Supportive periodontal therapy

CONTENTS Definition Introduction Rationale and goals Importance of SPT Maintenance program Risk assessment Merins classification SPT in Daily Practice Compliance and its Role Complication Maintenance of dental implant patient

3DEFINITIONAmerican Academy of Periodontology 1991.

Supportive periodontal treatment is an integral part of periodontal therapy. It is performed by a dentist, although components of supportive periodontal treatment can be performed by a dental hygienist under the supervision of the dentist.

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The 3rd World Workshop of the American Academy of

Periodontology (1989) has renamed this maintenance phase as

SUPPORTIVE PERIODONTAL THERAPY.

AAP position paper in 2003 termed it as PERIODONTAL

MAINTENANCE

BACKGROUND

5 Fauchard, 1746“Little or no care as to the cleaning of teeth is ordinarily the

cause of all diseases that destroy them”Interceptive professional supportive therapy compensates for the lack of personal compliance.

Lovdal et al.,1961

Repeated SRP and OHI result in low plaque levels, gingival inflammation, probing depth and increase attachment level

Hamp et al., 1975

Treated teeth can be maintained regardless of previous treatment modalities

BACKGROUND

6 Nyman et al., 1975

Experimental group• Professional care every 2 weeks• No further loss of attachment

Control group• Recalled every 6 months• Loss of attachment

BACKGROUND

7INTRODUCTION Patients not returning for regular recall 5.6 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)

8PHASE I

REEVALUATION

PHASE II ( Periodontal surgery)

PHASE III(Restorative)

PHASE IV( Maintenance phase)

PHASE I

REEVALUATION

PHASE II ( Periodontal surgery)

PHASE III(Restorative)

PHASE IV( Maintenance phase)

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Even after appropriate therapy disease progression maybe seen in case of:

Long junctional epitheliumWeak union Pocket formation

Bacteria in the gingival tissueRecolonization Recurrent disease

Incomplete removal of subgingival plaqueRegrowth of subgingival plaque Loss of attachment

RATIONALE

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Subgingival scaling alters the microflora of periodontal pockets - Rosenberg 1981, Slots 1979.

Subgingival bacteria had not returned to pretreatment proportions even after 3 to 6 months - Slots 1979.

RATIONALE

Listgarten et al., 1980Single session scaling

Decrease in motile rods for a week

Increase in coccoid cells for 21 days

Reduction in spirochetes for 7 weeks

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Mechanical debridement Motivational environment

Good maintenance

results

RATIONALE

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…RATIONALE Concept of SPT (Schallhorn and Snider,

1981)

1. Preventive SPT Primary

preventionPreserve

periodontal health

Simple, cost-effective

Early in life, large

population

Patient information +

OHI

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…RATIONALE

2. Post-treatment SPT prevents recurrence + maintains oral health achieved through active treatment SRP + OHI + chemotherapy

3. Palliative SPT prevent or slow down disease progression in patients who cannot receive appropriate treatment due to:o Lack of compliance with treatmento Poor oral hygieneo Systemic problems

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AIMS AND OBJECTIVES

Pathogenic factors

Host resistanc

e

Periodontal health

Aim of SPT reestablish the equilibrium

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GOALS OF SPT

Position paper given by the American Academy of

Periodontology (1998) recommends….

an update of the medical and dental histories

examination of extra- and intraoral soft tissues

dental examination

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radiographic review

evaluation of the patient’s oral hygiene performance

periodontal evaluation and risk assessment

supra- and subgingival removal of bacterial plaque

and calculus

retreatment of disease when so indicated.

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THERAPEUTIC GOALS OF SPT

prevent or minimize the recurrence and progression of

periodontal disease in patients who have been previously treated

for gingivitis, periodontitis, and peri-implantitis.

prevent or reduce the incidence of tooth loss by monitoring the

dentition and any prosthetic replacement of natural teeth.

increase the probability of locating and treating in a timely

manner, other diseases or conditions found within the oral cavity.

