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Dr. R. Ahmed Dental
College & Hospital
Periodontal Treatment Plan
The purpose of the periodontal treatment plan is to
organize an approach to provide comprehensive
treatment based on the patients’ oral, dental &
Short –term goals
Elimination of all infectious &
inflammatory process that
cause periodontal & other
oral problems that may
hinder the patients’ general
Long –term goals
Reconstruction of a healthy
dentition that fulfills all
functional & esthetic
Phases of Periodontal Treatment
• Dental or
• Diet counseling
• Removal of
• Excavation of
• Root planing
• Occlusal therapy
• Minor orthodontic
• Plaque &
• Pocket depth
• Bleeding on
Evaluation Evaluation Evaluation
Preferred sequence for periodontal
The 3rd World Workshop of
the American Academy
of Periodontology (1989)
renamed this treatment
Periodontal Therapy” (SPT).
What is SPT?
SPT = Supportive Periodontal Treatment
Also known as
Periodontal Maintenance Therapy
Procedures performed at selected intervals to assist
the periodontal patient in maintaining oral health.
Introduction of SPT
This term expresses the essential need for therapeutic measures to
support the patient’s own efforts to control periodontal infections
and to avoid reinfection.
An integral part of SPT is the continuous diagnostic
monitoring of the patient in order to intercept with
adequate therapy and to optimize the therapeutic
interventions tailored to the patient’s needs.
Basic paradigms for the prevention
of periodontal diseases
Periodontal maintenance care, or SPT,
follows the paradigms of the etiology and
pathogenesis of periodontal disease
Almost 45years ago, a cause–effect
relationship between the accumulation of
bacterial plaque on teeth and the
development of gingivitis was proven
(Löe et al. 1965).
This relationship was also documented by
the restoration of gingival health following
Ten years later, a corresponding relationship between
plaque accumulation and the development of
periodontal disease, characterized by;
-loss of connective tissue attachment and resorption
of alveolar bone, was shown in laboratory animals
(Lindhe et al. 1975).
Since some of these animals did not
develop periodontal disease despite a
persistent plaque accumulation for 48
It must be considered that the; composition of the microbiota or
the host’s defense mechanisms or susceptibility for disease may
vary from individual to individual.
Nevertheless, in the study mentioned, the initiation of periodontal
disease was always preceded by obvious signs of gingivitis.
Hence, 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
In fact, as early as 1746, Fauchard stated that “little or no care as
to the cleaning of teeth is ordinarily the cause of all diseases
that destroy them” .
• From the clinical point of view,
the mentioned results must be translated into the necessity for
proper and regular personal plaque elimination, at least in
patients treated for or susceptible to periodontal disease.
This simple principle may be difficult to implement in all patients.
Interceptive professional supportive therapy at regular intervals may, to a certain
extent, compensate for the lack of personal compliance with regard to oral
The etiology of gingivitis and periodontitis is fairly well understood.
However, the causative factors, i.e. the microbial challenge which induces and
maintains the inflammatory response, may not be completely eliminated from
the dentogingival environment for any length of time.
This requires the professional removal of all microbial deposits in the
supragingival and subgingival areas at regular intervals.
incomplete subgingival plaque removal
presence of bacteria in the gingival tissues in
chronic and aggressive periodontitis cases
microscopic nature of the dentogingival
unit healing after periodontal treatment
Long junctional epithelium
o inflammation may rapidly
Bacteria may recolonize the pocket and
cause recurrent disease
Subgingival scaling alters the pocket microflora
for variable but relatively long periods.
Decrease in the proportion of motile rods for 1
Marked elevation in the proportion of coccoid
cell for 21 days
Marked reduction in the proportion of
spirochetes for 7 weeks
The return of pathogens to pretreatment levels -
--- 9-11 weeks
3 months maintenance interval
base on microscopic monitoring of
At present there is no definitive periodontal
treatment that can cure the disease.
Examination & Evaluation
Change form last evaluation
Evaluation of caries, restoration
Periodontal & periimplant probing depth
Patient Condition/ Situation Type of Radiographic
Clinical caries or high risk factor for caries Posterior bite-wing examination at 12-18
Clinical caries and no high risk factor for caries Posterior bite-wing examination at 24-36
Periodontal disease not under good control Periapical and/or vertical bite wing
radiographs of problem areas every 12-14
months; full mouth series every 3-5 years.
History of periodontal treatment with disease
under good control
Bite wing examinations every 24-36 months;
full mouth series every 5 years.
