Periodontal Maintenance Care Research Articles

An Insight into Supportive Periodontal Therapy and Maintenance Care

Abstract: Periodontitis is a painless destructive disease of the tooth supporting structures that progresses silently, hence it’s a big challenge for clinicians to motivate the patients for therapy. Several factors influence the treatment outcome such as genetic variations, smoking, systemic complications, stress, trauma from occlusion, iatrogenic dentistry, etc. There is ever-growing evidence that recall visits are prerequisites for the success of therapy. At the personal level, maintenance is difficult for an average patient as this demands frequent elimination of soft and hard deposits from all the possible surfaces, hence highlighting the significance of repeated professional care at regular intervals. An effective outcome of the therapy can be achieved by a fruitful combination of both active and supportive periodontal therapy, hence reducing the possibility of re-infection and arresting the disease progression. Keywords: Supportive Periodontal therapy; an extended trimeric model; compliance; risk assessment.

A Low-Cost Protocol Using the Adjunctive Action of Povidone-Iodine Irrigations and Sodium Hypochlorite Rinsing Solution in Step 2 of Periodontal Therapy for Patients with Stage III-IV Periodontitis: A Single-Blind, Randomized Controlled Trial.

In severe stages of periodontitis, conventional periodontal therapy and maintenance care are usually insufficient due to the viral and bacterial etiology; thus, a mechanical approach alone may not be sufficient to eliminate a substantial portion of subgingival pathogens, especially in deep periodontal sites. Background and Objectives: This single-blind, randomized clinical trial aimed to compare the clinical and microbiological efficacy of a low-cost protocol using povidone-iodine and sodium hypochlorite formulations as adjuncts to non-surgical therapy for patients with stage IV periodontitis when compared with chlorhexidine, the most commonly employed substance to date for antimicrobial regimens in periodontal therapy. Materials and Methods: Forty-five patients were randomly divided into two groups: control (subgingival instrumentation, chlorhexidine-assisted) and test (antiviral medication, subgingival instrumentation with povidone-iodine, sodium hypochlorite rinsing solution, and antibiotics). Clinical measurements and microbiological analyses were performed at baseline and after three months. Results: After three months, notable differences were found in the bacterial detection scores for Porphyromonas gingivalis (a significant reduction in detection frequency was observed in the test compared to the control (p = 0.021)), and there were significant reductions in detection in the test group for Tannerella forsythia and Treponema denticola, showing undetectable levels (p < 0.0001 for both). In the test group, the pocket probing depth median value was reduced significantly (p = 0.0005); similarly, bleeding on probing showed a marked decrease (p < 0.0001). However, changes in clinical attachment loss and full-mouth plaque score were not statistically significant. Conclusions: Using the proposed protocol, substantial improvements in clinical and microbiological parameters were obtained when compared with the current antimicrobial recommendations.

Periodontal treatment and subsequent clinical outcomes and medical care costs: A retrospective cohort study.

Periodontitis is a common oral disease associated with coronary artery disease (CAD), cerebrovascular disease (CBVD) and type 2 diabetes (T2D). We studied if periodontitis treatment improves clinical outcomes and reduces medical care costs in patients with CAD, CBVD or T2D. We used clinic records and claims data from a health care system to identify patients with periodontitis and CAD, CBVD or T2D, and to assess periodontal treatments, hospitalizations, medical costs (total, inpatient, outpatient, pharmacy), glycated hemoglobin, cardiovascular events, and death following concurrent disease diagnoses. We compared clinical outcomes according to receipt of periodontal treatment and/or maintenance care in the follow-up period, and care costs according to treatment status within one year following concurrent disease diagnoses, while adjusting for covariates. The data were analyzed in 2019-21. We identified 9,503 individuals, 4,057 of whom were in the CAD cohort; 3,247 in the CBVD cohort; and 4,879 in the T2D cohort. Patients who were selected and elected to receive treatment and maintenance care were less likely to be hospitalized than untreated individuals (CAD: OR = 0.71 (95% CI: 0.55, 0.92); CBVD: OR = 0.73 (0.56, 0.94); T2D: OR = 0.80 (0.64, 0.99)). Selection to treatment and/or maintenance care was not significantly associated with cardiovascular events, mortality, or glycated hemoglobin change. Total care costs did not differ significantly between treated and untreated groups over 4 years. Treated patients experienced lower inpatient costs but higher pharmacy costs. Patients with periodontitis and CAD, CBVD or T2D who were selected and elected to undergo periodontal treatment or maintenance care had lower rates of hospitalizations, but did not differ significantly from untreated individuals in terms of clinical outcomes or total medical care costs.

