The significance of maintenance care in the …...Key words: Periodontal surgery ~ maiiilenance care - disease progression. Accepted for publication May 21, 1980 The significance of

Journal of Clinical Periodoniology 1981: 8: 281-294

Key words: Periodontal surgery ~ maiiilenance care - disease progression.

Accepted for publication May 21, 1980

The significance of maintenance care in thetreatment of periodontal disease

p. AXELSSON AND J. LINDHE

Department of Periodontology, School of Dentistry, University of Gothenburg, Sweden

Abstract. The present investigation was performed to assess the efficacy of a maintenance care programto prevent recurrence of disease in patients subjected to treatment of advanced periodontitis. Inaddition, the periodontai status was monitored of a group of patients who following the end of activetreatment were referred back to general practitioners for maintenance care. The material consisted of 90patients who in 1972 were referred for specialist treatment of advanced periodonta! disease. The patientswere first subjected to an initial examination including assessment of oral hygiene, gingivitis, probingdepths and attachment levels. They were on an individual basis given case presentation, instructed howto practice proper tooth-cleaning methods, their teeth were scaled and eventually the periodonta!pockets were treated using the modified Widman technique. During the first 2 months following surgerythe patients were recalled once every 2 weeks for professional tooth cleaning. Two months after the endof surgical treatment, the patients were reexamined to provide baseline data. Every third patient wasthereafter referred back to the general dentist for maintenance care. Two out of three patients weremaintained in a carefully designed and controlled maintenance care program at the university cHnic.This program involved recalls once every 2-3 months and included instruction and practice in oralhygiene, meticulous scaling and professional tooth cleaning. The patients were reexamined 3 and 6 yearsafter the baseline examination.

The results demonstrated that in patients suffering from destructive periodontitis, a treatmentprogram that involved oral hygiene instruction, scaling, root planing and modified Widman flapprocedures resulted in the establishment of clinically healthy gingiva and shallow pockets. Patients whowere placed on a carefully designed recall program were over a 6-year period able to maintain excellentoral hygiene standards and unaltered attachment levels. In contrast patients who subsequent to activetreatment were not maintained in a supervised program showed obvious signs of recurrent periodontitisat the follow-up examinations.

It is obvious from a nutnber of long- and short- dependent upon the effectiveness of the main-term studies that treatment of periodontai tenance care program's subsequent active treat-disease including oral hygiene instruction, ment. Hence, in patients who following comple-scaling, root planing and surgery - in order to tion of surgical treatment are placed on main-get access to the root surfaces for proper tenance care which includes recalls every 3debridement - can not only arrest the gradual months for prophylaxis and instruction in homebreakdown of the supporting apparatus but, care techniques, the long-term result of treat-indeed, also result in gain of clinical attachment ment seems to be successful. On the other handandregrowthof alveoiarbone(e.g.Ramfjordet in patients who are recalled for maintenanceal. 1973, Lindhe & Nyman 1975, Rosling et al. care at a less frequent interval (6-12 months)1976, Poison &Heijl 1978, Knowlesetal. 1979). there is an obvious risk for recurrence ofIt has also become apparent, however, that the periodontitis (Nyman et al. 1975, 1977).long-term success of periodontal treatment is Studies by Suomi et al. (1971), Bjorn (1974),

0303-6979/81/040281-14 $ 02.50/0 © 1981 Munksgaard, Copenhagen

AXELSSON AND LINDHE

Axelsson & Lindhe (1978), Soderhoim (1979)have revealed that traditional dental treatmentfrequently seems to be directed towards theelimination of symptoms of caries and perio-dontal disease rather than on the elimination ofthe cause of the two disorders. Recent observa-tions by Loe et ai. (1978) and Soderhoim (1979)compared to results by, e.g. Bjorn (1974) indi-cate, however, that the overall standard of oralhygiene in adult populations in Scandinavia hasimproved and that as a consequence the fre-quency and severity of caries and periodontaldisease are becoming less pronounced.

Patients who suffer from advanced perio-dontal disease are often referred by the generalpractitioner to a specialist for treatment. As arule the periodontitis patient is subjected to anelaborate treatment in the specialist's officeincluding periodontal surgery and active main-tenance care immediately postsurgically. Sub-sequently, in most instances, the patients arereferred back to the general practitioner forlong-term maintenance care. In 1978, Axelsson& Lindhe described a maintenance care pro-gram which involved prophylaxis once every2-3 months. The plaque control program des-cribed appeared to be effective not only againstthe recurrence of periodontitis - in patients notsubjected to periodontal surgery - but alsoagainst caries. The aim of the present investiga-tion was to assess the efficacy of this main-tenance care program in patients subjected totreatment of advanced periodontal disease in-cluding extensive surgery. The periodontal sta-tus of a group of patients who following thetermination of active treatment for periodontaldisease were referred back to the general prac-titioners for maintenance care was also moni-tored; ''

Material and Methods

The material consisted of 90 patients, 48 fe-males and 42 males (mean age 52 years) who in1972 were referred for specialist treatment ofadvanced periodonta! disease.

