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8

Maintenance Therapy/Necessary
for Long-Term Success

8.1

Introduction

The accumulation of bacterial plaque, food debris,


and eventually calculus on the non-shedding surfaces of the human dentition has long been recognized, since the time of Pierre Fauchard in the
eighteenth century, as the most fundamental factor
responsible for the initiation of dental caries and
periodontal diseases. This quintessential insight,
recognized by so many astute clinicians, should
not be ignored when treating patients with periodontal diseases. Whether the therapy is for gingivitis, periodontitis, pericoronitis, acute necrotizing
ulcerative gingivitis (ANUG), peri-implant mucositis, or peri-implantitis, the individual patients
level of cooperation in the therapy is crucial for
achieving immediate and long-term successful
results. Patients need to be empowered so they can
reverse the ravages of neglect and move forward
towards the new direction of clinical health and
comfort. The decision for this change in direction
must come from the individual patient, but dental
health professionals must be willing to accept their
responsibility to guide and motivate each patient.
The known methods whereby dentists can prevent
periodontal disease are more effective than those
available for any other chronic affliction of the
human body even more effective than caries preventive measures. But they are not widely used.
For no other chronic disease are there such effective uncomplicated patient administered preventive procedures. But judging from the high
incidence of periodontal disease they are hardly

used. Either the public has not been sufficiently


educated regarding what they can do for themselves or they are disinterested and satisfied to
unnecessarily sacrifice their teeth to preventable
disease.
Neglect is a principal cause of gingival and periodontal disease; neglect of the healthy mouth permits disease to occur; neglect of early disease
which permits the disease to destroy supporting
tissues and neglect of the treated mouth which
permits disease to occur.
Irving Glickman (1967)

8.1.1

The Maintenance Therapy


Program

After a period of healing, regardless of whether


periodontal health is reestablished with phase I
therapy services alone or with additional phase II
surgical services as needed, all patients need to
be assigned to a maintenance therapy program.
The purpose of the maintenance therapy program
is to provide a structured environment where
patients oral health needs are addressed with
appropriate therapeutic interventions.
The maintenance therapy program should be
characterized by a proactive staff, dedicated to
the following common goals:
(a) Preventing the recurrence of dental diseases
and mucosal lesions
(b) Identifying new lesions in their incipient state

Springer-Verlag Berlin Heidelberg 2016


P.A. Levi, Jr. et al., Non-Surgical Control of Periodontal Diseases: A Comprehensive Handbook,
DOI 10.1007/978-3-662-46623-0_8

175

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(c) Ensuring a positive relationship between the


specialists office and the referring general
dentists office
(d) Establishing clear communication channels
between the patient and both offices
(e) Advocating for the patient, when insurance
carriers require further clarification as to why
maintenance therapy services are necessary
and justified

8.2

Getting Started

In general, the idea of risk assessment can be


employed to help in determining the time interval
between maintenance therapy visits. Immediately
following phase I active therapy, all patients are
considered to be at high risk for recurrence of disease; therefore, the interval should be short,
between 2 and 3 months. This should continue for
12 years. Following 56 visits, the caries risk and
periodontal disease risk can be reassessed, and a
new interval can be established. The traditional
6-month interval should no longer be relied upon
to address the needs of each individual patient. In
addition, these visits should be scheduled in a
mutually agreed-upon alternating pattern between
the referring general dentist and the periodontist.

8.2.1

High-Risk Patients

Specific conditions that predispose the patient to


periodontitis and increased risk of root caries
require a shorter interval (810 weeks) and additional vigilance. Examples of high-risk patients
might include the following:

Diabetic patients
Smokers
Pregnant patients
Sjogrens patients
Head and neck cancer patients
Patients who take medications that compromise salivary flow
Patients who carry polymorphism of interleukin-1 genotype

Maintenance Therapy/Necessary for Long-Term Success

8.3

Treatment Principles
Regarding the Prevention
of Gingivitis
and Periodontitis

The two major responsibilities that must be


addressed by patients:
1. They must be willing to maintain excellent
personal plaque control at home.
2. They must be willing to cooperate and return
to the dental office setting on a regular basis
for maintenance therapy evaluation and preventive services.
The two major responsibilities that must be
addressed by clinicians:
1. They must remain involved in periodically
motivating the patient in lifestyle changes that
enhance oral hygiene standards.
2. They must remain alert and diligent in their
efforts to identify incipient disease and provide the necessary therapeutic interventions.
The three main etiologic factors responsible
for gingivitis:
(a) The patients inability to control the accumulation of bacterial plaque
(b) The clinicians deficiency in providing a
meaningful educational experience for
patients regarding plaque control measures,
and therefore not empowering patients to
prevent disease
(c) Iatrogenic causes: loose or open contacts
leading to food impaction, overhanging
restorative margins, bulky restorative cervical
contours, and violation of the biologic width
The three main principles regarding preventative dentistry:
(a) Educate and empower patients.
(b) Remove all etiologic factors that elicit
inflammation.
(c) Motivate patients to be cooperative and follow
professional guidance and recommendations.

8.4

Basic Features of a Structured Maintenance Therapy Program

The three main reasons for treating gingivitis and periodontitis:


(a) Reduce or eliminate symptoms of disease.
(b) Reduce or eliminate risk of periodontitis and
consequent attachment loss.
(c) Reduce or eliminate bacterial and cytokine
seeding into the general circulation and possible systemic consequences.
Success in treating gingivitis and
periodontitis:
Success in treating gingivitis and periodontitis
will be realized ONLY if the clinician strives to
thoroughly manage or correct all of the etiologic
factors:
(a) Help improve plaque control by motivational
counseling of the patient, which includes the
review of brushing and flossing techniques.
(b) Debride plaque and calculus from tooth
surfaces.
(c) Close all loose or open contacts if possible.
(d) Remove all restorative overhangs and reduce
bulky cervical contours.
(e) Resolve all biologic width violation situations.

