J Periodontol March 2012

Prospective Study in Periodontal Maintenance Therapy: Comparative Analysis Between Academic and Private Practices
Pereira Lages,* Lu vio nio Jose s Ota Fernando Oliveira Costa,* Camila Carvalho Santuchi,* Euge Roberto Cortelli, Telma Campos Medeiros Lorentz,* Miranda Cota,* Sheila Cavalca Cortelli, Jose Eusta quio Costa* and Jose

Background: This prospective study aims to evaluate and compare the periodontal status, periodontitis progression, tooth loss, and inuence of predictable risk variables of two periodontal maintenance therapy programs over a 12-month period. Methods: A total of 288 individuals diagnosed with chronic moderate-to-advanced periodontitis, who had nished active periodontal treatment, were evaluated in a public academic environment (AG) (n = 138), as well as in a private clinic (PG) (n = 150). A full-mouth periodontal examination was performed at baseline and at quadrimestral recalls, evaluating plaque index, probing depth, clinical attachment level, furcation involvement, bleeding on probing (BOP), and suppuration. Individuals social, demographic, and biologic data, as well as compliance with recalls, were recorded. The effect of variables of interest and confounders were tested by univariate and multivariate analysis. Results: The PG demonstrated lower rates of periodontitis progression and tooth loss than did the AG. After adjusting for confounders, the risk variables of BOP (P = 0.047), smoking (P = 0.003), and diabetes (P = 0.028) for the PG and smoking (P = 0.047) for the AG showed a negative inuence on periodontal status. Conclusions: In both groups, the periodontal maintenance therapy minimized the negative effect of the risk variables. However, PG showed signicantly less progression of periodontitis and tooth loss compared to AG. J Periodontol 2012;83:301-311. KEY WORDS Compliance, patient; maintenance; periodontal attachment loss; periodontitis; risk factor; tooth loss.
* Department of Periodontology, Dentistry School, Federal University of Minas Gerais, Belo Horizonte, Brazil. , Taubate , Department of Dentistry, Periodontics Research Division, University of Taubate Sa o Paulo, Brazil.

everal studies1-3 have demonstrated that periodontal disease can be treated successfully by means of both mechanical non-surgical and surgical therapy. However, without periodontal maintenance, which consists of a regular clinical reevaluation, adequate biolm control, and regular oral hygiene instructions, it becomes impossible to maintain the benets achieved by periodontal therapy.1,2 Thus, periodontal maintenance therapy (PMT) is a crucial factor for the success of periodontal treatment.3 According to the American Academy of Periodontology,4 because PMT is an extension of active periodontal therapy, it begins directly after therapy and continues at regular intervals for the entire period in which the teeth remain in the mouth. PMT aims to minimize the recurrence and progression of periodontal disease in individuals who have been treated previously for both gingivitis and periodontitis, to reduce the incidence of tooth loss by monitoring the dentition and prosthetic replacements of the natural teeth, and to increase the probability of periodically locating and treating other diseases and conditions found in the oral cavity.4 During clinical reevaluation of PMT, it is important to analyze the biologic,

doi: 10.1902/jop.2011.110101

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behavioral, and social risk variables related to periodontal disease, such as smoking habits and the presence of biolm and diabetes mellitus.5,6 Nevertheless, the assessment of cultural and socioeconomic variables as possible risk factors for periodontal disease has demonstrated controversial ndings.7-10 These studies have demonstrated that the socioeconomic variables are important risk factors in the development of periodontitis,7,8 but this nding was not corroborated by other studies on the issue.9,10 Although many authors have published epidemiologic studies related to PMT,11-16 the wide range of study designs has impeded us from reproducing them. For example, the literature presents no consensus concerning the diagnostic criteria used to dene periodontal disease. This study is justied considering that many studies use only a retrospective design1,13,14,17-21 and that there are no epidemiologic studies comparing PMT in both academic and private practices. The aim of the present study is to determine and compare periodontal status, periodontitis progression, and tooth loss related to predictable risk variables in a Brazilian sample of individuals found in PMT in both academic and private practices. MATERIALS AND METHODS The present study was previously approved by the Institutional Committee on Research Involving Human Subjects from the University Federal of Minas Gerais (UFMG), Belo Horizonte, Brazil. Study Sample The present study was made up of two open prospective cohorts, each of which consisted of individuals diagnosed with chronic moderate-to-advanced periodontitis (localized and generalized forms), according to the American Academy of Periodontology (Parameter on Chronic Periodontitis with Slight to Moderate and Advanced Loss of Periodontal Support),22,23 who had completed active periodontal treatment. The study population was chosen from a public dental school (UFMG, Belo Horizonte, Brazil), from June 2004 to March 2006, including a total of 138 individuals (academic group [AG)]), and from a private practice (dental clinic in Belo Horizonte, Brazil), from July 2007 to December 2009, with a total of 150 individuals (private group [PG]). Written consent was signed by all study participants. The AG cohort consisted of individuals with an education level of 11th grade and a family income of <3 times the Brazilian minimum salary per month (equivalent to $340). Individuals with an education level >11th grade and a family income of >5 times the Bra302

