The document discusses supportive periodontal therapy (SPT), which involves maintenance care after initial periodontal treatment. SPT aims to prevent recurrence of periodontal disease and maintain oral health achieved through active treatment. It includes risk assessment, examination, treatment if needed, and scheduling follow-up appointments. The risk assessment evaluates bleeding, pockets, tooth loss, bone loss, systemic factors, and smoking. Sites are assessed for bleeding, depth, attachment loss, and suppuration. Regular recall appointments including cleaning and exams help preserve periodontal health and reduce further loss of attachment.

1. Supportive periodontal therapy

2. CONTENTS
 Definition
 Introduction
 Rationale and goals
 Importance of SPT
 Maintenance program
 Risk assessment
 Merins classification
 SPT in Daily Practice
 Compliance and its Role
 Complication
 Maintenance of dental implant patient

3. DEFINITION
American Academy of Periodontology 1991.
Supportive periodontal treatment is an integral part of
periodontal therapy. It is performed by a dentist, although
components of supportive periodontal treatment can be
performed by a dental hygienist under the supervision of the
dentist.
3

4.  The 3rd World Workshop of the American Academy of
Periodontology (1989) has renamed this maintenance phase as
SUPPORTIVE PERIODONTAL THERAPY.
 AAP position paper in 2003 termed it as PERIODONTAL
MAINTENANCE
4BACKGROUND

5.  Fauchard, 1746
“Little or no care as to the cleaning of teeth is ordinarily the cause of all
diseases that destroy them”
Interceptive professional supportive therapy  compensates for the
lack of personal compliance.
 Lovdal et al.,1961
Repeated SRP and OHI result in low plaque levels, gingival
inflammation, probing depth and increase attachment level
 Hamp et al., 1975
Treated teeth can be maintained regardless of previous treatment
modalities
5BACKGROUND

6.  Nyman et al., 1975
6
Experimental group
• Professional care every 2 weeks
• No further loss of attachment
Control group
• Recalled every 6 months
• Loss of attachment
BACKGROUND

7. INTRODUCTION
 Patients not returning for regular recall  5.6 times greater
risk of tooth loss (Trombelli et al., 2002)
 Inadequate SPT  50-fold increase in risk of attachment
loss (Pini-Prato et al., 1994)
7

8. PHASE I
REEVALUATION
PHASE II
( Periodontal surgery)
PHASE III
(Restorative)
PHASE IV
( Maintenance phase)
8

9. PHASE I
REEVALUATION
PHASE II
( Periodontal surgery)
PHASE III
(Restorative)
PHASE IV
( Maintenance phase)
9

10.  Even after appropriate therapy disease progression maybe seen
in case of:
10
Long junctional epithelium
Weak union Pocket formation
Bacteria in the gingival tissue
Recolonization Recurrent disease
Incomplete removal of subgingival plaque
Regrowth of subgingival plaque Loss of attachment
RATIONALE

11.  Subgingival scaling alters the microflora of periodontal pockets
- Rosenberg 1981, Slots 1979.
 Subgingival bacteria had not returned to pretreatment
proportions even after 3 to 6 months - Slots 1979.
11RATIONALE
Listgarten et al., 1980
Single session scaling
Decrease in motile rods for a week
Increase in coccoid cells for 21 days
Reduction in spirochetes for 7 weeks

12. 12
Mechanical debridement
Motivational
environment
Good maintenance
results
RATIONALE

13. …RATIONALE

1. Preventive SPT 
13
Primary
prevention
Preserve
periodontal
health
Simple, cost-
effective
Early in life, large
population
Patient
information +
OHI

14. …RATIONALE
2. Post-treatment SPT  prevents recurrence +
maintains oral health achieved through active
treatment  SRP + OHI + chemotherapy
3. Palliative SPT  prevent or slow down disease
progression in patients who cannot receive
appropriate treatment due to:
o Lack of compliance with treatment
o Poor oral hygiene
o Systemic problems
14

