Periodontal maintenance in a specialist periodontal clinic and in general dental practice

Supportive periodontal care in dental practice: Part 2 - perceptions of locally referring UK general dental practitioners

Background Supportive periodontal care (SPC) is important in maintaining periodontal treatment outcomes. Hospital services provide specialist periodontal care at high costs. On completion of treatment, patients are discharged back to the general dental practitioner (GDP) to provide SPC. This project aimed to evaluate the change in GDPs' understanding of SPC over more than 20 years.Method A validated questionnaire about SPC was sent to GDPs during 1996 (397) and 2020 (300), with a response rate of 74% and 52%, respectively. The anonymous data were entered on a Microsoft Excel spreadsheet for analysis.Results In total, 98.5% of the GDPs in 1996 and 97% in 2020 perceived SPC to be highly important. Additionally, 49% in 2020 had a better understanding of SPC when compared to 1996 (42%). Finally, 70-74% (1996, 2020) of the GDPs indicated that they were responsible for SPC; however, 13-16% said that they were not.Conclusion and clinical relevance Notwithstanding the lower response rate in 2020, there has been an improvement in understanding and awareness of responsibility of SPC among GDPs. Reported challenges of provision were related to education and funding. If GDPs are to effectively deliver SPC, education and current funding should be addressed to prevent compromised treatment outcomes for patients.

Supportive periodontal care in dental practice: Part 1 - the importance and implications for general dental practitioners

Supportive periodontal care is an essential component of maintaining the outcome of periodontal treatment. It is essential to ensure cost benefit to both patients and the health services where millions are spent on treating patients with periodontal disease. The dentist must be able to recognise the crucial and important role they play in providing supportive care and therapy to periodontally compromised patients, either independently or as part of a wider dental team, over and above the various challenges they may experience in the provision of such care in general dental practice. The timely intervention with treatment or referral during this phase will help reduce the risk of tooth loss and adverse consequences to the dentist and their team by way of litigation. The aim of this paper is to provide an update on the delivery of supportive periodontal care in general dental practice with a particular reference to the role of the dentist.

Effect of compliance during periodontal maintenance therapy on c-reactive protein levels: a 6-year follow-up

AIMS

To longitudinally evaluate the effects of compliance during periodontal maintenance therapy (PMT) on C-reactive protein (CRP) levels and its relation to periodontal status.

MATERIALS AND METHODS

A subsample comprising of 30 matched pairs was taken from a previous 6-year longitudinal study under PMT. Pairs were composed of one regular (RC) and one irregular (IC) compliers, matched by age and sex. Periodontal parameters and plasma samples were collected at 3 times: T1[prior to active periodontal therapy (APT)], T2(after APT), and T3(after 6 years). CRP plasma levels were quantified using ELISA.

RESULTS

RC presented better clinical periodontal status, lower recurrence of periodontitis (sites with PD ≥4 mm and CAL ≥3 mm, together with the persistence and/or presence of BOP and/or suppuration, during any of the subsequent recall evaluations) and significant reductions in CRP levels over time [(T1: RC = 3.64 ± 2.13 and IC = 3.92 ± 2.02 mg/L) and (T3: RC = 2.12 ± 1.39 mg/L and IC = 3.71 ± 1.82 mg/L)]. Logistic regression analysis demonstrated that individuals with periodontitis recurrence presented 2.19 higher chances of presenting altered CRP levels (values ≥3 mg/L- T2 to T3) than those without periodontitis recurrence (95%CI:1.16-3.27; p = 0.017).

CONCLUSIONS

Higher CRP plasma levels were associated with higher recurrence of periodontitis and worse clinical periodontal parameters among IC when compared to RC.

Knowledge, dentist confidence and management of periodontal patients among general dentists from Belarus, Lithuania, Macedonia, Moldova and Romania

BACKGROUND

Evidence concerning periodontal practice in Eastern European countries is scarce. The aim of the present study was to investigate periodontal risk knowledge, patient management and self-perceived confidence among General Dentists (GDs) from five Eastern European regarding their provision of periodontal care.

