5

Periodontal Maintenance After Therapy

Educational ObjectivesUpon completion of this course, the clinician will be able to do the following:1. Understand the rationale for periodontal maintenance and the

components involved in a periodontal maintenance program.2. Be knowledgeable about patient compliance factors and the impact of non-

compliance on periodontal outcomes.3. Know the considerations involved in the selection and recommendation of oral

care devices and preventive therapies for patients.

AbstractPeriodontal disease occurs in the presence of pathogenic bacteria in a susceptible host. The overall objectives of periodontal therapy are to halt disease progression, reduce pocket depths and, ideally, obtain clinical attachment gains. Following active periodontal therapy, periodontal maintenance comprising both in-office and meticulous home care is key for long-term positive clinical outcomes. Consideration should be given to techniques and protocols that aid patient compliance, as well as to address root caries risk and prevent unwanted sequelae.

IntroductionPeriodontal disease occurs in the presence of periodontal bacteria in a susceptible host. As periodontal disease progresses, clinical attachment loss and bone loss increase (Figure 1). Advanced disease is found in up to 15% of adults, and the majority of people experience gingivitis or moderate levels of periodontal disease.1 It is known that it is mainly the host response that determines the onset and progression of periodontal disease, influenced by risk factors that include smoking, poor oral hygiene, gender, hormones and genetics.2,3,4 Nonetheless, in the absence of periodontal bacteria periodontal disease would not occur.

Periodontal TherapyThe standard treatment for periodontal disease is nonsurgical scaling and root planing. The overall objectives are to halt disease progression, reduce pocket depths and, ideally, obtain clinical attachment gains. Periodontal therapy, when properly performed, is effective

By William L. Balanoff, DDS, MS, FICD

Figure 1. Periodontal disease progression

CECourse

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Periodontal Maintenance After Therapy from page 5

at removing subgingival calculus, biofilm, debris and endotoxins and at reducing subgingival bacterial levels. At the end of therapy, the root surface must be intact, free of calculus and compatible with oral hygiene goals. The continued or renewed presence of high levels of periodontal bacteria after active periodontal therapy negatively influences treatment outcomes, and periodontal bacteria can return to pretreatment levels in as little as several days.5–8

Periodontal maintenance is key for long-term positive clinical outcomes following periodontal therapy, involving both in-office maintenance and meticulous home care.

Patients who do not receive regular periodontal maintenance have greater probing depths and more tooth loss than those who receive such care.9,10

Periodontal maintenance is key for

long-term positive clinical outcomes

In-office periodontal maintenanceIn-office periodontal maintenance should include a full evaluation and examination of the hard and soft tissues. Thorough removal of calculus and biofilm, including scaling and root planing at selected sites as indicated, is required (Table 1). The combination of periodic professional care and home care to remove plaque is effective in substantially reducing the level of periodontopathogens in periodontal pockets.11,12

Table 1. In-office periodontal maintenance

• Full evaluation of hard and soft tissues• Thorough removal of calculus and biofilm• Scaling and root planing at sites as indicated• Assessment of adequacy of patient’s oral hygiene • Patient education and motivation• Reinforcement of good oral hygiene habits

The standard of care for visits for periodontal maintenance visits at least four times per year. This can be adjusted based on the individual patient — less often or more often — depending on the presence of disease recurrence or progression, efficacy of home care, and predisposing risk factors. Regular in-office maintenance appointments enable the clinician to assess the current status of the patient’s oral care and the adequacy of his or her oral hygiene. The periodontal maintenance program must meet the individual patient’s needs.13,14

7

Regular professional care and adequate

daily oral hygiene are required for

periodontal maintenance

Patient compliance and motivationOne of the main issues in periodontal maintenance is patient compliance. One recent retrospective study found that 55% of patients were noncompliant with maintenance therapy.15 Another study found that 28% of patients did not comply with their first visit for periodontal maintenance.16 Non-compliance factors further underscore the need for regular periodontal maintenance recare appointments (Table 2). These visits provide an opportunity for patient motivation, repeated oral hygiene instruction and reinforcement of good daily oral hygiene habits.17

Table 2. Non-compliance factors

• Irregular contact with dental professional• Lack of understanding and retention of information• Lack of motivation to perform oral hygiene procedures• Lack of motivation to spend enough time on oral hygiene• Reverting to old habits• Novelty effect of a new oral care device wears off

Giving in-office instructions with a new brush — rather than asking a patient to buy one in a store and use it — has also been found to be effective in reinforcing the home care oral hygiene message and technique.