A Manual Bristleless Toothbrush Demonstrates Slight Improvement in Gingival Recession Compared to a Conventional Soft Manual Brush.

This randomized clinical trial tested whether a novel bristleless toothbrush design is more effective in preventing gingival recession in adults receiving periodontal maintenance than is a soft toothbrush with nylon bristles. Twenty-three subjects with gingival recession were recruited who received regular periodontal maintenance care at Western University of Health Sciences Dental Center, and who did not exhibit signs of acute dental or systemic disease, occlusal discrepancies or parafunctional habits. These subjects were randomly assigned to to two groups, one using a soft nylon-bristled toothbrush, and the other using the experimental toothbrush that contains a brush head with short, soft, rubbery cones. Both groups received regular periodontal maintenance and periodontal exams by blinded examiners every 3-4 months, measuring probing depth, bleeding on probing, and plaque indices. Gingival recession was assessed clinically and through use of a stent on diagnostic casts obtained at each visit. Average probing depths, plaque levels, and the number of sites with bleeding on probing did not change over at least 9 months. After 9 months, there was a small but statistically significant improvement in gingival recession (0.4 mm, p < 0.01) at sites with gingival recession in the experimental toothbrush group compared to the control group. In periodontal maintenance patients, the bristleless toothbrush used in this study was as effective in plaque removal and prevention of gingival inflammation than a conventional toothbrush with soft nylon bristles, while increasing the possibility of gingival tissue rebound over denuded root surfaces.

Periodontal Abscess: a Review and the Role of Antimicrobial Therapy

The aim was to summarize current knowledge about periodontal abscesses and describe recent research on antimicrobial treatment. For periodontal abscess treatment, antimicrobial therapy is implemented as an adjunct modality to subgingival debridement and/or abscess drainage. Among available systemic antimicrobial agents, amoxicillin (plus clavulanate), metronidazole, and azithromycin are often used with good clinical results. In our studies of patients with acute periodontal lesions, systemic administration of a new fluoroquinolone, sitafloxacin, yielded a significant improvement in clinical parameters, and was effective against subgingival bacteria, with no significant impact on the antimicrobial susceptibility of periodontal bacteria. Plaque control during initial periodontal therapy or maintenance care is critical for the prevention and treatment of periodontal abscesses. In the case of acute periodontal abscesses, drainage is considered first. When drainage is not possible or insufficient, antimicrobial therapy should then be considered. Microbiological testing can contribute to the successful treatment.

The Impact of Improved Oral Health on the Utilization of Dental Services.

Since the mid-20th century, there has been a remarkable decline in dental caries in the United States. The effects of that caries decline have now been demonstrated well into the adult population. These improvements in oral health are resulting in substantial declines in the reparative and restorative dental services being provided to the affected individuals, who comprise a growing part of the population. Because of fewer compromised teeth, extractions and their sequelae also are declining. Much of the recall and periodontal maintenance care can be provided by allied dental personnel. As the older age cohorts, who were children before the caries decline occurred, become an ever-smaller part of the population, the number of patients an individual dentist can treat in a year is likely to increase. This article was written as part of the project "Advancing Dental Education in the 21st Century."

