By Dr Nadine Strafela-Bastendorf & Dr Klaus-Dieter Bastendorf
Just under 45 years after the first publications by Axelsson and Lindhe, a rethink of the systematic “recall session” and the use of new aids have become necessary in line with scientific and technical advances.
In the first part of this article, a short summary of the most recent developments in maintenance therapy will be provided and the rationale from different perspectives. During a maintenance visit, the removal of hard mineralised deposits (calculus) with manual instruments such as curettes has been the classical approach. These manual instruments often caused soft tissue trauma. Today, biofilm management and soft tissue sparing play an important role in modern initial periodontal therapy as well as in maintenance therapy. Debridement has now been redefined as “the destruction and removal of biofilm and the removal of hard deposits (calculus) from tooth surfaces without deliberate injury of the dental hard and soft tissues”.
As a result of the publication of studies by Axelsson and Lindhe into the effects of controlled oral hygiene procedures on caries and periodontal disease in adults,1-3 a paradigm change followed, moving the direction of care “away from restoration, towards prevention”. Preventive care has now become based on two pillars, domestic (at home procedures) and professional prophylaxis in the dental office . These approaches have been used in many situations and have broad application in dentistry, allowing well motivated patients to be kept in a state of good oral health over many years. The important factors that contribute to success remain the same as those that were identified in the classic studies nearly 45 years ago, as are the components of a maintenance visit or “recall session”.
The physical removal of deposits, the removal of all supraand subgingival hard and soft deposits and subsequent polishing, which Axelsson called their “active intervention”, is one part of a systematic recall session. The appointment is, however, more than just a “scale and polish”, since there are other preventive components also included in the recall session. Today the terms that are often used are supportive periodontal therapy (SPT) or professional mechanical tooth cleaning (PMTC). The objective is removal of supragingival/subgingingival calculus and dental plaque biofilm on the surfaces of teeth and dental implants, including cleaning of all interdental spaces. This is typically combined with an appropriate fluoride therapy, such as a fluoride varnish or a varnish with fluoride and CPP-ACP. In other words, the concept is not to focus ONLY on periodontal disease (and peri-implant mucositis and periimplantitis), but to also take into account dental caries as another major dental plaque biofilm-induced disease. Patients cannot be expected to maintain ideal plaque control over extended periods. In fact, a large scale study showed that only two percent of the population in Germany was plaque-free and only 7.4 percent had no periodontal problems. The number of cases of moderate and severe periodontitis had increased substantially over past surveys, which is probably due in some ways to population aging, something that will continue in the coming years.
With more than 40 years after evidence on the great success that a proper professional maintenance or SPT visit has been known, it is concerning that this concept is still not being implemented well. A common problem with a “quick scale and polish” appointment is that rushing through the debridement aspects means that removal of deposits will be incomplete and there will not be any coaching to improve the patients oral hygiene practices. An analysis of patients attending for a “quick scale and polish” in 10 dental practices showed inadequate removal of deposits (with disclosing showing around 50 percent of the plaque was still present, especially in the interdental spaces), a lack of periodontal assessment and little or no motivation and instruction on mechanical oral hygiene procedures done at home.
So now, what remains and what is the latest concept of modern maintenance therapy, still based on the original studies by Axelsson and Lindhe, enhanced by scientific knowledge and technical advances?
What remains? Aims and team
The basis of successful professional prophylaxis in everyday practice is a practice philosophy that is guided by prevention. This means that the dental practice team has an agreed approach with aims and methods for achieving those aims and it is known to all members of the team so they all know where the journey should lead. A well-trained and motivated team is essential. This includes in-house education as well as external formal training of the members of the team.
What is new? From diagnosis to materials
There have been many technical improvements in diagnostic tests, including two-colour and multi-colour plaque disclosing, that can show plaque maturity and areas where patients struggle with cleaning. Various intraoral cameras make areas of disclosed plaque easy to show to patients in real time. Documentation can also include digital photographs. Electronic patient record systems are built to improve documentation and include open text fields to enter written treatment recommendations for home care and details for individual risk guided recall schedules. Modern electronic dental records can capture information on key clinical measures such as bleeding on probing [BOP], probing pocket depth [PPD], clinical attachment loss [CAL], the approximal plaque index [API], the plaque control record [PCR], etc.
Today there is also a wide range of aids for at home oral hygiene. The importance of powered toothbrushes, in particular, has increased and will continue to grow (e.g. with the use of smartphone apps showing how to brush).
A key change has been in how the debridement aspects of SPT or maintenance now focus on sparing the hard tissues. In the 1970’s, “active intervention” was dominated by removal of calculus, as well as “infected” root cementum, by scaling and root planing with manual instruments followed by polishing with rotating instruments, using rubber cups and polishing pastes. There was no emphasis on “sparing” or preserving the hard tissues of the roots of the teeth. In contrast, the emphasis today is on biofilm management and the preservation of all tooth structure.
