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SUPPORTIVE SUPPORTIVE PERIODONTAL PERIODONTAL THERAPYTHERAPY

SHILPA SHIVANANDIII MDS

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o Introduction o Rationale and objectiveso Complianceo Parts of SPTo Frequency and efficacyo SPT in daily practiceo Recurrence of periodontal

diseaseo Classification of post treatment

patients

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oReferral Of Patients To The PeriodontistoRisk Assessment Of Recurrence Of Disease During SPT And Multifactorial Risk DiagramoComplications Of Supportive Periodontal TherapyoSPT With Adjunct Use Of Antimicrobials/AntibioticsoMaintenance Care Of Patients With Dental Implants

INTRODUCTIO

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Continuous patient monitoring following active periodontal therapy is necessary to prevent •Reinfection•Continued progression of periodontal disease

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The American Academy of Periodontology 1989 renamed periodontal maintenance as, SUPPORTIVE PERIODONTAL THERAPY, which included

SEQUEN

CE OF

PERIO

DONTAL

THER

APY

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GOALS OF S

PT

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RATIONALE

S

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Waerhaug 1978

Cortellini 1994

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Intrafamilial transmission

of Aa Alalusua, Asikainen

1991Transmission of Pg

between spouses Van Steen

Bergen 1993

Mousques 1980

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Slots 1979 subgingival bacteria

not returned to pretreatment

proportions after 3-6 months

Rate of return of pathogens 9-11 weeks AAP position paper 2003

OBJECTIV

ES

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Resonable clinical indicator to evaluate stability of results Haffajee 1983

No maintenanceplaque accumulatereestablishinflammationNyman 1977

Well maintained patients low inflammation Rosling 1976

Bone height well maintained and improved in proper maintenance Rosling 1976

COMPLIANCE A

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COMPLIANCE A

ND

COMMUNICATION

COMMUNICATION

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“The extent to which a person’s behavior coincides with medical or health advice”

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Several hypothesis have put forth: reasons include-

• Self-destructive behaviours• Fear of dental treatment • Economic factors• Health beliefs• Stressful events in their lives

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The studies by Demetriou et al. and Demirel et al. suggested that females are more compliant than men.

Study by Novaes & Ojima showed that older patients are more compliant than younger patients, whereas the study by Demetriou et al. suggested the opposite .

COMMUNICATIONA successful long-term

maintenance program is based on a good communication. This involves:

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PARTS

OF SPT

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Schallhorn RG, 1981

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FREQ

UENCY &

EFFIC

ACY

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Numerous studies have shown that less attachment loss occurs, and fewer teeth are lost when patients maintain regular SPT.

In gingivitis patients: For most patients with gingivitis but no

previous attachment loss, SPT twice a year will suffice.

Lovdal et al (1961) - 2-4 times per year. Suomi et al 1978 - every 3 months Listgarten et al 1982 – every 6months

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In Periodontitis patients :Study by Lindhe and Nyman 1984, periodontal prophylaxis was provided to a group of 61 patients with excellent oral hygiene, every 3-6 month over 14 years, without significant recurrence of disease, although some of them lost significant amount of periodontal support in some places.

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However, Nyman et al (1992) demonstrated that if professional care were administered every 2nd week for 2 years, periodontal support would be preserved,

…..where as patients in the control group receiving root instrumentation every 6 months exhibited significant additional loss of attachment.

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Lightner et al (1971) studied the effectiveness of different frequencies for preventive treatment showing that 4 prophylaxis per year and tooth brushing instruction proved very effective in retarding alveolar bone loss.

SPT IN DAILY

PRACTICE

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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 Fluorides and Determination of future SPT (PFD)

Suomi JD 1971

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1. Examination, Re-evaluation and Diagnosis (ERD)

It includes updating the significant changes in their health status

Extraoral and intraoral soft and hard tissue examination

An evaluation of the patient's risk factors will also influence the choice of future SPT and the determination of the recall interval at the end of the maintenance visit.

…RADIOGRAPHIC EVALUATION Radiographic examination must be

individualized, depending on the initial severity of the case and the findings at the recall visit .

These are compared with findings on previous radiographs to check the bone height and look for repair of osseous defects, signs of trauma from occlusion, periapical pathologic changes, and caries.

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14 months after surgical therapy

7 years after surgery2 years after surgery

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Occasionally, conventional dental radiographs indicated in SPT

Bottomley et al, Finger et al 1990

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2. Motivation, Reinstruction and Instrumentation (MRI)

This aspect uses most of the available time of the SPT visit. Patients who have experienced a relapse in their adequate oral hygiene practices need to be further motivated. The patient reinstructed in tooth brushing techniques which emphasize vibratory rather than scrubbing movements.

