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Earn

2 CE credits This course was written for dentists, dental hygienists, and assistants.

Periodontal Maintenance in Disease Prevention A Peer-Reviewed Publication Written by William L. Balanoff, DDS, MS, FICD

Publication date: January 2008 Review date: February 2011 Expiry date: January 2014

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This course has been made possible through an unrestricted educational grant from Zila Pharmaceuticals, Inc. The cost of this CE course is $49.00 for 2 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.


Educational Objectives

Figure 1. Periodontal disease progression

Upon completion of this course, the clinician will be able to do the following: 1. List and describe the rationale for periodontal maintenance and the components involved in a periodontal maintenance program. 2. List and describe patient compliance factors and the impact of noncompliance on periodontal outcomes. 3. List the considerations involved in the selection and recommendation of oral care devices for patients. 4. List and describe the risk for root caries and dentinal sensitivity in patients following periodontal therapy, as well as prevention and treatment options.

Periodontal Therapy

Abstract Periodontal disease occurs in the presence of pathogenic bacteria — periodontopathogens or periodontal 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 is key for long-term positive clinical outcomes, involving both in-office maintenance and meticulous home care. Professional care is required to remove subgingival biofilm and deposits, and to prevent periodontal disease progression. 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. Consideration should be given to techniques and protocols that aid compliance, and care should be taken to address each patient’s ability and willingness to perform daily oral hygiene as well as to address root caries risk and prevent unwanted sequelae.

Introduction Periodontal disease occurs in the presence of pathogenic bacteria — periodontopathogens or periodontal bacteria — in a susceptible host. As periodontal disease progresses, clinical attachment loss and bone loss occur. This leads to the development of periodontal pockets of increasing depth and complexity in untreated periodontal disease, adding to the difficulties of treatment and periodontal maintenance and increasing the patient’s caries risk due to root exposure (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, including immune and inflammatory responses, that determines the onset and progression of periodontal disease. This in turn is influenced by risk factors that include smoking, poor oral hygiene, gender, hormones and genetics.2,3,4 Nonetheless, periodontal bacteria must be present for the onset and progression of periodontal disease; in their absence periodontal disease would not occur. 2

The overall objectives of periodontal therapy are to halt disease progression, reduce pocket depths and, ideally, obtain clinical attachment gains. The underlying goals in meeting these objectives are to thoroughly remove periodontal bacteria and biofilm, debris, calculus and endotoxins and the root surface must be intact, free of calculus and compatible with oral hygiene goals. Mature biofilm (plaque) contains high levels of periodontal bacteria in a well-organized matrix, and its disruption and removal are essential. Ensuring that the root surfaces are smooth avoids providing a rough site for adhesion and recolonization by periodontal bacteria and the development of subgingival biofilm following treatment. The standard treatment for periodontal disease is nonsurgical scaling and root planing. In specific cases, the clinician may determine that surgical treatment is required to access specific areas and adequately treat advanced or deep periodontal pockets. The overall objectives remain the same whether nonsurgical or surgical therapy is performed. Periodontal therapy, when properly performed, is effective at removing subgingival calculus, biofilm, debris and endotoxins and at reducing subgingival bacterial levels. The continued or renewed presence of high levels of periodontal bacteria and complexes after active periodontal therapy negatively influences treatment outcomes, and periodontal bacteria can return to pretreatment levels in months or in as little as several days.5,6,7,8

Periodontal bacteria can return to pretreatment levels in as little as several days. Following active periodontal therapy, periodontal maintenance is required throughout the patient’s life. In its absence, active periodontal disease is likely to recur, with further clinical attachment loss and bone loss. 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 following periodontal therapy, involving both inoffice maintenance and meticulous home care to effectively remove plaque on a daily basis. www.ineedce.com


Periodontal maintenance is key for long-term positive clinical outcomes In-office periodontal maintenance In-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). If an established subgingival biofilm is present, this cannot be effectively removed by home care. Professional care is required to remove subgingival biofilm and to prevent periodontal disease progression.11 The combination of periodic professional care and home care to remove plaque is effective in substantially reducing the level of periodontopathogens in periodontal pockets as well as the proportion consisting of Porphyromonas gingivalis.12 Patient compliance is associated with lower tooth loss during periodontal maintenance. 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

