Determining Recare Intervals for Periodontal Maintenance

In 2018 the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) published a new classification system for periodontal health and disease, changing the way oral health professionals consider clinical parameters.^1,2 For a complete description of the new criteria, Caton et al^1,2 published their comprehensive findings in both the Journal of Periodontology and the Journal of Clinical Periodontology. A thorough summary also appears in the September 2018 issue of Dimensions of Dental Hygiene.³

A major component of the new classification system is the use of staging and grading to focus on disease complexity and progression based on an individual’s risk factors and protective behaviors.^1,2 Implementation of the new classification system provides oral health professionals with another opportunity to educate patients on their role in maintaining and/or improving their oral health.³ One way dental hygienists can integrate staging and grading into patient education is through risk assessment to determine an individual’s periodontal maintenance recare interval. The most important function of risk assessment is tying that information back into the clinical determination of a patient’s treatment plan and recare intervals.^4,5 Once risk factors have been identified, the dental team and patient must work together to modify detrimental behaviors and conditions to improve periodontal health and treatment outcomes.⁵ Adequate risk factor determination changes the focus of treatment toward arresting the disease process instead of repairing the outcomes of disease destruction.⁶ Oral health professionals can use the completed risk assessment as a means of opening communication with patients as to how their behaviors affect oral health and the potential positive or negative outcomes based on how they incorporate recommended modifications.^6,7 When patients understand their role in maintaining or improving oral health, they are more likely to comply with recommendations in treatment planning—including recare intervals appropriate for the patient’s individual risk and needs. Risk-based recare intervals (RBRIs) can help clinicians establish a link between the completed clinical assessments and the proposed treatment plans.⁷

PERIODONTAL MAINTENANCE

The AAP describes periodontal maintenance as the treatment provided to individuals after the completion of initial (nonsurgical) periodontal therapy with the intention of preventing further disease progression and maintaining the health of the periodontium.^8,9 The purpose of a rigorous maintenance schedule is to allow time for tissues to heal after initial therapy, followed by appropriate support to preserve the treatment outcomes without relapse to a diseased state.¹⁰ A typical periodontal maintenance appointment includes a review of medical and dental histories, clinical assessments, scaling areas of new deposits, and other therapies determined by the dental team (Table 1).⁸

Because periodontal diseases can be treated, but not completely eradicated, periodontal maintenance intervals are often set at 3 months to 4 months for the life of the affected dentition or while the patient is at risk of losing more teeth from compromised periodontium due to disease (periodontitis stage III and IV). Yet, perhaps an opportunity is being missed for patient education and investment by using the same recare interval for all individuals.^1,2,8,11 However, with evidence showing many patients have poor compliance with routine periodontal maintenance, and no evidence demonstrating that the same interval is beneficial for all individuals, risk-based treatment approaches are the most appropriate.^9,12,13 Dental hygienists routinely perform risk-assessments for periodontal diseases and dental caries, and those findings should be integrated to determine an individualized RBRI.⁶

RISK ASSESSMENT

Risk assessment is the process of evaluating clinical, behavioral, genetic, and environmental factors to determine the overall protective or destructive influence on a patient’s oral health.^14,15 Risk factors can impact disease onset, presentation, and rate of progression.¹⁴ For periodontal diseases, common factors include clinical findings, such as bleeding on probing, periodontal probing depth, clinical attachment loss; response to past therapies; behavioral factors, such as oral hygiene practices, smoking, and nutrition; and environmental factors, such as socioeconomic status (access to dental insurance can impact an individual’s ability to comply with maintenance appointments) and fluoride intake.^10,14 A wide array of other factors contribute to the development of periodontal diseases that can be evaluated properly by a dental hygienist during routine clinical appointments as well as contributing genetic factors that can be considered when periodontitis does not resolve post-treatment (Table 2).^6,10,15,16 As behaviors and clinical findings can change over time, risk assessments should be completed for every periodontal treatment plan and included in all comprehensive and periodic evaluations.¹⁴

A host of computer-based programs can help oral health professionals in determining a patient’s overall risk level based on multidimensional analyses of independent risk factors.⁴ Although not the focus of this manuscript, several of these programs have been independently tested and validated in clinical studies since their development.^4,17 When determining the need for an adjunct risk assessment tool, or deciding which program to use, the dental team should consider if the tool has been independently validated, is easy to use during a routine appointment, is time-efficient, is easy to understand by both the clinician and the patient, includes sufficient risk factors in the analysis, is evidence-based, and provides accurate classification and prognosis until the next appointment.^18,19

