Supportive

Periodontal

Therapy

DR. SHIVI KHATTRI

ASSOCIATE PROFESSOR

DEPARTMENT OF PERIODONTOLOGY

E-LECTURE FOR BDS STUDENTS

The 3rd World Workshop of the American Academy of Periodontology (1989)

renamed this maintenance phase as SUPPORTIVE PERIODONTAL THERAPY.

AAP position paper in 2003 termed it as PERIODONTAL MAINTENANCE

The term SUPPORTIVE PERIODONTAL THERAPY expresses the essential need for therapeutic measures to support the patient’s

own efforts to control periodontal infections and to avoid

reinfection.

This phase is carried out immediately after Phase 1 therapy so that

all parts of the oral cavity are able to retain the same degree of

health that has been attained following Phase 1 therapy

Long term preservation of the dentition is closely associated with the

frequency and quality of recall maintenance.

Patients who do not return for SPT lose 5-6 times more teeth than

compliant patients.

MOTIVATIONAL TECHNIQUES and REINFORCEMENT of the importance of

the maintenance phase of treatment should be considered before performing

definitive periodontal surgery.

It is meaningless to simply inform patients that they are to return for periodic

recall visits without clearly explaining the significance of these visits and

describing what is expected of them between these visits.

Periodontal treatment includes:

Systemic evaluation of the patient’s health

A cause related therapeutic phase

A corrective phase involving periodontal surgical procedures

Maintenance phase

PHASE II ( Periodontal

surgery)

PHASE I

REEVALUATION

PHASE II ( Periodontal

surgery)

PHASE III (Restorative)

PHASE IV ( Maintenance

phase)

PHASE I

REEVALUATION

PHASE IV ( Maintenance

phase)

PHASE III (Restorative)

Rationale for SPT

• Incomplete Subgingival Plaque removal

• Bacteria are present in the gingival tissues mainly in

Aggressive Periodontitis cases

• Bacteria associated with periodontitis can be transmitted

between spouses and other family members.

• Subgingival scaling alters the microflora of periodontal

pockets.

RATIONALE FOR SPT

INCOMPLETE REMOVAL OF SUBGINGIVAL PLAQUE

REGROWTH OF SUBGINGIVAL PLAQUE

NO INFLAMMATORY RESPONSE AT THE GINGIVAL MARGIN

ADEQUATE SUPRAGINGIVAL PLAQUE CONTROL

CONTINUED LOSS OF ATTACHMENT

SLOW PROCESS OF REGROWTH

• Incomplete Subgingival Plaque removal

• Bacteria are present in the gingival tissues mainly in

Aggressive Periodontitis cases

• Bacteria associated with periodontitis can be transmitted

between spouses and other family members.

• Subgingival scaling alters the microflora of periodontal

pockets.

• Incomplete Subgingival Plaque removal

• Bacteria are present in the gingival tissues mainly in

Aggressive Periodontitis cases

• Bacteria associated with periodontitis can be transmitted

between spouses and other family members.

• Subgingival scaling alters the microflora of periodontal

pockets.

• Incomplete Subgingival Plaque removal

• Bacteria are present in the gingival tissues mainly in

Aggressive Periodontitis cases

• Bacteria associated with periodontitis can be transmitted

between spouses and other family members.

• Subgingival scaling alters the microflora of periodontal

pockets.

RATIONALE FOR SPT

Another possible explanation for the recurrence of

Periodontal Disease is the Microscopic Nature of the

Dentogingival unit healing after periodontal treatment.

Histologic studies have shown that after periodontal

procedures, tissues usually do not heal by formation of new

connective tissue attachment to root surface but result in

Long Junctional Epithelium.

RATIONALE FOR SPT

Both the Mechanical Debridement performed by the

therapist and the Motivational Environment provided by

the appointment seem to be necessary for good

maintenance results. Patients tend to reduce their oral

hygiene efforts between appointments. Knowing that

their hygiene will be evaluated Motivates them to

perform better oral hygiene in anticipation of the

appointment.

OBJECTIVES The therapeutic objectives of Supportive periodontal therapy are:

• To prevent the progression and recurrence of periodontal disease in patients who

have previously been treated for gingivitis and periodontitis.

• To prevent the loss of dental implants after clinical stability has been achieved.

• To reduce tooth loss by monitoring the dentition and any prosthetic replacements

of the natural teeth.

• To diagnose and manage, in a timely manner, other diseases or conditions found

within and related to the oral cavity.

Classification of Post

treatment patients

and Risk Assessment

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

CLASSIFICATIO

N

CHARACTERISTICS 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

CLASSIFICATI

ON

CHARACTERISTICS RECALL

INTERVAL

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

displays some of the following factors

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

- > 20% pockets bleed on probing

CLASSIFICA

TION

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 or financial reasons

-Many teeth with <50% bone support

-Smoking

- +ve family history

- > 20% pockets bleed on probing

1-3 months

RADIOGRAPHIC EXAMINATION

RECOMMENDATIONS

CLINICAL 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

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

Maintenance

Program

MAINTENANCE PROGRAM:

• Periodic recall visits form the foundation of a

meaningful long term prevention program.

• The interval between visits is initially set at 3 months

but may be varied according to the patient’s needs.

• The RECALL HOUR should be planned to meet the

individual’s needs.

• It basically consists of four different sections which

may require various amounts of time during a

regularly scheduled visit.

ERD

EXAMINATION, REVALUATION

DIAGNOSIS

(10-15 MINS)

60 0

15

30

45

MRI

MOTIVATION

RE-INSTRUCTION

(5-7 MINS)

INSTRUMENTATION

Scaling/root planing

(30-40 mins)

TRS

TREATMENT OF

RE-INFECTED

SITES

PFD

POLISHING, FLUORIDES

DETERMINATION OF FUTURE

SPT ( 8 MINS )

The recall hour is composed of

• 10-15 minutes diagnostic procedures (ERD)

• 30-40 minutes of motivation, reinstruction and

instrumentation (MRI) during which time the

instrumentation is concentrated on the sites diagnosed

with persistent inflammation.

• Treatment of reinfected sites may include small surgical corrections,

applications of local drug delivery devices or just intensive

instrumentation under local anesthesia. Such procedures if judged

necessary may require an additional appointment.

5-10 minutes (PFD) - The recall hour is normally

concluded with polishing of the entire dentition,

application of fluorides and another assessment of the

situation including the determination of future SPT visits.

Referral of patients

to the Periodontist

Conclusion

Recall visits are equally important as the treatment visits.

Motivational techniques are employed for making the patient willingly accept visiting the dental office during the recall phase.

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