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Management of disease recurrence

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Management of disease recurrence

The main components of supportive periodontal care are continual reassessment of risk factor management and assessment of the patient’s periodontal status at each visit. This aims to facilitate early recognition of any problems which may arise and appropriate management. Clinical signs and symptoms related to potential disease recurrence should be monitored and recorded at each recall visit. 

For some patients in periodontal maintenance, disease can recur at sites which were previously not active, or disease can develop at new sites. It is important to recognise new or recurrent disease and determine why this has occurred to inform the management of site(s) where disease is present.

New or recurrent disease may be identified during periodontal maintenance by changes in clinical signs (e.g. increased probing pocket depths or bleeding on probing), routine radiographs (i.e. bone levels on bitewings taken for caries prevention) or patient-reported symptoms (e.g. bleeding gums on brushing or interdental cleaning, drifting teeth, pain/swelling, a bad taste, recession or an increase in tooth mobility). If a change in periodontal status is recognised, the reasons for this should be determined to inform management of the problem.

Many factors can contribute to periodontal deterioration during maintenance; these can be patient-related or related to the clinical care they have received.

  • changes in risk profile, which can be local (e.g. teeth have been removed or interdental spaces have developed) or systemic (e.g. a diagnosis of diabetes);
  • change in habits (e.g. smoking, level of home care);
  • change in cognitive level or skill;
  • change in attendance pattern (e.g. longer than advised interval between recalls or non-attendance for recall).

  • disease which was not previously recognised;
  • disease which was inadequately or sub-optimally treated before patient entered maintenance; 
  • oral hygiene instruction from the clinical team which has been misunderstood or not delivered in a way the patient can understand;
  • a completely different pathology which may be contributing to breakdown at an existing site (e.g. a root fracture, endo-perio lesion). 

Once the reasons for periodontal deterioration are understood, active treatment which is tailored to address the causes can be provided. This may focus on:

  • risk factor control (see Managing risk factors);
  • improving oral hygiene (see Oral hygiene behaviour change); 
  • delivering more effective PMPR (see PMPR); this may involve detection of residual calculus on root surfaces, use of suitable, high-quality instruments, sufficient time to deliver care and developing PMPR skills. 

Note that there is a lack of evidence to support the use of local antiseptics, local antimicrobials and systemic antibiotics in the routine management of periodontal relapse and these interventions are not recommended (see Antimicrobial medication).

If attempts to resolve the disease recurrence are unsuccessful, various management options can be considered. For example:

  • If the patient is not engaged, discuss this with the patient, outline the possible consequences and continue to provide maintenance care at a more frequent recall interval;
  • If the patient is engaged, consider providing additional round(s) of treatment;
  • If the patient is engaged but the periodontal situation cannot be sufficiently controlled in primary care, consider referral. 

In situations where referral is not possible, or is not desired by the patient, the situation should be recorded in the clinical record and the options for treatment available within primary care should be discussed with the patient. It is important that the patient is aware that this course of action may not be ideal, but it may to some extent control periodontal breakdown.

In some situations, reoccurrence of disease during maintenance care is an indicator that a tooth/teeth may not be retainable in the long term (see Assessing tooth prognosis). If this is the case, the clinician and patient should discuss and agree the ongoing treatment plan, which might involve seeking a second opinion from a colleague. Note that many teeth of initially poor prognosis can be retained for long periods of time with the appropriate treatment.

For patients who relapse or develop new disease during periodontal maintenance:

Determine the cause of the periodontal deterioration, for example:

  • Change in risk factors (e.g. the patient has started smoking or has developed diabetes);
  • Continued presence of calculus or plaque biofilm on root surfaces;
  • Changes leading to inadequate oral hygiene (e.g. changes in manual skills or frequency of home care);
  • Changes in attendance (e.g. longer intervals between recall visits for maintenance or failure to attend for maintenance care).

Address the cause of the periodontal deterioration by providing relevant treatment/care related to that cause (see Treatment components).

  • Adjustments to the way oral hygiene instruction/coaching, sub-gingival PMPR or other relevant interventions are delivered may be required to achieve optimal outcomes.

Arrange review based on the severity of disease or the risk of further periodontal deterioration.

If no improvement is observed at review, consider whether additional treatment is likely to be beneficial or whether referral to secondary care should be considered.

  • If referral is not an option, provide ongoing support to the patient, which may include continued discussion regarding risk factor control, advice and coaching regarding home care, repeated PMPR or the shortening of recall visits to allow for more regular or frequent professional interventions.

If a tooth or teeth do not appear retainable in the long term, discuss with the patient the available options and agree a treatment plan.

  • Consider seeking a second opinion from a colleague.