Step 4 for the treatment of periodontal diseases: implementing a supportive periodontal care programme

As discussed extensively in other articles in this issue of Dental Update, the S3-level guidelines for periodontal care set out an evidence-based approach to the management of stage I–III periodontitis.¹ In this article, we describe the implementation of step 4 procedures, supportive periodontal care (SPC), as the final stage of the S3 guideline. The specific aims of this article are to describe the new guidelines for SPC and their implementation in a clinically practical way that is applicable for everyday dental practice settings in the UK.^1,2

An SPC programme is implemented after the satisfactory completion of active periodontal therapy using the procedures described in steps 1–3 of the guidelines. It is an essential component of periodontal treatment to provide long-term stability of the condition and initially depends on the achievement of adequate endpoints of active treatment. Active treatment aims at achieving the following:

• Control/eliminate inflammation;
• Eliminate deep pockets;
• Reduce number of bleeding sites;
• Control/reduce/modify risk factors;
• Preserve attachment levels;
• Prevent further loss of attachment;
• Maintain alveolar bone levels.

The concept of an endpoint in treatment is important because it identifies when further active treatment may be required, and when initiation of SPC is indicated. The defined endpoints of periodontal treatment are the lack of periodontal pockets of >4 mm with bleeding on probing, or any pockets ≥6 mm, together with an overall gingival bleeding score of <10%. This endpoint has been described as gingival health on a reduced periodontium. Where pockets are reduced, but bleeding persists in more than 10% of sites, this is described as stable periodontitis with gingival inflammation. Extensive studies have demonstrated that where these endpoints are not met, further progression is likely in the future, even with an SPC programme. It is recognized that some most severely affected teeth might never reach a satisfactory endpoint and pragmatically, it may be necessary to accept this in an otherwise successful treatment outcome.³

The goal of step 4 of therapy is to reduce the risk of oral disease and maintain health, and the S3 guidance gives a clear direction of how to achieve successful SPC. One of the aims of step 4 is to prevent and minimize the risk of periodontal or peri-implant relapse after successful therapy treating gingivitis, periodontal disease, peri-implant mucositis, and peri-implantitis. This also encompasses other oral conditions, and aims to prevent and minimize tooth loss by monitoring the dentition, as well as the periodontal health, of patients. The guidance highlights the importance of a holistic approach to monitoring and treatment, and to do so in a timely manner to reduce the risk of further oral disease. It is strongly stated that timely intervention is important in order to monitor and manage oral disease, and a recall period of between 3 and 12 months is recommended, dependent of the patient's risk assessment. In order to continue with SPC, a bleeding score of up to 10% and probing depths of 4 mm or less are advised. If either of these targets increases, the patient may need to be referred back for further stage 2 or 3 of treatment because this would suggest a disease relapse.

Supportive periodontal care

Why is it necessary?

The long-term success of periodontal therapy relies on regular and robust supportive care (previously referred to as periodontal maintenance care or supportive periodontal treatment). We know from extensive studies that patients who go without maintenance and regular assessments are more likely to have disease recurrence, and have an increased risk of developing new disease. The evidence clearly demonstrates that regular compliance with SPC is strongly associated with long-term success and periodontal stability. Numerous studies of long-term outcomes following periodontal care consistently demonstrate that patient compliance is one of the main determinants of outcome, with poorly compliant patients showing up to four times greater levels of progression and tooth loss.^4–6

An expert consensus-based recommendation from the guidance recommends ‘the adherence to SPC should be strongly promoted, since it is crucial for long-term periodontal stability and potential further improvement in periodontal status.’ This was a grade A, strong recommendation, and the implementation has been adopted by the BSP with a unanimous consensus. With EFP and BSP strongly advising that ongoing SPC is vital based on evidence, it highlights the value and necessity of SPC within a periodontal programme. The BSP stated that there is excellent evidence to support SPC and that it is crucial for long-term periodontal stability and further improvements in periodontal status.²

How does SPC work? What does it do?

SPC is one of the most important steps in the overall care of periodontal patients. A robust SPC programme is key to ensuring the long-term success of treatment.

SPC may be effective for several reasons. First, the very fact that a patient continues to be reviewed regularly, may be highly motivating for the patient per se. Regular SPC and professional interventions including a comprehensive review of oral hygiene together with supra- and subgingival professional mechanical plaque removal reduces the risk of deterioration and further attachment loss in patients who have completed a course of non-surgical/surgical therapy. Evidence of any deterioration or relapse can be detected quickly.

