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Muhimbili University Of Health And                        Allied Sciences                              (MUHAS).       DAR ...
Work plan.       Introduction and Definition.       Basic paradigms for the prevention of periodontal        diseases. ...
Introduction.         Periodontal treatment includes:    1. Systemic evaluation of the patient’s health    2. A cause-rela...
Introduction.       This term expresses the essential need for therapeutic        measures to support the patient’s own e...
Basic paradigms for the prevention     of periodontal diseases.       Periodontal maintenance care, or SPT, follows      ...
Cont…        Ten years later, a corresponding relationship        between plaque accumulation and the development        o...
       It must be considered that the; composition of the        microbiota or the host’s defense mechanisms or        su...
       In fact, as early as 1746, Fauchard stated that “little or        no care as to the cleaning of teeth is ordinaril...
       Interceptive professional supportive therapy at regular        intervals may, to a certain extent, compensate for ...
    This requires the professional removal of all microbial     deposits in the supragingival and subgingival areas at   ...
Rationale.    Significant efforts have been made to develop     antimicrobial treatments and regenerative     procedures....
Patients at risk for periodontitis          without SPT.    The effect of an omission of SPT in patients with     periodo...
Cont…    In this, an average loss of 0.3 mm per tooth surface and     year was encountered. Also, the laborers lost betwe...
Cont…    Such patients were either completely stable and lost no     teeth during maintenance periods ranging up to 22 ye...
Cont…    Non-complying, but periodontitis-susceptible patients     receiving no SPT following periodontal surgical     in...
Summary:    Patients susceptible to periodontal disease are at high     risk for reinfection and progression of periodont...
SPT for patients with gingivitis    Several studies, predominantly in children, have     documented that periodic profess...
    Adults whose effective oral hygiene is combined with     periodic professional prophylaxis are clearly healthier     ...
    Gingival conditions improved by approximately 60% and     tooth loss was reduced by about 50% of what would be     ex...
SPT for patients with periodontitis    SPT is an absolute prerequisite to guarantee beneficial     treatment outcomes wit...
Continuous multi-level risk               assessment.    clinical diagnosis during SPT has to be based on the     variati...
    Under optimal circumstances, supportive periodontal     care would maintain clinical attachment levels obtained     a...
    The intervals between diagnostic assessments must also     be chosen based on the overall risk profile and the     ex...
    it is important to determine the level of risk for     progression in each individual patient in order to be able    ...
Subject risk assessment.    The patient’s risk assessment for recurrence of     periodontitis may be evaluated on the bas...
1. Percentage of bleeding on probing 2. Prevalence of residual pockets greater than 5 mm 3. Loss of teeth from a total of ...
27   joshuagm/sem8/muhas/2011-12.   Friday, June 8, 2012
    Each parameter has its own scale for minor, moderate,     and high-risk profiles.     A comprehensive evaluation, th...
Compliance with recall system    Several investigations have indicated that only a minority     of periodontal patients c...
Oral hygiene.    Since bacterial plaque is by far the most important     etiologic agent for the occurrence of periodonta...
Percentage of sites with bleeding         on probing.    Bleeding on gentle probing represents an objective     inflammat...
    Although there is no established acceptable level of     prevalence of BOP in the dentition above which a higher     ...
    The percentage of BOP, therefore, is used as the first     risk factor in the functional diagram of risk assessment....
Prevalence of residual pockets greaterthan 4 mm.    The enumeration of the residual pockets with probing     depths great...
    it has to be realized that an increased number of residual     pockets does not necessarily imply an increased risk f...
    in assessing the patient’s risk for disease progression, the     number of residual pockets with a probing depth of ≥...
Loss of teeth from a total of 28          teeth.    Although the reason for tooth loss may not be known,     the number o...
    The number of teeth lost from the dentition without the     third molars (28 teeth) is counted, irrespective of their...
Loss of periodontal support in relation tothe patient’s age.    The extent and prevalence of periodontal attachment     l...
