Periodontal Maintenance in Disease Prevention - IneedCE.com

Earn 

2 CE credits 

This course was 

written for dentists, 

dental hygienists, 

and assistants. 

Periodontal Maintenance 

in Disease Prevention 

A Peer-Reviewed Publication 

Written by William L. Balanoff, DDS, MS, FICD 

Publication date: January 2008 

Review date: February 2011 

Expiry date: January 2014 

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This course has been made possible through an unrestricted educational grant from Zila Pharmaceuticals, Inc. The cost of this CE course is $49.00 for 2 CE credits. 

Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Educational Objectives 

Upon completion of this course, the clinician will be able to 

do the following: 

1. List and describe the rationale for periodontal maintenance 

and the components involved in a periodontal 

maintenance program. 

2. List and describe patient compliance factors and 

the impact of noncompliance on periodontal 

outcomes. 

3. List the considerations involved in the selection and 

recommendation of oral care devices for patients. 

4. List and describe the risk for root caries and dentinal 

sensitivity in patients following periodontal therapy, 

as well as prevention and treatment options. 

Abstract 

Periodontal disease occurs in the presence of pathogenic bacteria 

— periodontopathogens or periodontal bacteria — in a susceptible 

host. The overall objectives of periodontal therapy are 

to halt disease progression, reduce pocket depths and, ideally, 

obtain clinical attachment gains. Following active periodontal 

therapy, periodontal maintenance is key for long-term positive 

clinical outcomes, involving both in-office maintenance and 

meticulous home care. Professional care is required to remove 

subgingival biofilm and deposits, and to prevent periodontal 

disease progression. The goal of daily oral hygiene procedures 

for periodontal maintenance is to remove dental biofilm before 

it matures so as to prevent the development of gingivitis and a 

mature subgingival plaque. Consideration should be given to 

techniques and protocols that aid compliance, and care should 

be taken to address each patient’s ability and willingness to 

perform daily oral hygiene as well as to address root caries risk 

and prevent unwanted sequelae. 

Introduction 

Periodontal disease occurs in the presence of pathogenic 

bacteria — periodontopathogens or periodontal bacteria 

— in a susceptible host. As periodontal disease progresses, 

clinical attachment loss and bone loss occur. This leads to the 

development of periodontal pockets of increasing depth and 

complexity in untreated periodontal disease, adding to the 

difficulties of treatment and periodontal maintenance and increasing 

the patient’s caries risk due to root exposure (Figure 

1). Advanced disease is found in up to 15% of adults, and the 

majority of people experience gingivitis or moderate levels of 

periodontal disease. 1 

It is known that it is mainly the host response, including 

immune and inflammatory responses, that determines the 

onset and progression of periodontal disease. This in turn 

is influenced by risk factors that include smoking, poor oral 

hygiene, gender, hormones and genetics. 2,3,4 Nonetheless, 

periodontal bacteria must be present for the onset and progression 

of periodontal disease; in their absence periodontal 

disease would not occur. 

Figure 1. Periodontal disease progression 

Periodontal Therapy 

The overall objectives of periodontal therapy are to halt disease 

progression, reduce pocket depths and, ideally, obtain 

clinical attachment gains. The underlying goals in meeting 

these objectives are to thoroughly remove periodontal bacteria 

and biofilm, debris, calculus and endotoxins and the 

root surface must be intact, free of calculus and compatible 

with oral hygiene goals. Mature biofilm (plaque) contains 

high levels of periodontal bacteria in a well-organized matrix, 

and its disruption and removal are essential. Ensuring that 

the root surfaces are smooth avoids providing a rough site 

for adhesion and recolonization by periodontal bacteria and 

the development of subgingival biofilm following treatment. 

The standard treatment for periodontal disease is nonsurgical 

scaling and root planing. In specific cases, the clinician may 

determine that surgical treatment is required to access specific 

areas and adequately treat advanced or deep periodontal 

pockets. The overall objectives remain the same whether 

nonsurgical or surgical therapy is performed. 

Periodontal therapy, when properly performed, is effective 

at removing subgingival calculus, biofilm, debris and endotoxins 

and at reducing subgingival bacterial levels. The continued 

or renewed presence of high levels of periodontal bacteria and 

complexes after active periodontal therapy negatively influences 

treatment outcomes, and periodontal bacteria can return to 

pretreatment levels in months or in as little as several days. 5,6,7,8 

Periodontal bacteria can return to pretreatment 

levels in as little as several days. 

Following active periodontal therapy, periodontal maintenance 

is required throughout the patient’s life. In its absence, 

active periodontal disease is likely to recur, with further clinical 

attachment loss and bone loss. Patients who do not receive 

regular periodontal maintenance have greater probing depths 

and more tooth loss than those who receive such care. 9,10 

Periodontal maintenance is key for long-term positive clinical 

outcomes following periodontal therapy, involving both inoffice 

maintenance and meticulous home care to effectively 

remove plaque on a daily basis. 

