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Review Article
ISSN 2395-3608

UNIVERSAL RESEARCH JOURNAL OF DENTAL SCIENCES

Available online: www.ujponline.com

SUPPORTIVE PERIODONTAL THERAPY: NEED OF THE HOUR

Kaur Tabeya Deep1, Kapoor Shalini2, Bhardwaj Amit3*
1Final Year Post Graduate Student, Department of Periodontology Faculty of Dental Sciences, SGT University, Gurugram, Delhi-NCR
Delhi
2MDS Reader Department of Periodontology Faculty of Dental Sciences, SGT University, Gurugram, Delhi-NCR
Delhi
3MDS Professor Department of Periodontology, Faculty of Dental Sciences, SGT University, Gurugram, Delhi-NCR
Delhi
Received 20-10
10-2017; Revised 18-11-2017; Accepted 16-12-2017
*Corres
*Corresponding Author: Dr. Amit Bhardwaj,
MDS, Professor, Department of Periodontology, Faculty of Dental Sciences, Sgt University, Gurugram, Delhi-NCR
Delhi

ABSTRACT
Supportive periodontal therapy is the means by which proper maintenance and care can be given to the patient. Care’ implies
more than ‘therapy’ in supporting periodontal susceptible patients in the retention of aesthetically and functionally accepta
acceptable
periodontal
iodontal affected dentitions for life. Supportive periodontal treatment should include an update of medical and dental
histories, radiographic review, extraoral and intraoral soft tissue examination, dental examination, periodontal evaluation,
removal of bacterial
acterial plaque and calculus 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 behavior
modification. Supportive periodontal
odontal treatment is usually started after completion of active periodontal therapy and continues
at varying intervals for the life of the dentition or its implant replacements. The patient may move back into active care if the
disease undergoes a period off exacerbation. It expresses the essential need for therapeutic measures to support the patient’s
own efforts to control periodontal infections and to avoid reinfection. It plays a crucial role in maintaining the oral healt
health and
over all health of the patient.
ent. So it should be followed carefully by the patient as well as the periodontist
periodontist.
Keywords: Supportive periodontal therapy, Periodontal Maintenance, Maintenance Phase, Patient’s Care, Patient’s Health Health.

INTRODUCTION detection and treatment of new and recurring disease is

Gingival and periodontal diseases in their various forms
have afflicted humans since the dawn of history. Even after
continuous research, gingival and periodontal diseases are
the most common dental diseases to affect humans though
it dates back to 2500 B.C.
C. Since then, numerous treatment
strategies and various techniques have been designed &
described to treat periodontal diseases. All these therapies
ranging from scaling & root planing (SRP) to various flap
limitations1.
surgeries have their own advantages & limitation
Supportive periodontal treatment (SPT) is an integral part
of periodontal therapy2. Supportive Periodontal therapy is
the preferred term for those procedures formerly referred
to periodontal maintenance or periodontal recall and
includes maintenance of dental implants3.
The SPT varies greatly from office to office, therapist to
therapist, patient to patient, and for the same patient over
time.Preservation
reservation of the periodontal health of the treated
patient requires as positive a program as that required fo
for
the elimination of periodontal disease.
Supportive Periodontal Therapy
The continuing periodic assessment and prophylactic
treatment of periodontal structures, permitting early
Universal Research Journal of Dental Sciences, 04 (06), November
November-December
December 2017
supportive periodontal therapy4.
Procedures performed at selected intervals to assist the
periodontal patient in maintaining oral health. As part of
periodontal therapy, an interval is established for periodic
ongoing care. Maintenance procedures are under the
supervision of the
he dentist and typically include an update
of the medical and dental histories, radiographic review,
extraoral and intraoral soft tissue examination, dental
examination, periodontal evaluation, removal of the
bacterial flora from crevicular and pocket areas,
area scaling
and root planning where indicated, polishing of the teeth,
and a review of the patient's plaque control efficacy.
Periodontal maintenance procedures following active
therapy is not synonymous with a prophylaxis5.
GOALS AND OBJECTIVES OF SPT
Goals6
The American Academy of Periodontology specifically lists 3
main goals of Supportive Periodontal Therapy. They are:
• To prevent or minimize the recurrence and
progression of periodontal disease in patients who
have been previously treated for gingivitis, gingiv
periodontitis, and peri-implantitis.
implantitis.
1
 Bhardwaj et al. URJDS 2017, 04 (06): Page 1-7

