- Email: [email protected]
Maintaining Periodontal Treatment
J>AD)A_
----------u r v V
A
R T I C L E S
Dental maintenance care is now termed supportive periodontal treatment and has a vital role in keeping the periodontium ami peri-implant tissues healthy after active therapy. Typical supportive periodontal treatment includes a pretreatment review of the patient’s chart and an update of the medical and dental histories; a complete clinical examination; reviewing and modifying personal oral hygiene; removal of subgingival and supragingival accretions; and behavior modification. The average supportive periodontal treatment visit lasts 1 hour and is scheduled every 3 months. More aggressive and severe cases should be the responsibility of the periodontist.
Maintaining periodontal treatment Thomas G. Wilson, Jr., DDS
a in te n a n c e care is an essential p a rt o f p e rio d o n ta l therapy. It h as b e e n d e f in e d as “th e c o n t in u in g p e r io d ic a s s e s s m e n t a n d prophylactic treatm ent o f the periodontal structures that perm it early detection and tr e a tm e n t o f new o r r e c u r r in g a b n o r m alities o r d isease.”1 T h e goal o f m ain te n a n c e is to c o n tin u e th e stable sta te cre ate d by active therapy. T his phase o f tre a tm e n t has rec eiv ed little a tte n tio n ; h o w ev er, r e c e n t r e s e a r c h 2 show s th a t m aintenance is o f the utm ost im portance; the term supportive periodontal treatm ent (SPT) is preferred.2 This p aper addresses the im portance o f SPT, with detailed steps for a norm al SPT visit, ap p ro priate intervals betw een visits, an d who sh o u ld be resp o n sib le for this care. As dental im plants have many o f the sam e p ro b le m s th a t a re fo u n d a ro u n d n a tu r a l te e th , th e s e d e v ic e s a re also discussed.
M
Many studies d e m o n stra te d th e tr u th of this statem ent. T h e patien t who com plies to su g g e sted SPT in te rv a ls has a m o re stable periodontium an d loses fewer teeth
The importance of SPT Schluger1writes, “At the h ea rt o f therapy is m a in te n a n c e ; w h e th e r you win o r lose depends on m aintenance, and the dentist is always in partnership with the patient.”3
F ig 1 ■ P r o b in g p o c k e t d e p th s are b e in g r eco rd ed with a co m p u terized probe (Florida Probe Corp) using a reproducible 20-g force.
th an the p atien t who does n o t com ply or com plies erratically.4-10 O ne study found that patients who were c o m p le te c o m p ile rs to s u g g e s te d SPT in te r v a ls lo s t n o te e th in 5 y e a rs. A c o m p le te c o m p lie r in th is g r o u p was defined as a patien t who kept three of four su g g e s te d SPT v isits.4 O th e r w o rk h as shown th a t SPT can m aintain attachm ent levels after active therapy b o th in short-5 ; an d long-term® programs. Conversely, patients who did n o t comply o r com plied erratically to suggested SPT in te r v a ls te n d e d to lo se m o r e te e th . E rra tic c o m p lie rs a re d e fin e d as th o se p a tie n ts who receiv ed SPT ca re a t least o n c e .7 P atien ts in this erratic g ro u p lost 0.06 teeth p er p atien t p er year;4 p atients receiving active p erio d o n tal th erap y b u t n o SPT lo st 0.22 te e th p e r p a tie n t p e r year»; a n d u n tr e a te d p a tie n ts lo st 0.61 te e th p e r p a tie n t p e r year.« It has b een d e m o n stra te d th a t in fre q u e n t SPT afte r active therapy can lead to increasing loss o f attach m en t (increased pocket probing d e p th ).1» T h e answ er to co n tro llin g p erio d o n tal p r o b le m s w o u ld in c lu d e h a v in g all p e rio d o n tal p atien ts receive ap p ro p ria te active therapy, th en establish th e p ro p e r JADA, Vol. 121, O c to b e r 1990 ■ 491
A R T I C L E S
f re q u e n c y o f S PT v isits w ith p a t ie n t c o m p lia n c e . T h is is a w orthy goal, b u t many patients either d o n ’t com plete active th e r a p y ,11 o r d r o p o u t a f te r e n t e r in g SPT.71'2 This d ro p o u t rate has been as high as 4 5 % .1:1 N u m ero u s ap p ro a ch es can be u s e d to im p ro v e c o m p lia n c e in th e se cases. They include inform ing the patient o f th e im p o r ta n c e o f SPT, r e d u c in g b a rrie rs to co m p lian ce, a n d sim plifying d e s ir e d b e h a v io r a l c h a n g e s .14 T h e follow ing m aterial reviews a typical SPT visit. It presents an overview and should be m odified for individual office settings to better serve patient needs.
and behavior modification.
Chart review and update
Periodontal and dental examinations
Before seeing the p atien t, the clinician’s review o f th e p a tie n t’s c h a r t allows the clinician to refresh his or h e r knowledge o f the p atient’s special problem s or needs. T his in cludes th e use o f prem ed icatio n , past areas o f m edical o r dental concern, and history of com pliance. W h e n u p d a t in g th e h e a lth h isto ry , p ertin en t m edical changes can usually be elicited by asking the patient the following questions: Has th e re b een any change in y o u r h e a lth sin ce y o u r la st visit? H ave th e re b e e n any c h a n g e s in your m e d i cations o r are you taking any new m edica tions? Have you been hospitalized o r seen your physician for anything other than a ro u tin e physical e x a m in a tio n since your last visit? R e c e n t d e n t a l in f o r m a tio n c a n be o b tain ed by asking the patient: W hat are you d o ing to clean your te eth routinely? Do you have any facial, o ra l, o r d e n ta l problem s of concern to you? In a d d itio n , i n te r p e r s o n a l c o m m u nication can be enjoyable for both parties; e x p e r ie n c e h as show n th a t life ev en ts affect the periodontium both directly and indirectly. T h e g re a te r th e ra p p o rt, the m o re lik e ly th e p a t i e n t is to h e e d p r o fe s s io n a l s u g g e s tio n s f o r p o sitiv e lifestyle changes.
Probing pocket depths. P ro b in g p o c k e t depth is the distance between the gingival margin and the most apical penetration of the periodontal probe tip.15 M easurem ents are ta k en a t th e d e e p e s t in te rp ro x im a l area on the mesiolingual and mesiobuccal as well as the distolingual an d distobuccal a s p e c ts w ith th e p r o b e a p ic a l to th e c o n ta c t a re a a n d th e lo n g axis o f th e p ro b e as close to parallel to th e ro o t as possible. Midfacial and m idlingual depths a re also r e c o rd e d . P ro b in g d e p th s are checked at each m aintenance visit and any changes from baseline m easurem ents are recorded. A m o re d e sira b le m e asu re o f a tta c h m ent changes is th e pro b in g attach m en t level, b u t th is m easu re is d ifficult, tim e c o n s u m in g , a n d n o t fe a s ib le in m o st p riv ate p rac tice s. B oth p ro b in g p o c k e t d epth and attachm ent level are best taken with a probe with standardized markings, diam eter, and am o u n t of pressure placed o n th e p r o b e tip (Fig 1). A d v an ces in c o m p u te riz in g th ese m e asu rem en ts are being m ade so th at they may be used in the fu tu re in all private p ractices.16 T h e presence o f bone loss in furcations can be fo u n d using h o rizo n tal p en e tratio n o f a p e rio d o n ta l p ro b e o r a cu rv ed e x p lo re r designed for this purpose.
