BDS 11008 Supportive Periodontal Therapy 2 PDF

NEWGIZA UNIVERSITY BDS11008 supportive periodontal therapy Date: 02/04/2020 NEWGIZA UNIVERSITY Patient with periodontal condition NEWGIZA UNIVERSITY History and 1. Periodontal chart Patient with gingival condition Initial therapy (Oral Hygiene instructions & supragingival scaling) 2. Periodontal cha...

NEWGIZA UNIVERSITY BDS11008 supportive periodontal therapy Date: 02/04/2020 NEWGIZA UNIVERSITY Patient with periodontal condition NEWGIZA UNIVERSITY History and 1. Periodontal chart Patient with gingival condition Initial therapy (Oral Hygiene instructions & supragingival scaling) 2. Periodontal chart, Diagnosis, Treatment plan Yes Further treatment required No Subgingival scaling and root planing Anti-infective therapy Re-evaluation (after 8-12 weeks) Further treatment required No Yes Surgical Corrective phase Follow up for OH and supragingival every 1-2 months Re-evaluation (after 6 months) Supportive Periodontal therapy Re-evaluation NEWGIZA UNIVERSITY Supportive periodontal treatment A maintenance care program to prevent recurrence of the disease Motivational techniques Reinforcement of the importance of the maintenance phase of treatment Periodontitis treatment is ineffective in maintaining periodontal health if supportive maintenance care is neglected. Phase I therapy is completed patients placed on a schedule of periodic recall visits definitive periodontal surgery NEWGIZA UNIVERSITY Supportive periodontal treatment Phase I periodontal therapy reevaluation Phase IV maintenance Phase II periodontal surgery Phase III restorative x NEWGIZA UNIVERSITY Rationale and objectives of supportive periodontal treatment 1. progression of the disease is possible 2. Incomplete subgingival plaque removal leads to continued loss of attachment 3. Prevention of reinfection 4. Intragingival bacteria recolonize the pocket and cause recurrent disease. NEWGIZA UNIVERSITY Rationale and objectives of supportive periodontal treatment 5. Return of pathogens after 9-11 weeks to pretreatment levels 6. subgingival scaling alters the microflora of periodontal pockets. 7. Patients tend to reduce their oral hygiene efforts between appointments 8. Recall visits motivates the patients (3 months intervals) Rationale and objectives of supportive periodontal treatment NEWGIZA UNIVERSITY Healing by long junctional epithelium rather than CT weaker attachment inflammation spread easily separate the long junctional epithelium from the tooth recurrent pocket formation if maintenance care is not optimal Risk assessment NEWGIZA UNIVERSITY The diagnostic process must be based on continuous monitoring of the multi- level risk profile. microbiota ic m a n Dy rium lib i u q e host’s defense mechanisms Risk assessment NEWGIZA UNIVERSITY Based on: To decide: overall risk profile of the patient Risk of recurrence of the disease Risk for progression of the disease The expected benefit for the patient Intervals between diagnostic assessments Frequency and extent of professional support necessary to maintain the attachment levels obtained following active therapy. Prevent undertreatment or excessive overtreatment during SPT Cost-effective Risk assessment NEWGIZA UNIVERSITY Some clinical parameters can serve as early indicators for: new onset of periodontal disease recurrence of the periodontal disease re-infection progression of periodontal breakdown of a previously treated periodontal site NEWGIZA UNIVERSITY Periodontal Risk Assessment Subject risk assessment Tooth risk assessment Site risk assessment Subject periodontal risk assessment NEWGIZA UNIVERSITY overall risk profile for recurrence of periodontitis is evaluated on the basis of a number of clinical conditions no single parameter displays a paramount role. All risk factors are evaluated simultaneously. To finally construct a functional diagram (Lang & Tonetti 2003) Spider diagram Subject periodontal risk assessment Diagram includes the following: Percentage of bleeding on probing (BoP) Prevalence of residual pockets >4 mm (PPD≥ 5mm) Loss of teeth from a total of 28 teeth Loss of periodontal support in relation