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SUPPORTIVE
PERIODONTA
L
THERAPY
DR. MANISHA SINHA
II YR PG
DEPT OF PERIODONTOLOGY
1
RAJARAJESWARI DENTAL COLLEGE AND HOSPITAL
• PARTS OF SPT
• FREQUENCY AND EFFICACY
• MAINTENANCE RECALL
PROCEDURES
• CLASSIFICATION OF POST
TREATMENT PATIENTS
• REFERRAL TO THE
PERIODONTIST
TABLE OF CONTENTS
■ INTRODUCTION
■ DEFINITION
■ RATIONALE
■ SEQUENCE OF PERIODONTAL
TREATMENT
■ RECURRENCE OF PERIODNTAL
DISEASE
■ INDICATORS OF DISEASE
RECURRENCE
■ GOALS OF SPT
■ COMPLIANCE
■ COMMUNICATION
2
Supportive periodontal treatment is an integral part of periodontal therapy.
These procedures are performed at selected intervals to assist the periodontal
patient in maintaining oral health.
INTRODUCTION
AAP 1991
3
Periodontal treatment includes:
■ Systemic evaluation of the patient’s health
■ A cause-related therapeutic phase with
■ A corrective phase involving periodontal surgical procedures
■ Maintenance phase
4
DEFINITION
• Continuous diagnostic monitoring of the patient in order to intercept
with adequate therapy and to optimize the therapeutic interventions
tailored to the patient’s need. (Lindhe)
Periodontal maintenance, supportive
periodontal care and recall
The 3rd World Workshop of the American Academy of Periodontology(1989)
renamed this maintenance phase as SUPPORTIVE PERIODONTAL
THERAPY 5
American Academy of
Periodontology 1989
SUPPORTIVE PERIODONTAL
THERAPY
An update of the medical and
dental histories
Examination of extra and intraoral
soft tissues, dental examination,
Radiographic view
Supra and subgingival removal of
bacterial plaque and calculus
Periodontal evaluation and risk
assessment
Evaluation of the patient’s oral
hygiene performance
Retreatment of disease when
indicated
AAP position paper in 2003 termed it as PERIODONTAL
MAINTENANCE 6
• SPT therefore offers an opportunity for clinicians to
promote periodontal health, and rapidly detect and intercept recurrence
or progression of periodontal disease (Heasman 2008;
Ramfjord 1987).
• Patient not returning for regular recall- 5.5 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
History
Chace (1951)- maintenance of the treated periodontal patient
should be carefully considered and a definite routine established.
Chace (1967)- indicated that the general dentist who participates
in the maintenance of periodontal patients assumes far greater
responsibilities than he does in the care of average patient.
Chace (1977) – suggested that the patients treated for
periodontal disease may be susceptible to recurrent periodontitis.
Schick (1981)- noted that a maintenance program should provide
adequate therapy for previously existing periodontal conditions.
Lang et al (1986) - evaluated BOP as a predictor for the
progression of periodontal disease in 55 patients following
treatment and at least 4 years of maintenance.
8
■ Gingivitis left untreated may lead to periodontitis.
■ This progression can be prevented or limited by
1. optimal personal oral hygiene. (Loe H et al 1965)
2. periodic maintenance care under the supervision of a dentist ( since
patients rarely are completely effective in removing plaque accumulation)
(Ramfjord SP et al 1982)
EXTENT OF NEED
9
Changes in subgingival microbiota
(quantity and quality)
Listgarten et al 1978
Why is that?
Periodontal pathogenic
microbiota will take
several months to recolonize the
pocket
Listgarten et al 1978
Slots et al 1979
Caton et al 1982
Magnusson et al 1984
RATIONALE
10
Why is that?
Crucial role of SPT in
maintaining successful results
Patients treated for advanced
periodontal disease involving
surgery but not incorporated in
SPT
Rate of loss of attachment:
3x -5x higher than SPT
Ramfjord et al 1968
Lindhe & Nyman 1975
Rosling et al 1976
Nyman et al 1977
Isidor & Karring 1986
Kaldahl et al 1988
11
Waerhaug 1978
Cortellini 1994
INCOMPLETE
subgingival plaque
removal… bacteria are
present in the gingival
tissues in chronic and
aggressive periodontitis.
Eradication of intergingival
microorganisms may be
necessary for a stable
periodontal result.
Scaling , root planning and
even flap surgery may not
eliminate interginival
bacteria in some areas.
Bacteria associated with
periodontitis can be
transmitted between
spouses and other family
members.
Patients who appear to be
successfully treated can
become infected or
reinfected with potential
pathogens.
12
Treatment without SPT
Periodontal Therapy
SPT every 3 months
 Stable results at 15 yrs
(Nyman & Lindhe 1979)
 Only 1.3% of the teeth had
attachment loss (Hämmerle et
al 2000)
No SPT
 Obvious signs of
recurrent
periodontitis
 45% of patient
returned to values
similar to before
treatment
(Kerr 1981)
 Increased probing depth
 Increased furcation
involvment
 Increased tooth loss
 Radiographic bone loss
 Increased tooth loss
(Becker et al 1984)
13
Morrison et al 1979
14
SEQUENCE OF PERIODONTAL
TREATMENT
15
RECURRENCE OF PERIODONTAL DISEASE
Occasionally, lesions may recur.
This is often due to inadequate plaque control on the part of the patient or
failure to comply with recommended SPT schedules.
However, it is the dentist’s responsibility to teach, motivate and control the
patient’s oral hygiene technique, and the patient’s failure is the dentist’s failure.
Surgery should not be undertaken unless the patient has shown proficiency and
willingness to cooperate by adequately performing his or her part of therapy.16
Other
causes for
recurrence
are the
following
Failure of the patient to return
for periodic checkups
Inadequate or insufficient
treatment that has failed to
remove all the potential factors
favouring plaque accumulation
Presence of some systemic
diseases that may affect host
resistance to previously
acceptable levels of plaque
Inadequate restorations placed
after the periodontal treatment
was completed.
