MAINTENANCE PHASE OF PERIODONTAL CARE
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
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:
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.
Preservation of alveolar bone
support, by maintaining or even improving bone height after periodontal
Maintenance of stable clinical
The prevention of recession
Control of inflammation
Revaluation and reinforcement
of effective plaque control by the patient
Maintenance of healthy and functional
oral environment by monitoring any changes in the dentition and oral cavity
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.
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:
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.
provision of information and
reinforcement of motivation
instruction in plaque control
removal of all supra- and subgingival
plaque and calculus deposits
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
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.
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
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
WITH MAINTENANCE THERAPY
1. 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
2. Patients' oral
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 self-inflicted 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
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 oxalate-based
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
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.
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.
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.