to the patient’s age (BL/age) Systemic and genetic conditions Environmental factors such as cigarette smoking. NEWGIZA UNIVERSITY Subject periodontal risk assessment Performed after active therapy (new baseline) periodontal Decide frequency and complexity of SPT Modifications can be made if additional factors become important Example: patient quit smoking…… NEWGIZA UNIVERSITY NEWGIZA UNIVERSITY Subject periodontal risk assessment Compliance with recall system Oral hygiene Directly proportional to the risk of periodontal disease progression non-compliant or poorly compliant patients are considered at higher risk for periodontal disease progression Regular interference with the microbial ecosystem during periodontal maintenance will obscure such obvious associations. Subject periodontal risk assessment N E W G I Z A U N I V E R S IHigh T Y risk >25 % Percentage of sites with bleeding on probing (BOP) Low risk < 10% objective inflammatory parameter first risk factor in the diagram why???? Reflects: the patient’s compliance to oral hygiene performance. patient’s ability to perform proper plaque control. host response to the bacterial challenge. Cut off point 25% Subject periodontal risk assessment Prevalence of residual pockets of >4 mm NEWGIZA UNIVERSITY High risk >8 residual pockets second risk indicator for disease recurrence Reflects: existing ecologic niches liable for re-infection. in conjunction with other parameters (BoP/ suppuration) Low risk < 4 residual pockets Subject periodontal risk assessment Loss of teeth from a total of 28 teeth Reflects: functionality of the dentition patient’s history of oral diseases and trauma 3rd molars not included Shortened dental arch (20 teeth / premolar to premolar occlusion) Loss of >8 teeth mandibular dysfunction NEWGIZA UNIVERSITY Low risk Up to 4 teeth lost High risk >8 teeth lost Subject periodontal risk assessment Loss of periodontal support in relation to the patient’s age worst site affected Posterior region Periapical RG % of root length Bitewing 1mm= 10% %BL/age = NEWGIZA UNIVERSITY Low risk factor 20% bone loss/40 years = 0.5 Low risk High risk Subject periodontal risk assessment Systemic conditions Type I and type II diabetes mellitus Genetic: IL-1 genotype-positive patients (hyperreactive) more advanced periodontitis lesions higher tooth loss higher %BoP deeper PPD stress NEWGIZA UNIVERSITY Subject periodontal risk assessment Environment (smoking) Dose dependent High risk NEWGIZA UNIVERSITY Low risk Reflects: treatment outcome Refractory patients High recurrence rate Disease progression NS non smokers FS former smokers > 5 years OS occasional smokers < 10 cig/day MS moderate smokers 11–19 cig/day HS heavy smokers >20 cig/day Moderate risk NEWGIZA UNIVERSITY Calculating the individual periodontal risk assessment exercise http://www.perio-tools.com/en/index.asp NEWGIZA UNIVERSITY Calculating the individual periodontal risk assessment exercise Low periodontal risk (PR) patient All parameters at low risk At most 1 parameter moderate risk Moderate PR patient At least 2 parameters in moderate category At most only 1 parameter in the high-risk category High PR patient at least 2 parameters in the high-risk category http://www.perio-tools.com/en/index.asp Tooth risk assessment NEWGIZA UNIVERSITY Mobility Tooth position Progressive traumatic lesions 1. Widening of PL space due to high occlusal forces Multirooted teeth Tooth mobility Bone loss Furcation involvement 2. Amount of periodontal support Reduced periodontal support healthy Crowding Overjet/ overbite Axial inclinations Drifting malocclusion with traumatic occlusion Residual periodontal support Iatrogenic factors Overhangs iIl-fitting margins Subgingival margins Subgingival microflora Site risk assessment NEWGIZA UNIVERSITY BOP BOP Inflammation No BOP Periodontally stable High risk PPD/CAL Probe dimension Reference point CEJ Probing force Gingival condition Baseline periodontal evaluation Suppuration Presence of suppuration at follow up visits Indicate Exacerbation of periodontitis Disease progression Constant probing force 0.25 N After initial periodontal