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Periodontal maintenance is key for long-term 

positive clinical outcomes 

In-office periodontal maintenance 

In-office periodontal maintenance should include a full evaluation 

and examination of the hard and soft tissues. Thorough 

removal of calculus and biofilm, including scaling and root 

planing at selected sites as indicated, is required (Table 1). 

If an established subgingival biofilm is present, this cannot 

be effectively removed by home care. Professional care is 

required to remove subgingival biofilm and to prevent periodontal 

disease progression. 11 The combination of periodic 

professional care and home care to remove plaque is effective 

in substantially reducing the level of periodontopathogens 

in periodontal pockets as well as the proportion consisting of 

Porphyromonas gingivalis. 12 Patient compliance is associated 

with lower tooth loss during periodontal maintenance. 

Table 1. In-office periodontal maintenance 

Full evaluation of hard and soft tissues 

Thorough removal of calculus and biofilm 

Scaling and root planing at sites as indicated 

Assessment of adequacy of patient’s oral hygiene 

Patient education and motivation 

Reinforcement of good oral hygiene habits 

The standard of care for visits for periodontal maintenance 

is at least four times per year. This can be adjusted based on 

the individual patient — less often for patients who show no 

disease recurrence or progression and demonstrate effective 

home care; more often for patients who perform home care 

ineffectively or are noncompliant, have predisposing risk 

factors for progression (such as being a smoker or immunocompromised), 

or present with recurrence. Regular in-office 

maintenance appointments enable the clinician to assess the 

current status of the patient’s oral care and the adequacy of his 

or her oral hygiene. On an ongoing basis, both professional 

care and adequate daily oral hygiene are required to remove 

supragingival and subgingival plaque. The periodontal maintenance 

program must meet the individual patient’s needs. 13,14 

On an ongoing basis, both professional care and 

adequate daily oral hygiene are required to 

remove supragingival and subgingival plaque. 

Patient compliance and motivation 

One of the main issues in periodontal maintenance is 

patient compliance, a well-recognized problem for all 

oral hygiene regimens, whether in periodontally involved 

patients or not. One recent retrospective study found that 

55% of patients were noncompliant with maintenance 

therapy, 15 while an earlier five-year assessment found 46.8% 

of patients were noncompliant, with older patients (over 40 

years of age) being more compliant than younger patients. 16 

Another study found that 28% of patients did not comply 

with their first visit for periodontal maintenance. 17 Patients 

who participate in oral hygiene studies and receive training 

in oral hygiene regimens have been found to revert to old 

habits after the study is completed, even when they retain 

the acquired skill set required to adequately perform oral 

hygiene. 18 

Once patients are not in regular contact with dental 

professionals, their compliance and motivation decrease, 19 

further underscoring the need for regular periodontal 

maintenance recare appointments to aid compliance. These 

visits provide an opportunity for patient motivation and 

reinforcement of good daily oral hygiene habits. 20 Patients 

retain only a proportion of what they hear and are taught, 

and every individual learns at a different speed. Repeated 

instruction and reinforcement at regular recall appointments 

are indicated to help ensure that patients continue 

their oral hygiene protocol. It has been estimated that most 

patients brush for one minute, an inadequate length of time 

for thorough plaque removal. 21 Respondents to surveys 

have indicated that less than 10% of patients floss daily and 

more than half of all patients never floss. 22,23 

Table 2. Non-compliance factors 

Irregular contact with dental professional 

Lack of understanding and retention of information 

Lack of motivation to perform oral hygiene procedures 

Lack of motivation to spend enough time on oral hygiene 

Reverting to old habits 

Novelty effect of a new oral care device wears off 

It has also been demonstrated that patients experience 

a novelty effect with oral hygiene protocols and oral care 

devices. For instance, it has been shown that when a new 

powered toothbrush was recommended and selected for 

patients, after 12 months only 50% of the patients were still 

using the powered brush. 24 Giving in-office instructions 

with a new brush — rather than asking a patient to buy one 

in a store and use it — has also been found to be effective in 

reinforcing the home care oral hygiene message and technique. 

Erratic patient compliance (noncompliance) has 

also been found to be associated with higher levels of root 

caries in periodontal maintenance patients. 25 

Giving in-office instructions with a new 

brush has been found to be effective in 

reinforcing home care oral hygiene. 

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Home Care for Periodontal Maintenance 

The goal of daily oral hygiene procedures for periodontal 

maintenance is to remove dental biofilm before it matures so 

as to prevent the development of gingivitis and a mature subgingival 

plaque. A further home care goal is caries prevention. 

