Jan Lindhe. Clinical Periodontology

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SUPPORTIVE PERIODONTAL THERAPY (SPT) • 795

Clinical probing

In spite of the recognized method errors inherent in

clinical probing, this diagnostic procedure has not

only been the most commonly used but is also the

most reliable parameter for the evaluation of the peri-

odontal tissues. It has to be realized that increased

probing depth and loss of probing attachment are

parameters which reflect the history of periodontitis

rather than its current state of activity. In order to

obtain a more realistic assessment of the disease

pro-

gression or, more commonly, the healing

following

therapy, multiple evaluations should be

performed.

Obviously, the first evaluation prior to

therapy will

yield results confounded by greater

measurement er-

ror than evaluations following

therapy. The reference

point (cemento-enamel

junction) may be obstructed

by calculus or by dental

restorations, and the condi-

tion of the gingival

tissues may allow an easy penetra- tion of the

periodontal probe into the tissues, even

though the

probe position and force applied are stand-

ardized.

These biologic variables (tissue conditions

and

calculus) may be minimized following initial

periodontal therapy, and hence, repeated periodontal

evaluations using probing will improve the metric

assessment. Therefore, the first periodontal evalu-

ation after healing following initial periodontal ther-

• Fig. 32-6.

Regression analysis between mean

bleeding

on probing (BOP) percentage and probing

forces ap-

plied in young dental hygiene students with a healthy

gingiva and normal anatomy. A very high correlation

•

coefficient

(R = 0.87)

and an almost linear

correlation

between probing force and BOP% was

found. (Data

from Lang et al. 1991.)

Fig.

32-7.

Regression analysis between mean bleeding

on probing (BOP) percentage and probing forces ap-

plied in subjects with successfully treated periodonti

tis: a reduced, but healthy, periodontium. (Data from

Karayiannis et al. 1991.)

apy should be taken as the baseline for long-term

clinical monitoring (Claffey

1994).

Suppuration

a proportion of periodontal lesions pus will de-

velop and may drain through the orifice of a pocket.

This criterion of suppuration may be recognized while

clinically probing the lesion, or preferably, by using a

ball burnisher (Singh et al.

1977).

Several longitudinal

studies on the results of periodontal therapy have

evaluated clinical parameters, including suppuration,

for the prediction of future loss of attachment (Bader-

sten et al.

1985, 1990,

Claffey et al.

1990).

In all these

studies, the presence of suppuration increased the

positive predictive value for disease progression in

combination with other clinical parameters such as

bleeding on probing and increased probing depth.

Hence, following therapy a suppurating lesion may

provide evidence that the periodontitis site is under-

going a period of exacerbation (Kaldahl et al.

1990).

Summary

The tooth site risk assessment includes the registration

of bleeding on probing, probing depth, loss of attach-

ment, and suppuration. A risk assessment on the site

level may be useful in evaluating periodontal disease

796 • CHAPTER

Fig. 32-8. Continuous multiple

level risk assessment. Subject,

tooth and site parameters are com

bined to establish the clinical risk

for disease progression. Note that

different sites in the same patient

may have a different level of risk.

Subject-based risk factors are used

to put the tooth and /or site risk

assessment in perspective.

activity and determining periodontal stability or on-

going inflammation. The site risk assessment is essen-

tial for the identification of the sites to be instrumented

during SPT.

Radiographic evaluation of periodontal

disease progression

As a consequence of the clinical risk assessments the

decision may be made to gather radiographic infor-

mation on the periodontal conditions as well

(

Hirschmann et al. 1994). The task may be related to a

generalized pattern of disease progression or a local-

ized monitoring. Not only periodontal aspects, but a

comprehensive approach, should influence the choice

of the radiographic technique (Rohlin & Akerblom

1992). Periodic radiographic surveys not based on

clinical signs and symptoms should not be scheduled

simply to confirm health.

Radiographic perception of periodontal changes is

characterized by a high specificity, but a low sensitiv-

ity, with underestimation of the severity of a periodon-

tal defect (Hammerle et al. 1990, Akesson et al. 1992).