A Bristle-Less Tooth Brush Reduces Recession Risk Over One Year Compared to a Conventional Soft Manual Brush

Background: Aggressive tooth brushing can contribute to gingival recession, and we tested in a randomized clinical trial if use of a bristle-less tooth brush results in less recession compared to using a conventional soft brush. Methods: We recruited 23 subjects with gingival recession who received regular periodontal maintenance care at Western University of Health Sciences Dental Center, and who did not exhibit signs of acute dental and systemic disease, occlusal discrepancies and para-functional habits. We randomly assigned these subjects to two groups, one using a soft nylon-bristled tooth brush, and the other group using the experimental tooth brush that contains a brush head with short, soft, rubbery cones. Both groups received regular periodontal maintenance and periodontal exams by blinded examiners every 3-4 months measuring probing depth, bleeding on probing, plaque indices. Tooth brush use was monitored by phone follow-up and measuring tooth brush wear of the tooth brushes assigned to subjects. Gingival recession was assessed clinically and through use of a stent on diagnostic casts obtained at each visit. Results: Average probing depths, plaque levels, and the number of sites with bleeding on probing did not change over one year. Subjects were compliant with tooth brush use as tooth brushes showed consistent wear patterns, but with much less tooth brush damage in the bristle-less brushes. There was a small, but statistically significant improvement of gingival recession (0.4 mm, p<0.01) at sites with gingival recession in the experimental tooth brush group compared to the control group and compared to baseline gingival level. Conclusion: A bristle-less brush appears to be more suitable in preventing additional gingival recession in patients with a history of aggressive tooth brushing.

Adjunctive use of antibiotics in periodontal therapy.

Periodontal diseases are infectious diseases with a mixed microbial aetiology and marked inflammatory response leading to destruction of underlying tissue. Periodontal therapy aims to eliminate pathogens associated with the disease and attain periodontal health. Periodontitis is generally treated by nonsurgical mechanical debridement and regular periodontal maintenance care. Periodontal surgery may be indicated for some patients to improve access to the root surface; however, mechanical debridement alone may not be helpful in all cases. In such cases, adjunctive systemic antibiotic therapy remains the treatment of choice. It can reach microorganisms at the base of the deep periodontal pockets and furcation areas via serum, and also affects organisms residing within gingival epithelium and connective tissue. This review aims to provide an update on clinical issues regarding when and how to prescribe systemic antibiotics in periodontal therapy. The points discussed are the mode of antibiotic action, susceptible periodontal pathogens, antibiotic dosage, antibiotic use in treatment of periodontal disease, and mechanism of bacterial resistance to each antibiotic.

Implant therapy in oral and maxillofacial fields.

Dental implants have been established as a universal field of dental care. Dental implants are considered first when giving treatment for edentulous areas with sever bone deficiency, as well as when a single tooth is missing. Dental implant therapy is accompanied by a combination of oral and maxillofacial surgery, periodontology, and prosthodontic treatment. It is necessary to plan for upper prosthetic treatment before implant surgery. A top-down treatment plan is a basic principle of implant therapy. The oral and maxillofacial surgeon should consult with the prosthodontist and obtain a consensus on the implant treatment before surgery1,2. Some oral and maxillofacial surgeons have almost no knowledge of prosthodontic treatment or may even neglect the treatment. Implant placement for which upper prosthetic treatment cannot be properly performed may be entirely ineffective. Some operators believe that severe bone defects make implant misplacement inevitable. Even if an implant is successfully placed during major reconstructive surgery, it may be ineffective if it permits no upper prosthetic treatment or leads to improper prosthesis. Another consideration commonly neglected by oral and maxillofacial surgeons is implant maintenance care. Implant treatment should not be started if there are no postsurgical concerns about prosthodontic treatment or periodontal maintenance care. Dental implants are not considered to be an area in a specific department of professional care, but instead are a field that requires an integrative idea of dental care. We stress here that oral and maxillofacial surgeons also need to have positive concern about prosthodontic treatment, periodontal treatment, and about implant maintenance care so that they can prevent their own field of oral and maxillofacial surgery from becoming irrelevant with regards to dental implants.

Do Statin Medications Improve Periodontal Health and/or Outcomes? A Systematic Review

Focused Clinical Question:For adult patients (aged ≥30 years) with chronic periodontitis, does the use of 3‐hydroxy‐3‐methyl‐glutaryl coenzyme A reductase inhibitors (statins) improve periodontal health?Clinical Scenario:A 59‐year‐old female with a history of hyperlipidemia presents for periodontal maintenance care. She has been taking a statin medication for 4 years, during which time she received comprehensive periodontal therapy, including regenerative surgery in two quadrants. Post‐surgical evaluation revealed substantial gains in clinical attachment and probing depth reduction. Radiographically, significant fill of the intrabony defect was observed. Before treatment, she was very anxious about losing more teeth and is now curious about the stability of her periodontal treatment. For clinical and radiographic presentation of the patient, see Figures 1 and 2.

