periodontics

1. Dr.R.Dhivya .,MDS
Supportive Periodontal Therapy

2.  Introduction
 Rationaleandobjectives
 Compliance
 Partsof SPT
 Frequencyand efficacy
 SPTindaily practice
 Recurrenceof periodontal disease
 Classificationof posttreatment patients
2
 ReferralofPatientstothe periodontist
 RiskAssessmentOfRecurrenceOf Diseaseand
Multifactorial Risk Diagram
 ComplicationsOfSupportivePeriodontalTherapy
 SPTWith Adjunct UseOfAntimicrobials/Antibiotics
 MaintenanceCareOfPatientsWith DentalImplants

3. oReferralOf Patients ToThe Periodontist
oRisk AssessmentOf RecurrenceOf DiseaseDuring SPT
And Multifactorial Risk Diagram
oComplicationsOf SupportivePeriodontalTherapy oSPT
With Adjunct UseOf Antimicrobials/Antibiotics
oMaintenanceCareOf Patients With DentalImplants
3

4. 4

5. 5

6. 8
Continuous patient monitoring following active periodontal
therapy is necessary to prevent 
•Reinfection
•Continued progression of periodontal disease

7. 7

8. 8

9. 9

10. 10

11. 11

12. 12

13. Waerhaug 1978
Cortellini 1994
13

14. 14
1991
transmission
of Aa  A
lalusua, A
sikainen
Transmission o
f Pg b etween
spouses  
Van Steen
Berge n 1993
Mousques
1980

15. Slo ts 1979  s ubgingival
bacteria not returned to
pretreatm ent proportio ns
after 3- 6 months
Rate of return of pathogens 9-11
weeks  AAPpositio n paper
2003
15

16. 16

17. 17
No
maintenanceplaque
accumulatereestablish
inflammationNyman
1977
Well maintained
patients low
inflammation
Rosling 1976
Bone height well
maintained and
improved in proper
maintenance
 Rosling 1976

18. 18

19. 19

20. Severalhypothesishaveput forth: reasons include-
20
•
•
•
•
•
Self-destructive behaviours
Fearof dentaltreatment
Economicfactors
Health beliefs
Stressful eventsin their lives

21.  ThestudiesbyDemetriouet al.andDemirelet al.
suggestedthat femalesaremorecompliantthanmen.
 Study by Novaes & Ojima showed that older patients are more
compliant than younger patients, whereas the study by
Demetriouet al.suggestedthe opposite.
21

22. 22
A successfullong-
term maintenance
programisbased
onagood
communication.
This involves:

23. 23

24. Schallhorn RG, 1981
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25. 27

26. 26

27.  Numerousstudieshaveshownthat lessattachmentlossoccurs, and
fewerteeth arelost whenpatients maintainregular SPT.
 In gingivitispatients:
 Formostpatients with gingivitis but nopreviousattachment loss,
SPTtwice ayearwill suffice.
 Lovdal et al(1961)-2-4timesperyear.
 Suomiet al1978-every3months
 Listgarten et al 1982– every 6months
27

28.  In Periodontitispatients :
Study byLindheandNyman1984,periodontalprophylaxis was
providedto agroupof 61patients with excellentoralhygiene,every3-6 month
over14years,without significant recurrenceof disease,although someof them
lost significant amountof periodontalsupportin some places.
28

29.  However,Nymanet al(1992)demonstratedthat if professional care
wereadministeredevery2ndweekfor2years,periodontal support
wouldbe preserved,
 …..where aspatients in the controlgroupreceivingroot
instrumentationevery6monthsexhibitedsignificant additional lossof
attachment.
29

30. 
30

31. 31

32. 32
2.Motivation, Reinstructionand
Instrumentation (MRI)
3.Treatmentof ReinfectedSites (TRS)
4.Polishingof the entire dentition,
applicationof Fluoridesand
Determinationof future SPT(PFD)
Suomi JD
1971

33. 1. Examination,Re-evaluationandDiagnosis (ERD)
 It includesupdatingthe significant changesin theirhealthstatus
 Extraoraland intraoral soft andhardtissue examination
 An evaluationof the patient's riskfactorswill alsoinfluence the
choiceof future SPTandthe determinationof the recallinterval at the
endof the maintenance visit.
33

34. …RADIOGRAPHIC EVALUATION
 Radiographicexaminationmust beindividualized,
dependingonthe initial severityof the caseandthe
findings at the recallvisit .
 Thesearecomparedwith findingsonprevious radiographs
to checkthe boneheightandlookfor repairof osseous
defects,signsof traumafrom occlusion,periapical
pathologicchanges,andcaries.
34

