Supportive Periodontal Treatment (SPT) - an importanr prospective in periodontal treatment

1. Good
Afternoon…

2. SUPPORTIVE
PERIODONTAL TREATMENT
By
Suhasis Mondal
Internee
Dr. R. Ahmed Dental
College & Hospital

3. Periodontal Treatment Plan
 The purpose of the periodontal treatment plan is to
organize an approach to provide comprehensive
treatment based on the patients’ oral, dental &
periodontal needs.
Short –term goals
Elimination of all infectious &
inflammatory process that
cause periodontal & other
oral problems that may
hinder the patients’ general
health.
Long –term goals
Reconstruction of a healthy
dentition that fulfills all
functional & esthetic
requirements.

4. Phases of Periodontal Treatment
Preliminary
phase
(Treatment of
emergencies)
• Dental or
periapical
• Periodontal
• Other
Phase I
(Non- surgical)
• Diet counseling
• Removal of
plaque retentive
factors
• Excavation of
caries &
restoration
• Supragingival
scaling
• Subgingival
scaling
• Root planing
• Occlusal therapy
• Minor orthodontic
movement
• Antimicrobial
therapy.
Phase II
(Surgical)
• Periodontal
surgery
including
placement of
implants
• Endodontic
therapy
Phase III
(Restorative)
• Final
restoration
• FPD
• RPD
Phase IV
(Maintenance)
• Periodic
rechecking
• Plaque &
calculus indices
• Gingival
condition
• Attachment
level
• Pocket depth
• Bleeding on
probing
• Recession
Evaluation Evaluation Evaluation

6. Preferred sequence for periodontal
treatment plan
The 3rd World Workshop of
the American Academy
of Periodontology (1989)
renamed this treatment
phase “Supportive
Periodontal Therapy” (SPT).

7. What is SPT?
 SPT = Supportive Periodontal Treatment
Also known as
 Periodontal Maintenance Therapy
 Preventive Maintenance
 Recall Maintenance
 Procedures performed at selected intervals to assist
the periodontal patient in maintaining oral health.

8. Introduction of SPT
This term expresses the essential need for therapeutic measures to
support the patient’s own efforts to control periodontal infections
and to avoid reinfection.
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.

9. Basic paradigms for the prevention
of periodontal diseases
Periodontal maintenance care, or SPT,
follows the paradigms of the etiology and
pathogenesis of periodontal disease
Almost 45years ago, a cause–effect
relationship between the accumulation of
bacterial plaque on teeth and the
development of gingivitis was proven
(Löe et al. 1965).
This relationship was also documented by
the restoration of gingival health following
plaque removal.

10. Cont..
Ten years later, a corresponding relationship between
plaque accumulation and the development of
periodontal disease, characterized by;
-loss of connective tissue attachment and resorption
of alveolar bone, was shown in laboratory animals
(Lindhe et al. 1975).
Since some of these animals did not
develop periodontal disease despite a
persistent plaque accumulation for 48
months,

11. It must be considered that the; composition of the microbiota or
the host’s defense mechanisms or susceptibility for disease may
vary from individual to individual.
Nevertheless, in the study mentioned, the initiation of periodontal
disease was always preceded by obvious signs of gingivitis.
Hence, it seems reasonable to predict that the elimination of
gingival inflammation and the maintenance of healthy gingival
tissues will result in the prevention of both the initiation and the
recurrence of periodontal disease

12. In fact, as early as 1746, Fauchard stated that “little or no care as
to the cleaning of teeth is ordinarily the cause of all diseases
that destroy them” .
• From the clinical point of view,
the mentioned results must be translated into the necessity for
proper and regular personal plaque elimination, at least in
patients treated for or susceptible to periodontal disease.
This simple principle may be difficult to implement in all patients.

13. Interceptive professional supportive therapy at regular intervals may, to a certain
extent, compensate for the lack of personal compliance with regard to oral
hygiene standards.
The etiology of gingivitis and periodontitis is fairly well understood.
However, the causative factors, i.e. the microbial challenge which induces and
maintains the inflammatory response, may not be completely eliminated from
the dentogingival environment for any length of time.
This requires the professional removal of all microbial deposits in the
supragingival and subgingival areas at regular intervals.

