Periodontology

Edith Allen

Hassan Ziada , Chris Irwin

Brian Mullally and Patrick J Byrne

Periodontics: 10. Maintenance in

Periodontal Therapy
Abstract: Maintenance periodontal therapy is essential for the long-term stabilization of periodontal disease. An individualized programme
of maintenance requirements, based on patient risk assessment for disease progression, is important, as is the need for teamwork in long-
term patient management.
Clinical Relevance: Maintenance or supportive therapy is an essential requirement in the management of periodontal therapy. Patients
should be informed at their first visit that part of the management of their disease is regular maintenance visits.
Dent Update 2008; 35: 150–156

Periodontal therapy a b
The treatment of periodontal disease aims
to achieve a life-long stabilization of the
destructive inflammation within gingival
and periodontal tissues and therefore to
ensure that patients maintain a functioning,
symptom-free dentition with satisfactory
aesthetics and no deleterious effect on

E Allen, Lecturer, Department of Figure 1. (a, b) Good oral hygiene with low levels of plaque following non-surgical therapy and during
Restorative Dentistry, University College maintenance.
Cork, University Dental School and
Hospital, Wilton, Cork, H Ziada, Senior
Lecturer/Consultant, Department of
Restorative Dentistry, University College systemic health due to diseased periodontal factors are also identified and, where possible,
Cork, University Dental School and tissues. are modified, for example advice and support
Hospital, Wilton, Cork, Republic of Ireland, Treatment may be divided into in smoking cessation is offered (part 2).
CR Irwin, Reader/Consultant, Department the following phases: Studies show that initial
of Restorative Dentistry, Queen’s periodontal therapy is very successful in
University of Belfast, School of Clinical stabilizing periodontal disease,1,2 even in
Initial therapy
Dentistry, Royal Victoria Hospital, Belfast patients with advanced periodontal disease.3
This phase of periodontal
BT12 6BP, B Mullally, Consultant and therapy is concerned with the elimination of
Honorary Senior Lecturer, Department of pathogenic bacteria by sub-gingival scaling Corrective therapy
Restorative Dentistry, Queen’s University and root planing, together with the use of Once periodontal disease
of Belfast, School of Clinical Dentistry, adjunctive therapy where indicated (part 3). stabilization is achieved, any surgical
Royal Victoria Hospital, Belfast, BT12 6BP, Education in oral hygiene techniques and treatment or advanced restorative care that
PJ Byrne, Lecturer, Dublin Dental Hospital motivation is offered to ensure the patient may be required to restore function and
and Practice Limited to Periodontics, can achieve the level of plaque control that aesthetics to the dentition may be carried
Dublin, Republic of Ireland. is compatible with periodontal health. Risk out.
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achieve the aims outlined above. During

these supportive care visits the following
procedures are performed:
„ Examination of the patient to detect
disease recurrence and re-treatment of areas
with active disease;
„ Professional plaque and supra-gingival
calculus removal, and selective sub-gingival
debridement;
„ Reinforcement of oral hygiene and
re-motivation of the patient.

Maintenance visit
The schedule of procedures to be
completed at each maintenance visit is listed
in Table 1.

Table 1. Schedule of procedures carried out during a maintenance appointment.

