Periodontics ~ MDA Ch.

Periodontal Probing Examination

** A periodontal pocket results when the gingival sulcus becomes deeper than normal - Greater than 3 mm. ** Periodontal probing measures how much epithelial attachment has been lost to disease. ** The greater the depth of the periodontal pocket, the greater the loss of epithelial attachment and bone and the more serious the periodontal disease. ** Periodontal pockets are very difficult, and sometimes impossible, for the patient to clean. ** The bacteria in the periodontal pockets will multiply and, if left untreated, the disease will progress until the tooth is ultimately lost.

Postsurgical Patient Instructions

** After periodontal surgery, the periodontist will most likely prescribe an analgesic (pain med) and possible an antibiotic. ** Many periodontist recommend the use of an antibacterial rinse twice daily to help with plaque control. A chlorhexidine mouthwash may also be used during the first week to freshen the mouth and inhibit plaque formation during the early healing stages. Postoperative instructions should be given to the patient to ease discomfort and promote healing.

Incisional Surgery

** Also known as periodontal flap surgery or simply flap surgery, incisional surgery is performed when excisional surgery is not indicated. The dentist may perform: Through scaling and root planing of exposed root surfaces Moving the flap laterally to cover root surfaces of an adjacent tooth ** Recontouring of underlying bone

Early Signs of Periodontal Disease

** Changes in the gingiva - color, size, shape, texture ** Gingival inflammation ** Gingival bleeding ** Evidence of exudate ** Development of periodontal pockets

Dental Prophylaxis

** Commonly referred to as prophy or cleaning, prophylaxis is the complete removal of calculus, soft deposits, plaque, and stains from all supragingival and unattached subgingival tooth surfaces. Dentist & Dental Hygienist are the only members of the dental health team who are licensed to perform this procedure. Prophylaxis is indicated for patients with healthy gingiva as a preventive measure and is most commonly performed during recall appointments. Primary treatment for gingivitis

Universal Curettes

** Designed so that one instrument can be used on all tooth surfaces There are two cutting edges, one on each side of the blade Resemble the spoon excavators used in restorative dentistry

Ostectomy

** In Ostectomy, or subtractive surgery, bone is removed. This procedure is necessary when the patient has large exostoses or bony growths. For example, Ostectomy is performed if a patient needs a denture and the bony growth would interfere with the comfort and fit of the denture.

Osteoplasty

** In Osteoplasty, or additive surgery, bone is contoured and reshaped. In addition, bone may be added, either through bone grafting (taking bone from one area and placing it in another) or placement of bone substitute materials. This procedure is useful in some patients with bone defects caused by periodontal disease.

Gingivoplasty

** Involves the surgical reshaping and contouring of the gingival tissues. The presence of deep periodontal pockets with fibrous tissue is the main indication for both Gingivectomy and Gingivoplasty. ** Often both procedures are performed simultaneously. During Gingivoplasty, the gingivae are recontoured with the sue of periodontal knives, rotary diamond burs, curettes, and surgical scissors. Gingival margins are thinned and given scalloped edges.

Advantages of Laser Surgery over Conventional Surgery

** Laser incisions heal faster than incisions made with electrosurgery. Hemostasis (control of bleeding) is rapid The surgical field is relatively dry The opportunity for bloodborne contamination is reduced There is less trauma to adjacent tissues There is less postsurgical swelling, scarring, and pain Some procedures can be performed more quickly Patients who are afraid of "surgery" may accept this method

Periodontal Examination Includes:

** Medical & dental history ** Radiographic evaluations ** Examination of the teeth ** Examination of the oral tissues ** Supporting structures ** Periodontal charting, which includes; pocket readings, furcation's, tooth mobility, exudate (pus), and gingival recession

Noneugenol Dressing

** Noneugenol dressing is the most widely used type of periodontal dressing. It is supplied in two tubes; one of base material and the other of the accelerator. It is easy to mix and place and has a smooth surface for patient comfort. It has a rapid setting time if exposed to warm temperatures. It cannot be mixed in advance and stored.

Osseous (Bone) Surgery

** Periodontal surgery that involves modification of the supporting bone. ** This surgery is performed to eliminate pockets, remove defects, and to restore normal contours in the bone. Two types of bone surgeries are: Osteoplasty & Ostectomy Each one requires surgical exposure of the bone, followed by Recontouring with the use of a rotary diamond bur or a bone chisel.

Use of Lasers on Soft Tissue

** Removal of tumors and lesions ** Vaporization of excess tissues, as in Gingivoplasty, Gingivectomy, and frenectomy. ** Removal of or reduction in hyperplastic tissues ** Control of the bleeding of vascular lesions

Scaling, Root Planing, & Gingival Curettage

** Scaling & root planing are nonsurgical treatments for type I & !! cases and before periodontal surgery. In some cases gingival curettage, a nonsurgical technique, may also be indicated. A local anesthetic is usually administered before these procedures.

