periodontics dho (2)

PeriodonticsPeriodontics

GROUP 2GROUP 2

Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

PeriodontologyPeriodontology or or PeriodonticsPeriodontics (from (from Greek περί περί periperi "around"; and ὀδούς "around"; and ὀδούς odousodous "tooth", genitive "tooth", genitive ὀδόντος ὀδόντος odontosodontos) is the ) is the specialty of of dentistry that that studies supporting structures of studies supporting structures of teeth, diseases, and , diseases, and conditions that affect them. The supporting tissues conditions that affect them. The supporting tissues are known as the are known as the periodontium, which includes the , which includes the gingiva (gums), (gums), alveolar bone,,cementum, and the , and the periodontal ligament. A professional who practises . A professional who practises this speciality field of dentistry is known as this speciality field of dentistry is known as a a periodontistperiodontist..

http://en.wikipedia.org/wiki/Greek_language

http://en.wikipedia.org/wiki/Specialty_(dentistry)

http://en.wikipedia.org/wiki/Dentistry

http://en.wikipedia.org/wiki/Tooth

http://en.wikipedia.org/wiki/Periodontium

http://en.wikipedia.org/wiki/Gingiva

http://en.wikipedia.org/wiki/Alveolar_bone

http://en.wikipedia.org/wiki/Cementum

http://en.wikipedia.org/wiki/Periodontal_ligament

The Periodontal ExaminationThe Periodontal Examination

A periodontal examination includes:A periodontal examination includes: Medical and dental historiesMedical and dental histories Radiographic evaluationsRadiographic evaluations Examination of the teethExamination of the teeth Examination of the oral tissuesExamination of the oral tissues Supporting structures Supporting structures Periodontal charting Periodontal charting

The periodontal charting includes pocket The periodontal charting includes pocket readings, furcations, tooth mobility, exudate readings, furcations, tooth mobility, exudate (pus), and gingival recession. (pus), and gingival recession.


Fig. 55-1 Computerized diagram showing Fig. 55-1 Computerized diagram showing periodontal parameters.periodontal parameters.

(Courtesy of the University of California, Los Angeles, School of Dentistry) (Courtesy of the University of California, Los Angeles, School of Dentistry) (From Newman M, Takei H, Klokkevold P, et al: (From Newman M, Takei H, Klokkevold P, et al: Carranza’s clinical periodontologyCarranza’s clinical periodontology, ed 10, St , ed 10, St

Louis, 2006, Saunders.) Louis, 2006, Saunders.)


Fig. 55-2 A periodontal chart on a computer screen. This Fig. 55-2 A periodontal chart on a computer screen. This periodontist can easily refer to the chart as he treats periodontist can easily refer to the chart as he treats

the patient.the patient.


Early Signs of Periodontal DiseaseEarly Signs of Periodontal Disease

Changes in the gingiva (color, size, shape, Changes in the gingiva (color, size, shape, texture)texture)

Gingival inflammationGingival inflammation Gingival bleedingGingival bleeding Evidence of exudateEvidence of exudate Development of periodontal pocketsDevelopment of periodontal pockets


Medical and Dental HistoriesMedical and Dental Histories

Systemic diseases such as acquired Systemic diseases such as acquired immunodeficiency syndrome, human immunodeficiency syndrome, human immunodeficiency virus infection, and diabetes can immunodeficiency virus infection, and diabetes can decrease resistance of the tissue to infection. decrease resistance of the tissue to infection. Lowered resistance makes periodontal disease more Lowered resistance makes periodontal disease more severe and more difficult to treat.severe and more difficult to treat.

The dental history is used to gather information about The dental history is used to gather information about conditions that could indicate periodontal disease.conditions that could indicate periodontal disease.

For example, patients with periodontal disease often For example, patients with periodontal disease often complain of bleeding gums, loose teeth, or a bad complain of bleeding gums, loose teeth, or a bad taste in the mouth. taste in the mouth.


MobilityMobility

It is normal for teeth to have a slight amount It is normal for teeth to have a slight amount of mobility (tooth movement) because of the of mobility (tooth movement) because of the cushioning effect of the periodontal cushioning effect of the periodontal membranes. membranes.

Excessive mobility can be an important sign Excessive mobility can be an important sign of periodontal disease.of periodontal disease.


Fig. 55-3 Mobility is detected with the blunt ends of Fig. 55-3 Mobility is detected with the blunt ends of two instruments. two instruments.

(From Daniel SJ, Harfst SA, (From Daniel SJ, Harfst SA, Mosby’s dental hygiene: concepts, cases, and Mosby’s dental hygiene: concepts, cases, and competencies, 2004 updatecompetencies, 2004 update, St Louis, 2004, Mosby.), St Louis, 2004, Mosby.)


Examination of the Oral Tissues Examination of the Oral Tissues and Supporting Structuresand Supporting Structures

The periodontal examination includes:The periodontal examination includes: Assessment of the amounts of plaque and Assessment of the amounts of plaque and

calculuscalculus Changes in gingival health and bleedingChanges in gingival health and bleeding Assessment of the level of boneAssessment of the level of bone Detection of periodontal pockets Detection of periodontal pockets


Periodontal ProbingPeriodontal Probing

A periodontal pocket results when the gingival sulcus A periodontal pocket results when the gingival sulcus becomes deeper than normal (<3 mm). becomes deeper than normal (<3 mm).