    One millimeter is equated with 10% bone loss.     The percentage is then divided by the patient’s age. This     resu...
    The scale runs in increments of 0.25 of the factor BL/Age,     with 0.5 being the division between low and moderate  ...
Calculating the patient’s individualperiodontal risk assessment (PRA).    Based on the six parameters specified previousl...
    A moderate PR patient has at least two parameters in the     moderate category, but at most one parameter in the     ...
summary;    The subject risk assessment may estimate the risk for     susceptibility for progression of periodontal disea...
Summary cont…    All these factors should be contemplated and evaluated     together.     A functional diagram may help ...
Tooth risk assessment    Tooth position within the dental arch    Furcation involvement    Iatrogenic factors    Resid...
Tooth position within the dental arch.    Early clinical surveys have associated the prevalence and     severity of perio...
    Although a relationship between crowding and increased     plaque retention and gingival inflammation has been     es...
    crowding of teeth might affect the amount of plaque mass     formed in dentitions with irregular oral hygiene practic...
Furcation involvement.    Retrospective analyses of large patient populations in     private periodontal practices of per...
    The assumption that the prognosis for single-rooted     teeth and non-furcation-involved multi-rooted teeth is     be...
Iatrogenic factors.    Overhanging restorations and ill fitting crown margins     certainly represent an area for plaque ...
    It has been established that slightly subgingivally located     overhanging restorations will, indeed, change the eco...
Residual periodontal support.    Although many clinicians believe that teeth with reduced     periodontal support are una...
    Hence, successfully periodontally treated teeth can be     maintained over decades and function as abutments in     f...
Mobility.    tooth mobility may be an indicator for progressive     traumatic lesions, provided that the mobility is incr...
    If this is reduced due to prior periodontal disease, but     the width of the periodontal ligament is unchanged, the ...
    Several studies have indicated that tooth mobility    varies greatly before, during, and after periodontal    thera...
Summary:    The tooth risk assessment encompasses an estimation of     the residual periodontal support, an evaluation of...
Site risk assessment.    Bleeding on probing    Probing depth and loss of attachment.    suppuration    60             ...
Bleeding on probing (BOP).    Absence of bleeding on probing (BOP) is a reliable     parameter to indicate periodontal st...
    this clinical parameter is the most reliable for monitoring     patients over time in daily practice.    Non-bleedin...
    It is, therefore, advisable to register the sites with BOP in     a dichotomous way using a constant force of 0.25 N....
Probing depth and loss of attachment.    Clinical probing is the most commonly used parameter     both to document loss o...
    Among these are     (1) the dimension of the periodontal probe;     (2) the placement of the probe and obtaining a re...
    It has to be realized that increased probing depth and     loss of probing attachment are parameters which reflect   ...
    These biologic variables (tissue conditions and calculus)     may be minimized following initial periodontal therapy,...
Suppuration.    In a proportion of periodontal lesions, pus will develop     and may drain through the orifice of a pocke...
    the presence of suppuration increased the positive     predictive value for disease progression in combination     wi...
Radiographic evaluation ofperiodontal disease progression. Radiographs should be current and should be based on  the diag...
Summary.The tooth site risk assessment includes the registration of BOP, probing depth, loss of  attachment, and suppurat...
SUMMARY.(continuous multi-level riskassessment).    It is suggested that patients be evaluated on the three     different...
Summary, cont…     It should also provide a perspective for the evaluation of     risk assessment conducted at the tooth ...
THERAPEUTIC GOALS1. To minimize the recurrence and progression of  periodontal disease in patients who have been  previous...
Objectives of SPT.    to reduce probing pocket depths    to reduce bleeding on probing    to gain clinical attachment l...
SPT in daily practice.    The recall hour should be planned to meet the patient’s     individual needs.    It basically ...
Recall hour.77             joshuagm/sem8/muhas/2011-12.   Friday, June 8, 2012
Treatment     1. Removal of subgingival and supragingival       plaque and calculus     2. Behavior modification:       A....
