J Clin Periodomol 1996. 23: 89S-905Primed in Denmark . All rights reserved

Copyright © Munksgaard 1996

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clinical periodoiitolcjiyISSN 0303-697')

Supportive care after activeperiodontal treatmentA review

Jose J. Echeverria, GarciaCarolina Manau and Adrian GuerreroDental School, University of Barcelona. Spain

Echeverria JJ, Manau C. Guerrero A: Supportive care after active periodontattreatment. A review. J Ctin Periodontot 19%: 23: 898-905. © Munksgaard, 1996,

Abstract. This review concerns the most significant questions regarding support-ive (maintenatice) care after active periodontal treatment: the effectiveness andideal frequency of maintenance appointments, the adecuacy of the supportivetherapy according to patient needs, the possible alternatives to currently acceptedprotocols, and the relative value of personal oral hygiene in the overall contextof supportive care. Periodontal diseases are infections with a high potential forrecurrence, progressive loss of attachment and eventually, tooth loss. Currenttherapies for periodontal diseases are highly predictable in arresting diseaseactivity Supportive periodontal care has been shown to be very effective in main-taining support when adapted to each particular case. Nevertheless, current main-tenance therapies may be unsuccessful in preventing further loss of attachmentin a small numt>er of sites for some patients. Tests aiming at bacterial identificationand the subgingiva! application of antimicrobials may be helpful in the manage-ment of such cases, however the practical value in a specific setting is not known.There is growing evidence of the fundamental role of personal oral hygiene insupportive periodontal care. In cases with rapid and severe periodontal destruc-tion and where locai and/or systemic risk factors are present, personal oral hy-giene becomes a key factor in the long-term preservation of periodontal sup-port.

Key words: periodontal treaiment; periodontalmaintenance; supportive periodontal treatment:periodontal diseases

Accepted for publication 28 November 1995

Periodontal diseases constitute a groupof infections affecting the periodontaltissues. They include inflammatorylesions (gingivitis) and others with highlocai destructive capacity (peri-odontitis). Both gingivitis and peri-odontitis are chronic diseases of univer-sal distribution and high prevalence. Inrecent years, many studies have shownthat: (a) although it is true that thereare variations in the response of peri-odontal tissues according to bacterialflora (Socransky & Haffajee 1992), in-dividuai susceptibility (risk factors) canmodulate the response of the tissues tothe presence of bacteriai plaque: not aliperiodontal patients have been createdthe same; (b) traditional periodontaltreatment, with or without the aid ofsurgery has been shown to be effectivewhen eradication of piaque and calcu-lus is included (Badersten et al. 1987a,Lindhe & Nyman 1975, Ramfjord et al.

1987), without modifying the risk fac-tors; disease recurrence may occurwhen the presence of bacteria overcomehost resistance (Socransky & i-iaffajee1992).

Periodonta] diseases must be con-sidered chronic diseases and, in thiscontext, it would be of paramount im-portance to establish a clear distintionbetweeti the short- and long-term ef-fects of periodonta] treatment (Socran-sky & Haffajee 1985). The long-term ef-fectiveness relies on the maintenance ofan ecosystem at the levei of the gingivalsulcus that must be compatible with asituation of a balanced host-parasiteequilibrium (Genco & Slots 1984). Suchequilibrium mostly depends on thedaily elimination of plaque by the pa-tient. However, patient cooperation isdifficult to maintain in the long run(Wilson et a]. ]983); thus, some type ofprofessional help is usually needed (Su-

omi et al. 197]). As a consequence, pro-fessional supportive periodontal care ismostly based on; (a) the chronic natureof periodonta] diseases; (b) the com-mon inability of the patient to keepplaque leve]s compatibie with the main-tenance of periodonta] support; (c) thewillingness of the dentist to help the pa-tient.