14. Rationale
A. Recurrence
incomplete subgingival plaque removal
presence of bacteria in the gingival tissues in
chronic and aggressive periodontitis cases
microscopic nature of the dentogingival
unit healing after periodontal treatment

15. Long junctional epithelium
o Weak
o inflammation may rapidly
separate
Bacteria may recolonize the pocket and
cause recurrent disease

18. Subgingival scaling alters the pocket microflora
for variable but relatively long periods.
 Decrease in the proportion of motile rods for 1
week
 Marked elevation in the proportion of coccoid
cell for 21 days
 Marked reduction in the proportion of
spirochetes for 7 weeks
The return of pathogens to pretreatment levels -
--- 9-11 weeks

19. 3 months maintenance interval
 prevent recurrence
 base on microscopic monitoring of
subgingival flora
At present there is no definitive periodontal
treatment that can cure the disease.

20. Maintenance Program
Examination & Evaluation
Change form last evaluation
Evaluation of caries, restoration
Occlusion
Prosthesis
Tooth mobility
Gingival status
Periodontal & periimplant probing depth
Radiographic examination

21. Patient Condition/ Situation Type of Radiographic
Examination
Clinical caries or high risk factor for caries Posterior bite-wing examination at 12-18
months interval
Clinical caries and no high risk factor for caries Posterior bite-wing examination at 24-36
months interval
Periodontal disease not under good control Periapical and/or vertical bite wing
radiographs of problem areas every 12-14
months; full mouth series every 3-5 years.
History of periodontal treatment with disease
under good control
Bite wing examinations every 24-36 months;
full mouth series every 5 years.
Root form dental implants Periapical/vertical bite wing radiographs at 6,
12 & 36 months after prosthetic replacement,
then every 36 months unless clinical problem
arise.
Transfer of periodontal or implant
maintenance patients
Full mouth series including including implant
& periodontal problem areas should be taken.

22. Pic. A – The patient was
advised to have localized
areas of periodontal surgery
& periodontal recall every 3
months
Pic. B – Radiographs 4 years
later showing several bone
loss of premolars & molars

23. A – Pretreatment
B – 1yr. Post-treatment
C - 3 yr. post-treatment
D - 7 yr. post-treatment
Pic. A, B, C, D
showing a patient
treated with
surgical therapy
including bone
grafting with
poor maintenance

24. Patient with limited periodontal therapy & poor maintenance

25.  v

26. Checking of plaque control
 Patient should perform their hygiene regimen
immediately before the recall appointment.
 Plaque control must be reviewed and corrected
until the patient demonstrates the necessary
proficiency.
 Amount of supragingival plaque affects the
number of subgingival anaerobic organism.

27. Treatment
 Scaling and root planing.
 Oral prophylaxis
 Instrumentation should not be done at
normal site (shallow sulci – 1-3 mm deep)
 Irrigation with antimicrobial agents.

28. Maintenance of Recall Procedures
EXAMINATION (14 MINUTES)
• Patient greeting
• Medical history
changes
• Oral pathologic
examination
• Oral hygiene
status
• Gingival
changes
• Pocket depth
changes
• Mobility
changes
• Occlusal
changes
• Caries
• Restorative,
prosthetic &
implant status.
Treatment (36 minutes)
• Oral hygiene
reinforcement
• Scaling
• Polishing
• Chemical
irrigation or site
specific
antimicrobial
placement
Report, Clean-up & scheduling ( 10 mins.)
• Write report in
chart.
• Discuss report
with patient
• Clean &
disinfect
operatory.
• Schedule next
recall visit.
• Schedule
further
periodontal
treatment.
• Schedule or
refer for further
restorative or
prosthetic
treatment.