8.4

Basic Features
of a Structured Maintenance
Therapy Program

Both maintenance therapy and primary active


therapy must be introduced conceptually at the
same time to the patient. All patients must be
advised against the folly of relying on short-term
gains (via active primary treatment and brief periods of improved plaque control) when long term
retention of the teeth in function (via extended professional recall treatment and extended personal
plaque control) is the only sensible goal.
Successful long-term maintenance after treatment
is more than anything else, an attitude of mind,
both of the therapist and the patient. We all realize
that a short-term therapeutic improvement, essential though it is, can be only a beginning. By itself,
it means little. Ahead is the far more elusive goal
of preserving the dentition in a state of health for
the longest possible time. To attain this goal, the
therapist must generate resolve within the patient,

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and this resolve must stem from an even firmer


resolve within himself.
Alfred L. Ogilvie, DDS, MS
Professor of Oral Medicine
University of British Columbia, 1977

The maintenance therapy program is a proactive program that aims at preventing occurrence
of new dental disease (caries and periodontal disease) and recurrence of previously treated dental
disease. The objectives of the maintenance therapy appointment are essentially threefold in
nature:
1. Complete assessment of the present conditions and then compare with past records
does the new data suggest stability of
attachment levels or not?
2. Review motivational needs of each patient as
they pertain to helping them sustain their dedication to high standards of plaque control.
3. Make further recommendations that are essential to promoting dental and periodontal
health.

8.4.1

Guidelines for Evaluation:


What Are the Key Signs
to Look for in Early Disease?

(a) Are there gingival erythema and gingival


enlargement?
(b) Is there bleeding upon gentle probing?
(c) Are there any new pocket (gingival or periodontal) depths?
(d) Are older, previously noted, pocket depths
becoming deeper?
(e) Is there evidence of advancing attachment
loss?
(f) Is the advancing attachment loss generalized
or localized?
(g) Are root surfaces smooth and free of caries
and calculus deposits?
(h) Are tooth mobilities increasing?
Once the dental therapist is sensitized to the
above signs of early disease, the actual maintenance therapy appointment should proceed
smoothly and more expeditiously.

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8.5

The Maintenance Therapy


Appointment: The Basic
Protocol

1. Review medical history and update as necessary: for example, list all new medications,
dosages, and reasons for taking such; list any
recent hospitalizations and reasons for such;
take a new blood pressure reading and record;
determine level of diabetic control; determine status of smoking cessation efforts; and
determine if any new medications are reducing salivary flow or if they have the potential
to cause gingival enlargement.
2. Complete the extraoral and intraoral examination for pathology of skin, lymph nodes,
and oral mucosa.
3. Perform periodontal examination and rechart
findings.
(a) Assess mobility, probing depths, bleeding upon gentle probing, color, size, consistency, and position of the gingival
margin.
(b) Evaluate occlusal relations; determine if
there is fremitus or evidence of bruxism.
Determine if there is evidence of increasing mobility patterns.
(c) State the new periodontal diagnosis.
(d) Assess stability of attachment levels.
(e) Outline any new recommendations that
will foster periodontal health, including
a referral to a periodontal specialist.

Fig. 8.1 Hygiene index

Maintenance Therapy/Necessary for Long-Term Success

4. Perform a restorative examination and


rechart findings.
(a) Assess old restorations for breakage,
open margins, open contacts, or biologic
width violations.
(b) Assess caries risk activityuse magnification and transillumination to detect
new lesions.
(c) Outline any new recommendations
that will foster a zero caries rate
(activity).
5. Determine need for new radiographic
imaging.
6. Disclose the patient to determine plaque levels and use a plaque-free scoring system
(Fig. 8.1).
7. Review oral hygiene methodsby allowing
the patient to demonstrate their brushing and
flossing techniques. Determine level of
ability and actively re-instruct patient as
necessary.
8. Perform any necessary therapy such as: dental prophylaxis and root planing as needed,
topical application of fluoride, or desensitizing agents and rescheduling patient for
restorative procedures.
9. Enter personal notes about patient that are
deemed important or significant.
10. Determine whether the interval length
between maintenance therapy appointments
is correct or requires adjustment.

8.6

Implant Maintenance

179

Basic armamentarium for the maintenance


therapy visit:
(a) Examination instruments
(b) Paper or digital copy of the maintenance
therapy Basic Protocol
(c) Preventive dentistry supplies for demonstration purposes (timing device, patient mirror,
disclosing agents, brushes, interproximal
aides, rubber tip)
(d) Treatment instruments
(e) Topical fluoride agents
(f) Articulating paper or ribbon to evaluate the
occlusion

8.6

Implant Maintenance

During maintenance therapy, dental providers are


seeing an growing number of patients with implantsupported prostheses, and this trend is only going
to increase because more dentists are offering
implant therapies and more patients are keen to
accept implant therapy rather than a conventional
fixed partial denture or a removable partial denture.
Routine maintenance therapy is crucial for preserving a patients peri-implant health.

8.6.1

Anatomy of a Dental Implant


and its Supporting Prosthesis
(Fig. 8.2)

How does the attachment apparatus around


implants differ from that of natural teeth?
Lack of a periodontal ligament
Circular gingival fibers around implants as opposed
to perpendicular gingival fibers around teeth
Intimate contact between bone and implant
surface

8.6.2

Evaluation of Implant Health

8.6.2.1 Parameters
Presence of plaque and/or calculus
Appearance of the peri-implant tissue; signs of
inflammation such as bleeding or purulent exudate

Fig. 8.2 Left side of figure represents implant health.