Giving in-office instructions with a new

brush has been found to be effective in

reinforcing home care oral hygiene

Home Care for Periodontal MaintenanceThe goal of daily oral hygiene procedures for periodontal maintenance is to remove dental biofilm before it matures so as to prevent the development of gingivitis and a mature subgingival plaque.

The accepted home oral hygiene care regimen is use of a toothbrush (manual or powered) plus floss or interdental brushes. Most patients have been estimated to brush for only one minute,18 and survey respondents have indicated that more than 50% of patients never floss.19,20 In the absence of flossing, a reduction in bleeding sites of only 35% was obtained with brushing alone in one study.21 One study found

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Periodontal Maintenance After Therapy from page 7

that manual interdental brushes were more effective than floss;22 a second study concurred with these findings,23 while a third study found floss and interdental brushes to be equally effective.24 Electric interdental devices have also been found to be as effective as floss.25,26

Manual and powered toothbrushesManual and powered brushes have both been found to be effective. An extensive number of trials and studies have been conducted comparing manual and power brushing, using a variety of protocols. Powered brushes include rotary, sonic and rotary/oscillating powered brushes (Figure 2), and all have been found to be effective.

Haffajee et al. found both powered and manual toothbrushes effective over a six-month period in reducing the levels of bacteria in periodontal pockets when used to remove supragingival plaque (simultaneously removing periodontopathogens present supragingivally).27 Warren et al., however, found that this depended on toothbrush design and found that a novel-design manual toothbrush (Oral B Pulsar) was as effective as two powered toothbrushes (Oral B CrossAction Power and Crest SpinBrush Pro) in removing plaque when used in the participants’ normal manner (i.e., without additional training).28 Another study in which participants received five weeks of professional oral hygiene training found no differences in plaque removal efficacy between use of a manual toothbrush and a powered toothbrush (Braun Oral B Plak Control 3D).29

Sonic brushes (Sonicare) have been found to be more effective than manual brushes, especially in difficult-to-reach areas, for plaque removal.30 Robinson et al. found that use of either a sonic brush (Sonicare) or a rotary/oscillating brush improved oral health in periodontal patients, and that the improvements with the sonic brush were superior.31 In contrast, Bader and Boyd found use of a rotary brush (Rota-dent) over a period of 12 weeks significantly more effective than a sonic brush (Sonicare) in reducing plaque, the bleeding index and the gingival index.32 A small study involving dental hygiene students showed that a rotary powered brush (Rota-

Figure 2. Powered brushes

Rotary Oscillating Sonic

9

dent) was significantly more effective at visual plaque removal than a manual brush and removed 75% of the plaque present in 30 seconds versus 15 seconds.33 While care should be taken in extrapolating data gathered from clinical students to the general population, in this case such an extrapolation would seem to be valid since expertise could be expected to improve manual brush efficacy and thereby reduce the time required for a given level of plaque removal. Given patient compliance issues discussed earlier, increased efficacy of plaque removal in a reduced time is an important consideration when recommending an oral hygiene protocol and brush to patients. In general, powered brushes offer an opportunity to accelerate cleaning for inadequate brushers.