15. AIMS AND OBJECTIVES
Pathogenic
factors
Host
resistance
15
Periodontal health
 reestablish the equilibrium

16. GOALS OF SPT
Position paper given by the American Academy of
Periodontology (1998) recommends….
 an update of the medical and dental histories
 examination of extra- and intraoral soft tissues
 dental examination
16

17.  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 so indicated.
17

18. THERAPEUTIC GOALS OF SPT
 prevent or minimize the recurrence and progression of
periodontal disease in patients who have been previously
treated for gingivitis, periodontitis, and peri-implantitis.
 prevent or reduce the incidence of tooth loss by monitoring
the dentition and any prosthetic replacement of natural teeth.
 increase the probability of locating and treating in a timely
manner, other diseases or conditions found within the oral
cavity.
18

19. IMPORTANCE OF SUPPORTIVE
PERIODONTAL THERAPY
 5 year observation of 1428 adults from an industrial company
in Oslo  recall period 2-4 times/year (SRP + OHI) 
improvement of gingival condition by 60% and reduction in
tooth loss by 50% (Lovdal et al., 1961)
 Suomi et al., 1971  loss of periodontal tissue support over 3
years
19
Experimental group
SRP + OHI
every 3
months
Loss of
attachment
0.008mm/
surface
Control group
No special
efforts
Loss of
attachment of
0.3mm

20. …IMPORTANCE OF SUPPORTIVE
PERIODONTAL THERAPY
 52 patients with mild to moderate periodontitis  effect of
SPT for 8 years  gain in attachment followed by a loss of
0.5-0.8mm in 8 years  patients seeking SPT less than once
in a year showed greater loss of attachment (Bragger et al.,
1992)
 375 test patients received traditional maintenance care twice
a year  prophylactic visits every 2nd month for 2 years and
every 3-12 months for the next 28 years:
 0.4-1.8% teeth were lost
 1.2-2.1% carious lesions developed
 No attachment loss
20

21. SPT COMPRISES OF….
 Part I : Examination
 Part II : Treatment
 Part III: Next Schedule
21
PERIODONTAL RISK
ASSESSMENT
Oral hygiene
Reinforcement
Recall
Further Perio Treatment
Restorative/Prosthetic
Treatment
MULTI RISK ASSESSMENT
TOOTH RISK
ASSESSMEN
T
SITE RISK
ASSESSMENT

22. SPT begins with..
22
COMMUNICATION
REALIZATION
COMPLIANCE
MOTIVATION

23. PART-I : MULTI RISK ASSESSMENT
Periodontal Risk Assessment(PRA)
23
A.

24.  Assessment of level of infection(Bleeding scores)
 Prevalence of residual periodontal pockets
 Tooth loss
 Estimation of Age related loss of periodontal support
 Evaluation of Systemic conditions of the patient
 Evaluation of Environmental & Behavioral factors
24
No single parameter displays a more paramount role. The entire
spectrum of risk factors and risk indicators ought to be evaluated
simultaneously
PRA estimate the risk for susceptibility for
periodontal disease progression

25. FUNCTIONAL DIAGRAM TO EVALUATE THE
PATIENT’S RISK FOR RECURRENCE
25

26. BOP percentage-
first risk factor
 Represents an objective inflammatory parameter
 Reflects patient's ability to perform proper plaque control,
the patient's host response to the bacterial
challenge and the patient's compliance.
 While patients with mean BOP percentages > 25% should
be considered to be at high risk for periodontal
breakdown
 36 and > 49% being the critical values on the vector.
26

27. Prevalence of residual pockets ≥5 mm
(residual pocket greater than 4 mm): second risk indicator
 Represents - to a certain extent - the degree of
success of periodontal treatment rendered.
 Periodontal stability in a dentition would be reflected in a
minimal number of residual pockets.
 In conjunction with other parameters such as bleeding on
probing and/or suppuration are existing ecological niches from
and in which re-infection might occur.
27