55% of patients were noncompliant with maintenance therapy,15 while an earlier five-year assessment found 46.8% of patients were noncompliant, with older patients (over 40 years of age) being more compliant than younger patients.16 Another study found that 28% of patients did not comply with their first visit for periodontal maintenance.17 Patients who participate in oral hygiene studies and receive training in oral hygiene regimens have been found to revert to old habits after the study is completed, even when they retain the acquired skill set required to adequately perform oral hygiene.18 Once patients are not in regular contact with dental professionals, their compliance and motivation decrease,19 further underscoring the need for regular periodontal maintenance recare appointments to aid compliance. These visits provide an opportunity for patient motivation and reinforcement of good daily oral hygiene habits.20 Patients retain only a proportion of what they hear and are taught, and every individual learns at a different speed. Repeated instruction and reinforcement at regular recall appointments are indicated to help ensure that patients continue their oral hygiene protocol. It has been estimated that most patients brush for one minute, an inadequate length of time for thorough plaque removal.21 Respondents to surveys have indicated that less than 10% of patients floss daily and more than half of all patients never floss.22,23 Table 2. Non-compliance factors

The standard of care for visits for periodontal maintenance is at least four times per year. This can be adjusted based on the individual patient — less often for patients who show no disease recurrence or progression and demonstrate effective home care; more often for patients who perform home care ineffectively or are noncompliant, have predisposing risk factors for progression (such as being a smoker or immunocompromised), or present with recurrence. 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. On an ongoing basis, both professional care and adequate daily oral hygiene are required to remove supragingival and subgingival plaque. The periodontal maintenance program must meet the individual patient’s needs.13,14

On an ongoing basis, both professional care and adequate daily oral hygiene are required to remove supragingival and subgingival plaque. Patient compliance and motivation One of the main issues in periodontal maintenance is patient compliance, a well-recognized problem for all oral hygiene regimens, whether in periodontally involved patients or not. One recent retrospective study found that www.ineedce.com

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

It has also been demonstrated that patients experience a novelty effect with oral hygiene protocols and oral care devices. For instance, it has been shown that when a new powered toothbrush was recommended and selected for patients, after 12 months only 50% of the patients were still using the powered brush.24 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. Erratic patient compliance (noncompliance) has also been found to be associated with higher levels of root caries in periodontal maintenance patients.25

Giving in-office instructions with a new brush has been found to be effective in reinforcing home care oral hygiene.

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Home Care for Periodontal Maintenance 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 further home care goal is caries prevention. Young, immature dental plaque contains mainly grampositive streptococci, and the mature subgingival biofilm takes from 3 to 12 weeks to develop into a well-differentiated layer containing mainly periodontopathogens including Porphyromonas gingivalis and Treponema denticola.26,27,28 In addition, migrating bacteria can shift from supragingival plaque to subgingival sites as well as to different periodontal sites,29 further highlighting the importance of daily supragingival plaque removal. The accepted home oral hygiene care regimen is use of a toothbrush (manual or powered) plus either floss or interdental brushes. In the absence of flossing, investigators in one study found that a reduction in bleeding sites of only 35% was obtained with brushing alone.30 One study found that manual interdental brushes were more effective than floss for patients in periodontal maintenance;31 a second study concurred with these findings and found interdental brushes to be more effective even before thorough professional debridement,32 while a third study found floss and interdental brushes to be equally effective.33 Electric interdental devices (Hummingbird, Oral B; Interclean) have also been found to be as effective as floss.34,35 It has also been observed that patients experience more problems with dental floss than with interdental brushes.36 Table 3. Home care objectives Remove plaque before it matures Prevent development of gingivitis Prevent development of mature subgingival plaque

