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Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
Supportive periodontal therapy final1
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Supportive periodontal therapy final1

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SUPPORTIVE CARE

SUPPORTIVE CARE

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  • 1. SUPPORTIVE PERIODONTAL THERAPY Dr. VIVEK Kr. SHARMA ALIGARH MUSLIM UNIVERSITY
  • 2. GOAL OF PERIODONTAL TREATMENT Monday, April 28, 2014Dr Vivek Sharma.AMU 2 To maintain the natural dentition in functional health and comfort THROUGHOUT the LIFETIME. It requires a perfect plaque control
  • 3. Monday, April 28, 2014Dr Vivek Sharma.AMU 3 Even after appropriate Periodontal Therapy, some progression of disease is possible* Greenwell et al 1989,Hirschfield et al 1985,Tonetti et al 1998, Incomplete subgingival plaque removal
  • 4. PLAQUE CONTROL Monday, April 28, 2014Dr Vivek Sharma.AMU 4  MOTIVATION  MECHANICAL/CHEMICAL AIDS  PERIODIC REMOVAL OF PLAQUE/PROFESSIONAL MAINTENANCE Improper plaque control will results in Gingivitis Compromising functional comfort and longevity of the dentition
  • 5. To what extent should professional maintenance care be concerned with the treatment and prevention of gingivitis? Monday, April 28, 2014Dr Vivek Sharma.AMU 5  Minimal/No effect on functional comfort  No test that will predict in which patient gingivitis will progress to periodontitis  No predictability of progression rate of attachment loss.
  • 6. BUT, Compelling reasons are Monday, April 28, 2014Dr Vivek Sharma.AMU 6  Gingivitis is-  Form of disease.  May develop into periodontitis with loss of attachment.  Less evidence of gingivitis, the less severe is the loss of periodontal attachment over time.  To control periodontitis the only way is to control gingivitis and plaque control.  Gingivitis is a greater threat to loss of attachment in persons who already have lost some attachment Perfect Professional & Personal Plaque Control GINGIVITIS PERIODONTITIS Longevity of Dentition
  • 7. If After Active Periodontal Therapy… Monday, April 28, 2014Dr Vivek Sharma.AMU 7
  • 8. PERIODONTAL TREATMENT PLAN* Monday, April 28, 2014Dr Vivek Sharma.AMU 8 PHASE I(ICRT) REEVALUATION PHASE IV(Maintenance/SPT) PHASE II PHASE III (Periodontal Surgery) ( Restorative) *Carranza‟s 9th edition
  • 9. Supportive Periodontal Therapy Monday, April 28, 2014Dr Vivek Sharma.AMU 9  Definition.  Basic paradigms for the prevention of periodontal diseases.  Rationale of SPT.  Continuous multi-level risk assessment; Subject risk assessment, Tooth risk assessment, Site risk assessment  Therapeutic goals and objectives.  Complications  Conclusion
  • 10. Definition Monday, April 28, 2014Dr Vivek Sharma.AMU 10 1989,3rd world workshop of AAP, Rename the Maintenance Phase.  Continuous Diagnostic monitoring of the patient in order to intercept with adequate therapy and to optimize the therapeutic interventions tailored to the patient‟s need. Essential need for therapeutic measures to support the patient‟s own efforts to control periodontal infections and to avoid Re- infection.
  • 11. Basic Paradigms for prevention of periodontal Disease Monday, April 28, 2014Dr Vivek Sharma.AMU 11 Cause-Effect relationship: Plaque Gingivitis Löe et al 1965 Cause-Effect relationship: Plaque Accumulation Periodontal Disease Lindhe et al 1975
  • 12. Cont… Monday, April 28, 2014Dr Vivek Sharma.AMU 12  It seems reasonable to predict that the elimination of gingival inflammation and the maintenance of healthy gingival tissues will result in the prevention of both the initiation and the recurrence of periodontal disease.
  • 13. Cont…thus to prevent periodontal disease Monday, April 28, 2014Dr Vivek Sharma.AMU 13  Necessity for proper and regular personal plaque elimination, at least in patients treated for or susceptible to periodontal disease  Interceptive professional supportive therapy at regular intervals may, to a certain extent, compensate for the lack of personal compliance with regard to oral hygiene standards.