35. 14 months after surgical therapy
35
7 years after surgery
2 years after surgery

36. 36
in SPT
Bottomley et al, Finger et al 1990

37. 2.Motivation, ReinstructionandInstrumentation (MRI)
This aspect uses most of the available time of the SPT visit. Patients who
have experienced a relapse in their adequate oral hygiene practices need to be
furthermotivated.
The patient reinstructedin tooth brushingtechniqueswhich
emphasizevibratoryrather than scrubbing movements.
37

38. 38

39. 3.Treatmentof ReinfectedSites (TRS)
Single sites, especiallyfurcationsitesorsiteswith difficult access, maybe
reinfectedanddemonstratesuppuration.
Such sitesrequireathoroughinstrumentation, the localapplication of
antibioticsin controlledreleasedevicesorevenopendebridement
with surgicalaccesswhicharetime-consumingto beperformedduring the
routinerecallhour,andhence,it maybenecessaryto reschedule the patient for
another appointment.
39

40.  Generalizedreinfectionsareusuallythe resultof inadequateSPT.
 Localreinfectionsmayeitherbethe resultof inadequateplaque controlin a
localareaorthe formationof ecologicnichesconducive to periodontal
pathogens.
 Theriskassessmentonthe tooth levelmayidentify suchniches which
areinaccessibleforregularoralhygiene practices.
40

41. 4.Polishing,Fluorides,Determinationof recallinterval (PFD)
The recallhourisconcludedwith polishingthe entiredentition to remove
allremainingsoft depositsandstains.
Following polishing,fluoridesis appliedin highconcentrationin orderto
replacethe fluorideswhichisremovedduringinstrumentation.
Fluoride orchlorhexidinevarnishesmayalsobeappliedto prevent
rootsurfacecaries,especiallyin areaswith gingival recessions.
41

42. 42

43. 43

44.  Occasionally,lesionsmay recur.
 Thisisoften dueto inadequateplaquecontrolonthe partof the patient
orfailureto complywith recommendedSPTschedules.
 However,it isthe dentist's responsibilityto teach,motivate, and control
the patient's oralhygienetechnique,andthe patient's failureisthe
dentist's failure.
 Surgeryshouldnot beundertakenunlessthe patient has shown
proficiencyandwillingnessto cooperatebyadequatelyperforming hisor
herpartof therapy.
44

45. 45

46. 46

47. Becker
1984, Wilson
, Glover
1987
47

48. 48

49. 49

50. 50
 In addition, it maytake severalmonthsto accuratelyevaluate the
resultsof someperiodontalsurgicalprocedures.

51.  Consequently,someareasmayhaveto beretreatedbecausethe results
maynot be optimal.
 Furthermore, the first-year patient often has etiologic factors that may
havebeenoverlookedandmaybemoreamenableto treatment at this early
stage.
 Forthesereasons,the recallintervalforfirst-yearpatients should not be
longerthan 3months.
51

52. 54

53. 53

54. 54

55.  Themajorityof periodontalcarebelongsin the handsof the general dentist.
 Thequestionremainswhereto drawthe linebetweenthe casesto be treated
in the generaldentalofficeandthoseto bereferredto a specialistvariesfor
different practitionersand patients.
 Thediagnosisindicatesthe type of periodontaltreatment required.
55

56. 56
On the otherhand,patients whorequirelocalizedgingivectomyor flap
curettageusuallycanbetreatedbythe general dentist.

57. 57
The suggested rule is that the patient's disease should dictate
whether the general practitioner or the specialist should perform the
maintenancetherapy.

58. 58

59. Evaluated onthree levels.
 Subjectlevel
 Toothlevel
 Site level
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60. 62
1.Percentage of
bleeding on probing

61.  BOP percentagesreflectasummaryof the patient's ability
to performproperplaquecontrol,the patient's hostresponseto
the bacterialchallengeandthe patient's compliance first
riskfactor.
The scalerunsin aquadraticmodewith 4, 9, 16,25,36 and>
49%beingthe divisionsonthe vector.
Individuals with low meanBOPpercentages(<10%of the
surfaces) low riskforrecurrentdisease(Langet al.
1990),whilepatients with meanBOPpercentages>25%
highriskforreinfection.
63

62. 64

63. Presenceof highfrequenciesof deepresidualpockets and
deepeningof pocketsduringsupportiveperiodontal care 
highriskfordiseaseprogression
(Baderstenet al,Claffeyet al. 1990).
An increasednumberof residualpocketsdoesnot
necessarilyimplyanincreasedriskforre-infectionor disease
progression dependingonthe individual supportive
therapyprovided,evendeeperpocketsmay bestablewithout
furtherdiseaseprogressionfor years
(Knowleset al.1979,Lindhe, Nyman 1984).
63

