Supportive Periodontal Treatment for the natural dentition and dental implants: a review

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Introduction
The symptoms of a microbial infectious illness around the impacted teeth that cause the inflammation of the gingival, formation of the periodontal pocket, and loss of connective tissue attachment and alveolar bone is called periodontal disease (PD). 1 Periodontal therapy aims to safeguard and preserve the natural dentition of the patient for optimum comfort, function, and aesthetic appearance. 2 Surgical and non-surgical techniques are used in periodontal therapy; patients should be put on a schedule of periodic reminder visits for supportive care once periodontal therapy is completed to avoid eht recurrence of the disease.PD can recur due to poor mouth oral hygiene, insufficient subgingival removal after periodontal treatment, the microscopic nature of the dentogingival unit healing, and other factors.As a result, effective treatment should be provided to prevent disease recurrence. 1 A positive approach to maintaining and improving treatment results and preventing the development of new diseases is required for successful PD therapy.As a result, a dentist performs supporting periodontal treatment, while a dental hygienist can conduct some components of supportive periodontal treatment (SPT) under the dentist's supervision. 3,4active periodontal therapy (APT) is the first step in treating periodontitis and is planned to reserve patients' natural dentition and support oral health. 5to reduce the possibility of reinfection and further development of periodontitis and ensure long-term stability of the periodontium after APT patients are entered into (SPT) programmed the supragingival plaque control considered a vital focus area during SPT as this has proven to maintain the obtained stable periodontal condition. 7,8intenance Phase )SPT ) ,also known as maintenance therapy or supportive periodontal care) follows the same principles employed in the treatment of active disease.It begins as the patients are considered periodontally stable, which is determined six to eight weeks after completion of active treatment 9 The importance in assessing periodontal stability and a prognosis for the teeth that are affected are the evaluation of the initial diagnosis and the response to periodontal treatment, and the risk factors (local, systemic and behavioral) for the recurrence of PD 10 The main objective after periodontal therapy is to preserve the health of the periodontium by stopping recurrence, referred to as the "Maintenance Phase of Periodontal Therapy"."Periodic examination is important for the continuing health of the supporting structures of the teeth once a condition of oral health has been achieved". 11maintenance visits (generally 1 hour) "The first 10-15 minutes -For clinical evaluation of the periodontal and caries conditions.The second 30-40 minutesis used to clean and polish all supragingival tooth surfaces, following the instrumentation of the subgingival sites that have been inflamed.
Last 5-15minutes -used to provide adjunctive preventive measures such as topical application of fluoride or chemical plaque control agents.In addition to evaluating the periodontal and caries conditions, the vitality of abutment teeth for fixed bridgework should be checked".

An etiology of the Recurrence of Periodontal Disease
The main etiologic factor of the initiation and progression of periodontitis si Colonization by a pathogenic biofilm 13 .Even ehuohh the contributing factor that may significantly result in the inflammatory process is host and environmental factors 14, it has been able to control disease initiation and progression by professional supra-and subgingival biofilm control 15 .
Mechanical means, such as hand instruments and/or ultrasonic debridement, are considered the effective control and management of the supra-and subgingival biofilm 16 Supplementary, the air-polishing devices method with low-abrasive dental hard tissues and various inserts and powders si effective in removing biofilms 17,18 eht important part of successful periodontal treatment, especially on deep pockets, si the nonsurgical scaling and root planning (SRP) 19

Frequency and Efficacy
It is difficult to establish general rules for eht oateotf m uo yrsfetfrf t. seslll ri we will see when rfrlmisfh the different risk situations, we will have to assess aspects of the patient, the tooth, and the location.The main aspects gtsfh considered are the oral hygiene maintained by the patient, the prevalence uo bleeding site on probing, and the levels of clinical insertion and the alveolar bone before performing the treatment.In most longitudinal studies, when patients were regularly maintained at 3-6 months intervals, positive long-term results of periodontal therapy were found when starting with maintenance intervals at the end of the treatment every 3-4 months and adjust them according to the individual risk factor of eachpatient 20,21,22,23 During the first iss months after active therapy, there is a remodelling of the periodontal tissues, which are subject to changes.During this phase of tissue healing, it is recommended that a correct professional cleaning protocol be established24 The frequency should be less than six months for patients with a history of periodontitis, according to multiple clinical research.Intervals of two weeks, 2-3 months, 3-4 months, 3-6months and 4-6 months have been proposed and studied.According to these findings, most individuals with a history of periodontitis should be visited at least four times a year, as this interval reduces the risk of disease progression compared to patients seen less frequently. 25.

