Treatment of Periodontal Emergencies

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access to all posterior distal surfaces. The horizontal han- (Fig. 41-26). In the past, the only solution in most of dle position minimizes interference from opposing these areas of difficult access was to use the Gracey arches and allows a more relaxed hand position when curettes with a toe-down horizontal stroke. The Mini scaling distal surfaces. In addition, the blade is 1 mm Five curettes, along with other short-bladed instru- shorter to allow better adaptation of the blade to distal ments relatively recently introduced, open a new chap- tooth surfaces. ter in the history of root instrumentation by allowing EXTENDED SHANK CURETTES. Extended shank access to areas that previously were extremely difficult curettes such as the Hu-Friedy After Five curettes are or impossible to reach with standard instruments. The modifications of the standard Gracey curette design. The Mini Five curettes are available in both the finishing terminal shank is 3 mm longer, allowing extension into and rigid designs. Rigid Mini Fives are recommended deeper periodontal pockets of 5 mm or more (Figs. 41-23 for calculus removal. The more flexible shanked, finish- and 41-24). Other features include a thinned blade for ing Mini Fives are appropriate for light scaling and de- smoother subgingival insertion and reduced tissue disten- plaquing in periodontal maintenance patients with tion and a large-diameter, tapered shank. All standard tight pockets. As with the After Fives, the Mini Fives are Gracey numbers except for the #9-10 (i.e., #1-2, 3-4, 5-6, available in all standard Gracey numbers except for 7-8, 11-12, 13-14) are available in the After Five series. the #9-10. The After Five curettes are available in finishing or rigid The Gracey Curvettes. The Gracey curvettes are designs. For heavy or tenacious calculus removal, rigid another set of four mini-bladed curettes; the Sub-0 and After Fives should be used. For light scaling or deplaquing the #1-2 are used for anteriors and premolars, the #11- in a periodontal maintenance patient, the thinner, finish- 12 is used for posterior mesial surfaces, and the #13-14 ing After Fives will insert subgingivally more easily. is used for posterior distal surfaces. The blade length of MINI-BLADED CURETTES. Mini-bladed curettes these instruments is 50% shorter than that of the con- such as the Hu-Friedy Mini Five curettes are modifica- ventional Gracey curette, and the blade has been curved tions of the After Five curettes. They feature blades that slightly upward (Fig. 41-27). This curvature allows the are half the length of the After Five or standard Gracey Gracey curvettes to adapt more closely to the tooth sur- curettes (Fig. 41-25). The shorter blade allows easier in- face than any other curettes, especially on the anterior sertion and adaptation in deep, narrow pockets; furca- teeth and online angles (Fig. 41-28). However, this cur- tions; developmental grooves; line angles; and deep, vature also carries the potential for gouging or groov- tight, facial, lingual, or palatal pockets. In any area ing into the root surfaces on the proximal surfaces where root morphology or tight tissue prevents full of the posterior teeth when the Gracey curvette #11-12 insertion of the standard Gracey or After Five blade, the or 13-14 is used. Additional features that represent Mini Five curettes can be used with vertical strokes, with improvements on the standard Gracey curettes are a reduced tissue distention, and without tissue trauma precision-balanced blade tip in direct alignment with the handle, a blade tip perpendicular to the handle, and a shank closer to parallel with the handle.

Fig. 41-22 Gracey #15-16. New Gracey curette, designed for Fig. 41-23 After Five curette. Note the extra 3 mm in the terminal mesioposterior surfaces, combines a Gracey #11-12 blade with a shank of the After Five curette compared with the standard Gracey Gracey #13-14 shank. curette. A, #5-6; B, #7-8; C, #11-12; D, #13-14.

The Periodontal Instrumentarium . CHAPTER 41 57 5 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com For many years, the Morse scaler, a miniature sickle, was the only mini-bladed instrument available. How- ever, the mini-bladed curettes have largely replaced this instrument (Fig. 41-29).

Langer and Mini-Langer Curettes. This set of three curettes combines the shank design of the standard Gracey #5-6, 11-12 and 13-14 curettes with a universal blade honed at 90 degrees rather than the offset blade of the Gracey curette. This marriage of the Gracey and universal curette designs allows the advantages of the area-specific shank to be combined with the versatility of

Fig. 41-26 Comparison of a standard rigid Gracey #5-6 with a rigid Mini Five #5-6 on the palatal surfaces of the maxillary central incisors. The Mini Five can be inserted to the base of these tight anterior pockets and used with a straight vertical stroke. A standard Gracey or After Five usually cannot be inserted vertically in this area because the blade is too long.

Fig. 41-24 Comparison of the After Five curette with standard Gracey curette. Rigid Gracey #13-14 adapted to the distal surface of the first molar and rigid After Five #13-14 adapted to the distal surface of the second molar. Notice the extra long shank of the Af- ter Five, which allows deeper insertion and better access. Fig. 41-27 Gracey Curvette blade. This diagram shows the 50% shorter blade of the Gracey Curvette superimposed on the standard Gracey curette blade (dotted lines). Notice the upward curvature of the Curvette blade and blade tip. (Redrawn from Pattison G, Pattison A: Periodontal Instrumentation, ed 2. Norwalk, CT, Appleton & Lange, 1992.)

Fig. 41-28 Gracey Curvette Sub-0. Curvette Sub-0 on the palatal surface of a maxillary central. The long shank and short, curved, and Fig. 41-25 Comparison of the After Five curette and the Mini Five blunted tip make this a superior instrument for deep anterior pock- curette. The shorter Mini Five blade (half the length) allows in- ets. This curette provides excellent blade adaptation to the narrow creased access and reduced tissue trauma. root curvatures of the maxillary and mandibular anterior teeth.

576 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com the universal curette blade. The Langer #5-6 curette Schwartz Periotrievers. The Schwartz Periotrievers adapts to the mesials and distals of anterior teeth; the are a set of two double-ended, highly magnetized instru- Langer #1-2 curette (Gracey #11-12 shank) adapts to the ments designed for the retrieval of broken instrument mesial and distal surfaces of mandibular posterior teeth; tips from the periodontal pocket (Figs. 41-31 and 41-32). and the Langer #3-4 curette (Gracey #13-14 shank) adapts They are indispensable when the clinician has broken a to the mesial and distal surfaces of maxillary posterior curette tip in a furcation or deep pocket . 29 teeth (Fig. 41-30). These instruments can be adapted to both the mesial and distal tooth surfaces without chang- Plastic Instruments for Implants. Several differing instruments. The standard Langer curette shanks are ent companies are manufacturing plastic instruments for heavier than a finishing Gracey but less rigid than the use on titanium and other implant abutment materials. rigid Gracey. They are also available with either rigid or It is imperative that plastic rather than metal instru- finishing shanks and can be obtained in the extended ments be used to avoid scarring and permanent damage shank (After Five) and mini-bladed (Mini Five) versions. to the implants (Figs. 41-33 and 41-34). 5,6,8,10,13,20,28

Hoe Scalers. Hoe scalers are used for scaling of ledges or rings of calculus (Fig. 41-35). The blade is bent at a 99-degree angle; the cutting edge is formed by the junction of the flattened terminal surface with the inner aspect of the blade. The cutting edge is beveled at 45 degrees. The blade is slightly bowed so that it can maintain contact at two points on a convex surface. The back of the blade is rounded, and the blade has been reduced

A B C

Fig. 41-29 Comparison of mini-bladed instruments. Four different Fig. 41-31 Schwartz Periotriever tip designs. The long blade is for mini-bladed instruments designed for use on the maxillary and general use in pockets, and the contra-angled tip is for use in furca- mandibular anteriors. A, Morse sickle scaler; B, Gracey Curvette tions. (From Pattison G, Pattison A: Periodontal Instrumentation, ed Sub-0; C, Mini Five #5-6. 2. Norwalk, CT, Appleton & Lange, 1992.)

Fig. 41-30 Langer curettes combine Gracey-type shanks with uni- Fig. 41-32 Broken instrument tip attached to the magnetic tip of versal curette blades; from left to right: #5-6, #1-2, #3-4. the Schwartz Periotriever. (From Pattison G, Pattison A: Periodontal I nstrumentation, ed 2. Norwalk, CT, Appleton & Lange, 1992.)

The Periodontal Instrumentarium • CHAPTER 41 57 7

Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com to minimal thickness to permit access to the roots with- ting, and removing stain. 7,8,15,36 The two types of ultrasonic out interference from the adjacent tissues. units are magnetostrictive and piezoelectric. In both types, Hoe scalers are used in the following manner: alternating electrical current generates oscillations in materials in the handpiece that cause the scaler tip to vibrate. 1. The blade is inserted to the base of the periodontal Depending on the manufacturer, these ultrasonic vibrations pocket so that it makes two-point contact with the at the tip of the instruments of both types range from tooth (see Fig. 41-35). This stabilizes the instrument 20,000 to 45,000 cycles/second (also referred to as Hertz and prevents nicking of the root. [Hz]). In magnetostrictive units (Fig. 41-37), the pattern of 2. The instrument is activated with a firm pull stroke to- vibration of the tip is elliptical, which means that all sides ward the crown, with every effort being made to pre- of the tip are active and will work when adapted to the serve the two-point contact with the tooth. tooth. In piezoelectric units (Fig. 41-38), the pattern of vi- McCall's hoe scalers #3, 4, 5, 6, 7, and 8 are a set of six bration of the tip is linear, or back and forth, meaning that hoe scalers designed to provide access to all tooth sur- the two sides of the tip are the most active (see Chapter 43). faces. Each instrument has a different angle between the shank and handle.

Files. Files have a series of blades on a base (Fig. 41- 36). Their primary function is to fracture or crush tenacious calculus. Files can easily gouge and roughen root surfaces when used improperly. Therefore they are not suitable for fine scaling and root planing. Mini-bladed curettes are currently preferred for areas where files were once commonly used. Files are sometimes used for removing overhanging margins of dental restorations.

Chisel Scalers. The chisel scaler, designed for the proximal surfaces of teeth too closely spaced to permit the use of other scalers, is usually used in the anterior part of the mouth. It is a double-ended instrument with a curved shank at one end and a straight shank at the other (see Fig. 41-36); the blades are slightly curved and have a straight cutting edge beveled at 45 degrees. The chisel is inserted from the facial surface. The slight curve of the blade makes it possible to stabilize it Fig. 41-34 Implacare implant instruments. These implant instru- against the proximal surface, whereas the cutting edge ments from the Hu-Friedy Company have autoclavable stainless engages the calculus without nicking the tooth. The in- steel handles and three different cone-socket plastic tip designs. strument is activated with a push motion while the side A, The Columbia 4R-4L curette tip; B, The H6-H7 sickle scaler tip; of the blade is held firmly against the root. C, The 2045 sickle scaler tip.

Ultrasonic and Sonic Instruments. Ultrasonic instruments may be used for removing plaque, scaling, curet-

Fig. 41-33 Plastic probes. (Courtesy Professional Dental Technolo- Fig. 41-35 Hoe scalers. A, Hoe scalers designed for different tooth gies, Inc., Batesville, AR) surfaces, showing "two-point" contact. B, Hoe scaler in a periodontal pocket. The back of the blade is rounded for easier access. The instrument contacts the tooth at two points for stability.

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Fig. 41-36 Chisel scaler and file scaler. Fig. 41-38 Piezoelectric ultrasonic unit. Piezon Master 400. (Cour- tesy EMS-Electromedical Systems, Dallas, TX.)

