The University of Western Australia
Re-evaluation, Maintenance and Risk Assessment
Dr Celine Soon
A/P Leticia A Miranda
Dr Pradeep Koppolu
Dr Anna Hughes
SEEK WISDOM
UNIVERSITY OF WESTERN AUSTRALIA
The University of Western Australia
Dr Celine Soon
A/P Leticia A Miranda
Dr Pradeep Koppolu
Dr Anna Hughes
SEEK WISDOM
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A full-page color photograph of a large, historic-looking stone building with a prominent clock tower on the right side. The architecture features arched windows and colonnades. Lush green trees frame the left side of the image, and a manicured lawn is visible in the foreground under a clear blue sky.
Reading Resources
[BOOK]
**Periodontology at a Glance**
Clerehugh, Valerie. ; Tugnait, Aradhna. ; Genco, Robert J. ; Somerset : Wiley; 2013
Available Online >
[Clinical Periodontology and Implant Dentistry, 2 Volume Set]
by Niklaus P. Lang, , Jan Lindhe, , and Niklaus P Lang
PUBLISHER
John Wiley & Sons, Incorporated
DATE
2015-03-25
**Reading Resources**
- **Periodontology at a Glance**
Clerehugh, Valerie. ; Tugnait, Aradhna. ; Genco, Robert J. ; Somerset : Wiley; 2013
Available Online >
- **Clinical Periodontology and Implant Dentistry, 2 Volume Set**
by Niklaus P. Lang, Jan Lindhe, and Niklaus P Lang
Publisher: John Wiley & Sons, Incorporated
Date: 2015-03-25
<table>
<tr>
<td>
<b>Topics</b>
</td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td>
<p> <b>Re-evaluation</b> </p>
When do we re-assess?
Endpoints of periodontal therapy
Corrective or Maintenance
</td>
<td>
<p> <b>Step 4 Maintenance</b> </p>
Supportive Periodontal Care
Why is maintenance important?
</td>
<td>
<p> <b>Risk Assessment</b> </p>
Aim
Periodontal Risk Assessment
• Lang and Tonetti 2003
</td>
</tr>
</table>
#### Topics
**Re-evaluation**
- When do we re-assess?
- Endpoints of periodontal therapy
- Corrective or Maintenance
**Step 4 Maintenance**
- Supportive Periodontal Care
- Why is maintenance important?
**Risk Assessment**
- Aim
- Periodontal Risk Assessment
- Lang and Tonetti 2003
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A slide titled 'Topics' displaying three distinct colored boxes arranged horizontally. The left box (orange header) is labeled 'Re-evaluation' and lists: 'When do we re-assess?', 'Endpoints of periodontal therapy', and 'Corrective or Maintenance'. The middle box (green header) is labeled 'Step 4 Maintenance' and lists: 'Supportive Periodontal Care' and 'Why is maintenance important?'. The right box (blue header) is labeled 'Risk Assessment' and lists: 'Aim', 'Periodontal Risk Assessment', and a bullet point citing 'Lang and Tonetti 2003'.
# Periodontal Re-Evaluation
# RE-EVALUATION
* Maintenance of the health, function, comfort and aesthetics of all supporting and surrounding tissues of teeth and dental implants.
* **GOALS:**
* Preserve, improve and maintain natural dentition, implants and surrounding tissues.
* Obtain a healthy Periodontium/Peri-implant tissues:
**Absence of inflammation and progressive attachment/bone loss.**
Maintenance of the health, function, comfort and aesthetics of all supporting and surrounding tissues of teeth and dental implants.
**GOALS:**
- Preserve, improve and maintain natural dentition, implants and surrounding tissues.
- Obtain a healthy Periodontium/Peri-implant tissues:
- Absence of inflammation and progressive attachment/bone loss.
# Periodontal Re-evaluation
**Q. When should we re-evaluate?**
* 6-12 weeks post active periodontal treatment
**Q. Why do we re-evaluate at these time points and not earlier or even later?**
* *Healing is occurring*
**Q. Would individuals with certain systemic risk factors or grades have an effect on healing time?**
* Yes, *individuals with uncontrolled diabetes, smokers, and individuals with grade C may require a longer healing time.*
**Q. When should we re-evaluate?**
- 6-12 weeks post active periodontal treatment
**Q. Why do we re-evaluate at these time points and not earlier or even later?**
- Healing is occurring
**Q. Would individuals with certain systemic risk factors or grades have an effect on healing time?**
- Yes, individuals with uncontrolled diabetes, smokers, and individuals with grade C may require a longer healing time.
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Labelled medical diagram illustrating the progression of a periodontal pocket in three stages labeled (a), (b), and (c). Panel (a) shows initial inflammation with 'Loss of attachment', 'Subgingival calculus and plaque', 'Inflammatory infiltrate extending into connective tissue', 'Ulcerated pocket lining', and 'Alveolar bone loss'. Panel (b) depicts healing initiation with 'Numbers of neutrophils in pocket decrease', 'Inflammatory infiltrate reduces', 'Gingival swelling reduces', 'Pocket lining begins to heal', and 'Increase in fibroblasts'. Panel (c) shows mature tissue with 'Gingival recession', 'Formation of long junctional epithelium', 'Maturation of connective tissue, few inflammatory cells', and 'Remodelling of alveolar bone'.
Endpoints of periodontal therapy
No periodontal pockets >4 mm with bleeding on probing
OR
No deep periodontal pockets [≥6 mm]
Sanz, M., Herrera, D., Kebschull, M., Chapple, I., Jepsen, S., Berglundh, T., ... & Wennström, J. (2020). Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline. *Journal of Clinical Periodontology*, 47, 4-60.
<table><tr><td></td></tr></table>
Endpoints of periodontal therapy
- No periodontal pockets >4 mm with bleeding on probing
OR
- No deep periodontal pockets [≥6 mm]
Sanz, M., Herrera, D., Kebschull, M., Chapple, I., Jepsen, S., Berglundh, T., ... & Wennström, J. (2020). Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline. *Journal of Clinical Periodontology*, 47, 4-60.
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QR code labeled 'READ ME' in the top right corner.
