Periodontal Maintenance in Disease Prevention - IneedCE.com
Periodontal Maintenance in Disease Prevention - IneedCE.com
Periodontal Maintenance in Disease Prevention - IneedCE.com
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Earn<br />
2 CE credits<br />
This course was<br />
written for dentists,<br />
dental hygienists,<br />
and assistants.<br />
<strong>Periodontal</strong> <strong>Ma<strong>in</strong>tenance</strong><br />
<strong>in</strong> <strong>Disease</strong> <strong>Prevention</strong><br />
A Peer-Reviewed Publication<br />
Written by William L. Balanoff, DDS, MS, FICD<br />
Publication date: January 2008<br />
Review date: February 2011<br />
Expiry date: January 2014<br />
Go Green, Go Onl<strong>in</strong>e to take your course<br />
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.<br />
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contact<strong>in</strong>g PennWell <strong>in</strong> writ<strong>in</strong>g.
Educational Objectives<br />
Upon <strong>com</strong>pletion of this course, the cl<strong>in</strong>ician will be able to<br />
do the follow<strong>in</strong>g:<br />
1. List and describe the rationale for periodontal ma<strong>in</strong>tenance<br />
and the <strong>com</strong>ponents <strong>in</strong>volved <strong>in</strong> a periodontal<br />
ma<strong>in</strong>tenance program.<br />
2. List and describe patient <strong>com</strong>pliance factors and<br />
the impact of non<strong>com</strong>pliance on periodontal<br />
out<strong>com</strong>es.<br />
3. List the considerations <strong>in</strong>volved <strong>in</strong> the selection and<br />
re<strong>com</strong>mendation of oral care devices for patients.<br />
4. List and describe the risk for root caries and dent<strong>in</strong>al<br />
sensitivity <strong>in</strong> patients follow<strong>in</strong>g periodontal therapy,<br />
as well as prevention and treatment options.<br />
Abstract<br />
<strong>Periodontal</strong> disease occurs <strong>in</strong> the presence of pathogenic bacteria<br />
— periodontopathogens or periodontal bacteria — <strong>in</strong> a susceptible<br />
host. The overall objectives of periodontal therapy are<br />
to halt disease progression, reduce pocket depths and, ideally,<br />
obta<strong>in</strong> cl<strong>in</strong>ical attachment ga<strong>in</strong>s. Follow<strong>in</strong>g active periodontal<br />
therapy, periodontal ma<strong>in</strong>tenance is key for long-term positive<br />
cl<strong>in</strong>ical out<strong>com</strong>es, <strong>in</strong>volv<strong>in</strong>g both <strong>in</strong>-office ma<strong>in</strong>tenance and<br />
meticulous home care. Professional care is required to remove<br />
subg<strong>in</strong>gival biofilm and deposits, and to prevent periodontal<br />
disease progression. The goal of daily oral hygiene procedures<br />
for periodontal ma<strong>in</strong>tenance is to remove dental biofilm before<br />
it matures so as to prevent the development of g<strong>in</strong>givitis and a<br />
mature subg<strong>in</strong>gival plaque. Consideration should be given to<br />
techniques and protocols that aid <strong>com</strong>pliance, and care should<br />
be taken to address each patient’s ability and will<strong>in</strong>gness to<br />
perform daily oral hygiene as well as to address root caries risk<br />
and prevent unwanted sequelae.<br />
Introduction<br />
<strong>Periodontal</strong> disease occurs <strong>in</strong> the presence of pathogenic<br />
bacteria — periodontopathogens or periodontal bacteria<br />
— <strong>in</strong> a susceptible host. As periodontal disease progresses,<br />
cl<strong>in</strong>ical attachment loss and bone loss occur. This leads to the<br />
development of periodontal pockets of <strong>in</strong>creas<strong>in</strong>g depth and<br />
<strong>com</strong>plexity <strong>in</strong> untreated periodontal disease, add<strong>in</strong>g to the<br />
difficulties of treatment and periodontal ma<strong>in</strong>tenance and <strong>in</strong>creas<strong>in</strong>g<br />
the patient’s caries risk due to root exposure (Figure<br />
1). Advanced disease is found <strong>in</strong> up to 15% of adults, and the<br />
majority of people experience g<strong>in</strong>givitis or moderate levels of<br />
periodontal disease. 1<br />
It is known that it is ma<strong>in</strong>ly the host response, <strong>in</strong>clud<strong>in</strong>g<br />
immune and <strong>in</strong>flammatory responses, that determ<strong>in</strong>es the<br />
onset and progression of periodontal disease. This <strong>in</strong> turn<br />
is <strong>in</strong>fluenced by risk factors that <strong>in</strong>clude smok<strong>in</strong>g, poor oral<br />
hygiene, gender, hormones and genetics. 2,3,4 Nonetheless,<br />
periodontal bacteria must be present for the onset and progression<br />
of periodontal disease; <strong>in</strong> their absence periodontal<br />
disease would not occur.<br />
Figure 1. <strong>Periodontal</strong> disease progression<br />
<strong>Periodontal</strong> Therapy<br />
The overall objectives of periodontal therapy are to halt disease<br />
progression, reduce pocket depths and, ideally, obta<strong>in</strong><br />
cl<strong>in</strong>ical attachment ga<strong>in</strong>s. The underly<strong>in</strong>g goals <strong>in</strong> meet<strong>in</strong>g<br />
these objectives are to thoroughly remove periodontal bacteria<br />
and biofilm, debris, calculus and endotox<strong>in</strong>s and the<br />
root surface must be <strong>in</strong>tact, free of calculus and <strong>com</strong>patible<br />
with oral hygiene goals. Mature biofilm (plaque) conta<strong>in</strong>s<br />
high levels of periodontal bacteria <strong>in</strong> a well-organized matrix,<br />
and its disruption and removal are essential. Ensur<strong>in</strong>g that<br />
the root surfaces are smooth avoids provid<strong>in</strong>g a rough site<br />
for adhesion and recolonization by periodontal bacteria and<br />
the development of subg<strong>in</strong>gival biofilm follow<strong>in</strong>g treatment.<br />
The standard treatment for periodontal disease is nonsurgical<br />
scal<strong>in</strong>g and root plan<strong>in</strong>g. In specific cases, the cl<strong>in</strong>ician may<br />
determ<strong>in</strong>e that surgical treatment is required to access specific<br />
areas and adequately treat advanced or deep periodontal<br />
pockets. The overall objectives rema<strong>in</strong> the same whether<br />
nonsurgical or surgical therapy is performed.<br />
<strong>Periodontal</strong> therapy, when properly performed, is effective<br />
at remov<strong>in</strong>g subg<strong>in</strong>gival calculus, biofilm, debris and endotox<strong>in</strong>s<br />
and at reduc<strong>in</strong>g subg<strong>in</strong>gival bacterial levels. The cont<strong>in</strong>ued<br />
or renewed presence of high levels of periodontal bacteria and<br />
<strong>com</strong>plexes after active periodontal therapy negatively <strong>in</strong>fluences<br />
treatment out<strong>com</strong>es, and periodontal bacteria can return to<br />
pretreatment levels <strong>in</strong> months or <strong>in</strong> as little as several days. 5,6,7,8<br />
<strong>Periodontal</strong> bacteria can return to pretreatment<br />
levels <strong>in</strong> as little as several days.<br />
Follow<strong>in</strong>g active periodontal therapy, periodontal ma<strong>in</strong>tenance<br />
