CHAPTER 12: PHASE 4: PERIODONTAL MAINTENANCE

+ discussion and ppt

periodontal maintenance

aka: supportive periodontal treatment (SPT)

phase IV of periodontal therapy

long-term phase after active periodontal therapy

begins immediately after phase I (initial therapy)

surgical (phase II) and restorative (phase III) treatments occur during this phase

rationale of supportive periodontal treatment (SPT)

• high risk of disease recurrence due to:

  • incomplete bacterial removal

  • difficult tissue healing

• non-compliant patients have higher risk of tooth loss

significance of supportive periodontal treatment (SPT)

essential for long-term tooth preservation

• non-compliant patients:

  • 5.6× greater risk of tooth loss

• inadequate SPT after regenerative therapy:

  • 50× higher risk of probing attachment loss

classify patients based on:

severity

extent

location of periodontal disease

basis for recurrence and need for maintenance

cross-contamination

motivation and oral hygiene

healing pattern (histologic)

incomplete plaque removal (etiologic)

subgingival plaque regrowth

remaining plaque regrows inside periodontal pockets

regrowth is slow and may not show immediate inflammation

intragingival bacteria

bacteria remain within gingival tissues

• not fully removed by:

  • scaling

  • root planing

  • flap surgery

• can recolonize and cause recurrence

within 9–11 weeks

pathogens can return to original levels typically __

healing pattern (histologic)

healing usually forms long junctional epithelium

not true new connective tissue attachment

• this attachment may be:

  • weaker

  • more prone to pocket recurrence

cross-contamination

• periodontal bacteria can spread between:

  • spouses

  • family members

• reinfection risk increases, especially if pockets remain

part I: examination and evaluation (~14 minutes)

goal → identify changes since last visit

• clinical assessment:

  • update medical history, oral pathologic examination

  • check for:

    • gingival changes, pocket depth changes

    • mobility changes, occlusal changes

• plaque control check:

  • evaluate patient’s oral hygiene, reinforce it

  • patient should perform hygiene routine before appointment

• radiographic examination:

  • individualized based on severity and past findings

  • compare with previous radiographs to assess:

    • bone height, healing of osseous defects

    • trauma from occlusion, presence of caries

part II: treatment (~36 minutes)

• hygiene reinforcement

• scaling and root planing

  • perform where needed

  • avoid instrumenting normal sites (1–3 mm sulci)

  • prevent loss of attachment from repeated scaling

• polishing

• chemical irrigation / site-specific antimicrobials

  • used for patients with remaining pockets

part III: scheduling and administration (~10 minutes)

discuss findings with the patient

documentation

cleaning

schedule next recall visit

schedule additional periodontal/restorative treatment if needed

3 months

initial recall interval

first-year patients

recall not longer than 3 months

• purpose:

  • reinforce hygiene

  • evaluate surgical outcomes

1-2 months

recall intervals for difficult first year patients

merin classification and recall intervals

class A (excellent / well maintained)

class B (reasonably well maintained)

class C (poor results / multiple negative factors)

class A (excellent / well maintained)

good oral hygiene

no remaining pockets

no teeth with <50% bone support

managed by general dentist

recall intervals for class A patients

6 months – 1 year

class B (reasonably well maintained)

heavy calculus

systemic disease

inconsistent hygiene

some remaining pockets

smoking or some teeth with <50% bone support

alternating care: general dentist + specialist

recall intervals for class B patients

3–4 months

class C (poor results / multiple negative factors)

advanced disease

complicated prostheses

many remaining pockets

smoking or many teeth with <50% bone support

managed by specialist

recall intervals for class C patients

1–3 months

signs of a failing perio case

recurring inflammation

increased bone loss (radiographs)

gradual increase in tooth mobility

increasing sulcus depth (pocket formation)

causes of recurrence

inadequate restorations

failure to return for visits

incomplete calculus removal

poor patient plaque control

poor compliance with SPT schedule

systemic diseases affecting host resistance

1–2 weeks

decision to retreat should be delayed for __ after maintenance visit to allow resolution of edema

factors to consider referral

• pocket depth

  • ≥5 mm (from cementoenamel junction)

  • indicates risk of rapid deterioration

• location / extent

  • extensive osseous surgery

  • complex regenerative procedures

  • surgery on distal surfaces of second molars

  • teeth with furcation involvement (even if >50% bone support)

• other factors

  • systemic health problems

  • dental implant patients

  • complex prosthetic cases

• general rule

  • if case is not clearly simple → refer to specialist

peri-implantitis

bone loss around implant

susceptible for px with dental impants

more prone to plaque-induced inflammation than natural teeth

implant microflora link

similar to tooth microflora in partially edentulous patients

healthy tooth microflora is important for implant health

instrumentation when handling implants

special instruments required for titanium surfaces; a key difference

• avoid:

  • metal hand instruments

  • ultrasonic/sonic tips

  • (can damage or alter titanium surface)

• use:

  • plastic instruments

  • gold-plated curettes (specially designed)

  • for safe calculus removal

chemical / prophylactic agents when handling implants

• avoid:

  • acidic fluoride agents

  • daily acidic fluoride

• use:

  • nonabrasive prophy pastes

take periapical or vertical bite-wing radiographs at:

6 months

12 months

36 months after prosthesis placement

[ then every 36 months unless problems occur ]

correct sequence of treatment phases

maintenance begins immediately after phase I reevaluation with surgery and resto care performed during the maintenance phase

>6mm

probing depth which scaling is generally ineffective

2 automated risk calculators to predict perio progression

periodontal risk assessment (PRA)

periodontal risk calculator (PRC)

[ no universally accepted objective method exists, risk calculators should complement, not replace good clinical judgement ]

cases to refer a specialist

complex implants

regenerative procedures

extensive osseous surgery

systemic health complication

complex cases (distal surfaces of 2nd molars)

cases requiring co-management

cases general practitioner can handle

minor flap surgery

class A recall maintenance

localized nonsurgical therapy

>5mm pockets from the CEJ or furcation invasions

even with 50% bone support

it carries a questionable prognosis and are usually best treated by a specialist