Young, immature dental plaque contains mainly grampositive 

streptococci, and the mature subgingival biofilm 

takes from 3 to 12 weeks to develop into a well-differentiated 

layer containing mainly periodontopathogens including Porphyromonas 

gingivalis and Treponema denticola. 26,27,28 In addition, 

migrating bacteria can shift from supragingival plaque 

to subgingival sites as well as to different periodontal sites, 29 

further highlighting the importance of daily supragingival 

plaque removal. The accepted home oral hygiene care regimen 

is use of a toothbrush (manual or powered) plus either 

floss or interdental brushes. In the absence of flossing, investigators 

in one study found that a reduction in bleeding sites 

of only 35% was obtained with brushing alone. 30 One study 

found that manual interdental brushes were more effective 

than floss for patients in periodontal maintenance; 31 a second 

study concurred with these findings and found interdental 

brushes to be more effective even before thorough professional 

debridement, 32 while a third study found floss and interdental 

brushes to be equally effective. 33 Electric interdental 

devices (Hummingbird, Oral B; Interclean) have also been 

found to be as effective as floss. 34,35 It has also been observed 

that patients experience more problems with dental floss than 

with interdental brushes. 36 

Table 3. Home care objectives 

Remove plaque before it matures 

Prevent development of gingivitis 

Prevent development of mature subgingival plaque 

Manual and powered toothbrushes 

Manual and powered brushes have both been found to be 

effective. An extensive number of trials and studies have 

been conducted comparing manual and power brushing, 

as well as different power brushes, using a variety of protocols. 

Powered brushes include rotary, sonic and rotary/ 

oscillating powered brushes (Figure 2), and all have been 

found to be effective in trials. 

Haffajee et al. found both powered and manual toothbrushes 

effective over a six-month period in reducing 

the levels of bacteria in periodontal pockets when used 

to remove supragingival plaque (and simultaneously removing 

periodontopathogens present supragingivally). 37 

Warren et al., however, found that this depended on 

toothbrush design and found that a novel-design manual 

toothbrush was as effective as two powered toothbrushes 

in removing plaque when used in the participants’ normal 

manner (i.e., without additional training). 38 Another study 

in which participants received five weeks of professional 

oral hygiene training found no differences in plaque removal 

efficacy between use of a manual toothbrush and a 

powered toothbrush. 39 

Sonic brushes have been found to be more effective than 

manual brushes, especially in difficult-to-reach areas, for 

plaque removal. 40 The sonic brush removes plaque through 

the physical action of the bristles vibrating against the 

tooth surface as well as through fluid dynamics created by 

the ultra high speed of the sonic brush. The fluid dynamics 

result in the creation of minute bubbles that are propelled 

against the tooth and help to remove plaque. Robinson et 

al. found that use of either a sonic brush or a rotary/oscillating 

brush improved oral health in periodontal patients, 

and that the improvements with the sonic brush were superior. 

41 In contrast, Bader and Boyd found use of a rotary 

Figure 2. Powered brushes 

Rotary Oscillating Sonic 


ush over a period of 12 weeks significantly more effective 

than a sonic brush in reducing plaque, the bleeding index 

and the gingival index. 42 A small study involving dental 

hygiene students showed that a rotary powered brush was 

significantly more effective at visual plaque removal than 

a manual brush and removed 75% of the plaque present in 

30 seconds versus 15 seconds. 43 While care should be taken 

in extrapolating data gathered from clinical students to 

the general population, in this case such an extrapolation 

would seem to be valid since expertise could be expected 

to improve manual brush efficacy and thereby reduce the 

time required for a given level of plaque removal. Given 

patient compliance issues discussed earlier, increased efficacy 

of plaque removal in a reduced time is an important 

consideration when recommending an oral hygiene protocol 

and brush to patients. In general, powered brushes 

offer an opportunity to accelerate cleaning for inadequate 

brushers. 

Interdental cleaning 

Most periodontal disease begins in the col area interdentally, 

where manual brushing alone has been proven 

ineffective. Therefore, any oral hygiene regimen must 

adequately address interdental cleaning. In contrast to 

manual brushes, powered brushes have been found to be 

effective at cleaning interdentally as well as in furcation 

areas. When compared to the combined use of a manual 

toothbrush, floss and toothpicks, Murray et al. found a 

rotary brush equally effective at controlling gingivitis 

in study patients over a period of 12 months and equally 

effective at producing significant reductions in the levels 

of periodontopathic bacteria. 44 In comparing a rotary powered 

brush with another powered brushes, Bader and Williams 

found the rotary brush to be significantly superior 

interproximally and at furcations. 45 

Figure 3. Powered brush heads 

While clinical results vary in different studies, powered 

brush heads are typically smaller and more compact than 

manual brush heads, aiding access to difficult-to-reach areas. 

