This seminar explains various periodontal risk assessment tools at subject, tooth and site level risk assessment. Also, SPT with adjunct use of antimicrobials by professional and to be used by personals. Maintenance care for the implant patients has also been described with different conditions. The role played by dentist and by patient is being explained in flowcharts. And at last complications during SPT is described with references.

1. SUPPORTIVE
PERIODONTA
L
THERAPY- II
DR. MANISHA SINHA
II YR PG
DEPT OF PERIODONTOLOGY
1
RAJARAJESWARI DENTAL COLLEGE AND HOSPITAL

2. • PARTS OF SPT
• FREQUENCY AND EFFICACY
• MAINTENANCE RECALL
PROCEDURES
• CLASSIFICATION OF POST
TREATMENT PATIENTS
• REFERRAL TO THE
PERIODONTIST
TABLE OF CONTENTS
■ INTRODUCTION
■ DEFINITION
■ RATIONALE
■ SEQUENCE OF PERIODONTAL
TREATMENT
■ RECURRENCE OF PERIODNTAL
DISEASE
■ INDICATORS OF DISEASE
RECURRENCE
■ GOALS OF SPT
■ COMPLIANCE
■ COMMUNICATION
2

3. TABLE OF CONTENTS
• SPT WITH ADJUNCT USE OF
ANTIMICROBIALS
• MAINTENANCE CARE OF
PATIENTS WITH DENTAL
IMPLANTS
• ROLE OF DENTAL
PROFESSIONALAND PATIENT IN
SPT
• COMPLICATIONS DURING SPT
• CONCLUSION
• REFERENCES
• PERIODONTAL RISK ASSESSMENT TOOLS
1. The Oral Health Information Suite(OHIS):
2.Periodontal Risk Calculator (PRC)
3.Hexagonal risk diagram for Periodontal Risk
Assessment (PRA)
4. Periodontal risk assessment model
5. UniFe (Union of European Railway Industries)
6. AAP Risk Assessment Tool
7. Dentorisk
8. Cronin/Stassen BEDS CHASM Scale
9. Risk Assessment-Based Individualized Treatment
(RABIT)
10. Genetic tests
• TOOTH LEVEL RISK ASSESSMENT
• SITE LEVEL RISK ASSESSMENT
3

4. • SPT offers an opportunity for clinicians to
promote periodontal health, and rapidly detect and intercept recurrence
or progression of periodontal disease (Heasman 2008;
Ramfjord 1987).
PARTS OF SPT
PREVENTIVE SPT
TRIAL SPT
COMPROMISE SPT
POST TREATMENT MAINTENANCE SPT
SPT IN DAILY PRACTICE
1. Examination, Re-evaluation and
Diagnosis (ERD)
2. Motivation, Reinstruction and Instrumentation (MRI)
3. Treatment of Re-infected Sites (TRS)
4. Polishing of the entire Fluorides and Determination of
future SPT (PFD)
4

5. RISK ASSESSMENT
 Risk is defined as the probability that an event will occur in the future, or the
probability that an individual develops a given disease or experiences a change in
health status during a specified interval of time.
 Risk assessment has been defined as the process by which qualitative or
quantitative assessments are made of the likelihood for adverse events to occur as
a result of exposure to specified health hazards or by the absence of beneficial
influences (AAP).
5

6. Periodontal Risk Assessment Tools:
6. AAP Risk Assessment Tool
7. Dentorisk
8. Cronin/Stassen BEDS CHASM Scale
9. Risk Assessment-Based Individualized Treatment
(RABIT)
10. Genetic tests
1. The oral health information suite (OHIS)
2. Periodontal Risk Calculator (PRC)
3. Hexagonal risk diagram for Periodontal Risk
Assessment (PRA)
4. Periodontal risk assessment model developed by
Chandra
5. UniFe (Union of European Railway Industries)
for periodontal risk assessment
6

7. ■ Change in the risk and disease state are automatically analyzed by the system and
are used to update the risk and disease scores as well as to refine and improve
the most appropriate treatments for any given set of conditions.
1. The Oral Health Information Suite(OHIS):
7