RISK-BASED RECARE INTERVALS

Once risk assessments are completed, the next step is to take that information and apply it practically to determine the most appropriate recare interval for the patient. Using evidence-based clinical decision making, the dental hygienist can weigh the impact of different risk variables to determine the patient’s overall risk of disease progression.¹⁰ For example, in the new AAP classification system, all individuals begin at a presumed “Grade B,” indicating a predicted moderate rate of disease progression. Clinicians then use risk analysis and clinical evidence to determine if the patient should be classified instead at a “Grade A” or “Grade C.”^1–3 Individuals with Grade B may be placed on a typical 3-month to 4-month recare interval.^1–3,9,10

Patients who have responded well to previous treatment, comply with self-care, and have no additional systemic or behavioral risk factors, may have their classification adjusted to Grade A, which suggests longer intervals of 6 months to 12 months between periodontal maintenance appointments.^1–3,9,10 Individuals who show poor response to treatment or have increased risk due to systemic disease or smoking habits could be modified to a Grade C and seen on a bimonthly basis until periodontal stability has been achieved and the risk of disease progression is reduced to moderate or slow.^1–3,9,10 Discussing individuals’ grading classification as a means of scheduling intervals for future appointments gives dental hygienists another opportunity to reinforce the impact of behavior and self-care habits, empowering patients to take a more active role in maintaining their oral health.^1–3,7 The 2005 National Institute for Health and Care Excellence Guidelines recommend preventive maintenance recare intervals of anywhere between 3 months and 24 months for adults.²⁰ For periodontal maintenance appointments, studies have shown recare intervals as long as once per year to still be beneficial in maintaining periodontal health.^21,22 While many periodontal maintenance patients will still need to be seen multiple times per year, these findings allow the dental hygienist freedom in determining individualized RBRIs.

Most studies on recare intervals evaluate patient outcomes based on attending 3-month recare intervals or not (complete compliers vs erratic-compliers), but have not researched the effects of different recare intervals on periodontal health.²³ Currently, a 4-year, multicenter, parallel randomized control trial with blinded outcomes assessment is underway in the United Kingdom.²⁴ This study is evaluating the oral health and quality of life outcomes of patients assigned to preventive appointments at 6-month and 24-month intervals, as well as the effect of such recare intervals on provider workload and health-care costs.

A central tenet of the RBRI is patient education on how and why a specific interval was set. Dental hygienists can go through the patient’s risk assessment and point out areas where the individual is doing well, or areas that need to be improved, and elaborate on how those different changes could affect future recare intervals.¹⁰ Patient compliance significantly impacts the success of dental treatments and oral health maintenance. By using the RBRI as a concrete example of how the patient’s past behavior impacts future treatment plans, the oral health professional can reinforce the need for improved performance in self-care or attendance at dental appointments.^10,20

As risk factors can be modified, RBRIs are fluid. A patient who is on a 3-month recare now, may only need to be seen twice a year if his or her oral hygiene improves and attachment levels remain stable. If the patient relapses in self-care practices and bleeding on probing increases, the recare interval may need to be shortened to every 4 months.¹⁰ RBRIs have been pilot tested in different dental settings globally.^{10,13,25–27} With the success of implemented RBRIs and the updated periodontal classification scheme focusing on risk factors for disease progression, now is the time to implement RBRIs for periodontal maintenance appointments.^{1,2,10,13,25–27}

THE ROLE OF THE DENTAL HYGIENIST

The periodontal maintenance team includes office staff, dental assistants, dentists, periodontists, and dental hygienists. For proper patient-centered care, all members of the dental team need to work together in collaboration with the patient to determine effective treatment strategies and scheduling options. While dentists and periodontists are responsible for advanced periodontal treatment options (eg, surgical interventions), dental hygienists are at the forefront of patient care, performing many of the assessments, initial nonsurgical periodontal therapies, and maintenance work after active periodontal therapy has been completed. The dental hygienist is responsible for medical and health history reviews; complete periodontal charting; radiograph evaluation; oral hygiene education; communication with dentists, periodontists, and medical personnel about findings and recommendations; and communication with patients about the need for, risks, and benefits of proposed treatments.²⁸ The dental hygiene diagnosis—a written link between the assessments and treatment plans for the patient—is an important aspect of the dental hygiene process of care, is within the dental hygienist’s scope of practice, and should be included in every dental hygiene care plan.^3,7

