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Periodontal maintenance: kicking it up a notch!

April 30, 2010
While economic downturns are admittedly difficult, it’s also a time to focus on core clients and manage your practice proactively. Lynne Slim, RDH, MS, and Rhonda Jones, RDH, BS, offer six ways for dental professionals to refocus their efforts on patient compliance with periodontal maintenance and kick it up a notch.
By Lynne Slim, RDH, MS, and Rhonda Jones, RDH, BSMary, a baby boomer, presents for supportive periodontal therapy (periodontal maintenance), but you notice she’s about three months overdue. After updating her health history, you ask her why it’s been six months since you last saw her, especially since she has a history of severe chronic periodontitis and osseous surgery with a local periodontist. She’s no longer alternating with the periodontist and has a good relationship with your long-term hygienist. Mary is insurance-driven, and she admits that she doesn’t want to pay out-of-pocket for supportive periodontal care. While economic downturns are admittedly difficult, it’s also a time to focus on core clients and manage your practice proactively. Dental professionals need to refocus their efforts on patient compliance with periodontal maintenance and kick it up a notch. There’s strong scientific evidence showing that patients in teaching institutions who make more frequent visits for ongoing periodontal care show a marked improvement in their periodontal condition, compared to those who do not follow the same maintenance regimen.1 In addition, patients placed on strict recare were more likely to maintain excellent plaque biofilm control and stable attachment levels over a six-year period when participating in institutional studies. Those patients who returned to their referring dentists for maintenance developed recurrent periodontal disease.1The concept of periodontal maintenance was originally conceived based on these institutional studies, and it’s been recognized that professional periodontal maintenance therapy is mandatory for long-term periodontal stability.1The main goal of periodontal therapy, nonsurgical and surgical, is to establish an oral environment compatible with periodontal health. This is achieved by the physical disruption of plaque biofilm and adjunctive local delivery agents if required.1 After the initial phase of periodontal treatment, ongoing maintenance includes the detection and interception of new and recurrent disease, and these maintenance intervals must continue for the life of the dentition.1In studies that have assessed erratic compliers with periodontal maintenance, 14% (0.06 teeth per patient per year) lost teeth, whereas none of the complete compliers lost teeth.1 Even if patients are poor compliers, keep in mind that 0.06 teeth per patient per year is still better than the loss of 0.61 per patient in untreated cases of chronic periodontitis.1 Researchers who have studied the degree of compliance with periodontal maintenance discovered in one U.S. study that of the 961 patients who were followed up to eight years, only 16% completely complied and 34% never returned.1 The overall general consensus is a big dropout rate in the first year following active periodontal treatment (about 30%), followed by a reduced attrition rate of up to 50-60% within the first five years. A profitable dental practice requires the right procedure mix. If you determine that your periodontal maintenance utilization rate is low, here are some recommendations for improvement: 1. Value periodontal therapy (in-house and referrals on a case-by-case basis) and make sure your patients understand your commitment to oral and general health. Risk assessment is one way to make sure you’re not underdiagnosing periodontal disease, and it’s easy to implement. Invest in a good risk assessment tool such as PreViser. 2. A hygienist or dentist cannot perform quality periodontal maintenance in a 30- to 45-minute time slot. Allow a full hour for periodontal maintenance and make sure that your hygienist is committed to clinical excellence. During that one-hour appointment, meticulous full-mouth ultrasonic debridement is essential, followed by polishing. Focus instrumentation on “active” sites with bleeding on probing and/or probing depths exceeding 5 mm. Localized “active” sites that do not respond to debridement and local delivery antimicrobials should be reevaluated by a local periodontist. Don’t waste time instrumenting shallow, nonbleeding sites. Use disclosing solution to make sure that all visible plaque biofilm is gone. A high standard of self-care is essential for long-term success, so take time to review self-care procedures at each periodontal maintenance appointment. Use a disclosing agent that will serve two functions: assessment of self-care measures and a way to evaluate professional perio maintenance intrumentation/polishing procedures.3. Schedule future periodontal maintenance appointments in the operatory. Don’t ever ask patients if they want to schedule; instead, tell them which month they’re due to come in and give them a few choices of dates and times. Try to re-schedule with the same clinician. Patients like consistency, and they also like developing relationships with a hygienist.4. Not enough time is spent on assessing a patient’s self-care measures. A high standard of self-care is essential for long- term periodontal health. If self-care measures are not taught early on, it may be difficult to get patients to comply. Repetition and review of self-care measures at each appointment is essential, and make sure you compliment the patient on his or her successes. Avoid lecturing and negative messages. Positive reinforcement can make a significant improvement to home care and attendance compliance.15. The absence of bleeding on probing (BOP) is a good predictor of periodontal stability. If you are seeing a patient every four months and find areas of BOP, tighten the recare interval to every three months. Explain to the patient that the absence of BOP is a good predictor of periodontal stability and that repeated BOP is associated with a significantly increased risk for attachment and tooth loss.1 Keep in mind that residual deep pockets ≥ 6 mm require further treatment and represent a greater risk factor for tooth loss. 6. Develop a good working relationship with a local periodontist who shares your philosophy and whom you can learn from as treatment paradigms for periodontal diseases continue to change.
Lynne Slim RDH, MS, is the periodontal therapy columnist for RDH magazine. She is president of Periocdent, LLC, a practice-management firm specializing in coaching dental hygienists to become more proactive in assessing and treating periodontal diseases nonsurgically. Her coaching enables dental hygiene departments to become more profitable through clinical excellence.
Rhonda Jones, RDH, BS, is a practice-management consultant with a unique and practical perspective in practice growth and team dynamics. She is president of Anderson & Associates, a firm that holds firmly to the belief that the dental staff is the most valuable resource in the dental practice. Rhonda can be reached at [email protected].

1. Tan AES. Periodontal maintenance. Australian Dental Journal 2009; 54:(1 Suppl):S110-117.