Maintenance phase

Maintenance Phase (Supportive Periodontal Treatment)

IMPORTANCE OF MAINTENANCE PHASE
Chronic periodontitis, like most other chronic infections require supervision and maintenance overtime. Maintenance therapy after active treatment includes not only the care that patients receive through personal oral hygiene but also by the recall visits and re-evaluations done by the dental team. Maintenance therapy is often supportive in nature hence, it is also known as supportive periodontal treatment (SPT). In this phase, patients must be made to understand the purpose of a maintenance program, and the dentist must emphasize on the fact that the preservation of the teeth in question are dependent on it.

RATIONALE FOR SUPPORTIVE PERIODONTAL THERAPY

Rationale for maintenance phase is to prevent or minimize the recurrence of periodontal diseases by controlling factors known to contribute to the disease process.
The main aim of long-term therapy is to provide supervised control for the patient in order to maintain a healthy and functional, natural dentition for life. It is only with proper maintenance, including early detection and treatment of recurrent periodontal diseases that such an objective can be achieved.

CAUSES FOR RECURRENCE OF PERIODONTAL DISEASE

Incomplete subgingival plaque removal.
Nature of dentogingival unit.
Improper restorations placed after the periodontal treatment was completed.
Failure of the patient to return for periodic recall visits.
Presence of some systemic diseases that may affect host resistance to previously acceptable levels of plaque.

The American Academy of Periodontology position paper more specifically lists 3 main goals of SPT:
1. To prevent or rminimize the recurrence and progression of periodontal disease in patients who have been previously treated for gingivitis, periodontitis and for peri-implantitis.
To prevent or reduce the incidence of tooth loss by monitoring the dentition and by any prosthetic replacement of the natural teeth.
To increase the probability and treating in a timely manner, other diseases or conditions found in the oral cavity
OBJECTIVES OF MAINTENANCE PHASE
Preservation of alveolar bone support (radio-graphically).
Maintenance of stable, clinical attachment level.
Reinforcement and re-evaluation of proper home care.
Maintenance of a healthy and functional oral environment.
PARTS OF MAINTENANCE PHASE
Part-I: Examination (Approximate time -17 Min.)
Medical history changes
Oral pathological examination
Oral hygiene status
Gingival changes
Pocket depth changes
Mobility changes
Occlusal changes
Dental caries
Restorative and prosthetic changes.


Part—II: Treatment (Approximate time - 35 Min.)
Oral hygiene reinforcement
Scaling and polishing
Chemical irrigation.

Part-Ill: Schedule Next Procedure (Approximate time - 1 Min.)

Schedule next recall visit
Schedule further periodontal treatment
Schedule or refers to restorative or prosthetic treatment.

Incorrect sequence of periodontal treatment phases (chart 1)

Emergency phase
Phase I
Re-evaluation
Phase II (Periodontal surgery)
Phase III (Restorative)
Phase IV (Maintenance)
Correct sequence of periodontal treatment phases (chart 2)
Emergency phase
Phase I
Re-evaluation
Phase IV (Maintenance)


Phase II Phase1ll
(Periodontal surgery) (Restorative surgery)

Sequence of Maintenance Visits

Incorrect sequence of periodontal treatment phases ( chart 1).
Correct sequence of periodontal treatment phases ( chart 2).

Schallhorn and Snider(1981) proposed four separate categories of periodontal maintenance therapy. They are:
Preventive maintenance therapy—periodontally-healthy individuals.
Trial maintenance therapy—mild to moderate periodontitis.
Compromised maintenance therapy—medically-compromised patients where active therapy is not possible.
4. Post-maintenance treatment therapy—maintenance for prevention of recurrence of disease.

DETERMINATION OF MAINTENANCE RECALL INTERVALS

Based on studies of human periodontal treatment, it is recommended that the patient be seen initially for recall treatment 2 to 4 weeks following treatment (for transitional procedures). After 3 or 4 such sessions the interval can be extended to 3 months, but may be varied according to the patient's needs.
Following factors may be considered in determining the recall intervals:
Severity of disease: The more severe the disease, the more frequently the patient is recalled.
Effectiveness of home care: Good home care decreases the frequency of recall.
Degree of control of inflammation achieved: As the tissue regain the total health, the frequency decreases.

Procedure

At clinical
Examination


Radiographically
Assessmentof disease
Assessmentof patients oral hygiene
Treatment
Procedures to be Performed at Recall
Evaluation
All findings recorded at the base line are compared. Evaluations of complete oral and periodontal status, occlusal and prosthetic appliances, etc.

Assessment of bone levels. Any additional findings are recorded.

By comparing the findings obtained at base line.

Comparison with baseline data. Behavioral modification if necessary.

Removal of any fresh deposits, occlusal therapy, application of antimicrobial agents if indicated. Appointments for future periodontal therapy.

CLASSIFICATION OF POSTTREATMENT PATIENTS

maintenance care is a critical phase of therapy. The long-term preservation of the dentition is closely associated with the frequency and quality of recall maintenance.

Recall Intervals for Various Classes of Recall Patients

Merin
Classification Characteristics Recall Interval
First year First-year patient-routing therapy and uneventful healing 3 months
or
First-year patient-difficult case with complicated prosthesis, 1 to 2 months
furcation involvement, poor crown-to-root ratios, or
questionable patient cooperation


Class A Excellent results well maintained for 1 year or more 6 months to 1 year
Patient displays good oral hygiene, minimal calculus, no
occlusal problems, no complicated prostheses, no remaining
pockets, and no teeth with less than 50% of alveolar bone remaining

Class B Generally good results maintained reasonably well for 1 year 3-4 months(decide on
or more, but patient displays some of the following factors: recall interval on the
1. Inconsistent or poor oral hygiene basis of the number
2. Heavy calculus formation and severity of
3. Systemic disease that predisposes to periodont breakdown negative factors)
4. Some remaining pocket 5. Occlusal problem 6. Complicated prostheses
7. Ongoing orthodontic therapy 8. Recurrent dental caries
9. Some teeth with less than 50% of alveolar bone support
10. Smoking 11. Positive genetic test
12. Periodontal surgery indicated but not performed for medical,
psychologic, or financial reasons

Class C Generally poor results following periodontal therapy and/or 1-3 months (decide on several negative factors from the above list: recall interval on the
basis of the Number
and severity of
negative factors;
consider retreating
some areas or
extracting the
severely involved
teeth).
MAINTENANCE FOR DENTAL IMPLANT PATIENTS
Patients with implants are susceptible to a form of bone loss called periimplantitis, and evidence suggests that such patients may be more prone to plaque-induced inflammation with bone loss than those with natural teeth
In general, procedures for maintenance of patients with implants are similar to those with natural teeth with three differences:
1. Special instrument that will not scratch the implants are used for calculus removal on the implants.
2. Acidic fluoride prophylactic agents are avoided.
3. Nonabrasive prophylactic pastes are used.
Conclusion
Maintenance therapy is often supportive in nature hence it is also called supportive periodontal treatment (SPT).
The main objective of supportive periodontal therapy is to prevent or minimize the recurrence of periodontal diseases by controlling factors known to contribute to the disease process.
The interval of recall visits is determined by severity of disease, effectiveness of patients home care and degree of control of inflammation achieved.
Based on many long-term studies, the interval for maintenance visits has been recommended. The patient
should be seen initially for recall treatment at 2 to 4 weeks following treatment. After 3 or 4 such sessions the interval can be extended to 3 months (can be varied according to patient needs).