  • 14. Rationale for SPT : Monday, April 28, 2014Dr Vivek Sharma.AMU 14  PERIODONTITIS: Chronic in Nature 1
  • 15. Monday, April 28, 2014Dr Vivek Sharma.AMU 15  No definitive periodontal treatment that can cure the disease. •Antimicrobial Therapy •Regenerative Procedures •Host-Modulation Therapy •Diet /Antioxidant based Therapy •Tri-Immuno Phasic Therapy 2
  • 16. Monday, April 28, 2014Dr Vivek Sharma.AMU 16  The microbial challenge which induces and maintains the inflammatory response, may not be completely eliminated from the dento-gingival environment for any length of time. 3
  • 17. Monday, April 28, 2014Dr Vivek Sharma.AMU 17  Bacteria associated with periodontitis can be transmitted between spouses and other family members 4
  • 18. Monday, April 28, 2014Dr Vivek Sharma.AMU 18  The inability of existing clinical parameters to predict disease progression mean that continuous adjunct monitoring and treatments are necessary to prevent recurrence of the disease. 5
  • 19. Its SPT that… Monday, April 28, 2014Dr Vivek Sharma.AMU 19  Prevent /Minimize Recurrence of Disease Progression.  Prevent/Minimize the incidence of Teeth or Implant Loss  Increase the Probability of Locating and Treating other Disease and Conditions SPT has to be aimed at regular removal of the subgingival microbiota and must be supplemented by the patient‟s efforts for optimal supragingival plaque removal
  • 20. THERAPEUTIC GOALS Monday, April 28, 2014Dr Vivek Kumar Sharma AMU 20 1. To minimize the recurrence and progression of periodontal disease in patients who have been previously treated for gingivitis and periodontitis. 2. To reduce the incidence of tooth loss by monitoring the dentition and any prosthetic replacements of the natural teeth. 3. To increase the probability of locating and treating, in a timely manner, other diseases or conditions found within the oral cavity.
  • 21. SPT COMPRISES OF…. Monday, April 28, 2014Dr Vivek Sharma.AMU 21  Part I : Examination  Part II : Treatment  Part III: Next Schedule PERIODONTAL RISK ASSESSMENT Oral hygiene Reinforceme nt Recall Further Perio Tt.* Restorative/Prosthetic Tt.* MULTI RISK ASSESSMENT TOOTH RISK ASSESSME NT SITE RISK ASSESSMEN T
  • 22. SPT begins with.. Monday, April 28, 2014Dr Vivek Sharma.AMU 22 COMMUNICATIO N MOTIVATIO N COMPLIAN CE REALIZATI ON
  • 23. PART-I : MULTI RISK ASSESSMENT Monday, April 28, 2014Dr Vivek Sharma.AMU 23  PERIODONTAL RISK ASSESSMENT(PRA)A .
