Supportive periodontal therapy, Risk Factors

1. SUPPORTIVE PERIODONTAL THERAPY
PRESENTED BY:
PRABLEEN ARORA
MDS STUDENT1

2. INTRODUCTION
• Treatments with long term maintenance programs
following active therapy, once termed maintenance is
called as Supportive Periodontal Therapy (SPT)
American Academy of Periodontology (AAP), 1986.
• In 2003 AAP, position paper termed as Periodontal
Maintenance Therapy.
The continuing, periodic assessment and prophylactic treatment of
the periodontal structures permitting early detection and treatment of
new and recurring disease has been commonly referred to as
periodontal maintenance or recall.
(American Academy of Periodontology. Glossary of periodontal term, 1992)
2

3. Periodontal treatment includes:
1. systemic evaluation of the patient's health
2. a cause-related therapeutic phase
3. a corrective phase involving periodontal surgical
procedures
4. maintenance phase
• The 3rd World Workshop of the American Academy of
Periodontology (1989) has renamed this treatment
phase "supportive periodontal therapy" (SPT).
This term expresses the essential need for therapeutic
measures to support the patient's own efforts to control the
periodontal infections and to avoid reinfection. 3

4. • 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.
DENTIST
PATIENTSTAFF
4
ROLE

5. • Patients with inadequate SPT after successful
regenerative therapy have a fiftyfold increase in
risk of probing attachment loss compared with
those who have regular recall visits.
Pini-Prato G et al 1994
• Treated patients who do not return for regular
recall are at 5.6 times greater risk for tooth loss
than compliant patients.
Checchi L et al 2002
5

6. RATIONALE FOR SUPPORTIVE PERIODONTAL
TREATMENT
• Incomplete subgingival plaque removal (Waerhaug J
1978)
• Bacteria present in gingival tissues mainly in chronic
and aggressive periodontitis.
• Bacterial transmission between spouses and other
family members.
• Recurrence of periodontal disease is the microscopic
nature of the dentogingival unit healing after
periodontal treatment. 6

7. • Subgingival scaling alters the microflora of periodontal pockets.
• In a single session of scaling and root planing in patients with
chronic periodontitis resulted in significant changes in subgingival
microflora.
• Alterations included a decrease in the proportion of motile rods
for 1 week,
• a marked elevation in the proportion of coccoid for 21 days
• a marked reduction in the proportion of spirochetes for 7 weeks.
Phillips RW et al1980
• Although pocket debridement suppresses components of the
subgingival microflora associated with periodontitis, periodontal
pathogens may return to baseline levels within days or months.
• The return of pathogens to pretreatment levels generally occurs in
approximately 9 to 11 weeks but can vary dramatically among
patients.
American academy of periodontology:
Periodontal maitenance, J PERIODONTOL 20037

8. Therapeutic goals of SPT
• To prevent the progression and recurrence of
periodontal disease in patients who have previously
been treated for gingivitis and periodontitis.
• To prevent the loss of dental implants after clinical
stability has been achieved.
• To reduce tooth loss by monitoring the dentition and
any prosthetic replacements of the natural teeth.
• To diagnose and manage, in a timely manner, other
diseases or conditions found within or related to the
oral cavity
8

9. Periodontal Risk Assessment (PRA) for Patients in
Supportive Periodontal Therapy (SPT)
• 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.
9

10. • For this purpose, a functional diagram has been constructed
including the following aspects:
(Lang & Tonetti 2003)
1. Percentage of bleeding on probing,
2. Prevalence of residual pockets greater than 4 mm (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, and
6. Environmental factors, such as cigarette smoking.
• 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.
10

11. A low PR patient has all parameters within the low risk categories or
at the most one parameter in the moderate risk category.
11

12. A moderate PR patient has at least two parameters in the moderate
category, but at most one parameter in the high risk category
12

13. A high PR patient has at least two parameters in the high
risk category
13

14. SPT in daily practice
• What does it involve?
• When does it start?
• Who performs it?
• How frequently?
14

15. What does it involve?
SPT recall hour
• The recall hour should be planned to
meet the patient's individual needs.
4 different sections:
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 Fluorides and
Determination of future SPT (PFD) 15

