For Post-Graduate Examinations Supportive Periodontal Therapy A Comprehensive Review Dr. Suchetha Aghanashini Dr. Surya Suprabhan Dr. Darshan B.M. Dr. Sapna N. Supportive Periodontal Therapy : A Comprehensive Review IP Innovative Publication Pvt. Ltd. Supportive Periodontal Therapy : A Comprehensive Review Dr. Suchetha Aghanashini Dr. Surya Suprabhan Dr. Darshan B.M. Dr. Sapna N. IP Innovative Publication Pvt. Ltd. IP Innovative Publication Pvt. Ltd. A-2, Gulab Bagh, Nawada, Uttam Nagar, New Delhi-110059, India.Ph: +91-11-61364114, 61364115. E-mail: [email protected], [email protected] Web: www.innovativepublication.com Supportive Periodontal Therapy : A Comprehensive Review ISBN : 978-93-88022-29-3 Edition : First, 2019 Open Access Book Dedicated To All the post graduate dental students! About The Authors Dr. Suchetha Aghanashini Professor and HOD Department of Periodontology DAPMRV Dental College, Bangalore Dr. Surya Suprabhan Post Graduate Student Department of Periodontology DAPMRV Dental College, Bangalore Dr. Darshan B. M. Reader, Department of Periodontology DAPMRV Dental College, Bangalore Dr. Sapna N. Reader, Department of Periodontology DAPMRV Dental College, Bangalore Preface Supportive periodontal therapy (SPT) is the term given to care and proper maintenance of the patient after completion of periodontal therapy. One of the causes of failure of periodontal therapy is the inadequate follow-up. Hence, patients as well as specialists should be made to understand the significance of supportive periodontal therapy. The purpose of this book is to make the dental professionals/post-graduate students aware of the facts regarding the importance and the protocols of SPT. It is my great privilege to introduce my new textbook “Supportive Periodontal Therapy : A Comprehensive Review”, and I hope that it will be useful to the post- graduate students as well as dental professionals. ix Acknowledgement I acknowledge and appreciate my staff and post-graduate students for their complete support in writing this book. xi Contents Preface ix Acknowledgement xi 1. Introduction to Supportive Periodontal Therapy 1 2. Aims and Objectives 3 3. Biologic Basis and Rationale for Periodontal Maintenance 7 4. Recall Intervals for Various Classes of Recall Patients 9 5. Compliance and its Role in Periodontal Therapy 11 6. The Dental Professionals’ Role in Supportive Periodontal Therapy 14 7. Patients Role in Supportive Periodontal Therapy 21 8. Periodontal Risk Assessment (PRA) for Patients in Supportive Periodontal Therapy (SPT) 24 9. Role of Periodontist During SPT 32 10. Restorative Dentistry and its Effect on Periodontal Maintenance 45 11. Supportive Periodontal Therapy in Orthodontic Patients 50 12. Supportive Periodontal Therapy in Patients on Radiation Therapy 52 13. Supportive Periodontal Therapy for Chemotherapy Patients 54 14. Complications Seen During SPT 57 15. Conclusion 59 16. Review of Literature 61 Bibliography 113 Chapter 1 Introduction to Supportive Periodontal Therapy Periodontitis is a microbial infectious disease and is characterized by the presence of gingival inflammation, periodontal pocket formation, and loss of connective tissue attachment and alveolar bone around the affected teeth.1 The aim of periodontal therapy is to protect and maintain the patient’s natural dentition over their lifetime for optimal comfort, function and aesthetic appearance.2 Periodontal therapy includes surgical and non-surgical procedures. Once the periodontal therapy is completed, patients should be placed on a schedule of periodic recall visits for supportive care to prevent the recurrence of the disease. Recurrence of periodontal disease can occur due to improper oral hygiene habits, inadequate subgingival removal, because of the microscopic nature of the dentogingival unit healing after periodontal treatment etc. Hence proper treatment should be rendered so that the recurrence of disease doesn’t occur. Transfer of the patient from active treatment status to a maintenance care program is an ultimate step in total patient care that requires time and effort on the part of dentist, staff and patient. Thus, the maintenance phase has been considered as the cornerstone of successful periodontal therapy.1 Clinical trials on the long-term effects of treatment of periodontitis have clearly demonstrated that post-therapeutic professional maintenance care is an integral part of the treatment.2 Patients who are not maintained on a supervised recall program subsequent to active treatment show obvious signs of recurrent periodontitis (e.g. increased pocket depth, bone loss, or tooth loss).3,4,5 One study found that treated patients who do not return on regular recall