METHODS

GDs from Belarus, Lithuania, Macedonia, Moldova and Romania participated in a questionnaire survey. Power calculations were used to identify the sample size for each country. The structured questionnaire included several domains of inquiry. The socio-demographic domain inquired about dentist's age, gender and years of clinical experience. The dental practice domain inquired about practice location, practising or not practising in a group practice and having or not having a periodontist or a dental hygienist in the practice. The distributions of answers across-countries were compared employing one way ANOVA (comparison of means) or Chi square test (comparison of proportions). For each country, the predictors of the study outcomes: a summative knowledge score for periodontal risks and dentist's confidence level were identified employing either linear or logistic multiple regression models.

RESULTS

The sample comprised 390 Belarussian, 488 Lithuanian, 349 Macedonian, 316 Moldovan, and 401 Romanian GDs. The majority of GDs (~ 80%) practiced in urban areas. Age and gender distributions differed significantly among countries. Significant across-country differences were found regarding working/not working in a group practice, having/not having access to a periodontist/dental hygienist and in proportions of patients receiving periodontal treatments or being referred to specialists. None of Macedonian patients nor the majority of Moldovan patients (78%) were referred to periodontists. There were also significant across-country differences in diagnosis, patient management and periodontal knowledge. Only in the Lithuanian cohort were dentists' confidence levels associated significantly with their knowledge. In all countries, taking a medical history was a consistent and significant predictor of having higher periodontal knowledge score. Except in Belarus, periodontal risk assessment was a significantly consistent predictor of certainty levels associated with the provision of periodontal treatments.

CONCLUSIONS

There were substantial differences among GDs in the five countries regarding diagnosis, dentist's confidence and management of periodontal patients.

Effect of compliance during periodontal maintenance therapy on levels of bacteria associated with periodontitis: A 6-year prospective study

BACKGROUND

It is well established that regular compliance during periodontal maintenance therapy (PMT) maintains the stability of periodontal clinical parameters obtained after active periodontal therapy (APT). However, compliance during PMT has not yet been related to subgingival bacterial levels. Thus, this study followed individuals in PMT over 6 years and longitudinally evaluated the effects of compliance on periodontitis-associated bacterial levels and its relation to periodontal status.

METHODS

From a 6-year prospective cohort study with 212 individuals in PMT, 91 were determined to be eligible. From this total, 28 regular compliers (RC) were randomly selected and matched for age and sex with 28 irregular compliers (IC). Complete periodontal examination and microbiological samples were obtained 5 times: T1 (prior to APT), T2 (after APT), T3 (2 years), T4 (4 years), and T5 (6 years). Total bacteria counts and levels of Actinomyces naeslundii, Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola were evaluated through quantitative polymerase chain reaction.

RESULTS

RC had less tooth loss and better clinical and microbiological conditions over time when compared with IC. IC had higher total bacterial counts and higher levels of T. denticola. Moreover, among IC, total bacterial counts were positively associated with plaque index and bleeding on probing, while levels of A. naeslundii, T. forsythia, and T. denticola were negatively associated with clinical attachment loss (4 to 5 mm) among RC.

CONCLUSIONS

Compliance positively influenced subgingival microbiota and contributed to stability of periodontal clinical status. Regular visits during PMT sustained microbiological benefits provided by APT over a 6-year period.

Tooth loss after periodontal treatment-Mining an insurance database

OBJECTIVES

The aim of this study was to evaluate tooth loss after periodontal treatment.

METHODS

The data was collected from the digital database of a major German national health insurance company. Periodontal treatment was the intervention in the treatment group. Kaplan-Meier survival analyses on the patient level with the primary outcome extraction were carried out over four years. A control group without treatment was matched and analysed. Differences were tested with the Log-Rank-test. Extraction incidences were calculated over a matched observation period six years before and four years after treatment for both treatment and control group.

RESULTS

A total of 415,718 periodontal treatments could be traced. Focussing on the outcome "extraction", the cumulative four-year survival rate was 63.8% after periodontal treatment. The matched control group without periodontal treatment showed a survival rate of 72.5%. These differences were significant (p < 0.0001). The extraction incidence over time was higher in a four-year period after periodontal treatment compared to a six-year period before periodontal treatment.

