Importance of PM

Periodontal maintenance (PM) is therapy planned at appropriately timed intervals after initial periodontal therapy, continuing for the life of the dentition or implant replacement.¹ In the past, PM was referred to as supportive periodontal therapy, recare, and continuing care. However, the American Academy of Periodontology recently issued a position paper on periodontal maintenance stating that PM is the preferred terminology.¹

How is PM integrated into periodontal therapy?

PM is an extension of periodontal therapy involving continued assessment and individualized therapeutic interventions. The terms “active therapy,” “initial therapy,” and “etiotropic therapy” are names for Phase I periodontal therapy.² Nonsurgical periodontal therapy (NSPT) is a major component of Phase I therapy and includes initial periodontal assessment, diagnosis, care planning, implementation, and reevaluation.³ The intent of NSPT is to eliminate or suppress infectious microorganisms and other etiologic factors and to establish periodontal tissue health that precludes further loss of attachment. Clinical signs of a healthy periodontium include the absence of redness, swelling, suppuration, and bleeding on probing (BOP); maintenance of a functional attachment level; minimal or no recession in the absence of interproximal bone loss; and functional dental implants.⁴ After completion of NSPT, a 30 to 45 minute appointment (reevaluation) is scheduled 4 to 6 weeks postcare to evaluate the patient’s response.

Merin5 suggests that PM starts immediately after the completion of active therapy (Phase I) and that surgical care (Phase II) and restorative procedures (Phase III) are performed during the maintenance phase. The purpose of this revised model is to encourage the health status to remain the same or improve after NSPT. Therefore, a patient might return for PM therapy coinciding with surgical or restorative care to maintain the health of the mouth and specific sites of periodontal destruction.

What are the Goals of PM?

PM’s three therapeutic goals are to minimize the recurrence and progression of gingivitis, periodontitis, and peri-implantitis; to reduce tooth loss by monitoring the dentition and prosthetic replacements; and to increase the probability that other diseases and conditions are identified and treated in a timely manner.¹ These goals are communicated to the patient and included in written material disseminated by the office. The purpose and need for PM should be included in the initial consent for NSPT.

When Is PM Provided?

Patients with gingivitis but no previous attachment loss are indicated for periodontal maintenance two times per year. For those with periodontitis, intervals of less than 6 months are suggested (Table 1). The goal is to care for these patients three to four times per year. The guidelines for determining the interval are based on whether the NSPT goals have been met. If inflammation and bleeding are resolved, attachment levels are stable, probing depths are maintainable, and self-care practices are good to excellent, then PM therapy is warranted. In general, 3 to 4 months is an ideal time interval for patients who have generally good results from initial therapy but display some characteristics like inconsistent self-care practices, heavy calculus formation, some teeth with less than 50% alveolar bone support, and/or complicated prosthesis.

PM occurs 8 to 10 weeks from the reevaluation visit if the objectives of reevaluation are met. This interval coincides with the 3 to 4 month PM appointment after NSPT is completed. If the objectives of NSPT are not met and/or if multiple risk factors for continuing periodontal destruction are evident, the PM appointment should occur 4 weeks after NSPT, which is a 2-month interval.

Is There Enough Evidence to Support the Need and Expense of PM?

Numerous studies show that attachment loss is decreased and tooth loss is minimized with regular and individualized PM visits when compared with patients seen less often or not at all.⁶ The rationale for these intervals is based on the premise that specific subgingival microorganisms are suppressed following PM and that they may return to baseline levels days or months later. The average time for return to baseline is between 9 and 11 weeks.⁷

What Should PM Appointments Include?

The phases of the dental hygiene process of care are revisited in a 60 to 90 minute appointment.⁸ PM appointments should include the following: updating medical, personal, and dental histories; reassessment of oral conditions, risk factors, and self-care; reevaluation of the periodontal diagnosis; development of a new care plan; and implementation of therapies to treat recurrent and new disease sites.

