supportive periodontal therapy final1

SUPPORTIVE PERIODONTAL THERAPY

Dr. VIVEK Kr. SHARMAALIGARH MUSLIM UNIVERSITY

2

GOAL OF PERIODONTAL TREATMENT

Tuesday, April 11, 2023Dr Vivek Sharma.AMU

To maintain the natural dentition in functional health and comfort THROUGHOUT the LIFETIME.

It requires a perfect plaque control

3


Even after appropriate Periodontal Therapy, some progression of disease is possible*

Greenwell et al 1989,Hirschfield et al 1985,Tonetti et al 1998,

Incomplete subgingival plaque removal

4

PLAQUE CONTROL


MOTIVATION MECHANICAL/CHEMICAL AIDS PERIODIC REMOVAL OF

PLAQUE/PROFESSIONAL MAINTENANCE

Improper plaque control will results in Gingivitis

Compromising functional comfort and longevity of the dentition

5

To what extent should professional maintenance care be concerned with the treatment and prevention of gingivitis?


Minimal/No effect on functional comfort No test that will predict in which patient

gingivitis will progress to periodontitis No predictability of progression rate of

attachment loss.

6

BUT, Compelling reasons are


Gingivitis is- Form of disease. May develop into periodontitis with loss of

attachment. Less evidence of gingivitis, the less severe is the

loss of periodontal attachment over time. To control periodontitis the only way is to control

gingivitis and plaque control. Gingivitis is a greater threat to loss of attachment

in persons who already have lost some attachment

Perfect Professional & Personal Plaque ControlGINGIVITIS

PERIODONTITIS

Longevity of Dentition

7

If After Active Periodontal Therapy…


8

PERIODONTAL TREATMENT PLAN*


PHASE I(ICRT)

REEVALUATION

PHASE IV(Maintenance/SPT)

PHASE II PHASE III(Periodontal Surgery) ( Restorative)*Carranza’s 9th edition

9

Supportive Periodontal Therapy


Definition. Basic paradigms for the prevention of

periodontal diseases. Rationale of SPT. Continuous multi-level risk assessment;

Subject risk assessment, Tooth risk assessment, Site risk assessment

Therapeutic goals and objectives. Complications Conclusion

10

Definition


1989,3rd world workshop of AAP, Rename the Maintenance

Phase.

Continuous Diagnostic monitoring of the patient in order to intercept with adequate therapy and to optimize the therapeutic interventions tailored to the patient’s need.

Essential need for therapeutic measures to support the patient’s own efforts to control periodontal infections and to avoid Re-infection.

11

Basic Paradigms for prevention of periodontal Disease


Cause-Effect relationship: Plaque Gingivitis

Löe et al 1965

Cause-Effect relationship: Plaque Accumulation Periodontal Disease

Lindhe et al 1975

12

Cont…


It seems reasonable to predict that the elimination of gingival inflammation and the maintenance of healthy gingival tissues will result in the prevention of both the initiation and the recurrence of periodontal disease.

13

Cont…thus to prevent periodontal disease


Necessity for proper and regular personal plaque elimination, at least in patients treated for or susceptible to periodontal disease

Interceptive professional supportive therapy at regular intervals may, to a certain extent, compensate for the lack of personal compliance with regard to oral hygiene standards.

14

Rationale for SPT :


PERIODONTITIS: Chronic in Nature

1

15


No definitive periodontal treatment

that can cure the disease. •Antimicrobial Therapy•Regenerative Procedures•Host-Modulation Therapy•Diet /Antioxidant based Therapy•Tri-Immuno Phasic Therapy

2

16


The microbial challenge which induces and maintains the inflammatory response, may not be completely eliminated from the dento-gingival environment for any length of time.

3

17


Bacteria associated with periodontitis can be transmitted between spouses and other family members

4

18


The inability of existing clinical parameters to predict disease progression mean that continuous adjunct monitoring and treatments are necessary to prevent recurrence of the disease.

5

19

Its SPT that…


Prevent /Minimize Recurrence of Disease Progression.

Prevent/Minimize the incidence of Teeth or Implant Loss

Increase the Probability of Locating and Treating other Disease and Conditions

SPT has to be aimed at regular removal of the subgingival microbiota and must be supplemented by the patient’s efforts for optimal supragingival plaque removal

THERAPEUTIC GOALS

Tuesday, April 11, 2023Dr Vivek Kumar Sharma AMU

20

1. To minimize the recurrence and progression of periodontal disease in patients who have been previously treated for gingivitis and periodontitis.

2. To reduce the incidence of tooth loss by monitoring the dentition and any prosthetic replacements of the natural teeth.

