SUPPORTIVE PERIODONTAL THERAPY

1. Presented By – Dr. Fatima Gilani
Moderator –Dr.Shivjot Chhina
Perceptor – Dr.Kumar Saurav
SUPPORTIVE
PERIODONTAL THERAPY

3.  Introduction
 Rationale and objectives
 Compliance
 Parts of SPT
 Frequency and efficacy
 SPT in daily practice
 Recurrence of periodontal disease
CONTENTS

4.  Classification of post treatment patients
 Referral of patients to the periodontist
 Risk assessment of recurrence of disease during SPT and
multifactorial risk diagram
 Complications of supportive periodontal therapy
 SPT with adjunct use of antimicrobials/antibiotics
 Maintenance care of patients with dental implants

5.  Untreated chronic periodontitis has been described as a
slowly progressive disease affecting individual teeth or tooth
sites, showing evidence of periods of stability and periods of
progression.1
 Thus, at untreated tooth sites, clinical measures of oral
hygiene, gingivitis, pocket probing depths, and clinical
attachment levels are poor predictors of disease activity .
INTRODUCTION

6.  Thus the evaluation of the efficacy of supportive periodontal
therapy (SPT) must be carried out over an extended period of
time.
 Different terms such as periodontal maintenance, supportive
periodontal care, and recall have been used and represent
somewhat different entities.
 Supportive periodontal care is a broader term and focuses on
patients previously treated for periodontal disease.1

7. An update of the medical and dental histories
Examination of extra and
intraoral soft tissues, dental
examination
Radiographic review
Evaluation of the patient’s
oral hygiene performance
Periodontal evaluation
and risk assessment
Supra and subgingival
removal of bacterial
plaque and calculus
Retreatment of
disease when
indicated
The American Academy of Periodontology 1989 renamed periodontal
maintenance as, SUPPORTIVE PERIODONTAL THERAPY, which
included

8. INCORRECT SEQUENCE CORRECT SEQUENCE

9.  To prevent or minimize the recurrence and progression of
periodontal disease in patients who have been previously treated
for gingivitis, periodontitis, and peri-implantitis.2
 To prevent or reduce the incidence of tooth loss by monitoring the
dentition and any prosthetic replacement of natural teeth.
 To increase the probability of locating and treating in a timely
manner, other diseases or conditions found within the oral cavity.
GOALS OF SPT

10.  One likely explanation for the recurrence of periodontal
disease is incomplete subgingival plaque removal. Bacteria
are present in the gingival tissues in chronic and aggressive
periodontitis.2
 Eradication of intergingival microorganisms may be
necessary for a stable periodontal result.
 Scaling, root planning, and even flap surgery may not
eliminate intergingival bacteria in some areas. These bacteria
may recolonize the pocket and cause recurrent disease.
RATIONALES AND OBJECTIVES

11.  Bacteria associated with periodontitis can be transmitted between
spouses and other family members.
 Patients who appear to be successfully treated can become
infected or reinfected with potential pathogens.
 Subgingival scaling alters the microflora of periodontal pockets.
There is decrease in the proportion of motile rods for 1 week, a
marked elevation in the proportion of coccoid cells for 21 days,
and a marked reduction in the proportion of spirochetes for 7
weeks.3

12.  “The extent to which a persons
behaviour coincides with
medical or health advice”
COMPLIANCE

13. The studies by
Demetriou et al.5
and Demirel et al.6
suggested that
females are more
compliant than
men.
Study by Novaes
& Ojima showed
that older patients
are more compliant
than younger
patients, whereas
the study by
Demetriou et al5
suggested the
opposite.

14. PARTS OF SPT
• designed to prevent the inception of disease
in individuals without periodontal pathosis.
Preventive
SPT
• designed to maintain border line periodontal
conditions over a period to further assess the need
for corrective therapy for problems such as
inadequate gingiva, gingival architectural defects,
or furcation defects, while maintaining periodontal
health throughout the balance of the mouth.
Trial SPT

15. •designed to slow the progression of disease in
patients for whom periodontal corrective therapy
is indicated, but cannot be implemented for
reasons of health, economics, inadequate oral
hygiene, or other considerations, or when
recalcitrant defects persist after corrective
treatment.
Compromise
SPT
•designated to prevent the recurrence of disease
and maintain the periodontal health achieved
during therapy.
Post treatment
SPT

16.  Numerous studies have shown that less attachment loss occurs,
and fewer teeth are lost when patients maintain regular SPT.
 For most patients with gingivitis but no previous attachment loss,
SPT twice a year will suffice.
FREQUENCY AND EFFICACY

17. However, Nyman et al (1975)6
demonstrated that if professional
care were administered every 2nd
week for 2 years, periodontal support
would be preserved almost intact,
where as patients in the control
group receiving root instrumentation
every 6 months exhibited significant
additional loss of attachment.
Lightner et al (1971)7 studied the
effectiveness of different frequencies
for preventive treatment showing
that 4 prophylaxis per year and tooth
brushing instruction proved very
effective in retarding alveolar bone
loss.

