Supportive periodontal therapy

Supportive periodontal therapy, Risk Factors

1. SUPPORTIVE PERIODONTAL THERAPY PRESENTED BY: PRABLEEN ARORA MDS STUDENT 1

2. INTRODUCTION Treatments with long term maintenance programs following active therapy, once termed maintenance is called as Supportive Periodontal Therapy (SPT) American Academy of Periodontology (AAP), 1986. In 2003 AAP, position paper termed as Periodontal Maintenance Therapy. The continuing, periodic assessment and prophylactic treatment of the periodontal structures permitting early detection and treatment of new and recurring disease has been commonly referred to as periodontal maintenance or recall. (American Academy of Periodontology . Glossary of periodontal term, 1992) 2

3. Periodontal treatment includes: 1. systemic evaluation of the patient's health 2. a cause-related therapeutic phase 3. a corrective phase involving periodontal surgical procedures 4 . maintenance phase The 3rd World Workshop of the American Academy of Periodontology (1989) has renamed this treatment phase "supportive periodontal therapy" (SPT) . This term expresses the essential need for therapeutic measures to support the patient's own efforts to control the periodontal infections and to avoid reinfection . 3

4. An integral part of SPT is the continuous diagnostic monitoring of the patient in order to intercept with adequate therapy and to optimize the therapeutic interventions tailored to the patient's needs. 4 ROLE

5. Patients with inadequate SPT after successful regenerative therapy have a fiftyfold increase in risk of probing attachment loss compared with those who have regular recall visits. Pini -Prato G et al 1994 Treated patients who do not return for regular recall are at 5.6 times greater risk for tooth loss than compliant patients. Checchi L et al 2002 5

6. RATIONALE FOR SUPPORTIVE PERIODONTAL TREATMENT Incomplete subgingival plaque removal ( Waerhaug J 1978 ) Bacteria present in gingival tissues mainly in chronic and aggressive periodontitis. Bacterial transmission between spouses and other family members. Recurrence of periodontal disease is the microscopic nature of the dentogingival unit healing after periodontal treatment. 6

7. Subgingival scaling alters the microflora of periodontal pockets. In a single session of scaling and root planing in patients with chronic periodontitis resulted in significant changes in subgingival microflora . A lterations included a decrease in the proportion of motile rods for 1 week , a marked elevation in the proportion of coccoid for 21 days a marked reduction in the proportion of spirochetes for 7 weeks . Phillips RW et al1980 Although pocket debridement suppresses components of the subgingival microflora associated with periodontitis, periodontal pathogens may return to baseline levels within days or months. The return of pathogens to pretreatment levels generally occurs in approximately 9 to 11 weeks but can vary dramatically among patients. American academy of periodontology : Periodontal maitenance , J PERIODONTOL 2003 7

8. Therapeutic goals of SPT 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 or related to the oral cavity 8

9. Periodontal Risk Assessment (PRA) for Patients in Supportive Periodontal Therapy (SPT) The patient's risk assessment for recurrence of periodontitis may be evaluated on the basis of a number of clinical conditions whereby no single parameter displays a more paramount role. The entire spectrum of risk factors and risk indicators ought to be evaluated simultaneously. 9

10. For this purpose , a functional diagram has been constructed including the following aspects: (Lang & Tonetti 2003) 1. Percentage of bleeding on probing, 2. Prevalence of residual pockets greater than 4 mm (5 mm), 3. Loss of teeth from a total of 28 teeth, 4. Loss of periodontal support in relation to the patient's age, 5. Systemic and genetic conditions, and 6. Environmental factors, such as cigarette smoking. Each parameter has its own scale for minor, moderate and high risk profiles . A comprehensive evaluation, the functional diagram will provide an individualized total risk profile and determine the frequency and complexity of SPT visits. 10

11. A low PR patient has all parameters within the low risk categories or at the most one parameter in the moderate risk category. 11

12. A moderate PR patient has at least two parameters in the moderate category, but at most one parameter in the high risk category 12

13. A high PR patient has at least two parameters in the high risk category 13

14. SPT in daily practice What does it involve? When does it start? Who performs it? How frequently? 14

15. What does it involve? SPT recall hour The recall hour should be planned to meet the patient's individual needs. 4 different sections: 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) 15