Exam ination data
Gingival recession. T his is th e m easu red d is ta n c e fro m th e c e m e n to e n a m e l ju n ctio n or o th e r fixed point to the crest o f the free gingival m argin. Midfacial and m idlingual recessions are usually recorded on each tooth. T his m easurem ent, when c o m b in e d w ith p o ck e t p ro b in g d e p th s, gives th e clin ician an ap p ro x im atio n o f total attachm ent loss.
T h e se ite m s m ay be p e r f o rm e d o r re view ed a t ea ch SPT visit: e x tra o ra l an d n o n p e rio d o n ta l in tra o ra l tissue ex a m i n atio n s (th e te m p o ro m a n d ib u la r jo in ts, e x tr a o r a l a n d i n tr a o r a l so ft tis s u e s ); p e r io d o n ta l a n d d e n ta l e x a m in a tio n s; im p lan t a n d p eri-im p lan t exam inations; previous o r c u rre n t radiographs; m icro biological ex am ination s; a review o f the p atien t’s personal hygiene; the removal of subgingival and supragingival accretions; 4 9 2 ■ JADA, Vol. 121, O c to b e r 1990
(taken at th e same points w here p ro b in g pocket d epths are m easured) and should be p erfo rm ed and reco rd ed at each SPT visit. Fremitus. F rem itu s is th e m o v e m en t o f
F ig 2 ■ B le e d in g s e e n a f t e r g e n tle p r o b in g s h o u ld b e r e c o rd e d a t ea ch S P T visit.
te e th in f u n c tio n . It c a n b e f e lt o r visualized an d is usually m ost evident in the maxillary arch. This param eter should be checked routinely an d elim inated when in flam m atio n exists aro u n d th e involved te e th .17 Restorative/prosthetic/caries assessment.
F or p e rio d o n ta l p atien ts it is especially im p o rtan t to check for and elim inate any o v erh a n g in g restorative m arg in s o r any p ro s th e s is th a t is n e g a tiv e ly a ffe c tin g p erio d o n tal health. Routine exam ination for dental caries can also be p erfo rm ed at this time. Implant and peri-implant examinations Probing depths. C hecking an d rec o rd in g
p ro b in g d ep th s a ro u n d d en tal im p lan ts s h o u ld b e r o u tin e . A p la stic p r o b e is p r e fe rre d a ro u n d tita n iu m fix tu res (o r im plants with titanium collars) to prevent sc ra tc h in g th e im p la n t su rface (Fig 3). T he same six areas where probing pocket depths are recorded around natural teeth should be recorded around implants. Bleeding on probing. T h is p a r a m e te r is
d isc o v e re d a n d re c o rd e d in a m a n n e r similar to that used around natural teeth.
Bleeding on probing (Fig 2). Bleeding seen
Fig 3 ■ A p la stic p r o b e (P ro -D e n tec) is p r e f e r r e d
after gentle probing (usually about 25-g of force) is reco rd ed at six points per tooth
sc ra tc h in g .
f o r u s e a r o u n d d e n t a l im p la n ts to p r e v e n t
A R T I C L E S
rem oved, supragingival accretions should b e ad d re ssed . U ltraso n ic scalers can be used for calculus an d the judicious use o f an air p o w d er abrasive device is rec o m m e n d e d fo r any r e m a in in g stain s. Soft supragingival deposits on dental im plants can be rem o v e d e ith e r w ith g auze o r a fine-grit prophylaxis paste in a ru b b er cup on a slow-speed d ental h an dpiece.26
Prosthetic/occllisal check. S u p ra im p la n t
p ro sth etic devices th a t can be rem oved should be periodically checked outside the m outh. T he occlusion should be routinely checked an d any excessive forces removed. Sound. A metallic ringing sound produced w h e n an o s s e o in te g r a te d r o o t fo rm im plant is struck with a metal instrum ent is an in d ic ato r o f c o n tin u e d close b o n e apposition (Fig 4).
Behavior modification
Radiographic examination
It is im portant to m atch radiographs taken at SPT visits with previous sets to assess the new films for bone loss, but the nu m b er of films should be kept to a m inim um . The p a tie n t with signs o f active disease may require a full-m outh series o f right angle p e r ia p ic a l r a d io g r a p h s a n d p o s te r io r v e r tic a l b ite w in g s e v e ry 2 y ea rs. In in terv en in g years, seven vertical bitewing radiographs can be used.18 For individuals w ith r o o t fo rm d e n ta l im p la n ts , r ig h t a n g le p e r ia p ic a l o r v e r tic a l b ite w in g radiographs should be exposed 6 m onths, 12 m o n th s, a n d 3 years a fte r p ro sth etic p la c e m e n t, th e n ev e ry 3 y e a rs u n le s s c lin ic a l p r o b le m s a r i s e . 19 It m ay be necessary to d e p e n d on th e less d istinct im a g e o f p a n o r a m ic r a d io g r a p h s fo r assessm en t o f p o rtio n s o f la rg e r fibroo sseo u s in te g ra te d im p la n ts , b u t th e se sh o u ld be ac co m p an ie d by a p p ro p ria te periapical and bitewing radiographs. Microbiological examination
For those p a tie n ts w hose p e rio d o n tiu m d o es n o t re sp o n d to tra d itio n a l care, a m icrobiological sam pling with antibiotic sensitivity testing is often a p p ro p riate. It may be possible in th e fu tu re to pred ict b re a k d o w n u sin g m ic ro b io lo g ic a l a n d o th e r m e th o d s , b u t m o re r e s e a r c h is needed. Review of personal oral hygiene
O n e o f th e m o s t i m p o r ta n t ste p s to c o n tro l in fla m m a tio n a r o u n d te e th o r im plants is to m aintain optim al personal oral hygiene. Ideally this regim en would in clu d e a m anual to o th b ru sh an d som e type o f in te rp ro x im a l clea n in g aid. For p a tie n ts w ho c a n n o t o r w ill n o t u se in te r p r o m ix a l c le a n in g d e v ic e s, a m echanical toothbrush either with a single ro tatin g h ead 20 or with m ultiple rotatin g b ristle tu fts is re c o m m e n d e d . T h is last in s tru m e n t has b ee n show n to be m o re efficient in reducing dental plaque levels
Fig 4 ■ O nce the prosthetic superstructure is rem oved, a metallic ringing sound produced by s tr ik in g th e im p la n t is o n e in d ic a tio n o f continued osseo integration.