Interdental cleaningOral hygiene regimens must adequately address interdental cleaning. In contrast to manual brushes, powered brushes have been found to be effective at cleaning interdentally as well as in furcation areas. When compared to the combined use of a manual toothbrush, floss and toothpicks, Murray et al. found a rotary brush (Rota-dent) equally effective at controlling gingivitis in study patients over a period of 12 months and equally effective at producing significant reductions in the levels of periodontopathic bacteria.34 In comparing Rota-dent and Interplak (Bausch and Lomb) powered brushes, Bader and Williams found the Rota-dent to be significantly superior interproximally and at furcations.35

Powered brush heads are typically smaller and more compact than manual brush heads, aiding access to difficult-to-reach areas. Patients in one study of sonic brushes (Sonicare) reported finding smaller brush heads preferable to larger brush heads.36 Recent designs have improved interdental cleaning using a powered brush — an important consideration given patients’ unwillingness to use interdental cleaners (in particular, floss). Brush heads with rotating or spiraling filaments are effective for interdental cleaning, and other design features that aid this include specific brush head shapes and active brush tips that reach into interdental sites.37

Force and abrasionPowered brushes have been compared in several studies to manual brushes for applied force and abrasivity. Van der Weijden et al. also studied brushing forces and

Figure 3. Powered brush heads

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Periodontal Maintenance After Therapy from page 9

found that more force was applied using a manual toothbrush than a powered toothbrush and that the applied force depended on the brush used (Table 3).38 In one in vitro study, sonic, rotary/oscillating and ultrasonic brushes were all found to abrade both sound and demineralized dentin more than a manual brush.39 Boyd et al. studied the forces applied in vivo using either a Rota-dent, Braun Oral B or Interplak powered toothbrush or a manual toothbrush (Oral B P40) and regular dentifrice. The manual toothbrush was found to result in the most applied pressure and the Rota-dent the least applied pressure.40 In a similar comparison using in vitro testing, differences were also found in abrasivity with the same ranking of powered toothbrushes.41

McLey et al., in comparing three powered brushes and a manual brush, found that the Rota-dent was more effective at removing stains and simultaneously less abrasive than a Braun or Interplak brush, with the manual brush being the least abrasive (20 µg/minute of material removed versus 35 µg/minute for the Rota-dent, 57 µg/minute for the Braun and 117 µg/minute for the Interplak. In addition, stain removal was achieved at the 97.2% level (assessed spectrophotometrically) versus 78.5% for a manual brush and 70.6% for a Braun powered brush. The Rota-dent also left the smoothest surface.42 Schemehorn

Figure 4. Rota-dent brush head interdentally

Table 3. Force applied (van der Weijden et al.)

Brush Force applied (g)Manual 273Braun/Oral B Plak Control 146Interplak 119Rota-dent 96

Table 4. Toothbrush abrasivity

McLey et al. AbrasivityManual Brush 20 µg/minuteRota-dent Brush 35 µg/minuteBraun/Oral B Plak Control Brush

57 µg/minute

Interplak Brush 117 µg/minute

Schemehorn and Zwart Abrasivity (RDA)

Oral B Ultra Plak Remover Brush

16

Manual Brush 100

11

and Zwart found a powered brush (Oral B Ultra Plak Remover) to be less abrasive on dentin than a standard ADA reference manual toothbrush, with a relative dentin abrasivity (RDA) of 16 compared to 100 for the manual brush43 (Table 4).

A manual toothbrush is controlled solely by the patient, and the patient must brush gently and use a soft bristle toothbrush to help prevent abrasion — particularly important for the exposed root surfaces in periodontal patients. This is also an important concept when interpreting in vitro test results as these are carried out under controlled laboratory conditions, whereas in normal daily life this is not the case. Powered brushes are controlled mechanically, and while it is possible to apply more force momentarily, current powered brushes are designed to cut out if too much pressure is applied. Using a technique and brush that results in the least possible abrasion helps preserve tooth structure as well as the integrity and esthetics of direct and indirect esthetic restorations (Figure 5).

