Quiz 2

• NSPT

  Many nonsurgical steps to:

  • eliminate inflammation
  • attempt to restore the periodontium back to health
  • Combination of professional care and patient self-care
  • Initial/ initial periodontal therapy or Phase I treatment

  Gold standard

  • NSPT is a cornerstone of periodontal therapy
  • 1 st recommended approach to control periodontal infections
• Principles of NSPT

  *Nonsurgical periodontal therapy (NSPT) — the control of plaque induced gingivitis or chronic periodontitis through:

  • Patient daily self-care measures
  • Periodontal instrumentation
  • The use of chemical agents
• Objectives of NSPT

  • Eliminate inflammatory disease in the periodontium
  • Return the periodontium to health
  • Maintain health with professional care and daily patient self-care

  When planning NSPT

  • Plan treatment that controls or eliminates
  • Primary etiologic factors
  • Local risk factors
  • Systemic risk factors

  Selected procedures should meet the patient’s individual needs.
• * GENERAL PRINCIPLES FOR CONTROLLING PERIODONTAL INFECTION

  • Daily patient removal of supragingival plaque biofilm with a toothbrush and use of interdental aids and water flossing devices
  • Routine periodontal instrumentation to keep subgingival microbial biofilm under control
  • Office visits recommended every 3 months
• * General Indications for Nonsurgical Periodontal Therapy

  • NSPT is required for patients with dental biofilm-associated gingivitis or chronic periodontitis
  • Usually controls biofilm-induced gingivitis
  • Usually controls Stage I, II and III periodontal disease
  • Usually precedes periodontal surgery in those patients with Stage IV periodontitis
  • Surgery is indicated for patients with more advanced periodontitis AFTER NSPT is completed
  • NSPT may minimize the extent of surgery that is needed and improve outcome of the surgery.
• Nonsurgical periodontal therapy is NOT the best therapy for aggressive periodontitis
• Examples of risk factors

  Local:

  • calculus
  • tooth morphology
  • poorly fitted restorations; overhangs, open margins, bulky crowns

  Systemic

  • diabetes
  • smoking
  • stress
  • hormonal changes: pregnancy, puberty, menopause
  • HIV/AIDS
  • neutropenia
  • down syndrome
  • leukemia
  • a metabolic syndrome: increased blood pressure, blood sugar and obesity
• * Reevaluation of the Need for Periodontal Surgery Following NSPT

  • After NSPT, a reevaluation is done to determine if there is a need for surgical therapy (4 - 6 weeks)
  • As the severity of periodontitis increases, it becomes more likely that some periodontal surgery will be needed to bring the disease under control
• * Types of NSPT procedures

  • Patient education
  • Use of antimicrobial agents
  • Use of adjunctive supra and subgingival irrigation
  • Correction of local contributing factors
  • Interprofessional collaboration for correction of systemic risk factors
  • Modulation of host defenses
  • Instrumentation of tooth surfaces
• * Typical Treatment Plan for Dental Biofilm-Induced Gingivitis Customized self-care instructions

  • Periodontal instrumentation (dental prophylaxis)
  • Eliminate local factors like overhanging restorations, caries, and ill-fitting prostheses
  • Re-evaluating periodontal response
• * Typical Treatment Plan for Stage 1 or 2, Grade A Periodontitis

  • Customized self care instructions
  • Periodontal instrumentation (scaling and root planing)
  • Eliminate local factors like overhanging restorations, caries, and excessive occlusal forces
  • Correction of systemic risk factors — smoking cessation and control of diabetes
  • Re-evaluating periodontal response
• * Typical Treatment Plan for Stage 3 or 4, Grade B or C Periodontitis

  • Customized self-care instructions
  • Periodontal instrumentation (scaling and root planing)
  • Eliminate local factors like overhanging restorations, caries and excessive occlusal forces
  • Correction of systemic risk factors — smoking cessation and control of diabetes
  • Re-evaluating periodontal response — is surgery needed?
• objectives of instrumentation of NSPT

  • Physical removal of microorganisms and by-products to prevent and treat periodontal infection
  • Physical removal of bacterial plaque biofilm is the most effective mechanism of control
  • The goal is to remove or disturb the plaque biofilm and remove biofilm retentive calculus deposits to make the space optimal so tissue healing occurs
  • Subgingival plaque biofilm within pockets cannot be reached with a toothbrush or floss
  • Pockets must be instrumented to disrupt bacterial colonies
• Instrumentation of NSPT