Undetectability of minute changes at the alveolar crest

related to overprojections and variations in projection

geometry when taking repeated radiographs

(Lang &

Hill 1977, Goodson et al. 1984, Jenkins et al.

1992).

This may result in mimicked variations in the

alveolar

bone height, obscured furcation status, etc. In

addition,

film processing variations may result in un-

reliable

assessments of alveolar bone density changes

(Rams et

al. 1994).

The standard procedure for periodontal evalu

ations

is based on a filmholder system with an align-

ment for long-cone paralleling technique (Rushton &

Horner 1994). With the addition of simple pins to the

filmholders as a repositioning reference, the metho-

dologic error was impressively reduced (Carpio et al.

1994).

It is a fact that, in general, the standards in oral

radiology related to agreement in the choice of a tech-

nique, the quality of film processing and the agree-

ment in the diagnosis need to be improved (Bragger

1996).

Clinical implementation

The

three levels

of risk assessment presented represent

a logic sequence of clinical evaluation to be performed

prior to rendering treatment during maintenance. The

information gathered from a stepwise evaluation

should not impinge on, but rather improve, the effi-

cacy of secondary prophylactic periodontal care and

treatment. A logic sequence of checks and examina-

tions may be easily obtained in a short period of time

and at no extra cost for laboratory tests. The informa-

tion obtained from clinical monitoring and multilevel

risk assessment facilitates an immediate appreciation

of the periodontal health status of an individual and

the possible risk for further infection and/or disease

progression.

Most longitudinal studies published to date have

been based on single level, i.e. site or tooth, risk assess

ment, rather than accounting for the most evident

factor in risk assessment: the patient. Ample evidence

indicates that a minority of patients will continue to

present problems and hence, differ completely from

the

maintenance pattern visualized in the majority of

SUPPORTIVE PERIODONTAL THERAPY (SPT) • 797

the patients. Even in the studies where this fact has

been explicitly addressed (Hirschfeld & Wasserman

1978), the factors which determined whether or not a

patient belonged to a well-maintained group or to a

group with continuous loss of periodontal attachment

have not been identified.

Summary

It is suggested that patients be evaluated on the

three

different levels

mentioned. At the patient level, loss of

support in relation to patient age, full mouth plaque

and/or bleeding scores and prevalence of residual

pockets are evaluated together with the presence of

systemic conditions or environmental factors, such as

smoking, which can influence the prognosis. The clini

cal utility of this first level of risk assessment influ-

ences primarily the determination of the recall fre-

quency and time requirements. It should also provide

perspective for the evaluation of risk assessment

conducted at the tooth and site levels.

At the tooth and tooth site levels, residual peri-

odontal support, inflammatory parameters and their

persistence, presence of ecologic niches with difficult

access such as furcations, and presence of iatrogenic

factors have to be put into perspective with the

patient

overall risk profile (Fig. 32-8). The clinical

utility of

tooth and site risk assessment relates to

rational allo

cation of the recall time available for

therapeutic intervention to the sites with higher risk,

and possibly to

the selection of different forms of

therapeutic intervention.

OBJECTIVES FOR SPT

The objective of maintenance care must be the contin

ued preservation of gingival and periodontal health,

obtained as a result of the active periodontal treat-

ment. Irrespective of whether or not additional treat-

ment such as prosthetic reconstructions or placement

of implants has been rendered, the regular and ade-

quate removal of supragingival plaque by the patient

is, therefore, a prerequisite for a good long-term prog-

nosis. In order to reach these goals, regular clinical

re-evaluations with appropriate interceptive treat-

ment, continued psychologic support and encourage-

ment of the patient and a lifelong commitment by the

therapists are required.