Manual and powered toothbrushes Manual 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, as well as different power brushes, 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 in trials. 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 (and simultaneously removing periodontopathogens present supragingivally).37 Warren et al., however, found that this depended on toothbrush design and found that a novel-design manual toothbrush was as effective as two powered toothbrushes in removing plaque when used in the participants’ normal manner (i.e., without additional training).38 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.39 Sonic brushes have been found to be more effective than manual brushes, especially in difficult-to-reach areas, for plaque removal.40 The sonic brush removes plaque through the physical action of the bristles vibrating against the tooth surface as well as through fluid dynamics created by the ultra high speed of the sonic brush. The fluid dynamics result in the creation of minute bubbles that are propelled against the tooth and help to remove plaque. Robinson et al. found that use of either a sonic brush or a rotary/oscillating brush improved oral health in periodontal patients, and that the improvements with the sonic brush were superior.41 In contrast, Bader and Boyd found use of a rotary

Figure 2. Powered brushes

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Rotary

Oscillating

Sonic www.ineedce.com


brush over a period of 12 weeks significantly more effective than a sonic brush in reducing plaque, the bleeding index and the gingival index.42 A small study involving dental hygiene students showed that a rotary powered brush 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.43 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 cleaning Most periodontal disease begins in the col area interdentally, where manual brushing alone has been proven ineffective. Therefore, any oral hygiene regimen 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 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.44 In comparing a rotary powered brush with another powered brushes, Bader and Williams found the rotary brush to be significantly superior interproximally and at furcations.45 Figure 3. Powered brush heads

While clinical results vary in different studies, 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 reported finding smaller brush heads preferable to larger brush heads.46 In addition, 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.47 Figure 4. Rotary powered brush head interdentally

Force and abrasion Applied force and abrasion are factors when considering toothbrush selection. Powered 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 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 4).48 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.49 Boyd et al. studied the forces applied using a rotary powered brush, two other powered brushes or a manual toothbrush and regular dentifrice in vivo. The manual toothbrush was found to result in the most applied pressure and the rotary powered brush the least applied pressure.50 In a similar comparison using in vitro testing, differences were also found in abrasivity with the same ranking of powered toothbrushes.51 Table 4. Force applied (van der Weijden et al.) Brush

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Force applied (g)

Manual

273

Powered brush 1

146

Powered brush 2

119

Rotary powered brush

96 5


McLey et al., in comparing three powered brushes and a manual brush, found that a rotary powered brush was more effective at removing stains and simultaneously less abrasive than a powered brush (a or b), with the manual brush being the least abrasive (20 µg/minute of material removed versus 35 µg/minute for the rotary powered brush, 57 µg/minute for another powered brush and 117 µg/minute for a third powered brush. In addition, stain removal was achieved at the 97.2% level (assessed spectrophotometrically) versus 78.5% for a manual brush and 70.6% for one of the powered brushes. The rotary powered brush left the smoothest surface.52 Schemehorn and Zwart found a powered brush 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 brush53 (Table 5). Table 5. Toothbrush abrasivity McLey et al.

Abrasivity

Manual Brush

20 µg/minute

Rotary powered brush

35 µg/minute

Powered brush (a)

57 µg/minute

Powered brush (b)

117 µg/minute

Schemehorn and Zwart

Abrasivity (RDA)

Powered brush

16

Manual Brush

100

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; these are carried out under laboratory conditions and the applied force and technique used for manual brushing is well controlled, 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. Lack of abrasivity is particularly important for periodontal patients with exposed roots, since dentin and cementum are more easily abraded than enamel. Using a technique and brush that results in the least possible abrasion helps preserve tooth structure (Figure 5). It is also important for direct and indirect esthetic restorations to preserve the integrity and appearance of these and avoid abrasion and subsequent changes in shape, luster and staining. 6