16. Examination, Re-evaluation and Diagnosis (ERD) An extraoral and intraoral soft tissue examination should be performed at any SPT visit to detect any abnormalities and to act as a screening for oral cancer. 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. Following the assessment of the subject's risk factors, the tooth site-related risk factors are evaluated. Diagnostic procedure usually includes an assessment of the following: 1. the oral hygiene and plaque situation 2. the determination of sites with bleeding on probing, indicating persistent inflammation 3. the scoring of clinical probing depths and clinical attachment levels . 4. the inspection of reinfected sites with pus formation 5. the evaluation of existing reconstructions, including vitality checks for abutment teeth 6. the exploration for carious lesions. All these evaluations are performed for both teeth and oral implants. 16

17. Motivation, Reinstruction and Instrumentation (MRI) When informed about the results of the diagnostic procedures, e.g. the total percentage of the bleeding on probing (BOP) score or the number of pockets exceeding 4 mm, the patient may be motivated either in a confirmatory way in case of low scores or in a challenging fashion in case of high scores. Since encouragement usually has a greater impact on future positive developments than negative criticism, every effort should be made to acknowledge the patient's performance. Patients who have experienced a relapse in their adequate oral hygiene practices need to be further motivated. 17

18. Occasionally, patients present with hard tissue lesions (wedge-shaped dental defects) which suggest faulty mechanical tooth cleaning . Such habits should be broken and the patient reinstructed in tooth brushing techniques which emphasize vibratory rather than scrubbing movements. Since it appears impossible to instrument 168 tooth sites in a complete dentition in the time allocated, only those sites will be reinstrumented during SPT visits which exhibit signs of inflammation and/or active disease progression. Hence, all the BOP positive sites and all pockets with a probing depth exceeding 5 mm are carefully resealed and root planed. Repeated instrumentation of healthy sites will inevitably result in mechanically caused continued loss of attachment. Lindhe et al. 1982 18

19. Several longitudinal studies that probing attachment may be lost following instrumentation of pockets below a "critical probing depth" of approximately 2.9 mm. Instrumentation of shallow sulci is, therefore, not recommended. Lindhe et al. 1982 As it has been shown in several studies that non-bleeding on probing sites represent stable sites , it appears reasonable to leave non-bleeding sites for polishing only and concentrate on periodontal sites with a positive BOP test or probing depths exceeding 5 mm. Lang et al. 1986, 1990, Joss et al. 1994 19

20. Treatment of Reinfected Sites (TRS) Single sites, especially furcation sites or sites with difficult access, may occasionally be reinfected and demonstrate suppuration. Such sites require a thorough instrumentation under anesthesia , the local application of antibiotics in controlled release devices or even open debridement with surgical access. Therapeutic procedures may be too time-consuming to be performed during the routine recall hour, and hence, it maybe necessary to reschedule the patient for another appointment. Omission of thoroughly retreating such sites or only performing incomplete root instrumentation during SPT may result in continued loss of probing attachment ( Kaldahl et al. 1988, Kalkwarf et al. 1989). Treatment choices for reinfected sites should be based on an analysis of the causes most likely responsible for the reinfection . Generalized reinfections are usually the result of inadequate SPT. 20

21. Sometimes, a second visit 2-3 weeks after the recall maybe indicated to check the patient's performance in oral home care. It is particularly important to supervise patients closely for advanced periodontitis if they have a high subject risk assessment. Westfelt et al. 1983, Ramfjord 1987. 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. Eg: furcation involvement. 21

22. 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. This may provide freshness to the patient and facilitates the diagnosis of early carious lesions. Following polishing, fluorides should be applied in high concentration in order to replace the fluorides which might have been removed by instrumentation from the superficial layers of the teeth. Fluoride or chlorhexidine varnishes may also be applied to prevent root surface caries, especially in areas with gingival recessions. The determination of future SPT visits must be based on the patient's risk assessment. 22

23. Time required for a recall visit for patients with multiple teeth in both arches is ≈ 1 hour Schallhorn RG, 1981 23

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25. When does it start? The maintenance phase of periodontal treatment starts immediately after the completion of Phase I therapy . While the patient is in the maintenance phase, the necessary surgical and restorative procedures are performed. This ensures that all areas of the mouth retain the degree of health attained after Phase I therapy. 25