17
Recurring inflammation revelaed
by gingival changes and bleeding
of the sulcus on probing.
Increasing depth of sulci, leading
to the recurrence of pocket
formation
Gradual increase in bone loss as
determined by radiographs
Gradual increase in tooth mobility
as ascertained by clinical
examination.
A failing case can be
recognized by
18
Oral hygiene
Wilson et al 1993
Over zealous hygiene
Indicators for disease recurrence
19
BOP > 20%-30% higher risk for disease
progression
BOP <10% low risk for disease progression
Non bleeding site may be considered
periodontally stable
Bleeding on probing
Lang et al 1990
Claffey et al 1990
Badersten et al 1990
Lang et al 1990
20
Suppuration linked to disease progression
Suppuration
Badersten et al 1985
Badersten et al 1990
Claffey et al 1990
21
Residual pockets
Deep residual pockets and deepening
pockets associated with disease recurrence
Claffey et al 1990
Badersten et al 1990
22
Tooth loss
If >8 teeth are lost, oral function is impaired
Tooth loss represent the history of
periodontal disease and trauma
Käyser 1981
23
Bone loss
 Dentition may be functional even in
presence of a reduce periodontal support
Papapanou et al 1988
24
Systemic conditions
 Diabetes type I and type II-
 Interleukin-1 polymorphisms
 Smoking Ismail et al 1983
Bergström 1989
Haber 1993
Genco & Löe 1993
Kornman et al 1997
McGuire & Nunn 1999
25
Becker
1984, Wilson,
Glover 1987
26
27
GOALS OF SPT
■ The American Academy of Periodontology more specifically lists 3 main goals of
SPT:
TO PREVENT OR MINIMIZETHE
RCURRENCE AND
PROGRESSION OF
PERIODONTAL DISEASE IN
PATIENTSWHO HAVE BEEN
PREVIOUSLYTREATED FOR
GINGIVITIS, PERIODONTITIS,
AND PERI-IMPLANTITIS.
TO PREVENT OR REDUCETHE
INCIDENCE OFTOOTH LOSS BY
MONITORINGTHE DENTITION
AND ANY PROSTHETIC
REPLACEMENT OF NATURAL
TEETH.
TO INCREASETHE PROBABILITY
OF LOACTING ANDTREATING IN
ATIMELY MANNER, OTHER
DISEASE OR CONDITIONS
FOUND WITHINTHE ORAL
CAVITY.
28
Objectives
Preservation of
alveolar bone
support
(radiographically).
Maintenance of
stable, clinical
attachment level.
Reinforcement and
re-evaluation of
proper home care.
Maintenance of a
healthy and
functional oral
environment to
prevent occurrence
of new disease.
29
COMPLIANCE
 Compliance (also called adherence and therapeutic alliance) has been
defined as “the extent to which a person’s behavior coincides with
medical or health advice”.
Compliance can
be measured
directly –
the patients either come in, or
they do not.
the patients who clean their teeth will
lose less periodontal support than those
who do not .
It is also possible to measure home care
efficiency and efficacy
The relevant questions are then,
do patients clean as they are
asked, and do they come in for
supportive periodontal
treatment? 30
Types of compliance
1. Non compliance
2. Erratic compliance
3. Complete compliance
31
Compliance and its role in periodontal therapy
32
WHY DO PATIENTS FAILTO COMPLY?
Self-
destructive
behaviours
Fear of
dental
treatment
Economic
factors
Health
beliefs
Stressful
events in
their lives
33
Simplify
the simpler the required behavior,
the more likely it is to be carried
out.
Accommodate
The more your practice and your suggestions fit the
patients’ needs, the more likely they are to comply.
Possible methods of improving Compliance
34
Remind patients of appointments
Failed appointments create problems for
both the patient and the dentist.
Keep records of compliance
Patients can “get lost in the system”, and
efforts should be made to keep up with
them.
35
Inform
Put what you say in writing and give a copy
to the patient.
Provide positive reinforcement
Most patients do better when positive
feedback is given when compared with a
more negative approach to their
compliance problem.
36
Identify potential noncompliers
If there is suspicion that compliance will be
absent or erratic, discuss the problems this
may create for the patient before therapy
begins.
Ensure the dentist’s involvement
There is evidence that, in some cases, dentists
are more likely to encourage compliance than
the dental Hygienists.
37
COMMUNICATION
■ A successful long- term maintenance program is based on a good communication.
This involves:
Informing the patients of
their current periodontal
status and any alterations in
treatment if indicated;
Consultation with other
health care providers who
will be providing additional
dental care or participating
in the supportive periodontal
treatment program.
Future planning
38
PARTS OF SPT Schallhorn RG, 1981
PREVENTIVE SPT
TRIAL SPT
COMPROMISE SPT
POSTTREATMENT
MAINTENANCE SPT
39
40
FREQUENCY AND EFFICACY
■ Numerous studies have shown that less attachment loss occurs,
and fewer teeth are lost when patients maintain regular SPT.
■ In gingivitis patients:
■ For most patients with gingivitis but no previous attachment
loss, SPT twice a year will suffice.
Lovdal et al (1961) - 2-4 times per year.
Suomi et al 1978 - every 3 months
Listgarten et al 1982 – every 6months
41
■ In Periodontitis patients
:….Study by Lindhe and Nyman
1984, periodontal prophylaxis was
provided to a group of 61 patients
with excellent oral hygiene, every
3-6 month over 14 years, without
significant recurrence of disease,
although some of them lost
significant amount of periodontal
support in some places.
 However, Nyman et al (1992) demonstrated that if
professional care were administered every 2nd week
for 2 years, periodontal support would be preserved
whereas patients in the control group receiving root
instrumentation every 6 months exhibited significant
additional loss of attachment.
 Lightner et al (1971) studied the effectiveness of
different frequencies for preventive treatment
showing that 4 prophylaxis per year and tooth
brushing instruction proved very effective in
retarding alveolar bone loss.
