SUPPORTIVE PERIODONTAL THERAPY - Dr Smijal Gopalan Marath - Specialist Periodontist - Bin Aamer Dental Center.pptx

The purpose of periodontal therapy is to increase the longevity of the person’s natural dentition by preserving the supporting structures of the teeth
Periodontal maintenance is the act of continually caring for, and preserving the dentition in health and function
Therapeutic measures to complement patient’s efforts
Periodontal maintenance therapy - mandatory extension of periodontal management and should be performed by a dentist, even though components of periodontal maintenance therapy may be carried out by a hygienist, under the supervision of a dentist.

1. Supportive Periodontal Therapy By, Dr. Smijal Gopalan Marath Specialist Periodontist

2. From a periodontal perspective  SUCCESS  would mean the long term goal of preservation of teeth following periodontal therapy as against the short lived goal of elimination of disease Preservation of the periodontal health of the treated patient requires as much a POSITIVE PROGRAM as that required for the elimination of periodontal disease. INTRODUCTION

3. Transfer of the patient from active treatment status to a maintenance program is a definitive step in total patient care that requires time and effort on the part of the dentist and the staff. Patients must understand the purpose of the maintenance program…. and the dentist must emphasize that preservation of the teeth depends upon maintenance therapy.

4. Periodontal treatment includes: Systemic evaluation of the patient’s health A cause related therapeutic phase with, in some cases A corrective phase involving periodontal surgical procedures Maintenance phase

5. 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 SEQUENCE OF SPT

6. PHASE I REEVALUATION PHASE II ( Periodontal surgery) PHASE III (Restorative) PHASE IV ( Maintenance phase) PHASE I REEVALUATION PHASE IV ( Maintenance phase) PHASE II ( Periodontal surgery) PHASE III (Restorative)

7. Extent of Need Gingivitis left untreated may lead to periodontitis This progression can be prevented or limited by O ptimal personal oral hygiene Loe H et al. 1965 P eriodic maintenance care under the supervision of a dentist (Since patients rarely are completely effective in removing plaque accumulation) Ramfjord SP, et al 1982 : 53 Johansson La et al1984

8. Nyman et al .-1977  patients who were not on maintenance therapy after surgical treatment for advanced periodontal disease exhibited loss of attachment 3-5 times greater than documented for the natural progression of periodontal disease . Wilson et al 1987  Tooth loss in some periodontal patients has been shown to be inversely proportional to the frequency of periodontal maintenance Becker et al ( 1984)  In a group of periodontal patients treated but not maintained, a tooth loss of 0.22 teeth by the patients at the end of 1 year, which is similar to that found in periodontal patients without treatment.

9. Loe et al [1978, 1986] conducted a Longitudinal investigation to study the natural development and progression of periodontal disease. .

10. The first study group established in Oslo,Norway in 1969 ,consisted of 565 healthy male patients between 17 to 40 years of age . Members of this group experienced maximum exposure to conventional dental care through out their lives. The second study was established in Sri Lanka in 1970 the workers had never been exposed to any programmes relative to the prevention or treatment of dental diseases.

11. The results of this study showed that the Norwegian group, as the members approached 40 years of age , had a mean individual loss of attachment of slightly above 1.5mm, and the mean annual rate of attachment loss was 0.08mm for interproximal areas and 0.10mm for buccal areas.

12. The Srilankans as they approached 40 years of age the mean individual attachment loss was 4.5mm , and the mean annual rate of progression was of the lesion was 0.30mm for interproximal areas and 0.20mm for buccal areas. This study suggests that without interference, Periodontal lesions progress continually and at a relatively even pace.

13. Further analysis of the Sri Lankan study showed that- All areas showed gingival inflammation but attachment loss varied tremendously. 8% - Rapid Progression – 9mm 81% - Moderate Progression – 4mm 11% - No Progression - < 1mm (at age 35 years)

14. Ramfjord SP et al 1974 A longitudinal study of patients with moderate to advanced periodontitis at the UNIVERSITY OF MICHIGAN showed that the progression of periodontal disease could be stopped for 3 years post operatively regardless of the modality of treatment. With long term observations the average loss of attachment was only 0.3mm over 7 years. The results indicated a more favorable prognosis for treatment of advanced periodontal lesions.