is required throughout the patient’s life. In its absence,<br />
active periodontal disease is likely to recur, with further cl<strong>in</strong>ical<br />
attachment loss and bone loss. Patients who do not receive<br />
regular periodontal ma<strong>in</strong>tenance have greater prob<strong>in</strong>g depths<br />
and more tooth loss than those who receive such care. 9,10<br />
<strong>Periodontal</strong> ma<strong>in</strong>tenance is key for long-term positive cl<strong>in</strong>ical<br />
out<strong>com</strong>es follow<strong>in</strong>g periodontal therapy, <strong>in</strong>volv<strong>in</strong>g both <strong>in</strong>office<br />
ma<strong>in</strong>tenance and meticulous home care to effectively<br />
remove plaque on a daily basis.<br />
2 www.<strong>in</strong>eedce.<strong>com</strong>
<strong>Periodontal</strong> ma<strong>in</strong>tenance is key for long-term<br />
positive cl<strong>in</strong>ical out<strong>com</strong>es<br />
In-office periodontal ma<strong>in</strong>tenance<br />
In-office periodontal ma<strong>in</strong>tenance should <strong>in</strong>clude a full evaluation<br />
and exam<strong>in</strong>ation of the hard and soft tissues. Thorough<br />
removal of calculus and biofilm, <strong>in</strong>clud<strong>in</strong>g scal<strong>in</strong>g and root<br />
plan<strong>in</strong>g at selected sites as <strong>in</strong>dicated, is required (Table 1).<br />
If an established subg<strong>in</strong>gival biofilm is present, this cannot<br />
be effectively removed by home care. Professional care is<br />
required to remove subg<strong>in</strong>gival biofilm and to prevent periodontal<br />
disease progression. 11 The <strong>com</strong>b<strong>in</strong>ation of periodic<br />
professional care and home care to remove plaque is effective<br />
<strong>in</strong> substantially reduc<strong>in</strong>g the level of periodontopathogens<br />
<strong>in</strong> periodontal pockets as well as the proportion consist<strong>in</strong>g of<br />
Porphyromonas g<strong>in</strong>givalis. 12 Patient <strong>com</strong>pliance is associated<br />
with lower tooth loss dur<strong>in</strong>g periodontal ma<strong>in</strong>tenance.<br />
Table 1. In-office periodontal ma<strong>in</strong>tenance<br />
Full evaluation of hard and soft tissues<br />
Thorough removal of calculus and biofilm<br />
Scal<strong>in</strong>g and root plan<strong>in</strong>g at sites as <strong>in</strong>dicated<br />
Assessment of adequacy of patient’s oral hygiene<br />
Patient education and motivation<br />
Re<strong>in</strong>forcement of good oral hygiene habits<br />
The standard of care for visits for periodontal ma<strong>in</strong>tenance<br />
is at least four times per year. This can be adjusted based on<br />
the <strong>in</strong>dividual patient — less often for patients who show no<br />
disease recurrence or progression and demonstrate effective<br />
home care; more often for patients who perform home care<br />
<strong>in</strong>effectively or are non<strong>com</strong>pliant, have predispos<strong>in</strong>g risk<br />
factors for progression (such as be<strong>in</strong>g a smoker or immuno<strong>com</strong>promised),<br />
or present with recurrence. Regular <strong>in</strong>-office<br />
ma<strong>in</strong>tenance appo<strong>in</strong>tments enable the cl<strong>in</strong>ician to assess the<br />
current status of the patient’s oral care and the adequacy of his<br />
or her oral hygiene. On an ongo<strong>in</strong>g basis, both professional<br />
care and adequate daily oral hygiene are required to remove<br />
suprag<strong>in</strong>gival and subg<strong>in</strong>gival plaque. The periodontal ma<strong>in</strong>tenance<br />
program must meet the <strong>in</strong>dividual patient’s needs. 13,14<br />
On an ongo<strong>in</strong>g basis, both professional care and<br />
adequate daily oral hygiene are required to<br />
remove suprag<strong>in</strong>gival and subg<strong>in</strong>gival plaque.<br />
Patient <strong>com</strong>pliance and motivation<br />
One of the ma<strong>in</strong> issues <strong>in</strong> periodontal ma<strong>in</strong>tenance is<br />
patient <strong>com</strong>pliance, a well-recognized problem for all<br />
oral hygiene regimens, whether <strong>in</strong> periodontally <strong>in</strong>volved<br />
patients or not. One recent retrospective study found that<br />
55% of patients were non<strong>com</strong>pliant with ma<strong>in</strong>tenance<br />
therapy, 15 while an earlier five-year assessment found 46.8%<br />
of patients were non<strong>com</strong>pliant, with older patients (over 40<br />
years of age) be<strong>in</strong>g more <strong>com</strong>pliant than younger patients. 16<br />
Another study found that 28% of patients did not <strong>com</strong>ply<br />
with their first visit for periodontal ma<strong>in</strong>tenance. 17 Patients<br />
who participate <strong>in</strong> oral hygiene studies and receive tra<strong>in</strong><strong>in</strong>g<br />
<strong>in</strong> oral hygiene regimens have been found to revert to old<br />
habits after the study is <strong>com</strong>pleted, even when they reta<strong>in</strong><br />
the acquired skill set required to adequately perform oral<br />
hygiene. 18<br />
Once patients are not <strong>in</strong> regular contact with dental<br />
professionals, their <strong>com</strong>pliance and motivation decrease, 19<br />
further underscor<strong>in</strong>g the need for regular periodontal<br />
ma<strong>in</strong>tenance recare appo<strong>in</strong>tments to aid <strong>com</strong>pliance. These<br />
visits provide an opportunity for patient motivation and<br />
re<strong>in</strong>forcement of good daily oral hygiene habits. 20 Patients<br />
reta<strong>in</strong> only a proportion of what they hear and are taught,<br />
and every <strong>in</strong>dividual learns at a different speed. Repeated<br />
<strong>in</strong>struction and re<strong>in</strong>forcement at regular recall appo<strong>in</strong>tments<br />
are <strong>in</strong>dicated to help ensure that patients cont<strong>in</strong>ue<br />
their oral hygiene protocol. It has been estimated that most<br />
patients brush for one m<strong>in</strong>ute, an <strong>in</strong>adequate length of time<br />
for thorough plaque removal. 21 Respondents to surveys<br />
have <strong>in</strong>dicated that less than 10% of patients floss daily and<br />
more than half of all patients never floss. 22,23<br />
Table 2. Non-<strong>com</strong>pliance factors<br />
Irregular contact with dental professional<br />
Lack of understand<strong>in</strong>g and retention of <strong>in</strong>formation<br />
Lack of motivation to perform oral hygiene procedures<br />
Lack of motivation to spend enough time on oral hygiene<br />
Revert<strong>in</strong>g to old habits<br />
Novelty effect of a new oral care device wears off<br />
It has also been demonstrated that patients experience<br />
a novelty effect with oral hygiene protocols and oral care<br />
devices. For <strong>in</strong>stance, it has been shown that when a new<br />
powered toothbrush was re<strong>com</strong>mended and selected for<br />
patients, after 12 months only 50% of the patients were still<br />
us<strong>in</strong>g the powered brush. 24 Giv<strong>in</strong>g <strong>in</strong>-office <strong>in</strong>structions<br />