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IMPORTANCE OF SUPPORTIVE PERIODONTAL THERAPY

5 year observation of 1428 adults from an industrial company in Oslo recall period 2-4 times/year (SRP + OHI) improvement of gingival condition by 60% and reduction in tooth loss by 50% (Lovdal et al., 1961)

Suomi et al., 1971 loss of periodontal tissue support over 3 years

Experimental group

SRP + OHI every 3 months

Loss of attachment 0.008mm/

surface

Control group

No special efforts

Loss of attachment of 0.3mm

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…IMPORTANCE OF SUPPORTIVE PERIODONTAL THERAPY

52 patients with mild to moderate periodontitis effect of SPT for 8 years gain in attachment followed by a loss of 0.5-0.8mm in 8 years patients seeking SPT less than once in a year showed greater loss of attachment (Bragger et al., 1992)

375 test patients received traditional maintenance care twice a year prophylactic visits every 2nd month for 2 years and every 3-12 months for the next 28 years: 0.4-1.8% teeth were lost 1.2-2.1% carious lesions developed No attachment loss

(Axelsson et al., 2004)

21SPT COMPRISES OF….

Part I : Examination

Part II : Treatment

Part III: Next Schedule

PERIODONTAL RISK ASSESSMENT

Oral hygiene Reinforcement

RecallFurther Perio TreatmentRestorative/Prosthetic Treatment

MULTI RISK ASSESSMENTTOOTH RISK ASSESSMENT

SITE RISK ASSESSMENT

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SPT begins with..

COMMUNICATION

REALIZATION

COMPLIANCE

MOTIVATION

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PART-I : MULTI RISK ASSESSMENT

Periodontal Risk Assessment(PRA)A.

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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

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26BOP percentage-

first risk factor

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

36 and > 49% being the critical values on the vector.

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Prevalence of residual pockets ≥5 mm (residual pocket greater than 4 mm): second risk indicator

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.

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Loss of teeth from a total of 28 teeth

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

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Loss of periodontal support in relation to the patient's age

The rate of progression of disease has been positively affected by the treatment rendered

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 millimeter 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 risk

30Contd…

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).

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Systemic and genetic aspects

In this case, the area of high risk is marked for this vector. If it is not known or absent, systemic factors are not taken into accountfor the overall evaluation of risk.

Genetic marker like: IL-1

MICROBES

MICROBIAL By-ProductsLPS , MMP’s, PMN

Inflammatory MediatorsHost Response

Periodontal Disease

Systemic Disease

The Chemistry Of Destruction

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Environmental Factor: smoking

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) andmoderate 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

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

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

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

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

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TOOTH RISK ASSESSMENT:

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

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TOOTH POSITION WITHIN THE DENTAL ARCH. 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.

40FURCATION

INVOLVEMENT 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.

41IATROGENIC FACTORS.

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.

42Residual periodontal support.

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

43MOBILITY.

Following surgical procedures, tooth mobility may temporarily increase during the healing phase and may resume decreased values later on

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.

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

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Bleeding on probing Probing depth and loss of attachment. Suppuration

46Bleeding On Probing

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).

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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.

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 long term linical monitoring (Claffey 1994).

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SUPPURATION.

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.

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RADIOGRAPHIC EXAMINATION RECOMMENDATIONS

H/O PDL DISEASE TREATMENT WITH DISEASE UNDER GOOD CONTROL

BW every 24-36 months; full mouth every 5 years

ROOT FORM DENTAL IMPLANTS

IOPA/BW at 6, 12, 36 months after prosthetic replacement; then after 36 months unless a clinical problem arises

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RADIOGRAPHIC EXAMINATION RECOMMENDATIONSCLINICAL CARIES/HIGH RISK FACTOR FOR CARIES

Posterior BW at 12-24 month intervals

CLINICAL CARIES/ NO HIGH RISK FACTOR FOR CARIES

Posterior BW at 24-36 month intervals

PERIODONTAL DISEASE NOT UNDER GOOD CONTROL

•IOPA and/or BW of problem areas every 12-24 months•Full mouth 3-5 years

51Multi Risk Assessment….

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.

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PART II: TREATMENT

ORAL HYGIENE MEASURES IMPROVEMENT & PROFESSIONAL ORAL PROPHYLAXSIS

MOTIVATION/ BEHAVIOURAL MODIFICATION &COMPLIANCE

USE OF ANTIMICROBIALS

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ORAL HYGIENE MEASURES IMPROVEMENT

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 Toothbrushii. Use of Floss & Interdental Cleaning

Aidsiii. 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

.

