Supportive Periodontal Care Programme Research Articles

Step 4 for the treatment of periodontal diseases: implementing a supportive periodontal care programme

The long-term success of periodontal treatment is critically dependent on the implementation of a regular programme of supportive periodontal care (SPC). An SPC programme involves regular recall intervals of between 3 and 12 months according to a range of factors, including patient compliance, presence of risk factors and severity of initial disease. An SPC visit will include repeat examination of the periodontal tissues, assessments of gingival bleeding and probing depths, patient plaque control and presence of new deposits. Reinforcement of OH procedures is carried out, and any professional mechanical removal of deposits carried out as required. Evidence of relapse of disease may require referral for further active therapy. CPD/Clinical Relevance: Successful periodontal treatment in the long term is dependent on a regular supportive periodontal care programme.

Efectos de la furcación sobre la supervivencia molar en pacientes sometidos a tratamiento periodontal

Objective: This study aims to analyze the survival time of molar tooth according to furcation involvement (FI) classification among periodontally treated patients under a supportive periodontal care program. Materials and Methods: A retrospective study was con-ducted among 77 periodontitis patients with 240 molars who had undergone periodontal therapy that were followed up with supportive periodontal therapy (SPT) for at least five years. Periodontitis patients’ data were retrieved from the periodontic clinical record. The clinical parameters of all involved molars and treatment modality were recorded at baseline and SPT. Results: A total of 69 (28.8%) molars were extracted during active periodontal therapy, while 17 (7.1%) were lost during SPT. The 5-year survival rate of molars was 83.5% (95% confidence interval [CI], 76.9-88.4) for FI=0 (n=141), 81.0% (95% CI, 56.9-92.4) for FI=I (n=18), 50.0% (95% CI, 33.8-64.2) for FI=II (n=21), and 25.0% (95% CI, 6.9-48.8) for FI=III (n=4). Additionally, the 10-year survival rate for molars with FI = III was 12.5% (95% CI, 1.0-39.2), which was lower than that of molars with FI = 0 (77.1%; 95% CI, 69.7-83.0). Conclusions: The presence of a high degree of FI classifica-tion, especially Class III, is associated with a lower survival rate of molars among periodontally treated patients. Retention of molars is possible on a long-term basis through a maintenance program of periodontal therapy.

Efectos de la furcación sobre la supervivencia molar en pacientes sometidos a tratamiento periodontal

Objective: This study aims to analyze the survival time of molar tooth according to furcation involvement (FI) classification among periodontally treated patients under a supportive periodontal care program. Materials and Methods: A retrospective study was con-ducted among 77 periodontitis patients with 240 molars who had undergone periodontal therapy that were followed up with supportive periodontal therapy (SPT) for at least five years. Periodontitis patients’ data were retrieved from the periodontic clinical record. The clinical parameters of all involved molars and treatment modality were recorded at baseline and SPT. Results: A total of 69 (28.8%) molars were extracted during active periodontal therapy, while 17 (7.1%) were lost during SPT. The 5-year survival rate of molars was 83.5% (95% confidence interval [CI], 76.9-88.4) for FI=0 (n=141), 81.0% (95% CI, 56.9-92.4) for FI=I (n=18), 50.0% (95% CI, 33.8-64.2) for FI=II (n=21), and 25.0% (95% CI, 6.9-48.8) for FI=III (n=4). Additionally, the 10-year survival rate for molars with FI = III was 12.5% (95% CI, 1.0-39.2), which was lower than that of molars with FI = 0 (77.1%; 95% CI, 69.7-83.0). Conclusions: The presence of a high degree of FI classifica-tion, especially Class III, is associated with a lower survival rate of molars among periodontally treated patients. Retention of molars is possible on a long-term basis through a maintenance program of periodontal therapy.

Accuracy and applicability of periodontitis risk assessment tools: A critical appraisal.

