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1. Supportive Periodontal
Supportive Periodontal
Therapy
Therapy

2. Patients at risk for periodontitis
Patients at risk for periodontitis
without SPT.
without SPT.
Patients susceptible to periodontal
Patients susceptible to periodontal
disease are at high risk for reinfection
disease are at high risk for reinfection
and progression of periodontal lesions
and progression of periodontal lesions
without meticulously organized and
without meticulously organized and
performed SPT.
performed SPT.

3. All patients who where treated for
All patients who where treated for
periodontal diseases belong to this risk
periodontal diseases belong to this risk
category by virtue of their past history,
category by virtue of their past history,
an adequate maintenance care program is
an adequate maintenance care program is
of utmost importance for a beneficial
of utmost importance for a beneficial
tong-term treatment outcome. SPT has to
tong-term treatment outcome. SPT has to
be aimed at the regular removal of the
be aimed at the regular removal of the
subingival microbiota and must be
subingival microbiota and must be
supplemented by the patient’s efforts for
supplemented by the patient’s efforts for
optimal supragingival plaque control.
optimal supragingival plaque control.

4. SPT for patients with gingivitis
SPT for patients with gingivitis
The prevention of gingival inflammation
The prevention of gingival inflammation
and early loss of attachment in patients
and early loss of attachment in patients
with gingivitis depends primarily on the
with gingivitis depends primarily on the
level of personal plaque control, but also
level of personal plaque control, but also
on further measures to reduce the
on further measures to reduce the
accumulation of supragingival and
accumulation of supragingival and
subgingival plaque.
subgingival plaque.

5. SPT for patients with periodontitis
SPT for patients with periodontitis
SPT is an absolute prerequisite to guarantee
SPT is an absolute prerequisite to guarantee
beneficial treatment outcomes with maintained
beneficial treatment outcomes with maintained
level of clinical attachment over long periods of
level of clinical attachment over long periods of
time. While the maintenance of treatment
time. While the maintenance of treatment
results for the majority of patients has to be
results for the majority of patients has to be
realized that a small proportion of patients will
realized that a small proportion of patients will
experience recurrent infections with
experience recurrent infections with
progression of periodontal lesions in a few sites
progression of periodontal lesions in a few sites
in a completely unpredictable mode. The
in a completely unpredictable mode. The
continuous risk assessment at subject, tooth
continuous risk assessment at subject, tooth
the tooth site levels, therefore, represents a
the tooth site levels, therefore, represents a
challenge for the SPT concept.
challenge for the SPT concept.

6. Continuous multilevel risk assessment.
Continuous multilevel risk assessment.
Subject risk assessment following aspects:
Subject risk assessment following aspects:
1.
1. Percentage of bleeding on probing.
Percentage of bleeding on probing.
2.
2. Prevalence of residual pockets greater than 4
Prevalence of residual pockets greater than 4
mm
mm
3.
3. Loss of teeth from a total of 28 teeth.
Loss of teeth from a total of 28 teeth.
4.
4. Loss of periodontal support in relation to the
Loss of periodontal support in relation to the
patients age.
patients age.
5.
5. Systemic and genetic conditions.
Systemic and genetic conditions.
6.
6. Environmental factors such as cigarette
Environmental factors such as cigarette
smoking.
smoking.

7. Compliance with recall system
Compliance with recall system
Minority of periodontal patients comply with
Minority of periodontal patients comply with
the prescribed supportive periodontal care.
the prescribed supportive periodontal care.
Since it has been clearly established that
Since it has been clearly established that
treated periodontal patient who comply with
treated periodontal patient who comply with
regular periodontal maintenance appointments
regular periodontal maintenance appointments
have a better prognosis than patients who do
have a better prognosis than patients who do
not complex.
not complex.

8. Non-compliant or poorly compliant patients
Non-compliant or poorly compliant patients
should be considered at higher risk for
should be considered at higher risk for
periodontal disease progression.
periodontal disease progression.
Oral hygiene:-
Oral hygiene:-
Bacterial plaque is the most important etiologic
Bacterial plaque is the most important etiologic
agent for the occurrence of periodontal
agent for the occurrence of periodontal
diseases.
diseases.
Regular interference with the microbial
Regular interference with the microbial
ecosystem during a periodontal maintenance will
ecosystem during a periodontal maintenance will
eventually obscure such obvious associations.
eventually obscure such obvious associations.

