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Supportive Periodontal Treatment Dr Leonard Fabre BDS[Syd.Uni] Grad. Cert Dent [Adelaide uni] Grad . Cert. Pain Management [Syd. Uni] Grad. Dip. Sc. Med [ PM] (Syd. Uni.) Msc. Medicine [PM] (Syd Uni) The discipline of Periodontics is concerned with study of the tooth supporting structures. The periodontium and periodontal diseases have been researched extensively and there have been many controversies regarding certain aspects of treatment including periodontal maintenance e.g. root planing versus debridement, hand instrument versus mechanical debridement, surgical versus non surgical therapy, the use of local and systemic antimicrobials and lasers. The term Periodontal Maintenance [PM] includes implant maintenance and has superceded such terms as supportive periodontal therapy or periodontal recall. Periodontal Maintenance [PM] includes implant maintenance. There are many biological reasons for PM which will be discussed. The patient, dental surgeon, hygienist and periodontist are all involved in the process of PM. Cooperation is required between practitioners and their patients. (Research, science and therapy committee of AAP. Position paper (2003 A) & (1998)) The three main considerations within the discipline of Periodontics are the biological, the mechanical and the psychological considerations. This triad of considerations is called the treatment model. The biological considerations for periodontology address the structure and function of the periodontium, the categories of periodontal disease, diagnosis and prognosis determination, bacteriology, plaque biofilm, epidemiology, inherited and acquired risk factors, pathogenesis, local and systemic adjunctive antimicrobial therapy. The mechanistic considerations of periodontics include oral examination, data collection, initial therapy, corrective therapy and periodontal maintenance. The psychological factors are numerous. There are the coping strategies for psychosocial stress and fear of treatment. At the core of the psychological factors are patient compliance or non compliance with professional advice, attendance for therapy, and, periodontal maintenance.

It could be said that ultimately the success or failure of dental treatment, and, in particular periodontal treatment, is determined by the patient’s compliance with personal oral hygiene and attendance for periodontal maintenance at the requested time intervals (Axelsson P, Lindhe J. (1974), Wilson TG et al (1993), Wilson TG (1996,) Schou L. (2000), Ojima M et al. (2005)).

The term periodontal disease is a broad term that refers to all the acute and chronic periodontal diseases. It is generally used to refer to plaque induced chronic gingivitis, chronic periodontitis and aggressive periodontitis (Armitage GC. (1999)). It was in the mid 1960’s when the modern concept that bacteria caused periodontal disease emerged and by 1996 the causal bacteria of periodontitis were discovered to be Actinobacillus Actinomycetemcomitans [AA] , Porphyromonas Gingivalis [PG] and Tennerella Forsythensis [TF] (Williams RC, Paquette DW. (2000))

It is agreed that periodontal disease is an infection of the periodontium that is mediated by the immune system (Greenstein G. (2002) A, B). 

Plaque induced chronic gingivitis and chronic periodontitis are the two main types of diseases of the periodontium. Whilst most forms of gingivitis and periodontitis are due to the build up of microorganisms adherent to teeth, there are prominent risk factors for the development of chronic periodontitis which include the presence of AA, PG and TF , tobacco use, diabetes and other hormonal conditions, viral diseases[ HIV] ,blood dyscrasias [ leukaemias , anaemias, haemochromatosis] , age and male gender. (Research, science therapy committee. Academy report AAP (1999 & 2001)) Plaque induced chronic marginal gingivitis is defined as inflammation of the gingivae without loss of attachment of periodontal ligament and bony support. [(Research, science therapy committee. Position paper AAP (2003 B)) Chronic and aggressive periodontitis presents as an inflammation of the gingivae with loss of attachment of periodontal ligament and bony support. (Research, science therapy committee. Position paper AAP (2003 B), Slots J, Jorgensen M. (2000)). In spite of similarities histopathologically there is a lack of evidence that periodontitis is an inevitable consequence of gingivitis (Research, science and therapy committee AAP. Informational paper (1999)). The periodontal diseases are the common diseases of mankind; almost 100% of mankind has some form of periodontal disease (Papapanou P. (1999)). Greenstein and Lamster (2000), reported that 50% of adults 18 and over had gingivitis on 6 or more teeth and that 30% of adults have moderate periodontitis, with a further 10% being affected by severe periodontitis. Research in recent years has changed the previous periodontal disease model. There is a complex interplay of infection, host response with modification by host factors. Males are associated with more prevalence of periodontitis. The relation ship of periodontitis to oral hygiene is not straightforward as with gingivitis. (Weyant RJ. (2005), Westfelt E, Rylander H, Dahlen G, Lindhe J. (1998), Nyman S, Rosling B, Lindhe J (1975))

Epidemiological studies have challenged the assumption that periodontitis is an aging disease. It has also been shown that there is a higher prevalence of periodontitis in smokers and that smoking is a major risk factor. The risk factor for periodontitis is 2.5 to 6 times more in smokers.