zilian minimum salary per month were assigned to the PG cohort. The sampling strategy of the AG cohort was described previously by Lorentz et al.5 The AG cohort originally consisted of 250 individuals of whom 150 were complete compliers (100% of cooperation with recall visits). For this comparative study, 12 individuals were excluded, because they had an education level >11th grade and a family income of >3 times the Brazilian minimum salary per month. The PG cohort was originally composed of 238 individuals, and 176 individuals were determined to be complete compliers in the rst year of monitoring. From this group, 150 individuals were chosen by lottery to comprise the sample of the PG. The cooperation rates of the complete compliers for the AG and PG were 60% and 74%, respectively. In this study, individuals are considered regular compliers, according to the criteria proposed by Demirel and Efeodlu,24 after having completed a minimal follow-up time of 12 months. After active periodontal therapy, the maintenance regimens consisted of 3-month intervals, designated as T1, T2, T3, and T4. The average number of days between the quadrimestral recalls was 108 9.8 days for AG and 119 6.5 days for PG. Inclusion Criteria Individuals with good general health who had undergone basic periodontal therapy after non-surgical and/or surgical procedures (preferably Widman modied ap surgery) were recruited and included in the sample. In addition, these individuals presented the following criteria: 1) diagnosis of chronic moderateto-advanced periodontitis, before the active periodontal treatment, with 4 sites with probing depth (PD) 4 mm and clinical attachment level (CAL) 3 mm in different teeth, with bleeding on probing (BOP) and/or suppuration (SUP), and radiographic evidence of bone loss; 2) periodontal therapy completed no more than 4 months before the beginning of the program; and 3) have 14 teeth.5,25 Exclusion Criteria Potential participants were screened for exclusion criteria, including the following: 1) pregnancy or lactating; 2) debilitative diseases that impaired the immune system (such as autoimmune deciency syndrome, cancer, and autoimmune diseases); 3) gingival hyperplasia attributable to the use of immunosuppressive drugs or calcium-channel blockers; 4) antibiotic treatment within 4 months before the beginning of the program or clinical examinations; and 5) irregular compliers. Data Collection Clinical data and personal information were obtained regarding family income, education level, sex, age,

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number of teeth, smoking (smokers/former smokers, report of having smoked >100 cigarettes throughout their lives, and non-smokers26), as well as the presence of diabetes (glucose level >126 mg/dL or taking antiglucose for more than 2 weeks,27 performed in T1 and T4). There was no intention to characterize the sample according to ethnicity because of the difculties in determining race in the Brazilian population.5 Periodontal Clinical Examination A complete periodontal examination (all present teeth were evaluated) was conducted at baseline (previous active periodontal therapy) and recall visits after active periodontal therapy (T1, T2, T3, and T4), evaluating the following clinical parameters: PD, CAL, BOP, plaque index (PI),28 furcation involvement, and SUP from all study populations in four sites per tooth. The full-mouth periodontal examination was performed using manual probes by one previously trained and calibrated examiner (TL) in the AG cohort and by two trained and calibrated examiners (FC and EL) in the PG cohort. Data were recorded for each individual. In addition, participants underwent radiographic examination at the baseline, T1, and T4 to evaluate the periodontal condition. Methodology for data collection and periodontal clinical procedures during all PMT visits were the same as reported by Lorentz et al.5 Periodontal Monitoring At each reevaluation visit (T1, T2, T3, and T4), in both cohorts, the following procedures were performed: 1) interviews, including variables of interest (demographic, biologic, and behavioral), collected and conrmed through questionnaires, paying particular attention to those variables likely to change over time; 2) periodontal assessment through the evaluation of clinical parameters described previously; 3) the application of disclosing agents and oral hygiene instructions, using the Bass technique, interproximal toothbrushes, and dental oss; and 4) mechanical debridement, when appropriate, including coronal prophylaxis and uoride application. All procedures were performed by a trained and calibrated group consisting of three postgraduate students specialized in periodontics, from Federal University of Minas Gerais, and conferred by one specialist and professor in periodontics (TL); in the PG group, periodontal procedures were performed by two specialists in periodontics (FC and EL). Reliability Measurements of PD and CAL were recorded and repeated within a 1-week interval for 12 participants who had been randomly selected from the total sample (N = 288). Data were tested through a non-parametric k test and intraclass correlation. The presence and absence of periodontal alterations (dichotomized) were