8. 2. Periodontal Risk Calculator
(PRC):
 The risk calculation is a multi-step process involving mathematical algorithms
that use nine risk factors which include:
Page et al
(2002)
Patient age Smoking history
Diagnosis of
diabetes
History of
periodontal
surgery
BOP Root calculus Pocket depth
Furcation
involvements
Restorations or
calculus below
the gingival
margin
Radiographic
bone height
Vertical bone
lesions.
8

9. ■ Weighted mathematical algorithm was developed
■ Classifies from 1 (least risk ) to 5 (highest risk)
■ Quantifies disease level 1-100 scale (1=health, 100- severe disease)
■ To document pocket depth and radiographic bone height, a three-point scale is
used.
9

10. 3. The Hexagonal Risk Diagram For
Periodontal Risk Assessment (PRA): Lang and Tonetti
(2003)
Level of infection (proportion of
sites with bleeding on probing
(BOP),
Residual periodontal pockets
(PPD≥5 mm),
tooth loss,
An estimation of the loss of
periodontal support
(proportional relationship
between root length and
radiographic bone loss at the
worst site in the posterior region)
in relation to the patient’s age,
An evaluation of systemic and
genetic conditions and an
evaluation of the environmental/
behavioural factor smoking.
If a systemic or genetic factor is
known, the area of high risk is
marked for this parameter.
10

11. 11

12. CALCULATING THE PATIENT'S INDIVIDUAL PERIODONTAL RISK
ASSESSMENT (PRA)
12

13. Fig 3 Functional
diagram of a
medium-risk
maintenance
patient. BOP is 9%,
6 residual pockets
Ñ5 mm are
diagnosed,
4 teeth had been
lost, the bone factor
in relation to the age
is 0.75,the patient is
a Type I diabetic,
but a non-smoker.
13

14. 14

15. Functional diagram of another high-risk
maintenance patient.
 BOP is close to 50%, more than 12
residual pockets Ñ5 mm are diagnosed,
but only 2 teeth had been lost.
 The bone factor in relation to the age is
0.5, no systemic factor is known and the
patient is a non-smoker.
 Additional periodontal therapy may
change this patient's risk into the
moderate or even low-risk category,
since BOP and residual pockets would
be affected.
15

16. The Periodontal Risk Assessment
Model (Modified PRA)
Chandra
(2007)
Percentage of
sites with
bleeding on
probing,
number of sites
with pocket
depths ≥ 5mm,
number of teeth
lost, bone
loss/age ratio,
attachment
loss/age ratio,
diabetic smoking status,
dental status,
other systemic
factors and
psychosocial
factors
16

17. 17

18. The Simplified Method (UniFe) For
Periodontal Risk Assessment: Trombelli et al (2009)
smoking status,
diabetic status
(both type 1 and
type 2),
number of sites
with probing
depth ≥ 5mm,
bleeding on
probing score, and
bone loss/age
records
radiographic bone
loss-to-age ratio,
18

19. Each parameter assessed is allocated a score. The algebraic sum of the parameter
scores is calculated and relates to a risk score between 1 ( lowest risk) to 5 ( highest
risk)
19

20. American Academy Of
Periodontology Self- Assessment
Tool:■ Web based self assessment tool
■ The role of individual periodontal risk factors may be used in combination
to educate patients, raise awareness and assist in decision making.
■ Person’s age (three response options: <40; 40–65; >65 years) and
■ Their flossing behavior (daily, weekly, seldom).
■ Any of your family members had gum disease,
■ Are your teeth loose?
■ Do you currently have any of the following health conditions, i.e. heart
disease, osteoporosis, osteopenia, high stress or diabetes)?
20

21. Dentorisk:
Systemic Predictors:
• Age in relation to history of
chronic periodontitis,
• Family history of chronic
periodontitis,
• Systemic disease and related
diagnoses,
• Result of skin provocation test,
patient cooperation and
• Disease awareness,
• Socioeconomic status,
• Smoking,
• Clinician experience
Lindskog et al (2010)
Local Predictors:
• Bacterial plaque,
• Endodontic pathology,
• Furcation involvements,
• Vertical intrabony defects,
radiographic marginal bone
levels,
• PD,
• BOP,
• Marginal dental restorations,
• Increased tooth mobility,
• Missing teeth,
• Abutment teeth, 21