28. Loss of teeth from a total
of 28 teeth
 Tooth loss : a true end point outcome variable reflecting the
patient's history of oral diseases and trauma
 The number of remaining teeth in a dentition reflects the
functionality of the dentition
 If more than 8 teeth from a total of 28 teeth are lost, oral
function is usually impaired
28

29. Loss of periodontal support in relation to
the patient's age
 The rate of progression of disease has been positively
affected by the treatment rendered
 Previous attachment loss in relation to patient's age may be a
more accurate indicator during SPT than before active
periodontal treatment .
 On bitewing radiographs, one millimeter is considered to be
equal to 10% bone loss. The score = % OF BONE LOSS ÷
PATIENT’s AGE = BL/Age
 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
29

30. Contd… 30
It may be argued that the incorporation of only the worst site
with bone loss in the posterior segment may overestimate an
individual's rate of periodontal destruction when only an
isolated advanced bony lesion is present due to local etiologic
factors.
While an underestimation of the rate of destruction may exist
in a case of generalized advanced disease.
Worst site with bone loss in the posterior segment may,
indeed, represent the past history of destruction of the entire
dentition
(Persson et al, 2003).

31. 31Systemic and genetic
aspects
In this case, the area of
high risk is marked for
this vector. If it is not
known or absent,
systemic factors are not
taken into account
for the overall
evaluation of risk
.
Genetic marker like: IL-1
MICROBES
MICROBIAL By-Products
LPS , MMP’s, PMN
Inflammatory Mediators
Host Response
Periodontal
Disease
Systemic Disease
The Chemistry Of Destruction

32. Environmental Factor:
smoking
32
Smokers displayed less favorable healing responses both at
reevaluation and during a 6-year period of SPT (Baumert-Ah et
al, 1994).
It seems reasonable to incorporate heavy smokers (20
cigarettes/day) in a higher risk group during maintenance
Occasional smokers (OS; < 10 cigarettes a day) and
moderate smokers (MS;10-19 cigarettes a day) may be
considered at moderate risk for disease progression.
While non-smokers (NS) and former smokers (FS) have a
relatively low risk for recurrence of periodontitis
Not only does smoking increase the extent and severity of periodontal disease, it
compromises the outcomes of surgical and non-surgical therapy

33.  CALCULATING THE PATIENT'S INDIVIDUAL
PERIODONTAL RISK ASSESSMENT (PRA)
33

34. A low PRA patient
Has all parameters within the low-risk categories or - at the most - one
parameter in the moderate-risk category
34

35. 35
patient has at least two parameters in the moderate category, but at most
one parameter in the high-risk category

36. A high PRA patient
Has at least two parameters in the high-risk category
36

37. 37
TOOTH RISK ASSESSMENT:

38.  Tooth position within the dental arch
 Furcation involvement
 Iatrogenic factors
 Residual periodontal support
 Mobility.
38

39.  Malocclusion and Irregularities
39
CROWDING results in 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 with periodontal destruction has been
established
Tooth malposition within the dental arch will lead to an
increased risk for periodontal attachment loss.

40.  Retrospective analyses of large patient populations
(Hirschfeld & Wasserman 1978; McFall 1982, Ramfjord
et al. 1987) have clearly established that multi-rooted
teeth appear to be at high risk for tooth loss during
the maintenance phase.
 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.
40

41.  OVERHANGING RESTORATIONS
 ILL-FITTING CROWNS
 IMPROPERLY PLACED ORTHODONTIC BRACKETS
41
Change the ecologic niche, providing more favorable conditions for the
establishment of a Gram negative anaerobic microbiota (Lang et al. 1983).
This shifts in the subgingival microflora towards a more periodontopathic
microbiota, if unaffected by treatment, represent an increased risk for
periodontal breakdown.