than a m anual b ru sh 2>; however, patients in th is stu d y d id n o t co m p ly w ith th e recom m ended twice-a-day use.9 Baab and o th e rs22 suggested th a t p a tie n ts d id n o t com ply b ecause six o f 24 (25% ) o f the devices were inoperable 6 m onths into the study. F o r p a t ie n t s w h o se h o m e c a re efforts and SPT com pliance do n o t arrest th e ir p e rio d o n ta l o r p e ri-im p la n t p ro b lem s, c h e m o th e ra p e u tic a g e n ts such as c h lo r h e x id in e c a n o f te n be u s e fu l in controlling gingivitis. Removal of subgingival accretions
Successful rem oval o f subgingival accre tio n s usually involves sc alin g a n d ro o t p la n in g . In g e n e r a l, p r o b in g p o c k e t depths o f 3 mm o r less can be cleaned by the dental professional with diligent effort. As p o c k e t p ro b in g d e p th s in crease, the task becom es m o re d au n tin g , a n d w hen prob in g pocket d ep th s reach 6 m m , the p ro b a b ility o f re m o v in g all d e p o s its is slim.23-24 In those d eep er pockets where an e q u ilib r iu m b e tw e e n b a c te ria a n d th e body cannot be achieved, surgery is often necessary.25 If prophylaxis tim e is limited, a r e a s w h e re p r o b in g d e p th s have increased or bleeding on probing is seen should be treated first. F o r d e n ta l im p la n ts , n o d e fin itiv e studies in vivo have b een p e rfo rm e d on th e m ost effective m e th o d s o f SPT, b u t until fu rth e r d ata are am assed, calcified im plant-bound accretions aro u n d titanium im plants (or titan iu m collars) should be rem oved with plastic instrum ents.26
P atien t com pliance to professionals’ sug gested SPT an d oral hygiene m easures is im portant; however, m any patients d o n o t c o m p ly a n d b e h a v io r m o d if ic a tio n te c h n iq u e s a re o fte n in d ic a te d . T h e se involve reinforcing positive behavior an d discovering m ethods to improve erratic or n o n c o m p lia n t p e rfo rm a n c e s . T h e te c h n iq u e s f o r u s e in th o s e s itu a tio n s go beyond the scope o f this p ap e r b u t texts can provide assistance.27-28 Scheduling S PT T h e in te rv a l fo r SPT s h o u ld b e d e te r m ined by disease activity. T he g reater the in c re a se in p o c k e t p ro b in g d e p th s a n d bleeding points, the m ore often a patient should be seen.29 T h e average patien t with periodontal disease o r o n e who has dental im p lan ts sh o u ld be seen fo u r tim es p e r year. E n o u g h tim e m u s t b e a llo w e d to a d e q u a te ly assess th e d e n t i t i o n a n d p erio d o n tiu m o r p eri-im p lan t tissue an d to p e r f o r m all th e th e ra p y n e e d e d to m aintain h ealth . For th e average p atien t with perio d o n tal disease, this takes ab o u t an hour. SPT accountability
T h e re c e n t W orld W orkshop in C linical P eriodontics50 suggested SPT for patients w ith g in g iv itis a n d early fo rm s o f p e ri o d o n titis be p e r f o rm e d in th e g e n e ra l d e n t i s t ’s o ffic e . A d v a n c e d a d u lt p e r i od ontitis can b e th e responsibility o f the periodontist; patients with m oderate adult periodontitis can often be shared between the two offices. In these cases seen in the g en e ral p ra c titio n e r’s office th a t d o n o t r e m a in s ta b le , c o n s u lta tio n w ith a periodontist was suggested. O th er form s of p erio d o n titis are b est m a in ta in ed by the periodontist. Summary
Removal of supragingival deposits
A fte r s u b g in g iv a l d e p o s its h av e b e e n
D ental m ain te n an c e, o r supportive p eri o d o n ta l tre a tm e n t (SP T ), can k ee p th e JADA, Vol. 121, O cto b er 1990 ■ 4 9 3
A R T I C L E S
p e r io d o n tiu m a n d p e ri-im p la n t tissues healthy after active therapy. Patients who c o m p ly to s u g g e s te d SPT fa r e b e t te r periodon tally and keep their teeth longer. Data should be gathered by exam inations, ta lk in g w ith p a tie n ts , a n d rev ie w in g p e r s o n a l o ra l h y g ie n e . T h e n sub- a n d s u p ra -g in g iv a l d e p o s its s h o u ld be removed. T he average SPT visit should last 1 hour and should be scheduled every 3 m onths. S u p p o rtiv e p e r io d o n ta l tr e a tm e n t fo r patients with m ore advanced periodontal o r peri-im plant destruction should be the responsibility o f the periodontist.
----------------- J!£OA -----------------
5 . W e s tfe ld E , N y m a n S, S o c r a n s k y S, L i n d h e J . S ig n ifican c e o f p ro fe s s io n a l to o th c le a n in g f o r h e a lin g
c la s s if ic a tio n , a n d d is e a s e a c tiv ity f o r p a t ie n t s w ith p e r i o d o n t a l d is e a s e s . In :W ils o n T G , e d .D e n ta l
fo llo w in g p e r i o d o n t a l s u r g e r y . J C lin P e r i o d o n t o l 1983; 10:149.
m a in te n a n c e f o r p a tie n ts w ith p e r i o d o n ta l d ise a se s. C h ic a g o Q u in te s s e n c e ; 1989:91. 19. S tr id KG. R a d io g ra p h ic p ro ced u re s.
6. L in d h e J , N y m a n S. L o n g -te rm m a in te n a n c e o f p a t ie n t s tr e a te d f o r a d v a n c e d p e r i o d o n ta l d is e a se . J
in te g r a te d p ro sth e se s. C h ic a g o :Q u in te s se n c e ; 1985:327. 2 0 . Boyd RL, M u rra y PA, R o b e rtso n PB. E ffe c t o n
T. C o m p lia n c e w ith m a in te n a n c e th e ra p y in a p riv a te
p e r i o d o n t a l s ta t u s o f r o t a r y e l e c tr i c t o o t h b r u s h e s d u r in g p e r i o d o n ta l m a in te n a n c e I. c lin ic a l re s u lts. J
p e rio d o n ta l p ra c tic e . J P e rio d o n to l 1984;55:468. 8. B e c k e r W, B e c k e r BE, B e rg LE . P e r io d o n ta l tr e a tm e n t w ith o u t m a in te n a n c e . A re tro sp e c tiv e stu d y in 44 p a tie n ts. J P e rio d o n to l 1984;55:505. 9 . B e c k e r W, B e rg L, B e c k e r B E. U n tr e a t e d p e rio d o n ta l disease: a lo n g itu d in a l study. J P e rio d o n to l 1979;50:234. 10. A x e ls s o n P, L i n d h e J . T h e s i g n i f i c a n c e o f m a i n t e n a n c e c a r e in th e t r e a t m e n t o f p e r i o d o n t a l d isea se . J C lin P e rio d o n to l 1981;8:281. 11. E c h e v e rria -G a rc ia JJ. C o m p lia n c e -P ro b le m e b e i d e r N a c h s o rg e v o n p a tie n te n m it p a r o d o n to p a th ie n . P h illip J R esto ra tiv e Z a h n m e d 1989;4:235.