A good descriptor for this is “guided biofilm therapy”. This is a prophylactic, selective, individualised, age-appropriate systematic treatment, guided by risk and quality.
The concept of Guided Biofilm Therapy
There is a fundamental distinction between the procedure with a new patient in the practice and later maintenance therapy.
New patients: Dentist:
- Obtain a detailed dental and medical history;
- Perform a detailed clinical examination and document the results of this;
- Carry out any other necessary diagnostic investigations;
- Compile a treatment plan including details of maintenance and home care; and
- Discuss this in detail with the patient.
New patients: Dental hygienist:
- Undertake oral hygiene instruction and motivation to address individual needs for effective home care;
- Analyse where the patient has been struggling and over following visits, reinstruct and remotivate them in domestic oral hygiene; and
- Transfer the patient into the maintenance program.
Patients in maintenance therapy:
Guided Biofilm Therapy (GBT), the current concept in our practice, is a flexible protocol built on the needs of each patient. Both the entire framework (duration) and the single elements are adapted in line with the patient’s age and risk, taking into account their compliance. This means that the concept is applied to all patients including children, adults, and elderly patients.
The example detailed below is for a periodontitis patient on maintenance therapy:
- Explanation of what will happen today;
- Rinsing with 0.2% CHX;
- Periodontal diagnosis and documentation;
- Disclosing of plaque and recording of oral hygiene indices, re-evaluation of the diagnosis;12,13
- Re-motivation and re-instruction in oral hygiene;
- Application of PPE for the patient; in our practice this includes use of the OptraGate (Ivoclar Vivadent);
- Supra- and sub-gingival removal of stains and biofilm. In our practice, we use the EMS AIR-FLOW® with AIR-FLOW Powder PLUS and if applicable, using the subgingival PERIOFLOW® nozzle for pockets deeper than four millimetres;
- Removal of supragingival and subgingival calculus deposits using a piezoelectric scaler;
- Inspection of the cleaned surfaces with a fine probe (EXD 11/12, Hu-Friedy), and using repeated disclosing if needed;
- Inspection of hard and soft tissues by the dentist;
- Chemical plaque control (topical fluoride/CPP-ACP, etc.); and
- Determining date for the next recall appointment.
Scientific basis of GBT
All our patients rinse for 60 seconds with chlorhexidine before every treatment to reduce aerosol contamination as a protective measure for the practice team. The next step is to collect the diagnostic data. We always include a medical history update check, which the patient will sign. According to the initial diagnosis, a simplified reevaluation with continuing monitoring of caries, periodontitis and possibly erosion risk is necessary. Pocket probing depths, attachment levels, bleeding on probing, tooth mobility, furcation involvements etc, are recorded.
For all patients with a previous periodontal history, a complete periodontal status is recorded at least once a year. For other patients, a PSR score is recorded every two years.
We then disclose the plaque thoroughly in all patients. The advantages of disclosing for re-instruction and re-motivation for oral hygiene are well known. A summary of the plaque indices can also be recorded. The disclosed biofilm will be removed; as it is stained it is easier to target and remove. We generally first remove the supra- and subgingival biofilm (the primary cause of infection) with air-polishing using low-abrasive powders (AIR-FLOW Powder PLUS). It is now accepted that modern biofilm management with low-abrasion powders is superior to the classical procedure in all the important clinical parameters (effectiveness, bacterial reduction, bacterial recolonization, tissue sparing, fibroblast attachment and clinician and patient comfort). Once this has been done, the supragingival and subgingival calculus is then selectively removed with ultrasonic scalers.
Quality control measures comprise inspection of the cleaning outcome (repeat disclosing, tactile probing) by both the dental hygienist and the dentist. Any issues that occur with restorations can later be addressed by the dentist.
The final part of the visit is topical application of a remineralizing agent, after which the appointment for the next GBT visit is made, based on the risk assessment for the patient.
The advantages of this Guided Biofilm Therapy (GBT) procedure can be summarised as follows:
- Scientifically founded biofilm management;
- Substance sparing of all natural dental hard and soft tissues;
- Lowering of root surface hypersensitivity;
- Better infection control due to primary removal of the biofilm;
- Better visibility of the hard deposits, facilitating their selective removal;
- Shorter treatment time;
- Reduced workload for the team; and
- Maximum comfort for the patient.
The classic recall session (“quick scale and polish”) with manual instruments such as curettes followed by traditional polishing according to Axelsson and Lindhe should be adapted according to the latest literature. With systematic GBT, we can carry out “active intervention” (professional biofilm management) effectively, but sparing the tooth substance while doing this safely, rapidly, and comfortably.