42. Residual periodontal support.
 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.
42
should disease progression occur in severely compromised teeth,
this may lead to spontaneous tooth exfoliation

43.  Following surgical procedures, tooth mobility may
temporarily increase during the healing phase
and may resume decreased values later on
 Indicator for progressive traumatic lesions,
provided that the mobility is increasing
continuously.
(1) a widening of the periodontal ligament
(2) the height of the periodontal supporting tissues.
43

44. SITE RISK ASSESSMENT.
44
The site risk assessment is essential for the
identification of the sites to be instrumented
during SPT.

45. 45
 Bleeding on probing
 Probing depth and loss of attachment.
 Suppuration

46. Bleeding On Probing
 Absence of bleeding on probing is a reliable parameter
to indicate periodontal stability if the test
procedure for assessing BOP has been
standardize.
 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).
46

47.  Clinical probing is the most commonly used parameter both to document
loss of attachment and to establish a diagnosis of periodontitis.
 Reflect the history of periodontitis rather than its current state of activity.
47
(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
The first periodontal evaluation after healing following initial
periodontal therapy should, therefore, be taken as the baseline for long
term linical monitoring (Claffey 1994).

48.  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.
48

49. RADIOGRAPHIC EXAMINATION
RECOMMENDATIONS
H/O PDL DISEASE TREATMENT
WITH DISEASE UNDER GOOD
CONTROL
BW every 24-36 months; full
mouth every 5 years
ROOT FORM DENTAL IMPLANTS IOPA/BW at 6, 12, 36 months
after prosthetic replacement;
then after 36 months unless a
clinical problem arises
49

50. RADIOGRAPHIC
EXAMINATION
RECOMMENDATIONSCLINICAL CARIES/HIGH RISK
FACTOR FOR CARIES
Posterior BW at 12-24 month
intervals
CLINICAL CARIES/ NO HIGH RISK
FACTOR FOR CARIES
Posterior BW at 24-36 month
intervals
PERIODONTAL DISEASE NOT
UNDER GOOD CONTROL
•IOPA and/or BW of problem
areas every 12-24 months
•Full mouth 3-5 years
50

51. Multi Risk Assessment….
 influences primarily the determination of the recall
frequency and time requirements for therapeutic
intervention to the sites with higher risk, and possibly to the
selection of different forms of therapeutic intervention.
51

52. PART II: TREATMENT
 ORAL HYGIENE MEASURES IMPROVEMENT & PROFESSIONAL ORAL
PROPHYLAXSIS
 MOTIVATION/ BEHAVIOURAL MODIFICATION &COMPLIANCE
 USE OF ANTIMICROBIALS
52

53. ORAL HYGIENE MEASURES IMPROVEMENT53
1 .Removal of sub gingival and supra gingival plaque
and calculus
PROFESSIONAL ORAL PROPHYLAXIS
2. Behavior modification:
A. Oral hygiene reinstruction
i. Proper use of Toothbrush
ii. Use of Floss & Interdental Cleaning
Aids
iii. Use of water flosser/ oral irrigation
B. Compliance with suggested periodontal
maintenance intervals
C. Counseling on control of risk factors; e.g.,
cessation of smoking
.

54. 3. Use of Antimicrobials
*Adjunct to SPT
*Compensate for inadequate mechanical oral
hygiene
*Dentifrices, LDS, Solutions for oral rinses or
flushing of periodontal pockets.
54

55. PART-III: Next Schedule
 RECALL
 FURTHER PERIO TREATMENT
 RESTORATIVE/PROSTHETIC TREATMENT
55

56. Compliance and its role in periodontal
therapy
 Only few pt. comply completely with professional
suggestions…
 Reasons for noncompliance are highly variable…
 Pt. comply better when they are informed…
 Compliance became a significant concern only
after introduction of therapeutic drugs (Davidson
1976)…
56

57.  Pt. compliance in taking drug falls with time,
often dropping below 35% (Schwartz 1962)…
 Even patients with life-threatening diseases often
refuse to change their behavior…
 Pt. with chronic problems tend not to comply
with therapists suggestions…
57