  Plaque

  • Physical removal is most effective form of control
  • Most subg biofilm within pockets can’t be reached with toothbrush, floss, or rinse

  Calculus

  • Removal is a critical component
  • Calculus harbors living bacterial biofilms
  • calculus remains = bacteria

  Preserve cementum

  • Preservation -> quality of healing
  • Cementum can influence activities of cells
  • Reattachment relies on cementum
  • Cementum = tooth attachment & maintenance of occlusion
  • Instrumentation should be limited to what is needed for a tissue response
  • instrumented to where inflammation is arrested
• Rationale of NSPT instumentation

  • To arrest progress of periodontal disease
  • To induce positive changes in subgingival bacterial flora
  • To eliminate inflammation in the periodontium
  • To increase effectiveness of patient self-care
  • To prevent recurrence of periodontal disease during periodontal maintenance
• Instrumentation selection for NSPT treatment

  • Power instrumentation — optimum choice over hand instrumentation for periodontal debridement (Piezo or Cavitron – Tip Selection)
  • More effective in deplaquing tooth surfaces
  • More effective treatment of furcations
  • Slim tips reach deeper into periodontal pockets
  • Low / medium power setting less root surface damage
  • Water irrigation removes toxins
  • Reduced instrumentation time
• Terminology

  Instrumentation of the crown and root surfaces

  scaling
• Terminology

  The intentional removal of the cementum; believed necessary for the removal of biofilms that were thought to be imbedded in the cementum

  (We now know that biofilms are easily removed from the surface of the cementum.)

  Root planing
• Emerging NSPT technology

  Periodontal debridement

  • Removes or disrupts bacterial plaque biofilm and calculus from the crown and root surfaces
  • Does NOT include deliberate removal of the cementum
  • Limits the extent of instrumentation to that needed to obtain a favorable tissue response
• *Desired Endpoint of Instrumentation During Nonsurgical Therapy

  • Primary type of healing in the site of attachment loss after periodontal instrumentation is the formation of a long junctional epithelium
  • As inflammation resolves, epithelial cells readapt to the root surface
  • There will be no formation of new alveolar bone, cementum, or periodontal ligament ( No periodontal regeneration)
  • Reduced probing depths
• Terminology

  the return of the tissues of the periodontium to a state of health

  endpoint
• dentinal hypersensitivity

  • A short, sharp painful reaction that occurs when an area of exposed dentin is subjected to mechanical, thermal, or chemical stimuli
  • Can be felt when brushing, eating cold foods, eating sweet, sour or acidic foods, or even when breathing outside on a cold day
  • * Hypersensitivity can result during instrumentation of root surfaces. But not all teeth with exposed dentin are hypersensitive!
  • Associated with exposed dentin
  • Due to recession of gingival margin that normally covers the dentin
  • May be localized or generalized
  • Not all recession is hypersensitive.
• Stimuli for dentinal hypersensitivity

  Mechanical stimuli

  • Toothbrush bristles
  • Fingernail

  Thermal stimuli

  • Ice cream
  • Iced drinks

  Chemical stimuli

  • Grapefruit
• Precipitating factors for sensitivity

  • Gingival recession due to the destruction of the enamel
  • Successful surgical and nonsurgical periodontal therapy
  • Occasional slight dentin exposure after periodontal healing
  • Patients perceive sensitivity as a side effect from therapy
  • Actual sensitivity due to attachment loss prior to therapy
• Origins of dentinal hypersensitivity

  Hydrodynamic theory

  • Dentinal tubules penetrate the dentin
  • Tubules are long miniature tunnels extending through the dentin
  • Tubules are partially filled with cytoplasm from pulp cells
  • Changes in temperature create hydrodynamic forces in fluid-filled tubules that stimulate nerve endings
• Mechanism of dentinal hypersensitivity

  2 Phases:

  • The dentin loses its protective cementum covering. This leads to exposure of the dentinal tubules to the oral environment
  • There are three theories that have been proposed to explain the mechanism behind dentinal sensitivity. We will focus on the hydrodynamic theory
• Hydrodynamic theory