The view now is that 5-20% of the population has severe generalised periodontitis. Surveys have shown that 40% to 60% of school children in USA have gingivitis. The survey of employed adults in 1985 had a gingivitis prevalence of 47% for males and 39% for females. There are often differences in epidemiological prevalence figures, because there is no standard used to define periodontitis, and as such, depending on the established threshold used to define periodontitis, the data changes (Research, science, therapy committee. Position paper AAP (1996)). The causative agent of periodontal disease is dental plaque which is made up of a community of microbes organized into a complex and tenacious biofilm. More than 500 types of bacteria can be cultivated from gingival crevices and the oral cavity, so the causal relationship between periodontitis and oral bacteria is difficult to establish. It is difficult to determine when commensals play the role of pathogens or non pathogens. There is strong evidence that actinobacillus actinomycetemcomitans [AA], porphyromonas gingivalis [PG] and tennerella forsythensis [TF] are the significant periodontal pathogens (Chen (2001), Research, science and therapy committee of AAP. Position paper (2004), Tonetti M. (2002))

Dental plaque is a metabolically interconnected network of bacteria in an exo- polysaccahride substrate. The biofilm is mainly composed of bacteria [75%] and the remainder is an exo polysaccharide. It is both plaque quantity and quality that is a determinant of disease activity. The biofilm is present sub-gingivally or supra-gingivally. Once supragingival plaque forms sub-gingival plaques develops within 24 to 48 hours. Supragingival plaques provide nutrients and bacterial seeding for subgingival plaque. The supragingival bacterial biofilm is mainly composed of G+ aerobes and is firmly attached to the tooth, whilst the sub gingival plaque is mainly composed of G- anaerobes and is less firmly attached than the supragingival plaque and endotoxins are loosely attached to the root surface.  (Fanning DE, Palu ME. (1990), Greenstein G, Lamster I. (2000), Westfelt E. (1996)). 

Good supragingival plaque control decreases recolonization of pathogens in previously treated pockets (Westfelt E. (1996), Magnusson I, Lindhe J, et al (1984)). However Westfelt E and Lindhe J (1998), confirmed previous studies that supragingival plaque control alone was ineffective in controlling advanced periodontitis and that regular professional subgingival plaque control is required to halt the progress of advanced periodontal disease. Supragingival plaque control will affect sub gingival bacterial proliferation in gingival crevices that are less than 5mm (Greenstein G, Lamster I, (2000)). Gingivitis is a reversible disease. Treatment for gingivitis targets the causative agent and any calcified and non calcified deposits. In instances where there are no systemic illnesses and there are no calcified deposits improved personal oral hygiene may suffice as treatment.

Trials have shown that home care alone [no matter how efficient], cannot stop recurrence of gingivitis in the long term, without periodontal maintenance. 

Periodontal maintenance [PM] is essential for periodontal health. (Slots J, Jorgensen M. (2000)) Generally PM treatment for recurrent gingivitis and mild chronic periodontitis is provided by the general dentist or the hygienist under practitioner supervision .At other times when a patient has chronic periodontitis with moderate attachment loss treatment is alternated between dentist and periodontist. Periodontists perform the PM for aggressive periodontitis or severe chronic periodontitis (Research, science and therapy committee of AAP. Position paper (2003 A) & (1998))

The efficacy of PM has been verified by many studies; with tooth loss in maintained patients, being inversely proportional to the frequency of PM. Regular PM intervals results in less loss of attachment. Importantly in today’s advanced dental milieu PM is essential for monitoring implants and detecting and controlling peri-implantitis as early as possible (Research, science and therapy committee of AAP. Position paper (2003 A).  