Periodontal probing measures how much epithelial Periodontal probing measures how much epithelial attachment has been lost to disease. attachment has been lost to disease.

The greater the depth of the periodontal pocket, the The greater the depth of the periodontal pocket, the greater the loss of epithelial attachment and bone and greater the loss of epithelial attachment and bone and the more serious the periodontal disease. the more serious the periodontal disease.

Periodontal pockets are very difficult, and sometimes Periodontal pockets are very difficult, and sometimes impossible, for the patient to clean. impossible, for the patient to clean.

The bacteria in the periodontal pockets will multiply The bacteria in the periodontal pockets will multiply and, if left untreated, the disease will progress until the and, if left untreated, the disease will progress until the tooth is ultimately lost. tooth is ultimately lost.


Fig. 55-4 Fig. 55-4 Cross-section of a tooth, gingiva, and bone. Cross-section of a tooth, gingiva, and bone. The A side shows normal sulcus depth. The A side shows normal sulcus depth. The B side shows a periodontal pocket.The B side shows a periodontal pocket.


Periodontal ProbesPeriodontal Probes

Used to locate and measure the depth of periodontal Used to locate and measure the depth of periodontal pockets. pockets.

On some types of probes, the tip is color-coded to On some types of probes, the tip is color-coded to make the measurements easier to read. make the measurements easier to read.

The periodontal probe is tapered to fit into the The periodontal probe is tapered to fit into the gingival sulcus and has a blunt or rounded tip. gingival sulcus and has a blunt or rounded tip.

Six measurements are taken and recorded for each Six measurements are taken and recorded for each tooth. tooth.

Periodontal probes are available in many designs; Periodontal probes are available in many designs; selection depends on the personal preference of the selection depends on the personal preference of the operator. operator.


Fig. 55-5 Fig. 55-5 Diagram showing probing the periodontal pocket depth. Diagram showing probing the periodontal pocket depth. The millimeter measurement indicates the distance The millimeter measurement indicates the distance from the gingival margin to the base of the pocket. from the gingival margin to the base of the pocket.

(From Perry D, Beemsterboer P, Taggart E: (From Perry D, Beemsterboer P, Taggart E: Periodentology for the dental hygienistPeriodentology for the dental hygienist , Philadelphia, 2001, Saunders.), Philadelphia, 2001, Saunders.)


Fig. 55-6 Fig. 55-6 Six probing depths are taken for each tooth. Six probing depths are taken for each tooth. (From Perry DA, Beemsterboer P, Carranza FA: (From Perry DA, Beemsterboer P, Carranza FA: Techniques and theory of Techniques and theory of

periodontal instrumentationperiodontal instrumentation, Philadelphia, 1990, Saunders.), Philadelphia, 1990, Saunders.)


Fig. 55-7 Bone loss in periodontal disease. Fig. 55-7 Bone loss in periodontal disease. A, Vertical bone defect. B, Crestal ridge at near-normal height. A, Vertical bone defect. B, Crestal ridge at near-normal height.

C, Alveolar crest. D, Severe vertical defect. C, Alveolar crest. D, Severe vertical defect. (From Miles DA, Van Dis ML, Jensen CW, et al: (From Miles DA, Van Dis ML, Jensen CW, et al: Radiographic imagingRadiographic imaging

for dental auxiliaries for dental auxiliaries, ed 3, Philadelphia, 1999, Saunders.), ed 3, Philadelphia, 1999, Saunders.)


Fig 55-8 A, Molar vertical bite-wing. B, Premolar Fig 55-8 A, Molar vertical bite-wing. B, Premolar vertical bite-wing.vertical bite-wing.

A B


Fig. 55-9 Fig. 55-9 Working end of a periodontal probe.Working end of a periodontal probe.


Periodontal InstrumentsPeriodontal Instruments

Periodontal therapy requires the use of Periodontal therapy requires the use of specialized instruments to remove calculus, specialized instruments to remove calculus, smooth root surfaces, measure periodontal smooth root surfaces, measure periodontal pockets, and perform periodontal surgery.pockets, and perform periodontal surgery.

In general, the dentist or registered dental In general, the dentist or registered dental hygienist who uses these instruments takes hygienist who uses these instruments takes responsibility for maintaining their sharpness.responsibility for maintaining their sharpness.


ExplorersExplorers

Used to locate supragingival and subgingival calculus Used to locate supragingival and subgingival calculus deposits and provide tactile information to the deposits and provide tactile information to the operator about the roughness or smoothness of the operator about the roughness or smoothness of the root surfaces.root surfaces.

Explorers used in periodontics are longer and more Explorers used in periodontics are longer and more curved than those used for caries detection.curved than those used for caries detection.

The working ends of periodontal explorers are thin, The working ends of periodontal explorers are thin, fine, and easily manipulated around root surfaces. fine, and easily manipulated around root surfaces.

They also are long enough to be capable of reaching They also are long enough to be capable of reaching to the bases of deep pockets and furcations.to the bases of deep pockets and furcations.


Fig. 55-10 Fig. 55-10 Various styles of periodontal explorers.Various styles of periodontal explorers.(Courtesy of Hu-Friedy Manufacturing, Chicago, Ill.)(Courtesy of Hu-Friedy Manufacturing, Chicago, Ill.)