Figure 5. Advanced periodontal disease and abrasion

With respect to gingival abrasions, a recent study found no differences between two powered toothbrushes and soft manual brushes but did find that a powered toothbrush removed significantly more plaque than a manual toothbrush.54 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.55 Patient preference and selection considerations Given 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 and, additionally, depending on the powered brush selected, offers interdental cleaning where the patient may be noncompliant with manual interdental cleaning. Powered brushes with interdental cleaning heads offer a suitable compromise for such patients — 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 51%, while it was 92% for the patient group using rotary toothbrushes.56 He also found that 67% of rotary powered brush users exhibited good oral hygiene scores, compared to 25% of manual toothbrush users. Lack of abrasivity and reduced applied force favor powered brushes. Preventive care — caries and hypersensitivity In patients with periodontal disease, root exposure due to clinical attachment and bone loss ranges from minimal to a substantial length of the root being exposed, including the furcation areas of bicuspids and molars. 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.57 While individual experience was related to plaque levels, no relationship was found between coronal caries experience and root caries experience. Other studies have found root caries experience in periodontal maintenance patients of 88%.58 www.ineedce.com


Figure 6. Root caries

The root caries risk for periodontal patients is compounded by dentinal hypersensitivity. Such hypersensitivity results in painful episodes of sharp pain for the patient and 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, for both the prevention and treatment of pain and caries as well as patient compliance, the prevention and treatment of both conditions is an important consideration.

A recent study of patients under periodontal maintenance found that 82% had experienced root caries during the maintenance phase. 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 (Gluma), iontophoresis, lasers, amorphous calcium phosphate (ACP) and resins. Fluoride varnishes provide hypersensitivity relief and have the additional advantage of exposing the root surface to a very high concentration of fluoride for an extended period of time. Sodium fluoride varnish contains 5% sodium fluoride (22,600 ppm fluoride) and relieves hypersensitivity by forming globules that block the dentinal tubules — as well as initially providing relief through its temporary action as a physical barrier. At the same time the fluoride forms a protective layer that is available during acidogenic challenges. Consideration should be given to prescribing a prescription-only high-fluoride dentifrice containing 1.1% sodium fluoride for caries prevention. This has been shown to be effective in preventing and arresting root caries and offers the most fluoride available for home use.59 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.60 www.ineedce.com

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 rotary powered toothbrush in the rinse was found in one study to increase the efficacy of chlorhexidine gluconate rinse more than rinsing alone.61 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.62 Chewing gum can effectively combat a cariogenic challenge when used for at least 20 minutes immediately after eating or drinking. The use of a chewing gum containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) has also been shown in in situ studies to help remineralize teeth.63

Summary Periodontal therapy when appropriately utilized results in good clinical outcomes. However, patients are often noncompliant. Consideration should be given to techniques and protocols that aid compliance. The use of powered brushes has been shown to be at least as effective as use of manual brushes in general, including in periodontal maintenance patients. The use of a powered brush offers the patient efficacy with reduced time involvement and, depending on the brush head, may enable interdental cleaning in patients who are non-compliant with manual interdental cleaning techniques. In addition, it has been found that the risk of tooth abrasion and the application of force may be reduced with the use of a powered brush. Continued periodontal improvements depend on regular periodontal maintenance, encompassing both regular in-office maintenance visits and adequate home care. Periodontal maintenance is imperative for patients following active therapy. In addition to thorough in-office assessment, treatment and education of patients, care should be taken to address each patient’s ability and willingness to perform daily oral hygiene as well as to address root caries risk and prevent unwanted sequelae.

References

1 American Academy of Periodontology Research, Science and Therapy Committee Position Paper: 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

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manual toothbrush for efficacy in supragingival plaque removal and reduction of gingivitis. J Clin Periodontol. 1996;23(7):641–648. 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. 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. 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. 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. 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. 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. Heasman PA, McCraken GI. Powered toothbrushes: a review of clinical trials. J Clin Periodontol. 1999;26:407– 420. 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. Wiegand A, Lemmrich F, Attin T. Influence of rotatingoscillating, sonic and ultrasonic action of power toothbrushes on abrasion of sound and eroded dentine. J Periodontal Res. 2006;41(3):221–227. 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. 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. McLey L, Zahradnik R, Sarker S. Relative abrasiveness and cleaning efficiency of three powered brushing instruments. IADR Abstract, 1994;#501. Schemehorn BR, Zwart AC. The dentin abrasivity potential of a new electric toothbrush. Am J Dent. 1996;9 Spec No:S19–20. 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. 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.