64. The scalerunsin alinearmodewith 2, 4, 6, 8, 10and 12%
beingthe divisionsonthe vector.
Individuals with upto four residual pockets 
relativelylow risk.
More than eightresidualpockets  highriskfor
recurrentdisease
64

65. 67

66. The numberof teeth lost fromthe dentition without the third
molars(28teeth)iscounted,irrespectiveof their replacement.
The scalerunsalsoin alinearmodewith 2, 4, 6, 8,10 and
12%beingthe divisionsonthe vector.
Individuals with upto four teeth lost low risk
More than eightteeth lost  highrisk.
66

67. 4.Loss of periodontal support in relation to the
 Tphaeteiset
ni
mta
'st
i
o
an
geo
fthe lossof
alveolarboneis performed
in the posteriorregionon
eitherperiapical
radiographs,in which the
worst site affected is
estimatedgrossasa
%of the rootlength, oron
bite-wing radiographsin
which the worst site
affected isestimatedin mm.
67

68.  Onemmisequatedwith 10%boneloss.Thepercentageisthen divided
bythe patient's age
 As anexample,a40-year-oldpatient with 20%of bonelossat the
worst posteriorsite affected wouldbescoredBL/Age =0.5.
68

69. 71

70. IL-1 genotypepositive patients  advanced
periodontitis lesions (Kornmanet al. 1997)
Higher tooth lossin the IL-1 genotypepositivesubjects
(McGuire,Nunn 1999)
IL-1 genotypepositive patients higher BOP
percentagesandahigherproportionof patients with
higherBOPpercentagesduringa1-yearrecallperiod (Lang
et al. 2000) 72

71. 73

72. Non-smokers (NS)andformersmokers(FS)(morethan 5
years sincecessation)  low riskforrecurrenceof
periodontitis
Heavy smokers(HS),asdefinedbysmokingmorethan one
packperday, highrisk.
Occasional(OS;<10cigarettesaday)andmoderate smokers
(MS) moderate riskfordiseaseprogression
72

73. 73

74. 74
In this diagram,the vectorshavebeenconstructedon the
basisof the scientificevidence available.

75. 77
Low Periodontal
Risk Patient
risk categories or at the most one
parameter in the
moderate risk category

76. CALCULATING THE PATIENT'S INDIVIDUAL
PERIODONTAL RISK ASSESSMENT (PRA)
Moderate Periodontal
Risk Patient

77. 79
High
Periodontal
At least two parameters
in the
high risk category

78. 78

79. 79

80. 80

81. 81

82. 82
Overhangingrestorationsandill-fitting crown
marginsarea for plaqueretention : abundance
of associationstudies documenting increased
prevalenceof periodontallesionsin the presenceof
iatrogenicfactors
Leon1977

83. 83

84. 84
When assessingtooth mobility,it hasto berealized that
two factorsmaycontributeto hypermobility :

85. 87
Persson1980, 1981

86. 86

87.  Thetooth site riskassessmentincludesthe registrationof bleeding
onprobing,probingdepth, lossof attachment, and suppuration.
 …..useful in evaluatingperiodontaldiseaseactivity and
determiningperiodontalstability oron-goinginflammation.
 ……essential forthe identification of the sitesto be
instrumentedduring SPT.
87

88. BOP
88

89. 89

90. 90

91. SUPPURATION
The presenceof suppurationincreasedthe positive predictive
valuefordiseaseprogressionin combination with other
clinicalparameterssuchasBOPand increasedprobing
depth.
Baderstenet al.1985,1990,Claffeyet al. 1990
 Hence,followingtherapyasuppuratinglesionmay
provideevidencethat the periodontitissite is undergoing
aperiodof exacerbation
Kaldahlet al. 1990
91

92. Continuous multiple level risk assessment. Subject, tooth and site parameters are combined to
establish the clinical risk for disease progression. Note that different sites in the same patient may
have a different level of risk. Subject-based risk factors are used to put the toot9h4 and /or site risk

93. 95

94. 96
Few studies specificallyaddressedrootcariesasa
complicationduringaperiodof SPT
Endodontic complicationsduringSPTmayresultin tooth
extraction.
Data suggest that approximately 30% of all extractions of teeth
over a 4-year period of SPT are the consequence of peri- apical
lesions

95. 2.Periodontalabscesses
 Periodontal abscesses appear to occur in approximately 35% of
subjectson SPT.
It appears that subjects on SPT who only received nonsurgical
therapymaybeat agreaterriskof periodontalabscessesduringthe SPT
phase.
95