The Evolution of tiie UntreatedPeriodontal Patient

Numerous ciinical and epidemiologicstudies have shown that loss of peri-odonta] support is a fact in most indi-viduals, is generally moderate, and isnot directly caused by age (for review,see Papapanou (1994)). It is assumedthat periodontitis is the most importantreason for attachment ioss, aithoughnot the only one (Loe et al, ]992,

\

Supportive periodontal care 901

gingivatis and A. actinomicetemcomit-ans, and without further ioss of attach-ment.

The maintenance of exceiient orai hy-giene does indeed affect the mainten-ance of periodonta] support after fin-ishing the active phase of the treatment(Lindhe & Nyman i984, Lindhe et al.i984, Renvert et ai. 1990, Ai-Yahfoufiet a], 1995, Kornman et al. 1994). Theseand other studies (Axelsson et al. 1991,Aibandar et al. 1994) suggest that themaintenance of a high standard of per-sonal oral hygiene depends to a certainextent on periodica] reinforcement andmotivation on the part of the pro-fessiona]. Without that, oral hygienetends to deteriorate over time. Further-more, due to technical and individua]inadequacies, toothbrushing alone canbe insufficient to control denta] plaque.This justifies the use of chemothera-peutic agents as adjuncts to mechanica]remova] of piaque. However, their iong-term efficacy in supportive periodonta]care has never been determined (for re-view, see Addy (]994)).

In conc]usion, except m those caseswhere professionai prophy]axis is so fre-quent that bacteriai recolonization is re-duced, adequate persona] ora] hygieneis the best guarantee of the maintenanceof periodonta] support. In a traditionalsystem of supportive periodonta] care,the impact on periodontai stabiiitycou]d be even superior to that of thefrequency of maintenance visits(Westfeid et al, i983).

Aiternatives to TraditionaiMaintenance Care

Traditicnaiiy. periodontal instrumen-tation in maintenance visits is carriedout for ail teeth, although it is well-documented that in heaithy sites, thisresults in a certain ioss of attachmentand gingival recession (Lindhe et a].1982a, Claffey et al. 1988) and may re-move significant amounts of root den-tine (Games et al. 1992). If this is so,invasive instrumentation with curettesplaced subgingivally does not seem tobe either appropiate or necessary. As aconsequence, the current tendency con-sists of subgingival instrumentation toonly those areas showing disease activ-ity, e,g., bleeding on probing (Joss et al.1994). it seems to be clear that the qual-ity of supportive care is the determinantto ensure the maintenance of peri-odontal attachment (Bragger et al.1992) especially around teeth with new

restorations or furcation involvement(Loos et al. 1989, Joss et al, 1994).

Some patients consider periodontalmstrumentation to be too traumaticand time-consuming and non-invasiveaiternatives would be welcome, es-pecially through the use of chemothera-peutic agents. However, at the presenttime, none have made obsolete themechanical elimination of plaque andcalculus by the professional. Subgingi-val application of antibiotics, althougheffective in some cases (Goodson et al,1984), cannot be considered a substitutetherapy, and its effect on subgingivalfiora is selective and incomplete (Ped-razzoli et al. 1992), whereas other sub-stances used subgingivally, e.g., clorhex-idine or hydrogen peroxide, alone or incombination with mechanica] debride-ment. show contradictory results(Wennstrom et al. 1987, Stabhoiz et al.199]),

Regardless of maintenance therapy,some patients experience significantfurther loss of periodontal support. Inthe presence of recurrences, differenttherapeutic approaches can be con-sidered, including repeated root planingand periodonta] surgery (Chace 1977,Ramljord ]993). In recent years, somestudies have shown the usefulness ofantibiotic therapy in such cases, ai-though the effects may last temporariiy(Listgarten et ai. 1989, Kornman &Kari ]982, Newman et a]. 1994). Suchan approach ideally requires properidentification of the bacteria] species in-vo]ved (Van Steenberghen et a]. 1991,Fine 1994), although this is not yetdone on a routine basis. As an ad-ditiona] problem, there are no con-troiied studies demonstrating the ]ong-term surviva] of teeth with recalcitrantiesions after the active phase of peri-odonta] disease, treated with either io-ca] or systemic antibiotics.