Fig. 41-37 Magnetostrictive ultrasonic unit. The Cavitron SPS ul- Fig. 41-39 Sonic scaler. The Titan-S sonic scaler from Star Dental trasonic scaler. (Courtesy Dentsply International Inc., York, PA.) Products, Valley Forge, PA.

Sonic units consist of a handpiece that attaches to a however, thinner, more delicate tips designed for subgin- compressed air line and uses a variety of specially de- gival debridement have become available15 (Fig. 41-41). signed tips (Fig. 41-39). Vibrations at the sonic tip All tips are designed to operate in a wet field and have range from 2000 to 6500 cycles per second, which pro- attached water outlets. The spray is directed at the end vides less power for calculus removal than ultrasonic of the tip to dissipate the heat generated by the ultra- units. sonic vibrations. Within the water droplets of this spray A comparison of the three types of power-driven mist are tiny vacuum bubbles that quickly collapse, scalers is shown in Table 41-2. releasing energy in a process known as cavitation. The Ultrasonic and sonic tips with different shapes are cavitating water spray also serves to flush calculus, available for scaling, curetting, root planing, and debrid- plaque, and debris dislodged by the vibrating tip from ing during periodontal surgery (Fig. 41-40). For many the pocket. Sonic units do not release heat the way ul- years, only large, bulky tips designed for supragingival trasonic units do, but they still have water for cooling removal of heavy calculus were available. In recent years, and flushing away debris.

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Comparison of Sonic and Ultrasonic Scaling Units

ULTRASONIC

Sonic Magnetostrictive Piezoelectric Advantages Calculus removal good excellent excellent Treatment time low low low Tip action orbital elliptical linear Tip adaptability fair fair fair Patient comfort good good good Asepsis good good good Operator control good good good Space requirement low high high

Disadvantages Enamel abrasion medium medium medium Tissue abrasion low low low Cemental roughening medium medium medium Restoration damage medium medium medium Heat production low high high Cost medium high high Maintenance medium high high Noise level high medium medium

NOTE: This table is meant merely as a guide to choosing power-operated instruments. The clinician is advised to investigate the various types and models of sonic and ultrasonic scaling devices, because technical improvements and changes have affected and will continue to affect the way powered instruments are used in dentistry. From Perry DA, Beemsterboer P, Carranza FA: Techniques and Theory of Periodontal Instrumentation. Philadelphia, WB Saunders, 1990.

Fig. 41-40. Ultrasonic and sonic tips. A, Triple bend 1000 insert Fig. 41-41 Cavitron FSI® Slim Line ultrasonic tips. Thin inserts from Dentsply Cavitron, York, PA. B, Ultrasonic insert for the EMS from Dentsply Cavitron allow better insertion into deep periodontal scaler. C, Sonic insert for the Titan-S. pockets and furcations.

The Dental Endoscope. A dental endoscope has fiberoptic endoscope over which is fitted a disposable, been introduced recently for use subgingivally in the di- sterile sheath. The fiberoptic endoscope fits onto peri- agnosis and treatment of periodontal disease (Fig 41-42). odontal probes and ultrasonic instruments that have Produced by DentalView, Inc. and called the Perioscopy been designed to accept it (Fig 41-43). The sheath de- System, it consists of a 0.99 mm-diameter reusable livers water irrigation that flushes the pocket while the

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Fig. 41-44 Perioscope® instrumentation permits deep subgingival visualization in pockets and furcations. (Courtesy DentaIView, Inc., I rvine, CA.)

device allows clear visualization deep subgingivally in pockets and in furcations (Fig. 41-44). It enables the operator to detect the presence and location of subgingival deposits and guides the operator in their thorough removal.

Fig. 41-42 The Perioscopy® System, dental endoscope. (Courtesy Magnification ranges from 24x to 46x, enabling visual- DentaIView, Inc., Irvine, CA.) ization of even minute deposits of plaque and calculus. Using this device, it is possible to achieve levels of root debridement and cleanliness that are much more difficult or impossible to produce without it. The Perioscopy System' can also be used to evaluate subgingivally for caries, defective restorations, root fractures, and resorption.

The EVA System. Probably the most efficient and least traumatic instruments for correcting overhanging or overcontoured proximal alloy and resin restorations are the motor-driven diamond files of the EVA prophylaxis instrument. These files, which come in symmetric pairs, are made of aluminum in the shape of a wedge protruding from a shaft; one side of the wedge is diamond coated; the other side is smooth. The files can be mounted on a special dental handpiece attachment that generates reciprocating strokes of variable frequency. When the unit is activated interproximally with the diamond-coated side of the file touching the restoration and the smooth side adjacent to the papilla, the oscillat- Fig. 41-43 Viewing periodontal explorers (left/right/full viewing) ing file swiftly planes the contour of the restoration and for the Perioscopy® system. (Courtesy DentaIView, Inc., Irvine, CA.) reduces it to the desired shape.

Cleansing and Polishing Instruments endoscope is in use and keeps the field clear. The fiberop- Rubber Cups. Rubber cups consist of a rubber shell tic endoscope attaches to a medical grade charged cou- with or without webbed configurations in the hollow in- pled device (CCD) video camera and light source that pro- terior (Fig. 41-45). They are used in the handpiece with a duces an image on a flat panel video monitor for viewing special prophylaxis angle. The handpiece, prophylaxis during subgingival exploration and instrumentation. This angle, and rubber cup must be sterilized after each

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Fig. 41-45 Prophylaxis handpiece with rubber cup and brush.

Fig. 41-47 Prophy-Jet air-powder polishing device. (Courtesy Dentsply International, Inc., York, PA.)

Fig. 41-46 Disposable plastic prophylaxis angle with rubber cup. vides warm water for rinsing and lavage. The flow rate of abrasive cleansing power can be adjusted to increase the amount of powder for heavier stain removal. The results of studies on the abrasive effect of the patient use, or a disposable plastic prophylaxis angle and air-powder polishing device on cementum and dentin rubber cup (Fig. 41-46) may be used and then discarded. show that tooth substance can be lost.4.23 Damage to gin- A good cleansing and polishing paste that contains fluo- gival tissue is transient and insignificant clinically, but ride should be used and kept moist to minimize fric- amalgam restorations, composite resins, cements, and tional heat as the cup revolves. Polishing pastes are avail- other nonmetallic materials can be roughened . 2,9,19,23 Air- able in fine, medium, or coarse grits and are packaged in powder polishing can be used safely on titanium im- small, convenient, single-use containers. Aggressive use plant surfaces. 16,26 of the rubber cup with any abrasive may remove the Patients with medical histories of respiratory illnesses, layer of cementum, which is thin in the cervical area. hypertension, hemodialysis, sodium-restricted diets and those on medications affecting the electrolyte balance Bristle Brushes. Bristle brushes are available in are not candidates for the use of the air-powder polish- wheel and cup shapes (see Fig. 41-45). The brush is used ing device . 25,32,34 Patients with infectious diseases should in the handpiece with a polishing paste. Because the bris- not be treated with this device because of the large quan- tles are stiff, use of the brush should be confined to the tity of aerosol created. A preprocedural rinse with 0.12% crown to avoid injuring the cementum and the gingiva. chlorhexidine gluconate should be used to minimize the microbial content of the aerosol . 3 High speed evacuation Dental Tape. Dental tape with polishing paste is should also be used to eliminate as much of the aerosol used for polishing proximal surfaces that are inaccessible as possible .14 to other polishing instruments. The tape is passed interproximally while being kept at a right angle to the long axis of the tooth and is activated with a firm labiolingual SURG ICAL INSTRUMENTS motion. Particular care is taken to avoid injury to the Periodontal surgery is accomplished with numerous in- gingiva. The area should be cleansed with warm water to struments; Fig. 41-48 shows a typical surgical cassette. remove all remnants of paste. Periodontal surgical instruments are classified as follows: Air-Powder Polishing. In the early 1980s, a spe- 1. Excisional and incisional instruments cially designed handpiece was introduced that delivers 2. Surgical curettes and sickles an air-powered slurry of warm water and sodium bicar- 3. Periosteal elevators bonate; this instrument is called the Prophy-jet (Fig. 41- 4. Surgical chisels 47). This system is effective for the removal of extrinsic 5. Surgical files stains and soft deposits. The slurry removes stains 6. Scissors rapidly and efficiently by mechanical abrasion and pro- 7. Hemostats and tissue forceps

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Fig. 41-49 Gingivectomy knives. A, Kirkland knife. B, Orban interdental knife.

Excisional and Incisional Instruments Periodontal Knives (Gingivectomy Knives). The Kirkland knife is representative of knives commonly used for gingivectomy. These knives can be obtained as either double-ended or single-ended instruments. The entire periphery of these kidney-shaped knives is the cutting edge (Fig. 41-49, A).

Interdental Knives. The Orban knife #1-2 (Fig. 41-49, B) and the Merrifield knife #1, 2, 3, and 4 are examples of knives used for interdental areas. These spear-shaped knives have cutting edges on both sides of the blade and are designed with either double-ended or single-ended blades.

Surgical Blades. Scalpel blades of different shapes and sizes are used in periodontal surgery. The most commonly used blades are #12D, 15, and 15C (Fig. 41-50). The #12D blade is a beak-shaped blade with cutting edges on both sides, allowing the operator to engage narrow, restricted areas with both pushing and pulling cut- Fig. 41-48 Instrument cassettes for periodontal surgery. Cassettes ting motions. The #15 blade is used for thinning flaps shown in A and B are to be used together for involved cases, while and for all-around use. The #15C blade, a narrower ver- the cassette shown in C is a reduced set for simple cases. Additional sion of the #15 blade, is useful for making the initial, instruments may be used according to individual preferences and scalloping type incision. The slim design of this blade al- case requirements. A, Mirror, explorer, probe, furcation probe, chisels, periosteal elevator, file, knives, surgical curette, dressing pliers, lows for incising into the narrow interdental portion of tissue pliers, aspirator tip. B, Retractor, scalpel handle, root planing the flap. All of these blades are discarded after one use. curettes, universal curette, hemostat, scissors, needleholders, suture scissors, scalpel blade remover. C, Simplified set: mirror, explorer- Electrosurgery (Radiosurgery) Techniques and probe, furcation probe, knives, periosteal elevator, file, root planing Instrumentation. The term electrosurgery or radio- curettes, universal curette, chisel, scalpel handle, dressing pliers, tis- surgery30 is currently used to identify surgical techniques sue pliers, needleholder, scissors, scalpel blade remover. (Courtesy performed on soft tissue using controlled high-frequency Hu-Friedy Instrument Company, Chicago.) electrical (radio) currents in the range of 1.5 to 7.5 million cycles per second or megahertz (Fig. 41-51). There are three classes of active electrodes: single-wire electrodes for incising or excising; loop electrodes for planing tissue; and heavy, bulkier electrodes for coagulation procedures. 11,21

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Fig. 41-50 Surgical blades. A, #15C, 15, and 12D. B, Contra- Fig. 41-51 Radiosurgical (electrosurgical) unit. Dento-Surg 90 UP angled scalpel handle. (Courtesy Ellman International Inc., Hewlett, NY.)

