perio

1. Dr. Biju Thomas
Prof & Head
(Periodontics)
Ss

2. Success is a journey…….
not a
destination!
SUPPORTIVE PERIODONTAL THERAPY

3. • 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.

4. If a person once has developed periodontitis, it
has to be assumed that he/she is at risk for future loss
of periodontal attachment if bacterial action is not
contained in some way (Loe et al 1978).

5. There is at present no definitive periodontal treatment
that will cure all periodontal infections without
residual predisposition to a recurrent infection.
Periodontal disease is a result of opportunistic infection
(Lang et al 1985) by infective organisms which
cannot be eliminated from the mouth over a
prolonged time, and so far we have no way to boost
the patient's immunoresponses to the extent that these
organisms would be innocuous.

6. GINGIVITIS
Plaque induced
Erythematous gingiva

7. SICKLE SCALER

8. Universal
curettes

9. |
MAGNETOSTRICTIVE
ULTRASONIC
SCALER
PIEZOELECTRIC
ULTRASONIC
SCALER
|

10. HEALTHY GINGIVA

11. • 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.

12. • Patients who are not maintained in a supervised recall
programme subsequent to active treatment show
obvious signs of recurrent periodontitis ( eg. Bone
loss, tooth loss and increased pocket depth).
• The more often patients present for the recommended
supportive periodontal treatment, the less likely they
are to lose teeth.

13. Motivational techniques and reinforcement of the
importance of the maintenance phase of treatment should be
considered before performing definitive periodontal surgery.
It is meaningless to simply inform patients that they are
to return for periodic recall visits without clearly explaining
the significance of these visits and describing what is expected
of them between these visits.

14. 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

15. • The 3rd World Workshop of the American Academy of
Periodontology (1989) and renamed this maintenance
phase as SUPPORTIVE PERIODONTAL THERAPY.
• AAP position paper in 2003 termed it as
PERIODONTAL MAINTENANCE

16. The term supportive periodontal therapy
expresses the essential need for therapeutic
measures to support the patient’s own efforts
to control periodontal infections and to avoid
reinfection.
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

17. 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)

18. Disease recurrence and
retreatment

19. 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.

20. In spite of proper supportive periodontal treatment and
patient compliance, progressive periodontal disease may
reappear in some patients.
Destructive periodontal disease may be associated with
the rebound of periodontal pathogens from remaining
oral tissue reservoirs or the emergence of superinfecting
opportunistic pathogens, or it may occur as a result of low
host resistance.

21. 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).

23. Rationale for supportive periodontal treatment
• Incomplete subgingival plaque removal
• Bacteria are present in the gingival tissues mainly
in aggressive periodontitis cases
• Bacteria associated with periodontitis can be
transmitted between spouses and other family
members.
• Subgingival scaling alters the microflora of
periodontal pockets.

24. OBJECTIVES
The therapeutic objectives of supportive periodontal therapy are:
• 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 and related to the oral cavity.

25. S.P.T. follows the paradigms of the etiology
and prevention of periodontal disease.
Harrold Loe et al.-1964, experimental gingivitis model.
Not all gingivitis proceeded to periodontitis
(role of host defence mechanism).

26. Should we treat gingivitis ?
Or confine our treatment to areas of progressive
periodontal breakdown?
• Physicians- treat only cases of fatal prognosis,
• Quality of life and elimination of disease are the main
concerns in health care, although length of life may
be given the primary attention.

27. From a practical public health standpoint, it has
been suggested that it would be very important to
determine who can tolerate a certain amount of
plaque and gingivitis over time without developing
periodontitis, and only in susceptible individuals to
intercept the infective process before periodontal
attachment is lost (Polson and Goodson 1985).
• Tests for disease activity.

28. Longitudinal studies outlining the crucial role of S.P.T.
1. Ramfjord et al.- 1968, 1975.
2.Lindhe and Nyman- 1975, 1984.
3.Rosling et al.- 1976.
4.Philstrom et al.- 1983.
5.Axelson and Lindhe- 1981.