ScalersScalers

Sickle scalers are used primarily to remove Sickle scalers are used primarily to remove large deposits of supragingival calculus.large deposits of supragingival calculus.

Chisel scalers are used to remove Chisel scalers are used to remove supragingival calculus in the contact area of supragingival calculus in the contact area of anterior teeth. The blade on the chisel scaler is anterior teeth. The blade on the chisel scaler is curved slightly to adapt to the tooth surfaces. curved slightly to adapt to the tooth surfaces.

Hoe scalers are used to remove heavy Hoe scalers are used to remove heavy supragingival calculus. Hoes are most supragingival calculus. Hoes are most effective when used on the buccal and lingual effective when used on the buccal and lingual surfaces of the posterior teeth.surfaces of the posterior teeth.


CurettesCurettes

Curettes are used to remove subgingival Curettes are used to remove subgingival calculus, smooth rough root surfaces (root calculus, smooth rough root surfaces (root planing), and remove the diseased soft-tissue planing), and remove the diseased soft-tissue lining of the periodontal pocket (soft-tissue lining of the periodontal pocket (soft-tissue curettage). curettage).

A curette has a rounded end, unlike a scaler, A curette has a rounded end, unlike a scaler, which has a pointed end. which has a pointed end.

There are two basic designs of curettes:There are two basic designs of curettes: UniversalUniversal GraceyGracey


Fig. 55-11 A, Anterior curette. B, Posterior curette.Fig. 55-11 A, Anterior curette. B, Posterior curette.


Fig. 55-12 Fig. 55-12 Comparison of the end of the scaler Comparison of the end of the scaler (pointed) (pointed)

and the end of a curette (rounded).and the end of a curette (rounded).


Types of CurettesTypes of Curettes

Universal curettes are designed so that one Universal curettes are designed so that one instrument can be used on all tooth surfaces. instrument can be used on all tooth surfaces. There are two cutting edges, one on each side of There are two cutting edges, one on each side of

the blade. Universal curettes resemble the spoon the blade. Universal curettes resemble the spoon excavators used in restorative dentistry. excavators used in restorative dentistry.

Gracey curettes have only one cutting edge Gracey curettes have only one cutting edge and are area-specific; this means that they are and are area-specific; this means that they are designed for use on specific tooth surfaces designed for use on specific tooth surfaces (mesial or distal). (mesial or distal). Treatment of the entire dentition requires the use of Treatment of the entire dentition requires the use of

several curettesseveral curettes


Fig. 55-13 Universal cFig. 55-13 Universal curette. urette. Note the cutting edge on each side of the blade.Note the cutting edge on each side of the blade.


Periodontal Surgical InstrumentsPeriodontal Surgical Instruments

Periodontal knivesPeriodontal knives The Kirkland knife is one of the most commonly The Kirkland knife is one of the most commonly

used knives in periodontal surgery. Thes used knives in periodontal surgery. Thes instruments are usually double-ended, with instruments are usually double-ended, with kidney-shaped blades.kidney-shaped blades.

The Orban knife is used to remove tissue from the The Orban knife is used to remove tissue from the interdental areas. These knives are shaped like interdental areas. These knives are shaped like spears and have cutting edges on both sides of spears and have cutting edges on both sides of their blades. their blades.


Fig. 55-14 Assorted Gracey curettes. Fig. 55-14 Assorted Gracey curettes. (Courtesy of Hu-Freidy Manufacturing, Chicago, Ill.)(Courtesy of Hu-Freidy Manufacturing, Chicago, Ill.)


Fig. 55-15 Gingivectomy knives. Fig. 55-15 Gingivectomy knives. A, Kirkland knife. B, Orban interdental knife.A, Kirkland knife. B, Orban interdental knife.

(From Newman M, Takei H, Klokkevold P, et al: (From Newman M, Takei H, Klokkevold P, et al: Carranza’s clinical periodontologyCarranza’s clinical periodontology, ed 10, St Louis, 2006, , ed 10, St Louis, 2006, Saunders.) Saunders.)


Pocket MarkersPocket Markers

Pocket markers are similar in appearance to Pocket markers are similar in appearance to cotton pliers; however, one tip is smooth and cotton pliers; however, one tip is smooth and straight and the other is sharp and bent at a right straight and the other is sharp and bent at a right angle. angle.

The smooth tip of the pocket marker is inserted at The smooth tip of the pocket marker is inserted at the base of the pocket, and when the instrument the base of the pocket, and when the instrument is pressed together the sharp tip makes small is pressed together the sharp tip makes small perforations in the gingivae. perforations in the gingivae.

These perforations, which are referred to as These perforations, which are referred to as bleeding points, are used to outline the area for bleeding points, are used to outline the area for an incision on the gingivae. an incision on the gingivae.


Fig. 55-16 The pFig. 55-16 The periodontal pocket marker is used to make eriodontal pocket marker is used to make pinpoint perforations that indicate the line for a pinpoint perforations that indicate the line for a

surgical incision.surgical incision.


The Ultrasonic ScalerThe Ultrasonic Scaler

The ultrasonic scaler allows rapid calculus removal and The ultrasonic scaler allows rapid calculus removal and reduces hand fatigue for the operator.reduces hand fatigue for the operator.