The four basic types of electrosurgical techniques are electrosection, electrocoagulation, electrofulguration, and electrodesiccation. Electrosection, also referred to as electrotomy or acusec- tion, is used for incisions, excisions, and tissue planing. Incisions and excisions are performed with single-wire active electrodes that can be bent or adapted to accomplish any type of cutting procedure. Electrocoagulation provides a wide range of coagulation or hemorrhage control obtained by using the electrocoagulation current. Electrocoagulation can prevent bleeding or hemorrhage at the initial entry into soft tissue, but it cannot stop bleeding after blood is present. All forms of hemorrhage must be stopped first by some form of direct pressure (e.g., air, compress, or hemostat). After bleeding has momentarily stopped, final sealing of the capillaries or large vessels can be accomplished by a short application of the electrocoagulation current. The active electrodes used for coagulation are much bulkier than the fine tungsten wire used for electrosection. Electrosection and electrocoagulation are the proce- Fig. 41-52 Kramer heavy surgical curettes #11, 2, and 3. dures most commonly used in all areas of dentistry. The two monoterminal techniques, electrofulguration and electrodesiccation, are not in general use in dentistry. The most important basic rule of electrosurgery is: contraindicated for patients who have noncompatible or always keep the tip moving. Prolonged or repeated appli- poorly shielded cardiac pacemakers. cation of current to tissue induces heat accumulation and undesired tissue destruction, whereas interrupted Surgical Curettes and Sickles application at intervals adequate for tissue cooling (5 to 10 seconds) reduces or eliminates heat buildup. Elec- Larger and heavier curettes and sickles are often needed trosurgery is not intended to destroy tissue; it is a con- during surgery for the removal of granulation tissue, fi- trollable means of sculpturing or modifying oral soft brous interdental tissues, and tenacious subgingival de- tissue with little discomfort and hemorrhage for the posits. The Kramer curettes #1, 2, and 3 (Fig. 41-52) and patient. the Kirkland surgical instruments are heavy curettes, The indications for electrosurgery in periodontal ther- whereas the Ball scaler #B2-B3 is a popular heavy sickle. apy and a description of wound healing after electro- The wider, heavier blades of these instruments make surgery are presented in Chapter 58. Electrosurgery is them suitable for surgical procedures.

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Fig. 41-54 Lateral (A) and frontal (B) views of a surgical hoe. Fig. 41-53 Glickman periosteal elevator #24G.

Fig. 41-55 Surgical chisels. A, Ochsenbein chisels. B, Rhodes Fig. 41-56 Schluger #9-10 surgical file. chisel.

The Periodontal Instrumentarium • CHAPTER 41 585

Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com Periosteal Elevators design and can be used with a push-and-pull stroke, pri- These instruments are necessary to reflect and move the marily in the interdental areas. flap after the incision has been made for flap surgery. The #24G (Fig. 41-53) and the Goldman-Fox #14 are Scissors and Nippers well-designed periosteal elevators. Scissors and nippers are used in periodontal surgery for such purposes as removing tabs of tissue during gingivec- Surgical Chisels and Hoes tomy, trimming the margins of flaps, enlarging incisions Chisels and hoes are used during periodontal surgery in periodontal abscesses, and removing muscle attach- for removing and reshaping bone. The hoe shown in ments in mucogingival surgery. There are many types, Fig. 41-54 has a curved shank and blade, whereas the and the choice is a matter of individual preference. Fig. Wiedelstadt and Todd-Gilmore chisels are straight 41-57 shows the Goldman-Fox #16 scissors with a curved shanked. The surgical hoe has a flattened, fishtail-shaped beveled blade with serrations and the nippers. blade with a pronounced convexity in its terminal portion. The cutting edge is beveled with rounded edges Needleholders and projects beyond the long axis of the handle to preserve the effectiveness of the instrument when the blade Needleholders are used to suture the flap at the desired is reduced by sharpening. The surgical hoe is generally position after the surgical procedure has been com- used for detaching pocket walls after the gingivectomy pleted. The regular type of needleholder is illustrated in incision, but it is also useful for smoothing root and Figure 41-58, A, whereas Fig. 41-58, B shows the Castro- bone surfaces made accessible by any surgical procedure. viejo needleholder, which is used for delicate, precise The Ochsenbein #1-2 (Fig. 41-55, A) is a useful chisel techniques requiring quick and easy release and grasp of with a semicircular indentation on both sides of the the suture. shank that allows the instrument to engage around the tooth and into the interdental area. Surgical hoes are SHARPENING OF PERIODONTAL usually used with a pull stroke, whereas chisels are en- I NSTRU MENTS gaged with a push stroke. The Rhodes chisel is shown in Fig. 41-55, B. It is impossible to carry out periodontal procedures efficiently with dull instruments. A sharp instrument cuts more precisely and quickly than a dull instrument. To do Surgical Files its job at all, a dull instrument must be held more firmly Periodontal surgical files are used primarily to smooth and pressed harder than a sharp instrument. This re- rough bony ledges and to remove all areas of bone. The duces tactile sensitivity and increases the possibility that Schluger (Fig. 41-56) and Sugarman files are similar in the instrument will inadvertently slip. Therefore to avoid

Fig. 41-57 A, Goldman-Fox #16 scissors. B, Nippers.

586 PART 5 • Treatment o f Periodontal Disease

Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com The Objective of Sharpening The objective of sharpening is to restore the fine, thin, linear cutting edge of the instrument. This is done by grinding the surfaces of the blade until their junction is once again sharply angular rather than rounded. For any given instrument, several sharpening techniques may produce this result. A technique is acceptable if it produces a sharp cutting edge without unduly wearing the instrument or altering its original design. To maintain the original design, the operator must understand the location and course of the cutting edges and the angles between the surfaces that form them. It is important to restore the cutting edge without distorting the original angles of the instrument. When these angles have been altered, the instrument does not function as it was designed to function, which limits its effectiveness.

Fig. 41-58 A, Conventional needleholder. B, Castroviejo needleholder. Sharpening Stones Sharpening stones may be quarried from natural mineral deposits or produced artificially. In either case, the surface of the stone is made up of abrasive crystals that are harder than the metal of the instrument to be sharp- wasting time and operating haphazardly, clinicians must be ened. Coarse stones have larger particles and cut more thoroughly familiar with the principles of sharpening and rapidly; they are used on instruments that are dull. Finer able to apply them to produce a keen cutting edge on the in- stones with smaller crystals cut more slowly and are struments they are using. Development of this skill re- reserved for final sharpening to produce a finer edge quires patience and practice, but clinical excellence can- and for sharpening instruments that are only slightly not be attained without it. dull .27-31 India and Arkansas oilstones are examples of natural abrasive stones. Carborundum, ruby, and ce- SHARPNESS AND HOW TO EVALUATE IT ramic stones are synthetically produced (Fig. 41-62). Sharpening stones can also be categorized by their The cutting edge of an instrument is formed by the an- method of use. gular junction of two surfaces of its blade. The cutting edges of a curette, for example, are formed where the Mounted Rotary Stones. These stones are face of the blade meets the lateral surfaces (Fig. 41-59). mounted on a metal mandrel and used in a motor- When the instrument is sharp, this junction is a fine driven handpiece. They may be cylindric, conical, or disc line running the length of the cutting edge. As the in- shaped. These stones are generally not recommended for strument is used, metal is worn away at the cutting edge, routine use, because (1) they are difficult to control pre- and the junction of the face and lateral surface becomes cisely and can ruin the shape of the instrument, (2) they rounded or dulled' ," (Fig. 41-60). Thus the cutting edge tend to wear down the instrument quickly, and (3) they becomes a rounded surface rather than an acute angle. can generate quite a bit of frictional heat, which may af- This is why a dull instrument cuts less efficiently and re- fect the temper of the instrument. quires more pressure to do its job. 12 Sharpness can be evaluated by sight and touch in one Unmounted Stones. These come in a variety of of the following ways: sizes and shapes. Some are rectangular with flat or grooved surfaces, whereas others are cylindric or cone 1. When a dull instrument is held under a light, the shaped. Unmounted stones may be used in two ways: rounded surface of its cutting edge reflects light back the instrument may be stabilized and held stationary to the observer. It appears as a bright line running the while the stone is drawn across it, or the stone may be length of the cutting edge (Fig. 41-61). The acutely stabilized and held stationary while the instrument is angled cutting edge of a sharp instrument, on the drawn across it. other hand, has no surface area to reflect light. When a sharp instrument is held under a light, no bright line can be observed (see Fig. 41-59). Principles of Sharpening 2. Tactile evaluation of sharpness is performed by draw- 1. Choose a stone suitable for the instrument to be ing the instrument lightly across an acrylic rod sharpened-one that is of an appropriate shape and known as a sharpening "test stick." A dull instrument abrasiveness. will slide smoothly, without "biting" into the surface 2. Use a sterilized sharpening stone if the instrument to and raising a light shaving as a sharp instrument be sharpened will not be resterilized before it is used would.36 on a patient.

The Periodontal Instrumentarium • CHAPTER 41 587

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Fig. 41-59 The cutting edge of a curette is formed by the angular Fig. 41-61 Light reflected from the rounded cutting edge of a junction of the face and the lateral surfaces of the instrument. dull instrument appears as a bright line. When the instrument is sharp, the cutting edge is a fine line.

Fig. 41-60 The cutting edge of a dull curette is rounded.

3. Establish the proper angle between the sharpening stone and the surface of the instrument on the basis of an understanding of its design. 4. Maintain a stable, firm grasp of both the instrument and the sharpening stone. This ensures that the proper angulation is maintained throughout the controlled sharpening stroke. In this manner, the entire surface of the instrument can be reduced evenly, and the cutting edge is not improperly beveled. 5. Avoid excessive pressure. Heavy pressure causes the stone to grind the surface of the instrument more quickly and may shorten the instrument's life unnecessarily. 6. Avoid the formation of a "wire edge," characterized Fig. 41-62 Sharpening stones. Top to bottom, A flat India stone, a by minute filamentous projections of metal extending flat Arkansas stone, a cone-shaped Arkansas stone, and a ceramic as a roughened ledge from the sharpened cutting stone. edge. 1,12,24,36 When the instrument is used on root surfaces, these projections produce a grooved surface rather than a smooth surface. A wire edge is produced when the direction of the sharpening stroke is away 1,24 from, rather than into or toward, the cutting edge. Sharpening Individual Instruments When back-and-forth or up-and-down sharpening strokes are used, formation of a wire edge can be Universal Curettes. Several techniques will pro- avoided by finishing with a down stroke toward the duce a properly sharpened curette. Regardless of the cutting edge." technique used, the clinician must keep in mind that the 7. Lubricate the stone during sharpening. This mini- angle between the face of the blade and the lateral sur- mizes clogging of the abrasive surface of the sharpen- face of any curette is 70 to 80 degrees (Fig. 41-63). This is ing stone with metal particles removed from the in- the most effective design for removing calculus and root strument. 12,24,36 It also reduces heat produced by planing. Changing this angle distorts the design of the friction. Oil should be used for natural stones and wa- instrument and makes it less effective. A cutting edge of ter for synthetic stones. less than 70 degrees is quite sharp but also thin (Fig. 41- 8. Sharpen instruments at the first sign of dullness. A 64). It wears down quickly and becomes dull. A cutting grossly dull instrument is inefficient and requires edge of 90 degrees or more requires heavy lateral pres- more pressure when used, which hinders control. sure to remove deposits. Calculus removal with such an Furthermore, sharpening such an instrument requires instrument is often incomplete, and root planing cannot the removal of a great deal of metal to produce a be done effectively (see Fig. 41-64). sharp cutting edge. This shortens the effective life of The following technique is recommended because the instrument. it enables the clinician to visualize the critical 70- to

