resulting in a dry mouth), or in their social situation (resulting in a more cariogenic diet). Root caries is often an aggressive disease and can rapidly destroy tooth substance. It is

best prevented through the use of fluoride mouth rinses, combined with a fluoride toothpaste. Maintenance therapy often provides the best opportunity to detect and treat root caries lesions. 5. Cost It can become expensive for patients to attend the dentist on a three monthly basis. Private health insurance companies provide little in the way of rebates for periodontal maintenance. A way of minimising the costs to the patient may be to delegate maintenance therapy to a dental hygienist within your practice. SUMMARY The provision of periodontal treatment, without the follow-up of maintenance therapy, is unlikely to be of any benefit to the patient. Maintenance therapy is the cornerstone of a successf`ul practice that aims to provide good quality general dental care to achieve on-going oral health for their patients. This material has been compiled with the assistance of Dr Louise Brown, Lecturer in Periodontics at the University of Melbourne.