______J'A \D )A ______ REVIEW
ARTICLES
Periodontics in general practice: professional plaque control H e n r y G reenw ell, D M D , JD , MSD; N a b il F. Bissada, D D S, MSD; J o h n W. W ittwer, D D S, MS
T ra d itio n a lly the p r im a r y em phasis o f preventive periodontics was daily p a tie n t p erfo rm ed plaque control. Recent studies indicate that frequent professional subgingival toothcleaning is a mandatory treatment fo r p re ve n tio n o f recu rren t p erio d o n titis. Pathogenic subgingival bacterial complexes are disrupted by frequent cleaning and require tim e to reestablish. Disease progression is prevented if the recall interval does not exceed the tim e required fo r reestablishment o f a pathogenic plaque. Legally, patients have a cq u ired the duty to com ply w ith the prescribed recall interval. Both the patient a n d the p ra c titio n e r w ill benefit fro m a preventive program that includes frequent professional subgingival toothcleaning.
rofessional p laq u e c o n tro l is n o t a p u b lic h e a lth m e a s u re , as in th e c a s e o f f l u o r i d e , b u t it is la b o r in te n siv e th e ra p y availab le o n ly to th o s e w illing to seek a n d a c c e p t p r o p e r d e n ta l care. A d u lt p e rio d o n titis affects on ly 15% to 25% o f th e p o p u la tio n , a n d m a n a g e m e n t by in tensive su p p o rtiv e p e rio d o n ta l th e ra p y is a viable o p tio n . A n im p o rta n t re q u ire m e n t o f such su p p o rtiv e ca re is th e p r a c t i t i o n e r ’s r e c o g n i t i o n o f d is e a s e r e c u r r e n c e in th e p a tie n t. P ro fe s s io n a l p la q u e c o n tro l will m ain ta in m ost p ro p e rly tr e a te d cases o f a d u lt p e rio d o n titis ; p a ti e n ts w h o c o n t i n u e to p r o g r e s s a re c a n d id a tes fo r refe rra l to a specialist. S uccess o f p ro fe ssio n a l p la q u e c o n tro l
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64 2 ■ JADA, Vol. 121, N o v em b er 1990
c lo s e ly r e l a t e s to m a n a g e m e n t o f th e q u a li ta t iv e c o m p o s it io n o f t h e p la q u e m ic ro flo ra . T h o ro u g h to o th c le a n in g d isru p ts th e o rg a n iz a tio n a n d stru c tu re o f aging, p a th o g e n ic p laq u e. T h e n fewer, less p a th o g e n ic b ac te ria are left to re b u ild th e s tru c tu re n ece ssa ry fo r re d e v e lo p m e n t o f p a th o g e n ic c o m p o n e n ts . B e fo re p a th o g e n ic b a c te r ia r e e s ta b lis h , p r o f e s s io n a l to o th c le a n in g a g a in in te r r u p ts th e cycle a g a in b e fo re th e b a c te ria l c a n d o h a rm . T h e c o n c e p t th a t sp ecific b a c te ria c au se p e rio d o n ta l disease d escrib es this specific p la q u e hyp o th esis. T h e success o f p ro fes sional p la q u e c o n tro l c o n firm s h y p othesis as a d e s c r ip to r o f th e ro le o f m ic ro b ia l p la q u e in th e p a th o g e n e sis o f a d u lt p e ri o d o n titis. T h is article reviews th e stu d ies n o t only a b o u t e s t a b li s h e d p r o f e s s i o n a l p la q u e c o n tro l as a re co g n ize d sta n d a rd re q u ire d f o r th e s u c c e s s f u l t r e a t m e n t o f a d u l t p e rio d o n titis, b u t also studies th a t ex p lain th e r a tio n a le fo r p ro f e s s io n a l p la q u e c o n tro l a n d d e m o n s tra te its effectiv en ess in large p o p u la tio n s.
Posttreatment professional plaque control L in d h e a n d o th e r s 1 r e p o r te d th a t te e th tre a te d by e ith e r su rg ica l o r n o n su rg ic a l m e th o d s te n d to m a in ta in h e a lth as lo n g as o p tim u m p la q u e c o n tro l was su stain ed . A f te r t r e a t m e n t e a c h p a t i e n t re c e iv e d p ro fe ssio n a l to o th c le a n in g e v e ry 2 w eeks in th e firs t 6 m o n th s . T h e in te r v a l w as le n g th e n e d to 3 m o n th s fo r th e re m a in d e r o f th e 2-year study. T e e th th a t w ere p laque-
free m a in ta in e d a tta c h m e n t levels; plaquea ss o c ia te d sites o fte n lo st a tta c h m e n t to th e t o o t h . In c o n t r a s t , R a m f jo r d a n d o t h e r s 2 r e p o r t e d , in a n 8 -y e a r stu d y o f s u r g ic a l th e r a p y , t h a t p e r f e c t p e r s o n a l p la q u e c o n tr o l w as n o t c r itic a l f o r th e m a in te n a n c e o f a tta c h m e n t levels. Twentyfive p e rc e n t o f th e p a tie n ts w ith th e best p la q u e scores w ere c o m p a re d w ith 25% o f th e p atien ts w ith th e low est p laq u e scores. N o sig n ific a n t d iffe re n c e s in a tta c h m e n t lev el d a ta w e re f o u n d b e tw e e n th e two g ro u p s over th e lo n g -term . T h e success o f th e th e r a p y d e s p i te i m p e r f e c t p la q u e c o n tro l was a ttrib u te d to th e 2 to 3 m o n th recall fo r p ro fessio n al to o th c lean in g . P i h l s t r o m a n d o t h e r s 3-4 e v a l u a t e d p a tie n ts t r e a te d s u rg ic a lly a n d n o n s u r g ic a lly , a n d th e y f o u n d t h a t e v e n w ith re la tiv e ly p o o r p e r s o n a l s u p r a g in g iv a l p la q u e c o n tro l, a tta c h m e n t levels c o u ld b e m a i n t a i n e d w h e n c o m p l y in g w ith t h e recall fo r p ro fessio n al to o th c le a n in g . T his s u p p o r te d th e fin d in g s o f R am Q ord a n d o th e rs,2 a n d it c re a te d a co n flict c o n c e rn in g th e ro le o f p o s t tr e a t m e n t p e r s o n a l p la q u e c o n t r o l in th e m a i n t e n a n c e o f p e rio d o n ta l a tta c h m e n t levels. Isid o r a n d o th e r s 5-6 reso lv ed th is c o n flic t in a 5-year stu d y o f p a tie n ts t r e a te d s u rg ic a lly a n d n o n s u r g ic a lly f o r p e r i o d o n t a l d is e a s e . T h e y fo u n d th a t o ra l h y g ie n e sta tu s d id n o t c o r r e l a t e w ith t h e n u m b e r o f d e t e r i o r a t i n g s ite s , c o n f i r m i n g th e fi n d in g s o f R a m f jo r d a n d o t h e r s 2 a n d P ih ls tr o m a n d o t h e r s . 3-4 T h e r e s u lts o f p re v io u s stu d ie s d id n o t actually co n flict b u t m erely re fle c te d th e u se o f d iffe re n t ty p e s o f p r o f e s s i o n a l t o o t h c l e a n i n g .
