Supportive periodontal therapy0 (2)

Muhimbili University Of Health And
Allied Sciences
(MUHAS).
DAR ES SALAAM,TANZANIA.

SUPPORTIVE PERIODONTAL
THERAPY, (SPT).
JOSHUA Gideon;
DDS-sem-8, 6th June 2012.

1 joshuagm/sem8/muhas/2011-12. Friday, June 8, 2012

Work plan.
 Introduction and Definition.
 Basic paradigms for the prevention of periodontal
diseases.
 Rationale of SPT.
 Patients at risk for periodontitis without SPT.
 SPT for patients with gingivitis and periodontitis
 Continuous multi-level risk assessment; Subject risk
assessment, Tooth risk assessment, Site risk assessment
 Therapeutic goals and objectives.
 Conclusion
 References.


Introduction.
Periodontal treatment includes:
1. Systemic evaluation of the patient’s health
2. A cause-related therapeutic phase with, in some
cases
3. A corrective phase involving periodontal surgical
procedures
4. Maintenance phase.
The 3rd World Workshop of the American Academy
of Periodontology (1989) renamed this treatment
phase “supportive periodontal therapy” (SPT).


Introduction.

 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.


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.


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,


 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


 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.


 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.


Rationale.
 Significant efforts have been made to develop
antimicrobial treatments and regenerative
procedures.
 At present there is no definitive periodontal
treatment that can cure the disease.
 Furthermore, the chronic nature of periodontitis as
well as the inability of existing clinical parameters to
predict disease progression mean that continuous
adjunct monitoring and treatments are necessary to
prevent recurrence of the disease.
 The principles of periodontal maintenance care are
well established and considered the standard of care.


Patients at risk for periodontitis
without SPT.
 The effect of an omission of SPT in patients with
periodontitis may best be studied either in untreated
populations or patient groups with poor compliance.
 One of the few studies documenting untreated
periodontitis-susceptible patients reported on the
continuous loss of periodontal attachment as well as
teeth in Sri Lankan tea plantation workers receiving no
dental therapy (Löe et al. 1986).


Cont…
 In this, an average loss of 0.3 mm per tooth surface and
year was encountered. Also, the laborers lost between
0.1 and 0.3 teeth per year as a result of periodontitis.
 In another untreated group in the United States, 0.61
teeth had been lost per year during an observation
period of 4 years (Becker et al. 1979).
 This is in dramatic contrast to reports on tooth loss in
well maintained patients treated for periodontitis (e.g.
Hirschfeld & Wasserman 1978; McFall 1982; Becker et al.
1984; Wilson et al. 1987).


Cont…
 Such patients were either completely stable and lost no
teeth during maintenance periods ranging up to 22 years
or lost only very little periodontal attachment and only
0.03 teeth (Hirschfeld & Wasserman 1978) or 0.06 teeth
(Wilson et al. 1987), respectively.


Cont…
 Non-complying, but periodontitis-susceptible patients
receiving no SPT following periodontal surgical
interventions continued to lose periodontal attachment
at a rate of approximately 1 mm per year regardless of
the type of surgery chosen (Nyman etal. 1977).
 This is almost three times more than would have to be
expected as a result of the “natural” course of
periodontal disease progression (Löe et al. 1978,1986).


Summary:
 Patients susceptible to periodontal disease are at high
risk for reinfection and progression of periodontal lesions
without meticulously organized and performed SPT.
 Since all patients who were treated for periodontal
diseases belong to this risk category by virtue of their
past history, an adequate maintenance care program
is of utmost importance for a beneficial long-term
treatment outcome.
 SPT has to be aimed at the regular removal of the
subgingival microbiota and must be supplemented by the
patient’s efforts for optimal supragingival plaque control.


SPT for patients with gingivitis
 Several studies, predominantly in children, have
documented that periodic professional prophylactic visits
in conjunction with reinforcement of personal oral
hygiene are effective in controlling gingivitis (Badersten et
al. 1975;).
 This, however, does not imply that maintenance visits in
childhood preclude the development of more severe
disease later in life.
 It is obvious that SPT, therefore, must be a lifelong
commitment of both the patient and the profession.