```html
<table>
<tr>
<th>Definitions</th>
</tr>
<tr>
<td><b>Periodontal Disease Stability</b></td>
</tr>
<tr>
<td>
<ul>
<li>Successfully treated periodontitis with control of local and systemic factors.</li>
<li>Minimal Bleeding on Probing (BoP).</li>
<li>Optimized Periodontal Probing Depth (PPD) and Clinical Attachment Levels.</li>
<li>No progressive periodontal destruction.</li>
</ul>
</td>
</tr>
<tr>
<td>Lang, N. P., &amp; Bartold, P. M. (2018). Periodontal health. <i>Journal of periodontology</i>, 89, S9-S16.</td>
</tr>
</table>
```
**Definitions**
**Periodontal Disease Stability**
- Successfully treated periodontitis with control of local and systemic factors.
- Minimal Bleeding on Probing (BoP).
- Optimized Periodontal Probing Depth (PPD) and Clinical Attachment Levels.
- No progressive periodontal destruction.
Lang, N. P., & Bartold, P. M. (2018). Periodontal health. *Journal of periodontology*, 89, S9-S16.
# Definitions
## Periodontal Disease Remission / Control
- Inflammation reduced but not fully resolved.
- Some improvement in PPD and Clinical Attachment Levels.
- Local and systemic contributing factors remain uncontrolled.
- Acceptable outcome for patients with persistent risk factors (e.g., smoking, diabetes).
Lang, N. P., & Bartold, P. M. (2018). Periodontal health. Journal of periodontology, 89, S9-S16.
**Periodontal Disease Remission / Control**
- Inflammation reduced but not fully resolved.
- Some improvement in PPD and Clinical Attachment Levels.
- Local and systemic contributing factors remain uncontrolled.
- Acceptable outcome for patients with persistent risk factors (e.g., smoking, diabetes).
Lang, N. P., & Bartold, P. M. (2018). Periodontal health. Journal of periodontology, 89, S9-S16.
Supported by **gsk**
**BSP UK CLINICAL PRACTICE GUIDELINES FOR THE TREATMENT OF PERIODONTAL DISEASES**
**ORAL HEALTH AND RISK ASSESSMENT, DIAGNOSIS & CARE PLAN**
**Diagnosis** | **Periodontal Health** <--> **Gingivitis** ---> **Periodontitis**
Extract teeth with hopeless prognosis or unsavable teeth – eg grade III mobile
**STEP 1** Building foundations for optimal treatment outcomes
I: Explain disease, risk factors & treatment alternatives, risks & benefits including no treatment
II: Explain importance of Oral Hygiene (OH), encourage and support behaviour change for OH improvement
III: Reduce risk factors including removal of plaque retentive features, smoking cessation and diabetes control interventions
IV: Provide individually tailored OH advice including interdental cleaning, + / - adjunctive efficacious toothpaste & mouthwash, + / - Professional Mechanical Plaque Removal (PMPR) including supra and subgingival scaling of the clinical crown
V: Select recall period following published guidance and considering risk factors such as smoking and diabetes
VI: Oral Health Educator (I, II), Hygienist, Therapist (I – IV), Dentist, Practitioner accredited for Level 2 and 3 care (I – V)
Re-evaluate
Non-engaging patient – return to **STEP 1** & repeat
Engaging patient – move to **STEP 2**
Consider referral
**STEP 2** (see over)
British Society of Periodontology and Implant Dentistry
**BSP UK CLINICAL PRACTICE GUIDELINES FOR THE TREATMENT OF PERIODONTAL DISEASES**
**ORAL HEALTH AND RISK ASSESSMENT, DIAGNOSIS & CARE PLAN**
**Diagnosis** | **Periodontal Health** <--> **Gingivitis** ---> **Periodontitis**
Extract teeth with hopeless prognosis or unsavable teeth – eg grade III mobile
**STEP 1** Building foundations for optimal treatment outcomes
I: Explain disease, risk factors & treatment alternatives, risks & benefits including no treatment
II: Explain importance of Oral Hygiene (OH), encourage and support behaviour change for OH improvement
III: Reduce risk factors including removal of plaque retentive features, smoking cessation and diabetes control interventions
IV: Provide individually tailored OH advice including interdental cleaning, + / - adjunctive efficacious toothpaste & mouthwash, + / - Professional Mechanical Plaque Removal (PMPR) including supra and subgingival scaling of the clinical crown
V: Select recall period following published guidance and considering risk factors such as smoking and diabetes
VI: Oral Health Educator (I, II), Hygienist, Therapist (I – IV), Dentist, Practitioner accredited for Level 2 and 3 care (I – V)
Re-evaluate
Non-engaging patient – return to **STEP 1** & repeat
Engaging patient – move to **STEP 2**
Consider referral
**STEP 2** (see over)
![]()
Flowchart diagram illustrating the 'BSP UK Clinical Practice Guidelines for the Treatment of Periodontal Diseases'. The diagram features a central green box labeled 'STEP 1: Building foundations for optimal treatment outcomes' containing six numbered steps (I-VI). Above this is a diagnosis flow showing progression from 'Periodontal Health' to 'Gingivitis' and 'Periodontitis', with arrows indicating extraction of hopeless teeth. Below Step 1 is a 'Re-evaluate' decision node branching into 'Non-engaging patient' (return to STEP 1) and 'Engaging patient' (move to STEP 2).