16. Examination, Re-evaluation and
Diagnosis (ERD)
• An extraoral and intraoral soft tissue examination should be performed at any SPT
visit to detect any abnormalities and to act as a screening for oral cancer.
• An evaluation of the patient's risk factors will also influence the choice of future
SPT and the determination of the recall interval at the end of the maintenance visit.
• Following the assessment of the subject's risk factors, the tooth site-related risk
factors are evaluated.
Diagnostic procedure usually includes an assessment of the following:
1. the oral hygiene and plaque situation
2. the determination of sites with bleeding on probing, indicating persistent
inflammation
3. the scoring of clinical probing depths and clinical attachment levels.
4. the inspection of reinfected sites with pus formation
5. the evaluation of existing reconstructions, including vitality checks for abutment
teeth
6. the exploration for carious lesions.
All these evaluations are performed for both
teeth and oral implants.
16

17. Motivation, Reinstruction and
Instrumentation (MRI)
• When informed about the results of the diagnostic
procedures, e.g. the total percentage of the bleeding on
probing (BOP) score or the number of pockets exceeding 4
mm, the patient may be motivated either in a confirmatory
way in case of low scores or in a challenging fashion in case of
high scores.
• Since encouragement usually has a greater impact on future
positive developments than negative criticism, every effort
should be made to acknowledge the patient's performance.
• Patients who have experienced a relapse in their adequate
oral hygiene practices need to be further motivated.
17

18. • Occasionally, patients present with hard tissue lesions (wedge-
shaped dental defects) which suggest faulty mechanical tooth
cleaning.
• Such habits should be broken and the patient reinstructed in tooth
brushing techniques which emphasize vibratory rather than
scrubbing movements.
• Since it appears impossible to instrument 168 tooth sites in a
complete dentition in the time allocated, only those sites will be
reinstrumented during SPT visits which exhibit signs of
inflammation and/or active disease progression.
• Hence, all the BOP positive sites and all pockets with a probing
depth exceeding 5 mm are carefully resealed and root planed.
• Repeated instrumentation of healthy sites will inevitably result in
mechanically caused continued loss of attachment.
Lindhe et al. 198218

19. • Several longitudinal studies that probing
attachment may be lost following instrumentation
of pockets below a "critical probing depth" of
approximately 2.9 mm.
• Instrumentation of shallow sulci is, therefore, not
recommended. Lindhe et al. 1982
• As it has been shown in several studies that non-
bleeding on probing sites represent stable sites , it
appears reasonable to leave non-bleeding sites for
polishing only and concentrate on periodontal sites
with a positive BOP test or probing depths
exceeding 5 mm.
Lang et al. 1986, 1990, Joss et al. 1994 19

20. Treatment of Reinfected Sites (TRS)
• Single sites, especially furcation sites or sites with difficult access,
may occasionally be reinfected and demonstrate suppuration.
Such sites require a thorough instrumentation under anesthesia,
the local application of antibiotics in controlled release devices or
even open debridement with surgical access.
• Therapeutic procedures may be too time-consuming to be
performed during the routine recall hour, and hence, it maybe
necessary to reschedule the patient for another appointment.
• Omission of thoroughly retreating such sites or only performing
incomplete root instrumentation during SPT may result in
continued loss of probing attachment
(Kaldahl et al. 1988, Kalkwarf et al. 1989).
• Treatment choices for reinfected sites should be based on an
analysis of the causes most likely responsible for the reinfection.
• Generalized reinfections are usually the result of inadequate SPT.
20

21. • Sometimes, a second visit 2-3 weeks after the recall
maybe indicated to check the patient's performance
in oral home care.
• It is particularly important to supervise patients
closely for advanced periodontitis if they have a
high subject risk assessment.
Westfelt et al. 1983, Ramfjord 1987.
• Local reinfections may either be the result of
inadequate plaque control in a local area or the
formation of ecologic niches conducive to
periodontal pathogens. Eg: furcation involvement.
21