Root form dental implants Periapical/vertical bite wing radiographs at 6,
12 & 36 months after prosthetic replacement,
then every 36 months unless clinical problem
Transfer of periodontal or implant
Full mouth series including including implant
& periodontal problem areas should be taken.
Pic. A – The patient was
advised to have localized
areas of periodontal surgery
& periodontal recall every 3
Pic. B – Radiographs 4 years
later showing several bone
loss of premolars & molars
A – Pretreatment
B – 1yr. Post-treatment
C - 3 yr. post-treatment
D - 7 yr. post-treatment
Pic. A, B, C, D
showing a patient
Patient with limited periodontal therapy & poor maintenance
Checking of plaque control
Patient should perform their hygiene regimen
immediately before the recall appointment.
Plaque control must be reviewed and corrected
until the patient demonstrates the necessary
Amount of supragingival plaque affects the
number of subgingival anaerobic organism.
Scaling and root planing.
Instrumentation should not be done at
normal site (shallow sulci – 1-3 mm deep)
Irrigation with antimicrobial agents.
Maintenance of Recall Procedures
EXAMINATION (14 MINUTES)
• Patient greeting
• Medical history
• Oral pathologic
• Oral hygiene
• Pocket depth
Treatment (36 minutes)
• Oral hygiene
irrigation or site
Report, Clean-up & scheduling ( 10 mins.)
• Write report in
• Discuss report
• Clean &
• Schedule next
• Schedule or
refer for further
Subject risk assessment
The patient’s risk assessment for recurrence of
periodontitis may be evaluated on the basis of a
number of clinical conditions whereby no single
parameter displays a more paramount role.
The entire spectrum of risk factors and risk
indicators ought to be evaluated simultaneously.
For this purpose, a functional diagram has been
constructed including the following aspects:
1. Percentage of bleeding on probing
2. Prevalence of residual pockets greater than 5
3. Loss of teeth from a total of 28 teeth
4. Loss of periodontal support in relation to the
5. Systemic and genetic conditions
6. Environmental factors such as cigarette
Compliance with recall system
Several investigations have indicated that only a
minority of periodontal patients comply with the
prescribed supportive periodontal care
treated periodontal patients who comply with
regular periodontal maintenance appointments
have a better prognosis than patients who do
non-compliant or poorly compliant patients
should be considered at higher risk for
periodontal disease progression.
Since bacterial plaque is by far the most
important etiologic agent for the occurrence of
periodontal diseases, it is evident that the full-mouth
assessment of the bacterial load must
have a pivotal impact in the determination of the
risk for disease recurrence.
It has to be realized, however, that regular
interference with the microbial ecosystem
during periodontal maintenance will eventually
obscure such obvious associations.
Percentage of sites with
bleeding on probing
Bleeding on gentle probing represents an
objective inflammatory parameter which has
been incorporated into index systems for the
evaluation of periodontal conditions and is also
used as a parameter by itself.
In a patient’s risk assessment for recurrence of
periodontitis, bleeding on probing (BOP)
reflects, at least in part, the patient’s compliance
and standards of oral hygiene performance.
Prevalence of residual pockets
greater than 4 mm
The enumeration of the residual pockets with probing
depths greater than 4 mm represents, to a certain extent,
the degree of success of periodontal treatment rendered.
Although this figure per se does not make much sense when
considered as a sole parameter, the evaluation in
conjunction with other parameters, such as BOP and/or
suppuration, will reflect existing ecologic niches from and
in which reinfection might occur.
therefore, periodontal stability in a dentition would be
reflected in a minimal number of residual pockets.
it has to be realized that an increased number
of residual pockets does not necessarily imply
an increased risk for reinfection or disease
progression, since a number of longitudinal
studies have established the fact that,
depending on the individual supportive
therapy provided, even deeper pockets may
be stable without further disease
progression for years (Knowles et al. 1979;
Lindhe & Nyman 1984).
in assessing the patient’s risk for disease progression, the
number of residual pockets with a probing depth of ≥5
mm is assessed as the second risk indicator for recurrent
disease in the functional diagram of risk assessment.
Individuals with up to 4 residual pockets may be regarded
as patients with a relatively low risk, while patients with
more than 8 residual pockets may be regarded as
individuals with high risk for recurrent disease.
Loss of teeth from a total of 28
Although the reason for tooth loss may not be
known, the number of remaining teeth in a
dentition reflects the functionality of the
Mandibular stability and individual optimal
function may be assured even with a shortened
dental arch of premolar to premolar occlusion,
i.e. 20 teeth.
if more than eight teeth from a total of 28 teeth
are lost, oral function is usually impaired (Käyser
1981, 1994, 1996).