Patients in one study of sonic brushes reported finding 

smaller brush heads preferable to larger brush heads. 46 In 

addition, recent designs have improved interdental cleaning 

using a powered brush — an important consideration 

given patients’ unwillingness to use interdental cleaners (in 

particular, floss). Brush heads with rotating or spiraling filaments 

are effective for interdental cleaning, and other design 

features that aid this include specific brush head shapes and 

active brush tips that reach into interdental sites. 47 

Figure 4. Rotary powered brush head interdentally 

Force and abrasion 

Applied force and abrasion are factors when considering 

toothbrush selection. Powered brushes have been compared 

in several studies to manual brushes for applied force and 

abrasivity. Van der Weijden et al. also studied brushing forces 

and found that more force was applied using a manual toothbrush 

than a powered toothbrush and that the applied force 

depended on the brush used (Table 4). 48 In one in vitro study, 

sonic, rotary/oscillating and ultrasonic brushes were all found 

to abrade both sound and demineralized dentin more than a 

manual brush. 49 Boyd et al. studied the forces applied using a 

rotary powered brush, two other powered brushes or a manual 

toothbrush and regular dentifrice in vivo. The manual toothbrush 

was found to result in the most applied pressure and the 

rotary powered brush the least applied pressure. 50 In a similar 

comparison using in vitro testing, differences were also found 

in abrasivity with the same ranking of powered toothbrushes. 51 

Table 4. Force applied (van der Weijden et al.) 

Brush 

Force applied (g) 

Manual 273 

Powered brush 1 146 

Powered brush 2 119 

Rotary powered brush 96 


McLey et al., in comparing three powered brushes and a 

manual brush, found that a rotary powered brush was more 

effective at removing stains and simultaneously less abrasive 

than a powered brush (a or b), with the manual brush being 

the least abrasive (20 µg/minute of material removed versus 

35 µg/minute for the rotary powered brush, 57 µg/minute 

for another powered brush and 117 µg/minute for a third 

powered brush. In addition, stain removal was achieved at 

the 97.2% level (assessed spectrophotometrically) versus 

78.5% for a manual brush and 70.6% for one of the powered 

brushes. The rotary powered brush left the smoothest surface. 

52 Schemehorn and Zwart found a powered brush to 

be less abrasive on dentin than a standard ADA reference 

manual toothbrush, with a relative dentin abrasivity (RDA) 

of 16 compared to 100 for the manual brush 53 (Table 5). 

Table 5. Toothbrush abrasivity 

McLey et al. 

Manual Brush 

Rotary powered brush 

Powered brush (a) 

Powered brush (b) 

Schemehorn and Zwart 

Abrasivity 

20 µg/minute 




Abrasivity (RDA) 

Powered brush 16 

Manual Brush 100 

A manual toothbrush is controlled solely by the patient, 

and the patient must brush gently and use a soft 

bristle toothbrush to help prevent abrasion — particularly 

important for the exposed root surfaces in periodontal patients. 

This is also an important concept when interpreting 

in vitro test results; these are carried out under laboratory 

conditions and the applied force and technique used for 

manual brushing is well controlled, whereas in normal daily 

life this is not the case. Powered brushes are controlled 

mechanically, and while it is possible to apply more force 

momentarily, current powered brushes are designed to cut 

out if too much pressure is applied. 

Lack of abrasivity is particularly important for periodontal 

patients with exposed roots, since dentin and cementum 

are more easily abraded than enamel. Using a technique 

and brush that results in the least possible abrasion helps 

preserve tooth structure (Figure 5). It is also important 

for direct and indirect esthetic restorations to preserve the 

integrity and appearance of these and avoid abrasion and 

subsequent changes in shape, luster and staining. 

Figure 5. Advanced periodontal disease and abrasion 

With respect to gingival abrasions, a recent study found 

no differences between two powered toothbrushes and soft 

manual brushes but did find that a powered toothbrush removed 

significantly more plaque than a manual toothbrush. 54 

It should be noted that this study involved dental students 

well trained in the manual Bass tooth-brushing technique. 

Niemi et al., however, found more gingival abrasions using a 

V-shaped manual brush than a powered brush. 55 

Patient preference and selection considerations 

Given the issues of patient compliance addressed above, use 

of a powered brush offers a reduced time requirement for 

the same level of plaque efficacy and a “quicker” brushing 

experience and, additionally, depending on the powered 

brush selected, offers interdental cleaning where the patient 

may be noncompliant with manual interdental cleaning. 

Powered brushes with interdental cleaning heads offer 

a suitable compromise for such patients — they may be 

willing to “brush interdentally” even if they are noncompliant 

with flossing or using individual manual interdental 

brushes. Bader found that patient compliance with recall 

was 51%, while it was 92% for the patient group using rotary 

toothbrushes. 56 He also found that 67% of rotary powered 

brush users exhibited good oral hygiene scores, compared to 

25% of manual toothbrush users. 

