6. Periodontal Maintenance Flashcards
What is Periodontal Maintenance?
• Procedures performed at selected ____ to assist the periodontal patient in ____ oral health
• Periodontal maintenance following active therapy is NOT synonymous with ____
- Prophylaxis refers to procedures that are done ____, on a patient who has a healthy periodontium.
- Once the periodontium is not healthy, any procedure done on it to maintain it is called periodontal ____, not prophylaxis
• These are two different types of patients with different susceptibility rates. So we will be doing things at different ____ (prophylaxis vs maintenance). We will also encounter and charge the patient differently. Both are ____ differently for insurance and financial purposes.
intervals
maintaining
prophylaxis
preventively
maintenance
intervals
coded
What are the Goals of Periodontal Maintenance?
- To ____ the results of active treatment
- To ____ the results of active treatment
- To prevent ____ progression on all sites in the pt’s mouth.
- To prevent ____ of new disease
As long term studies have shown us, if the pt is ____ with recommended recall interval, things get better, you may get further improvement, both with regards to probing depth and bleeding on probing and hence inflammation.
Periodontal disease can be treated but cannot be ____. So once we treat the pt our goal is to insure that the pt is gonna be stable enough or is gonna lose as less attachment as possible over the course of their lifetime so that they don’t risk losing their teeth.
maintain
improve
progression
development
compliant
cured
Is Periodontal Treatment Effective?
• Long-term Randomized Controlled Clinical Trials w/ Split Mouth Design
• Minnesota studies: SRP - MWF, 6.5 years
• Michigan studies: SRP - SC - APF - MWF, 8 years
• Gothenburg studies: SRP - APF - MWF w/ or w/o OS, 14 years
• Aarhus studies: SRP - APF - MWF, 5 years
• Michigan-Tucson-Houston studies: SRP - MWF - APF w/ OS, 5 years
• Nebraska studies: CS - SRP - MWF - APF w/ OS, 7 years
- Periodontal treatment is an effective treatment whether that is ____ or ____.
- We reviewed the studies - the long term, randomized clinical trials.
surgical
non-surgical
Is Periodontal Treatment Effective?
• All treatment modalities were effective in halting disease ____
• Overall, no significant difference in ____ between treatments
• Overall, no significant difference in ____ between treatments
• Differences between treatments were noted mainly in ____
____ is the key to success
• One of the common thing that all the studies found is that recall, periodontal
maintenance was the key to success.
• The terms recall and periodontal maintenance are terms that are used interchangeably
progression PD CAL molars recall
What is the Ideal Recall Interval?
- Michigan studies: SRP - SC - APF - MWF, 8 years
- Michigan-Tucson-Houston studies: SRP - MWF - APF w/ OS, 5 years
- Nebraska studies: CS - SRP - MWF - APF w/ OS, 7 years
- Recall every ____ months
- Supra- and sub-gingival plaque removal
• In patients who are not periodontal patients but are healthy or gingivitis patients, we perform their prophylaxis every ____ months.
• For periodontal patients the recall interval is every ____ months.
• During that recall period, they would bring in the pt every ____ months and remove both supra
and sub gingival plaque.
• Important to know how often they are called in (3months) and what is done (supra and sub gingival plaque removal).
3
6
3
3
What is the Ideal Recall Interval?
• Minnesota studies: SRP - MWF, 6.5 years
• Recall every ____ months
• ____- and ____-gingival plaque removal
• Minessota study shows a recall interval thats similar but a little wider -
3-4 months
• They also removed supra and sub gingival plaque.
3-4
supra
sub
What is the Ideal Recall Interval?
- Gothenburg studies: SRP - APF - MWF w/ or w/o OS, 14 years
- Recall every ____ weeks for 6 months, then every ____ months
- ____-gingival plaque removal only
• In Gothenburg they used a much more stringent recall interval. Every 2 weeks for 6 months and then every 3 months.
• They were testing the limits of periodontal therapy.
• They were removing supra gingival plaque only - they were removing this before it
becomes sub gingival and hence pathogenic.
• This is the ____ standard, but not very practical for everyone.
2
3
supra
gold
What is the Ideal Recall Interval?
Aarhus studies: SRP - APF - MWF, 5 years
Recall every ____ weeks for year 1, every ____ months for year 2, then
every ____ months for years 3-5
____- and ____-gingival plaque removal
In Denmark, they used something in between, where they recalled the patient every 2 weeks for the first year, then every 3 months for the second year and every 6 months for years 3-5
• The rational here was that they would help the pt achieve as good oral hygiene as possible within the first year and then they would make that recall less frequent.
• After the ____ year they performed both supra and sub gingival plaque removal.
2 3 6 supra sub
Is a 6-month Recall Interval Adequate for Patients Treated for Periodontitis?
20 patients with generalized severe chronic periodontitis treated with full mouth periodontal surgery
Randomized controlled clinical trial
• Control: recall every ____ months —- which is what happens in non-periodontitis
• Test: recall every ____ weeks — which is the model that gothenburg was using
PD, BOP, CAL assessed at baseline and ____months
6
2
24
Is a 6-month Recall Interval Adequate for Patients Treated for Periodontitis?
- ____-week recall: shallow PD and gain of CAL that were maintained for 2 years
- ____-month recall: repocketing and continuous loss of CAL over 2 years
- A 6-month recall interval results in ____ to halt periodontal disease progression
2
6
failure
The Key to Success
the key to success for periodontal treatment is the ____-month recall
for removal of all ____- and ____-gingival plaque
- The other studies have used a more reasonable recall of 3-4 or 3 months and we have seen that those studies did not really differ from the Gothenburg studies that used the 2 week recall interval
- Given that 3 months is a much easier interval to employ in clinical practice our conclusion is that: READS slide
- So we are either gonna see pts very frequently, every ____ weeks and not remove supra gingival or we r gonna see them every ____ months and remove both supra and sub gingival plaque - this appears to be very adequate for maintaining periodontal health.
