Supportive Periodontal Therapy

The results of extensive periodontal therapy (treatment of periodontal inflammation) can only be permanently stabilized if the patient subsequently undergoes the program of supportive periodontal therapy (UPT; synonyms: Supportive Periodontal Therapy; Periodontal Maintenance Therapy; PET). Periodontitis (synonyms: periodontitis apicalis; alveolar pyorrhea; pyorrhea alveolaris; inflammatory periodontopathy; ICD-10 – Acute periodontitis: K05.2; Chronic periodontitis: K05. 3; colloquialism: periodontosis) refers to inflammatory processes of the periodontium that cause the alveolar bone surrounding the tooth roots to recede, eventually leading to tooth loosening and, ultimately, to the loss of the affected teeth. Periodontitis does not manifest itself without the presence of germs that have a destructive effect on the hard and soft tissues of the periodontium (periodontium). The bacterial load (amount of incriminating bacteria) that ultimately leads to the outbreak of the disease is significantly influenced by certain risk factors. Within the framework of UPT, these are determined and an attempt is made to reduce them. The treatment of periodontitis is complex and aims, among other things, to eliminate the subgingival biofilm (bacterial deposits in the gingival pockets on the root surfaces), but it cannot end there. Particularly in the chronic form of progression, permanent measures must be taken to prevent recolonization of the gingival pockets with periodontopathogenic germs (germs that damage the periodontium) from leading to a new outbreak of the disease.

Indications (areas of application)

  • For long-term stabilization of the result of periodontal treatment.
  • To prevent recolonization of periodontal pathogens (recolonization with bacteria that damage the periodontium) by regular removal of the biofilm.
  • To preserve the periodontium under largely free of inflammation.

Contraindications

  • None

Before the procedure

UPT is preceded by scaling, professional dental cleaning (PZR), anti-infective periodontal therapy and, if necessary, subsequent periodontal surgical procedures.

The procedure

I. Determination of the individual periodontitis risk.

An important contribution to the stabilization of the treatment result is made, on the one hand, by the patient’s efforts to maintain intensive oral hygiene at home with implementation of all recommended measures and, on the other hand, by regular recalls (follow-up appointments) in the dental practice. Without regular attendance at the recall, periodontal therapy will generally not be successful in the long term. Since the frequency of recalls depends on the individual periodontitis risk of each patient, this must first be determined. The examination results are used to determine the intervals at which a recall is required. The following factors are included in the result:

  • Systemic factors
  • Genetic factors
  • Nicotine consumption (smoking)
  • Periodontal status with information on bleeding on probing and probing depths.
  • Oral hygiene index
  • Degradation of periodontal bone
  • Tooth loss
  • Stress

I.1. systemic factors

All general medical findings influence the resistance of the periodontium. For example, patients with diabetes mellitus (diabetes) are a risk group. I.2 Genetic factors

Among genetic factors, IL-1α/1β polymorphism plays a role. The inflammatory tendency of the periodontium is mediated by interleukin-1. Interleukin-1 is produced only in the inflammatory state and is used for communication between immune defense cells. With a positive IL-1 genotype, interleukin-1 is more readily and increasingly released from monocytes (cells of the immune system, precursors of macrophages/eating cells) when they have surface contact with periodontopathogenic, Gram-negative bacteria. If an interleukin-1 gene test provides a positive test result, this does not necessarily mean the onset of the disease for a periodontally healthy person. For a patient with periodontitis that has already progressed with severe bone loss, a test is not absolutely necessary, since the patient belongs to the high-risk group anyway.However, for patients with still mild disease progression, a positive test result can be a strong motivator for consistent implementation of oral hygiene recommendations. I.3. nicotine consumption

Smoking is clearly the strongest risk factor for periodontal disease: 30 cigarettes a day lead to an increased risk of periodontitis by a factor of almost 6. The number of years the patient has already spent as a smoker is also included in the result, since nicotine effects on the periodontium over many years add up. I.4 Periodontal status

It is advisable to take pocket depth measurements at least once a year to check the stability of the result achieved by periodontal therapy. The risk of recurrence of the disease increases with the number of probing depths above 5 mm. The probing depths are supplemented by the collection of an index that provides information about possible signs of inflammation (BOP: bleeding on probing). If no bleeding occurs during probing of a pocket, it can be considered stable. The higher the BOP value for the dentition, the greater the risk of suffering renewed attachment loss (loss of attachment due to loss of periodontal tissue). The BOP value is also the indicator of successfully performed oral hygiene at home. I.5 Oral hygiene index

Staining of the biofilm (plaque, dental plaque) clearly shows the patient deficits in his home oral hygiene and serves to refresh his knowledge of the individually appropriate technique for plaque removal. The more difficult it is for the patient to remove plaque adequately, the more important it is to schedule close recalls. I.6 Periodontal bone loss / tooth loss

If periodontal disease has already led to the loss of one or more teeth, this finding leads to an increased risk assessment. The same applies to teeth that are still present but already at risk due to loss of surrounding alveolar bone. I.7 Stress

The fact that stress has a negative influence on the body’s defense mechanisms is now well recognized. And so it can also have a weakening effect on the defenses that the tissues of the periodontium must put up against periodontopathogenic bacteria. II. Determining the recall interval

As a rule, the first recall after successful completion of periodontal treatment will be after four to eight weeks. Further recalls will follow at intervals of three to six months, depending on the estimated risk. UPT should be continued throughout life. With appropriate UPT, tooth loss caused by periodontitis, although not completely prevented, can be reduced by half on average. III. Procedure of the recall appointment

A recall appointment may include the following:

  • Updating the general medical history with regard to risk factors.
  • Survey of clinical parameters of inflammation (BOP).
  • Periodontal status – pocket depth measurements.
  • Caries risk assessment – Due to the loss of periodontal tissues, root surfaces are exposed. These are more susceptible to caries than enamel.
  • Professional dental cleaning (PZR) – Removal of supra- and subgingival tartar and biofilm (removal of hard and soft plaque above and in the gingival pockets) with subsequent polishing of all accessible surfaces.
  • Treatment of inflamed pockets – by scaling (mechanical cleaning) of the root surface to mechanically destroy the biofilm and, if necessary, subsequent application of a locally acting antibiotic or alternatively an antibacterial chlorhexidine chip (PerioChip).
  • Remotivation – refreshing knowledge about oral hygiene techniques, the importance of fluorides (caries prophylaxis), nicotine consumption, etc.
  • Treatment of sensitive tooth necks
  • Determine the next recall appointment

Possible complications

  • Lack of compliance – unwillingness to cooperate and/or keep recall appointments.
  • Lack of manual ability to implement the plaque removal techniques
  • Transition of a chronic phase to an acute phase – flare-up of periodontitis.