Supportive Periodontal Therapy: Maintenance and Supervision Overview
S
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C
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R
A
M
M
E
P
R
E
S
E
N
T
E
D
B
Y
:
KURESHI NAVAL ANJUM
DEFINITION
•
Procedures
performed
at selected
intervals
to
assist
the
p
e
r
i
o
d
o
n
t
a
l
p
a
t
i
e
n
t
i
n
m
a
i
n
t
a
i
n
i
n
g
o
r
a
l
h
e
a
l
t
h
.
-
G
P
T
2
0
0
1
.
•
Therapeutic
measures
to
support
the
patient’s
own
efforts
to
c
o
n
t
r
o
l
a
n
d
t
o
a
v
o
i
d
r
e
‐
i
n
f
e
c
t
i
o
n
.
-
J
a
n
L
i
n
d
h
e
.
CO
RR
E
C
T
S
EQUE
N
C
E
O
F
T
R
EA
T
M
E
N
T
RA
T
I
ON
AL
E
F
O
R
SP
T
1.
Limitation
of
mechanical
subgingival
debridement
2.
Recolonization
of
3.
Long
JE
(weak
attachment)
4.
Subgingival
scaling
alters
the
microflora
of
periodontal
pockets
5.
To
prevent
interception
GOAL
S
O
F
SPT
•
3
m
a
i
n
g
o
a
l
s
a
c
c
o
r
d
i
n
g
t
o
t
h
e
A
A
P
p
o
s
i
t
i
o
n
p
a
p
e
r
(
1
9
9
8
)
1)
To
prevent or
minimize
the
recurrence
and
progression
of
periodontal
disease
in patients
who
have been previously
treated
for gingivitis,
periodontitis
and
for
peri-implantitis.
2)
To
prevent
or
reduce
the
incidence
of
tooth
loss
by
monitoring
the dentition
3)
To
locate
and
treat
other
diseases
or
conditions
found
in
the
oral
cavity
in
a
timely
manner
OBJE
C
T
I
V
E
S
O
F
SP
T
Periodontal
•
Preservation
of
bone
support
•
Maintenance
of
stable
CAL.
•
Reinforcement
of
proper
home
care.
•
Maintenance
of
a
healthy
and functional oral
environment
General
•
Assessment
of
the
general
health
status
•
Encouragement of
patients
oral
hygiene
efforts
•
Continuation
of
patient
education
•
Establishment
of
the
future maintenance
regime
T
Y
P
E
S
O
F
S
P
T
•
S
c
h
a
l
l
h
o
r
n
a
n
d
S
n
i
d
e
r
(
1
9
8
1
)
1.
Preventive
maintenance
therapy
•
Periodontally
healthy
individuals.
2.
Trial
maintenance
therapy
•
Mild
to
moderate
periodontitis
3.
Compromised
maintenance
therapy
•
Medically
compromised
patients
where
active
therapy
is
not
possible.
4.
Post-maintenance
treatment
therapy
•
maintenance
for
prevention
of
recurrence
of
disease
M
A
I
N
T
E
N
A
N
C
E
PR
OG
R
A
M
(
CA
RR
A
N
Z
A
)
SPT
1.
Examination
and
Evaluation
(14
mins.)
2.
Maintenance
R
x
and
oral
hygiene
reinforcement
(36
mins.)
3.
Report,
Cleanup,
and
Scheduling
(10
mins.)
P
A
RT
-
1
:
E
X
A
MI
NA
TI
O
N
AN
D
E
V
A
L
UA
TI
O
N
•
Patient
greeting
•
Medical
history
changes
•
Oral
hygiene
status
•
Gingival
changes
•
depth
changes
•
Mobility
changes
•
Occlusal
changes
•
Dental
caries
•
Oral
pathologic
examination
•
Restorative, prosthetic,
and
implant
status
Examination of
prosthesis/abutment
components;
Evaluation
of
implant
stability;
Occlusal
ex
a
m
in
a
t
i
o
n
;
Other signs and
symptoms of
disease
activity.
R
AD
I
OG
R
A
P
H
I
C
E
X
A
MI
NA
TI
O
N
O
F
R
E
C
A
L
L
P
A
TI
EN
T
S
Clinical
caries
and
no
high-risk
factors
for caries.