Dr. W ilso n is in p riv a te p ra c tic e o f p e rio d o n tic s a n d i m p l a n t d e n t i s t r y in D a lla s ; a n a f f i l i a t e a s s i s t a n t
12. S c h m id t JK . P a tie n t c o m p lia n c e w ith su g g e s te d m a in te n a n c e re c a ll in a p riv a te p e r io d o n ta l p r a c tic e
p r o f e s s o r in g r a d u a t e p e r i o d o n t i c s , U n iv e rs ity o f W a s h i n g t o n ; l e c t u r e r in g r a d u a t e p e r i o d o n t i c s ,
( M a s te rs T h e s is ) . M ich ig an ;1 9 8 8 .
U n iv ersity o f N e b ra s k a ; a n d visiting associate p ro fe s s o r in g r a d u a te p e rio d o n tic s , B aylor U n iv ersity S c h o o l o f D en tistry . A d d re s s r e p r i n t re q u e s ts to Dr. W ilson, 8350 N C e n tr a l Expressw ay, S u ite M -2112, D allas 75206.
A nn
A rb o r:U n iv e rs ity
of
13. K now les JW , B u r g e tt FG, N issle RR, S h ick RA, M o r r is o n E C , R a m f jo r d SP. R e s u lts o f p e r i o d o n t a l t r e a t m e n t r e l a te d to p o c k e t d e p t h a n d a t t a c h m e n t level— e ig h t years. J P e rio d o n to l 1979;50:225. 14 . W i ls o n T G . C o m p l i a n c e . A r e v ie w o f t h e
1. A m e ric a n A c a d e m y o f P e rio d o n to lo g y . G lossary o f P e r i o d o n t i c T e r m s . J P e r i o d o n t o l . C h ic a g o :
lite ra tu r e w ith p o ssib le a p p lic a tio n s to p e rio d o n tic s. J P e r io d o n to l 1987;58:706.
A m e r i c a n A c a d e m y o f P e r i o d o n t o lo g y ;1 9 8 6 : (S u p p le m e n t);1 7 .
15. C a to n J . P e r io d o n ta l d ia g n o sis a n d d ia g n o s tic a id s. C h ic a g o :A m e ric a n A c a d e m y o f P e rio d o n to lo g y
2. A m e ric a n A c a d e m y o f P e r io d o n to lo g y . C u r r e n t p r o c e d u r a l te rm in o lo g y fo r p e rio d o n tic s . 5 th e d . C h ic a g o :A m e ric a n A c a d e m y o f P e r io d o n to l ogy; 1988:14. 3. M cC an n D. P e rio d o n ta l re s e a rc h : e x p lo rin g new h o riz o n s. JA D A 1989; 119:487. 4. W ils o n T G , G lo v e r M E , M a lik A K, S c h o e n JA ,
1989:1-6. 16. G ib b s C H , H ir s c h f e ld JW , L e e J G , L o w SB , M a g n u s s o n I, T h o u s a n d R R , e t al. D e s c r ip tio n a n d clin ic a l e v a lu a tio n o f a new c o m p u te riz e d p e rio d o n ta l p r o b e — T h e F l o r i d a p r o b e . J C li n P e r i o d o n t o l 1988;15:137. 17 . P i h l s t r o m
B L , A n d e r s o n K A, A e p p o l i D ,
D o r s e tt D . T o o th loss in m a i n t e n a n c e p a tie n ts in a
S c h a ffe r EM . A sso ciatio n b e tw e e n signs o f tr a u m a fro m
p riv a te p e r io d o n ta l 1987;58:231.
o c c lu s io n a n d p e r io d o n titis . J P e rio d o n to l 1986;57:1. 18. W i ls o n TG. E x a m in a tio n , d ia g n o s is ,
p ra c tic e .
494 ■ J A D A , V o l. 121, O ctober 1990
J
P e rio d o n to l
In :B ra n e m a rk P I, Z a rb GA, A lb rek tsso n T, ed s. T issu e
C lin P e rio d o n to l 1 9 8 4 ;1 1:504. 7. W ilson T G , G lo v er M E, S c h o e n J , B au s C, J a c o b s
P e rio d o n to l 1989;60:390. 2 1 . K illoy W J, L ove JW , L o v e J , F e d i PF, T ir a D E. T h e e ffec tiv e n ess o f a c o u n te r - r o ta r y a c tio n p o w e re d to o t h b r u s h a n d c o n v e n tio n a l to o t h b r u s h o n p la q u e re m o v a l a n d g in g iv al b le e d in g . A s h o r t te r m study. J P e rio d o n to l 1989;60:473. 2 2 . B a a b D A , J o h n s o n R H . T h e e f f e c t o f a n ew e l e c t r i c t o o t h b r u s h o n s u p r a g in g i v a l p l a q u e a n d g ingivitis. J P e rio d o n to l 1989;60:336. 2 3 . W a e r h a u g J . H e a l in g o f th e d e n t o e p i t h e l i a l ju n c t i o n fo llo w in g su b g in g iv a l p la q u e c o n tr o l. 11. As o b serv ed on 1978;49:119.
e x tra c te d
te e th . J
P e rio d o n to l
24. S ta m b a u g h RV, D ra g o o M , S m ith D M , C ara sal L. T h e lim its o f su b g in g iv a l sc a lin g . I n t J P e r io d o n tic s R esto ra tiv e D e n t 1981 ;1:31. 25. C affesse RG , S w eeney PL, S m ith BA. S calin g a n d r o o t p l a n i n g w ith a n d w i t h o u t p e r i o d o n t a l f la p su rg ery . J C lin P e rio d o n to l 1986; 13:205. 26 . T h o m so n -N e a l D, E vans G H , M e ffe rt RM . E ffects o f v ario u s p ro p h y la ctic tr e a tm e n t o n tita n iu m , s a p p h ire , a n d h y d ro x y la p atite-co a ted im p la n ts: an SEM study. I n t J P e rio d o n tic s R esto ra tiv e D e n t 1989;9:301. 27 . M e rc h e n b a u m D , T u rk D C. F a c ilita tin g tr e a tm e n t a d h e re n c e . N ew Y o rk :P len u m P ress; 1987. 2 8 . H a y n e s R B , S a c k e t t D C . C o m p l i a n c e w ith th e r a p e u ti c re g im e n s . B a l tim o r e jo h n s H o p k in s U n iv ersity P ress; 1976. 2 9 . W i ls o n T G . A t y p i c a l m a i n t e n a n c e v is it. In :W ilso n T G Jr. D e n ta l m a in te n a n c e fo r p a tie n ts w ith p e r io d o n ta l d iseases. C h ic a g o :Q u in te s se n c e ; 1989:90-5. 30. A m e ric a n
A cadem y
of
P e rio d o n to lo g y :
P r o c e e d i n g s o f t h e W o r ld W o r k s h o p in C li n ic a l P e r io d o n t ic s . C h ic a g o :A m e ric a n A c a d e m y o f P e rio d o n to lo g y ; 1989:IX-25.