  • 24. Monday, April 28, 2014Dr Vivek Sharma.AMU 24  Assessment of level of infection(Bleeding scores)  Prevalence of residual periodontal pockets  Tooth loss  Estimation of Age related loss of periodontal support  Evaluation of Systemic conditions of the patient  Evaluation of Environmental & Behavioral factors No single parameter displays a more paramount role. The entire spectrum of risk factors and risk indicators ought to be evaluated simultaneously PRA estimate the risk for susceptibility for periodontal disease progression
  • 25. FUNCTIONAL DIAGRAM TO EVALUATE THE PATIENT’S RISK FOR RECURRENCE Monday, April 28, 2014Dr Vivek Sharma.AMU 25
  • 26. BOP percentage- first risk factor Monday, April 28, 2014Dr Vivek Sharma.AMU 26  Represents an objective inflammatory parameter  Reflects patient's ability to perform proper plaque control, the patient's host response to the bacterial challenge and the patient's compliance.  While patients with mean BOP percentages > 25% should be considered to be at high risk for periodontal breakdown 1
  • 27. Prevalence of residual pockets ≥5 mm (residual pocket greater than 4 mm): second risk indicator Monday, April 28, 2014Dr Vivek Sharma.AMU 27  Represents - to a certain extent - the degree of success of periodontal treatment rendered.  Periodontal stability in a dentition would be reflected in a minimal number of residual pockets.  In conjunction with other parameters such as bleeding on probing and/or suppuration are existing ecological niches from and in which re-infection might occur. 2
  • 28. Loss of teeth from a total of 28 teeth Monday, April 28, 2014Dr Vivek Sharma.AMU 28  Tooth loss : a true end point outcome variable reflecting the patient's history of oral diseases and trauma  The number of remaining teeth in a dentition reflects the functionality of the dentition  If more than 8 teeth from a total of 28 teeth are lost, oral function is usually impaired 3
  • 29. Loss of periodontal support in relation to the patient's age Monday, April 28, 2014Dr Vivek Sharma.AMU 29  Previous attachment loss in relation to patient's age may be a more accurate indicator during SPT than before active periodontal treatment .  On bitewing radiographs, one milli-meter is considered to be equal to 10% bone loss. The score = % OF BONE LOSS PATIENT‟s AGE = BL/Age  A patient who has lost a higher percentage of posterior alveolar bone than his/her own age is at high risk regarding this vector in a multi-factorial assessment of The rate of progression of disease has been positively affected by the treatment rendered 4
  • 30. Contd… Monday, April 28, 2014Dr Vivek Sharma.AMU 30 It may be argued that the incorporation of only the worst site with bone loss in the posterior segment may overestimate an individual's rate of periodontal destruction when only an isolated advanced bony lesion is present due to local etiologic factors. While an underestimation of the rate of destruction may exist in a case of generalized advanced disease. Worst site with bone loss in the posterior segment may, indeed, represent the past history of destruction of the entire dentition (Persson et al, 2003).
  • 31. Monday, April 28, 2014Dr Vivek Sharma.AMU 31 Systemic and genetic aspects In this case, the area of high risk s marked for this vector. If it is not known or absent, systemic factors are not taken into account for the overall evaluation of risk . Genetic marker like: IL-1 MICROBE S MICROBIAL By- Products LPS , MMP‟s, PMN Inflammatory Mediators Host Response Periodontal Disease Systemic Disease The Chemistry Of Destruction 5
  • 32. Environmental Factor: smoking Monday, April 28, 2014Dr Vivek Sharma.AMU 32 Smokers displayed less favorable healing responses both at reevaluation and during a 6-year period of SPT (Baumert-Ah et al, 1994). It seems reasonable to incorporate heavy smokers (20 cigarettes/day) in a higher risk group during maintenance Occasional smokers (OS; < 10 cigarettes a day) and moderate smokers (MS;10-19 cigarettes a day) may be considered at moderate risk for disease progression. While non-smokers (NS) and former smokers (FS) have a relatively low risk for recurrence of periodontitis Not only does smoking increase the extent and severity of periodontal disease, it compromises the outcomes of surgical and non-surgical therapy 6
  • 33. Monday, April 28, 2014Dr Vivek Sharma.AMU 33  CALCULATING THE PATIENT'S INDIVIDUAL PERIODONTAL RISK ASSESSMENT (PRA)
  • 34. A low PRA patient has all parameters within the low-risk categories or - at the most - one parameter in the moderate- risk category Monday, April 28, 2014Dr Vivek Sharma.AMU 34
  • 35. Monday, April 28, 2014Dr Vivek Sharma.AMU 35 A moderate PRA patient has at least two parameters in the moderate category, but at most one parameter in the high-risk category
  • 36. A high PRA patient has at least two parameters in the high-risk category Monday, April 28, 2014Dr Vivek Sharma.AMU 36
  • 37. B . Monday, April 28, 2014Dr Vivek Sharma.AMU 37 TOOTH RISK ASSESSMENT:
  • 38. Monday, April 28, 2014 38  Tooth position within the dental arch  Furcation involvement  Iatrogenic factors  Residual periodontal support  Mobility.