42
SPT IN DAILY PRACTICE
1. Examination, Re-evaluation and
Diagnosis (ERD)
2. Motivation, Reinstruction and
Instrumentation (MRI)
3. Treatment of Re-infected Sites (TRS)
4. Polishing of the entire Fluorides and
Determination of future SPT (PFD)
43
Examination, Re-evaluation and Diagnosis (ERD)
■ It includes updating the significant changes in their health status
■ Extraoral and intraoral soft and hard tissue examination
■ 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.
44
Checking of Plaque/Biofilm Control
To assess the effectiveness of their plaque control, patients should perform
their hygiene regimen immediately before the recall appointment.
Plaque/bioilm control must be reviewed and corrected until the patient
demonstrates the necessary proiciency, even if additional instruction sessions
are required.
45
RADIOGRAPHIC
EVALUATION
 Radiographic examination must
be individualized, depending
on the initial severity of the
case and the findings at the
recall visit .
 These are compared with
findings on previous
radiographs to check the bone
height and look for repair of
osseous defects, signs of
trauma from occlusion,
periapical pathologic changes,
and caries.
14 months after surgical therapy
2 years after surgery 7 years after surgery
46
OCCASIONALLY,
CONVENTIONAL
DENTAL
RADIOGRAPHS
INDICATED IN SPT
Bottomley et al, Finger et al
1990
47
Motivation, Reinstruction and Instrumentation (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 further
motivated.
■ The patient reinstructed in tooth brushing techniques which emphasize
vibratory rather than scrubbing movements.
48
Treatment of Reinfected Sites (TRS)
■ Single sites, especially furcation sites or sites with difficult access, may be
reinfected and demonstrate suppuration.
■ Such sites require a thorough instrumentation, the local application of antibiotics in
controlled release devices or even open debridement with surgical access which are
time-consuming to be performed during the routine recall hour, and hence, it may be
necessary to reschedule the patient for another appointment.
49
■ Generalized reinfections are usually the result of inadequate SPT.
■ 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.
■ The risk assessment on the tooth level may identify such niches
which are inaccessible for regular oral hygiene practices.
50
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.
■ Following polishing, fluorides is applied in high concentration in order to replace
the fluorides which is removed during instrumentation.
■ Fluoride or chlorhexidine varnishes may also be applied to prevent root surface
caries, especially in areas with gingival recessions.
51
Schallhorn &
Snider, 1981
52
CLASSIFICATION OF POSTTREATMENT PATIENTS
■ The first year after periodontal therapy is important in terms of assessing
the patient in a recall pattern and reinforcing oral hygiene techniques.
■ In addition, it may take several months to accurately evaluate the results of
some periodontal surgical procedures.
■ Consequently, some areas may have to be retreated because the results
may not be optimal.
53
■ Furthermore, the first-year patient often has etiologic factors that may
have been overlooked and may be more amenable to treatment at this
early stage.
■ For these reasons, the recall interval for first-year patients should not be
longer than 3 months.
54
55
56
 Any patient with periodontal
inflammation/infection and the following
systemic conditions:
D i a b e t e s
P r e g n a n c y
C a r d i o v a s c u l a r d i s e a s e
C h r o n i c r e s p i r a t o r y d i s e a s e
AAP 2005Referral to the periodontist
LEVEL 1: PATIENTS WHO MAY BENEFIT FROM COMANAGEMENT BY THE REFERRING
DENTIST AND THE PERIODONTIST
 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:
C a n c e r t h e r a p y
C a r d i o v a s c u l a r s u r g e r y
J o i n t - r e p l a c e m e n t s u r g e r y
O r g a n t r a n s p l a n t a t i o n
57
Any patient with periodontitis who
demonstrates at re evaluation or any dental
examination one or more of the following
risk factors/indicators* known to contribute
to the progression of periodontal diseases:
• Periodontal Risk Factors/Indicators 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
• A deteriorating risk profile
• Medical or Behavioral Risk
Factors/Indicators Smoking/tobacco use
Diabetes Osteoporosis/osteopenia Drug-
induced gingival conditions (e.g.,
phenytoins, calcium channel blockers,
immunosuppressants, and long-term
systemic steroids)
• Compromised immune system, either
acquired or drug induced
• A deteriorating risk profile
LEVEL 2: PATIENTS WHO WOULD LIKELY BENEFIT FROM COMANAGEMENT BY THE
REFERRING DENTIST AND THE PERIODONTIST
58
Any patient with:
• Severe chronic periodontitis Furcation involvement Vertical/angular
bony defect(s)
• Aggressive periodontitis (formerly known as juvenile, early-onset, or
rapidly progressive periodontitis)
• Periodontal abscess and other acute periodontal conditions
• Significant root surface exposure and/or progressive gingival
recession
• Peri-implant disease
• Any patient with periodontal diseases, regardless of severity, whom
the referring dentist prefers not to treat.
LEVEL 3: PATIENTS WHO SHOULD BE TREATED BY A PERIODONTIST
59
60
CONTENTSTO BE CONTINUED…
■ RISKASSESSMENTOF RECURRENCEOF DISEASE DURING SPT
■ MULTIFATORIAL RISK DIAGRAM
■ CALCULATINGTHE PATIENTS INDIVIDUAL PERIODONTAL RISKASSESSMENT
■ COMPLICATIONS DURING SPT
■ SPTWITHADJUNCT USEOF ANTIMICROBIALS
■ MAINTENANCECARE OF PATIENTSWITH DENTAL IMPLANTS
■ ROLE OF DENTAL PROFESSIONALAND PATIENT IN SPT
■ CONCLUSION
61
62
REFERENCES
■ Newman, takei, fermin a carranza. Clinical periodontology, 13th edition.
■ Jan lindhe. Clinical periodontology and implant dentistry, 5th edition, (2003),
blackwell munkgard publication.