15. Suomi et al (1971) found a mean annual loss of 0.03 mm of periodontal support in well maintained patients, whereas those receiving only one oral examination and no further reinforcement in oral hygiene, showed an annual mean loss of 0.1mm of periodontal support. Axelsson (1981) demonstrated that frequent prophylaxis and oral hygiene have a significant effect on the maintenance of periodontal support following the treatment of the disease.

16. These well controlled studies clearly show that periodontal support can be adequately maintained if frequent prophylaxis, including oral hygiene instruction, is carried out, while the results with inadequate maintenance are poor .

17. Therapeutic objectives 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

18. Loss of attachment of 2 mm or more and the associated deepening of the periodontal pocket or gingival recession ; Bleeding on probing ; Suppuration or Exudate; Gingival Recession, Furcation involvement, Parameters for monitoring periodontal health during SPT

19. Caries, Open contacts and status of occlusion and arch relationship, including any anomalies . Clinical history ; Loss of Alveolar Bone Crown-Root ratio Increase in Mobility Changes in the patient’s Immune system and response;

20. Effectiveness in daily removal of Bacterial Plaque Smoking ; Patient’s Age ; Root Surface Smoothness ; Evidence of Calculus or Root Surface Accretions;

21. Compliance “The extent to which a person’s behavior coincides with medical or health advice” Also called adherence and therapeutic alliance

22. When patients comply with suggested supportive periodontal treatment schedules, the vast majority keep their teeth over long periods of time

23. P atients who clean well (or have their teeth cleaned) have less dental caries and periodontitis compared with those with less conscientious habits The average patient has difficulty in changing oral hygiene habits. After instruction in oral hygiene in a group of 44 patients treated for moderate periodontitis, less than half the patients still used interproximal cleaning aids at the end of 3 years

24. Methods of Improving Compliance Simplify Accommodate Remind patients of appointments Keep records of compliance

25. Inform Provide positive reinforcement Identify potential noncompliers Ensure dentist involvement

26. Typical SPT Visit for patients with Periodontal disease Chart review Operatory and instrument infection control Health history update Conversation with the patient Extraoral examination Clinical examination Radiographic examination Microbiological monitoring Personal oral hygiene review Removal of subgingival accretions Removal of supragingival deposits Behavior modification

27. Clinical Examination Dental examination Tooth loss Caries and prosthetic examination Fremitus Periodontal examination Gingival recession Inflammation

28. Checking of Plaque Control Patients should perform their hygiene regimen immediately before the recall appointment. Plaque control must be reviewed and corrected until the patient demonstrates the necessary proficiency, even if additional instruction sessions are required.

29. Radiographic examination Conventional radiographs  show only gross amounts of bone loss No. of radiographs limited for safety reasons In cases of apparently active disease, a full-mouth series every 3-5 years with seven vertical bite-wing radiographs every year is helpful in making an accurate assessment of bone stability.

30. Patient Condition/Situation Type of Examination Clinical caries or high-risk factors for caries Posterior bite-wing examination at 12- to 18-month intervals. Clinical caries and no high-risk factors for caries Posterior bite-wing examination at 24- to 36-month intervals. 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.

31. Patient Condition/Situation Type of Examination History of periodontal treatment with disease under good control. Bite-wing examination every 24 to 36 months; full-mouth series every 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. Transfer of periodontal or implant maintenance patients. Full-mouth series if a current set is not available. If full-mouth series has been taken within 24 months, radiographs of implants and periodontal problem areas should be taken.

32. Microbiological Monitoring For patients who have an aggressive form of periodontitis, microbiological monitoring and anti- biotic sensitivity testing can be useful. When the possible causal organisms remain after this therapy or if generalized attachment loss or inflammation continues or recurs, periodic microbial monitoring is suggested .

