Perio Maint SPT PDF

Periodontal Maintenance How is periodontal maintenance different from a ‘regular’ recall? CDT code 4910 instead of 1110 Insurance will reimburse more than a regular maintenance Insurance can also only pay for 4910 if periodontal treatment was within a certain # of months, even though once a perio pa...

Periodontal Maintenance How is periodontal maintenance different from a ‘regular’ recall? CDT code 4910 instead of 1110 Insurance will reimburse more than a regular maintenance Insurance can also only pay for 4910 if periodontal treatment was within a certain # of months, even though once a perio patient, always a perio patient Medical history reviewed completely and carefully Vitals (including blood sugar) Medications updated, Lexicomp completed Comprehensive exam (probe and record every pocket, record GM measurements) Home care education is ongoing Changes noted, patient informed Treatment planned: is maintenance warranted? o Periodontal pathogen testing needed? o Do you need to scale and root plane any areas? o Laser surgery? o Osseous surgery? o Meticulous biofilm removal o Make sure that patient’s next appointment is scheduled with their GP and with Perio Gingival Inflammation The role of gingival inflammation in disease pathogenesis has been increasingly recognized. In a classic longitudinal study: teeth with consistently inflamed gingiva showed greater clinical loss of attachment As pts get older, gingival inflammation is more recognized Subgingival calculus increased the odds of progressing from gingivitis to periodontitis (attachment loss) Significantly more tooth loss occurred for those with the high consistently of bleeding on probing in all sites INCREASED tooth survival rate for with no bleeding on probing DECREASED survival rate for teeth with persistent inflammation Healthy gingiva are an important prognosis for tooth longevity If patients can eliminate inflammation they have a high chance of keeping their teeth for a lifetime Eliminating inflammation has a high chance of keeping teeth for a lifetime Gingival inflammation is a precursor and risk factor to: o Periodontitis o Periodontal attachment loss and tooth loss The findings emphasize the importance of: o Prevention and treatment of periodontal diseases o maintaining periodontal health o Avoiding recurrence of disease and inflammation o Role of supportive therapy Criteria for the gingival index system 0: Normal gingiva 1: Mild inflammation – a slight color change, slight edema. No bleeding on probing. 2: Moderate inflammation – redness, edema, and glazing. Bleeding on probing. 3: Severe inflammation – marked redness and edema. o During exam, grade four areas on each tooth (add together, divide by 4 for each tooth. Add all teeth together and divide by number of teeth) Aging Biologic effects of aging have either NO impact or a minimal impact on an individual's response to periodontal treatment. o Other factors: cognitive and motor skills, medical history can have an impact as well as medical history. o Aging affect management of periodontal health (e.g. the risk of root caries, limited dexterity) o No differences seen due to aging, in response to NON-SURGICAL or SURGICAL treatment o No plaque control à continued loss of attachment is inevitable o No periodontal therapyà fast progression of disease with increasing age. o Supportive maintenance has greater compliance among older individuals as compared with younger pts. Interaction between bacteria and keratinocytes results in the up-regulation of IL-8 and ICAM-1 expression in the gingival epithelium, stimulating neutrophil migration into gingival sulcus. Similar effects are present in the gingiva of periodontally healthy individuals as well (infiltrating neutrophils) SPT Supportive periodontal therapy: therapeutic measures to support the patient's own efforts to control periodontal infections and avoid re-infections Dental professional provides therapeutic measures but the patient has a key role in maintaining this. Other important goals are to: o Prevent or minimize any disease recurrence or progression o Prevent/reduce tooth loss or implant loss by monitoring dentition, prosthetic replacements and implants o Treat any diseases found during the examination o Ensure adequate control of supragingival plaque by the patient. To achieve these goals, it is necessary to ensure: o Regular clinical assessments o Appropriate interceptive therapy o Continued psychological support, encouragement and motivation for the patient o life-long commitment by the patient o life-long commitment by the dental professionals supporting the patient Biological Basis of SPT (supportive periodontal treatment or recare) Plaque etiology of periodontal diseases Balance between microbial challenge, Host defenses, conducive environment/plaque ecology Individual patient risk assessment Role of inflammation Less clinical attachment loss (CAL) and tooth loss occur with regular SPT Tooth loss is inversely proportional to SPT frequency Recurrent periodontitis can be limited or prevented by optimal oral hygiene SPT provides for monitoring following periodontal treatment or implant provision Value of Supportive Periodontal Therapy Supportive periodontal therapy (SPT: therapeutic measures to support patient's