The periodontal maintenance phase forms part of periodontal treatment, and its objective is to prevent recurrence and to ensure long term preservation of the periodontal health achieved in the previous phases.
Numerous research studies have proven the importance of the periodontal maintenance phase, and it has become an essential part of comprehensive periodontal disease therapy. Since 1989, The American Academy of Periodontology has referred to this as Supportive Periodontal Therapy, given the need to establish therapeutic measures aside from patient involvement to maintain periodontal health throughout life.
The basic objectives of periodontal maintenance include:
Preventing or minimising periodontal disease progression and recurrence (relapse) in already treated patients.
Preventing or reducing the occurrence of tooth loss.
Detecting and treating other diseases or lesions of the oral cavity.
Examination, re-evaluation and diagnosis
In the first periodontal maintenance visit after the active periodontal treatment phase, it is essential to evaluate overall health as well as oral and periodontal health and to identify possible risk factors that might lead to repeated disease progression (recurrence).
This evaluation will include:
- Anamnesis: update the patient’s medical history, taking into account possible disorders or discomforts that have emerged after the initial treatment.
- Plaque control: to ensure the patient is effective at removing biofilm, both chemically and mechanically, plaque index should be assessed by using plaque disclosing products.
- Dental and periodontal evaluation using a periodontal chart, where the following are determined:
- Periodontal pocket depth: attachment loss is measured to verify the extent of periodontal destruction.
- Gingival recession: indicates total attachment loss and the presence of hypersensitivity and root caries.
- Bleeding on probing and suppuration: bleeding on probing indicates gingival inflammation; suppuration indicates active periodontal disease.
- Tooth mobility: an increase in tooth mobility is a sign of periodontal disease progression, although it can also occur from other causes such as occlusal trauma.
- Furcation lesions: because these areas are difficult to access, biofilm build-up may be greater and should therefore be evaluated regularly.
- Root cementum exposure: because these areas are more sensitive and biofilm removal is more complex, greater care must be taken.
- Radiological examination: Radiological testing should be performed every 2-4 years to monitor possible changes in the alveolar bone, periapical disease and caries.
Patient motivation and re-instruction
Some studies have been able to prove that patients who do not adhere to the maintenance program tend to return to their deficient hygiene habits, showing signs of periodontal deterioration. This justifies the need for reinforcing oral hygiene measures, with positive personalised instruction for each type of patient.
Treating reinfected sites
Supragingival plaque and calculus build-up should be removed by tartrectomy. Subsequently, the areas that show signs of inflammation should be instrumented to remove subgingival plaque.
Polishing and Fluoride Application
Polishing is a process that involves removing stains, excluding the areas where the dentin is exposed. Polishing is absolutely contraindicated in areas with caries, thin enamel or cementum, in newly erupted teeth, demineralisation, implants or restorations.
Fluoride application prevents the onset of dentin hypersensitivity from tooth root exposure, which commonly occurs in periodontal patients.
Establishing the frequency of maintenance visits
The interval between visits will depend on the patient’s individual risk for periodontal disease progression.
A patient’s risk depends on multiple causes, including systemic health, genetic factors, smoking and/or alcohol intake, psychological factors and stress, sex, race and socioeconomic level, among others.
Generally, it is recommended to perform regular maintenance visits every 3 months for the first year following periodontal treatment, and then increase or decrease the frequency of visits depending on patient response.
Adjunctive treatment with antiseptics to prevent recurrence
Despite having performed adequate periodontal therapy, some sites may show progressive periodontal attachment loss due to the multifactorial environment, which may again trigger disease progression (aka. disease recurrence). Recurrence is very common in patients who do not achieve adequate control of biofilm due to incorrect oral hygiene technique or lack of consistency in its performance.
To avoid such consequences and to improve clinical and microbiological parameters in the oral cavity, it is justified to use an antiseptic as adjunctive therapy. Among the antiseptic agents available for recurrence prevention, chlorhexidine at low concentrations (0.05%) and cetylpyridinium chloride have been shown to provide excellent results in the maintenance phase, even in non-compliant patients. Chlorhexidine at low concentrations (0.05%) has an anti-plaque effect (inter- and intra-group) and anti-gingivitis activity (intra-group) and acts directly on subgingival microflora, reducing the total microbial load and the detection rate of P. gingivalis. Numerous studies support the 0.05% CHX + 0.05% CPC formulation as an anti-plaque agent that can be used continually for months, with reduced side effects.