Posterior
bite-wing
examination
at
24 to
36-month
intervals.
Clinical caries
or high-risk
factors
for
caries
Posterior
bite-wing
examination
at
12 to
18-month
intervals.
History
of
periodontal
treatment
with
disease
under good
control.
Bite-wing examination every
24 to 36
months;
full-
mouth
series
every
5
years.
Periodontal
disease
not under
good
control.
Periapical and/or vertical
bite-wing radiographs of
problem
areas every
12 to 24
months;
full-mouth
series
every
3
to
5
years
Root
form
dental
implants
Periapical or vertical bite-wing
radiographs at 6, 12, and 36
months
after
prosthetic
placement,
then every 36
months
unless
clinical problems
arise.
M
I
C
R
OBIA
L
T
E
S
T
IN
G
P
A
RT-
2
:
M
A
I
N
T
ENANC
E
TR
EA
TM
EN
T
AND
O
R
A
L
H
Y
G
I
EN
E
R
E
I
N
F
O
R
C
E
ME
N
T
•
Oral
hygiene
reinforcement
•
Scaling
•
Polishing
•
Chemical
irrigation
or
site-specific
antimicrobial
placement
P
A
R
T
-
3
:
R
EPO
R
T
,
C
LEANUP
,
AN
D
S
C
HEDULIN
G
•
Write
report
in
chart.
•
Discuss
report
with
patient.
•
Clean
and
disinfect
operatory.
•
Schedule
next
recall
visit.
•
Schedule
further
periodontal
treatment.
•
Schedule
or
refer
for
restorative
or
prosthetic
treatment.
F
R
EQUE
N
C
Y
O
F
SP
T
•
Ramfjord
et
al.
(1993)
For
most
patients
with
gingivitis
but
no
previous
attachment
loss, supportive periodontal
treatment
twice
a
year.
•
For
patients
with
a
previous
history
of
periodontitis,
3
months
interval
(less than
6
months)
•
Various
clinical
trails
suggest-
four
times
a
year.
Decem
b
er
2015
C
L
ASS
IFI
CA
T
I
O
N
O
F
P
OS
T
-TR
EA
T
M
EN
T
P
A
TI
EN
T
S
(M
E
RI
N
)
SP
T
P
R
OG
R
A
M
M
E
(
L
I
NDH
E
)
E
F
F
E
C
TI
VEN
E
S
S
O
F
SP
T
(FOR
PATIENTS
WITH
GINGIVITIS)
•
Axelsson
and
Lindhe
(1974-1976):
demonstrated
that
gingivitis
could
be
prevented
by
regular
professional
cleaning
in
children
aged
7 to
14
years.
•
Axelsson
and
Lindhe
(1981):
reduced
caries
and
BOP
•
Badersten
et al.(1990):
Routine
mechanical
subgingival
debridement
of
shallow
bleeding
sites
at
SPT
visits
results
in
attachment
loss.
•
Gingival
conditions
improved
by
60%
and
tooth
loss
was
reduced
by
about 50%
(Lovdal
et al
.
1961)
•
The
mean
loss
of
probing
attachment
was
only
0.08
mm
per
surface
as
opposed
to
0.3
mm
in
the
control
group
(Suomi
et al
.
1971).
E
F
F
EC
T
I
VE
NE
S
S
O
F
SP
T
(FOR
PATIENTS
WITH
PERIODONTITIS)
•
Nyman
et al.
(1977) reported
on 25 patients
for 2
years
(No
SPT)
•
Regular
SPT
at
3-4
times
a
year
allows
disease
monitoring
Early
detection
and
Rx
Nyman
et
al.
(1975)
Test
OHI
and
SPT
2
weeks
Control
OHI
and
SPT
6
months
•
Dahlen
et al. (1992)
Professionally delivered supragingival
toothcleaning,
in
combination
with
self-performed
plaque
control
for
2-year
period
effectively
change
the
quantity
and
the
composition
of the
subgingival
microbiota
•
Hellstrom
et al. (1996)
same
protocol
has
a significant
effect
on
the
subgingival
microbiota
of
moderate
to
deep
periodontal
pockets
clinically.
•
(Lindhe
&
Nyman
1984)
•
75
patients
with
extremely
advanced
periodontitis,
•
recurrent
infection
occurred
in
only
very
few
sites
during
a
14
‐
year
period
of
effective
SPT.