■ Krishna kripal, kavita C, supportive periodontal therapy – maintenance to prevent
recurrence
■ Supportive periodontal treatment introduction - definition, extent of need,
therapeutic objectives, frequency and efficacv .Thomasg .W ilsonj,r ,
periodontology 2000, vol. 12, 1996, 11-15
■ Renvert S, persson GR. Supportive periodontal therapy. Periodontology 2000. 2004
oct;36(1):179-95.
■ Lang ,tonetti. Periodontal risk assessment (pra) for patients in supportive periodontal therapy
(spt). oralhealth& preventivedentisty 2003. 63
■ Renvert S, persson GR. Supportive periodontal therapy. Periodontology
2000. 2004 oct;36(1):179-95.
■ Bhardwaj et al. supportive periodontal therapy: need of the hour urjds
2017, 04 (06): page 1-7
■ Supportiveperiodontaltreatment.Periodontalliteraturereviews.1996
■ Manresa C, sanz‐miralles EC, twigg J, bravo M. Supportive periodontal
therapy (SPT) for maintaining the dentition in adults treated for
periodontitis. Cochrane database of systematic reviews. 2018(1).
■ Katta rc, chava vk, nagarakanti s. Supportive periodontal therapy-a
review. Annals & essences of dentistry. 2016 jan 1;8(1).
64
THANKYOU
65

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Supportive Periodontal Therapy Part 1

  • 1. SUPPORTIVE PERIODONTA L THERAPY DR. MANISHA SINHA II YR PG DEPT OF PERIODONTOLOGY 1 RAJARAJESWARI DENTAL COLLEGE AND HOSPITAL
  • 2. • PARTS OF SPT • FREQUENCY AND EFFICACY • MAINTENANCE RECALL PROCEDURES • CLASSIFICATION OF POST TREATMENT PATIENTS • REFERRAL TO THE PERIODONTIST TABLE OF CONTENTS ■ INTRODUCTION ■ DEFINITION ■ RATIONALE ■ SEQUENCE OF PERIODONTAL TREATMENT ■ RECURRENCE OF PERIODNTAL DISEASE ■ INDICATORS OF DISEASE RECURRENCE ■ GOALS OF SPT ■ COMPLIANCE ■ COMMUNICATION 2
  • 3. Supportive periodontal treatment is an integral part of periodontal therapy. These procedures are performed at selected intervals to assist the periodontal patient in maintaining oral health. INTRODUCTION AAP 1991 3
  • 4. Periodontal treatment includes: ■ Systemic evaluation of the patient’s health ■ A cause-related therapeutic phase with ■ A corrective phase involving periodontal surgical procedures ■ Maintenance phase 4
  • 5. DEFINITION • Continuous diagnostic monitoring of the patient in order to intercept with adequate therapy and to optimize the therapeutic interventions tailored to the patient’s need. (Lindhe) Periodontal maintenance, supportive periodontal care and recall The 3rd World Workshop of the American Academy of Periodontology(1989) renamed this maintenance phase as SUPPORTIVE PERIODONTAL THERAPY 5
  • 6. American Academy of Periodontology 1989 SUPPORTIVE PERIODONTAL THERAPY An update of the medical and dental histories Examination of extra and intraoral soft tissues, dental examination, Radiographic view Supra and subgingival removal of bacterial plaque and calculus Periodontal evaluation and risk assessment Evaluation of the patient’s oral hygiene performance Retreatment of disease when indicated AAP position paper in 2003 termed it as PERIODONTAL MAINTENANCE 6
  • 7. • SPT therefore offers an opportunity for clinicians to promote periodontal health, and rapidly detect and intercept recurrence or progression of periodontal disease (Heasman 2008; Ramfjord 1987). • Patient not returning for regular recall- 5.5 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. History Chace (1951)- maintenance of the treated periodontal patient should be carefully considered and a definite routine established. Chace (1967)- indicated that the general dentist who participates in the maintenance of periodontal patients assumes far greater responsibilities than he does in the care of average patient. Chace (1977) – suggested that the patients treated for periodontal disease may be susceptible to recurrent periodontitis. Schick (1981)- noted that a maintenance program should provide adequate therapy for previously existing periodontal conditions. Lang et al (1986) - evaluated BOP as a predictor for the progression of periodontal disease in 55 patients following treatment and at least 4 years of maintenance. 8
  • 9. ■ Gingivitis left untreated may lead to periodontitis. ■ This progression can be prevented or limited by 1. optimal personal oral hygiene. (Loe H et al 1965) 2. periodic maintenance care under the supervision of a dentist ( since patients rarely are completely effective in removing plaque accumulation) (Ramfjord SP et al 1982) EXTENT OF NEED 9
  • 10. Changes in subgingival microbiota (quantity and quality) Listgarten et al 1978 Why is that? Periodontal pathogenic microbiota will take several months to recolonize the pocket Listgarten et al 1978 Slots et al 1979 Caton et al 1982 Magnusson et al 1984 RATIONALE 10
  • 11. Why is that? Crucial role of SPT in maintaining successful results Patients treated for advanced periodontal disease involving surgery but not incorporated in SPT Rate of loss of attachment: 3x -5x higher than SPT Ramfjord et al 1968 Lindhe & Nyman 1975 Rosling et al 1976 Nyman et al 1977 Isidor & Karring 1986 Kaldahl et al 1988 11
  • 12. Waerhaug 1978 Cortellini 1994 INCOMPLETE subgingival plaque removal… bacteria are present in the gingival tissues in chronic and aggressive periodontitis. Eradication of intergingival microorganisms may be necessary for a stable periodontal result. Scaling , root planning and even flap surgery may not eliminate interginival bacteria in some areas. Bacteria associated with periodontitis can be transmitted between spouses and other family members. Patients who appear to be successfully treated can become infected or reinfected with potential pathogens. 12
  • 13. Treatment without SPT Periodontal Therapy SPT every 3 months  Stable results at 15 yrs (Nyman & Lindhe 1979)  Only 1.3% of the teeth had attachment loss (Hämmerle et al 2000) No SPT  Obvious signs of recurrent periodontitis  45% of patient returned to values similar to before treatment (Kerr 1981)  Increased probing depth  Increased furcation involvment  Increased tooth loss  Radiographic bone loss  Increased tooth loss (Becker et al 1984) 13
  • 14. Morrison et al 1979 14