Proefschriften 25 jaar na dato 37. Vatbaarheid voor parodontale aandoeningen

In the eighties of the former century it was observed that individuals had different modes of development of periodontitis, largely for unknown reasons. It was assumed that periodontal disease developed as a result of the presence of virulent micro-organisms in combination with an inadequate host response. The concept of this (im)balance in host parasite interactions developed further, in part because of new research techniques. With respect to oral bacteria it was shown that periodontal pathogens like Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and Tannerella forsythia are risk factors for periodontitis. Furthermore, genetic polymorphisms (SNP's) have been shown to modulate the host response against the periopathogens. Medical and lifestyle factors, e.g. diabetes mellitus, smoking, psychological stress and, to a minor extent, also hormonal changes can have an impact on the progression of periodontitis. All this information contributes to determining the individual risk profile of a patient for developing periodontitis and for estimating the prognosis of periodontal treatment and maintenance care on an individual basis.

Retrospective Study of the Survival and Associated Risk Factors of Wedge-Shaped Implants

To assess the long-term behavior of wedge-shaped implants and evaluate the influence of the associated risk factors on implant survival rates. A retrospective review of clinical records of patients treated with wedge-shaped implants between 1992 and 2011 was conducted. Data on patient sex, age, smoking habits, and history of periodontitis; details of implant length, diameter, angle, and location; and data on surgical, reconstructive, and prosthetic procedures, and systemic disease were selected for analysis. A total of 1,169 implants placed in 154 patients (mean age 55.17 ± 11.33 years) were evaluated. Women received 637 implants, and men received 532 implants; 60.4% were placed in patients who were undergoing periodontal maintenance care, 17.9% in smokers, 17.7% in hypertensive patients, 5.7% in diabetic patients, and 4.4% in cardiac patients. The mean overall survival for implants was 194.26 ± 9.91 months. Seventy-three implants were lost: 3 before implant loading and 70 after loading. The cumulative survival rates at 5 and 10 years were 96.6% (confidence interval [CI]: 95.5% to 97.7%) and 91.8% (CI: 90.1% to 94.1%), respectively. Univariate analysis indicated tobacco smoking (P = .014) and implant location (P < .001) as significant risk factors for implant failure. The multivariate analysis showed tobacco smoking (P = .016), location (P = .001), and male sex (P = .038) as significant, and the latter factor was associated with previous periodontal disease. Overall survival of the wedge-shaped implant showed good long-term results. Male sex, tobacco smoking, and posterior maxillary location were associated with a greater risk of implant failure.

Adjunctive clinical effect of a water‐cooled Nd:YAGlaser in a periodontal maintenance care programme: a randomized controlled trial

Various laser systems are currently available for intra-oral use. Neodymium:Yttrium-Aluminium Garnet lasers(Nd:YAG) have been approved by the US Food and Drug Administration for soft tissue treatment in the oral cavity. The aim of this study was to test whether the use of a water-cooled Nd:YAG laser during a maintenance care programme as an adjunct to supragingival and subgingival debridement (scaling and root planing, SRP) with hand and ultrasonic instruments results in clinical improvement compared with SRP alone. This study was an examiner-blind, randomized and controlled clinical trial using a split-mouth design. Thirty subjects were selected, originally diagnosed with moderate to severe generalized periodontitis, following a periodontal maintenance care programme (PMC). Immediately after SRP in two randomly assigned contra-lateral quadrants, all pockets ≥5mm were additionally treated with a Nd:YAG laser (1064nm, 4W, 250-μsec pulse). Clinical assessments [probing pocket depth PPD, bleeding on pocket probing (BOPP)] were performed pre-treatment and at 6months. Based on these assessments, the periodontal inflamed surface area (PISA) was calculated. At 6months, the clinical parameters had significantly improved for both regimens. No statistically significant differences between treatment modalities were observed for PPD and BOPP scores at any time. PISA scores supported these findings. In residual pockets ≥5mm, treated in a PMC, the adjunctive use of an Nd:YAG laser does not provide a clinically significant additional advantage.

