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Supportive Periodontal Therapy



Supportive Periodontal Treatment

Supportive Periodontal Treatment (SPT) - an importanr prospective in periodontal treatment

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Supportive Periodontal Treatment

  1. 1. Good Afternoon…
  2. 2. SUPPORTIVE PERIODONTAL TREATMENT By Suhasis Mondal Internee Dr. R. Ahmed Dental College & Hospital
  3. 3. 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 & periodontal needs. Short –term goals Elimination of all infectious & inflammatory process that cause periodontal & other oral problems that may hinder the patients’ general health. Long –term goals Reconstruction of a healthy dentition that fulfills all functional & esthetic requirements.
  4. 4. Phases of Periodontal Treatment Preliminary phase (Treatment of emergencies) • Dental or periapical • Periodontal • Other Phase I (Non- surgical) • Diet counseling • Removal of plaque retentive factors • Excavation of caries & restoration • Supragingival scaling • Subgingival scaling • Root planing • Occlusal therapy • Minor orthodontic movement • Antimicrobial therapy. Phase II (Surgical) • Periodontal surgery including placement of implants • Endodontic therapy Phase III (Restorative) • Final restoration • FPD • RPD Phase IV (Maintenance) • Periodic rechecking • Plaque & calculus indices • Gingival condition • Attachment level • Pocket depth • Bleeding on probing • Recession Evaluation Evaluation Evaluation
  5. 5. Preferred sequence for periodontal treatment plan The 3rd World Workshop of the American Academy of Periodontology (1989) renamed this treatment phase “Supportive Periodontal Therapy” (SPT).
  6. 6. What is SPT?  SPT = Supportive Periodontal Treatment Also known as  Periodontal Maintenance Therapy  Preventive Maintenance  Recall Maintenance  Procedures performed at selected intervals to assist the periodontal patient in maintaining oral health.
  7. 7. 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.
  8. 8. 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 plaque removal.
  9. 9. Cont.. 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 months,
  10. 10. 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
  11. 11. 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.
  12. 12. 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. 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.
  13. 13. Rationale A. Recurrence 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
  14. 14. Long junctional epithelium o Weak o inflammation may rapidly separate Bacteria may recolonize the pocket and cause recurrent disease
  15. 15. Subgingival scaling alters the pocket microflora for variable but relatively long periods.  Decrease in the proportion of motile rods for 1 week  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
  16. 16. 3 months maintenance interval  prevent recurrence  base on microscopic monitoring of subgingival flora At present there is no definitive periodontal treatment that can cure the disease.
  17. 17. Maintenance Program Examination & Evaluation Change form last evaluation Evaluation of caries, restoration Occlusion Prosthesis Tooth mobility Gingival status Periodontal & periimplant probing depth Radiographic examination
  18. 18. Patient Condition/ Situation Type of Radiographic Examination Clinical caries or high risk factor for caries Posterior bite-wing examination at 12-18 months interval Clinical caries and no high risk factor for caries Posterior bite-wing examination at 24-36 months interval 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 arise. Transfer of periodontal or implant maintenance patients Full mouth series including including implant & periodontal problem areas should be taken.
  19. 19. Pic. A – The patient was advised to have localized areas of periodontal surgery & periodontal recall every 3 months Pic. B – Radiographs 4 years later showing several bone loss of premolars & molars
  20. 20. A – Pretreatment B – 1yr. Post-treatment C - 3 yr. post-treatment D - 7 yr. post-treatment Pic. A, B, C, D showing a patient treated with surgical therapy including bone grafting with poor maintenance
  21. 21. Patient with limited periodontal therapy & poor maintenance
  22. 22.  v
  23. 23. 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 proficiency.  Amount of supragingival plaque affects the number of subgingival anaerobic organism.
  24. 24. Treatment  Scaling and root planing.  Oral prophylaxis  Instrumentation should not be done at normal site (shallow sulci – 1-3 mm deep)  Irrigation with antimicrobial agents.
  25. 25. Maintenance of Recall Procedures EXAMINATION (14 MINUTES) • Patient greeting • Medical history changes • Oral pathologic examination • Oral hygiene status • Gingival changes • Pocket depth changes • Mobility changes • Occlusal changes • Caries • Restorative, prosthetic & implant status. Treatment (36 minutes) • Oral hygiene reinforcement • Scaling • Polishing • Chemical irrigation or site specific antimicrobial placement Report, Clean-up & scheduling ( 10 mins.) • Write report in chart. • Discuss report with patient • Clean & disinfect operatory. • Schedule next recall visit. • Schedule further periodontal treatment. • Schedule or refer for further restorative or prosthetic treatment.
  26. 26. 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:
  27. 27. 1. Percentage of bleeding on probing 2. Prevalence of residual pockets greater than 5 mm 3. Loss of teeth from a total of 28 teeth 4. Loss of periodontal support in relation to the patient’s age 5. Systemic and genetic conditions 6. Environmental factors such as cigarette smoking.
  28. 28. 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 not comply.  non-compliant or poorly compliant patients should be considered at higher risk for periodontal disease progression.
  29. 29. Oral hygiene  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.
  30. 30. 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.
  31. 31. 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.
  32. 32. Cont…  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).
  33. 33. Cont…  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.
  34. 34. Loss of teeth from a total of 28 teeth  Although the reason for tooth loss may not be known, the number of remaining teeth in a dentition reflects the functionality of the dentition.  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).
  35. 35. Cont…  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 vector.  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.
  36. 36. 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.
  37. 37. Cont…  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 BL/Age =1.25.  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.
  38. 38. Cont…  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.
  39. 39. Calculating the patient’s individual periodontal risk assessment (PRA)  Based on the six parameters specified previously, a multifunctional diagram is constructed for the PRA.  In this diagram, the vectors have been constructed on the basis of the scientific evidence available.  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 category.
  40. 40.  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.
  41. 41. Summary  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 bleeding scores),  the prevalence of residual periodontal pockets,  tooth loss,  loss of periodontal support in relation to the patient’s age,  an evaluation of the systemic conditions of the patient, and finally,  evaluation of environmental and behavioral factors such as smoking and stress.
  42. 42. Summary cont…  All these factors should be contemplated and evaluated together.  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.
  43. 43. Recall intervals for various classes of recall patient Merin Classification Characteristics Recall interval First year Routine therapy & uneventful healing Difficult case with complicated prosthesis, furcation involvement, poor crown-root ratio, questionable patient cooperation. 3 months 1-2 months. 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.
  44. 44. Merin classification Characteristics Recall interval 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 Systemic disease Some remaining pockets Occlusal problems Some teeth with < 50% of alveolar bone support Smoking More than 20% of pockets bleed on probing. 3 -4 months (decide on recall interval based on number & severity of negative factors) 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 periodontal surgery More than 20% of pockets bleed on probing 1 – 3 months (decide on recall interval based on number & severity of negative factors; consider re- treating some areas or extracting severly involved teeth)
  45. 45. SPT with adjunct use of antimicrobials/antibiotics 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 time . However, the advantage of adjunct antibiotic therapy during SPT is unknown.
  46. 46. References  Carranza’s Clinical Periodontology. 11th edition  Lindhe J, KarringT, Lang NP. Clinical periodontology and implant dentistry, 4th. Ed. Munksgaard 2003, Copenhagen.  Claffey, N. (1991). Decision making in periodontal therapy. The re-evaluation. Journal of Clinical Periodontology 18, 384–389.
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Supportive Periodontal Treatment (SPT) - an importanr prospective in periodontal treatment


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