33. Listgarten & Levin found increased proportions of subgingival spirochetes to predict subsequent periodontitis progression in treated adults receiving no or sporadic maintenance care; Listgarten MA et al 1981 Listgarten et al. detected no spirochetal relationship with future breakdown in patients on regular maintenance Listgarten MA, et al 1986

34. Slots incriminated A.a.comitans as a major putative pathogen in refractory supportive periodontal treatment lesions. Presumably, A. a. comitans escapes the effect of mechanical cleaning because of its ability to invade periodontal tissues Slots J. 1986 Slots J, et al 1984

35. Wennstrom et al. detected additional breakdown after 12 months in 20% of periodontal pockets harboring either A. a. comitans , Porphyromonas gingivalis or Prevotella intermedia; however, the authors concluded that the absence of these organisms was a better predictor of no further loss of periodontal attachment than the presence of these organisms was for disease progression Wennstrom JL et al 1987

36. Listgarten et al. showed that A.a.comitans , P.gingivalis or P.intermedia were not quite adequate to predict future disease in supportive periodontal treatment patients, even though 33% of bacterial positive patients demonstrated breakdown at 2 or more teeth versus only 11% in the bacterial negative group Listgarten Ma et al1991

37. Personal oral hygiene review Removal of subgingival accretions Removal of supragingival deposits

38. Behavior modification It is possible to improve patient compliance to some degree in almost every case using accepted practices for behavior modification.

39. Manual Periodontal Probing in SPT Probing depth is the distance from the gingival margin to the base of the probeable crevice. It is a clinical approximation of the depth of a periodontal pocket  Armitage GC. 1995

40. Data from multiple longitudinal studies indicate that sites with probing depths of 2-6 mm are at a significantly higher risk of developing additional attachment loss if left untreated Badersten A, et al 1985 Claffey N et al 1990 Grbic IT et al 1992 Vanooteghem R et al 1987.

41. Glickman suggested that merely characterizing the probing depths as “slight”, “moderate” or “severe” was sufficient for treatment planning purposes. “ Determination of the exact depth in millimeters constitutes little additional information which is of clinical use”. The main difficulty with this approach is that the criteria for slight, moderate or severe probing depths were not stated. Glickman I. 1953

42. Clinical attachment level Clinical attachment level is the distance from the cementoenamel junction to the base of the probeable crevice . It is a clinical approximation of the loss of connective tissue attachment from the root surface Armitage GC. 1995

43. Relative attachment level The distance from a fixed landmark, other than the cementoenamel junction to the base of the probeable crevice. When the cementoenamel junction is not detectable or is missing due to a dental restoration, the clinical attachment level cannot be measured. Miller SC. 1943

44. Probe penetration At sites with moderate to severe inflammation,  probes penetrated an average of less than 0.5 mm past the apical termination of the junctional epithelium when gentle insertion forces (approximately 0.2 to 0.5 N) were used

45. Probe penetration increases at inflamed sites and with increased probing force- Armitage et al 1977 Birek r: et al 1989 Caton J et al 1981 Fowler C et al 1982 Garnick JJ et al 1989 Mombelli A et al 1992 Non-inflamed sites probe tends to stop coronal to apical termination of junctional epithelium Fowler C et al 1982 Garnick JJ et al 1980 Magnusson I et al1980 van der Velden U et al 1981 :

46. The clinically important conclusions that can be drawn from these studies are that Probes do not precisely measure the true level of the connective tissue attachment Gains in clinical attachment level after treatment do not necessarily mean that new connective tissue attachment has been achieved Most of the time, clinical attachment level measurements are within 1 mm of the connective tissue attachment level and are therefore clinically useful approximations of attachment loss.

47. Reproducibility of probing measurements Insertion force Probe placement and angulation Inflammatory status of the tissues Diameter of the probe tip Probe-to-probe variations in calibration markings

48. In many studies, perfect agreement (±0.0 mm) for P robing depth =33 to 70% C linical attachment level =32 to 71.7% Relative attachment level =39.8 to 55.4% . When the agreement threshold was set at ±1.0 mm, Probing depth=81.2 to 99.6% Clinical attachment loss=84 to 98.8%, Relative attachment loss=90 to 94.1% Agreement threshold was set at ±2.0 mm, the reproducibility of all measurements approached 100%.

49. Probing measurements for patients on SPT It is not reasonable, or in the best interest of patients, to wait until 3 mm of additional attachment loss has occurred before clinical intervention is initiated The exact set of clinical conditions that must be in place before additional treatment is rendered has not been established. In SPT program, clinical attachment levels are the best measurements to monitor the stability of the periodontal tissues.