The patients were first subjected to an initialexamination which included assessments of oralhygiene, gingivitis and degree of periodontaltissue destruction (probing depth, attachmentlevel). In addition, the degree of furcationinvolvement, when present, was recorded ac-cording to a technique described by Lindhe &Nyman (1975). The level of the alveolar boneand the configuration of the bone crest wereassessed in roentgenographs obtained using along-cone technique and with the use of a device(Eggen 1969) that ensures a reproducible geo-metrical relationship between the cental x-raybeam, the tooth and the film.

Presurgical treatmentSubsequent to the initial examination, the pa-tients received, on an individual basis, detailedinformation about the role of dental plaque inthe etiology of periodontitis. The proposedtreatment plan was presented. The patientswere instructed how to practice proper tooth-cleaning methods. Following motivation theirteeth were carefully scaled, plaque and calculuswere removed and ill-fitting margins of restora-tions eliminated. The presurgical treatment wasdelivered by one periodontist and requiredseveral sessions for each patient. Cariologic andendodontic treatment was provided when in-dicated. Teeth which from an endodontic, ca-riologic or periodontic view point could not besuccessfully treated were extracted. Hence, somepatients were given extensive dental treatmentincluding restorations and, in a few instances,provisional prosthetic reconstructions.

Surgical treatmentAfter completion of the presurgical treatmentphase, the patients were subjected to periodontalsurgery in all four jaw quadrants using themodified Widman technique including curet-tage of bony defects but no resection of bone.During the first 2 weeks subsequent to surgery,the patients were placed on a chlorhexidinemouthrinsing regimen (0.2% chlorhexidine di-gluconate, twice daily, 10 ml, for 2 min). In

MAINTENANCE CARE IN THE TREATMENT OE PBRIODONTITIS 283

addition, during a 2-raonth period the patientswere recalled once every 2 weeks for professio-nal tooth cleaning (Axeisson & Lindhe 197S).Two months after the end of the final surgicalprocedure, the patients were reexamined toprovide baseline data {baseline examination) forthe maintenance care program. The same para-meters as those used in conjunction with theinitial examination were recorded anew.

Maintenance treatmenlFollowing the baseline examination, every thirdpatient was sent back to the referring dentistwith written information that the periodontallesions had been treated and that in order tomaintain periodontal health the oral hygiene,calculus formation, gingival conditions andprobing depths had to be checked regularly.The need to follow a detailed plaque controlprogram was also emphasized (Non-recallgroup). Two out of every three patients weremaintained at the university clinic in a carefullydesigned and controlled maintenance care pro-gram {Recall group). This program involvedrecalls once every 2 months during the first 2years and subsequently, i.e. during the last 4years of observation, once every 3 months. Eachrecall visit included 1) instruction and practicein oral hygiene techniques, (2) meticulous scal-ing, and (3) professional tooth cleaning.

The prophylactic sessions were handled by adenta! hygienist and required about 30 min.During such a session, the dental plaque wasstained with a disclosing solution and the Bassmethod of tooth brushing demonstrated. Thepatients were instructed in the use of dental flossand toothpicks for interdental plaque control.Supra- and subgingivally located deposits wereremoved and, if needed, the root surfacespianed.

All patients were reexamined at follow-upexaminations 3 and 6 years after the baselineexamination. At the follow-up examinations theparameters studied at the initial and baselineexaminations were recorded anew.

During the maintenance period of 6 years.

eight persons in the recall group were lost (onedied and seven moved from the area). In thenon-recall group five patients were lost (onedied and four moved from the area). Hence thedata reported in this study involve 52 recall and25 non-recall patients.

At the initial, baseline and follow-up exami-nations (3 and 6 years), the following para-meters were studied.Oral hygiene status. The teeth were stained witha disclosing solution. The presence or absenceof continuous plaque in the cervical portion ofthe buccal, lingual and proximal surfaces ofeach tooth in the dentition was determined. Foreach individual, the percentage of tooth sur-faces with plaque was calculated.

Gingivitis. The presence or absence of gingivitis(bleeding on probing) in four gingival unitsaround each tooth was assessed following pro-bing. The percentage of inflamed gingival unitsin relation to the total number of gingival unitspresent was assessed.

Probing depth. The depths of the periodontalpockets were measured with a flat, graduatedperiodontal probe (Hu-Friedy® probe) on foursurfaces around each tooth. On the mesial anddistal surfaces, the pockets were measured fromthe mesio-bucca! (disto-buccai), and mesio-lingual (disto-lingual) line angles. Of the twomeasurements made on the mesial/distal sur-faces only the largest value was recorded. Thepockets on the buccal tooth surfaces of upperand lower molars were recorded at the mostbuccal aspect of the mesial root. In the lowermolar region the lingual pockets were recordedat the lingual aspect of the mesial root.

Attachment levels. The largest distance betweenthe cemento-ename! junction and the bottom ofthe clinical pocket was assessed at all buccal,lingual and mesial tooth surfaces according to atechnique described by Ramfjord et al. (1973).The attachment level assessments were made

AXELSSON AND LINDHE

with the same graduated probe as the one usedfor scoring probing depths and the measure-ments were made at the same location points.

Probing depths as well as attachment levelmeasurements were adjusted to the nearest mm.

Sources of error. Al! measurements were madeby one of the authors (P.A.). The errors in-herent in the various assessments were deter-mined in a manner described by Rosling et al.(1976). For details regarding the evaluation ofthe assessment errors, see Rosling et al. (1976).