588 PART 5 • Treatment of Periodontal Disease

Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com 80-degree angle easily and thereby consistently restores tire blade from shank end to toe. When approaching an effective cutting edge: the toe, be sure to sharpen around it to preserve its rounded form (Fig. 41-66). Sharpening the Lateral Surface. When a flat, 4. As the stone is moved along the cutting edge, finish hand-held stone is correctly applied to the lateral surface each section with a down stroke into or toward the of a curette to maintain the 70- to 80-degree angle, the cutting edge. This will minimize the formation of a angle between the face of the blade and the surface of wire edge. Check the cutting edge under a light. the stone will be 100 to 110 degrees (see Fig. 41-63). This 5. Sharpening the curette in this manner tends to flatten can best be visualized by holding the curette so that the the lateral surface. This can be corrected by lightly face of the blade is parallel with the floor. A palm grasp grinding the lateral surface and the back of the instru- should be used and the upper arm braced against the ment, away from the cutting edge, each time the in- body for support. strument is sharpened. 6. When one edge has been properly sharpened, the opposite cutting edge can be sharpened in the same 1. Apply the sharpening stone to the lateral surface of manner. the curette so that the angle between the face of the blade and the stone is 100 to 110 degrees (Fig. 41-65; Sharpening the Face of the Blade. This may be see Fig. 41-63). done by moving a hand-held cylindric or cone-shaped 2. Beginning at the shank end of the cutting edge and stone back and forth across the face of the blade. A simi- working toward the toe, activate the stone with short lar stone mounted in a hand-piece may also be used by up-and-down strokes. Use consistent, light pressure applying it to the face of the blade with the stone rotat- and keep the stone continuously in contact with the ing toward the toe. These methods are not recom- blade. Make sure that the 100- to 110-degree angle is mended for routine use for the following reasons: constantly maintained (see Fig. 41-65). 3. Check for sharpness as previously described, and con- 1. The angulation between the instrument and the stone tinue sharpening as necessary. To prevent the toe of is difficult to maintain, and therefore the blade may the curette from becoming pointed, sharpen the en- be improperly beveled (Fig. 41-67).'

Fig. 41-63 When the sharpening stone forms a 100- to 110- Fig. 41-65 Using a palm grasp, one holds the universal curette so degree angle with the face of the blade, the 70- to 80-degree angle that the face of the blade is parallel to the floor. The stone makes a between the face and the lateral surface is automatically preserved. 1 00- to 110-degree angle with the face of the blade.

Fig. 41-64 At the left is a properly sharpened curette that maintains a 70- to 80-degree angle between its face and lateral surface. The curette in the center has been sharpened so that one of its cutting edges is less than 70 degrees. This fine edge is quite sharp but Fig. 41-66 At the left is a new, unsharpened curette viewed from di- dulls easily. One of the cutting edges of the curette on the right has rectly above the face of the blade. The curette in the center has been been sharpened to 90 degrees. Heavy lateral pressure must be ap- correctly sharpened to maintain the rounded toe. The curette at the plied to the tooth to remove deposits with such an instrument. right has been incorrectly sharpened, producing a pointed toe.

The Periodontal Instrumentarium • CHAPTER 41 589

Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com 2. Sharpening the face of the blade narrows the working 2. Identify the edge to be sharpened. Remember that end from face to back. This weakens the blade and only one cutting edge is used, so only that edge must makes it likely to bend or break while in use 1,18,24,29 be sharpened. Apply the stone to the lateral surface so (see Fig. 41-67). that the angle between the face of the blade and the 3. Sharpening the face of the blade with a handheld stone is 100 to 110 degrees. stone using a back-and-forth motion produces a wire 3. Activate short up-and-down strokes, working from the edge that interferes with the sharpness of the blade.' shank end of the blade to the curved toe. Finish with a down stroke. Area-Specific (Gracey) Curettes. Like a universal 4. Remember that the cutting edge is curved. Preserve curette, a Gracey curette has an angle of 70 to 80 degrees the curve by turning the stone while sharpening from between the face and lateral surface of its blade. There- shank to toe. If the stone is kept in one place for too fore the technique described for sharpening a universal many strokes, the blade will be flattened (Fig. 41-71). curette can be used to sharpen a Gracey curette. How- 5. Evaluate sharpness as previously described. Continue ever, several unique design features that distinguish a sharpening as necessary. Gracey from a universal curette must be understood to avoid distorting the design of the instrument while Extended Shank and Mini-Bladed Gracey sharpening (see Gracey Curettes, pp. 571-574). Curettes. Extended shank Gracey curettes such as Gracey curettes have what is known as an offset blade the After Fives are sharpened in exactly the same man- (i.e., the face of the blade is not perpendicular to the ner as the standard Gracey curettes. Although the termi- shank of the instrument, as it is on a universal curette, nal shank is 3 mm longer, the blade size and shape are but is offset at a 70-degree angle [Fig. 41-68]). A Gracey curette is further distinguished by the curvature of its cutting edges. When viewed from directly above the face of the blade, the cutting edges of a universal curette extend in straight lines from shank to toe; both cutting edges can be used for scaling and root planing. The cutting edges of a Gracey curette, on the other hand, curve gently from shank to toe, and only the larger, outer cutting edge is used for scaling and root planing (Fig. 41-69). With these points in mind, a Gracey curette is sharpened in the following manner: 1. Hold the curette so that the face of the blade is parallel with the floor. Because the blade is offset, the shank of the instrument will not be perpendicular to the floor, as it is with universal curettes (Fig. 41-70). Fig. 41-69 The cutting edges of a universal curette extend straight from shank to toe. The cutting edges of a Gracey curette gently curve from shank to toe. Only the larger, outer cutting edge at the right is used for scaling and needs to be sharpened.

Fig. 41-67 Angulation is difficult to control when sharpening the face of the blade and often results in unwanted beveling, as shown at the left. Sharpening the face also weakens the blade by narrowing it from face to back, as shown at the right.

Fig. 41-70 Note that when a Gracey curette is held in proper sharpening position, its shank is not perpendicular to the floor, ow- Fig. 41-68 A, The face of a universal curette is at 90 degrees to its ing to its offset blade angle. The stone meets the blade at an angle shank. B, The face of a Gracey curette is offset, forming a 70-de- of 100 to 110 degrees. Compare this position with the sharpening gree angle with its shank. position of a universal curette, as shown in Fig. 41-65.

590 PART 5 . Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com very similar, and therefore, there is no difference in the ened in a manner much like that described for the sharpening technique. curette except that the sickle has a sharp, pointed toe Mini-bladed Gracey curettes such as the Mini Fives or that must not be rounded. Gracey Curvettes are also sharpened with the same tech- A large, flat stone may also be used to sharpen sickles nique. These blades are only half the length of a stan- (Fig. 41-74). The stone is stabilized on a table or cabinet dard Gracey blade, but the angle between the face and with the left hand. The sickle is held in the right hand the lateral surface of the blade is still 70 to 80 degrees. with a modified pen grasp and applied to the stone so However, sharpening too heavily or too often around that the angle between the face of the blade and the the toe of a mini-bladed curette should be avoided to stone is 100 to 110 degrees. The fourth finger is placed on prevent excessive shortening of the blade. the right-hand edge of the stone to stabilize and guide the sharpening movement. The right hand then pushes Sickle Scalers. The two types of sickle scalers are and pulls the sickle across the surface of the stone. To the straight sickle and curved sickle. On a straight sickle, avoid a wire edge, finish with a pull stroke, being sure the face of the blade is flat from shank to tip, whereas on that the proper angulation is always maintained. a curved sickle, the face of the blade forms a gentle curve (Fig. 41-72). The straight and curved sickles have similar Chisels and Hoes. Chisels have a single, straight cross-sectional designs, however. As in the curette, the cutting edge that is perpendicular to the shank. The face angle between the face of the blade and the lateral sur- of the blade is continuous with the shank of the instru- face of a sickle is 70 to 80 degrees (Fig. 41-73). When a ment, which may be directly in line with the handle or sharpening stone is correctly applied to the lateral sur- slightly curved. The end of the blade is beveled at 45 de- face to preserve this angle, the angle between the face of grees to form the cutting edge. the blade and the surface of the stone is 100 to 110 de- To sharpen a chisel, stabilize a flat sharpening stone grees. With this in mind, the sickle scaler can be sharp- on a flat surface. Grasp the instrument with a modified

Fig. 41-73 Like the curette, the sickle has an angle of 70 to 80 degrees between the face of the blade and the lateral surface. Fig. 41-71 The Gracey curette on the left has been properly sharpened to maintain a symmetric curve on its outer cutting edge. For the curette on the right, the sharpening stone was activated too long in one place, thereby flattening the blade.

Fig. 41-72 The face of the blade on a straight sickle is flat from Fig. 41-74 A large, flat stone may also be used to sharpen the shank to tip, whereas on the curved sickle the blade face forms a sickle. The stone is stabilized on a flat surface. The fourth finger of gentle arc. the right hand guides the sharpening stroke as the instrument is pulled across the face of the stone toward the operator.

The Periodontal Instrumentarium • CHAPTER 41 591 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com pen grasp. Establish a finger rest with the pads of the Periodontal Knives. There are two general types third and fourth fingers against the straight edge of of periodontal knives. The first type includes the dispos- the sharpening stone. Apply the flat beveled surface of able scalpel blades that come prepackaged. They are pre- the chisel to the surface of the stone. If the entire surface sharpened and sterilized by the manufacturer. These are of the bevel is contacting the stone, then the 45-degree not resharpened when they become dull but are dis- angle between the beveled surface and the face of the carded and replaced. blade will be maintained and the design of the instru- The second type of periodontal knives is reusable ment will not be altered (Figs. 41-75 and 41-76). and must be sharpened when they become dull. The Using moderate, steady pressure, with the hand and most commonly used knives in this group are the flat- arm acting as a unit and the finger resting on the edge of bladed gingivectomy knives (e.g., the Kirkland knives the stone as a guide, push the instrument across the sur- #15K and 16K) and the narrow, pointed interproximal face of the sharpening stone. Release pressure slightly knives. and draw the instrument back to its starting point. Re- FLAT-BLADED GINGIVECTOMY KNIVES. These peat the sharpening stroke until a sharp edge has been knives have broad, flat blades that are nearly perpendicu- obtained. Remember to finish with a push stroke to pre- lar to the lower shank of the instrument. The curved cut- vent the formation of a wire edge. Check for sharpness ting edge extends around the entire outer edge of the as previously described. Examine the instrument care- blade and is formed by bevels on both the front and fully to be sure that its design has not been inadvertently back surfaces of the blade (Fig. 41-78). altered. When sharpening these instruments, only the bevel Back-action surgical chisels and hoe scalers are sharp- on the back surface of the instrument needs be ground. ened with exactly the same technique described for chis- This can be done by drawing the blade across a station- els except that a pull stroke is used rather than a push ary flat sharpening stone or by holding the instrument stroke (Fig. 41-77). stationary and drawing the stone across its blade.

Fig. 41-75 When the entire bevel on a chisel contacts the sharpening stone, the angle between the instrument and the stone is 45 degrees. The cutting edge will be properly sharpened if this angle is maintained as the instrument is pushed across the stone.

Fig. 41-77 Back-action chisels and hoes are sharpened with a pull stroke.