  • 39. Tooth position within the dental arch. Monday, April 28, 2014Dr Vivek Sharma.AMU 39  Malocclusion and Irregularities CROWDING results in increased plaque retention and gingival inflammation has been established. No significant correlation between anterior overjet and overbite, crowding and spacing or axial inclinations and tooth drifts with periodontal destruction has been established Tooth malposition within the dental arch will lead to an increased risk for periodontal attachment loss.
  • 40. Furcation involvement Monday, April 28, 2014Dr Vivek Sharma.AMU 40  Retrospective analyses of large patient populations (Hirschfeld & Wasserman 1978; McFall 1982, Ramfjord et al. 1987) have clearly established that multi-rooted teeth appear to be at high risk for tooth loss during the maintenance phase.  These results are not intended to imply that furcation-involved teeth should be extracted, since all the prospective studies have documented a rather good overall prognosis for such teeth if regular supportive care is provided by a well organized maintenance program.
  • 41. Iatrogenic factors. Monday, April 28, 2014Dr Vivek Sharma.AMU 41  OVERHANGING RESTORATIONS  ILL-FITTING CROWNS  IMPROPERLY PLACED ORTHODONTIC BRACKETS Change the ecologic niche, providing more favorable conditions for the establishment of a Gram negative anaerobic microbiota (Lang et al. 1983). This shifts in the subgingival microflora towards a more periodontopathic microbiota, if unaffected by treatment, represent an increased risk for periodontal breakdown.
  • 42. Residual periodontal support. Monday, April 28, 2014Dr Vivek Sharma.AMU 42  There is clear evidence from longitudinal studies that teeth with severely reduced, but healthy, periodontal support can function either individually or as abutments for many years without any further loss of attachment. should disease progression occur in severely compromised teeth, this may lead to spontaneous tooth exfoliation
  • 43. Mobility. Monday, April 28, 2014Dr Vivek Sharma.AMU 43 Indicator for progressive traumatic lesions, provided that the mobility is increasing continuously. (1) a widening of the periodontal ligament (2) the height of the periodontal supporting tissues. following surgical procedures, tooth mobility may temporarily increase during the healing phase and may resume decreased values later on
  • 44. C . Monday, April 28, 2014Dr Vivek Sharma.AMU 44 SITE RISK ASSESSMENT.The site risk assessment is essential for the identification of the sites to be instrumented during SPT.
  • 45. Monday, April 28, 2014Dr Vivek Sharma.AMU 45  Bleeding on probing  Probing depth and loss of attachment.  suppuration
  • 46. Bleeding On Probing Monday, April 28, 2014Dr Vivek Sharma.AMU 46  Absence of bleeding on probing is a reliable parameter to indicate periodontal stability if the test procedure for assessing BOP has been standardize.  On the other hand, bleeding sites seem to have an increased risk for progression of periodontitis, especially when the same site is bleeding at repeated evaluations over time (Lang et al. 1986; Claffey et al. 1990).
  • 47. Probing depth and loss of attachment. Monday, April 28, 2014Dr Vivek Sharma.AMU 47  Clinical probing is the most commonly used parameter both to document loss of attachment and to establish a diagnosis of periodontitis.  Reflect the history of periodontitis rather than its current state of activity. (1) the dimension of the periodontal probe; (2) the placement of the probe and obtaining a reference point; (3) the crudeness of the measurement scale; (4) the probing force; and (5) the gingival tissue conditions The first periodontal evaluation after healing following initial periodontal therapy should, therefore, be taken as the baseline for longterm linical monitoring (Claffey 1994).
  • 48. Suppuration. Monday, April 28, 2014Dr Vivek Sharma.AMU 48  the presence of suppuration increased the positive predictive value for disease progression in combination with other clinical parameters, such as BOP and increased probing depth.  Hence, following therapy a suppurating lesion may provide evidence that the periodontitis site is undergoing a period of exacerbation.
  • 49. Radiographic evaluation of periodontal disease progression. Monday, April 28, 2014 49 Radiograph : *Assist in clinician‟s judgement *Current *Based on diagnostic needs of patient *Permit proper evaluation and interpretation of the status of the periodontium. *Radiographic abnormalities must be noted and co-relate them with degree of disease activity Bitewing Examination at 12-18 month interval : high risk caries patient every 24-36 month : patient with good control over periodontal disease Peri-apical and/or at 12-24 months : Patient with poor control over Vertical bite wings periodontal disease 6-12-36 months : Patient with root form dental implants after prosthetic placement.