basis are at 5.6 times greater risk for tooth loss than compliant patients.6 Another study showed that patients with inadequate maintenance care after successful regenerative therapy have a 50-fold increase in risk of attachment loss when compared with those who have regular recall visits.7 Studies8-10 have indicated patients who return for their regular periodic visits of scaling, root planning, oral hygiene reinforcement, and disease reassessment demonstrate better periodontal health and a better prognosis in the long term than those patients who do not return for these appointments. Treatments with long term maintenance programs following active therapy,11 once termed maintenance is called as Supportive Periodontal Therapy (SPT) according to 5th American Academy of Periodontology (AAP), 1986.12 In 1989 the World workshop 1 Supportive Periodontal Therapy : A Comprehensive Review in clinical periodontics described the term ‘supportive periodontal treatment’ (SPT)13 and in 2003 AAP, position paper termed it as Periodontal Maintenance Therapy.1 An old Chinese proverb holds true explaining the importance of the interval treatment sessions in Supportive Periodontal Treatment–“It is better to take many small steps in the right direction than to make a great leap forward only to stumble backward.” A successful treatment of periodontal disease requires a positive program directed at maintaining and improving the results of treatment as well as preventing the development of new disease. Hence supportive periodontal treatment is performed by a dentist, although components of supportive periodontal treatment can be executed by a dental hygienist under the supervision of the dentist. Supportive periodontal treatment should include an update of medical and dental history, radiographic review, extra oral and intraoral soft tissue examination, dental examination, periodontal evaluation, removal of bacterial plaque from the supragingival and subgingival regions, scaling and root planing where indicated, polishing of the teeth and a review of the patient’s plaque control efficacy and other appropriate behaviour modification.14,15 In SPT, periodontal diseases and conditions are monitored, etiological factors reduced or eliminated and continued at periodic intervals for the life of the dentition or its implant replacement.12 Patient should be informed and explained about the importance of this therapy for management of the disease.16 This makes the patient to maintain the teeth for their life time which suggests that the evaluation of the efficacy of SPT can be carried out over an extended period.17 Attempts are being made to individualize and tailor SPT regimen according to the patient's profile and needs i.e. in various clinical aspects like patients with gingivitis, periodontitis, implants and also its role in other different clinical aspects of dentistry. Recent trends also show increased use of antimicrobials as adjuncts to mechanical procedures for controlling the etiologic agents.16 The term ‘supportive periodontal treatment’ expresses the essential need for corrective measures to support the patient’s own efforts to control the periodontal infections and to avoid re-infection.18 q 2 Chapter 2 Aims and Objectives The prime objective of maintenance care is to secure optimal supra and subgingival plaque control. First by encouraging optimal oral hygiene by the patient, and secondly by professional removal of all supra and subgingival plaque and calculus.19 The therapeutic objectives of supportive periodontal therapy are: to prevent the progression and recurrence of disease in patients who has been previously 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 to diagnose and manage other diseases or conditions found within or related to the oral cavity.15 Objectives of supportive periodontal therapy: 1. Preservation of alveolar bone support: as evaluated with radiograph. i. Bone height may not only be maintained but also improved when proper maintenance is provided after periodontal therapy. 2. Maintenance of stable clinical attachment levels. i. Despite all the variability associated with clinical measurement maintenance of stable clinical attachment levels represents a reasonable clinical indicator to evaluate the stability of results. 3. Control inflammation: without proper maintenance dental plaque will re- accumulate and inflammation would be re-established in periodontal tissues. On the contrary well maintained patient will have low levels of inflammation after therapy. 4. Re-evaluation and reinforcement of proper home care. i. Although 3-4 month recall seems to compensate for improper plaque control as far as its effects on clinical attachment