In conclusion, the traditiona] proto-co] carried out during maintenancevisits still holds appropiate in mostcases. However, in the near future, peri-odontal sites showing recurrence maybenefit from the use of selected anti-microbials loca])y applied.

Discussion

One long-term goal of periodontal ther-apy is the maintenance of the dentition.This can be obtained by proper controlof bacterial piaque throughout thecombined efforts of the patient and theprofessionai (Lindhe & Nyman i975).

The need for professionai care relies onthe inability of most patients to per-form an "adequate" elimination ofsupragingival bacteriai deposits in or-der to avoid the buiid-up of subgingivalplaque (Magnusson et ai. 1984), How-ever, what represents an "adequate"personai controi of plaque can be thesubject of different interpretations.Ideally, an adequate contro] of p]aqueshou]d avoid the emergence of gingivalinflamation (Ramljord 1987), since it isaccepted that gingivitis may lead toperiodontitis. In the absence of optimaloral hygiene, to prevent the presence ofgingivitis would require prophylaxis tobe done every two-three weeks, sincethis is the time needed for gingival in-flamation to develop into a clinical en-tity (Loe et al. 1965, Seymour et al.]983). Such a regimen has shown veryeffective in clinical trials, however itsfeasibility applied to the regular at-tender at a periodontal office is imprac-tical and in most instances probabiy un-necessary. In fact, a significant numberof patients may show gingivitis withoutfurther overt ioss of attachment(Ramfjord et ai. 1982, Listgarten et al.1985), Thus, a realistic objective ofmaintenance therapy would accept acertain degree of gingival inflamation insome patients, even if those patients arereceiving prophylaxis on a routine basis(Ramfjord et ai. 1982, Listgarten et al.1985). In such a way. they may reachthe iast years of their iives with enoughattachment as to retain most teeth, withadequate function and esthetics(Wennstrom et ai. 199.3). In cases ofmiid and moderate aduit periodontitis,supportive periodonta] care, even ad-ministered both irregulariy and in-frequently, may be compatible with lowvalues of tooth mortality similar tothose found in well-maintained peri-odonta] patients (0,05-0.1 tooth/year),a]though with higher values of ioss ofattachment (0,06-0,1 mm/year) (Brag-ger et al. 1992). However, in individuaiswith high susceptibiiity to periodontaibreakdown or where identified risk fac-tors cannot be adequatly controlled,host tolerance to even minute amountsof bacterial accumulations may be bemuch lower. In such cases, the primor-dial goa] of supportive care is to main-tain the attachment apparatus in asstab]e a state as possible. This aiwaysrequires excellent plaque contro], fre-quent prophylaxis (3^/year) and care-ful supervision. Even so. minimal lossof attachment should be expected.

902 Echeverria et al.

sometimes related to the maititenanceof high standards of oral hygiene(Serino et al, 1994). In other cases, ad-ditional loss of attachment can be theresult of disease activity (Wennstrom etal. 1993), which can be more significantin some sites, with treatment failuresoccurring repeatedly in the same sub-jects (Haffajee et a!. 1988).

Personal oral hygiene is of utmostimportance in the preservation of peri-odontal support, especially when thefrequency of professional prophylaxis islow and patient susceptibility to the dis-ease is high. However, good oral hy-giene depends on repeated professionalreinforcement and motivation (Axels-son & Lindhe 1978), although most in-dividuals do not seem to comply ad-equately with maintenance visits (Men-doza et al. 1991). Thus, the periodontistshould pay special attention to thosepatients most at risk of developingfurther disease episodes as regards oralhygiene reinforcement and the need tocomply with maintenance appoint-ments. This means that careful con-sideration of personal risk factors re-lated to the disease is essential in thelong-term management of the peri-odontal patient after the completion ofactive treatment.

Acknowledgements

The authors wish to thank Dr, S.Ramfjord for his support and assist-ance during the preparation of the finaldraft of this paper.