Relationship between masticatory performance and heart rate variability: A pilot study

Objective. Little information is available on how impaired masticatory performance relates to heart-rate variability (HRV). The aim of this study was to investigate the relationship between HRV indices and masticatory performance. Materials and methods. Sixty-five subjects (19 men and 46 women, 66.1 ± 9.9 years old) who had received periodontal maintenance care at the Clinic of Preventive Dentistry of Okayama University Hospital were selected for the study. All subjects completed written questionnaires, a chewing (colour-changing gum) test for masticatory performance and measurement of occlusal force and HRV as well as oral examination. Results. The high sympathetic activity (LF ≥ 49.6) group showed a significantly lower level of masticatory performance (a* value) than the low sympathetic activity group (p < 0.05). There were also significant correlations of masticatory performance with LF and LF/HF (p < 0.05). Conclusion. These findings suggest that there is relationship between masticatory performance and HRV indices and impaired masticatory performance may be a risk factor for inducing high sympathetic activity.

Parameters Affecting Tooth Loss during Periodontal Maintenance in a Greek Population

Investigators have evaluated predictive parameters of tooth loss during the maintenance phase (MP). The authors conducted a retrospective study to evaluate the rate of tooth loss and to explore the parameters that affect tooth loss during MP in a Greek population. A periodontist administered periodontal treatment and maintenance care to 280 participants with severe periodontitis for a mean period +/- standard deviation of 10.84 +/- 2.13 years. The periodontist recorded the following parameters for each participant: oral hygiene index level, simplified gingival index level, clinical attachment level, probing depth measurements, initial tooth prognosis, smoking status, tooth loss during active periodontal treatment and MP, and compliance with suggested maintenance visits. The authors found that total tooth loss during active treatment (n = 1,427) was greater than during MP (n = 918) and was associated with the initial tooth prognosis, tooth type group, participants' compliance with suggested maintenance visits, smoking status and acceptability of the quality of tooth restorations. Most of the teeth extracted during maintenance had an initial guarded prognosis (n = 612). Participants whose compliance was erratic had a greater risk of undergoing tooth extraction than did participants whose compliance was complete. Participants' initial tooth prognosis, tooth type, compliance with suggested maintenance visits and smoking status affected tooth loss during MP. Initial guarded prognosis and erratic compliance increased the risk of undergoing tooth extraction during maintenance. Determining predictive parameters for disease progression and tooth loss provides critical information to clinicians so that they can develop and implement rational treatment planning.

Systemic antibiotics in periodontal therapy

Periodontitis is a biofilm infection with a mixed microbial aetiology. Periodontitis is generally treated by non-surgical mechanical debridement and regular periodontal maintenance care. Periodontal surgery may be indicated for some patients to improve access to the root surface for mechanical debridement. A range of systemic antibiotics for treatment of periodontitis has been documented, with some studies showing superior clinical outcomes following adjunctive antibiotics while others do not. This has resulted in controversy as to the role of systemic antibiotics in the treatment of periodontal diseases. Recent systematic reviews have provided an evidence-based assessment of the possible benefits of adjunctive antibiotics in periodontal therapy. This review aims to provide an update on clinical issues of when and how to prescribe systemic antibiotics in periodontal therapy.

The use of a linear oscillating device in periodontal treatment: a review

The Vector system is an ultrasonic instrument that was introduced in 1999, and treatment outcomes with Vector have been compared with those achieved with the "gold standard" of scaling and root planing with Gracey curettes as well as conventional ultrasonic scalers. The aim of this paper is to review the existing literature regarding the Vector method. This review is based on a MEDLINE search of the use of Vector up to January 2008 (focused on in vitro findings, periodontal treatment, peri-implantitis therapy, clinical and microbiological data, and patient considerations). The MEDLINE search identified 128 papers, of which 18 were found to be relevant to this review. A hand search of the periodontal literature over the same period resulted in identification of a further 10 relevant papers. Vector used for treatment of chronic periodontitis results in clinical and microbiological outcomes comparable to those achieved by manual instrumentation and conventional ultrasonic instruments. Vector is less efficient when removing large masses of calculus, however, and cannot be recommended for the treatment of peri-implantitis. Vector may be particularly useful in periodontal maintenance care as it is well tolerated by patients and results in less removal of cementum than other instruments.