<table>
<tr>
<td>
<b>BSP</b>
</td>
<td>
<b>Periodontitis (continued)</b>
</td>
<td>
Supported by
</td>
</tr>
<tr>
<td>
<b>STEP 2</b>
<b>Subgingival Instrumentation</b>
<i>(root surface debridement / PMPR on root)</i>
</td>
<td>
</td>
<td>
</td>
</tr>
<tr>
<td>
I: Reinforce OH, risk factor control, behaviour change
</td>
<td>
</td>
<td>
</td>
</tr>
<tr>
<td>
II: Subgingival instrumentation, hand or powered (sonic / ultrasonic), either alone or in combination
</td>
<td>
</td>
<td>
</td>
</tr>
<tr>
<td>
III: Use of adjunctive systemic antimicrobials determined by Practitioner accredited for Level 2 and 3 care
</td>
<td>
</td>
<td>
<b>gsk</b>
</td>
</tr>
<tr>
<td>
<b>STEP 3</b>
<b>Managing non-responding sites:</b>
I:\tReinforce OH, risk factor control, behaviour change II:\tModerate (4–5mm) residual pockets – re-perform subgingival instrumentation III:\tDeep residual pocketing ($\geq$6mm). Consider alternative causes IV.\tConsider referral for pocket management or regenerative surgery V:\tIf referral not possible, re-perform subgingival instrumentation (If all sites stable after <b>STEP 3</b> proceed to <b>STEP 4</b>)
</td>
<td>
<b>Re-evaluate after 3 months</b>
</td>
<td>
</td>
</tr>
<tr>
<td>
</td>
<td>
<b>Unstable</b>
\textrightarrow
</td>
<td>
</td>
</tr>
<tr>
<td>
</td>
<td>
Stable\ exitedbox
</td>
<td>
</td>
</tr>
<tr>
<td>
</td>
<td>
<b>STEP 4</b>
<b>Maintenance</b>
I:\tSupportive periodontal care strongly encouraged II: Reinforce OH, risk factor control, behaviour change III:\tRegular targeted PMPR as required to limit tooth loss IV:\tConsider evidence based adjunctive efficacious toothpaste and / or mouthwash to control gingival inflammation
</td>
<td>
</td>
<td>
</td>
</tr>
<tr>
<td>
</td>
<td>
<b>Maintenance recall</b>
<b>STEP 4</b>
– individuals tailored intervals from 3-12 months
</td>
<td>
</td>
<td>
</td>
</tr>
</table>
**BSP** | **Periodontitis (continued)**
**STEP 2**
**Subgingival Instrumentation** *(root surface debridement / PMPR on root)*
I: Reinforce OH, risk factor control, behaviour change
II: Subgingival instrumentation, hand or powered (sonic / ultrasonic), either alone or in combination
III: Use of adjunctive systemic antimicrobials determined by Practitioner accredited for Level 2 and 3 care
**STEP 3**
**Managing non-responding sites:**
I: Reinforce OH, risk factor control, behaviour change
II: Moderate (4–5mm) residual pockets – re-perform subgingival instrumentation
III: Deep residual pocketing (≥6mm). Consider alternative causes.
IV: Consider referral for pocket management or regenerative surgery
V: If referral not possible, re-perform subgingival instrumentation (If all sites stable after **STEP 3** proceed to **STEP 4**)
**Re-evaluate after 3 months**
**Unstable** →
**Stable**
**STEP 4**
**Maintenance**
I: Supportive periodontal care strongly encouraged
II: Reinforce OH, risk factor control, behaviour change
III: Regular targeted PMPR as required to limit tooth loss
IV: Consider evidence based adjunctive efficacious toothpaste and / or mouthwash to control gingival inflammation
**Maintenance recall**
**STEP 4** – individuals tailored intervals from 3-12 months
![]()
Flowchart diagram illustrating the treatment pathway for Periodontitis (continued) as per BSP guidelines. The diagram is structured into three main steps: STEP 2 (Subgingival Instrumentation), STEP 3 (Managing non-responding sites), and STEP 4 (Maintenance). It includes decision points ('Unstable' vs 'Stable') leading to re-evaluation after 3 months. Each step contains detailed sub-points (I-V) describing clinical actions such as risk factor control, instrumentation techniques, referral criteria, and maintenance protocols. Visual elements include colored boxes (red headers, green content areas, purple decision nodes), arrows indicating flow direction, and embedded text annotations.
<table>
<thead>
<tr>
<th colspan="2">Defining engaging & non-engaging patients (this is a guide)</th>
</tr>
</thead>
<tbody>
<tr>
<td>
I: Favourable improvement in OH – indicated by ≥50% improvement in plaque and marginal bleeding scores OR<br>
II: Plaque levels ≤20% & bleeding levels ≤30% OR<br>
III: Patient has met targets outlined in their personal self-care plan as determined by their healthcare practitioner
</td>
<td>
I: Insufficient improvement in OH – indicated by <50% improvement in plaque and marginal bleeding scores OR<br>
II: Plaque levels >20% & bleeding levels >30% OR<br>
III: Patient states preference to a palliative approach to periodontal care
</td>
</tr>
</tbody>
</table>
**Defining engaging & non-engaging patients (this is a guide)**
| Engaging Patient | Non-Engaging Patient |
|---|---|
| I: Favourable improvement in OH – indicated by ≥50% improvement in plaque and marginal bleeding scores OR<br>II: Plaque levels ≤20% & bleeding levels ≤30% OR<br>III: Patient has met targets outlined in their personal self-care plan as determined by their healthcare practitioner | I: Insufficient improvement in OH – indicated by <50% improvement in plaque and marginal bleeding scores OR<br>II: Plaque levels >20% & bleeding levels >30% OR<br>III: Patient states preference to a palliative approach to periodontal care |
![]()
A structured comparison table titled 'Defining engaging & non-engaging patients (this is a guide)'. The table is divided into two colored columns: green for 'Engaging' and orange for 'Non-engaging', with three rows labeled I, II, III. It outlines criteria for patient engagement based on oral health improvement (OH), plaque levels, bleeding levels, and self-care plan adherence.
# If endpoints are not met…
## Step 3: Corrective Phase
**Aim:** Treating those sites non-responding to the second step of therapy with the purpose of getting access to deep pocket sites, or aiming at regenerating or resecting those lesions, that add complexity in the management of periodontitis (infrabony and furcation lesions).
If periodontal pockets > 4 mm with bleeding on probing and/or deep pockets [≥ 6 mm] are still present at re-evaluation, different options for step 3 can be considered:
* Repeated subgingival instrumentation with or without adjunctive therapies.
* Access flap periodontal surgery.
* Resective periodontal surgery.
* Regenerative periodontal surgery.
**_REFERRAL TO PERIODONTIST_**
**If endpoints are not met…**
#### Step 3: Corrective Phase
**Aim:** Treating those sites non-responding to the second step of therapy with the purpose of getting access to deep pocket sites, or aiming at regenerating or resecting those lesions, that add complexity in the management of periodontitis (infrabony and furcation lesions).
If periodontal pockets > 4 mm with bleeding on probing and/or deep pockets [≥ 6 mm] are still present at re-evaluation, different options for step 3 can be considered:
- Repeated subgingival instrumentation with or without adjunctive therapies.
