Abstract
Introduction
Adherence to supportive periodontal care (SPC) is essential for preventing disease recurrence and maintaining oral health. Psychological and emotional support from family members may play a vital role in sustaining long-term adherence, yet the influence of family function on SPC adherence and outcomes remains underexplored.
Objective
To evaluate the impact of family function on adherence to SPC and its subsequent effect on periodontal prognosis.
Methods
This retrospective study included 400 patients aged 20–73 years who received active periodontal therapy between January 2018 and January 2020 and entered SPC for at least one year. Family functioning was assessed using the Apgar score. Patient adherence was evaluated based on adherence to scheduled follow-up visits within a 3-month period. Clinical parameters, including probing depth and bleeding on probing, were recorded at baseline and follow-up visits. Multivariable logistic regression was used to assess the relationship between family functioning, patient adherence, and treatment outcomes.
Results
The regular adherence group had an adherence rate of 38%, and their family care index was significantly higher than that of the irregular group (9.58 ± 0.58 vs. 9.00 ± 0.90, p < .01). Both groups showed improvements in periodontal prognosis following SPC (p < .01). Patients with a higher family care index exhibited better adherence, with a more pronounced improvement in prognosis (p < .01). Logistic regression analysis identified gender (odds ratio [OR] = 2.730, 95% CI [1.683, 4.430], p < .01), age (OR = 0.999, 95% CI [0.970, 1.02], p < .01), and orthodontic history (OR = 7.941, 95% CI [1.497, 42.116], p < .05) as significant factors influencing SPC adherence.
Conclusion
Patients with higher family function scores demonstrate better adherence with SPC, resulting in more favorable treatment outcomes. The involvement of family members plays a critical role in enhancing patient adherence to treatment protocols, thereby improving both oral health and overall quality of life.
Keywords
Background
Periodontitis is a leading cause of tooth loss in adults worldwide (Tonetti et al., 2017), with severe cases affecting approximately 10.8% of the population, posing significant public health challenges due to its high prevalence and its impact on the overall health and quality of life (Bawaskar & Bawaskar, 2020). Supportive Periodontal Care (SPC) refers to a structured maintenance phase following active periodontal therapy (APT; Sonnenschein et al., 2020). It involves periodic professional care, including scaling, root planning, and reinforcement of oral hygiene, aimed at preventing recurrence of periodontitis and maintaining long-term periodontal stability. Despite achieving initial treatment success, patient adherence to SPC often declines over time, with nonadherence being a significant factor contributing to disease relapse (Gao et al., 2021). Studies report a wide variation in SPC adherence, ranging from 3.3% to 86.8% (Amerio et al., 2020; De Wet et al., 2018; Lee et al., 2019), with a study by Lee et al. (2019) finding that only 14.1% of chronic periodontitis patients adhered to regular follow-up over 3–5 years.
Adherence with SPC is influenced by multiple factors, including individual motivation, financial constraints, and psychosocial support (Bittencourt et al., 2022). Among these, family support has emerged as a key determinant, with studies indicating that strong family functioning can enhance adherence to medical recommendations and promote healthier behaviors (Gazzaz et al., 2021). This finding supports the principles of family-centered nursing care, which emphasize involving family members in care planning and decision-making to improve patient adherence and long-term outcomes, which emphasizes the strategic integration of family engagement to optimize chronic disease management outcomes (Rina & Mahendro Prasetyo, 2023). Within this framework, nurses serve as crucial mediators between clinical protocols and daily implementation, employing patient education and behavioral coaching techniques to operationalize oral health guidelines into sustainable self-care routines. This synergistic approach, combining professional healthcare interventions with strengthened family support systems, establishes a comprehensive strategy for improving SPC adherence. However, few studies have explored how family functioning influences SPC adherence, particularly regarding other oral health outcomes beyond periodontitis (Yuen, Fuligni, Gonzales & Telzer, 2018). This study aims to assess the impact of family function, measured by the Family APGAR Index, on patient adherence with SPC and its subsequent effects on periodontal prognosis. By addressing this gap in the literature, the study seeks to inform strategies for improving SPC adherence and optimizing long-term periodontal care outcomes.