50. Computerized periodontal probe A precision of ±0.1mm A measurement range of 10 mm Constant probing force Noninvasive, light weight for comfortable use over an extended period of time and easy to learn to use Able to access any location around all teeth A guidance system to insure that measurements were taken from the same part of the sulcus each time (desirable but not mandatory); Complete sterilization of all portions entering or near the mouth cold sterilization not acceptable; No biohazard from material or electric shock Digital output.

51. Gibbs et al., developed the Florida Probe@ system (Florida Probe Corporation, Gainesville, FL) that combined the advantages of constant probing force with precise electronic measurement and computer storage of the data. Gibbs CH, et al 1988 Magnusson et al ., compared the performance with that of standard probe measurements.  reproducibility of pocket depth measurements obtained with the electronic probe was significantly superior to the reproducibility of those obtained with a standard probe . Magnusson I, et al 1988

52. Goodson JM, et al 1988  evaluated an electronic probe, InterprobeTM (Bausch & Lomb, Tucker, GA) using an optical encoder transduction element. They reported slightly higher reproducibility with the electronic probe compared to conventional probing Magnusson I, et al 1988 investigated the re- producibility of attachment level measurements taken with the Florida Stent Probe. a high level of agreement was achieved for attachment level measurements made by different exam- iners or by a single examiner during different visits

53. Jeffcoat Mk et al1989 have described a new electronic periodontal probe, the Foster-Miller Probe, that can automatically detect the cementoenamel junction . In a study by Jeff- coat et al . in human subjects The overall mean standard deviation of the repeated measurements was ±0.17 mm.

54. Karim M et al 1990 tested a modified Toronto Probe equipped with an electronic tilt sensor device in 6 subjects and found a standard deviation of 0.05 mm when the deviation of probe angulation was <5º. When the deviation was >5 º , the mean difference and standard deviation in- creased significantly, but was still low (±0.11 mm). The Florida Disk Probe was used independently by Low et al. and Osborn et al. to assess reproducibility of repeated measurements of the similar sites in two groups of subjects. Both studies produced highly reproducible measurements.‘These probes do not require prefabricated acrylic stents. Low SB, et al 1989 : Osborn Jet al 1990 :

55. Gerlach et al 1995 . described repeatability of controlled pressure relative attachment level measurements collected in a multicenter clinical trial setting. The reproducibility demonstrated in this study supports use of controlled pressure probing to evaluate changes in relative attachment level in multicenter trials. Electronic probes appear to be superior to manual probes with regard to reproducibility measurements

56. Bleeding on Probing Absence of bleeding on probing is a reliable parameter to indicate periodontal stability Lang NP et al 1986 : The presence of bleeding on standardized probing indicates gingival inflammation. Whether or not repeated bleeding on probing over time predicts the progression of a lesion is, however, questionable Vanooteghem R, et al 1987

57. Study by Lang showed that pockets with a probing depth of >5 mm had a significantly higher incidence of bleeding on probing. Patients with 16% or more bleeding on probing sites had a higher chance of loosing attachment than patients with<16 % bleeding on probing. Pockets with an incidence of bleeding on probing of 4/4 had a 30% chance of loosing attachment. 14 % with bleeding on probing of 3/4 , 6 % with bleeding on probing of 2/4, 3 % with bleeding on probing of 1 /4 1.5 % with bleeding on probing of 0/4 .

58. CONTINUOUS MULTI LEVEL RISK ASSESSMENT 1. Subject Risk Assessment 2. Tooth Risk Assessment 3. Site Risk Assessment

59. SUBJECT RISK ASSESSMENT: - 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.

60. Lang and Tonetti’s functional diagram (2003) for Subject Risk Assessment includes the following aspects: 1. Prevalence of bleeding on probing 2. Prevalence of residual pockets greater than 4mm 3. Loss of teeth from a total 28 teeth 4. Loss of periodontal support in relation to the patient’s age

61. 5. Systemic and genetic conditions 6. Environmental factors such as cigarette smoking. A comprehensive evaluation of the functional diagram will provide an individualised total risk profile and determine the frequency and complexity of SPT visits.

62. 1. PERCENTAGE OF SITES WITH BOP: Bleeding on probing represents an objective inflammatory parameter which has been incorporated into index systems for the evaluation of periodontal conditions. It is also used as a parameter by itself. In a patient’s risk assessment for recurrence of periodontitis, BOP reflects at least in part the patient’s compliance and standards of oral hygiene.