Lack of abrasivity and reduced applied force favor powered 

brushes. 

Preventive care — caries and hypersensitivity 

In patients with periodontal disease, root exposure due to clinical 

attachment and bone loss ranges from minimal to a substantial 

length of the root being exposed, including the furcation 

areas of bicuspids and molars. Exposed roots are susceptible to 

caries due to the softness of dentin and any remaining overlying 

cementum (Figure 6). A recent study of patients under 

periodontal maintenance for between 11 and 22 years found 

that 82% had experienced root caries during the maintenance 

phase. 57 While individual experience was related to plaque 

levels, no relationship was found between coronal caries experience 

and root caries experience. Other studies have found root 

caries experience in periodontal maintenance patients of 88%. 58 


Figure 6. Root caries 

The root caries risk for periodontal patients is compounded 

by dentinal hypersensitivity. Such hypersensitivity 

results in painful episodes of sharp pain for the patient and 

can be a factor in noncompliance, since the root surface becomes 

painful upon contact with stimuli such as toothpaste 

or water (temperature) or the action of a toothbrush (touch) 

against the exposed dentin. Therefore, for both the prevention 

and treatment of pain and caries as well as patient compliance, 

the prevention and treatment of both conditions is 

an important consideration. 

A recent study of patients under periodontal 

maintenance found that 82% had experienced 

root caries during the maintenance phase. 

Relief from hypersensitivity can be obtained by using a 

number of techniques at home or in-office. At-home remedies 

include the use of dentifrices containing either potassium 

nitrate, potassium chloride or stannous fluoride. In-office 

techniques include the use of glutaraldehyde (Gluma), iontophoresis, 

lasers, amorphous calcium phosphate (ACP) and 

resins. Fluoride varnishes provide hypersensitivity relief and 

have the additional advantage of exposing the root surface to 

a very high concentration of fluoride for an extended period 

of time. Sodium fluoride varnish contains 5% sodium fluoride 

(22,600 ppm fluoride) and relieves hypersensitivity by 

forming globules that block the dentinal tubules — as well 

as initially providing relief through its temporary action as a 

physical barrier. At the same time the fluoride forms a protective 

layer that is available during acidogenic challenges. 

Consideration should be given to prescribing a prescription-only 

high-fluoride dentifrice containing 1.1% sodium 

fluoride for caries prevention. This has been shown to be 

effective in preventing and arresting root caries and offers 

the most fluoride available for home use. 59 Remineralization 

and the prevention of demineralization are also important to 

help prevent abrasion of the dentin root surface, as demineralized 

dentin has been shown to abrade more easily than 

sound dentin. 60 

Utilizing chemotherapeutics such as chlorhexidine 

gluconate to reduce microbial loads has also been shown 

to be effective as part of a preventive program. Applying 

0.12% chlorhexidine gluconate rinse by dipping the microfilaments 

of a rotary powered toothbrush in the rinse was 

found in one study to increase the efficacy of chlorhexidine 

gluconate rinse more than rinsing alone. 61 However, the 

side effect of tooth staining precludes its long-term use for 

most patients. 

Consideration should also be given to advising patients 

to chew sugar-free gum at least three times daily for an extended 

period of time, as this has been shown to reduce the 

incidence of caries. 62 Chewing gum can effectively combat 

a cariogenic challenge when used for at least 20 minutes 

immediately after eating or drinking. The use of a chewing 

gum containing casein phosphopeptide-amorphous calcium 

phosphate (CPP-ACP) has also been shown in in situ studies 

to help remineralize teeth. 63 

Summary 

Periodontal therapy when appropriately utilized results in 

good clinical outcomes. However, patients are often noncompliant. 

Consideration should be given to techniques and 

protocols that aid compliance. The use of powered brushes 

has been shown to be at least as effective as use of manual 

brushes in general, including in periodontal maintenance 

patients. The use of a powered brush offers the patient efficacy 

with reduced time involvement and, depending on 

the brush head, may enable interdental cleaning in patients 

who are non-compliant with manual interdental cleaning 

techniques. In addition, it has been found that the risk of 

tooth abrasion and the application of force may be reduced 

with the use of a powered brush. Continued periodontal 

improvements depend on regular periodontal maintenance, 

encompassing both regular in-office maintenance visits 

and adequate home care. Periodontal maintenance is imperative 

for patients following active therapy. In addition to 

thorough in-office assessment, treatment and education of 

patients, care should be taken to address each patient’s ability 

and willingness to perform daily oral hygiene as well as 

to address root caries risk and prevent unwanted sequelae. 

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powered toothbrushes (II). Effect on microbiological 

parameters. J Clin Periodontol. 2001;28(10):947–954. 