Patient histories identify new risk factors such as tobacco use, diabetes, stress, or other systemic health conditions. Assessment focuses on periodontal examination, risk factors, periodontal restorative interactions, and needed radiographs (see Table 2).⁹ Implementation includes interventions such as ultrasonic and hand instrumentation for periodontal debridement, and chemotherapy. Table 3 provides an overview of the components of care.¹⁰ Also, an appropriate interval for PM should be re-established and confirmed with the patient.

PM emphasizes treating areas of previous attachment loss and areas where clinical signs of inflammation are present.⁶ Patients who do not qualify for PM after NSPT due to nonadherence to suggested intervals with generalized disease indicated by BOP, increased pocket depth, and/or further loss of attachment, are indicated for NSPT again and, perhaps, evaluation for appropriate surgical interventions. Thus, a patient’s care can move from PM to nonsurgical and/or surgical care depending on periodontal conditions.¹

Are Antimicrobial or Antibiotic Therapies of Value in PM?

Locally delivered antimicrobials or antibiotics may be useful in the treatment of recurrent disease activity or when only a few individual sites of destruction are present, eg, 5 mm pocket depth or greater with persistent inflammation. Using systemic antibiotics seems to be especially appropriate with aggressive periodontitis. In aggressive or refractory periodontitis, the use of appropriate antibiotics frequently improves the clinical response when compared to the use of mechanical therapy alone.¹¹ Decision making for antimicrobials or antibiotics should consider the thoroughness and effectiveness of NSPT and the patient’s self-care practices in addition to the pharmacologic history. NSPT must be meticulously completed in order to achieve expected results and the patient should understand and adhere to the individualized self-care practices before recommending additional and costly therapeutic interventions.

What is the Role of the Dental Hygienist?

Compliance improves when patients are informed and positively reinforced, and when barriers to treatment are reduced.¹² Adherence with PM refers to the patient seeking PM at the recommended interval and the incorporation of the recommended self-care practices at home. The dental hygienist recommends the individualized interval based on patient needs and spends adequate time educating the patient about periodontitis. A well-informed patient will know and, hopefully, understand that periodontitis is a chronic disease state that needs maintenance care at appropriate intervals and that daily and effective disruption of the bacterial biofilm is essential for control. Patients should also understand how risk factors, such as tobacco use and systemic diseases, enhance periodontal destruction and what to do to eliminate or control risk factors.

Wilson^12,13 recommends eight methods for improving compliance. Simplify the behavior, which increases the likelihood that it will get carried out. For example, recommend one interdental aid, such as the toothpick and holder, to address open embrasures and furcations instead of multiple aids such as floss, a toothpick and holder, and an interdental brush.

When your practice and suggestions meet patient needs, patient compliance will increase. Remind patients of appointments via postcards and/or telephone calls. Advanced booking of appointments seems to enhance adherence because patients make the commitment at the end of NSPT to come back in 3 months. Keep records of compliance by tracking need and missed visits, and contact the patient to reschedule if this occurs.

Inform the patient in writing of the etiology, risk factors, and individualized self-care and care plan recommendations. Many offices inform the patient verbally and in writing with an overview of the disease process, the recommended self-care, the need to comply, and the individualized PM interval. Pamphlets and websites with patient-centered information (www.perio.org, www.adha.org, www.ada.org) are suggested to enhance education and communication.

Provide positive reinforcement and constructive guidance to enhance compliance. Reward the patient for improvements in eliminating or reducing risk factors, positive changes in self-care practices, and/or adherence with PM intervals. Identify potential noncompliers early in care, strive to educate and communicate well, and track these patients’ care. Have the dentist review assessment information, provide a periodontal diagnosis, and reinforce self-care recommendations and PM intervals.

When Are Patients Referred To A Specialist?

The decision to refer patients to the periodontist focuses on the type and severity of disease present and if the hygienist in the general dentist’s office possesses the skills and has ample time to maintain periodontal patients.⁹ The capabilities of the general practitioner and the staff as well as the patient’s needs and desires are considered. Some patients decline referral to the periodontist due to cost, geographic constraints, or not being familiar with a new office and new dental professionals. Many periodontists will encourage alternating visits for PM with the general practitioner’s office, and this is perhaps the ideal situation for all involved.