  • 16. RECURRENCE OF PERIODONTAL DISEASE Occasionally, lesions may recur. This is often due to inadequate plaque control on the part of the patient or failure to comply with recommended SPT schedules. However, it is the dentist’s responsibility to teach, motivate and control the patient’s oral hygiene technique, and the patient’s failure is the dentist’s failure. Surgery should not be undertaken unless the patient has shown proficiency and willingness to cooperate by adequately performing his or her part of therapy.16
  • 17. Other causes for recurrence are the following Failure of the patient to return for periodic checkups Inadequate or insufficient treatment that has failed to remove all the potential factors favouring plaque accumulation Presence of some systemic diseases that may affect host resistance to previously acceptable levels of plaque Inadequate restorations placed after the periodontal treatment was completed. 17
  • 18. Recurring inflammation revelaed by gingival changes and bleeding of the sulcus on probing. Increasing depth of sulci, leading to the recurrence of pocket formation Gradual increase in bone loss as determined by radiographs Gradual increase in tooth mobility as ascertained by clinical examination. A failing case can be recognized by 18
  • 19. Oral hygiene Wilson et al 1993 Over zealous hygiene Indicators for disease recurrence 19
  • 20. BOP > 20%-30% higher risk for disease progression BOP <10% low risk for disease progression Non bleeding site may be considered periodontally stable Bleeding on probing Lang et al 1990 Claffey et al 1990 Badersten et al 1990 Lang et al 1990 20
  • 21. Suppuration linked to disease progression Suppuration Badersten et al 1985 Badersten et al 1990 Claffey et al 1990 21
  • 22. Residual pockets Deep residual pockets and deepening pockets associated with disease recurrence Claffey et al 1990 Badersten et al 1990 22
  • 23. Tooth loss If >8 teeth are lost, oral function is impaired Tooth loss represent the history of periodontal disease and trauma Käyser 1981 23
  • 24. Bone loss  Dentition may be functional even in presence of a reduce periodontal support Papapanou et al 1988 24
  • 25. Systemic conditions  Diabetes type I and type II-  Interleukin-1 polymorphisms  Smoking Ismail et al 1983 Bergström 1989 Haber 1993 Genco & Löe 1993 Kornman et al 1997 McGuire & Nunn 1999 25
  • 27. 27
  • 28. GOALS OF SPT ■ The American Academy of Periodontology more specifically lists 3 main goals of SPT: TO PREVENT OR MINIMIZETHE RCURRENCE AND PROGRESSION OF PERIODONTAL DISEASE IN PATIENTSWHO HAVE BEEN PREVIOUSLYTREATED FOR GINGIVITIS, PERIODONTITIS, AND PERI-IMPLANTITIS. TO PREVENT OR REDUCETHE INCIDENCE OFTOOTH LOSS BY MONITORINGTHE DENTITION AND ANY PROSTHETIC REPLACEMENT OF NATURAL TEETH. TO INCREASETHE PROBABILITY OF LOACTING ANDTREATING IN ATIMELY MANNER, OTHER DISEASE OR CONDITIONS FOUND WITHINTHE ORAL CAVITY. 28
  • 29. Objectives Preservation of alveolar bone support (radiographically). Maintenance of stable, clinical attachment level. Reinforcement and re-evaluation of proper home care. Maintenance of a healthy and functional oral environment to prevent occurrence of new disease. 29
  • 30. COMPLIANCE  Compliance (also called adherence and therapeutic alliance) has been defined as “the extent to which a person’s behavior coincides with medical or health advice”. Compliance can be measured directly – the patients either come in, or they do not. the patients who clean their teeth will lose less periodontal support than those who do not . It is also possible to measure home care efficiency and efficacy The relevant questions are then, do patients clean as they are asked, and do they come in for supportive periodontal treatment? 30
  • 31. Types of compliance 1. Non compliance 2. Erratic compliance 3. Complete compliance 31
  • 32. Compliance and its role in periodontal therapy 32
  • 33. WHY DO PATIENTS FAILTO COMPLY? Self- destructive behaviours Fear of dental treatment Economic factors Health beliefs Stressful events in their lives 33
  • 34. Simplify the simpler the required behavior, the more likely it is to be carried out. Accommodate The more your practice and your suggestions fit the patients’ needs, the more likely they are to comply. Possible methods of improving Compliance 34
  • 35. Remind patients of appointments Failed appointments create problems for both the patient and the dentist. Keep records of compliance Patients can “get lost in the system”, and efforts should be made to keep up with them. 35
  • 36. Inform Put what you say in writing and give a copy to the patient. Provide positive reinforcement Most patients do better when positive feedback is given when compared with a more negative approach to their compliance problem. 36
  • 37. Identify potential noncompliers If there is suspicion that compliance will be absent or erratic, discuss the problems this may create for the patient before therapy begins. Ensure the dentist’s involvement There is evidence that, in some cases, dentists are more likely to encourage compliance than the dental Hygienists. 37
  • 38. COMMUNICATION ■ A successful long- term maintenance program is based on a good communication. This involves: Informing the patients of their current periodontal status and any alterations in treatment if indicated; Consultation with other health care providers who will be providing additional dental care or participating in the supportive periodontal treatment program. Future planning 38
  • 39. PARTS OF SPT Schallhorn RG, 1981 PREVENTIVE SPT TRIAL SPT COMPROMISE SPT POSTTREATMENT MAINTENANCE SPT 39
  • 40. 40
  • 41. FREQUENCY AND EFFICACY ■ Numerous studies have shown that less attachment loss occurs, and fewer teeth are lost when patients maintain regular SPT. ■ In gingivitis patients: ■ For most patients with gingivitis but no previous attachment loss, SPT twice a year will suffice. Lovdal et al (1961) - 2-4 times per year. Suomi et al 1978 - every 3 months Listgarten et al 1982 – every 6months 41