General examination
Any change in the patient’s
general health, which may alter his/her risk
Maintenance periodontal therapy experienced a greater number of teeth lost for periodontal disease, is noted, for example
Good oral hygiene, with low owing to periodontal disease in the period the development of diabetes mellitus.
levels of supra-gingival plaque, is essential since treatment.10 Details of current medications are updated.
for continued periodontal health (Figure 1). It is clear that, for successful
The accumulation of supra-gingival plaque long-term periodontal health, supportive Dental examination
is associated with the recolonization of sub- periodontal therapy is essential and life- The dental examination records
gingival pockets by pathogenic bacteria and long stabilization of periodontal disease any deterioration in oral and dental health
the recurrence of active periodontal disease.4 is possible in the majority of patients.11 since the previous visit.
When reinforcement of the It is essential that patients are aware of Intra-oral examination of the soft
oral hygiene instruction given during the the need for this life-long commitment tissues is performed.
initial phase of periodontal therapy does to maintenance care at the very outset of The presence of carious lesions,
not occur, plaque levels tend to rise with treatment. marginal deficiencies around restorations
time − even in well-motivated patients who While appropriately prescribed, and poorly fitting removable prostheses are
have demonstrated the ability to achieve low maintenance care is successful in achieving recorded. The detection of caries or deficient
plaque levels.5 Periodic reinforcement of oral long-term periodontal health in the majority restorations may require further visits to be
hygiene instruction helps to control long- of patients; a minority of patients do less well scheduled for the patient.
term supra-gingival plaque levels. and are responsible for the majority of tooth
Longitudinal, follow-up loss during maintenance care. These patients
studies, carried out on patients who were are generally in the high-risk category for Periodontal examination
successfully treated for periodontal disease, periodontal disease and their programme Periodontal examination allows
have compared the periodontal status of maintenance requirements must be for the detection of any periodontal disease
of patients enrolled on a maintenance considered at the start of active treatment.12 recurrence and prompt intervention.
programme after treatment with those The aims of maintenance therapy The clinical parameters examined
who were not. These studies found a are: are compared with the previous baseline
continued stabilization of periodontal „ To prevent the recurrence of periodontal measurements taken and any change is
disease in the majority of patients enrolled disease; noted.
on a maintenance programme up to 8 „ To prevent further tooth loss due to A BPE examination is performed
years after treatment, while patients who periodontal disease; and, if indicated, periodontal pocket depths
were not enrolled on such a programme „ To detect early and treat promptly any are recorded (part 1). An increase in pocket
showed significantly greater deterioration signs of disease recurrence; depth indicates active periodontal disease at
in their periodontal health with increases „ To maintain the function and aesthetics of that site.
in plaque levels, probing pocket depths, the dentition. Bleeding on probing: the
together with further attachment loss and Regular patient appointments gingival sulci are measured. An absence of
bone resorption.6-9 Patients who were not at appropriate intervals form the essential bleeding on probing is an accurate predictor
seen for regular maintenance visits had also scaffold for supportive care designed to of low risk for disease progression.13

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Continued bleeding on probing indicates respond well to periodontal therapy periodontal disease and the patient’s
inflammation at the site of bleeding, during the active phase of treatment. power to prevent disease progression
which may lead to further attachment loss Attendance for appointments is generally with good oral hygiene practice. The
(although this predictor is less accurate good and oral hygiene efforts improve, information and advice should be given
than an absence of bleeding at a site is sometimes dramatically so. Long term in language which is non-threatening, and
for no further attachment loss at that changes in patient behaviour with in layman’s terms. Positive reinforcement
site). Persistent bleeding on probing with continued adherence to the advice given and acknowledgement of the successes
shallow pocketing (3 mm or less) is treated and continued practice of good oral achieved by the patient are important for
by re-enforcement of plaque control (see hygiene techniques is difficult to achieve.16 ensuring on-going compliance.
below). If sites with pockets of 4 mm or As mentioned previously, even in patients It can be difficult to change
more demonstrate persistent bleeding, who are well educated in oral hygiene a non-complying patient into a very
these sites must be re-debrided in addition techniques and who demonstrate an ability compliant one, but with re-motivation
to plaque control efforts. to achieve low plaque levels, compliance at least the small improvements in oral
Any areas of suppuration over time may diminish.17 hygiene behaviour achieved will be
are noted. These areas will need to be Compliance with the behaviour maintained.
re-treated with further sub-gingival scaling, changes needed to manage all chronic
while the use of adjunctive therapy, for diseases which are not immediately life-
Anti-smoking advice
example topical antibiotics, should be threatening, for example in patients with
National statistics show that
considered14 (part 3). diabetes mellitus, has been found to be
26% of adults aged over 16 in the UK
The mobility of teeth is poor.18 Patients slip back easily into their
smoke.19 Smoking cessation reduces the
examined. An increase in mobility of a tooth old ways!
risk of periodontal disease and improves
may signify further disease inflammation Re-motivation and positive
the response to treatment in patients who
in the tissues surrounding that tooth, reinforcement of patients is usually
had stopped smoking for more than 10
or may be a sign of traumatic occlusion necessary to maintain the high
years; these factors are reduced to that of
to that tooth which will require further standard of oral hygiene required for
non-smokers.20
investigation and intervention. periodontal health. The motivation to
Smoking also has very well
change behaviour requires a change
documented detrimental effects on the
in knowledge and attitude. The patient
Evaluation of oral hygiene overall health of the patient. The dentist, as
must have knowledge or understanding
Successful periodontal disease a healthcare provider, has a responsibility
of periodontal disease, what causes
treatment requires low levels of plaque to offer advice and support with regards to
it, what are the signs of disease and
accumulation − daily removal of dental smoking cessation to patients who smoke,
what are the problems associated with
plaque from all tooth surfaces is necessary in an effort to promote better overall
untreated disease. A change in attitude is
for periodontal health. A recent survey of health and well being and to improve the
expressed in the patient, acknowledging
adults indicated that a third brushed their prognosis for periodontal health.
the implications of having periodontal
teeth once a day or less and two-thirds did Details of support available to
disease for them and the realization that
not practice daily inter-proximal cleaning.15 individuals in their efforts to stop smoking
they need to take responsibility for their
Recording a plaque score (part are given in Table 2. Practitioners should be
own periodontal health. The final step
1) is an essential part of a maintenance visit. aware of these aids to smoking cessation
is patients changing their behaviour in
and be in a position to advise patients
response to their new beliefs (Figure 2).
about them.
Re-education Re-motivation involves
The plaque score record may be reminding the patient about the nature
used as an educational tool, highlighting to of periodontal disease and the potential Supra-gingival prophylaxis and sub-gingival
the patient specific areas where plaque is consequences of untreated disease, debridement
accumulating. the relationship between plaque and Traditionally, maintenance
Many patients will just require
‘fine-tuning’ of their oral hygiene routine
with specific advice needed for the more
difficult areas − interproximal areas,
furcation areas and root surfaces. The
importance of daily plaque removal from
these areas must be emphasized.