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L in d h e and o th e rs1 p erform ed p rofes sional supragingival toothcleaning alone while Ramfjord and others,2 Pihlstrom and o th e r s ,3’4 and Isidor and o th e r s5 6 also in clu d ed professional subgingival tooth clean ing. Thus professional subgingival t o o th c le a n in g p r e v e n te d s ig n ific a n t attachment loss even when personal oral h y g ie n e was im p e r fe c t; p r o fe ssio n a l su p ra g in g iv a l t o o th c le a n in g d id n o t prevent attachment loss if personal plaque control was imperfect. T h e 3-m onth recall for p rofessio n a l supra- and subgingival too th clea n in g appears to maintain periodontal health. T he nonspecific plaque hypothesis calls for pocket elimination to expose all areas o f th e to o th su b jec t to p la q u e a c c u m u la tio n in p e r io d o n ta l tre a tm en t. Subgingival p laqu e is ren d ered supra gingival and accessible to the patient for c o m p le te d aily rem oval th a t a c c o m m odates the m ost fundam ental ten et o f th e n o n sp ec ific p laq u e h ypothesis: all plaque must be removed to prevent dental diseases. Lindhe and others1 demonstrated that loss o f periodontal attachment can be ex p ec ted with im p erfect supragingival plaque control. Few patients can maintain ideal standards o f plaque control and the n onsp ecific plaque hypothesis fails as a practical rationale for pocket elimination surgery. On the other hand, periodontal treatm ent based on the specific plaque h y p o th e sis p erm its th e p r e s e n c e o f n o n p a th o g en ic plaque w hich d o es n ot provoke loss o f clinical attachm ent. The specific plaque hypothesis is clear: it is the qualitative composition o f the plaque, not its presence, that is harmful. Pathogenic plaque harbors either bacteria or bacterial c o m p le x e s th at p r e d isp o se to lo ss o f attachment. Thé flora that causes disease progression may vary from individual to in d iv id u a l; it is s p e c ific in th a t it is pathogenic and not necessarily because of eq u iv a len t bacterial co m p o sitio n . T he professional subgingival plaque control p e r fo r m e d by R am fjord an d o t h e r s ,2 Pihlstrom and others,3-4 and Isidor and others5-6 did prevent loss o f attachm ent, even when personal supragingival plaque control was imperfect.2-6 Interrupting the d e v e lo p m e n t o f a p a th o g e n ic flo r a , illustrates the specific plaque hypothesis as the prim ary rationale for using p rofes sio n a l subgingival p laqu e co n tro l as a m ethod to preserve periodontal health in supportive therapy. Maintaining qualita tive control o f the flora by converting a p a th o g e n ic su b g in g iv a l p la q u e to a tem porarily n o n p a th o g en ic state is an essential com ponent o f the specific plaque
hypothesis. The foregoing studies do not support n eg lect o f oral h ygien e procedures; all p a tie n ts w ere o n a c lo se ly su p erv ised p erson al p laq u e c o n tro l program and were evaluated at frequent intervals by a p e r io d o n tis t. W h ile p a tie n t s ’ p la q u e control was often far from perfect, there w ere no cases o f gross n e g le c t. T h ree p oin ts n eed to b e reco g n ized and em phasized: many patients will fall short of th e g o a l o f p e r fe c t p la q u e c o n tr o l; fre q u en t p ro fessio n a l supra- and sub gingival p laque co n tro l is an ironclad, in fle x ib le re q u ir e m e n t fo r lo n g -term supportive care; and in the absence o f professional subgingival plaque control, loss o f attachment and ultimate failure of the case should be expected. Although not all patients or all sites within the mouth are susceptible to breakdown, we cannot p r e d ic t w h ich o n e s w ill b reak dow n. T h erefo re, th ese p rin cip le s sh o u ld be applied to all patients with periodontitis, whether the disease is considered active or inactive.
Rationale for professional subgingival plaque control Listgarten and Hellden7 reported that the bacterial m orphotype proportions in the subgingival m icroflora were different in health and disease. Periodontally healthy sites were predom inated by coccoid cells an d stra ig h t rods; d ise a s e d sites had increased proportions o f m otile rods and sp iroch etes.7 W hen d iseased sites were treated by scaling and root planing, the flo ra c o m p o se d o f m o tile ro d s and spirochetes was converted to a coccoid cell and straight rod flora in healthy mouths.8 It to o k a p p r o x im a tely 42 days for sp iroch etes to return to b a selin e (pre treatment) levels. The posttreatm ent shift in subgingival m orp hotype p ro p o rtio n s from d isease associated to health associated bacteria followed by a slow return to pretreatment le v e ls was ter m e d by G r een w ell and Bissada9 as the “baseline tendency effect.” Disease-associated m orphotypes are not n e c e ssa r ily p e r io d o n ta l p a th o g e n s. Presumably pathogenic com ponents o f the subgingival m icroflora follow the same r e p o p u la tio n tren d s as m o rp h o ty p e proportions, accou n tin g for the associ ation with disease. Pathogenic bacteria re establishes in approximately 3 m onths.1-6 Morphotypes may return to pretreatment levels in 42 days; however, th e role o f disease associated morphotypes must not be m isinterpreted and equated with the
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ro le o f sp e c ific b a c te r ia id e n tifie d as periodontal pathogens. The return time o f pathogenic com plexes, capable o f induc ing attachment loss, cannot be identified from m o rp h o ty p e c o u n ts u sin g p h ase co n trast or d ark field m icroscop y. T he m orphotype exam ination is valuable as a research tool and illustrates the trends o f microbial succession, the direction o f the q u a lita tiv e sh ift tow ard e ith e r h ea lth associated or disease associated bacteria. T h e q u a lita tiv e sh ift tow ard a h ea lth associated flora is critically im portant to the success o f the 3-month recall. Listgarten and o th ers10 com pared the c lin ic a l and m ic r o b io lo g ic a l e ffe c t o f SC/RP with systemic tetracycline, 1 g per day for two periods o f 2 weeks separated by a 1 m o n th in te r v a l. T h e e f f e c t o f SC /R P was eq u ivalen t to the antibiotic therapy in terms o f producing a shift in subgingival m orp hotypes. T his d em o n strates the powerful effect o f professional subgingival to o th clea n in g in producing qualitative bacterial changes. The distinc tion betw een the two therapies was the a n tib io t ic ’s sh o rt liv e d e f f e c t o n th e bacteria if it was n ot accom panied with SC/RP. Professional subgingival plaque control is th e m o st im p o r ta n t a sp e c t o f a supportive care plaque control program, in co n ju n ctio n with p atient-perform ed supragingival plaque control. Magnusson and others11 reported that patients with poor supragingival plaque control typically show a rapid return o f sp irochetes and motile rods to baseline levels. Patients with e x c e lle n t supragingival p laqu e co n trol b e n e fit from a su sta in ed red u ctio n o f sp iro ch etes and m o tile rods. T h e tim e required for the baseline tendency effect to cycle varies, depending on the patients’ lev el o f su pragingival p la q u e co n tro l. Good oral hygiene results in a prolonged return to b aselin e (d isea se associated) values w hile p oor oral h ygien e yields a rapid return. The frequency o f the recall may depend on the level o f supragingival plaque control. Patients with poor supra gin gival p laq u e c o n tro l may requ ire a sh o rter in te rv a l th an th e stan d ard 3month period. At some point, shortening the recall interval becom es impractical. T he initial developm ent o f subgingival plaque m ost likely d erives from supra gingival plaque. Yet, Tabita and others12 dem onstrate that even daily professional removal o f supragingival plaque will not p revent the reform ation o f subgingival plaque. This is possibly the result o f the inability to achieve total plaque removal consistently. Even professional supraginJADA, Vol. 121, November 1990 ■ 643
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gival and subgingival toothcleaning cannot halt subgingival plaque growth. The fact that subgingival plaque formation cannot b e p r e v e n te d e x p la in s why re ca ll for p r o fe ssio n a l su b g in g iv a l c le a n in g is essential for all patients with p eriodon titis.1
Professional plaque control and large populations In a 6-year study on th e e ffe c t o f pro fessional plaque control on adult dental health, Axelsson and Lindhe1«-1 evaluated tw o d iffe r e n t system s o f d e n ta l care: tra d ition al, sym ptom atic care versus a preventive care program. The traditional care group (375 subjects) received SC/RP, treatment o f all carious lesions including replacement o f ill-fitting restorations, and o n e session o f oral hygiene instructions fo llo w e d by 1-year reca ll w ith a cc o m panying sym ptom atic dental treatm ent. The preventive care group (180 subjects) received the same initial SC/RP and caries treatment; however, this was followed by 2m onth recall in the first 2 years and 3m o n th recall in th e last 4 years. Each patient-recall for professional supra- and subgingival tooth cleaning also included detailed oral hygiene instructions. Results show that traditional dental care does not h a lt th e p r o g r e ssio n o f ca r ie s and periodontal disease. Preventive care with fr e q u e n t p r o fe ssio n a l t o o th c le a n in g motivates individuals to adopt proper oral h y g ien e habits, resolves gingivitis, and prevents the p rogression o f caries and periodontal disease. Axelsson and Lindhe1314 applied the 3m o n th reca ll p rogram to th e g en er a l p o p u lation with overw helm ing success, not only in the prevention o f periodontal disease but also den tal caries. T h e fre quent professional toothcleaning and oral hygiene instruction also serves as m oti vational therapy and stimulates patients to exercise g ood oral hygiene habits. Fre quent, thorough toothcleaning keeps the teeth largely calculus-free which simplifies a n d fa c ilita te s p e r so n a l o ral h y g ien e efforts. In an ev a lu a tio n o f an ev e n larger population Loe and others15-1« compared the periodontal health o f subjects receiv ing a high level o f dental care to a group receiv in g m inim al care. A total o f 565 N orw egian stud en ts and acad em ician s re p r esen te d th e u p p er so c io e c o n o m ic strata, receiving a high level o f dental care, and the group with deprived econom ic conditions and m inimal dental care was made up o f 480 Sri Lankan tea laborers. 644 ■ JADA, Vol. 121, November 1990
At the last report, the group receiving a high level o f dental care had only little loss o f periodontal attachment and a very low tooth mortality rate. In contrast, the Sri Lankans receiving m inim al d en tal care exhibited significant loss o f periodontal attachm en t and a m uch h ig h er rate o f tooth mortality. Two studies in the United States reveal a dram atic d eclin e in prevalence o f peri odontitis. In 1955 Marshall-Day and others report that 88% to 92% o f a group aged 40-60 had p e r io d o n ta l d ise a se and p o ck ets.19 A 1987 report by M iller and others20 evaluating 20,818 individuals from across the United States based conclusions on both loss o f attachment and probing pocket depths. It shows only 15% to 25% o f th e p o p u la tio n w ith s ig n ific a n t pocketing or attachm ent loss. W hile the two studies use different methodology and are not directly comparable, it is clear that periodontitis has declined in the U nited States. Some o f the factors contributing to this d e c lin e in clu d e: the h igh level o f dental care provided by the average US p ra c titio n e r , p a tie n t e d u c a tio n and aw aren ess o f th e im p o r ta n c e o f oral h y g ien e and reg u la r d en ta l care, and freq u en t m ed ia advertisem ents o f oral hygiene products, which accentuate the social unacceptability o f poor oral hygiene and oral m alodor. With m ore frequ en t professional toothcleaning and preventive care, p rev a len ce o f p e r io d o n titis w ill decline even further.