determined by a cutoff point of 4 mm.5 In the AG cohort, results showed satisfactory k values for PD and CAL (0.83 and 0.81, respectively; P <0.001). In the T4 sites, measurements of clinical parameters were repeated with another 12 randomly selected participants, and satisfactory k values were again assigned (0.79 for PD and 0.82 for CAL). In both evaluations, intraclass correlation coefcients of 0.82 were attained. For the PG cohort, k values for intra-examiner and inter-examiner and intraclass correlation were made using the same methodology for AG. The results also proved to be >0.84. Inter-examiner agreement between AG and PG for the same clinical parameters were performed and revealed values of k and intraclass correlation >0.86. Determination of Recurrent Sites and Progression of Periodontitis Sites were determined to present retreatment needs if they showed PD 4 mm and CAL 3 mm, together with the presence of BOP and/or SUP, in any of the subsequent recall evaluations.5 Progression of periodontitis was dened as interproximal CAL 3 mm in 2 teeth between two different observation points, according to the Fifth European Workshop of Periodontology.29 In the present study, this denition is adapted to dene progression of periodontitis from T1 to T4. Statistical Analyses Statistical analyses included a characterization of the sample, descriptive, and comparative analysis of variables of interest (tables of frequency, averages, and percentage values), a univariate analysis, and a multivariate logistic regression for the two cohorts. The parametric and non-parametric tests (x2, KruskalWallis, Friedman, Fisher exact, and Mann-Whitney U tests) related to the sample, dependency, or independency of the variables and comparison models were used when appropriate. To avoid spurious significance among multiple comparisons, the Bonferroni correction was used. A logistic regression analysis was performed to investigate the association between the progression of periodontitis and independent predictor risk variables. The regression logistic models were analyzed separately for periodontitis progression and tooth loss. Odds ratio estimates and their condence intervals were calculated and reported. All tests were performed using statistical software. Results were considered signicant if a P value <5% was attained (P <0.05). RESULTS A total of 288 participants were enrolled in this survey. Of these participants,138 individuals (mean
PCP UNC-15, Hu-Friedy, Chicago, IL. SPSS v.14.0, IBM, Chicago, IL.

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age: 44.9 9.5 years) were from the AG (48 males and 90 females) and 150 individuals (mean age: 41.6 10.3 years) were from PG (65 males and 85 females). Table 1 shows the data from all study populations regarding the variables investigated, such as age, sex, marital status, smoking habits, and the presence of diabetes. Periodontal status was represented by PD and CAL values and was stratied in 3 mm, 4 and 5 mm, and 6 mm for all individuals in both programs. The results at baseline (previous active periodontal therapy) are shown in Table 2. It is important to highlight that periodontal status in both cohorts was homogeneous, and there was no statistically signicant differences between PG and AG for any of the clinical parameters evaluated. The periodontal status of the study populations regarding PD, CAL, BOP, and SUP between time points T1, T2, T3, and T4 is shown in Table 3. At T1, higher values of PD 4 to 5 mm and PD 6 mm were observed in AG compared to PG, but at T4, >95% of sites showed PD 3 mm in both groups. It should be noted that from T1 to T4 in both cohorts, a statistically signicant reduction in BOP, SUP, and for PD 4 mm could be observed, thus highlighting the major reduction for PD 6 mm and, as expected, an increase in CAL for values 4 mm. Periodontal progression and periodontal clinic variables from participants with and without progresTable 1.

Characterization of the Sample Regarding Variables of Interest (N = 288)

PG Characteristic Sex Female Male n = 150 85 65 % 57.0 43.0 AG n = 138 90 48 % 65.2 34.8

Age groups (range: 18 to 74 years) 30 years 31 to 40 years 41 to 50 years >50 years Marital status With companion Without companion Smoking Non-smoker Smoker/former smoker Diabetes*
* P = 0.023.

14 42 58 36 112 38 82 68 21

9.3 28.0 38.7 24.0 74.7 25.3 54.7 45.3 14.0

16 33 57 32 83 55 77 61 15

11.6 23.9 41.3 26.6 60.1 39.9 55.7 44.3 10.9

sion in PG and AG, over the 12-month period (from T1 to T4), are shown in Table 4. PG showed 12 cases (8%) of periodontitis progression, whereas AG showed 19 cases (13.9%). Moreover, statistically signicant differences between the two cohorts could be observed. The comparison of the percentage average of sites that presented PD 4 mm, CAL 3 mm, and BOP revealed that participants with periodontitis progression exhibited higher progressive averages of these variables compared to participants who showed no periodontitis progression. In addition, regardless of the occurrence of periodontitis progression, AG showed higher averages for PD and BOP and less reductions in CAL from T1 to T4 when compared to PG (P <0.023). During the active periodontal treatment phase, from baseline to T1, 61 teeth in PG cohort and 97 teeth in AG were lost. During the 12-month monitoring period (from T1 to T4), AG lost signicantly more teeth (n = 46) than PG (n = 22) (P <0.0016). In both instances, the main reason for tooth loss was periodontal involvement (AG, n = 34 teeth; PG, n = 18 teeth). Univariate analysis for the association between independent variables and periodontitis progression, during the 12-month monitoring period, is shown in Table 5. For PG, the variables signicantly associated with progression of periodontitis were diabetes and smoking (P = 0.021 and P = 0.018, respectively). For AG, none of the independent variables showed any association with periodontitis progression (P >0.05). Regarding tooth loss, univariate analysis showed statistically signicant differences for AG only for PD 4 to 6 mm in 10% of the sites, and, for PG, smoking, diabetes, and BOP in >30% of the sites (data not shown; P <0.005). For the PG, the nal multivariate logistic regression models (Table 6) showed that smoking, >30% of the sites with BOP, and diabetes were considered risk variables for periodontitis progression. For the AG program, in contrast, only smoking was considered. For tooth loss, the following variables were retained in the multivariate models as signicant variables: the PG presented PD 4 to 6 mm in 10% of the sites, smoking, and diabetes, whereas the AG presented only PD 4 to 6 mm in 10% of the sites. DISCUSSION For decades, studies1-3,5,13,15,17 have shown that adequate periodontal therapy clearly includes an appropriate maintenance program. Therefore, authors have published epidemiologic studies regarding PMT; however, these studies have mainly presented only retrospective designs.1,5,11,13,14,17-21,24 To date, there are no known epidemiologic studies comparing PMT in both academic and private practices. Considering this fact, the present investigation aims to develop

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Table 2.