Communication1. Informing the patient of current status and alterations  in treatment if indicated.2. Consultation with ot...
Planning1*****. For most patients with a history of periodontitis,  visits at 3-month intervals have been found to be  eff...
Outcomes Assessment     The desired outcome for patients on periodontal     maintenance should result in maintenance of t...
Frequency of supportive maintenancecare recall intervals could be extended to at least 1 year in subjects with a history o...
SPT with adjunct use ofantimicrobials/antibiotics     A number of short-term studies (12 months or less)  imply that the u...
Conclusion.• SPT should be based on assessment of the patient risk  profile for further periodontal disease progression.  ...
References.    Lindhe J, Karring T, Lang NP. Clinical periodontology     and implant dentistry, 4th. Ed. Munksgaard 2003,...
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Supportive periodontal therapy0 (2)

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Supportive periodontal therapy0 (2)

  1. 1. Muhimbili University Of Health And Allied Sciences (MUHAS). DAR ES SALAAM,TANZANIA.SUPPORTIVE PERIODONTAL THERAPY, (SPT). JOSHUA Gideon; DDS-sem-8, 6th June 2012.1 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  2. 2. Work plan. Introduction and Definition. Basic paradigms for the prevention of periodontal diseases. Rationale of SPT. Patients at risk for periodontitis without SPT. SPT for patients with gingivitis and periodontitis Continuous multi-level risk assessment; Subject risk assessment, Tooth risk assessment, Site risk assessment Therapeutic goals and objectives. Conclusion References. 2 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  3. 3. Introduction. Periodontal treatment includes: 1. Systemic evaluation of the patient’s health 2. A cause-related therapeutic phase with, in some cases 3. A corrective phase involving periodontal surgical procedures 4. Maintenance phase. The 3rd World Workshop of the American Academy of Periodontology (1989) renamed this treatment phase “supportive periodontal therapy” (SPT).3 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  4. 4. Introduction. 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. 4 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  5. 5. 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. 5 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  6. 6. 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,6 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  7. 7.  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 7 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  8. 8.  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. 8 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  9. 9.  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. 9 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  10. 10.  This requires the professional removal of all microbial deposits in the supragingival and subgingival areas at regular intervals. 10 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  11. 11. Rationale. Significant efforts have been made to develop antimicrobial treatments and regenerative procedures. At present there is no definitive periodontal treatment that can cure the disease. Furthermore, the chronic nature of periodontitis as well as 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. The principles of periodontal maintenance care are well established and considered the standard of care. 11 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  12. 12. Patients at risk for periodontitis without SPT. The effect of an omission of SPT in patients with periodontitis may best be studied either in untreated populations or patient groups with poor compliance. One of the few studies documenting untreated periodontitis-susceptible patients reported on the continuous loss of periodontal attachment as well as teeth in Sri Lankan tea plantation workers receiving no dental therapy (Löe et al. 1986). 12 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  13. 13. Cont… In this, an average loss of 0.3 mm per tooth surface and year was encountered. Also, the laborers lost between 0.1 and 0.3 teeth per year as a result of periodontitis. In another untreated group in the United States, 0.61 teeth had been lost per year during an observation period of 4 years (Becker et al. 1979). This is in dramatic contrast to reports on tooth loss in well maintained patients treated for periodontitis (e.g. Hirschfeld & Wasserman 1978; McFall 1982; Becker et al. 1984; Wilson et al. 1987). 13 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  14. 14. Cont… Such patients were either completely stable and lost no teeth during maintenance periods ranging up to 22 years or lost only very little periodontal attachment and only 0.03 teeth (Hirschfeld & Wasserman 1978) or 0.06 teeth (Wilson et al. 1987), respectively. 14 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  15. 15. Cont… Non-complying, but periodontitis-susceptible patients receiving no SPT following periodontal surgical interventions continued to lose periodontal attachment at a rate of approximately 1 mm per year regardless of the type of surgery chosen (Nyman etal. 1977). This is almost three times more than would have to be expected as a result of the “natural” course of periodontal disease progression (Löe et al. 1978,1986). 15 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  16. 16. Summary: Patients susceptible to periodontal disease are at high risk for reinfection and progression of periodontal lesions without meticulously organized and performed SPT. Since all patients who were treated for periodontal diseases belong to this risk category by virtue of their past history, an adequate maintenance care program is of utmost importance for a beneficial long-term treatment outcome. SPT has to be aimed at the regular removal of the subgingival microbiota and must be supplemented by the patient’s efforts for optimal supragingival plaque control. 