 Adults whose effective oral hygiene is combined with
periodic professional prophylaxis are clearly healthier
periodontally than patients who do not participate in SPT
programs (Lövdal et al. 1961;Suomi et al. 1971).
 One particular study of historical significance was
performed on 1428 adults from an industrial company in
Oslo, Norway (Lövdal et al.1961).
 Over a 5-year observation period, the subjects were
recalled two to four times per year for instruction in oral
hygiene and supragingival and subgingival scaling.


 Gingival conditions improved by approximately 60% and
tooth loss was reduced by about 50% of what would be
expected without these efforts.

Summary:
 the prevention of gingival inflammation and early loss of
attachment in patients with gingivitis depends on
 the level of personal plaque control,
 further measures to reduce the accumulation of
supragingival and subgingival plaque.


SPT for patients with periodontitis
 SPT is an absolute prerequisite to guarantee beneficial
treatment outcomes with maintained levels of clinical
attachment over long periods oftime.
 The maintenance of treatment results for the majority of
patients has been documented up to 14 years, and in a private
practice situation even up to 30 years.
 but it has to be realized that a small proportion of patients will
experience recurrent infections with progression of
periodontal lesions in a few sites in a completely unpredictable
mode.
 The continuous risk assessment at subject, tooth and tooth
site levels, therefore, represents a challenge for the SPT
concept.


Continuous multi-level risk
assessment.
 clinical diagnosis during SPT has to be based on the
variations of the health status obtained following
successful active periodontal treatment.
 This, in turn, means that a new baseline will have to be
established once the treatment goals of active
periodontal therapy (i.e. phases 1–3) are reached and
periodontal health is restored (Claffey 1991).
 This baseline includes the level of clinical attachment
achieved while the inflammatory parameters are
supposed to be under control.


 Under optimal circumstances, supportive periodontal
care would maintain clinical attachment levels obtained
after active therapy for the years to come.
 From a clinical point of view, the stability of periodontal
conditions reflects a dynamic equilibrium between
bacterial aggression and effective host response.
 As such, this homeostasis is prone to sudden changes
whenever one of the two factors prevails.
 Hence, it is evident that the diagnostic process must be
based on continuous monitoring of the multi-level risk
profile.


 The intervals between diagnostic assessments must also
be chosen based on the overall risk profile and the
expected benefit.
 To schedule patients for supportive periodontal therapy
on the basis of an individual risk evaluation for
recurrence of disease has been demonstrated to be cost
effective.


 it is important to determine the level of risk for
progression in each individual patient in order to be able
to determine the frequency and extent of professional
support necessary to maintain the attachment levels
obtained following active therapy.
 The determination of such risk level would thus prevent
under-treatment, and also excessive overtreatment,
during SPT.


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:


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.


 Each parameter has its own scale for minor, moderate,
and high-risk profiles.
 A comprehensive evaluation, the functional diagram will
provide an individualized total risk profile and determine
the frequency and complexity of SPT visits.
 Modifications may be made to the functional diagram if
additional factors become important from future
evidence.


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.


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.


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.


 Although there is no established acceptable level of
prevalence of BOP in the dentition above which a higher
risk for disease recurrence has been established, a BOP
prevalence of 25% has been the cut-off point between
patients with maintained periodontal stability for 4 years
and patients with recurrent disease in the same
timeframe in a prospective study in a private practice
(Joss et al.1994).


 The percentage of BOP, therefore, is used as the first
risk factor in the functional diagram of risk assessment.
 Individuals with low mean BOP percentages (<10% of the
surfaces) may be regarded as patients with a low risk for
recurrent disease (Lang et al. 1990),
 while patients with mean BOP percentages >25% should
be considered to be at high risk for reinfection.


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.


 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).


 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.


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).


 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.


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.


 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.


 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.


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.


 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.


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.


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.