with a new brush — rather than ask<strong>in</strong>g a patient to buy one<br />
<strong>in</strong> a store and use it — has also been found to be effective <strong>in</strong><br />
re<strong>in</strong>forc<strong>in</strong>g the home care oral hygiene message and technique.<br />
Erratic patient <strong>com</strong>pliance (non<strong>com</strong>pliance) has<br />
also been found to be associated with higher levels of root<br />
caries <strong>in</strong> periodontal ma<strong>in</strong>tenance patients. 25<br />
Giv<strong>in</strong>g <strong>in</strong>-office <strong>in</strong>structions with a new<br />
brush has been found to be effective <strong>in</strong><br />
re<strong>in</strong>forc<strong>in</strong>g home care oral hygiene.<br />
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Home Care for <strong>Periodontal</strong> <strong>Ma<strong>in</strong>tenance</strong><br />
The goal of daily oral hygiene procedures for periodontal<br />
ma<strong>in</strong>tenance is to remove dental biofilm before it matures so<br />
as to prevent the development of g<strong>in</strong>givitis and a mature subg<strong>in</strong>gival<br />
plaque. A further home care goal is caries prevention.<br />
Young, immature dental plaque conta<strong>in</strong>s ma<strong>in</strong>ly grampositive<br />
streptococci, and the mature subg<strong>in</strong>gival biofilm<br />
takes from 3 to 12 weeks to develop <strong>in</strong>to a well-differentiated<br />
layer conta<strong>in</strong><strong>in</strong>g ma<strong>in</strong>ly periodontopathogens <strong>in</strong>clud<strong>in</strong>g Porphyromonas<br />
g<strong>in</strong>givalis and Treponema denticola. 26,27,28 In addition,<br />
migrat<strong>in</strong>g bacteria can shift from suprag<strong>in</strong>gival plaque<br />
to subg<strong>in</strong>gival sites as well as to different periodontal sites, 29<br />
further highlight<strong>in</strong>g the importance of daily suprag<strong>in</strong>gival<br />
plaque removal. The accepted home oral hygiene care regimen<br />
is use of a toothbrush (manual or powered) plus either<br />
floss or <strong>in</strong>terdental brushes. In the absence of floss<strong>in</strong>g, <strong>in</strong>vestigators<br />
<strong>in</strong> one study found that a reduction <strong>in</strong> bleed<strong>in</strong>g sites<br />
of only 35% was obta<strong>in</strong>ed with brush<strong>in</strong>g alone. 30 One study<br />
found that manual <strong>in</strong>terdental brushes were more effective<br />
than floss for patients <strong>in</strong> periodontal ma<strong>in</strong>tenance; 31 a second<br />
study concurred with these f<strong>in</strong>d<strong>in</strong>gs and found <strong>in</strong>terdental<br />
brushes to be more effective even before thorough professional<br />
debridement, 32 while a third study found floss and <strong>in</strong>terdental<br />
brushes to be equally effective. 33 Electric <strong>in</strong>terdental<br />
devices (Humm<strong>in</strong>gbird, Oral B; Interclean) have also been<br />
found to be as effective as floss. 34,35 It has also been observed<br />
that patients experience more problems with dental floss than<br />
with <strong>in</strong>terdental brushes. 36<br />
Table 3. Home care objectives<br />
Remove plaque before it matures<br />
Prevent development of g<strong>in</strong>givitis<br />
Prevent development of mature subg<strong>in</strong>gival plaque<br />
Manual and powered toothbrushes<br />
Manual and powered brushes have both been found to be<br />
effective. An extensive number of trials and studies have<br />
been conducted <strong>com</strong>par<strong>in</strong>g manual and power brush<strong>in</strong>g,<br />
as well as different power brushes, us<strong>in</strong>g a variety of protocols.<br />
Powered brushes <strong>in</strong>clude rotary, sonic and rotary/<br />
oscillat<strong>in</strong>g powered brushes (Figure 2), and all have been<br />
found to be effective <strong>in</strong> trials.<br />
Haffajee et al. found both powered and manual toothbrushes<br />
effective over a six-month period <strong>in</strong> reduc<strong>in</strong>g<br />
the levels of bacteria <strong>in</strong> periodontal pockets when used<br />
to remove suprag<strong>in</strong>gival plaque (and simultaneously remov<strong>in</strong>g<br />
periodontopathogens present suprag<strong>in</strong>givally). 37<br />
Warren et al., however, found that this depended on<br />
toothbrush design and found that a novel-design manual<br />
toothbrush was as effective as two powered toothbrushes<br />
<strong>in</strong> remov<strong>in</strong>g plaque when used <strong>in</strong> the participants’ normal<br />
manner (i.e., without additional tra<strong>in</strong><strong>in</strong>g). 38 Another study<br />
<strong>in</strong> which participants received five weeks of professional<br />
oral hygiene tra<strong>in</strong><strong>in</strong>g found no differences <strong>in</strong> plaque removal<br />
efficacy between use of a manual toothbrush and a<br />
powered toothbrush. 39<br />
Sonic brushes have been found to be more effective than<br />
manual brushes, especially <strong>in</strong> difficult-to-reach areas, for<br />
plaque removal. 40 The sonic brush removes plaque through<br />
the physical action of the bristles vibrat<strong>in</strong>g aga<strong>in</strong>st the<br />
tooth surface as well as through fluid dynamics created by<br />
the ultra high speed of the sonic brush. The fluid dynamics<br />
result <strong>in</strong> the creation of m<strong>in</strong>ute bubbles that are propelled<br />
aga<strong>in</strong>st the tooth and help to remove plaque. Rob<strong>in</strong>son et<br />
al. found that use of either a sonic brush or a rotary/oscillat<strong>in</strong>g<br />
brush improved oral health <strong>in</strong> periodontal patients,<br />
and that the improvements with the sonic brush were superior.<br />
41 In contrast, Bader and Boyd found use of a rotary<br />
Figure 2. Powered brushes<br />
Rotary Oscillat<strong>in</strong>g Sonic<br />
4 www.<strong>in</strong>eedce.<strong>com</strong>
ush over a period of 12 weeks significantly more effective<br />
than a sonic brush <strong>in</strong> reduc<strong>in</strong>g plaque, the bleed<strong>in</strong>g <strong>in</strong>dex<br />
and the g<strong>in</strong>gival <strong>in</strong>dex. 42 A small study <strong>in</strong>volv<strong>in</strong>g dental<br />
hygiene students showed that a rotary powered brush was<br />
significantly more effective at visual plaque removal than<br />
a manual brush and removed 75% of the plaque present <strong>in</strong><br />
30 seconds versus 15 seconds. 43 While care should be taken<br />
<strong>in</strong> extrapolat<strong>in</strong>g data gathered from cl<strong>in</strong>ical students to<br />
the general population, <strong>in</strong> this case such an extrapolation<br />
would seem to be valid s<strong>in</strong>ce expertise could be expected<br />
to improve manual brush efficacy and thereby reduce the<br />
time required for a given level of plaque removal. Given<br />
patient <strong>com</strong>pliance issues discussed earlier, <strong>in</strong>creased efficacy<br />
of plaque removal <strong>in</strong> a reduced time is an important<br />
consideration when re<strong>com</strong>mend<strong>in</strong>g an oral hygiene protocol<br />
and brush to patients. In general, powered brushes<br />
offer an opportunity to accelerate clean<strong>in</strong>g for <strong>in</strong>adequate<br />