16 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  17. 17. SPT for patients with gingivitis Several studies, predominantly in children, have documented that periodic professional prophylactic visits in conjunction with reinforcement of personal oral hygiene are effective in controlling gingivitis (Badersten et al. 1975;). This, however, does not imply that maintenance visits in childhood preclude the development of more severe disease later in life. It is obvious that SPT, therefore, must be a lifelong commitment of both the patient and the profession. 17 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  18. 18.  Adults whose effective oral hygiene is combined with periodic professional prophylaxis are clearly healthier periodontally than patients who do not participate in SPT programs (Lövdal et al. 1961;Suomi et al. 1971). One particular study of historical significance was performed on 1428 adults from an industrial company in Oslo, Norway (Lövdal et al.1961). Over a 5-year observation period, the subjects were recalled two to four times per year for instruction in oral hygiene and supragingival and subgingival scaling. 18 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  19. 19.  Gingival conditions improved by approximately 60% and tooth loss was reduced by about 50% of what would be expected without these efforts. Summary: the prevention of gingival inflammation and early loss of attachment in patients with gingivitis depends on  the level of personal plaque control,  further measures to reduce the accumulation of supragingival and subgingival plaque. 19 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  20. 20. SPT for patients with periodontitis SPT is an absolute prerequisite to guarantee beneficial treatment outcomes with maintained levels of clinical attachment over long periods oftime. The maintenance of treatment results for the majority of patients has been documented up to 14 years, and in a private practice situation even up to 30 years. but it has to be realized that a small proportion of patients will experience recurrent infections with progression of periodontal lesions in a few sites in a completely unpredictable mode. The continuous risk assessment at subject, tooth and tooth site levels, therefore, represents a challenge for the SPT concept. 20 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  21. 21. Continuous multi-level risk assessment. clinical diagnosis during SPT has to be based on the variations of the health status obtained following successful active periodontal treatment. This, in turn, means that a new baseline will have to be established once the treatment goals of active periodontal therapy (i.e. phases 1–3) are reached and periodontal health is restored (Claffey 1991). This baseline includes the level of clinical attachment achieved while the inflammatory parameters are supposed to be under control. 21 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  22. 22.  Under optimal circumstances, supportive periodontal care would maintain clinical attachment levels obtained after active therapy for the years to come. From a clinical point of view, the stability of periodontal conditions reflects a dynamic equilibrium between bacterial aggression and effective host response. As such, this homeostasis is prone to sudden changes whenever one of the two factors prevails. Hence, it is evident that the diagnostic process must be based on continuous monitoring of the multi-level risk profile. 22 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  23. 23.  The intervals between diagnostic assessments must also be chosen based on the overall risk profile and the expected benefit. To schedule patients for supportive periodontal therapy on the basis of an individual risk evaluation for recurrence of disease has been demonstrated to be cost effective. 23 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  24. 24.  it is important to determine the level of risk for progression in each individual patient in order to be able to determine the frequency and extent of professional support necessary to maintain the attachment levels obtained following active therapy. The determination of such risk level would thus prevent under-treatment, and also excessive overtreatment, during SPT. 24 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  25. 25. 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: 25 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  26. 26. 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.26 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  27. 27. 27 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  28. 28.  Each parameter has its own scale for minor, moderate, and high-risk profiles. A comprehensive evaluation, the functional diagram will provide an individualized total risk profile and determine the frequency and complexity of SPT visits. Modifications may be made to the functional diagram if additional factors become important from future evidence. 28 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  29. 29. 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 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  30. 30. 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 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  31. 31. 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 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  32. 32.  