Materials and Methods
Study Design and Setting
This retrospective study included 400 patients who entered SPC following completion of APT between January 2018 and January 2020. Patient data were retrieved from electronic medical records, covering their SPC treatment and visit history up to October 31, 2022. Depending on the time of SPC entry, individual observation durations ranged from 34 to 58 months. The study design was informed by the approach of Lee et al. (2019), and the sample size was expanded by approximately twofold to enhance the reliability and reproducibility of the findings. The study was approved by the hospital's Ethics Committee (Approval No: 2022054 Review Research No. 2022054), and informed consent was obtained from all participants. The patients’ ages ranged from 20 to 73 years, with a mean age of 45.2 ± 12.4 years.
Eligibility Criteria
Inclusion Criteria
Patients were included if they met the 2018 World Workshop criteria for Stage IIIB or IIIC periodontitis (Tonetti et al., 2018) and completed ≥1 year of SPC after APT.
Stage IIIB, Severe Periodontitis with Potential for Tooth Loss: Characterized by severity (clinical attachment loss [CAL] ≥ 5 mm at the worst site, radiographic bone loss 33%–66% of root length, ≤4 teeth lost due to periodontitis) and complexity (probing depths [PDs] ≥6 mm, vertical bone defects ≥3 mm, Class II/III furcation involvement). Stage IIIC, Advanced Periodontitis with Extensive Tooth Loss: Characterized by severity (CAL ≥5 mm at the worst site, radiographic bone loss >66% of root length, ≥5 teeth lost due to periodontitis) and complexity (posterior bite collapse, severe ridge defects, tooth mobility ≥2, <20 remaining teeth).
Exclusion Criteria
Patients who discontinued periodontal support therapy before completion;
Patients with incomplete clinical or imaging data;
Pregnant women;
Patients older than 80 years.
All patients received oral hygiene instructions, including the Bass method of brushing and the use of additional aids such as flossing or interdental brushes.
Variables and Definitions
Family Function Assessment
During SPC, family functioning was assessed using the Family APGAR Index, a validated tool developed by Dr. David Smilkstein to measure five dimensions of perceived family support: Adaptability, Partnership, Growth, Affection, and Resolve (Wartberg et al., 2016). Each item is rated on a 3-point Likert scale (0 = rarely, 1 = sometimes, 2 = often), yielding a total score from 0 to 10, where 7–10 indicates good functioning, 4–6 moderate dysfunction, and 0–3 severe dysfunction. The questionnaire was administered online or in person, with telephone follow-ups conducted for nonrespondents to maximize data completeness. Widely adopted (Cheng et al., 2017; Mayorga-Muñoz et al., 2019) in both clinical and research settings, the APGAR Index offers a concise, reliable measure of family dynamics. Its use in this study provides a structured lens to examine how familial support influences adherence to periodontal maintenance, reinforcing the value of integrating psychosocial determinants into long-term care planning.
Supportive Periodontal Care Adherence Classification
Regular Compliers (RC): Patients who attended their scheduled appointments within 3 months of the designated follow-up date. Irregular Compliers (IC): Patients who were more than 3 months late, missed one or more visits, or interrupted their follow-up.
Clinical Parameter
Periodontal clinical parameters, including baseline PD, CAL, bleeding on probing (BOP), and plaque index, were recorded at the time of SPC enrollment using standardized protocols. Periodontal health was assessed by two key clinical parameters: PD: Measured at the baseline (PD1) and at the final follow-up (PD2). Bleeding on Probing: Measured at the baseline (BOP1) and at the final follow-up (BOP2). Changes in PD and BOP between the initial and final assessments (PD2/PD1 and BOP2/BOP1) were used to evaluate the impact of SPC on periodontal health.
Data Analysis
Statistical analyses were conducted using SPSS version 20. Participants were categorized into two adherence groups: RC and IC. Continuous variables were expressed as means ± standard deviations and compared using independent samples t-tests. Categorical variables were presented as frequencies (percentages) and assessed using the chi-square (χ²) test. Fisher's exact test was applied when the assumptions of the χ² test were not met.