brushers.<br />
Interdental clean<strong>in</strong>g<br />
Most periodontal disease beg<strong>in</strong>s <strong>in</strong> the col area <strong>in</strong>terdentally,<br />
where manual brush<strong>in</strong>g alone has been proven<br />
<strong>in</strong>effective. Therefore, any oral hygiene regimen must<br />
adequately address <strong>in</strong>terdental clean<strong>in</strong>g. In contrast to<br />
manual brushes, powered brushes have been found to be<br />
effective at clean<strong>in</strong>g <strong>in</strong>terdentally as well as <strong>in</strong> furcation<br />
areas. When <strong>com</strong>pared to the <strong>com</strong>b<strong>in</strong>ed use of a manual<br />
toothbrush, floss and toothpicks, Murray et al. found a<br />
rotary brush equally effective at controll<strong>in</strong>g g<strong>in</strong>givitis<br />
<strong>in</strong> study patients over a period of 12 months and equally<br />
effective at produc<strong>in</strong>g significant reductions <strong>in</strong> the levels<br />
of periodontopathic bacteria. 44 In <strong>com</strong>par<strong>in</strong>g a rotary powered<br />
brush with another powered brushes, Bader and Williams<br />
found the rotary brush to be significantly superior<br />
<strong>in</strong>terproximally and at furcations. 45<br />
Figure 3. Powered brush heads<br />
While cl<strong>in</strong>ical results vary <strong>in</strong> different studies, powered<br />
brush heads are typically smaller and more <strong>com</strong>pact than<br />
manual brush heads, aid<strong>in</strong>g access to difficult-to-reach areas.<br />
Patients <strong>in</strong> one study of sonic brushes reported f<strong>in</strong>d<strong>in</strong>g<br />
smaller brush heads preferable to larger brush heads. 46 In<br />
addition, recent designs have improved <strong>in</strong>terdental clean<strong>in</strong>g<br />
us<strong>in</strong>g a powered brush — an important consideration<br />
given patients’ unwill<strong>in</strong>gness to use <strong>in</strong>terdental cleaners (<strong>in</strong><br />
particular, floss). Brush heads with rotat<strong>in</strong>g or spiral<strong>in</strong>g filaments<br />
are effective for <strong>in</strong>terdental clean<strong>in</strong>g, and other design<br />
features that aid this <strong>in</strong>clude specific brush head shapes and<br />
active brush tips that reach <strong>in</strong>to <strong>in</strong>terdental sites. 47<br />
Figure 4. Rotary powered brush head <strong>in</strong>terdentally<br />
Force and abrasion<br />
Applied force and abrasion are factors when consider<strong>in</strong>g<br />
toothbrush selection. Powered brushes have been <strong>com</strong>pared<br />
<strong>in</strong> several studies to manual brushes for applied force and<br />
abrasivity. Van der Weijden et al. also studied brush<strong>in</strong>g forces<br />
and found that more force was applied us<strong>in</strong>g a manual toothbrush<br />
than a powered toothbrush and that the applied force<br />
depended on the brush used (Table 4). 48 In one <strong>in</strong> vitro study,<br />
sonic, rotary/oscillat<strong>in</strong>g and ultrasonic brushes were all found<br />
to abrade both sound and dem<strong>in</strong>eralized dent<strong>in</strong> more than a<br />
manual brush. 49 Boyd et al. studied the forces applied us<strong>in</strong>g a<br />
rotary powered brush, two other powered brushes or a manual<br />
toothbrush and regular dentifrice <strong>in</strong> vivo. The manual toothbrush<br />
was found to result <strong>in</strong> the most applied pressure and the<br />
rotary powered brush the least applied pressure. 50 In a similar<br />
<strong>com</strong>parison us<strong>in</strong>g <strong>in</strong> vitro test<strong>in</strong>g, differences were also found<br />
<strong>in</strong> abrasivity with the same rank<strong>in</strong>g of powered toothbrushes. 51<br />
Table 4. Force applied (van der Weijden et al.)<br />
Brush<br />
Force applied (g)<br />
Manual 273<br />
Powered brush 1 146<br />
Powered brush 2 119<br />
Rotary powered brush 96<br />
www.<strong>in</strong>eedce.<strong>com</strong> 5
McLey et al., <strong>in</strong> <strong>com</strong>par<strong>in</strong>g three powered brushes and a<br />
manual brush, found that a rotary powered brush was more<br />
effective at remov<strong>in</strong>g sta<strong>in</strong>s and simultaneously less abrasive<br />
than a powered brush (a or b), with the manual brush be<strong>in</strong>g<br />
the least abrasive (20 µg/m<strong>in</strong>ute of material removed versus<br />
35 µg/m<strong>in</strong>ute for the rotary powered brush, 57 µg/m<strong>in</strong>ute<br />
for another powered brush and 117 µg/m<strong>in</strong>ute for a third<br />
powered brush. In addition, sta<strong>in</strong> removal was achieved at<br />
the 97.2% level (assessed spectrophotometrically) versus<br />
78.5% for a manual brush and 70.6% for one of the powered<br />
brushes. The rotary powered brush left the smoothest surface.<br />
52 Schemehorn and Zwart found a powered brush to<br />
be less abrasive on dent<strong>in</strong> than a standard ADA reference<br />
manual toothbrush, with a relative dent<strong>in</strong> abrasivity (RDA)<br />
of 16 <strong>com</strong>pared to 100 for the manual brush 53 (Table 5).<br />
Table 5. Toothbrush abrasivity<br />
McLey et al.<br />
Manual Brush<br />
Rotary powered brush<br />
Powered brush (a)<br />
Powered brush (b)<br />
Schemehorn and Zwart<br />
Abrasivity<br />
20 µg/m<strong>in</strong>ute<br />
35 µg/m<strong>in</strong>ute<br />
57 µg/m<strong>in</strong>ute<br />
117 µg/m<strong>in</strong>ute<br />
Abrasivity (RDA)<br />
Powered brush 16<br />
Manual Brush 100<br />
A manual toothbrush is controlled solely by the patient,<br />
and the patient must brush gently and use a soft<br />
bristle toothbrush to help prevent abrasion — particularly<br />
important for the exposed root surfaces <strong>in</strong> periodontal patients.<br />
This is also an important concept when <strong>in</strong>terpret<strong>in</strong>g<br />
<strong>in</strong> vitro test results; these are carried out under laboratory<br />
conditions and the applied force and technique used for<br />
manual brush<strong>in</strong>g is well controlled, whereas <strong>in</strong> normal daily<br />
life this is not the case. Powered brushes are controlled<br />
mechanically, and while it is possible to apply more force<br />
momentarily, current powered brushes are designed to cut<br />
out if too much pressure is applied.<br />
Lack of abrasivity is particularly important for periodontal<br />
patients with exposed roots, s<strong>in</strong>ce dent<strong>in</strong> and cementum<br />
are more easily abraded than enamel. Us<strong>in</strong>g a technique<br />
and brush that results <strong>in</strong> the least possible abrasion helps<br />
preserve tooth structure (Figure 5). It is also important<br />
for direct and <strong>in</strong>direct esthetic restorations to preserve the<br />
<strong>in</strong>tegrity and appearance of these and avoid abrasion and<br />
subsequent changes <strong>in</strong> shape, luster and sta<strong>in</strong><strong>in</strong>g.<br />
Figure 5. Advanced periodontal disease and abrasion<br />
With respect to g<strong>in</strong>gival abrasions, a recent study found<br />
no differences between two powered toothbrushes and soft<br />
