Guided Biofilm Therapy

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?