• To Prevent or reduce the incidence of tooth or implant the dentistt must emphasize that preservation of the teeth
loss by monitoring the dentition and any prosthetic depends on maintenance therapy. Patients who are not
replacement of natural teeth. maintained in a supervised recall program subsequent to
• To Increase the probability of locating and treating in active treatment show obvious signs of recurrent
a timely manner, other diseases or conditions found periodontitis (e.g., increased pocket depth, bone loss, or
within the oral cavity. tooth loss)7,9,10.
Objectives6 PHASES OF PERIODONTAL TREATMENT (Figure 1)
The objectives of SPT are to prevent the occurrence of new Preliminary phase
disease and prevent the recurrence of previous disease. Treatment of emergencies such as dental or periapical or
• Preservation of alveolar bone support periodontal abscesses. Extraction of hopeless teeth and
(radiographically). provisional replacement if needed.11
• Maintenance of stable, clinical attachment level. Non surgical phase (phase 1 therapy)
• Reinforcement and re-evaluation
evaluation of proper home care. Plaque control and patient education:
• Maintenance of a healthy and functional oral 1. Diet control.
environment to prevent occurrence of new disease. 2. Removal of calculus and root planning.
PARTS OF SUPORTIVE PERIODONTAL THERAPY 3. Correction of restorative and prosthetic irritational
Preservation of the periodontal health of the treated factors.
patient requires as positive a program as that required for 4. Excavation of caries and restoration.
the elimination of periodontal disease. After Phase I 5. Antimicrobial therapy.
therapy is completed, patients are placed on a schedule of 6. Occlusal therapy.
periodic recall visits for maintenance care to prevent 7. Minor orthodontic therapy.
recurrence of the disease7. 8. Provisional splinting and prosthesis.
There are 4 parts of SPT namely: Evaluation of response to non surgical phase11.
1. Preventive SPT Surgical phase(phase 2 therapy)
2. Trial SPT 1. Periodontal therapy, including placement of implants
3. Compromise SPT 2. Endodontic therapy
4. Post treatment SPT Restorative phase (phase 3 therapy)
• Preventive SPT: Intended to prevent inception of disease 1. Final restorations
in those who currently do not have periodontal pathology 2. Fixed and removable prosthodontics appliances
(eg,, patients at high risk for development of periodontal or 3. Evaluation of response to restorative procedures
peri-implant
implant problems because of systemic disease or 4. Periodontal examination
dexterity problems that prevent practicing hygiene).7
Trial SPT : designed to maintain border line periodontal
conditions over a period to further assess the need for
corrective therapy for problems such as –
- inadequate attached gingiva,
- gingival architectural defects, or
eriodontal health
- furcation defects, while maintaining periodo
throughout the balance of the mouth.
• Compromise SPT: designed to slow the progression of
disease in patients for whom periodontal corrective
therapy is indicated, but cannot be implemented for
reasons of health, economics, inadequate oral ral hygiene, or
other considerations, or when recalcitrant defects persist
after corrective treatment.
This type also includes situations in which periodontal or
peri-implant
implant defects persist after corrective therapy
attempts (eg: patients with moderate chronic onic periodontitis
or periimplantitis who cannot undergo treatment because
of current gastric cancer treatment)8.
• Post treatment SPT: designated to prevent the
recurrence of disease and maintain the periodontal health
achieved during therapy.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 staff. Patients must
understand the purpose of the maintenance program, and