The accepted consensus for PM is 4 times a year as baseline starting point. The concept of three monthly maintenance was adopted to provide a cyclic interruption of the bacterial challenge enabling equilibrium to be achieved between host and parasite (Greenstein, (2002) A). The frequency for PM is dependant on a patient’s susceptibility to disease as well as the presence of implants. The recommendation is at least 3monthly care for patients with a history of periodontitis and until the results of research predicting disease activity are available PM schedules must be adapted to the specific needs of patients. Pocket debridement causes suppression of periodontopathogens, however the pathogens can return to base line within days or months. It takes 9 to 11 weeks for pathogen levels to return to pre-treatment levels (Slots J, Jorgensen M. (2000), Research, science and therapy committee of AAP. Position paper (2003 A), Greenstein (2002), Westfelt E. (1996)). Any patients who smoke or have other risk factors such as hormonal disorders [thyroid disorders, insulin disorders, pregnancy], haematological dyscrasias [leukaemia, anaemia, haemochromatosis], inherited traits [a positive test for IL-1 genotype] , HIV, psycho social stress, smoking, poor home care compliance, poor manual dexterity [Parkinson’s, dementia, senility, paraplegias] or have implants have an increased need for PM. These high risk patients need more frequent PM (Wilson T.G. (1999) Brown L. (1995)). Following periodontal surgery patients require PM each 2-4 weeks for 6 months (Prato P (1998)). [Greenstein (2002) disagrees with Wilson 1999 that the genetic susceptibility test can be used to alter patient’s PM intervals (Greenstein G, Hart T. (2002)). Periodontal treatment and periodontal maintenance are centered on establishing and maintaining infection control at the dentogingival area to below the patients’ threshold for disease expression (Research, science and therapy committee of AAP. Position paper (2001), Greenstein G, Lamster I. (2000) Tonetti M. (2002)). The biofilm is repeatedly disrupted in order to slow down or arrest the disease process, so that the functioning dentition outlives the patient. This is achieved by removal of the causative agent [supra and sub-gingival plaque] and controlling its reformation to below the patients threshold level for disease (Fanning DE, Palu ME. (1990), Greenstein G. (2002)A,B) The patient threshold level to disease is affected by hormonal disorders [thyroid disorders, insulin disorders, pregnancy], haematological dyscrasias[ leukaemia, anaemias , haemochromatosis], inherited traits, HIV, psycho social stress and smoking. Treatment also requires the removal and modification of natural forming local risk factors [ supra gingival calculus, sub gingival calculus, periodontal pockets]; the rectification of iatrogenic local risk factors[ e.g. defective restorative margins, overhangs etc];being aware of and modifying if possible morphological risk factors such as grooves [disto palatal of upper centrals and laterals] root concavities [mesial of maxillary first premolars and second molars , lower first molars] and furcation and trifurcation areas(Research, science and therapy committee of AAP. Position paper (2001), Greenstein G, Lamster I. (2000) Tonetti M. (2002)). The target for periodontal maintenance [and treatment] should not only be the dentogingival pathogens but periodontal pathogens in other sites in the oral cavity acting as reservoirs e.g. tongue, throat, oral mucosa. This is the concept of full mouth disinfection. (Slots J, Jorgensen M. (2000)). The specific aim of PM is threefold, firstly to control or reduce to a minimum disease recurrence, secondly to monitor the dentition thereby reducing the incidence of tooth or implant loss and thirdly early detection of disease in the mouth. (Research, science and therapy committee of AAP. Position paper (2003 A). It is important to monitor the stability of the periodontium at each maintenance visit because there is continual bacterial presence in the sulcus. This is achieved by recording probing depths, clinical attachment levels etc. Unfortunately there is no diagnostic test at present that can be used to monitor the periodontium at a PT or PM visit (Greenstein .G (2002) B). Chair side tests are being developed in this regard. The test for aspartate aminotransferase [AST] and non specific neutral proteinases has been developed and are being longitudinally studied (Research, science and therapy committee of AAP. Position paper (2003 B). Treatment is achieved by root planing or debridement in conjunction with supragingival plaque control measures by the patient. The goal of root planing is the removal of supra and subgingival plaque, calculus and endotoxin with the intentional removal of root cementum. The more current approach is root surface debridement which is the removal of supra subgingival plaque, calculus and endotoxin with no intentional removal of root cementum. The outstanding difference between root planing and debridement is that with root planing there is intentional removal of root cementum.(Color Atlas of Dental Medicine. Periodontology 3rd ed Thieme. P253) Whilst both surgical and non surgical approaches to treatment are effective in mild and moderate chronic periodontitis open root debridement is more effective in deep pocket and furcation areas (Slots J, Jorgensen M. (2000)) Greenstein reports that there is a decreased predictability of removing subgingival deposits as probing depths increase. Caffesse et al showed that when pockets exceeded 5 mm , clinicians removed deposits completely only 32% of the time. (Greenstein G (2000)) The reduction of periodontal pockets to less than 5mm is a desired outcome of initial and corrective therapy, because studies have also shown that supragingival plaque control can affect sub gingival proliferation in gingival crevices that are less than 5mm. This outcome makes home care effective. (Research, science, therapy committee of AAP. Position paper (2001), Greenstein G, Lamster I, (2000)). Surgical therapy therefore is used to access deeply positioned causative agent and sub-gingival calculus, as well as, to reduce probing depths, to depths more amenable to patients’ home care efforts [5mm]. The total elimination of plaque and supragingival / subgingival calculus is not always attainable (Fanning DE, Palu ME. (1990)) and complete calculus removal may not be possible however even with open debridement (Research, science and therapy committee of AAP. Position paper (2001), Wilson TG. (1990)). The difference between initial therapy and PM is that whilst initial therapy may be

