Periodontics Dho

Periodontics
GROUP 2
Copyright 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Periodontology or Periodontics (from Greek p eri "around"; and odous "tooth", genitive odontos) is the specialty of dentistry that studies supporting structures of teeth, diseases, and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone,cementum, and the periodontal ligament. A professional who practises this speciality field of dentistry is known as a periodontist.
The Periodontal Examination
A periodontal examination includes:

Medical and dental histories Radiographic evaluations Examination of the teeth Examination of the oral tissues Supporting structures Periodontal charting
The periodontal charting includes pocket readings, furcations, tooth mobility, exudate (pus), and gingival recession.
(Courtesy of the University of California, Los Angeles, School of Dentistry) (From Newman M, Takei H, Klokkevold P, et al: Carranzas clinical periodontology, ed 10, St Louis, 2006, Saunders.)
Fig. 55-1 Computerized diagram showing periodontal parameters.
Fig. 55-2 A periodontal chart on a computer screen. This periodontist can easily refer to the chart as he treats the patient.
Early Signs of Periodontal Disease
Changes in the gingiva (color, size, shape, texture) Gingival inflammation Gingival bleeding Evidence of exudate Development of periodontal pockets
Medical and Dental Histories
Systemic diseases 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. The dental history is used to gather information about conditions that could indicate periodontal disease. For example, patients with periodontal disease often complain of bleeding gums, loose teeth, or a bad taste in the mouth.
Mobility
It is normal for teeth to have a slight amount of mobility (tooth movement) because of the cushioning effect of the periodontal membranes. Excessive mobility can be an important sign of periodontal disease.
Fig. 55-3 Mobility is detected with the blunt ends of two instruments.
(From Daniel SJ, Harfst SA, Mosbys dental hygiene: concepts, cases, and competencies, 2004 update, St Louis, 2004, Mosby.)
Examination of the Oral Tissues and Supporting Structures
The periodontal examination includes:

Assessment of the amounts of plaque and calculus Changes in gingival health and bleeding Assessment of the level of bone Detection of periodontal pockets
Periodontal Probing
A periodontal pocket results when the gingival sulcus becomes deeper than normal (<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.
Fig. 55-4 Cross-section of a tooth, gingiva, and bone. The A side shows normal sulcus depth. The B side shows a periodontal pocket.
Periodontal Probes
Used to locate and measure the depth of periodontal pockets. On some types of probes, the tip is color-coded to make the measurements easier to read. The periodontal probe is tapered to fit into the gingival sulcus and has a blunt or rounded tip. Six measurements are taken and recorded for each tooth. Periodontal probes are available in many designs; selection depends on the personal preference of the operator.
Fig. 55-5 Diagram showing probing the periodontal pocket depth. The millimeter measurement indicates the distance from the gingival margin to the base of the pocket.
(From Perry D, Beemsterboer P, Taggart E: Periodentology for the dental hygienist, Philadelphia, 2001, Saunders.)
Fig. 55-6 Six probing depths are taken for each tooth.
(From Perry DA, Beemsterboer P, Carranza FA: Techniques and theory of periodontal instrumentation, Philadelphia, 1990, Saunders.)
Fig. 55-7 Bone loss in periodontal disease. A, Vertical bone defect. B, Crestal ridge at near-normal height. C, Alveolar crest. D, Severe vertical defect.
(From Miles DA, Van Dis ML, Jensen CW, et al: Radiographic imaging for dental auxiliaries, ed 3, Philadelphia, 1999, Saunders.)
Fig 55-8 A, Molar vertical bite-wing. B, Premolar vertical bite-wing.
Fig. 55-9 Working end of a periodontal probe.
Periodontal Instruments
Periodontal therapy requires the use of specialized instruments to remove calculus, smooth root surfaces, measure periodontal pockets, and perform periodontal surgery. In general, the dentist or registered dental hygienist who uses these instruments takes responsibility for maintaining their sharpness.
Explorers
Used to locate supragingival and subgingival calculus deposits and provide tactile information to the operator about the roughness or smoothness of the root surfaces. Explorers used in periodontics are longer and more curved than those used for caries detection. The working ends of periodontal explorers are thin, fine, and easily manipulated around root surfaces. They also are long enough to be capable of reaching to the bases of deep pockets and furcations.
Fig. 55-10 Various styles of periodontal explorers.