With respect to gingival abrasions, a recent study found no differences between two powered toothbrushes (Braun Oral B Plak Control Ultra, Braun Oral B Plak Control 3D) and soft manual brushes.44 It should be noted that this study involved dental students well trained in the manual Bass tooth-brushing technique. Niemi et al., however, found more gingival abrasions using a V-shaped manual brush than a powered brush.45

Patient preference and selection considerationsGiven the issues of patient compliance addressed above, use of a powered brush offers a reduced time requirement for the same level of plaque efficacy and a “quicker” brushing experience. Powered brushes with interdental cleaning heads offer a suitable compromise for patients who are noncompliant with manual interdental cleaning — they may be willing to “brush interdentally” even if they are noncompliant with flossing or using individual manual interdental brushes. Bader found that patient compliance with recall was 92% for the patient group using rotary toothbrushes (Rota-dent), while it was 51% for patients using manual brushes.46 He also found that 67% of rotary-powered brush users exhibited good oral hygiene scores, compared to 25% of manual toothbrush users.

Preventive care — caries and hypersensitivityIn patients with periodontal disease, root exposure due to clinical attachment and bone loss occurs. Exposed roots are susceptible to caries due to the softness of dentin and any remaining overlying cementum (Figure 6). A recent study of patients under periodontal maintenance for between 11 and 22 years found that 82% had experienced root caries during the maintenance phase.47 Erratic patient compliance (noncompliance) has also been found to be associated with higher levels of root caries.48

Figure 5. Abrasion

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Periodontal Maintenance After Therapy from page 9

The root caries risk for periodontal patients is compounded by dentinal hypersensitivity that can be a factor in noncompliance, since the root surface becomes painful upon contact with stimuli such as toothpaste or water (temperature) or the action of a toothbrush (touch) against the exposed dentin. Therefore, the prevention and treatment of both caries and dentinal hypersensitivity is an important consideration.

Relief from hypersensitivity can be obtained by using a number of techniques at home or in-office. At-home remedies include the use of dentifrices containing either potassium nitrate, potassium chloride or stannous fluoride. In-office techniques include the use of glutaraldehyde, iontophoresis, lasers, amorphous calcium phosphate and resins, as well as fluoride varnishes (Vanish™, OMNII™; ProDenRx, Pro-Dentec®; Duraphat®, Colgate Oral Pharmaceuticals; Duraflor, Pharmascience). Fluoride varnishes have the additional advantage of exposing the root surface to a very high concentration of fluoride (22,600 ppm) for an extended period of time while relieving hypersensitivity by forming globules that block the dentinal tubules; a protective fluoride-rich layer forms on the tooth surface and is available during acidogenic challenges.

Consideration should be given to prescribing a prescription-only high-fluoride dentifrice containing 1.1% sodium fluoride for caries prevention49 (ProDenRx, Pro-Dentec®; PreviDent 5000 Plus®, Colgate Oral Pharmaceuticals; Fluoridex Daily Defense, Discus Dental; ControlRx™, OMNII™). Remineralization and the prevention of demineralization are also important to help prevent abrasion of the dentin root surface, as demineralized dentin has been shown to abrade more easily than sound dentin.50

Utilizing chemotherapeutics such as chlorhexidine gluconate to reduce microbial loads has also been shown to be effective as part of a preventive program. Applying 0.12% chlorhexidine gluconate rinse by dipping the microfilaments of a powered toothbrush (Rota-dent) in the rinse was found in one study to increase the efficacy of chlorhexidine gluconate rinse more than rinsing alone.51 However, the side effect of tooth staining precludes its long-term use for most patients. Consideration should also be given to advising patients to chew sugar-free gum at least three times daily for an extended period of time, as this has been shown to reduce the incidence of caries.52

SummaryPeriodontal therapy when appropriately utilized results in good clinical outcomes. Consideration should be given to techniques and protocols that aid patient compliance. The use of a powered brush offers the patient efficacy with reduced

Figure 6. Root caries

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time involvement and, depending on the brush head, may enable interdental cleaning in patients who are non-compliant with manual interdental cleaning techniques. It has been found that the risk of tooth abrasion may be reduced with the use of a powered brush. Periodontal maintenance is imperative for patients following active therapy. Care should be taken to address each patient’s ability and willingness to perform daily oral hygiene as well as his or her root caries risk.