Re-motivation
Compliance is the most difficult
aspect of periodontal care. Patients usually Figure 2. The process which results in behavioural change.

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outcomes of pocket depth reduction and

Anti-smoking aid Details
clinical attachment gain when compared
to SRP only during maintenance care.25
Nicotine replacement therapy Available ‘over the counter’ or on
Similar results have been found with the
prescription.
adjunctive use of a 25% metronidazole gel
Available in the form of patches, gum or
in combination with SRP.26
inhalers.
Therefore, current evidence
supports adjunctive use of antimicrobial
Anti-depressant drug Bupropion (Zyban) Acts at the CNS level. Prescription only.
agents during maintenance care. In
Avoid in patients with history of seizures.
addition to the superior clinical outcomes
reported with their use, adjunctive agents
Web-sites www.giveupsmoking.co.uk
can offer further benefits of shorter
clinical time and post-operative patient
NHS smoking helpline Support, advice, details of local stop
sensitivity if they reduce the requirement
smoking services.
for repeated sub-gingival debridement.
Table 2. Support available for smoking cessation. They are, however, expensive and some
concern has been expressed about the
risk of bacterial resistance from repeated
topical application of these agents. They
„ Sites which show an increased pocket should therefore be used only for the
probing depth; maintenance care of patients with good
„ Sites which demonstrate re-infection plaque control in residual pockets of 5
and suppuration; mm or greater. Non-responding sites, or
„ Sites which are difficult for the patient those with persistent bleeding, should be
to access and demonstrate persistent especially targeted.
bleeding on probing, for example furcation
areas and pockets >4 mm.
Application of topical fluorides
Figure 3. Inadequate supra-gingival plaque control
during maintenance. Adjunctive use of antimicrobial agents Gingival recession and
The evidence-based rationale exposure of the root surface is a common
supporting the use of adjunctive side-effect of periodontal disease or
antimicrobials within maintenance care is periodontal disease therapy. Gingival
care has included regular supra-gingival increasing. recession increases the risk for root caries
prophylaxis, in combination with sub- Minocycline is a bacteriostatic, and predisposes to cervical sensitivity. In
gingival debridement, to remove sub- antimicrobial agent, which is available in a one study, 82% of patients on periodontal
gingival plaque and bacteria, which has gel and microsphere formulation for local supportive care had evidence of root
accumulated as a result of inadequate application within periodontal pockets. A caries (either treated or untreated) and
supra-gingival plaque control (Figure 3). case-control study comparing the efficacy the number of root lesions in an individual
However, repeated and excessive of a 2% minocycline gel versus scaling was related to his/her plaque score.27 The
sub-gingival debridement can result and root planing (SRP) alone, in treating regular application of topical fluoride
in tooth surface loss, sensitivity and sites with pocket depths greater than or will help to prevent root caries and may
even attachment loss within shallow equal to 5 mm, with bleeding on probing relieve some of the symptoms of sensitivity.
pockets.21 A systematic review comparing during a 12-month period of maintenance Dietary counselling and further emphasis
the effectiveness of regular supra- care, resulted in similar clinical outcomes.23 on plaque removal should also be offered
gingival prophylaxis versus sub-gingival A further study, comparing SRP alone to patients at risk of root caries.
debridement for maintenance care did with SRP and adjunctive minocycline
not find any difference with respect to microspheres application, found more
clinical outcomes of probing depth and pocket depth reduction with the Maintenance care for patients with dental
attachment levels after 12 months.22 adjunctive therapy.24 implants
Therefore, regular supra- Doxycycline in a sub- Plaque accumulation around
gingival prophylaxis and calculus removal antimicrobial dose (20 mg BID) acts by dental implants is associated with peri-
should be performed at appropriate modulating the host response to plaque implantitis (inflammation in the tissues
intervals based on individual need during bacteria and thus attenuates the injurious around implants) and this inflammation
maintenance care. inflammatory response. Adjunctive sub- may lead to implant failure and loss. Plaque
Sub-gingival debridement antimicrobial dose doxycycline has also control is as critical around implants as
should be confined to: been shown to enhance the clinical it is around natural teeth.28 Recent work