31. Subject risk assessment
 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.
 For this purpose, a functional diagram has been
constructed including the following aspects:

32. 1. Percentage of bleeding on probing
2. Prevalence of residual pockets greater than 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
6. Environmental factors such as cigarette
smoking.

38. Compliance with recall system
 Several investigations have indicated that only a
minority of periodontal patients comply with the
prescribed supportive periodontal care
 treated periodontal patients who comply with
regular periodontal maintenance appointments
have a better prognosis than patients who do
not comply.
 non-compliant or poorly compliant patients
should be considered at higher risk for
periodontal disease progression.

40. Oral hygiene
 Since bacterial plaque is by far the most
important etiologic agent for the occurrence of
periodontal diseases, it is evident that the full-mouth
assessment of the bacterial load must
have a pivotal impact in the determination of the
risk for disease recurrence.
 It has to be realized, however, that regular
interference with the microbial ecosystem
during periodontal maintenance will eventually
obscure such obvious associations.

42. Percentage of sites with
bleeding on probing
 Bleeding on gentle probing represents an
objective inflammatory parameter which has
been incorporated into index systems for the
evaluation of periodontal conditions and is also
used as a parameter by itself.
 In a patient’s risk assessment for recurrence of
periodontitis, bleeding on probing (BOP)
reflects, at least in part, the patient’s compliance
and standards of oral hygiene performance.

44. Prevalence of residual pockets
greater than 4 mm
 The enumeration of the residual pockets with probing
depths greater than 4 mm represents, to a certain extent,
the degree of success of periodontal treatment rendered.
 Although this figure per se does not make much sense when
considered as a sole parameter, the evaluation in
conjunction with other parameters, such as BOP and/or
suppuration, will reflect existing ecologic niches from and
in which reinfection might occur.
 therefore, periodontal stability in a dentition would be
reflected in a minimal number of residual pockets.

45. Cont…
 it has to be realized that an increased number
of residual pockets does not necessarily imply
an increased risk for reinfection or disease
progression, since a number of longitudinal
studies have established the fact that,
depending on the individual supportive
therapy provided, even deeper pockets may
be stable without further disease
progression for years (Knowles et al. 1979;
Lindhe & Nyman 1984).

46. Cont…
 in assessing the patient’s risk for disease progression, the
number of residual pockets with a probing depth of ≥5
mm is assessed as the second risk indicator for recurrent
disease in the functional diagram of risk assessment.
 Individuals with up to 4 residual pockets may be regarded
as patients with a relatively low risk, while patients with
more than 8 residual pockets may be regarded as
individuals with high risk for recurrent disease.

48. Loss of teeth from a total of 28
teeth
 Although the reason for tooth loss may not be
known, the number of remaining teeth in a
dentition reflects the functionality of the
dentition.
 Mandibular stability and individual optimal
function may be assured even with a shortened
dental arch of premolar to premolar occlusion,
i.e. 20 teeth.
 if more than eight teeth from a total of 28 teeth
are lost, oral function is usually impaired (Käyser
1981, 1994, 1996).

49. Cont…
 The number of teeth lost from the dentition
without the third molars (28 teeth) is
counted, irrespective of their replacement.
 The scale runs also in a linear mode with 2, 4,
6, 8, 10, and ≥12% being the divisions on the
vector.
 Individuals with up to four teeth lost may be
regarded as patients in low risk, while
patients with more than eight teeth lost may
be considered as being in high risk.

51. Loss of periodontal support in
relation to the patient’s age
 The extent and prevalence of periodontal
attachment loss (i.e. previous disease experience
and susceptibility), as evaluated by the height of the
alveolar bone on radiographs, may represent the
most obvious indicator of subject risk when related
to the patient’s age.
 The estimation of the loss of alveolar bone is
performed in the posterior region on either
periapical radiographs, in which the worst site
affected is estimated gross as a percentage of the
root length, or on bite-wing radiographs in which the
worst site affected is estimated in millimeters.