18. SPT IN DAILY PRACTICE
1.
Examination,
Re-evaluation
and Diagnosis
(ERD)
2. Motivation,
Reinstruction
and
Instrumentatio
n (MRI
3. Treatment
of Reinfected
Sites (TRS)
4.Polishing of the
entire dentition,
application of
Fluorides and
Determination of
future SPT (PFD)

19.  It includes updating the significant changes in their health status
 Extraoral and intraoral soft tissue examination for screening oral
cancer.
 An evaluation of the patient's risk factors will also influence the
choice of future SPT and the determination of the recall interval
at the end of the maintenance visit.
1. EXAMINATION, RE-EVALUATION AND
DIAGNOSIS (ERD)

20. OCCASIONALLY, CONVENTIONAL
DENTAL RADIOGRAPHS INDICATED
IN SPT
Carranza’s clinical Periodontology 10th edition chapter 82 Page No - 1199

21.  This aspect uses most of the available time of the SPT visit.
Patients who have experienced a relapse in their adequate oral
hygiene practices need to be further motivated.
 The patient reinstructed in tooth brushing techniques which
emphasize vibratory rather than scrubbing movements.
2. MOTIVATION, REINSTRUCTION AND
INSTRUMENTATION (MRI)

22.  Since it is impossible to instrument all the tooth sites in the time
allocated, only those sites are reinstrumented during SPT visits
which exhibit signs of inflammation and/or active disease
progression.5
 Root surface instrumentation is aimed at the removal of sub-
gingival plaque rather than “diseased” cementum.

23.  Single sites, especially furcation sites or sites with difficult
access, may be reinfected and demonstrate suppuration.
 Such sites require a thorough instrumentation, the local
application of antibiotics in controlled release devices or even
open debridement with surgical access.
3.TREATMENT OF REINFECTED SITES
(TRS)

24.  Generalized reinfections are usually the result of
inadequate SPT.
 Local reinfections may either be the result of inadequate
plaque control in a local area or the formation of ecologic
niches conducive to periodontal pathogens.
 The risk assessment on the tooth level may identify such
niches which are inaccessible for regular oral hygiene
practices.

25.  The recall hour is concluded with polishing the entire
dentition to remove all remaining soft deposits and stains.
 Following polishing, fluorides is applied in high
concentration in order to replace the fluorides which is
removed during instrumentation.
 Fluoride or chlorhexidine varnishes may also be applied to
prevent root surface caries, especially in areas with gingival
recessions.
4. POLISHING, FLUORIDES,
DETERMINATION OF RECALL INTERVAL
(PFD)

26.  Occasionally, lesions may recur. This is often due to
inadequate plaque control on the part of the patient or
failure to comply with recommended SPT schedules.
 However, it is the dentist's responsibility to teach,
motivate, and control the patient's oral hygiene technique,
and the patient's failure is the dentist's failure.
 Surgery should not be undertaken unless the patient has
shown proficiency and willingness to cooperate by
adequately performing his or her part of therapy.
RECURRENCE OF PERIODONTAL DISEASE

27.  Inadequate or insufficient treatment that has failed to remove
all the potential factors favoring plaque accumulation .
 Inadequate restorations placed after the periodontal treatment
was completed.
 Failure of the patient to return for periodic checkups .
 Presence of some systemic diseases that may affect host
resistance to previously acceptable levels of plaque.
OTHER CAUSES FOR RECURRENCE ARE
THE FOLLOWING:

28. 1. Recurring inflammation
revealed by gingival changes
and bleeding of the sulcus on
probing.
2. Increasing depth of sulci,
leading to the recurrence of
pocket formation.
3. Gradual increase in bone
loss as determined by
radiographs.
4. Gradual increase in tooth
mobility as ascertained by
clinical examination
A failing case can
be recognized by
the following:

29.  The first year after periodontal therapy is important in terms of
indoctrinating the patient in a recall pattern and reinforcing oral
hygiene techniques.
 In addition, it may take several months to accurately evaluate the
results of some periodontal surgical procedures.
CLASSIFICATION OF POST
TREATMENT PATIENTS

30.  Consequently, some areas may have to be retreated because the
results may not be optimal. Furthermore, the first-year patient
often has etiologic factors that may have been overlooked and
may be more amenable to treatment at this early stage.
 For these reasons, the recall interval for first-year patients should
not be longer than 3 months.