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Since it is impossible to instrument all the tooth sites in the time allocated, only those sites are reinstrumented during SPT visits which exhibit signs of inflammation and/or active disease progression.

Root surface instrumentation is aimed at the removal of sub-gingival plaque/calculus.

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3.Treatment of Reinfected Sites (TRS)Single sites, especially furcation sites or sites with difficult access, may be reinfected and demonstrate suppuration. Such sites require a thorough instrumentation, the local application of antibiotics in controlled release devices or even open debridement with surgical access which are time-consuming to be performed during the routine recall hour, and hence, it may be necessary to reschedule the patient for another appointment.

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Generalized reinfections are usually the result of inadequate SPT.

Local reinfections may either be the result of inadequate plaque control in a local area or the formation of ecologic niches conducive to periodontal pathogens.

The risk assessment on the tooth level may identify such niches which are inaccessible for regular oral hygiene practices.

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4. Polishing, Fluorides, Determination of recall interval (PFD)The recall hour is concluded with polishing the entire dentition to remove all remaining soft deposits and stains.Following polishing, fluorides is applied in high concentration in order to replace the fluorides which is removed during instrumentation.Fluoride or chlorhexidine varnishes may also be applied to prevent root surface caries, especially in areas with gingival recessions.

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Schallhorn & Snider,1981

RECURREN

CE OF

PERIO

DONTAL

DISEASE

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Occasionally, lesions may recur. This is often due to inadequate plaque control

on the part of the patient or failure to comply with recommended SPT schedules.

However, it is the dentist's responsibility to teach, motivate, and control the patient's oral hygiene technique, and the patient's failure is the dentist's failure.

Surgery should not be undertaken unless the patient has shown proficiency and willingness to cooperate by adequately performing his or her part of therapy.

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Becker 1984,

Wilson , Glover 1987

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CLASS

IFICATIO

N OF

POST TREA

TMEN

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PATIE

NTS

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The first year after periodontal therapy is The first year after periodontal therapy is important in terms of assessing the patient important in terms of assessing the patient in a recall pattern and reinforcing oral in a recall pattern and reinforcing oral hygiene techniques. hygiene techniques.

In addition, it may take several months to In addition, it may take several months to accurately evaluate the results of some accurately evaluate the results of some periodontal surgical procedures. periodontal surgical procedures.

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Consequently, some areas may have to be retreated because the results may not be optimal.

Furthermore, the first-year patient often has etiologic factors that may have been overlooked and may be more amenable to treatment at this early stage.

For these reasons, the recall interval for first-year patients should not be longer than 3 months.

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REFER

RAL OF

PATIE

NTS TO

PERIO

DONTIST

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The majority of periodontal care belongs in the hands of the general dentist.

The question remains where to draw the line between the cases to be treated in the general dental office and those to be referred to a specialist varies for different practitioners and patients.

The diagnosis indicates the type of periodontal treatment required.

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If periodontal destruction necessitates surgery on the distal surfaces of second molars, extensive osseous surgery, or complex regenerative procedures, the patient is usually best treated by a specialist. On the other hand, patients who require localized gingivectomy or flap curettage usually can be treated by the general dentist.

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Should the maintenance phase of therapy be performed by the general practitioner or the specialist?

The suggested rule is that the patient's disease should dictate whether the general practitioner or the specialist should perform the maintenance therapy.

RISK ASSES

SMENT

OF REC

URRENCE O

F

DISEASE D

URING

SPT

MULTIFA

CTORIAL R

ISK DIAGRAM

MULTIFA

CTORIAL R

ISK DIAGRAM

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Evaluated on three levels.

Subject level Tooth level Site level

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Subject Level

1.Percentage of bleeding on

probing

BOP percentages reflect a summary of the patient's ability to perform proper plaque control, the patient's host response to the bacterial challenge and the patient's compliance first risk factor .

The scale runs in a quadratic mode with 4, 9, 16, 25, 36 and > 49% being the divisions on the vector.

Individuals with low mean BOP percentages (< 10% of the surfaces) low risk for recurrent disease (Lang et al. 1990), while patients with mean BOP percentages > 25% high risk for reinfection.

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2.Prevalence of residual pockets greater than 4 mm

Presence of high frequencies of deep residual pockets and deepening of pockets during supportive periodontal care high risk for disease progression (Badersten et al, Claffey et al. 1990).