3. To increase the probability of locating and treating, in a timely manner, other diseases or conditions found within the oral cavity.

21

SPT COMPRISES OF….


Part I : Examination

Part II : Treatment

Part III: Next Schedule

PERIODONTAL RISK ASSESSMENT

Oral hygiene Reinforcement

RecallFurther Perio Tt.*Restorative/Prosthetic Tt.*

MULTI RISK ASSESSMENT

TOOTH RISK ASSESSMENT

SITE RISK ASSESSMENT

22

SPT begins with..


COMMUNICATION

MOTIVATION

COMPLIANCE

REALIZATION


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

Tuesday, April 11, 2023Dr Vivek Sharma.AMU25

26

BOP 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.

1

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.

2

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

3

29

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


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 milli-meter 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

The rate of progression of disease has been positively affected by the treatment rendered 4

30

Contd…


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 caseof 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 s 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

5

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) and moderate 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 periodontitisNot only does smoking increase the extent and severity of periodontal

disease, it compromises the outcomes of surgical and non-surgical therapy

6

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

B.


TOOTH RISK ASSESSMENT:

Tuesday, April 11, 2023

38

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

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.

40

Furcation 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.

41

Iatrogenic factors.


OVERHANGING RESTORATIONS ILL-FITTING CROWNS IMPROPERLY PLACED ORTHODONTIC

BRACKETSChange 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.

42

Residual 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

43

Mobility.


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.

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

44

C.


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

46

Bleeding 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 longterm 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.

Radiographic evaluation ofperiodontal disease progression.

Tuesday, April 11, 2023

49

Radiograph : *Assist in clinician’s judgement *Current *Based on diagnostic needs of patient *Permit proper evaluation and interpretation of the

status of the periodontium. *Radiographic abnormalities must be noted and co-

relate them with degree of disease activity

Bitewing Examination at 12-18 month interval : high risk caries patient

every 24-36 month : patient with good control over periodontal diseasePeri-apical and/or at 12-24 months : Patient with poor control over Vertical bite wings periodontal disease 6-12-36 months : Patient with root form dental implants after prosthetic placement.

50

Multi 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.

51

PART II: TREATMENT


ORAL HYGIENE MEASURES IMPROVEMENT & PROFESSIONAL ORAL PROPHYLAXSIS

MOTIVATION/ BEHAVIOURAL MODIFICATION &COMPLIANCE

USE OF ANTIMICROBIALS

52

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.

53


3. Use of Antimicrobials*Adjunct to SPT

*Compensate for inadequate mechanical oral hygiene

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


54

PART-III: Next Schedule

RECALL FURTHER PERIO TREATMENT RESTORATIVE/PROSTHETIC

TREATMENT

55

RECALL INTERVALS


SHORT INTERVAL RECALL: 3-4 Month Recall intervals for SPT is recommended

as frequent maintenance care is necessary to eliminate/reduce sub-gingival proportions of pathogens.

LONG INTERVAL 6-12 Month interval for SPT can effectively prevent

further disease progression.

56


CLASS “A”: Patient displays good oral hygiene,minimal calculus, no occlusal problems, no complicated prosthesis, no remaining pockets & no teeth with less than 50% of alveolar bone remaining .

CLASS “B”: Patients with inconsistent/poor oral hygiene, heavy calculus, systemic disesase, occlusal problems, complicated prosthesis, recurrent caries, some teeth with less than 50% of alveolar bone support, smoking, positive genetic test

CLASS”C” : Patient with poor maintenance after 1 year with more aggressive problem s of class B, condition too far advanced to be improved by periodontal surgery

RECALL INTERVALS: After 1yr well maintenance

6-12 month recall

3-4 month recall

1-3 month recall

Compliance with recall system

Tuesday, April 11, 2023Dr Vivek Kr Sharma,AMU

57

Treated periodontal patients who comply with regular periodontal maintenance appointments have a better prognosis than patients who do not comply.

Non-compliant or poorly compliant patients should be considered at higher risk for periodontal disease progression.


58

COMPLICATIONS OF SUPPORTIVE PERIODONTAL THERAPY

Caries: removal of root cementum during ICRT and during SPT

Endodontic lesions: exposure of accessory root canal

Periodontal Abscesses:

Root sensitivity:

59Conclusion


The programme of Supportive periodontal therapy is essential to long-term stability of patients with chronic periodontitis.

The clinical strategy for SPT is determined according to ‘clinical needs’ of the patient and is thus clinical observation and individual discretion is of utmost importance rather than best available ‘clinical evidence’

60

SPT


THANKS

supportive periodontal therapy final1

Health & Medicine