  • 42. ■ In Periodontitis patients :….Study by Lindhe and Nyman 1984, periodontal prophylaxis was provided to a group of 61 patients with excellent oral hygiene, every 3-6 month over 14 years, without significant recurrence of disease, although some of them lost significant amount of periodontal support in some places.  However, Nyman et al (1992) demonstrated that if professional care were administered every 2nd week for 2 years, periodontal support would be preserved whereas patients in the control group receiving root instrumentation every 6 months exhibited significant additional loss of attachment.  Lightner et al (1971) studied the effectiveness of different frequencies for preventive treatment showing that 4 prophylaxis per year and tooth brushing instruction proved very effective in retarding alveolar bone loss. 42
  • 43. SPT IN DAILY PRACTICE 1. Examination, Re-evaluation and Diagnosis (ERD) 2. Motivation, Reinstruction and Instrumentation (MRI) 3. Treatment of Re-infected Sites (TRS) 4. Polishing of the entire Fluorides and Determination of future SPT (PFD) 43
  • 44. Examination, Re-evaluation and Diagnosis (ERD) ■ It includes updating the significant changes in their health status ■ Extraoral and intraoral soft and hard tissue examination ■ 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. 44
  • 45. Checking of Plaque/Biofilm Control To assess the effectiveness of their plaque control, patients should perform their hygiene regimen immediately before the recall appointment. Plaque/bioilm control must be reviewed and corrected until the patient demonstrates the necessary proiciency, even if additional instruction sessions are required. 45
  • 46. RADIOGRAPHIC EVALUATION  Radiographic examination must be individualized, depending on the initial severity of the case and the findings at the recall visit .  These are compared with findings on previous radiographs to check the bone height and look for repair of osseous defects, signs of trauma from occlusion, periapical pathologic changes, and caries. 14 months after surgical therapy 2 years after surgery 7 years after surgery 46
  • 48. Motivation, Reinstruction and Instrumentation (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 further motivated. ■ The patient reinstructed in tooth brushing techniques which emphasize vibratory rather than scrubbing movements. 48
  • 49. Treatment of Reinfected Sites (TRS) ■ Single sites, especially furcation sites or sites with difficult access, may be reinfected and demonstrate suppuration. ■ Such sites require a thorough instrumentation, the local application of antibiotics in controlled release devices or even open debridement with surgical access which are time-consuming to be performed during the routine recall hour, and hence, it may be necessary to reschedule the patient for another appointment. 49
  • 50. ■ Generalized reinfections are usually the result of inadequate SPT. ■ 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. ■ The risk assessment on the tooth level may identify such niches which are inaccessible for regular oral hygiene practices. 50
  • 51. 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. ■ Following polishing, fluorides is applied in high concentration in order to replace the fluorides which is removed during instrumentation. ■ Fluoride or chlorhexidine varnishes may also be applied to prevent root surface caries, especially in areas with gingival recessions. 51
  • 53. CLASSIFICATION OF POSTTREATMENT PATIENTS ■ The first year after periodontal therapy is important in terms of assessing the patient in a recall pattern and reinforcing oral hygiene techniques. ■ In addition, it may take several months to accurately evaluate the results of some periodontal surgical procedures. ■ Consequently, some areas may have to be retreated because the results may not be optimal. 53
  • 54. ■ Furthermore, the first-year patient often has etiologic factors that may have been overlooked and may be more amenable to treatment at this early stage. ■ For these reasons, the recall interval for first-year patients should not be longer than 3 months. 54
  • 55. 55
  • 56. 56
  • 57.  Any patient with periodontal inflammation/infection and the following systemic conditions: D i a b e t e s P r e g n a n c y C a r d i o v a s c u l a r d i s e a s e C h r o n i c r e s p i r a t o r y d i s e a s e AAP 2005Referral to the periodontist LEVEL 1: PATIENTS WHO MAY BENEFIT FROM COMANAGEMENT BY THE REFERRING DENTIST AND THE PERIODONTIST  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: C a n c e r t h e r a p y C a r d i o v a s c u l a r s u r g e r y J o i n t - r e p l a c e m e n t s u r g e r y O r g a n t r a n s p l a n t a t i o n 57
  • 58. Any patient with periodontitis who demonstrates at re evaluation or any dental examination one or more of the following risk factors/indicators* known to contribute to the progression of periodontal diseases: • Periodontal Risk Factors/Indicators 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 • A deteriorating risk profile • Medical or Behavioral Risk Factors/Indicators Smoking/tobacco use Diabetes Osteoporosis/osteopenia Drug- induced gingival conditions (e.g., phenytoins, calcium channel blockers, immunosuppressants, and long-term systemic steroids) • Compromised immune system, either acquired or drug induced • A deteriorating risk profile LEVEL 2: PATIENTS WHO WOULD LIKELY BENEFIT FROM COMANAGEMENT BY THE REFERRING DENTIST AND THE PERIODONTIST 58
  • 59. Any patient with: • Severe chronic periodontitis Furcation involvement Vertical/angular bony defect(s) • Aggressive periodontitis (formerly known as juvenile, early-onset, or rapidly progressive periodontitis) • Periodontal abscess and other acute periodontal conditions • Significant root surface exposure and/or progressive gingival recession • Peri-implant disease • Any patient with periodontal diseases, regardless of severity, whom the referring dentist prefers not to treat. LEVEL 3: PATIENTS WHO SHOULD BE TREATED BY A PERIODONTIST 59
  • 60. 60
  • 61. CONTENTSTO BE CONTINUED… ■ RISKASSESSMENTOF RECURRENCEOF DISEASE DURING SPT ■ MULTIFATORIAL RISK DIAGRAM ■ CALCULATINGTHE PATIENTS INDIVIDUAL PERIODONTAL RISKASSESSMENT ■ COMPLICATIONS DURING SPT ■ SPTWITHADJUNCT USEOF ANTIMICROBIALS ■ MAINTENANCECARE OF PATIENTSWITH DENTAL IMPLANTS ■ ROLE OF DENTAL PROFESSIONALAND PATIENT IN SPT ■ CONCLUSION 61
  • 62. 62
