Supportive Periodontal Therapy
“Supportive periodontal therapy (SPT)” is a term suggested by the 3rd World Workshop of the American Academy of Periodontology (AAP, 1989). It refers to the phase of treatment concerned with maintenance of patients following active periodontal therapy and includes maintenance of dental implants. This therapy has also been referred to as periodontal maintenance (Cohen, 2003). Such maintenance or supportive therapy is important to assess long-term success of periodontal therapies, prevent recurrence or continued progression of disease, and importantly, to facilitate timely interception and adequate treatment when recurrent disease becomes apparent. Implicit in the phrase is the understanding that the patient’s own efforts to control periodontal disease are key, and that therapeutic measures from the dental team are necessary to maintain these in the long term.
This maintenance entails regular recall of patients at chosen intervals. The clinician would normally conduct an update of the medical and dental histories, extraoral and intraoral soft tissue examination, dental examination, periodontal evaluation, implant evaluation, radiographic review, removal of bacterial plaque and calculus from supragingival and subgingival regions, selective root planing or implant debridement if indicated, polishing of teeth, and a review of the patient’s plaque removal efficiency (AAP, 2001).
In general terms, supportive periodontal therapy is considered a necessary condition of successful long-term management of periodontal disease after initial treatment. Teleologically, this maintenance is designed to control, over the longer term, the causes of periodontal disease. Historically, supportive periodontal therapy has largely focused on the control of bacterial plaque (Loe et al., 1965; Lindhe et al., 1975). As our understanding of the pathogenesis of periodontitis has grown substantially over recent decades, the importance of elements of host susceptibility in general, specific risk factors such as smoking and diabetes, and the individual composition of microbial flora has become evident. This has important implications for the scope of supportive periodontal therapy.
While maintenance of adequate plaque control remains important, it is clear that in supportive periodontal therapy, individual patients may require more or less maintenance than others, depending on their risk profile. Furthermore, risk factor modification and maintenance should be an integral part of supportive periodontal therapy (see Chapter 3). Inherent in the therapy, therefore, is the need to assess risk to patients on an individual basis. Otherwise, application of standardized protocols for treatment may permit supervised neglect and reinfection in some patients or overtreatment with poor cost effectiveness or unnecessary adverse effects in others. Although there is general agreement on these principles, evidence-based protocols for determining adequate recall intervals are lacking (Needleman et al., 2005).
Supportive periodontal therapy follows initial periodontal therapy. Initial therapy normally comprises a cause-related therapeutic phase, i.e., plaque control measures, smoking cessation therapy, and removal of local plaque retentive factors. This is often followed by a corrective phase comprising surgical and non-surgical periodontal management. Clearly, where initial cause-related therapy or corrective therapy has been unsuccessful, these elements may either require revisitation or treatment planning may need to reflect a more aggressive management of the periodontally involved dentition. Where therapy has been successful in controlling active disease, however, the patient enters the maintenance phase, SPT. Thus, SPT is an integral part of any periodontal therapy and should always follow initial non-surgical or surgical therapy.
No single technique or recall interval for SPT is appropriate for every patient; therefore, each patient must be assessed on an individual basis and therapy prescribed accordingly. Such prescriptions should assess an individual’s risk, and that is an important element of the treatment planning process. In principle it has been demonstrated that such an approach can produce stable results in long-term longitudinal studies (Axelsson et al., 1991).
A number of factors contribute to a patient’s overall risk. It is useful to consider all factors simultaneously. Lang and Tonetti (2003) have developed a functional diagram to evaluate the risk of disease progression. They consider the following as important factors:
- Percentage of bleeding on probing sites
- Prevalence of residual pockets greater than 4 mm
- Loss of teeth from a total of 28
- Loss of periodontal support relative to patient age
- Systemic and genetic conditions
- Environmental factors, e.g., smoking
Each factor has its own scale describing risk as low, medium, or high.
It should be noted that for some of the risk factors, particularly the genetic factors, there is insufficient evidence to support their use in a clinical prediction tool. Furthermore, the contribution of each of these risk factors or risk factor domains is arbitrarily weighted to yield an overall risk score and the method has not been validated prospectively. Nevertheless, the proposal of such risk assessment tools illustrates the growing interest and need to individualize supportive periodontal therapy and at the very least, these tools may have value for patient motivation. However, in the absence of a validated tool, risk assessment during supportive periodontal therapy remains a matter of clinical judgment. While such a scale may be useful for patient motivation, decision making based on such risk assessment remains a matter of clinical judgment.
Measuring Baseline Values
A baseline measure of periodontal health should be recorded when the patient completes active periodontal therapy (Claffey, 1991). This should include details of the level of clinical attachment under such optimal circumstances. Continuous monitoring of such measurements over time can provide an indication of further attachment loss and thus active disease. Normally, baseline health values should be measured three months after initial periodontal therapy. It appears that after this time limited amelioration is possible (Becker et al., 2001).
The American Academy of Periodontology offers guidance on SPT with its position paper on periodontal maintenance (Cohen, 2003). It includes a detailed checklist of items which may be included in a maintenance visit. With limited evidence available for appropriate management, such guidelines are to an extent anecdotal or based on evidence of limited quality. In the absence of clear evidence-based protocols for treatment it would appear reasonable to follow such guidelines as the considered opinion of an expert group. A précis of this guidance is presented below (see Box 10.1). Sensibly, the academy has suggested that the clinician’s judgment should guide adaptation of such protocols to individual cases.