completed in the traditional manner over several sessions or as a single visit full ,mouth therapy [FMT] ; PM is usually a one hour visit. The traditional approach for periodontal disease therapy has been scaling and root planing by quadrant over several visits. Alternatively there is an approach whereby a full mouth ultrasonic debridement is completed in one day. The results were equivocal because whilst the Leuven group results reported significant improvements as a result of full mouth therapy carried out over 24hours, two other treatment centres found no significant improvement between the efficacy of the traditional individual quadrant approach spaced at 2 weeks and full mouth therapy (Greenstein G. (2002) A). Apatzidou et al (2004) found that based on attachment levels and pocket depths neither FMT nor multi session SRP were superior to one another. Wenstrom et al (2005) demonstrated that the alternative one stage FMT approach was comparable to the traditional approach and also that there was no significant difference between hand and ultrasonic instrumentation. Some of the patients developed post treatment root surface sensitivity (Wenstrom JL, Tomasi C, Bertelle A. (2005). Large trials are required to detect real differences in therapy between the two techniques as well as corroboration of results from different treatment centres. From a psychological perspective the FMT approach is purely mechanistic. The traditional approach allows clinician to observe many factors including patient healing potential, patients’ oral hygiene standard allowing for gentle reinforcement and redirection of oral hygiene by educational intervention. This has been shown to improve a patient’s compliance with plaque control and prophylaxis (Phillipot P, Lenoir N, D’Hoore W, Bercy P. (2005) Ojima M, et al. (2005) Rateitschak KL (1994), Wilson TG (1996)). Even though, the aim of treatment is to return the patient to health and to achieve this in a manner that is maintainable by the patient, with support from the practitioner, at a time interval that is appropriate and commensurate with the periodontal diagnosis (Greenstein G. (2002) A, B), a perplexing development is, that in spite of therapy and maintenance some periodontitis and gingivitis patients do not improve or improved patients relapse quickly. Gingivitis is a reversible disease and persistence of gingivitis in spite of compliance with oral hygiene, therapy and maintenance requires investigation for systemic risk factors e.g. hormonal, blood disorders etc (Research , science, therapy committee. Academy report AAP (2001)) This leads us to an area of contention which is the use of adjunctive systemic and local antimicrobial therapy. The 1996 World Workshop in Periodontics approved research directed towards the use of chemical adjuncts to control plaque ( Newman HN (1995))

The persistence of periodontal pathogens [AA, PG, TF] in the oral cavity could be a reason for poor treatment outcomes. Mechanical debridement cannot eliminate AA and PG entirely from the gingival crevice due to limited access, morphological factors [ grooves , concavities furrows] and the tissue penetrating traits of the bacteria [AA,PG] ; furthermore instrumentation has no effect on extra crevicular reservoirs in the mouth . Adjunctive therapy can affect periodontal pathogens via saliva and gingival crevicular fluid and any areas sub gingivally not debrided effectively by instruments. Antimicrobial therapy may be considered in moderate to severe chronic periodontitis due to high levels of AA and or PG (Ehmke et al 2005) Establishing the quantitative and qualitative levels of AA, PG and TF prior to debridement for initial therapy and PM may be a helpful indicator for selecting mechanical therapy alone or mechanical therapy in conjunction with local or systemic antibiotic support (Fujise O et al (2002).  Slots (2000)  proposes that combating periodontal disease is best accomplished by combined therapy, using mechanical therapy and antimicrobials (Slots J, Jorgensen M. (2000)).  

The review of the literature by Walker (Walker C, Kaprinia K. (2002)) revealed few large controlled studies comparing the efficacy of mechanical therapy combined with adjunctive antibiotic therapy to mechanical therapy alone. The review confirms that adjunctive use of an antibiotic with mechanical therapy for the treatment of AA associated periodontitis is acceptable. Strong evidence supports adjunctive antibiotic use for aggressive forms of periodontitis also. Good responses have been recorded with amoxyl /clavulanic acid, clindamycin, metronizadole and combination therapy of metronizadole / amoxyl due to the emergence of tetracycline resistant AA. Culture and antibiotic resistance testing is required in these instances. The local delivery of antibiotics has also been studied. Local delivery achieves a potent concentration of drug into the periodontal pocket. These include tetracycline fibres, doxycycline in a gel, minocycline in microspheres, and chlorhexidine wafers. (Walker C, Kaprinia K. (2002), Fanning DE, Palu ME. (1990)).

