Supportive Periodontal Treatment

Rationale for PMT

Phase I (disease control)

Reevaluation

Phase II (srgical phase)

Phase III (restorative)

Phase IV ( maintenance)

Phase I (disease control) Reevaluation

Phase IV (SPT)

Phase II
(Periodontal surgery)

Phase III
(Restorative)

Need for a comprehensive treatment plan

Maintenance prevents disease recurrence

SPT is time & effort consuming Dentist: knowledge, time, patience, interest, understanding, good communication skills, programming

Patient

Understand & appreciate the benefit Find time Make effort Keep coming back

Is SPT Really Effective?

Yes

Whats the evidence?

Patients maintaimed on long term maintenance programs have:

Better periodontal health Better dental condiditon Better tooth preservation

(Axelsson & Lindhe, 1978; 1981)

More Evidence

Patients who were not maintained had:

Periodontally: deeper pockets, more bone loss & tooth loss. Caries Tooth loss

(Axelsson & Lindhe, 1981) (Becker & Becker, 1984)

The more often patients present for SPT, the less likely they are to lose teeth
(Wilson et al, 1987)

People who fail to attend regular recall are at 5.6 times greater risk of losing teeth than people who attend SPT.
(Checchi et al, 2002)

In Addition

Inadequate SPT after successful regenerative therapy: 50-fold increase in risk of attachment loss (CAL), compared to patients with regular SPT.
(Cortellini et al, 1994)

Why?

Rationale behind oral hygiene practices

Accumulation of plaque results in the development of gingivitis, & its removal & control result in the resolution of the lesion in humans
Le et al. (1965)
Dr Hayder Alwaeli

Rationale 2
Subgingival

plaque forms from the apical downgrowth of supragingival plaque.

(Listgarten, 1975)

Plaque

Gingivitis

Periodontitis
(In Susceptible Individuals)

Axelsson & Lindhe, 1978

1.

It is possible with regular instructions & prophylaxis to stimulate adults to adopt proper oral hygiene habits. Persons who practice good OH have negligible signs of gingivitis, no attachment loss & no caries

2.

3.

Persons who received only symptomatic treatment had gingivitis, AL, caries & recurrent caries.

Plaque control leads to change in the ecology of the periodontal crevice/pocket by resolution of inflammation.

Plaque Control is the 1st step in periodontal treatment planning Should be reinforced in every appointment Without proper plaque control, Periodontal treatment will

Fail

Sc Vs OHI in maintaining periodontal health: :more OHI & less Sc is better than more Sc & less OHI.
(Lightner, 1971)

When to Discuss?

Before surgery Depends on patient responsiveness, education and personality Dont shock the patient with it, just tell it to them by the way, e.g.: I would like to check your gums every few months or from time to time

When does SPT Start?

Immediately after R/V of phase I Why? Because periodontal diseases may RECUR

Reasons for Recurrence

1. Incomplete removal of subgingival plaque

Re-established within 2-3 months Doesnt always cause visible changes (you have to probe)

2. Inadequate plaque control by the patient THEIR job But YOUR DUTY!

3. Healing after SRP is usually by long junctional epithelium

may be less resistant to spread of inflammation

4. Inadequate restorations

These factors do not initiate periodontitis 5. Systemic but diseases/conditions predispose to it

6. Madications

Research has shown that subgingival scaling alters the microflora of periodontal pockets
(Rosenberg et al, 1981)

Even supragingival scaling does so to a lower extent

(Katsanoulas et al, 1992)

One study:

Single session of SRP:

1 week: less motile microorganisms (mo)

21 days: more cocci

7 weeks: reduced spirochetes
(Mosques, Listgarten & Phillips, 1980)

The Maintenance Program

3 parts:

Examination
Treatment & OH reinforcement Scheduling the next appointment (perio, restorative, orthoetc)

Examination

Patient greeting Ask the patient about their opinion & smoking cessation Medical history update, testsetc Dental history Look for changes: oral mucosa & gingiva Oral hygiene PPD Mobility Recession Occlusal changes Restorations & implants

Treatment

Oral hygiene reinforcement Scaling Polishing Local antimicrobials ? Splinting Desensitizing agents Fluoride application

Good Plaque Control

Educate your patient Provide efficient treatment Put on Maintenance program

Notice That

You should not repeat Phase I again, but unfortunately, you repeat treatment for many of your patients WHY?

Inadequate/improper motivation & OHI No reinforcement

Lack of dental education

Conflicting sources of knowledge

Take care not to instrument (subgingivally) normal sites with shallow PD (1-3 mm) as repaeated SRP in shallow sites loss of attachment
(Lindhe, Nyman & Karring, 1982)

Uninstructed patients

Spend 39 sec on average cleaning their teeth Remove about 60% of plaque (those who brush) De la Rosa

Keep doing what they are used to do

Instructed patients

Have less plaque, gingivitis, periodontitis, caries and tooth loss Usually do less than required Do not forget: instructions regarding attrition, erosion & abrasion; prostheses; other family members; diet; smoking & systemic diseases.

Report, clean up, scheduling

Write report in file

Clean & disinfect Schedule next recall visit

When?

Minimum probing timing: 2 weeks after root planing

Depends on patient motivation, OH status, dexterity, general health & susceptibility Dont leave most patients > 3 months

Classification of Maintenance patients

Classified after 1st yr of trt. & SPT

Class A, B, C Patients may improve or relapse to a different classification

Carranzas Clinical Periodontology, 10th ed, Saunders, Elsevier

Carranzas Clinical Periodontology, 10th ed, Saunders, Elsevier

Maintenance of implants

Special plastic instruments No acidic topical fluoride preparations Cleaning must be very thorough & patients should receive regular checkups

Some Pratical Guidelines

Dental Health Education

Motivation

Demonstration

Practical Guidelines 1
1.

Try to give dental health education in a special room

2.

Meet the patient at his own level (attitude, language, avoid insult)
Explanatory leaflets

3.

4.

Demonstrate periodontal disease in the patients mouth (disclosing)

Help the patient to recognise the benefits of prevention (prevention of tooth loss, financial benefit, aesthetics, others)

5.

Practical Guidelines 2
6.

7.

8. 9.

10.

Do not build up false hopes, or create false fears. In periodontics, patients need constant encouragement, as treatment takes a long time. Stress every positive result at R/V appointments, but tell the patient the truth. Respect the values and experiences that patients bring. Show interest Make the patient participate in each stage of the dental education.

Your Hygiene

Your Attire and Attitude

YOUR GUMS And TEETH SHOULD BE CLEAN AND HEALTHY

Your Attire and Attitude

Always be professionally dressed, with clean, ironed clothes and white coat Shoes should be closed, comfortable & clean Take special care of personal hygiene & odour Keep nails short Be serious but kind and polite Addressing the patient

Infection Control

Take care of cleanliness and sterilization of instruments, equipment and all working surfaces Operator & assistant : Always wear protective clothing, gloves, mask, and glasses

Psychological factors
Establish a humane, professional relationship with your patients

Give the patient the necessary care and support; dont be too bossy (although you are the one who decides the treatment). Help the patient with personal problems by discussing them, without getting involved in the problems yourself!

Recall Visits

Arrange recall visits, which are convenient to the patient and yourself

Forget the 6-month myth

Recall programs for SPT must be tailored for each patient

When Does SPT End? Never!