- Access flap periodontal surgery.
- Resective periodontal surgery.
- Regenerative periodontal surgery.
**_REFERRAL TO PERIODONTIST_**
# Maintenance/SPC
Step 4: Supportive Periodontal Care
**Aim:**
Preventing periodontitis recurrence/progression after successful completion of active treatment.
SPC must be performed in all patients.
#### Step 4: Supportive Periodontal Care
**Aim:**
Preventing periodontitis recurrence/progression after successful completion of active treatment.
SPC must be performed in all patients.
# Supportive Periodontal Care (Maintenance)
- **Continuous patient monitoring** following active periodontal therapy in order to maintain the clinical outcomes and prevent progression of periodontal diseases following therapy.
- Every **3–4 months** to **maintain treatment outcomes** following APT in highly susceptible patients (Lindhe & Nyman 1984)
**Supportive Periodontal Care (Maintenance)**
- Continuous patient monitoring following active periodontal therapy in order to maintain the clinical outcomes and prevent progression of periodontal diseases following therapy.
- Every **3–4 months** to **maintain treatment outcomes** following APT in highly susceptible patients (Lindhe & Nyman 1984)
- Lôe et al 1965 – Experimental Gingivitis in Man
- Lindhe et al 1975 – Experimental periodontitis in dogs
- Allowed plaque accumulation in a dog model
- NOT ALL DOGS DEVELOPED PERIODONTITIS
- MICROBIAL COMPOSITION
- HOST DEFENSE
- HOST SUCCEPTIBILITY
- Periodontitis was preceded by gingivitis
- Elimination of gingivitis can prevent occurrence of periodontitis
- Lôe et al 1965 – Experimental Gingivitis in Man
- Lindhe et al 1975 – Experimental periodontitis in dogs
- Allowed plaque accumulation in a dog model
- NOT ALL DOGS DEVELOPED PERIODONTITIS
- MICROBIAL COMPOSITION
- HOST DEFENSE
- HOST SUCCEPTIBILITY
- Periodontitis was preceded by gingivitis
- Elimination of gingivitis can prevent occurrence of periodontitis
![]()
Text-based procedure image outlining the Lindhe et al 1975 study on experimental periodontitis in dogs. It details that plaque accumulation was allowed in a dog model but not all dogs developed periodontitis due to factors like microbial composition, host defense, and host susceptibility. It also notes that periodontitis was preceded by gingivitis and elimination of gingivitis can prevent its occurrence.
![]()
Clinical comparison photo showing two states of dental health. The left panel depicts inflamed, red gingiva (gingivitis) with visible plaque accumulation at the gumline, illustrating the 'Role of biofilm as etiological factor'. The right panel shows healthy, pale pink gingiva with clean teeth, demonstrating the result of effective 'Biofilm control'. The images serve as a visual diagnosis comparing pathological inflammation against a healthy baseline.
There is a need of proper and regular personal biofilm control.
Interceptive professional support at regular intervals, may, to a certain extent, compensate for the non-optimal personal biofilm control.
There is a need of proper and regular personal biofilm control.
Interceptive professional support at regular intervals, may, to a certain extent, compensate for the non-optimal personal biofilm control.
![]()
Clinical photo showing a close-up of inflamed gingiva (redness and swelling) adjacent to teeth with visible plaque accumulation. This visual demonstrates the consequences of poor personal biofilm control.
![]()
Clinical photo showing healthy pink gingiva and clean tooth surfaces. This visual represents the outcome of proper and regular personal biofilm control.
Longitudinal Clinical Studies
**Michigan and Gothenburg studies:**
Series of clinical follow up studies on the outcome of different types of periodontal therapy where the crucial role of SPT in maintaining successful results has been documented.
- Well organized professional care program
- Regular = every 3 – 6 months
- Probing depth and attachment levels maintained
#### Longitudinal Clinical Studies
**Michigan and Gothenburg studies:**
Series of clinical follow up studies on the outcome of different types of periodontal therapy where the crucial role of SPT in maintaining successful results has been documented.
- Well organized professional care program
- Regular = every 3 – 6 months
- Probing depth and attachment levels maintained
Rosling et al 1976
* Studied the healing outcome after different types of surgical periodontal treatment in patients maintained with regular professional care after 2 years.
* Rosling et al. (1976) reported that in test group of humans who had received modified Widman flap surgery and strict post-surgical oral hygiene, all two and three-wall osseous periodontal defects healed.
Rosling et al 1976
- Studied the healing outcome after different types of surgical periodontal treatment in patients maintained with regular professional care after 2 years.
- Rosling et al. (1976) reported that in test group of humans who had received modified Widman flap surgery and strict post-surgical oral hygiene, all two and three-wall osseous periodontal defects healed.
# Nyman et al., 1977
• Studied the healing outcome after different types of surgical periodontal treatment in patients without regular professional care after 2 years.
• Resulted in recurrent periodontitis including loss of attachment 3-5x the rate documented for natural progression of periodontal disease.
Nyman, S., Lindhe, J., & Rosling, B. (1977). Periodontal surgery in plaque-infected dentitions. Journal of clinical periodontology, 4(4), 240-249
Nyman et al., 1977
- Studied the healing outcome after different types of surgical periodontal treatment in patients without regular professional care after 2 years.
- Resulted in recurrent periodontitis including loss of attachment 3-5x the rate documented for natural progression of periodontal disease.
Nyman, S., Lindhe, J., & Rosling, B. (1977). Periodontal surgery in plaque-infected dentitions. Journal of clinical periodontology, 4(4), 240-249
Axelsson & Lindhe 1981
- 90 pts w/ adv perio
- OHI, S/RP, exo of hopeless teeth → MWF → CHX for 2 weeks, and professional mechanical plaque removal every 2 weeks for a period of 2 months
- Recall group: 2/3 retained in the Periodontal clinic for maintenance → OHI, S/RP every 2/12 for 0-2nd yr and 3/12 for 2-6th yr.