Although there is no established acceptable level of prevalence of BOP in the dentition above which a higher risk for disease recurrence has been established, a BOP prevalence of 25% has been the cut-off point between patients with maintained periodontal stability for 4 years and patients with recurrent disease in the same timeframe in a prospective study in a private practice (Joss et al.1994). 32 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  33. 33.  The percentage of BOP, therefore, is used as the first risk factor in the functional diagram of risk assessment. Individuals with low mean BOP percentages (<10% of the surfaces) may be regarded as patients with a low risk for recurrent disease (Lang et al. 1990), while patients with mean BOP percentages >25% should be considered to be at high risk for reinfection. 33 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  34. 34. Prevalence of residual pockets greaterthan 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. 34 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  35. 35.  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). 35 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  36. 36.  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. 36 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  37. 37. 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). 37 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  38. 38.  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. 38 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  39. 39. Loss of periodontal support in relation tothe 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. 39 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  40. 40.  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. 40 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  41. 41.  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. 41 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  42. 42. Calculating the patient’s individualperiodontal 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. 42 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  43. 43.  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. 43 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  44. 44. 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. 44 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  45. 45. 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. 45 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  46. 46. Tooth risk assessment Tooth position within the dental arch Furcation involvement Iatrogenic factors Residual periodontal support Mobility. 46 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  47. 47. Tooth position within the dental arch. Early clinical surveys have associated the prevalence and severity of periodontal diseases with malocclusion and irregularities of tooth position (Ditto & Hall 1954; Bilimoria 1963). However, many subsequent studies using clinical evaluation methods could not confirm these conclusions. 47 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  48. 48.  Although a relationship between crowding and 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 and periodontal destruction, i.e. attachment loss subsequent to gingival inflammation, could be established. 48 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  49. 49.  crowding of teeth might affect the amount of plaque mass formed in dentitions with irregular oral hygiene practices, thus contributing to the development of chronic gingivitis, but, as of Tooth malposition within the dental arch will lead to an increased risk for periodontal attachment loss. 49 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  50. 50. Furcation involvement. Retrospective analyses of large patient populations in private periodontal practices of periodontal specialists (Hirschfeld & Wasserman 1978; McFall 1982) have clearly established that multi-rooted teeth appear to be at high risk for tooth loss during the maintenance phase. 50 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  51. 51.  The assumption that the prognosis for single-rooted teeth and non-furcation-involved multi-rooted teeth is better than the prognosis for furcation involved multi- rooted teeth was also confirmed by Ramfjord et al. (1987) in a prospective study over 5 years. 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. 51 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  52. 52. Iatrogenic factors. Overhanging restorations and ill fitting crown margins certainly represent an area for plaque retention, and there is an abundance of association studies documenting increased prevalence of periodontal lesions in the presence of iatrogenic factors. Depending on the supragingival or subgingival location of such factors, their influence on the risk for disease progression has to be considered. 52 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  53. 53.  It has been established that slightly subgingivally located overhanging restorations will, indeed, change the ecologic niche, providing more favorable conditions for the establishment of a Gram negative anaerobic microbiota (Lang et al. 1983). There is no doubt that shifts in the subgingival microflora towards a more periodontopathic microbiota, if unaffected by treatment, represent an increased risk for periodontal breakdown. 53 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  54. 54. Residual periodontal support. Although many clinicians believe that teeth with reduced periodontal support are unable to function alone and should be extracted or splinted, 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. 54 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  55. 55.  