32. Carranza’s clinical Periodontology 10th edition, Chapter 82.8

33.  The majority of periodontal care belongs in the hands of the
general dentist.
 The question remains where to draw the line between the cases to
be treated in the general dental office and those to be referred to
a specialist varies for different practitioners and patients.
 The diagnosis indicates the type of periodontal treatment
required.
REFERRAL OF PATIENTS TO THE
PERIODONTIST

34.  If periodontal destruction necessitates surgery on the distal
surfaces of second molars, extensive osseous surgery, or complex
regenerative procedures, the patient is usually best treated by a
specialist.
 On the other hand, patients who require localized gingivectomy
or flap curettage usually can be treated by the general dentist.

35. Should the maintenance phase of therapy be performed by the
general practitioner or the specialist?
The suggested rule is that the patient's disease should dictate
whether the general practitioner or the specialist should perform
the maintenance therapy.8

36. Evaluated on three levels:
RISK ASSESSMENT OF RECURRENCE OF
DISEASE DURING SPT AND
MULTIFACTORIAL RISK DIAGRAM9
1. Percentage of
bleeding on probing
Subject Level
Subject
level
Tooth
level
Site
level

37. 2.Prevalence of residual pockets greater than 4
mm9

38. 3.Loss of teeth from a total of 28 teeth

39. 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 % of the root
length, or on bite-wing
radiographs in which the worst
site affected is estimated in mm.9
4.Loss of periodontal support in relation to the patient's age

40. One mm is equated with 10% bone
loss. The percentage is then divided
by the patient's age
As an example, a 40-year-old
patient with 20% of bone loss at the
worst posterior site affected would
be scored BL/Age = 0.5.

41. 5.Systemic conditions

42. 6.Cigarette smoking

43. CALCULATING THE
PATIENT'S INDIVIDUAL
PERIODONTAL RISK
ASSESSMENT (PRA)9

44. Low Periodontal Risk Patient

45. Moderate Periodontal
Risk Patient

46. High Risk Patients

47. an estimation of the residual
periodontal support
an evaluation of tooth positioning
furcation involvements
presence of iatrogenic factors
residual periodontal support and
a determination of tooth mobility to
evaluate functional stability.
TOOTH LEVEL
RISK
ASSESSMENT

48.  A risk assessment on the tooth level may be useful in evaluating
the prognosis and function of an individual tooth and may
indicate the need for specific therapeutic measures during SPT
visits.

49.  The tooth site risk assessment includes the registration of
bleeding on probing, probing depth, loss of attachment,
and suppuration.
 A risk assessment on the site level may be useful in
evaluating periodontal disease activity and determining
periodontal stability or ongoing inflammation.
 The site risk assessment is essential for the identification
of the sites to be instrumented during SPT.
SITE LEVEL RISK ASSESSMENT

50.  It appears that many patients are unable to achieve an oral
hygiene consistent with periodontal health.
 Therefore antimicrobials have been used to compensate
for inadequate mechanical oral hygiene.
SPT WITH ADJUNCT USE OF
ANTIMICROBIALS/ANTIBIOTICS

51.  Antimicrobials can be administered using different delivery
systems, i.e. dentifrices, solutions for oral rinses or flushing of
the periodontal pockets, and other local delivery systems.
 There are few long-term studies suggesting the efficacy of such
antimicrobials in SPT programs.

52. 1 .Dentifrices :
 Rosling et al.10 demonstrated that a triclosan/copolymer
containing dentifrice reduced the subgingival microbiota
both quantitatively and qualitatively over a 3-year period
without concomitant use of subgingival mechanical
treatment.
 The frequency of deep periodontal pockets and number of
sites exhibiting additional probing attachment and bone
loss was also reduced .

53.  Furuichi et al.11 reported that patients using a
triclosan/copolymer dentifrice demonstrated significantly more
gain of attachment and decrease in mean pocket probing depth as
compared to a control group.