To facilitate meaningful subgroup comparisons, age was stratified into four categories: <35, 35–44, 45–54, and >54 years. This stratification is consistent with age groupings used in epidemiological surveillance studies on periodontitis (Eke et al., 2012) and helps balance statistical power with clinical interpretability.
To examine factors associated with SPC nonadherence, a binary logistic regression model was constructed using a forward stepwise approach. The dependent variable was adherence status (RC vs. IC), and independent variables included gender, age group, family APGAR score, and baseline periodontal parameters. Variables with p < .1 in univariate analysis were entered into the multivariate model. Results were reported as odds ratios (ORs) with 95% confidence intervals (CIs), and a p < .05 was considered statistically significant.
Results
A total of 400 patients receiving supportive periodontal therapy were enrolled in this study, including 198 men (49.5%) and 202 women (50.5%). The participants’ ages ranged from 20 to 73 years. Participants were categorized into four age groups: <35 years, 35–44 years, 45–54 years, and >54 years, following the stratification outlined in “Methods” section to ensure consistency with epidemiological standards (Eke et al., 2012).
Among the participants, 46 (11.5%) had a history of periodontal surgery, 20 (5.0%) had hypertension, 27 (6.8%) had undergone orthodontic treatment, and 40 (10.0%) had received dental implants. Of these, 152 (38.0%) were RC, and 248 (62.0%) were IC. Detailed results are presented in Table 1. The mean Family APGAR score was significantly higher in the regular adherence group (9.58 ± 0.58) than in the irregular group (9.00 ± 0.90; p < .01). No significant difference was observed in baseline probing depth 1 (PD1) between the regular and irregular adherence groups (p > .05). No significant difference was observed in baseline PD1 between the two groups (p > .05). However, at follow-up, both PD2 and BOP2 were significantly lower in the regular adherence group compared to the irregular group (p < .01). Additionally, the degree of improvement in PD (PD3) and BOP3 was significantly greater in the regular adherence group (p < .01).
General Information and Univariate Analysis among Different Groups of the Study Subjects (n = 400).
Note: * Variable is a continuous variable, expressed in the form of “mean (standard deviation),” and T-test is used for intergroup comparison; The rest were categorical variables, expressed in the form of “frequency (component ratio),” and χ2 test was used for comparison between groups.
To further identify factors associated with SPC adherence, a multivariable logistic regression analysis was performed. The results showed that gender (OR = 2.730, 95% CI [1.683, 4.430] p < .01), age (OR = 0.999, 95% CI [0.970, 1.02] p < .01), and orthodontics (OR = 0.164; 95% CI [0.038, 0.712] p < .05) were statistically significant for periodontal treatment adherence. Results can be seen in Table 2.
Logistic Regression Analysis of Nonadherence (n = 400).
Notes: β(Coefficients): The β values represent the change in the log odds of the outcome for a one-unit increase in the predictor variable, holding all other variables constant; Wals(Wald Statistic): The Wald statistic is a test of the null hypothesis that the β coefficient is equal to zero. Larger absolute values suggest stronger evidence against the null hypothesis.
Discussion
This study demonstrates that good family functioning is positively associated with adherence in SPC, which, in turn, significantly improves periodontal prognosis. These findings underscore the importance of family involvement in enhancing adherence to treatment protocols, ensuring stable long-term outcomes.
Factors Influencing Adherence
Periodontitis is a chronic disease requiring ongoing maintenance and self-care (Botelho et al., 2019). Unlike acute dental conditions, its early symptoms are subtle, but advanced stages severely impact patients’ quality of life through pain, tooth mobility, and eventual tooth loss (Kim et al., 2023; Rösing et al., 2024). Adequate adherence with SPC is essential for reducing the risk of disease relapse. Previous studies have reported that noncompliant patients exhibit a three- to five-fold higher recurrence rate of periodontitis compared to those adhering to maintenance protocols (Marín-Jaramillo & Agudelo-Suárez, 2022; Schützhold et al., 2015). Effective SPC combines professional care with self-managed oral hygiene, both of which are heavily influenced by social and familial factors (Shao et al., 2020). In this study, patients with higher family APGAR scores (mean 9.58 vs. 9.00 in the noncompliant group, p < .01) demonstrated stronger adherence, suggesting that family support not only alleviates logistical burdens (e.g., appointment reminders) but also reinforces health behaviors through emotional stability. Family members play an essential role in encouraging adherence by offering emotional support, monitoring oral hygiene, and fostering healthy behaviors (Mou et al., 2022). However, socioeconomic factors such as education and income may confound this relationship. For instance, families with higher health literacy might better understand SPC's long-term benefits, a variable not directly measured here but critical for future research.