Loesche WJ et al (1995)) reported that 93% of periodontal surgical patients could be managed by debridement and local or systemic antimicrobials. 

It has not been possible to predict if or when untreated gingivitis is converting to periodontitis. PM can provide that regular monitoring to detect conversion. At times when disease progresses in spite of all effort, microbial analysis and adjunctive local and systemic antibiotics are required. (Research, science and therapy committee of AAP. Position paper (2003 A) Successful clinical outcomes for periodontal therapy [PT] and PM are very similar. The expected outcomes of PT and PM are absence of clinical inflammation [redness, bleeding, swelling or exudates] stable or decreasing probing depths, unchanged or reducing clinical attachment and bone levels and unvarying or decreasing mobility. Other expected outcomes are tooth retention and comfortable function. (Greenstein .G (2002) B).

The treatment algorithm for periodontal disease has been greatly modified due to the gathering of new evidence in the last decade. The traditional approach has been initial therapy followed by surgical therapy [if indicated] then to periodontal maintenance.  The recent approach to periodontal therapy is based on the individuality of patient response to therapy with the need to continually monitor the patients’ response to therapy. The traditional concept was challenged by two facts. The first being that in spite of good oral hygiene and a good standard of initial therapy not all patients and sites improved well due to other risk factors[ systemic disease, inheritance, smoking etc] and secondly  evidence of the benefits of many different treatment options e.g. anti infective therapy, reconstructive therapy, implants, and developing areas of host modulation therapy [HMT]  (Tonetti M. (2002)). When conventional periodontal therapy and PM does not provide the desired clinical outcome because the patient has non microbial risk factors that are difficult to remove or reduce [ diabetes, smoking genetic predisposition]. HMT in conjunction with anti biofilm treatments may prove to be advantageous in these type of compromised patients. Controlled clinical trials are required to validate these treatments (Research, science and therapy committee of AAP. Position paper (2002))B). 