Statistical analysis. The statistical analysis wasbased on Mann-Whitney-Wilcoxon two-sampletest, corrected for ties when needed.

Results

The results from the initial examination arepresented in Table L The average number ofteeth in the recall and non-recall patients were21.1 (±6.3) and 20.6 (±4.4). Most of the toothsurfaces examined harbored dental plaque (78-83 %) and seven to eight gingival units out of 10

examined were bleeding on gentle probing(71-78%). The individual mean probing depthswere 4.3 (±0.6) and 4.2 (±1.0) mm.

Tooth mortalityDuring the period of active treatment a numberof teeth had to be extracted. Therefore thenumber of teeth present at the baseline exam-ination was smaller than that recorded at theinitial examination (Table 2). The loss of teethin the recall group was on average 1.6 and in the

Table 2. Number of teeth (X, s.d.) present at initialand baseline examinations

Anzahl Zdhne (X, s.d.} bei der Initial- und Ausgangs-untersuchung

Nombre de denl.'i (moyenne =X el ecart-type=s.d.)presenies mix exameas initial el de reference (baseline)

GroupsExatninations

Initial Baseline

Recall

Non-recaH

21.26.27

20.64.38

19.67.02

18.05.05

Table J. Data describing the results of the initial exatnination. Total = individual mean values

Dalen, die die Remltate der initialen Untersuchung beschreiben. Totai= individuelle Mittelwerte

Resultais de I'examen initial Total= vaieurs moyennes individuelles

Groups

RecallNon-recall

RecallNon-recail

RecallNon-recall

RecallNon-recall

Proximal97±n.599±10.8

Interproximal99 ±2.795±S.O

lnterproxirnal5.3±0.85.2±1.2

No. of teeth (X21.2±6.320.6±4.4

Plaque % (X,Buccal

53 ±22.242 ±17.4

Gingivitis % (XBuccal

45 ±22.632±I7.3

Probing depth mmBuccal

3.0±0.72.9±0.9

, s.d.)

s.d.)Lingual84 ±16.973 ±17.1

, s.d.)Lingual74±21.461 ±19.7

(X, s.d.)Lingual3.5±0.73.6±1.0

total83±11.378 ± 7.9

Total78±n.771±10.6 .

Total4.3±0.64.2±L0

MAINTENANCE CARE IN THE TREATMENT OF PERIODONTITIS 285

Table 3. Number of molars, preraolars + canines and incisors present at the baseline and the foilow-upexamination after 6 years (X, s.d.)

Anzah! Molaren. Prainolaren+Eckzahne undSchneidezahne. die bei der Ausgangs- undNachuntersuchung nach 6Jahren vorhanden waren (Xm s.d.)

Nombre de ma!aire.s, de premolaires +canines el d'incisives presentes aux examens de reference et du rappel de 6ans (moyenne et ecari-iype)

Groups

Recall

Non-recall

Baseline

6 years

Baseline

6 years

Molars

3.52.553.52.55

2.62.022.42.04

Premolars +Canines

9.42.909.42.90

9.01.958.B2.14

Incisors

6.62.306.52.30

6.42.206.02.35

Total No.of Teeth

19.67.02

19.47.02

1S.05.05

17.35.48

non-recall group 2.6 teeth. The difference in

tooth loss between the two groups during the

period of active treatment was not statistically

significant.

Table 3 shows the number of different types

of teeth present at the baseline and follow-up

examinations after 6 years. In both categories of

patients the loss of teeth during the 6 years of

observation was small; the number of remaining

teeth was 19.6-19.4 (recall group) and 18.0-17.3

(non-recall group). The difference between the

two groups of patients regarding tooth morta-

lity during the maintenance period was statis-

tically insignificant.

Table 4. Plaque. Frequency distribution of surfaces (%) harboring plaque (X, s.d.). P= proximal, B = buccal,L=lingual, T=tota! = individual mean scores

Plaque. Hdufigkeilsverieilung der Oberfldehen (in%) mit adharierender Plaque (X, s.d.). V^approximal,B=bukkal. i=lingual, T = tolQl=individuelle Mitlehverte der "scores" (Bewertungseinheiten)Plaque. Distribution de frequence des faces (%) ou la plaque etait presente (moyenne; ecart-type). P=proximales,B=vestibulaires. L—linguales. T—total=^scores moyens individuels

GroupsExaminations

Initial

Baseline

Follow-up3 years

6 years

P

9711.5

3020.5

29"19.9

25"20.6

B

53^'22.2

55.9

5̂ ^13.3

6"8.7

RecallL

84!6.9

21='14.6

11"19.1

8"10.8

T

83il.3

2114.6

18"16.6

16"10.7

P

9910.8

3413.2

83"19.3

90"13.6

Non-reca]3B L

4217.4

34.4

17"12.0

28"23.3

7317.1

li='6.4

42 '̂22.9

56"28.7

T

787.9

206.8

56"16.7

66"14.9

In Tables 4-8 statistically significant differences between recall and non-recall groups have been identified in thefollowing manner:1) P<0.052) p<om3) P<0.001