Tooth risk assessment
 Tooth position within the dental arch
 Furcation involvement
 Iatrogenic factors
 Residual periodontal support
 Mobility.


Tooth position within the dental arch.
 Early clinical surveys have associated the prevalence and
severity of periodontal diseases with malocclusion and
irregularities of tooth position (Ditto & Hall 1954;
Bilimoria 1963).
 However, many subsequent studies using clinical
evaluation methods could not confirm these conclusions.


 Although a relationship between crowding and increased
plaque retention and gingival inflammation has been
established,
 no significant correlation between anterior overjet and
overbite, crowding and spacing or axial inclinations and
tooth drifts and periodontal destruction, i.e. attachment
loss subsequent to gingival inflammation, could be
established.


 crowding of teeth might affect the amount of plaque mass
formed in dentitions with irregular oral hygiene practices,
thus contributing to the development of chronic
gingivitis, but, as of
 Tooth malposition within the dental arch will lead to an
increased risk for periodontal attachment loss.


Furcation involvement.
 Retrospective analyses of large patient populations in
private periodontal practices of periodontal specialists
(Hirschfeld & Wasserman 1978; McFall 1982) have clearly
established that multi-rooted teeth appear to be at high
risk for tooth loss during the maintenance phase.


 The assumption that the prognosis for single-rooted
teeth and non-furcation-involved multi-rooted teeth is
better than the prognosis for furcation involved multi-
rooted teeth was also confirmed by Ramfjord et al.
(1987) in a prospective study over 5 years.
 these results are not intended to imply that furcation-
involved teeth should be extracted, since all the
prospective studies have documented a rather good
overall prognosis for such teeth if regular supportive care
is provided by a well organized maintenance program.


Iatrogenic factors.
 Overhanging restorations and ill fitting crown margins
certainly represent an area for plaque retention, and
there is an abundance of association studies documenting
increased prevalence of periodontal lesions in the
presence of iatrogenic factors.
 Depending on the supragingival or subgingival location of
such factors, their influence on the risk for disease
progression has to be considered.


 It has been established that slightly subgingivally located
overhanging restorations will, indeed, change the ecologic
niche, providing more favorable conditions for the
establishment of a Gram negative anaerobic microbiota
(Lang et al. 1983).
 There is no doubt that shifts in the subgingival microflora
towards a more periodontopathic microbiota, if
unaffected by treatment, represent an increased risk for
periodontal breakdown.


Residual periodontal support.
 Although many clinicians believe that teeth with reduced
periodontal support are unable to function alone and
should be extracted or splinted,
there is clear evidence from longitudinal studies that
teeth with severely reduced, but healthy, periodontal
support can function either individually or as abutments
for many years without any further loss of attachment.


 Hence, successfully periodontally treated teeth can be
maintained over decades and function as abutments in
fixed bridgework irrespective of the amount of residual
periodontal support, provided that physiologic
masticatory forces do not subject such teeth to a
progressive trauma which may lead to spontaneous
extraction.
 by virtue of the already reduced support, should disease
progression occur in severely compromised teeth, this
may lead to spontaneous tooth exfoliation.


Mobility.
 tooth mobility may be an indicator for progressive
traumatic lesions, provided that the mobility is increasing
continuously.
 Two factors may contribute to hypermobility:
(1) a widening of the periodontal ligament as a result
of unidirectional or multidirectional forces to the
crown, high and frequent enough to induce
resorption of the alveolar bone walls; and
(2) the height of the periodontal supporting tissues.


 If this is reduced due to prior periodontal disease, but
the width of the periodontal ligament is unchanged, the
amplitude of root mobility within the remaining
periodontium is the same as in a tooth with normal
height, but the leverage on the tooth following
application of forces to the crown is changed.
 Therefore, it has to be realized that all teeth that have
lost periodontal support have increased tooth mobility as
defined by crown displacement upon application of a
given force.
 Nevertheless, this hypermobility should be regarded as
physiologic (Nyman & Lindhe 1976).


