DR UMI

Maintenance therapy
Also known as Supportive Periodontal Therapy (SPT)

(American Academy of Periodontology 1998), supportive periodontal care (SPC) (Heasman et al. 2002), periodontal maintenance (American Academy of Periodontology [AAP] Cohen 2003)

Theory: Why we need maintenance in periodontal therapy?

To prevent recurrent of disease
Definitive step on total pts care Pts not maintained in supervised recall program shows

obvious sign of recurrent ( Axelson P, 1981) Reality: meaningless to ask patient to return for periodic recall without clearly explaining the significant of the visit.

 Againwhy we need maintenance therapy?? Rationale?? Even with appropriate periodontal therapy, progression of disease is possible. ( Greenwell H. et al, 1989) Recurrent can be because of incomplete subging. plaque removal. Slow regrowth of subgingival plaque may not induce inflammation reaction and therefore without presence of clinical gingival inflammation. Patient with apparent successfull treatment may become infected-reinfected by pathogen Long junctional epithelium present as healing after perio tx may be weaker and any inflammation may rapidly separate the epi from tooth. (Caton JG et al, 1979) Although after perio tx, subging microb decrease in number but it can return to baseline number within days/month depending on pts. Reality : pts oral hygiene effort tend to reduce between appointment. Therefore, there is sound scientific evidence that maintenance recall is needed.

Theory : therapeutic goal

prevent or minimize the recurrence and progression of periodontal

disease in patients who have been previously treated for gingivitis, periodontitis, and peri-implantitis.

prevent or reduce the incidence of tooth loss by monitoring the

dentition and any prosthetic replacement of natural teeth. increase the probability of locating and treating in a timely manner, other diseases or conditions found within the oral cavity.
Renvert & Persson, Periodontology 2000, Vol. 36, 2004, 179195 Maintenance has proved to be effective in the majority of periodontal patients in general (Hirschfeld & Wasserman1978, McFall 1982, Goldman et al.1986, Nabers et al. 1988)

Theory: When is pts eligible to be in maintenance phase?

Starts immediately after

completion and re-evaluation (reassessment) of 1st phase therapy. In maintenance phase , necessary surgical and restorative procedures are performed. This ensures all areas in mouth retain degree of health attained after 1st phase therapy.
(Supportive Periodontal Treatment chapter by Robert L.Merin in Carranzas Clinical Periodontology , 10th ed, 2006)

Phase 1
Nonhealing

Reevaluation

Phase 4 (maintenance)

Reality : what we do practice??

Phase 2 (periodontal surgery)

Phase 3 (restorative)

Theory: Periodontal maintenance therapy

Include: Update of medical and dental history Evaluate E/O and I/O, referral when indicated (for tx. Carious, pulpal pathosis) Assess oral hygiene status with reinstruction when indicated Best way to assess loss of attachment nowadays is still by full charting. (Wilson TG, 1996) Mechanical toothcleanig done. Local delivery/systemic chemotheraputic agent used in adjucntive treatment for recurrent or refactory disease. Eliminate of new or persistent risk ad etiological factor with appropriate tx. Identify and tx new, recurrent, or refractory areas of periodontal pathosis. Establish of appropriate , individualized interval for periodontal maintenance tx.

Maintenance therapy procedure

Part 1 Examination Medical history Oral patho examination Oral hygiene status Gingival changes Pocket depth changes Mobility changes Occusal changes Dental caries Restorative, prosthesis, implant status Part 2 Treatment Oral hygiene reinforcement Scaling Polishing Chemical irrigation of sitespecific antimicrobial placement Part 3 Report, clean-up and sceduling Write report Discuss with patient schedule visit/treatment Schedule/refer for resto/prosthetic treatment

(Supportive Periodontal Treatment chapter by Robert L.Merin in Carranzas Clinical Periodontology , 10th ed, 2006)

Theory: need of radiograph?