The ultrasonic scaler works by converting very high The ultrasonic scaler works by converting very high frequency sound waves into mechanical energy in the form frequency sound waves into mechanical energy in the form of very rapid vibrations.of very rapid vibrations.

A spray of water at the tip prevents the buildup of heat and A spray of water at the tip prevents the buildup of heat and provides a continuous flushing of debris and bacteria from provides a continuous flushing of debris and bacteria from the base of the pocket. the base of the pocket.

Because of the spray of water at the tip, there is a large Because of the spray of water at the tip, there is a large amount of potentially contaminated aerosol spray.amount of potentially contaminated aerosol spray.

It is highly desirable for the operator of an ultrasonic scaler It is highly desirable for the operator of an ultrasonic scaler to have the dental assistant help by using the high-volume to have the dental assistant help by using the high-volume evacuator to minimize aerosol contamination. evacuator to minimize aerosol contamination.


Fig. 55-17 A series of ultrasonic tips designed Fig. 55-17 A series of ultrasonic tips designed to reach every area of the mouth. to reach every area of the mouth.

(From Daniel SJ, Harfst SA, (From Daniel SJ, Harfst SA, Mosby’s dental hygiene: concepts, cases, and Mosby’s dental hygiene: concepts, cases, and competencies, 2004 updatecompetencies, 2004 update, St Louis, 2004, Mosby.), St Louis, 2004, Mosby.)


Fig. 55-18 Fig. 55-18 A, Positioning of the ultrasonic scaler. A, Positioning of the ultrasonic scaler. B, Ultrasonic scaler with water source turned on. B, Ultrasonic scaler with water source turned on.

(Courtesy of Hu-Friedy Manufacturing, Chicago, Ill.)(Courtesy of Hu-Friedy Manufacturing, Chicago, Ill.)


Indications for Use of the Ultrasonic Indications for Use of the Ultrasonic ScalerScaler

Removal of supragingival calculus and difficult Removal of supragingival calculus and difficult stainsstains

Removal of subgingival calculus, attached Removal of subgingival calculus, attached plaque, and endotoxins from the root surfaceplaque, and endotoxins from the root surface

Cleaning of furcation areasCleaning of furcation areas Removal of deposits before periodontal surgeryRemoval of deposits before periodontal surgery Removal of orthodontic cements; debondingRemoval of orthodontic cements; debonding Removal of overhanging margins of Removal of overhanging margins of

restorationsrestorations


Contraindications and PrecautionsContraindications and Precautions

Communicable disease: A patient with a known Communicable disease: A patient with a known communicable disease that can be transmitted by aerosols, communicable disease that can be transmitted by aerosols, such as tuberculosis, poses a risk to the operator.such as tuberculosis, poses a risk to the operator.

Immunocompromise: A compromised patient is open to Immunocompromise: A compromised patient is open to infection.infection.

Respiratory problems: Materials can be aspirated into the Respiratory problems: Materials can be aspirated into the lungs of a patient with respiratory problems.lungs of a patient with respiratory problems.

Swallowing difficulty: Problems with swallowing or a severe Swallowing difficulty: Problems with swallowing or a severe gag reflex makes treatment hazardous.gag reflex makes treatment hazardous.

Cardiac pacemaker: Consultation with the patient’s Cardiac pacemaker: Consultation with the patient’s cardiologist is necessary. The newer models of ultrasonic cardiologist is necessary. The newer models of ultrasonic scalers have protective coatings.scalers have protective coatings.


Oral Conditions Contraindicating Use Oral Conditions Contraindicating Use of Ultrasonic Toolsof Ultrasonic Tools

Demineralized areas: The ultrasonic vibrations can Demineralized areas: The ultrasonic vibrations can remove the areas of remineralization that begin to remove the areas of remineralization that begin to cover the demineralization.cover the demineralization.

Exposed dentinal surfaces: Tooth structure can be Exposed dentinal surfaces: Tooth structure can be removed, resulting in cause tooth sensitivity.removed, resulting in cause tooth sensitivity.

Restorative materials: Some restorative materials, such Restorative materials: Some restorative materials, such as porcelain, amalgam, composite resins, and laminate as porcelain, amalgam, composite resins, and laminate veneers, can be damaged by ultrasonic vibrations.veneers, can be damaged by ultrasonic vibrations.

Titanium implant abutments: Unless a special plastic Titanium implant abutments: Unless a special plastic sheath is used to cover the tip, the ultrasonic tool will sheath is used to cover the tip, the ultrasonic tool will damage titanium surfaces.damage titanium surfaces.


Learning ObjectivesLearning Objectives

Describe the goals of nonsurgical periodontal Describe the goals of nonsurgical periodontal therapy.therapy.

Assist with a dental prophylaxis procedure.Assist with a dental prophylaxis procedure. Describe the types of nonsurgical periodontal Describe the types of nonsurgical periodontal

therapy.therapy. Describe the types of surgical periodontal Describe the types of surgical periodontal

therapy.therapy. Assist with gingivectomy and gingivoplasty.Assist with gingivectomy and gingivoplasty.