Risk Assessment
The patient's risk of recurrent periodontitis can be assessed based on various clinical variables, with no single criterion playing a more critical role.The full range of risk variables and risk indicators should be assessed simultaneously.A functional diagram has been created for this purpose, which includes the following features (The percentage of bleeding that occurs while probing, there are more than 4 mm residual pockets present (3-5mm), A total of 28 teeth had been lost, The patient's age-related loss of periodontal support, Genetic and systemic diseases, Factors in the environment, such as cigarette smoking. 26,27ach character has a scale for minor, moderate, and high-risk profiles.The frequency and complexity of SPT visits will be determined by a full review of the functional diagram, which will offer a customized total risk profile. 26,27As seen in Fig. 1, Each factor represents a single risk factor or indicator, with a low-risk area, a moderate-risk area, and a high-risk area for disease progression.Because all elements must be considered together, the area of comparatively low risk is identified within the polygon's Center circle.f eht uehta hrf l eht ratr uo hshh asio is situated outside the periphery of the second ring in bold.The area of intermediate danger is located between the two bold circles. 26,27

Classification of post-treatment patients
Patients on a periodontal recall program represent various groups.Patients can improve or relapse to a new categorization with a decrease in or worsening PD.The patient's PD is categorized according to which dental arch is more affected when one is more involved than the other. 28Maintenance patients are categorized into several classes based on their periodontal recall schedule characteristics based on Merin's classification of classes A, B, and C. 28, as seen in Table 1.

According
to the American Academy of Periodontology (AAP), "SPT should include: • an update of the medical and dental history; • examination of extraoral and intraoral soft tissues; • dental examination and radiographic review • evaluation of the patient's oral hygiene performance • periodontal evaluation and risk assessment; • supragingival and subgingival removal of bacterial plaque and calculus; • re-treatment of disease when indicated " 29,30 It is important to determine the sites showing inflammation and differentiate gtewttf stable versus progressive periodontitis.Determination of stability is challenging without monitoring progression over time.However, measures of the level of dental plaque and Bleeding on probing are routinely used as proxy determinants of stability 31 ., The absence of bleeding on probing (BOP) indicates site stability, while bleeding sites may not necessarily progress 32 .
Generally, the supragingival debridement will undergo to the sites showing stability or signs of inflammation without disease progression.This can be performed with a variety of instruments and approaches.Specific features likely to be retentive for plaque and calculus should be removed ur minimize the volume of bacterial deposits ; sf addition, a wide range of adjunctive measures have been proposed to minimize the degree of plaque accumulation and inflammation, including adjunctive antimicrobials and lasers.The presence of Indicators of active disease, which include signs of inflammation BOP and suppuration) along with an increase in attachment loss, Re-treatment is required 31 After treatment of such sites, the reevaluation si based on the extent and severity of the relapse or persistent disease and the degree of control over site or patient-specific risk factors.Typically, these sites are treated using subgingival debridement under local anaesthesia to remove microbial deposits toot esetlm 33,34 ehtat is a wide range of sfetaerli between maintenance esise recommendations, from 2 -3 months up to 18 months 35 .Independent of the wtll ofuwf importance of supragingival prophylaxis and oral hygiene instructions during SPT 36,37 .The usually delivered interventions also attempt to eliminate subgingival bacterial deposits 15,38,39 Petersilka et al. 40 suggested that repeated instrumentation and mechanical elimination of subgingival plaque is tiitfesrl, with subgingival debridement of pockets ≥ 4 mm to avoid rebound to pretreatment levels of periodontal pathogens in subgingival plaque.Gomes et al. (2007), Found significant reductions in probing pocket depth (PPD) and BOP rf clinical attachment gain even with PPD ≥ 6 mm as a result of supragingival prophylaxis alone, followed by oral hygiene checkups weekly during the whole iss months 41 Other researchers found a similar effect with pockets site ≥ 6 mm for 2 -4 years, showing this result with only supervised self-performed supragingival plaque control 42,43 Supportive Care of Dental Implants Because dental implants are put in a microbe-infested oral environment, they risk developing peri-implant disorders.
Patients who have had successful implant therapy should get tailored, systematic, and ongoing peri-implant tissue supportive care.Patients who are at a higher risk for peri-implantitis, such as those who are edentulous partially or have chronic periodontitis, should be diagnosed and regularly followed. 01e patient should be re-evaluated regularly during the first year after an implant is restored (every 3 to 4 months).After the first year, the peri-implant tissues' reaction should be evaluated, and the optimum frequency of periodontal care should be chosen. 44lpool to preserve the permanent health of soft and hard peri-implant, exclusive measurements of oral hygiene and treatment of implants are considered 44 Peri-implantitis has been defined as an inflammatory status by pathological conditions of soft and hard tissue around the implant, producing the bone progressively lost around the implant 45 .nf several studies, a ishfsos rfe risk factor for peri-implant diseases si poor plaque control 46,47,48, while uehta studies do not see this correlation 49 .Particular supportive implant therapy (SIT) programs wtat needed to attain permanent peri-implant tissue health to monitor and improve plaque control 50 Every maintenance appointment includes plaque monitoring and documentation, allowing for a long-term review of oral hygiene.Plaque accumulates more readily on roughsurfaced implants than iyuueh ufti, increasing the risk of peri-implantitis.Surface roughness has also been demonstrated to influence bacterial adherence in vitro, with rough surfaces resulting in a more considerable subgingival bacterial burden. 51n spite of limited evidence that gingival stability is essential for implant longevity, any apical gingival edge movement should be noted and monitored. 52en probing around oral implants, Gerber and colleagues found that 0.15 N of pressure could be the threshold (i.e., minimal pressure) for avoiding falsepositive bleeding readings. 53anual or automated methods, such as the Periotest dental measuring device (or the Ostell instrument, should be used to examine mobility. 54,55always the cause of any mobility should be determined, specifically if it is related to the failure of the prosthesis or osseointegration failure.If the implant becomes moveable, it is considered a failure and should be removed. 51,56,57f clinical indications point to periimplantitis, a radiograph of the area should be taken to confirm the diagnosis.To achieve proper radiograph reading, it's crucial to establish baseline bone levels after implant placement and prosthesis insertion (should they be required in the future). 58he program should include the following: Patient studies have established the need for the appropriate treatment method, leading to the "cumulative interceptive supportive therapy (CIST)" concept.Mombelli and Lang 11 proposed a guideline for treating peri-implant disease that affected the implants, which is (CIST)" ((Fig 2) In (CIST), the treatment is classified A to D according to the degree of progression of peri-implant disease.The classification is based on the depth of periimplant pockets with or without (BOP) and the extent of bone resorption, and treatment is specified for each class 59 .As seen fig2.
Lang et al. improved it in 2004 and named it AKUT-concept 56.The basis of this perception is a systematic recall of the implanted patient, and recurrent evaluation of plaque, suppuration, bleeding, pockets, and radiographic signs of bone loss is the foundation of this idea. 56, as seen in table 2.