There is general agreement in the literature about the duration of a PM appointment, the treatment protocol and the armamentarium used during a PM visit. (Research, science and therapy committee of AAP. Position paper (2003 A), Color Atlas of Dental Medicine. Periodontology, 3rd Ed, Thieme p253-280, Periodontology 2000. (1996): 12) The protocol for PM follows a systematic approach. The examination proceeds from an extra oral examination to an intra oral soft tissue evaluation and oral cancer check. Any missing teeth are recorded and the standing teeth are then examined for mobility, fremitus and any occlusal factors. A caries assessment is then completed as well as recording any iatrogenic dental treatment. Any open contacts or mal positioned teeth are recorded. The periodontal examination follows the dental examination. The presence and distribution of dental plaque is recorded and personal oral hygiene is re assessed and advice is given accordingly. Pocket depths and recession measurements are recorded. Clinical attachment levels are calculated for comparison to previous records .The presence of any signs of clinical infection [ redness, bleeding, swelling , exudates] are noted, furcations are evaluated as well. Microbial testing may be carried if required. (Research, science and therapy committee of AAP. Position paper (2003A)). Dietrich et al 2004 studied the effect of smoking on gingival bleeding. The study found a strong suppressive effect for smokers of over 10 cigarettes a day. Therefore the predictive value of bleeding on probing between smokers and non smokers is affected. Numerous studies have shown the detrimental effect on treatment outcome for surgical and non surgical therapy in smokers (Johnson GK, Hill M (2004)) Implants and peri implant tissues are examined. The implant components are evaluated and the fixture’s stability is tested. Any bleeding on probing [BOP] and probing depths are recorded. BOP has a very weak predictive value for future periodontal breakdown. However the repeated absence of bleeding on probing is associated with no disease progression (Page RC, Beck JD (1997)). The currency of radiographs is confirmed and clinical judgment is used to determine the frequency of radiographs. All the clinical and radiographic data collected is then evaluated to arrive at a diagnosis and to compare to baseline records. All the conventional methods of periodontal diagnosis are only capable of retrospective diagnosis. What is required is the clinical ability to detect periodontal disease activity. Chairside tests are being developed in this regard. The test for aspartate aminotransferase [AST] and non specific neutral proteinases has been developed and are being longitudinally studied (Research, science and therapy committee of AAP. Position paper (2003 B). After the data collection is complete, oral hygiene advice is provided and reinforced by referring to the pattern of disclosed dental plaque deposits in the patients’ mouth. Counseling and discussion on risk factor control such as smoking and psychosocial stress. (Wimmer G, Janda M et al. (2002), Research, science and therapy committee of AAP. Position paper (2003), Greenstein G, Lamster I. (2000)). The mechanical component of PM follows the oral examination. The same armamentarium is used to perform initial therapy and PM. The armamentarium is used to disrupt and remove supra and sub gingival plaque and calculus and bacterial endotoxin. This is performed by hand instruments [curettes, scalers] or powered instruments [rubber cups, air polishers ultrasonic scalers etc]. Repetitive root planing is contraindicated due to its tooth structure damaging effects because root planing intentionally removes root cementum. Because the aim of root surface debridement [the more current concept] is the removal of supra subgingival plaque, calculus, endotoxin with no intentional removal of root cementum; repetitive debridement has a less damaging effect. Both techniques can cause pain and result in post treatment sensitivity but hand scaling and root planing more so. In cases of bleeding in shallow pockets a correction of oral hygiene is required because mechanical therapy in shallow pockets can lead to further loss of attachment (Slots J, Jorgensen M. (2000,) (Westfelt E. (1996)). Thorough tooth and root smoothing was one of the most important requirements in periodontal disease treatment. The concept was that root surface exposed to plaque was cytotoxic. This justified extensive root planing and smoothing. Studies by Eide et al in 1983, 1984 and Moore et al in 1986 have shown however that endotoxins bind to the cementum surface weakly (Westfelt E. (1996)). Oberholzer R, Rateitschak KH (1996) found that root cleaning provides evidence of therapeutic improvement but that root smoothing [ root planing] does not. A smooth root did not result in periodontal attachment gain or pocket depth reduction. Corbet et al in a review in 1993 concluded that root surface debridement effectiveness should be assessed by the healing outcome. The aim should be to remove plaque from the root surface rather than remove the root surface. Hand scalers [e.g. Morse scaler] are used to remove supragingival calculus. Gracey curettes are used for subgingival scaling, and debridement. The instrument is only sharp on the edge that meets the tooth surface. The blade is offset at 70degrees to horizontal. These are site specific instruments and are usually double ended. Gracey curettes 1/2, 3/4, 5/6 are used anteriorly and for premolars. The Gracey 11/12 are for the mesial aspect of premolars and molars, and the 15/16 are for the distal aspect of premolars and molars. The Gracey 7/8 and 9/10 are used for the facial and palatal surfaces of premolars and molars. Universal curettes by comparison to Gracey curettes have a blade that is horizontal and sharp on both sides; the tooth side and the pocket side. A controversial area of therapy is gingival curettage during debridement. Gingival curettage aims at removing the soft lining of the periodontal pocket with a curette, leaving only connective tissue lining in order to promote connective tissue attachment. The result achieved is long junctional epithelium. Both short and long term studies have validated that curettage provides no additional benefit in comparison to SRP alone. There was “no justifiable application during active therapy for chronic adult periodontitis” (Research, science and therapy committee of AAP. Position paper (2002)(A)). However current research demonstrates the ability of AA, PG to penetrate pocket connective tissue and cells and may justify curettage (Color Atlas of Dental Medicine. Periodontology 3rd ed Thieme P242-280). Rubber cups and prohylaxis paste are used to polish remnants of calculus and remove plaque. There are differing grades of paste abrasiveness as well as differing rigidities of rubber cups. The less rigid rubber cups are preferable. The more rigid the rubber cup the more pressure is required to flare the cup for increased surface area of cleaning as well as achieving the optimal subgingival penetration of 2mm. This increased pressure can generate more heat and as a result pain (Color Atlas of Dental Medicine. Periodontology 3rd ed Thieme P242-280). Ultrasonic debridement and hand instrument debridement with curettes have shown similar outcomes in both moderate and deep pockets with respect to probing depth and clinical attachment gain. The cavitation effect of ultrasonics seems to have a supplementary bacteriocidal effect making it suitable for use during maintenance. Curettes achieve a smoother root surface than ultrasonics however the difference has no clinical significance. The use of ultrasonic tips or micro ultrasonic tips less than 0.5mm wide has been shown to be as effective as scaling and root planing (Westfelt E. (1996) Greenstein G (2000)) A study by Tan et al in 2004 discovered that there are viable aerobic and anaerobic bacteria within supragingival calculus. Several studies have shown the incomplete removal of supragingival calculus may expose reservoirs of bacteria and could be a factor in disease recurrence, therefore the thorough removal of supragingival calculus is required.

