Supportive

Periodontal
Therapy

Fourthmolar.com
Patients at risk for periodontitis
without SPT.

Patients susceptible to periodontal

disease are at high risk for reinfection
and progression of periodontal lesions
without meticulously organized and
performed SPT.
All patients who where treated for
periodontal diseases belong to this risk
category by virtue of their past history,
an adequate maintenance care program is
of utmost importance for a beneficial
tong-term treatment outcome. SPT has to
be aimed at the regular removal of the
subingival microbiota and must be
supplemented by the patient’s efforts for
optimal supragingival plaque control.
SPT for patients with gingivitis

The prevention of gingival inflammation

and early loss of attachment in patients
with gingivitis depends primarily on the
level of personal plaque control, but also
on further measures to reduce the
accumulation of supragingival and
subgingival plaque.
SPT for patients with periodontitis

SPT is an absolute prerequisite to guarantee

beneficial treatment outcomes with maintained
level of clinical attachment over long periods of
time. While the maintenance of treatment
results for the majority of patients has to be
realized that a small proportion of patients will
experience recurrent infections with
progression of periodontal lesions in a few sites
in a completely unpredictable mode. The
continuous risk assessment at subject, tooth
the tooth site levels, therefore, represents a
challenge for the SPT concept.
Continuous multilevel risk assessment.

Subject risk assessment following aspects:

1. Percentage of bleeding on probing.
2. Prevalence of residual pockets greater than 4
mm
3. Loss of teeth from a total of 28 teeth.
4. Loss of periodontal support in relation to the
patients age.
5. Systemic and genetic conditions.
6. Environmental factors such as cigarette
smoking.
Compliance with recall system

Minority of periodontal patients comply with

the prescribed supportive periodontal care.

Since it has been clearly established that

treated periodontal patient who comply with
regular periodontal maintenance appointments
have a better prognosis than patients who do
not complex.
 Non-compliant or poorly compliant patients
should be considered at higher risk for
periodontal disease progression.

Oral hygiene:-
Bacterial plaque is the most important etiologic
agent for the occurrence of periodontal
diseases.

Regular interference with the microbial

ecosystem during a periodontal maintenance will
eventually obscure such obvious associations.
Percentage of sites with bleeding on probing

Bleeding on gentle probing represents an objective

inflammatory parameter which has been
incorporated into index systems for the
evaluation of periodontal conditions and 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 performance. There is no established
acceptable level of prevalence of bleeding on
probing in the dentition above which a higher risk
for disease recurrence has been established.
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 the bacterial challenge and the
patient’s compliance. The percentage of BOP,
therefore, as the first risk factor in the
functional diagram of risk assessment.

Individuals with low mean BOP percentages

may be regarded as patients with a low risk
for recurrent disease.
Prevalence of residual pockets greater
than 4 mm

The enumeration of the residual pockets

with probing depths greater than 4 mm
represents-to a certain extent-the
degree of rendered.

Loss of teeth from a total of 28 teeth

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

The extent and prevalence of periodontal

attachment loss, 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 the
rate of progression of progression of disease
has been positively affected by the
treatment rendered and, hence, previous
attachment loss in relation to patient’s age
may be a more accurate indicator during SPT
than before active periodontal treatment.
Systemic conditions

The most substantiated evidence for

modification of disease susceptibility and/or
progression of periodontal disease arises from
studies on Type land Type II diabetes mellitus
populations.

The impact of diabetes on periodontal diseases

has been documented in patients with
untreated periodontal disease.
 In recent years, genetic markers have become
available to determine various genotypes regarding
their susceptibility for periodontal diseases.
Research on the intereukin-1 (IL-1) polymorphisms
has indicated that IL-1 genotype positive patients
show more advanced periodontitis lesions than IL-1
genotype negative patients of the same age group
there is a trend to higher tooth loss in the IL-1
genotype positive subjects.
Cigarette smoking

Consumption of tobacco, in the form of smoking or

chewing, affects the susceptibility and the treatment
outcome of patients with adult periodontitis.

In a young population 51-56% smoking will affect the

treatment outcome after scaling and root planning.

The impact of cigarette smoking on the long-term

effects of periodontal therapy in a population
undergoing supportive periodontal care has been
reported. Smokers displayed less favorable healing
responses both at re-evaluation and during a 6-years
period of supportive periodontal care.
Tooth risk assessment
Tooth position with the dental arch
Furcation involvement
Iatrogenic factors
Residual periodontal support
Mobility

The tooth risk assessment encompasses an estimation

of the residual periodontal support, an evaluation of
tooth positioning, furcation involvements, presence of
iatrogenic factors and a determination of tooth
mobility to evaluated functional stability a risk
assessment on the 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.
Site risk assessment

Bleeding on probing
Probing depth and loss of attachment
Clinical probing
Suppuration

The tooth site risk assessment includes the

registration of bleeding on probing, probing
depth, loss of attachment, and suppuration. A
risk assessment on the site level may be
useful in evaluating periodontal disease.
 Radiographic evaluation of periodontal
disease progression

Radiographic perception of periodontal changes is

characterized by a high specificity, but a low
sensitivity, with underestimation of the severity
of a periodontal defect. Undetectability of minute
changes at the alveolar crest is related to over
projections and variations in projection geometry
when taking repeated radiographs. This may result
in mimicked variations in the alveolar bone height,
obscured furcation status, etc. In addition, film
processing variations may result in unreliable
assessments of alveolar bone density changes.
The standard procedure for periodontal
evaluations in based on a film holder
system with an alignment for long-cone
paralleling technique. With the addition
of simple pins to the film holders as a
repositioning reference, the
methodologic error was impressively
reduced.
Clinical implementation

At the patient level, loss of support in relation to

patient age, full mouth plaque and/or bleeding
scores and prevalence of residual pockets are
evaluated together with the presence of systemic
conditions or environmental factors, such as
smoking, which can influence the prognosis, The
clinical utility of this first level of risk assessment
influences primarily the determination of the recall
frequency and time requirements. It should also
provide a perspective for the evaluation of risk
assessment conducted at the tooth and site levels.
SPT IN DAILY PRACTICE

The recall hour should be planned to meet the

patient’s individual needs. It basically consists of
four different sections which may require various
amounts of time during a regularly scheduled visit.
1. Examination, Re-evaluation and Diagnosis (ERD)
5 - 10 gm

2. Motivation, Reinstruction and Instrumentation

(MRI) 30-40

3. Treatment of Re infected Sites (TRS)

4. Polishing of the entire dentition, application of

Fluorides and Determination of future SPT (PFD)
5-10 gm.
Examination, Re-evaluation and Diagnosis (ERD)

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 re infected sites with pus formation.
5.The evaluation of existing reconstructions, including
vitality checks for abutment teeth.
6.The exploration for carious lesions.
Dentist treatment of other problems
Polishing, Fluorides, Determination of recall interval
(PFD)

The SPT recall hour is divided into four sections.

While the first 10-15 min are reserved for
Examination, Re-evaluation and Diagnosis, the second
and most time-consuming section 30-40 min is
devoted to reinstruction and instrumentation of sites
at risk identified in the diagnostic process. Some
reinfected sited may require further treatment, and
hence, the patient may have to be rescheduled for an
additional appointment. The recall hour is concluded
by polishing the dentition, applying fluorides and
determining the frequency of future SPT visits.