General rules regarding frequency of maintenance

care visits are difficult to define. However, there are a

few aspects to consider in this respect: the patient's

individual oral hygiene standard, the prevalence of

sites exhibiting bleeding on probing, and the pre-

therapeutic attachment level and alevolar bone

height. This in turn means that patients with subopti

mal plaque control and/or concomitant high preva-

lence of bleeding sites should be recalled more fre-

quently than patients exhibiting excellent plaque con-

trol and healthy gingival tissues. Nevertheless, pa-

tients with healthy gingival conditions, but with a

severely reduced height of periodontal support,

should also be recalled with short time intervals (not

exceeding 3-4 months) in order to exclude or at least

reduce the risk of additional tooth loss. In most of the

longitudinal studies referred to above, positive treat-

ment results were maintained with regular mainte-

nance care provided at 3-6-month intervals. It seems

reasonable to commence post-therapeutic mainte-

nance with recall visits once every 3-4 months and

then shorten or prolong these intervals in accordance

with the aspects discussed above.

Since clinical attachment levels are usually stable 6

months following active periodontal therapy, it has

been suggested that the first 6 months after comple-

tion of therapy be considered a healing phase (Westfelt

et al. 1983b) during which frequent professional tooth

cleaning has been recommended. Following this heal-

ing phase, it is generally agreed to recall patients

treated for periodontal disease at intervals of 3-4

months in a well-organized system of SPT. It has to be

realized that tissue contours may be subjected to re-

modeling processes despite stable clinical attachment

levels and, hence, morphologic changes may still im-

prove the accessibility of all tooth surfaces to oral

hygiene practices for months and years. Proper oral

hygiene practices appear to be the most important

patient factor to guarantee long-term stability of treat

ment results (Knowles et al. 1979, Ramfjord et al. 1982,

1987, Lindhe & Nyman 1984). This, in turn, necessi-

tates optimization of the patient's skills and continu-

ous motivation and reinforcement to perform ade-

quate mechanical oral hygiene practices, although

chemical agents such as the potent antiseptic chlor-

hexidine may substitute and later complement the

patient's efforts during the healing phase, when me-

chanical practices are difficult (Westfelt et al. 1983a). It

is obvious that regular recall visits for SPT should be

scheduled soon after completion of cause-related ther

apy, even if periodontal surgical procedures are still to

be performed following a careful re-evaluation of the

tissue response. To postpone the organization of a

maintenance care program until corrective proce-

dures such as surgery, endodontic, implant, operative

or reconstructive therapy have been performed may

reinforce a possible misconception of the patient that

the professional visits to a therapist or hygienist guar

antee positive treatment outcomes and optimal long-

term prognosis rather than the patient's own regular

performance of individually optimal and adequate oral

hygiene practices.

SPT IN DAILY PRACTICE

The recall hour should be planned to meet the pa-

tient's individual needs. It basically consists of four

different sections which may require various amounts

of time during a regularly scheduled visit:

798 • CHAPTER 32

MRI

Motivation

instruction

(5-7 min)

Instrumentation (

Scaling/Root planing)

(30-40 min)

Fig. 32-9. The SPT recall hour is divided into four sec

tions: 1. Examination, re-evaluation and diagnosis

(

ERD) providing information on stable and inflamed

sites. This segment uses 10-15 min. 2. Motivation, rein

struction of oral hygiene where indicated and instru-

mentation (MRI) will use the bulk of the recall hour (30

40 min). Sites which were diagnosed as not stable are

instrumented. 3. Treatment of reinfected sites (TRS)

may require a second appointment. 4. Polishing all

tooth surfaces, application of fluorides and determina

tion of the future recall interval (PFD) conclude the re

call hour (5-10 min).

Examination, Re-evaluation and Diagnosis (ERD)

Motivation, Reinstruction and Instrumentation

(

MRI)

Treatment of Reinfected Sites (TRS)

Polishing of the entire dentition, application of

Fluorides and Determination of future SPT (PFD)

The SPT recall hour (Fig. 32-9) is generally composed

of 10-15 min of diagnostic procedures (ERD) followed

by 30-40 min of motivation, reinstruction and instru-

mentation (MRI) during which time the instrumenta-

tion is concentrated on the sites diagnosed with per-

sistent inflammation. Treatment of reinfected sites

(

TRS) may include small surgical corrections, applica

tions of local drug delivery devices or just intensive

instrumentation under local anesthesia. Hence, such

procedures, if judged necessary, may require an addi

tional appointment. The recall hour is normally con-

cluded with polishing of the entire dentition, applica-

tion of fluorides and another assessment of the situ-

ation including the determination of future SPT visits

(

PFD). Approximately 5-10 min have to be reserved

for

this section.