References1 Epidemiology of Periodontal Diseases. J Periodontol. 2005;76:1406–1419.2 Mark LL, Haffajee AD, Socransky SS, et al. Effect of the interleukin-1genotype on monocyte IL-1beta expression

in subjects with adult periodontitis. J Perio Res. 2000;35:172–177.3 Koreeda N, Iwano Y et al. Periodic exacerbation of gingival inflammation during the menstrual cycle. J Oral Sci.

2005;47(3):159–164.4 American Academy of Periodontology Research, Science and Therapy Committee Position Paper:

Epidemiology of periodontal diseases. J Periodontol. 2005;76:1406–1419.5 Mousques T, Listgarten MA, Phillips RW. Effect of scaling and root planing on the composition of human

subgingival microbial flora. J Perio Res. 1980;15:144–151. 6 Magnusson I, Lindhe J, Yoneyama T, Liljenberg B. Recolonization of a subgingival microbiota following scaling

in deep pockets. J Clin Periodontol. 1984;11:193–207.7 Lavanchy D, Bickel M, Bachni P. The effect of plaque control after scaling and root planing on the subgingival

microflora in human periodontitis. J Clin Periodontol. 1987:14:295–299.8 van Winkelhoff AJ, van der Velden U, de Graaff J. Microbial succession in recolonizing deep periodontal

pockets after a single course of supra- and subgingival debridement. J Clin Periodontol. 1988;15:116–122.9 Bostanci HS, Arpak MN. Long-term evaluation of surgical periodontal treatment with and without maintenance

care. J Nihon Univ Sch Dent. 1991;33:152–159.10 DeVors CH, Duckworth DM, Beck FM, et al. Bone loss following periodontal therapy in subjects without

frequent periodontal maintenance. J Periodontol. 1986;57:354–359.11 Westfelt E, Rylander H, Dahlen G, Lindhe J. The effect of supragingival plaque control on the progression of

advanced periodontal disease. J Clin Periodontol. 1998;25(7):536–541.12 Hellström MK, Ramberg P, Krok L, Lindhe J. The effect of supragingival plaque control on the subgingival

microflora in human periodontitis. J Clin Periodontol. 1996;23(10):934–940.13 Axelsson P, Lindhe J. The significance of maintenance care in the treatment of periodontal disease. J Clin

Periodontol. 1981;8:281–294.14 Ramfjord SP, Morison EC, Burgett FG, et al. Oral hygiene and maintenance of periodontal support. J

Periodontol, 1982;53:26–30.15 Novaes Júnior AB, Novaes AB. Compliance with supportive periodontal therapy. Part II: Risk of non-compliance

in a 10-year period. Braz Dent J. 2001;12(1):47–50.16 Ojima M, Hanioka T, Shizukuishi S. Survival analysis for degree of compliance with supportive periodontal

therapy. J Clin Periodontol 2001;28:1091–1095.17 Huntley, DE. Five principles of patient education. Dent Hyg. September 1979.18 Baehni PC. Takeuchi Y. Antiplaque agents in the prevention of biofilm-associated oral disease. Oral Diseases.

2003;9 (suppl):23–29.19 Craig T, Montigue J. Family oral health survey. J Am Dent Assoc. 1976;92:326–332. 20 www.docere.com. HygieneTown Survey. July 2005.21 Graves R et al. Comparative effectiveness of flossing and brushing in reducing interproximal bleeding. J

Periodontol. 1989;60(5):243–247.22 Rösing CK, Daudt FA, Festugatto FE, Oppermann RV. Efficacy of interdental plaque control aids in periodontal

maintenance patients: A comparative study. Oral Health Prev Dent. 2006;4(2):99–103.23 Jackson MA, Kellett M, Worthington HV, Clerehugh V. Comparison of interdental cleaning methods: a

randomized controlled trial. J Periodontol. 2006;77(8):1421–1429.24 Noorlin I, Watts TL. A comparison of the efficacy and ease of use of dental floss and interproximal brushes

in a randomised split mouth trial incorporating an assessment of subgingival plaque. Oral Health Prev Dent. 2007;5(1):13–18.