58. Definition of Compliance
 Also called adherence and therapeutic alliance.
 It has been defined as "the extent to which a
person's behavior coincides with medical or
health advice" (Hayness 1976).
Types of compliance
1. Non-compliance
2. Erratic compliance
3. Complete compliance
58

59. 59TYPES OF COMPLIANCE

60. Compliance with suggested oral hygiene
regime:
 When pt. stop cleaning their teeth, bacterial plaque
collects which leads to (Loe H 1965)…Gingivitis
 It has also been shown that pt. who clean well have less
dental caries and periodontitis…
 A group of 123 patients randomly selected from a single
dental practice was studied by (Boyer 1983).
 About one third of these pt. said they were…
60

61.  Strack et al. found that
1. 51% of pt. given OHI were in highly compliant.
2. 38% were moderately compliant.
3. 11% non-compliant 30 days after instruction.
 Glavind et al found that positive feedback to a group of 63
adults lowered plaque and bleeding scores compared with
controls.
61

62.  Schwartz 1952 reported that 2/3rd of pt. who drop out of
suggested OHI do so within 3 months.
 The study suggested that self-care is a positive alternative
to professional care.
 The keys to adequate self-care include…
 Reinforcing the idea that efficacy is more important than
the amount of time spent on cleaning.
62

63.  One indicator of the future efficacy of plaque removal may
be the level of (OH) before therapy…
 Oral hygiene standards tend to decrease during
SPT…Flossing less than5%…(Craig 1976).
 If properly instructed pt. can slightly improve (OH)
compared with professional reinforcement.
 Use of a disclosing agent (erythrosin) was found helpful in
improving the efficacy of plaque removal.
63

64. Why do patients fail to comply
 This is a complex question because ans.is diff…
1. Negligent attitudes toward their illness…
2. Pt. wants to deny that they have problem at all…
3. They want dentist to take responsibility…
4. Fear of dental treatment is a major reason…
5. Economic problems…
6. Fee reduction program…
Socio-economic status of pt. is a best methods for
improving compliance…
64

65. Methods of improving compliance
1. Simplify
2. Accommodate to the pt. needs
3. Remind patients of appointments
4. Keep records of pt.compliance
5. Inform the pt. (Bowden 1975)
6. Provide positive reinforcement
7. Identify potential non-compliers
8. Ensure the dentist's involvement
Noncompliance decreased by 50% when these
general approaches were applied (Wilson 1993).
65

66. Disease progression and its influence on SPT
 Manner in which periodontal diseases advance can
profoundly affect maintenance…
 Repair and breakdown may occur simultaneously in the
same mouth…
 Monitor the patient and intervene when 2 mm or more of
attachment loss has occur.
66

67. MERIN’S CLASSIFICATION FOR
FREQUENCY OF RECALL INTERVAL
CLASSIFICATION CHARACTERISTICS RECALL INTERVAL
FIRST YEAR Routine therapy and
uneventful healing
3 months
FIRST YEAR Difficult case with
-furcation involvements
-poor crown to root
ratio
-complicated prosthesis,
-questionable patient
co-operation
1-2 months
67

68. CLASSIFICA
TION
CHARACTERISTICS RECALL
INTERVAL
CLASS A Excellent results, well maintained for 1
year or more,
-minimal calculus
-good oral hygiene
-no occlusal problems
- no complicated prostheses
-no remaining pockets
-no teeth with less than 50% bone
remaining
6 months to
1 year
68

69. CLASSIFI
CATION
CHARACTERISTICS RECALL
INTERVAL
CLASS B Generally good results, maintained
well for 1 year or more but for
3-4 months
-Heavy calculus formation
-Inconsistent or poor oral hygiene
-Occlusal problems
-Some remaining pockets
-Complicated prostheses
-Few teeth with <50% bone support
-Systemic disease predisposing to PDL
breakdown
-Ongoing orthodontic therapy
-Recurrent dental caries
-Smoking
- +ve family history
69