An increased number of residual pockets does not necessarily imply an increased risk for re-infection or disease progression 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).

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The scale runs in a linear mode with 2, 4, 6, 8, 10 and 12% being the divisions on the vector.

Individuals with up to four residual pockets relatively low risk.

More than eight residual pockets high risk for recurrent disease

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3.Loss of teeth from a total of 28 teeth

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 low riskMore than eight teeth lost high risk.

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4.Loss of periodontal support in relation 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 % of the root length, or on bite-wing radiographs in which the worst site affected is estimated in mm.

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One mm is equated with 10% bone loss. One mm is equated with 10% bone loss. The percentage is then divided by the The percentage is then divided by the patient's age patient's age

As an example, a 40-year-old patient with As an example, a 40-year-old patient with 20% of bone loss at the worst posterior site 20% of bone loss at the worst posterior site affected would be scored BL/Age = 0.5.affected would be scored BL/Age = 0.5.

715.Systemic conditions

Most substantiated evidence studies on Type I and Type II DM (Gusberti et al. 1983, Emrich et al. 1991, Genco ,Loe 1993)

IL-1 genotype positive patients advanced periodontitis lesions (Kornman et al. 1997)

Higher tooth loss in the IL-1 genotype positive subjects (McGuire, Nunn 1999)

IL-1 genotype positive patients higher BOP percentages and a higher proportion of patients with higher BOP percentages during a 1-year recall period (Lang et al. 2000)

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736.Cigarette smoking

Non-smokers (NS) and former smokers (FS) (more than 5 years since cessation) low risk for recurrence of periodontitis

Heavy smokers (HS), as defined by smoking more than one pack per day, high risk.

Occasional (OS; < 10 cigarettes a day) and moderate smokers ( MS) moderate risk for disease progression

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Based on the six parameters specified above, a multifunctional diagram is constructed for the PRA.

In this diagram, the vectors have been constructed on the basis of the scientific evidence available.

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Low Periodontal Risk Patient

All parameters within the lowrisk categories or at the most one parameter in themoderate risk category

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

Moderate Periodontal Risk Patient

At least two parameters inthe moderate category, but at most one parameterin the high risk category

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High Periodontal Risk Patient

At least two parameters in thehigh risk category

TOOTH

LEVEL

RISK

ASSES

SMENT

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The tooth risk assessment encompasses

TOOTH POSITION WITHIN DENTAL ARCH

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FURCATION INVOLVEMENT

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IATROGENIC FACTORS

Overhanging restorations and ill-fitting crown margins area for plaque retention : abundance of association studies documenting increased prevalence of periodontal lesions in the presence of iatrogenic factors

Leon 1977

RESIDUAL PERIODONTAL SUPPORT

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MOBILITYWhen assessing tooth mobility, it has

to be realized that two factors may contribute to hypermobility :

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87Persson 1980,

1981

SITE LE

VEL RISK

ASSES

SMENT

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The tooth site risk assessment includes the registration of bleeding on probing, probing depth, loss of attachment, and suppuration.

…..useful in evaluating periodontal disease activity and determining periodontal stability or on going inflammation.

……essential for the identification of the sites to be instrumented during SPT.

BOP

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PROBING DEPTH & LOSS OF ATTACHMENT

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ERRORS IN PROBING

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SUPPURATIONThe presence of suppuration increased the

positive predictive value for disease progression in combination with other clinical parameters such as BOP and increased probing depth. Badersten et al. 1985, 1990, Claffey et al. 1990

Hence, following therapy a suppurating lesion may provide evidence that the periodontitis site is undergoing a period of exacerbation Kaldahl et al. 1990

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Continuous multiple level risk assessment. Subject, tooth and site parameters are combined to establish the clinical risk for disease progression. Note that different sites in the same patient may have a different level of risk. Subject-based risk factors are used to put the tooth and /or site risk assessment in perspective.

OTHER

COMPLICATIO

NS

DURING SPT

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1.Caries / endodontic complications

Few studies specifically addressed root caries as a complication during a period of SPT Endodontic complications during SPT may result in tooth extraction. Data suggest that approximately 30% of all extractions of teeth over a 4-year period of SPT are the consequence of peri-apical lesions

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2.Periodontal abscessesPeriodontal abscesses appear to occur in approximately 35% of subjects on SPT. It appears that subjects on SPT who only received nonsurgical therapy may be at a greater risk of periodontal abscesses during the SPT phase.

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3.Root sensitivityRoot sensitivity is common, especially if treatment involved surgical procedures which decreases over time. Reports on root sensitivity during SPT vary from 15% to 98% and are often associated with root surface exposure and gingival recession.