Traditionally rubber cups and prophylaxis paste are used to polish remnants of supragingival calculus away after debridement and to disrupt any residual plaque remnants supra and sub gingivally. Rubber cups can cause root sensitivity during use on dentinal surfaces. 
A novel plaque removal alternative to rubber cups in the form of low abrasiveness slurry of salt crystals and sodium bicarbonate delivered under pressure with air and water, termed air polishing [AP] is described by Slots J et al (2000) and Petersilka GJ et al (2003). Slots reported that in untreated periodontitis with probing depths of 5-7 mm supragingival air polishing directed at a 90 degree angle to each tooth surface for 10 seconds significantly decreased subgingival pathogenic bacteria. Petersilka GJ et al (2003) assessed the efficacy of subgingival plaque removal during PM by air polishing and found that the removal of subgingival plaque from pockets 3-5mm deep using air polishing was superior to curettes. The clinical significance of air polishing is that greater comfort is afforded to the patient than conventional instruments for the removal of sub gingival plaque. Routine 60 second pre treatment rinses with chlorhexidine 0.12% greatly reduce the bacterial aerosol effect (Buckner et al 1994). 

Mombelli A, Lang N (1998) recommend that instruments and techniques softer than titanium are used to maintain implants. Air polishing is suitable for implant maintenance as are rubber cups and prophylaxis paste. Otherwise polymer or plastic tipped hand or ultrasonic instruments are required to maintain implants (Slots J et al (2000)). Different maintenance methods on implant surfaces have been investigated. It was found that manual or electric toothbrushes or rubber cup polishing with fine abrasive particles cause only minimal surface alterations. A study comparing AP to gold tipped scalers, resin or graphite reinforced scalers and rubber cup polish, found AP produced no significant surface alterations on implant surfaces, and that all the other methods left alteration or particles or both. Evidence suggests that AP effectively removes microorganisms and allows normal fibroblast growth in vitro (Research, science and therapy committee of AAP. Position paper (2003 A) In recent years lasers have been promoted for periodontal therapy. Cobb reported in his review of the literature that there is only minimal evidence of the efficacy of lasers in periodontal therapy in providing any additional benefit (Cobb CM. (2006)) Whilst clinicians are competent to provide successful mechanical treatment for periodontal disease, ultimately the success or failure of periodontal disease treatment depends on the patient complying with attendance for periodontal maintenance and complying oral hygiene requirements (Schou L(2000)). Compliance is defined as “the extent to which a person’s behaviour coincides with medical and health advice”. Improving patient compliance and patient acceptance of responsibility for their part in therapy or maintenance is essential. There is a high degree of variability regarding patients’ reasons for not complying. These include lack of understanding of the condition, fear of pain, payment of fees, lack of rapport with the therapist and lack of compassion by the therapist. If patients comply with recommended PM intervals a vast majority keep their teeth over long periods of time. Compliance improves if treatment time is reduced and the complexity of oral hygiene tasks is simplified (Wilson TG (1996), Wilson TG. (1990)). Nuttal N. (1997) in his review of attendance behaviour, determined that improved attendance can be obtained by giving patients reasons for future attendance, persisting with recall reminders and personalizing the recall method to the patients’ requests [either a fixed future appointment or a mailed reminder]. Over two thirds of patients with chronic illnesses, that are not life threatening, fail to comply fully with practitioner recommendations. Wilson et al 1984, established a categorization system for compliance to PM. The categories were complete compliance, erratic compliance and no compliance [none]. Complete compliance meant strict adherence to the prescribed PM interval e.g. attendance 4 times a year for 3 monthly PM. Erratic compliance meant there was a lesser degree of attendance whilst none referred to non returning patients. The more recent study by Wilson et al showed that out of 604 patients 32% were complete compliers (Wilson TG, Hale S, Temple R. (1993)). A study by Mendoza et Al (1991) using similar definitions found complete compliance at the level of 36% (Mendoza A, Newcombe G, Nixon K (1991)). This agreed with the Wilson studies of 1984 and 1993. Complete compliers showed reduction in plaque scores and bleeding on probing (Miyamoto T Kumagai T et Al.(2006). Mendoza A, and al (1991) found that the highest drop out rate was in the first year of PM. This drop out rate was 42.8%. These figures suggested that if patients comply with PM attendance in the first year there is more of a chance of compliance in the longer term. Other clues to a patient compliance profile may be obtained by trying to identify patients who have a higher risk of non compliance by investigating the relationship between attitudes at the first visit so that efforts are made to improve compliance during the course of therapy. A study by Ojima M et al. (2005) found that four factors predicted low compliance potential significantly. These were lack of careful brushing at the gingival margin, non use of inter-dental cleaning, non use of fluoride toothpaste and frequent consumption of sugar containing drinks. Patients were then encouraged to make small changes over time (Ojima M, Kanagawa H, Nishida N et al. (2005)). Setting goals that are achievable, giving choices of alternatives for inter dental cleaning encourages improved compliance, realizing that changes in behaviour take time (Vaile L. (1998)). This technique is referred to as the Stepwise re-shaping technique, where small achievable oral hygiene goals are requested of the patient. Dependant on outcome at follow on appointments the goal is increased until the desired behaviour is achieved. However if the patient does not achieve the required goal the goal is simplified until some compliance is achieved.