25 Gordon JM, Frascella JA, Reardon RC. A clinical study of the safety and efficacy of a novel electric interdental cleaning device. J Clin Dent. 1996;7(3 Spec No):70–73.

26 Isaacs RL, Beiswanger BB, Crawford JL, Mau MS, Proskin H, Warren PR. Assessing the efficacy and safety of an electric interdental cleaning device. J Am Dent Assoc. 1999;130(1):104–108.

27 Haffajee AD, Smith C, Torresyap G, Thompson M, Guerrero D, Socransky SS. Efficacy of manual and powered toothbrushes (II). Effect on microbiological parameters. J Clin Periodontol. 2001;28(10):947–954.

28 Warren P, Thompson M, Cugini M. Plaque removal efficacy of a novel manual toothbrush with MicroPulse bristles and an advanced split-head design. J Clin Dent. 2007;18(2):49–54.

29 Danser MM, Timmerman MF, Jzerman Y, Piscaer MI, van der Velden U, van der Weijden GA. Plaque removal with a novel manual toothbrush (X-Active) and the Braun Oral-B 3D Plaque Remover. J Clin Periodontol. 2003;30(2):138–144.

30 Tritten CB, Armitage GC. Comparison of a sonic and a manual toothbrush for efficacy in supragingival plaque removal and reduction of gingivitis. J Clin Periodontol. 1996;23(7):641–648.

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About the Author:William L. Balanoff, DDS, MS, FICD received his dental degree from Northwestern University and his masters in craniofacial research from Nova Southeastern University. He is an adjunct assistant clinical professor at University of Tennessee and a former assistant clinical professor at Nova Southeastern University teaching postgraduate prosthodontics; specifically implant surgery and reconstruction to the prosthodontic residents.

Dr. Balanoff is the owner of a multilocation fee for service group practice in the south Florida area. He is on staff at Broward General Hospital and North Broward Hospital with privileges for implant surgery and

reconstruction. Dr. Balanoff is on the editorial board of Compendium and is a consultant for Zila Pharmaceuticals.

Best of all he has three wonderful children and an incredible wife who allows him to live his dreams.

31 Robinson PJ, Maddalozzo D, Breslin S. A six-month clinical comparison of the efficacy of the Sonicare and the Braun Oral-B electric toothbrushes on improving periodontal health in adult periodontitis patients. J Clin Dent. 1997;8(1 Spec No):4–9.

32 Bader HI, Boyd RL. Comparative efficacy of a rotary and a sonic powered toothbrush on improving gingival health in treated adult periodontitis patients. Am J Dent. 1999;12(3):143–147.

33 Preber H, Ylipaa V, Bergstrom J, Ryden H. A comparative study of plaque removing efficiency using rotary electric and manual toothbrushes. Swed Dent J. 1991;15:229–234.

34 Murray PA, Boyd RL, Robertson PB. Effect on periodontal status of rotary electric toothbrushes vs. manual toothbrushes during periodontal maintenance. II. Microbiological results. J Periodontol. 1989;60(7):396–401.

35 Bader H, Williams R. Clinical and laboratory evaluation of powered electric toothbrushes: comparative efficacy of two powered brushing instruments in furcations and interproximal areas. J Clin Dent. 1997;8(3 Spec No):91–94.

36 Harpenau L. Clinical comparison of plaque removal and gingival bleeding reduction by two different brush heads on a sonic toothbrush. J Clin Dent. 2000;11(2):29–34.

37 Heasman PA, McCraken GI. Powered toothbrushes: a review of clinical trials. J Clin Periodontol. 1999;26:407–420.

38 van der Weijden GA, Timmerman MF, Reijerse E, Snoek CM, van der Velden U. Toothbrushing force in relation to plaque removal. J Clin Periodontol. 1996;23(8):724–729.