Maladies gingivales induites par la plaque

Dental plaque-induced gingival diseases are infectious diseases. They reflect the local inflammatory and host-specific immune responses to the dental bacterial biofilm. According to the new classification, they include those gingivitis associated with dental plaque only, and the gingival diseases that are modified by general factors. The diagnosis of gingivitis is based on gingival changes in colour, consistency and texture, without epithelial connective attachment loss. Systemic factors such as the modification of the endocrine system, diabetes, blood dyscrasias, stress, tobacco or medications can modify the initial clinical signs of gingivitis. Moreover, localized tooth-related factors can modify or predispose to plaque-induced gingival diseases. The evolution of a plaque-induced gingival disease in periodontitis, as well as its prognosis, will depend on the periodontal risk which is determined by the reaction of the host immune system and the nature of the dental biofilm. The medical and dental care of a patient with dental plaque-induced gingival disease depends on the diagnosis of periodontal risk. It includes the management of host-specific parameters, bacterial aetiology, correction of localized tooth-related factors and periodontal maintenance care.

Can we successfully maintain risk patients?

The most fundamental premise in the current view of periodontal disease is that not all individuals are at equal risk for disease and disease progression. Studies reveal that about 5-20% of the population is at risk for severe disease progression. The purpose of this paper is to define at-risk patients, review risk factors and indicators of disease progression, and outline an evidence-based strategy that includes both self-care and professional care for maintaining periodontal health. Risk factors/risk indicators considered include history of previous disease, increased pocket depth and loss of clinical attachment, frequency of dental care, specific bacterial pathogens, and systemic/environmental host factors such as smoking, diabetes mellitus, genetics, and stress. Because host factors may have more influence on disease progression than periodontal pathogens, personal and professional maintenance care must include the role of the host in periodontal disease progression. By examining the evidence surrounding these complex issues, dentists and dental hygienists are able to determine the extent to which evidence supports available approaches to maintain periodontal health and control disease progression.

Long-term results of supportive periodontal therapy (SPT) in HIV-seropositive and HIV-seronegative patients.

The aim of the present study was to investigate the long-term results of periodontal supportive therapy in HIV-seropositive and HIV-seronegative patients. Baseline examination of 18 HIV-seropositive patients (14 males and four females, median age of 29.7 years) revealed the following periodontal diagnoses: eight patients with linear gingival erythema, four patients with necrotizing periodontitis, five patients with conventional gingivitis and one patient with chronic periodontitis. In the HIV-seronegative group, out of 16 patients (12 males and four females, median age 35.5 years), one patient presented with conventional gingivitis and 15 patients with chronic periodontitis. Periodontal therapy and maintenance care consisted of supra- and subgingival removal of plaque and calculus and instruction in oral hygiene. Based on the individual patient's needs, the mechanical therapy was repeated. In the test group, the mean maintenance period was 22.7 +/- 9.4 months (range 11.0-37.4) and in the control group, 48.9 +/- 32.0 months (range 9.3-110.8). In the test group, the mean PlI (1.1 +/- 0.8) remained at the same level (1.1 +/- 0.5; p = 0.73, Wilcoxon sign rank test, p < 0.05) throughout the observation period, the mean GI was reduced from 1.6 +/- 0.5 to 1.4 +/- 0.4 (p = 0.18), the mean PPD was reduced from 2.9 +/- 0.3 to 2.8 +/- 0.2 (p = 0.15) and the mean PAL (3.1 +/- 0.5) remained unaltered as well (3.1 +/- 0.4; p = 0.83). None of these differences was statistically significant. In the control group, PPD (3.0 +/- 0.4) and PAL (3.0 +/- 0.5) were significantly reduced: PPD = 2.7 +/- 0.2 (p = 0.0003) and PAL = 2.9 +/- 0.5 (p = 0.0034). In HIV-seropositive patients, attachment level can be maintained. However, oral hygiene and compliance are the key factors for this.