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56 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. 57 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. 58 Ravald N, Birkhed D, Hamp SE. Root caries susceptibility in periodontally treated patients. Results after 12 years. J Clin Periodontol. 1993 Feb;20(2):124–129. 59 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. 60 Wiegand A, Lemmrich F, Attin T. Influence of rotatingoscillating, sonic and ultrasonic action of power toothbrushes on abrasion of sound and eroded dentine. J Periodontal Res. 2006 Jun;41(3):221–227. 61 Bader HI, Williams RC. Chlorhexidine efficacy enhancement by local application with powered rotary device. IADR Abstract, 1992. 62 van Loveren C. Sugar alcohols: what is the evidence for caries preventive and caries-therapeutic effects? Caries Res, 2004;38:286–293. 63 Touger-Decker R. Role of nutrition in the dental practice. Quintessence Int. Jan 2004;35(1):67–70.

Author Profile William L. Balanoff, DDS, MS, FICD Dr. Balanoff 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.

Disclaimer The author of this course is a speaker for Zila Pharmaceuticals, Inc.

Reader Feedback We encourage your comments on this or any PennWell course. For your convenience, an online feedback form is available at www.ineedce.com. 9


Online Completion

Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions 1. Periodontal bacteria must be present for the _________ of periodontal disease. a. onset b. absences c. progression d. a and c

2. The overall objectives of periodontal therapy include _________. a. to halt disease progression b. to reduce pocket depths c. to obtain clinical attachment gains d. all of the above

3. Mature biofilm (plaque) contains _________.

a. high levels of diphtheroids b. high levels of periodontal bacteria in a wellorganized matrix c. high levels of periodontal bacteria in a poorlyorganized matrix d. a and c

4. Periodontal bacteria can return to pretreatment levels in as little as _________. a. several days b. several weeks c. several months d. none of the above

5. Patients who do not receive regular periodontal maintenance have _________ than those who receive such care. a. fewer teeth with furcation involvement b. shallower probing depths and more tooth loss c. greater probing depths and more tooth loss d. none of the above

6. An _________ biofilm cannot be effectively removed by home care. a. early supragingival b. established supragingival c. early subgingival d. established subgingival

7. In-office periodontal maintenance should include _________.

a. a full evaluation and examination of the hard and soft tissues b. thorough removal of calculus and biofilm c. an assessment of the patient’s oral care and the adequacy of his or her oral hygiene d. all of the above

8. One of the main issues in periodontal maintenance is _________. a. finding appointment time for maintenance visits b. patient compliance c. the availability of scaler units d. all of the above

9. One recent retrospective study found that _________ of patients were noncompliant with maintenance therapy, while another five-year study found _________ to be noncompliant. a. 25%; 38% b. 35%; 42.6% c. 45%; 45.5% d. 55%; 46.8%

10. Once patients are not in regular contact with dental professionals, their _________. a. compliance decreases b. motivation decreases c. motivation increases d. a and b

10

11. It has been estimated that most patients brush for _________. a. thirty seconds b. forty-five seconds c. one minute d. two minutes

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

13. Erratic patient compliance has been found to be associated with _________ in periodontal maintenance patients. a. lower levels of oral cancer b. lower levels of root caries c. higher levels of root caries d. none of the above

14. The goal of daily oral hygiene procedures for periodontal maintenance is to _________. a. prevent biofilm from forming b. remove dental biofilm before it matures c. remove dental biofilm after it matures d. none of the above

15. Migrating bacteria can _________.

a. shift from supragingival plaque to subgingival sites b. shift to different periodontal sites c. cause paratitis d. a and b

16. The accepted home oral hygiene care regimen is _________. a. use of a toothbrush (manual or powered) b. use of a tongue irrigator c. use of either floss or interdental brushes d. a and c

17. _________ brushes have been found to be effective in trials. a. Rotary powered b. Powered c. Sonic d. all of the above