  • 63. REFERENCES ■ Newman, takei, fermin a carranza. Clinical periodontology, 13th edition. ■ Jan lindhe. Clinical periodontology and implant dentistry, 5th edition, (2003), blackwell munkgard publication. ■ Krishna kripal, kavita C, supportive periodontal therapy – maintenance to prevent recurrence ■ Supportive periodontal treatment introduction - definition, extent of need, therapeutic objectives, frequency and efficacv .Thomasg .W ilsonj,r , periodontology 2000, vol. 12, 1996, 11-15 ■ Renvert S, persson GR. Supportive periodontal therapy. Periodontology 2000. 2004 oct;36(1):179-95. ■ Lang ,tonetti. Periodontal risk assessment (pra) for patients in supportive periodontal therapy (spt). oralhealth& preventivedentisty 2003. 63
  • 64. ■ Renvert S, persson GR. Supportive periodontal therapy. Periodontology 2000. 2004 oct;36(1):179-95. ■ Bhardwaj et al. supportive periodontal therapy: need of the hour urjds 2017, 04 (06): page 1-7 ■ Supportiveperiodontaltreatment.Periodontalliteraturereviews.1996 ■ Manresa C, sanz‐miralles EC, twigg J, bravo M. Supportive periodontal therapy (SPT) for maintaining the dentition in adults treated for periodontitis. Cochrane database of systematic reviews. 2018(1). ■ Katta rc, chava vk, nagarakanti s. Supportive periodontal therapy-a review. Annals & essences of dentistry. 2016 jan 1;8(1). 64

Hinweis der Redaktion

  1. From a periodontal persepective, success would mean the long term goal of preservation of teeth following periodontal therapy as against the short lived goal of elimination of disease. Preservation of the periodontal health of the treated patient requires as much a positiveprogram as that required for the elimination of periodontal disease. Supportive periodontal treatment is usually started after completion of active periodontal therapy and continues at varying intervals for the life of the dentition or its implant replacements. The patient may move back into active care if the disease undergoes a period of exacerbation.
  2. The goal of periodontal treatment is to maintain the natural dentition in functional health and comfort throughout the life time
  3. Different terms- periodontal maintenance, supportive periodontal care and recall have been used.
  4. AAP RECOMMENDS
  5. DECREASE IN MOTILE RODS FOR 1 WEEK MARKED ELEVATION IN COCCOID CELLS FOR 21 DAYS MARKED INCREASE IN SPIROCHETES FOR 7 WEKS RETURN OF PATHOGENS TO PRETREATMENT LEVELS- 9-11 WEEKS SUBGINGIVAL SCALING ALTERS THE POCKET MICROFLORA FOR VARIABLE BUT RELATIVELY LONG PERIODS
  6. Axelsson & Lindhe 1981
  7. Fig. 59-1 (a) Mean probing depth reduction (+) or increase in probing depth (−) in millimeters with or without repeated scaling and root planing in experimental (oral hygiene) and control (no oral hygiene) animals relative to baseline means. (Data from Morrison et al. 1979.)
  8. The maintenance phase of periodontal treatment starts immediately after the completion of phase I therapy (see Figs. 72.1 and 72.2). 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.
  9. Recurring inflammation revelaed by gingival changes and bleeding of the sulcus on probing. Increasing depth of sulci, leading to the recurrence of pocket formation Gradual increase in bone loss as determined by radiographs Gradual increase in tooth mobility as ascertained by clinical examination.
  10. THERAPEUTIC GOALS
  11. The objectives of SPT are to prevent the occurrence of new disease and prevent the recurrence of previous disease.
  12. It is also possible to measure home care efficiency (by examining for bacterial plaque) and efficacy (by detecting bleeding upon probing, increased probing depth or attachment loss). When patients comply with suggested supportive periodontal treatment schedules, the vast majority keep their teeth over long periods of time (23, 84, 101).
  13. Patient does not comply at all. Patient complies occasionally Patient complies 75% of the time.
  14. This section addresses the questions: Do patients comply? If not, what are the consequences of noncompliance? The first study on the degree of compliance with supportive periodontal treatment schedules was published in 1984 (102). It reviewed all the patients whose progress could be followed after treatment for periodontitis in a private periodontal office (102). Of the approximately 1000 patients followed for up to 8 years, only 16% complied with suggested supportive periodontal treatment intervals, 34% never came back for maintenance, and the rest complied erratically. Two follow-up studies were done, the first on this same group, who could be followed for at least 5 years. These patients were surveyed for tooth loss (101). It was found that 14% of the erratic compliers lost teeth versus none by the complete compliers (noncompliers were not included in this study). In general, the better the compliance, the fewer teeth were lost. This is a tooth loss frequency of zero teeth per year for complete compliers and 0.06 teeth per patient per year for erratic compliers. These figures compare favorably with those of another report (13) that showed 0.6 teeth per year per patient lost in untreated, unmaintained patients in another private periodontal practice. The 1984 study has been repeated and its results confirmed in other widely separated private practices of periodontics
  15. 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.
  16. Satisfied patients tend to comply with more of the recommended therapy than dissatisfied patients.
  17. Remind patients of appointments - Patients break appointments for various reasons. Communication is a key element along with the absence of perceived need for the visit and the absence of a designated dental therapist who will treat the patient . Other factors that may contribute are age, race, psychosocial problems and the percentage of previous noncancelled appointments (52). Many of the studies on failed appointments have been done in hospital settings with groups of lower socioeconomic status and may not be applicable to all private practice settings (8, 90, 93). Appropriate vehicles for appointment reminders include postcards and telephone contact. Keep records of compliance- . This often requires advanced systems, and a computer for appointment control and tracking missed visits. Communication with the patient should be initiated as quickly as possible when noncompliant behavior is noted. The sooner the patient is contacted after missing the appointment, the more likely they are to keep their new appointment.
