Supportive periodontal therapy
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This document discusses supportive periodontal therapy (SPT), including its objectives, components, efficacy, and role in daily practice. SPT involves regular patient monitoring after active periodontal treatment to prevent reinfection and continued disease progression. Key aspects of SPT include patient motivation and reinstruction, treatment of reinfected sites, polishing and fluoride application, and determining the appropriate recall interval. The success of long-term SPT relies on effective communication and compliance. SPT can help maintain bone height and attachment levels if performed regularly.
Supportive periodontal therapy
- 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
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- 6. 8 Continuous patient monitoring following active periodontal therapy is necessary to prevent •Reinfection •Continued progression of periodontal disease
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- 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
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- 17. 17 No maintenanceplaque accumulatereestablish inflammationNyman 1977 Well maintained patients low inflammation Rosling 1976 Bone height well maintained and improved in proper maintenance Rosling 1976
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- 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
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- 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
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- 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
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- 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
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- 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
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- 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
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- 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.
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- 59. Evaluated onthree levels. Subjectlevel Toothlevel Site level 59
- 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
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- 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
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- 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
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- 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
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- 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
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- 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
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- 82. 82 Overhangingrestorationsandill-fitting crown marginsarea for plaqueretention : abundance of associationstudies documenting increased prevalenceof periodontallesionsin the presenceof iatrogenicfactors Leon1977
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- 84. 84 When assessingtooth mobility,it hasto berealized that two factorsmaycontributeto hypermobility :
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- 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
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- 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
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- 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
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- 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
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- 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
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- 104. 4.Study byLoescheandJohnson(2002)implythat the useof antibioticsareeffective adjunctsto mechanicaldebridement and that the effect maybesustainedoveralongerperiodof time. However, the advantageof adjunctantibiotictherapy duringSPTis unknown. 104
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- 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
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- 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
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- 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
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- 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. 120
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