Dental ProphylaxisDental Prophylaxis

Commonly referred to as prophy or cleaning, Commonly referred to as prophy or cleaning, prophylaxis is the complete removal of calculus, soft prophylaxis is the complete removal of calculus, soft deposits, plaque, and stains from all supragingival and deposits, plaque, and stains from all supragingival and unattached subgingival tooth surfaces. unattached subgingival tooth surfaces.

The dentist and dental hygienist are the only members The dentist and dental hygienist are the only members of the dental health team who are licensed to perform of the dental health team who are licensed to perform this procedure.this procedure.

Prophylaxis is indicated for patients with healthy Prophylaxis is indicated for patients with healthy gingiva as a preventive measure and is most gingiva as a preventive measure and is most commonly performed during recall appointments.commonly performed during recall appointments.

Dental prophylaxis also is the primary treatment for Dental prophylaxis also is the primary treatment for gingivitis. gingivitis.


Scaling, Root Planing, Scaling, Root Planing, and Gingival Curettageand Gingival Curettage

Scaling and root planing are nonsurgical Scaling and root planing are nonsurgical treatments for type II and III cases and before treatments for type II and III cases and before periodontal surgery. periodontal surgery.

In some cases gingival curettage, a In some cases gingival curettage, a nonsurgical technique, may also be indicated. nonsurgical technique, may also be indicated.

A local anesthetic is usually administered A local anesthetic is usually administered before these procedures.before these procedures.


Fig. 55-19 A Gracey currette is used during scaling and root planing. (From Newman M, Takei H, Klokkevold P, et al: Carranza’s clinical periodontology, ed 10, St Louis, 2006, Saunders.)


ScalingScaling

Scalers are used to remove supragingival Scalers are used to remove supragingival calculus from the tooth surface.calculus from the tooth surface.

Curettes are used to remove supragingival Curettes are used to remove supragingival and subgingival calculus.and subgingival calculus.

Some areas on the root surface may remain Some areas on the root surface may remain rough after calculus removal.rough after calculus removal.

This is because the cementum has become This is because the cementum has become necrotic (dead) or because the scaling has necrotic (dead) or because the scaling has produced grooves and scratches in the produced grooves and scratches in the cementum.cementum.


Root PlaningRoot Planing

Root planing is performed after scaling Root planing is performed after scaling procedures to remove any remaining particles procedures to remove any remaining particles of calculus and necrotic cementum of calculus and necrotic cementum embedded in the root surface. embedded in the root surface.

After root planing, the surfaces of the root are After root planing, the surfaces of the root are smooth and glasslike.smooth and glasslike.

Smooth root surfaces resist new calculus Smooth root surfaces resist new calculus formation and are easier for the patient to formation and are easier for the patient to keep clean.keep clean.


Gingival CurettageGingival Curettage

Curettage means scraping or cleaning with a Curettage means scraping or cleaning with a curette. curette.

Some patients also require gingival curettage Some patients also require gingival curettage in addition to scaling and root planing.in addition to scaling and root planing.

Gingival curettage, also referred to as Gingival curettage, also referred to as subgingival curettage, is the scraping of the subgingival curettage, is the scraping of the gingival lining of a periodontal pocket. This is gingival lining of a periodontal pocket. This is performed to remove necrotic (dead) tissue performed to remove necrotic (dead) tissue from the pocket wall.from the pocket wall.


Antimicrobial and Antibiotic AgentsAntimicrobial and Antibiotic Agents

Tetracycline is an antibiotic that is particularly useful for the Tetracycline is an antibiotic that is particularly useful for the treatment of periodontitis, early-onset periodontitis, and rapidly treatment of periodontitis, early-onset periodontitis, and rapidly destructive periodontitis. An important side effect of tetracycline destructive periodontitis. An important side effect of tetracycline is its interference with the effectiveness of birth-control pills.is its interference with the effectiveness of birth-control pills.

Penicillin is less effective against periodontal disease infections Penicillin is less effective against periodontal disease infections than other antibiotics because many periodontal pathogens are than other antibiotics because many periodontal pathogens are resistant to it.resistant to it.

Fluoride mouth rinses have been shown to reduce bleeding by Fluoride mouth rinses have been shown to reduce bleeding by delaying bacterial growth in the periodontal pockets.delaying bacterial growth in the periodontal pockets.

A twice-daily chlorhexidine rinse is the most effective means A twice-daily chlorhexidine rinse is the most effective means available for reducing plaque and gingivitis. Chlorhexidine can available for reducing plaque and gingivitis. Chlorhexidine can cause some temporary brown staining of the teeth, tongue, and cause some temporary brown staining of the teeth, tongue, and resin restorations.resin restorations.


Periodontal SurgeryPeriodontal Surgery

Periodontal surgery is indicated to control the Periodontal surgery is indicated to control the progress of periodontal destruction and loss progress of periodontal destruction and loss of attachment when nonsurgical treatment is of attachment when nonsurgical treatment is not enough to arrest the disease process.not enough to arrest the disease process.


Advantages of Periodontal SurgeryAdvantages of Periodontal Surgery

The primary advantage of periodontal surgery is that it The primary advantage of periodontal surgery is that it allows access to the root surface for scaling and root allows access to the root surface for scaling and root planing. planing.

Surgery makes it easier for the patient to clean difficult Surgery makes it easier for the patient to clean difficult areas.areas.