Currently, periodontal risk assessment finds application at first visit (to identify individuals at high risk of either disease incidence, if still healthy, or disease progression, if already diseased) as well as at patient monitoring after active treatment and enrolment in a supportive periodontal care program. Although the current case definition of periodontitis embeds a prognostic determination (ie, periodontitis grade) that showed a predictive value for periodontitis-related tooth loss, some limitations of periodontitis grade call for the implementation of different risk assessment tools in clinical practice. For some of these, significantly higher accuracy in predicting tooth loss during supportive periodontal care was reported compared with periodontitis grade. Validated periodontal risk assessment tools may be functional to obtain greater adherence to the suggested preventive and treatment protocols, improve oral hygiene performance, and tailor supportive periodontal care. Interestingly, periodontal risk can also be informative of the risk of peri-implantitis in patients programmed for implant placement or rehabilitated with dental implants. A critical appraisal on the rationale behind risk assessment and the balance between the advantages and limitations of exercising risk assessment in periodontology is presented.

Modified minimally invasive surgical technique in human intrabony defects with or without regenerative materials-10-year follow-up of a randomized clinical trial: Tooth retention, periodontitis recurrence, and costs.

The modified minimally invasive surgical technique (M-MIST) optimizes wound stability in the treatment of intrabony defects. Short-term observations show similar results as with flap alone or adjunctive regenerative materials. This study aims to compare the stability of the long-term outcomes, complication-free survival, and costs of the three treatment options. Forty-five intrabony defects in 45 patients were randomized to M-MIST alone (N= 15), combined with enamel matrix derivative (M-MIST + EMD, N= 15), or EMD plus bone-mineral-derived xenograph (M-MIST + EMD + BMDX, N= 15). Supportive periodontal care (SPC) and necessary re-treatment were provided for 10 years. Three subjects were lost to follow-up. Clinical attachment level differences between 1 and 10 years were -0.1± 0.7 mm for M-MIST, -0.1± 0.8 mm for M-MIST + EMD, and -0.3± 0.6 mm for M-MIST + EMD + BMDX (p> .05 for within- and between-group differences). Four episodes of recurrence occurred in the M-MIST group, four in the M-MIST + EMD group, and five in the M-MIST + EMD + BMDX group. No significant differences in complication-free survival were observed between the three groups (p= .47). Complication-free survival was 7.46 years (95% confidence interval: 7.05-7.87) for the whole population. The M-MIST + EMD + BMDX group lost one treated tooth. Data indicated no significant inter-group difference of the total cost of recurrence over 10 years. When the baseline cost of treatment was considered, the total cost was lower for M-MIST alone. Teeth with deep pockets associated with intrabony defects can be successfully maintained over the long term with either M-MIST alone or by adding a regenerative material in the context of a careful SPC programme. M-MIST alone provided similar short- and long-term benefits as regeneration, at a lower cost. These findings need to be confirmed in larger, independent studies.

Tooth loss in complying and non-complying periodontitis patients with different periodontal risk levels during supportive periodontal care

ObjectivesTo evaluate yearly tooth loss rate (TLR) in periodontitis patients with different periodontal risk levels who had complied or not complied with supportive periodontal care (SPC).Materials and methodsData from 168 periodontitis patients enrolled in a SPC program based on a 3-month suggested recall interval for at least 3.5 years were analyzed. For patients with a mean recall interval within 2–4 months (“compliers”) or > 4 months (“non-compliers”) with different PerioRisk levels (Trombelli et al. 2009), TLR (irrespective of the cause for tooth loss) was calculated. TLR values were considered in relation to meaningful TLR benchmarks from the literature for periodontitis patients either under SPC (0.15 teeth/year; positive benchmark) or irregularly complying with SPC (0.36 teeth/year; negative benchmark).ResultsIn both compliers and non-compliers, TLR was significantly below or similar to the positive benchmark in PerioRisk level 3 (0.08 and 0.03 teeth/year, respectively) and PerioRisk level 4 (0.12 and 0.18 teeth/year, respectively). Although marked and clinically relevant in non-compliers, the difference between TLR of compliers (0.32 teeth/year) and non-compliers (0.52 teeth/year) with PerioRisk level 5 and the negative benchmark was not significant.ConclusionA SPC protocol based on a 3- to 6-month recall interval may effectively limit long-term tooth loss in periodontitis patients with PerioRisk levels 3 and 4. A fully complied 3-month SPC protocol seems ineffective when applied to PerioRisk level 5 patients.Clinical relevancePerioRisk seems to represent a valid tool to inform the SPC recall interval as well as the intensity of active treatment prior to SPC enrollment.