Disease progression and professional plaque control T h e p rev io u sly d isc u sse d stu d ie s by Axelsson and Lindhe1314 have shown that 3-m onth p ro fessio n a l to o th cle a n in g is beneficial for the population at large; and therefore, it could be a useful option for any patient in need o f improved preven tive care. Patients who have b een diag nosed and treated for adult periodontitis, however, require 3-m onth p rofessional to o th c le a n in g to p rev e n t c o n tin u e d p rogression o f d isease. G reenw ell and o th e r s 21 have p ro p o se d a m e th o d o f diagnosis for treated periodontitis, termed a response diagnosis, to help identify the c u r r e n t d ise a se statu s o f in d iv id u a ls treated for adult periodontitis at each 3m onth recall visit. Patients who have no fu r th e r p r o g r e ssio n o f d ise a se w ere diagnosed as having controlled periodon titis an d n e e d n o a d d itio n a l th erap y b eyond the 3-m onth recall. T hose who c o n tin u e to lo se a tta c h m en t d e sp ite proper treatm en t and 3-m onth profes
sional tooth clean in g were diagnosed as having eith er advancing p erio d o n titis, u n c o n tro lled p erio d o n titis, refractory periodontitis, or nonresponding periodon titis. T h e se p a tie n ts m ay n e e d m o re frequ en t professional to o th clea n in g or other sophisticated diagnostic testing and treatm ent, and they are candidates for referral to a specialist. This m eth od o f d ia g n o sis w ill h e lp a v o id law suits for failure to diagnose periodontal disease or supervised neglect.
Compliance with professional plaque control S tu dies o f co m p lia n ce with a 3-m onth recall interval follow ing treatm ent by a periodontist show wide variation. Wilson and others22 reported that only 16% o f patients complied with the recommended interval; Schmidt and others23 found 95% compliance. The reason for the difference is n o t clear. As with oral hygiene, m oti vation is undoubtedly an important factor. P a tien ts sh o u ld be in fo r m e d b e fo r e p eriodon tal therapy that frequ en t pro fessional toothcleaning is a requirem ent for successful treatm en t and failure to co m p ly w ill m o st lik ely y ie ld a p o o r treatm ent result. S chm idt and o th ers23 fo u n d that erratic co m p liers requ ired more surgical treatment than patients in full com pliance with the recom m ended interval. Compliance was good for patients who alternated recall between the peri o d o n tist an d g e n e r a l d e n tis t an d this system was e ffe c tiv e in m a in ta in in g excellent periodontal health in supportive therapy.
Professional toothcleaning procedures It is im portant to make the d istinction b etw e en th e th r e e d iffe r e n t types o f professional to o th clea n in g procedures: ro u tin e p ro p h y la x is, SC /R P , and p ro fessional subgingival plaque control in a 3m onth recall for supportive periodontal therapy. Routine prophylaxis is primarily a supragingival p ro ce d u re p ro v id ed for patients who are periodontally healthy or have mild gingivitis. All plaque, calculus, and stain are removed and since there is no pathologic deepening o f the sulcus this procedure is often accomplished in 30-45 minutes. Subgingival areas may be cleaned but since the sulcus is 3 mm or less this can be achieved with little difficulty. As w ith o th er p ro fessio n a l to o th cle a n in g procedures, com plete plaque removal is equally as important as com plete calculus removal.
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T h e S C /R P p r o c e d u r e is g en er a lly reserved for patients who have n ot had recent active treatm ent for periodontitis (ro o t in str u m e n ta tio n ) a n d typ ically exhibit deposits o f older calculus that are tig h tly a tta c h e d to th e r o o t su rfa ce. R em oval o f th e s e te n a c io u s d e p o sits req u ires sh arp , n ew c u r e ts th a t can withstand the lateral forces required for com plete calculus removal. Older curets, th in n ed by sh a rp en in g , are su bject to fracture. A very sharp curets blade is need to rem o v e th e su p e r fic ia l layer o f cem en tu m w hich con tain s en d oto x in s, p erp etu a to r s o f th e in fla m m a to r y process.2425 Ultrasonic instrumentation is h e lp fu l an d o fte n u se d b e fo r e ro o t p la n in g .26 S C /R P may requ ire up to 2 hours per quadrant with local anesthesia if the procedure is performed in accordance with the principles o f nonsurgical peri odontal therapy.2728 As SC/RP is a difficult procedure, calculus is frequently missed; therefore, patients m ust be reevaluated after SC /R P so that all areas o f m issed calculus can be detected and removed.2»-31 Recall for treated periodontal patients is a completely different situation. Residual pockets, usually shallow, may be present to complicate the toothcleaning procedure. S ince th e tissu e is h ea lth y and tightly adapted to the tooth, older, thinner curets may be easier to use and m ore com fort able for the p atien t. A n esth esia is n ot required and the appointment, complete with periodontal examination, can usually be accom plished in 1 hour. Deposits on the tee th are im m atu re and ea sier to remove than older, more tightly attached ca lcu lu s. R em oval o f ro o t ce m en tu m an d /o r dentin is n ot a goal o f the recall appointment as it is with SC/RP. In fact, co n tin u ed p la n in g o f th e ro o t surface would be an abusive procedure resulting in excessive and unnecessary removal o f tooth structure. The critical factor is that all plaque and calculus must be removed. Total plaque rem oval is an often over looked requirem ent o f this appointm ent but in terms o f p rod ucing a p rolon ged baseline tendency effect this is a critically important objective. The subgingival tooth surface should be curetted until no more visible soft d ep osits can be withdrawn. S u p ragin givally, th e p ro x im a l to o th surfaces should be flossed until plaque free, then all buccal and lingual plaque rem oved by rubber cup p olish ing. T he th o r o u g h n e ss o f th e to o th c le a n in g is im p o r ta n t sin c e in c o m p le te p la q u e removal will result in a shortened cycle for the baseline tendency effect and fuel an earlier return o f pathogenic bacteria.