Scalers & Flies

** Sickle scalers are used primarily to remove large deposits of supragingival calculus. Has pointed end Chisel scalers are used to remove supragingival calculus in the contact area of anterior teeth. The blade on the chisel scaler is curved slightly to adapt to the tooth surfaces. ** Hoe scalers are used to remove heavy supragingival calculus. Hoes are most effective when used on the buccal and lingual surfaces of the posterior teeth.

Antimicrobial & Antibiotic Agents

** Tetracycline is an antibiotic that is particularly useful for treatment of periodontitis, early-onset periodontitis, and rapidly destructive periodontitis. An important side effect of tetracycline is its interference with the effectiveness of birth control pills. Penicillin is less effective against periodontal disease infections than other antibiotics because many periodontal pathogens are resistant to it. Fluoride mouth rinses have been shown to reduce bleeding by delaying bacterial growth in the periodontal pockets. A twice-daily chlohexidine rinse is the most effective means available for reducing plaque and gingivitis. Chlorhexidine can cause some temporary brown staining of the teeth, tongue, and resin restorations.

Most Common Radiograph Taken in Perio

** The Vertical Bitewing or VBWX

Disadvantages of Periodontal Surgery

** The health status of the patient or age of the patient, as well as limitations of the procedures, may mean that periodontal surgery is not an option. ** From the patients point of view, the disadvantages of surgery usually include time cost, aesthetics, and discomfort. The dental assistant usually has developed a good rapport with the patient and is in a unique position to discuss these concerns with the patient.

Advantages of Periodontal Surgery

** The primary advantage of periodontal surgery is that it allows access to the root surface for scaling and root planing. ** Surgery makes it easier for the patient to clean difficult areas. Periodontal surgery also results in better access to furcations and other areas that are very difficult to reach during traditional scaling and root planing. Numerous new techniques are being used to improve patient aesthetics by altering the position of the gingival margin. These new techniques are being used extensively in cosmetic dentistry procedures.

Gingivectomy

** The surgical removal of diseased gingival tissues. This procedure is performed when it is necessary to reduce the depth of the periodontal pocket and to remove fibrous gingival tissue. The surgical procedure involves making bleeding pints with the use of pocket markers and removing the gingival tissues with periodontal knives and scissors. Recently the use of dental laser equipment in Gingivectomy has become popular. After healing, it is easier for the patient to clean an area in which the pockets have been reduced.

Excisional Periodontal Surgery

** This surgery is used to remove the excess tissue. It is the most rapid means of reducing periodontal pockets. ** Gingivectomy and Gingivoplasty are common types of excisional surgeries.

Periodontal Explorer

** Used to locate supragingival & subgingival calculus deposits and provide tactile information to the operator about the roughness or smoothness of the root surfaces. Longer & more curved than those used for caries detection. Working ends are thin, fine, & easily manipulated around root surfaces Long enough to be capable of reaching to the base of deep pockets & furcation's.

Curettes

** Used to remove subgingival calculus, smooth rough root surfaces (root planing), and remove the diseased soft-tissue lining of the periodontal pocket (soft-tissue curettage). Has a rounded end Two basic designs: Universal & Gracey

Locally Delivered Antibiotics ~ Applied Directly Into Periodontal Pockets

A fiber that contains tetracycline is packed into periodontal pockets that have not responded to other methods. Other methods include using a syringe to insert dissolvable materials such as a gel into the pocket. Dissolvable chip that releases chlorhexidine is inserted into deeps pockets.

Sickle scaler

A hook-shaped instrument that is available in various sites and shapes and is used for the removal of tenacious supragingival deposits of calculus.

File

A metal instrument of varying size and form with numerous ridges or teeth on its cutting surfaces.

Periodontal Surgical Dressing

A periodontal surgical dressing is much like a bandage over the surgical site. Periodontal dressings, also known as periopacks, are used to: ** Hold the flaps in place ** Protect the newly forming tissues ** Minimize postoperative pain, infection, and hemorrhage ** Protect the surgical site from trauma during eating & drinking ** Support mobile teeth during the healing process

Crown Lengthening

A surgical procedure that is designed to expose more tooth structure for the placement of a restoration such as a crown. Crown lengthening is becoming a very common procedure for esthetic anterior restorations. Surgical crown lengthening may involve the removal of soft tissue and alveolar bone. In addition to esthetics, indications for crown lengthening include: A tooth that is fractured close to the gingival margin or alveolar crest. Subgingival caries

Types of Periodontal Surgical Dressing

A variety of materials for periodontal dressings are on the market. The most commonly used materials are: ** Zinc oxide-eugenol or (ZOE) dressing ** Noneugenol dressing

Occlusal trauma

Abnormal Occlusal relationships of the teeth, causing injury to the periodontium.