Self-reported bleeding on brushing as a predictor of bleeding on probing: Early observations from the deployment of an internet of things network of intelligent power-driven toothbrushes in a supportive periodontal care population.

BackgroundBleeding on brushing (BoB) is an important sign of gingival inflammation. Recently, the use of intelligent toothbrushes and oral health Apps has shown potential to improve oral and periodontal health. In the context of the introduction of an Internet of things network of intelligent power‐driven toothbrushes in a supportive periodontal care programme, the aim of this study was (a) to audit the adoption and retention of this new technology; and (b) to preliminarily assess the feasibility to gather data on BoB and associate them with clinical periodontal parameters.Methods100 subjects with different periodontal case diagnoses participating in supportive periodontal care (SPC) were provided with and instructed on the use of an intelligent power‐driven toothbrush connected with an App (I‐Brush). Brushing sessions and occurrence of BoB were recorded through the App and stored in a data protection compliant backend. Subject retention was audited over time. BoB recorded in the two weeks before the SPC appointment was associated with clinical parameters observed by the clinician blind to App data.Results75% of subjects provided data from using the power toothbrush and the App for a minimum of 10 brushing sessions over an average period of 362 days. Compared with baseline, subjects’ oral hygiene, bleeding on probing and prevalence of residual pockets improved gradually while using the I‐Brush. The number of BoB episodes in the two weeks leading to the SPC appointment and the number of residual pockets predicted BOP (p < .001) detected during the examination. App use in the previous two weeks was associated with lower plaque scores at SPC.ConclusionsThese preliminary observations indicate good adoption and retention of a mobile health system built around an intelligent power toothbrush in a SPC population. The App was able to gather clinically relevant information predicting the observed degree of gingival inflammation. Deployment of mHealth systems seems feasible in dental practice and may bring significant oral health benefits. More investigations are needed in this area.

Influence of maintenance care in periodontally susceptible and non-susceptible subjects following implant therapy.

To compare the periodontal and peri-implant conditions of periodontally susceptible and periodontally healthy subjects under maintenance care for a period of at least 3years. Sixty periodontally susceptible patients (PSP) and 56 periodontally non-susceptible subjects (PHS) were treated with dental implants in the National Dental Centre Singapore (NDCS) and were maintained in a regular supportive periodontal care program for a mean of 6years. Full mouth bleeding on probing (BoP), full mouth probing pocket depths (PPD), implant loss, and absence of crestal bone loss were recorded at the time of prosthesis delivery and following a mean follow-up of 6years 2months. Although there were significant differences in the BoP and the percentage of subjects with tooth probing pocket depth ≥5mm between PSP and PHS at the time of implant prosthesis installation (T0 ), there were no significant differences between the two subject groups in the various parameters assessed at the follow-up visit (T1 ) (total number of teeth, percentage of subjects with implant probing pocket depth ≥5mm, percentage of subjects with implant probing pocket depth ≥ 6mm, absence of crestal bone loss, implant loss). Owing to a rigid regular SPT program, implants placed in PSP perform equally well when compared to implants installed in PHS over a mean period of 6-year follow-up.

Efficacy of a low-concentration chlorhexidine mouth rinse in non-compliant periodontitis patients attending a supportive periodontal care programme: A randomized clinical trial

Efficacy of a low-concentration chlorhexidine mouth rinse in non-compliant periodontitis patients attending a supportive periodontal care programme: A randomized clinical trial

Efficacy of a low‐concentration chlorhexidine mouth rinse in non‐compliant periodontitis patients attending a supportive periodontal care programme: a randomized clinical trial

To assess the clinical and microbiological efficacy of a 0.05% chlorhexidine and 0.05% cetyl-pyridinium chloride mouth rinse in supportive periodontal care (SPC) in patients with inadequate plaque control. The study was a randomized, double-blinded, placebo-controlled clinical trial in patients with moderate to severe chronic periodontitis under SPC with an inadequate plaque control (Turesky index >1). After supragingival prophylaxis and oral hygiene reinforcement, participants rinsed twice a day for 3 months with the test or placebo solutions, in addition to conventional hygiene. Primary clinical outcome variables included plaque and gingival indices. As secondary outcomes, periodontal and microbiological variables were studied. ancova and chi(2) tests were used to compare the variables. Forty-seven patients (22 placebo and 25 test group) participated. After 3 months, plaque levels increased in the placebo group, while diminished in the test group (p<0.001). Similar effects were found for bleeding on probing. The other clinical parameters did not show significant differences. Microbiological variables demonstrated inter-group significant reductions in subgingival counts of Fusobacterium nucleatum and Prevotella intermedia and a decrease of the total bacterial counts in saliva. The tested mouth rinse demonstrated efficacy in reducing plaque and gingivitis, as well as in decreasing the microbial load in saliva and gingival sulcus.