Periodontal surgery also results in better access to Periodontal surgery also results in better access to furcations and other areas that are very difficult to furcations and other areas that are very difficult to reach during traditional scaling and root planing.reach during traditional scaling and root planing.

Numerous new techniques are being used to improve Numerous new techniques are being used to improve patient aesthetics by altering the position of the gingival patient aesthetics by altering the position of the gingival margin. These new techniques are being used margin. These new techniques are being used extensively in cosmetic dentistry procedures.extensively in cosmetic dentistry procedures.


Disadvantages of Periodontal Disadvantages of Periodontal SurgerySurgery

The health status of the patient or age of the The health status of the patient or age of the patient, as well as limitations of the procedures, patient, as well as limitations of the procedures, may mean that periodontal surgery is not an may mean that periodontal surgery is not an option. option.

From the patient’s point of view, the From the patient’s point of view, the disadvantages of surgery usually include time, disadvantages of surgery usually include time, cost, aesthetics, and discomfort. cost, aesthetics, and discomfort.

The dental assistant usually has developed a The dental assistant usually has developed a good rapport with the patient and is in a unique good rapport with the patient and is in a unique position to discuss these concerns with the position to discuss these concerns with the patient. patient.


Reasons for Periodontal SurgeryReasons for Periodontal Surgery

The amount of bone remaining around a tooth is an The amount of bone remaining around a tooth is an important consideration in the decision to perform important consideration in the decision to perform periodontal surgery. periodontal surgery.

When there is a large amount of bone around a tooth, When there is a large amount of bone around a tooth, the dentist may take a wait-and-see approach, the dentist may take a wait-and-see approach, postponing or avoiding periodontal surgery.postponing or avoiding periodontal surgery.

When this approach is taken, it is important for the When this approach is taken, it is important for the patient to practice excellent home care and routine patient to practice excellent home care and routine dental care. dental care.

If the amount of bone is already reduced, delaying the If the amount of bone is already reduced, delaying the surgery may drastically lessen the chance of saving the surgery may drastically lessen the chance of saving the tooth.tooth.


Fig. 55-21 Fig. 55-21 Prognosis based on amount of bone loss. A, When some bone is Prognosis based on amount of bone loss. A, When some bone is present, it may be safe to postpone surgery and take a wait-and-see approach. An present, it may be safe to postpone surgery and take a wait-and-see approach. An

additional bone loss of 2 mm may not alter the prognosis of the tooth.additional bone loss of 2 mm may not alter the prognosis of the tooth.(From Perry D, Beemsterboer P, Taggart E: (From Perry D, Beemsterboer P, Taggart E: Periodontology for the dental hygienistPeriodontology for the dental hygienist , ,

Philadelphia, 2001, Saunders.)Philadelphia, 2001, Saunders.)


Fig. 55-21 B, Fig. 55-21 B, When half of the bone has been lost, an additional 2-mm loss can When half of the bone has been lost, an additional 2-mm loss can seriously jeopardize the tooth; therefore surgery is highly recommended. seriously jeopardize the tooth; therefore surgery is highly recommended.

(From Perry D, Beemsterboer P, Taggart E: (From Perry D, Beemsterboer P, Taggart E: Periodontology for the dental hygienistPeriodontology for the dental hygienist , , Philadelphia, 2001, Saunders.)Philadelphia, 2001, Saunders.)


Fig. 55-21 C, Fig. 55-21 C, With advanced bone loss, surgery may With advanced bone loss, surgery may be performed in an effort to save the tooth, but the prognosis is poor. be performed in an effort to save the tooth, but the prognosis is poor.

(From Perry D, Beemsterboer P, Taggart E: (From Perry D, Beemsterboer P, Taggart E: Periodontology for the dental hygienistPeriodontology for the dental hygienist , , Philadelphia, 2001, Saunders.)Philadelphia, 2001, Saunders.)


Types of Periodontal SurgeryTypes of Periodontal Surgery

Excisional periodontal surgery Excisional periodontal surgery This surgery is used to remove the excess tissue. This surgery is used to remove the excess tissue.

It is the most rapid means of reducing periodontal It is the most rapid means of reducing periodontal pockets. Gingivectomy and gingivoplasty are pockets. Gingivectomy and gingivoplasty are common types of excisional surgeries.common types of excisional surgeries.

Incisional surgery Incisional surgery Also known as periodontal flap surgery or simply Also known as periodontal flap surgery or simply

flap surgery, incisional surgery is performed when flap surgery, incisional surgery is performed when excisional surgery is not indicated. excisional surgery is not indicated.


GingivectomyGingivectomy

Gingivectomy is the surgical removal of diseased gingival Gingivectomy is the surgical removal of diseased gingival tissues. tissues.

This procedure is performed when it is necessary to This procedure is performed when it is necessary to reduce the depth of the periodontal pocket and to remove reduce the depth of the periodontal pocket and to remove fibrous gingival tissue.fibrous gingival tissue.

The surgical procedure involves making bleeding points The surgical procedure involves making bleeding points with the use of pocket markers and removing the gingival with the use of pocket markers and removing the gingival tissues with periodontal knives and scissors. tissues with periodontal knives and scissors.