22. 22

23. Cronin/Stassen BEDS CHASM
Scale:
B-BMI. Score 2
E-Ethnicity. Score 1.5
D-Diabetic Score 2.5
S-Stressed Score 2
C-College Score 2.5
H-Hygiene Score 2
A-Age 65+. Score 3.5
S –Smoker Score 1.5
M –Male Score 1.5
The total score of 19 indicates the highest risk.
Cronin in 2008
23

24. Risk Assessment-Based
Individualized Treatment (RABIT)
Sorin in 2013
First, risk assessment is done as
part of the initial diagnosis;
recall schedules should be
automatically generated in the
electronic health record (EHR),
immediately following risk
determination.
Second, multiple recall
schedules that address different
risk factors need to be
implemented; not every recall
appointment should include the
same prophylactic treatments
and/ or recommendations.
24

25. Third, following periodic re-
evaluation, the risk for a
particular category may
change requiring a new recall
schedule for that category.
Fourth, whenever possible,
recall appointments driven by
different risk factors should
be combined into single recall
appointments in order to
enhance efficiency and patient
compliance.
Fifth, the electronic recall
system should automatically
delete caries risk- and
periodontal risk-driven recall
schedules when a patient
becomes edentulous.
25

26. Genetic Tests:
■ This test determines whether people possess a combination of alleles in
two IL-1 genes.
■ Studies have reported an increased frequency of a different IL-1 genotype
in people with advanced adult periodontitis compared with those with
early or moderate disease.
■ There is also retrospective evidence that genetic testing for the specific
IL-1 genotype may give indication of increased susceptibility to tooth loss
in periodontal maintenance patients.
■ A more recent prospective study reported that this composite genotype
was not associated with progressive clinical attachment loss during a 2
year period after periodontal therapy.
■ However, it may be concluded that genetic testing has potential for the
future, but more research is needed to evaluate its utility.
26

27. TOOTH LEVEL RISK ASSESSMENT
 Tooth positioning in dental arch
 Residual alveolar bone support
 Mobility
 Iatrogenic factors
 Furcation involvements
27

28. Tooth positioning in dental arch
• A positive correlation between malocclusion and periodontal health
-Helm and Petersen 1989, Gabris et al 2006
• Whereas no association between the amount of plaque or periodontal parameters and
malocclusion including crowding and spacing
- Geiger et al in 1974, Katz in 1978, Buckley in 1980.
• However, in one study Geiger et al 2011 found a possible association between periodontal
problems and certain malocclusions such as anterior overjet and overbite, crossbite, etc.
28

29. Residual alveolar bone support
■ Teeth with severely reduced, but healthy, periodontal support- function either
individually or as abutments for many years without any further loss of
attachment
(Nyman& Lindhe 1979, Nyman & Ericsson 1982, ragger et al 1990)
■ By virtue of the already reduced support, should disease progression occur in
severely compromised teeth, this may lead to spontaneous tooth exfoliation.
29

30. MOBILITY
■ Loss of periodontal support or increased occlusal load.
■ Another important factor to be considered here is crown root ratio.
■ An increased crown root ratio results in increased lateral tooth
mobility.
30

31. • It has been demonstrated by various studies that tooth mobility may vary before,
during and after periodontal treatment.
• After non-surgical and surgical periodontal therapy, tooth mobility is usually
reduced.
• However, tooth mobility may temporarily increase following surgical periodontal
therapy during the healing period and gradually reduce later on. ( Persson 1980,
1981)
31

32. FURCATION INVOLVEMENT
• Multirooted teeth appear to be at high risk for tooth loss during the maintenance phase
- Hirschfield & Wasserman 1978, McFall 1982
• Periodontal therapy in multirooted tooth- revealed significant differences between non-molar sites
and molar flat surfaces on the one hand and molar furcation sites on the other
- Nordland et al in 1987
32

33. IATROGENIC FACTORS
• Overhanging restorations and ill fitting crown margins.
- Leon 1977
• The constant presence of plaque in subgingival areas such the under the margins of
subgingival restorations has been shown to change the ecological niche, which provides
more favorable conditions for the establishment of Gram –ve anaerobic microorganisms.
• Hence, during maintenance therapy any such restoration and crown margin should be
identified and corrected to prevent the progression of periodontal disease.
33

34. SITE LEVEL RISK ASSESSMENT
• Registration of bleeding on probing,
• Probing depth,
• Loss of attachment, and
• suppuration.
34