Long‐term effects of supportive therapy in periodontal patients treated with fibre retention osseous resective surgery. II: tooth extractions during active and supportive therapy

Long-term tooth retention is the main objective of periodontal treatment. The aim of this retrospective study was to describe the prevalence and reasons of tooth extraction during active periodontal therapy (APT) and supportive periodontal care (SPC) in periodontal patients. Three hundred and four periodontal patients were examined. APT consisted of non-surgical periodontal treatment and fibre retention osseous resective surgery, where needed, to obtain no sites with PD>3 mm. All patients participated in an SPC programme for 3-17 years (mean time 7.8 years). At the initial examination, 45% of the patients had moderate periodontitis and 41% severe periodontitis. During APT, 576 teeth were extracted (7.5%). The main reason for tooth extraction during APT was the presence of advanced periodontal lesions (44%). The number of tooth extractions was higher in cases with severe periodontitis. Extracted teeth showed a mean bone loss of 76% of the total root length. During SPT, a total of 67 teeth were removed (0.9%) in a subgroup of 50 patients. The clinical problems were primarily related to the incidence of root fracture (48%) and secondarily to the progression of periodontal disease (30%). Prevalence of tooth extraction during APT is associated with the severity of periodontal disease. Tooth loss during supportive periodontal care may be negligible when a meticulous SPC programme is performed in patients where minimal probing depth is consequential to APT.

Long‐term effects of supportive therapy in periodontal patients treated with fibre retention osseous resective surgery. I: recurrence of pockets, bleeding on probing and tooth loss

Periodontal surgery is indicated in the treatment of persistent pockets following cause-related therapy. The aim of this study was to evaluate the long-term effect of supportive therapy in periodontal patients treated with fibre retention osseous resective surgery. Three-hundred and four consecutive patients were identified and retrospectively examined while presenting for a supportive periodontal care (SPC) appointment (T2). All had received non-surgical periodontal treatment and osseous resective surgery as needed, to obtain no sites with probing depth (PD) >3 mm before being enrolled in the SPC programme. The mean SPC duration for the patients was 7.8+/-3.2 years while the mean interval of SPC was 3.4+/-0.8 months. During SPC, a total of 67 teeth had been removed (0.9%). At T2, mean full-mouth plaque scores (FMPS) was 13+/-11.3% and full-mouth bleeding scores (FMBS) was 2+/-3%. In 98.5% of the sites, PD was minimal (<or=3 mm). The majority of pockets at T2 showed PDs of 4-5 mm (83.4% of pockets). At the same time, the total number of pockets >or=6 mm was 68 and limited to 41 patients (13.8% of sample). Initial periodontal diagnosis of severe periodontitis, smoking habits, FMBS, number of teeth at completion of active periodontal therapy (T1), number of surgically treated teeth, number of teeth with furcation involvement and number of multi-rooted teeth were associated with the number of pockets at T2. A total of 598 sites (2.1%) displayed bleeding on probing (BOP) at T2. The odds ratio of sites 4 mm or deeper to be BOP positive was 32.9 compared with sites of <3 mm depth. Gender, FMBS, FMPS, furcation involvements and overall number of pockets were associated with the number of bleeding pockets at T2. Shallow PDs achieved by treatment of the persistent pockets by fibre retention osseous resective surgery can be maintained over time. These patients displayed minimal gingival inflammation and tooth loss during SPC.