manual brushes but did f<strong>in</strong>d that a powered toothbrush removed<br />
significantly more plaque than a manual toothbrush. 54<br />
It should be noted that this study <strong>in</strong>volved dental students<br />
well tra<strong>in</strong>ed <strong>in</strong> the manual Bass tooth-brush<strong>in</strong>g technique.<br />
Niemi et al., however, found more g<strong>in</strong>gival abrasions us<strong>in</strong>g a<br />
V-shaped manual brush than a powered brush. 55<br />
Patient preference and selection considerations<br />
Given the issues of patient <strong>com</strong>pliance addressed above, use<br />
of a powered brush offers a reduced time requirement for<br />
the same level of plaque efficacy and a “quicker” brush<strong>in</strong>g<br />
experience and, additionally, depend<strong>in</strong>g on the powered<br />
brush selected, offers <strong>in</strong>terdental clean<strong>in</strong>g where the patient<br />
may be non<strong>com</strong>pliant with manual <strong>in</strong>terdental clean<strong>in</strong>g.<br />
Powered brushes with <strong>in</strong>terdental clean<strong>in</strong>g heads offer<br />
a suitable <strong>com</strong>promise for such patients — they may be<br />
will<strong>in</strong>g to “brush <strong>in</strong>terdentally” even if they are non<strong>com</strong>pliant<br />
with floss<strong>in</strong>g or us<strong>in</strong>g <strong>in</strong>dividual manual <strong>in</strong>terdental<br />
brushes. Bader found that patient <strong>com</strong>pliance with recall<br />
was 51%, while it was 92% for the patient group us<strong>in</strong>g rotary<br />
toothbrushes. 56 He also found that 67% of rotary powered<br />
brush users exhibited good oral hygiene scores, <strong>com</strong>pared to<br />
25% of manual toothbrush users.<br />
Lack of abrasivity and reduced applied force favor powered<br />
brushes.<br />
Preventive care — caries and hypersensitivity<br />
In patients with periodontal disease, root exposure due to cl<strong>in</strong>ical<br />
attachment and bone loss ranges from m<strong>in</strong>imal to a substantial<br />
length of the root be<strong>in</strong>g exposed, <strong>in</strong>clud<strong>in</strong>g the furcation<br />
areas of bicuspids and molars. Exposed roots are susceptible to<br />
caries due to the softness of dent<strong>in</strong> and any rema<strong>in</strong><strong>in</strong>g overly<strong>in</strong>g<br />
cementum (Figure 6). A recent study of patients under<br />
periodontal ma<strong>in</strong>tenance for between 11 and 22 years found<br />
that 82% had experienced root caries dur<strong>in</strong>g the ma<strong>in</strong>tenance<br />
phase. 57 While <strong>in</strong>dividual experience was related to plaque<br />
levels, no relationship was found between coronal caries experience<br />
and root caries experience. Other studies have found root<br />
caries experience <strong>in</strong> periodontal ma<strong>in</strong>tenance patients of 88%. 58<br />
6 www.<strong>in</strong>eedce.<strong>com</strong>
Figure 6. Root caries<br />
The root caries risk for periodontal patients is <strong>com</strong>pounded<br />
by dent<strong>in</strong>al hypersensitivity. Such hypersensitivity<br />
results <strong>in</strong> pa<strong>in</strong>ful episodes of sharp pa<strong>in</strong> for the patient and<br />
can be a factor <strong>in</strong> non<strong>com</strong>pliance, s<strong>in</strong>ce the root surface be<strong>com</strong>es<br />
pa<strong>in</strong>ful upon contact with stimuli such as toothpaste<br />
or water (temperature) or the action of a toothbrush (touch)<br />
aga<strong>in</strong>st the exposed dent<strong>in</strong>. Therefore, for both the prevention<br />
and treatment of pa<strong>in</strong> and caries as well as patient <strong>com</strong>pliance,<br />
the prevention and treatment of both conditions is<br />
an important consideration.<br />
A recent study of patients under periodontal<br />
ma<strong>in</strong>tenance found that 82% had experienced<br />
root caries dur<strong>in</strong>g the ma<strong>in</strong>tenance phase.<br />
Relief from hypersensitivity can be obta<strong>in</strong>ed by us<strong>in</strong>g a<br />
number of techniques at home or <strong>in</strong>-office. At-home remedies<br />
<strong>in</strong>clude the use of dentifrices conta<strong>in</strong><strong>in</strong>g either potassium<br />
nitrate, potassium chloride or stannous fluoride. In-office<br />
techniques <strong>in</strong>clude the use of glutaraldehyde (Gluma), iontophoresis,<br />
lasers, amorphous calcium phosphate (ACP) and<br />
res<strong>in</strong>s. Fluoride varnishes provide hypersensitivity relief and<br />
have the additional advantage of expos<strong>in</strong>g the root surface to<br />
a very high concentration of fluoride for an extended period<br />
of time. Sodium fluoride varnish conta<strong>in</strong>s 5% sodium fluoride<br />
(22,600 ppm fluoride) and relieves hypersensitivity by<br />
form<strong>in</strong>g globules that block the dent<strong>in</strong>al tubules — as well<br />
as <strong>in</strong>itially provid<strong>in</strong>g relief through its temporary action as a<br />
physical barrier. At the same time the fluoride forms a protective<br />
layer that is available dur<strong>in</strong>g acidogenic challenges.<br />
Consideration should be given to prescrib<strong>in</strong>g a prescription-only<br />
high-fluoride dentifrice conta<strong>in</strong><strong>in</strong>g 1.1% sodium<br />
fluoride for caries prevention. This has been shown to be<br />
effective <strong>in</strong> prevent<strong>in</strong>g and arrest<strong>in</strong>g root caries and offers<br />
the most fluoride available for home use. 59 Rem<strong>in</strong>eralization<br />
and the prevention of dem<strong>in</strong>eralization are also important to<br />
help prevent abrasion of the dent<strong>in</strong> root surface, as dem<strong>in</strong>eralized<br />
dent<strong>in</strong> has been shown to abrade more easily than<br />
sound dent<strong>in</strong>. 60<br />
Utiliz<strong>in</strong>g chemotherapeutics such as chlorhexid<strong>in</strong>e<br />
gluconate to reduce microbial loads has also been shown<br />
to be effective as part of a preventive program. Apply<strong>in</strong>g<br />
0.12% chlorhexid<strong>in</strong>e gluconate r<strong>in</strong>se by dipp<strong>in</strong>g the microfilaments<br />
of a rotary powered toothbrush <strong>in</strong> the r<strong>in</strong>se was<br />
found <strong>in</strong> one study to <strong>in</strong>crease the efficacy of chlorhexid<strong>in</strong>e<br />
gluconate r<strong>in</strong>se more than r<strong>in</strong>s<strong>in</strong>g alone. 61 However, the<br />
side effect of tooth sta<strong>in</strong><strong>in</strong>g precludes its long-term use for<br />
most patients.<br />
Consideration should also be given to advis<strong>in</strong>g patients<br />
to chew sugar-free gum at least three times daily for an extended<br />
period of time, as this has been shown to reduce the<br />
<strong>in</strong>cidence of caries. 62 Chew<strong>in</strong>g gum can effectively <strong>com</strong>bat<br />
a cariogenic challenge when used for at least 20 m<strong>in</strong>utes<br />
immediately after eat<strong>in</strong>g or dr<strong>in</strong>k<strong>in</strong>g. The use of a chew<strong>in</strong>g<br />
gum conta<strong>in</strong><strong>in</strong>g case<strong>in</strong> phosphopeptide-amorphous calcium<br />