Legal ramifications In ad eq u ate p a tie n t p erfo rm ed plaque control was considered the primary cause o f case failure in periodontal maintenance therapy when the treatment rationale was b ased on th e n o n s p e c ific p la q u e hy pothesis. T h e goal o f treatm ent was to create a situation whereby all plaque could be removed by the patient on a daily basis. If the patient failed to com ply this duty, the resulting periodon tal deterioration was attribu ted to p a tien t n eg le ct. The professional’s duty was to provide 6-month recall for examination, toothcleaning, and oral h y g ie n e in s tr u c tio n s to su p p o rt conditions that would permit the patient to maintain periodontal health through personal oral h ygien e m easures. N egli g e n c e arisin g from p erio d o n ta l m ain tenance therapy based on the nonspecific plaque hypothesis was usually attributable to the patient because any failure o f daily p la q u e c o n tr o l c o u ld le a d to d isea se recurrence. The recent World Workshop in Clinical P e r io d o n tic s rejected th e term “p eri odontal maintenance therapy” in favor of the m ore descrip tive “supportive peri o d o n ta l th e r a p y ” (S P T ).32 A reca ll ap p oin tm en t sh ould in clu d e com p lete p e r io d o n ta l e x a m in a tio n , re sp o n se diagnosis, professional supra- and subgin gival to o th c le a n in g , an d r e c o m m e n dations for any additional treatment. From a legal standpoint, both the patient and the practitioner have acquired new duties. The professional is obligated to inform the patient that professional plaque control is necessary on a 2 to 3 month basis and to p ro v id e p r o p e r p r o fe ssio n a l to o th clea n in g , ex a m in a tio n , and diagnosis. Providing periodontal treatment without accompanying SPT should be considered n egligen t care by the practitioner. The p a tie n t r e ta in s th e p rev io u s duty to perform adequate personal plaque control and acquires the duty o f com plying with the prescribed interval for professional plaque control. Failure o f the patient to com ply with th ese d u ties will result in disease p rogression , w hich th e p rofes sional will be powerless to prevent. Studies by Axelsson and Lindhe1314 show that 3-month professional toothcleaning may be b en eficial for the gen eral p op ulation as a preventive measure. There is a duty h ere to in fo r m p a tie n ts w ith o u t p e r io d o n titis th a t th is is a trea tm en t o p tio n . P a tien ts w ith p e r io d o n titis , however, must be informed that 3-month professional toothcleaning is a mandatory c o m p o n e n t o f su c c e ssfu l tre a tm en t.
A R T I C L E S
Irrespective o f the type o f therapy, elective or r e q u ir e d , th e p a tie n t n e e d s to b e informed o f the role o f that treatment in esta b lish in g a n d /o r m a in ta in in g their periodontal health. If the practitioner’s recom m endations are rejected, a written “informed refusal” should be obtained to ensure that the patient understands the c o n s e q u e n c e s o f th e ir refu sa l an d to p r o te c t th e d e n tis t in ca se o f fu tu r e litigation.
Summary Studies o f treatment o f adult periodontitis follow ed by professional plaque control have show n th a t c o m p le te supra- and subgingival plaque and calculus removal on a 3-month basis is n eed ed to prevent additional loss o f periodontal attachment. The success o f the procedure is dependent on m aintaining control o f the qualitative composition o f the subgingival flora. This is a cc o m p lish e d by su b g in g iv a l to o th cleaning which disrupts established plaque structure, delays the reestablishm ent o f periodontal p athogens, and produces a b a selin e ten d e n c y e ffe c t. Large p o p u lations that have a high level o f dental care have less disease progression than those with minimal care. For patients with adult periodontitis, supportive 3-month recall is n o t an o p tio n — but a req u irem en t for successful tlierapy. These patients need a r e sp o n se d ia g n o sis to d o c u m e n t th e current disease status at each recall visit and to identify the n eed for additional trea tm en t. T h o se that e x h ib it d isea se progression are candidates for referral to a specialist. The p rocedure used for pro fessio n a l subgingival p laq u e co n tro l is vastly different than the scaling and root planing procedure. The thoroughness o f plaque removal in the recall appointment is critically important and may increase for the time the baseline tendency effect to complete its cycle.
Essays o f o p in io n o n c u rre n t issues in d entistry are published in this section o f The Journal T h e opinions expressed o r im plied are strictly those of" th e a u th o rs an d d o n o t necessarily re fle c t th e o p in io n o r official policies o f th e A m erican D ental A ssociation. Dr. G reenw ell is assistant professor, a n d Dr. W ittwer is p ro fesso r o f p e rio d o n tic s, U niversity o f Louisville; Dr. Bissada is professor an d chairm an, d e p a rtm e n t o f p e r io d o n tic s , S c h o o l o f D e n tis try , C ase W e s te rn R ese rv e U niversity, 2123 A b in g to n R d , C le v ela n d , 44106. A ddress requests fo r re p rin ts to Dr. Bissada.
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1. L in d h e J , Socransky S, N ym an S, e t al. C ritical p r o b i n g d e p t h s in p e r i o d o n t a l th e ra p y . J C lin P erio d o n to l 1982;3:421-30. 2. R am fjo rd SP, M o rriso n EC, B u rg e tt FG, e t al. O ra l h y g ie n e a n d th e m a in te n a n c e o f p e rio d o n ta l support. J P erio d o n to l 1982;53:26-30. 3. P ihlstro m BL, O rtiz-C am pos C, M cH ugh RB. A ran d o m ized four-years study o f p erio d o n tal therapy. J P erio d o n to l 1981;52:227-42. 4. Pihlstrom BL, M cH ugh RB, O lip h a n t T H , e t al. C om pariso n o f surgical an d nonsurgical treatm en t o f p e rio d o n ta l disease. A review o f c u rre n t studies an d additional results after 6 1 /2 years. J Clin Periodontol 1983;10:524-41. 5. Isidor F, K arring T, A ttstrom R. T h e effect o f ro o t p la n in g as c o m p a re d to th a t o f surgical treatm en t. J C lin P erio d o n to l 1984;11:669-81. 6. Isidor F, K arrin g T. L ong-term effect o f surgical a n d n o n s u r g ic a l p e r io d o n ta l tr e a tm e n t. A 5-y ear clinical study. J P e rio d o n t Res 1986;21:462-72. 7. L istgarten MA, H elld en L. Relative distribution o f b acteria a t clinically healthy a n d periodontally diseased sites in hum ans. J Clin P erio d o n to l 1978;5:115-32. 8. M ousques T, L istg arten M, Phillips R. E ffect o f scaling a n d r o o t p la n in g o n th e co m p o sitio n o f th e h u m a n subgingival m icro b ial flo ra. J P e rio d o n t Res 1980;15:144-51. 9. G r e e n w e ll H II I, B iss a d a NF. V a ria tio n s in subgingival m icroflora fro m h ealthy an d in tervention s ite s u s in g p r o b i n g d e p t h a n d b a c t e r io lo g ic identification criteria. J Perio d o n to l 1984;55:391-7. 10. L istg a rte n M, L in d h e J , H e lld e n L. E ffect o f te tra c y c lin e a n d / o r scalin g o n h u m a n p e rio d o n ta l d is e a s e . C lin ic a l, m ic ro b io lo g ic a l a n d h isto lo g ic a l observations. J C lin P erio d o n to l 1978;5:246-71. 11. M a g n u s so n I, L in d h e J , Y oneyam a T, e t al. R ecolonizatio n o f a subgingival m icro b io ta following s c a lin g in d e e p p o c k e ts . J C lin P e r io d o n t o l
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1984;11:193-207. 12. T abita PV, Bissada NF, M ayburyJE. Effectiveness o f supragingival plaque control on the developm ent of su b g in g iv a l p la q u e a n d g in g iv a l in fla m m a tio n in p a tie n ts w ith m o d e ra te p o c k et d e p th . J P e rio d o n to l 1981;52:88-93. 13. A xelsson P, L in d h e J. Effect o f c o n tro lle d oral hygiene p ro ced u res on caries and periodontal disease in adults. J Clin Periodontol 1978;5:133-51. 14. A xelsson P, L in d h e J. Effect o f c o n tro lle d oral hygiene p ro c e d u re s on caries and perio d o n tal disease in ad u lts. R esults a fte r six years. J C lin P e rio d o n to l 1981;8:239-48. 15. Loe H , A n e ru d A, Boysen H , et al. T h e natural histo ry o f p e rio d o n ta l disease in m an . Study design an d baseline data. J P e rio d o n t Res 1978;13:550-62. 16. Loe H , A n e ru d A, Boysen H , et al. T h e natural history o f p erio d o n tal disease in m an. Tooth m ortality r a te s b e f o r e 40 y e a rs o f a g e . J P e r i o d o n t R es 1978;13:563-72. 17. Loe H , A n e ru d A, Boysen H , e t al. T h e natural h is to ry o f p e rio d o n ta l disease in m an . T h e ra te o f p e r io d o n ta l d e s tr u c tio n b e fo re 40 y e ars o f a g e . J Perio d o n to l 1978;49:607-20. 18. A n e ru d A, Loe H , Boysen H , e t al. T h e natural h is to ry o f p e rio d o n ta l disease in m a n . C h an g e s in gingival h e alth a n d oral hygiene before 40 years o f age. J P e rio d o n t Res 1979;14:526-40. 19. M a rs h a ll-D a y C , S te p h e n s R , Q u ig le y L. P e r io d o n ta l d is e a s e : P re v a le n c e a n d in c id e n c e . J Perio d o n to l 1955;26:185-203. 20. M iller A, B runelle J , Carlos J , e t al. O ral health o f th e U n ite d States. B ethesda, M aryland: N atio n al In s titu te s o f H e a lth , 1987; N IH P u b lica tio n No. 872868. 21. G reenw ell H , Bissada N, W ittwer J . Periodontics in g e n e r a l p ra c tic e : P e rs p e c tiv e s o n p e r io d o n ta l diagnosis. JADA 1989;119:537-41.