own efforts to control periodontal infection and avoid re-infections While the dental professional is responsible for providing the necessary therapeutic measures to achieve the best periodontal health possible, the patient has a key role in maintaining this. Many studies have been published since the 1970s that have demonstrated the value of SPT Compared to patients without SPT or with less SPT, patients receiving regular SPT have: o reduced risk of tooth loss o reduced risk of attachment loss o decreased pocket depth Recurrence of periodontitis can be prevented, or limited by optimal personal plaque control and through periodic professional SPT Age, smoking habit and initial tooth prognosis affected tooth loss outcome and, overall, there were low rates of tooth loss for periodontal reasons. The findings demonstrated that long-term periodontal supportive therapy was able to maintain periodontal health and prevent tooth loss and the importance of regular periodontal maintenance and smoking cessation in preventing further tooth loss. Assessment of Treatment Outcomes At all stages of periodontal therapy (either initial, corrective, or supportive phase), it is important to recognize that the ability to remove all deposits is limited by the depth of the pocket, and this influences the amount of pocket reduction and attachment level gain ultimately achieved. Removal of all subgingival calculus is difficult Clinically acceptable healing does occur despite microscopic aggregates of residual subgingival calculus. The critical mass of biofilm (plaque) needs to be reduced to a threshold where there is a balance between the microbial deposits and patient's host response which is conducive to periodontal stability. Successful treatment: healing forms long junctional epithelium, replacing leaky, ulcerated pocket epithelium Radiographically, there may be bony infill at the base of angular defects where vertical bone loss had previously occurred. After scaling and root surface debridement (RSD), junctional epithelium re-establishes quickly, within two weeks, but the granulation tissue is not yet mature and not replaced by collagen fibers. In fact, repair of connective tissue continues for four to eight weeks after scaling and RSD and, therefore, while monitoring could be done at this stage, it is pertinent to wait eight to twelve weeks to re-evaluate probing depths and measure the clinical attachment level in order to monitor the success of the treatment outcome. As subgingival microbial recolonization can occur within four to eight weeks of scaling and RSD in the absence of improved plaque control, an essential aspect of SPT is the maintenance of optimal oral hygiene and effective plaque control 8-12 weeks for reevaluation. Schedule maintenance at 3 months and re-eval then. It will not look moth eaten, the JE will condense (baker) Perio maint plan is individually tailored following initial and corrective therapy The frequency of SPT should be based on the patient's risk of disease progression. Long intervals between SPT visits is under-treatment with the potential for disease recurrence and a lack of support to help the patient to maintain adherence to oral hygiene procedures. Biological Basis of SPT Plaque etiology of periodontal diseases Balance between microbial challenge, patient's host defenses, conducive environment/plaque ecology Individual patient risk assessment Role of inflammation Less clinical attachment loss (CAL) and tooth loss occur with regular SPT Tooth loss is inversely proportional to SPT frequency Recurrent periodontitis can be limited or prevented by optimal oral hygiene SPT provides for monitoring following periodontal treatment or implant provision SPT steps start with a NP appt Review medical history Vitals Head and neck examination, advanced oral cancer screening Radiographs as needed (based on patient’s caries risk, periodontal status), check with insurance for coverage Comprehensive periodontal examination Restorative examination Assess plaque control Oral hygiene training as needed- dispense and demo any new tools needed Treatment plan any active therapy- perio or restorative Deplaque teeth and remove any calculus Polish (rubber cup, air polish, glycine polisher) If heavy soft plaque present, polish first. Fluoride Make next appointment with patient’s alternating (or not) schedule you have determined at this visit Determine PM schedule How do I determine the periodontal maintenance schedule? How stable is the patient? Re-do Staging and Grading if big changes How good is their home care? Any changes in their medical history? Any changes in their caries history or CAMBRA? Any changes in Mallampati scale? Any major stresses in patient’s life? Usually- start every 3 months. Usually alternating with periodontist (if appropriate). Then adjust according to patient’s home care and their periodontal condition. Poor home care: change to every 2 months. Good home care and stable pt: go to every 4 months, then 5, then 6. Do not recommend longer than 6. Pt is not taking recommendations: pt must sign form with your recommendations refusing treatment. o Pt do not always remember what we have told them o Document if they do not follow recommendations o Document ALL broken and cancelled appointments.