Recently the use of dental laser equipment in Recently the use of dental laser equipment in gingivectomy has become popular.gingivectomy has become popular.

After healing, it is easier for the patient to clean an area in After healing, it is easier for the patient to clean an area in which the pockets have been reduced. which the pockets have been reduced.


GingivoplastyGingivoplasty

Gingivoplasty involves the surgical reshaping and Gingivoplasty involves the surgical reshaping and contouring of the gingival tissues. contouring of the gingival tissues.

The presence of deep periodontal pockets with The presence of deep periodontal pockets with fibrous tissue is the main indication for both fibrous tissue is the main indication for both gingivectomy and gingivoplasty.gingivectomy and gingivoplasty.

Often both procedures are performed simultaneously.Often both procedures are performed simultaneously. During gingivoplasty, the gingivae are recontoured During gingivoplasty, the gingivae are recontoured

with the use of periodontal knives, rotary diamond with the use of periodontal knives, rotary diamond burs, curettes, and surgical scissors. burs, curettes, and surgical scissors.

Gingival margins are thinned and given scalloped Gingival margins are thinned and given scalloped edges.edges.


Osseous (Bone) SurgeryOsseous (Bone) Surgery

This surgery is performed to remove defects This surgery is performed to remove defects and to restore normal contours in the bone. and to restore normal contours in the bone.

Two types of bone surgeries are:Two types of bone surgeries are: OsteoplastyOsteoplasty OstectomyOstectomy

Each one requires surgical exposure of the Each one requires surgical exposure of the bone, followed by recontouring with the use bone, followed by recontouring with the use of a rotary diamond bur or a bone chisel.of a rotary diamond bur or a bone chisel.


OsteoplastyOsteoplasty

In osteoplasty, or additive surgery, bone is In osteoplasty, or additive surgery, bone is contoured and reshaped.contoured and reshaped.

In addition, bone may be added, either In addition, bone may be added, either through bone grafting (taking bone from one through bone grafting (taking bone from one area and placing it in another) or placement area and placing it in another) or placement of bone substitute materials. of bone substitute materials.

This procedure is useful in some patients with This procedure is useful in some patients with bone defects caused by periodontal disease.bone defects caused by periodontal disease.


OstectomyOstectomy

In ostectomy, or subtractive surgery, bone is In ostectomy, or subtractive surgery, bone is removed.removed.

This procedure is necessary when the patient This procedure is necessary when the patient has large exostoses (bony growths). has large exostoses (bony growths).

For example, ostectomy is performed if a For example, ostectomy is performed if a patient needs a denture and the bony growth patient needs a denture and the bony growth would interfere with the comfort and fit of the would interfere with the comfort and fit of the denture.denture.


Postsurgical Patient InstructionsPostsurgical Patient Instructions

After periodontal surgery, the periodontist will most After periodontal surgery, the periodontist will most likely prescribe an analgesic and possibly an likely prescribe an analgesic and possibly an antibiotic. antibiotic.

Many periodontists recommend the use of an Many periodontists recommend the use of an antibacterial rinse twice a day to help with plaque antibacterial rinse twice a day to help with plaque control.control.

A chlorhexidine mouthwash may also be used during A chlorhexidine mouthwash may also be used during the first week to freshen the mouth and inhibit plaque the first week to freshen the mouth and inhibit plaque formation during the early stages of healing.formation during the early stages of healing.

Postoperative instructions should be given to the Postoperative instructions should be given to the patient to ease discomfort and promote healing.patient to ease discomfort and promote healing.


Chapter 55Chapter 55

Lesson 55.3 Lesson 55.3


Learning ObjectivesLearning Objectives

Identify the indications for the placement of Identify the indications for the placement of periodontal surgical dressings and describe periodontal surgical dressings and describe the technique for proper placement.the technique for proper placement.

Prepare and place noneugenol periodontal Prepare and place noneugenol periodontal dressings (expanded function).dressings (expanded function).

Remove a periodontal surgical dressing Remove a periodontal surgical dressing (expanded function).(expanded function).


Periodontal Surgical DressingsPeriodontal Surgical Dressings

A periodontal surgical dressing is much like a A periodontal surgical dressing is much like a bandage over the surgical site. Periodontal bandage over the surgical site. Periodontal dressings, also known as periopacks, are used dressings, also known as periopacks, are used to:to: Hold the flaps in placeHold the flaps in place Protect the newly forming tissuesProtect the newly forming tissues Minimize postoperative pain, infection, and Minimize postoperative pain, infection, and

hemorrhagehemorrhage Protect the surgical site from trauma during eating Protect the surgical site from trauma during eating

and drinkingand drinking Support mobile teeth during the healing processSupport mobile teeth during the healing process


Types of Periodontal DressingsTypes of Periodontal Dressings

A variety of materials for periodontal A variety of materials for periodontal dressings are on the market. The most dressings are on the market. The most commonly used materials are:commonly used materials are: Zinc oxide–eugenol (ZOE)Zinc oxide–eugenol (ZOE) NoneugenolNoneugenol


ZOE DressingZOE Dressing

The patient may experience redness and burning The patient may experience redness and burning pain in the area of the dressing. ZOE dressings are pain in the area of the dressing. ZOE dressings are supplied as a powder and a liquid that are mixed supplied as a powder and a liquid that are mixed before use. before use.