- ALoss ≥1mm for 1% of sites
- 0.2 tooth loss
- Non-recall group: 1/3 returned to referring dentist → unknown treatment
- **ALoss ≥1mm for 56% of sites**
- **ALoss 2-5mm for 55% sites**
- PD ≥4mm 20%
- Proximal PD ≥4mm at 32% sites
- 0.7 tooth loss
Axelsson & Lindhe 1981
- 90 pts w/ adv perio
- OHI, S/RP, exo of hopeless teeth → MWF → CHX for 2 weeks, and professional mechanical plaque removal every 2 weeks for a period of 2 months
- Recall group: 2/3 retained in the Periodontal clinic for maintenance → OHI, S/RP every 2/12 for 0-2nd yr and 3/12 for 2-6th yr.
- ALoss ≥1mm for 1% of sites
- 0.2 tooth loss
- Non-recall group: 1/3 returned to referring dentist → unknown treatment
- **ALoss ≥1mm for 56% of sites**
- **ALoss 2-5mm for 55% sites**
- PD ≥4mm 20%
- Proximal PD ≥4mm at 32% sites
- 0.7 tooth loss
**What have we learnt from these longitudinal studies?**
* Reinforces the importance of having scheduled supervised maintenance program for all periodontitis patients.
* Frequency of periodontal maintenance care for each patient will vary depending on each individual’s risk for recurrence of periodontitis.
……Leading us to discuss RISK ASSESSMENT……
**What have we learnt from these longitudinal studies?**
- Reinforces the importance of having scheduled supervised maintenance program for all periodontitis patients.
- Frequency of periodontal maintenance care for each patient will vary depending on each individual’s risk for recurrence of periodontitis.
……Leading us to discuss RISK ASSESSMENT……
# Risk Assessment
# Risk Assessment
* Following Active Periodontal Therapy (APT), individualised Supportive Periodontal Care (SPC) is initiated.
* The goal is to prevent disease recurrence and maintain periodontal stability.
## Variability in Patient Susceptibility
* Not all treated patients have the same risk of periodontal disease progression (Rosling et al., 2001).
* Some patients require shorter intervals for SPC due to higher susceptibility.
* Risk evaluation is based on multiple clinical factors.
* No single parameter is solely responsible for determining risk.
- Following Active Periodontal Therapy (APT), individualised Supportive Periodontal Care (SPC) is initiated.
- The goal is to prevent disease recurrence and maintain periodontal stability.
#### Variability in Patient Susceptibility
- Not all treated patients have the same risk of periodontal disease progression (Rosling et al., 2001).
- Some patients require shorter intervals for SPC due to higher susceptibility.
- Risk evaluation is based on multiple clinical factors.
- No single parameter is solely responsible for determining risk.
# Periodontal Risk Assessment
## Comprehensive Evaluation Approach
- All risk factors should be considered simultaneously.
- A structured framework enhances clinical decision-making.
**→ Functional Diagram (Lang & Tonetti, 2003)**
- Developed to systematically assess risk.
- Incorporates key parameters influencing periodontitis recurrence.
#### Comprehensive Evaluation Approach
- All risk factors should be considered simultaneously.
- A structured framework enhances clinical decision-making.
**→ Functional Diagram (Lang & Tonetti, 2003)**
- Developed to systematically assess risk.
- Incorporates key parameters influencing periodontitis recurrence.
# Assessment of Periodontitis Recurrence Risk
* Patient-level percentage of bleeding on probing (BoP)
* Prevalence (number) of residual pockets ≥4 mm following active periodontal therapy
* Loss of teeth from a total of 28 teeth
* Loss of periodontal support in relation to the patient’s age
* Systemic and genetic conditions
* Environmental factors such as cigarette smoking.
<div style="float: right; width: 150px; height: 150px; margin-left: 15px; margin-bottom: 15px;">
<img style="width: 100%; height: 100%; object-fit: contain;" src="data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAIAAAACACAYAAADDPmHLAAAABHNCSVQICAgIfAhkiAAAAAlwSFlzAAALEwAACxMBAJqcGAAAA09JREFUeJztnTXgzCkQRX/81oCuvz5gf30gGAWeAPgIwdGBR0QAVQ0EBmGEOPaBciwc+f7+7QmE+dAAzDAEE2/WAAAAjA3gAJEAgHAAAABRQQql8OMN86/3G6W5T1dycVvu/t/8P1_on18AAA3ArTgZvO5Uz+erX5zlPn07q9n+5egAAJgX4UnB+pulk+fjudfrXb5u27Zl29l dzuFwHR4e8urVq21n9+vrW9i3f6/2eV4/AVvu/v7+Etzl6+tb+N/vv9+3ZTQBGx8fXxyx/f39F/WPP4xYa/m/PnKe6P8YhsfiPnvwn2c4AHfv39fCkriP6+vrfT8R/YZ20X9xP3JSehrXH+GTnUsAAIBHZ6Bc149nOp1iapuz3NhD2RXB0NDQYi3v378fz3S6faR5jZSwsLCwsMrbGx8f/t4riXNbUvreAUQAAMh+oc1TLg1mT7kAAOA0icwmYHx8fNjr7K9fgPVoAABg7ykYPQAAAJgp4B0A/oa/y32+BPjYALPCJwCAJSOASAACAMAUAAQR0AS8AwAAQkAHgJMAAIAJAqJ9MNPpNGRwrBvAkAN8AfCjVePGT+AFQNAEFkxBWBwIuNVKQCNHTDQZnFDlVLXydD6aH0pnLwIAohkGgFYDAMcmgbd3auxoYyulnQAAhRr8DAcF75BENLdN0Gz3 JM0xOYCLd19aKg/ncIAE0NYzI6vSxUA0oXr7YCJXhwAAEbF3Dw0CAyebMIoU2hdzuOHYulNTovIioj/opuR05O4e2tjmj/th7T/nE6nfO8XAAAAAAAARsPYBgAAAABgkmILAAEAAAABRgAQqANg5hYAAIaOASIhAgAAwCydbgAhARip33 kedepan dari pada itu, karna antara lain:; dan lain sebagainya.
Wait, let me re-read the source image text properly, specifically the right side.
Ah, the "READ ME" is standard text, and the QR code is just an image. There is no text *inside* the QR code that is legible enough for OCR in a standard text generation task (it encodes binary data or a URL). The TXT provided has "READ ME" as text, which matches the image. The "DATA"... Wait, the TXT text was cut off or hallucinated "ONC" and "TUMOR" which is not in the image. The TXT is likely coming from a different context or I need to be very careful not to hallucinate.