22. W ilson T, Glover M, Schoen J, et al. C om pliance w ith m a in te n a n c e th e ra p y in a priv ate p e rio d o n ta l practice. J Periodontol 1984;55:468-73. 23. S c h m id t J , M orrison E, K erry G, e t al. P atien t c o m p lia n c e w ith suggested m a in te n a n c e recall in a p r iv a te p e r i o d o n t a l p r a c tic e . J P e r io d o n t o l 1990;61:316. 24. Aleo J , DeRenzis F, F ärber P, et al. T h e presence an d biological activity o f cem entum bou n d endotoxin. J P erio d o n to l 1974;45:672-5. 2 5 . N a k ib N , B issa d a N , S im m e lin k J , e t al. E n d o t o x in p e n e t r a t i o n in to r o o t c e m e n tu m o f p e rio d o n ta lly h e a lth y a n d diseased h u m a n te e th . J P eriodontol 1982;53:368-78. 26. B ad e rste n A, N ilveus R, E g e lb e rg j . E ffect o f nonsurgical perio d o n tal therapy. II. Severely advanced periodontitis. J Clin Periodontol 1984;11:63-76. 27. G reenw ell H , Stovsky D, Bissada N. P eriodontics in g e n e r a l p ra c tic e : P e rs p e c tiv e s o n n o n s u rg ic a l therapy. JADA 1987;115:591-5. 2 8 . G re e n w e ll H , B issa d a NF, S to v sk y D. P e rio d o n tic s in g e n e r a l p ra c tic e : P e rs p e c tiv e s o n surgical therapy. J A cad G en D ent 1989;37:228-33. 29. Caffesse RG, Sweeney PL, Sm ith BA. Scaling and r o o t p la n in g w ith a n d w ith o u t p e r i o d o n t o l fla p surgery. J Clin P erio d o n tal 1986;13:205-10. 30. S tam baugh RV, D ragoo M, Smith DM, e t al. T he lim its o f s u b g in g iv a l s c a lin g . I n t J P e r io d o n t ic s R estorative D ent 1982;1:30-41. 3 1 . M a tia J I , B iss a d a N F, M a y b u r y J E , e t al. Efficiency o f scaling o f the m olar furcation area with a n d w ith o u t s u r g ic a l a c c e ss . I n t J P e r io d o n t ic s R estorative D en t 1986;6:24-35. 32 . N e v in s M, B e c k e r W, K o rn m a n K, e d s. P r o c e e d in g s o f th e W o rld W o rk s h o p in C lin ic a l P e r io d o n t ic s . C h ic a g o : A m e ric a n A c a d e m y o f Periodontology, 1989;9:24-6.
ARTICLES
Periodontics in general practice: professional plaque control H e n r y G reenw ell, D M D , JD , MSD; N a b il F. Bissada, D D S, MSD; J o h n W. W ittwer, D D S, MS
T ra d itio n a lly the p r im a r y em phasis o f preventive periodontics was daily p a tie n t p erfo rm ed plaque control. Recent studies indicate that frequent professional subgingival toothcleaning is a mandatory treatment fo r p re ve n tio n o f recu rren t p erio d o n titis. Pathogenic subgingival bacterial complexes are disrupted by frequent cleaning and require tim e to reestablish. Disease progression is prevented if the recall interval does not exceed the tim e required fo r reestablishment o f a pathogenic plaque. Legally, patients have a cq u ired the duty to com ply w ith the prescribed recall interval. Both the patient a n d the p ra c titio n e r w ill benefit fro m a preventive program that includes frequent professional subgingival toothcleaning.
rofessional p laq u e c o n tro l is n o t a p u b lic h e a lth m e a s u re , as in th e c a s e o f f l u o r i d e , b u t it is la b o r in te n siv e th e ra p y availab le o n ly to th o s e w illing to seek a n d a c c e p t p r o p e r d e n ta l care. A d u lt p e rio d o n titis affects on ly 15% to 25% o f th e p o p u la tio n , a n d m a n a g e m e n t by in tensive su p p o rtiv e p e rio d o n ta l th e ra p y is a viable o p tio n . A n im p o rta n t re q u ire m e n t o f such su p p o rtiv e ca re is th e p r a c t i t i o n e r ’s r e c o g n i t i o n o f d is e a s e r e c u r r e n c e in th e p a tie n t. P ro fe s s io n a l p la q u e c o n tro l will m ain ta in m ost p ro p e rly tr e a te d cases o f a d u lt p e rio d o n titis ; p a ti e n ts w h o c o n t i n u e to p r o g r e s s a re c a n d id a tes fo r refe rra l to a specialist. S uccess o f p ro fe ssio n a l p la q u e c o n tro l
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c lo s e ly r e l a t e s to m a n a g e m e n t o f th e q u a li ta t iv e c o m p o s it io n o f t h e p la q u e m ic ro flo ra . T h o ro u g h to o th c le a n in g d isru p ts th e o rg a n iz a tio n a n d stru c tu re o f aging, p a th o g e n ic p laq u e. T h e n fewer, less p a th o g e n ic b ac te ria are left to re b u ild th e s tru c tu re n ece ssa ry fo r re d e v e lo p m e n t o f p a th o g e n ic c o m p o n e n ts . B e fo re p a th o g e n ic b a c te r ia r e e s ta b lis h , p r o f e s s io n a l to o th c le a n in g a g a in in te r r u p ts th e cycle a g a in b e fo re th e b a c te ria l c a n d o h a rm . T h e c o n c e p t th a t sp ecific b a c te ria c au se p e rio d o n ta l disease d escrib es this specific p la q u e hyp o th esis. T h e success o f p ro fes sional p la q u e c o n tro l c o n firm s h y p othesis as a d e s c r ip to r o f th e ro le o f m ic ro b ia l p la q u e in th e p a th o g e n e sis o f a d u lt p e ri o d o n titis. T h is article reviews th e stu d ies n o t only a b o u t e s t a b li s h e d p r o f e s s i o n a l p la q u e c o n tro l as a re co g n ize d sta n d a rd re q u ire d f o r th e s u c c e s s f u l t r e a t m e n t o f a d u l t p e rio d o n titis, b u t also studies th a t ex p lain th e r a tio n a le fo r p ro f e s s io n a l p la q u e c o n tro l a n d d e m o n s tra te its effectiv en ess in large p o p u la tio n s.