Periodontal Status at Baseline for PG and AG

PG (n = 150) Periodontal Parameters Sites with BOP PD 3 mm 4 to 5 mm 6 mm CAL 3 mm 4 to 5 mm 6 mm SUP
NS = not signicant.

AG (n = 138) % 71.4 70.6 22.3 7.1 45.3 31.0 23.7 10.2 Sites (n = 12,844) 9,700 8,807 3,442 949 5,946 4,720 2,694 1,371 % 75.5 68.6 26.8 4.6 NS 46.3 36.7 17.0 10.7 NS P NS NS

Sites (n = 14,824) 10,584 10,466 3,252 1,106 6,716 4,595 3,513 1,512

a prospective study comparing the periodontal status, periodontitis progression, and tooth loss related to predictable risk variables in Brazilian participants. In the present study, it is important to emphasize that both cohorts were homogeneous regarding the variables such as sex, marital status, and smoking, which in turn facilitates comparisons among the variables and allows one to deduce that differences in results can be associated with the dissimilar characteristics found within the cohorts, such as education level, socioeconomic status, and public or private program. This consideration is important to minimize bias related to different samples. Thus, the increase in disparities attributable to socioeconomic inequalities can directly inuence health programs as has been reported for years. Studies report that individuals with low socioeconomic levels show worse health indices than do individuals with high socioeconomic levels.30,31 Additionally, some research has shown an association between socioeconomic indicators and periodontal health;31-33 however, there is a lack of evidence in the literature of comparative studies to properly evaluate the impact of socioeconomic and cultural variables on periodontitis progression and PMT programs. In the present study, family income and education level were methodologically very different between the two cohorts. AG showed a family income and an education level of lower than the PG cohort. Because, at the baseline, the periodontal status within the two groups was very similar, it can be hypothetically deduced that the differences observed between the cohorts, regarding education and socioeconomic levels, may well be a determining factor in the reported differences in periodontitis progression and tooth loss.

Studies reported that socioeconomic levels are risk indicators for periodontal disease.8,34,35 Additionally, a higher education level, and thus a better socioeconomic condition, may well have inuenced the rate of compliance to the maintenance program, which can be observed by the higher rates of compliance among PG individuals (74%) when compared to AG individuals (60%). Similar results were reported in studies conducted in a private practice and observed higher compliance rates among participants with high education levels.12,13 The recall interval is another discussion point in the literature. In the present study, the recalls are at 3-month recall periods. The American Academy of Periodontology36 proposed that the frequency of recalls, for individuals with a previous history of periodontitis, may be based on particular necessities. Evaluating these individuals four times per year is appropriate, but it is notable that this schedule is very difcult to establish in clinical practice. The present study reveals a gradual reduction in PI within the PG cohort (Table 4). Similar to that reported by Hugosson and Laurell,37 an increase in the T4 period in the AG cohort, for the same parameter, could also be observed. A similar result in the AG cohort was reported in previous studies that investigated the importance of motivation for oral hygiene, considering that individuals have difculty maintaining new habits over time.14,38 Hypothetically, it can be deduced that lower values of PI and BOP, when monitoring the PG cohort, can be associated with high education levels and individual motivation. An interesting result was also observed in our population study regarding the PD between time
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points T1 to T4. Both cohorts showed a signicant reduction in PD between T1 and T4. The AG cohort, compared to the PG cohort, showed signicantly higher PD averages between T1 and T4 (Table 3). These results are in accordance with previous studies.5,20,38 All the participants, from both cohorts, were regular compliers nig to PMT and, according to Ko et al.,18 participants similar to those in our study demonstrated low PD values during the maintenance period. Both cohorts showed low rates of periodontitis progression. These results are in agreement with previous studies.1,2,37,39 Although our results did show a lower level of decrease in periodontal disease progression between T1 and T4 for both cohorts (Table 4) when compared to ndings from Miyamoto et al.15 and Fisher et al.,16 it could be inferred that the low periodontitis progression in PG may in fact be associated with specic characteristics of this cohort, such as high education and socioeconomic levels. The differences between the two groups, regarding the professionals, academics, and specialists in both public and private programs, do not seem to have caused this result, given that all procedures in AG were supervised by a professor and specialist in periodontics. In both cohorts, all professionals were trained as described previously. Data from the present study are in agreement with Leung et al.20 regarding the prevalence of diabetes mellitus in both populations (PG and AG). In the PG cohort, diabetes proved to be associated with periodontitis progression (P = 0.021). In addition, the nal multivariate logistic regression model (P >0.05) revealed that patients with diabetes, compared to those patients without diabetes, had a 3.7 times greater chance of periodontitis progression (Table 6). The fact that diabetes mellitus can affect periodontal disease progression serves to reafrm that the factors related to the susceptibility of the host should be carefully monitored during periodontal

306

Comparisons between PG and AG in T1 followed by capital letters (A,B) are signicantly different (P <0.05). Comparisons between PG and AG in T4 followed by lowercase letters (a,b) are signicantly different (P <0.05). Multiple comparisons adjusted by Bonferroni correction (P <0.008).