phosphate (CPP-ACP) has also been shown <strong>in</strong> <strong>in</strong> situ studies<br />
to help rem<strong>in</strong>eralize teeth. 63<br />
Summary<br />
<strong>Periodontal</strong> therapy when appropriately utilized results <strong>in</strong><br />
good cl<strong>in</strong>ical out<strong>com</strong>es. However, patients are often non<strong>com</strong>pliant.<br />
Consideration should be given to techniques and<br />
protocols that aid <strong>com</strong>pliance. The use of powered brushes<br />
has been shown to be at least as effective as use of manual<br />
brushes <strong>in</strong> general, <strong>in</strong>clud<strong>in</strong>g <strong>in</strong> periodontal ma<strong>in</strong>tenance<br />
patients. The use of a powered brush offers the patient efficacy<br />
with reduced time <strong>in</strong>volvement and, depend<strong>in</strong>g on<br />
the brush head, may enable <strong>in</strong>terdental clean<strong>in</strong>g <strong>in</strong> patients<br />
who are non-<strong>com</strong>pliant with manual <strong>in</strong>terdental clean<strong>in</strong>g<br />
techniques. In addition, it has been found that the risk of<br />
tooth abrasion and the application of force may be reduced<br />
with the use of a powered brush. Cont<strong>in</strong>ued periodontal<br />
improvements depend on regular periodontal ma<strong>in</strong>tenance,<br />
en<strong>com</strong>pass<strong>in</strong>g both regular <strong>in</strong>-office ma<strong>in</strong>tenance visits<br />
and adequate home care. <strong>Periodontal</strong> ma<strong>in</strong>tenance is imperative<br />
for patients follow<strong>in</strong>g active therapy. In addition to<br />
thorough <strong>in</strong>-office assessment, treatment and education of<br />
patients, care should be taken to address each patient’s ability<br />
and will<strong>in</strong>gness to perform daily oral hygiene as well as<br />
to address root caries risk and prevent unwanted sequelae.<br />
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49 Wiegand A, Lemmrich F, Att<strong>in</strong> T. Influence of rotat<strong>in</strong>goscillat<strong>in</strong>g,<br />
sonic and ultrasonic action of power<br />
toothbrushes on abrasion of sound and eroded dent<strong>in</strong>e. J<br />
<strong>Periodontal</strong> Res. 2006;41(3):221–227.<br />
50 Boyd RL, McLey L, Zahradnik R. Cl<strong>in</strong>ical and laboratory<br />
evaluation of powered electric toothbrushes: <strong>in</strong> vivo<br />
determ<strong>in</strong>ation of average force for use of manual and<br />
powered toothbrushes. J Cl<strong>in</strong> Dent. 1997;8(3 Spec<br />
No):72–75.<br />
51 McLey L, Boyd RL, Sarker S. Cl<strong>in</strong>ical and laboratory<br />
evaluation of powered electric toothbrushes: laboratory<br />
determ<strong>in</strong>ation of relative abrasion of three powered<br />
toothbrushes. J Cl<strong>in</strong> Dent. 1997;8(3 Spec No):76–80.<br />
52 McLey L, Zahradnik R, Sarker S. Relative abrasiveness<br />
and clean<strong>in</strong>g efficiency of three powered brush<strong>in</strong>g<br />
<strong>in</strong>struments. IADR Abstract, 1994;#501.<br />
53 Schemehorn BR, Zwart AC. The dent<strong>in</strong> abrasivity<br />
potential of a new electric toothbrush. Am J Dent. 1996;9<br />
Spec No:S19–20.<br />
54 Mantokoudis D, Joss A, Christensen MM, Meng HX,<br />
Suvan JE, Lang NP. Comparison of the cl<strong>in</strong>ical effects<br />
and g<strong>in</strong>gival abrasion aspects of manual and electric<br />
toothbrushes. J Cl<strong>in</strong> Periodontol. 2001 Jan;28(1):65–72.<br />
55 Niemi ML, A<strong>in</strong>amo J, Etemadzadeh H. G<strong>in</strong>gival<br />
abrasion and plaque removal with manual versus electric<br />
toothbrush<strong>in</strong>g. J Cl<strong>in</strong> Periodontol. 1986 Aug;13(7):709–<br />
713.<br />
56 Bader HI. Ten-year retrospective observations of the<br />
impact of a rotary-powered brush vs. manual techniques<br />
<strong>in</strong> periodontal ma<strong>in</strong>tenance. Compendium. 2004;25(6):1–<br />
7.<br />
57 Reiker J, van der Velden U, Barendregt DS, Loos BG. A<br />
cross-sectional study <strong>in</strong>to the prevalence of root caries<br />
<strong>in</strong> periodontal ma<strong>in</strong>tenance patients. J Cl<strong>in</strong> Periodontol.<br />
1999 Jan;26(1):26–32.<br />
58 Ravald N, Birkhed D, Hamp SE. Root caries susceptibility<br />
<strong>in</strong> periodontally treated patients. Results after 12 years. J<br />
Cl<strong>in</strong> Periodontol. 1993 Feb;20(2):124–129.<br />
59 Baysan A, et al. Reversal of primary root caries us<strong>in</strong>g<br />
dentifrices conta<strong>in</strong><strong>in</strong>g 5,000 and 1,000 ppm fluoride.<br />
Caries Res. 2001;35:41–46.<br />
60 Wiegand A, Lemmrich F, Att<strong>in</strong> T. Influence of rotat<strong>in</strong>goscillat<strong>in</strong>g,<br />
sonic and ultrasonic action of power<br />
toothbrushes on abrasion of sound and eroded dent<strong>in</strong>e. J<br />
<strong>Periodontal</strong> Res. 2006 Jun;41(3):221–227.<br />
61 Bader HI, Williams RC. Chlorhexid<strong>in</strong>e efficacy<br />
enhancement by local application with powered rotary<br />
device. IADR Abstract, 1992.<br />
62 van Loveren C. Sugar alcohols: what is the evidence for<br />
caries preventive and caries-therapeutic effects? Caries<br />
Res, 2004;38:286–293.<br />
63 Touger-Decker R. Role of nutrition <strong>in</strong> the dental practice.<br />
Qu<strong>in</strong>tessence Int. Jan 2004;35(1):67–70.<br />
Author Profile<br />
William L. Balanoff, DDS, MS, FICD<br />
Dr. Balanoff received his dental degree<br />
from Northwestern University and his<br />
masters <strong>in</strong> craniofacial research from<br />
Nova Southeastern University. He is<br />
an adjunct assistant cl<strong>in</strong>ical professor<br />
at University of Tennessee and a former<br />
assistant cl<strong>in</strong>ical professor at Nova Southeastern<br />
University teach<strong>in</strong>g postgraduate prosthodontics;<br />
specifically implant surgery and reconstruction to the<br />
prosthodontic residents.<br />
Dr. Balanoff is the owner of a multilocation fee for<br />
service group practice <strong>in</strong> the south Florida area. He is on<br />
staff at Broward General Hospital and North Broward<br />
Hospital with privileges for implant surgery and reconstruction.<br />
Dr. Balanoff is on the editorial board of Compendium<br />
and is a consultant for Zila Pharmaceuticals.<br />
Best of all he has three wonderful children and an<br />
<strong>in</strong>credible wife who allows him to live his dreams.<br />
Disclaimer<br />
The author of this course is a speaker for Zila Pharmaceuticals,<br />
Inc.<br />
Reader Feedback<br />
We encourage your <strong>com</strong>ments on this or any PennWell course.<br />
For your convenience, an onl<strong>in</strong>e feedback form is available at<br />
www.<strong>in</strong>eedce.<strong>com</strong>.<br />
www.<strong>in</strong>eedce.<strong>com</strong> 9
Onl<strong>in</strong>e Completion<br />
Use this page to review the questions and answers. Return to www.<strong>in</strong>eedce.<strong>com</strong> and sign <strong>in</strong>. If you have not previously purchased the program select it from the “Onl<strong>in</strong>e Courses” list<strong>in</strong>g and <strong>com</strong>plete the<br />
