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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.
4
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)
9
10
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
11
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
12
Mechanical debridement Motivational environment
Good maintenance
results
RATIONALE
13
…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
14
…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
15
AIMS AND OBJECTIVES
Pathogenic factors
Host resistanc
e
Periodontal health
Aim of SPT reestablish the equilibrium
16
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
17
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.
18
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.
19
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
20
…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
22
SPT begins with..
COMMUNICATION
REALIZATION
COMPLIANCE
MOTIVATION
23
PART-I : MULTI RISK ASSESSMENT
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
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.
27
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.
28
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
29
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).
31
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
32
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
33
CALCULATING THE PATIENT'S INDIVIDUAL PERIODONTAL RISK ASSESSMENT (PRA)
34
A low PRA patient Has all parameters within the low-risk categories or - at the most - one parameter in the moderate-risk category
35
A MODERATE PRA patient has at least two parameters in the moderate category, but at most one parameter in the high-risk category
36
A high PRA patient Has at least two parameters in the high-risk category
37
TOOTH RISK ASSESSMENT:
Tooth position within the dental arch Furcation involvement Iatrogenic factors Residual periodontal support Mobility.
38
39
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.
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
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).
47
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).
48
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.
49
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
50
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.
52
PART II: TREATMENT
ORAL HYGIENE MEASURES IMPROVEMENT & PROFESSIONAL ORAL PROPHYLAXSIS
MOTIVATION/ BEHAVIOURAL MODIFICATION &COMPLIANCE
USE OF ANTIMICROBIALS
53
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
.
54
3. Use of Antimicrobials
*Adjunct to SPT
*Compensate for inadequate mechanical oral hygiene
*Dentifrices, LDS, Solutions for oral rinses or flushing of periodontal pockets.
55
PART-III: Next Schedule
RECALL FURTHER PERIO TREATMENT RESTORATIVE/PROSTHETIC TREATMENT
56
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)…
57
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…
58
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
59
TYPES OF COMPLIANCE
60
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…
65
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.
67
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
69
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
70
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
71
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
72
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
73
…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
74
…SPT IN DAILY PRACTICE
Diagnostic procedure includes assessment of:
Oral hygiene and plaqueBOP
PD and CAL
Pus formationExisting reconstructionsCarious lesions
75
…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
76
…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
77
…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
78
79complications
Caries: removal of root cementum during ICRT and during SPT
Endodontic lesions: exposure of accessory root canal
Periodontal Abscesses:
Root sensitivity:
80
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