26. Incorrect sequence of periodontal treatment phases correct sequence of periodontal treatment phases 26

27. Who should provide? IF Periodontal destruction necessitates surgery On distal surfaces of second molars Extensive osseous surgery Complex regenerative procedures Patients who require Localized gingivectomy Flap curettage Specialists are needed to treat particularly difficult periodontal cases, patients with systemic health problems, dental implant patients, and those with a complex prosthetic construction that requires reliable results. American Academy of Periodontology 2006 has issued guidelines to help the general practitioner decide when co-management with a periodontist is indicated. The diagnosis indicates the type of periodontal treatment required. Should the maintenance phase of therapy be performed by the general practitioner or the specialist? This should be determined by the amount of periodontal deterioration present. 27

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29. SPT FOR PATIENTS WITH GINGIVITIS Badersten et al. 1975, Poulsen et al. 1976, Axelsson & Lindhe 1981, Bellini et al. 1981 documented that periodic professional prophylactic visits in conjunction with reinforcement of personal oral hygiene are effective in controlling gingivitis. Adults whose effective oral hygiene was combined with periodic professional prophylaxes clearly were healthier periodontally than patients who did not participate in such programs. Lovdal et al. 1961, Suomi et al. 1971 . Lovdal et al. 1961 performed a study on 1428 adults from an industrial company in Oslo, Norway . Over a 5-year observation period, the subjects were recalled 2-4 times per year for instruction in oral hygiene and supragingival and subgingival scaling. Gingival conditions improved by approximately 60% and tooth loss was reduced by about 50% of what would be expected without these efforts. 29

30. A study in which loss of periodontal tissue support in young individuals with gingivitis or only loss of small amounts of attachment was followed over 3 years. An experimental group receiving scaling and instruction in oral hygiene every 3 months yielded significantly less plaque and gingival inflammation than the control group in which no special efforts had been made. The mean loss of probing attachment was only 0.08 mm per surface in the experimental as opposed to 0.3 mm in the control group. Suomi et al. 1971 30

31. SPT FOR PATIENTS WITH PERIODONTITIS Patients with advanced periodontitis may need SPT at a regular and rather short time interval (3-4 months) , while for mild to moderate forms of periodontitis, one annual visit may be enough to prevent further loss of attachment. PPD and CAL were maintained as a result of a well-organized professional maintenance care program (recall intervals varying between 3 and 6 months), irrespective of the initial treatment modality performed. Ramfjord et al.-1968, Lindhe and Nyman-1975,1984 31

32. Listgarten MA et al 1978,1986 concluded that the arbitrary assignment of treated periodontitis patients to 3-month maintenance intervals appears to be as effective in preventing recurrences of periodontitis as assignment of recall intervals based on microscopic monitoring of the subgingival flora. Microscopic monitoring was found not to be a reliable predicto r of future periodontal destruction in patients on 3-month recall programs, presumably because of the alteration of subgingival flora produced by subgingival instrumentation. 32 The rationale for 3-month recall intervals for SPT is most likely based on Recolonization of pathogens in previously treated periodontal pockets that occurs quickly if oral hygiene is not properly maintained. Therefore, 3–4-month maintenance care intervals have been suggested. Ramfjord SP 1987.

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34. SPT with adjunct use of antimicrobials/antibiotics Antimicrobials have been used to compensate for inadequate mechanical oral hygiene . Antimicrobials can be administered using different delivery systems: dentifrices, solutions for oral rinses or flushing of the periodontal pockets other local delivery systems. 34

35. 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 when using such a dentifrice over 3 years. Use of chlorhexidine rinse over 3 years at varying intervals may also prevent tooth loss. Administration of chlorhexidine in a controlled release delivery system ( Periochip ) in patients with residual pockets after ICRT (initial cause related therapy )appeared to be effective in a 6-month study . 35

36. Recurrence of Periodontal Disease 36

37. F ailing case can be recognized by the following: Recurring inflammation revealed by gingival changes and bleeding of the sulcus on probing. Increasing depth of sulci , leading to the recurrence of pocket formation. 3 . Gradual increases in bone loss , as determined by radiographs. 4. Gradual increases in tooth mobility , as ascertained by clinical examination. The decision to re-treat a periodontal patient should not be made at the preventive maintenance appointment but should be postponed for 1 to 2 weeks. ( Chace R 1977) 37