22. Polishing, Fluorides, Determination of recall
interval (PFD)
• The recall hour is concluded with polishing the entire dentition to
remove all remaining soft deposits and stains.
• This may provide freshness to the patient and facilitates the
diagnosis of early carious lesions.
• Following polishing, fluorides should be applied in high
concentration in order to replace the fluorides which might have
been removed by instrumentation from the superficial layers of
the teeth.
• Fluoride or chlorhexidine varnishes may also be applied to prevent
root surface caries, especially in areas with gingival recessions.
• The determination of future SPT visits must be based on the
patient's risk assessment.
22

23. Time required for a recall visit for
patients with multiple teeth in both
arches is ≈ 1 hour
Schallhorn RG, 1981
23

24. 24

25. When does it start?
• The maintenance phase of periodontal treatment
starts immediately after the completion of Phase I
therapy .
• While the patient is in the maintenance phase, the
necessary surgical and restorative procedures are
performed.
• This ensures that all areas of the mouth retain the
degree of health attained after Phase I therapy.
25

26. • Incorrect sequence of
periodontal
treatment phases
correct sequence of
periodontal treatment
phases
26

27. Who should provide?
IF Periodontal destruction
necessitates surgery
On distal surfaces of second molars
Extensive osseous surgery
Complex regenerative procedures
Patients who
require
Localized
gingivectomy
Flap curettage
Specialists are needed to treat particularly difficult
periodontal cases, patients with systemic health
problems, dental implant patients, and those with a
complex prosthetic construction that requires
reliable results.
American Academy of Periodontology 2006
has issued guidelines to help the general
practitioner decide when co-management
with a periodontist is indicated. The
diagnosis indicates the type of periodontal
treatment required.
Should the maintenance phase of
therapy be performed by the general
practitioner or the specialist?
This should be determined by the
amount of periodontal deterioration
present.
27

28. 28
LEVEL 3: PATIENTS WHO SHOULD
BE TREATED BY A PERIODONTIST
•Severe chronic periodontitis.
•Furcation involvement
•Vertical/angular bony defect(s)
• Aggressive periodontitis
•Periodontal abscess
•Significant root surface exposure /
progressive gingival recession
Peri-implant disease.
LEVEL 2: PATIENTS WHO WOULD
LIKELY BENEFIT FROM
COMANAGEMENT BY THE
REFERRING DENTIST AND THE
PERIODONTIST
•Early onset of periodontal
diseases (prior to the age of 35
years)
•Unresolved inflammation at any
site (e.g., bleeding upon probing,
pus, and/or redness)
•Pocket depths ‡ 5 mm
•Vertical bone defects
• Radiographic evidence of
progressive bone loss
•Progressive tooth mobility
•Progressive attachment loss
•Anatomic gingival deformities
•Exposed root surfaces
•Medical or Behavioral Risk
Factors/Indicators
•Smoking/tobacco use
•Diabetes
•Osteoporosis/osteopenia
•Drug-induced gingival conditions
•Compromised immune system,
LEVEL 1: PATIENTS WHO MAY
BENEFIT FROM COMANAGEMENT
BY THE REFERRING DENTIST AND
THE PERIODONTIST
•Any patient with periodontal
inflammation/infection and the
following systemic conditions:
• Diabetes
• Pregnancy
• Cardiovascular disease
•Chronic respiratory disease
• Any patient who is a candidate
for the following therapies who
might be exposed to risk from
periodontal infection, including
but not limited to the following
treatments:
• Cancer therapy
•Cardiovascular surgery
• Joint-replacement surgery
•Organ transplantation

29. SPT FOR PATIENTS WITH GINGIVITIS
• Badersten et al. 1975, Poulsen et al. 1976, Axelsson & Lindhe 1981, Bellini
et al. 1981
• documented that periodic professional prophylactic visits in conjunction
with reinforcement of personal oral hygiene are effective in controlling
gingivitis.
• Adults whose effective oral hygiene was combined with periodic
professional prophylaxes clearly were healthier periodontally than patients
who did not participate in such programs.
Lovdal et al. 1961, Suomi et al. 1971.
• Lovdal et al. 1961 performed a study on 1428 adults from an industrial
company in Oslo, Norway .
• Over a 5-year observation period, the subjects were recalled 2-4 times per
year for instruction in oral hygiene and supragingival and subgingival
scaling.
• Gingival conditions improved by approximately 60% and tooth loss was
reduced by about 50% of what would be expected without these efforts.
29

