NSPT (questions in red and answers from ppt) WIP

What is considered the "gold standard" of the initial phase of periodontal therapy?

- Management or elimination of modifiable risk factors for periodontal disease.

- Patient education for preventive strategies including control of biofilm, tobacco cessation, and nutritional counseling with ongoing evaluation and reinforcement

What tooth accumulated material/deposits are removed during periodontal debridement?

dental biofilm, endotoxins, other bacterial products, and calculus

What is the therapeutic goal of NSTP?

manage or eliminate plaque biofilm and risk factors for periodontitis in order to stop progression of disease and maintain oral health

How does the microbiome (bacterial composition) change following periodontal debridement?

Changes from:

anerobic -> aerobic

gram negative -> gram positive

motile -> nonmotile

spirochetes/rods -> cocccoid

high bacterial loads -> lower bacterial loads

What should determine the frequency of periodontal maintenance appointments?

patient's individual risk factors to monitor and manage periodontal disease.

Therapeutic goals differ for patients with Gingivitis

Reversal of inflammation to establish gingival health through elimination of etiologic factors

Therapeutic goals differ for patients with Stage I or II Periodontitis

• Reduction in gingival inflammation and BOP.

• Reduction in pocket depths.

• CALs are stabilized or improved.

• Decrease in detectable dental biofilm to a level consistent with health

Therapeutic goals differ for patients with Stage III or IV Periodontitis

Gain access to deep pockets to regenerate/resect areas that negatively impact periodontitis

I.• Same goals as mild-to-moderate periodontal conditions.

II.• Radiographic improvement in osseous lesions.

III.• Occlusal stabilization.

Therapeutic goals differ for Patients Who Require Surgical or Other Advanced Periodontal Therapy

I. Gingival augmentation therapy: periodontal plastic surgeries, gingival grafts.

II.• Regenerative procedures: bone grafting, guided tissue regeneration.

III.• Resective therapy: gingival flaps with or without osseous surgery, root resective therapy, gingivectomy

What is considered the ideal endpoint of periodontal debridement?

disruption of biofilm and removal of calculus along with preservation of the cementum

Why is the complete removal of cementum during periodontal debridement not recommended?

serves as a source of growth factors for new attachment.

What are example of restorative biofilm-retentive factors?

Overhanging margins

rough surfaces of restorations

Personal oral self-care efforts by the patient are impeded by overhanging margins, irregular margins that are breaking down, and poorly contoured restorations.

How is the number of appointments for NSTP determined?

extent of periodontal involvement as shown by probing measurements, distribution and extent of calculus deposits, and adequate biofilm removal

What are examples of modifiable risk factors?

tobacco cessation and biofilm removal

Explain evaluation during NSPT and re-evaluation following NSPT?

At each appointment, the healing of the quadrants previously treated should be assessed.

▶▶ Any residual calculus remaining can be removed.

▶▶ Best done 4-8 weeks following completion of NSPT to allow for connective tissue healing

Explain the difference between full-mouth disinfection and the quadrant/sextant approach.

full mouth disenfection is a ssystem of performing NSPT in two long appointments completed within a 24-hour period with adjunctive chlorhexidine mouthrinse.

quadrant/sextant is more appoints with smaller areas t work with

Why should the patient's radiographs and periodontal chart be on the computer screen during debridement?

observe bone level, root anatomy, and contour of restorations for each area.

can also see where calculus is

Explain the difference between SRP (Scaling and Root Planning) and periodontal debridement?

SRP - removed calc and 'diseased' cementum

periodontal debridement - disruption/ removal of biofilm and endotocins along with calc from the root (ultrasonic instrumentation reserves cementum and dentin)

What instructions should be provided to the patient following periodontal debridement regarding discromfort in tissues?

▶ inform of possible soft-tissue discomfort when local anesthesia wears off.

• discomfort can usually be managed with OTC analgesics (acetaminophen (Tylenol®), aspirin, or ibuprofen (Advil®))

What instructions should be provided to the patient following periodontal debridement regarding dentin hypersensitivity ?

- dentin hypersensitivity -> a toothpaste for sensitivity(5% potassium nitrate dentifrice) may be recommended.

• The patient should understand that it 𝐦𝐚𝐲 𝐭𝐚𝐤𝐞 𝐬𝐞𝐯𝐞𝐫𝐚𝐥 𝐰𝐞𝐞𝐤𝐬

of repeated used for the dentin hypersensitivity 𝐟𝐨𝐫 𝐢𝐦𝐩𝐫𝐨𝐯𝐞𝐦𝐞𝐧𝐭 of sensitivity.

What instructions should be provided to the patient following periodontal debridement regarding mouth rinses to help with healing/soothing tissues ?

A warm solution may be soothing to the tissues helping healing.

▶▶ Possible solutions for rinsing may include:

• Hypertonic salt solution: 1/2 teaspoonful of salt in 1/2 cup (4 oz) of warm water.

• Sodium bicarbonate solution: 1/2 teaspoonful of baking soda in 1 cup (8 oz) of warm water.

• Rinsing directions: Every 2 hours; after eating; after toothbrushing; before retiring.

What instructions should be provided to the patient following periodontal debridement regarding OHI?

The patient needs to understand the significance of daily biofilm disruption/removal, particularly in the quadrant or sextant receiving treatment to support optimal healing.

▶▶ A soft toothbrush should be used. The patient may find that moistening the toothbrush with warm water and brushing without toothpaste initially may be more comfortable for the tissues. The fluoride toothpaste can then be added at the end of brushing.

▶▶ There may be slight bleeding during oral self-care, but this should stop as the tissues heal.

What instructions should be provided to the patient following periodontal debridement regarding diet ?