   A study by Galgut (1994) discovered that changes in plaque levels during active treatment could be used to predict if patients would keep to long term PM guidelines. Whilst psychological and psychosocial factors could influence the development of periodontal disease, these factors have not been well studied in relation to maintenance or treatment outcome. Wimmer G et al (2002) investigated whether patients with periodontitis and inadequate defensive coping were at greater risk of severe periodontal disease. The study’s data corroborated the thesis but further studies are required. A pilot study by Gamboa et al (2005) tested emotional intelligence [EI] which is a psychological concept indicating the degree of coping skills an individual has. It was found that patients who had higher scores in specific EI domains had better responses to treatment. Interventions determining and improving EI may be beneficial with periodontal therapy outcomes 

Improving compliance with personal oral hygiene requires behaviour modification which is a psychological issue. Phillipot et Al in 2005 studied a group of 30 patients. The patients in the control group were given standard treatment based on oral hygiene instruction. The experimental group were educated about disease symptoms, causes, consequences of the disease over time and reasons for controlling and how to control disease outcomes. The experimental group was also asked to keep a diary of the effects of home care on the periodontitis symptoms. Informing and training the patient during each treatment visit proved effective in improving plaque score to acceptable levels (Phillipot P, Lenoir N, D’Hoore W, Bercy P. (2005)). Other methods for improving compliance are simplification of requests regarding home care, ensuring patients are satisfied with the practice by providing convenient appointments so that time away from work is reduced, reminding patients about their appointments with quick follow up for missed appointments, providing the patient with a progress report of their mouth condition and informing the patient about their condition and providing reasons for the need for care. It is important to always provide some positive feedback to a patient as well as ensuring practitioner involvement rather than delegating completely to a hygienist. An attempt to identify potential non compliers should be made and techniques used to improve compliance. (Wilson TG (1996). Schou L (2000)) There are many inhibitors to patient attendance for treatment. There is denial by the patient and a negligent attitude towards their disease because often periodontal disease is not painful. It is common for patients to not want to participate in their treatment. (Wilson TG (1996), Schou L (2000)) One of the great inhibitors to patients attending for periodontal therapy [whether it be initial therapy or periodontal maintenance] is the experience of pain during treatment and from the needle stick for local anaesthetic. Perry et al 2005 tested the effectiveness of a transmucosal lidocaine containing patch against placebo in 40 adults over the course of treatment of 160 quadrants. Sufficient anaesthesia was produced for therapeutic debridement without requiring injection. Dentsply has recently released a periodontal anaesthetic gel that is topically administered into the periodontal pocket, no needle stick is involved. The liquid contains 25mg each of lidocaine and prilocaine that gels at body temperature. The onset of effect takes 30 seconds and the duration of effect is 20 minutes. Subsequent to initial therapy and periodontal maintenance, root sensitivity [dentinal hypersensitivity] and root caries can develop which can affect attendance behaviour and home oral hygiene efforts. Oedematous tissue shrinks as it heals and as well as resulting in sensitivity, contributes to food impaction. Both these outcomes affect patient satisfaction with treatment and attendance for supportive care. Whilst the food impaction problem is difficult to rectify, tooth sensitivity can be greatly improved by using fluoride varnishes, potassium nitrate. Fluoride has been shown to prevent root caries and reduce dentinal hypersensitivity subsequent to therapy (Paine et al 1998) Other compliance inhibitors are concerns about fees, practitioner indifference to wards the patient, as well as, health beliefs, culture and lack of knowledge (Wilson TG (1996), Schou L (2000)). There have been huge advances in our biological and mechanistic knowledge in the treatment and maintenance of periodontal disease. Periodontal maintenance is essential for the success of periodontal therapy. Success of periodontal maintenance is determined by a systematic approach to therapy, as well as, friendly, empathetic, efficient and up to date practitioner and support staff, with good mechanistic skills and up to date evidence based biological knowledge.

Ensuring patient compliance with attendance for PM as well as compliance with home oral hygiene requests is the challenge facing the profession. 

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