Supportive periodontal therapy final1

SUPPORTIVE
PERIODONTAL
THERAPY
Dr. VIVEK Kr. SHARMA
ALIGARH MUSLIM UNIVERSITY

GOAL OF PERIODONTAL
TREATMENT
Monday, April 28, 2014Dr Vivek Sharma.AMU
2
To maintain the natural dentition in functional
health and comfort THROUGHOUT the
LIFETIME.
It requires a perfect plaque control

3
Even after appropriate Periodontal Therapy,
some progression of disease is possible*
Greenwell et al 1989,Hirschfield et al 1985,Tonetti et al 1998,
Incomplete
subgingival plaque
removal

PLAQUE CONTROL
4
 MOTIVATION
 MECHANICAL/CHEMICAL AIDS
 PERIODIC REMOVAL OF
PLAQUE/PROFESSIONAL MAINTENANCE
Improper plaque control will results in Gingivitis
Compromising functional comfort
and longevity of the dentition

To what extent should professional
maintenance care be concerned with the
treatment and prevention of gingivitis?
5
 Minimal/No effect on functional comfort
 No test that will predict in which patient gingivitis
will progress to periodontitis
 No predictability of progression rate of attachment
loss.

BUT, Compelling reasons are
6
 Gingivitis is-
 Form of disease.
 May develop into periodontitis with loss of attachment.
 Less evidence of gingivitis, the less severe is the loss of
periodontal attachment over time.
 To control periodontitis the only way is to control gingivitis
and plaque control.
 Gingivitis is a greater threat to loss of attachment in
persons who already have lost some attachment
Perfect Professional & Personal Plaque
Control GINGIVITIS
PERIODONTITIS
Longevity of Dentition

If After Active Periodontal
Therapy…
7

PERIODONTAL TREATMENT PLAN*
8
PHASE I(ICRT)
REEVALUATION
PHASE IV(Maintenance/SPT)
PHASE II PHASE III
(Periodontal Surgery) ( Restorative)
*Carranza‟s 9th edition

Supportive Periodontal Therapy
9
 Definition.
 Basic paradigms for the prevention of periodontal
diseases.
 Rationale of SPT.
 Continuous multi-level risk assessment; Subject
risk assessment, Tooth risk assessment, Site risk
assessment
 Therapeutic goals and objectives.
 Complications
 Conclusion

Definition
10
1989,3rd world workshop of AAP, Rename the Maintenance Phase.
 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.
Essential need for therapeutic measures to support the patient‟s
own efforts to control periodontal infections and to avoid Re-
infection.

Basic Paradigms for prevention
of periodontal Disease
11
Cause-Effect relationship: Plaque
Gingivitis
Löe et al 1965
Cause-Effect relationship: Plaque Accumulation Periodontal
Disease
Lindhe et al 1975

Cont…
12
 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.

Cont…thus to prevent periodontal disease
13
 Necessity for proper and regular personal
plaque elimination, at least in patients treated
for or susceptible to periodontal disease
 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.

Rationale for SPT :
14
 PERIODONTITIS: Chronic in
Nature
1

15
 No definitive periodontal treatment that
can cure the disease.
•Antimicrobial Therapy
•Regenerative Procedures
•Host-Modulation Therapy
•Diet /Antioxidant based
Therapy
•Tri-Immuno Phasic Therapy
2

16
 The microbial challenge which
induces and maintains the inflammatory
response, may not be completely
eliminated from the dento-gingival
environment for any length of time.
3

17
 Bacteria associated with periodontitis can be
transmitted between spouses and
other family members
4

18
 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.
5

Its SPT that…
19
 Prevent /Minimize Recurrence of Disease
Progression.
 Prevent/Minimize the incidence of Teeth or
Implant Loss
 Increase the Probability of Locating and
Treating other Disease and Conditions
SPT has to be aimed at regular removal of the subgingival
microbiota and must be supplemented by the patient‟s efforts for
optimal supragingival plaque removal

THERAPEUTIC GOALS
Monday, April 28, 2014Dr Vivek Kumar Sharma AMU
20
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.

SPT COMPRISES OF….
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 Part I : Examination
 Part II : Treatment
 Part III: Next Schedule
PERIODONTAL RISK
ASSESSMENT
Oral hygiene
Reinforceme
nt
Recall
Further Perio Tt.*
Restorative/Prosthetic
Tt.*
MULTI RISK ASSESSMENT
TOOTH
RISK
ASSESSME
NT
SITE RISK
ASSESSMEN
T

SPT begins with..
22
COMMUNICATIO
N
MOTIVATIO
N
COMPLIAN
CE
REALIZATI
ON

PART-I : MULTI RISK
ASSESSMENT
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 PERIODONTAL RISK ASSESSMENT(PRA)A
.