29. Nyman et al.-1977 reported that 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.

30. Biologic basis for periodontal
maintenance:
Tooth loss in some periodontal patients has been shown
to be inversely proportional to the frequency of
periodontal maintenance (Wilson et al 1987)
• Studies have shown the efficacy of periodontal
maintenance (PM) and have shown that recurrent
periodontitis can be prevented or limited by optimal
personal oral hygiene or through periodic periodontal
maintenance.

31. Periodontal treatment without maintenance
• An inadequate control of bacterial plaque on the part of the
patient and/or the professional predispose to the recurrence
of the disease
• A 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, Becker et al (1984) reported 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.
• Nyman et al (1977) reported that lack of maintenance will
result in disease recurrence showing that surgical
periodontal treatment per se cannot guarantee the
maintenance of periodontal support.

32. Loe et al [1978, 1986] conducted a longitudinal
investigation to study the natural development and
progression of periodontal disease.
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 throught out their lives.

33. 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.
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.

34. 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.

35. 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)

36. 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.

37. Maintenance after periodontal treatment
• In a pioneer study on this subject, 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.
• Similar results were found by Axelsson (1981)
demonstrating that frequent prophylaxis and oral hygiene
have a significant effect on the maintenance of periodontal
support following the treatment of the disease.

38. • 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.

39. Parameters for monitoring
periodontal health during
supportive periodontal treatment

40. Important clinical parameters
 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,
 caries,
 open contacts and status of occlusion and arch
relationship, including any
 anomalies.

41.  clinical history;
 loss of alveolar bone;
 crown-root ratio;
 increase in mobility;
 changes in the patient’s immune system and
response;
 effectiveness in daily removal of bacterial plaque;
 smoking;
 patient’s age;
 root surface smoothness;
 evidence of calculus or root surface accretions;

42. BASIC PARADIGMS FOR THE
PREVENTION OF PERIODONTAL DISEASE
• The etiology of ginigivitis and periodontitis is fairly
well understood.
• However the causative factors i.e the microbial
challenge which induces and maintains the
inflammatory response, may not be completely
eliminated from the dentogingival environment for
any length of time.

43. • This requires the professional removal of all
microbial deposits in the supra and subgingival areas
at regular intervals since the recolonization will occur
following the debridement procedures leading to
reinfection of the ecologic niche and hence giving rise
to further progression of the disease process.

44. Numerous well controlled trials have documented that
such a development can be prevented over very long
periods of time only by regular interference with the
subgingival environment which aims at removal of the
subgingival bacteria
From all these studies it is evident that periodontal
treatment is ineffective in maintaining periodontal health
if supportive maintenance care is neglected, denied or
omitted.

45. RATIONALE FOR SPT
INCOMPLETE REMOVAL OF SUBGINGIVAL PLAQUE
REGROWTH OF SUBGINGIVAL PLAQUE
NO INFLAMMATORY RESPONSE AT THE GINGIVAL MARGIN
ADEQUATE
SUPRAGINGIVAL
PLAQUE
CONTROL
CONTINUED LOSS OF ATTACHMENT
SLOW PROCESS OF
REGROWTH

46. RATIONALE FOR SPT
Another possible explanation for the recurrence of
periodontal disease is the microscopic nature of the
dentogingival unit healing after periodontal treatment.
Histologic studies have shown that after periodontal
procedures, tissues usually do not heal by formation of new
connective tissue attachment to root surface but result in
long junctional epithelium.

47. RATIONALE FOR SPT
Both the mechanical debridement performed by the
therapist and the motivational environment provided by
the appointment seem to be necessary for good
maintenance results.Patients tend to reduce their oral
hygiene efforts between appointments. Knowing that
their hygiene will be evaluated motivates them to
perform better oral hygiene in anticipation of the
appointment.

48. RATIONALE FOR SPT
• There is certainly a sound scientific basis for
recall maintenance because subgingival scaling
alters the pocket microflora for variable but
relatively long periods.

49. GOALS OF SPT
Position paper given by the American Academy of
Periodontology (1998) recommends….
• an update of the medical and dental histories
• examination of extra- and intraoral soft tissues
• dental examination

50. • radiographic review
• evaluation of the patient’s oral hygiene performance
• periodontal evaluation and risk assessment
• supra- and subgingival removal of bacterial plaque
and calculus
• retreatment of disease when so indicated.