CONCLUSIONS

The outcome of periodontal treatment was acceptable. In about two thirds of the patients, extractions could be completely avoided within a four year period after treatment.

CLINICAL SIGNIFICANCE STATEMENT

This study within the German national health insurance system shows that extractions were not observed after periodontal treatment in the majority of cases. Although periodontitis is a chronic disease, patients suffering from periodontitis have a considerable chance to prevent further tooth loss.

Supportive periodontal therapy (SPT) for maintaining the dentition in adults treated for periodontitis

BACKGROUND

Periodontitis is a bacterially-induced, chronic inflammatory disease that destroys the connective tissues and bone that support teeth. Active periodontal treatment aims to reduce the inflammatory response, primarily through eradication of bacterial deposits. Following completion of treatment and arrest of inflammation, supportive periodontal therapy (SPT) is employed to reduce the probability of re-infection and progression of the disease; to maintain teeth without pain, excessive mobility or persistent infection in the long term, and to prevent related oral diseases.According to the American Academy of Periodontology, SPT should include all components of a typical dental recall examination, and importantly should also include periodontal re-evaluation and risk assessment, supragingival and subgingival removal of bacterial plaque and calculus, and re-treatment of any sites showing recurrent or persistent disease. While the first four points might be expected to form part of the routine examination appointment for periodontally healthy patients, the inclusion of thorough periodontal evaluation, risk assessment and subsequent treatment - normally including mechanical debridement of any plaque or calculus deposits - differentiates SPT from routine care.Success of SPT has been reported in a number of long-term, retrospective studies. This review aimed to assess the evidence available from randomised controlled trials (RCTs).

OBJECTIVES

To determine the effects of supportive periodontal therapy (SPT) in the maintenance of the dentition of adults treated for periodontitis.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 8 May 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 5), MEDLINE Ovid (1946 to 8 May 2017), and Embase Ovid (1980 to 8 May 2017). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating SPT versus monitoring only or alternative approaches to mechanical debridement; SPT alone versus SPT with adjunctive interventions; different approaches to or providers of SPT; and different time intervals for SPT delivery.We excluded split-mouth studies where we considered there could be a risk of contamination.Participants must have completed active periodontal therapy at least six months prior to randomisation and be enrolled in an SPT programme. Trials must have had a minimum follow-up period of 12 months.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results to identify studies for inclusion, assessed the risk of bias in included studies and extracted study data. When possible, we calculated mean differences (MDs) and 95% confidence intervals (CIs) for continuous variables. Two review authors assessed the quality of evidence for each comparison and outcome using GRADE criteria.

MAIN RESULTS

We included four trials involving 307 participants aged 31 to 85 years, who had been previously treated for moderate to severe chronic periodontitis. Three studies compared adjuncts to mechanical debridement in SPT versus debridement only. The adjuncts were local antibiotics in two studies (one at high risk of bias and one at low risk) and photodynamic therapy in one study (at unclear risk of bias). One study at high risk of bias compared provision of SPT by a specialist versus general practitioner. We did not identify any RCTs evaluating the effects of SPT versus monitoring only, or of providing SPT at different time intervals, or that compared the effects of mechanical debridement using different approaches or technologies.No included trials measured our primary outcome 'tooth loss'; however, studies evaluated signs of inflammation and potential periodontal disease progression, including bleeding on probing (BoP), clinical attachment level (CAL) and probing pocket depth (PPD).There was no evidence of a difference between SPT delivered by a specialist versus a general practitioner for BoP or PPD at 12 months (very low-quality evidence). This study did not measure CAL or adverse events.Due to heterogeneous outcome reporting, it was not possible to combine data from the two studies comparing mechanical debridement with or without the use of adjunctive local antibiotics. Both studies found no evidence of a difference between groups at 12 months (low to very low-quality evidence). There were no adverse events in either study.The use of adjunctive photodynamic therapy did not demonstrate evidence of benefit compared to mechanical debridement only (very low-quality evidence). Adverse events were not measured.The quality of the evidence is low to very low for these comparisons. Future research is likely to change the findings, therefore the results should be interpreted with caution.