AXELSSON AND LINDHE

Oral hygieneThe oral hygiene conditions are presented inTable 4 and Fig. 1. Between the initial examina-tion and the baseline examination there was inall patients a marked improvement of the oralhygiene status. The individual mean plaquescores were reduced from 83 to 21% (recallgroup) and from 78 to 20% (non-recall group).At the follow-up examinations 3 and 6 yearslater, the recall group patients had maintainedexcelient orai hygiene levels (18 and 16%),whereas the non-recall group patients showed

Plaque

Initial Treatment Baseline Follow-up Follow-up_Ej<am Exam 3 years 6 years

CH Recall groupNon-recBll group

Fig. I. Histograms describing the frequency distribu-tion of tooth surfaces with plaque and inflamedgingivai units in the two groups of patients at theinitial, baseline and fol!ow-up examinations 3 and 6years after the baseiine.

Das Histogramm beschreibt die Verteilung der Ober-Jlachen mit adhdrierender Plaque und entziindetengingivalen Einheiten in zwei Patientengruppen, bei derinitialen Vntersuehung, der Ausgangsuntersuchung(baseline) und den Nachuntersuchungen 3 und 6 Jahrenach der Ausgang.<iuntersuchung.

Histogramme representant la distribution de frequencedes faces dentaires avec plaque et des localisationsgingivalesenflammees dans les deux groupesde patients,a I'examen initial, a I'examen de referenee (baseline) etaux examens de rappel 3 ans et 6 ans apres I'examen deriference.

* Significant difference /*<0.05*** Significant difference / '<0.001.

recurrence of large numbers of plaque-carryingtooth surfaces (56 and 66%).

Gingival conditionsActive treatment resulted in both groups ofpatients in a marked reduction of the frequencydistribution of bleeding gingival units. Hence,at the baseline examination only 7% (recallgroup) and 4% (non-recall group) of the gingi-val units were bleeding on probing (Table 5,Fig. 1). At the follow-up examinations the recallgroup patients had maintained very low gingi-vitis scores (2%) whereas the non-recall patientsshowed recurrence of gingivitis: 37% bleedingunits after 3 years and 55% after 6 years.

lng depth All surfaces

Initial Baseline Follow-up: 3 years 6 years

Attachment levelmm

CH Recall groupm Non-recall group

Fig. 2. Individual mean pocket (probing) depth andattachment level data from the initial, basehne andfollow-up examinations after 3 and 6 years.

Individuelle Mittelwerte der Taschen-(Sondierungs-)tiefen und der Daten iiber das Attachmentniveau derinitialen, der Ausgangs- und der Nachuntersuchungennach 3 und 6 Jahren.

Moyenne individuelle de la profondeur des poehes ausandage (probing depth) et du niveau de I'attachement(attaehment level) a I'examen initial, a I'examen dereference et aux examens de rappel 3 ans et 6 ans plustard.*** Significant difference/'<0.001

MAINTENANCE CARE IN THE TREATMENT OF PERIODONTITIS 287

Table 5. Gingivitis. Frequency distribution of units (%) which were bleeding on gentle probing (X, s.d.).P=interproximal, B —buccal, L —Unguai, T=total=individual mean scores

Gingivitis. Hdufigkeitsverieilung der Einheiten (in%), die bei leichtem Sondieren bluteien. (X. s.d.). P=approx-imal, B=^bukkal, L—lingual. T—total=individueUe Miltelwerte der "'scores"

Gingivite. Distribution de frequence des localisations (%) ou ilseprodui.sait un saignementlors dusondageprudentde la poche (moyenne: ecart-iype). P=proximales, B=vestibulaires, L = linguales. T~ tolal= scores moyensindividueis

GroupsExaminations

Initial

Baseline

Follow-up3 years

6 years

P

992.7

108.0

2"6.4

3"6.4

B

45"22.6

12.4

0 '̂1.4

1̂ '2.0

RecallL

74='21.4

5"7.5

2"4.0

1"4.5

T

78^'11.7

7"4.8

2"3.7

2=>4.0

P

958.0

107.1

57"27.8

76"26.1

Non-recallB L

32"17.3

11.8

8"10.5

26"36.9

6f'19.7

2"3.1

25"15.1

41"29.9

T

7P'J0.6

4"2.7

37"17.7

55"23.0

Probing depths and auachmeni levelsThe average probing depths (Fig. 2, Table 6)were in both groups reduced from the initial tothe baseline examinations from 4.3 (±0.66) to1.9 mm (±0.32) and 4.2 (±0.99) to 1.8 (±0.24mm). The probing depths were consistentlylarger on approximal surfaces than on buccal orlingual surfaces (Table 6, Fig. 3). The main-tenance program delivered to the recall grouppatients made it possible for these patients to

maintain shallow pockets over the 6 years ofstudy (Figs. 2, 3, Table 6). In the non-recalipatients, however, deeper pockets graduallyshowed a tendency to recur. Hence, after 3 and 6years the average individual mean probingdepths were 2.6 (±0.38) and 2.9 (±0.51) mm(Table 6). These figures should be comparedboth with the baseline data (1.8 mm) and withthe corresponding figures for the recall group(1.5 mm/3 years; L6 mm/6 years).