Let me look at the image again.
Title: "Assessment of Periodontitis Recurrence Risk"
Bullets:
- Patient-level percentage of bleeding on probing (BoP)
- Prevalence (number) of residual pockets ≥4 mm following active periodontal therapy
- Loss of teeth from a total of 28 teeth
- Loss of periodontal support in relation to the patient’s age
- Systemic and genetic conditions
- Environmental factors such as cigarette smoking.
Right side: "READ ME" (bold) and a QR code.
Footer: "Lang, N. P., & Tonetti, M. S. (2003). Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral Health Prev Dent, 1(1), 7-16."
I will ignore the hallucinated "ANDA DARHUD..." which was not in the image.
The instruction "READ ME" is text.
The QR code is an image.
The header/footer are text.
Okay, final plan:
Markdown for title and list.
HTML blockquote for the footer.
Image tag for the QR code.
Bold the "READ ME" as per instructions.
# Assessment of Periodontitis Recurrence Risk
* Patient-level percentage of bleeding on probing (BoP)
* Prevalence (number) of residual pockets ≥4 mm following active periodontal therapy
* Loss of teeth from a total of 28 teeth
* Loss of periodontal support in relation to the patient’s age
* Systemic and genetic conditions
* Environmental factors such as cigarette smoking.
```markdown
<div style="float: right; width: 150px; height: 150px; margin-left: 15px; margin-bottom: 15px;">
<img src="qr_code_url" alt="QR code image">
</div>
**READ ME**
```
---
Lang, N. P., & Tonetti, M. S. (2003). Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). *Oral Health Prev Dent*, 1(1), 7-16.
- Patient-level percentage of bleeding on probing (BoP)
- Prevalence (number) of residual pockets ≥4 mm following active periodontal therapy
- Loss of teeth from a total of 28 teeth
- Loss of periodontal support in relation to the patient’s age
- Systemic and genetic conditions
- Environmental factors such as cigarette smoking.
Lang, N. P., & Tonetti, M. S. (2003). Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). *Oral Health Prev Dent*, 1(1), 7-16.
![]()
QR code image with the text 'READ ME' above it.
Percentage of Bleeding on Probing (BoP) Sites
* BoP = Objective inflammatory marker (Loe & Silness, 1963).
* Used to assess risk of disease recurrence and patient compliance with biofilm control.
* No universally established BoP threshold for high risk, but:
* Ramseier et al. (2015): Patients with BoP ≤ 20% maintained stability for 5 years.
* Claffey et al. (1990), Badersten et al. (1990):
* <10% BoP → Low risk for recurrence.
* >25% BoP → High risk for recurrence.
#### Percentage of Bleeding on Probing (BoP) Sites
- BoP = Objective inflammatory marker (Loe & Silness, 1963).
- Used to assess risk of disease recurrence and patient compliance with biofilm control.
- No universally established BoP threshold for high risk, but:
- Ramseier et al. (2015): Patients with BoP ≤ 20% maintained stability for 5 years.
- Claffey et al. (1990), Badersten et al. (1990):
- <10% BoP → Low risk for recurrence.
- >25% BoP → High risk for recurrence.
![]()
Text-based summary table listing BoP thresholds and associated risk levels. It contains two primary rows: one stating '<10% BoP → Low risk for recurrence' in green text, and another stating '>25% BoP → High risk for recurrence' in red text.
**Prevalence of Residual Pockets (≥5mm)**
• Matuliene et al. (2008): Retrospective study on periodontal disease progression and tooth loss over 11 years.
• Odds ratios for tooth loss based on probing depth (PD):
• PD 5mm: 5.8 (site-level), 7.7 (tooth-level).
• PD 6mm: 9.3 (site-level), 11.0 (tooth-level).
• PD 7mm: 37.9 (site-level), 64.2 (tooth-level).
• Key finding: Presence of ≥1 site with PD >6mm + BoP ≥30% significantly increases risk of tooth loss.
**Prevalence of Residual Pockets (≥5mm)**
- Matuliene et al. (2008): Retrospective study on periodontal disease progression and tooth loss over 11 years.
- Odds ratios for tooth loss based on probing depth (PD):
- PD 5mm: 5.8 (site-level), 7.7 (tooth-level).
- PD 6mm: 9.3 (site-level), 11.0 (tooth-level).
- PD 7mm: 37.9 (site-level), 64.2 (tooth-level).
- Key finding: Presence of ≥1 site with PD >6mm + BoP ≥30% significantly increases risk of tooth loss.
# Tooth Loss
**1. Importance of Remaining Teeth**
* The number of remaining teeth reflects dental functionality.
* Mandibular stability and function can be maintained with a shortened dental arch (premolar to premolar occlusion = 20 teeth) (*Witter et al.*, 1990, 1994).
* No increased risk of mandibular dysfunction with a shortened dental arch.
**2. Impact of Tooth Loss on Oral Function**
* Loss of >8 teeth (excluding third molars) leads to impaired oral function (*Käyser*, 1981, 1994, 1996).
* Tooth loss is a key outcome measure, reflecting a patient’s history of:
* Oral diseases
* Trauma
**3. Risk Assessment Based on Tooth Loss**
* Number of lost teeth (excluding third molars) = Risk indicator in periodontal risk assessment.
* Critical thresholds for risk categorization:
* Low risk: Up to 4 teeth lost
* High risk: More than 8 teeth lost
* Rationale:
* Further tooth loss impacts overall dentition function.
* Preservation of remaining teeth is crucial for maintaining oral health and function.
#### Tooth Loss
**1. Importance of Remaining Teeth**
- The number of remaining teeth reflects dental functionality.
- Mandibular stability and function can be maintained with a shortened dental arch (premolar to premolar occlusion = 20 teeth) (*Witter et al.*, 1990, 1994).
- No increased risk of mandibular dysfunction with a shortened dental arch.
**2. Impact of Tooth Loss on Oral Function**
- Loss of >8 teeth (excluding third molars) leads to impaired oral function (*Käyser*, 1981, 1994, 1996).