AUTHORS' CONCLUSIONS

Overall, there is insufficient evidence to determine the superiority of different protocols or adjunctive strategies to improve tooth maintenance during SPT. No trials evaluated SPT versus monitoring only. The evidence available for the comparisons evaluated is of low to very low quality, and hampered by dissimilarities in outcome reporting. More trials using uniform definitions and outcomes are required to address the objectives of this review.

Periodontal maintenance following active specialist treatment: Should patients stay put or return to primary dental care for continuing care? A comparison of outcomes based on the literature

OBJECTIVES

To review the evidence for the efficacy of periodontal maintenance (PM) carried out in primary dental care (PDC) compared to the specialist setting for patients previously treated in a specialist setting for chronic (ChP) or aggressive (AgP) periodontitis.

METHODS

A focused PICO question and search protocol were developed. Online databases including MEDLINE, EMBASE, WEB OF SCIENCE™ and COCHRANE LIBRARY were searched along with specialist journals in the subject area of periodontal research. Selection criteria included studies that investigated delivery of PM in both specialist and PDC settings for patients with ChP or AgP over a minimum 12 months. We looked for studies that reported changes in clinical attachment levels (CAL), tooth loss, pocket probing depths (PPDs) and bleeding on probing (BoP) as outcome measures.

RESULTS

Eight cohort studies were chosen for inclusion. There was considerable heterogeneity found between the eight studies, which did not allow for quantitative (meta) analysis and statistical testing of differences between groups. Clinical attachment levels remained relatively stable in patients who received specialist PM with mean changes of -0.42 mm to +0.2 mm, while for those enrolled in PDC-based PM for periods >12 months, mean CAL losses were between -0.13 mm and -2.80 mm. PPD reduction for those subjects receiving specialist PM was between 0.05 and 1.8 mm for five studies but two cohorts experienced increases of 0.32 and 0.80 mm, respectively. Increases of up to 2.90 mm (range: -0.1 to +2.90) and a higher proportion of deeper pockets were noted among PDC PM cohorts. Higher rates of BoP among those in receipt of PDC PM were reported in half of all studies. There were insufficient long-term data to make any firm conclusions about the effect of the delivery of PM on tooth loss.

CONCLUSION

Within the limitations of the data available, it appears that specialist PM is effective in sustaining periodontal stability following active specialist intervention. There is limited evidence that PDC provides the same level of care; however, the limited comparative data available suggest that outcomes could be slightly worse in PDC.

Site-specific treatment outcome in smokers following 12 months of supportive periodontal therapy

Aim

To evaluate the effect of cigarette smoking on periodontal health at patient, tooth, and site levels following supportive therapy.

Materials and Methods

Eighty chronic periodontitis patients, 40 smokers and 40 non‐smokers, were recruited to a single‐arm clinical trial. Periodontal examinations were performed at baseline (T0), 3 months following active periodontal therapy (T1), and 12 months following supportive periodontal therapy (T2). Smoking status was validated measuring serum cotinine levels. Probing depth (PD) ≥ 5 mm with bleeding on probing (BoP) was defined as the primary outcome. Logistic regression analyses adjusted for clustered observations of patients, teeth, and sites and mixed effects models were employed to analyse the data.

Results

All clinical parameters improved from T0 to T2 (p < 0.001), whereas PD, bleeding index (BI), and plaque index (PI) increased from T1 to T2 in smokers and non‐smokers (p < 0.001). An overall negative effect of smoking was revealed at T2 (OR = 2.78, CI: 1.49, 5.18, p < 0.001), with the most pronounced effect at maxillary single‐rooted teeth (OR = 5.08, CI: 2.01, 12.78, p < 0.001). At the patient level, less variation in treatment outcome was detected within smokers (ICC = 0.137) compared with non‐smokers (ICC = 0.051).

Conclusion

Smoking has a negative effect on periodontal health following 12 months of supportive therapy, in particular at maxillary single‐rooted teeth.