63. Although there is no acceptable level of prevalence of BOP in the dentition above which a higher risk for disease recurrence is established, a BOP prevalence of 25% has been the cut off point between patients with maintained periodontal stability for 4 years and patients with recurrent disease in the same time frame. (Jeff et al 1994)

64. In assessing the patient’s risk for disease progression, BOP percentages reflect a summary of the patient’s ability to perform proper plaque control, the patient’s host response to bacterial challenge and the patient’s compliance. The percentage of BOP is therefore used as the first risk factor in any functional diagram of risk assessment.

65. SUBJECT RISK ASSESSMENT PERCENTAGE OF SITES WITH BOP Less than 10% of the surfaces BOP +ve More than 25% surfaces BOP +ve Low risk High risk

66. 2. PREVALENCE OF RESIDUAL POCKETS GREATER THAN 4MM The presence of residual pockets with probing depth greater than 4mm represents to a certain extent , the degree of success of periodontal treatment rendered.

67. Although this figure per se does not make much sense when considered as a sole parameter, its evaluation in conjunction with other parameters such as BOP/suppuration, will reflect existing ecologic niches from and in which reinfection might occur.

68. It is therefore conceivable that periodontal stability in a dentition would be reflected in a minimal number of residual pockets. Nevertheless in assessing the patient’s risk for disease progression, the number of residual pockets with a probing depth ≥ 4mm is assessed as the second risk indicator for recurrent disease in the functional diagram of risk assessment.

69. SUBJECT RISK ASSESSMENT RESIDUAL POCKETS > 4mm Upto 4 residual pockets More than 8 residual pockets Low risk High risk

70. 3. LOSS OF TEETH FROM A TOTAL 28 TEETH Although the reason for tooth loss may not be known the number of remaining teeth in a dentition reflects functionality of the dentition. Mandibular stability and individual optimal function may be assured even with a shortened dental arch of premolar to premolar occlusion i.e. 20 teeth.

71. Some tooth loss also represents a true end point outcome variable reflecting the patient’s history of oral diseases and trauma it is logical to incorporate this risk indicator as the third parameter in functional risk assessment.

72. SUBJECT RISK ASSESSMENT LOSS OF TEETH FROM A TOTAL 28 TEETH Low risk High risk Loss of upto 4 teeth Loss of more than 8 teeth

73. 4. LOSS OF PERIODONTAL SUPPORT IN RELATION TO AGE. The extent and prevalence of periodontal attachment loss ( i.e. previous disease experience and susceptibility) as evaluated by the height of the alveolar bone on radiographs, may represent the most obvious indicator of subject risk when related to the patient’s age.

74. The estimation of bone loss is performed in the posterior region on either the periapical radiographs, in which the worst site affected is estimated gross as a percentage of the root length , or on bitewing radiographs in which the worst site affected is measured in millimetres.

75. One mm = 10% BoneLoss The percentage is then divided by the patient’s age resulting in a factor. Bone loss /Age 0.5 = division between low and moderate risk 1.0 = division between moderate and high risk

76. In assessing the patient’s risk for disease progression, the extent of alveolar bone loss in relation to the patient’s age is estimated as the fourth risk indicator for recurrent disease in the functional diagram of risk assessment. Thus a patient with higher bone loss in relation to age has a higher risk regarding this vector in a multifactorial assessment of risk

77. SUBJECT RISK ASSESSMENT LOSS OF PERIODONTAL SUPPORT IN RELATION TO AGE BONE LOSS IN % PATIENT’S AGE Lower bone loss %age Higher bone loss %age Low risk High risk

78. 5. SYSTEMIC CONDITIONS The most substantiated evidence for modification of disease susceptibility and/or progression of periodontal disease arises from studies on type I and Type II diabetes mellitus. Genetic markers such as polymorphisms of IL-1 have also show association with advanced periodontitis.

79. Assessing the patient’s risk for disease progression, systemic factors are only considered, if known, as the fifth risk indicator for recurrent disease in the functional diagram. If not known or absent, systemic factors are not taken into account for the overall evaluation of risk.