onl<strong>in</strong>e purchase. Once purchased the exam will be added to your Archives page where a Take Exam l<strong>in</strong>k will be provided. Click on the “Take Exam” l<strong>in</strong>k, <strong>com</strong>plete all the program questions and submit your<br />
answers. An immediate grade report will be provided and upon receiv<strong>in</strong>g a pass<strong>in</strong>g grade your “Verification Form” will be provided immediately for view<strong>in</strong>g and/or pr<strong>in</strong>t<strong>in</strong>g. Verification Forms can be viewed<br />
and/or pr<strong>in</strong>ted anytime <strong>in</strong> the future by return<strong>in</strong>g to the site, sign <strong>in</strong> and return to your Archives Page.<br />
Questions<br />
1. <strong>Periodontal</strong> bacteria must be present 11. It has been estimated that most 22. Increased efficacy of plaque removal<br />
for the _________ of periodontal<br />
patients brush for _________.<br />
<strong>in</strong> a reduced time is an important consideration<br />
given _________.<br />
disease.<br />
a. thirty seconds<br />
a. onset<br />
b. forty-five seconds<br />
a. brush head wear and fatigue<br />
b. absences<br />
c. one m<strong>in</strong>ute<br />
b. patient <strong>com</strong>pliance issues<br />
c. progression<br />
d. two m<strong>in</strong>utes<br />
c. memory lapse<br />
d. a and c<br />
12. Less than ______ of patients floss daily. d. all of the above<br />
2. The overall objectives of periodontal<br />
a. 50%<br />
23. Powered brush heads with rotat<strong>in</strong>g or<br />
therapy <strong>in</strong>clude _________.<br />
b. 35%<br />
spiral<strong>in</strong>g filaments are _________ for<br />
a. to halt disease progression<br />
c. 15%<br />
b. to reduce pocket depths<br />
d. 10%<br />
<strong>in</strong>terdental clean<strong>in</strong>g.<br />
a. <strong>in</strong>effective<br />
c. to obta<strong>in</strong> cl<strong>in</strong>ical attachment ga<strong>in</strong>s<br />
13. Erratic patient <strong>com</strong>pliance has been b. effective<br />
d. all of the above<br />
found to be associated with _________ c. not re<strong>com</strong>mended<br />
3. Mature biofilm (plaque) conta<strong>in</strong>s<br />
<strong>in</strong> periodontal ma<strong>in</strong>tenance patients. d. not <strong>in</strong> existence<br />
_________.<br />
a. lower levels of oral cancer<br />
a. high levels of diphtheroids<br />
b. lower levels of root caries<br />
24. _________ is a design feature that aids<br />
b. high levels of periodontal bacteria <strong>in</strong> a wellorganized<br />
matrix<br />
d. none of the above<br />
a. An <strong>in</strong>terdental brush head shape<br />
c. higher levels of root caries<br />
<strong>in</strong>terdental clean<strong>in</strong>g.<br />
b. Active brush tips<br />
c. high levels of periodontal bacteria <strong>in</strong> a poorlyorganized<br />
matrix<br />
14. The goal of daily oral hygiene procedures<br />
for periodontal ma<strong>in</strong>tenance is to<br />
c. A round brush head shape<br />
d. a and c<br />
d. a and b<br />
_________.<br />
4. <strong>Periodontal</strong> bacteria can return to<br />
a. prevent biofilm from form<strong>in</strong>g<br />
25. _________ et al. found that more force<br />
pretreatment levels <strong>in</strong> as little as<br />
b. remove dental biofilm before it matures<br />
was applied with use of a manual brush<br />
_________.<br />
c. remove dental biofilm after it matures<br />
than with use of a powered brush.<br />
d. none of the above<br />
a. van der Veen<br />
a. several days<br />
b. several weeks<br />
15. Migrat<strong>in</strong>g bacteria can _________.<br />
b. van der Leijden<br />
c. several months<br />
a. shift from suprag<strong>in</strong>gival plaque to subg<strong>in</strong>gival c. van der Weijden<br />
d. none of the above<br />
sites<br />
d. none of the above<br />
b. shift to different periodontal sites<br />
26. Powered brushes with <strong>in</strong>terdental<br />
5. Patients who do not receive regular periodontal<br />
ma<strong>in</strong>tenance have _________ d. a and b<br />
patients who are non<strong>com</strong>pliant with<br />
c. cause paratitis<br />
clean<strong>in</strong>g heads offer _________ for<br />
than those who receive such care.<br />
16. The accepted home oral hygiene care manual <strong>in</strong>terdental clean<strong>in</strong>g.<br />
a. fewer teeth with furcation <strong>in</strong>volvement<br />
regimen is _________.<br />
a. noth<strong>in</strong>g<br />
b. shallower prob<strong>in</strong>g depths and more tooth loss<br />
a. use of a toothbrush (manual or powered)<br />
c. greater prob<strong>in</strong>g depths and more tooth loss<br />
b. an unsuitable <strong>com</strong>promise<br />
b. use of a tongue irrigator<br />
d. none of the above<br />
c. a suitable <strong>com</strong>promise<br />
c. use of either floss or <strong>in</strong>terdental brushes<br />
d. none of the above<br />
6. An _________ biofilm cannot be<br />
d. a and c<br />
effectively removed by home care.<br />
27. Lack of abrasivity while brush<strong>in</strong>g is<br />
17. _________ brushes have been found to<br />
a. early suprag<strong>in</strong>gival<br />
particularly important for periodontal<br />
be effective <strong>in</strong> trials.<br />
b. established suprag<strong>in</strong>gival<br />
patients _________.<br />
a. Rotary powered<br />
c. early subg<strong>in</strong>gival<br />
a. with exposed roots, s<strong>in</strong>ce dent<strong>in</strong> and cementum<br />
b. Powered<br />
d. established subg<strong>in</strong>gival<br />
are more difficult to abrade than enamel<br />
c. Sonic<br />
b. with exposed roots, s<strong>in</strong>ce dent<strong>in</strong> and cementum<br />
are more easily abraded than enamel<br />
7. In-office periodontal ma<strong>in</strong>tenance<br />
d. all of the above<br />
should <strong>in</strong>clude _________.<br />
18. The rotary powered brush removes<br />
c. with sialitis<br />
a. a full evaluation and exam<strong>in</strong>ation of the hard plaque through _________.<br />
d. none of the above<br />
and soft tissues<br />
a. the physical action of the brush head aga<strong>in</strong>st<br />
b. thorough removal of calculus and biofilm<br />
28. A recent study of patients under<br />
the tooth<br />
c. an assessment of the patient’s oral care and the b. fluid dynamics<br />
periodontal ma<strong>in</strong>tenance for between<br />
adequacy of his or her oral hygiene<br />
c. hydrodynamics<br />
11 and 22 years found that _________<br />
d. all of the above<br />
d. a and b<br />
had experienced root caries dur<strong>in</strong>g the<br />
8. One of the ma<strong>in</strong> issues <strong>in</strong> periodontal<br />
ma<strong>in</strong>tenance phase.<br />
19. The sonic powered brush removes<br />
ma<strong>in</strong>tenance is _________.<br />
a. 65%<br />
plaque through _________.<br />
a. f<strong>in</strong>d<strong>in</strong>g appo<strong>in</strong>tment time for ma<strong>in</strong>tenance<br />
b. 73%<br />
a. the physical action of the brush head aga<strong>in</strong>st<br />
visits<br />
the tooth<br />
c. 82%<br />
b. patient <strong>com</strong>pliance<br />
b. fluid dynamics<br />
d. 91%<br />
c. the availability of scaler units<br />
c. hydrodynamics<br />
29. Fluoride varnish _________.<br />
d. all of the above<br />
d. a and b<br />
a. provides hypersensitivity relief<br />
9. One recent retrospective study found 20. _________ found that improvements b. exposes the root surface to a very high<br />