----------u r v V
A
R T I C L E S
Dental maintenance care is now termed supportive periodontal treatment and has a vital role in keeping the periodontium ami peri-implant tissues healthy after active therapy. Typical supportive periodontal treatment includes a pretreatment review of the patient’s chart and an update of the medical and dental histories; a complete clinical examination; reviewing and modifying personal oral hygiene; removal of subgingival and supragingival accretions; and behavior modification. The average supportive periodontal treatment visit lasts 1 hour and is scheduled every 3 months. More aggressive and severe cases should be the responsibility of the periodontist.
Maintaining periodontal treatment Thomas G. Wilson, Jr., DDS
a in te n a n c e care is an essential p a rt o f p e rio d o n ta l therapy. It h as b e e n d e f in e d as “th e c o n t in u in g p e r io d ic a s s e s s m e n t a n d prophylactic treatm ent o f the periodontal structures that perm it early detection and tr e a tm e n t o f new o r r e c u r r in g a b n o r m alities o r d isease.”1 T h e goal o f m ain te n a n c e is to c o n tin u e th e stable sta te cre ate d by active therapy. T his phase o f tre a tm e n t has rec eiv ed little a tte n tio n ; h o w ev er, r e c e n t r e s e a r c h 2 show s th a t m aintenance is o f the utm ost im portance; the term supportive periodontal treatm ent (SPT) is preferred.2 This p aper addresses the im portance o f SPT, with detailed steps for a norm al SPT visit, ap p ro priate intervals betw een visits, an d who sh o u ld be resp o n sib le for this care. As dental im plants have many o f the sam e p ro b le m s th a t a re fo u n d a ro u n d n a tu r a l te e th , th e s e d e v ic e s a re also discussed.
M
Many studies d e m o n stra te d th e tr u th of this statem ent. T h e patien t who com plies to su g g e sted SPT in te rv a ls has a m o re stable periodontium an d loses fewer teeth
The importance of SPT Schluger1writes, “At the h ea rt o f therapy is m a in te n a n c e ; w h e th e r you win o r lose depends on m aintenance, and the dentist is always in partnership with the patient.”3
F ig 1 ■ P r o b in g p o c k e t d e p th s are b e in g r eco rd ed with a co m p u terized probe (Florida Probe Corp) using a reproducible 20-g force.
th an the p atien t who does n o t com ply or com plies erratically.4-10 O ne study found that patients who were c o m p le te c o m p ile rs to s u g g e s te d SPT in te r v a ls lo s t n o te e th in 5 y e a rs. A c o m p le te c o m p lie r in th is g r o u p was defined as a patien t who kept three of four su g g e s te d SPT v isits.4 O th e r w o rk h as shown th a t SPT can m aintain attachm ent levels after active therapy b o th in short-5 ; an d long-term® programs. Conversely, patients who did n o t comply o r com plied erratically to suggested SPT in te r v a ls te n d e d to lo se m o r e te e th . E rra tic c o m p lie rs a re d e fin e d as th o se p a tie n ts who receiv ed SPT ca re a t least o n c e .7 P atien ts in this erratic g ro u p lost 0.06 teeth p er p atien t p er year;4 p atients receiving active p erio d o n tal th erap y b u t n o SPT lo st 0.22 te e th p e r p a tie n t p e r year»; a n d u n tr e a te d p a tie n ts lo st 0.61 te e th p e r p a tie n t p e r year.« It has b een d e m o n stra te d th a t in fre q u e n t SPT afte r active therapy can lead to increasing loss o f attach m en t (increased pocket probing d e p th ).1» T h e answ er to co n tro llin g p erio d o n tal p r o b le m s w o u ld in c lu d e h a v in g all p e rio d o n tal p atien ts receive ap p ro p ria te active therapy, th en establish th e p ro p e r JADA, Vol. 121, O c to b e r 1990 ■ 491
A R T I C L E S
f re q u e n c y o f S PT v isits w ith p a t ie n t c o m p lia n c e . T h is is a w orthy goal, b u t many patients either d o n ’t com plete active th e r a p y ,11 o r d r o p o u t a f te r e n t e r in g SPT.71'2 This d ro p o u t rate has been as high as 4 5 % .1:1 N u m ero u s ap p ro a ch es can be u s e d to im p ro v e c o m p lia n c e in th e se cases. They include inform ing the patient o f th e im p o r ta n c e o f SPT, r e d u c in g b a rrie rs to co m p lian ce, a n d sim plifying d e s ir e d b e h a v io r a l c h a n g e s .14 T h e follow ing m aterial reviews a typical SPT visit. It presents an overview and should be m odified for individual office settings to better serve patient needs.
and behavior modification.
Chart review and update
Periodontal and dental examinations
Before seeing the p atien t, the clinician’s review o f th e p a tie n t’s c h a r t allows the clinician to refresh his or h e r knowledge o f the p atient’s special problem s or needs. T his in cludes th e use o f prem ed icatio n , past areas o f m edical o r dental concern, and history of com pliance. W h e n u p d a t in g th e h e a lth h isto ry , p ertin en t m edical changes can usually be elicited by asking the patient the following questions: Has th e re b een any change in y o u r h e a lth sin ce y o u r la st visit? H ave th e re b e e n any c h a n g e s in your m e d i cations o r are you taking any new m edica tions? Have you been hospitalized o r seen your physician for anything other than a ro u tin e physical e x a m in a tio n since your last visit? R e c e n t d e n t a l in f o r m a tio n c a n be o b tain ed by asking the patient: W hat are you d o ing to clean your te eth routinely? Do you have any facial, o ra l, o r d e n ta l problem s of concern to you? In a d d itio n , i n te r p e r s o n a l c o m m u nication can be enjoyable for both parties; e x p e r ie n c e h as show n th a t life ev en ts affect the periodontium both directly and indirectly. T h e g re a te r th e ra p p o rt, the m o re lik e ly th e p a t i e n t is to h e e d p r o fe s s io n a l s u g g e s tio n s f o r p o sitiv e lifestyle changes.
Probing pocket depths. P ro b in g p o c k e t depth is the distance between the gingival margin and the most apical penetration of the periodontal probe tip.15 M easurem ents are ta k en a t th e d e e p e s t in te rp ro x im a l area on the mesiolingual and mesiobuccal as well as the distolingual an d distobuccal a s p e c ts w ith th e p r o b e a p ic a l to th e c o n ta c t a re a a n d th e lo n g axis o f th e p ro b e as close to parallel to th e ro o t as possible. Midfacial and m idlingual depths a re also r e c o rd e d . P ro b in g d e p th s are checked at each m aintenance visit and any changes from baseline m easurem ents are recorded. A m o re d e sira b le m e asu re o f a tta c h m ent changes is th e pro b in g attach m en t level, b u t th is m easu re is d ifficult, tim e c o n s u m in g , a n d n o t fe a s ib le in m o st p riv ate p rac tice s. B oth p ro b in g p o c k e t d epth and attachm ent level are best taken with a probe with standardized markings, diam eter, and am o u n t of pressure placed o n th e p r o b e tip (Fig 1). A d v an ces in c o m p u te riz in g th ese m e asu rem en ts are being m ade so th at they may be used in the fu tu re in all private p ractices.16 T h e presence o f bone loss in furcations can be fo u n d using h o rizo n tal p en e tratio n o f a p e rio d o n ta l p ro b e o r a cu rv ed e x p lo re r designed for this purpose.