Sites (n = 14,580) Sites (n = 12,487) Sites (n = 14,536) Sites (n = 12,463) Sites (n = 14,508) Sites (n = 12,373) Sites (n = 14,492) Sites (n = 12,313)

69.3a 22.7b 8.0b

68.4b 31.6b 58.0a 42.0a 8,405 6,087 63.5 36.5 59.8 40.4 56.2 43.8 62.8 38.2 46.6A 53.4A 45.6A 54.4A BOP No Yes 6,648 7,932 5,824 7,260 9,129 5,407 7,010 5,453 8,676 5,862 7,855 4,518 8,427 3,886

95.6a 4.0a 0.4a

AG

11,774 503 36

T4

96.6a 3.1a 0.3a

70.a 18.2a 11.2a

PG

13,999 449 44

10,231 2,638 1,623

95.2 4.5 0.3

AG

11,772 560 41

T3

96.0 3.8 0.2

70.4 17.0 12.6

Periodontal Status of the Sample at Recalls T1, T2, T3, and T4 (N = 288)

PG

13,928 551 29

10,214 2,466 1,828

94.0 5.4 0.6

66.6 24.9 8.5

AG

11,724 669 70

T2

95.1 4.5 0.3

71.6 18.7 9.7

PG

13,824 667 44

61.5B 27.3A 11.2B

88.4A 9.1B 2.5B

AG

11,044 1,132 311

T1

92.6A 6.0A 1.4A

66.2A 25.8A 9.0A

PG

13,501 875 204

Periodontal Parameters

PD 3 mm 4 to 5 mm 6 mm

Table 3.

CAL 3 mm 4 to 5 mm 6 mm

SUP No Yes

14,347 233

9,652 3,761 1,167

98.4A 1.2A

12,250 225

7,676 3,412 1,399

98.1A 1.9A

14,507 29

10,408 2,718 1,410

99.8 0.2

12,405 58

8,299 3,107 1,057

99.5 0.5

14,494 17

99.9 0.1

12,338 35

8,371 2,942 1,060

99.7 0.3

67.7 23.7 8.6

14,507 29

99.8a 0.2a

12,285 28

8,526 2,799 988

99.8a 0.2a

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treatment, in both the active and maintenance phases. However, the AG did not support this association, which, hypothetically, may well be related to the low number of patients with diabetes in this cohort or to the fact that the PMT program played a benecial role in an important risk variable. Several studies have shown that smoking increases the risk for attachment and tooth loss and that smokers react less favorably to all types of periodontal treatment. In addition, smokers many times show less improvement in PD and clinical attachment.24,33,38 In the present study, smoking was also considered an important risk variable in both cohorts, presenting odds ratios of 3.1 and 2.68 for PG and AG, respectively (Table 6). Similar results were reported in previous studies.29,38 Fisher et al.16 over a 3-year period assessed smokers and non-smokers in a PMT, regarding PD, CAL, BOP, PI and tooth loss, and found no signicant differences in disease progression. However, it is important to emphasize that the sample of this study was rather small, which may well have contributed to this result. At the baseline of the present study, the mean number of teeth per participant was 24.7 (PG) and 23.8 (AG). During the period between the baseline and T4, 68 teeth were lost (52 were for periodontal reasons, 76.4%), which corresponds to an average of 0.18 teeth per participant in 1 year. This nding is similar to that reported previously.1,17,18,33 However, most studies in the literature reported higher results, varying from 0.36 to 0.5 teeth per participant.11,18,40 In both programs, the main reason for tooth loss was periodontal involvement (AG, n = 34 teeth; PG, n = 18 teeth). Furthermore, AG lost signicantly more teeth than did PG. In this light, it can be suggested that tooth retention may well be related to the differences between the two cohorts regarding low rates of periodontitis progression, periodontal condition from T1 to T4, better compliance, as well as high education and socioeconomic levels. Some studies in the literature report on this issue. Some key studies
307

Friedman test: comparisons between PG and AG in T1 followed by capital letters (A,B) are signicantly different (P <0.05); comparisons between PG and AG in T4 followed by lowercase letters (a,b) are signicantly different (P <0.05). Multiple comparisons adjusted by Bonferroni correction (P <0.004). * Mean SD percentage of affected sites.

28.1 14.2a 31.9 12.8b

Clinical Periodontal Variables From T1 to T4 in Participants With (Yes) and Without (No) Periodontitis Progression

3.56 4.1a 8.7 5.5a

T4

29.3 13.6a 34.6 11.6a

33.1 14.3 35.9 14.4

T3

32.6 12.4 39.7 12.8

41.5 16.3 42.8 14.4

T2

38.7 17.4 42.4 13.2

51.0 19.2B 56.1 19,8B

10.1 9.4B 13.2 8.4A

12.1 9.1A 14.0 9.3A

T1

38.7 16.7A 66.2 19.3A

AG (n = 138)

11.3 8.1A 13.6 8.3A

119 19 138 12 SUP* No Yes

119 19

119 19

Subjects (N)

PG (n = 150)

119 19

138 12

138 12

138 12

Clinical Variables

Table 4.