During SPC, active sites are identified and brought to the attention of the patient, who is then trained in accessing and performing more effective daily plaque and biofilm removal/disruption in those sites. The clinician should focus their time and instrumentation in sites that are clinically active based on the bleeding chart, aiming to lower the bacterial load in deep and bleeding sites as a priority during that recall (SPC) appointment time. The highest value tasks during SPC are identifying and highlighting sites that are bleeding on probing and training the patient in specific aids and techniques to reach those sites.

Who can do it?

The delivery of SPC requires a collaborative effort among dental professionals, particularly general dentists, dental hygienists and dental therapists. With a focus on early detection and timely intervention, dental hygienists and dental therapists are uniquely positioned to identify subtle changes in periodontal status, ineffective homecare, adherence issues or emerging risk factors.

Dental hygienists, through their consistent patient engagement, are trained to detect subtle alterations in periodontal health. By closely monitoring patients and their oral hygiene practices, dental hygienists can swiftly identify deviations from the norm. This heightened awareness facilitates early intervention, ensuring that any potential issues are addressed promptly.

Consequently, this proactive approach significantly contributes to preventing disease relapse and maintaining periodontal stability. Regular monitoring and support, with different clinicians, also embraces the philosophy of MECC – make every contact count – which advocates maximizing the impact of every patient interaction.

What should the examination entail?

The SPC examination should consist of a detailed medical, dental, and social history, combined with a thorough assessment of the periodontal tissues. Pocket charts, together with plaque and bleeding indices will provide quantitative data to compare with previous data. Additional periodontal indices should be used where applicable to monitor furcation and mobility.

It is also necessary to check any changes in the patient's medical and social history to identify any new risk factors that may contribute to disease recurrence such as diabetes, stress, poor diet etc.

During the first step of therapy the guidance suggests risk-factor control interventions, such as smoking cessation and diabetes checks. Owing to such risk factors having such a large impact on periodontal health and disease, it is advisable that these are monitored throughout SPC to note any changes that may affect the response to treatment. This way, we can intervene quickly and treat accordingly. A short summary of procedures for a SPC appointment are shown in Table 1

A record of the patient's current hygiene regimen should be discussed and recorded, and if needed, modified to ensure that they understand how to effectively disrupt biofilm at home. If manual dexterity is an issue, this should be noted and factored in when determining an appropriate OH programme.

Oral hygiene

Reinforce and re-instruct

Patients who are enrolled in SPC have already had extensive training in oral hygiene methods as part of the initial treatment phase (steps 1 and 2); however, patients may need constant/ongoing support as they transition to different steps. At an SPC visit, oral hygiene should be reinforced by positively acknowledging and supporting their existing oral hygiene efforts. If there is a need for improvement, this is referred to as re-instruction, which involves providing detailed, personalized guidance to address specific areas where improvement is needed. Both practices are crucial in promoting and maintaining optimal adherence and effective self-care.

Re-instruction in toothbrushing, interdental cleaning or more specialized aids should include an intra-oral demonstration, targeting specific areas of concern. It is vital that patients have mastered each technique to increase the likelihood of engagement and improved clinical outcomes. Some clinicians will record the OH demonstration on the patient's mobile phone, which gives the patient continued access to their bespoke oral hygiene instructions at home.

Toothbrushing

Demonstration of effective toothbrushing techniques, manual or power brush, is important so effect of each brushing episode. According to ‘Delivering better oral health’, an oscillating rotating electric toothbrush is advised for optimum biofilm disruption. Several studies have found an association between increased frequency of toothbrushing and tooth retention.^7,8

Interdental cleaning

Interdental aids, particularly brushes, are essential for biofilm removal from interdental areas. Demonstrating interdental aids on patients will help them to understand visually how to use them, but also how they should feel in the mouth, and what to expect when using them. For example, this would be a good opportunity to explain how interdental aids with gingivitis may induce bleeding from the gums, and then go on to explain how they will also help.⁹

This can be done by demonstrating with interdental brushes for example, on the patient and showing them in a mirror how they should be used and feel. Another method would be to carry out demonstrations on mouth models.

SPC sessions are a good opportunity to discuss with the patient their recall intervals and assess whether they need to be altered. Discussing this with the patient, while reinforcing the importance of a meticulous oral hygiene regimen is more likely to motivate the patient and result in improved home care.