Right side of figure depicts peri-implantitis

Radiographic appearance
Probing depths
Patient comfort
Maintenance/re-care interval

The peri-implant soft tissue should be visually


examined for signs of inflammation such as erythema, bleeding, swelling, and suppuration. If an
infection or inflammation is present, the clinician
will have to develop a treatment plan. The treatment plan may include nonsurgical therapy, antibiotics, shortening re-care intervals, or a referral
for evaluation by a specialist.
The protocol for probing dental implants was
in the past controversial; however, the consensus
is that it is not only safe but is essential in order
to evaluate peri-implant health.
The gingival attachment to implants is weaker
than that of natural teeth, as there is no connective
tissue attachment. The Junctional epithelium
attaches to the implant surface via a glycocalyx
secreted through hemidesmosomes, and the gingival fibers of the connective tissue, do not insert
into the implant. Collagen fiber bundles originate
from the bone and run vertically and parallel to
the implant surfaces. Clinicians could inadvertently probe beyond this weak attachment and
break the seal; hence, the probing depth reading
may be exaggerated and subsequently interpreted

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as peri-implant disease. An experienced clinician


should be able to probe dental implants without
continual perforation of the epithelial attachment.
When interpreting a probing depth around an
implant, implant positioning in the coronoapical
dimension should be taken into consideration.
To create an adequate emergence profile, implant
fixtures are often placed slightly deeper than that
of the location of the cementoenamel junction of
a clinical crown, especially in the maxillary
anterior region. Therefore, interproximal probing depth as deep as 6 mm may be observed if
the proximal crestal bone levels of the adjacent
teeth are more coronal than the implant
platform.
This deeper probing depth reading does not
indicate peri-implant tissue pathology unless:
1. There is bleeding upon probing or suppuration.
2. There is increased probing depth over time.
3. There is radiographic evidence of bone loss
compared to the baseline radiographic image.
Some have argued against using metallic
probes, concerned that the metallic probes might
scratch and damage the implant surface. However,
the probe tip does not touch the implant surfaceonly the abutment surface in most cases.
Thus, the surface alteration is minimal. A conventional metallic periodontal probe and a plastic
periodontal probe are equally effective, though
some practitioners prefer a plastic probe because
it is more flexible (Fig. 8.3).
Inflammation around an implant is a critical
factor that determines whether intervention will
be required. Although many etiological factors
exist, one of the most common causes of inflammation around dental implants is excess cement
that was not removed during crown cementation.
Excessive subgingival cement remaining after
cementation leads to a foreign body reaction that
causes pathologic soft tissue inflammation and
bone loss. In addition, the surface topography of
the dental implant may provide a favorable environment for bacterial attachment. Accessing the
subgingival space of the implant restoration nonsurgically because of implant positioning and
subsequent suprastructure design could be

Maintenance Therapy/Necessary for Long-Term Success

Fig. 8.3 Plastic and metal periodontal probes

challenging. Moreover, many commonly used


types of dental cement are not detectable in
radiographs. Meticulous attempts to remove
excess cement must be practiced.
Another source of peri-implant inflammation
is ill-fitting suprastructures. A loose abutment or
screw may contribute to the accumulation of
plaque, which may then lead to peri-implant
inflammation.

8.6.2.2 Signs of a Healthy Implant


Surrounded by tissue that is firm and of normal color with no evidence of erythema,
edema, bleeding, or suppuration.
The implant fixture should be non-movable.
No bone loss beyond crestal bone remodeling.
Clinicians have established that most bone
remodeling around healthy implants occurs
during the early healing phase and is then followed by stabilization of the bone during the
years in function. Documenting baseline bone
levels after implant placement and after insertion of the prosthesis is important.

8.6.2.3 Diagnosis of Peri-implant


Diseases
Peri-implant mucositis: a disease in which the
presence of inflammation is confined to the
soft tissue surrounding a dental implant with
no signs of supporting bone loss following the
initial bone remodeling that occurs during

8.6

Implant Maintenance

181

Fig. 8.5 Peri-implantitis

8.6.3

Instrumentation of Dental
Implants

We are still in the early stages of investigating


factors that could be responsible for peri-implant
diseases. No one standardized method of implant
maintenance has been identified. However, the
importance of an adequate maintenance therapy
for implant survival has not been disputed. The
main objective when the clinician is instrumenting the dental implant prosthesis is to eliminate
the bacterial microfilm by removing both hard
and soft tissue deposits.
Fig. 8.4 Peri-implant mucositis

healing. Peri-implant mucositis may be identified clinically by erythema and bleeding upon
probing and/or suppuration (Fig. 8.4).
Peri-implantitis: an inflammatory process
around an implant that exhibits both soft tissue inflammation and progressive loss of
bone beyond the initial bone remodeling
(Fig. 8.5).

8.6.3.1 Using Hand Instruments


When we are instrumenting an implant-supported
prosthesis, we are usually cleaning the prosthetic
parts, not the implant fixture. Cleaning implant
prostheses requires only gentle scaling, and care
must be taken to preserve the delicate periimplant seal. Thus, vigorous scaling will not be
of any benefit. In the event that the implant fixture becomes exposed, it needs to be debrided as
well. Only gentle debridement is recommended
because the titanium surfaces may become

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Maintenance Therapy/Necessary for Long-Term Success

Fig. 8.6 Titanium


instruments used for implant
maintenance

scratched. Such scratches could result in greater


plaque accumulation, biofilm growth, inflammation of the soft tissues, and potential bone loss
around the implant fixtures. To decrease the
possibility of scratching, the use of plastic
curettes has been advocated. However, some
plastic instruments are too flexible to be efficient.
Plastic instruments reinforced with graphite are
more rigid and can be sharpened. Titanium
curettes are also available for purposes of implant
debridement (Fig. 8.6).

8.6.3.2 Using Ultrasonic Scalers


Traditional ultrasonic tips may damage the
implant abutment surfaces. However, clinicians
have found no evidence that has linked mechanical implant surface alterations to an increased
incidence of peri-implant inflammation. Recent
research findings show that plastic-covered and
novel metallic copper alloy ultrasonic scaler tips
have a minimal negative effect on the titanium
surface of implants (Fig. 8.7).