Table 6. Probing depth (mm, X, s.d.). P=interproxinial, B = buccal, L—lingual, T = total=individual meanvalues

Sondierungsliefe (mm. ^. s.d.) P= approximal, B^buickal, L~lingual, T~ total=individuelle Miitelwerle

Profondeur de sondage (mm, moyenne, ecart-iype). P~proximales, B=vestibulaires, L—linguales. T=total—valeurs moyennes individuelles

GroupsExaminations

Initial

Baseline

Follow-up3 years

6 years

P

5.30.79

2.30.36

1.7"0.46

1.9"0.44

B

3.00.67

1.50.33

1.2"0.27

1.4"0.33

Recai!L

3.50.70

1.60.40

1.3"0.32

1.4"0.33

T

4.30.66

1.90.32

1.5"0.35

i.6"0.35

P

5.21.21

2.10.26

3.0"0.44

3.4"0.60

Non-recallB

2.90.85

1.30.33

2.2"0.35

2.4"0.34

L

3.60.99

1.40.29

2.2"0.39

2.6"0.50

T

4.20.99

1.80.24

2.6"0.38

2.9"0.51

2 0 AXELSSON AND LINDHE

Probing depthmm

6-5432 -

• 1

Buccal surfacesProbin

Approximal sgrlaces

m * * * ***

mInitial Baseline Follow-up: 3 years 6 years Initial Baseline Fpilow-up: 3 years 6 years

3

4-

5—

6 -

Allachment levelmni

* * *m

* * * ** * * * * * *Attachment levelmm

• Recall group^ Non-recail group

Fig. 3- Pocket (probing) depth and attachment level data from buccal and approximal surfaces obtained at theinitial, baseline and foilow-up examinations.Taschen-(Sondierungs-)tiefen imdAttachm^ntniveaudaten der bukkalen iindapproximalen Oherflachen, erhaltenbei der initialen, der Ausgangs- und den Nachuntersuchungen.

Profondeur despoches au sondage (probing depih) el iiiveau de I'anachemeni(atiachmentlevel) au niveau desfacesvestibulaires (buccal) et proximales (approximal) aiix examens initial, de reference ei de rappel.

* Significant difference /'<0.05** Significant difference P< 0.01

*** Significant difference /'<0.001.

Table 7 presents the frequency distribution ofdifferent categories ofprobing depths; ̂ 3 mm,4-6 mm and > 7 mm. At the initial examinationa large number of pockets were >3 mm deep(recall group—66%, non-reeall group—50%).At the baseline examination only isolatedpockets could be identified which were >3 mm.At the follow-up examinations there were in therecall group practically no pockets>3 mm. Inthe non-recall group, however, 9 % (3 years) and20 % (6 years) of the pockets examined were > 3mm. The majority of the deep pockets werefound on approximal surfaces.

Table 8 demonstrates the effect of activetreatment and maintenance care on the attach-ment levels. The recall group patients were ableto maintain their attachment levels unalteredbetween the baseline and 6-year follow-up

examinations. The non-recall group patients,however, lost on the average 1.8 mm of attach-ment over the 6 years of observation (Figs. 2,3).The attachment loss was most pronounced atapproximal surfaces (Fig. 3). Table 9 shows theattachment alterations between the baselineand 6-year follow-up examinations. It is obviousthat only isolated surfaces in the recall grouppatients lost attachment whereas more than halfof the surfaces examined in the non-recall grouplost between 2-5 mm of attachment. The attach-ment loss was most pronounced in the molartooth regions.

Discussion

The present investigation demonstrated that inpatients suffering from destructive periodon-

MAINTENANCE CARE IN THE TREATMENT OF PERIODONTITIS 289

Table 7. Probing depth. Frequency distribution (X, s.d.) of probing depths ^ 3 mm, 4-6 tnm, > 7 mm.P=interproxima!, B = buccal, L = Iingual, T —total = individual mean values

Sondierungstiefe, Hdufigkeitsverteilung (X. s.d.) der Sondierungsiiefen < 3mm, 4-6mm, > 7mm. P= approximal,B^bukkal, L=Ungual, T=total=indmdueUe Miilelwerte

Profondeur de sondage. Distribution de frequence (moyenne; ecart-type) desprofondeurs de sondage < 3 mm, 4-6mm, ^ 7 mm. P=proximales, B—vestihu!aires, L=linguaies. T=total=valeiirs moyennes individuelles

GroupsExaminations

Initial mm< 3

4-6

> 7

P

6

83

12

B

81

19

0

RecaliL

57

42

1

T

35"15.258"13,289.4

P

29

50

21

Non-recallB

83

16

2

L

67

30

3

T

50"16.938"10,91212.3

Baseline <3

4-6-

99 100 99 99 99 100 100 99

Follow-up3 years

Follow-up6 years

< 3

> 7

< 3

4-0

> 7

99

1

0

99

1

0

iOO

0

0

IOO

0

0

100

0

0

100

0

0

99"-1"_0

99"_1"

0"

84

16

0

68

30

2

98

2

0

95

4

0

97

3

0

88

1!