Zusammenfassung

Erhaitungstherapie nach aktiver Parodontal-behandtung. Ein UbersichtsartikeiDieser Ubersichtsartikei behandelt die wich-tigsten Fragen hinsichtlich der Erhaitungs-therapie nach aktiver Parodontalbehandlung:Effektivitat und ideaie Haufigkeit der Recall-sitzungen, die Anpassung der Erhaitungsthe-rapie an die Bedurfnisse des Patienten, diemoglichcn Alternativen zu den momentanakzeptierten Vorgehensweisen und die relati-ve Wichtigkeit der personlichen Mundhygie-ne im Zusammenhang mit der Erhaitungs-therapie. Parodontalerkrankungen sind In-fektionen mit einer hohen Rezidivhaufigkeit,progressivem Attachmentverlust und schlieB-lich Zahnverlust. Die aktuellen parodontaienBehandlungsmoglichkeiten konnen mit ho-her Wahrscheinlichkeit die Erkrankungsakti-vitat zum Stillstand bringen. Es wurde ge-zeigt, daB die Erhaitungstherapie, wenn sie injedem besonderen Fall angepaflt wird, sehrwirkungsvoil beim Erhalt des Parodonts ist.Trotzdem kann die Erhaitungstherapie bei ei-

ner geringen Anzahi von Parodontien undbei einigen Patienten erfolglos bei der Verhin-derung weiteren Attaehmentverlusts sein.Tests mit dem Ziel der bakterielien Identifi-kation und die subgingivale Apphkation vonantimikrobiellen Substanzen kann bei derBeherrschung von solehen Fallen hilfreichsein, jedoch ist der praktische Wert bei ainerbestimmten Konfiguration unbekannt. Esgibt immer mehr Beweise fur die grundlegen-de Rolie der personlichen Mundhygiene imZusammenhang mit der Erhaitungstherapie.Bei Fallen mit rascher und schwerer paro-dontaler Destruktion und wo lokale und/Oder systemische Risikofaktoren vorhandensind, ist die personliche Mundhygiene derwichtigste Faktor ftir den langfristigen Er-halt des Parodonts.

Resume

Soins de maintien apres le traitement parodon-tai actif. Revue de la litteratureLa presente revue de la iitterature concerneles questions les plus significatives pour lessoins de soutien (maintenance) apres le trai-tement parodontai actif: efficacite et fre-quence ideaie des seances de maintenance,choix du traitement adequat de soutien sui-vant les besoins du patient, alternativespossibles aux methodes couramment accep-tees, et vaieur relative de Thygiene bucco-dentaire personnelle dans le contexte globaldes soins de maintien. Les maladies paro-dontales sont des infections avec une ten-dance elevee a la recidive, a la perte pro-gressive d'attache et, plus tard, a la perte dedents. Uarret de I'activite pathoiogique pro-duit par les traitements courants des mala-dies parodontales est hautement previsible,Les soins parodontaux de soutien ont prou-ve leur efficacite pour maintenir le supportparodontai lorsqu'ils sont adaptes a chacundes cas particuliers. Cependant, chez quel-ques patients, les traitements de maintenan-ce courants peuvent dans un petit nombrede sites echouer a prevenir une perte d'atta-che ulterieure. Pour prendre en main de telscas, il peut etre utile d'employer des testsd'identification bacterienne et des applica-tions sous-gingivales d'agents antimicro-biens, mais sans qu'on puisse connaitre lavaieur pratique dans une situation specifi-que. Le role fondamental de I'hygjene buc-co-dentaire personnelle dans les soins demaintien parodontaux apparait de manierede plus en plus evidente. Dans les cas ou ily a une destruction parodontale rapide etsevere et oil il existe des facteurs de risquelocaux et/ou generaux, I'hygiene bucco-den-taire personnejie devient im facteur cle pourla preservation du support parodontai along terme.

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904 Ectieverria et at.

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