Hence, successfully periodontally treated teeth can be maintained over decades and function as abutments in fixed bridgework irrespective of the amount of residual periodontal support, provided that physiologic masticatory forces do not subject such teeth to a progressive trauma which may lead to spontaneous extraction. by virtue of the already reduced support, should disease progression occur in severely compromised teeth, this may lead to spontaneous tooth exfoliation. 55 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  56. 56. Mobility. tooth mobility may be an indicator for progressive traumatic lesions, provided that the mobility is increasing continuously. Two factors may contribute to hypermobility: (1) a widening of the periodontal ligament as a result of unidirectional or multidirectional forces to the crown, high and frequent enough to induce resorption of the alveolar bone walls; and (2) the height of the periodontal supporting tissues. 56 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  57. 57.  If this is reduced due to prior periodontal disease, but the width of the periodontal ligament is unchanged, the amplitude of root mobility within the remaining periodontium is the same as in a tooth with normal height, but the leverage on the tooth following application of forces to the crown is changed. Therefore, it has to be realized that all teeth that have lost periodontal support have increased tooth mobility as defined by crown displacement upon application of a given force. Nevertheless, this hypermobility should be regarded as physiologic (Nyman & Lindhe 1976). 57 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  58. 58.  Several studies have indicated that tooth mobility varies greatly before, during, and after periodontal therapy (Persson 1980, 1981a,b). From these studies it can be concluded that periodontally involved teeth show a decrease in mobility following non-surgicaland/or surgical periodontal procedures. However, following surgical procedures, tooth mobility may temporarily increase during the healing phase and may resume decreased values later on 58 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  59. 59. Summary: The tooth risk assessment encompasses an estimation of the residual periodontal support, an evaluation of tooth positioning, furcation involvements, presence of iatrogenic factors, and a determination of tooth mobility to evaluate functional stability. A risk assessment at 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. 59 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  60. 60. Site risk assessment. Bleeding on probing Probing depth and loss of attachment. suppuration 60 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  61. 61. Bleeding on probing (BOP). Absence of bleeding on probing (BOP) is a reliable parameter to indicate periodontal stability if the test procedure for assessing BOP has been standardize. Presence of bleeding upon standardized probing will indicate presence of gingival inflammation. Whether or not repeated BOP overtime will predict the progression of a lesion is, however, questionable (Lang et al. 1986, 1990; Vanooteghem et al. 1987). 61 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  62. 62.  this clinical parameter is the most reliable for monitoring patients over time in daily practice. Non-bleeding sites may be considered periodontally stable. 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). 62 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  63. 63.  It is, therefore, advisable to register the sites with BOP in a dichotomous way using a constant force of 0.25 N. This allows the calculation of the mean BOP for the patient, and also yields the topographic location of the bleeding site. Repeated scores during maintenance will reveal the surfaces at higher risk for loss of attachment. 63 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  64. 64. Probing depth and loss of attachment. Clinical probing is the most commonly used parameter both to document loss of attachment and to establish a diagnosis of periodontitis. There are, however, some sources of error inherent in this method which contribute to the variability in the measurements. 64 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  65. 65.  Among these are (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. 65 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  66. 66.  It has to be realized that increased probing depth and loss of probing attachment are parameters which reflect the history of periodontitis rather than its current state of activity. Obviously, the first evaluation prior to therapy will yield results confounded by greater measurement error than evaluations following therapy. The reference point (cemento-enamel junction) may be obstructed by calculus or by dental restorations, and the condition of the gingival tissues may allow an easy penetration of the periodontal probe into the tissues, even though the probe position and force applied are standardized. 66 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  67. 67.  These biologic variables (tissue conditions and calculus) may be minimized following initial periodontal therapy, and hence, repeated periodontal evaluations using probing will improve the metric assessment. The first periodontal evaluation after healing following initial periodontal therapy should, therefore, be taken as the baseline for longterm linical monitoring (Claffey 1994). 67 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  68. 68. Suppuration. In a proportion of periodontal lesions, pus will develop and may drain through the orifice of a pocket. This criterion of suppuration may be recognized while clinically probing the lesion, or preferably, by using a ball burnisher. 68 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  69. 69.  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. 69 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  70. 