1

91"6,393)

6.40

80"13,319"13,31"

Table 8. Attachment level (mm, X, s.d.). P=interproximal, B = buccal, L —lingual, T=total (individual mean)values

Altachmentniveau (mm. X, s.d.). P=approximal. B=biikkaL L = lingual. T=tota/ (individuelle Mitlelwerle)

Niveau de I'attachement (mm, X. s.d.). P=proximal, B=vestibulaire. L = liitgual, T—vaiews totales (moyenneindividuelle)

GroupsExaminations

Baseline

Follow-up3 years

6 years

P

4.3"0.99

4.2"0.98

4.0^'1.02

B

4.3"1,10

4,3"1.01

4.3"1.07

RecallL

3,90.87

3.8"0.86

3.7"0.88

T

4.2'>0.90

4. i"0.88

4.0"0.93

P

3.7='1.30

5.1"0.85

5.7"1.22

Non-re cailB L

3.7"0.95

5.0"0.86

5.4"LIO

3.71.26

5.8"0.89

5,3"1,13

T

3.7"1.11

5.0"0.86

5.5"1.13

AXELSSON AND LINDHE

Table 9. Loss of attachment between the baseline and 6-year folSow-up examinations. Frequency distribution(%) of surfaces. Mol. —Molars, Premol. = Premolars, inc.= Incisors, Tot. = total = individual mean values.M—mesial, B = buccal, L = lingual

Attachmemverhisi zwischen der Auxgaiigs- und den Nachuniersuchungen nach 6 Jahren. HdufigkeitsvertcHung(in%) der Oberfidchen. Mol. — Molaren. Premol.=Pramolaren, [nc. = Schneidezahne, Tol.~iola/—individuel/eMitlelwerie. M= mesial, B=bukka/, L~lingua!

Perie de I'atiachemertl survenue enve I'examen de reference (baseline) ei I'examen du rappel (follow-up) de 6 arts.Distribution de frequence (%) des faces. MoL=molaires. PremoL=premolaires. lnc. = ineisives. Tot. = toial=valeurs moyennes indh'iduelles. M~mesia!es. B = vestibula!res. L = linguales

<lmm

2-5 mm

>6 mm

M

B

L

Tot.

M

B

L

Tot.

MBL

Tot.

MoL

99

98

100

99

!

2

Q

1

RecallPremol. +Canines

iOO

98

99

99

0

2

1

i

Inc.

99

98

100

99

1

2

0

I

Tot.

993.0

983.9

99i.7

992.1

1

2

I

i

MoL

34

36

33

34

62

64

64

63

3

32

No n-re callPremol. +Canines

43

49

54

49

56

51

46

5!

11•0

I

Inc-

32

51

53

45

68

49

47

55

0000

Tot.

3618.64819.64919.14415.5

6318.55218.75018.855!4.7

1J1

i

titis, a treatment program that involved oralhygiene instruction, scaling, root planing andmodified Widman flap procedures, resulted inthe establishment of clinically healthy gingivaeand shallow periodontal pockets. It was alsodemonstrated that patients who after a baselineexamination carried out at the end of the activetreatment phase, i.e. 2 months after surgery,were placed on a carefully designed recaiiprogram involving prophylaxis once every 2-3months during a 6-year period were able tomaintain (1) excellent oral hygiene standards,(2) healthy gingivae, (3) shallow periodontalpockets and (4) unaltered attachment levels. Inaddition the patients within the recall group didnot, during the 6 years, suffer from tooth loss.

In contrast, patients who subsequent to thebaseline examination were not maintained in asimilar carefully supervised program showedafter 3 and 6 years obvious signs of recurrentperiodontitis including frank gingivitis, in-creasing frequency of deepened pockets, furtherloss of attachment, and some tooth loss.

In all respects the findings made in thepresent trial confirm data reported by, e.g.Ramfjordet al. (1973), Lindbe &Nyman (1975),RosUng et al. (1976), Poison & Heijl (1978),Knowles et al. (1979), Nyman & Lindhe (1979).They demonstrated that patients who subse-quent to the end of active treatment of per-iodontal disease were placed on a maintenanceprogram involving regularly repeated prophyl-

MAINTENANCE CARE IN THE TREATMENT OF PERIODONTITIS 291

axis did not experience recurrence of disease.Our findings also support data presented bySuomi et al. (1971), Nyman et al. (1977) atidAxelsson & Lindhe (1978) by showing thatpatients who are not properly maintained sub-sequent to active periodontal therapy frequent-ly develop recurrent periodontitis. Further-more, the observations made in the non-recallgroup patients at the reexaminations 3 and 6years following active treatment demonstratethat traditional dental care rarely includesproper plaque control measures. Hence, itseems justified to emphasize the responsibilityof the specialist, the periodontist, not only forthe active treatment and design of the main-tenance care program but also for the deliveryof regularly repeated prophylaxis.