•
recurrent
periodontitis was
noted at
completely unpredictable
time
intervals,
in
about
25%
of
the
patient
population
(15
of
61)
30‐YEARS
PLAQUE‐CONTROL-BASED
MAINTENANCE
PROGRAM
•
Axelsson
et
al
.
2004
375
test
and
180 control
The test
group- prophylactic
visits every second
month
for
the first 2 years and every
3–12
months
(according
to
their
individual
needs)
over
3–30
years
very
few
teeth
were lost
(0.4–1.8)
1.2–2.1 new carious lesions (>80% secondary caries)
2–4%
of
all
sites
exhibited
attachment
loss
of
≥2
mm.
CO
M
P
L
I
A
N
C
E
A
F
F
EC
T
I
N
G
SP
T
•
Wilson
stated that “Patients
who
comply
to suggested
recall
visits
are
periodontally
healthy
and
keep
their
teeth
longer.”
I
M
P
R
O
VI
N
G
C
O
M
P
L
I
A
N
C
E
•
Wilson
suggests:
•
Counselling
them
about
their
condition,
the
role
of
treatment
and
the
importance
of
compliance
•
Simplify
instructions
to
patients
•
Teach
them
self
performed
plaque
control
•
Acccommodating
patient
needs
•
Positive
reinforcement
W
RI
TT
E
N
IN
S
T
R
U
C
T
I
O
N
M
A
I
N
T
E
N
A
N
C
E
O
F
I
M
P
L
AN
T
S
•
Lang
et
al.
2004,
Cumulative
Interceptive
supportive
Therapy
MAINTENANCE
INTERVALS
FOR
IMPLANT
PATIENTS
1.
Patients
with
both
teeth
and
implants
should
see
the
periodontist
as often as necessary to keep the
periodontium
and
peri-implant
tissues
healthy.
2.
Totally
edentulous
patients
with
implants
should be
seen
at
least
once
per
year.
Con
cl
u
s
i
o
n
an
d
r
e
c
o
mm
e
nd
a
t
io
n
s
•
SPT
should
be
based
on
profile
of
risk
assessment
•
No
scientific
evidence
for
subgingival
debridement
of sites
with
BOP
without
concomitant
increase in pocket depth. (it should
better
be avoided)
•
SPT
minimizes
the
risk
of
periodontal
disease
progression
and
tooth
mortality
•
In
absence
of long-term
evaluation
of
SPT
for
dental
implants,
same
principles
of
SPT
that
is
used
for periodontitis is
also
apropriate
R
E
C
O
MM
ENDA
T
IO
N
F
O
R
RE
S
EAR
C
H
•
Studies
are
needed:
1.
to
evaluate
the
efficacy
of
supragingival
Rx
alone
as
compared
to
subgingival
debridement
2.
To
assess the value of
antibiotics as
adjunct and stand alone
Rx
during
SPT
3.
Patient
based
factors
must
be
considered
in
analysis
4.
Prospective
and multicenter
studies
to
findout
efficacy
of
SPT
Incterceptives
SPT
R
E
F
REN
C
E
S
:
•
American
Academy
of
Periodontology.
Glossary
of
Periodontal
Terms.
4th
ed.
Chicago:
American
Academy
of
Periodontology; 2001.
p.
39.
•
Kerry
GJ.
Supportive
periodontal
treatment.
Periodontology
2000,
vol.
9,
1995,
176-185.
•
Renvert
S.
Supportive
periodontal
therapy.
Periodontology
2000,
vol.
36,
2004,
179–195.
•
Hancock
EB.
Preventive
strategies
and
supportive
treatment.
Periodontology
2000,
vol. 25,
2001, 59–76.
•
Wilson
TG
Jr.
Supportive
periodontal
treatment
introduction
-
definition,
extent
of
need,
therapeutic objectives,
frequency
and
efficacv.
Periodontology
2000,
vol.
12,
1996,
11-15.
•
Slots
J.
Microbial
analysis
in
supportive
periodontal
treatment.
Periodontology
2000.
Voz.
12,
1996,
56-59.
•
Farooqi
AO.
Appropriate
recall interval
for
periodontal
maintenance:
A
systematic
review.
J
evid
base
dent pract
2015;15:171-181.