Posttreatment professional plaque control L in d h e a n d o th e r s 1 r e p o r te d th a t te e th tre a te d by e ith e r su rg ica l o r n o n su rg ic a l m e th o d s te n d to m a in ta in h e a lth as lo n g as o p tim u m p la q u e c o n tro l was su stain ed . A f te r t r e a t m e n t e a c h p a t i e n t re c e iv e d p ro fe ssio n a l to o th c le a n in g e v e ry 2 w eeks in th e firs t 6 m o n th s . T h e in te r v a l w as le n g th e n e d to 3 m o n th s fo r th e re m a in d e r o f th e 2-year study. T e e th th a t w ere p laque-
free m a in ta in e d a tta c h m e n t levels; plaquea ss o c ia te d sites o fte n lo st a tta c h m e n t to th e t o o t h . In c o n t r a s t , R a m f jo r d a n d o t h e r s 2 r e p o r t e d , in a n 8 -y e a r stu d y o f s u r g ic a l th e r a p y , t h a t p e r f e c t p e r s o n a l p la q u e c o n tr o l w as n o t c r itic a l f o r th e m a in te n a n c e o f a tta c h m e n t levels. Twentyfive p e rc e n t o f th e p a tie n ts w ith th e best p la q u e scores w ere c o m p a re d w ith 25% o f th e p atien ts w ith th e low est p laq u e scores. N o sig n ific a n t d iffe re n c e s in a tta c h m e n t lev el d a ta w e re f o u n d b e tw e e n th e two g ro u p s over th e lo n g -term . T h e success o f th e th e r a p y d e s p i te i m p e r f e c t p la q u e c o n tro l was a ttrib u te d to th e 2 to 3 m o n th recall fo r p ro fessio n al to o th c lean in g . P i h l s t r o m a n d o t h e r s 3-4 e v a l u a t e d p a tie n ts t r e a te d s u rg ic a lly a n d n o n s u r g ic a lly , a n d th e y f o u n d t h a t e v e n w ith re la tiv e ly p o o r p e r s o n a l s u p r a g in g iv a l p la q u e c o n tro l, a tta c h m e n t levels c o u ld b e m a i n t a i n e d w h e n c o m p l y in g w ith t h e recall fo r p ro fessio n al to o th c le a n in g . T his s u p p o r te d th e fin d in g s o f R am Q ord a n d o th e rs,2 a n d it c re a te d a co n flict c o n c e rn in g th e ro le o f p o s t tr e a t m e n t p e r s o n a l p la q u e c o n t r o l in th e m a i n t e n a n c e o f p e rio d o n ta l a tta c h m e n t levels. Isid o r a n d o th e r s 5-6 reso lv ed th is c o n flic t in a 5-year stu d y o f p a tie n ts t r e a te d s u rg ic a lly a n d n o n s u r g ic a lly f o r p e r i o d o n t a l d is e a s e . T h e y fo u n d th a t o ra l h y g ie n e sta tu s d id n o t c o r r e l a t e w ith t h e n u m b e r o f d e t e r i o r a t i n g s ite s , c o n f i r m i n g th e fi n d in g s o f R a m f jo r d a n d o t h e r s 2 a n d P ih ls tr o m a n d o t h e r s . 3-4 T h e r e s u lts o f p re v io u s stu d ie s d id n o t actually co n flict b u t m erely re fle c te d th e u se o f d iffe re n t ty p e s o f p r o f e s s i o n a l t o o t h c l e a n i n g .
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L in d h e and o th e rs1 p erform ed p rofes sional supragingival toothcleaning alone while Ramfjord and others,2 Pihlstrom and o th e r s ,3’4 and Isidor and o th e r s5 6 also in clu d ed professional subgingival tooth clean ing. Thus professional subgingival t o o th c le a n in g p r e v e n te d s ig n ific a n t attachment loss even when personal oral h y g ie n e was im p e r fe c t; p r o fe ssio n a l su p ra g in g iv a l t o o th c le a n in g d id n o t prevent attachment loss if personal plaque control was imperfect. T h e 3-m onth recall for p rofessio n a l supra- and subgingival too th clea n in g appears to maintain periodontal health. T he nonspecific plaque hypothesis calls for pocket elimination to expose all areas o f th e to o th su b jec t to p la q u e a c c u m u la tio n in p e r io d o n ta l tre a tm en t. Subgingival p laqu e is ren d ered supra gingival and accessible to the patient for c o m p le te d aily rem oval th a t a c c o m m odates the m ost fundam ental ten et o f th e n o n sp ec ific p laq u e h ypothesis: all plaque must be removed to prevent dental diseases. Lindhe and others1 demonstrated that loss o f periodontal attachment can be ex p ec ted with im p erfect supragingival plaque control. Few patients can maintain ideal standards o f plaque control and the n onsp ecific plaque hypothesis fails as a practical rationale for pocket elimination surgery. On the other hand, periodontal treatm ent based on the specific plaque h y p o th e sis p erm its th e p r e s e n c e o f n o n p a th o g en ic plaque w hich d o es n ot provoke loss o f clinical attachm ent. The specific plaque hypothesis is clear: it is the qualitative composition o f the plaque, not its presence, that is harmful. Pathogenic plaque harbors either bacteria or bacterial c o m p le x e s th at p r e d isp o se to lo ss o f attachment. Thé flora that causes disease progression may vary from individual to in d iv id u a l; it is s p e c ific in th a t it is pathogenic and not necessarily because of eq u iv a len t bacterial co m p o sitio n . T he professional subgingival plaque control p e r fo r m e d by R am fjord an d o t h e r s ,2 Pihlstrom and others,3-4 and Isidor and others5-6 did prevent loss o f attachm ent, even when personal supragingival plaque control was imperfect.2-6 Interrupting the d e v e lo p m e n t o f a p a th o g e n ic flo r a , illustrates the specific plaque hypothesis as the prim ary rationale for using p rofes sio n a l subgingival p laqu e co n tro l as a m ethod to preserve periodontal health in supportive therapy. Maintaining qualita tive control o f the flora by converting a p a th o g e n ic su b g in g iv a l p la q u e to a tem porarily n o n p a th o g en ic state is an essential com ponent o f the specific plaque
hypothesis. The foregoing studies do not support n eg lect o f oral h ygien e procedures; all p a tie n ts w ere o n a c lo se ly su p erv ised p erson al p laq u e c o n tro l program and were evaluated at frequent intervals by a p e r io d o n tis t. W h ile p a tie n t s ’ p la q u e control was often far from perfect, there w ere no cases o f gross n e g le c t. T h ree p oin ts n eed to b e reco g n ized and em phasized: many patients will fall short of th e g o a l o f p e r fe c t p la q u e c o n tr o l; fre q u en t p ro fessio n a l supra- and sub gingival p laque co n tro l is an ironclad, in fle x ib le re q u ir e m e n t fo r lo n g -term supportive care; and in the absence o f professional subgingival plaque control, loss o f attachment and ultimate failure of the case should be expected. Although not all patients or all sites within the mouth are susceptible to breakdown, we cannot p r e d ic t w h ich o n e s w ill b reak dow n. T h erefo re, th ese p rin cip le s sh o u ld be applied to all patients with periodontitis, whether the disease is considered active or inactive.