The patient should be instructed to avoid chewing solid food or drinking hot liquids until the anesthetic has worn off to avoid trauma to the tongue, cheek, and lips.

▶▶ If the tissues are tender during healing, consume bland foods without strong, spicy seasonings, as well as use of nutrient-dense, high-protein foods to promote healing.

What is the clinical endpoint of NSTP?

▶▶ BOP: eliminated.

▶▶ Probing depths: reduced.

▶▶ Attachment levels: same or improved.

▶▶ Inflammation: resolved.

▶▶ Gingival appearance: size reduced, color normal.

▶▶ Subgingival microflora: lowered in numbers, delay in repopulation.

▶▶ Dental biofilm control record: improvement in scores approaching 100% biofilm free.

▶▶ Tooth surfaces: smooth; no biofilm-retentive irregularities.

▶▶ Quality-of-life factors: oral comfort with freedom from pain.

When should the re-evaluation of initial therapy take place?

4-8 weeks after NSPT

What is assessed at the re-evaluation appointment?

A comprehensive periodontal examination is performed and documented to compare pre- and post-treatment findings.

• Changes in BOP, CAL, biofilm, and inflammation in particular are evaluated and discussed with the patient.

LDA stands for

local delivery agents

When would the use of LDA be considered?

At the completion of initial periodontal therapy, a re-evaluation is completed 4-6 weeks later.

• Residual calculus is removed.

• Control of dental biofilm is assessed, and reinforcement is provided for the patient.

• For areas of residual pocket depth and/or BOP, adjunctive therapy may be considered, such as systemic antibiotics or a local delivery antimicrobial agent

List the LDAs used as an adjunct to NSPT.

Minocycline Hydrochloride (Arestin)

Doxycycline Hyclate (Atridox)

List contraindications for use - Minocycline Hydrochloride (Arestin)

• Patients sensitive to tetracycline.

• Women who are pregnant or breastfeeding.

• Do not use in children less than 8 years of age due to possible enamel hypoplasia or permanent tooth discoloration.

• Gastrointestinal issues.

• Photosensitivity may occur, so protect the skin from prolonged sun exposure.

• Prolonged use can result in fungal or bacterial superinfection.

Describe how they are applied - Minocycline Hydrochloride (Arestin)

Site selection:

• Use as an adjunct to periodontal debridement.

• Probing depth of at least 5 mm.

▶▶ Cartridge loading:

• Insert unit-dose cartridge into dispenser handle.

• Exert slight pressure.

• Twist cartridge until it locks securely into place.

▶▶ Tip preparation

1. Cartridge tip can be manipulated to reposition the angle for difficult-to-reach areas.

2. Leave cap covering the cartridge in place prior to manipulating the angle to prevent agent from being inadvertently expelled.

3. Remove cap.

▶▶ Delivery of agent:

1. Place cartridge tip into the site selected for treatment.

2. Keep tip parallel to the long axis of the tooth as it enters the periodontal pocket (Figure 39-9).

3. Do not force the tip to the base of the pocket.

4. Gently press thumb ring of handle to express the agent while withdrawing cartridge tip coronally from the base of the pocket.

5. With delivery complete, retract thumb ring and remove cartridge with free hand.

6. Discard contaminated cartridge.

7. Sterilize handle prior to reuse.

Discuss post-treatment instructions for LDA - minocycline hydrochloride

Instruct patient on proper care of treated areas. Give written guidelines to prevent misunderstanding.

▶▶ Avoid touching treated area(s).

▶▶ Do not use interdental cleaners or floss between teeth that have been treated for at least 10 days.

▶▶ Avoid eating hard, crunchy, or sticky foods that could disturb retention of the product for 1 week.

▶▶ Avoid brushing for 12 hours.

▶▶ Some mild-to-moderate sensitivity may be present the first week after scaling and root debridement and placement of minocycline HCl, but the patient needs to contact the dentist if pain or swelling occurs.

▶▶ Schedule a follow-up appointment for continuing maintenance care.

contraindications - doxyclycline hyclate

Patients sensitive to tetracycline.

• Women who are pregnant or breastfeeding.

• Do not use in children less than 8 years of age due to possible enamel hypoplasia or permanent tooth discoloration.

• Photosensitivity may occur, so protect the skin from prolonged sun exposure.

• Prolonged use can result in fungal or bacterial superinfection.

administration -doxycycline hyclate

▶▶ Site selection

• Probing depth of at least 5 mm.

▶▶ Preparation of agent

• If refrigerated, take pouches with product out of refrigerator at least 15 minutes before mixing.

• Mixing: Two syringes are coupled, and the substances are passed back and forth, which is one mixing cycle. Mixing continues for 100 mixing cycles (Figure 39-10A). Follow the manufacturer's instructions.

• Adapt cannula: Attach 23-gauge blunt cannula to syringe. As the cap is removed, the cannula is held part way and bent against the wall of the cover to provide an angle appropriately similar to a periodontal probe for insertion into the periodontal pocket (Figure 39-10B).

▶▶ Delivery of agent

1. Place cartridge tip into the site selected for treatment.

2. Keep tip parallel to the long axis of the tooth as it enters the periodontal pocket.

3. Do not force the tip to the base of the pocket.

4. Express the agent as the cannula is withdrawn to the gingival margin (Figure 39-10C).

5. Use a blunt instrument to pack the agent down.

6. Placing a periodontal dressing or adhesive over the area to aid retention.

post treatment instruction

▶▶ Instruct patient on proper care of treated areas including the following:

• Prevent accidental removal.

• Routine brushing and other oral self-care on all other areas, but avoid toothbrushing or flossing the treated areas for 7 days.

• Schedule a follow-up appointment to remove periodontal dressing and evaluate tissue response.

▶▶ Schedule periodontal maintenance.