80. 6. ENVIRONMENTAL CONDITIONS Cigarette smoking Consumption of tobacco, predominantly in the form of smoking or chewing, affects the susceptibility and the treatment outcome of patients with adult periodontitis. Smoking per se represents not only a risk marker but also possibly a true risk factor for periodontitis. In assessing the patient’s risk for disease progression environmental factors such as smoking and stress must be considered as the sixth risk factor for recurrent disease in the functional risk diagram of risk assessment.

81. SUBJECT RISK ASSESSMENT CIGARETTE SMOKING Low risk NON-SMOKERS/ FORMER SMOKERS High risk HEAVY SMOKERS

82. Compliance with recall system Non-compliant or poorly compliant patients should be considered at higher risk for periodontal disease progression.   Oral hygiene In a clinical set-up a plaque control record of 20-40% is tolerable by most patients. It is important to realise that full mouth plaque score has to be related to the host response of the patient i.e. compared to the inflammatory parameters.

83. CALCULATING THE PATIENTS’S INDIVIDUAL PERIODONTAL RISK ASSESMENT(PRA): Based on the parameters mentioned above, a multifunctional diagram is constructed for PRA, A low PR patient has all parameters within the low risk category or at the most one parameter in the moderate risk parameter.

84. A moderate PR patient has atleast 2 parameters in the moderate category, but at the most one parameter in the high risk category. A high PR risk patient has atleast 2 parameters in the high risk category.

85. SUBJECT RISK ASSESSMENT Lang & Tonnetti’s functional diagram (2003) PD>4mm TOOTH LOSS BOP SYSTEMIC ENVIRONMENTAL FACTORS BL/AGE 4 9 16 25 36 49 2 4 6 8 10 12 2 4 6 8 10 12 0.25 0.5 0.75 1 1.25 1.5

86. The subject risk assessment may estimate the susceptibility for progression of periodontal disease. All the above factors together should be contemplated and evaluated. A functional assessment of the risk for disease progression on the subject level may help in customizing the frequency and content of SPT visits.

87. TOOTH RISK ASSESSMENT 1. Tooth Position Within The Dental Arch 2. Furcation Inolvement 3. Iatrogenic Factors 4. Residual Periodontal Support 5. Mobility

88. 1. Tooth position within the dental arch: Crowding of teeth might eventually affect the amount of plaque mass formed in dentitions with irregular oral hygiene practices, thus contributing to the development of Chronic Gingivitis, but, it remains to be demonstrated whether Tooth Malposition within the dental arch will lead to an increased risk for periodontal attachment loss.

89. 2. Furcation involvement: It has to be understood that its not implied that furcation involved teeth must be extracted since all prospective studies have documented a rather good overall prognosis for such teeth if regular supportive care is provided by a well organised maintenance program.

90. 3. Iatrogenic factors: Overhanging restorations and Ill Fitting Crown margins certainly represent an area for plaque retention and there is an abundance of studies documenting an increased prevalence of periodontal lesions in the presence of iatrogenic factors .

91. Depending on the supragingival or subgingival location of such factors, their influence on the risk for disease progression has to be considered. It has been established that slightly Subgingivally Located overhanging restorations will indeed change the ecologic niche, providing more favourable condition for establishing a Gram negative microbiota.

92. There is also no doubt that shifts in the subgingival microflora towards a more periodontopathic microbiota , if unaffected by treatment represents an increased risk for periodontal breakdown . A risk assessment at tooth level may be useful in evaluating the prognosis and function of an individual tooth and may indicate the need for specific therapeutic measures during SPT visits.

93. SITE RISK ASSESSMENT The tooth site risk assessment includes the registration of: 1. B O P 2. Probing Depth 3. Loss Of Attachment 4. Suppuration. A risk assessment on the site level may be useful in evaluating the periodontal disease activity and determining periodontal stability or ongoing inflammation. The Site Risk Assessment is essential for the identification of the sites to be instrumented during SPT.

94. CLINICAL IMPLEMENTATION The clinical utility of the first level of risk assessment influences primarily the determination of the recall frequency and time requirements. It will also provide a perspective for the evaluation of risk assessment conducted at the tooth and site levels.

95. The clinical utility of tooth and site risk assessment relates to rational allocation of the recall time available for therapeutic intervention to the sites with higher risk, and possibly to the selection of different forms of therapeutic intervention.