- Tooth loss is a key outcome measure, reflecting a patient’s history of:
- Oral diseases
- Trauma
**3. Risk Assessment Based on Tooth Loss**
- Number of lost teeth (excluding third molars) = Risk indicator in periodontal risk assessment.
- Critical thresholds for risk categorization:
- Low risk: Up to 4 teeth lost
- High risk: More than 8 teeth lost
- Rationale:
- Further tooth loss impacts overall dentition function.
- Preservation of remaining teeth is crucial for maintaining oral health and function.
\radiographic Bone Loss \& Age
* Extent \& rate of bone loss provide insight into disease progression risk.
* Helps guide SPC interval selection.
#### Radiographic Bone Loss & Age
- Extent & rate of bone loss provide insight into disease progression risk.
- Helps guide SPC interval selection.
# Systemic Conditions
**Diabetes Mellitus:**
* Affects periodontal disease progression and recurrence.
* Poor glycemic control increases risk.
**Genetic Factors (IL-1 Genotype):**
* IL-1 positive individuals exhibit more advanced periodontitis lesions.
* May require more frequent SPC.
#### Systemic Conditions
**Diabetes Mellitus:**
- Affects periodontal disease progression and recurrence.
- Poor glycemic control increases risk.
**Genetic Factors (IL-1 Genotype):**
- IL-1 positive individuals exhibit more advanced periodontitis lesions.
- May require more frequent SPC.
Smoking (Cigarettes)
Increases disease susceptibility and worsens treatment outcomes.
**Baumert-Ah et al. (1994):** Smokers have less favorable healing responses at reevaluation and after 6 years of SPT.
**Baumer et al. (2011):**
* Heavy smoking = Significant risk factor for periodontal recurrence after 10.5 years of SPT.
* Smokers need shorter SPT intervals to compensate for increased risk.
#### Smoking (Cigarettes)
Increases disease susceptibility and worsens treatment outcomes.
**Baumert-Ah et al. (1994):** Smokers have less favorable healing responses at reevaluation and after 6 years of SPT.
**Baumer et al. (2011):**
- Heavy smoking = Significant risk factor for periodontal recurrence after 10.5 years of SPT.
- Smokers need shorter SPT intervals to compensate for increased risk.
![]()
Radar chart showing functional diagram for low-risk periodontal status. Axes include BoP% = 0, PD ≥5 mm, Tooth loss, BL/Age = 0.00, Systemic/General, and Environmental. The shaded area is minimal, indicating low values across all parameters.
![]()
Radar chart showing functional diagram for medium-risk periodontal status. Axes include BoP% = 9, PD ≥5 mm, Tooth loss, BL/Age = 0.75, Systemic/General, and Environmental. The shaded area shows moderate expansion compared to low-risk, particularly in the tooth loss and environmental sectors.
# Matuliene et al., 2010
Matuliene et al. 2010 “Significance of periodontal risk assessment on the recurrence of periodontitis and tooth loss.”
* Retrospective study
* 160 pts treated with active therapy and in SPT
* Recurrence of periodontitis: 18.2% in low-risk, 42.4% in moderate-risk, 49.2% in high-risk
* 1.61 teeth/pt lost during SPT
* TL: 1.18/pt in low-risk, 1.02/pt in mod-risk, 2.59/pt in high-risk
* TL in compliant pts 1.07 vs. non-compliant 3.11
* High-risk profile according to PRA associated with recurrence
* SPT >10yrs also associated with recurrence
#### Matuliene et al., 2010
Matuliene et al. 2010 “Significance of periodontal risk assessment on the recurrence of periodontitis and tooth loss.”
- Retrospective study
- 160 pts treated with active therapy and in SPT
- Recurrence of periodontitis: 18.2% in low-risk, 42.4% in moderate-risk, 49.2% in high-risk
- 1.61 teeth/pt lost during SPT
- TL: 1.18/pt in low-risk, 1.02/pt in mod-risk, 2.59/pt in high-risk
- TL in compliant pts 1.07 vs. non-compliant 3.11
- High-risk profile according to PRA associated with recurrence
- SPT >10yrs also associated with recurrence
![]()
Table: Summary of tooth loss (TL) statistics per patient. Rows include 'TL: 1.18/pt in low-risk', '1.02/pt in mod-risk', and '2.59/pt in high-risk'. The table visually presents comparative data on tooth loss across risk categories.
![]()
Table: Comparison of tooth loss based on compliance status. Displays values for 'compliant pts' (1.07) versus 'non-compliant' patients (3.11). This visual element highlights the impact of patient compliance on treatment outcomes.
Ramseier et al., 2019
• Retrospective study. 883 patients
**Key Findings:**
Impact of Time Between SPT Visits on Periodontal Stability
• Longer intervals between SPT visits were linked to:
• Higher residual PPDs
• Increased risk of periodontal disease progression
• More frequent tooth loss
• Shorter intervals between SPT visits led to:
• Improved periodontal stability
• Lower mean % of PPDs ≥4mm
• Reduced frequency of tooth loss over 20 years
• Patients returning >50% of visits earlier had:
• Lower PPDs after 5 years (*p = 0.0002*)
• Fewer teeth extracted after 20 years (*p < 0.0001*)
Ramseier, C. A., Nydegger, M., Walter, C., Fischer, G., Sculean, A., Lang, N. P., Salvi, G. E. (2019). Time between recall visits and residual probing depths predict long-term stability in patients enrolled in supportive periodontal therapy. *Journal of Clinical Periodontology*, 46(2), 218-230. doi:10.1111/jcpe.13041.
#### Ramseier et al., 2019
- Retrospective study. 883 patients
**Key Findings:**
Impact of Time Between SPT Visits on Periodontal Stability
- Longer intervals between SPT visits were linked to:
- Higher residual PPDs
- Increased risk of periodontal disease progression
- More frequent tooth loss
- Shorter intervals between SPT visits led to:
- Improved periodontal stability
- Lower mean % of PPDs ≥4mm
- Reduced frequency of tooth loss over 20 years
- Patients returning >50% of visits earlier had:
- Lower PPDs after 5 years (*p = 0.0002*)
- Fewer teeth extracted after 20 years (*p < 0.0001*)
Ramseier, C. A., Nydegger, M., Walter, C., Fischer, G., Sculean, A., Lang, N. P., Salvi, G. E. (2019). Time between recall visits and residual probing depths predict long-term stability in patients enrolled in supportive periodontal therapy. *Journal of Clinical Periodontology*, 46(2), 218-230. doi:10.1111/jcpe.13041.