39 Wiegand A, Lemmrich F, Attin T. Influence of rotating-oscillating, sonic and ultrasonic action of power toothbrushes on abrasion of sound and eroded dentine. J Periodontal Res. 2006;41(3):221–227.

40 Boyd RL, McLey L, Zahradnik R. Clinical and laboratory evaluation of powered electric toothbrushes: in vivo determination of average force for use of manual and powered toothbrushes. J Clin Dent. 1997;8(3 Spec No):72–75.

41 McLey L, Boyd RL, Sarker S. Clinical and laboratory evaluation of powered electric toothbrushes: laboratory determination of relative abrasion of three powered toothbrushes. J Clin Dent. 1997;8(3 Spec No):76–80.

42 McLey L, Zahradnik R, Sarker S. Relative abrasiveness and cleaning efficiency of three powered brushing instruments. IADR Abstract, 1994;#501.

43 Schemehorn BR, Zwart AC. The dentin abrasivity potential of a new electric toothbrush. Am J Dent. 1996;9 Spec No:S19–20.

44 Mantokoudis D, Joss A, Christensen MM, Meng HX, Suvan JE, Lang NP. Comparison of the clinical effects and gingival abrasion aspects of manual and electric toothbrushes. J Clin Periodontol. 2001 Jan;28(1):65–72.

45 Niemi ML, Ainamo J, Etemadzadeh H. Gingival abrasion and plaque removal with manual versus electric toothbrushing. J Clin Periodontol. 1986 Aug;13(7):709–713.

46 Bader HI. Ten-year retrospective observations of the impact of a rotary-powered brush vs. manual techniques in periodontal maintenance. Compendium. 2004;25(6):1–7.

47 Reiker J, van der Velden U, Barendregt DS, Loos BG. A cross-sectional study into the prevalence of root caries in periodontal maintenance patients. J Clin Periodontol. 1999 Jan;26(1):26–32.

48 Pepelassi E, Tsami A, Komboli M. Root caries in periodontally treated patients in relation to their compliance with suggested periodontal maintenance intervals. Compend Contin Educ Dent. 2005;26(12):835–844.

49 Baysan A, et al. Reversal of primary root caries using dentifrices containing 5,000 and 1,000 ppm fluoride. Caries Res. 2001;35:41–46.

50 Wiegand A, Lemmrich F, Attin T. Influence of rotating-oscillating, sonic and ultrasonic action of power toothbrushes on abrasion of sound and eroded dentine. J Periodontal Res. 2006 Jun;41(3):221–227.

51 Bader HI, Williams RC. Chlorhexidine efficacy enhancement by local application with powered rotary device. IADR Abstract, 1992.

52 van Loveren C. Sugar alcohols: what is the evidence for caries preventive and caries-therapeutic effects? Caries Res, 2004;38:286–293.

15

Questions

1. Periodontal bacteria must be present for the onset and progression of periodontal disease.a. Trueb. False

2. The overall objectives of periodontal therapy include _________.a. to halt disease progressionb. to reduce pocket depthsc. to obtain clinical attachment gainsd. all of the above

3. Periodontal bacteria can return to pretreatment levels in as little as several days.a. Trueb. False

4. In-office periodontal maintenance should include _________.a. a full evaluation and examination of the hard and soft tissuesb. thorough removal of calculus and biofilmc. an assessment of the patient’s oral care and the adequacy of his

or her oral hygiened. all of the above

5. One of the main issues in periodontal maintenance is _________. a. finding appointment time for maintenance visitsb. patient compliancec. the availability of scaler unitsd. all of the above

6. One recent retrospective study found that _________ of patients were noncompliant with maintenance therapy, while another study found _________ did not comply with their first visit for periodontal maintenance.a. 25%; 38%b. 35%; 42%c. 45%; 45% d. 55%; 28%

7. It has been estimated that most patients brush for _________.a. thirty seconds b. forty-five secondsc. one minuted. two minutes

8. Less than _________ of patients floss daily.a. 50%b. 35%c. 15%d. 10%

9. Erratic patient compliance has been found to be associated with higher levels of root caries in periodontal maintenance patients.a. Trueb. False