CAL 3 mm* No Yes

PD 4 mm* No Yes

BOP* No Yes

Plaque Index (%) No Yes

138 12

119 19

52.1 17.7A 58.9 18.6A

7.6 8.3A 12.1 8.9A

0.9 1.8A 3.1 2.7A

PG

65.2 19.4B 66.2 18.1A

1.5 3.0B 2.2 2.3B

AG

41.3 17.7 53.7 16.2

4.9 8.3 6.3 6.1

5.9 7.8 7.3 5.2

0.3 0.9 0.5 1.1

PG

55.1 19.8 51.2 17.5

5.1 6.2 7.3 4.1

6.0 6.9 8.1 4.9

0.4 1.2 0.7 0.8

AG

35.2 18.5 52.9 15.3

4.5 5.6 6.1 4.2

6.0 5.3 7.8 5.2

0.2 0.4 0.3 0.7

PG

51.9 20.6 42.2 13.2

4.1 5.0 7.6 4.4

5.9 6.4 8.1 5.8

0.2 0.7 0.4 0.2

AG

33.4 15.7a 49.1 14.2a

4.7 4.1a 5.2 4.3a

6.1 4.8a 8.4 6.1a

0.1 0.5a 0.4 0.7a

PG

50.3 19.1b 47.4 18.2b

5.2 4.7a 9.1 6.6a

0.2 0.7a 0.5 1.2b

AG

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Table 5.

Association Among Independent Variables and Periodontitis Progression (From T1 to T4)

Periodontitis Progression PG No Variables Number of Subjects Sex Female Male Age groups (years) 30 31 to 40 41 to 50 >50 Diabetes No Yes Marital status With companion Without companion Smoking Non-smoker Smoker/former smoker Alcohol consumption No Yes Total n 135 91 44 15 30 55 35 123 12 82 53 85 40 36 99 135 % 90.0 91.9 86.3 93.8 90.1 90.1 87.5 92.5 70.5 90.1 89.8 95.5 98.0 92.3 89.1 n 15 8 7 1 3 6 5 10 5 9 6 4 11 3 12 15 Yes % 10.0 8.1 13.7 6.2 9.9 9.9 12.5 7.5 29.5 9.9 10.2 4.5 2.0 7.7 10.9 Total 150 99 51 16 33 61 40 133 17 91 59 89 51 39 111 150 0.75* P n 119 77 42 16 29 49 25 105 14 77 42 74 45 59 60 119 No % 86.2 85.5 87.5 100.0 87.9 85.9 78.1 86.1 87.5 85.5 87.5 91.4 78.9 88.0 84.5 86.2 n 19 13 6 0 4 8 7 17 2 13 6 7 12 8 11 19 AG Yes % 13.8 14.5 12.5 0.0 12.1 14.1 21.8 13.9 12.5 14.5 12.5 8.6 21.1 12.0 15.5 13.8 Total 138 90 48 16 33 57 32 122 16 90 48 81 57 67 71 138 0.68* P

0.67

0.40

0.02

1.00

0.23*

0.16*

0.02

0.06*

0.66*

0.44*

Signicant P values are shown in bold. 2 * x test. Fisher exact test. Mann-Whitney U test.

afrm these suppositions. According to Checchi et al.,14 erratic compliers to PMT have a 5.6 times greater chance of tooth loss compared to regular compliers. In addition, the PG cohort in the present study shows tooth loss related to classic risk variables. For example, smoking, a PD of 4 to 6 mm in 10% of the sites, and diabetes had, in this cohort, a 3 times to 5 times greater chance of tooth loss, whereas in the AG cohort, participants with a PD of 4 to 6 mm in 10% of the sites showed a 5 times greater chance of tooth loss (Table 6). Novaes et al.41 reported that cultural and economic factors and different modalities of treatment proposed by the different professionals may well affect tooth retention. Leung et al.20 observed a relation between tooth loss and lower education levels. Some studies report that
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age (>60 years) and smoking have a negative inuence on tooth loss.14,18 However, the tooth loss observed in the present study is lower than that reported in previous studies and reects the importance of PMT regarding the maintenance of periodontal health and the reduction of tooth mortality over time.5,18,42 It is important to emphasize once again that, to our knowledge, there are no previous studies with a methodology that is similar to that of the present study, which evaluated and compared participants in PMT academic and private practices, with different socioeconomic and cultural characteristics. Studies have referred to only one, public or private program, to a specialized practice,40 or to those which compare specialized and clinical practices.38 Hence, it is to highlight that, although the

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Table 6.