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suggests that, in patients with a history of example a patient who smokes and has a that time, may be given to the hygienist.
periodontal disease, implants may be at large amount of attachment loss for his/ It is recommended that
higher risk of failure as a result of a similar her age with deep residual pockets has a maintenance care be provided by a
hyper-inflammatory response to dental high risk for disease recurrence and will specialist periodontist for patients
plaque accumulation around their implants as require more frequent maintenance visits with aggressive disease. Patients with
occurred around their natural teeth.29,30 than a non-smoking patient with good severe attachment loss may have their
Patients with implants should oral hygiene, shallow pockets and mild care alternated between a specialist
have regular maintenance visits to assess attachment loss. It is important to tailor- periodontist and their general practitioner.
the condition of the peri-implant tissues, to make the maintenance programme on an A study has shown that patients with
evaluate plaque control and to reinforce good individual basis to prevent either over- or severe disease do as well when receiving
oral hygiene practice. Peri-implant probing under-treatment. their maintenance care from general
depths, mucosal condition, implant mobility Under-treatment will run the practitioners, provided that the practitioner
and plaque levels should be recorded. risk of periodontal disease recurrence has received specific instructions with
Effective implant oral hygiene while over-treatment may result in an regard to the maintenance care required.33
techniques may include the use of dental floss, unnecessarily demanding series of recall Patients with recurrent gingivitis or chronic
dental tape and inter-proximal brushes. appointments with which studies have mild to moderate periodontitis should
It has been reported that shown patients eventually don’t comply.17 receive their maintenance care with their
scratching of the surfaces of titanium implants Over-treatment may also cause attachment general dental practitioner.
may occur with the use of ultrasonic scalers loss due to repeated unnecessary
and metal instruments.31 Plastic instruments instrumentation of shallow pockets.21
have been developed to overcome this Therefore, to maximize Conclusion
problem and professional cleaning of compliance and to prevent over-treatment, Maintenance periodontal
the implant surfaces may be undertaken the frequency of visits should be the therapy prevents the recurrence of
with these instruments or with careful minimum required to maintain health. periodontal disease and it has been shown
use of metal instruments. Prophylaxis Studies that examined the to be successful in maintaining periodontal
with rubbercup and abrasive may also be success of maintenance periodontal health over long periods.
performed. Ultrasonic instruments should therapy over a number of years found Appropriate maintenance
be avoided. that a recall frequency of 3−4 months was care entails a detailed analysis of risk for
associated with disease stabilization. further disease and an individual tailor-
Patients with a moderate to made programme for each patient, which
Scheduling of next appointment high risk of periodontal disease recurrence includes the frequency of recall and plaque
Regular recalls are important. It should be recalled every 3−4 months. control regime. The maintenance care of
is important that patients schedule these Patients with a lower risk for disease may dental implants should be considered in a
appointments into their already busy lives. be recalled every 6 months. similar manner.
Communication of the importance of these Low risk patients who
visits is important and initial discussions have experienced chronic gingivitis
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