Examination, Re-evaluation and Diagnosis

(

ERD)

Since patients on SPT may experience significant

changes in their health status and the use of medica-

tions, an update of the information on general health

issues is appropriate. Changes in health status and

medications should be noted. Especially in the mid-

dle-aged to elderly patients, these aspects might

influ-

ence the future management of the patient. An ex-

traoral and intraoral soft tissue examination should be

performed at any SPT visit to detect any abnormalities

and to act as a screening for oral cancer. Especially the

lateral borders of the tongue and the floor of the mouth

should be inspected. An evaluation of the patient's

risk factors will also influence the choice of future SPT

and the determination of the recall interval at the end

of the maintenance visit. Following the assessment of

the subject's risk factors, the tooth site-related risk

factors are evaluated. As indicated above, the diagnos

tic procedure usually includes an assessment of the

following:

the oral hygiene and plaque situation

the determination of sites with bleeding on prob-

ing, indicating persistent inflammation

the scoring of clinical probing depths and clinical

attachment levels. The latter is quite time-consum-

ing and requires the assessment of the location of

the cemento-enamel junction as a reference mark

on all (six) sites of each root. Therefore, an SPT

evaluation usually only includes scoring of clinical

probing depths

the inspection of reinfected sites with pus forma-tion

the evaluation of existing reconstructions, includ-

ing vitality checks for abutment teeth

the exploration for carious lesions.

All these evaluations are performed for both teeth and

oral implants. Occasionally, conventional dental ra-

diographs should be obtained at SPT visits. Especially

for devitalized teeth, abutment teeth and oral im-

SUPPORTIVE PERIODONTAL THERAPY (SPT) • 799

Fig. 32-10. Wedge-shaped defects apical to the cemento

enamel junction following recession of the gingival tis

sues resulting from overzealous or faulty toothbrush

ing.

plants, single periapical films exposed with a parallel

and preferably standardized technique are of great

value. Bite-wing radiographs are of special interest for

caries diagnostic purposes. They also reveal plaque

retentive areas such as overhanging fillings and ill-fit-

ting crown margins. Since only approximately 10-15

min are available for this section, these assessments

have to be performed in a well-organized fashion. It

preferable to have a dental assistant available to note

all the results of the diagnostic tests unless a voice-

activating computer-assisted recording system is used.

Motivation, Reinstruction and

Instrumentation (MRI)

This aspect uses most of the available time of the SPT

visit. When informed about the results of the diagnos

tic procedures, e.g. the total percentage of the bleeding

on probing (BOP) score or the number of pockets

exceeding 4 mm, the patient may be motivated either

in a confirmatory

way

in case of low scores or in a

challenging fashion in case of high scores. Since en-

couragement usually has a greater impact on future

positive developments than negative criticism, every

effort should be made to acknowledge the patient's

performance.

Patients who have experienced a relapse in their

adequate oral hygiene practices need to be further

motivated. Especially if the personal life situation has

influenced the performance, positive encouragement

is appropriate. Standard "lecturing" should be re-

placed by an individual approach.

Occasionally, patients present with hard tissue le-

sions (wedge-shaped dental defects) which suggest

overzealous and/or faulty mechanical toothcleaning

(

Fig. 32-10). Such habits should be broken and the

patient reinstructed in toothbrushing techniques

which emphasize vibratory rather than scrubbing

movements.

Since it appears impossible to instrument 168 tooth

sites in a complete dentition in the time allocated, only

those sites will be reinstrumented during SPT visits

which exhibit signs of inflammation and/or active

disease progression. Hence, all the BOP positive sites

and all pockets with a probing depth exceeding 5 mm

are carefully resealed and root planed. Repeated in-

strumentation of healthy sites will inevitably result in

mechanically caused continued loss of attachment

(

Lindhe et al. 1982a).