8.6.3.3 Use of Air Polishing


The literature contains conflicting reports about
the efficacy of air polishing when it comes to

Fig. 8.7 Plastic-covered ultrasonic tip used for implant


maintenance

dental implants. Air polishing seems to be more


efficient in debris removal compared to the
curette. However, some studies have reported that
air polishing might alter the surface of the abutment and leave a powder deposit on the surface of
the implant.
Air polishing with glycine powder seems to be
less abrasive than air polishing with sodium
bicarbonate powder. Moreover, the use of glycine
powder seems to inhibit bacterial recolonization
within implants in the first 24 h after application
(Fig. 8.8).

8.6

Implant Maintenance

183

Fig. 8.8 Air polisher

8.6.3.4 Using a Rubber Cup


with Polishing Paste
It appears that using polishing paste with a rubber
cup does not scratch the implant surface. An
in vitro study showed that polishing with a rubber
cup employing flour of pumice on an implant
abutment left the surface smoother compared to
nontreated machined abutments.

the necessary width of keratinized mucosa for the


adequate maintenance of healthy peri-implant tissue. Some studies have shown an association
between reduced or lack of keratinized mucosa and
peri-implant inflammation. Compared to keratinized mucosa, alveolar mucosa is sensitive to touch
and manipulation. Thus, this sensitivity might prevent the patient from removing plaque from the
implant prosthesis and/or sulcus.

8.6.4

8.6.4.1 Implant Care with Manual


Toothbrushes
Exposed facial and lingual areas of the dental
implant, its fixed prosthesis, and gingival tissues
should be cleaned using a soft-bristled, multitufted
toothbrush. Patients should be instructed to practice the stationary bristle technique of holding the
toothbrush at an angle where the prosthesis meets
the gingival tissue. It is important that patients concentrate on working the bristle tips on the implant
crown beneath the soft tissue margin. Toothpaste
can be utilized safely because there has been no
evidence to date showing contraindication of toothpaste for patients with implant prostheses.

Protocol for Home Care


for Patients

Maintenance of healthy peri-implant tissues is


the key factor in the long-term success of dental
implant therapy. Studies have shown a relationship between bacterial microfilm and inflammatory changes in the soft tissues surrounding the
implants. Therefore, patients must be educated
about the importance of personal hygiene and
willing to accept the responsibilities of an intensive routine of care. Many of the current homecare regimens for natural teeth also can be used
with dental implants. (Details of home-care regimens are discussed in Chap. 3 of this book.)
No one particular device has been proven to
remove plaque from all surfaces of an implant
and its prosthesis. Numerous types of toothbrushes, interdental brushes, flosses, and other
oral hygiene devices are on the market. However,
patient compliance often depends on the simplicity of the oral hygiene regimen. The dental provider should make a recommendation for each
patient that considers his or her particular needs.
The role of the width of keratinized mucosa
around an implant in terms of patient compliance is
worth noting. Differing opinions exist concerning

8.6.4.2 Implant Care with Electric/


Power Toothbrushes
Power toothbrushes do not damage polished
implant surfaces and can be used to clean the
implant. The bristles should be placed against the
implant prosthesis and gently guided into the sulcus. Although some studies have shown that
power brushes were more efficient in plaque
removal compared with manual brushes, many
other reviews reported no significant difference.
Once again, patient acceptance and concordance
should be the determining factor.

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Maintenance Therapy/Necessary for Long-Term Success

Fig. 8.9 Floss with floss


threader

8.6.4.3 Dental Floss for Implant Care


The market offers many types of dental floss
including waxed, thick, thin, and waxed ribbon,
so dental providers must assist their patients in
selecting the one that suits their individual needs.
A floss threader may be required to access
implant-supported fixed partial dentures or
around connector bars. Using floss around
implant-supported restorations daily, practicing
the same techniques used for natural teeth, is recommended (Fig. 8.9).
8.6.4.4 Super Floss for Implant Care
Super floss, a wide band of ribbon with one end
designed for the use as a threading device, can be
particularly effective in removing debris in
implant-supported, fixed partial dentures. The
stiff end can be introduced between the abutment
and the pontic area. Next, using a shoeshine
motion, the ribbon (i.e., the spongy portion) may
be effectively used for the pontic area (Fig. 8.10).

Fig. 8.10 Superfloss

tissue against the implant prosthesis to help dislodge interproximal plaque.

8.6.4.7 Oral Irrigator for Implant Care


8.6.4.5 Interproximal Brush
for Implant Care
An interproximal (interdental) brush is an effective device for plaque removal in the interproximal areaif used properly. The patient should be
instructed to insert the tip interdentally in an
occlusal direction while applying a gentle rotary
motion. The brush head should be small enough
to fit into the interproximal area without traumatizing the soft tissue (Fig. 8.11).
8.6.4.6 Rubber Tip for Implant Care
A rubber tip can be used safely for plaque control
around implants. This device compresses the soft

The oral irrigator can be a beneficial adjunct for biofilm removal around implants. One study showed
that an oral irrigator was more effective than floss in
interproximal plaque removal. However, patients
should be instructed not to use excessive water pressure. The flow of irrigation should be aimed to pass
through contact and should not be directed into tissue. An oral rinse containing chlorhexidine gluconate may be used as an irrigant.