The material may be mixed ahead of time, wrapped The material may be mixed ahead of time, wrapped in waxed paper, and frozen for future use. in waxed paper, and frozen for future use.

ZOE has a slow set time, which allows for a longer ZOE has a slow set time, which allows for a longer working time.working time.

ZOE sets to a firm, heavy consistency and provides ZOE sets to a firm, heavy consistency and provides good support and protection for tissues and flaps.good support and protection for tissues and flaps.

Some patients are allergic to the eugenol.Some patients are allergic to the eugenol.


Fig. 55-27 Fig. 55-27 Zinc oxide powder and liquid Zinc oxide powder and liquid eugenol are mixed in advance.eugenol are mixed in advance.


Noneugenol DressingNoneugenol Dressing

Noneugenol dressing is the most widely used Noneugenol dressing is the most widely used type of periodontal dressing. type of periodontal dressing.

It is supplied in two tubes: one of base It is supplied in two tubes: one of base material and the other of the accelerator.material and the other of the accelerator.

It is easy to mix and place and has a smooth It is easy to mix and place and has a smooth surface for patient comfort. surface for patient comfort.

It has a rapid setting time if exposed to warm It has a rapid setting time if exposed to warm temperatures.temperatures.

It cannot be mixed in advance and stored.It cannot be mixed in advance and stored.


Fig. 55-28 PFig. 55-28 Paste for noneugenol dressing is ready to aste for noneugenol dressing is ready to be mixed.be mixed.


Lasers in PeriodonticsLasers in Periodontics

The term laser is an acronym for light The term laser is an acronym for light amplification by simulated emission of radiation. amplification by simulated emission of radiation.

A laser beam is a highly concentrated beam of A laser beam is a highly concentrated beam of light. The power of this beam can be adjusted to light. The power of this beam can be adjusted to enable it to cut, vaporize, or cauterize tissue.enable it to cut, vaporize, or cauterize tissue.

The use of lasers is a promising new technology The use of lasers is a promising new technology in dentistry.in dentistry.

Research that may lead to more widespread Research that may lead to more widespread uses of lasers in clinical dentistry continues. uses of lasers in clinical dentistry continues.


Use of Lasers on Soft Tissue Use of Lasers on Soft Tissue

Removal of tumors and lesionsRemoval of tumors and lesions Vaporization of excess tissues, as in Vaporization of excess tissues, as in

gingivoplasty, gingivectomy, and frenectomy gingivoplasty, gingivectomy, and frenectomy Removal of or reduction in hyperplastic Removal of or reduction in hyperplastic

tissuestissues Control of the bleeding of vascular lesionsControl of the bleeding of vascular lesions


Advantages of Laser Surgery Over Advantages of Laser Surgery Over Conventional SurgeryConventional Surgery

Laser incisions heal faster than incisions made with Laser incisions heal faster than incisions made with electrosurgery. electrosurgery.

Hemostasis (control of bleeding) is rapid.Hemostasis (control of bleeding) is rapid. The surgical field is relatively dry.The surgical field is relatively dry. The opportunity for bloodborne contamination is The opportunity for bloodborne contamination is

reduced.reduced. There is less trauma to adjacent tissues.There is less trauma to adjacent tissues. There is less postsurgical swelling, scarring, and pain.There is less postsurgical swelling, scarring, and pain. Some procedures can be performed more quickly.Some procedures can be performed more quickly. Patients who are afraid of “surgery” may accept this Patients who are afraid of “surgery” may accept this

method.method.


Laser TherapyLaser Therapy

Precautions must be taken to protect both the Precautions must be taken to protect both the patient and dental staff during laser patient and dental staff during laser procedures.procedures.

Any person who operates a laser or assists Any person who operates a laser or assists during a laser operation must be thoroughly during a laser operation must be thoroughly trained in the use of this powerful instrument. trained in the use of this powerful instrument.


Guidelines for Laser SafetyGuidelines for Laser Safety

Shielded eyeglasses: To protect the eyes, the dental staff Shielded eyeglasses: To protect the eyes, the dental staff and the patient must wear special shielded eyeglasses.and the patient must wear special shielded eyeglasses.

Matte-finished instruments: Reflective surfaces such as Matte-finished instruments: Reflective surfaces such as instruments, mirrors, and even polished restorations can instruments, mirrors, and even polished restorations can reflect laser energy. reflect laser energy.

Protection of nontarget tissues: Nontarget oral tissue Protection of nontarget tissues: Nontarget oral tissue (tissues not being treated with the laser) should be (tissues not being treated with the laser) should be shielded with the use of wet gauze packs.shielded with the use of wet gauze packs.

High-volume evacuation: High-volume evacuation should High-volume evacuation: High-volume evacuation should be used to draw off the plume (cloud) created when be used to draw off the plume (cloud) created when tissue vaporizes. This plume should be considered tissue vaporizes. This plume should be considered infectious.infectious.


Fig. 55-31 As a means of helping prevent injury to the eyes of persons Fig. 55-31 As a means of helping prevent injury to the eyes of persons who are not wearing special light-filter glasses,who are not wearing special light-filter glasses,

warning signs must be posted in areas where lasers are used.warning signs must be posted in areas where lasers are used.


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