Bone augmentation

Addition of natural or synthetic bone to a surgical site.

Oral Tissues & Supporting Tissues Examination

Assessment of the amounts of plaque and calculus Changes in gingival health and bleeding Assessment of the level of bone Detection of periodontal pockets

Common Complaint among Periodontal Patients

Bleeding gums Loose teeth Bad taste in the mouth

Periodontal charting

Commonly accepted notations that are mode to the patient's chart to indicate the condition, position, and restorative history of individual teeth.

Ultrasonic Scaler Contraindications & Precautions

Communicable disease: A patient with a known communicable disease that can be transmitted by aerosols, such as tuberculosis, poses a risk to the operator. Immunocompromised: A compromised patient is open to infection. Respiratory problems: Materials can be aspirated into the lungs of a patient with respiratory problems. Swallowing difficulty: Problems with swallowing or a severe gag reflex makes treatment hazardous. Cardiac pacemaker: Consultation with the patient's cardiologist is necessary. The newer models of ultrasonic scalers have protective coatings.

Gingival Curettage

Curettage means scraping or cleaning with a curette. Some patients also require gingival curettage in addition to scaling and root planing. **Gingival curettage, also referred to as subgingival curettage, is the scraping of the gingival lining of the periodontal pocket. This is performed to remove necrotic or dead tissue from the pocket wall. The patient is usually numb for this procedure.

Gracey curette

Curette with one cutting edge, "area specific"; it is designed to adapt to specific tooth surfaces - mesial or distal.

Periodontal pocket

Deepening of the gingival sulcus beyond normal; results from periodontal disease.

Ultrasonic Scalers - Oral Conditions Contraindicating

Demineralized areas: The ultrasonic vibrations can remove the areas of remineralization that begin to cover the demineralization. Exposed dentinal surfaces: Tooth structure can be removed, resulting in tooth sensitivity. Restorative materials; Some restorative materials, such as porcelain, amalgam, composite resins, and laminate veneers, can be damaged by ultrasonic vibrations. Titanium implant abutments: Unless a special plastic sheath is used to cover the tip, the ultrasonic tool will damage the titanium surfaces. Narrow periodontal pockets: The tip will not fit into very narrow subgingival pockets.

Nonsurgical Periodontal Treatment

Dental Prophylaxis Scaling Root Planing Gingival Curettage

Periodontics

Dental specialty involved with the diagnosis and treatment of diseases of the supporting tissues.

Periodontist

Dentist with advanced education in the specialty of periodontics;

Ultrasonic scaler

Device used for rapid calculus removal; it operates on high-frequency sound waves.

Kirkland knife

Double-ended knife with kidney-shaped blades; commonly used in periodontal surgery.

Periodontal explorer

Fine, thin instrument that is easily adapted around root surfaces used to locate deposits of calculus.

Gracey Curettes

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

Laser

Highly concentrated beam of light; acronym for light amplification by stimulated emission of radiation.

Periodontal flap surgery or Flap surgery

Incisional surgery performed when excisional surgery is not indicated. In flap surgery, the tissues are not removed but are pushed away from the underlying tooth roots and alveolar bone, similar to the flap of an envelope.

Periotomes

Instrument used to cut periodontal ligaments for atraumatic tooth extraction.

Chisel scaler

Instrument used to remove Supragingival calculus in the contact area of anterior teeth. The blade on the chisel scaler is curved slightly to adapt to the tooth surfaces.

Mobility Examination

It is normal for teeth to have a slight amount of mobility because of the cushioning effect of the periodontal membranes. Excessive mobility an be an important sign of periodontal disease.

Orban knife

Knife with a spearlike shape and cutting edges on both sides of the blade; it is used to remove tissue from the interdental areas.

Bleeding index

Method of scoring the amount of bleeding present.

Soft Tissue Grafts

Pedicle graft: Used to move gingivae from an adjacent tooth or edentulous area to a recipient site on another tooth. The pedicle graft is "freed" on three sides but remains attached on one side and retains its blood supply Free gingival soft tissue graft or FGG: Has a donor site that is located away from the grafted site The blood supply is not attached to the graft and depends on the recipient site.

Root Planing

Performed after scaling to remove any remaining particles of calculus and necrotic cementum embedded in the root surface. After root planing, the surfaces of the root are smooth and glasslike. Smooth root surfaces resist new calculus formation and are easier for the patient to keep clean.

Surgical Periodontal Treatment

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

Dental Assistant responsibilities (depending of the state dental practice act)

Place and remove periodontal dressings Remove sutures Perform coronal polishing Take impressions for study models Administer topical fluoride applications

Laser Safety

Precautions must be taken to protect both the patient and the dental staff during laser procedures. Any person who operates a laser or assists during a laser operation must be thoroughly trained in the use of this powerful instrument.