24
 Assessment of level of infection(Bleeding scores)
 Prevalence of residual periodontal pockets
 Tooth loss
 Estimation of Age related loss of periodontal
support
 Evaluation of Systemic conditions of the patient
 Evaluation of Environmental & Behavioral factors
No single parameter displays a more paramount role. The entire
spectrum of risk factors and risk indicators ought to be evaluated
simultaneously
PRA estimate the risk for susceptibility for
periodontal disease progression

FUNCTIONAL DIAGRAM TO EVALUATE THE
PATIENT’S RISK FOR RECURRENCE
25

BOP percentage-
first risk factor
26
 Represents an objective inflammatory parameter
 Reflects patient's ability to perform proper plaque
control, the patient's host response to
the bacterial challenge and the patient's compliance.
 While patients with mean BOP percentages > 25%
should be considered to be at high risk for periodontal
breakdown
1

Prevalence of residual pockets ≥5
mm
(residual pocket greater than 4 mm): second risk
indicator
27
 Represents - to a certain extent - the degree of
success of periodontal treatment rendered.
 Periodontal stability in a dentition would be reflected
in a minimal number of residual pockets.
 In conjunction with other parameters such as
bleeding on probing and/or suppuration are existing
ecological niches from and in which re-infection might
occur.
2

Loss of teeth from a total
of 28 teeth
28
 Tooth loss : a true end point outcome variable
reflecting the patient's
history of oral diseases and trauma
 The number of remaining teeth in a dentition
reflects the functionality of the dentition
 If more than 8 teeth from a total of 28 teeth are
lost, oral function is usually impaired
3

Loss of periodontal support
in relation to the patient's age
29
 Previous attachment loss in relation to patient's age
may be a more accurate indicator
during SPT than before active periodontal treatment .
 On bitewing radiographs, one milli-meter is considered
to be equal to 10% bone loss. The score = % OF
BONE LOSS PATIENT‟s AGE = BL/Age
 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
The rate of progression of
disease has been positively
affected by the treatment
rendered 4

Contd…
30
It may be argued that the incorporation of only the worst site with bone
loss in the posterior segment may overestimate an individual's rate
of periodontal destruction when only an isolated advanced bony lesion is
present due to local etiologic factors.
While an underestimation of the rate of destruction may exist in a
case
of generalized advanced disease.
Worst site with bone loss in the posterior segment
may, indeed, represent the past history of
destruction of the entire dentition
(Persson et al, 2003).

31
Systemic and genetic
aspects
In this case, the area of
high risk s marked for
this vector. If it is not
known or absent,
systemic factors are not
taken into account
for the overall
evaluation of risk
.
Genetic marker like:
IL-1
MICROBE
S
MICROBIAL By-
Products
LPS , MMP‟s, PMN
Inflammatory Mediators
Host Response
Periodontal
Disease
Systemic
Disease
The Chemistry Of
Destruction
5

Environmental Factor:
smoking
32
Smokers displayed less favorable healing responses
both at reevaluation and during a 6-year period of SPT
(Baumert-Ah et al, 1994).
It seems reasonable to incorporate heavy smokers
(20 cigarettes/day) in a higher risk group during maintenance
Occasional smokers (OS; < 10 cigarettes a day) and moderate smokers
(MS;10-19 cigarettes a day) may be considered at moderate risk for disease
progression.
While non-smokers (NS) and former smokers (FS) have a relatively low
risk for recurrence of periodontitis
Not only does smoking increase the extent and severity of periodontal disease, it
compromises the outcomes of surgical and non-surgical therapy
6

33
 CALCULATING THE PATIENT'S
INDIVIDUAL PERIODONTAL RISK
ASSESSMENT (PRA)

A low PRA patient has all parameters within the
low-risk categories or - at the most - one parameter in the moderate-
risk category
34

35
A moderate PRA patient has at least two parameters
in the moderate category, but at most one parameter in the high-risk
category

A high PRA patient has at least two parameters in
the high-risk category
36

B
.
37
TOOTH RISK ASSESSMENT:

Monday, April 28, 2014
38
 Tooth position within the dental arch
 Furcation involvement
 Iatrogenic factors
 Residual periodontal support
 Mobility.

Tooth position within the dental
arch.
39
 Malocclusion and Irregularities
CROWDING results in 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 with
periodontal destruction has been established
Tooth malposition within the dental arch will lead to an increased risk for
periodontal attachment loss.

Furcation involvement
40
 Retrospective analyses of large patient
populations (Hirschfeld & Wasserman 1978; McFall 1982, Ramfjord et al. 1987) have
clearly established that multi-rooted teeth appear
to be at high risk for tooth loss during the
maintenance phase.
 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.
41
 OVERHANGING RESTORATIONS
 ILL-FITTING CROWNS
 IMPROPERLY PLACED ORTHODONTIC
BRACKETS
Change the ecologic niche, providing more favorable conditions
for the establishment of a Gram negative anaerobic microbiota
(Lang et al. 1983). This shifts in the subgingival microflora towards a
more periodontopathic microbiota, if unaffected by treatment,
represent an increased risk for periodontal breakdown.