(Courtesy of Hu-Friedy Manufacturing, Chicago, Ill.)
Scalers
Sickle scalers are used primarily to remove large deposits of supragingival calculus. 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.
Curettes
Curettes are 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). A curette has a rounded end, unlike a scaler, which has a pointed end. There are two basic designs of curettes:

Universal Gracey
Fig. 55-11 A, Anterior curette. B, Posterior curette.
Fig. 55-12 Comparison of the end of the scaler (pointed) and the end of a curette (rounded).
Types of Curettes
Universal curettes are designed so that one instrument can be used on all tooth surfaces.
There are two cutting edges, one on each side of the blade. Universal curettes resemble the spoon excavators used in restorative dentistry.
Gracey curettes have only one cutting edge and are area-specific; this means that they are designed for use on specific tooth surfaces (mesial or distal).
Treatment of the entire dentition requires the use of several curettes

Fig. 55-13 Universal curette. Note the cutting edge on each side of the blade.
Periodontal Surgical Instruments
Periodontal knives
The Kirkland knife is one of the most commonly used knives in periodontal surgery. Thes instruments are usually double-ended, with kidney-shaped blades. The Orban knife is used to remove tissue from the interdental areas. These knives are shaped like spears and have cutting edges on both sides of their blades.
Fig. 55-14 Assorted Gracey curettes.

(Courtesy of Hu-Freidy Manufacturing, Chicago, Ill.)
Fig. 55-15 Gingivectomy knives. A, Kirkland knife. B, Orban interdental knife.

(From Newman M, Takei H, Klokkevold P, et al: Carranzas clinical periodontology, ed 10, St Louis, 2006, Saunders.)
Pocket Markers
Pocket markers are similar in appearance to cotton pliers; however, one tip is smooth and straight and the other is sharp and bent at a right angle. The smooth tip of the pocket marker is inserted at the base of the pocket, and when the instrument is pressed together the sharp tip makes small perforations in the gingivae. These perforations, which are referred to as bleeding points, are used to outline the area for an incision on the gingivae.
Fig. 55-16 The periodontal pocket marker is used to make pinpoint perforations that indicate the line for a surgical incision.
The Ultrasonic Scaler
The ultrasonic scaler allows rapid calculus removal and reduces hand fatigue for the operator. The ultrasonic scaler works by converting very high frequency sound waves into mechanical energy in the form of very rapid vibrations. A spray of water at the tip prevents the buildup of heat and provides a continuous flushing of debris and bacteria from the base of the pocket. Because of the spray of water at the tip, there is a large amount of potentially contaminated aerosol spray. It is highly desirable for the operator of an ultrasonic scaler to have the dental assistant help by using the highvolume evacuator to minimize aerosol contamination.
Fig. 55-17 A series of ultrasonic tips designed to reach every area of the mouth.
(From Daniel SJ, Harfst SA, Mosbys dental hygiene: concepts, cases, and competencies, 2004 update, St Louis, 2004, Mosby.)
Fig. 55-18 A, Positioning of the ultrasonic scaler. B, Ultrasonic scaler with water source turned on.
(Courtesy of Hu-Friedy Manufacturing, Chicago, Ill.)
Indications for Use of the Ultrasonic Scaler
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
Contraindications and 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. Immunocompromise: 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 patients cardiologist is necessary. The newer models of ultrasonic scalers have protective coatings.
Oral Conditions Contraindicating Use of Ultrasonic Tools
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 cause 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 titanium surfaces.
Learning Objectives
Describe the goals of nonsurgical periodontal therapy. Assist with a dental prophylaxis procedure. Describe the types of nonsurgical periodontal therapy. Describe the types of surgical periodontal therapy. Assist with gingivectomy and gingivoplasty.
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. The dentist and 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. Dental prophylaxis also is the primary treatment for gingivitis.
Scaling, Root Planing, and Gingival Curettage
Scaling and root planing are nonsurgical treatments for type II and III 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.
Fig. 55-19 A Gracey currette is used during scaling and root planing.
(From Newman M, Takei H, Klokkevold P, et al: Carranzas clinical periodontology, ed 10, St Louis, 2006, Saunders.)
Scaling
Scalers are used to remove supragingival calculus from the tooth surface. Curettes are used to remove supragingival and subgingival calculus. 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.
Root Planing
Root planing is performed after scaling procedures 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.
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 a periodontal pocket. This is performed to remove necrotic (dead) tissue from the pocket wall.
Antimicrobial and Antibiotic Agents
Tetracycline is an antibiotic that is particularly useful for the treatment of periodontitis, early-onset periodontitis, and rapidly destructive periodontitis. An important side effect of tetracycline is its interference with the effectiveness of birthcontrol 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 chlorhexidine 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.
Periodontal Surgery
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.
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.
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.
Reasons for Periodontal Surgery
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, postponing or avoiding periodontal surgery. 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.
Fig. 55-21 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 additional bone loss of 2 mm may not alter the prognosis of the tooth.
(From Perry D, Beemsterboer P, Taggart E: Periodontology for the dental hygienist, Philadelphia, 2001, Saunders.)
Fig. 55-21 B, When half of the bone has been lost, an additional 2-mm loss can seriously jeopardize the tooth; therefore surgery is highly recommended.
Fig. 55-21 C, With advanced bone loss, surgery may be performed in an effort to save the tooth, but the prognosis is poor.
Types of Periodontal Surgery
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. Also known as periodontal flap surgery or simply flap surgery, incisional surgery is performed when excisional surgery is not indicated.
Incisional surgery
Gingivectomy
Gingivectomy is 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 points 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.
Gingivoplasty
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 use of periodontal knives, rotary diamond burs, curettes, and surgical scissors. Gingival margins are thinned and given scalloped edges.
Osseous (Bone) Surgery
This surgery is performed to 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.
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.
Ostectomy
In ostectomy, or subtractive surgery, bone is removed. This procedure is necessary when the patient has large exostoses (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.
Postsurgical Patient Instructions
After periodontal surgery, the periodontist will most likely prescribe an analgesic and possibly an antibiotic. Many periodontists recommend the use of an antibacterial rinse twice a day 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 stages of healing. Postoperative instructions should be given to the patient to ease discomfort and promote healing.
Chapter 55 Lesson 55.3
Learning Objectives
Identify the indications for the placement of periodontal surgical dressings and describe the technique for proper placement. Prepare and place noneugenol periodontal dressings (expanded function). Remove a periodontal surgical dressing (expanded function).
Periodontal Surgical Dressings
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 and drinking Support mobile teeth during the healing process
Types of Periodontal Dressings
A variety of materials for periodontal dressings are on the market. The most commonly used materials are:

