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15. supportive periodontal therapy
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.
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15. supportive periodontal therapy
- 1.
- 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 ofPeriodontology 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 3rdWorld 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 “Littleor 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 etal., 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 notreturning 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 afterappropriate 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 scalingalters 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.
- 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 Periodontalhealth reestablish the equilibrium
- 16. GOALS OF SPT Positionpaper 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 OFSPT 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 PERIODONTALTHERAPY 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 PERIODONTALTHERAPY 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.
- 23. PART-I : MULTIRISK ASSESSMENT Periodontal Risk Assessment(PRA) 23 A.
- 24. Assessment oflevel 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 TOEVALUATE THE PATIENT’S RISK FOR RECURRENCE 25
- 26. BOP percentage- first riskfactor 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 residualpockets ≥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 teethfrom 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 periodontalsupport 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 maybe 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 Inthis 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 displayedless 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 THEPATIENT'S INDIVIDUAL PERIODONTAL RISK ASSESSMENT (PRA) 33
- 34. A low PRApatient Has all parameters within the low-risk categories or - at the most - one parameter in the moderate-risk category 34
- 35. 35 patient has atleast two parameters in the moderate category, but at most one parameter in the high-risk category
- 36. A high PRApatient Has at least two parameters in the high-risk category 36
- 37.
- 38. Tooth positionwithin the dental arch Furcation involvement Iatrogenic factors Residual periodontal support Mobility. 38
- 39. Malocclusion andIrregularities 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 analysesof 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 surgicalprocedures, 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 Thesite risk assessment is essential for the identification of the sites to be instrumented during SPT.
- 45. 45 Bleeding onprobing 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 probingis 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 presenceof 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 PDLDISEASE 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 FACTORFOR 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 MEASURESIMPROVEMENT53 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 ofAntimicrobials *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 itsrole 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. compliancein 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.
- 60. Compliance with suggestedoral 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 etal. 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 1952reported 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 indicatorof 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 patientsfail 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 improvingcompliance 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 andits 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 FREQUENCYOF 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 AExcellent 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 BGenerally 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 CGenerally 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 DAILYPRACTICE 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.
- 73. …SPT IN DAILYPRACTICE 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 DAILYPRACTICE Diagnostic procedure includes assessment of: 74 Oral hygiene and plaque BOP PD and CAL Pus formation Existing reconstructions Carious lesions
- 75. …SPT IN DAILYPRACTICE 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 DAILYPRACTICE 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 DAILYPRACTICE 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.
- 79. complications Caries: removalof 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.
- 82.
- 83. references Clinical Periodontologyand 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.
Editor's Notes
- #8 Pt. must be made to understand the purpose of the maintenance program… It is evident that periodontal treatment is ineffective in maintaining periodontal health if supportive maintenance care is denied or omitted. 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.
- #13 Both the mechanical debridement performed by the therapist and the motivational environment provided by the appointment seem to be necessary for good maintenance results. Patients tend to reduce their oral hygiene efforts between appointments. Knowing that their hygiene will be evaluated motivates them to perform better oral hygiene in anticipation of the appointment. There is certainly a sound scientific basis for recall maintenance because subgingival scaling alters the pocket microflora for variable but relatively long periods.