In this study, male patients demonstrated higher SPC adherence than females, and this difference was statistically significant (p < .01). While some studies have reported greater adherence among women, others have shown higher adherence in men, suggesting potential variations based on sociocultural or behavioral factors (Marín-Jaramillo & Agudelo-Suárez, 2022; Navarro-Pardo et al., 2022). For instance, men may feel social pressure to maintain a healthy appearance, including oral health, which could drive their adherence to SPC (Navarro-Pardo et al., 2022). In contrast, women's lower adherence may stem from heightened dental anxiety and stress associated with treatment (Taqi et al., 2023; Varela-Centelles et al., 2019). Studies (Aimetti et al., 2015) have suggested that women often experience greater fear of dental procedures, potentially contributing to avoidance behavior. Additionally, women may juggle multiple responsibilities, such as family and work, limiting their ability to attend appointments regularly.
In our analysis, age group did not emerge as a statistically significant predictor of nonadherence (p > .05), which diverges from previous studies reporting that older adults generally demonstrate better adherence to periodontal maintenance due to increased health awareness (Perrell-Jones & Ireland, 2016; Varela-Centelles et al., 2019). However, younger patients, who are often more concerned with aesthetics, may also prioritize SPC to maintain their appearance (Eke et al., 2015). These contrasting trends suggest that adherence motivations may vary across age groups and warrant further investigation.
Patients with prior orthodontic treatment, periodontal surgery, or dental implants demonstrated better adherence, likely due to heightened awareness of the importance of maintenance care (Lee et al., 2022). Implant patients, for example, often face significant financial and functional investments, which motivate them to adhere to follow-up care and prevent complications (Monje et al., 2017). Similarly, surgical patients may recognize the severity of their condition and the need for ongoing care (Elemek, 2022; Hu et al., 2017). Studies indicate (Atarbashi-Moghadam et al., 2020) that patients who undergo more invasive procedures are often more committed to preserving treatment outcomes, possibly due to their firsthand experience with the consequences of neglecting oral health. Orthodontic patients, accustomed to regular follow-ups during treatment, may carry this habit into SPC, demonstrating higher adherence rates (Schützhold et al., 2015). This aligns with findings from a cross-sectional study during COVID-19, where structured health education improved adherence among biomedical students, underscoring the role of habitual behavior and informed decision-making (Špiljak et al., 2025). This finding underscores the importance of establishing good habits early in dental care to ensure long-term adherence.
Barriers and Strategies to Improve Adherence
The overall adherence rate of 38% observed in this study was notably lower than previously reported averages, which may reflect the compounding effects of the COVID-19 pandemic's disruption to dental services. Adherence with SPC is influenced by multifaceted barriers, as highlighted in both historical and contemporary research. Early foundational work by Mendoza et al. (1991) identified logistical challenges such as time constraints and financial burdens, alongside psychological barriers including dental anxiety and a perceived lack of urgency, as key drivers of nonadherence. These findings remain relevant today, with additional modern complexities exacerbating these issues. For instance, low-income patients often prioritize immediate financial needs over long-term oral health, while dental anxiety—frequently rooted in past negative experiences—can deter patients from attending follow-up appointments (Sonnenschein et al., 2020). Furthermore, a lack of understanding of SPC's benefits may lead patients to underestimate its importance, resulting in missed appointments (Arnett et al., 2022). Socioeconomic disparities and fragmented family support systems further compound these challenges, creating systemic obstacles to adherence.