Adjunctive use of modified Yunu-Jian in the non-surgical treatment of male smokers with chronic periodontitis: a randomized double-blind, placebo-controlled clinical trial

Background

Yunu-Jian (YJ) is a Chinese medicine (CM) heat purging formula, which is used to reduce wei huo (stomach-heat, SH) and enrich shen yin (kidney-yin, KY). This formula is also commonly used to manage diabetes mellitus and gum/oral inflammation. The activity of YJ can be modified or refined by the addition of other CM herbs and/or minor changes to one of its five key ingredients. The aim of this study was to evaluate the adjunctive use of modified YJ (mYJ) or YJ containing additional osteoblast-stimulating and inflammation-modulating CM herbs in the non-surgical periodontal treatment of smokers with chronic periodontitis in a randomized, double-blind, prospective, placebo-controlled study.

Methods

Healthy adult male smokers with untreated chronic periodontitis who showed CM syndrome of SH and KY deficiency (KYD) whilst attending a dental teaching hospital from October to December, 2005, were invited to participate in a randomized double-blind, placebo-controlled clinical trial. The trial itself involved the once-daily oral administration of a placebo or mYJ for 3 months as an adjunct to non-surgical periodontal therapy. Several periodontal parameters, including radiographic alveolar bone density, were measured by computer-assisted densitometric image analysis (CADIA) on selected sites, and CM signs of SH and KYD were followed from their baseline values to various time points up to 12 months or the end of study.

Results

Twenty-five smokers (consumed 25.0 ± 15.3 smoking-pack years, ranged 7.5–80; aged 46.3 ± 6.8 years) with periodontitis and SH and KYD were recruited (Placebo, n = 14; mYJ, n = 11). All of the participants showed good tolerance towards the CM recipe. All of the periodontal parameters had improved after 12-month follow-up, and no statistically significant differences were detected between the control group and test group, except for the higher CADIA values observed compared with the baseline at 12 months for test sites (P = 0.025). 4/3/3 test vs 14/13/13 control participants had persisting SH and KYD at 6, 9 and 12 months (P < 0.001), respectively.

Conclusions

The adjunctive use of mYJ preserved the post-treatment increases in the radiographic alveolar bone density at the study sites and led to an overall improvement in SH and KYD compared with the controls.

Trial registration HKU Clinical Trial Register, HKCTR-1848 (www.hkuctr.com/Study/Show/3acbf983831244d29d50b543540bf6e9)

Electronic supplementary material

The online version of this article (doi:10.1186/s13020-016-0111-z) contains supplementary material, which is available to authorized users.

The cost-effectiveness of supportive periodontal care: a global perspective

AIM

To evaluate the cost-effectiveness of supportive periodontal care (SPC) provided in generalist and periodontal specialist practices under publicly subsidized or private dental care.

MATERIAL AND METHODS

SPC cost data and the costs of replacing teeth were synthesized with estimates of the effectiveness of SPC in preventing attachment and tooth loss and adjusted for differences in clinician's time. Incremental cost-effectiveness ratios were calculated for both outcomes assuming a time horizon of 30 years.

RESULTS

SPC in specialist periodontal practice provides improved outcomes but at higher costs than SPC provided by publicly subsidized or private systems. SPC in specialist periodontal practice is usually more cost-effective than in private dental practice. For private dental practices in Spain, United Kingdom and Australia, specialist SPC is cost-effective at modest values of attachment loss averted. Variation in the threshold arises primarily from clinician's time.

CONCLUSION

SPC in specialist periodontal practice represents good value for money for patients (publicly subsidized or private) in the United Kingdom and Australia and in Spain if they place relatively modest values on avoiding attachment loss. For patients in Ireland, Germany, Japan and the United State, a higher valuation on avoiding attachment loss is needed to justify SPC in private or specialist practices.

Tooth loss in individuals under periodontal maintenance therapy: prospective study