In general, patients diagnosed with chronic periodontitis with advanced loss of periodontal support or aggressive periodontitis are referred to the periodontist. Also, patients who are diagnosed with other forms of periodontal diseases (nonplaque-induced gingival diseases and those associated with systemic disease or oral defects) might be referred to a periodontist.

From Mattson JS. Periodontal maintenance procedures. In: Hodges KO, ed. Concepts in Nonsurgical Periodontal Therapy. Ed. Albany, NY: Delmar Publishers; 1998:443.

Patients diagnosed with chronic periodontitis with moderate loss of periodontal support may also be referred if risk factors exist, supporting structures are not stable, and/or the disease status is close to the advanced stages. Patients with recurrent gingivitis and chronic periodontitis with slight loss of periodontal support can usually be maintained in the general dentist’s office.

The 5 mm standard for periodontal probing depth is a traditional guideline for referral² and is based on root length, normal gingival contour, probing depth, and attachment loss. Patients who, upon reevaluation or at PM visits, have probing depths greater than 5 mm (with normal gingival contour) or apical migration of the epithethial attachment or both should be considered for referral. The typical root length is 13 mm and a 5 mm probing depth coupled with 1 mm width of the epithelial attachment represents loss of approximately half of the bone support for most teeth. Deep sites are associated with BOP, elevated subgingival temperatures, higher levels of periodontal pathogens, decreased effectiveness of selfcare, and reduced ability to remove subgingival deposits when compared to shallow sites. Therefore, deep sites seem to be at greater risk for disease progression.¹⁴

BOP should also be considered during decision making for referral because its presence or absence may be a factor in predicting loss of attachment over time. Periodontally involved sites with significant clinical attachment loss that demonstrate BOP at sequential PM visits are associated with an increased risk of loss of attachment.^15,16 Consequently, periodontal probing depths greater than 5 mm with associated BOP at multiple PM visits are areas for concern.

The deeper the pockets, the more difficult to treat and the stronger the indication for referral. Short roots are more compromised than long roots with 5 mm of clinical attachment loss. Hypermobility suggests a more guarded prognosis. Difficulty of periodontal debridement is considered when furcations, flutings, and other root anomalies as well as deep pockets are present. The long-term prognosis of the tooth is also a consideration for restorative therapy. The younger the patient, the more aggressive the disease is likely to be. Lastly, tissue that is thick and fibrotic does not resolve or shrink after NSPT when compared to tissue that is edematous.²

Additionally, consider other referrals for caries prevention and therapy, implant assessment and maintenance, perio-endodontic lesion evaluation, malocclusion correction, and systemic disease diagnosis and therapy.

How Do Third Party Payors Affect PM?

Dental benefit plans usually cover a portion—not all—of the needed oral care. The best approach is to plan for the patient’s needs and not for the dental benefit plan. The American Dental Association (ADA) defines PM as “therapy for preserving the state of health of the periodontium.”¹⁷ The code for PM is D4910 and is described as a procedure for patients previously treated for periodontal disease. Typically, maintenance starts after completion of active (surgical or nonsurgical) periodontal therapy and continues for the life of the dentition at varying intervals determined by the clinical diagnosis. PM includes removal of the supra and subgingival microbial flora and calculus, site-specific scaling and root planing, and/or polishing of the teeth. When new or recurring periodontal disease appears, additional diagnostic and treatment procedures are considered.¹⁷

Dental benefit plans may or may not cover PM. If PM is a benefit, the plan might cover this procedure two to four times per year. Often, patients experience out-of-pocket expenses for PM. Again, a thorough explanation of need and education are essential for a patient’s consent to multiple PM appointments each year.