Exam ination data
Gingival recession. T his is th e m easu red d is ta n c e fro m th e c e m e n to e n a m e l ju n ctio n or o th e r fixed point to the crest o f the free gingival m argin. Midfacial and m idlingual recessions are usually recorded on each tooth. T his m easurem ent, when c o m b in e d w ith p o ck e t p ro b in g d e p th s, gives th e clin ician an ap p ro x im atio n o f total attachm ent loss.
T h e se ite m s m ay be p e r f o rm e d o r re view ed a t ea ch SPT visit: e x tra o ra l an d n o n p e rio d o n ta l in tra o ra l tissue ex a m i n atio n s (th e te m p o ro m a n d ib u la r jo in ts, e x tr a o r a l a n d i n tr a o r a l so ft tis s u e s ); p e r io d o n ta l a n d d e n ta l e x a m in a tio n s; im p lan t a n d p eri-im p lan t exam inations; previous o r c u rre n t radiographs; m icro biological ex am ination s; a review o f the p atien t’s personal hygiene; the removal of subgingival and supragingival accretions; 4 9 2 ■ JADA, Vol. 121, O c to b e r 1990
(taken at th e same points w here p ro b in g pocket d epths are m easured) and should be p erfo rm ed and reco rd ed at each SPT visit. Fremitus. F rem itu s is th e m o v e m en t o f
F ig 2 ■ B le e d in g s e e n a f t e r g e n tle p r o b in g s h o u ld b e r e c o rd e d a t ea ch S P T visit.
te e th in f u n c tio n . It c a n b e f e lt o r visualized an d is usually m ost evident in the maxillary arch. This param eter should be checked routinely an d elim inated when in flam m atio n exists aro u n d th e involved te e th .17 Restorative/prosthetic/caries assessment.
F or p e rio d o n ta l p atien ts it is especially im p o rtan t to check for and elim inate any o v erh a n g in g restorative m arg in s o r any p ro s th e s is th a t is n e g a tiv e ly a ffe c tin g p erio d o n tal health. Routine exam ination for dental caries can also be p erfo rm ed at this time. Implant and peri-implant examinations Probing depths. C hecking an d rec o rd in g
p ro b in g d ep th s a ro u n d d en tal im p lan ts s h o u ld b e r o u tin e . A p la stic p r o b e is p r e fe rre d a ro u n d tita n iu m fix tu res (o r im plants with titanium collars) to prevent sc ra tc h in g th e im p la n t su rface (Fig 3). T he same six areas where probing pocket depths are recorded around natural teeth should be recorded around implants. Bleeding on probing. T h is p a r a m e te r is
d isc o v e re d a n d re c o rd e d in a m a n n e r similar to that used around natural teeth.
Bleeding on probing (Fig 2). Bleeding seen
Fig 3 ■ A p la stic p r o b e (P ro -D e n tec) is p r e f e r r e d
after gentle probing (usually about 25-g of force) is reco rd ed at six points per tooth
sc ra tc h in g .
f o r u s e a r o u n d d e n t a l im p la n ts to p r e v e n t
A R T I C L E S
rem oved, supragingival accretions should b e ad d re ssed . U ltraso n ic scalers can be used for calculus an d the judicious use o f an air p o w d er abrasive device is rec o m m e n d e d fo r any r e m a in in g stain s. Soft supragingival deposits on dental im plants can be rem o v e d e ith e r w ith g auze o r a fine-grit prophylaxis paste in a ru b b er cup on a slow-speed d ental h an dpiece.26
Prosthetic/occllisal check. S u p ra im p la n t
p ro sth etic devices th a t can be rem oved should be periodically checked outside the m outh. T he occlusion should be routinely checked an d any excessive forces removed. Sound. A metallic ringing sound produced w h e n an o s s e o in te g r a te d r o o t fo rm im plant is struck with a metal instrum ent is an in d ic ato r o f c o n tin u e d close b o n e apposition (Fig 4).
Behavior modification
Radiographic examination
It is im portant to m atch radiographs taken at SPT visits with previous sets to assess the new films for bone loss, but the nu m b er of films should be kept to a m inim um . The p a tie n t with signs o f active disease may require a full-m outh series o f right angle p e r ia p ic a l r a d io g r a p h s a n d p o s te r io r v e r tic a l b ite w in g s e v e ry 2 y ea rs. In in terv en in g years, seven vertical bitewing radiographs can be used.18 For individuals w ith r o o t fo rm d e n ta l im p la n ts , r ig h t a n g le p e r ia p ic a l o r v e r tic a l b ite w in g radiographs should be exposed 6 m onths, 12 m o n th s, a n d 3 years a fte r p ro sth etic p la c e m e n t, th e n ev e ry 3 y e a rs u n le s s c lin ic a l p r o b le m s a r i s e . 19 It m ay be necessary to d e p e n d on th e less d istinct im a g e o f p a n o r a m ic r a d io g r a p h s fo r assessm en t o f p o rtio n s o f la rg e r fibroo sseo u s in te g ra te d im p la n ts , b u t th e se sh o u ld be ac co m p an ie d by a p p ro p ria te periapical and bitewing radiographs. Microbiological examination
For those p a tie n ts w hose p e rio d o n tiu m d o es n o t re sp o n d to tra d itio n a l care, a m icrobiological sam pling with antibiotic sensitivity testing is often a p p ro p riate. It may be possible in th e fu tu re to pred ict b re a k d o w n u sin g m ic ro b io lo g ic a l a n d o th e r m e th o d s , b u t m o re r e s e a r c h is needed. Review of personal oral hygiene
O n e o f th e m o s t i m p o r ta n t ste p s to c o n tro l in fla m m a tio n a r o u n d te e th o r im plants is to m aintain optim al personal oral hygiene. Ideally this regim en would in clu d e a m anual to o th b ru sh an d som e type o f in te rp ro x im a l clea n in g aid. For p a tie n ts w ho c a n n o t o r w ill n o t u se in te r p r o m ix a l c le a n in g d e v ic e s, a m echanical toothbrush either with a single ro tatin g h ead 20 or with m ultiple rotatin g b ristle tu fts is re c o m m e n d e d . T h is last in s tru m e n t has b ee n show n to be m o re efficient in reducing dental plaque levels
Fig 4 ■ O nce the prosthetic superstructure is rem oved, a metallic ringing sound produced by s tr ik in g th e im p la n t is o n e in d ic a tio n o f continued osseo integration.