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3. Use of Antimicrobials

*Adjunct to SPT

*Compensate for inadequate mechanical oral hygiene

*Dentifrices, LDS, Solutions for oral rinses or flushing of periodontal pockets.

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PART-III: Next Schedule

RECALL FURTHER PERIO TREATMENT RESTORATIVE/PROSTHETIC TREATMENT

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Compliance and its role in periodontal therapy

Only few pt. comply completely with professional suggestions…

Reasons for noncompliance are highly variable…

Pt. comply better when they are informed…

Compliance became a significant concern only after introduction of therapeutic drugs (Davidson 1976)…

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Pt. compliance in taking drug falls with time, often dropping below 35% (Schwartz 1962)…

Even patients with life-threatening diseases often refuse to change their behavior…

Pt. with chronic problems tend not to comply with therapists suggestions…

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Definition of Compliance

Also called adherence and therapeutic alliance.

It has been defined as "the extent to which a person's behavior coincides with medical or health advice" (Hayness 1976).

Types of compliance 1. Non-compliance 2. Erratic compliance 3. Complete compliance

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TYPES OF COMPLIANCE

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Compliance with suggested oral hygiene regime:

When pt. stop cleaning their teeth, bacterial plaque collects which leads to (Loe H 1965)…Gingivitis

It has also been shown that pt. who clean well have less dental caries and periodontitis…

A group of 123 patients randomly selected from a single dental practice was studied by (Boyer 1983).

About one third of these pt. said they were…

61 Strack et al. found that

1. 51% of pt. given OHI were in highly compliant.

2. 38% were moderately compliant.

3. 11% non-compliant 30 days after instruction.

Glavind et al found that positive feedback to a group of 63 adults lowered plaque and bleeding scores compared with controls.

62 Schwartz 1952 reported that 2/3rd of pt. who drop out of

suggested OHI do so within 3 months.

The study suggested that self-care is a positive alternative to professional care.

The keys to adequate self-care include…

Reinforcing the idea that efficacy is more important than the amount of time spent on cleaning.

63 One indicator of the future efficacy of plaque removal may

be the level of (OH) before therapy…

Oral hygiene standards tend to decrease during SPT…Flossing less than5%…(Craig 1976).

If properly instructed pt. can slightly improve (OH) compared with professional reinforcement.

Use of a disclosing agent (erythrosin) was found helpful in improving the efficacy of plaque removal.

64Why do patients fail to comply

This is a complex question because ans.is diff…

1. Negligent attitudes toward their illness…

2. Pt. wants to deny that they have problem at all…

3. They want dentist to take responsibility…

4. Fear of dental treatment is a major reason…

5. Economic problems…

6. Fee reduction program…

Socio-economic status of pt. is a best methods for improving compliance…

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Methods of improving compliance

1. Simplify 2. Accommodate to the pt. needs3. Remind patients of appointments 4. Keep records of pt.compliance 5. Inform the pt. (Bowden 1975)6. Provide positive reinforcement 7. Identify potential non-compliers 8. Ensure the dentist's involvementNoncompliance decreased by 50% when these general approaches were applied (Wilson 1993).

66Disease progression and its influence on SPT

Manner in which periodontal diseases advance can profoundly affect maintenance…

Repair and breakdown may occur simultaneously in the same mouth…

Monitor the patient and intervene when 2 mm or more of attachment loss has occur.

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MERIN’S CLASSIFICATION FOR FREQUENCY OF RECALL INTERVAL

CLASSIFICATION CHARACTERISTICS RECALL INTERVAL

FIRST YEAR Routine therapy and uneventful healing

3 months

FIRST YEAR Difficult case with -furcation involvements -poor crown to root ratio-complicated prosthesis, -questionable patient co-operation

1-2 months

68CLASSIFICA

TIONCHARACTERISTICS RECALL

INTERVAL

CLASS A Excellent results, well maintained for 1 year or more, -minimal calculus -good oral hygiene-no occlusal problems - no complicated prostheses-no remaining pockets-no teeth with less than 50% bone remaining