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PERIODONTAL RISK ASSSESSMENT FOR PATIENTS In case of progressive periodontitis such as aggressive
WITH SPT periodontitis cases etc tc SRP (Scaling, Root planing) is
Subject risk assessment (Figure 2) performed along with anti microbial therapy and then
The patient's risk assessment for recurrence of patient is recalled and microbiological re evaluation is
periodontitis may be evaluated on the basis of a number of done for the patient. After which the patient is again
clinical conditions whereby no single parameter displays a recalled and the periodontal status is checked for the
more paramount role. The entire spectrum of risk factors patient,
tient, in case it is stable then the patient is kept on
and risk indicators ought to be evaluated
valuated simultaneously. periodic supportive periodontal therapy and in case if the
For this purpose, a functional diagram has been progressive periodontitis persists then the selection of
constructed including the following aspects: alternative clinical treatment or antimicrobial regimen is
1. Percentage of bleeding on probing. done after which again thee patient is recalled and the
2. Prevalence of residual pockets greater than 4 mm (3 (3-5 periodontal status checked and finally kept on periodic
mm). supportive periodontal therapy14.
3. Loss of teeth from a total of 28 teeth.
4. Loss of periodontal support in relation to the patient's
age.
5. Systemic and genetic conditions.
6. Environmental factors, such as cigarette smoking.12,13
Each parameter has its own scale for minor, moderate and
high risk profiles. A comprehensive evaluation of the
functional diagram will provide an individualized total risk
profile and determine the frequency and complexity of SPT
visits. 12.13

INSTRUMENTATION IN SPT
Instrument selection for supportive periodontal
treatment
A variety of hand instruments have been used for scaling
s
and root debridement. These include curets, sickles, hoes,
DIAGNOSIS AND SPT files and chisels15.
MICROBIAL TESTING IN SUPPORTIVE PERIODONTAL -Gracey Curette
THERAPY (Figure 3) -Mini bladed instruments
Initially clinical evaluation for supportive periodontal -Gracey Curvette
therapy is done. If the periodontal status is stable then the -Plastic
Plastic instruments for implants
patient is kept on periodic supportive periodontal therapy. -Micro ultrasonic instruments
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Ultrasonic scaling technique Part I: Examination

mentation is accomplished with a light
Ultrasonic instrumentation (Approximate time: 14 minutes)
touch and light pressure, keeping the tip parallel to the • Patient greeting
tooth surface and constantly in motion. Leaving the tip in • Medical history changes
one place for too long or using the point of the tip against • Oral pathologic examination
the tooth can produce gouging and rougheningening of the root • Oral hygiene status
surface or overheating of the tooth. • Gingival changes
The working end of the ultrasonic instrument must come • Pocket depth changes
in contact with the calculus deposit to fracture and remove • Mobility changes
it. As with hand instruments, instrument adaptation to the • Occlusal changes
tooth is critical to success.
• Dental caries
ANTIMICROBIAL THERAPY IN SPT
• Restorative, prosthetic, and implant status
Single agent antibiotic therapy in current periodontics
Part II: Treatment
includes metronidazole (500 mg three times daily for 8
(Approximate time: 36 minutes)
days), clindamycin (300 mg three times daily for 8 days)
• Oral hygiene reinforcement
and ciprofloxacin (500 mg twice daily for 8 days) (all adult
• Scaling
dosages assuming normal renal function). Common
combination therapy in periodontics includes • Polishing
metronidazole and amoxicillin (250 mg each three times • Chemical irrigation or site-specific
site antimicrobial
daily for 8 days) and metronidazole and criprofloxacin placement
(500 mg each twice daily for 8 days)16. Part III: Report, Cleanup, and Scheduling
MAINTENANCE RECALL PROGRAM (Approximate time: 10 minutes)
Periodic recall visits form the foundation of a meaningful • Write report in chart.
long term prevention program. The interval between visits • Discuss report with patient.
is initially set at 3 months but may be varied according to • Clean and disinfect operatory.
the patients needs. Periodontal care at each recall visit • Schedule next recall visit.
comprises three parts.11 (Table 1) • Schedule further periodontal treatment.
• Schedule or refer for restorative or prosthetic
treatment.11
SPT IN GINGIVITIS AND PERIODONTITIS
A treatment plan for active therapy should be developed
that may include the following:
1. Patient education and customized oral hygiene
instruction.
2. Debridement of tooth surfaces to remove supra and
subgingival plaque and calculus.
3. Antimicrobial
obial and antiplaque agents or devices may be
used to augment the oral hygiene efforts of patients
who are partially effective with traditional mechanical
methods.
retentive factors such as over-
4. Correction of plaque-retentive over
contoured crowns, open and/or overhanging
overhangin margins,
narrow embrasure spaces, open contacts, ill-fitting
ill
fixed or removable partial dentures, caries, and tooth
mal-position.
5. In selected cases, surgical correction of gingival
deformities that hinder the patient’s ability to perform
adequate plaque control may be indicated.
6. Following the completion of active therapy, the
patient’s condition should be evaluated to determine
the course of future treatment.
IMPLANT MAINTENANCE THERAPY
Guidelines for follow-up up of implant treated
patients17,18
1. Supportive therapy – infection control
2. Radiographic examination
3. Clinical examination