3 supra sub 2 3
What is the Patient Compliance with the Recommended Recall Interval?
961 ____ practice patients with periodontitis treated with SRP or combination of SRP and surgical treatment
Recommended recall interval 3-4 months: ____%
0-2 months: ____%
5-7 months: ____%
Compliance evaluated at ____ years
• When we are talking about shorter intervals, a good q is whether compliance happens with pts.
• There are a series of good studies by Wilson (a private practitioner) and collegues. He looked at about 1000 private practice pts who have either been treated with SRP alone or a combination of SRP and surgical treatment as needed.
• The recommended recall interval was 3-4 months for 92% of his pts.
• 6% of the pts were placed on a shorter recall interval of 0-2 months. That has to do with
____. If you have a pt with a lot of risk factors such as smoking, systemic diseases, diabetes, then we may shorten the recall interval to less than 3 months.
• There are some patients who are less susceptible to periodontal disease and who have excellent oral hygiene, for those pts he recommended a 5-7 month recall interval (2%)
• These were the recommendations, so now lets see what happened when Wilson evaluated
the compliance 8 years later.
private 92 6 2 8 risk factors
What is the Patient Compliance with the Recommended Recall Interval?
- Complete compliance: ____%
- Erratic compliance: ____%
- No compliance: ____%
- Complete compliance ____ over time
These compliance percentages recorded are across all three groups.
• This is not what u wanna have in your practice for a number of reasons.
• A lot of effort, time and money has been put into these pts and still at best they comply
erratically at the recommended interval at around 50%.
• About a third never came back
• Complete compliance decreased with time. The further from our treatment, the lower
the complete compliance.
16
49
34
What is the patient compliance with the recommended recall interval?
- they had pts in ____ groups depending on what type of treatment they had received (osseous surgery, flap procedure and SRP)
- complete compliance was a little ____ when patients received surgical therapy vs non-surgical therapy but w/o any significant difference
3
higher
-poor prognosis = no compliance was ____
higher
- they looked at compliance by ____ interval
- they saw that the ____ the interval was (i.e. 5-7 mo) the higher the complete compliance
- ideally, if we want our pts to comply we don’t want to ask them to come back every ____ weeks or every month bc that will reduce compliance
maintenance
longer
2
What Measures Can Improve Compliance?
• Accommodating patients’ ____
• Making next appointment before leaving the office
• Post-card and ____ reminders
• Explain to the patient the importance of periodontal maintenance
• Educate ____ on the importance of periodontal maintenance
• Positive ____ showing improvement in PD and BOP
• 604 private practice patients with periodontitis treated with SRP or combination of SRP and surgical treatment
• Compliance evaluated at ____ years
• When we see less BOP and shallower pockets we need to show that to our patients. With
electronic health records we can make comparisons and give them something to take home.
• After Wilson implemented all these changes he looked at his pts 5 years later to evaluate
compliance
schedule telephone staff reinforcement 5
What measures can improve compliance
- The right hand bar looks at data once the changes had been implemented.
- Complete compliance ____ after these changes had been implemented.
- No compliance went down to 50% of what it was initially.
- Still ____ showed erratic compliance.
- Now a fifth did not comply at all.
- No matter what u do some people will not ____
doubled
half
comply
What is the Rate of Progression of Untreated Periodontal Disease?
- 82 and 30 patients with periodontitis
- No ____ over 10 years
- Tooth loss was ____ teeth/year/pt
The patients showed up 10 years later and an examination was performed. The primary outcome variable was ____.
In the 70’s - when this study was done, ____ level measurements were not a gold standard and instead tooth loss is an easy and quick way to assess disease progression.
Tooth loss could be due to other reasons too of course, but in this case, assume its due to ____ disease
treatment 0.25-0.36 tooth loss clinical attachment periodontal
What is the Rate of Progression of Treated Periodontal Disease?
• 2000 patients with periodontitis
• SRP and surgical periodontal treatment with ____ months recall over 10 - 22 years
• Tooth loss was ____ teeth/year/pt
- Other studies looked at progression of treated periodontal disease.
- READS bullets
- Tooth loss here was about ____ times less than in pts with untreated periodontal disease
3-6
0.02-0.03
10
What is the Rate of Progression of Treated Periodontal Disease Without Maintenance?
• 44 patients with periodontitis
• SRP and surgical periodontal treatment without ____
over 5.25 years
• Tooth loss was ____ teeth/year/pt
maintenance
0.22
What is the Rate of Progression of Periodontitis?
- Periodontal treatment reduces tooth loss ____-fold
- Treated periodontitis but without maintenance progresses at the same rate as ____ periodontitis
10
untreated
hat is the Sequence of Treatment in Periodontal Disease?
- ____ Treatment (non-surgical)
- Re-____• — - remember this is ____ weeks
- Periodontal ____ (recall) - after phase 1 has been completed every ____ months
phase I evaluation 4-6 maintenance 3
Progression of Treated Periodontal Disease With and Without Maintenance
• In panel C we can see that as long as the pt comes in every ____ months for maintenance,
the bone level remains stable
• However if the patient vanishes and does not show up, within a year not only do things go back to where they were initially, so theres bone loss on the distal of the second molar
but now there is bone loss on the distal of the ____ as well.
3
bone loss