Pts condition/situation Clinical caries on high risk factor for caries Clinical caries and no high-risk factor for caries Periodontal dis not under good control History of periodontal tx. With disease under good control Root form dental implant Type of examination Post. Bitewing 12-18mth interval Post. Bitewing 24-48mth interval Pa/vertical bw of problem area every 1224mth, full mouth series every 3-5 yr. Bitewing examination every 24 to 36 mth, full mouth series every 5 yr pa, or vertical bitewing at 6, 12,36 mth after prosthetic tx., then every 36 mth unless clinical problem arises. Full mouth series if a current set is unavailable If full mouth series has been taken wothin 24 mth, r/gph of implant and problem area should be taken

Transfer of periodontal or implantmaintenance pts.

Theory : What to tell patient?

Area of persistent, recurrent, refractory or new

periodontal prognosis Changes in periodontal prognosis Advisability of further periodontal tx or re-tx of indicated site Status of dental implant Other oral health problem noted (caries, defective restoration, non-perio mucosal disease)

Q: efficacy of standardized SPT

difficult to draw definitive conclusions about the

efficacy of standardized SPT programs due to differences in study design Studies vary in SPT standard procedure SPT programs should be individualized in accordance to the patients risk profile
Renvert & Persson, Periodontology 2000, Vol. 36, 2004, 179195

Theory :Pts risk assessment

1. Percentage of bleeding on probing, 2. Prevalence of residual pockets greater than 4 mm ( 5 mm), 3. Loss of teeth from a total of 28 teeth, 4. Loss of periodontal support in relation to the patient's age, 5. Systemic and genetic conditions, and 6. Environmental factors, such as cigarette smoking.
Niklaus P. Langa / Maurizio S. Tonettib ,2003,

Functional diagram to evaluate the patient's risk for recurrence of periodontitis. Each vector represents one risk factor or indicator with an area of relatively low risk, an area of moderate risk and an area of high risk for disease progression. All factors have to be evaluated together and hence, the area of relatively low risk is found within the center circle of the polygon, while the area of high risk is found outside the periphery of the second ring in bold. Between the two rings in bold, there is the area of moderate risk.

 A low PRA patient has

all parameters within the low-risk categories or - at the most - one parameter in the moderate-risk category A moderate PRA patient has at least two parameters in the moderate category, but at most one parameter in the highrisk category A high PRA patient has at least two parameters in the high-risk category

Theory: When to recall pts? How frequent?

3-month recall intervals for SPT is most likely based on

published studies that used 34- month intervals as part of study design short intervals between clinic visits is the understanding that frequent maintenance care is necessary to eliminate/reduce subgingival proportions of pathogens associated with periodontitis suggest that recall intervals could be extended to at least 1 year in subjects with a history of limited susceptibility to periodontitis

Recall Interval for Various Classes of Recall Patients

Merin Classsification

Characteristic 1st yr pts ; routine therapy and uneventful healing . 1st yr pts; difficult case with complicated prosthesis , furcation involvement , poor crown-to-root ratio , or questionable patient cooperation . Excellent results well maintained for 1 yr or more Pts displays good oral hygiene, minimal calculus, no occlusal problem, no complicated prostheses , no remaining pockets, and no teeth with less than 50% of alveolar bone remaining.

Recall Interval 3 month 1-2month

1st year

Class A

6 mth to 1 yr

Merin Classsification

Characteristic Good results maintained well for 1 yr or more, but pts displays factor: -Inconsistent or poor OH -Heavy callculus formation -Systemic disease that predispose perio breakdown -Remained pocket -Occlusal problem -Complicated prostheses -Ongoing ortho therapy -Recurrent dental caries -Some teeth with less than 50% alveolar bone support -Smoking -+ve family history ->20% pockets BOP

Recall Interval 3-4 months (decide on recall interval based on number and severity of negative factors)

Class B

Merin Classsification

Characteristic
Poor results after periodontal therapy , with/or several negative factor: -Inconsistent or poor OH -Heavy callculus formation -Systemic disease that predispose perio breakdown -MANY Remained pocket -Occlusal problem -Complicated prostheses -Recurrent dental caries -Some teeth with less than 50% alveolar bone support -Smoking -+ve family history ->20% pockets BOP -Perio surgery needed but not performed for medical , physiological or financial problem.