THANK YOU
Supportive Periodontal Therapy (SPT) is a critical phase in periodontal care designed to assist patients in maintaining oral health, prevent disease recurrence, and preserve bone support. It involves a series of procedures performed at intervals to support the patient's efforts in controlling and avoiding reinfection. The goals, objectives, types, and maintenance program of SPT outlined in this content provide a comprehensive understanding of this essential aspect of periodontal treatment.
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Presentation Transcript
SUPPORTIVEPERIODONTALTHERAPY MAINTENANCE PHASE RECALL/RE-EVALUATION SUPERVISED RE-CALL PROGRAMME PRESENTED BY: KURESHI NAVAL ANJUM
DEFINITION Procedures performed at selected intervals to assist the periodontal patient in maintaining oral health.-GPT 2001. Therapeutic measures to support the patient s own efforts to control and to avoid re infection.- Jan Lindhe.
RATIONALE FOR SPT 1. Limitation of mechanical subgingival debridement 2. Recolonization of pocket 3. Long JE (weak attachment) 4. Subgingival scaling alters the microflora of periodontal pockets 5. To prevent interception
GOALS OF SPT 3 main goals according to theAAP position paper (1998) 1) To prevent or minimize the recurrence and progression of periodontal disease in patients who have been previously treated for gingivitis, periodontitis and for peri-implantitis. 2) To prevent or reduce the incidence of tooth loss by monitoring the dentition 3) To locate and treat other diseases or conditions found in the oral cavity in a timely manner
OBJECTIVES OF SPT Periodontal Preservation of bone support Maintenance of stable CAL. Reinforcement of proper home care. Maintenance of a healthy and functional oral environment General Assessment of the general health status Encouragement of patients oral hygiene efforts Continuation of patient education Establishment of the future maintenance regime
Schallhorn and Snider (1981) TYPES OF SPT Preventive maintenance therapy Periodontally healthy individuals. Trial maintenance therapy Mild to moderate periodontitis Compromised maintenance therapy Medically compromised patients where active therapy is not possible. Post-maintenance treatment therapy maintenance for prevention of recurrence of disease 1. 2. 3. 4.
MAINTENANCE PROGRAM (CARRANZA) 1. Examination and Evaluation (14 mins.) 2. Maintenance Rxand oral hygiene reinforcement (36 mins.) SPT 3. Report, Cleanup, and Scheduling (10 mins.)
PART- 1: EXAMINATION AND EVALUATION Patient greeting Medical history changes Oral hygiene status Gingival changes Pocket depth changes Mobility changes Occlusal changes Dental caries Oral pathologic examination Restorative, prosthetic, and implant status Examination of prosthesis/abutment components; Evaluation of implant stability; Occlusal examination; Other signs and symptoms of disease activity.
RADIOGRAPHIC EXAMINATION OF RECALL PATIENTS Clinical caries or high-risk factors for caries Posterior bite-wing examination at 12 to 18-month intervals. dental implants Periodontal disease not under good control. Root form Periapical and/or vertical bite-wing radiographs of problem areas every 12 to 24 months; full-mouth series every 3 to 5 years Periapical or vertical bite-wing radiographs at 6, 12, and 36 months after prosthetic placement, then every 36 months unless clinical problems arise. History of periodontal treatment with disease under good control. Clinical caries and no high-risk factors for caries. Posterior bite-wing examination at 24 to 36-month intervals. Bite-wing examination every 24 to 36 months; full- mouth series every 5 years.
MICROBIAL TESTING
PART-2: MAINTENANCE TREATMENT AND ORAL HYGIENE REINFORCEMENT Oral hygiene reinforcement Scaling Polishing Chemical irrigation or site-specific antimicrobial placement
PART-3: REPORT, CLEANUP, AND SCHEDULING Write report in chart. Discuss report with patient. Clean and disinfect operatory. Schedule next recall visit. Schedule further periodontal treatment. Schedule or refer for restorative or prosthetic treatment.
FREQUENCY OF SPT Ramfjord et al. (1993) For most patients with gingivitis but no previous attachment loss, supportive periodontal treatment twice a year. For patients with a previous history of periodontitis, 3 months interval (less than 6 months) Various clinical trails suggest- four times a year.