Fig. 41-76 The chisel is also sharpened on a stationary flat sharp- Fig. 41-78 Flat-bladed gingivectomy knives such as this Kirkland ening stone. knife have a cutting edge that extends around the entire blade. The entire cutting edge must be sharpened.

S92 PART S • Treatment o f Periodontal Disease

Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com INTERPROXIMAL KNIVES. The blades of inter- at one end of the cutting edge and continue around the proximal knives have two long, straight cutting edges blade by rolling the handle of the instrument slightly be- that come together at the sharply pointed tip of the in- tween the thumb and the first and second fingers. Finish strument. The cutting edges are formed by bevels on the each section of the blade with a pull stroke to prevent front and back surfaces of the blade. The entire blade is formation of a wire edge. Check for sharpness as de- roughly perpendicular to the lower shank of the instru- scribed previously. ment (Fig. 41-79). Stationary Instrument Technique. Grasp the in- As with the flat-bladed gingivectomy knives, only the strument with the palm. Apply the flat surface of a hand- bevels on the back surface of the interproximal knives held sharpening stone to the bevel on the back surface need to be sharpened. Again, this can be accomplished of the blade (Fig. 41-82). Begin at one end of the cutting by drawing the instrument across a stationary stone or edge and, with moderate pressure, draw the stone back by holding the instrument stationary and moving the and forth across the instrument. To prevent the forma- stone across it. tion of a wire edge, finish each section with a stroke into Stationary Stone Technique. Stabilize a flat sharp- or toward the cutting edge. Proceed around the entire ening stone on a flat surface. Grasp the handle of the in- length of the cutting edge by gradually rotating the instrument with a modified pen grasp, and apply the bevel strument and the stone in relation to one another. on the back surface of the blade to the flat surface of the sharpening stone. With moderate pressure, pull the instrument toward you (Fig. 41-80 and Fig. 41-81). Release pressure slightly and return to the starting point. Begin

Fig. 41-79 The two cutting edges of an interproximal knife are Fig. 41-81 The interproximal knife may be sharpened on a flat formed by bevels on the front and back surfaces of the blade. stationary stone. The blade is drawn toward the operator.

Fig. 41-80 The gingivectomy knife may be sharpened on a sta- Fig. 41-82 The interproximal knife may also be sharpened with a tionary flat stone. The instrument is held with a modified pen hand-held stone. The instrument is held with a palm grasp, and the grasp. The fourth finger guides the sharpening stroke as the instru- stone is applied to the entire cutting edge. ment is rolled between the fingers so that all sections of the blade are sharpened.

The Periodontal Instrumentarium • CHAPTER 41 593

Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com REFERENCES 18. Lindhe J, Jacobson L: Evaluation of periodontal scalers. I. Wear following clinical use. Odontol Revy 1966; 17:1. 1. Antonini CJ, Brady JM, Levin MP, et al: Scanning electron 19. Lubow RM, Cooley RL: Effect of air-powder abrasive instru- microscope study of scalers. J Periodontol 1977; 48:45. ment on restorative materials. J Prosthet Dent 1986; 55:462. 2. Barnes C, Hayes E, Leinfelder K: Effects of an air abrasive 20. Mengel R, Buns CE, Mengel C, et al: An in vitro study of the polishing system on restored surfaces. Gen Dent 1987; treatment of implant surfaces with different instruments. 35:186. Int J Oral Maxillofac Implants. 1998; 13(1):91. 3. Bay N, Overman P, Krust-Bray K, Cobb C, et al: Effectiveness 21. Moore DA: Electrosurgery in dentistry: Past and present. of antimicrobial mouthrinses on aerosols produced by an Gen Dent. 1995; 43(5):460. air polisher. J Dent Hyg 1993; 67:312. 22. Orban B, Manella VB: A macroscopic and microscopic study 4. Berkstein S, Reiff RL, McKinney JF, et al: Supragingival root of instruments designed for root planing. J Periodontol surface removal during maintenance procedures utilizing an 1956; 27:120. air-powder abrasive system or hand scaling. An in vitro 23. Orton GS: Clinical use of an air-powder abrasive system. study. J Periodontol 1987; 58:327. Dent Hyg 1987; 75:513. 5. Brookshire FV, Nagy WW, Dhuru VB, et al: The qualitative 24. Paquette OF, Levin MP: The sharpening of scaling instru- effects of various types of hygiene instrumentation on com- ments. 1. An examination of principles. J Periodontol 1977; mercially pure titanium and titanium alloy implant abut- 48:163. ments: an in vitro and scanning electron microscope study. 25. Rawson RD, Nelson BN, Jewell BD, et al: Alkalosis as a po- J Prosthet Dent 1997; 78(3):286. tential complication of air polishing systems. A pilot study. 6. Cross-Poline GN, Shaklee RL, Stach DJ: Effect of implant Dent Hyg 1985; 59:500. curets on titanium implant surfaces. Am J Dent 1997; 26. Razzoog ME, Koka S: In vitro analysis of the effects of two 10(1):41. air-abrasive prophylaxis systems and inlet air pressure on 7. Drisko CL: Scaling and root planing without overinstru- the surface of titanium abutment cylinders. J Prosthodont mentation: hand versus power-driven scalers. Curr Opin Pe- 1994; 3(2):103. riodontol 1993; 78. 27. Rossi R, Smukler H: A scanning electron microscope study 8. Drisko CL, Cochran DL, Blieden T, et al: Position paper: comparing the effectiveness of different types of sharpening sonic and ultrasonic scalers in periodontics. Research, Sci- stones and curets. J Peridontol 1995; 66(11):956. ence and Therapy Committee of the American Academy of 28. Ruhling A, Kocher T, Kreusch J, et al: Treatment of subgingi- Periodontology. J Periodontol 2000; 71(11):1792. val implant surfaces with Teflon-coated sonic and ultrasonic 9. Eliades GC, Tzoutzas JG, Vougiouklakis GJ: Surface alter- scaler tips and various implant curettes. An in vitro study. ations on dental restorative materials subjected to an air- Clin Oral Implants Res 1994; 5(1):19. powder abrasive instrument. J Prosthet Dent 1991; 65(1):27. 29. Schwartz M: The prevention and management of the bro- 10. Fox SC, Moriarty JD, Kusy RP: The effects of scaling a tita- ken curet. Compend Contin Educ Dent 1998; 19(4):418- nium implant surface with metal and plastic instruments: 420,422,424. an in vitro study. J Periodontol 1990; (8):485. 30. Sherman JA: Oral Radiosurgery: An Illustrated Clinical 11. Gnanasekhar JD, al-Duwairi YS: Electrosurgery in dentistry. Guide, ed 2. London, Martin Dunitz, 1997. Quintessence Int 1998; 29(10):649. 31. Smith BA, Setter MS, Caffesse RG, et al: The effect of sharp- 12. Green E, Seyer PC: Sharpening Curets and Sickle Scalers, ed ening stones upon curette surface roughness. Quintessence 2. Berkeley, CA, Praxis, 1972. Int 1987; 18:603. 13. Hallmon WW, Waldrop TC, Meffert RM, et al: A compara- 32. Snyder JA, McVay JT, Brown FH, et al: The effect of air abra- tive study of the effects of metallic, nonmetallic, and sonic sive polishing on blood pH and electrolyte concentrations instrumentation on titanium abutment surfaces. Int J Oral in healthy mongrel dogs. J Periodontol 1990; 64:81. Maxillofac Implants. 1996; 11(1):96. 33. Stach DJ, Cross-Poline GN, Newmand SM, et al: Effect of re- 14. Harrel SK, Barnes JB, Rivera-Hidalgo F: Aerosol reduction peated sterilization and ultrasonic cleaning on curet blades. during air polishing. Quintessence Int 1999; 30(9):623. J Dent Hyg. 1995; 69(1):31. 15. Holbrook T, Low S: Power-driven scaling and polishing in- 34. Suzuki JB, Delisle AL: Pulmonary actinomycosis of peri- struments. In Hardin JF (ed): Clarke's Clinical Dentistry. odontal origin. J Periodontol 1984; 55:581. Philadelphia, JB Lippincott, 1991. 35. Waerhaug J, Arno A, Lovdal A: The dimension of instru- 16. Koka S, Han J, Razzoog ME, et al: The effects of two air- ments for removal of subgingival calculus. J Periodontol powder abrasive prophylaxis systems on the surface of ma- 1954; 25:281. chined titanium: a pilot study. Implant Dent 1992; 1(4):259. 36. Wilkins EM: Clinical Practice of the Dental Hygienist, ed 7. 17. Lindhe J: Evaluation of periodontal scalers. II. Wear follow- Baltimore, Williams & Wilkins, 1994. ing standardized or diagonal cutting tests. Odontol Revy 1966; 17:121. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Manual Instrumentation

Gordon L. Pattison and Anna M. Pattison*

CHAPTER

CHAPTER OUTLINE

GENERAL PRINCIPLES OF INSTRUMENTATION Maintaining a Clean Field Accessibility (Positioning of Patient and Operator) Instrument Stabilization Visibility, Illumination, and Retraction Instrument Activation Condition of Instruments (Sharpness) Instruments for Scaling and Root Planing

GENERAL PRINCIPLES OF I NSTRUMENTATION The clinician should be seated on a comfortable operating stool that has been positioned so that his or her feet Effective instrumentation is governed by a number of are flat on the floor with the thighs parallel to the floor. general principles that are common to all periodontal in- The clinician should be able to observe the field of opera- struments. Proper position of the patient and the operation while keeping the back straight and the head erect. tor, illumination and retraction for optimal visibility, The patient should be in a supine position and placed and sharp instruments are fundamental prerequisites. so that the mouth is close to the resting elbow of the A constant awareness of tooth and root morphologic fea- clinician. For instrumentation of the maxillary arch, the tures and of the condition of the periodontal tissues is patient should be asked to raise his or her chin slightly also essential. Knowledge of instrument design enables to provide optimal visibility and accessibility. For instru- the clinician to efficiently select the proper instrument mentation on the mandibular arch, it may be necessary for the procedure and the area in which it will be per- to raise the back of the chair slightly and request that formed. In addition to these principles, the basic con- the patient lower his or her chin until the mandible is cepts of grasp, finger rest, adaptation, angulation, and parallel to the floor. This will especially facilitate work stroke must be understood before clinical instrument- on the lingual surfaces of the mandibular anterior teeth. handling skills can be mastered. Visibility, Illumination, and Retraction Accessibility (Positioning of Patient and Operator) Whenever possible, direct vision with direct illumination Accessibility facilitates thoroughness of instrumentation. from the dental light is most desirable (Fig. 42-1). If this The position of the patient and operator should provide is not possible, indirect vision may be obtained by using maximal accessibility to the area of operation. Inade- the mouth mirror (Fig. 42-2), and indirect illumination quate accessibility impedes thorough instrumentation, may be obtained by using the mirror to reflect light to prematurely tires the operator, and diminishes his or her where it is needed (Fig. 42-3). Indirect vision and indirect effectiveness. illumination are often used simultaneously (Fig. 42-4). Retraction provides visibility, accessibility, and illumi- * Material in this chapter was drawn freely from Pattison A, nation. Depending on the location of the area of opera- Pattison G: Periodontal Instrumentation, ed 2. Reprinted by permis- tion, the fingers and/or the mirror are used for retrac- sion of Pearson Education, Inc., Upper Saddle River, NJ. tion. The mirror may be used for retraction of the cheeks

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Manual Instrumentation • CHAPTER 42 595 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 42-1 Direct vision and direct illumination in the mandibular Fig. 42-3 Indirect illumination using the mirror to reflect light left premolar area. onto the maxillary left posterior lingual region.