51. THERAPEUTIC GOALS OF SPT
• prevent or minimize the recurrence and progression of
periodontal disease in patients who have been previously
treated for gingivitis, periodontitis, and peri-implantitis.
• prevent or reduce the incidence of tooth loss by
monitoring the dentition and any prosthetic replacement
of natural teeth.
• increase the probability of locating and treating in a
timely manner, other diseases or conditions found within
the oral cavity.

52. PATIENTS AT RISK FOR
PERIODONTITIS WITHOUT SPT:
Various studies by Loe et al (1986), Nyman et al
(1977), Axelsson and Lindhe ( 1981) have shown that
patients susceptible to periodontal disease are at a high
risk for reinfection and progression of periodontal
lesions without meticulously organised and performed
SPT.

53. Since all patients who were treated for periodontal
disease belong to this risk category by virtue of their
past history, an adequate maintenance program is of
utmost importance for a beneficial long term treatment
outcome.

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

55. SPT FOR PATIENTS WITH GINGIVITIS
& PERIODONTITIS:
The available information indicates that the
prevention of gingival inflammation and early loss of
attachment in patients with gingivitis depends not only
on the level of personal plaque control, but also on
further measures to reduce the accumulation of
suprgingival and subgingival plaque.

56. SPT is an absolute prerequisite to guarantee
beneficial treatment outcomes with maintained levels of
clinical attachment over long periods of time. The
maintenance of treatment results for the majority of
patients has been documented over 14 years and in
private practice upto almost 30 years……

57. …..but it has to be realised that a small proportion of
patients will experience recurrent infection with
progression of periodontal lesions in a few sites in a
completely unpredictable mode. The continuous risk
assessment at subject, tooth, site levels therefore
represents a challenge for the SPT concept.

58. CONTINOUS MULTILEVEL RISK
ASSESSMENT
• 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.

59. • Lang and Tonetti’s functional diagram (2003) for the
above purpose 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

60. 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.

61. 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.

62. • 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)

63. • 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.

64. 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

65. 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.

66. 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.

67. • 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.

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

69. 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.

70. • 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.

71. 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

72. 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.

73. • 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.

74. • 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

75. •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

76. 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

77. 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.

78. • 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.

79. 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.

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

81. • 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.

82. 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.

83. • 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.

84. 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

85. • 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.

86. TOOTH RISK ASSESSMENT
1. Tooth position within the dental arch
2. furcation inolvement
3. iatrogenic factors
4. residual periodontal support
5. mobility

87. 1. Tooth position within the dental arch:
It is evident from literature that 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.

88. 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.

89. 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.

90. 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.

91. • 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.

92. SITE RISK ASSESSMENT
• The tooth site risk assessment includes the registration of:
1. BOP
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.

93. 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.

94. • 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.

95. 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

96. CLASSIFICA
TION
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

97. CLASSIFI
CATION
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

98. CLASSIFI
CATION
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
1-3
months

99. 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

100. 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

101. REFERAL OF THE PATIENT TO
THE PERIODONTIST

102. - 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

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

104. 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.

105. • 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.

106. 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 )

107. 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.

108. • 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.

109. 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.

110. • 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.

111. • 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.

112. 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.

113. • 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.

114. • 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.

115. • 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
confirmatory way in the case of low scores or in a
challenging 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)

116. • 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.

117. • 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.

118. • 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)

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

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

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

122. 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.

123. • 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.

124. COMPLICATIONS OF SPT
• Root caries
• Endodontic lesions
• Periodontal abcesses – downhill cases
• Root sensitivity

125. 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.

126. • 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.

127. • 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.

128. • 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.

129. Strategic tree for SPT

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

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

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

133. TREATMENT STRATEGY
PERI-IMPLANT
LESION
CUMULATIVE
INTERCEPTIVE
THERAPY
PURULENT
PERIODONTITIS
NO
YES YES
TREATMENT OF
ACTIVE SITES
INSTRU
MENTAT
ION
NO
NO

134. PROPHYLAXIS
REMOTIVATION
REINSTRUCTION
POLISHING
FLUORIDE APPLICATION

135. LOGISTICS
ORGANISATION OF
FURTHER RECALL
VISITS

136. 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

137. 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.

138. 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. 5th Edition, Vol 2,
Chapter 59.