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Step 1: Review of the patient’s medical history Regenerative or resective therapy, CIST protocol
Step 2: Assessment of implants A+B+C+D.
-Visual soft tissue assessment SPT IN DAILY PRACTICE (Figure 4)
-Protocol for inflammation The recall hour should be planned to meet the patient’s
-Visual examination upon probing individual needs. It basically consists of four different
-Visual signs of failing implant sections
ections which may require various amounts of time
-Monitoring the implant during a regularly scheduled visit:
Step 3: Safe instrumentation and polishing of dental 1. Examination, Re-evaluation
evaluation and Diagnosis (ERD)
implants 2. Motivation, Reinstruction and Instrumentation
Plastic, graphite and titanium coated implant scalers
-Plastic, (MRI)
-Polishing dental implant restorations infected Sites (TRS)
3. Treatment of Re-infected
Lang et al suggested a novel, systematic step wise 4. Polishing of the entire dentition, application of
approach for the prevention and treatment of peri peri-implant Fluorides and Determination of future SPT (PFD)20
diseases referred to as the cumulative interceptive
supportive therapy (CIST) protocol. This system is based
on periodic monitoring with implementation of treatment
as thresholds for a particular condition
ndition are met. The first
step is protocol (A), then (B) and, if conditions continue to
worsen, the case may require more advanced treatment,
which may include co-management
management with a specialist who
has implant training to execute protocol (C), and finally
(D).
D). Protocol (A) is used to control inflammation in periperi-
implant mucositis, that is, implants with minimal increase
in pocket depth, slight (+) bleeding on probing, marginal
erythema, plaque, and/or calculus. The therapeutic
endpoint is to resolve inflammation tion with cautious
mechanical debridement (using plastic curettes and
rubber cup prophylaxis), twice daily swabbing with 0.12%
chlorhexidine, and a review of home care and patient
motivation. Protocol (B) is initiated for conditions that
exhibit similar mucositis
cositis features but with deeper pocket
depths (4 mm to 5 mm); however, there is still no loss of
supporting bone. The treatment should include the
therapies of protocol (A), plus locally delivered antibiotic
(minocycline microspheres, doxycycline gel) at the
infected implant site(s). Recent studies have shown the use
of minocycline microspheres may be beneficial in
treatment of peri-implant
implant mucositis and peri
peri-implantitis.
Management of early peri-implantitis,
implantitis, protocol (C),
requires a more robust approach and nd is used in conditions
with evidence of osseointegrated bone loss of < 2 mm and
pocket depths > 5 mm. The strategy should comprise the
modalities for protocols (A) and (B) with the addition of
systemic antibiotic therapy (metronidazole 250 mg t.i.d.
for 7 days or amoxicillin 500 mg t.i.d. for 10 days)19.
Protocol (D) is initiated in circumstances of frank peri peri-
implantitis that reveal probing depths (> 5 mm), (+)
bleeding on probing, plaque/calculus, and peri peri-implant
bone loss of > 2 mm. This strategy requires ires periodontal
surgical intervention for chemical disinfection, osseous
resection, and/or guided bone regeneration (GBR).
The 4 steps are:-
COMPLIANCE AND SUPPORTIVE PERIODONTAL
Mechanical debridement, CIST protocol A
THERAPY
Antiseptic therapy, CIST protocol A & B
Compliance (also called adherence and therapeutic
Antibiotic therapy, CIST protocol A + B
alliance) has been defined as “the extent to which a
Antibiotic therapy, CIST protocol A + B + C
person’s behavior coincides with
