It's all about perio maintenance

Richard H. Nagelberg, DDS

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Periodontal therapy involves many factors and events, including probing, radiographs, diagnosis, case typing, treatment planning, scaling, irrigating, surgery, prescribing, re-evaluating, and perio maintenance, among others. Some or all of these activities are necessary to arrive at a successful clinical outcome; however, only one of them determines the longevity of our successful treatment results. It's all about perio maintenance.

Periodontal disease is a chronic, noncurable bacterial infection that requires ongoing therapy. When we achieve disease resolution, the patient is healed – not cured. The patient is never cured; the disease is just stabilized. Periodontal disease is very similar to other diseases such as diabetes and hypertension. These are not infectious disorders; they are chronic and noncurable but very controllable, just like periodontal disease.

Perio maintenance is every three months for life – the life of the patient or life of the dentition. This is not an arbitrary interval. When a biofilm is forming, the early colonizing bacteria are not pathogenic; they cannot cause perio disease. If this biofilm is not eliminated or adequately dismantled, the later colonizing perio pathogens come onboard the biofilm. They become the predominant species in three to 12 weeks, and 12 weeks is obviously three months. That's when we want to get them, not one or three months later. The timing of biofilm development provides a sound bacterial rationale for maintenance every three months.

When someone has diabetes or hypertension, he or she must continually take meds, insulin, eat a healthy diet, exercise, etc., to control the disease. If the person fails to do so, the signs and symptoms return and health potentially deteriorates.

Perio disease is identical. The treatment we undertake – surgical, nonsurgical, laser, chemotherapeutic, or any other therapy – is designed to achieve disease resolution. The treatment, however, is not curative. It is not a one-and-done disease.

Ongoing therapy is required. Effective home care is daily therapy to reduce the bacterial load. Perio maintenance is professional therapy every three months. Without adequate home care and maintenance, the signs and symptoms of the disease will always return and the patient's health will potentially deteriorate.

Patients can only get periodontitis if they are genetically susceptible to it, which is true for all diseases. Some people smoke nonfiltered cigarettes for 40 years and never get cancer because they do not have the oncogenes necessary for it to develop; i.e., they are not genetically susceptible to cancer.

When we provide effective perio treatment of any type, we have not done genetic engineering. The patient is genetically susceptible to periodontitis forever; he or she never gets over it. All it takes is the genetic predisposition and enough perio pathogens, and the disease will always return.

This is the essence of why perio disease is noncurable. If a Type 1 diabetic individual does not take his or her insulin and consumes an excessive amount of carbohydrates, hyperglycemia and an elevated risk for diabetic complications will always occur – different disease entities, same requirements for maintenance.

As clinicians, it is vitally important to make patients aware of these requirements when periodontal disease is diagnosed. The response to the common patient question, "How often am I going to need my gums scraped?" should be, "It's up to you. It is literally in your hands." Educating patients about the critical importance of effective home care and three-month maintenance visits at the time of diagnosis enrolls them in their care.

Dental professionals have the primary role in diagnosis and treatment, but the patient has the primary role in maximizing the longevity of successful treatment results. It is critically important that our patients understand their role. Without patient compliance we will never be able to achieve long-lasting, favorable results. Appropriate, effective treatment will achieve disease resolution, but only appropriate maintenance and home care will perpetuate the favorable results. Without it, the disease will recur every time.

Research shows that perio patients who do not receive proper maintenance lose two to three times more teeth and need active therapy twice as often as those having proper perio maintenance. Successful perio therapy requires considerable attention to the patient's dental, medical, and family histories, clinical presentation, risk factors, and underlying biological processes. Proper perio maintenance to enhance the longevity of the favorable results we achieve is simple: every three months for life. It's all about perio maintenance.

Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 27 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].