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39. MAINTENANCE FOR DENTAL IMPLANT PATIENTS Patients with periodontitis-associated tooth loss are at significantly increased risk of developing periimplantitis . The overall periodontal condition in partially edentulous implant patients can influence the clinical condition around implants. The microflora of implants in partially edentulous patients differs from that in edentulous patients. The implant microflora is similar to tooth microflora in the partially edentulous mouth. Periodontal and implant maintenance are linked because maintenance of a tooth microflora consistent with periodontal health is necessary to maintain implant microflora consistent with periimplant health. Because periimplantitis is difficult to treat,it is extremely important to treat periodontal disease before implant placement and to provide good supportive therapy with implant patients. 39

40. In general, procedures for maintenance of patients with implants are similar to those for patients with natural teeth, with the following three differences : Special instrumentation. Metal hand instruments and ultrasonic and sonic tips should be avoided because they can alter the titanium surface. Only plastic instruments or specially designed gold plated curettes should be used for calculus removal. The rubber cup with pumice , tin oxide, or special implant-polishing pastes should be used on abutment surfaces with light, intermittent pressure 2. Acidic fluoride prophylactic agents are avoided. 3. Nonabrasive prophy pastes are used. 40

41. Known as the cumulative interceptive supportive therapy (CIST). Depending on the clinical and eventually the radiographic diagnosis, protocols for preventive and therapeutic measures designed to intercept the development of peri -implant lesions. This system of supportive therapy is cumulative in nature and includes four steps . 1 . Antiseptic therapy, CIST protocol A and B 2. Antibiotic therapy, CIST protocol A + B 3. Antibiotic therapy, CIST protocol A + B + C 4. Regenerative or resective therapy, CIST protocol A+B+C+D 41

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43. Compliance with maintenance therapy Compliance has been defined as “the extent to which a person’s behavior coincides with medical or health advice”. The first study on the degree of compliance with supportive periodontal treatment was published in 1984 by Wilson et al . 1000 patients followed for up to 8 years. only 16% complied with suggested SPT intervals, 34% never came back for maintenance, 49% rest complied erratically. Compliance with maintenance therapy in 961 patients studied for 1 to 8 years. ) 43

44. Why do patients fail to comply? • The behaviour of these non-compliant patients is characterized by denial and negligent attitude towards their illness. • Fear of dental treatment is a major reason for noncompliance • Perceived indifference or indifferent behavior on the dentist’s part has also been cited as the reason for non-compliance. • Economic problems are another factor that keeps patients from complying. • Lack of satisfaction on the patient’s part also contributes to non-compliance. 44

45. Possible methods of improving compliance 45

46. Clinical recommendations SPT should be based on assessment of the patient risk profile for further periodontal disease progression. Such risk assessment should be performed after the completion of ICRT and be revisited continuously. • A standardized SPT routine cannot be considered to be consistent with best practice and an individualized approach is needed. • SPT resulting in good oral hygiene is essential to minimize the risks of periodontal disease progression. Issues of compliance must be considered. • The use of a triclosan /copolymer dentifrice could be of value to enhance oral hygiene. • In patients with inadequate oral hygiene, chlorhexidine rinses could be advocated. • There does not seem to be scientific evidence of additional value of routine subgingival debridement of sites presenting with bleeding on probing at SPT visits without concomitant increase in probing depth. Such treatment should therefore be avoided in sites without increasing probing depth. 46

47. Summary SPT can keep periodontium and peri -implant tissues healthy after active therapy. Patients who comply to suggested SPT keep their teeth longer. Average SPT visit should last 1 hour and should be scheduled every 3 months depending on patients. 47

48. References Carranza’s 8th, 10th,11th,12 th edition of Clinical Periodontology . Lindhe’s 6 th edition of Clinical Periodontology and Implant dentistry. Supportive periodontal therapy. STEFAN RENVERT & G. RUTGER PERSSON. Periodontology 2000, Vol. 36, 2004, 179–195. Supportive periodontal treatment introduction - definition, extent of need, therapeutic objectives, frequency and efficacy. THOMAS G .W ILSONJ,R . Periodontology 2000, Vol. 12, 1996, 11-15 SUPPORTIVE PERIODONTAL THERAPY- A REVIEW. Annals and Essences of Dentistry Vol. VIII Issue 1 Jan–Mar 2016 48

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