The D4910 PM code does not include a periodic evaluation, thus a D0120 code is used when an assessment is recorded on a patient to determine changes in dental and medical health status since a comprehensive or periodic evaluation.¹⁷ This evaluation includes periodontal screening. However, additional diagnostic procedures (radiographs) that are indicated are reported and coded separately. The code D4381 is applied when localized delivery of a chemotherapeutic agent is used to treat periodontal pockets. D4381 is defined as an “adjunctive procedure for specific sites that are unresponsive to conventional therapy or for cases in which systemic disease or other factors preclude conventional or surgical therapy.”¹⁷

A space is available on the dental claim form for remarks relating to PM such as “special needs client, 2 hour appointment indicated” or “rapid calculus former, 2 hour appointment needed every 3 months.” The remarks section on the dental claim form can be used to justify length of time for the appointment and/or need for increasing the fee due to complex periodontal status. A D4341 or D4342 code for periodontal scaling and root planing (NSPT) or a surgical procedure code must be used prior to the D4910 PM code.¹⁷

In conclusion, PM is a vital component of periodontal therapy for your patients. Building PM into a practice is challenging because of the time, cost, and third party payor issues. However, dental hygienists have a legal and ethical professional responsibility to develop the best perio- dontal care plans for their patients.

References

1. American Academy of Periodontology. Periodontal maintenance. Position paper. J Periodontol. 2003;74:1395-1401.
2. Perry DA, Schmid MO. Phase I periodontal therapy. In: Newman MG, Takei HH, Carranza, FA. Clinical Periodontology. 9th ed. Philadelphia: WB Saunders Co; 2002:646-650.
3. Hodges KO. Nonsurgical, supportive, and mechanized periodontal therapies. In: Darby ML, Walsh MM. Dental Hygiene Theory and Practice. 2nd ed. St Louis; 2003:457-492.
4. American Academy of Periodontology. Guidelines for periodontal therapy. J Periodontol. 2001;72:1624-1628.
5. Merin RL. Supportive periodontal treatment. In: Newman MG, Takei HH, Carranza FA. Clinical Periodontology. 9th ed. Philadelphia: WB Saunders Co; 2002: 966-977.
6. Wilson TG. Supportive periodontal treatment introduction—definition, extent of need, therapeutic objectives, frequency and efficacy. Periodontol 2000.1996;12:11-15.
7. Greenstein G. Periodontal response to mechanical non-surgical therapy: a review. J Periodontol. 1992;63:118-130.
8. Darby ML. The evolving profession of dental hygiene. In: Darby ML, Walsh MM. Dental Hygiene Theory and Practice. 2nd ed. St Louis; 2003: 2-18.
9. Mattson JS. Periodontal maintenance procedures. In: Hodges KO. Concepts in Nonsurgical Periodontal Therapy. Albany, NY: Delmar Publisher; 1998:439-457.
10. Lautar CJ, Pimlott JFL. Periodontal diagnosis and care planning. In: Hodges KO. Concepts in Nonsurgical Periodontal Therapy. Albany, NY: Delmar Publisher; 1998:153-179.
11. Walker C, Karpinia K. Rationale for use of antibiotics in periodontics. State of the art review. J Periodontol. 2002;73(10):1188-1196.
12. Wilson TG. Compliance and its role in periodontal therapy. Periodontol 2000. 1996;12;16-23.
13. Wilson TG. How patient compliance to suggested oral hygiene and maintenance affect periodontal therapy. Dental Clinics ofNorth America. 1998;42(2);389-403.
14. Greenstein G. Contemporary interpretation of probing depth assessments: diagnostic and therapeutic implications. A literature review. J Periodontol. 1997;68(12);1194-1205.
15. Joss A, Adler R, Lang NP. Bleeding on probing. A parameter for monitoring periodontal conditions in clinical practice. J Clin Periodontol. 1994;21(6);402-408.
16. Lang NP, Joss A, Orsanic T, Gusberti FA, Siegrist BE. Bleeding on probing. A predictor for the progression of periodontal disease. J Clin Periodontol. 1986;13(6):590-596.
17. American Dental Association. Current Dental Terminology. Chicago: American Dental Association; 2002.