  18. inform- This and other exercises of the dentist’s authority have been recommended as useful in reducing noncompliance (19). Telling the patient the causes of the disease process and their role in its treatment, improves compliance. In addition, find out what the patients’ goals are for their teeth and then show them how they may achieve their goals only if they participate in the management of the disease. Provide positive reinforcement- No one enjoys criticism, but positive reinforcement and constructive guidance can be helpful.
  19. Identify potential noncompliers- Then track these patients closely. Ensure the dentist’s involvement- . Noncompliance decreased by 50% when these general approaches were applied to a private periodontal practice over a 5-year period
  20. Preservation of the periodontal health of the treated patient requires as positive a program as that required for the elimination of periodontal disease. After Phase I therapy is completed, patients are placed on a schedule of periodic recall visits for maintenance care to prevent recurrence of the disease. There are 4 parts of SPT namely: 1. Preventive SPT 2. Trial SPT 3. Compromise SPT 4. Post treatment SPT
  21. Preventive SPT: Intended to prevent inception of disease in those who currently do not have periodontal pathology (eg, patients at high risk for development of periodontal or peri-implant problems because of systemic disease or dexterity problems that prevent practicing hygiene). Trial SPT : designed to maintain border line periodontal conditions over a period to further assess the need for corrective therapy for problems such as – - inadequate attached gingiva, - gingival architectural defects, or - furcation defects, while maintaining periodo throughout the balance of the mouth. • Compromise SPT: designed to slow the progression of disease in patients for whom periodontal corrective therapy is indicated, but cannot be implemented for reasons of health, economics, inadequate oral hygiene, or other considerations, or when recalcitrant defects persist after corrective treatment. This type also includes situations in which periodontal or peri-implant defects persist after corrective therapy attempts (eg: patients with moderate chronic periodontitis or periimplantitis who cannot undergo treatment because of current gastric cancer treatment)8. • Post treatment SPT: designated to prevent the recurrence of disease and maintain the periodontal health achieved during therapy.Transfer of the patient from active treatment status to a maintenance program is a definitive step in total patient care that requires time and effort on the part of the dentist and staff. Patients must understand the purpose of the maintenance program, and the dentist must emphasize that preservation of the teeth depends on maintenance therapy. Patients who are not maintained in a supervised recall program subsequent to active treatment show obvious signs of recurrent periodontitis (e.g., increased pocket depth, bone tooth loss
  22. Numerous studies have shown that less attachment loss occurs, and fewer teeth are lost when patients maintain regular SPT. In gingivitis patients: For most patients with gingivitis but no previous attachment loss, SPT twice a year will suffice. Lovdal et al (1961)- 2-4 times per year Suomi et al 1978- every 3 months Listgarten et al 1982- every 6 months
  23. SUOMI jd 1971- The recall hour should be planned to meet the patient’s individual needs. It basically consists of four different sections which may require various amounts of time during a regularly scheduled visit:
  24. Updating of changes in the medical history and evaluation of restorations, caries, prostheses, occlusion, tooth mobility, gingival status, and periodontal and periimplant probing depths are important parts of the recall appointment. The oral mucosa should be carefully inspected for pathologic Conditions. Radiographic examination must be individualized,22 depending on the initial severity of the case and the indings during the recall visit. These are compared with indings on previous radiographs to check the bone height and look for repair of osseous defects, signs of trauma from occlusion, periapical pathologic changes, and caries.
  25. A motivational interviewing technique of teaching may help to produce positive results. Patients instructed in plaque/bioilm control have less bioilm and gingivitis than uninstructed patients, and because the amount of supragingival plaque/bioilm is less, there is a decrease in the number of subgingival anaerobic organisms.
  26. Since it is impossible to instrument all the tooth sites in the time allocated, only those sites are reinstrumented during SPT visits which exhibit signs of inflammation and/or active disease progression. Root surface instrumentation is aimed at the removal of sub- gingival plaque/calculus
  27. Following consultation, examination, consultation, and oral hygiene instruction, the required scaling and root planing are performedCare must be taken not to instrument healthy sites with shallow sulci (1 to 3 mm deep) and an absence of gingival inflammation because studies have indicated that repeated subgingivalscaling and root planing of sites not periodontally involved result in signiicant loss of attachment and gingival recession, which willaffect aesthetics.29 Irrigation with antimicrobial agents or placementof site-speciic antimicrobial devices may be performed in maintenance patients with remaining pockets
  28. Periodic recall visits form the foundation of a meaningful long-term prevention program. The interval between visits is initially set at 3 months but may vary according to the patient’s needs.5,20,26,27 Periodontal care at each recall visit comprises three parts (Box 72.1). The irst part involves examination and evaluation of the patient’s current oral health. The second part includes the necessary maintenance treatment and oral hygiene reinforcement. The third part involves scheduling the patient for the next recall appointment, additional periodontal treatment, or restorative dental procedures. The time required for a recall visit for patients with multiple teeth in both arches is approximately 1 hour.
  29. Should the maintenance phase of therapy be performed by the general practitioner or the specialist? This should be determined by the extent and severity of periodontal disease present. General dentists must know when co-management with a periodontist is indicated. Specialists are needed to treat dificult periodontal cases, patients with systemic health problems, dental implant patients, and those with a complex prosthetic construction that requires predictable results.
  30. Scheme for determining which practitioner should perform periodontal maintenance in patients with different degrees of periodontitis. Class A recall patients should be maintained by the general dentist, whereas class C patients should be maintained by the specialist (see Table 72.3). Class B patients can alternate recall visits between the general practitioner and the specialist (Fig. 72.11). The suggested rule to decide who should maintain the recall therapy is determined by the initial category of the patient’s disease and the result of the therapy. Patients with moderate to severe initial bone loss, advanced grades 2 or 3 furcation invasions, or pockets that could not be completely eradicated are those who should be seen by the periodontist. The specialist and the general dentist must work together, respect the other’s knowledge and skills, and decide on a maintenance schedule that is in the best interest of the patient.