8.6.4.8 Concluding Remarks


No doubt the use of titanium dental implants will
remain a part of the practice of dentistry for many
years to come. Edentulism has been reduced but

8.7

Knowing Your Diagnostic Goals

185

Fig. 8.11 Interproximal


brushes

not eliminated among the general public, and for


many patients, a need to replace missing elements
of their natural dentitions remains. Long-term,
clinically successful results of implant therapy,
unfortunately, cannot be guaranteed to patients
who assume, and rightly so, that their new implants
will be maintained for the rest of their lives.
With this in mind:
All reasonable efforts should be made to
establish gingival and periodontal health prior
to the surgical placement of dental implants.
All reasonable efforts should be made to surgically place an implant in a position that can
be easily cleaned by the patient following the
fabrication of the final prosthesis.
All reasonable efforts should be made to surround the implant with a zone of keratinized
mucosa and adequate vestibular depth on the
facial aspect.
All reasonable efforts should be made to ensure
the complete removal of excess cement if cementretained crowns are the final prosthetic option.
All reasonable efforts should be made by the
patient to thoroughly remove plaque around
healthy implants every day.
All reasonable efforts should be made to monitor the health of dental implants by encouraging
patients to participate in a maintenance therapy
program so that accumulated plaque, calculus,
and food debris can be removed regularly.

8.7

Knowing Your
Diagnostic Goals

It is of critical importance, for all clinicians to


state to the patient, at the recall appointment, the
findings from the examination regarding the

health status of their periodontal tissues. The


ideal periodontal diagnosis would be gingival
and periodontal clinical health, or if there have
been past episodes of attachment loss, the ideal
new diagnosis would be clinical health on an anatomically reduced periodontium.
Many patients are disciplined and diligent
enough to present at the recall appointment with
signs of clinical health. They should be complimented for their high level of concordance with
the aims of periodontal therapy and for their dedication to sustaining excellent plaque control
measures at home.
A significant number of patients on recall, however, are often not fastidious with their home-care
measures and present with superficial inflammatory
changes in evidence, but without pocket depths
(gingival or periodontal). These patients should also
be complimented for their home-care efforts but
encouraged, in addition, to concentrate their techniques and their time commitmentboth may need
some adjustment. The new diagnosis, in these circumstances, is either slight gingivitis on an anatomically reduced periodontium or slight periodontitis
on an anatomically reduced periodontiumeither
diagnosis is acceptable because the clinical distinction is moot. It is moot for two reasons:
1. Only an excisional biopsy and histopathologic
evaluation would allow the clinician to delineate the difference between the two situations
at that particular moment in time.
2. In both situations, when there is healing and
elimination of the exiatant signs of inflammation (subsequent to a dental scaling and prophylaxis and improvement in personal
home-care measures), the exact same diagnosis must be rendered, namely, clinical health
on an anatomically reduced periodontium.

186

For those patients who present with obvious


signs of inflammation and obvious accumulations of plaque and calculus, no compliments
should be forthcoming from any member of the
dental health team. The patient is not well served
if the dental clinician tolerates clear evidence of
incomplete plaque control efforts. What needs to
take place, at this critical moment, is a frank discussion of the morbid consequences of losing
further attachment support and losing more teeth,
as well as the systemic effects of chronic oral
inflammation. Inner resolve of the clinician in the
face of obvious patient neglect and passivity is
being tested at this moment. The dental health
professional must not demonstrate frustration or
anger, but, rather, with calm conviction, review
once again with the patient, the salient advantages of periodontal healthin terms of maintaining the natural dentition and in terms of
obviating systemic consequences of overt periodontal inflammation. The dental health professional must remain an unfailing beacon of hope
and encouragement to their patients.
In the final analysis, the patient who is choosing to entertain the life-altering event of edentulism and/or systemic comorbidities needs to
step back from the edge of this cliff, before it
is too late. Dental clinicians should be on the
lookout for those patients in the recall system
who seem to no longer care, who are permitting
inflammatory changes to become re-established,
and who are risking further destruction of their
supporting tissues and their general health. It is
at this critical point in patient care that the dental health professional must try to again light the
lamp of enthusiasm, in the patients mind, for
dental and periodontal health. Edentulism, while
not life threatening in the mechanical sense, is
life altering and immediately ushers into the
patients life a toxic stew of potentially morbid
consequences. These consequences should be
reviewed very carefully with the patient because
the patient is most likely unaware of them and
needs guidance at this critical moment in time.
This is our opportunity to, once again, champion the best interests of our patients. Some
of the unfortunate consequences of edentulism
include the following:

Maintenance Therapy/Necessary for Long-Term Success

(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)

Difficulty with mastication


Difficulty with phonetics
Difficulty with changes in esthetics
Decline in the enjoyment of eating foods
Depression
Dementia
Loss of self-esteem
Loss of edentulous ridge width and height

8.8

Knowing the Treatment Goal


of Periodontal Therapy

The ultimate goal of periodontal therapy is to stabilize attachment levels over time, so that patients
can enjoy the physical and psychological advantages of their natural dentitions. From a practical,
clinical point of view, the only treatment method
that has proven effective is the prudent application and juxtaposition of nonsurgical, surgical,
and maintenance therapies:
The selection of the surgical alternative in the treatment of a periodontal lesion imposes a special
responsibility on the operator. The creation of a new
wound in a human being, in the attempt to abort a
disease process, cannot and should not be taken
lightly. The drama, the vicarious thrill of a well-executed surgical procedure with its rewards of ego satisfaction, patient admiration, respect and financial gain
all too often may tip the balance of the scales in
weighing the treatment perogatives. Periodontal surgery, per se, cannot be equated with periodontal therapy. Perhaps no treatment method in dentistry has
been more misunderstood and misapplied than periodontal surgery. The expectation that the excision of
diseased gingival tissue will, in itself, cure periodontal disease is a delusion. Although some temporary
respite of the disease process may occur through the
elimination of diseased gingival tissues, one can
expect a reappearance of the disease unless periodontal surgery is properly placed in the treatment triad of
pre-surgical (environmental) periodontics, periodontal surgery and post-surgical periodontics.
Periodontal surgery is only one facet of a much
larger and extremely pertinent therapeutic regimen
and, unless one is prepared to place periodontal
surgery in its proper perspective, he/she must be
prepared for surgical failures.
Dr. Gerald M. Kramer (1972)