Rationale for professional subgingival plaque control Listgarten and Hellden7 reported that the bacterial m orphotype proportions in the subgingival m icroflora were different in health and disease. Periodontally healthy sites were predom inated by coccoid cells an d stra ig h t rods; d ise a s e d sites had increased proportions o f m otile rods and sp iroch etes.7 W hen d iseased sites were treated by scaling and root planing, the flo ra c o m p o se d o f m o tile ro d s and spirochetes was converted to a coccoid cell and straight rod flora in healthy mouths.8 It to o k a p p r o x im a tely 42 days for sp iroch etes to return to b a selin e (pre treatment) levels. The posttreatm ent shift in subgingival m orp hotype p ro p o rtio n s from d isease associated to health associated bacteria followed by a slow return to pretreatment le v e ls was ter m e d by G r een w ell and Bissada9 as the “baseline tendency effect.” Disease-associated m orphotypes are not n e c e ssa r ily p e r io d o n ta l p a th o g e n s. Presumably pathogenic com ponents o f the subgingival m icroflora follow the same r e p o p u la tio n tren d s as m o rp h o ty p e proportions, accou n tin g for the associ ation with disease. Pathogenic bacteria re establishes in approximately 3 m onths.1-6 Morphotypes may return to pretreatment levels in 42 days; however, th e role o f disease associated morphotypes must not be m isinterpreted and equated with the
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ro le o f sp e c ific b a c te r ia id e n tifie d as periodontal pathogens. The return time o f pathogenic com plexes, capable o f induc ing attachment loss, cannot be identified from m o rp h o ty p e c o u n ts u sin g p h ase co n trast or d ark field m icroscop y. T he m orphotype exam ination is valuable as a research tool and illustrates the trends o f microbial succession, the direction o f the q u a lita tiv e sh ift tow ard e ith e r h ea lth associated or disease associated bacteria. T h e q u a lita tiv e sh ift tow ard a h ea lth associated flora is critically im portant to the success o f the 3-month recall. Listgarten and o th ers10 com pared the c lin ic a l and m ic r o b io lo g ic a l e ffe c t o f SC/RP with systemic tetracycline, 1 g per day for two periods o f 2 weeks separated by a 1 m o n th in te r v a l. T h e e f f e c t o f SC /R P was eq u ivalen t to the antibiotic therapy in terms o f producing a shift in subgingival m orp hotypes. T his d em o n strates the powerful effect o f professional subgingival to o th clea n in g in producing qualitative bacterial changes. The distinc tion betw een the two therapies was the a n tib io t ic ’s sh o rt liv e d e f f e c t o n th e bacteria if it was n ot accom panied with SC/RP. Professional subgingival plaque control is th e m o st im p o r ta n t a sp e c t o f a supportive care plaque control program, in co n ju n ctio n with p atient-perform ed supragingival plaque control. Magnusson and others11 reported that patients with poor supragingival plaque control typically show a rapid return o f sp irochetes and motile rods to baseline levels. Patients with e x c e lle n t supragingival p laqu e co n trol b e n e fit from a su sta in ed red u ctio n o f sp iro ch etes and m o tile rods. T h e tim e required for the baseline tendency effect to cycle varies, depending on the patients’ lev el o f su pragingival p la q u e co n tro l. Good oral hygiene results in a prolonged return to b aselin e (d isea se associated) values w hile p oor oral h ygien e yields a rapid return. The frequency o f the recall may depend on the level o f supragingival plaque control. Patients with poor supra gin gival p laq u e c o n tro l may requ ire a sh o rter in te rv a l th an th e stan d ard 3month period. At some point, shortening the recall interval becom es impractical. T he initial developm ent o f subgingival plaque m ost likely d erives from supra gingival plaque. Yet, Tabita and others12 dem onstrate that even daily professional removal o f supragingival plaque will not p revent the reform ation o f subgingival plaque. This is possibly the result o f the inability to achieve total plaque removal consistently. Even professional supraginJADA, Vol. 121, November 1990 ■ 643
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gival and subgingival toothcleaning cannot halt subgingival plaque growth. The fact that subgingival plaque formation cannot b e p r e v e n te d e x p la in s why re ca ll for p r o fe ssio n a l su b g in g iv a l c le a n in g is essential for all patients with p eriodon titis.1
Professional plaque control and large populations In a 6-year study on th e e ffe c t o f pro fessional plaque control on adult dental health, Axelsson and Lindhe1«-1 evaluated tw o d iffe r e n t system s o f d e n ta l care: tra d ition al, sym ptom atic care versus a preventive care program. The traditional care group (375 subjects) received SC/RP, treatment o f all carious lesions including replacement o f ill-fitting restorations, and o n e session o f oral hygiene instructions fo llo w e d by 1-year reca ll w ith a cc o m panying sym ptom atic dental treatm ent. The preventive care group (180 subjects) received the same initial SC/RP and caries treatment; however, this was followed by 2m onth recall in the first 2 years and 3m o n th recall in th e last 4 years. Each patient-recall for professional supra- and subgingival tooth cleaning also included detailed oral hygiene instructions. Results show that traditional dental care does not h a lt th e p r o g r e ssio n o f ca r ie s and periodontal disease. Preventive care with fr e q u e n t p r o fe ssio n a l t o o th c le a n in g motivates individuals to adopt proper oral h y g ien e habits, resolves gingivitis, and prevents the p rogression o f caries and periodontal disease. Axelsson and Lindhe1314 applied the 3m o n th reca ll p rogram to th e g en er a l p o p u lation with overw helm ing success, not only in the prevention o f periodontal disease but also den tal caries. T h e fre quent professional toothcleaning and oral hygiene instruction also serves as m oti vational therapy and stimulates patients to exercise g ood oral hygiene habits. Fre quent, thorough toothcleaning keeps the teeth largely calculus-free which simplifies a n d fa c ilita te s p e r so n a l o ral h y g ien e efforts. In an ev a lu a tio n o f an ev e n larger population Loe and others15-1« compared the periodontal health o f subjects receiv ing a high level o f dental care to a group receiv in g m inim al care. A total o f 565 N orw egian stud en ts and acad em ician s re p r esen te d th e u p p er so c io e c o n o m ic strata, receiving a high level o f dental care, and the group with deprived econom ic conditions and m inimal dental care was made up o f 480 Sri Lankan tea laborers. 644 ■ JADA, Vol. 121, November 1990
At the last report, the group receiving a high level o f dental care had only little loss o f periodontal attachment and a very low tooth mortality rate. In contrast, the Sri Lankans receiving m inim al d en tal care exhibited significant loss o f periodontal attachm en t and a m uch h ig h er rate o f tooth mortality. Two studies in the United States reveal a dram atic d eclin e in prevalence o f peri odontitis. In 1955 Marshall-Day and others report that 88% to 92% o f a group aged 40-60 had p e r io d o n ta l d ise a se and p o ck ets.19 A 1987 report by M iller and others20 evaluating 20,818 individuals from across the United States based conclusions on both loss o f attachment and probing pocket depths. It shows only 15% to 25% o f th e p o p u la tio n w ith s ig n ific a n t pocketing or attachm ent loss. W hile the two studies use different methodology and are not directly comparable, it is clear that periodontitis has declined in the U nited States. Some o f the factors contributing to this d e c lin e in clu d e: the h igh level o f dental care provided by the average US p ra c titio n e r , p a tie n t e d u c a tio n and aw aren ess o f th e im p o r ta n c e o f oral h y g ien e and reg u la r d en ta l care, and freq u en t m ed ia advertisem ents o f oral hygiene products, which accentuate the social unacceptability o f poor oral hygiene and oral m alodor. With m ore frequ en t professional toothcleaning and preventive care, p rev a len ce o f p e r io d o n titis w ill decline even further.
Disease progression and professional plaque control T h e p rev io u sly d isc u sse d stu d ie s by Axelsson and Lindhe1314 have shown that 3-m onth p ro fessio n a l to o th cle a n in g is beneficial for the population at large; and therefore, it could be a useful option for any patient in need o f improved preven tive care. Patients who have b een diag nosed and treated for adult periodontitis, however, require 3-m onth p rofessional to o th c le a n in g to p rev e n t c o n tin u e d p rogression o f d isease. G reenw ell and o th e r s 21 have p ro p o se d a m e th o d o f diagnosis for treated periodontitis, termed a response diagnosis, to help identify the c u r r e n t d ise a se statu s o f in d iv id u a ls treated for adult periodontitis at each 3m onth recall visit. Patients who have no fu r th e r p r o g r e ssio n o f d ise a se w ere diagnosed as having controlled periodon titis an d n e e d n o a d d itio n a l th erap y b eyond the 3-m onth recall. T hose who c o n tin u e to lo se a tta c h m en t d e sp ite proper treatm en t and 3-m onth profes
sional tooth clean in g were diagnosed as having eith er advancing p erio d o n titis, u n c o n tro lled p erio d o n titis, refractory periodontitis, or nonresponding periodon titis. T h e se p a tie n ts m ay n e e d m o re frequ en t professional to o th clea n in g or other sophisticated diagnostic testing and treatm ent, and they are candidates for referral to a specialist. This m eth od o f d ia g n o sis w ill h e lp a v o id law suits for failure to diagnose periodontal disease or supervised neglect.
Compliance with professional plaque control S tu dies o f co m p lia n ce with a 3-m onth recall interval follow ing treatm ent by a periodontist show wide variation. Wilson and others22 reported that only 16% o f patients complied with the recommended interval; Schmidt and others23 found 95% compliance. The reason for the difference is n o t clear. As with oral hygiene, m oti vation is undoubtedly an important factor. P a tien ts sh o u ld be in fo r m e d b e fo r e p eriodon tal therapy that frequ en t pro fessional toothcleaning is a requirem ent for successful treatm en t and failure to co m p ly w ill m o st lik ely y ie ld a p o o r treatm ent result. S chm idt and o th ers23 fo u n d that erratic co m p liers requ ired more surgical treatment than patients in full com pliance with the recom m ended interval. Compliance was good for patients who alternated recall between the peri o d o n tist an d g e n e r a l d e n tis t an d this system was e ffe c tiv e in m a in ta in in g excellent periodontal health in supportive therapy.