96. 3.Root sensitivity
 Root sensitivity is common, especially if treatment involved
surgicalprocedureswhichdecreasesovertime.
Reports onrootsensitivity duringSPTvaryfrom15%to 98%and areoften
associatedwith rootsurfaceexposureandgingival recession.
96

97. 97

98. 98

99.  Antimicrobialscanbeadministeredusingdifferent delivery systems,
i.e.dentifrices,solutionsfororalrinsesorflushing of the periodontal
pockets,andotherlocaldeliverysystems.
 Therearefew long-termstudiessuggestingthe efficacyof such
antimicrobialsin SPT programs.
99

100. 1 .Dentifrices
 Roslinget al.demonstratedthat atriclosan/copolymercontaining
dentifricereducedthe subgingivalmicrobiotabothquantitatively and
qualitatively overa3-yearperiodwithout concomitantuseof subgingival
mechanical treatment.
The frequency of deep periodontal pockets and number of sites
exhibiting additionalprobingattachment andbonelosswasalso reduced
.
100

101. 101

102. 2. Chlorhexidine
 Christie et al(1998)in hisstudy found that chlorhexidineis effective
whenused asan adjunctrinseto inadequatemechanical oral
hygienein nonsurgicaltreatment of chronicto advanced periodontitis
patients overanobservationperiodof 1year.
 Useof chlorhexidinerinseover3yearsat varyingintervalsmay also
preventtooth loss(Personet al1998) .
102

103. 103

104. 4.Study byLoescheandJohnson(2002)implythat the useof
antibioticsareeffective adjunctsto mechanicaldebridement and
that the effect maybesustainedoveralongerperiodof time.
However, the advantageof adjunctantibiotictherapy
duringSPTis unknown.
104

105. 105

106. In general,proceduresformaintenanceof patients with
implantsaresimilarto thosewith naturalteeth, with three
differences:
1. Specialinstrumentationthat will not scratchthe implants .
2. Acidicfluorideprophylacticagentsareavoided.
3. Nonabrasiveprophypastesare used.
106

107.  Dependingonthe clinical,radiographic,diagnosis, protocols
forpreventiveandtherapeuticmeasureswere designedto
interceptthe developmentof peri-implant lesions.
 Themajorclinicalparametersto beusedinclude:
• Presenceorabsenceof plaque
• Presenceorabsenceof BoP
• Presenceorabsenceof suppuration
• Increasedperi-implantprobing depth
• Evidenceandextent of radiographicalveolarboneloss.
107

108. 110

109. 109
 Patients often areafraidto touchthe implantsbut must be
encouragedto keepthe areasclean.

110.  Metal handinstrumentsandultrasonicandsonictips shouldbe
avoidedbecausethey canalterthe titanium surface.
 Onlyplasticinstrumentsorspeciallydesignedgold-plated curettes
shouldbeusedforcalculusremovalbecausethe implant surfacescanbe
easilyscratched.
110

111.  Therubbercupwith pumice,tin oxide,orspecialimplant polishing
pastesshouldbeusedonabutmentsurfaceswith light, inter-mittent
pressure.
 Althoughdailyuseof topicallyappliedantimicrobialsisadvised, acidic
fluorideagentsshouldnot beusedbecausethey cause surfacedamageto
titaniumabutments.
111

112. 4
11

113. 115

114. 116

115. 117

116. 116

117.  Fauchardin 1746stated that "little ornocareasto the cleaning of
teeth isordinarilythe causeof alldiseasesthat destroy them”
 It impliesthe necessityfor properandregularpersonalplaque
elimination,at leastin patients treatedfor orsusceptibleto
periodontaldisease.
117

118. 118

119.  Carranza-10th,12thedition
 Lindhe– 5thedition
 Supportiveperiodontaltreatment Perio2000vol 9 1995
 Periodontalmaintenance. Journalof PeriodontologyMay 2000
 Evaluation of the safety and efficiency of novel metallic ultrasonic
scalertip ontitanium surfaces.Clinoralimplantres 2012.
 TheEffects of ScalingaTitanium Implant SurfaceWith Metal and
PlasticInstruments:An in Vitro Study. JOP 1990.
119

120.  Lang,Tonetti. PeriodontalRisk Assessment(PRA)for Patients in
SupportivePeriodontalTherapy(SPT). OralHealth & Preventive
Dentisty 2003.
 PandeyV et al.SupportivePeriodontalTreatmentandPatient
Compliance-A Review. Journalof AdvancedMedicaland Dental
SciencesResearch 2014.
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