Fig. 42-2 Indirect vision using the mirror for the lingual surfaces Fig. 42-4 Combination of indirect illumination and indirect vision of the mandibular anterior teeth. for the lingual surfaces of the maxillary anterior teeth.

or the tongue, the index finger is used for retraction of When retracting, care should be taken to avoid irrita- the lips or cheeks. The following methods are effective tion to the angles of the mouth. If the lips and skin for retraction: are dry, softening the lips with petroleum jelly before instrumentation is begun is a helpful precaution against 1. Use of the mirror to deflect the cheek while the fin- cracking and bleeding. Careful retraction is especially gers of the nonoperating hand retract the lips and important for patients with a history of recurrent herpes protect the angle of the mouth from irritation by the labialis, because these patients may easily develop her- mirror handle petic lesions after instrumentation. 2. Use of the mirror alone to retract the lips and cheek (Fig. 42-5) Condition of Instruments (Sharpness) 3. Use of the fingers of the nonoperating hand to retract the lips (Fig. 42-6) Before any instrumentation, all instruments should be 4. Use of the mirror to retract the tongue (Fig. 42-7) inspected to make sure that they are clean, sterile, and in 5. Combinations of the preceding methods good condition. The working ends of pointed or bladed

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Fig. 42-5 Retracting the cheek with the mirror. Fig. 42-7 Retracting the tongue with the mirror.

Fig. 42-6 Retracting the lip with the index finger of the nonoper- Fig. 42-8 Modified pen grasp. The pad of the middle finger rests ating hand. on the shank.

instruments must be sharp to be effective. Sharp instru- Gingival bleeding is an unavoidable consequence of ments enhance tactile sensitivity and allow the clinician subgingival instrumentation. In areas of inflammation to work more precisely and efficiently. Dull instruments this is not necessarily an indication of trauma from in- may lead to incomplete calculus removal and unneces- correct technique; instead, it indicates ulceration of the sary trauma because of the excess force usually applied pocket epithelium. Blood and debris can be removed to compensate for their ineffectiveness (see Chapter 41). from the operative field with suction and by wiping or blotting with gauze squares. The operative field should Maintaining a Clean Field also be flushed occasionally with water. Compressed air and gauze squares can be used to fa- Despite good visibility, illumination, and retraction, in- cilitate visual inspection of tooth surfaces just below the strumentation can be hampered if the operative field is gingival margin during instrumentation. A jet of air di- obscured by saliva, blood, and debris. The pooling of rected into the pocket deflects a retractable gingival mar- saliva interferes with visibility during instrumentation gin. Retractable tissue can also be deflected away from and impedes control because a firm finger rest cannot be the tooth by gently packing the edge of a gauze square established on wet, slippery tooth surfaces. Adequate into the pocket with the back of a curette. Immediately suction is essential and can be achieved with a saliva after the gauze is removed, the subgingival area should ejector or, if working with an assistant, an aspirator. be clean, dry, and clearly visible for a brief interval.

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Fig. 42-9 Standard pen grasp. The side of the middle finger rests on the shank.

Fig. 42-10 Palm and thumb grasp, used for stabilizing instru- I nstrument Stabilization ments during sharpening. Stability of the instrument and the hand is the primary requisite for controlled instrumentation. Stability and control are essential for effective instrumentation and The palm and thumb grasp (Fig. 42-10) is useful for sta- avoidance of injury to the patient or clinician. The two bilizing instruments during sharpening and for manipu- factors of major importance in providing stability are the lating air and water syringes, but it is not recommended instrument grasp and the finger rest. for periodontal instrumentation. Maneuverability and tactile sensitivity are so inhibited by this grasp that it is Instrument Grasp. A proper grasp is essential for unsuitable for the precise, controlled movements neces- precise control of movements made during periodontal sary during periodontal procedures. instrumentation. The most effective and stable grasp for all periodontal instruments is the modified pen grasp (Fig. Finger Rest. The finger rest serves to stabilize the 42-8). Although other grasps are possible, this modifica- hand and the instrument by providing a firm fulcrum as tion of the standard pen grasp (Fig. 42-9) ensures the movements are made to activate the instrument. A good greatest control in performing intraoral procedures. finger rest prevents injury and laceration of the gingiva and surrounding tissues by poorly controlled instruments. The fourth (ring) finger is preferred by most clinicians for the finger rest. Although it is possible to use the third (middle) finger for the finger rest, this is not recommended, because it restricts the arc of movement during the activation of strokes and severely curtails the use of the middle finger for both control and tactile sensitivity. Maximal control is achieved when the middle finger is kept between the instrument shank and the fourth finger. The pad of the thumb is placed midway between the This "built-up" fulcrum is an integral part of the wrist- middle and index fingers on the opposite side of the han- forearm action that activates the powerful working stroke dle. This creates a triangle of forces, or tripod effect, that for calculus removal. Whenever possible, these two fingers enhances control because it counteracts the tendency of should be kept together to work as a one-unit fulcrum the instrument to turn uncontrollably between the fingers during scaling and root planing. Separation of the middle when scaling force is applied to the tooth. This stable and fourth fingers during scaling strokes results in a loss modified pen grasp enhances control because it enables of power and control because it forces the clinician to rely the clinician to roll the instrument in precise degrees with solely on finger flexing for activation of the instrument. the thumb against the index and middle fingers to adapt Finger rests may be generally classified as intraoral fin- the blade to the slightest changes in tooth contour. The ger rests or extraoral fulcrums. Intraoral finger rests on modified pen grasp also enhances tactile sensitivity, be- tooth surfaces ideally are established close to the working cause slight irregularities on the tooth surface are best per- area. Variations of intraoral finger rests and extraoral ful- ceived when the tactile-sensitive pad of the middle finger crums are used whenever good angulation and a sufficient is placed on the shank of the instrument. arc of movement cannot be achieved by a finger rest

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close to the working area. The following examples illus- 4. Finger-on-finger: The finger rest is established on the trate the different variations of the intraoral finger rest: index finger or thumb of the nonoperating hand (Fig. 42-14). 1. Conventional: The finger rest is established on tooth surfaces immediately adjacent to the working area Extraoral fulcrums are essential for effective instru- (Fig. 42-11). mentation of some aspects of the maxillary posterior 2. Cross-arch: The finger rest is established on tooth sur- teeth. When properly established, they allow optimal ac- faces on the other side of the same arch (Fig. 42-12). cess and angulation while providing adequate stabiliza- 3. Opposite-arch: The finger rest is established on tooth tion. Extraoral fulcrums are not finger rests in the literal surfaces on the opposite arch (e.g., mandibular arch sense, because the tips or pads of the fingers are not used finger rest for instrumentation on the maxillary arch) for extraoral fulcrums as they are for intraoral finger (Fig. 42-13). rests. Instead, as much of the front or back surface of

Fig. 42-11 Intraoral conventional finger rest. The fourth finger Fig. 42-13 Intraoral opposite-arch finger rest. The fourth finger rests on the occlusal surfaces of adjacent teeth. rests on the mandibular teeth while the maxillary posterior teeth are instrumented.

Fig. 42-12 Intraoral cross-arch finger rest. The fourth finger rests Fig. 42-14 Intraoral finger-on-finger rest. The fourth finger rests on the incisal surfaces of teeth on the opposite side of the same on the index finger of the nonoperating hand. arch.

Manual Instrumentation • CHAPTER 42 599 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com the fingers as possible is placed on the patient's face to Both intraoral finger rests and extraoral fulcrums provide the greatest degree of stability. The two most may be reinforced by applying the index finger or commonly used extraoral fulcrums are as follows: thumb of the nonoperating hand to the handle or shank of the instrument for added control and pressure 1. Palm-up: The palm-up fulcrum is established by rest- against the tooth. The reinforcing finger is usually em- ing the backs of the middle and fourth fingers on the ployed for opposite-arch or extraoral fulcrums when skin overlying the lateral aspect of the mandible on precise control and pressure are compromised by the the right side of the face (Fig. 42-15). longer distance between the fulcrum and the working 2. Palm-down: The palm-down fulcrum is established by end of the instrument. Fig. 42-17 shows the index fin- resting the front surfaces of the middle and fourth ger-reinforced rest, and Fig. 42-18 shows the thumb- fingers on the skin overlying the lateral aspect of the reinforced rest. mandible on the left side of the face (Fig. 42-16).

Fig. 42-15 Extraoral palm-up fulcrum. The backs of the fingers Fig. 42-17 Index finger-reinforced rest. The index finger is placed rest on the right lateral aspect of the mandible while the maxillary on the shank for pressure and control in the maxillary left posterior right posterior teeth are instrumented. lingual region.

Fig. 42-16 Extraoral palm-down fulcrum. The front surfaces of the Fig. 42-18 Thumb-reinforced rest. The thumb is placed on the fingers rest on the left lateral aspect of the mandible while the max- handle for control in the maxillary right posterior lingual region. illary left posterior teeth are instrumented.

600 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com I nstrument Activation discomfort. A curette that is improperly adapted in this Adaptation. Adaptation refers to the manner in manner can be particularly damaging, because the toe which the working end of a periodontal instrument is can gouge or groove the root surface. placed against the surface of a tooth. The objective of adaptation is to make the working end of the instrument Angulation. Angulation refers to the angle between conform to the contour of the tooth surface. Precise the face of a bladed instrument and the tooth surface. It adaptation must be maintained with all instruments to may also be called the tooth-blade relationship. avoid trauma to the soft tissues and root surfaces and to Correct angulation is essential for effective calculus ensure maximum effectiveness of instrumentation. removal. For subgingival insertion of a bladed instru- Correct adaptation of the probe is quite simple. The ment such as a curette, angulation should be as close to tip and side of the probe should be flush against the 0 degree as possible (Fig. 42-21). The end of the instru- tooth surface as vertical strokes are activated within the ment can be inserted to the base of the pocket more eas- crevice. Bladed instruments such as curettes and sharp- ily with the face of the blade flush against the tooth. pointed instruments such as explorers are more difficult During scaling and root planing, optimal angulation is to adapt. The ends of these instruments are sharp and between 45 and 90 degrees (see Fig. 42-21). The exact can lacerate tissue, so adaptation in subgingival areas be- blade angulation depends on the amount and nature of comes especially important. The lower third of the work- the calculus, the procedure being performed, and the ing end, which is the last few millimeters adjacent to the condition of the tissue. Blade angulation is diminished toe or tip, must be kept in constant contact with the or closed by tilting the lower shank of the instrument to- tooth while it is moving over varying tooth contours ward the tooth. It is increased or opened by tilting the (Fig. 42-19). Precise adaptation is maintained by care- lower shank away from the tooth. During scaling strokes fully rolling the handle of the instrument against the in- on heavy, tenacious calculus, angulation should be just dex and middle fingers with the thumb. This rotates the less than 90 degrees so that the cutting edge "bites" into instrument in slight degrees so that the toe or tip leads the calculus. With angulation of less than 45 degrees, into concavities and around convexities. On convex sur- the cutting edge will not bite into or engage the calculus faces such as line angles, it is not possible to adapt more properly (see Fig. 42-21). Instead, it will slide over the than 1 or 2 mm of the working end against the tooth. calculus, smoothing or "burnishing" it. If angulation is Even on what appear to be broader, flatter surfaces, no more than 90 degrees, the lateral surface of the blade, more than 1 or 2 mm of the working end can be rather than the cutting edge, will be against the tooth, adapted, because the tooth surface, although it may and the calculus will not be removed and may become seem flat, is actually slightly curved. burnished (see Fig. 42-21). After the calculus has been re- If only the middle third of the working end is adapted moved, angulation of just less than 90 degrees may be on a convex surface so that the blade contacts the tooth maintained, or the angle may be slightly closed as the at a tangent, the toe or sharp tip will jut out into soft tis- root surface is smoothed with light root planing strokes. sue, causing trauma and discomfort (Fig. 42-20). If the When gingival curettage is indicated, angulation instrument is adapted so that only the toe or tip is in greater than 90 degrees is deliberately established so that contact, the soft tissue can be distended or compressed the cutting edge will engage and remove the pocket lin- by the back of the working end, also causing trauma and ing (see Fig. 42-21).