54. 2. Chlorhexidine :
 Christie et al (1998)12 in his study found that
chlorhexidine is effective when used as an adjunct rinse
to inadequate mechanical oral hygiene in nonsurgical
treatment of chronic to advanced periodontitis patients
over an observation period of 1 year.

 Use of chlorhexidine rinse over 3 years at varying
intervals may also prevent tooth loss (Person et al 1998)13
.

55. 3. Administration of chlorhexidine in a controlled release
delivery system (Periochip) in patients with residual pockets
appeared to be effective in a 6-months study conducted by Heasman
( 2001)14.
 The long-term effects of such treatments are unknown.

56. 4.Study by Loesche and Johnson ( 2002)15 imply that the use of
antibiotics are effective adjuncts to ICRT and that the effect may be
sustained over a longer period of time.
 However, the advantage of adjunct antibiotic therapy during SPT
is unknown.

57. MAINTENANCE CARE OF PATIENTS
WITH DENTAL IMPLANTS
1. Special
instrumentation that
will not scratch the
implants are used for
calculus removal on
the implants.
2. Acidic
fluoride
prophylactic
agents are
avoided.
3.
Nonabrasive
prophylactic
paste are used.
In general, procedures for maintenance of patients with implants
are similar to those with natural teeth, with three differences:

58.  During the phase after uncovering the implants, patients must use
ultrasoft brushes, chemotherapeutic rinses, tartar control pastes,
irrigation devices, and yarn-like materials to keep the implants
clean.
 Patients often are afraid to touch the implants but must be
encouraged to keep the areas clean.

59.  Metal hand instruments and ultrasonic and sonic tips should be
avoided because they can alter the titanium surface.
 Only plastic instruments or specially designed gold-plated
curettes should be used for calculus removal because the implant
surfaces can be easily scratched.

60.  The rubber cup with flour of pumice, tin oxide, or special implant
polishing pastes should be used on abutment surfaces with light,
intermittent pressure.
 Although daily use of topically applied antimicrobials is advised,
acidic fluoride agents should not be used because they cause
surface damage to titanium abutments.

61.  When prosthetics must be unscrewed and removed for
maintenance, it is best done in the office responsible for placing
the prosthetics.
 Each time the prosthetics are reattached, a slight change in the
occlusion occurs. Time must be allowed for occlusal corrections.

62.  Periodic recall visits form the foundation of a meaningful
long term prevention program.
 Prevention is better than cure.
CONCLUSION

63. 1. Axelsson, P. & Lindhe, J. Effect of controlled oral hygiene procedures on
caries and periodontal disease in adults. Results after 6 years. Journal of
Clinical Periodontology;1981:8, 239–248.
2. Becker, W., Berg, L.E. & Becker, B.E. Untreated periodontal disease: A
longitudinal study. Journal of Periodontology.1979: 50, 234–244.
3. Mousquès, T., Listgarten, M.A. & Phillips, R.W. (1980). Effect of scaling
and root planing on the composition of the human subgingival microbial fl
ora. Journal of Periodontal Research 15, 144–151.
4. Kerr, N.W. (1981). Treatment of chronic periodontitis. 45% failure rate.
British Dental Journal 150, 222–224.
5. Demetriou, N., Tsami-Pandi, A. & Parashis, A. (1995). Compliance with
supportive periodontal treatment in private periodontal practice. A 14-year
retrospective study. Journal of Periodontology 66, 145–149.
REFERENCES

64. 6. Nyman, S., Rosling, B. & Lindhe, J. (1975). Effect of professional tooth
cleaning on healing after periodontal surgery. Journal of Clinical
Periodontology 2, 80–86.
7. Hind al-joha. Oral Hygiene Practice among Saudi Patients in Jeddah.
Cairo Dental Journal (24) Number (3), 395:401 September, 2008.
8. Carranza’s clinical Periodontology 10th edition, Chapter 82.
9. Clinical periodontology and implant dentistry , 5th edition , vol 1 , Jan
Lindhe.
10. Rosling, B., Nyman, S., Lindhe, J. & Jern, B. (1976). The healing
potential of the periodontal tissues following different techniques of
periodontal surgery in plaque-free dentitions. Journal of Clinical
Periodontology 3, 233–250.
11. Furuichi et al. (1982). Oral hygiene and maintenance of periodontal
support. Journal of Periodontology 53, 26–30.
12. Christie et al. Evidence-based control of plaque and gingivitis. J Clin
Periodontal 1998; 30 (Suppl. 5): 13–16.