therapy Summary NEWGIZA UNIVERSITY Tooth risk assessment Site risk assessment residual periodontal support BOP tooth positioning PPD/CAL furcation involvements Suppuration iatrogenic factors tooth mobility & functional stability. evaluate periodontal disease activity. determine periodontal stability. To evaluate prognosis and function of an individual tooth Identify ongoing inflammation. Identify sites to be instrumented during SPT. indicate the need for specific therapeutic measures during SPT visits. Maintenance phase N E W G I Z A UNIVERSITY 3 months intervals Or according to Patients needs Periodontal care at recall visits 3 parts Examination and evaluation Treatment and oral hygiene reinforcement 1 hour Patient recall s e t nu i m 5 1 10 Examination and evaluation 1. 2. 3. 4. 5. 6. 7. 8. Changes in: Medical Hx Restorations Caries Prostheses Occlusion tooth mobility gingival status BOP PPD Maintenance phase N E W G I Z A Treatment and oral hygiene reinforcement Examination and evaluation Changes occurred Current OH UNIVERSITY Patient recall 1. 2. 3. 4. 5. Radiographic examination bone height repair of osseous defects signs of trauma from occlusion periapical pathologic changes caries Check plaque control Additional instructions Oral mucosa (pathological conditions) Maintenance phase N E W G IeZs A Examination and evaluation Treatment and oral hygiene reinforcement t nu i m 0 -4 Patient recall 30 Treatment and oral hygiene reinforcement SRP (PPD≥ 4mm/ BOP) Avoid subgingival scaling of normal sites (1-3 mm sulcus) Irrigation with antimicrobial agent Site-specific antimicrobial devices (remaining active pockets) Motivation Confirmatory way Challenging way UNIVERSITY & h t o To er t i s is s ka se nt e ssm Maintenance phase N E W G I Z A Examination and evaluation Treatment and oral hygiene reinforcement UNIVERSITY Patient recall Patient recall nt e ssm Polishing / fluoride or chlorhexidine e ss a application / identify the future SPT recall isk r ct e j Phase IV maintenance intervals b u s Specific therapeutic procedures for re- Phase II periodontal infected sites rescheduled surgery ØOFD ØControlled release devices NEWGIZA UNIVERSITY Recurrence of periodontal disease The patient’s failure is the dentist’s failure. Teaching Motivation Control patient’s OH technique Decision for surgery first patient should be willing to cooperate NEWGIZA UNIVERSITY Recurrence of periodontal disease Symptoms of recurrence: BOP Increase PPD Increased bone loss in radiograph Increased mobility by clinical examination Recurrence of periodontal disease NEWGIZA UNIVERSITY Main causes of recurrence: Inadequate treatment / incomplete calculus removal Patient incompliant for periodic recall visits (patient decision/ dentist failure) Inadequate restorations Systemic diseases Recurrence of periodontal disease Symptoms: Mobility Mobility + no RG bone loss + no PPD NEWGIZA UNIVERSITY Possible causes: Inflammation/ poor OH/ bad prosthesis/ systemic Occlusal trauma Recession Tooth brush trauma/ frenum pull/ keratinized tissue inadequate PPD inc. + no bone loss PPD inc. + bone loss Poor OH/ new periodontitis/ no recall/ systemic condition/ deteriorating prosthesis/ inadequate surgery Classification of post-care patients NEWGIZA UNIVERSITY 1st year is critical Evaluate results of periodontal therapy Evaluate results of periodontal surgery Evaluate the patient compliance to OH Evaluate the patient response to treatment Any overlooked etiological factors Classify the patient in which category Recall visits should not exceed 3 months intervals in the first year Decide the recall intervals for the patient Class A Class B Class C According to the worst condition Classification of post-care patients NEWGIZA UNIVERSITY 1st year 1st year Complicated case: ØFurcation ØComplicated prosthesis ØDoubt Patient cooperation 1-2 months Routine therapy + poor healing 3 months Classification of post-care patients NEWGIZA UNIVERSITY Class A Excellent results Good OH Patient compliant to self performed plaque control Minimal calculus No complicated prosthesis No occlusal problems No bone loss > 50% Recall visits every 