This prospective study aimed to evaluate the incidence, the underlying reasons, and the influence of predictors of risk for the occurrence of tooth loss (TL) in a program of Periodontal Maintenance Therapy (PMT). The sample was composed of 150 complier individuals diagnosed with chronic moderate-severe periodontitis who had finished active periodontal treatment and were incorporated in a program of PMT. Social, demographic, behavioral and biological variables were collected at quarterly recalls, over a 12-month period. The effect of predictors of risk of and confounding for the dependent variable TL was tested by univariate and multivariate analysis, as well as the underlying reasons and the types of teeth lost. During the monitoring period, there was a considerable improvement in periodontal clinical parameters, with a stability of periodontal status in the majority of individuals. Twenty-eight subjects (18.66%) had TL, totaling 47 lost teeth (1.4%). The underlying reasons for TL were: periodontal disease (n = 34, 72.3%), caries (n = 3, 6.4%), prosthetic reasons (n = 9, 19.2%), and endodontic reasons (n = 1, 2.1%). Additionally, subjects with 10% of sites with probing depth between 4 and 6 mm were 5 times more likely to present TL (OR = 5.13, 95% CI 2.04-12.09). In this study, the incidence of TL was small and limited to few individuals. Additionally, gender and severity of periodontitis were significantly associated with TL during the monitoring period.

An introduction to latent growth curve modelling for longitudinal continuous data in dental research

Many studies in dental research are based on repeated measurements of several continuous variables. Statistical analyses of such data require advanced methods to explore the complexity of information within the data. Currently, the most frequently adopted approach is to undertake multiple univariate tests. Occasionally, more advanced and sophisticated statistical methodologies, such as multilevel modelling and generalized estimating equation, have been used. In the last decade, a novel statistical methodology known as latent growth curve modelling has been developed in the social sciences. Latent growth curve modelling can be considered a special application of structural equation modelling and is generally conducted using structural equation modelling software. Recent development of statistical theory shows that latent growth curve modelling is equivalent to multilevel modelling, and both approaches yield identical results. However, in some study designs latent growth curve modelling can provide a more flexible framework of statistical modelling than multilevel modelling and generalized estimating equation for longitudinal data. The aim of this article was to present a non-technical introduction to latent growth curve modelling for dental researchers. The emphasis was on conceptual understanding, rather than mathematical rigor, so path diagrams were used for visual presentations of various statistical models. When properly applied, latent growth curve modelling has great potential to give new directions for future longitudinal dental research.

Direct and indirect effects of interdental hygiene in a clinical trial

Many randomized controlled trials (RCTs) in dental research test the efficacy of interventions on more than one outcome variable. Univariate methods, such as the t test or analysis of covariance, cannot evaluate the efficacy of interventions on multiple outcomes simultaneously. The aim of this study was to use structural equation modeling (SEM) to re-analyze a RCT, comparing the effects of pre-curved interdental brushes and flossing on probing pocket depth (PPD), plaque indices, and bleeding on probing (BOP) measured at baseline, intermediate, and final examinations. Results of SEM showed that the observed greater reduction in PPD and BOP in persons using interdental brushing than in those flossing is due mainly to the greater efficiency in plaque removal with the interdental brushes (indirect effect) rather than to the compression of the interdental papillae (direct effect). In contrast, smokers showed less BOP at baseline but also less improvement in BOP through direct effects.

Tooth loss in treated periodontitis patients responsible for their supportive care arrangements

AIM

To identify risk indicators associated with tooth loss and periodontitis in treated patients responsible for arranging supportive periodontal care (SPC).

MATERIALS AND METHODS

Ninety-seven Chinese subjects (34-77 years) who showed favourable responses to periodontal therapy provided in a teaching hospital 5-12 years previously were recalled. They were advised to seek regular SPC on discharge. Background information, general health status, smoking, oral hygiene habits, follow-up dental care, tooth loss, and periodontal parameters were investigated. Multiple regression analysis was performed.

RESULTS

Two hundred and fifty-six teeth had been lost, 195 because of self-reported periodontal reasons. Up to 26.8% sites were with pockets > or =6 mm. Positive correlations were found between total/periodontal tooth loss and (i) smoking pack-years, (ii) time spent on oral hygiene, (iii) years since therapy's conclusion, (iv) age, and negative correlations with (v) inter-dental brush use, and (vi) education levels. Tooth loss by arch was correlated with wearing of removable partial denture in that arch. Percentage sites with pockets > or =6 mm were significantly negatively correlated with percentage sites without bleeding on probing.

CONCLUSIONS

Smokers, more elderly patients, removable partial denture wearers, and patients with lower education levels or not using inter-dental brushes ought to be targeted for clinic-based SPC.