  • 50. Multi Risk Assessment…. Monday, April 28, 2014Dr Vivek Sharma.AMU 50  influences primarily the determination of the recall frequency and time requirements for therapeutic intervention to the sites with higher risk, and possibly to the selection of different forms of therapeutic intervention.
  • 51. PART II: TREATMENT Monday, April 28, 2014Dr Vivek Sharma.AMU 51  ORAL HYGIENE MEASURES IMPROVEMENT & PROFESSIONAL ORAL PROPHYLAXSIS  MOTIVATION/ BEHAVIOURAL MODIFICATION &COMPLIANCE  USE OF ANTIMICROBIALS
  • 52. ORAL HYGIENE MEASURES IMPROVEMENT Monday, April 28, 2014Dr Vivek Sharma.AMU 52 1.Removal of sub gingival and supra gingival plaque and calculus PROFESSIONAL ORAL PROPHYLAXIS 2. Behavior modification: A. Oral hygiene reinstruction i. Proper use of Toothbrush ii. Use of Floss & Interdental Cleaning Aids iii. Use of water flosser/ oral irrigation B. Compliance with suggested periodontal maintenance intervals C. Counseling on control of risk factors; e.g., cessation of smoking
  • 53. Monday, April 28, 2014Dr Vivek Sharma.AMU 53 3. Use of Antimicrobials *Adjunct to SPT *Compensate for inadequate mechanical oral hygiene *Dentifrices, LDS, Solutions for oral rinses or flushing of periodontal pockets.
  • 54. PART-III: Next Schedule Monday, April 28, 2014Dr Vivek Sharma.AMU 54  RECALL  FURTHER PERIO TREATMENT  RESTORATIVE/PROSTHETIC TREATMENT
  • 55. RECALL INTERVALS Monday, April 28, 2014Dr Vivek Sharma.AMU 55  SHORT INTERVAL RECALL:  3-4 Month Recall intervals for SPT is recommended as frequent maintenance care is necessary to eliminate/reduce sub-gingival proportions of pathogens.  LONG INTERVAL  6-12 Month interval for SPT can effectively prevent further disease progression.
  • 56. Monday, April 28, 2014Dr Vivek Sharma.AMU 56  CLASS “A”: Patient displays good oral hygiene,minimal calculus, no occlusal problems, no complicated prosthesis, no remaining pockets & no teeth with less than 50% of alveolar bone remaining .  CLASS “B”: Patients with inconsistent/poor oral hygiene, heavy calculus, systemic disesase, occlusal problems, complicated prosthesis, recurrent caries, some teeth with less than 50% of alveolar bone support, smoking, positive genetic test  CLASS”C” : Patient with poor maintenance after 1 year with more aggressive problem s of class B, condition too far advanced to be improved by periodontal surgery RECALL INTERVALS: After 1yr well maintenance 6-12 month recall 3-4 month recall 1-3 month recall
  • 57. Compliance with recall system Monday, April 28, 2014Dr Vivek Kr Sharma,AMU 57  Treated periodontal patients who comply with regular periodontal maintenance appointments have a better prognosis than patients who do not comply.  Non-compliant or poorly compliant patients should be considered at higher risk for periodontal disease progression.
  • 58. COMPLICATIONS OF SUPPORTIVE PERIODONTAL THERAPY Monday, April 28, 2014Dr Vivek Sharma.AMU 58  Caries: removal of root cementum during ICRT and during SPT  Endodontic lesions: exposure of accessory root canal  Periodontal Abscesses:  Root sensitivity:
  • 59. Conclusion Monday, April 28, 2014Dr Vivek Sharma.AMU 59  The programme of Supportive periodontal therapy is essential to long-term stability of patients with chronic periodontitis.  The clinical strategy for SPT is determined according to „clinical needs‟ of the patient and is thus clinical observation and individual discretion is of utmost importance rather than best available „clinical evidence‟
  • 60. SPT Monday, April 28, 2014Dr Vivek Sharma.AMU 60 THANKS

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