38 Warren P, Thompson M, Cugini M. Plaque removal 

efficacy of a novel manual toothbrush with MicroPulse 

bristles and an advanced split-head design. J Clin Dent. 

2007;18(2):49–54. 

39 Danser MM, Timmerman MF, Jzerman Y, Piscaer MI, 

van der Velden U, van der Weijden GA. Plaque removal 

with a novel manual toothbrush (X-Active) and the 

Braun Oral-B 3D Plaque Remover. J Clin Periodontol. 

2003;30(2):138–144. 

40 Tritten CB, Armitage GC. Comparison of a sonic and a 


manual toothbrush for efficacy in supragingival plaque 

removal and reduction of gingivitis. J Clin Periodontol. 

1996;23(7):641–648. 

41 Robinson PJ, Maddalozzo D, Breslin S. A six-month 

clinical comparison of the efficacy of the Sonicare and 

the Braun Oral-B electric toothbrushes on improving 

periodontal health in adult periodontitis patients. J Clin 

Dent. 1997;8(1 Spec No):4–9. 

42 Bader HI, Boyd RL. Comparative efficacy of a rotary 

and a sonic powered toothbrush on improving gingival 

health in treated adult periodontitis patients. Am J Dent. 

1999;12(3):143–147. 

43 Preber H, Ylipaa V, Bergstrom J, Ryden H. A comparative 

study of plaque removing efficiency using rotary electric 

and manual toothbrushes. Swed Dent J. 1991;15:229–234. 

44 Murray PA, Boyd RL, Robertson PB. Effect on 

periodontal status of rotary electric toothbrushes vs. 

manual toothbrushes during periodontal maintenance. 

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401. 

45 Bader H, Williams R. Clinical and laboratory evaluation 

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of two powered brushing instruments in furcations and 

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94. 

46 Harpenau L. Clinical comparison of plaque removal and 

gingival bleeding reduction by two different brush heads 

on a sonic toothbrush. J Clin Dent. 2000;11(2):29–34. 

47 Heasman PA, McCraken GI. Powered toothbrushes: a 

review of clinical trials. J Clin Periodontol. 1999;26:407– 

420. 

48 van der Weijden GA, Timmerman MF, Reijerse E, Snoek 

CM, van der Velden U. Toothbrushing force in relation to 

plaque removal. J Clin Periodontol. 1996;23(8):724–729. 

49 Wiegand A, Lemmrich F, Attin T. Influence of rotatingoscillating, 

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50 Boyd RL, McLey L, Zahradnik R. Clinical and laboratory 

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51 McLey L, Boyd RL, Sarker S. Clinical and laboratory 

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determination of relative abrasion of three powered 

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52 McLey L, Zahradnik R, Sarker S. Relative abrasiveness 

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instruments. IADR Abstract, 1994;#501. 

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Spec No:S19–20. 

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56 Bader HI. Ten-year retrospective observations of the 

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58 Ravald N, Birkhed D, Hamp SE. Root caries susceptibility 

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Clin Periodontol. 1993 Feb;20(2):124–129. 

59 Baysan A, et al. Reversal of primary root caries using 

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sonic and ultrasonic action of power 

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Periodontal Res. 2006 Jun;41(3):221–227. 

61 Bader HI, Williams RC. Chlorhexidine efficacy 

enhancement by local application with powered rotary 

device. IADR Abstract, 1992. 

62 van Loveren C. Sugar alcohols: what is the evidence for 

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Quintessence Int. Jan 2004;35(1):67–70. 

Author Profile 

William L. Balanoff, DDS, MS, FICD 

Dr. Balanoff received his dental degree 

from Northwestern University and his 

masters in craniofacial research from 

Nova Southeastern University. He is 

an adjunct assistant clinical professor 

at University of Tennessee and a former 

assistant clinical professor at Nova Southeastern 

University teaching postgraduate prosthodontics; 

specifically implant surgery and reconstruction to the 

prosthodontic residents. 

Dr. Balanoff is the owner of a multilocation fee for 

service group practice in the south Florida area. He is on 

staff at Broward General Hospital and North Broward 

Hospital with privileges for implant surgery and reconstruction. 

Dr. Balanoff is on the editorial board of Compendium 

and is a consultant for Zila Pharmaceuticals. 

Best of all he has three wonderful children and an 

incredible wife who allows him to live his dreams. 

Disclaimer 

The author of this course is a speaker for Zila Pharmaceuticals, 

Inc. 

Reader Feedback 

We encourage your comments on this or any PennWell course. 

For your convenience, an online feedback form is available at 

www.ineedce.com. 


Online Completion 

Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the 

online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your 

answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed 

and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page. 