The regular use of topical antimicrobial agents should not normally be required as part of an SPC programme, but can be used in selected cases if required.¹⁰

Professional mechanical plaque removal (PMPR)

Supragingival PMPR can be carried out using hand instruments, ultrasonic devices, or a combination of both (Figure 1).^11,12 PMPR should target sites where calculus and biofilm deposits are present. Non-bleeding sites, and sites without calculus/biofilm should not be instrumented. Biofilm removal can be achieved during oral hygiene demonstration, or with rotary or air polishing devices.¹³

For subgingival PMPR, a minimally invasive non-surgical approach to treatment (MINST) favours the use of magnification and light, miniature site-specific curettes, and long tapered ultrasonic tips. The technique requires careful subpapillary insertion of instruments, with minimal tissue distension, and a thorough and conservative decontamination of the root surface, ensuring post-operative clot stabilization to reduce recession and facilitate periodontal regeneration.¹⁴

Duration of appointments?

Duration of SPC appointments will vary depending on the severity of the patient's disease and their engagement in treatment. Longer appointment times may need to be considered if patients are generally presenting with poor oral hygiene and are not engaging well with homecare advice; however, as OH and patient engagement improves, these can be reduced as needed by the treating clinician for well-maintained patients. Similarly, if a patient has multiple risk factors for potential relapse, such as diabetes, smoking, stress, or a family history of periodontal disease, then longer sessions may be required. This may also be advised when a patient presents with multiple deep pockets and subgingival calculus deposits. If this is the case, they may require longer sessions in order to carry out subgingival PMPR. Local anaesthetic can be administered if required. At this stage, it is good to bear in mind the patient's recall intervals and reassess.

How to determine maintenance intervals?

The frequency of SPC intervals should be based on an individual and on their risk-factor profiles, and be between between 3 and 12 months approximately. Thus, it is not easy to be dogmatic about recall intervals, but may need to be determined empirically on an individual basis. It is advisable to introduce shorter recall intervals of, say, 2–3 months initially, after steps 2 and 3, to keep the patient motivated and engaged in treatment.¹⁵ The length of time between recalls can be increased when the patient has demonstrated persistently low bleeding scores, low probing depths and high levels of motivation/adherence according to the treatment endpoint criteria.³ As patients demonstrate a continued high standard of home care, with low plaque and bleeding indices and pocket depths continuing to remain stable, recall intervals may be extended. It is important to remember that patient compliance, as well as risk factors, play a large role in determining recall intervals.

Recall (SPC) should be based on individual risk, susceptibility, severity, rate of progression, bleeding scores, number of deep pockets and patient adherence to oral hygiene and recall recommendations. Other factors to consider include the presence of dental implants, complex restorations, crown and bridgework, prosthesis, orthodontic appliances/retainers etc.¹⁵

Specific risk factors that may suggest shorter intervals include diabetes, high susceptibility (grade C cases) and smoking (although there is currently very little information on the periodontal effects of e-cigarettes/vaping). There may also be other conditions that may result in changes to recall intervals, such as someone receiving a course of chemotherapy for malignancy.

Recall intervals can always be subject to change. If after extending the recall from 3 to 6 months, but then signs of relapse are noticed, patients can be put back to a shorter recall. It is all about open and honest communication with the patient from the start so that they understand that this is an ongoing process that will most likely fluctuate.

Factors associated with higher risk of periodontal deterioration are shown in Table 2.

When to refer?

With persistent pocket depths of >5 mm, with bleeding on probing, and areas of furcation with BOP, a referral may be necessary for the prescribing clinician to re-assess the patient and review the treatment plan. The patient's engagement would also need to be assessed at this point. If the patient has multiple risk factors and/or has poor compliance with homecare, showing plaque scores over 20%, a referral will be needed. At this point, further subgingival PMPR or surgical intervention may be advised.

Conclusion and summary

Periodontal health is a team effort between the patient and the dental team, with general dentists, dental hygienists and dental therapists collectively forming the backbone of supportive periodontal care. Patients are integral to the success of periodontal treatment and achieving long-term oral health. Their active and ongoing participation in maintaining meticulous oral hygiene practices, attending regular appointments, and communicating any concerns with their oral and systemic health is vital. Studies of long-term outcomes of treatment for periodontitis consistently identify compliance as one of the main determinants of long-term success.

The patient needs to actively engage with homecare recommendations and make a commitment to attend mutually agreed recalls. Recall intervals should be reviewed at each appointment after assessment, and be set accordingly. The patient must be made aware that recall interval periods may change.

Without SPC, the risk of relapse, loss of attachment, bone loss, inflammation, increasing pocket depths, increased mobility, and ultimately tooth loss, is increased.