The number of teeth lost from the dentition
without the third molars (28 teeth) is
counted, irrespective of their replacement.
The scale runs also in a linear mode with 2, 4,
6, 8, 10, and ≥12% being the divisions on the
Individuals with up to four teeth lost may be
regarded as patients in low risk, while
patients with more than eight teeth lost may
be considered as being in high risk.
Loss of periodontal support in
relation to the patient’s age
The extent and prevalence of periodontal
attachment loss (i.e. previous disease experience
and susceptibility), as evaluated by the height of the
alveolar bone on radiographs, may represent the
most obvious indicator of subject risk when related
to the patient’s age.
The estimation of the loss of alveolar bone is
performed in the posterior region on either
periapical radiographs, in which the worst site
affected is estimated gross as a percentage of the
root length, or on bite-wing radiographs in which the
worst site affected is estimated in millimeters.
One millimeter is equated with 10% bone loss.
The percentage is then divided by the patient’s age.
This results in a factor.
example, a 40-year-old patient with 20% of bone
loss at the worst posterior site affected would be
scored BL/Age = 0.5. Another 40-year-old patient
with 50% bone loss at the worst posterior site scores
In assessing the patient’s risk for disease
progression, the extent of alveolar bone loss in
relation to the patient’s age is estimated as the
fourth risk indicator for recurrent disease in the
functional diagram of risk assessment.
The scale runs in increments of 0.25 of the
factor BL/Age, with 0.5 being the division
between low and moderate risk and 1.0 being
the division between moderate and high risk
for disease progression.
This, in turn, means that 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 risk.
Calculating the patient’s individual
periodontal risk assessment (PRA)
Based on the six parameters specified previously,
a multifunctional diagram is constructed for the
In this diagram, the vectors have been
constructed on the basis of the scientific
It is obvious that ongoing validation may result
in slight modifications.
A low periodontal risk (PR) patient has all
parameters within the low-risk categories or at
the most one parameter in the moderate-risk
A moderate PR patient has at least two
parameters in the moderate category, but at
most one parameter in the high-risk category.
A high PR patient has at least two
parameters in the high-risk category.
The subject risk assessment may estimate the risk for
susceptibility for progression of periodontal disease.
It consists of an
assessment of the level of infection (full-mouth
the prevalence of residual periodontal pockets,
loss of periodontal support in relation to the patient’s
an evaluation of the systemic conditions of the
patient, and finally,
evaluation of environmental and behavioral factors
such as smoking and stress.
All these factors should be contemplated and
A functional diagram may help the clinician
in determining the risk for disease
progression on the subject level.
This may be useful in customizing the
frequency and content of SPT visits.
Recall intervals for various classes of
Characteristics Recall interval
First year Routine therapy & uneventful healing
Difficult case with complicated
prosthesis, furcation involvement, poor
crown-root ratio, questionable patient
Class A Excellent results well maintained for 1
yr. or more
Good oral hygiene, no occlusal
problems, no complicated prosthesis, no
remaining pockets, & no teeth with <50%
of alveolar bone remaining.
6 months – 1 yr.
Class B Generally good results maintained reasonably well for
1 yr or more, but patient displays following factors –
Inconsistent or poor oral hygiene
Heavy calculus formation
Some remaining pockets
Some teeth with < 50% of alveolar bone support
More than 20% of pockets bleed on probing.
3 -4 months
(decide on recall
interval based on
number & severity
Class C Generally poor results after periodontal therapy &
with several negative factors
Inconsistent or poor oral hygiene
Many remaining pockets
Periodontal surgery indicated but not performed
due to medical, psychological or financial reason.
Many teeth with < 50% of alveolar bone support
Condition too far advanced to be improved by
More than 20% of pockets bleed on probing
1 – 3 months
(decide on recall
interval based on
number & severity
re- treating some
areas or extracting
SPT with adjunct use of
A number of short-term studies (12 months or less)
imply that the use of antibiotics are effective adjuncts and
that the effect may be sustained over a longer period of
the advantage of adjunct antibiotic therapy during SPT is
Carranza’s Clinical Periodontology. 11th edition
Lindhe J, KarringT, Lang NP. Clinical periodontology
and implant dentistry, 4th. Ed. Munksgaard 2003,
Claffey, N. (1991). Decision making in
periodontal therapy. The re-evaluation. Journal
of Clinical Periodontology 18, 384–389.