Maintenance Therapy/Necessary
for Long-Term Success
8.1
Introduction
8.1.1
175
176
8.2
Getting Started
8.2.1
High-Risk Patients
Diabetic patients
Smokers
Pregnant patients
Sjogrens patients
Head and neck cancer patients
Patients who take medications that compromise salivary flow
Patients who carry polymorphism of interleukin-1 genotype
8.3
Treatment Principles
Regarding the Prevention
of Gingivitis
and Periodontitis
8.4
8.4
Basic Features
of a Structured Maintenance
Therapy Program
177
The maintenance therapy program is a proactive program that aims at preventing occurrence
of new dental disease (caries and periodontal disease) and recurrence of previously treated dental
disease. The objectives of the maintenance therapy appointment are essentially threefold in
nature:
1. Complete assessment of the present conditions and then compare with past records
does the new data suggest stability of
attachment levels or not?
2. Review motivational needs of each patient as
they pertain to helping them sustain their dedication to high standards of plaque control.
3. Make further recommendations that are essential to promoting dental and periodontal
health.
8.4.1
178
8.5
1. Review medical history and update as necessary: for example, list all new medications,
dosages, and reasons for taking such; list any
recent hospitalizations and reasons for such;
take a new blood pressure reading and record;
determine level of diabetic control; determine status of smoking cessation efforts; and
determine if any new medications are reducing salivary flow or if they have the potential
to cause gingival enlargement.
2. Complete the extraoral and intraoral examination for pathology of skin, lymph nodes,
and oral mucosa.
3. Perform periodontal examination and rechart
findings.
(a) Assess mobility, probing depths, bleeding upon gentle probing, color, size, consistency, and position of the gingival
margin.
(b) Evaluate occlusal relations; determine if
there is fremitus or evidence of bruxism.
Determine if there is evidence of increasing mobility patterns.
(c) State the new periodontal diagnosis.
(d) Assess stability of attachment levels.
(e) Outline any new recommendations that
will foster periodontal health, including
a referral to a periodontal specialist.
8.6
Implant Maintenance
179
8.6
Implant Maintenance
8.6.1
8.6.2
8.6.2.1 Parameters
Presence of plaque and/or calculus
Appearance of the peri-implant tissue; signs of
inflammation such as bleeding or purulent exudate
Radiographic appearance
Probing depths
Patient comfort
Maintenance/re-care interval
180
8.6
Implant Maintenance
181
8.6.3
Instrumentation of Dental
Implants
healing. Peri-implant mucositis may be identified clinically by erythema and bleeding upon
probing and/or suppuration (Fig. 8.4).
Peri-implantitis: an inflammatory process
around an implant that exhibits both soft tissue inflammation and progressive loss of
bone beyond the initial bone remodeling
(Fig. 8.5).
182
8.6
Implant Maintenance
183
8.6.4
184
The oral irrigator can be a beneficial adjunct for biofilm removal around implants. One study showed
that an oral irrigator was more effective than floss in
interproximal plaque removal. However, patients
should be instructed not to use excessive water pressure. The flow of irrigation should be aimed to pass
through contact and should not be directed into tissue. An oral rinse containing chlorhexidine gluconate may be used as an irrigant.
8.7
185
8.7
Knowing Your
Diagnostic Goals
186
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
8.8
The ultimate goal of periodontal therapy is to stabilize attachment levels over time, so that patients
can enjoy the physical and psychological advantages of their natural dentitions. From a practical,
clinical point of view, the only treatment method
that has proven effective is the prudent application and juxtaposition of nonsurgical, surgical,
and maintenance therapies:
The selection of the surgical alternative in the treatment of a periodontal lesion imposes a special
responsibility on the operator. The creation of a new
wound in a human being, in the attempt to abort a
disease process, cannot and should not be taken
lightly. The drama, the vicarious thrill of a well-executed surgical procedure with its rewards of ego satisfaction, patient admiration, respect and financial gain
all too often may tip the balance of the scales in
weighing the treatment perogatives. Periodontal surgery, per se, cannot be equated with periodontal therapy. Perhaps no treatment method in dentistry has
been more misunderstood and misapplied than periodontal surgery. The expectation that the excision of
diseased gingival tissue will, in itself, cure periodontal disease is a delusion. Although some temporary
respite of the disease process may occur through the
elimination of diseased gingival tissues, one can
expect a reappearance of the disease unless periodontal surgery is properly placed in the treatment triad of
pre-surgical (environmental) periodontics, periodontal surgery and post-surgical periodontics.
Periodontal surgery is only one facet of a much
larger and extremely pertinent therapeutic regimen
and, unless one is prepared to place periodontal
surgery in its proper perspective, he/she must be
prepared for surgical failures.
Dr. Gerald M. Kramer (1972)
8.9
Knowing the Psychological Difficulties Associated with the Maintenance Therapy Program
own desire, attitude, and effort. Periodontal disease is essentially a surface infection caused by
bacterial colonization of the non-shedding tooth
surfaces. The entire inflammatory response,
which is so essential for life, and which has
evolved as a protective mechanism over millions
and millions of years, can be, if one chooses, strategically obviated, if the patient is willing and
able to take diligent control of the oral environment. The patients attitude and desire to achieve
periodontal health must be translated into sustained and fastidious plaque control measures.
If the anatomical consequences of past episodes of periodontitis are not too severe, the clinician, in many cases, will realize the possibility
of achieving a new status of clinical health, albeit
on an anatomically reduced periodontium. The
bone tissue lost in the past, cannot be substantially reformed; it is more or less a permanent
anatomical changea residual anatomical scar
sustained after many years of persistent and
sometimes recurrent episodes of the surface
infection called periodontitis. Periodontitis is not
a systemic disease from an etiologic point of
view or from a therapeutic point of view; only
local factors initiate the infection and only the
meticulous mechanical removal of local factors
can be used to treat the infection.
Teeth in perfect polish do not illicit an inflammatory response
John M. Riggs (1867)
8.9
187
Personal involvement in the maintenance therapy program also gives the clinician a special
188
8.10
Understanding Anatomic
Realities: The Degree
of Attachment Loss
and the Presence of Pockets
The management of severe periodontitis is surprisingly not difficult for the clinician, in terms
of the treatment plan and its execution; it involves
easy extractions of relatively loose teeth. For the
patient, the treatment may be more challengingit involves either edentulism or the adjust-
8.10 Understanding Anatomic Realities: The Degree of Attachment Loss and the Presence of Pockets
plane, or file--- into the pocket and bringing it to
bear on the surface of the root in such a way as to
remove anything of a foreign or septic nature that
may be upon it, leaving a smooth and polished surface. In pockets that are accessible and not too
deep, excellent results are obtained in this way.
Many still regard it as the operation of choice.
It is, however, a difficult operation. To remove
from a surface that cannot be seen whatever there
may be upon it of a foreign nature is always an
uncertain and in some instances an impossible
operation. It has, moreover, another disadvantage.
Unless reattachment occurs, which is the exception
and not the rule, the pocket will continue, with the
possibility of reinfection later. In non-cooperative
patients and those not under constant supervision,
this is a situation which needs to be seriously considered in deciding what form of treatment should
be undertaken in a given case. It is this uncertainty
in cases fairly well advanced that has caused those
engaged in the practice of periodontia to consider
the possibilities of surgery.
Dr. Arthur Hastings Merritt President A.D.A. (1942)
189
8.11
190
8.12
8.12
191
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