35. BLEEDING ON PROBING
■ Absence of BOP- a reliable indicator of periodontal stability.
- -Lang et al, 1990
■ Also demonstrated almost a linear relationship between probing force and
percentage of sites that bleed on probing.
■ Presence of bleeding upon standardized probing will indicate presence of
gingival inflammation.
35

36. CLINICAL ATTACHMENT LOSS
• Various factors that may affect the measurement of the attachment loss clinically
are probe dimension, probing force, the direction of probe placement and
condition of gingival tissue.
• Therefore, the first periodontal evaluation after healing following initial
periodontal therapy should be taken as the baseline for long-term clinical
monitoring.
(Claffey, 1994)
36

37. SUPPURATION
 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.
(Badersten et al. 1985, 1990, Claffey et al. 1990)
 Hence, following therapy a suppurating lesion may provide evidence that the
periodontitis site is undergoing a period of exacerbation.
(Kaldahl et al. 1990)
37

38. CLINICAL IMPLEMENTATION OF
MULTILEVEL RISK ASSESSMENT
■ After the patient has been assessed for a person based, tooth based and
site based risk assessment, a combination of these parameters can be
used as a guide to determine the overall risk profile of the patient and to
plan the maintenance therapy for the patient.
■ Multilevel risk assessment helps in more accurate planning of the
maintenance therapy for a patient as compared to single-level risk
assessment because it allows the assessment of the influence of patient-
based factors such as smoking, diabetes etc. on periodontal disease
recurrence.
■ It also helps in more accurate determination of recall frequency and time
requirements.
38

39. SPT WITH ADJUNCT USE OF
ANTIMICROBIALS
1. Subgingival irrigation
■ The delivery of the solutions to the depth of the
pocket may be executed by using irrigating
cannulas or ultrasonic cleaning devices.
■ Nosal et al (1991) have shown that antimicrobial
solutions delivered during debridement through
the ultrasonic scaler penetrated to most of the
pockets, up to 9 mm in depth.
■ Similarly, subgingival irrigation via a cannula
placed several millimeters under the gingival
margins resulted in 70–80% penetration to deep
pockets (Boyd et al, 1992).
• Several studies demonstrated that
subgingival irrigation with antimicrobials
effectively reduced pathogenic bacteria and
more than 100 days were needed for the
bacteria to re-infect the pockets (MacAlpine
et al, 1985; Southard et al, 1989).
SPT by the professional
39

40. 2. Sustained release delivery systems
■ The largest one investigated the use of sustained-
release chlorhexidine chip during SPT.
■ Using a one-arm, multicenter uncontrolled design
(phase IV), Soskolne et al (2003) examined the
adjunctive use of chlorhexidine chip during routine
SPT over 2 years in 595 patients with good
compliance to SPT appointments. the use of the
chlorhexidine chip during SPT in sites with a
probing depth of 5 mm and more is an effective
treatment option.
• Study of van steenberghe et al (1999),
showed that after stabilization of the clinical
parameters by mechanical treatment, a
further reduction in PPD of 0.7 mm was
obtained over the rest of the 15-month study
period.
• In addition, microbiological (DNA) analysis
revealed that sites treated with minocycline
always produced statistically significantly greater
reduction in the number of periodontal pathogens,
which is one of the primary goals of SPT.
40

41. ■ Newman et al (1994) compared the adjunctive use
of tetracycline fibers with scaling and root planing
vs. scaling and root planing alone, during SPT in
deep sites with signs of bleeding on probing
(BOP).
■ It was found that the adjunctive therapy
significantly enhanced the effectiveness of the
mechanical therapy for the entire 6-month follow-
up duration of the study. An increased reduction of
0.7 mm was observed in mean probing depth and
the percentage of bleeding sites was lower.
• In addition, Tonetti et al (1998b), who
evaluated the effectiveness of adjunctive
tetracycline fibers used in mandibular class
II furcations during SPT, found a significant
effect, although it was found to last for only
3 months.
41