A retrospective study of compliance (adherence) with a care pathway in periodontal therapy in a primary care setting

Recently the issue of patient adherence with prolonged periodontal therapy and the importance of smoking and its influence as a significant co-factor in the outcome of treatment for patients with periodontal disease has been of interest to health care professionals. This paper is an audit of adherence in regard to both smoking cessation for those who admitted to a smoking habit at the initial examination and patient compliance with a periodontal treatment protocol. During the initial examination, patients referred to the practice with periodontal problems were photographed both with and without lip retractors as part of their clinical record, and a charting of the teeth made with any 5 mm or greater probing depths recorded. Tooth mobility and furcation involvement of molar teeth were also charted. Two separate time periods (Series 1 and Series 2) were audited in this study. Patients enrolled in Series 2 were routinely asked about their smoking habits at the initial examination. Two time periods were audited, as the initial purpose of the investigation was to audit the success of the practice in treating this group of patients, and to identify any improvements that could be made in care provision as each audit cycle was completed. Primary care setting. Patient adherence rates were high through all the various stages of periodontal therapy, even though the treatment protocol took over 18 months to complete. Approximately 55% of patients in both time periods presented for the one-year post treatment re-evaluation appointments. 56.5% of the patients reported they had smoked to within five years of their initial consultation, of which 38% reported that they had stopped by the time they had completed the initial hygiene phase of treatment. With a comprehensive and clearly defined supportive periodontal care programme (SPC), this paper demonstrates that high adherence levels can be achieved in a primary care setting. The results suggest that treatment should include not only the teaching of an effective oral hygiene regime, but also include giving advice in relation to smoking cessation for those patients who admit to a smoking habit at the initial examination. Patients who smoked and chose to have treatment for their periodontal condition went on to report good adherence with smoking cessation advice. Continuing supportive smoking cessation (SSC) advice should be part of any effective SPC programme. New methods of treating periodontal disease that become available to practitioners in the future should use established benchmarks against which to evaluate the success of any new treatment strategy.

Long‐Term Outcome Following Treatment of Multiple Miller Class I and II Recession Defects in Esthetic Areas of the Mouth

Multiple recession defects can be successfully treated using envelope-type coronally advanced flaps. The aim of the present study was to evaluate the long-term (5 years) stability of clinical outcomes achieved with the surgery and the association between patient variables and long-term stability. Seventy-three Miller Class I and II gingival recessions affecting 22 young, systemically healthy subjects were treated with coronally advanced flaps with no releasing incisions. All patients were instructed to perform a coronally directed roll technique to minimize the toothbrushing trauma to the gingival margin. The clinical reevaluation was made 1 year after the surgery. At this point, 13 patients took part in a supportive periodontal care program consisting of oral hygiene instructions, control of toothbrushing technique, and professional tooth cleaning every 4 months. The remaining nine patients did not participate and received only sporadic care by general dentists. At 5 years post-surgery, all patients were reexamined. At the 5-year examination, 94% of the root surfaces initially exposed due to gingival recession were still covered with soft tissue, and 85% of the treated recession defects showed complete coverage. Complete root coverage in all recessions was maintained in 15 out of 22 patients (68%). The long-term stability of the soft-tissue margin in the treated sites was significantly influenced by the patient's regular participation in the recall program and the susceptibility to gingival recession in other areas of the mouth. A statistically significant increase of keratinized tissue (0.80 +/- 0.64 mm) was observed between the 1- and 5-year observation visits, and the average increase of keratinized tissue between the baseline and the 5-year follow-up amounted to 1.38 +/- 0.90 mm. This increase was significantly affected by the baseline keratinized tissue (KT) and recession (REC) depth: in particular, the 5-year increase in the amount of keratinized tissue was greater in sites with a greater recession depth and lower amount of keratinized tissue at baseline. 1) The successful root coverage results obtained with the coronally advanced flap for multiple recession defects were well maintained over the 4-year observation period. 2) Negative patient characteristics such as a lack of compliance with a supportive care program and individual susceptibility to gingival recession were significantly associated with the recurrence in gingival recession. 3) The increase in keratinized tissue height that followed the coronally advanced flap procedure may be attributed to the tendency of the mucogingival line to regain its genetically determined position.