 Several studies have indicated that tooth mobility
 varies greatly before, during, and after periodontal
 therapy (Persson 1980, 1981a,b).
 From these studies
 it can be concluded that periodontally involved teeth
 show a decrease in mobility following non-surgicaland/or
surgical periodontal procedures. However,
 following surgical procedures, tooth mobility may
 temporarily increase during the healing phase and
 may resume decreased values later on


Summary:
 The tooth risk assessment encompasses an estimation of
the residual periodontal support, an evaluation of tooth
positioning, furcation involvements, presence of
iatrogenic factors, and a determination of tooth mobility
to evaluate functional stability.
 A risk assessment at tooth level may be useful in
evaluating the prognosis and function of an individual
tooth and may indicate the need for specific therapeutic
measures during SPT visits.


Site risk assessment.
 Bleeding on probing
 Probing depth and loss of attachment.
 suppuration


Bleeding on probing (BOP).
 Absence of bleeding on probing (BOP) is a reliable
parameter to indicate periodontal stability if the test
procedure for assessing BOP has been standardize.
 Presence of bleeding upon standardized probing will
indicate presence of gingival inflammation.
 Whether or not repeated BOP overtime will predict the
progression of a lesion is, however, questionable (Lang et
al. 1986, 1990; Vanooteghem et al. 1987).


 this clinical parameter is the most reliable for monitoring
patients over time in daily practice.
 Non-bleeding sites may be considered periodontally
stable.
 On the other hand, bleeding sites seem to have an
increased risk for progression of periodontitis, especially
when the same site is bleeding at repeated evaluations
over time (Lang et al. 1986; Claffey et al. 1990).


 It is, therefore, advisable to register the sites with BOP in
a dichotomous way using a constant force of 0.25 N.
 This allows the calculation of the mean BOP for the
patient, and also yields the topographic location of the
bleeding site.
 Repeated scores during maintenance will reveal the
surfaces at higher risk for loss of attachment.


Probing depth and loss of attachment.
 Clinical probing is the most commonly used parameter
both to document loss of attachment and to establish a
diagnosis of periodontitis.
 There are, however, some sources of error inherent in
this method which contribute to the variability in the
measurements.


 Among these are
(1) the dimension of the periodontal probe;
(2) the placement of the probe and obtaining a reference
point;
(3) the crudeness of the measurement scale;
(4) the probing force; and
(5) the gingival tissue conditions.


 It has to be realized that increased probing depth and
loss of probing attachment are parameters which reflect
the history of periodontitis rather than its current state
of activity.
 Obviously, the first evaluation prior to therapy will yield
results confounded by greater measurement error than
evaluations following therapy.
 The reference point (cemento-enamel junction) may be
obstructed by calculus or by dental restorations, and the
condition of the gingival tissues may allow an easy
penetration of the periodontal probe into the tissues,
even though the probe position and force applied are
standardized.

 These biologic variables (tissue conditions and calculus)
may be minimized following initial periodontal therapy,
and hence, repeated periodontal evaluations using
probing will improve the metric assessment.
 The first periodontal evaluation after healing following
initial periodontal therapy should, therefore, be taken as
the baseline for longterm linical monitoring (Claffey
1994).


Suppuration.
 In a proportion of periodontal lesions, pus will develop
and may drain through the orifice of a pocket.
 This criterion of suppuration may be recognized while
clinically probing the lesion, or preferably, by using a ball
burnisher.


 the presence of suppuration increased the positive
predictive value for disease progression in combination
with other clinical parameters, such as BOP and
increased probing depth.
 Hence, following therapy a suppurating lesion may
provide evidence that the periodontitis site is undergoing
a period of exacerbation.


Radiographic evaluation of
periodontal disease progression.
 Radiographs should be current and should be based on
the diagnostic needs of the patient and should permit
proper evaluation and interpretation of the status of the
periodontium.
 Radiographs of diagnostic quality are necessary for these
purposes,the judgement of the clinician, as well as the
degree of disease activity.
 Radiographic abnormalities should be noted.


Summary.