9. Percentage of sites with bleeding on probing
Percentage of sites with bleeding on probing
Bleeding on gentle probing represents an objective
Bleeding on gentle probing represents an objective
inflammatory parameter which has been
inflammatory parameter which has been
incorporated into index systems for the
incorporated into index systems for the
evaluation of periodontal conditions and is also
evaluation of periodontal conditions and is also
used as a parameter by itself.
used as a parameter by itself.
In a patient’s risk assessment for recurrence of
In a patient’s risk assessment for recurrence of
periodontitis, BOP reflects, at least in part the
periodontitis, BOP reflects, at least in part the
patient’s, compliance and standards of oral
patient’s, compliance and standards of oral
hygiene performance. There is no established
hygiene performance. There is no established
acceptable level of prevalence of bleeding on
acceptable level of prevalence of bleeding on
probing in the dentition above which a higher risk
probing in the dentition above which a higher risk
for disease recurrence has been established.
for disease recurrence has been established.

10. In assessing the patient’s risk for disease
In assessing the patient’s risk for disease
progression, BOP percentages reflect a
progression, BOP percentages reflect a
summary of the patient’s ability to perform
summary of the patient’s ability to perform
proper plaque control, the patient’s host
proper plaque control, the patient’s host
response to the bacterial challenge and the
response to the bacterial challenge and the
patient’s compliance. The percentage of BOP,
patient’s compliance. The percentage of BOP,
therefore, as the first risk factor in the
therefore, as the first risk factor in the
functional diagram of risk assessment.
functional diagram of risk assessment.
Individuals with low mean BOP percentages
Individuals with low mean BOP percentages
may be regarded as patients with a low risk
may be regarded as patients with a low risk
for recurrent disease.
for recurrent disease.

11. Prevalence of residual pockets greater
Prevalence of residual pockets greater
than 4 mm
than 4 mm
The enumeration of the residual pockets
The enumeration of the residual pockets
with probing depths greater than 4 mm
with probing depths greater than 4 mm
represents-to a certain extent-the
represents-to a certain extent-the
degree of rendered.
degree of rendered.
Loss of teeth from a total of 28 teeth
Loss of teeth from a total of 28 teeth

12. Loss of periodontal support in relation
Loss of periodontal support in relation
to the patient’s age
to the patient’s age
The extent and prevalence of periodontal
The extent and prevalence of periodontal
attachment loss, as evaluated by the height
attachment loss, as evaluated by the height
of the alveolar bone on radiographs, may
of the alveolar bone on radiographs, may
represent the most obvious indicator of
represent the most obvious indicator of
subject risk when related to the patient’s the
subject risk when related to the patient’s the
rate of progression of progression of disease
rate of progression of progression of disease
has been positively affected by the
has been positively affected by the
treatment rendered and, hence, previous
treatment rendered and, hence, previous
attachment loss in relation to patient’s age
attachment loss in relation to patient’s age
may be a more accurate indicator during SPT
may be a more accurate indicator during SPT
than before active periodontal treatment.
than before active periodontal treatment.

13. Systemic conditions
Systemic conditions
The most substantiated evidence for
The most substantiated evidence for
modification of disease susceptibility and/or
modification of disease susceptibility and/or
progression of periodontal disease arises from
progression of periodontal disease arises from
studies on Type land Type II diabetes mellitus
studies on Type land Type II diabetes mellitus
populations.
populations.
The impact of diabetes on periodontal diseases
The impact of diabetes on periodontal diseases
has been documented in patients with
has been documented in patients with
untreated periodontal disease.
untreated periodontal disease.

