Problems associated with Maintenance Therapy
1. Patient motivation
Patient motivation is of great importance since it affects compliance and home care of a patient. Not enough reinforcement and emphasis on the importance of maintenance therapy will result in decreased motivation of the patient. Inadequate knowledge of` the nature of periodontal problems, and the need for on-going therapy, may effect the patient’s motivation. Many patients envisage that the active phase of periodontal treatment is a ‘cure’, and express surprise at the need for further treatment of recurrent disease, or the need to attend 3-monthly for maintenance therapy.
This may be caused by a lack of communication between the dentist and the patient at the start of treatment. Problems with communication may arise from language difficulties, as well as from different patterns of reasoning. Patients often operate on their beliefs, that may not correlate with the facts on which dentists base their work. Personal crises of patients may at any time create problems with motivation.
2. Patients’ oral hygiene
Due to poor manual dexterity or simply lack of effort, patients may not be able to effectively control their plaque accumulations. Inadequate and irregular toothbrushing produces generalised inflammation, and patients may avoid brushing near the inflamed tissues due to the bleeding it produces. This cycle of thinking must be challenged if periodontal treatment is to succeed.
Patients may develop a habit of missing certain areas of their dentition during teeth cleaning, which may correlate with localised recurrences of periodontal lesions. Selection of a smaller toothbrush, such as an end-tufted brush or an interproximal brush may help the patient overcome such localised cleaning problems. Some undesirable habits during brushing may result in self-inflicted trauma to the dentition and the gingival tissues. This may produce areas of recession, and toothbrush abrasion lesions.
Plaque retentive factors within the dentition include furrows and concavities in crown and root surfaces, poorly contoured restorations, subgingival margins, crowding of` teeth, and exposed narrow furcation openings. All of these factors make oral hygiene challenging, and also increase the complexity of the maintenance therapy.
3. Dentinal sensitivity
Patients suffering dentinal hypersensitivity following periodontal therapy can pose a problem at the maintenance phase. Ideally, maintenance therapy should be carried out without the use of local anaesthetic, as it involves only lightly cleaning the root surfaces. However, some patients may resist even the lightest touch of a curette against the root surface, and the use of ultrasonic cleaners would be definitely contra-indicated.
Therefore, in order to prevent these problems arising, it is important to treat dentinal hypersensitivity as it occurs during periodontal treatment. The professionally applied oxalate-based desensitising solutions eg, Protect or Sensodyne Sealant are extremely effective in minimising dentinal sensitivity. The adjunctive use of desensitising agent at home by the patient eg, Colgate Gel-Kam further minimises the problems.
4. Root caries
One of the unfortunate things that may follow periodontal therapy is root caries lesions on the exposed root surfaces. The appearance of root caries may correlate with a change in the patient’s medical status (resulting in a dry mouth), or in their social situation (resulting in a more cariogenic diet). Root caries is often an aggressive disease and can rapidly destroy tooth substance. It is best prevented through the use of fluoride mouth rinses, combined with a fluoride toothpaste. Maintenance therapy often provides the best opportunity to detect and treat root caries lesions.
It can become expensive for patients to attend the dentist on a three monthly basis. Private health insurance companies provide little in the way of rebates for periodontal maintenance. A way of minimising the costs to the patient may be to delegate maintenance therapy to a dental hygienist within your practice.