6 months to 1 year Classification of post-care patients NEWGIZA UNIVERSITY Class B Good results of periodontal therapy + some negative factors Poor OH Heavy calculus Remaining pockets / BOP >20% Some teeth bone loss > 50% Recurrent caries Systemic disease / smoking Occlusal problems Complicated prostheses / ortho genetic Recall visits every 3-4 months According to severity Classification of post-care patients NEWGIZA UNIVERSITY Class C Poor results of periodontal therapy + negative factors Poor OH Heavy calculus Remaining pockets / BOP >20% Many teeth bone loss > 50% Advanced periodontitis Recurrent caries Systemic disease / smoking Occlusal problems Complicated prostheses / ortho Genetic Postponed periodontal surgery Recall visits every 1-3 months According to severity Consider extraction involved teeth of severely Referral to periodontist and its criteria 2 important questions When to call the periodontist ???? Should the maintenance phase of therapy be performed by the general practitioner or the specialist ???? NEWGIZA UNIVERSITY NEWGIZA UNIVERSITY Referral to periodontist and its criteria Age ……………………risk for systemic diseases Systemic disease and periodontitis………………………. The need for SPT üDifficult periodontal cases üPatients with systemic health problems üDental implant patients üComplex prosthetic construction. NEWGIZA UNIVERSITY Referral to periodontist and its criteria Guidelines of the American Academy of Periodontology (2006) When to refer to a periodontist ???? periodontal destruction necessitates surgery on the distal surfaces of second molars extensive osseous surgery complex regenerative procedures Degree of risk to lose a tooth Referral to periodontist and its criteria NEWGIZA UNIVERSITY Guidelines of the American Academy of Periodontology (2006) When to refer to a periodontist ???? Risk of periodontitis to affect systemic health Extent & location of periodontal disease ØPockets ≥ 5mm / bone loss ≥ 50% ØFurcation lesions ØStrategically important teeth localized gingivectomy or flap curettage usually can be treated by the general dentist. NEWGIZA UNIVERSITY Referral to periodontist and its criteria Should the maintenance phase of therapy be performed by the general practitioner or the specialist ???? Class B : can alternate between both Suggested rule: the patient’s disease should dictate whether the general practitioner or the specialist should perform the maintenance therapy. Summary NEWGIZA UNIVERSITY What is supportive periodontal therapy?? When to perform the maintenance phase?? What are the objectives for SPT?? Periodontal risk assessment 1. Subject risk assessment (BOP / PPD / tooth loss/ BL to age/ systemic & genetic/ smoking) How to calculate the subject risk assessment in the spider diagram 2. Tooth risk assessment (mobility/ position/ furcation/ iatrogenic/ periodontal support) 3. Site risk assessment (BOP/ PPD CAL / suppuration) Summary NEWGIZA UNIVERSITY Maintenance phase: ØExamination & evaluation (10-15 minutes) ØTreatment (30-40 minutes) ØPatient report & recall (decide frequent visits intervals) Recurrence of periodontal disease ØSymptoms of recurrence/ causes of recurrence Classification of post-care patients (1st year recall visits + class A/B/C) When to refer to a specialist / periodontist?? Patient with periodontal condition NEWGIZA UNIVERSITY History and 1. Periodontal chart Patient with gingival condition Initial therapy (Oral Hygiene instructions & supragingival scaling) 2. Periodontal chart, Diagnosis, Treatment plan Yes Further treatment required No Subgingival scaling and root planing Anti-infective therapy Re-evaluation (after 8-12 weeks) Further treatment required No Yes Surgical Corrective phase Follow up for OH and supragingival every 1-2 months Re-evaluation (after 6 months) Supportive Periodontal therapy Re-evaluation Reading material NEWGIZA UNIVERSITY Carranza`s clinical periodontology, Newman, Takei, Klokkevold, Carranza (Chapter 69) Clinical periodontology and implant dentistry, Jan Lindhe and Niklaus P. Lang, volume 2 (chapter 60) NEWGIZA UNIVERSITY NEWGIZA UNIVERSITY Towards unbounded thinking. ) ( ' & % $ # " !