The tooth site risk assessment includes
 the registration of BOP, probing depth, loss of
attachment, and suppuration.
 A risk assessment on the site level may be useful in
evaluating periodontal disease activity and determining
periodontal stability or ongoing inflammation.
 The site risk assessment is essential for the identification
of the sites to be instrumented during SPT.


SUMMARY.(continuous multi-level risk
assessment).
 It is suggested that patients be evaluated on the three
different levels mentioned.
 At the patient level, loss of support in relation to patient
age, full mouth plaque and/or bleeding scores, and
prevalence of residual pockets are evaluated, together
with the presence of systemic conditions or
environmental factors, such as smoking, which can
influence the prognosis.
 The clinical utility of this first level of risk assessment
influences primarily the determination of the recall
frequency and time requirements.


Summary, cont…
 It should also provide a perspective for the evaluation of
risk assessment conducted at the tooth and site levels.
 At the tooth and tooth site levels, residual periodontal
support, inflammatory parameters and their persistence,
presence of ecologic niches with difficult access such as
furcations, and presence of iatrogenic factors have to be
put into perspective with the patient overall risk profile.
 The clinical utility of tooth and site risk assessment
relates to rational allocation of the recall time available
for therapeutic intervention to the sites with higher risk,
and possibly to the selection of different forms of
therapeutic intervention.


THERAPEUTIC GOALS
1. To minimize the recurrence and progression of
periodontal disease in patients who have been
previously treated for gingivitis and periodontitis.

2. To reduce the incidence of tooth loss by monitoring
the dentition and any prosthetic replacements of the
natural teeth.

3. To increase the probability of locating and treating,
in a timely manner, other diseases or conditions
found within the oral cavity.


Objectives of SPT.
 to reduce probing pocket depths
 to reduce bleeding on probing
 to gain clinical attachment levels


SPT in daily practice.
 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:
1. Examination, re-evaluation, and diagnosis (ERD)
2. Motivation, reinstruction, and instrumentation
(MRI)
3. Treatment of reinfected sites (TRS)
4. Polishing of the entire dentition, application of fl
uorides,
and determination of future SPT (PFD).


Recall hour.


Treatment
1. Removal of subgingival and supragingival
plaque and calculus
2. Behavior modification:
A. Oral hygiene reinstruction
B. Compliance with suggested periodontal
maintenance intervals
C. Counseling on control of risk factors; e.g.,
cessation of smoking
3. Antimicrobial agents as necessary
4. Surgical treatment of recurrent disease

Communication
1. Informing the patient of current status and alterations
in treatment if indicated.
2. Consultation with other health care practitioners
who will be providing additional therapy or participating
in the periodontal maintenance program.


Planning
1*****. For most patients with a history of periodontitis,
visits at 3-month intervals have been found to be
effective in maintaining the established gingival
health.******
2. Based on evaluation of clinical findings and
assessment of disease status, periodontal maintenance
frequency may be modified or the patient may
be returned to active treatment.


Outcomes Assessment
 The desired outcome for patients on periodontal
maintenance should result in maintenance of the
periodontal health status attained as a result of active
therapy.
 Inadequate periodontal maintenance or noncompliance
may result in recurrence or progression of the disease
process.
 3. Despite adequate periodontal maintenance and patient
compliance, patients may demonstrate recurrence or
progression of periodontal disease. In these patients
additional therapy may be warranted.


Frequency of supportive maintenance
care
recall intervals could be extended to at least 1 year in
subjects with a history of limited susceptibility to
periodontitis.


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.


Conclusion.
• SPT should be based on assessment of the patient risk
profile for further periodontal disease progression.
Such risk assessment should be performed after the
completion of Initial Cause-Related Therapy (ICRT)
and be revisited continuously.
• A standardized SPT routine cannot be considered to
be consistent with best practice and an individualized
approach is needed.
• SPT resulting in good oral hygiene is essential to
minimize the risks of periodontal disease progression.
Issues of compliance must be considered.

References.
 Lindhe J, Karring T, 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.


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