96. Three areas need to be addressed in disease recurrence in a patient who has been previously treated surgically for pocket reduction: 1. ANATOMICAL PROBLEMS 2. COMPROMISED THERAPY 3. PLAQUE CONTROL DISEASE RECCURENCE & RETREATMENT

97. Patients with progressive periodontal disease after conventional, diligent supportive periodontal treatment (“ refractory ”) may need additional antimicrobial therapy. The composition of the periodontopathic microbiota determines in part the choice of antimicrobial agent(s).

98. 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

99. CLASSIFICATION 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

100. CLASSIFICATION CHARACTERISTICS RECALL INTERVAL CLASS B Generally good results, maintained well for 1 year or more but for 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

101. CLASSIFICATION 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

102. 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

103. 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

104. REFFERAL OF THE PATIENT TO THE PERIODONTIST

105. The majority of periodontal care belongs in the hands of the general dentist Patients disease should dictate whether the general practitioner or the specialist should perform the maintenance therapy

106. C A A - MILD PERIODONTITIS B- MODERATE PERIODONTITIS C- ADVANCED PERIODONTITIS B

107. 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.

108. 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.

109. 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 )

110. 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 .

111. 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.

112. EXAMINATION, RE-EVALUATION AND DIAGNOSIS: Since patients on SPT may experience significant changes in the health status and use medications, an update of their information on general health issues is appropriate. Changes in health status and medications should be noted. In middle-aged to elderly patients, these aspects might have an influence on future patient management of the patient.

113. 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. The lateral borders of the tongue and the floor of the mouth should be inspected in particular.

114. 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 risk factors, tooth& site related risk factors are evaluated.

115. As indicated above, the diagnostic procedure usually includes an assessment of the following- The oral hygiene and plaque situation The determination of sites with bleeding on probing, indicating persistent inflammation The scoring of clinical probing depths and clinical attachment levels. The inspection of reinforced sites with pus formation. The evaluation of existing reconstructions, including vitality checks for abutment teeth. The exploration for carious lesions.

116. Evaluations are performed for both teeth and oral implants. Conventional Dental Radiographs should be obtained at SPT visits. Single periapical films exposed with a paralleled view and preferably standardised technique are of great value. Bite wing radiographs are of special interest for caries diagnostic purposes.

117. Since only approximately 10-15 minutes are available for this section, these assessments should have to be performed in a well organised fashion. It is preferable to have a dental assistant available to note all the results of the diagnostic tests unless a voice activated computer assisted recording system is used.

118. This aspect uses most of the available time of the SPT visit. When informed about the results of the diagnostic procedures, the patient may be MOTIVATED either in a challenging way in the case of low scores or in a confirmatory fashion in the case of high scores. ENCOURAGEMENT usually has a greater impact on future positive developments than negative criticism, hence every effort should be made to acknowledge the patient’s performance. MOTIVATION, REINSTRUCTION AND INSTRUMENTATION ( MRI)

119. Patients who have experienced a relapse in their adequate oral hygiene practices need to be further motivated. If the personal life situation has influenced the performance, positive encouragement is appropriate. Standard ‘lecturing’ should be replaced by an individual approach.

120. Occasionally, the patients present with hard tissue lesions (wedge shaped dental defects) which suggest overzealous and/or faulty mechanical tooth cleaning. Such habits should be broken and the patient reinstructed in toothbrushing techniques which emphasize vibratory rather than scrubbing movements.

121. Since it appears impossible to instrument 168 tooth sites in a complete dentition in the time allocated, only those sites which exhibit signs of inflammation and/or active disease progression will be re-instrumented during SPT visits. Hence, all the BOP positive sites and all pockets with a probing depth exceeding 5mm are carefully rescaled and root planed. Repeated instrumentation of healthy sites will inevitably results in mechanically caused continued loss of attachment (Lindhe 1982)

122. PLAQUE CONTROL Toothbrushing techniques a. Bass technique – the most commonly prescribed toothbrushing technique

123. b. Modified Stillman technique - Prescribed for patients with gingival recession c. Charter’s technique – prescribed mainly for patients following periodontal surgery Modified Stillman technique

124. INTERDENTAL CLEANING AIDS Dental floss Wooden tips Interproximal brushes – single tufted, multitufted Rubber tip stimulator

125. POLISHING, FLUORIDES, DETERMINATION OF RECALL INTERVAL The recall hour is concluded with POLISHING the entire dentition to remove all the remaining soft deposits and stains. This may provide freshness to the patient and facilitates in the diagnosis of early carious lesions.