53. Cont…
 One millimeter is equated with 10% bone loss.
 The percentage is then divided by the patient’s age.
This results in a factor.
 example, a 40-year-old patient with 20% of bone
loss at the worst posterior site affected would be
scored BL/Age = 0.5. Another 40-year-old patient
with 50% bone loss at the worst posterior site scores
BL/Age =1.25.
 In assessing the patient’s risk for disease
progression, the extent of alveolar bone loss in
relation to the patient’s age is estimated as the
fourth risk indicator for recurrent disease in the
functional diagram of risk assessment.

54. Cont…
 The scale runs in increments of 0.25 of the
factor BL/Age, with 0.5 being the division
between low and moderate risk and 1.0 being
the division between moderate and high risk
for disease progression.
 This, in turn, means that a patient who has
lost a higher percentage of posterior alveolar
bone than his/her own age is at high risk
regarding this vector in a multi-factorial
assessment of risk.

56. Calculating the patient’s individual
periodontal risk assessment (PRA)
 Based on the six parameters specified previously,
a multifunctional diagram is constructed for the
PRA.
 In this diagram, the vectors have been
constructed on the basis of the scientific
evidence available.
 It is obvious that ongoing validation may result
in slight modifications.
 A low periodontal risk (PR) patient has all
parameters within the low-risk categories or at
the most one parameter in the moderate-risk
category.

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

58. Summary
 The subject risk assessment may estimate the risk for
susceptibility for progression of periodontal disease.
 It consists of an
 assessment of the level of infection (full-mouth
bleeding scores),
 the prevalence of residual periodontal pockets,
 tooth loss,
 loss of periodontal support in relation to the patient’s
age,
 an evaluation of the systemic conditions of the
patient, and finally,
 evaluation of environmental and behavioral factors
such as smoking and stress.

59. Summary cont…
 All these factors should be contemplated and
evaluated together.
 A functional diagram may help the clinician
in determining the risk for disease
progression on the subject level.
 This may be useful in customizing the
frequency and content of SPT visits.

60. Recall intervals for various classes of
recall patient
Merin
Classification
Characteristics Recall interval
First year Routine therapy & uneventful healing
Difficult case with complicated
prosthesis, furcation involvement, poor
crown-root ratio, questionable patient
cooperation.
3 months
1-2 months.
Class A Excellent results well maintained for 1
yr. or more
Good oral hygiene, no occlusal
problems, no complicated prosthesis, no
remaining pockets, & no teeth with <50%
of alveolar bone remaining.
6 months – 1 yr.

61. Merin
classification
Characteristics Recall
interval
Class B Generally good results maintained reasonably well for
1 yr or more, but patient displays following factors –
Inconsistent or poor oral hygiene
Heavy calculus formation
Systemic disease
Some remaining pockets
Occlusal problems
Some teeth with < 50% of alveolar bone support
Smoking
More than 20% of pockets bleed on probing.
3 -4 months
(decide on recall
interval based on
number & severity
of negative
factors)
Class C Generally poor results after periodontal therapy &
with several negative factors
Inconsistent or poor oral hygiene
Many remaining pockets
Periodontal surgery indicated but not performed
due to medical, psychological or financial reason.
Many teeth with < 50% of alveolar bone support
Condition too far advanced to be improved by
periodontal surgery
More than 20% of pockets bleed on probing
1 – 3 months
(decide on recall
interval based on
number & severity
of negative
factors; consider
re- treating some
areas or extracting
severly involved
teeth)

78. SPT with adjunct use of
antimicrobials/antibiotics
A number of short-term studies (12 months or less)
imply that the use of antibiotics are effective adjuncts and
that the effect may be sustained over a longer period of
time .
However,
the advantage of adjunct antibiotic therapy during SPT is
unknown.

79. References
 Carranza’s Clinical Periodontology. 11th edition
 Lindhe J, KarringT, Lang NP. Clinical periodontology
and implant dentistry, 4th. Ed. Munksgaard 2003,
Copenhagen.
 Claffey, N. (1991). Decision making in
periodontal therapy. The re-evaluation. Journal
of Clinical Periodontology 18, 384–389.

81. Any question??