10. The goal of daily oral hygiene procedures for periodontal maintenance is to remove dental biofilm before it matures so as to prevent the development of gingivitis and a mature subgingival plaque. a. Trueb. False

11. The accepted home oral hygiene care regimen is _________.a. use of a toothbrush (manual or powered)b. use of a tongue irrigatorc. use of either floss or interdental brushesd. a and c

12. Rotary, sonic and rotary/oscillating powered brushes have all been found to be effective in trials. a. Trueb. False

13. _________ found that use of either a sonic brush (Sonicare) or a rotary/oscillating brush improved oral health in periodontal patients, and that the improvements with the sonic brush were superior.a. Robinson et al.b. Haraldsen et al.c. Boyd et al.d. none of the above

14. Bader and Boyd found use of a rotary brush (Rota-dent) over a period of 12 weeks significantly more effective than use of a sonic brush (Sonicare).a. Trueb. False

15. Increased efficacy of plaque removal in a reduced time is an important consideration given _________.a. brush head wear and fatigueb. patient compliance issuesc. memory lapsed. all of the above

16. Design features that aid interdental cleaning include specific brush head shapes and active brush tips that reach into interdental sites. a. Trueb. False

17. van der Weijden et al. found that more force was applied with use of a manual brush than with use of a powered brush.a. Trueb. False

18. Powered brushes with interdental cleaning heads offer a suitable compromise for patients who are noncompliant with manual interdental cleaning.a. Trueb. False

19. Lack of abrasivity while brushing is particularly important for periodontal patients _________. a. with exposed roots, since dentin and cementum are more difficult

to abrade than enamel b. with exposed roots, since dentin and cementum are more easily

abraded than enamelc. with sialitisd. none of the above

20. The prevention of demineralization and remineralization of root surface _________.a. can be aided by the use of a 1.1% sodium fluoride dentifriceb. are important to help prevent abrasion of the dentin root surfacec. is an important component of care for patients at risk for

root caries d. all of the above

16

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SPONSOR/PROVIDERThis course was made possible through an unrestricted educational grant. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to the ADTS or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com.

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INSTRUCTIONSAll questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a certificate. Certificates will be mailed within two weeks after taking an examination.

EDUCATIONAL DISCLAIMERThe opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of the ADTS.

Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

COURSE CREDITS/COSTAll participants scoring at least 70% (answering 14 or more questions correctly) on the examination will receive a certificate verifying 2 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact ADTS for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. The ADTS is a California Provider. The California Provider number is 3274. The cost for courses ranges from $24.00 to $110.00.

Many ADTS self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANB’s annual continuing education requirements. To find out if this course or any other ADTS course has been approved by DANB, please contact DANB’s Recertification Department at 1-800-FOR-DANB, ext. 445.

RECORD KEEPINGThe ADTS maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt.

CANCELLATION/REFUND POLICYAny participant who is not 100% satisfied with this course can request a full refund by contacting the Academy of Dental Therapeutics and Stomatology in writing.

© 2008 by the Academy of Dental Therapeutics and Stomatology

AGD Code 490,149

ANSWER SHEET

Periodontal Maintenance After Therapy

Name: Title: Specialty:

Mailing Address: E-mail Address:

City: State: ZIP:

Telephone: Home ( ) Office ( )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to The Academy of Dental Therapeutics and Stomatology OR PennWell Corp.

Educational Objectives1. Understand the rationale for periodontal maintenance and the components involved in a periodontal

maintenance program.

2. Be knowledgeable about patient compliance factors and the impact of non-compliance on periodontal outcomes.

3. Know the considerations involved in the selection and recommendation of oral care devices and preventive therapies

for patients.

Course EvaluationPlease evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No

Objective #2: Yes No

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Do you feel that the references were adequate? Yes No

9. Would you participate in a similar program on a different topic? Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them.

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11. Was there any subject matter you found confusing? Please describe.

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12. What additional continuing dental education topics would you like to see?

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