14. In recent years, genetic markers have become
In recent years, genetic markers have become
available to determine various genotypes
available to determine various genotypes
regarding their susceptibility for periodontal
regarding their susceptibility for periodontal
diseases. Research on the intereukin-1 (IL-1)
diseases. Research on the intereukin-1 (IL-1)
polymorphisms has indicated that IL-1
polymorphisms has indicated that IL-1
genotype positive patients show more
genotype positive patients show more
advanced periodontitis lesions than IL-1
advanced periodontitis lesions than IL-1
genotype negative patients of the same age
genotype negative patients of the same age
group there is a trend to higher tooth loss in
group there is a trend to higher tooth loss in
the IL-1 genotype positive subjects.
the IL-1 genotype positive subjects.

15. Cigarette smoking
Cigarette smoking
Consumption of tobacco, in the form of smoking or
Consumption of tobacco, in the form of smoking or
chewing, affects the susceptibility and the treatment
chewing, affects the susceptibility and the treatment
outcome of patients with adult periodontitis.
outcome of patients with adult periodontitis.
In a young population 51-56% smoking will affect the
In a young population 51-56% smoking will affect the
treatment outcome after scaling and root planning.
treatment outcome after scaling and root planning.
The impact of cigarette smoking on the long-term
The impact of cigarette smoking on the long-term
effects of periodontal therapy in a population
effects of periodontal therapy in a population
undergoing supportive periodontal care has been
undergoing supportive periodontal care has been
reported. Smokers displayed less favorable healing
reported. Smokers displayed less favorable healing
responses both at re-evaluation and during a 6-years
responses both at re-evaluation and during a 6-years
period of supportive periodontal care.
period of supportive periodontal care.

16. Tooth risk assessment
Tooth risk assessment
Tooth position with the dental arch
Tooth position with the dental arch
Furcation involvement
Furcation involvement
Iatrogenic factors
Iatrogenic factors
Residual periodontal support
Residual periodontal support
Mobility
Mobility
The tooth risk assessment encompasses an estimation
The tooth risk assessment encompasses an estimation
of the residual periodontal support, an evaluation of
of the residual periodontal support, an evaluation of
tooth positioning, furcation involvements, presence of
tooth positioning, furcation involvements, presence of
iatrogenic factors and a determination of tooth
iatrogenic factors and a determination of tooth
mobility to evaluated functional stability a risk
mobility to evaluated functional stability a risk
assessment on the tooth level may be useful in
assessment on the tooth level may be useful in
evaluating the prognosis and function of an individual
evaluating the prognosis and function of an individual
tooth and may indicate the need for specific
tooth and may indicate the need for specific
therapeutic measures during SPT visits.
therapeutic measures during SPT visits.

17. Site risk assessment
Site risk assessment
Bleeding on probing
Bleeding on probing
Probing depth and loss of attachment
Probing depth and loss of attachment
Clinical probing
Clinical probing
Suppuration
Suppuration
The tooth site risk assessment includes the
The tooth site risk assessment includes the
registration of bleeding on probing, probing
registration of bleeding on probing, probing
depth, loss of attachment, and suppuration. A
depth, loss of attachment, and suppuration. A
risk assessment on the site level may be
risk assessment on the site level may be
useful in evaluating periodontal disease.
useful in evaluating periodontal disease.

18. Radiographic evaluation of periodontal
Radiographic evaluation of periodontal
disease progression
disease progression
Radiographic perception of periodontal changes is
Radiographic perception of periodontal changes is
characterized by a high specificity, but a low
characterized by a high specificity, but a low
sensitivity, with underestimation of the severity
sensitivity, with underestimation of the severity
of a periodontal defect. Undetectability of minute
of a periodontal defect. Undetectability of minute
changes at the alveolar crest is related to over
changes at the alveolar crest is related to over
projections and variations in projection geometry
projections and variations in projection geometry
when taking repeated radiographs. This may result
when taking repeated radiographs. This may result
in mimicked variations in the alveolar bone height,
in mimicked variations in the alveolar bone height,
obscured furcation status, etc. In addition, film
obscured furcation status, etc. In addition, film
processing variations may result in unreliable
processing variations may result in unreliable
assessments of alveolar bone density changes.
assessments of alveolar bone density changes.