EFFECTIVENESS OF SPT (FOR PATIENTS WITH GINGIVITIS) Axelsson and Lindhe (1974-1976): demonstrated that gingivitis could be prevented by regular professional cleaning in children aged 7 to 14 years. Axelsson and Lindhe (1981): reduced caries and BOP Badersten et al.(1990): Routine mechanical subgingival debridement of shallow bleeding sites at SPT visits results in attachment loss.
Gingival conditions improved by 60% and tooth loss was reduced by about 50% (Lovdal et al. 1961) The mean loss of probing attachment was only 0.08 mm per surface as opposed to 0.3 mm in the control group (Suomi et al. 1971).
EFFECTIVENESS OF SPT (FOR PATIENTS WITH PERIODONTITIS) Nyman et al. (1977) reported on 25 patients for 2 years (No SPT) Regular SPT at 3-4 times a year allows disease monitoring Early detection and Rx Nyman et al. (1975) Test Control OHI and SPT 6 months OHI and SPT 2 weeks
Dahlen et al. (1992) Professionally delivered supragingival toothcleaning, in combination with self-performed plaque control for 2-year period effectively change the quantity and the composition of the subgingival microbiota Hellstrom et al. (1996) same protocol has a significant effect on the subgingival microbiota of moderate to deep periodontal pockets clinically.
(Lindhe & Nyman 1984) 75 patients with extremely advanced periodontitis, recurrent infection occurred in only very few sites during a 14 year period of effective SPT. recurrent periodontitis was noted at completely unpredictable time intervals, in about 25% of the patient population (15 of 61)
30YEARS PLAQUECONTROL-BASED MAINTENANCE PROGRAM Axelsson et al. 2004 375 test and 180 control The test group- prophylactic visits every second month for the first 2 years and every 3 12 months (according to their individual needs) over 3 30 years very few teeth were lost (0.4 1.8) 1.2 2.1 new carious lesions (>80% secondary caries) 2 4% of all sites exhibited attachment loss of 2 mm.
COMPLIANCE AFFECTING SPT Wilson stated that Patients who comply to suggested recall visits are periodontally healthy and keep their teeth longer.
IMPROVING COMPLIANCE Wilson suggests: Counselling them about their condition, the role of treatment and the importance of compliance Simplify instructions to patients Teach them self performed plaque control Acccommodating patient needs Positive reinforcement
MAINTENANCE OF IMPLANTS Lang et al. 2004, Cumulative Interceptive supportive Therapy
MAINTENANCEINTERVALSFORIMPLANTPATIENTS 1. Patients with both teeth and implants should see the periodontist as often as necessary to keep the periodontium and peri-implant tissues healthy. 2. Totally edentulous patients with implants should be seen at least once per year.
Conclusionand recommendations SPT should be based on profile of risk assessment No scientific evidence for subgingival debridement of sites with BOP without concomitant increase in pocket depth. (it should better be avoided) SPT minimizes the risk of periodontal disease progression and tooth mortality In absence of long-term evaluation of SPT for dental implants, same principles of SPT that is used for periodontitis is also apropriate
RECOMMENDATION FOR RESEARCH Studies are needed: 1. to evaluate the efficacy of supragingival Rx alone as compared to subgingival debridement 2. To assess the value of antibiotics as adjunct and stand alone Rx during SPT 3. Patient based factors must be considered in analysis 4. Prospective and multicenter studies to findout efficacy of SPT
Incterceptives SPT
REFRENCES: AmericanAcademy of Periodontology. Glossary of PeriodontalTerms. 4th ed. Chicago:AmericanAcademy of Periodontology; 2001. p. 39. Kerry GJ. Supportive periodontal treatment. Periodontology 2000, vol. 9, 1995, 176-185. Renvert S. Supportive periodontal therapy. Periodontology 2000, vol. 36, 2004, 179 195. Hancock EB. Preventive strategies and supportive treatment. Periodontology 2000, vol. 25, 2001, 59 76. WilsonTG Jr. Supportive periodontal treatment introduction - definition, extent of need, therapeutic objectives, frequency and efficacv. Periodontology 2000, vol. 12, 1996, 11-15. Slots J. Microbial analysis in supportive periodontal treatment. Periodontology 2000. Voz. 12, 1996, 56-59. FarooqiAO.Appropriate recall interval for periodontal maintenance:A systematic review. J evid base dent pract 2015;15:171-181.