18. The rotary powered brush removes plaque through _________.

a. the physical action of the brush head against the tooth b. fluid dynamics c. hydrodynamics d. a and b

19. The sonic powered brush removes plaque through _________.

a. the physical action of the brush head against the tooth b. fluid dynamics c. hydrodynamics d. a and b

20. _________ found that improvements in periodontal health were superior with a sonic brush compared to a rotary powered brush. a. Robinson et al. b. Haraldsen et al. c. Boyd et al. d. none of the above

21. Bader and Boyd found use of a rotary powered brush over a period of _________ significantly more effective than use of a sonic brush. a. 10 weeks b. 12 weeks c. 14 weeks d. 16 weeks

22. Increased efficacy of plaque removal in a reduced time is an important consideration given _________. a. brush head wear and fatigue b. patient compliance issues c. memory lapse d. all of the above

23. Powered brush heads with rotating or spiraling filaments are _________ for interdental cleaning. a. ineffective b. effective c. not recommended d. not in existence

24. _________ is a design feature that aids interdental cleaning. a. An interdental brush head shape b. Active brush tips c. A round brush head shape d. a and b

25. _________ et al. found that more force was applied with use of a manual brush than with use of a powered brush. a. van der Veen b. van der Leijden c. van der Weijden d. none of the above

26. Powered brushes with interdental cleaning heads offer _________ for patients who are noncompliant with manual interdental cleaning. a. nothing b. an unsuitable compromise c. a suitable compromise d. none of the above

27. 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 enamel c. with sialitis d. none of the above

28. A recent study of patients under periodontal maintenance for between 11 and 22 years found that _________ had experienced root caries during the maintenance phase. a. 65% b. 73% c. 82% d. 91%

29. Fluoride varnish _________.

a. provides hypersensitivity relief b. exposes the root surface to a very high concentration of fluoride for an extended period of time c. exposes the root surface to a very high concentration of fluoride for a few minutes d. a and b

30. Remineralization and the prevention of demineralization of the root surface _________. a. can be aided by the use of a 1.1% sodium fluoride dentifrice b. are important to help prevent abrasion of the dentin root surface c. are not significant factors for periodontal patients d. a and b

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ANSWER SHEET

Periodontal Maintenance in Disease Prevention THIS COURSE ONLY AVAILABLE ONLINE Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information. 3) Complete test online. 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 online. For Questions Call 216.398.7822

Educational Objectives 1. List and describe the rationale for periodontal maintenance and the components involved in a periodontal maintenance program.

For immediate results, go to

www.ineedce.com The cost of this course is $49.00

2. List and describe patient compliance factors and the impact of non-compliance on periodontal outcomes. 3. List the considerations involved in the selection and recommendation of oral care devices for patients. 4. List and describe the risk for root caries and dentinal sensitivity in patients following periodontal therapy, prevention and treatment options.

Course Evaluation Please 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

Objective #4: 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

Yes

No

9. Would you participate in a similar program on a different topic?

10. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________ 11. Was there any subject matter you found confusing? Please describe. ___________________________________________________________________ ___________________________________________________________________ 12. What additional continuing dental education topics would you like to see? ___________________________________________________________________ ___________________________________________________________________

AGD Code 490, 149

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. AUTHOR DISCLAIMER The author of this course has lectured for the sponsors or the providers of the unrestricted educational grant for this course. SPONSOR/PROVIDER This 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 PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: macheleg@pennwell.com.

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INSTRUCTIONS All questions should have only one answer. This course can only be taken online. Participants will receive confirmation of passing once the test is taken online. Verification forms will be mailed within two weeks after taking an examination. EDUCATIONAL DISCLAIMER The 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 PennWell. 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/COST All participants scoring at least 70% on the examination will receive a verification form verifying 2 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 3274. The cost for courses ranges from $49.00 to $110.00. Many PennWell 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 PennWell course has been approved by DANB, please contact DANB’s Recertification Department at 1-800-FOR-DANB, ext. 445.

Customer Service 216.398.7822

RECORD KEEPING PennWell 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 POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. © 2011 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

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