42. ■ In a 9-month SPT study, Garrett et al
(2000) compared the use of
doxycycline polymer to mechanical
debridement and the results showed
that there were no differences in the
clinical parameters between the test
and control group, suggesting that the
pharmacologic SPT therapy may
replace mechanical instrumentation.
■ Similar conclusions were drawn from
studies using metronidazole gel as
monotherapy during SPT.
• Meinberg et al (2002) compared conventional
SPT vs. the use of subgingival Minocycline
microsphers for 1 year and it showed further
reduction of 0.5 mm in mean probing depth and
25% of these patients showed significant
attachment gain suggesting superiority for
pharmacologic intervention over traditional
SPT.
42

43. Mouthrinsing
■ Data from the group of Quirynen et al (Quirynen et al,
1995; Vandekerckhove et al, 1996; Mongardini et al,
1999; Quirynen et al, 1999) suggest that SPT with a
full-mouth disinfection approach, including starting
mouthrinses during the SPT appointment, may be of
importance, particularly due to the suppression of
periodontal pathogens in the entire oropharyngeal cavity.
43

44. Use of antimicrobials for personal
SPT
■ Mouthrinses
■ Chlorhexidine rinses for 8 days may be
recommended after each SPT appointment,
to ensure prevention of re-infection during
the 3–4-month interval between SPT
appointments (Slots and Jorgensen, 2000)
• Irrigation
• Jet irrigator devices project the
antimicrobial solution 3 mm
subgingivally or to half the probing
depth (Eakle et al, 1986; Boyd et al,
1992; Larner and Greenstein, 1993)
and the attachment of a subgingival
tip to the irrigator may augment
subgingival penetration of the
antimicrobial solution (Braun and
Ciancio, 1992).
44

45. Toothpastes
■ Rosling et al (1997a, 1997b) have shown, in a 36-month study, that the use of
triclosan-containing toothpaste exhibited more pronounced alternations of
the subgingival microbiota than control toothpaste, particularly for Prevotella
intermedia.
■ Bruhn et al (2002) were not able to demonstrate any advantage for triclosan
regarding BOP and probing depth reduction, which are major outcome
variables for SPT.
45

46. Listgarten MA. A rationale for
monitoring the periodontal
microbiota after periodontal
treatment. J Periodontol 1988
46

47. Step 1: Review of the patient’s medical
history
Step 2: Assessment of implants
-Visual soft tissue assessment
-Protocol for inflammation
-Visual examination upon probing
-Visual signs of failing implant
-Monitoring the implant
Step 3: Safe instrumentation and
polishing of dental implants
-Plastic, graphite and titanium coated
implant scalers
-Polishing dental implant restorations
MAINTENANCE CARE OF PATIENTS
WITH DENTAL IMPLANTS
47

48. Implant Disease Risk Assessment (IDRA)
1. History of periodontitis
2. Percentage of sites with BOP
3. Prevalence of PD ≥ 5 mm.
4. Bone loss in relation to the patient's age.
5. Periodontitis susceptibility as analyzed by the 2017 World Workshop on the Classification of
Periodontal and Peri-implant Diseases (Tonetti, Greenwell, & Kornman, 2018)
6. Supportive periodontal therapy
7. Implant restorative depth
8. Prosthesis-related factors.
Heitz et al in 2019
48

49. 49

50. ■ Oral hygiene instructions should include detailed verbal guidance and
visual demonstration for the long-term success of the implant and its
restoration. Also, the oral hygiene techniques and aids used by patients
should be re evaluated during every hygiene visit.
■ Therefore, it is important to use and recommend those home care aids
that will not alter the implant abutment surface and are also safe and
effective with daily use
At-Home Implant Care
50

51. Implant Maintenance: A
Clinical Update
Int Sch Res Notices. 2014
51

52. Implant
Maintenance: A
Clinical Update
Int Sch Res Notices.
2014
52

53. 53

54. 54

55. 55

56. Lang et al in 200
56

57. ■ A study by Renvert et al. on nonsurgical mechanical
treatment on sites with peri-implantitis lesions with
microencapsulated minocycline (Arestin) and 0.12%
chlorhexidine gel found reductions of pocket depths
and bleeding on probing for as long as 12 months
• The surface roughnesses of pure titanium implants were compared
with scaling in vitro with curettes of dissimilar composition in a study
done by S C Fox et al in 1990. It was found that the plastic
instruments produced an insignificant alteration of the titanium implant
surface following instrumentation, while metal instruments
significantly altered the titanium surface.
57