Tables 6-9 and Figs. 2 and 3 describe thealterations in probing depths and attachmentlevels from the initial, baseline and follow-upexaminations. The data from the initial exam-ination (Tabies 6,7) show that in the recall as

well as in the non-recall group patients theprobing depths at the buccai tooth surfaceswere significantly smaller than on the proximaland lingual surfaces. Also following surgicaltreatment the average probing depths at thebuccai tooth surfaces remained smaller than atthe interproximal surfaces (Table 6). It is inter-esting to note (Table 7) that only 1% of allsurfaces examined in the recall group at thefollow-up examinations had periodontalpockets with probing depths > 3 mm. Alipockets measured on buccal/lingua] surfaceswere < 3 mm. The corresponding attachmentloss figures are reported in Tabies 8 and 9. It isobvious from these figures that only in raresituations did attachment loss occur in the recallgroup between the baseline and the follow-upexaminations after 6 years. When attachmentchanges occurred in this group of patients, thebucca! surfaces showed a higher frequency ofloss than mesial and lingual surfaces. Hence,whereas most gain in clinical attachment (Table

Table 10. Alterations ( + ) of attachment levels between the baseline and 6-year follow-up examinations.Frequency distribution (X, s.d.); see also Table 9

Anderungen (±) der Attachmeniniveaus zwischen der AusgangsuniersuchimgunddenNachuntersuchungen nach 6Jahren. Hdufigkeitsverteiiung (X, s.d.): siehe auch Table 9

Modifications (+) du niveau de }'attachement entre I'examen de reference (baseline) et I'examen du rappel de 6 ans.Distribution de frequence (moyenne: ecart-type): voir au.ssi tableau 9

+ (>lnim} M

B

L

Tot.

- (>lnim) M

B

L

'tot,

Mol.

27

14

1!

17

5

16

4

9

RecallPreraol.+Canines

32

11

14

19

5

!8

6

9

Inc.

23

U

9

14

6

19

9

12

Tot,

2822.21114.41212.3

n14.1

57.0

1914.479.5

107.3

Mol.

0

0

2

1

30

26

26

27

Non-recallPremol.+Canines

1

1

0

1

29

39

43

37

Inc.

2

3

3

3

24

38

37

33

Tot,

i

1

1

1

2611.73714.53718.63451.5

292 AXELSSON AND LINDHE

10) occurred al interproxiraa! surfaces (28%),attachment loss, when occurring, was mostobvious on buccal tooth surfaces (19%). In ailrespects these findings are in agreement withRamQord et al. (1973). They reported that someloss of attachment occurred at buccal toothsurfaces subsequent to periodonta! surgery alsoin well-maintained patients.

It is obvious that the average figuresdescribing attachment level alterations onlypoorly illustrate the true alterations of theattachment over the 6 years of observation. Forinstance, if the data for the recall group pa-tients, described in Tables 8, 9 and 10 arecompared, it can be seen that the individualmean figures (Table 8) describe a gain inattachment amounting to 0.2 mm over the 6years. In fact, 17% of all surfaces examinedshowed a gain in attachment (>] mm), 10%showed a loss of attachment (> 1 mm) whereasaround 70% of the surfaces showed no signs ofattachment level alterations during the observa-tion period. In the non-recall group there was amarked loss of attachment (Table 8) betweenthe baseline and the 6-year follow-up examina-tion. During the first 3 years after active treat-ment on the average 1.3 mm of attachment waslost, whereas during the second 3-year period anadditional 0.5 mm was lost. Also for the non-recall group patients the attachment loss figuresbecome more meaningful if the frequency dis-tribution of degree of loss is presented ratherthan the average figures. Thus, from Table 9 itcan be seen that whereas 44% of all surfaces lost1 mm or less as many as 55% of all surfaces lostbetween 2-5 mm, 1 % of the surfaces lost morethan 6 mm of attachment. Attachment losstended to be somewhat more frequent at themesial than at the buccal and lingual surfaces.Even if limited information has been publishedregarding the natural loss of periodontal tissuesupport in an adult population (Axelsson &.Lindhe 1978, Loe et al. 1978, Becker et al. 1979,S5derholm 1979), the attachment loss in thepresent non-recaii material was pronouncedand similar to that reported by Nyman et al.

(1977) in a 2-year study on the effect of per-iodontal surgery in plaque-infected dentitions.

Zusammenfassung

Die Bedeulung der Nachsorge bei der Behandlung derParodonlalkrankhehDie vorliegende Uniersuchung wurde durchgefiihrtum die Effizienz eines Nachsorgeprogrammes zu