Final Multivariate Logistic Regression Model for Periodontitis Progression and Tooth Loss (From T1 to T4)
Logistic Models Periodontitis progression Final model: PG Smoking BOP >30% of sites Diabetes Constant Final model: AG Smoking Constant Tooth loss Final model: PG Smoking Diabetes PD 4 to 6 mm in 10% of sites Constant Final model: AG PD 4 to 6 mm in 10% of sites Constant 1.73 1.59 1.23 -1.81 1.6310 -3.71 4.03 4.27 3.78 30.42 12.30 24.01 0.021 0.0042 0.028 0.000 0.0003 0.000 3.1 5.1 3.6 0.010 5.01 0.030 1.98 1.13 1.23 11.6 9.3 7.29 1.03 1.31 1.71 -2.21 0.97 -3.41 4.27 4.73 5.27 33.72 3.91 25.58 0.0036 0.047 0.0028 0.000 0.047 0.000 3.1 4.2 3.7 0.012 2.68 0.033 1.05 1.46 1.65 8.61 13.7 11.3 Coefcient Wald P Valor Odds Ratio Lower Limit Upper Limit

1.03

7.42

2.14

12.80

majority of the studies on PMT contain a retrospective design, prospective studies tend to produce an even greater impact, because retrospective designs, when compared to prospective studies, can generate greater bias in their results. However, a limitation of our study is the observation time (1 year) requiring studies with larger follow up and use of different criteria for progression of periodontitis to conrm these ndings. CONCLUSIONS The present study highlighted a considerable improvement in clinical periodontal parameters, with low rates of periodontitis progression and a reduction in tooth mortality, in the majority of participants in both cohorts over 1 year. However, PG showed signicantly less progression of periodontitis and tooth loss compared to AG. The differences between the two cohorts show that biologic, behavioral, and socioeconomic variables can inuence periodontitis progression and tooth loss. These variables, therefore, should be considered when determining the risk variables for PMT programs. Furthermore, PMT programs may also produce a direct inuence in minimizing or neutralizing the inuence of predictable risk variables, thus promoting an efcient management of individuals who are susceptible to periodontal problems.

ACKNOWLEDGMENTS Financial support was obtained from National Council for Scientic and Technological Development (CNPq) Grant #471616/2007-9. Dr. Costa is a research fellow at CNPq. The authors report no conicts of interest related to this study. REFERENCES
1. Tonetti MS, Steffen P, Muller-Campanile V, Suvan J, Lang NP. Initial extractions and tooth loss during supportive care in a periodontal population seeking comprehensive care. J Clin Periodontol 2000;27: 824-831. m B, Lindhe J. The long-term effect 2. Axelsson P, Nystro of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. J Clin Periodontol 2004;31: 749-757. 3. Shumaker ND, Metcalf BT, Toscano NT, Holtzclaw DJ. Periodontal and periimplant maintenance: A critical factor in long-term treatment success. Compend Contin Educ Dent 2009;30:388-390, 392, 394 passim, quiz 407, 418. 4. American Academy of Periodontology. Parameter on periodontal maintenance. J Periodontol 2000; 71(Suppl. 5):849-850. 5. Lorentz TC, Cota LO, Cortelli JR, Vargas AM, Costa FO. Prospective study of complier individuals under periodontal maintenance therapy: Analysis of clinical periodontal parameters, risk predictors and the 309

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6.

7. 8. 9. 10. 11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

progression of periodontitis. J Clin Periodontol 2009; 36:58-67. tzle M, Faddy MJ, Cullinan MP, et al. The clinical Scha course of chronic periodontitis. V. Predictive factors in periodontal disease. J Clin Periodontol 2009;36: 365-371. Brown LJ, Garcia R. Utilization of dental services as a risk factor for periodontitis. J Periodontol 1994; 65(Suppl. 5)551-563. Elter JR, Beck JD, Slade GD, Offenbacher S. Etiologic models for incident periodontal attachment loss in older adults. J Clin Periodontol 1999;26:113-123. Moore PA, Weyant RJ, Mongelluzzo MB, et al. Type 1 diabetes mellitus and oral health: Assessment of periodontal disease. J Periodontol 1999;70:409-417. Klinge B, Norlund A. A socio-economic perspective on periodontal diseases: A systematic review. J Clin Periodontol 2005;32(Suppl. 6):314-325. nig J, Dzierzon U, Sawaf H, Plagmann Kocher T, Ko HC. Disease progression in periodontally treated and untreated patientsa retrospective study. J Clin Periodontol 2000;27:866-872. Wilson TG Jr., Hale S, Temple R. The results of efforts to improve compliance with supportive periodontal treatment in a private practice. J Periodontol 1993;64: 311-314. Demetriou N, Tsami-Pandi A, Parashis A. Compliance with supportive periodontal treatment in private periodontal practice. A 14-year retrospective study. J Periodontol 1995;66:145-149. Checchi L, Montevecchi M, Gatto MR, Trombelli L. Retrospective study of tooth loss in 92 treated periodontal patients. J Clin Periodontol 2002;29: 651-656. Miyamoto T, Kumagai T, Jones JA, Van Dyke TE, Nunn ME. Compliance as a prognostic indicator: retrospective study of 505 patients treated and maintained for 15 years. J Periodontol 2006;77:223-232. Fisher S, Kells L, Picard JP, et al. Progression of periodontal disease in a maintenance population of smokers and non-smokers: A 3-year longitudinal study. J Periodontol 2008;79:461-468. Wood WR, Greco GW, McFall WT Jr. Tooth loss in patients with moderate periodontitis after treatment and long-term maintenance care. J Periodontol 1989; 60:516-520. nig J, Plagmann HC, Langenfeld N, Kocher T. Ko Retrospective comparison of clinical variables between compliant and non-compliant patients. J Clin Periodontol 2001;28:227-232. Chambrone LA, Chambrone L. Tooth loss in wellmaintained patients with chronic periodontitis during long-term supportive therapy in Brazil. J Clin Periodontol 2006;33:759-764. Leung WK, Ng DK, Jin L, Corbet EF. Tooth loss in treated periodontitis patients responsible for their supportive care arrangements. J Clin Periodontol 2006;33:265-275. Carnevale G, Cairo F, Tonetti MS. Long-term effects of supportive therapy in periodontal patients treated with bre retention osseous resective surgery. I. Recurrence of pockets, bleeding on probing and tooth loss. J Clin Periodontol 2007;34:334-341. American Academy of Periodontology. Parameter on chronic periodontitis with slight to moderate loss of periodontal support. J Periodontol 2000;71:853-855.