Zinc oxideeugenol (ZOE) Noneugenol
ZOE Dressing
The patient may experience redness and burning pain in the area of the dressing. ZOE dressings are supplied as a powder and a 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.
Fig. 55-27 Zinc oxide powder and liquid eugenol are mixed in advance.
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.
Fig. 55-28 Paste for noneugenol dressing is ready to be mixed.
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.
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
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.
Laser Therapy
Precautions must be taken to protect both the patient and 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.
Guidelines 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 nontarget tissues: Nontarget oral tissue (tissues not being treated with the laser) should be shielded with the use of wet gauze packs. High-volume evacuation: High-volume evacuation should be used to draw off the plume (cloud) created when tissue vaporizes. This plume should be considered infectious.
Fig. 55-31 As a means of helping prevent injury to the eyes of persons who are not wearing special light-filter glasses, warning signs must be posted in areas where lasers are used.

Periodontics Dho

Uploaded by

Copyright:

Available Formats

Periodontics Dho

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Periodontics Dho

Uploaded by

Copyright:

Available Formats

Periodontics

The Periodontal Examination

A periodontal examination includes:

Fig. 55-1 Computerized diagram showing periodontal parameters.

Early Signs of Periodontal Disease

Medical and Dental Histories

Examination of the Oral Tissues and Supporting Structures

The periodontal examination includes:

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

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

Fig. 55-10 Various styles of periodontal explorers.

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

Treatment of the entire dentition requires the use of several curettes

Periodontal Surgical Instruments

Fig. 55-14 Assorted Gracey curettes.

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

The Ultrasonic Scaler

Indications for Use of the Ultrasonic Scaler

Contraindications and Precautions

Oral Conditions Contraindicating Use of Ultrasonic Tools

Scaling, Root Planing, and Gingival Curettage

Antimicrobial and Antibiotic Agents

Advantages of Periodontal Surgery

Disadvantages of Periodontal Surgery

Reasons for Periodontal Surgery

Types of Periodontal Surgery

Excisional periodontal surgery

Osseous (Bone) Surgery

Postsurgical Patient Instructions

Chapter 55 Lesson 55.3

Periodontal Surgical Dressings

Types of Periodontal Dressings

Zinc oxideeugenol (ZOE) Noneugenol

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

Use of Lasers on Soft Tissue

Advantages of Laser Surgery Over Conventional Surgery

Guidelines for Laser Safety

You might also like