Residual periodontal support.
42
 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.
should disease progression occur in severely
compromised teeth, this may lead to spontaneous tooth
exfoliation

Mobility.
43
Indicator for progressive traumatic lesions, provided that the
mobility is increasing continuously.
(1) a widening of the periodontal ligament
(2) the height of the periodontal supporting tissues.
following surgical procedures, tooth mobility may temporarily increase
during the healing phase and may resume decreased values later on

C
.
44
SITE RISK
ASSESSMENT.The site risk assessment is essential for
the identification of the sites to be
instrumented during SPT.

45
 Bleeding on probing
 Probing depth and loss of attachment.
 suppuration

Bleeding On Probing
46
 Absence of bleeding on probing is a reliable
parameter to indicate periodontal stability if the test
procedure for assessing BOP has been standardize.
 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).

Probing depth and loss of
attachment.
47
 Clinical probing is the most commonly used parameter both
to document loss of attachment and to establish a diagnosis
of periodontitis.
 Reflect the history of periodontitis rather than its current state
of activity.
(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
The first periodontal evaluation after healing following initial periodontal
therapy should, therefore, be taken as the baseline for longterm linical
monitoring (Claffey 1994).

Suppuration.
48
 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.
Monday, April 28, 2014
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Radiograph : *Assist in clinician‟s judgement
*Current
*Based on diagnostic needs of patient
*Permit proper evaluation and interpretation of the status of
the periodontium.
*Radiographic abnormalities must be noted and co-relate
them with degree of disease activity
Bitewing Examination at 12-18 month interval : high risk caries patient
every 24-36 month : patient with good control over
periodontal disease
Peri-apical and/or at 12-24 months : Patient with poor control over
Vertical bite wings periodontal disease
6-12-36 months : Patient with root form dental
implants after prosthetic
placement.

Multi Risk Assessment….
50
 influences primarily the determination of the
recall frequency and time requirements for
therapeutic intervention to the sites with higher
risk, and possibly to the selection of different
forms of therapeutic intervention.

PART II: TREATMENT
51
 ORAL HYGIENE MEASURES IMPROVEMENT &
PROFESSIONAL ORAL PROPHYLAXSIS
 MOTIVATION/ BEHAVIOURAL MODIFICATION
&COMPLIANCE
 USE OF ANTIMICROBIALS

ORAL HYGIENE MEASURES
IMPROVEMENT
52
1.Removal of sub gingival and supra gingival
plaque and calculus
PROFESSIONAL ORAL
PROPHYLAXIS
2. Behavior modification:
A. Oral hygiene reinstruction
i. Proper use of Toothbrush
ii. Use of Floss & Interdental
Cleaning Aids
iii. Use of water flosser/ oral
irrigation
B. Compliance with suggested
periodontal maintenance intervals
C. Counseling on control of risk
factors; e.g., cessation of smoking

53
3. Use of Antimicrobials
*Adjunct to SPT
*Compensate for inadequate mechanical oral
hygiene
*Dentifrices, LDS, Solutions for oral rinses or
flushing of periodontal pockets.

PART-III: Next Schedule
54
 RECALL
 FURTHER PERIO TREATMENT
 RESTORATIVE/PROSTHETIC TREATMENT

RECALL INTERVALS
55
 SHORT INTERVAL RECALL:
 3-4 Month Recall intervals for SPT is recommended as
frequent maintenance care is necessary to eliminate/reduce
sub-gingival proportions of pathogens.
 LONG INTERVAL
 6-12 Month interval for SPT can effectively prevent further
disease progression.

56
 CLASS “A”: Patient displays good oral hygiene,minimal calculus,
no occlusal problems, no complicated prosthesis, no
remaining pockets & no teeth with less than 50% of
alveolar bone remaining .
 CLASS “B”: Patients with inconsistent/poor oral hygiene, heavy
calculus, systemic disesase, occlusal problems, complicated
prosthesis, recurrent caries, some teeth with less than 50% of
alveolar bone support, smoking, positive genetic test
 CLASS”C” : Patient with poor maintenance after 1 year with more
aggressive problem s of class B, condition too
far advanced to be improved by periodontal surgery
RECALL INTERVALS: After 1yr
well maintenance
6-12 month
recall
3-4 month recall
1-3 month
recall

Compliance with recall
system
Monday, April 28, 2014Dr Vivek Kr Sharma,AMU
57
 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.

COMPLICATIONS OF SUPPORTIVE
PERIODONTAL THERAPY
58
 Caries: removal of root cementum during ICRT
and during SPT
 Endodontic lesions: exposure of accessory
root canal
 Periodontal Abscesses:
 Root sensitivity:

Conclusion
59
 The programme of Supportive periodontal
therapy is essential to long-term stability of
patients with chronic periodontitis.
 The clinical strategy for SPT is determined
according to „clinical needs‟ of the patient and
is thus clinical observation and individual
discretion is of utmost importance rather than
best available „clinical evidence‟

SPT
60
THANKS

Supportive periodontal therapy final1

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