At the heart of whether or not we can achieve


and maintain periodontal health is the patients

8.9

Knowing the Psychological Difficulties Associated with the Maintenance Therapy Program

own desire, attitude, and effort. Periodontal disease is essentially a surface infection caused by
bacterial colonization of the non-shedding tooth
surfaces. The entire inflammatory response,
which is so essential for life, and which has
evolved as a protective mechanism over millions
and millions of years, can be, if one chooses, strategically obviated, if the patient is willing and
able to take diligent control of the oral environment. The patients attitude and desire to achieve
periodontal health must be translated into sustained and fastidious plaque control measures.
If the anatomical consequences of past episodes of periodontitis are not too severe, the clinician, in many cases, will realize the possibility
of achieving a new status of clinical health, albeit
on an anatomically reduced periodontium. The
bone tissue lost in the past, cannot be substantially reformed; it is more or less a permanent
anatomical changea residual anatomical scar
sustained after many years of persistent and
sometimes recurrent episodes of the surface
infection called periodontitis. Periodontitis is not
a systemic disease from an etiologic point of
view or from a therapeutic point of view; only
local factors initiate the infection and only the
meticulous mechanical removal of local factors
can be used to treat the infection.
Teeth in perfect polish do not illicit an inflammatory response
John M. Riggs (1867)

8.9

Knowing the Psychological


Difculties Associated
with the Maintenance
Therapy Program

We are not engaged in the tooth cleaning business


but rather the business of achieving and maintaining oral health. For those patients who see themselves paying for teeth cleaning services and who
are confused about or even distrust the basic
value of maintenance therapy, it should be
brought to their attention that they are making a
financial investment in their own oral health.
The monotomy and boredom often expressed
by those members of the dental health team,

187

whether they are hygienists, general dentists, or


periodontists, who perform maintenance therapy
on a frequent and repetitive basis, is a result of
seeing themselves as tooth cleaners. Clinicians
also refer to the maintenance visit as a cleaning, and thus it is no wonder that the patients
think of their maintenance visit much like hiring
a cleaning service to clean their home or like taking their car to the carwash. From a psychological point of view, this is a potentially dangerous
and emotionally destructive way to define the
very necessary procedures one is tasked to perform. Clinicians must keep in the forefront of
their minds the importance of the maintenance
visit as assisting the patient to maintain dental
health.
Once health of the bone, roots, ligaments, and
gingival tissues has been achieved, members of the
health team can then layer over this investment
with an additional financial investment in dental
beautyin the form of porcelain crowns, porcelain
laminates, orthodontic services, tooth bleaching
services, and bonded composite restorations.
Lastly, a word of advice to those clinicians who
limit their involvement in the maintenance therapy program in their offices.
It cannot be overstated that the maintenance
therapy program provides the dedicated clinician
the only opportunity to see the long-term results
of the original active therapy decisions. Failure,
once found, needs to be faced with courage and
honesty; it must not be allowed to go unattended,
hidden in the flurry of activity surrounding the
care of new patients.
Failures must be allowed to stimulate true professional growth and judgment, so that future
patients can truly benefit from the clinicians
practice experience.
The profession is not just about cleaning and
restoring teethits about treating patients. You
cant rest on todays laurels. Dont let yourself get
old and stale like a crust of bread. Protect the
profession. Love it, respect it, nurture it.will you
have failures or mistakes? Of course you will. How
you respond to those failures and mistakes will
define you as a professional.
Dr. Robert H. Johnson (2012)

Personal involvement in the maintenance therapy program also gives the clinician a special

Maintenance Therapy/Necessary for Long-Term Success

opportunity to receive a special gift. That gift is


the patients heartfelt gratitude, which is
expressed each time that they return for their
maintenance therapy. In addition, this positive
patient feedback is nourishing to the clinician,
even the seasoned clinician, providing the necessary reserves of professional satisfaction and
confidence which are then relied upon when he or
she turns to face the myriad of challenges and
question marks inherent in the day-to-day care of
new patients in the early phases of periodontal
therapy. The following letter is an example of
why we are clinicians and not just technicians:

ment to wearing artificial plastic or porcelain


teeth set in an acrylic base that moves around in
the mouth.
The more difficult clinical situations to manage successfully in terms of maintaining the natural dentition involve those cases where
attachment loss is only slight to moderate in
degree (not more than 50 % attachment loss for
the specific length of the involved root). These
cases are multifactorial in their etiologies, and
attention to detail is required if successful clinical results are to be achieved on a regular basis.
Once achieved, long-term success is ensured by
active participation in a structured, but customized, maintenance therapy program. Attention
must be made to: removal of restorative overhangs, removal of cervically bulky restorations,
closure of open or loose contacts, correction of
biologic width violations, equilibration of occlusal forces, enhancement of daily plaque control
measures, and meticulous removal of diseased
altered cementum and calculus, in supragingival
or subgingival locations.
There is, however, one other major factor, in the
management of periodontal disease, that has
undoubtedly proven to be controversialboth
among periodontal specialists and many generalists, which is the presence of inflamed pocket walls.
Whether it is a gingival pocket wall (induced by
inflammatory vasodilation, cellular infiltration,
hyperplasia, or edema) or a periodontal pocket wall
(induced by detachment and apical re-positioning
of the dentogingival structures), the architectural
nature of the wall itself introduces problems of
major consequencenamely, its presence essentially blinds the clinician and impairs his/her ability
to identify and remove subgingival plaque, calculus, and disease altered cementum. As long ago as
1942, sophisticated clinicians well versed in subgingival curettage (nonsurgical therapy) recognized both the potential benefits and the profound
limitations of this form of therapy.