30. • A study in which loss of periodontal tissue support
in young individuals with gingivitis or only loss of
small amounts of attachment was followed over 3
years.
• An experimental group receiving scaling and
instruction in oral hygiene every 3 months yielded
significantly less plaque and gingival inflammation
than the control group in which no special efforts
had been made.
• The mean loss of probing attachment was only 0.08
mm per surface in the experimental as opposed to
0.3 mm in the control group.
Suomi et al. 197130

31. SPT FOR PATIENTS WITH PERIODONTITIS
• Patients with advanced periodontitis may need SPT
at a regular and rather short time interval (3-4
months), while for mild to moderate forms of
periodontitis, one annual visit may be enough to
prevent further loss of attachment.
• PPD and CAL were maintained as a result of a well-
organized professional maintenance care program
(recall intervals varying between 3 and 6 months),
irrespective of the initial treatment modality
performed.
Ramfjord et al.-1968, Lindhe and Nyman-1975,1984
31

32. •Listgarten MA et al 1978,1986 concluded that the arbitrary assignment
of treated periodontitis patients to 3-month maintenance intervals
appears to be as effective in preventing recurrences of periodontitis as
assignment of recall intervals based on microscopic monitoring of the
subgingival flora.
• Microscopic monitoring was found not to be a reliable predictor of
future periodontal destruction in patients on 3-month recall programs,
presumably because of the alteration of subgingival flora produced by
subgingival instrumentation.
32
The rationale for 3-month recall intervals for SPT is most likely based on
Recolonization of pathogens in previously treated periodontal pockets
that occurs quickly if oral hygiene is not properly maintained.
Therefore, 3–4-month maintenance care intervals have been suggested.
Ramfjord SP 1987.

33. 33

34. SPT with adjunct use of antimicrobials/antibiotics
• Antimicrobials have been used to compensate for
inadequate mechanical oral hygiene.
• Antimicrobials can be administered using different
delivery systems:
 dentifrices,
 solutions for oral rinses or flushing of the
periodontal pockets
other local delivery systems.
34

35. • Rosling et al. demonstrated that a triclosan/copolymer
containing dentifrice reduced the subgingival microbiota both
quantitatively and qualitatively over a 3-year period without
concomitant use of subgingival mechanical treatment.
• The frequency of deep periodontal pockets and number of sites
exhibiting additional probing attachment and bone loss was also
reduced when using such a dentifrice over 3 years.
• Use of chlorhexidine rinse over 3 years at varying intervals may
also prevent tooth loss.
• Administration of chlorhexidine in a controlled release delivery
system (Periochip) in patients with residual pockets after ICRT
(initial cause related therapy )appeared to be effective in a 6-
month study.
35

36. Recurrence of Periodontal Disease
Inadequate plaque
control.
Inadequate or
insufficient treatment
Inadequate
restorations
Failure of the patient to
return for periodic
checkups
Presence of some
systemic diseases
36

37. Failing case can be recognized by the
following:
1. Recurring inflammation revealed by gingival changes and
bleeding of the sulcus on probing.
2. Increasing depth of sulci, leading to the recurrence of
pocket formation.
3. Gradual increases in bone loss, as determined by
radiographs.
4. Gradual increases in tooth mobility, as ascertained
by clinical examination.
The decision to re-treat a periodontal patient should not be
made at the preventive maintenance appointment but should
be postponed for 1 to 2 weeks. (Chace R 1977)
37