that _________ of patients were non<strong>com</strong>pliant<br />
with ma<strong>in</strong>tenance therapy, with a sonic brush <strong>com</strong>pared to a rotary period of time<br />
<strong>in</strong> periodontal health were superior<br />
concentration of fluoride for an extended<br />
while another five-year study found powered brush.<br />
c. exposes the root surface to a very high<br />
_________ to be non<strong>com</strong>pliant.<br />
a. Rob<strong>in</strong>son et al.<br />
concentration of fluoride for a few m<strong>in</strong>utes<br />
a. 25%; 38%<br />
b. Haraldsen et al.<br />
d. a and b<br />
b. 35%; 42.6%<br />
c. Boyd et al.<br />
30. Rem<strong>in</strong>eralization and the prevention<br />
c. 45%; 45.5%<br />
d. none of the above<br />
of dem<strong>in</strong>eralization of the root surface<br />
d. 55%; 46.8%<br />
21. Bader and Boyd found use of a<br />
_________.<br />
10. Once patients are not <strong>in</strong> regular<br />
rotary powered brush over a period of a. can be aided by the use of a 1.1% sodium<br />
contact with dental professionals, their _________ significantly more effective<br />
fluoride dentifrice<br />
_________.<br />
than use of a sonic brush.<br />
b. are important to help prevent abrasion of the<br />
a. <strong>com</strong>pliance decreases<br />
a. 10 weeks<br />
dent<strong>in</strong> root surface<br />
b. motivation decreases<br />
b. 12 weeks<br />
c. are not significant factors for periodontal<br />
c. motivation <strong>in</strong>creases<br />
c. 14 weeks<br />
patients<br />
d. a and b<br />
d. 16 weeks<br />
d. a and b<br />
10 www.<strong>in</strong>eedce.<strong>com</strong>
ANSWER SHEET<br />
<strong>Periodontal</strong> <strong>Ma<strong>in</strong>tenance</strong> <strong>in</strong> <strong>Disease</strong> <strong>Prevention</strong><br />
THIS COURSE ONLY AVAILABLE ONLINE<br />
Requirements for successful <strong>com</strong>pletion of the course and to obta<strong>in</strong> dental cont<strong>in</strong>u<strong>in</strong>g education credits: 1) Read the entire course. 2) Complete all<br />
<strong>in</strong>formation. 3) Complete test onl<strong>in</strong>e. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete<br />
the Course Evaluation onl<strong>in</strong>e. For Questions Call 216.398.7822<br />
Educational Objectives<br />
1. List and describe the rationale for periodontal ma<strong>in</strong>tenance and the <strong>com</strong>ponents <strong>in</strong>volved <strong>in</strong> a periodontal ma<strong>in</strong>tenance<br />
program.<br />
2. List and describe patient <strong>com</strong>pliance factors and the impact of non-<strong>com</strong>pliance on periodontal out<strong>com</strong>es.<br />
For iMMediate results, go to<br />
www.<strong>in</strong>eedce.<strong>com</strong><br />
The cost of this course is $49.00<br />
3. List the considerations <strong>in</strong>volved <strong>in</strong> the selection and re<strong>com</strong>mendation of oral care devices for patients.<br />
4. List and describe the risk for root caries and dent<strong>in</strong>al sensitivity <strong>in</strong> patients follow<strong>in</strong>g periodontal therapy, prevention and<br />
treatment options.<br />
Course Evaluation<br />
Please evaluate this course by respond<strong>in</strong>g to the follow<strong>in</strong>g statements, us<strong>in</strong>g a scale of Excellent = 5 to Poor = 0.<br />
1. Were the <strong>in</strong>dividual course objectives met? Objective #1: Yes No Objective #3: Yes No<br />
Objective #2: Yes No Objective #4: Yes No<br />
2. To what extent were the course objectives ac<strong>com</strong>plished overall? 5 4 3 2 1 0<br />
3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0<br />
4. How would you rate the objectives and educational methods? 5 4 3 2 1 0<br />
5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0<br />
6. Please rate the <strong>in</strong>structor’s effectiveness. 5 4 3 2 1 0<br />
7. Was the overall adm<strong>in</strong>istration of the course effective? 5 4 3 2 1 0<br />
8. Do you feel that the references were adequate? Yes No<br />
9. Would you participate <strong>in</strong> a similar program on a different topic? Yes No<br />
10. If any of the cont<strong>in</strong>u<strong>in</strong>g education questions were unclear or ambiguous, please list them.<br />
___________________________________________________________________<br />
11. Was there any subject matter you found confus<strong>in</strong>g? Please describe.<br />
___________________________________________________________________<br />
___________________________________________________________________<br />
12. What additional cont<strong>in</strong>u<strong>in</strong>g dental education topics would you like to see?<br />
___________________________________________________________________<br />
___________________________________________________________________<br />
AGD Code 490, 149<br />
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.<br />
AUTHOR DISCLAIMER<br />
The author of this course has lectured for the sponsors or the providers of the<br />
unrestricted educational grant for this course.<br />
SPONSOR/PROVIDER<br />
This course was made possible through an unrestricted educational grant. No<br />
manufacturer or third party has had any <strong>in</strong>put <strong>in</strong>to the development of course content.<br />
All content has been derived from references listed, and or the op<strong>in</strong>ions of cl<strong>in</strong>icians.<br />
Please direct all questions perta<strong>in</strong><strong>in</strong>g to PennWell or the adm<strong>in</strong>istration of this course to<br />
Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.<strong>com</strong>.<br />
COURSE EVALUATION and PARTICIPANT FEEDBACK<br />
We encourage participant feedback perta<strong>in</strong><strong>in</strong>g to all courses. Please be sure to <strong>com</strong>plete the<br />
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All questions should have only one answer. This course can only be taken onl<strong>in</strong>e.<br />
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Verification forms will be mailed with<strong>in</strong> two weeks after tak<strong>in</strong>g an exam<strong>in</strong>ation.<br />
EDUCATIONAL DISCLAIMER<br />
The op<strong>in</strong>ions of efficacy or perceived value of any products or <strong>com</strong>panies mentioned<br />
<strong>in</strong> this course and expressed here<strong>in</strong> are those of the author(s) of the course and do not<br />
necessarily reflect those of PennWell.<br />
Complet<strong>in</strong>g a s<strong>in</strong>gle cont<strong>in</strong>u<strong>in</strong>g education course does not provide enough <strong>in</strong>formation<br />
to give the participant the feel<strong>in</strong>g that s/he is an expert <strong>in</strong> the field related to the course<br />
topic. It is a <strong>com</strong>b<strong>in</strong>ation of many educational courses and cl<strong>in</strong>ical experience that<br />
allows the participant to develop skills and expertise.<br />
COURSE CREDITS/COST<br />
All participants scor<strong>in</strong>g at least 70% on the exam<strong>in</strong>ation will receive a verification<br />
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is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for<br />
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