Perio-Tools
**Supportive Periodontal Therapy (SPT)**
The goal of the online **supportive periodontal therapy (SPT)** interval tool is to offer suggestions for scheduling subsequent intervals for SPT.
We currently offer this tool in **6** languages.
#### Perio-Tools
**Supportive Periodontal Therapy (SPT)**
The goal of the online **supportive periodontal therapy (SPT)** interval tool is to offer suggestions for scheduling subsequent intervals for SPT.
We currently offer this tool in **6** languages.
![]()
Screenshot of the Perio-Tools interface displaying an 'Analysis' table with columns for 4mm, 5mm, and ≥6mm pockets. It includes rows for 'No. of pockets', 'Pockets (%)', and 'Cumulative (%)'. A 'Functional Diagram' section is visible below with a color-coded timeline (yellow and green blocks) indicating intervals of 4, 6, 9, and 12 months alongside corresponding percentage thresholds.
Thank You
![]()
Aerial photograph of a bridge spanning turquoise water. The image shows the top-down view of a multi-lane road with vehicles traveling on it, set against a textured blue-green ocean background.
[^1]: Original PDF page 1: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=1|L8 Re-assessment and Maintenance, Risk Assessment, p.1]]
[^2]: Original PDF page 2: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=2|L8 Re-assessment and Maintenance, Risk Assessment, p.2]]
[^3]: Original PDF page 3: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=3|L8 Re-assessment and Maintenance, Risk Assessment, p.3]]
[^4]: Original PDF page 4: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=4|L8 Re-assessment and Maintenance, Risk Assessment, p.4]]
[^5]: Original PDF page 5: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=5|L8 Re-assessment and Maintenance, Risk Assessment, p.5]]
[^6]: Original PDF page 6: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=6|L8 Re-assessment and Maintenance, Risk Assessment, p.6]]
[^7]: Original PDF page 7: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=7|L8 Re-assessment and Maintenance, Risk Assessment, p.7]]
[^8]: Original PDF page 8: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=8|L8 Re-assessment and Maintenance, Risk Assessment, p.8]]
[^9]: Original PDF page 9: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=9|L8 Re-assessment and Maintenance, Risk Assessment, p.9]]
[^10]: Original PDF page 10: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=10|L8 Re-assessment and Maintenance, Risk Assessment, p.10]]
[^11]: Original PDF page 11: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=11|L8 Re-assessment and Maintenance, Risk Assessment, p.11]]
[^12]: Original PDF page 12: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=12|L8 Re-assessment and Maintenance, Risk Assessment, p.12]]
[^13]: Original PDF page 13: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=13|L8 Re-assessment and Maintenance, Risk Assessment, p.13]]
[^14]: Original PDF page 14: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=14|L8 Re-assessment and Maintenance, Risk Assessment, p.14]]
[^15]: Original PDF page 15: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=15|L8 Re-assessment and Maintenance, Risk Assessment, p.15]]
[^16]: Original PDF page 16: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=16|L8 Re-assessment and Maintenance, Risk Assessment, p.16]]
[^17]: Original PDF page 17: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=17|L8 Re-assessment and Maintenance, Risk Assessment, p.17]]
[^18]: Original PDF page 18: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=18|L8 Re-assessment and Maintenance, Risk Assessment, p.18]]
[^19]: Original PDF page 19: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=19|L8 Re-assessment and Maintenance, Risk Assessment, p.19]]
[^20]: Original PDF page 20: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=20|L8 Re-assessment and Maintenance, Risk Assessment, p.20]]
[^21]: Original PDF page 21: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=21|L8 Re-assessment and Maintenance, Risk Assessment, p.21]]
[^22]: Original PDF page 22: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=22|L8 Re-assessment and Maintenance, Risk Assessment, p.22]]
[^23]: Original PDF page 23: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=23|L8 Re-assessment and Maintenance, Risk Assessment, p.23]]
[^24]: Original PDF page 24: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=24|L8 Re-assessment and Maintenance, Risk Assessment, p.24]]
[^25]: Original PDF page 25: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=25|L8 Re-assessment and Maintenance, Risk Assessment, p.25]]
[^26]: Original PDF page 26: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=26|L8 Re-assessment and Maintenance, Risk Assessment, p.26]]
[^27]: Original PDF page 27: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=27|L8 Re-assessment and Maintenance, Risk Assessment, p.27]]
[^28]: Original PDF page 28: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=28|L8 Re-assessment and Maintenance, Risk Assessment, p.28]]
[^29]: Original PDF page 29: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=29|L8 Re-assessment and Maintenance, Risk Assessment, p.29]]
[^30]: Original PDF page 30: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=30|L8 Re-assessment and Maintenance, Risk Assessment, p.30]]
[^31]: Original PDF page 31: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=31|L8 Re-assessment and Maintenance, Risk Assessment, p.31]]
[^32]: Original PDF page 32: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=32|L8 Re-assessment and Maintenance, Risk Assessment, p.32]]
[^33]: Original PDF page 33: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=33|L8 Re-assessment and Maintenance, Risk Assessment, p.33]]
[^34]: Original PDF page 34: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=34|L8 Re-assessment and Maintenance, Risk Assessment, p.34]]
[^35]: Original PDF page 35: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=35|L8 Re-assessment and Maintenance, Risk Assessment, p.35]]
[^36]: Original PDF page 36: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=36|L8 Re-assessment and Maintenance, Risk Assessment, p.36]]
[^37]: Original PDF page 37: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=37|L8 Re-assessment and Maintenance, Risk Assessment, p.37]]
[^38]: Original PDF page 38: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=38|L8 Re-assessment and Maintenance, Risk Assessment, p.38]]
[^39]: Original PDF page 39: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=39|L8 Re-assessment and Maintenance, Risk Assessment, p.39]]
[^40]: Original PDF page 40: [[L8 Re-assessment and Maintenance, Risk Assessment.pdf#page=40|L8 Re-assessment and Maintenance, Risk Assessment, p.40]]