Regeneration of class II furcation defects: determinants of increased success

One of the most important indications for guided tissue regeneration (GTR) treatment is class II furcation lesion. However, periodontal regeneration of this type of defect, although possible, is not considered totally predictable, especially in terms of complete bone fill. Many factors may account for variability in the response to regenerative therapy in class II furcation. The purpose of this review is to assess the prognostic significance of factors related to the patient (smoking, stress, diabetes mellitus, acquired immunodeficiency syndrome and other acute and debilitating diseases, and the presence of multiple deep periodontal pockets), local factors (furcal anatomy, defect morphology, thickness of gingival tissue and tooth mobility), surgical treatment (infection control, bone replacement grafts combined with barriers or GTR alone, type of barrier and surgical technique), and postoperative period (plaque control, membrane exposure, membrane retrieval and a regular supportive periodontal care program) for successful of GTR in class II furcations.

Changes in the prevalence of residual pockets and tooth loss in treated periodontal patients during a supportive maintenance care program.

Bleeding on probing and the presence of deep periodontal pockets are considered to be the best site-specific indicators for periodontal disease progression during the maintenance phase of periodontal therapy. A major emphasis of supportive periodontal care (SPC) programs, therefore, has been the control of bleeding pockets. This investigation retrospectively evaluated the changes in the prevalence of bleeding on probing, periodontal pockets, bleeding periodontal pockets and the prevalence of tooth loss in a random sample of 273 periodontal patients participating in a supportive maintenance care program at a University Clinic. During an observation period of 67+/-46 months (range 5 months to 23 years), the overall incidence of all causes of tooth mortality was 0.23+/-0.49 teeth per patient per year of observation. 56% of subjects, however, did not experience any tooth loss, while less than 10% of patients lost more than 3 teeth. Thus, participation in the SPC program was effective in preventing tooth loss in the majority of patients. During the SPC period, however, a significant increase in the prevalence of periodontal pockets, and of bleeding on probing positive periodontal pockets, in particular, was observed. At completion of active periodontal therapy, 56.4% of patients were free from bleeding pockets. This decreased to a mere 13.6% at the latest SPC evaluation. The observed increases in the number of bleeding pockets was significantly associated with: longer times since completion of active periodontal therapy, more advanced periodontal diagnosis, higher %s of bleeding sites in the dentition, cigarette smoking, lack of inclusion of periodontal surgery in the active treatment phase, tooth loss, and the response to the active phase of periodontal treatment. The data presented in the paper indicate that the observed increase in the prevalence of bleeding pockets and tooth loss was not homogeneously distributed in the studied SPC population. Rather, high risk groups of individuals could be identified. It is suggested that better knowledge of risk indicators may lead to improved and more efficient risk management efforts during periodontal maintenance care.

Long-term stability of clinical attachment following guided tissue regeneration and conventional therapy.

44 patients (34% smokers) presenting with severe periodontitis were treated with full mouth root planing (RPL). In each patient, 1 intrabony defect was treated with guided tissue regeneration (GTR). After 1 year of monthly prophylaxis, full mouth plaque (FMPS) and bleeding (FMBS) scores were 8.3 +/- 4.1% and 5.6 +/- 3.8%. At 1 year, the GTR treated sites were matched, in each patient, with 1 RPL site, in terms of probing attachment level (PAL 6.8 +/- 2.4 mm GTR, and 6.5 +/- 2.3 mm RPL). At this point, 24 patients took part in a supportive periodontal care program. 20 patients did not participate, and received only sporadic care by general dentists. At 5 years, all patients were reexamined. FMPS was 10.5 +/- 6.8% and FMBS 7.7 +/- 6.4%. A significant PAL loss was observed in both sites (1.2 +/- 1.4 mm GTR, 1.3 +/- 1.3 mm RPL, p < 0.0001) between 1 and 5 years. Differences in PAL loss between GTR and RPL sites were not statistically significant. Only a minority of sites (34%), however, lost PAL, while 66% remained stable. 75% of the matched sites (GTR and RPL) within the same patients were concordant in terms of PAL stability. The 23 patients in which both sites remained stable, had good oral hygiene, complied with the recall system, and did not smoke. The 10 patients in which both sites lost PAL showed deteriorating oral hygiene, did not comply with the recall system, and smoked. PAL loss in the GTR and/or RPL sites was consistently observed in patients (losers) showing PAL loss in other teeth. Losers had, in general, negative subjects characteristics, and showed a higher prevalence of tooth loss. (i) GTR and RPL sites showed comparable susceptibility to periodontal breakdown; (ii) stability of outcomes was consistently associated with good oral hygiene, compliance with a supportive periodontal care program, and no cigarette smoking.