58. ■ In a study done by Hatice Hasturk et al in
2013 with the aim to compare the impact of
the removal of biofilm with hand scalers of
different material composition on the surface
of implant abutments by assessing the surface
topography and residual plaque after scaling
using scanning electron microscopy (SEM). It
was found that the Unfilled resin was found
consistently to be the least damaging to
abutment surfaces, although all scalers of all
compositions caused detectable surface
changes to polished surfaces of implant
abutments.
• In a study done by Seung-Ho Baek in 2012,
with the aim To evaluate the safety and
efficiency of novel ultrasonic scaler tips,
conventional stainless-steel tips, and plastic
tips on titanium surfaces and concluded that
Novel metallic copper alloy ultrasonic scaler
tips may minimally influence the titanium
surface, similar to plastic tip. Therefore, they
can be a suitable instrument for implant
maintenance therapy.
58

59. COMPLICATIONS DURING SPT
1. Caries
• Studies have also shown a relationship between root
caries and subgingival presence of S. mutans. Van der
Reijden WA et al in 2001.
• Molars treated with a root resection also carry a
higher risk of root caries, resulting in treatment failure
in spite of SPT
59

60. Endodontic lesions
■ Endodontic complications during
SPT may result in tooth extraction.
Data suggest that approximately 30%
of all extractions of teeth over a 4-
year period of SPT are the
consequence of peri-apical lesions.
Tonetti MS et al in 2000
• Periodontal abscesses appear to occur in
approximately 35% of subjects on SPT and
predominantly in subjects who can be
identified as rapid downhill cases.
McLeod DE et al in 1997
• It appears that subjects on SPT who only
received nonsurgical therapy during the ICRT
may be at a greater risk of periodontal
abscesses during the SPT phase.
Periodontal abscesses
60

61. Root sensitivity
• It is well established that following ICRT, root sensitivity is
common, especially if treatment involved surgical procedures.
• In most cases such sensitivity decreases over time.
• Reports on root sensitivity during SPT vary from 15% to 98% and
are often associated with root surface exposure and gingival
recession.
Christie CH, Claffey N et al in 1998,
Karadottir H, et al in 2002.
• The very high prevalence of root sensitivity reported by Chabanski
et al. Chabanski MB, et al in 1997
61

62. Published in Journal of
the American Dental
Association 2000
Efficient antimicrobial
treatment in periodontal
maintenance care
62

63. Published in Journal of the
American Dental Association
2000
Efficient antimicrobial treatment
in periodontal maintenance care
63

64. CONCLUSION
64

65. REFERENCES
■ Newman, takei, fermin a carranza. Clinical periodontology, 13th edition.
■ Jan lindhe. Clinical periodontology and implant dentistry, 5th edition, (2003),
blackwell munkgard publication.
■ Krishna kripal, kavita C, supportive periodontal therapy – maintenance to prevent
recurrence
■ Renvert S, persson GR. Supportive periodontal therapy. Periodontology 2000. 2004
oct;36(1):179-95.
■ Lang ,tonetti. Periodontal risk assessment (pra) for patients in supportive periodontal therapy
(spt). oralhealth& preventivedentisty 2003.
■ Darcey J, Ashley M. See you in three months! The rationale for the three monthly
peridontal recall interval: a risk based approach. British Dental Journal. 2011
Oct;211(8):379.
65

66. ■ Cronin AJ, Claffey N, Stassen LF. Who is at risk? Periodontal disease risk
analysis made accessible for the general dental practitioner. British dental journal.
2008 Aug;205(3):131-7.
■ SLOTS J, Jorgensen MG. Efficient antimicrobial treatment in periodontal
maintenance care. The journal of the American dental association. 2000 Sep
1;131(9):1293-304.
■ Gulati M, Govila V, Anand V, Anand B. Implant maintenance: a clinical update.
International scholarly research notices. 2014;2014.
■ Todescan S, Lavigne S, Kelekis-Cholakis A. Guidance for the maintenance care
of dental implants: clinical review. J Can Dent Assoc. 2012;78(1):107.
■ Kanathila H, Pangi A, Benakatti V, Patil S. Maintenance of dental implants: A
way to long term success: A review. Int J of Appl Dent Sci 2018. 2018;4(2):104-7.
66

67. THANKYOU
67