Professional toothcleaning procedures It is im portant to make the d istinction b etw e en th e th r e e d iffe r e n t types o f professional to o th clea n in g procedures: ro u tin e p ro p h y la x is, SC /R P , and p ro fessional subgingival plaque control in a 3m onth recall for supportive periodontal therapy. Routine prophylaxis is primarily a supragingival p ro ce d u re p ro v id ed for patients who are periodontally healthy or have mild gingivitis. All plaque, calculus, and stain are removed and since there is no pathologic deepening o f the sulcus this procedure is often accomplished in 30-45 minutes. Subgingival areas may be cleaned but since the sulcus is 3 mm or less this can be achieved with little difficulty. As w ith o th er p ro fessio n a l to o th cle a n in g procedures, com plete plaque removal is equally as important as com plete calculus removal.
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T h e S C /R P p r o c e d u r e is g en er a lly reserved for patients who have n ot had recent active treatm ent for periodontitis (ro o t in str u m e n ta tio n ) a n d typ ically exhibit deposits o f older calculus that are tig h tly a tta c h e d to th e r o o t su rfa ce. R em oval o f th e s e te n a c io u s d e p o sits req u ires sh arp , n ew c u r e ts th a t can withstand the lateral forces required for com plete calculus removal. Older curets, th in n ed by sh a rp en in g , are su bject to fracture. A very sharp curets blade is need to rem o v e th e su p e r fic ia l layer o f cem en tu m w hich con tain s en d oto x in s, p erp etu a to r s o f th e in fla m m a to r y process.2425 Ultrasonic instrumentation is h e lp fu l an d o fte n u se d b e fo r e ro o t p la n in g .26 S C /R P may requ ire up to 2 hours per quadrant with local anesthesia if the procedure is performed in accordance with the principles o f nonsurgical peri odontal therapy.2728 As SC/RP is a difficult procedure, calculus is frequently missed; therefore, patients m ust be reevaluated after SC /R P so that all areas o f m issed calculus can be detected and removed.2»-31 Recall for treated periodontal patients is a completely different situation. Residual pockets, usually shallow, may be present to complicate the toothcleaning procedure. S ince th e tissu e is h ea lth y and tightly adapted to the tooth, older, thinner curets may be easier to use and m ore com fort able for the p atien t. A n esth esia is n ot required and the appointment, complete with periodontal examination, can usually be accom plished in 1 hour. Deposits on the tee th are im m atu re and ea sier to remove than older, more tightly attached ca lcu lu s. R em oval o f ro o t ce m en tu m an d /o r dentin is n ot a goal o f the recall appointment as it is with SC/RP. In fact, co n tin u ed p la n in g o f th e ro o t surface would be an abusive procedure resulting in excessive and unnecessary removal o f tooth structure. The critical factor is that all plaque and calculus must be removed. Total plaque rem oval is an often over looked requirem ent o f this appointm ent but in terms o f p rod ucing a p rolon ged baseline tendency effect this is a critically important objective. The subgingival tooth surface should be curetted until no more visible soft d ep osits can be withdrawn. S u p ragin givally, th e p ro x im a l to o th surfaces should be flossed until plaque free, then all buccal and lingual plaque rem oved by rubber cup p olish ing. T he th o r o u g h n e ss o f th e to o th c le a n in g is im p o r ta n t sin c e in c o m p le te p la q u e removal will result in a shortened cycle for the baseline tendency effect and fuel an earlier return o f pathogenic bacteria.
Legal ramifications In ad eq u ate p a tie n t p erfo rm ed plaque control was considered the primary cause o f case failure in periodontal maintenance therapy when the treatment rationale was b ased on th e n o n s p e c ific p la q u e hy pothesis. T h e goal o f treatm ent was to create a situation whereby all plaque could be removed by the patient on a daily basis. If the patient failed to com ply this duty, the resulting periodon tal deterioration was attribu ted to p a tien t n eg le ct. The professional’s duty was to provide 6-month recall for examination, toothcleaning, and oral h y g ie n e in s tr u c tio n s to su p p o rt conditions that would permit the patient to maintain periodontal health through personal oral h ygien e m easures. N egli g e n c e arisin g from p erio d o n ta l m ain tenance therapy based on the nonspecific plaque hypothesis was usually attributable to the patient because any failure o f daily p la q u e c o n tr o l c o u ld le a d to d isea se recurrence. The recent World Workshop in Clinical P e r io d o n tic s rejected th e term “p eri odontal maintenance therapy” in favor of the m ore descrip tive “supportive peri o d o n ta l th e r a p y ” (S P T ).32 A reca ll ap p oin tm en t sh ould in clu d e com p lete p e r io d o n ta l e x a m in a tio n , re sp o n se diagnosis, professional supra- and subgin gival to o th c le a n in g , an d r e c o m m e n dations for any additional treatment. From a legal standpoint, both the patient and the practitioner have acquired new duties. The professional is obligated to inform the patient that professional plaque control is necessary on a 2 to 3 month basis and to p ro v id e p r o p e r p r o fe ssio n a l to o th clea n in g , ex a m in a tio n , and diagnosis. Providing periodontal treatment without accompanying SPT should be considered n egligen t care by the practitioner. The p a tie n t r e ta in s th e p rev io u s duty to perform adequate personal plaque control and acquires the duty o f com plying with the prescribed interval for professional plaque control. Failure o f the patient to com ply with th ese d u ties will result in disease p rogression , w hich th e p rofes sional will be powerless to prevent. Studies by Axelsson and Lindhe1314 show that 3-month professional toothcleaning may be b en eficial for the gen eral p op ulation as a preventive measure. There is a duty h ere to in fo r m p a tie n ts w ith o u t p e r io d o n titis th a t th is is a trea tm en t o p tio n . P a tien ts w ith p e r io d o n titis , however, must be informed that 3-month professional toothcleaning is a mandatory c o m p o n e n t o f su c c e ssfu l tre a tm en t.
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Irrespective o f the type o f therapy, elective or r e q u ir e d , th e p a tie n t n e e d s to b e informed o f the role o f that treatment in esta b lish in g a n d /o r m a in ta in in g their periodontal health. If the practitioner’s recom m endations are rejected, a written “informed refusal” should be obtained to ensure that the patient understands the c o n s e q u e n c e s o f th e ir refu sa l an d to p r o te c t th e d e n tis t in ca se o f fu tu r e litigation.
Summary Studies o f treatment o f adult periodontitis follow ed by professional plaque control have show n th a t c o m p le te supra- and subgingival plaque and calculus removal on a 3-month basis is n eed ed to prevent additional loss o f periodontal attachment. The success o f the procedure is dependent on m aintaining control o f the qualitative composition o f the subgingival flora. This is a cc o m p lish e d by su b g in g iv a l to o th cleaning which disrupts established plaque structure, delays the reestablishm ent o f periodontal p athogens, and produces a b a selin e ten d e n c y e ffe c t. Large p o p u lations that have a high level o f dental care have less disease progression than those with minimal care. For patients with adult periodontitis, supportive 3-month recall is n o t an o p tio n — but a req u irem en t for successful tlierapy. These patients need a r e sp o n se d ia g n o sis to d o c u m e n t th e current disease status at each recall visit and to identify the n eed for additional trea tm en t. T h o se that e x h ib it d isea se progression are candidates for referral to a specialist. The p rocedure used for pro fessio n a l subgingival p laq u e co n tro l is vastly different than the scaling and root planing procedure. The thoroughness o f plaque removal in the recall appointment is critically important and may increase for the time the baseline tendency effect to complete its cycle.
Essays o f o p in io n o n c u rre n t issues in d entistry are published in this section o f The Journal T h e opinions expressed o r im plied are strictly those of" th e a u th o rs an d d o n o t necessarily re fle c t th e o p in io n o r official policies o f th e A m erican D ental A ssociation. Dr. G reenw ell is assistant professor, a n d Dr. W ittwer is p ro fesso r o f p e rio d o n tic s, U niversity o f Louisville; Dr. Bissada is professor an d chairm an, d e p a rtm e n t o f p e r io d o n tic s , S c h o o l o f D e n tis try , C ase W e s te rn R ese rv e U niversity, 2123 A b in g to n R d , C le v ela n d , 44106. A ddress requests fo r re p rin ts to Dr. Bissada.
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