Periodontal probe

Probe used to locate and measure the depth of periodontal pockets; tapered to fit into the gingival sulcus with a blunt or rounded tip.

Root planing

Procedure that smooth's the surface of a root by removing abnormal toxic cementum or dentin that is rough, contaminated, or permeated with calculus.

Scaling

Removal of deposits of calculus deposits from the teeth with the use of suitable instruments .

Ultrasonic Scaler Indications for Use

Removal of supragingival calculus and difficult stains. Removal of subgingival calculus, attached plaque, and endotoxins from the root surface. Cleaning of furcation areas. Removal of deposits before periodontal surgery. Removal of orthodontic cements; debonding. Removal of overhanging margins of restorations

Guideline for Laser Safety

Shielded eyeglasses: To protect the eyes, the dental staff and the patient must wear special shielded eyeglasses. Matte-finished instruments: Reflective surfaces such as instruments, mirrors, and even polished restorations can reflect laser energy. Protection of nonarget tissues: Nontarget oral tissue (tissues not being treated with the laser) should be shielded with the use of wet gauze packs. High-volume evacuation: HVE should be used to draw off the plume (cloud) created when tissue vaporizes. This plume should be considered infectious.

Osteoplasty

Surgery in which bone is added, contoured, and reshaped.

Ostectomy

Surgery involving the removal of bone.

Periodontal dressing or Perio Pak

Surgical dressing applied to a surgical site for protection, similar to a bandage.

Curette

Surgical instrument used to remove tissue from the tooth socket; also curet.

Crown lengthening

Surgical procedure to expose more tooth surface.

Periodontal plastic surgery

Surgical procedures of mucogingival tissues.

Osseous surgery

Surgical specialty of removing defects in bone.

Medical & Dental History

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

Remaining Bone

The amount of bone remaining around a tooth is an important consideration in the decision to perform periodontal surgery. When there is a large amount of bone around a tooth the dentist may take a wait-and-see approach. ** When this approach is taken, it is important for the patient to practice excellent home care and routine dental care. If the amount of bone is already reduced, delaying the surgery may drastically lessen the chance of saving the tooth.

ZOE Dressing

The patient may experience redness and burning pain in the area of the dressing ZOE dressings are supplied as a powder and liquid that are mixed before use: ** The material may be mixed ahead of time, wrapped in waxed paper, and frozen for future use. ** ZOE has a slow set time, which allows for a longer working time. ** ZOE sets to a firm, heavy consistency and provides good support and protection for tissues and flaps. ** Some patients are allergic to the eugenol

Lasers in Periodontics

The term laser is an acronym for light amplification by simulated emission of radiation. A laser beam is a highly concentrated beam of light. The power of this beam can be adjusted to enable it to cut, vaporize, or cauterize tissue. The use of lasers is a promising new technology in dentistry. Research that may lead to more widespread uses of lasers in clinical dentistry continues.

Esthetic & Plastic Periodontal Surgery

To enhance the patient's esthetic appearance, the teeth and tissues must appear natural and healthy. The relationship between periodontal health and the restoration of teeth is critical. ** For restorations to be functional and esthetic, the periodontium must be healthy. ** For the periodontium to remain healthy, restorations must be properly designed and placed. ** Periodontal plastic surgery procedures are used to correct defects in the shape, position, or amount of gingival tissue.

Mobility

To have movement.

Hoe scaler

Type of scaler used to remove heavy supragingival calculus; it is most effective when used on buccal and lingual surfaces of the posterior teeth.

Periodontal Probes

Used to locate & measure the periodontal pockets Tip can be color-coded Tapered to fit into the gingival sulcus - has a blunt or rounded tip Six measurements are taken for each tooth - DB, B, MB & DL, L, ML available in many designs; selection depends on the personal preference of the operator.

Furcation probe

Used to measure horizontal and vertical pocket depths of multirooted teeth in furcation areas.

Scaling

Used to remove supragingival calculus from the tooth surfaces. Some areas on the root surface may remain rough after calculus removal. This is because the cementum has become necrotic (dead) or because the scaling has produced grooves and scratches in the cementum.

Ultrasonic Scalers - Precautions for Children

Young tissues are very sensitive to ultrasonic vibrations. These vibrations and heat may damage the pulp tissue of primary and newly erupted permanent teeth. ** The use of ultrasonic scalers is contraindicated on primary and newly erupted permanent teeth.

Universal curette

hand instrument used to treat subgingival surfaces; it has a blade with an unbroken cutting edge that curves around the toe and a flat face set at a 90-degree angle to the lower shank.