Most of the research on dental hygiene risk assessment has been conducted in caries risk management. Many of the lessons learned from these studies can be applied to periodontal risk assessment as well.^6,29 However, as disease pathogenesis and risk evaluations for dental caries and periodontitis are not identical, further research should be conducted regarding dental hygienists’ knowledge, attitude, and practices regarding periodontal risk assessment. Dental hygienists report a high level of comfort and confidence (89% to 97%) in performing risk assessments for all patients, regardless of age or special needs.⁶

As the primary provider of oral hygiene instruction, dental hygienists develop a strong rapport with patients, placing them in a unique position within the dental team to provide individualized patient education on RBRIs, especially why and how those intervals were determined.⁶ A study by Francisco et al⁶ reported 71% of dental hygienists had sufficient time to implement caries risk assessments during a regular dental hygiene appointment. This finding is especially encouraging considering lack of time is generally considered a barrier to implementing new procedures during appointments.

As personalized precision dentistry is the way of the future, oral health professionals need to be prepared to conduct proper risk assessments and identify independent risk factors, developing that knowledge into implementable therapeutic care tailored to each individual. Risk assessment tools can aid dental hygienists in clinical decision-making processes as an adjunct to their clinical judgment and training.²⁹ Through adequate assessment and documentation of past and current risk factors, along with previous treatment strategies and outcomes, dental hygienists can determine the most appropriate care plan, including the determination of a proper RBRI for periodontal maintenance.

CONCLUSION

With an increased focus on disease risk and no evidence that a single recare interval is beneficial for all individuals, it is time to incorporate formal risk assessment procedures into clinical appointments, including the development of RBRIs in scheduling periodontal maintenance appointments.¹³ Risk assessments should include a thorough evaluation of patient behaviors, systemic conditions, and environment, as well as risk factors on the tooth, mouth, and patient level to determine the risk of disease progression in individual sites and the dentition overall. Risk factors are modifiable and need to be evaluated at all clinical appointments to ensure timely detection of disease and implementation of treatment strategies paired with patient education to improve oral health.¹⁰

As prevention specialists, dental hygienists should use their extensive training to evaluate patient risks and protective factors to determine an appropriate dental hygiene diagnosis, which includes dental hygiene treatment options and recare intervals based on the individual’s unique needs at a specific point in time.^6,7 By using risk assessment strategies and determining individualized RBRIs for each periodontal maintenance patient, dental hygienists can help patients increase their understanding and compliance with self-care and professional treatment options to improve and maintain periodontal health.