19. The standard procedure for periodontal
The standard procedure for periodontal
evaluations in based on a film holder
evaluations in based on a film holder
system with an alignment for long-cone
system with an alignment for long-cone
paralleling technique. With the addition
paralleling technique. With the addition
of simple pins to the film holders as a
of simple pins to the film holders as a
repositioning reference, the
repositioning reference, the
methodologic error was impressively
methodologic error was impressively
reduced.
reduced.

20. Clinical implementation
Clinical implementation
At the patient level, loss of support in relation to
At the patient level, loss of support in relation to
patient age, full mouth plaque and/or bleeding
patient age, full mouth plaque and/or bleeding
scores and prevalence of residual pockets are
scores and prevalence of residual pockets are
evaluated together with the presence of systemic
evaluated together with the presence of systemic
conditions or environmental factors, such as
conditions or environmental factors, such as
smoking, which can influence the prognosis, The
smoking, which can influence the prognosis, The
clinical utility of this first level of risk assessment
clinical utility of this first level of risk assessment
influences primarily the determination of the recall
influences primarily the determination of the recall
frequency and time requirements. It should also
frequency and time requirements. It should also
provide a perspective for the evaluation of risk
provide a perspective for the evaluation of risk
assessment conducted at the tooth and site levels.
assessment conducted at the tooth and site levels.

21. SPT IN DAILY PRACTICE
SPT IN DAILY PRACTICE
The recall hour should be planned to meet the
The recall hour should be planned to meet the
patient’s individual needs. It basically consists of
patient’s individual needs. It basically consists of
four different sections which may require various
four different sections which may require various
amounts of time during a regularly scheduled visit.
amounts of time during a regularly scheduled visit.
1.
1. Examination, Re-evaluation and Diagnosis
Examination, Re-evaluation and Diagnosis
(ERD) 5 - 10 gm
(ERD) 5 - 10 gm
2.
2. Motivation, Reinstruction and Instrumentation
Motivation, Reinstruction and Instrumentation
(MRI) 30-40
(MRI) 30-40
3.
3. Treatment of Re infected Sites (TRS)
Treatment of Re infected Sites (TRS)
4.
4. Polishing of the entire dentition, application
Polishing of the entire dentition, application
of Fluorides and Determination of future SPT
of Fluorides and Determination of future SPT
(PFD) 5-10 gm.
(PFD) 5-10 gm.

22. Examination, Re-evaluation and Diagnosis (ERD)
Examination, Re-evaluation and Diagnosis (ERD)
1.The oral hygiene and plaque situation.
1.The oral hygiene and plaque situation.
2.The determination of sites with bleeding on probing
2.The determination of sites with bleeding on probing
indicating persistent inflammation.
indicating persistent inflammation.
3.The scoring of clinical probing depths and clinical
3.The scoring of clinical probing depths and clinical
attachment levels.
attachment levels.
4.The inspection of re infected sites with pus formation.
4.The inspection of re infected sites with pus formation.
5.The evaluation of existing reconstructions, including
5.The evaluation of existing reconstructions, including
vitality checks for abutment teeth.
vitality checks for abutment teeth.
6.The exploration for carious lesions.
6.The exploration for carious lesions.

23. Dentist treatment of other problems
Dentist treatment of other problems
Polishing, Fluorides, Determination of recall interval
Polishing, Fluorides, Determination of recall interval
(PFD)
(PFD)
The SPT recall hour is divided into four sections.
The SPT recall hour is divided into four sections.
While the first 10-15 min are reserved for
While the first 10-15 min are reserved for
Examination, Re-evaluation and Diagnosis, the second
Examination, Re-evaluation and Diagnosis, the second
and most time-consuming section 30-40 min is
and most time-consuming section 30-40 min is
devoted to reinstruction and instrumentation of sites
devoted to reinstruction and instrumentation of sites
at risk identified in the diagnostic process. Some
at risk identified in the diagnostic process. Some
reinfected sited may require further treatment, and
reinfected sited may require further treatment, and
hence, the patient may have to be rescheduled for an
hence, the patient may have to be rescheduled for an
additional appointment. The recall hour is concluded
additional appointment. The recall hour is concluded
by polishing the dentition, applying fluorides and
by polishing the dentition, applying fluorides and
determining the frequency of future SPT visits.
determining the frequency of future SPT visits.