Recall Interval
1-3 months (decide on recall interval based on number and severity of negative factors)=co nsider retreatment of some area or XLA of some severely involved teeth

Class C

Robert L.Merin,Supportive Periodontal Treatment ,Carranzas Clinical Periodontology , 10th ed, 2006

Reality : Challenges
Pts compliance
Uncompliant pts has 5.6 time higher risk to lost teeth

compare to compliant pts.

Percentage pts compliance in 961 pts
16.44% 34.13% 49.43% complete

erratic
none

From Wilson TG jr. et al, 1984)

Compliance with the recall system

Several investigations have indicated that only a

minority of periodontal patients complies with the prescribed supportive periodontal care (Wilson et al, 1984; Mendoza et al, 1991; Checchi et al, 1994; Demetriou et al,1995).
Furthermore, it has been established that treated

periodontal patients who comply with regular periodontal maintenance appointments have a better prognosis than patients who do not comply (Axelsson and Lindhe, 1981a; Kerr, 1981; Becker et al, 1984; Cortellini et al, 1994, 1996).

Compliance with the recall system

Non- or poorly compliant patients should be

considered to be at higher risk for periodontal disease progression.

A report that investigated the personality differences

of patients participating in a regular recall program as compared to patients who did not, revealed that patients who did not take part in a maintenance program following periodontal therapy had higher incidences of stressful life events and less stable personal relationships in their lives (Becker et al, 1988).

Reality : What affect the compliant of patient to recall appointment

Patient factor: Time Stress Financial (Wilson, Wilson TG Jr. Compliance and its role in periodontal therapy. Periodontol
2000 1966: 12: 1623.)

Dental fear Gender-female more compliance ( Demetriou et al., J Periodontol 2001: 72:
977989.) 50.)

Age younger less compliances (Novaes Jr. & Novaes, Braz Dent J 2001: 12: 47

Dentist factor Not able to convince pts on the importance of maintenancedue to lack knowledge and experience
Renvert & Persson, Periodontology 2000, Vol. 36, 2004, 179195

Theory: Maintenance therapy when is the end??

Pts have undergone extensive perio therapy subjected

at risk recurrence for the rest of life.(Halazonetis TD et al, 1985)

Reality :What modify the outcomes of maintenance therapy.

Pts Systemic disease Inadequate plaque control Pts unable to follow maintence program Adverse health factor: smoking, stress, structural or iatrogenic factor Pts refused tx plan Dentist factor Hopeless tooth is saved bcoz it serves as abutment of RPD/FPD; maintain OVD Others Unknown/undetermined etiologic factor Endo-perio problem

Summary
SPT planning should be based on assessment of the

patient risk profile SPT must be individualized to ensure optimal treatment During SPT, good oral hygiene is essential to minimize the risks of periodontal disease progression Both clinician and patient are responsible for the success or failure of maintenance therapy

Reference
Niklaus P. Langa / Maurizio S. Tonettib , Periodontal Risk

Assessment (PRA) for Patients in Supportive Periodontal Therapy (SPT) , Oral Health & Preventive Dentisty 1/2003, S. 7-16 Stefan Renvert & G.Rutger Persson, Supportive periodontal therapy, Periodontology 2000, Vol. 36, 2004, 179195 Robert L.Merin,Supportive Periodontal Treatment ,Carranzas Clinical Periodontology , 10th ed, 2006 Naoshi Sato,Periodontics & Restorative Maintenance ,2009 E. Brady hancock & donald h. Newell , Preventive strategies and supportive treatment, Periodontology 2000, Vol. 25, 2001, 5976