70. CLASSIFI
CATION
CHARACTERISTICS RECALL
INTERVAL
CLASS C Generally poor results and/or several negative
factors
-Inconsistent or poor oral hygiene
-Heavy calculus formation
-Systemic disease predisposing to PDL
breakdown
-Many remaining pockets
-Occlusal problems
-Complicated prostheses
-Recurrent dental caries
-Periodontal surgery indicated but not
performed for medical, psychologic reason
-Many teeth with <50% bone support
-Smoking
- +ve family history
- > 20% pockets bleed on probing
1-3 months
70

71. SPT IN DAILY PRACTICE
 Recall hour is divided as follows:
71
Examination, re-
evaluation and
diagnosis (ERD)
Motivation,
reinstruction and
instrumentation
(MRI)
Treatment of
reinfected sites (TRS)
Polishing, application
of fluorides and
determination of the
future SPT

72. MAINTENANCE PROGRAM
72
MOTIVATION,
REINSTRUCTION,
INSTRUMENTATION
30-40 min

73. …SPT IN DAILY PRACTICE
 Examination, Re-evaluation and Diagnosis (ERD)
 Note changes in health status
 Extraoral and intraoral soft tissue examination
 Assess subject’s risk factors and tooth site related risk factors
 Radiographic evaluation of devitalized teeth, abutment teeth,
implants
73

74. …SPT IN DAILY PRACTICE
 Diagnostic procedure includes assessment of:
74
Oral hygiene and
plaque
BOP
PD and CAL
Pus formation
Existing
reconstructions
Carious lesions

75. …SPT IN DAILY PRACTICE
 Motivation, Reinstruction and Instrumentation (MRI)
 Acknowledge the patient’s performance
 Individual approach
 Emphasize on a vibratory tooth brushing technique
 Instrument sites with BOP +ve and pockets > 5mm 
repeated instrumentation below a critical depth of 2.9mm, in
healthy sites, causes loss of attachment (Lindhe et al., 1981)
 non bleeding sites are polished
75

76. …SPT IN DAILY PRACTICE
 Treatment of Reinfected Sites (TRS)
 Furcation sites/ sites with difficult access
occasionally get reinfected  thorough instrumentation
or open debridement with surgical access
 Inadequate SPT  generalized reinfection
 High BOP percentage  recall patient after 2-3 weeks to
check patient complaince with home care
76

77. …SPT IN DAILY PRACTICE
 Polishing, application of fluorides and determination of the
future SPT
 Polish the entire dentition to remove all remaining soft
deposits and stains
 Fluoride  prevents root surface caries in recessed areas
 Determine future SPT visits based on  risk assessment
77

78. 78

79. complications
 Caries: removal of root cementum during ICRT and during SPT
 Endodontic lesions: exposure of accessory root canal
 Periodontal Abscesses:
 Root sensitivity:
79

80. MAINTAINING THE IMPLANT
PATIENT
 More prone to plaque induced inflammation and
susceptible to bone loss (peri-implantitis)
 Differences in maintenance:
 Special instrumentation  plastic instruments
and gold coated curettes
 Acidic fluoride prophylactic agents avoided
 Nonabrasive prophy pastes are used  rubber
cup with tin oxide with light, intermittent
pressure
80

81. Cist protocol 81

82. conclusion 82

83. references
 Clinical Periodontology and Implant Dentistry. 5th
ed. Niklaus P. Lang, Jan Lindhe
 Carranza’s Clinical Periodontology. 10th ed.
Michael G. Newman, Henry H. Takei, Perry R.
Klokkevold, Fermin A. Carranza.
 Supportive periodontal therapy. Stefan Renvert,
G. Rutger Persson. Perio 2000, Vol. 36, 2004.
83

84. Thank you 84