, prufen das zur Aufgabe hat, Krankheitsrezidive beiPatienten mit fortgeschrittener Parodontitis zu ver-hinciern. Weiterhin wurde der Parodomalstatus einerGruppe Patienten aufgenommen, die nach Abschlussder aktiven Behandlung ihrem Privatzahnartz zurNachsorge uberwiesen wurden. Das Material bestandaus 90 Patienten, die im Jahre 1972 dem Spezialistentiberwiesen worden waren. Eine initiate Untersuchungwurde vorgenommen, die aus dcT Beurteilung desoralen Hygieneniveaus, Registrierung vorliegenderGingivitis, der Messung der Sondierungstiefen undder Attachmentniveaus bestand. Die Patientenwurden mit ihrer Situation bekannt gemacht (casepresentation) und instruiert, wie zweckmassigeZahn-reinigungsmethoden durchzufuhren seien. Der Zahn-stein wiirde entfernt und eventiiell wurden die paro-dontalen Taschen mit der modifizierten Widman-Technik behandelt. Wahrend der ersten zwei Monatenach der Parodonlalchirurgie wurden die Patienteneinmal wochenElich zur professionelien Zahnreini-gung einbestelit. Zwei Monate iiachcieni Abschiussderchirurgischen Behandlung wurden die Patienten er-neut untersucht um Daten fur eine Ausgangsunter-suchung (baseline) festzulegen. Jeder dritte Patientwurde darauf zur Nachsorge an seinen Privatzahnarztuberwiesen. Zwei von drei Patienten erhielten sorg-faitig programmierte Nachsorgebehandlung an derUniversitatsklinik. Dieses Programm bedeutete eineEinbestellung in Abstanden von 2-3 Monaten undbeinhaltete Instruktion und praktische Ubungen inoralen Hygienemassnahmen, sorgfaltige Zahnstein-entfernung und professionelle Zahnreinigung. 3 und 6Jahre nach der Ausgangsuntersuchung wurden diePatienten nachuntersucht. Die Resultate dieser Studiezeigten, dass bei Patienten mit destruktiver Paro-dontitis ein Behandlungsprogramm mit oraler Hy-gieneinstruktion, Zahnsteinentfernung, Wurzelglat-tung und modifizierter Lappenoperation nach Wid-man, kiinisch gesunde Gingiva und flache Zahn-fleischtaschen erreichen konnte. Patienten, die aneinem sorgfaltig geplanten Nachsorgeprogramm teil-nahmen, konnten wahrend eines Zekabschnittes von6 Jahren einen ausgezeichneten oralen Hygienestatusund unverandertes Attachmentniveau aufrcchterhal-ten. Im Gegensatz dazu wurden bei den Patienten, dienach der aktiven Behandlung nicht an einem uber-wachten Nachsorgeprogramm teilnehmen konnten.

MAINTENANCE CARE IN THE TREATMENT OF PERIODONTITIS 293

bei den Nachuntersuchungen Zeichen rezidivierenderParodontitis festgestelU-

surveille (groupe non-recall), presentaieni aux exa-mens de rappels des signes manifestes de recidive desparodoniiies.

Resume

L'importance des soins de maintien dans le irahementdes affections parodontalesLa presente etude a ete effectuee dans ie but d'evaluerl'efficacite d'un programme de soins de maintiendestines a prevenir les recidives chez des patientsayant subi le traitement d'une parodontite a un Ktadeavance. On a de plus surveille l'etat du parodonte chezun groupe de patients qui, apres la fm du trahementactif, avaient ete renvoyes a leur praticien pour lessoins de maintien. L'ensemble consistait en 90 pa-tients, adresses par leur praticien pQui traitementspecialise d'une affection parodoniale a un stadeavance. Les patients ont d'abord subi un exameninitial comprenant l'enregistrement de I'hygiene buc-cale, de lagingivite, delaprofondeurdesondageet duniveau de rattachement. Us ont re?u individuellementdes renseignement sur leur cas, des instructions sur lamaniere de pratiquer le nettoyage habituel suivant desmethodes adequates, ies dents ont ete detartrees, enfmles culs-de-sac ont ete traites par la methode deWidman modifiee. Pendant les deux premiers moissuivant chaque operation, les patients ont ete con-voques tous les quinze jours pour un nettoyagedentaire professionnel- Deux mois apres la fin dutraitement chirurgical, les patients ont de nouveau eteexamines pour l'enregistrement des donnees devantservir de reference (baseline). Lin patient sur trois aensuite ete renvoye a son praticien pour les soins demaintien. Deux patients sur trois ont ete maintenu entraitement dans les services de l'universite et y ont subiles soins de maintien suivant un programme dirigeconfU specialement. Ce programme etait base sur desrappels tous les 2-3 mois ct comprenaitPenseignementet l'entrainement des soins personnels d'hygienebucco-dentaire et l'execution de nettoyages dentairesprofessionnels minutieux. Les patients ont de nou-veau ete examines 3 ans et 6 ans apres I'examen dereference.

Les resuitats ont mis en evidence que, chez despatients atteints de parodontite destructrice, un pro-gramme de traitement comportant les instructions enmatiere d'hygiene bucco-dentaire, des detartrages,polissages radiculaires et operations a lambeau suivantla technique de Widman modifiee permettait d'obtenirdes gencives cliniquement saines et des poches peuprofondes, Les patients qui ont participe h un pro-gramme de rappels speciaiement con^u (groupe re-eall) ont ete capable de maintenir sur une periode de 6ans une hygiene bucco-dentaire tres satisfaisante, etles niveaux de Tattachement restaient chez euxinchanges. Par centre, les patients qui, apres !etraitement actif, n'etaient pas soumis a un programme

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Rosling, B., Nyman, S., Lindhe, J. & Jem, E. (1976)The healing potential of the periodontal tissuesfollowing different techniques of periodonial sur-gery in plaque-free dentitions. A 2-year clinicalstudy. Journal of Clinical Periodoniology 3, 233-250.

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AXELSSON AND LINDHE

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Soderholm, G. (1979) Effect of a dental care programon dental health conditions. A study of employeesof a Swedish shipyard. Department of Periodon-tology. Faculty of Odontology, University of Lund,Malmo, Sweden.

Address:Jan LindheDepartmem of PeriodontologyUniversity of GothenburgBox 33070S-400 33 Gothenburg, Sweden