126. 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. Fluorides or chlorhexidine varnishes may also be applied to prevent root surface caries, especially in areas with gingival recession. The determination of future SPT visits must be based on the patient’s risk assessment.

127. Maintenance visit for dental implants Update the patient’s medical and dental history. Review oral hygiene and modification if needed. Examine implants and peri -implant tissues and record the results. A . Probe around each implant. B . Assess the soft tissue using among other parameters bleeding on probing and suppuration. C . Examine prosthetic abutment; this may necessitate removal of the prosthesis on a per- iodic basis (when screw retained). D . Carry out an occlusal examination. Check for wear of the prosthesis. Examine for loosened occlusal screws or abutment cylinders Locate broken abutment screws, abutments or implants. Evaluate patient complaints in the area of the implant. E . Evaluate implant stability : manually with computerized devices.

128. Check and modify behavior where needed as related to the patient’s oral hygiene. Remove any implant-retained plaque and calculus Take radiographs, vertical bite wings, or periapical radiographs once a year (more often in cases with active breakdown). Panoramic radiographs may also be helpful for evaluating dental implants. Setting maintenance intervals A . Patients with both teeth and implants should see the periodontist as often as necessary to keep the periodontium or periimplant tissues healthy. B . Totally edentulous patients with implants should be seen at least once per year

129. COMPLICATIONS OF SPT Root Caries Endodontic Lesions Periodontal Abcesses – Downhill Cases Root Sensitivity

130.   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 CIST (Cumulative Interceptive Supportive Therapy) and be revisited continuously. A standardized SPT routine cannot be considered to be consistent with best practice and an INDIVIDUALIZED APPROACH is needed.

131. 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.

132. 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. In the absence of long-term evaluation of SPT programs for dental implants it seems appropriate to use the same principles of SPT as listed above.

133. Procedures for maintenance of implants are similar to those with natural teeth. The major differences are 1. Use Of Plastic Instruments To Avoid Scratching The Implant Surface. 2. Acidic Prophylactic Agents Are Avoided. 3. Non-abrasive Prophy Pastes Are Used.

134. Strategic tree for SPT

135. HISTORY CHECK NECESSARY MEASURES ?? HISTORY CHECK APPROPRIATE MEASURES YES NO

136. RE-EVALUATION PROBING DEPTHS BOP SUPPURATION FURCATION PLAQUE/CALCULUS CARIES X-RAYS

137. TREATMENT STRATEGY TREATMENT NEED PERIODONTAL PROBLEMS DENTIST NO YES GENERALISED ? DENTIST NO YES YES NO

138. TREATMENT STRATEGY PERI-IMPLANT LESION CUMULATIVE INTERCEPTIVE THERAPY PURULENT PERIODONTITIS NO YES YES TREATMENT OF ACTIVE SITES INSTRUMENTATION NO NO

139. PROPHYLAXIS REMOTIVATION REINSTRUCTION POLISHING FLUORIDE APPLICATION

140. LOGISTICS ORGANISATION OF FURTHER RECALL VISITS

141. CONCLUSION All types of Periodontal and Implant Therapy require continous follow up and periodontal maintenance care because of the constant microbial challenge, and this response must be effective to prevent further tissue damage. Maintenance therapy that has proved effective over time is PERIODIC, PROFESSIONAL VISITS

142. References 1. Periodontal Maintenance Therapy- Schallhorn R.G et al- J.A.D.A – 103: 227; 1981. 2. Maintenance Care For Treated Periodontitis Patients- Review Article, Ramfjord S.P JCP 1987; 14: 433-437. 3. Supportive Periodontal Therapy- Position Paper-J.P 1998- 69: 502-506.

143. 4. Periodontal Maintenance- Position Paper- J.P- 74: 1395-1399; 2003. 5. Supportive Periodontal Therapy Periodontology 2000, Vol 12; 1996. 6. Supportive Periodontal Therapy. Periodontology 2000. Vol 36 ,2004: 179-195. 7. Clinical Periodontology And Implant Dentistry. Niklaus P Lang, Jan Lindhe. 5 th Edition, Vol 2, Chapter 59.

144. Thank you