70. Radiographic evaluation ofperiodontal disease progression. Radiographs should be current and should be based on the diagnostic needs of the patient and should permit proper evaluation and interpretation of the status of the periodontium. Radiographs of diagnostic quality are necessary for these purposes,the judgement of the clinician, as well as the degree of disease activity. Radiographic abnormalities should be noted. 70 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  71. 71. Summary.The tooth site risk assessment includes the registration of BOP, 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. 71 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  72. 72. SUMMARY.(continuous multi-level riskassessment). It is suggested that patients be evaluated on the three different levels mentioned. At the patient level, loss of support in relation to patient age, full mouth plaque and/or bleeding scores, and prevalence of residual pockets are evaluated, together with the presence of systemic conditions or environmental factors, such as smoking, which can influence the prognosis. The clinical utility of this first level of risk assessment influences primarily the determination of the recall frequency and time requirements. 72 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  73. 73. Summary, cont… It should also provide a perspective for the evaluation of risk assessment conducted at the tooth and site levels. At the tooth and tooth site levels, residual periodontal support, inflammatory parameters and their persistence, presence of ecologic niches with difficult access such as furcations, and presence of iatrogenic factors have to be put into perspective with the patient overall risk profile. The clinical utility of tooth and site risk assessment relates to rational allocation of the recall time available for therapeutic intervention to the sites with higher risk, and possibly to the selection of different forms of therapeutic intervention. 73 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  74. 74. THERAPEUTIC GOALS1. 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. 74 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  75. 75. Objectives of SPT. to reduce probing pocket depths to reduce bleeding on probing to gain clinical attachment levels 75 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  76. 76. SPT in daily practice. The recall hour should be planned to meet the patient’s individual needs. It basically consists of four different sections which may require various amounts of time during a regularly scheduled visit: 1. Examination, re-evaluation, and diagnosis (ERD) 2. Motivation, reinstruction, and instrumentation (MRI) 3. Treatment of reinfected sites (TRS) 4. Polishing of the entire dentition, application of fl uorides, and determination of future SPT (PFD). 76 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  77. 77. Recall hour.77 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  78. 78. Treatment 1. Removal of subgingival and supragingival plaque and calculus 2. Behavior modification: A. Oral hygiene reinstruction B. Compliance with suggested periodontal maintenance intervals C. Counseling on control of risk factors; e.g., cessation of smoking 3. Antimicrobial agents as necessary 4. Surgical treatment of recurrent disease78 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  79. 79. Communication1. Informing the patient of current status and alterations in treatment if indicated.2. Consultation with other health care practitioners who will be providing additional therapy or participating in the periodontal maintenance program. 79 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  80. 80. Planning1*****. For most patients with a history of periodontitis, visits at 3-month intervals have been found to be effective in maintaining the established gingival health.******2. Based on evaluation of clinical findings and assessment of disease status, periodontal maintenance frequency may be modified or the patient may be returned to active treatment. 80 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  81. 81. Outcomes Assessment The desired outcome for patients on periodontal maintenance should result in maintenance of the periodontal health status attained as a result of active therapy. Inadequate periodontal maintenance or noncompliance may result in recurrence or progression of the disease process. 3. Despite adequate periodontal maintenance and patient compliance, patients may demonstrate recurrence or progression of periodontal disease. In these patients additional therapy may be warranted. 81 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  82. 82. Frequency of supportive maintenancecare recall intervals could be extended to at least 1 year in subjects with a history of limited susceptibility to periodontitis.82 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  83. 83. SPT with adjunct use ofantimicrobials/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.83 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  84. 84. Conclusion.• SPT should be based on assessment of the patient risk profile for further periodontal disease progression. Such risk assessment should be performed after the completion of Initial Cause-Related Therapy (ICRT) and be revisited continuously.• A standardized SPT routine cannot be considered to be consistent with best practice and an individualized approach is needed.• SPT resulting in good oral hygiene is essential to minimize the risks of periodontal disease progression. Issues of compliance must be considered. 84 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012
  85. 85. References. Lindhe J, Karring T, 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. 85 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012

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