38. 38

39. MAINTENANCE FOR DENTAL
IMPLANT PATIENTS
• Patients with periodontitis-associated tooth loss are at significantly increased risk
of developing periimplantitis.
• The overall periodontal condition in partially edentulous implant patients can
influence the clinical condition around implants.
• The microflora of implants in partially edentulous patients differs from that in
edentulous patients.
• The implant microflora is similar to tooth microflora in the partially edentulous
mouth.
• Periodontal and implant maintenance are linked because maintenance of a tooth
microflora consistent with periodontal health is necessary to maintain implant
microflora consistent with periimplant health.
• Because periimplantitis is difficult to treat,it is extremely important to treat
periodontal disease before implant placement and to provide good supportive
therapy with implant patients.
39

40. • In general, procedures for maintenance of patients with
implants are similar to those for patients with natural teeth,
with the following three differences:
1. Special instrumentation.
• Metal hand instruments and ultrasonic and sonic tips should
be avoided because they can alter the titanium surface.
• Only plastic instruments or specially designed gold plated
curettes should be used for calculus removal.
• The rubber cup with pumice, tin oxide, or special implant-
polishing pastes should be used on abutment surfaces with
light, intermittent pressure
2. Acidic fluoride prophylactic agents are avoided.
3. Nonabrasive prophy pastes are used. 40

41. • Known as the cumulative interceptive supportive
therapy (CIST).
• Depending on the clinical and eventually the
radiographic diagnosis, protocols for preventive and
therapeutic measures designed to intercept the
development of peri-implant lesions.
• This system of supportive therapy is cumulative in
nature and includes four steps.
• 1. Antiseptic therapy, CIST protocol A and B
• 2. Antibiotic therapy, CIST protocol A + B
• 3. Antibiotic therapy, CIST protocol A + B + C
• 4. Regenerative or resective therapy, CIST protocol
• A+B+C+D 41

42. 42

43. Compliance with maintenance
therapy
• Compliance has been defined as
“the extent to which a person’s
behavior coincides with medical or
health advice”.
• The first study on the degree of
compliance with supportive
periodontal treatment was
published in 1984 by Wilson et al.
• 1000 patients followed for up to 8
years.
• only 16% complied with suggested
SPT intervals,
• 34% never came back for
maintenance,
• 49% rest complied erratically.
Compliance with maintenance therapy
in 961 patients studied for 1 to 8 years.)
43

44. Why do patients fail to comply?
• The behaviour of these non-compliant patients is
characterized by denial and negligent attitude towards
their illness.
• Fear of dental treatment is a major reason for noncompliance
• Perceived indifference or indifferent behavior on the dentist’s
part has also been cited as the reason for non-compliance.
• Economic problems are another factor that keeps patients
from complying.
• Lack of satisfaction on the patient’s part also contributes to
non-compliance.
44

45. Possible methods of improving
compliance
45

46. Clinical recommendations
• 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 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.
• The use of a triclosan/copolymer dentifrice could be of value to enhance oral
hygiene.
• In patients with inadequate oral hygiene, chlorhexidine rinses could be advocated.
• There does not seem to be scientific evidence of additional value of routine
subgingival debridement of sites presenting with bleeding on probing at SPT visits
without concomitant increase in probing depth. Such treatment should therefore
be avoided in sites without increasing probing depth. 46

47. Summary
• SPT can keep periodontium and peri-implant tissues
healthy after active therapy.
• Patients who comply to suggested SPT keep their
teeth longer.
• Average SPT visit should last 1 hour and should be
scheduled every 3 months depending on patients.
47

48. References
• Carranza’s 8th, 10th,11th,12th edition of Clinical Periodontology.
• Lindhe’s 6th edition of Clinical Periodontology and Implant
dentistry.
• Supportive periodontal therapy. STEFAN RENVERT & G. RUTGER
PERSSON. Periodontology 2000, Vol. 36, 2004, 179–195.
• Supportive periodontal treatment introduction - definition,
extent of need, therapeutic objectives, frequency and efficacy.
THOMASG .W ILSONJ,R . Periodontology 2000, Vol. 12, 1996, 11-15
• SUPPORTIVE PERIODONTAL THERAPY- A REVIEW. Annals and
Essences of Dentistry Vol. VIII Issue 1 Jan–Mar 2016
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49. THANK YOU
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