Addressing these barriers requires evidence-based, patient-centered interventions. Behavioral approaches such as motivational interviewing have proven effective in resolving ambivalence and fostering commitment to healthier oral health practices (Arnett et al., 2022; Newton & Asimakopoulou, 2015). Educational campaigns tailored to patients’ literacy levels—using tools such as brochures, videos, or interactive workshops—can demystify SPC and emphasize its role in preventing disease recurrence. Proactive measures, including automated appointment reminders via text or phone calls, have been shown to significantly improve attendance rates (Mendoza et al., 1991), while flexible scheduling options accommodate patients’ busy lifestyles and reduce logistical burdens.
Family-centered strategies are particularly critical, as familial engagement can mitigate both psychological and practical barriers. Involving caregivers in oral hygiene routines or treatment discussions fosters accountability and emotional support, aligning with findings that strong family functioning enhances adherence (Manresa et al., 2018). For example, family members can assist with appointment reminders or reinforce daily oral care habits, thereby reducing the psychological burden on patients. Clinicians should also consider socioeconomic contexts; subsidized care models or sliding-scale fees may alleviate financial constraints for vulnerable populations. Ultimately, a holistic approach integrating behavioral science, systemic flexibility, and familial collaboration is essential to bridge the gap between SPC protocols and patient adherence. By addressing barriers through multidisciplinary strategies, clinicians can empower patients to prioritize long-term periodontal health, reducing relapse risks and improving overall quality of life.
Clinical Implications and Future Directions
This study highlights the importance of integrating family support into periodontal care planning. Clinicians should assess family dynamics using tools like the Family APGAR Index to identify patients at risk of nonadherence and tailor interventions accordingly. For instance, patients from families with lower APGAR scores may benefit from additional educational sessions or counseling to address specific barriers. Enhancing family involvement not only mitigates logistical and psychological obstacles but also reinforces the importance of long-term oral health.
Future research should adopt multicenter prospective designs with broader demographic sampling, systematically incorporate socioeconomic indicators, and explore culturally specific family dynamics to validate the causal relationship between family functioning and adherence. Additionally, quantifying interactions between family support and health literacy could clarify mechanisms underlying adherence disparities (Petsos et al., 2021).
Strengths and Limitations
This study benefits from a relatively large sample size and the integration of psychosocial measures with clinical periodontal outcomes, which adds value to the understanding of adherence behavior.
However, several limitations should be noted. First, socioeconomic factors such as educational attainment, income level, and healthcare accessibility were not systematically measured, which may confound the relationship between family support and adherence. Second, the sample was drawn from a single tertiary hospital in Zhejiang Province, limiting the representativeness of findings across broader populations. Third, the retrospective design and reliance on self-reported data may introduce recall and selection bias. Additionally, the regional focus and sample size restrict the generalizability of the results.
Conclusion
This study underscores the critical role of family support in promoting adherence to SPC and improving periodontal outcomes. By addressing barriers to adherence and fostering family involvement, clinicians can enhance the long-term effectiveness of periodontal therapy, ultimately improving patients’ oral and overall health. Continued research and tailored interventions are essential to further optimize SPC outcomes and ensure equitable access to quality care.
Footnotes
Ethics Considerations and Consent to Participate
All procedures involving human participants were performed in accordance with the Declaration of Helsinki and relevant guidelines and regulations. This study was approved by the Ethics Committee of Zhejiang University Stomatology Hospital (Approval No. 2022054). Written informed consent was obtained from all participants prior to inclusion. The study was registered in the National Universal Healthcare Information Platform Medical Research Registration and Filing Information System (MR-33-24-024313).
Author Contributions
Fei Lu contributed to conceptualization, methodology, data curation, formal analysis, writing—original draft, visualization, and revision of the manuscript. Enhong Li contributed to writing—review & editing and critical revision. Feiruo Hong contributed to conceptualization, methodology, and resources. Wen Fang contributed to conceptualization, methodology, and resources. Dongni Shen contributed to conceptualization and methodology. Xuefen Yu contributed to conceptualization and methodology. All authors reviewed and approved the final manuscript.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Medical Science and Technology Project of Zhejiang Province, (grant number 2024KY1160).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
All data generated or analyzed during this study are included in this published article. No additional data files are available.