  • There have been many theories how dentinal pain is generated
  • Most widely accepted theory is the hydrodynamic theory
  • Movement of dentinal fluid in the tubules activates nerve cell endings that initiate the pain response at the dental pulpal complex
  • Cold, hot, and pressure stimuli cause dentinal fluid to shift back and forth within the tubule

  
• Origins of hypersensitivity

  • Instrumenting areas with existing hypersensitivity may result in sharp pain.
  • Local anesthesia may be necessary for patient comfort
  • Most instrumentation of root surfaces does not cause dental hypersensitivity
  • The smear layer is crystalline debris from the tooth surface that covers dentinal tubules inhibiting fluid flow, thus preventing sensitivity
• strategies for managing hypersensitivity

  • Most areas of hypersensitivity eventually desensitize on their own
  • Dentinal tubules go through a natural process of crystallization and occlusion
  • Natural process takes several weeks
  • Chemical management
  • Patient education
  • Treating exposed dentin surfaces with lasers
  • Blocking dentinal tubules with restorative materials
  • Cover exposed dentin with gingival graft
• Chemical hypersensitivity management

  • Chemicals can be used to seal tubules.
  • Fluoride, calcium hydroxide, cavity varnish
  • Recommend toothpaste for sensitive teeth
  • Potassium nitrate, strontium chloride, sodium citrate

  
• Patient education on NSPT hypersensitivity

  Any patient undergoing nspt should be told about the possibility of hypersensitivity before beginning any treatment

  • Sensitivity can increase after periodontal instrumentation
  • Gradually disappears over a few weeks time
  • Meticulous plaque control is one of the most important factors in prevention and control of sensitivity
  • Special toothpastes may be helpful, but do not expect immediate results
• Healing after NSPT instrumentation

  • Following periodontal instrumentation, there is NO formation of new alveolar bone, new cementum, or new periodontal ligament
  • Tissue healing does not occur overnight
  • It is not possible to assess true tissue response for at least one month after the completion of instrumentation
• Tissue responses to instrumentation

  • Shrinkage of the soft tissue and a shallow pocket depth
  • Readaptation of the tissues to the root forming a long junctional epithelium
  • Little change in the level of soft tissues resulting in a residual periodontal pocket
• Healing after NSPT instrumentation

  • The primary type of healing after periodontal instrumentation is through the formation of a long junctional epithelium
• Reevaluation of NSPT

  • Formal step following nonsurgical therapy
  • Reassess
  • Compare with initial assessment
  • Decide on a plan for periodontal maintenance
  • Usually 4 to 6 weeks after completion of periodontal therapy
  • Allows time for complete tissue healing
• Steps in reevaluation of NSPT

  • Medical status update
  • Thorough periodontal assessment
  • Compare results with initial assessment
  • Decide on the next step in therapy
  • Additional nonsurgical therapy
  • Periodontal maintenance schedule
  • Possible referral for periodontal surgery
• Nonresponsive sites of NSPT

  • Nonresponsive sites are areas that show continuing loss of attachment and inflammation in spite of thorough nonsurgical therapy
  • Evidence of deeper probing depths, continued loss of attachment, continued signs of inflammation (bleeding)
• Evaluation of nonresponsive sites of NSPT

  • Recheck for thoroughness of patient self-care
  • If dental plaque biofilm found subgingival, site should be deplaqued
  • Patient to receive additional motivation & training
  • Recheck for residual calculus
  • If calculus is found, additional debridement
  • Dental team should consider other factors might be contributing to the disease process (faulty restoration or systemic disease (possibly undiagnosed), smoking)
  • Some sites might represent areas where advanced destruction from disease process has occurred & may need advanced care -> periodontal surgery
• Establish a program of periodontal maintenance

  • Suggested interval is 3 months
  • At each visit, perform a reassessment of periodontium to determine if periodontitis is controlled
  • If condition is stable, perform periodontal maintenance procedures
  • If condition is not stable, referral to periodontist may be indicated

  
• Indications for periodontal surgery

  • dental biofilm associated gingivitis - surgery usually not indicated
  • stage 1 and 2 periodontitis - surgery usually not indicated
  • stage 3 periodontitis - surgery sometimes indicated
  • stage 4 periodontitis - surgery usually indicated

  Exceptions

  • gingival enlargement may require recontouring
  • gingivectomy - recontouring/removal of gum
  • incipient periodontitis with severe recession - surgery may be indicated to correct severe recession
  • gum graft - to correct gum recession