REFERENCES

1. Caton JG, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and peri-implant diseases and conditions – Introduction and key changes from the 1999 classification. J Periodontol. 2018;89(Suppl 1):S1–S8.
2. Caton JG, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and peri-implant diseases and conditions – Introduction and key changes from the 1999 classification. J Clin Periodontol. 2018;45(Suppl 20):S1–S8.
3. Gurenlian JR. An update on the classification of periodontal diseases. Dimensions of Dental Hygiene. 2018;16(9):10–17.
4. Lang NP, Suvan JE, Tonetti MS. Risk factor assessment tools for the prevention of periodontitis progression a systematic review. J Clin Periodontol. 2015;42(Suppl 16):S59–S70.
5. Ramseier CA. Potential impact of subject-based risk factor control on periodontitis. J Clin Periodontol. 2005;32(Suppl 6):283–290.
6. Francisco EM, Johnson TL, Freudenthal JJ, Louis G. Dental hygienists’ knowledge, attitudes and practice behaviors regarding caries risk assessment and management. J Dent Hyg. 2013;87:353–361.
7. Gurenlian JR, Swigart DJ. Dental hygiene diagnosis. Dimensions of Dental Hygiene. 2018;(12):16:36–39.
8. Cohen RE, Research, Science and Therapy Committee, American Academy of Periodontology. Position paper: periodontal maintenance. J Periodontol. 2003;74:1395–1401.
9. Ramseier CA, Nydegger M, Walter C, et al. Time between recall visits and residual probing depths predict long-term stability in patients enrolled in supportive periodontal therapy. J Clin Periodontol. 2019;46:218–230.
10. Darcey J, Ashley M. See you in three months! The rationale for the three monthly periodontal recall interval: a risk based approach. Br Dent J. 2011;211:379–385.
11. Echeverria JJ, Echeverria A, Caffesse RG. Adherence to supportive periodontal treatment. Periodontol 2000. 2019;79:200–209.
12. Lee CT, Huang HY, Sun TC, Karimbux N. Impact of patient compliance on tooth loss during supportive periodontal therapy: a systematic review and meta-analysis. J Dent Res. 2015;94:777–786.
13. Patel S, Bay RC, Glick M. A systematic review of dental recall intervals and incidence of dental caries. J Am Dent Assoc. 2010;141:527–539.
14. American Academy of Periodontology. American Academy of Periodontology statement on risk assessment. J Periodontol. 2008;79:202.
15. Rudick, CP, Lang, MS, Miyamoto, T. Understanding the pathophysiology behind chairside diagnostics and genetic testing for IL‐1 and IL‐6. Oral Dis. 2019;00:1–7.
16. Hodges KO. Evaluate disease potential. Dimensions of Dental Hygiene. 2015;13(6):24–26.
17. Mullins JM, Even JB, White JM. Periodontal management by risk assessment: a pragmatic approach. J Evid Based Dent Pract. 2016;16(Suppl):91–98.
18. McGowan T, McGowan K, Ivanovski S. A novel evidence-based periodontal prognosis model. J Evid Based Dent Pract. 2017;17:350–360.
19. Brocklehurst PR, Ashley JR, Tickle M. Patient assessment in general dental practice—risk assessment or clinical monitoring? Br Dent J. 2011;210:351–354.
20. Bader J. Risk-based recall intervals recommended. Evid Based Dent. 2005;6:2–4.
21. Rosén B, Olavi G, Badersten A, Rönström A, Söderholm G, Egelberg J. Effect of different frequencies of preventive maintenance treatment on periodontal conditions. 5-Year observations in general dentistry patients. J Clin Periodontol. 1999;26:225–233.
22. Gay IC, Tran DT, Weltman R, et al. Role of supportive maintenance therapy on implant survival: a university-based 17 years retrospective analysis. Int J Dent Hyg. 2016;14:267–271.
23. Farooqi OA, Wehler CJ, Gibson G, Jurasic MM, Jones JA. Appropriate recall interval for periodontal maintenance: a systematic review. J Evid Based Dent Pract. 2015;15:171–181.
24. Clarkson JE, Pitts NB, Bonetti D, et al. INTERVAL (investigation of NICE technologies for enabling risk-variable-adjusted-length) dental recalls trial: a multicentre randomised controlled trial investigating the best dental recall interval for optimum, cost-effective maintenance of oral health in dentate adults attending dental primary care. BMC Oral Health. 2018;18:135.
25. Bader JD, Shugars DA, Kennedy JE, Hayden WJ, Jr, Baker S. A pilot study of risk-based prevention in private practice. J Am Dent Assoc. 2003;134:1195–1202.
26. Jepsen S, Blanco J, Buchalla W, et al. Prevention and control of dental caries and periodontal diseases at individual and population level: consensus report of group 3 of joint EFP/​ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol. 2017;44(Suppl 18):S85–S93.
27. Mettes TG, van der Sanden WJ, Mulder J, Wensing M, Grol RP, Plasschaert AJ. Predictors of recall assignment decisions by general dental practitioners performing routine oral examinations. Eur J Oral Sci. 2006;114:396–402.
28. General Dental Council. Scope of practice: dental hygienists. Nature BDJ Team. 2018;5:18072.
29. Pitts EI, Fontana M. The role of the dental hygienist in caries risk assessment. Dimensions of Dental Hygiene. 2018;16(7):21–24.
30. Lang NP, Tonetti MS. Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral Health Prev Dent. 2003;1:7–16.
31. Angst PDM, Stadler AF, Oppermann RV, Gomes SC. Microbiological outcomes from different periodontal maintenance interventions: a systematic review. Braz Oral Res. 2017;4:e33.
32. Leavy PG, Robertson DP. Periodontal maintenance following active specialist treatment: Should patients stay put or return to primary dental care for continuing care? A comparison of outcomes based on the literature. Int J Dent Hyg. 2018;16:68–77.
33. Renvert S, Persson GR. Supportive periodontal therapy. Periodontol 2000. 2004;36:179–195.
34. Costa FO, Vieira TR, Cortelli SC, et al. Effect of compliance during periodontal maintenance therapy on levels of bacteria associated with periodontitis: A 6-year prospective study. J Periodontol. 2018;89:519–530.

From Dimensions of Dental Hygiene. January 2020;18(1):30–33.