SUPPORTIVE PERIODONTAL THERAPY and maintenance period

SUPPORTIVE PERIODONTAL THERAPY and maintenance period

1. ADHERENCE TO SUPPORTIVE PERIODONTAL THERAPY

2. contents Introduction Studies assessing spt Rationale Goal Objectives Biological basis Treatment without maintenance Factors affecting maintenance Art of dosing maintenance Recall for maintenance Biofilm suppression in maintenance period Spt in implants Conclusions Reference

3. INTRODUCTION Treatments with long term maintenance programs following active therapy, called as Supportive Periodontal Therapy (SPT) Positive feedback mechanism In SPT periodontal diseases are monitored, etiological factors reduced and continued at periodic intervals for the life of the dentition This term expresses the essential need for therapeutic measures to support the patient’s own efforts to control the periodontal infections and to avoid re-infection.

4. ( Axelsson and Lindhe 1980) patients with periodontitis following SPT resulted in the establishment of clinically healthy gingiva and shallow pockets and also results in re-growth of alveolar bone ( William Becker, Burton E Becker and Lawrence E. Berg 1984 ) patients with periodontitis were treated and for various reasons not participated in the SPT and found that high incidence of tooth loss, worsening of the health status of furcations , no reduction of probing depth significant loss of alveolar bone was observed

5. Studies assessing SPT have found frequent-recall patients were able to maintain excellent oral hygiene standards and stable attachment levels ( Axelsson 1981 ); Suomi 1971 found 0.03 mm mean loss in a well-maintained group versus 0.1 mm in patients who received only one oral examination and no further reinforcement of oral hygiene instructions Becker 1979 observed a mean tooth loss per year 0.22 in people who were treated but did not enrol in a SPT programme (Becker 1984a), and 0.11 in people who received treatment of active periodontal disease followed by SPT (Becker 1984b).

6. Gingival condition was improved by 60% and tooth loss reduced by 50% ( lovdal et al 1961) Regular recall allows easy disease monitoring ( Nymann et al 1977) Mombelli et al., 199747, Jones et al., 199448 and Tonetti 1998 demonstrated the importance of oral hygiene for the benefit of antibiotics during SPT Pihlstrom BL 20006 regardless of the type of treatment provided, periodontal therapy will fail or will be less effective in the absence of adequate supportive periodontal therapy

7. The three components of maintenance

8. Rationale for spt Healing after non surgical treatment is long J.E which is weak and less resistant to microbial insults and inflammation ( Stahl et al 1967 ) Poor motivation and plaque control Incomplete removal of plaque

9. Goals of spt Prevent and minimize recurrence and progression of diseases Prevent and reduce incidence of tooth loss by regular monitoring To provide treatment in a timely manner

10. Objectives of spt Preservation of alveolar bone support (*radiographically) Maintenance of stable clinical attachment level Reinforcement and re-evaluation of proper oral hygiene Maintenance of healthy oral environment

11. Types of maintenance ( schallhorn rg et al )

12. Biologic basis for periodontal maintenance Tooth loss in periodontal patients has shown to be inversely proportional to the frequency of periodontal maintenance. ( Axelsson p, Lindhe J )patients who maintain regular periodontal maintenance intervals experience less attachment loss and lose fewer teeth than patients who receive less periodontal maintenance or none at all. Since patients rarely are completely effective in removing plaque, adherence to a periodontal maintenance program reduces the risk of future attachment loss.

13. Periodontal treatment without maintenance An inadequate control of bacterial plaque by the part of the patient and / or the professional predispose to the recurrence of the disease. Few studies have shown that bone loss continues if the periodontal patient is treated but not maintained or receiving “Traditional Dental care”. In a group of periodontal patients treated but not maintained, reported a tooth loss of 0.22 teeth by patients 1 year, which is similar to that found in periodontal patients without treatment.

14. Big questions What does it involves When does it start Who performs it How frequently

15. When does it start It starts when initial / corrective phase has been completed Ongoing for the life of patient

16. Who provides it

17. FREQUENCY Ramfjord et al – for patients with gingivitis but no attachment loss- twice a year For patients with previous history of periodontitis – 3 months interval as most patients, the return to near-baseline bacterial levels occurs within 3 to 6 months. needs to be tailored to each patient’s level of disease activity and his or her ability and willingness to perform adequate oral hygiene dental implants may require more frequent visits ( ie , every 2 months instead of every 3 months ).

18. Shumaker et al

19. COMPLIANCE the extent to which a person’s behavior coincides with medical or health advice Compliance is a multidimensional phenomenon determined by the interplay of different factors related to the patient, and the provider(s) Consequences final outcomes of interplay, tooth loss being the most significant one.

20. Wilson et al 1984 -after treatment for periodontitis of approximate 1000 patients followed for up to 8 years, only 16% complied with suggested SPT intervals, 34% never came back for maintenance Matuliene et al 2010 - Out of 3751 patients. Compliant patients lost only 4.7% of teeth, while patients with erratic compliance lost 14.7% of the teeth present after active periodontal treatment Miyamoto et al2006 - used compliance as a prognostic indicator of different clinical variables, including tooth loss.

21. Why do patients fail to comply The behavior of these non-compliant patients is characterized by denial and negligent attitude towards their illness. • Fear of dental treatment Perceived indifference or indifferent behavior on the dentist’s part. Economic problems Lack of satisfaction on the patient’s part .