w medical or health
advice”.
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 Bhardwaj et al. URJDS 2017, 04 (06): Page 1-7
Reasons for poor compliance
1. It has been suggested that noncompliance with health
care recommendations is a indirect self destructive
behavior (Farberow N; 1986).21 The behavior of these
non compliant patients is characterized by denial and
negligent attitudes towards their illness.
2. Lack of pertinent information
3. Fear of dental treatment is a major reason for non-
compliance several approaches have been suggested
to diminish this concern.
I Use of relaxation and symbolic modeling
II. Group education or videotapes
III. Changing the behavior of dentists toward patients.
4. Economic problems: In groups with lower
socioeconomic status, monetary rewards have been
shown to improve compliance.
Possible methods of improving compliance
1. Simplify: the simpler the required behavior, the more
likely it is to be carried out.
2. Accommodate more the suggestions fit the patients’
needs, the more likely they are to comply.
3. Remind patient of appointments
Communication is a key factor. Factors that influence
breakage of Appointments:-
a. Age
b. Race
c. Psychosocial problems
d. Race
e. Psychosocial problems
f. Percentage of previous non cancelled appointments
4. Keep records of compliance
5. Communication with the patient should be initiated as
quickly as possible when non-compliant behavior is
noted. The sooner the patient is contacted after
missing the appointment, the more likely they are to
keep their new appointments.
6. Inform.
FUTURE TRENDS
Photodynamic therapy (PDT) is a technique based on the
use of a photoactivatable non-toxic chemical that can
absorb light of a specific wavelength for targeting
pathogenic microorganisms. PDT as an adjunct to SRP may
be considered as an encouraging therapeutic approach for
initial periodontal therapy, i.e. cause-related therapy, and
for periodontal maintenance treatment, displaying
promising clinical results in patients with chronic
periodontitis (CP) and also presenting encouraging effects
in modulating the local level of key cytokines associated
with periodontal disease22.
CONCLUSION
Periodontal treatment success, including both nonsurgical
and surgical therapy, is dependent on appropriate
maintenance. Periodontal maintenance therapy also
applies to dental implants, as they have been shown to be
susceptible to peri-implant disease. In addition, long-term
control of periodontal inflammation may reduce the risk of
Universal Research Journal of Dental Sciences, 04 (06), November-December 2017
several systemic diseases and conditions. It is the general
practitioner’s responsibility to evaluate each patient’s
dental history and prescribe appropriate periodontal and
peri-implant maintenance care, as well as to identify when
conventional treatment is failing and to execute a prompt
and appropriate solution, which includes use of adjunctive
agents, surgery, or referral to a periodontist. The keys to
success include consistent reminders sent to the patients
on the importance of long term maintenance in preventing
periodontal or peri-implant disease progression, as well as
early identification and treatment of inflammatory and
biomechanical problems to minimize their impact. This
will maximize the likelihood of maintenance of natural
teeth and dental implants in health, comfort, function, and
esthetics for the duration of the patient’s life.
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Source of support: Nil, Conflict of interest: None Declared

Universal Research Journal of Dental Sciences, 04 (06), November-December 2017 7

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