23. American Academy of Periodontology. Parameter on chronic periodontitis with advanced loss of periodontal support. J Periodontol 2000;71:856-858. 24. Demirel K, Efeodlu A. Retrospective evaluation of patient compliance with supportive periodontal treatment. J Nihon Univ Sch Dent 1995;37:131-137. 25. Papantonopoulos GH. Effect of periodontal therapy in smokers and non-smokers with advanced periodontal disease: Results after maintenance therapy for a minimum of 5 years. J Periodontol 2004;75: 839-843. 26. Tomar SL, Asma S. Smoking-attributable periodontitis in the United States: Findings from NHANES III. National Health and Nutritional Examination Survey. J Periodontol 2000;71:743-751. 27. American Diabetes Association. Diagnosis and classication of diabetes mellitus. Position statement. Diabetes Care 2005;28(Suppl. 1):S37-S42. e H. Periodontal disease in pregnancy. II. 28. Silness J, Lo Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:121-135. 29. Tonetti MS, Claffey N; European Workshop in Periodontology Group C. Advances in the progression of periodontitis and proposal of denitions of a periodontitis case and disease progression for use in risk factor research. Group C consensus report of the 5th European Workshop in Periodontology. J Clin Periodontol 2005;32(Suppl. 6):210-213. 30. Williams SA, Godson JH, Ahmed IA. Dentists perceptions of difculties encountered in providing dental care for British Asians. Community Dent Health 1995; 12:30-34. 31. Borrell LN, Burt BA, Warren RC, Neighbors HW. The role of individual and neighborhood social factors on periodontitis: The Third National Health and Nutrition Examination Survey. J Periodontol 2006;77:444-453. e H. Periodontal diseases in the 32. Oliver RC, Brown LJ, Lo United States population. J Periodontol 1998;69:269-278. 33. Costa FO, Cota, LO, Lages, EJ et al. Progression of periodontitis in a sample of regular and irregular compliers under maintenance therapy: A 3-year follow-up study. J Periodontol 2011;82:1279-1287. 34. Drury TF, Garcia I, Adesanya M. Socioeconomic disparities in adult oral health in the United States. Ann N Y Acad Sci 1999;896:322-324. 35. Craig RG, Boylan R, Yip J, et al. Prevalence and risk indicators for destructive periodontal diseases in 3 urban American minority populations. J Clin Periodontol 2001;28:524-535. 36. American Academy of Periodontology. Periodontal maintenance (position paper). J Periodontol 2003; 74:1395-1401. 37. Hugosson A, Laurell L. A prospective longitudinal study on periodontal bone height changes in a Swedish population. J Clin Periodontol 2000;27:665-674. 38. Preshaw PM, Heasman PA. Periodontal maintenance in a specialist periodontal clinic and in general dental practice. J Clin Periodontol 2005;32:280-286. m MK, Socransky SS, 39. Rosling B, Serino G, Hellstro Lindhe J. Longitudinal periodontal tissue alterations during supportive therapy. Findings from subjects with normal and high susceptibility to periodontal disease. J Clin Periodontol 2001;28:241-249. 40. Fardal O, Johannessen AC, Linden GJ. Tooth loss during maintenance following periodontal treatment in a periodontal practice in Norway. J Clin Periodontol 2004;31:550-555.

310

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41. Novaes AB Jr., Novaes AB, Bustamanti A, Villavicencio JJ, Muller E, Pulido J. Supportive periodontal therapy in South America. A retrospective multipractice study on compliance. J Periodontol 1999; 70:301-306. 42. Fardal O. Interviews and assessments of returning non-compliant periodontal maintenance patients. J Clin Periodontol 2006;33:216-220.

Correspondence: Fernando Oliveira Costa, Department of nio Periodontology, Federal University of Minas Gerais, Anto Carlos Avenue, 6627, Pampulha, PO Box 359, Belo Horizonte, 31270-901, MG, Brazil. Fax: 55-31-3282-6787; e-mail: focperio@uol.com.br. Submitted February 18, 2011; accepted for publication June 25, 2011.

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