188

After our last appointment I realized that I had not


told you how pleased I am at the progress and conduct of the work on my mouth. I am very glad that the
gains made have exceeded your expectations. While I
take credit for carrying out a thorough and conscientious program of brushing and flossing, I know that
the effectiveness of this program is due to you carefully training me in the proper use of brush, proxabrush, floss, and gauze pads. This is in contrast with
my previous periodontist who delegated cleaning and
scaling to a technician and who failed to school me in
flossing and proxabrushing, or in the use gauze pads.
While I am very pleased at the way therapy is going I
hope you will bring to my attention any problems
with my cleaning program. It is easy to slide and I am
very eager to keep what I have left in good shape.
In summary, while perio-work is not much fun I
feel the positive thrust of our mouth- health program (rationally discussed and arrived at) has been
psychologically tolerable, and even encouraging.
This again is in contrast to the rage and depression
generated by my previous periodontal treatment.
Keep up the good work! Regards, Henry

8.10

Understanding Anatomic
Realities: The Degree
of Attachment Loss
and the Presence of Pockets

The management of severe periodontitis is surprisingly not difficult for the clinician, in terms
of the treatment plan and its execution; it involves
easy extractions of relatively loose teeth. For the
patient, the treatment may be more challengingit involves either edentulism or the adjust-

From that day to this, the operation initiated


and taught by Riggs has, with many refinements,
held the center of the stage. This operation, which
has since come to be known as subgingival curettage, consists in passing an instrument---curet,

8.10 Understanding Anatomic Realities: The Degree of Attachment Loss and the Presence of Pockets
plane, or file--- into the pocket and bringing it to
bear on the surface of the root in such a way as to
remove anything of a foreign or septic nature that
may be upon it, leaving a smooth and polished surface. In pockets that are accessible and not too
deep, excellent results are obtained in this way.
Many still regard it as the operation of choice.
It is, however, a difficult operation. To remove
from a surface that cannot be seen whatever there
may be upon it of a foreign nature is always an
uncertain and in some instances an impossible
operation. It has, moreover, another disadvantage.
Unless reattachment occurs, which is the exception
and not the rule, the pocket will continue, with the
possibility of reinfection later. In non-cooperative
patients and those not under constant supervision,
this is a situation which needs to be seriously considered in deciding what form of treatment should
be undertaken in a given case. It is this uncertainty
in cases fairly well advanced that has caused those
engaged in the practice of periodontia to consider
the possibilities of surgery.
Dr. Arthur Hastings Merritt President A.D.A. (1942)

In spite of the difficulty of the procedure, there


remain many sound reasons for clinicians to master the techniques for identifying and removing
all calculus deposits:
(a) Supragingival and interproximal calculus
deposits interfere with oral hygiene measures
(e.g., flossing is not possible with significant
deposits of interproximal calculus).
(b) Broad rough surfaces of calculus enhance
plaque retention and formation.
(c) Porosity of calculus surfaces serves as a reservoir for antigenic toxins that can trigger
inflammatory changes in the adjacent periodontal tissues.
(d) Expansive deposits of calculus produce ischemia of adjacent periodontal tissues by
mechanical pressure and thereby enhance
the environment for anaerobic bacterial
growth.
(e) If calculus is allowed to remain on the cervical
portions of the crowns and root surfaces, a
chronic irritation is induced in the adjacent supporting periodontal tissues (dentogingival structures, the periodontal ligament, and the crestal
portion of the alveolar process); subsequent
chronic inflammation will invariably, over time,
lead to hard and soft tissue destruction.

189

Several other leading clinicians also agreed


with Dr. Merritts assessment of the limitations of
the conservative approach for treating periodontitis, or Riggs disease, and suggested surgical alternatives to achieve pocket elimination.
While robust competition existed between proponents of different specific surgical techniques, the
ultimate goal of pocket elimination was a shared
goal. Leaders in the field at the time, like Drs.
Olin Kirkland, Balint Orban, Charles Williams,
and Saul Schluger, all contributed to the advancement of surgical therapy, and their techniques are
still useful and valid to this day.
Surgery should be resorted to only when the
pocket cannot be eliminated by conservative means
or when time is an important factor in treatment....
where conservative treatment is feasible it is preferable to surgery, but the one constant in treatment
must be pocket elimination by any means before a
patient may be dismissed as cured.
Dr. Saul Schluger

At the moment, while it is true that there are


no long-term controlled studies of 1520 years
duration that prove beyond doubt that pocket
elimination is a necessary requirement for preventing further attachment loss and thereby prolonging the useful lifetime of the natural dentition,
it remains equally true that there are many advantages to both the patient and the clinician if all
pockets can be eliminated. Two of the more significant advantages are the following:
1. With the re-establishment of normal sulcus
depths (albeit at a more apical position), daily
access is provided to patients, to all bacterial
plaque deposits on the root surfacea root
surface previously covered up by the inflamed
pocket wall.
2. Elimination of gingival and periodontal pockets facilitates maintenance therapy programs
because it is much easier for the clinician to
perform coronal scaling and prophylaxis as
compared to performing subgingival scaling
of numerous pockets.
Because of these two reasons, all efforts
should be brought to bear on the elimination of
the pocket wall, thereby facilitating plaque

Maintenance Therapy/Necessary for Long-Term Success

control for patients and facilitating management of hundreds of patients in maintenance


therapy programs.

repeated opportunities to empower patients with


plaque control counseling.
The following salient insights can be drawn
from their work:

8.11

(a) There is an overwhelming risk, in clinical


practice, that neither the initial treatment nor
the subsequent personal oral hygiene will be
perfect for every tooth for every treated periodontitis patient. Periodic maintenance visits
reduce this risk.
(b) Main influences on progressive attachment loss
are: unfavorable immune response, inaccessible exposed furcations, poor personal plaque
control, and iatrogenic factors. Every effort
should be made to provide plaque control counseling to patients and remove all restorative
overhangs and close all open contacts.
(c) Surgical treatment without maintenance therapy may be worse than no treatment at all.
Optimal wound healing following surgical
therapy is enhanced with participation in a
structured maintenance program.
(d) Patients who were treated for moderate to
severe periodontitis were at greater risk for
more rapid attachment loss if they did not comply with a scheduled maintenance program,
when compared to patients who did comply.
(e) For patients with a history of treatment for
periodontitis, a maintenance program every
23 months is superior to one scheduled
every 612 months.
(f) For patients with a history of gingivitis, without attachment loss, maintenance therapy
scheduled every 612 months is most appropriate assuming that they do not show a susceptibility to smooth surface caries.
(g) Re-treatment of selected teeth, with obvious
signs of inflammation and progressive attachment loss, identified during maintenance visits, should proceed expeditiously.