than a m anual b ru sh 2>; however, patients in th is stu d y d id n o t co m p ly w ith th e recom m ended twice-a-day use.9 Baab and o th e rs22 suggested th a t p a tie n ts d id n o t com ply b ecause six o f 24 (25% ) o f the devices were inoperable 6 m onths into the study. F o r p a t ie n t s w h o se h o m e c a re efforts and SPT com pliance do n o t arrest th e ir p e rio d o n ta l o r p e ri-im p la n t p ro b lem s, c h e m o th e ra p e u tic a g e n ts such as c h lo r h e x id in e c a n o f te n be u s e fu l in controlling gingivitis. Removal of subgingival accretions
Successful rem oval o f subgingival accre tio n s usually involves sc alin g a n d ro o t p la n in g . In g e n e r a l, p r o b in g p o c k e t depths o f 3 mm o r less can be cleaned by the dental professional with diligent effort. As p o c k e t p ro b in g d e p th s in crease, the task becom es m o re d au n tin g , a n d w hen prob in g pocket d ep th s reach 6 m m , the p ro b a b ility o f re m o v in g all d e p o s its is slim.23-24 In those d eep er pockets where an e q u ilib r iu m b e tw e e n b a c te ria a n d th e body cannot be achieved, surgery is often necessary.25 If prophylaxis tim e is limited, a r e a s w h e re p r o b in g d e p th s have increased or bleeding on probing is seen should be treated first. F o r d e n ta l im p la n ts , n o d e fin itiv e studies in vivo have b een p e rfo rm e d on th e m ost effective m e th o d s o f SPT, b u t until fu rth e r d ata are am assed, calcified im plant-bound accretions aro u n d titanium im plants (or titan iu m collars) should be rem oved with plastic instrum ents.26
P atien t com pliance to professionals’ sug gested SPT an d oral hygiene m easures is im portant; however, m any patients d o n o t c o m p ly a n d b e h a v io r m o d if ic a tio n te c h n iq u e s a re o fte n in d ic a te d . T h e se involve reinforcing positive behavior an d discovering m ethods to improve erratic or n o n c o m p lia n t p e rfo rm a n c e s . T h e te c h n iq u e s f o r u s e in th o s e s itu a tio n s go beyond the scope o f this p ap e r b u t texts can provide assistance.27-28 Scheduling S PT T h e in te rv a l fo r SPT s h o u ld b e d e te r m ined by disease activity. T he g reater the in c re a se in p o c k e t p ro b in g d e p th s a n d bleeding points, the m ore often a patient should be seen.29 T h e average patien t with periodontal disease o r o n e who has dental im p lan ts sh o u ld be seen fo u r tim es p e r year. E n o u g h tim e m u s t b e a llo w e d to a d e q u a te ly assess th e d e n t i t i o n a n d p erio d o n tiu m o r p eri-im p lan t tissue an d to p e r f o r m all th e th e ra p y n e e d e d to m aintain h ealth . For th e average p atien t with perio d o n tal disease, this takes ab o u t an hour. SPT accountability
T h e re c e n t W orld W orkshop in C linical P eriodontics50 suggested SPT for patients w ith g in g iv itis a n d early fo rm s o f p e ri o d o n titis be p e r f o rm e d in th e g e n e ra l d e n t i s t ’s o ffic e . A d v a n c e d a d u lt p e r i od ontitis can b e th e responsibility o f the periodontist; patients with m oderate adult periodontitis can often be shared between the two offices. In these cases seen in the g en e ral p ra c titio n e r’s office th a t d o n o t r e m a in s ta b le , c o n s u lta tio n w ith a periodontist was suggested. O th er form s of p erio d o n titis are b est m a in ta in ed by the periodontist. Summary
Removal of supragingival deposits
A fte r s u b g in g iv a l d e p o s its h av e b e e n
D ental m ain te n an c e, o r supportive p eri o d o n ta l tre a tm e n t (SP T ), can k ee p th e JADA, Vol. 121, O cto b er 1990 ■ 4 9 3
A R T I C L E S
p e r io d o n tiu m a n d p e ri-im p la n t tissues healthy after active therapy. Patients who c o m p ly to s u g g e s te d SPT fa r e b e t te r periodon tally and keep their teeth longer. Data should be gathered by exam inations, ta lk in g w ith p a tie n ts , a n d rev ie w in g p e r s o n a l o ra l h y g ie n e . T h e n sub- a n d s u p ra -g in g iv a l d e p o s its s h o u ld be removed. T he average SPT visit should last 1 hour and should be scheduled every 3 m onths. S u p p o rtiv e p e r io d o n ta l tr e a tm e n t fo r patients with m ore advanced periodontal o r peri-im plant destruction should be the responsibility o f the periodontist.
----------------- J!£OA -----------------
5 . W e s tfe ld E , N y m a n S, S o c r a n s k y S, L i n d h e J . S ig n ifican c e o f p ro fe s s io n a l to o th c le a n in g f o r h e a lin g
c la s s if ic a tio n , a n d d is e a s e a c tiv ity f o r p a t ie n t s w ith p e r i o d o n t a l d is e a s e s . In :W ils o n T G , e d .D e n ta l
fo llo w in g p e r i o d o n t a l s u r g e r y . J C lin P e r i o d o n t o l 1983; 10:149.
m a in te n a n c e f o r p a tie n ts w ith p e r i o d o n ta l d ise a se s. C h ic a g o Q u in te s s e n c e ; 1989:91. 19. S tr id KG. R a d io g ra p h ic p ro ced u re s.
6. L in d h e J , N y m a n S. L o n g -te rm m a in te n a n c e o f p a t ie n t s tr e a te d f o r a d v a n c e d p e r i o d o n ta l d is e a se . J
in te g r a te d p ro sth e se s. C h ic a g o :Q u in te s se n c e ; 1985:327. 2 0 . Boyd RL, M u rra y PA, R o b e rtso n PB. E ffe c t o n
T. C o m p lia n c e w ith m a in te n a n c e th e ra p y in a p riv a te
p e r i o d o n t a l s ta t u s o f r o t a r y e l e c tr i c t o o t h b r u s h e s d u r in g p e r i o d o n ta l m a in te n a n c e I. c lin ic a l re s u lts. J
p e rio d o n ta l p ra c tic e . J P e rio d o n to l 1984;55:468. 8. B e c k e r W, B e c k e r BE, B e rg LE . P e r io d o n ta l tr e a tm e n t w ith o u t m a in te n a n c e . A re tro sp e c tiv e stu d y in 44 p a tie n ts. J P e rio d o n to l 1984;55:505. 9 . B e c k e r W, B e rg L, B e c k e r B E. U n tr e a t e d p e rio d o n ta l disease: a lo n g itu d in a l study. J P e rio d o n to l 1979;50:234. 10. A x e ls s o n P, L i n d h e J . T h e s i g n i f i c a n c e o f m a i n t e n a n c e c a r e in th e t r e a t m e n t o f p e r i o d o n t a l d isea se . J C lin P e rio d o n to l 1981;8:281. 11. E c h e v e rria -G a rc ia JJ. C o m p lia n c e -P ro b le m e b e i d e r N a c h s o rg e v o n p a tie n te n m it p a r o d o n to p a th ie n . P h illip J R esto ra tiv e Z a h n m e d 1989;4:235.