22. Possible methods of improving Compliance Simplify: the simpler the required behavior, the more likely it is to be carried out. Accommodate more the suggestions fit the patients’ needs, the more likely they are to comply. Remind patient of appointments and keep records of compliance. Provide positive reinforcement Ensure the dentists involvement:

23. ADHERENCE the extent to which a person's behaviour , taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider

24. Adherence is an active process in which a patient takes responsibility for their overall well-being, while compliance is a passive behavior in which a patient is following a list of recommendations from the doctor.

25. PERSISTENCE length of time during which the patient continues the prescribed treatment, that is, the time that elapses since the implementation until the interruption. In this sense, for a patient to be adherent they must be at the same time compliant, but also persistent. It is obvious that in the case of the periodontal patient, persistence is a key factor, because, as with any other chronic disease, periodontal treatment lasts forever

26. ART OF DOSING MAINTENANCE Habits develop when people give a response repeatedly in a particular context and thereby form associations in memory, between the response and recurring context cues. When people have a strong habit, perception of recurring context cues activates the response in memory In order to develop a habit ( eg , toothbrushing or getting used to receiving supportive periodontal treatment twice a year) the patient, first of all, needs motivation to change his/her behavior, Then introduce  accept  get used to the new behavior  perform the new one automatically (since the behavior has already become a habit).

27. once habits have developed, they are performed with only limited influence from supporting motivations

28. customize maintenance after periodontal therapy according to risk person's individual risk for disease recurrence using a spider‐chart – a graph showing 6 variables, potentially increasing the risk on axes The predictive value of the periodontal risk‐assessment diagram area on long‐term treatment outcome LANG AND TONEETI 2008

29. RECALL FOR MAINTENANCE The type and frequency of maintenance care may influence the incidence and severity of recurrent periodontal disease and biologic complications of dental implants showed that a rigorous recall program during the first 6 months after therapy, with visits every 2 or 4 weeks, followed by maintenance care at 3‐month intervals, gave better clinical outcomes than the 3‐month maintenance program only the first signs of a shift toward pretreatment conditions were noticed after 3 weeks,

30. Factors determining recall

31. Maintenance protocol tools for programming recall intervals, the following practice is recommended: • Upon completion of periodontal and/or implant therapy, maintenance care should start at a frequency of 3 months. • The stability of the situation should be evaluated continuously, and the recall frequency should be adapted individually based on longitudinal monitoring. • high recall frequency is needed only because of the presence of a high local risk that affects a single tooth or a few sites.

32. Merin’s classification for recall

33. BIOFILM SUPPRESSION IN RESIDUAL POCKETS It is vital to explore and evaluate mechanical and nonmechanical alternatives that are less aggressive than use of steel instruments, yet efficient enough to remove the nonmineralized subgingival bacterial deposits that grow between 2 maintenance visits distinguish between prophylaxis in the sense of biofilm control, supportive therapy addressing “refractory” disease antimicrobial rinses, ointments, gels, and sustained drug‐release devices

34. The microbiological and clinical effects of a varnish containing 1% chlorhexidine and 1% thymol, applied upon completion of periodontal therapy, were studied over 12 weeks( Mombelli et al 1999 ) The effects of photodynamic therapy, delivererd twice in a 1‐week interval after a short ultrasonic debridement, were studied in 28 patients with residual pockets in maintenance phase shows significant results( Muller et al2015 )

35. Spt for implants 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.

36. Mechanical debridement, CIST protocol A 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

37. CONCLUSIONS The nature and the rate of disease progression will affect supportive periodontal treatment. The converse is also true. It would be beneficial to record the results of treatment on all the patients, even those who drop out of therapy, to determine the part supportive periodontal treatment plays. Disappointing behavior of patients during the maintenance period should make professionals to conduct an intense program during the first year of maintenance, to educate and motivate patients on the importance of oral health Reinforcement and motivational intervention should become a primary concern of the dental team prior to the completion of active therapy and throughout the supportive periodontal treatment of the patient.

38. REFRENCES Katta RC, Chava VK, Nagarakanti S. SUPPORTIVE PERIODONTAL THERAPY-A REVIEW. Annals & Essences of Dentistry. 2016 Jan 1;8(1). Mombelli A. Maintenance therapy for teeth and implants. Periodontology 2000. 2019 Feb;79(1):190-9 Manresa C, Sanz‐ Miralles EC, Twigg J, Bravo M. Supportive periodontal therapy (SPT) for maintaining the dentition in adults treated for periodontitis. Cochrane Database of Systematic Reviews. 2018(1).

39. Echeverría JJ, Echeverría A, Caffesse RG. Adherence to supportive periodontal treatment. Periodontology 2000. 2019 Feb;79(1):200-9. De Wet LM, Slot DE, Van der Weijden GA. Supportive periodontal treatment: Pocket depth changes and tooth loss. International journal of dental hygiene. 2018 May;16(2):210-8. Wilson Jr TG. Supportive periodontal treatment introduction–definition, extent of need, therapeutic objectives, frequency and efficacy. Periodontology 2000. 1996 Oct;12(1):11-5. Lindhe J, Nyman S. Long-term maintenance of patients treated for advanced periodontal disease. J Clin Periodontol . 1984 Sep;11(8):504-14. doi : 10.1111/j.1600-051x.1984.tb00902.x. PMID: 6384275 .

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