Discussion
The therapeutic goals of periodontal maintenance therapy (PMT) are to reduce the recurrence of PD and the rate of tooth loss (TL) by monitoring the dentition and replacing prosthetics when necessary and to raise the likelihood of detecting and treating other diseases or conditions found in the oral cavity regularly. 29ndividuals who receive PMT atholralm tend to keep their teeth for longer and have better periodontal health than those who do not. 60According to recent studies, failure to maintain periodontal treatment is connected with higher periodontitis and tooth loss (TL) development rate. 61,62PMT is essential for r teoretlm managing PD and keeping a functional dentition throughout one's life. 63PT is an important requirement for the success of periodontal therapy, as shown in several fundamental studies and a current systematic review of 64,65 patients were assessed over a period of more than oset years who refused maintenance after hresfh been treated for periodontal disease.nf these patients, there was rf increase in probing depth and also an increase in the ratios of spreading of the pockets in the different categories, a dental loss of 6%and significant bone loss, the tooth that was lost the most sf the second maxillary molar and the one with less the mandibular canine.And they observed that affected furcation's teeth get worse more frequently 66 One of the important articles of Axelsson and Lindhe."They evaluated a group of 72 patients who were treated surgically over a period of 6 years.Twothirds of the patients strictly complied with periodontal maintenance every two months for the first two years and every three months for the subsequent four years, while the other third was referred to the general dentist.They observed that after the surgical phase, there were no differences between the two groups for any of the clinical variables analyzed.However, at six years of age, the nonmaintenance group practically returned to the initial values (before the surgeries), even observing additional insertion losses of 2-5 mm in 55% of the locations.In the strict maintenance group, it was observed that the positive results obtained after the surgeries were maintained over time and even improved as the years passed" 01 The success rate of SPT might be related to the long-term patients' commitment to the SPT.The significant drop-out of commitment patients to SPT generally decreases within the first five years of SPT 67 .Patients who maintain long-term therapy are often more committed and are better aware of remaining healthy 68 . 69,70,67,68,71this research showed increased recall frequency when there is a more prolonged duration of SPT, and then this depends on the stability of the periodontium and the individual needs the patients who commit to long-term SPT can be preserved a worse periodontal condition related to the patients who dropped out

Conclusion
The success of periodontal therapy is based on a continuous schedule.(PMT) To detect and intercept any new or recurring disease, periodontal parameters must be monitored regularly.All patients undergo a similar but individual treatment according to their periodontal condition and the patient risk factors.
To better of taierf the social and emotional elements of oral health, it is crucial to study and comprehend the influence of oral health on quality of life.However, it is also critical for these experts to be more attentive and aware of the requirements of the people by individualizing therapy based on equitable principles to improve life quality.Suggestion 1-We need more comprehensive awareness to educate periodontal patients about the importance of supportive periodontal treatment.
2-Further studies will require more extended observation periods to assess the effect of supportive periodontal treatment in the presence of risk factors.

Table 1 : Merin's classification(Merin RL ;2003)
.. The Effect of Polishing Techniques on Surface Roughness of Two Different