Fig. 42-19 Gracey curette blade divided into three segments: the Fig. 42-20 glade adaptation. The curette on the left is properly lower one third of the blade, consisting of the terminal few millime- adapted to the root surface. The curette on the right is incorrectly ters adjacent to the toe (A); the middle one third (B); and the up- adapted; the toe juts out, lacerating the soft tissues. per one third, which is adjacent to the shank (C).

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Lateral Pressure. Lateral pressure refers to the pres- deep pockets that cannot be negotiated with vertical or sure created when force is applied against the surface of a oblique strokes. The direction, length, pressure, and tooth with the cutting edge of a bladed instrument. The number of strokes necessary for either scaling or root exact amount of pressure applied must be varied accord- planing are determined by four major factors: gingival ing to the nature of the calculus and according to position and tone, pocket depth and shape, tooth con- whether the stroke is intended for initial scaling to re- tour, and the amount and nature of the calculus or move calculus or for root planing to smooth the root roughness. surface. The exploratory stroke is a light, "feeling" stroke Lateral pressure may be firm, moderate, or light. that is used with probes and explorers to evaluate the di- When removing calculus, lateral pressure is applied mensions of the pocket and to detect calculus and irreg- firmly or moderately initially and is progressively dimin- ularities of the tooth surface. With bladed instruments ished until light lateral pressure is applied for the final such as the curette, the exploratory stroke is alternated root planing strokes. When insufficient lateral pressure is with scaling and root planing strokes for these same pur- applied for the removal of heavy calculus, rough ledges poses of evaluation and detection. The instrument is or lumps may be shaved to thin, smooth sheets of bur- grasped lightly and adapted with light pressure against nished calculus that are difficult to detect and remove. the tooth to achieve maximal tactile sensitivity. This burnishing effect often occurs in areas of develop- The scaling stroke is a short, powerful pull stroke mental depressions and along the cementoenamel junc- that is used with bladed instruments for the removal of tion (CEJ). both supragingival and subgingival calculus. The mus- Although firm lateral pressure is necessary for the cles of the fingers and hands are tensed to establish a se- thorough removal of calculus, indiscriminate, unwar- cure grasp, and lateral pressure is firmly applied against ranted, or uncontrolled application of heavy forces dur- the tooth surface. The cutting edge engages the apical ing instrumentation should be avoided. Repeated appli- border of the calculus and dislodges it with a firm move- cation of excessively heavy strokes often nicks or gouges ment in a coronal direction. The scaling motion should the root surface. be initiated in the forearm and transmitted from the The careful application of varied and controlled wrist to the hand with a slight flexing of the fingers. Ro- amounts of lateral pressure during instrumentation is an tation of the wrist is synchronized with movement of integral part of effective scaling and root planing tech- the forearm. The scaling stroke is not initiated in the niques and is absolutely critical to the success of both of wrist or fingers, nor is it carried out independently with- these procedures. out the use of the forearm. It is possible to initiate the scaling motion by rotating Strokes. Three basic types of strokes are used during the wrist and forearm or by flexing the fingers. The use instrumentation: the exploratory stroke, the scaling of wrist and forearm action versus finger motion has stroke, and the root planing stroke. Any of these basic long been debated among clinicians. Perhaps the strong strokes may be activated by a pull or a push motion in a opinions on both sides should be the most valid indica- vertical, oblique, or horizontal direction (Fig. 42-22). tion that there is a time and a place for each. Neither Vertical and oblique strokes are used most frequently. method can be advocated exclusively, because a careful Horizontal strokes are used selectively on line angles or analysis of effective scaling and root planing technique

Fig. 42-21 Blade angulation. A, 0 degrees: correct angulation for Fig. 42-22 Three basic stroke directions. A, Vertical; B, oblique; blade insertion. B, 45 to 90 degrees: correct angulation for scaling and C, horizontal. root planing. C, Less than 45 degrees: incorrect angulation for scaling and root planing. D, More than 90 degrees: incorrect angulation for scaling and root planing, correct angulation for gingival curettage.

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In any given quadrant, when approaching the tooth from the facial aspect, one end of the universal curette adapts to the mesial surfaces and the other end adapts to the distal surfaces. When approaching from the lingual aspect in the same quadrant, the double-ended universal curette must be turned end for end, because the blades are mirror images. This means that the end that adapts to the mesial surfaces on the facial aspect also adapts to the distal surfaces on the lingual aspect, and vice versa. Both ends of the universal curette are used to instrument the anterior teeth. On posterior teeth, however, owing to the limited access to distal surfaces, a single working end can be used to treat both mesial and distal surfaces by using both of its cutting edges. To do this, the instrument is first adapted to the mesial surface with the handle nearly parallel to the mesial surface. Because the face of the universal curette blade is honed at 90 degrees to the lower shank, if the lower shank is positioned so that it is absolutely parallel to the surface being instru- Fig. 42-23 Adaptation of the universal curette on a posterior mented, the tooth-blade angulation is 90 degrees. To tooth. Cross-sectional representations of the same universal curette close this angle and thus obtain proper working angula- blade as its cutting edges (a and b) are adapted to the mesial and tion, the lower shank must be tilted slightly toward the distal surfaces of a posterior tooth. tooth. The distal surface of the same posterior tooth can be instrumented with the opposite cutting edge of the same blade. This cutting edge can be adapted at proper reveals that, indeed, both types of stroke activation are working angulation by positioning the handle so that it necessary for complete instrumentation. The wrist and is perpendicular to the distal surface (Fig. 42-23). forearm motion, pivoting in an arc on the finger rest, When adapting the universal curette blade, as much of produces a more powerful stroke and is therefore pre- the cutting edge as possible should be in contact with the ferred for scaling. Finger flexing is indicated for precise tooth surface, except on narrow convex surfaces such as control over stroke length in areas such as line angles line angles. Although the entire cutting edge should con- and when horizontal strokes are used on the lingual or tact the tooth, pressure should be concentrated on the facial aspects of narrow-rooted teeth. lower third of the blade during scaling strokes. During The push scaling motion has been advocated by some root planing strokes, however, lateral pressure should clinicians. In the push stroke, the instrument engages be distributed evenly along the cutting edge. the lateral or coronal border of the calculus, and the fin- The primary advantage of these curettes is that they gers provide a thrust motion that dislodges the deposit. are designed to be used universally on all tooth surfaces, Because the push stroke may force calculus into the sup- in all regions of the mouth. However, universal curettes porting tissues, its use, especially in an apical direction, have limited adaptability for the treatment of deep pock- is not recommended. ets in which apical migration of the attachment has ex- The root planing stroke is a moderate to light pull posed furcations, root convexities, and developmental stroke that is used for final smoothing and planing of depressions. For this reason, the Gracey curettes and the the root surface. Although hoes, files, and ultrasonic in- new modifications of Gracey curettes, which are area struments have been used for root planing, curettes are specific and specially designed for subgingival scaling widely acknowledged to be the most effective and versa- and root planing in periodontal patients, are preferred tile instruments for this procedure. 1-6,8,12-15 The design of by many clinicians. the curette, which allows it to be more easily adapted to subgingival tooth contours, makes curettes particularly Gracey Curettes. Gracey curettes (see Fig. 42-18) suitable for root planing in periodontal patients. With a are a set of area-specific instruments that were designed moderately firm grasp, the curette is kept adapted to the by Dr. Clayton H. Gracey of Michigan in the mid-1930s. tooth with even, lateral pressure. A continuous series of Four design features make the Gracey curettes unique: long, overlapping shaving strokes is activated. As the sur- (1) they are area specific, (2) only one cutting edge on face becomes smoother and resistance diminishes, lateral each blade is used, (3) the blade is curved in two planes, pressure is progressively reduced. and (4) the blade is "offset." (These features have been summarized in Table 41-1.) Each of these features di- I nstruments for Scaling and Root Planing rectly influences the manner in which the Gracey curettes are used and should be discussed individually. Universal Curettes. The working ends of the uni- AREA SPECIFICITY. There are seven pairs of versal curette are designed in pairs so that all surfaces of curettes in the set. The Gracey curettes #1-2 and 3-4 are the teeth can be treated with one double-ended instru- used on anterior teeth. The Gracey #5-6 may be used on ment or a matched pair of single-ended instruments (see both anterior and premolar teeth. The facial and lingual Fig. 42-16). surfaces of posterior teeth are instrumented with Gracey