190

Extending the Vision


of Success: Does
Maintenance Therapy Work?

As previously noted by Drs. Kramer and Ogilvie,


the initial improvements in gingival and periodontal health, achieved after successful administration of phase I and phase II surgical therapies,
while desirable, are short lived.
Clinical health achieved after disease elimination must be valued by the patient as a hard won
achievement, and a new commitment must be
formulated to guarantee that initial successes will
be extended deep into the future. This new commitment frequently requires an attitude adjustment on the part of both the clinician and the
patient. In recognition of this need to change attitudes, there has evolved within the dental profession, during the last 70 years, a sincere willingness
to value the importance of maintenance therapy
as a necessary preventive dentistry strategya
strategy clearly aimed at reducing the risk of
recurrence of caries and periodontal diseases.
Fortunately, in addition to this attitude adjustment by the profession, fluoridation of communal water supplies and topical application of
different formulations of fluoride are now readily
available to enhance the power and promise of
preventive dentistry.
The tremendous importance of maintenance
therapy in preventing the transformation of gingivitis into periodontitis and in helping patients with
a past history of periodontitis with attachment loss
avoid further destruction of their supporting tissues has been fully reviewed by several prominent
authors in the late 1970s and early 1980s. These
authors, taken collectively, helped lay the groundwork for the professions attitude adjustment by
documenting the value of a structured, periodic,
maintenance program. The hallmark of such a
valuable program is a proactive approach to early
diagnosis and early intervention, coupled with

In spite of these insights based on documented


research, there are, however, no long-term studies
of 1020 years duration that prove that maintenance
therapy alone is responsible for long-term clinical
successi.e., the retention of the natural dentition

8.12

The Challenge of Compliance

in comfort and function. Such a study, if it existed,


would have to compare the post-treatment results of
healthy patients entering maintenance therapy to the
post-treatment results of healthy patients who do
not participate at all in maintenance therapy.
The periodic removal of bacterial plaque and
calculus, achieved during the scaling and dental
prophylaxis procedure, has indeed been shown to
reduce significantly the total number of bacteria
on each tooth, as well as the GI score and the
plaque index score. The authors are cognizant of
these beneficial, but essentially, transient results,
induced by the structure of the clinical study
itself. Long-term beneficial clinical results, however, will require the enduring cooperation of the
patient, in terms of being diligent, on a daily
basis, with their own plaque control measures at
home.
Fortunately, we do not need a scientific study
to validate the obvious; rather, common sense
dictates that a periodic maintenance program will
provide repeated opportunities to re-motivate and
re-instruct the patient in their plaque control
measures. It is the consensus opinion of the
authors, drawn from decades of clinical experience, that once patients get excited about staying
healthyand they make the time commitment to
a personal home-care program of fastidious
plaque controlthen, and only then, will caries
prevention become a reality and further gingival
disease and periodontal attachment loss be obviated. Periodic removal (every 46 months) of
local etiologic factors by itself, without the concomitant participation at home by the patient,
will have limited power to influence, let alone
prevent disease recurrence.

8.12

The Challenge of Compliance

The problems surrounding the issue of patient


compliance both from the point of view of
patients being diligent with their daily plaque
control measures at home and their willingness to
stay on schedule with their supportive therapy
appointments have been thoroughly discussed in
many fine publications. One study of 1,000

191

treated patients found that only 16 % complied


with supportive therapy protocols. Many reasons
have been put forth to account for the disconnect
between the advice given by the dental health
professional and the subsequent action, or lack
thereof, taken by patients:
fear, economic concerns, lack of rapport with the
dentists, and self-destructive behavior.
Wilson, 1989

To counterbalance this reality, one needs to


emphasize the idea, at the beginning of the new
patient consultation/tissue examination appointment, that the goal of the dental therapist and the
patient is long-term successful clinical results and
not merely short-lived improvements. Proactive
steps must be embraced and practiced by our
patients in order to ensure that oral and dental
health is sustained over a meaningful number of
years. Of course pain relief is an immediate problem that must be addressed, but pain is, in general,
a very late indicator of periodontal attachment
loss and frequently when encountered is associated with the need for tooth removal. In other
words, reacting only to painful dental conditions
is really not a prudent strategy when it comes to
preventing tooth loss or preventing systemic consequences of inflammatory periodontal diseases.
The initial working relationship between the
patient and the dental health therapist must lead
to an agreement of purpose, such as saying: lets
not see any new carious lesions in the next two
years, or lets not see any more attachment loss
in the next five years, or lets not see any gingival bleeding in the next six months. Mutual goal
setting is at the very foundation of a successful
maintenance therapy program because the patient
can then start to take personal control of his/her
dental destiny, and compliance (i.e., being submissive to following the commands of the dental
health professional) can start to be transformed
for concordance (being in agreement with the
goals of the dental health professional). Active
therapy should not be allowed to begin until a
discussion of the long-term goals, and shared
responsibilities are reviewed and agreed upon
thus forming the basis of a therapeutic alliance.

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Further Reading

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J Dent. 2013;26(6):3138.

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Wilson TG. Dental maintenance for patients with periodontal diseases. Quintessence Int. 1989:2178.
Wilson TG, Glover ME, Schoen J, Baus C, Jacobs
T. Compliance with maintenance therapy in a private
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