Similar observations were made in clinical studies

by Claffey et al. (1988) where loss of clinical attach-

ment levels immediately following instrumentation

was observed in 24% of the sites. Also, it is known

from regression analyses of several longitudinal stud-

ies (e.g. Lindhe et al. 1982b) that probing attachment

may be lost following instrumentation of pockets be-

low a "critical probing depth" of approximately 2.9

mm. Instrumentation of shallow sulci is, therefore, not

recommended. As it has been shown in several studies

that non-bleeding on probing sites represent stable

sites (Lang et al. 1986, 1990, Joss et al. 1994), it appears

reasonable to leave non-bleeding sites for polishing

only and concentrate on periodontal sites with a posi-

tive BOP test or probing depths exceeding 5 mm. To

protect the hard tissues, root planing should be per-

formed with great caution. The deliberate removal of

contaminated" cementum during SPT is no longer

justified (Nyman et al. 1986, 1988, Mombelli et al.

1995). Especially during SPT visits, root surface instru

mentation should be aimed at the removal of sub-

gingival plaque rather than "diseased" cementum.

This may require a more differentiated approach than

hitherto recommended. In this respect, the use of ul-

trasonics may have to be re-evaluated.

Treatment of Reinfected Sites (TRS)

Single sites, especially furcation sites or sites with

difficult access, may occasionally be reinfected and

demonstrate suppuration. Such sites require a thor-

ough instrumentation under anesthesia, the local ap-

plication of antibiotics in controlled release devices or

80o •

CHAPTER

Fig. 32-11. Flow sheet of sup-

portive periodontal therapy

(

SPT) with strategic decision

tree for the recall visit.

SUPPORTIVE PERIODONTAL THERAPY (SPT)

• 8o1

even open debridement with surgical access. It is evi-

dent that such therapeutic procedures may be too

time-consuming to be performed during the routine

recall hour, and hence, it maybe necessary to resched

ule the patient for another appointment. Omission of

thoroughly retreating such sites or only performing

incomplete root instrumentation during SPT may re-

sult in continued loss of probing attachment (Kaldahl

et al. 1988, Kalkwarf et al. 1989).

Treatment choices for reinfected sites should be

based on an analysis of the causes most likely respon

sible for the reinfection.

Generalized reinfections are usually the result of

inadequate SPT. Although not all sites positive for

bleeding on probing may further progress and lose

attachment, high BOP percentages call for more inten

sive care and more frequent SPT visits. Sometimes, a

second visit 2-3 weeks after the recall maybe indicated

to check the patient's performance in oral home care.

It is particularly important to supervise patients

closely for advanced periodontitis if they have a high

subject risk assessment (Westfelt et al. 1983b, Ramfjord

1987).

Local reinfections may either be the result of inade

quate plaque control in a local area or the formation

of ecologic niches conducive to periodontal patho-

gens. The risk assessment on the tooth level may

identify such niches which are inaccessible for regular

oral hygiene practices. Furcation involvements often

represent special periodontal risk factors which may

require additional therapy to be performed following

diagnosis in the regular SPT visit.

Polishing, Fluorides, Determination of recall

interval (PFD)

The recall hour is concluded with polishing the entire

dentition to remove all remaining soft deposits and

stains. This may provide freshness to the patient and

facilitates the diagnosis of early carious lesions. Fol-

lowing polishing, fluorides should be applied in high

concentration in order to replace the fluorides which

might have been removed by instrumentation from

the superficial layers of the teeth. Fluoride or chlor-

hexidine varnishes may also be applied to prevent

root surface caries, especially in areas with gingival

recessions. The determination of future SPT visits

must be based on the patient's risk assessment.

Summary

Fig. 32-11 provides a flow sheet for SPT. The SPT recall

hour is divided into four sections. While the first 10-15

min are reserved for Examination, Re-evaluation and

Diagnosis, the second and most time-consuming sec-

tion of 30-40 min is devoted to reinstruction and in-

strumentation of sites at risk identified in the diagnos

tic process. Some reinfected sites may require futher

treatment, and hence, the patient may have to be

rescheduled for an additional appointment. The recall

hour is concluded by polishing the dentition, apply-

ing fluorides and determining the frequency of future

SPT visits.

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