6 months to 1 year

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CLASSIFICATION

CHARACTERISTICS RECALL INTERVAL

CLASS B Generally good results, maintained well for 1 year or more but for

3-4 months

-Heavy calculus formation-Inconsistent or poor oral hygiene-Occlusal problems-Some remaining pockets-Complicated prostheses-Few teeth with <50% bone support-Systemic disease predisposing to PDL breakdown-Ongoing orthodontic therapy-Recurrent dental caries-Smoking- +ve family history

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CLASSIFICATION

CHARACTERISTICS RECALL INTERVAL

CLASS C Generally poor results and/or several negative factors-Inconsistent or poor oral hygiene-Heavy calculus formation-Systemic disease predisposing to PDL breakdown-Many remaining pockets-Occlusal problems-Complicated prostheses-Recurrent dental caries-Periodontal surgery indicated but not performed for medical, psychologic reason-Many teeth with <50% bone support-Smoking- +ve family history- > 20% pockets bleed on probing

1-3 months

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SPT IN DAILY PRACTICE

Recall hour is divided as follows:

Examination, re-evaluation and diagnosis (ERD)

Motivation, reinstruction and instrumentation

(MRI)

Treatment of reinfected sites (TRS)

Polishing, application of fluorides and

determination of the future SPT

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MAINTENANCE PROGRAM

EXAMINATION,

RE-EVALUATION,

DIAGNOSIS

10-15 min

MOTIVATION, REINSTRUCTION, INSTRUMENTATION30-40 min

POLIS

HING,

FLUORI

DE AP

PLIC

ATIO

N

5-10

min

TRS TREATMENT OF REINFECTED SITES

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…SPT IN DAILY PRACTICE

Examination, Re-evaluation and Diagnosis (ERD)

Note changes in health status

Extraoral and intraoral soft tissue examination

Assess subject’s risk factors and tooth site related risk factors

Radiographic evaluation of devitalized teeth, abutment teeth, implants

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…SPT IN DAILY PRACTICE

Diagnostic procedure includes assessment of:

Oral hygiene and plaqueBOP

PD and CAL

Pus formationExisting reconstructionsCarious lesions

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…SPT IN DAILY PRACTICE

Motivation, Reinstruction and Instrumentation (MRI)

Acknowledge the patient’s performance

Individual approach

Emphasize on a vibratory tooth brushing technique

Instrument sites with BOP +ve and pockets > 5mm repeated instrumentation below a critical depth of 2.9mm, in healthy sites, causes loss of attachment (Lindhe et al., 1981) non bleeding sites are polished

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…SPT IN DAILY PRACTICE

Treatment of Reinfected Sites (TRS)

Furcation sites/ sites with difficult access

occasionally get reinfected thorough instrumentation

or open debridement with surgical access

Inadequate SPT generalized reinfection

High BOP percentage recall patient after 2-3 weeks to check patient complaince with home care

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…SPT IN DAILY PRACTICE

Polishing, application of fluorides and determination of the future SPT

Polish the entire dentition to remove all remaining soft deposits and stains

Fluoride prevents root surface caries in recessed areas

Determine future SPT visits based on risk assessment

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79complications

Caries: removal of root cementum during ICRT and during SPT

Endodontic lesions: exposure of accessory root canal

Periodontal Abscesses:

Root sensitivity:

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MAINTAINING THE IMPLANT PATIENT

More prone to plaque induced inflammation and susceptible to bone loss (peri-implantitis)

Differences in maintenance: Special instrumentation plastic instruments

and gold coated curettes Acidic fluoride prophylactic agents avoided Nonabrasive prophy pastes are used rubber

cup with tin oxide with light, intermittent pressure

81Cist protocol

82conclusion

83

references Clinical Periodontology and Implant Dentistry. 5th

ed. Niklaus P. Lang, Jan Lindhe

Carranza’s Clinical Periodontology. 10th ed. Michael G. Newman, Henry H. Takei, Perry R. Klokkevold, Fermin A. Carranza.

Supportive periodontal therapy. Stefan Renvert, G. Rutger Persson. Perio 2000, Vol. 36, 2004.

84Thank you