Dr. W ilso n is in p riv a te p ra c tic e o f p e rio d o n tic s a n d i m p l a n t d e n t i s t r y in D a lla s ; a n a f f i l i a t e a s s i s t a n t
12. S c h m id t JK . P a tie n t c o m p lia n c e w ith su g g e s te d m a in te n a n c e re c a ll in a p riv a te p e r io d o n ta l p r a c tic e
p r o f e s s o r in g r a d u a t e p e r i o d o n t i c s , U n iv e rs ity o f W a s h i n g t o n ; l e c t u r e r in g r a d u a t e p e r i o d o n t i c s ,
( M a s te rs T h e s is ) . M ich ig an ;1 9 8 8 .
U n iv ersity o f N e b ra s k a ; a n d visiting associate p ro fe s s o r in g r a d u a te p e rio d o n tic s , B aylor U n iv ersity S c h o o l o f D en tistry . A d d re s s r e p r i n t re q u e s ts to Dr. W ilson, 8350 N C e n tr a l Expressw ay, S u ite M -2112, D allas 75206.
A nn
A rb o r:U n iv e rs ity
of
13. K now les JW , B u r g e tt FG, N issle RR, S h ick RA, M o r r is o n E C , R a m f jo r d SP. R e s u lts o f p e r i o d o n t a l t r e a t m e n t r e l a te d to p o c k e t d e p t h a n d a t t a c h m e n t level— e ig h t years. J P e rio d o n to l 1979;50:225. 14 . W i ls o n T G . C o m p l i a n c e . A r e v ie w o f t h e
1. A m e ric a n A c a d e m y o f P e rio d o n to lo g y . G lossary o f P e r i o d o n t i c T e r m s . J P e r i o d o n t o l . C h ic a g o :
lite ra tu r e w ith p o ssib le a p p lic a tio n s to p e rio d o n tic s. J P e r io d o n to l 1987;58:706.
A m e r i c a n A c a d e m y o f P e r i o d o n t o lo g y ;1 9 8 6 : (S u p p le m e n t);1 7 .
15. C a to n J . P e r io d o n ta l d ia g n o sis a n d d ia g n o s tic a id s. C h ic a g o :A m e ric a n A c a d e m y o f P e rio d o n to lo g y
2. A m e ric a n A c a d e m y o f P e r io d o n to lo g y . C u r r e n t p r o c e d u r a l te rm in o lo g y fo r p e rio d o n tic s . 5 th e d . C h ic a g o :A m e ric a n A c a d e m y o f P e r io d o n to l ogy; 1988:14. 3. M cC an n D. P e rio d o n ta l re s e a rc h : e x p lo rin g new h o riz o n s. JA D A 1989; 119:487. 4. W ils o n T G , G lo v e r M E , M a lik A K, S c h o e n JA ,
1989:1-6. 16. G ib b s C H , H ir s c h f e ld JW , L e e J G , L o w SB , M a g n u s s o n I, T h o u s a n d R R , e t al. D e s c r ip tio n a n d clin ic a l e v a lu a tio n o f a new c o m p u te riz e d p e rio d o n ta l p r o b e — T h e F l o r i d a p r o b e . J C li n P e r i o d o n t o l 1988;15:137. 17 . P i h l s t r o m
B L , A n d e r s o n K A, A e p p o l i D ,
D o r s e tt D . T o o th loss in m a i n t e n a n c e p a tie n ts in a
S c h a ffe r EM . A sso ciatio n b e tw e e n signs o f tr a u m a fro m
p riv a te p e r io d o n ta l 1987;58:231.
o c c lu s io n a n d p e r io d o n titis . J P e rio d o n to l 1986;57:1. 18. W i ls o n TG. E x a m in a tio n , d ia g n o s is ,
p ra c tic e .
494 ■ J A D A , V o l. 121, O ctober 1990
J
P e rio d o n to l
In :B ra n e m a rk P I, Z a rb GA, A lb rek tsso n T, ed s. T issu e
C lin P e rio d o n to l 1 9 8 4 ;1 1:504. 7. W ilson T G , G lo v er M E, S c h o e n J , B au s C, J a c o b s
P e rio d o n to l 1989;60:390. 2 1 . K illoy W J, L ove JW , L o v e J , F e d i PF, T ir a D E. T h e e ffec tiv e n ess o f a c o u n te r - r o ta r y a c tio n p o w e re d to o t h b r u s h a n d c o n v e n tio n a l to o t h b r u s h o n p la q u e re m o v a l a n d g in g iv al b le e d in g . A s h o r t te r m study. J P e rio d o n to l 1989;60:473. 2 2 . B a a b D A , J o h n s o n R H . T h e e f f e c t o f a n ew e l e c t r i c t o o t h b r u s h o n s u p r a g in g i v a l p l a q u e a n d g ingivitis. J P e rio d o n to l 1989;60:336. 2 3 . W a e r h a u g J . H e a l in g o f th e d e n t o e p i t h e l i a l ju n c t i o n fo llo w in g su b g in g iv a l p la q u e c o n tr o l. 11. As o b serv ed on 1978;49:119.
e x tra c te d
te e th . J
P e rio d o n to l
24. S ta m b a u g h RV, D ra g o o M , S m ith D M , C ara sal L. T h e lim its o f su b g in g iv a l sc a lin g . I n t J P e r io d o n tic s R esto ra tiv e D e n t 1981 ;1:31. 25. C affesse RG , S w eeney PL, S m ith BA. S calin g a n d r o o t p l a n i n g w ith a n d w i t h o u t p e r i o d o n t a l f la p su rg ery . J C lin P e rio d o n to l 1986; 13:205. 26 . T h o m so n -N e a l D, E vans G H , M e ffe rt RM . E ffects o f v ario u s p ro p h y la ctic tr e a tm e n t o n tita n iu m , s a p p h ire , a n d h y d ro x y la p atite-co a ted im p la n ts: an SEM study. I n t J P e rio d o n tic s R esto ra tiv e D e n t 1989;9:301. 27 . M e rc h e n b a u m D , T u rk D C. F a c ilita tin g tr e a tm e n t a d h e re n c e . N ew Y o rk :P len u m P ress; 1987. 2 8 . H a y n e s R B , S a c k e t t D C . C o m p l i a n c e w ith th e r a p e u ti c re g im e n s . B a l tim o r e jo h n s H o p k in s U n iv ersity P ress; 1976. 2 9 . W i ls o n T G . A t y p i c a l m a i n t e n a n c e v is it. In :W ilso n T G Jr. D e n ta l m a in te n a n c e fo r p a tie n ts w ith p e r io d o n ta l d iseases. C h ic a g o :Q u in te s se n c e ; 1989:90-5. 30. A m e ric a n
A cadem y
of
P e rio d o n to lo g y :
P r o c e e d i n g s o f t h e W o r ld W o r k s h o p in C li n ic a l P e r io d o n t ic s . C h ic a g o :A m e ric a n A c a d e m y o f P e rio d o n to lo g y ; 1989:IX-25.