SPT WITH

ADJUNCT

USE OF

ANTIMICROBIALS

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It appears that many patients are unable to achieve an oral hygiene consistent with periodontal health.

Therefore antimicrobials have been used to compensate for inadequate mechanical oral hygiene.

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Antimicrobials can be administered using different delivery systems, i.e. dentifrices, solutions for oral rinses or flushing of the periodontal pockets, and other local delivery systems.

There are few long-term studies suggesting the efficacy of such antimicrobials in SPT programs.

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1 .Dentifrices Rosling et al. demonstrated that a triclosan/copolymer containing dentifrice reduced the subgingival microbiota both quantitatively and qualitatively over a 3-year period without concomitant use of subgingival mechanical treatment.The frequency of deep periodontal pockets and number of sites exhibiting additional probing attachment and bone loss was also reduced .

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Furuichi et al. reported that patients using a triclosan/copolymer dentifrice demonstrated significantly more gain of attachment and decrease in mean pocket probing depth as compared to a control group.

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2. Chlorhexidine Christie et al (1998) in his study found that

chlorhexidine is effective when used as an adjunct rinse to inadequate mechanical oral hygiene in nonsurgical treatment of chronic to advanced periodontitis patients over an observation period of 1 year.

Use of chlorhexidine rinse over 3 years at varying intervals may also prevent tooth loss (Person et al 1998) .

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3.Administration of chlorhexidine in a controlled release delivery system (Periochip) in patients with residual pockets appeared to be effective in a 6-months study conducted by Heasman ( 2001)

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4.Study by Loesche and Johnson ( 2002) imply that the use of antibiotics are effective adjuncts to mechanical debridement and that the effect may be sustained over a longer period of time. However, the advantage of adjunct antibiotic therapy during SPT is unknown.

MAINTENANCE C

ARE

OF PATIE

NTS W

ITH

DENTA

L IMPLA

NTS

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In general, procedures for maintenance of patients with implants are similar to those with natural teeth, with three differences:1. Special instrumentation that will not scratch the implants .2. Acidic fluoride prophylactic agents are avoided.3. Nonabrasive prophypastes are used.

Depending on the clinical, radiographic, diagnosis, protocols for preventive and therapeutic measures were designed to intercept the development of peri-implant lesions.

The major clinical parameters to be used include:• Presence or absence of plaque• Presence or absence of BoP• Presence or absence of suppuration• Increased peri-implant probing depth• Evidence and extent of radiographic alveolar bone loss.

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During the phase after uncovering the implants, patients must use ultrasoft brushes, chemotherapeutic rinses, irrigation devices, to keep the implants clean.

Patients often are afraid to touch the implants but must be encouraged to keep the areas clean.

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Metal hand instruments and ultrasonic and Metal hand instruments and ultrasonic and sonic tips should be avoided because they sonic tips should be avoided because they can alter the titanium surface. can alter the titanium surface.

Only plastic instruments or specially Only plastic instruments or specially designed gold-plated curettes should be used designed gold-plated curettes should be used for calculus removal because the implant for calculus removal because the implant surfaces can be easily scratched. surfaces can be easily scratched.

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The rubber cup with pumice, tin oxide, or special implant polishing pastes should be used on abutment surfaces with light, inter mittent pressure.

Although daily use of topically applied antimicrobials is advised, acidic fluoride agents should not be used because they cause surface damage to titanium abutments.

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CONCLUSIO

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Fauchard in 1746 stated that "little or no care as to the cleaning of teeth is ordinarily the cause of all diseases that destroy them”

It implies the necessity for proper and regular personal plaque elimination, at least in patients treated for or susceptible to periodontal disease.

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REFER

ENCES

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Carranza- 10th ,12th edition Lindhe – 5th edition Supportive periodontal treatment Perio 2000 vol 9 1995 Periodontal maintenance . Journal of Periodontology May

2000 Evaluation of the safety and efficiency of novel metallic

ultrasonic scaler tip on titanium surfaces. Clin oral implant res 2012.

The Effects of Scaling a Titanium Implant Surface With Metal and Plastic Instruments: An in Vitro Study. JOP 1990.

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Lang ,Tonetti. Periodontal Risk Assessment (PRA) for Patients in Supportive Periodontal Therapy (SPT) . Oral Health & Preventive Dentisty 2003.

Pandey V et al. Supportive Periodontal Treatment and Patient Compliance- A Review. Journal of Advanced Medical and Dental Sciences Research 2014.

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