Questions 

1. Periodontal bacteria must be present 11. It has been estimated that most 22. Increased efficacy of plaque removal 

for the _________ of periodontal 

patients brush for _________. 

in a reduced time is an important consideration 

given _________. 

disease. 

a. thirty seconds 

a. onset 

b. forty-five seconds 

a. brush head wear and fatigue 

b. absences 

c. one minute 

b. patient compliance issues 

c. progression 

d. two minutes 

c. memory lapse 

d. a and c 

12. Less than ______ of patients floss daily. d. all of the above 

2. The overall objectives of periodontal 

a. 50% 

23. Powered brush heads with rotating or 

therapy include _________. 

b. 35% 

spiraling filaments are _________ for 

a. to halt disease progression 

c. 15% 

b. to reduce pocket depths 

d. 10% 

interdental cleaning. 

a. ineffective 

c. to obtain clinical attachment gains 

13. Erratic patient compliance has been b. effective 

d. all of the above 

found to be associated with _________ c. not recommended 

3. Mature biofilm (plaque) contains 

in periodontal maintenance patients. d. not in existence 

_________. 

a. lower levels of oral cancer 

a. high levels of diphtheroids 

b. lower levels of root caries 

24. _________ is a design feature that aids 

b. high levels of periodontal bacteria in a wellorganized 

matrix 

d. none of the above 

a. An interdental brush head shape 

c. higher levels of root caries 

interdental cleaning. 

b. Active brush tips 

c. high levels of periodontal bacteria in a poorlyorganized 

matrix 

14. The goal of daily oral hygiene procedures 

for periodontal maintenance is to 

c. A round brush head shape 

d. a and c 

d. a and b 

_________. 

4. Periodontal bacteria can return to 

a. prevent biofilm from forming 

25. _________ et al. found that more force 

pretreatment levels in as little as 

b. remove dental biofilm before it matures 

was applied with use of a manual brush 

_________. 

c. remove dental biofilm after it matures 

than with use of a powered brush. 


a. van der Veen 

a. several days 

b. several weeks 

15. Migrating bacteria can _________. 

b. van der Leijden 

c. several months 

a. shift from supragingival plaque to subgingival c. van der Weijden 


sites 


b. shift to different periodontal sites 

26. Powered brushes with interdental 

5. Patients who do not receive regular periodontal 

maintenance have _________ d. a and b 

patients who are noncompliant with 

c. cause paratitis 

cleaning heads offer _________ for 

than those who receive such care. 

16. The accepted home oral hygiene care manual interdental cleaning. 

a. fewer teeth with furcation involvement 

regimen is _________. 

a. nothing 

b. shallower probing depths and more tooth loss 

a. use of a toothbrush (manual or powered) 

c. greater probing depths and more tooth loss 

b. an unsuitable compromise 

b. use of a tongue irrigator 


c. a suitable compromise 

c. use of either floss or interdental brushes 


6. An _________ biofilm cannot be 

d. a and c 

effectively removed by home care. 

27. Lack of abrasivity while brushing is 

17. _________ brushes have been found to 

a. early supragingival 

particularly important for periodontal 

be effective in trials. 

b. established supragingival 

patients _________. 

a. Rotary powered 

c. early subgingival 

a. with exposed roots, since dentin and cementum 

b. Powered 

d. established subgingival 

are more difficult to abrade than enamel 

c. Sonic 

b. with exposed roots, since dentin and cementum 

are more easily abraded than enamel 

7. In-office periodontal maintenance 


should include _________. 

18. The rotary powered brush removes 

c. with sialitis 

a. a full evaluation and examination of the hard plaque through _________. 


and soft tissues 

a. the physical action of the brush head against 

b. thorough removal of calculus and biofilm 

28. A recent study of patients under 

the tooth 

c. an assessment of the patient’s oral care and the b. fluid dynamics 

periodontal maintenance for between 

adequacy of his or her oral hygiene 

c. hydrodynamics 

11 and 22 years found that _________ 


d. a and b 

had experienced root caries during the 

8. One of the main issues in periodontal 

maintenance phase. 

19. The sonic powered brush removes 

maintenance is _________. 

a. 65% 

plaque through _________. 

a. finding appointment time for maintenance 

b. 73% 

a. the physical action of the brush head against 

visits 

the tooth 

c. 82% 

b. patient compliance 

b. fluid dynamics 

d. 91% 

c. the availability of scaler units 

c. hydrodynamics 

29. Fluoride varnish _________. 


d. a and b 

a. provides hypersensitivity relief 

9. One recent retrospective study found 20. _________ found that improvements b. exposes the root surface to a very high 

that _________ of patients were noncompliant 

with maintenance therapy, with a sonic brush compared to a rotary period of time 

in periodontal health were superior 

concentration of fluoride for an extended 

while another five-year study found powered brush. 

c. exposes the root surface to a very high 

_________ to be noncompliant. 

a. Robinson et al. 

concentration of fluoride for a few minutes 

a. 25%; 38% 

b. Haraldsen et al. 

d. a and b 

b. 35%; 42.6% 

c. Boyd et al. 

