Many people wonder why they need ongoing supportive care appointments after finishing the initial phase of their treatment to eliminate the infection around their gums. This brief summary will hopefully answer this question.
Presenting Concern :
- A history revealing a susceptibility to Periodontal Disease.
History of Presenting Concern :
- In a similar way to the variation within the general population to blood pressure and diabetes susceptibility – a certain number of people in the population will also be susceptible to developing gum infection issues.
- These infections caused by bacteria are collectively called “Periodontitis”
- Periodontitis is extremely common – with 90% of us susceptible to some degree. About 30% of us will need ‘extra dental care’ (periodontal treatment) to manage the risk and maintain the health of our teeth.
Treatment Delivered at Supportive Care Appointments :
- Removal of any new build up of soft (biofilm) and hard (calculus) deposits.
- Targeted re-treatment of any areas that show signs of ‘relapse’
- Ongoing home care reinforcement and professional support for areas difficult to clean.
Rationale for Ongoing Care
Periodontal Disease (also known as Periodontitis, Pyorrhoea, Gum Disease or Riggs Disease) is the most prevalent infective process affecting mankind. It is also the most common cause of tooth loss for people aged 35 years or older.
However – it is also known as the ‘silent disease’ of dentistry with people often unaware of the attachment loss being caused around their teeth by the low-grade chronic bacterial infection. Eventually, the tooth literally “falls out”. Hence the saying ; “long in the tooth” , or that “your teeth fall out when you are old” are actually referring to untreated periodontal disease (and related unnecessary tooth loss).
The good news is that with meticulous deep debridement and regular reviews – the majority of sufferers can have their mouth returned to a ‘stable’ situation and keep their teeth. This is not only a “win” for the individual – but also avoids expensive dental work (via implants, bridges and dentures) to replace failed teeth.
Conversely, the research shows that a failure to provide adequate treatment or follow-up supportive care appointments to people susceptible to periodontitis will inevitably see the disease process progress or relapse with widespread tooth loss. This leads to significant clinical discomfort and problems with both appearance and function. Teeth drift and tilt, gums recede and bad breath and gum abscesses can occur.
One of the most distressing problems in dentistry is the under-diagnosis, under-treatment or lack of follow-up for people susceptible to periodontal infections.
The research studies unanimously confirm that a failure to adequately treat periodontal issues or follow this up with regular reviews will inevitably lead to ‘relapse’ of the disease process and loss of teeth.
Effectively, this wastes the previous treatment efforts (and expense) to stabilise the clinical situation.
Standard periodontal treatment as accepted by dental schools around the world includes a number of formal steps :
- Detailed Initial Oral Examination and identification of any risk factors (Systemic Phase of Treatment).
- Infection Control via deep thorough debridement over a number of appointments. Often with anaesthetic needed or minor surgery to push the gum back (eg access surgery). The aim of this phase of therapy (often called “Initial Phase” or “Hygienic Phase”) is to remove the general deep build of bacteria and related debris.
- Formal post “Initial Phase” review and possible “Additional Targeted Treatment” of any areas that have failed to resolve. This may also involve adjunctive tests (to rule out complicating systemic factors such as diabetes or blood dyscrasias) and also include the possible targeted use of antibiotics.
- Corrective Phase = once the general ‘active’ infection has been addressed (as indicated by a reduction in inflammation levels and repair (ie closing of the probing depths) then missing teeth may be replaced or other general dental ‘re-build’ or corrective steps undertaken.
- The patient then is ready to enter “Supportive Care” or the “Maintenance Phase” of therapy. This is akin to a person who has had past blood pressure issues having the clinical readings regularly reviewed and interceptive care delivered to avoid any recurrence of the original problem. In the periodontal treatment plan – this half hour appointment includes :
- A review of the medical health (including possible complicating medications)
- Oral Examination and review of attachment levels (periodontal chart review)
- Light debridement of ALL gingival margins – with a removal of all soft tissue deposits (biofilm) and harder material (calculus). In every mouth there are always areas that are difficult or impossible to reach using standard home care tools . Problems with home care may be compounded by dexterity, eyesight or general health issues.
- Deeper targeted retreatment of any areas of possible early recurrence of infection.
- Feed back on how satisfactory the home care techniques are – with modifications recommended (both tools and techniques).
A recommendation on the date for the next recall appointment is based on :
- Time taken to perform the above steps (ideal = half an hour)
- Clinical history of disease behaviour (aggressive or quiescent)
- Patient dexterity and general ability to look after their mouth
- How difficult the mouth is to maintain (eg crowding, drifted teeth, bridgework, implants etc).
- Other risk factors in the medical history (eg diabetes / smoking / age issues etc)
- Amount of attachment left around the teeth and how ‘critical’ these teeth are (ie. if many teeth only have 25% of their support remaining and there are only a minimum number of teeth – then a ‘relapse’ of periodontal infection must be avoided at all costs)
From a financial point of view – a “tight” periodontal review program is far less expensive and more economical then replacing missing or failing teeth. For example, the cost of a single dental implant is equivalent to the cost of a periodontal support program for the average patient over 5-10 years.
Hopefully, the above letter explains why a “tight” supportive care recall program at FDS is needed.
This program will be tailored to the individual clinical needs of each patient.
Sometimes, the general dental practice can assist with this program.
The aim at FDS is to eventually try to have all our patients so ‘stable’ they can move back out to just needing a single annual support appointment at FDS. However, as explained above, many patients will need a ‘tighter’ program than this to maintain the stability of their teeth.
In summary, treating the active infection causing periodontitis is really “just the start”.
True successful treatment is provided by an appropriate supportive care program that sees the maintenance of a disease free dentition over many many years.
Happy brushing !
John Carrigy MDSc (Melb) BDS (Syd) MRACDS
Senior Clinician – Foundation Dental Services
Registered Dental Specialist – Periodontist