30. Remineralization and the prevention 

c. 45%; 45.5% 


of demineralization of the root surface 

d. 55%; 46.8% 

21. Bader and Boyd found use of a 

_________. 

10. Once patients are not in regular 

rotary powered brush over a period of a. can be aided by the use of a 1.1% sodium 

contact with dental professionals, their _________ significantly more effective 

fluoride dentifrice 

_________. 

than use of a sonic brush. 

b. are important to help prevent abrasion of the 

a. compliance decreases 

a. 10 weeks 

dentin root surface 

b. motivation decreases 

b. 12 weeks 

c. are not significant factors for periodontal 

c. motivation increases 

c. 14 weeks 

patients 

d. a and b 

d. 16 weeks 

d. a and b 


ANSWER SHEET 

Periodontal Maintenance in Disease Prevention 

THIS COURSE ONLY AVAILABLE ONLINE 

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all 

information. 3) Complete test online. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete 

the Course Evaluation online. For Questions Call 216.398.7822 

Educational Objectives 

1. List and describe the rationale for periodontal maintenance and the components involved in a periodontal maintenance 

program. 

2. List and describe patient compliance factors and the impact of non-compliance on periodontal outcomes. 

For iMMediate results, go to 

www.ineedce.com 

The cost of this course is $49.00 

3. List the considerations involved in the selection and recommendation of oral care devices for patients. 

4. List and describe the risk for root caries and dentinal sensitivity in patients following periodontal therapy, prevention and 

treatment options. 

Course Evaluation 

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 

1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No 

Objective #2: Yes No Objective #4: Yes No 

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 

7. Was the overall administration of the course effective? 5 4 3 2 1 0 

8. Do you feel that the references were adequate? Yes No 

9. Would you participate in a similar program on a different topic? Yes No 

10. If any of the continuing education questions were unclear or ambiguous, please list them. 

___________________________________________________________________ 

11. Was there any subject matter you found confusing? Please describe. 

___________________________________________________________________ 

___________________________________________________________________ 

12. What additional continuing dental education topics would you like to see? 

___________________________________________________________________ 

___________________________________________________________________ 

AGD Code 490, 149 

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. 

AUTHOR DISCLAIMER 

The author of this course has lectured for the sponsors or the providers of the 

unrestricted educational grant for this course. 

SPONSOR/PROVIDER 

This course was made possible through an unrestricted educational grant. No 

manufacturer or third party has had any input into the development of course content. 

All content has been derived from references listed, and or the opinions of clinicians. 

Please direct all questions pertaining to PennWell or the administration of this course to 

Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com. 

COURSE EVALUATION and PARTICIPANT FEEDBACK 

We encourage participant feedback pertaining to all courses. Please be sure to complete the 

survey included with the course. Please e-mail all questions to: macheleg@pennwell.com. 

INSTRUCTIONS 

All questions should have only one answer. This course can only be taken online. 

Participants will receive confirmation of passing once the test is taken online. 

Verification forms will be mailed within two weeks after taking an examination. 

EDUCATIONAL DISCLAIMER 

The opinions of efficacy or perceived value of any products or companies mentioned 

in this course and expressed herein are those of the author(s) of the course and do not 

necessarily reflect those of PennWell. 

Completing a single continuing education course does not provide enough information 

to give the participant the feeling that s/he is an expert in the field related to the course 

topic. It is a combination of many educational courses and clinical experience that 

allows the participant to develop skills and expertise. 

COURSE CREDITS/COST 

All participants scoring at least 70% on the examination will receive a verification 

form verifying 2 CE credits. The formal continuing education program of this sponsor 

is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for 

current term of acceptance. Participants are urged to contact their state dental boards 

for continuing education requirements. PennWell is a California Provider. The California 

Provider number is 3274. The cost for courses ranges from $49.00 to $110.00. 

Many PennWell self-study courses have been approved by the Dental Assisting National 

Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet 

DANB’s annual continuing education requirements. To find out if this course or any other 

PennWell course has been approved by DANB, please contact DANB’s Recertification 

Department at 1-800-FOR-DANB, ext. 445. 

RECORD KEEPING 

PennWell maintains records of your successful completion of any exam. Please contact our 

offices for a copy of your continuing education credits report. This report, which will list 

all credits earned to date, will be generated and mailed to you within five business days 

of receipt. 

CANCELLATION/REFUND POLICY 

Any participant who is not 100% satisfied with this course can request a full refund by 

contacting PennWell in writing. 

© 2011 by the Academy of Dental Therapeutics and Stomatology, a division 

of PennWell 

ROTO0108DE 

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