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curettes #7-8 and 9-10. The Gracey #11-12 is designed for mesial surfaces of posterior teeth, and the #13-14 adapts to the distal surfaces of posterior teeth. Although these guidelines for areas of use were originally established by Dr. Clayton H. Gracey, it is possible to use a Gracey curette in an area of the mouth other than the one for which it was specifically designed if the general principles regarding these curettes are understood and applied. Gracey curettes need not be reserved exclusively for periodontal patients. In fact, many clinicians prefer Gracey curettes for general scaling because of their excellent adaptability. SINGLE CUTTING EDGE USED. Like a universal Fig. 42-24 Determining the correct cutting edge of a Gracey curette. When viewed from directly above the face of the blade, the curette, the Gracey curette has a blade with two cutting correct cutting edge is the one forming the larger, outer curve on edges. Unlike the universal curette, however, the Gracey the right. instrument is designed so that only one cutting edge is used. To determine which of the two is the correct cutting edge to adapt to the tooth, the blade should be held face up and parallel to the floor. When viewed from this lium and to embed fragments of dislodged calculus in angle, the blade can be seen to curve to the side. One the soft tissues. cutting edge forms a larger outer curve and the other PRINCIPLES OF USE. The following general prin- forms a shorter, small inner curve. The larger outer ciples of use of the Gracey curettes are essentially the curve, which has also been described as the inferior cut- same as those for the universal curette; italicized princi- ting edge or as the cutting edge farther away from the ples apply only to Gracey curettes: handle, is the correct cutting edge (Fig. 42-24). BLADE CURVES IN TWO PLANES. Like the toe of 1. Determine the correct cutting edge. The correct cutting the universal curette, the toe of the Gracey curette curves edge should be determined by visually inspecting the upward. However, the toe of the Gracey curette also blade and confirmed by lightly adapting the chosen curves to the side, as mentioned in the preceding discus- cutting edge to the tooth with the lower shank parallel sion. This unique curvature enhances the blade's adapta- to the surface of the tooth. With the toe pointed in the tion to convexities and concavities as the working end is direction to be scaled (e.g., mesially with a #7-8 advanced around the tooth. Only the lower third or half curette), only the back of the blade can be seen if the of the Gracey blade is in contact with the tooth during incorrect cutting edge has been selected (Fig. 42-25). If strumentation. The cutting edge of a universal curette the wrong cutting edge has been adopted, the flat, blade, on the other hand, is straight and does not curve to shiny face of the blade will be seen instead (Fig. 42-26). the side. This makes it less adaptable to root concavities. 2. Make sure the lower shank is parallel to the surface to be in- OFFSET BLADE. Gracey curette blades are honed strumented. The lower shank of a Gracey curette is that at an offset angle, which means that the face of the portion of the shank between the blade and the first blade is not perpendicular to the lower shank as it is on a bend in the shank. Parallelism of the handle or upper universal curette. Instead, Gracey curettes are designed shank is not an acceptable guide with Gracey curettes, so that the tooth-blade working angulation is 60 to 70 because the angulations of the shanks vary. On ante- degrees when the lower shank is held parallel to the rior teeth, the lower shank of the Gracey #1-2, 3-4, or tooth surface. Gracey curettes were originally designed 5-6 should be parallel to the mesial, distal, facial, or lin- to be used with push strokes and were beveled to provide gual surfaces of the teeth (Fig. 42-27). On posterior a tooth-blade angulation of 40 degrees when the lower teeth the lower shank of the #7-8 or 9-10 should be shank was parallel to the tooth surface; for many years, parallel to the facial or lingual surfaces of the teeth Gracey curettes were available only in this form. Cur- (Fig. 42-28); the lower shank of the #11-12 should be rently Gracey curettes are available not only in the origi- parallel to the mesial surfaces of the teeth (Fig. 42-29); nal push design, but also in a modified version to be and the lower shank of the #13-14 should be parallel to used with pull strokes. It is important to understand this the distal surfaces of the teeth (Fig. 42-30). when purchasing Gracey curettes to avoid obtaining in- 3. When using intraoral finger rests, keep the fourth and struments that are not properly designed for pull strokes. middle fingers together in a built-up fulcrum for max- If Gracey curettes that are designed to be used with push imum control and wrist-arm action. strokes are used with pull strokes instead, they are likely 4. Use extraoral fulcrums or mandibular finger rests for to burnish calculus rather than completely remove it. optimal angulation when working on the maxillary The design of the Gracey curette was modified in re- posterior teeth. sponse to requests from clinicians who liked the shank 5. Concentrate on using the lower third of the cutting design and adaptability of the original Gracey instru- edge for calculus removal, especially on line angles or ments but were opposed to the use of push strokes for when attempting to remove a calculus ledge by break- scaling and root planing. The push stroke is not recom- ing it away in sections, beginning at the lateral edge. mended, especially for the novice clinician, because it is 6. Allow the wrist and forearm to carry the burden of likely to cause undue trauma to the junctional epithe- the stroke, rather than flexing the fingers.

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Fig. 42-27 Gracey #5-6 curette adapted to an anterior tooth.

Fig. 42-25 Correct cutting edge of a Gracey curette adapted to pecially to deep mesial and distal pockets (see Fig. 41-24). the tooth. Although the longer lower shank makes access easier while using a conventional intraoral finger rest, the use of an extraoral fulcrum allows better access and adaptation to all of the maxillary posterior teeth. After Five curettes with rigid shanks should be used for scaling of heavy calculus; those with regular, finishing shanks should be used for periodontal maintenance patients with deep residual pockets. MINI-BLADED GRACEY CURETTES. Mini-bladed Gracey curettes such as the Mini Five curettes and the Gracey Curvette curettes have a terminal shank that is 3 mm longer than the standard Gracey curettes and a blade that is 50% shorter (see Fig. 42-26 and Fig. 42-27). These mini-bladed instruments are generally used in the same manner as the Gracey curettes except for the following specific differences: 1. Mini-bladed curettes should not be used routinely in place of standard Gracey or After Five curettes. In- stead, they should be used to supplement conventional curettes and ultrasonic instruments in areas of difficult access such as furcations; line angles, and deep, tight, or narrow pockets. Fig. 42-26 Incorrect cutting edge of a Gracey curette adapted to 2. Large #4 handles are recommended for any mini- the tooth. bladed instruments, because the larger diameter of the handles allows better control of the small blades. 3. Mini-bladed curettes can be used to scale with the toe 7. Roll the handle slightly between the thumb and fin- directed either mesially or distally. In fact, the Mini gers to keep the blade adapted as the working end is Five curettes often adapt more effectively to the root advanced around line angles and into concavities. curvatures of many posterior teeth when the blade is 8. Modulate lateral pressure from firm to moderate to inserted with the toe pointed distally and strokes are light depending on the nature of the calculus, and re- activated from the mesial toward the distal line angle duce pressure as the transition is made from scaling to (Fig. 42-31). root planing strokes. 4. Use rigid shank mini-bladed curettes for calculus removal. Use the thinner, standard shank mini-bladed EXTENDED SHANK GRACEY CURETTES. Ex- curettes for deplaquing during maintenance. tended shank Gracey curettes such as the After Five 5. When using mini-bladed curettes for calculus removal, curettes are 3 mm longer in the terminal shank than the use intraoral finger rests close to the working area. standard Gracey curettes but are used with the same tech- When performing light root planing or deplaquing, ei- nique (see Fig. 41-23). They are most useful for deep ther intraoral or extraoral rests may be used. Extraoral pockets on maxillary and mandibular posterior teeth, rests are usually necessary to gain access to deep pock- where the longer terminal shank allows better access, es- ets on maxillary second and third molars.

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Fig. 42-28 Gracey #7-8 curette adapted to the facial surface of a Fig. 42-30 Gracey #13-14 curette adapted to the distal surface of posterior tooth. a posterior tooth.

Fig. 42-29 Gracey #11-12 curette adapted to the mesial surface Fig. 42-31 Mini Five 13/14 curette adapted to the palatal surface of a posterior tooth. of a maxillary molar with the toe directed distally.

6. Mini Fives are generally used with straight vertical comparison of hand instruments and modified slim ul- strokes. They may also be used with oblique or hori- trasonic tips can be made unless mini-bladed curettes zontal strokes but due to the shortness of the blade, have been fully employed. To date, some research has these strokes might not extend far enough subgingi- been done to compare the effectiveness of mini-bladed vally unless the tissue is very retractable. Horizontal instruments with the modified slim ultrasonic tips. strokes with the Mini Fives are most effective when There is a need for more of these studies to be performed used in the CEJ or in developmental depressions just in vivo to guide clinicians in the optimal utilization of below it. these new types of instruments."

When properly used, mini-bladed Gracey curettes al- REFERENCES low unprecedented access and effectiveness for both nonsurgical and surgical root debridement. One study 1. Barnes JE, Schaffer EM: Subgingival root planing: A compari- has shown that Gracey Curvette curettes performed bet- son using files, hoes, and curets. J Periodontol 1960; 31:300. ter than standard Gracey curettes in deep anterior pock- 2. Garnick JJ, Dent J: A scanning electron micrographical ets.' In areas such as line angles; furcations; and narrow, study of root surfaces and subgingival bacteria after hand scaling and ultrasonic instrumentation. J Periodontol 1989; curved, facial, or palatal root surfaces, these miniature 60:441. curettes provide excellent adaptation with better tactile 3. Garrett JS: Effects of non-surgical periodontal therapy on sensitivity than modified slim ultrasonic tips. Studies periodontitis in humans. A review. J Clin Periodontol 1983; have shown that Gracey Curvette curettes performed 10:515. better than ultrasonic slim tips on deep mandibular an- 4. Green E, Ramfjord SR: Tooth roughness after subgingival terior pockets, furcations and furcation entrances.9,10 No root planing. J Periodontol 1966; 37:396.

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5. Greenstein G: Nonsurgical periodontal therapy in 2000: A 10. Otero-Cagide FJ, Long BA: Comparative in vitro effective- literature review. J Am Dent Assoc 2000; 131(111):1580. ness of closed root debridement with fine instruments on 6. Kerry GJ: Roughness of root surfaces after use of ultrasonic specific areas of mandibular first molar furcations. 1. Furca- instruments and hand curets. J Periodontol 1967; 38:340. tion area. J Periodontol 1997; 68(11):1098. 7. Landry C, Long B, Singer D, et al: Comparison between a 11. Pattison AM: The use of hand instruments in supportive pe- short and a conventional blade periodontal curet: an in riodontal treatment. Periodontol 2000 1996; 12:71. vitro study. J Clin Periodontol 1999; 26(8):548. 12. Schlageter L, Rateitschak-Pluss EM, Schwarz JP: Root surface 8. Orban B, Manella V: Macroscopic and microscopic study of smoothness or roughness following open debridement. An instruments designed for root planing. J Periodontol 1956; in vivo study. J Clin Periodontol 1996; 23(5):460. 27:120. 13. Schaffer EM: Histologic results of root curettage on human 9. Otero-Cagide FJ, Long BA: Comparative in vitro effectiveness teeth. J Periodontol 1956; 27:269. of closed root debridement with fine instruments on specific 14. Van Volkinburg J, Green E, Armitage G: The nature of root areas of mandibular first molar furcations. 1. Root trunk and surfaces after curette, cavitron, and alpha-sonic instrumen- furcation entrance. J Periodontol 1997; 68(11):1093. tation. J Periodont Res 1976; 11:374. 15. Wilkinson RF, Maybury J: Scanning electron microscopy of the root surface following instrumentation. J Periodontol 1973; 44:559. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Color Fig. 30-1 A, Incipient marginal gingivitis. Note the slight puffiness and bleeding (arrow) around the upper right lateral incisor. B, Ede- matous type of gingival inflammation. Note the loss of stippling, increase in size, abundant plaque and materia alba, and change in color. C, Close-up view of edematous type of gingival inflammation. Note the red, shiny, smooth gingiva. D, Fibrocytic type gingival inflammation. Pockets of moderate depth are present, but the gingiva retains its stippling in some areas. E, Severe generalized gingival inflammation and inflammatory gingival enlargement. F, Fibrotic gingival inflammation. Note the abundant calculus and the gingival recession. The patient has pockets of moderate-to-severe depth in the mandibular anterior teeth and more shallow pockets in the maxillary teeth. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Color Fig. 48-1 Results of Phase I therapy. A and B, Severe chronic periodontitis. A, Severe chronic periodontitis characterized by deep pockets, attachment loss, and severe swelling and redness of the gingiva. B, Healing results, 3 weeks after elimination of irritants. Tissue has returned to a more normal contour with redness and swelling dramatically reduced. C to H, Moderate chronic periodontitis. C, Patient presenting with moderate attachment loss and probe depths in the 4- to 6-mm range. Note the gingiva appears pink because it is fibrotic and the inflammation is deep in the periodontal pockets. D, Lingual view pretreatment with more visible inflammation and heavy deposits of calculus. E and F, The same areas with significant improvement in gingival health 18 months after scaling, root planing, and plaque control therapy were provided; the patient returned for regular maintenance visits. G, Presenting radiograph of the lower anterior teeth. H, Radi- ograph taken 18 months after Phase I therapy and maintenance. The follow-up radiograph shows no increase in bone loss during the 18 months. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Sonic and Ultrasonic Instrumentation

Gregor J. Petersilka and Thomas F. Flemmig

CHAPTER

CHAPTER OUTLINE

SONIC SCALERS AND MAGNETOSTRICTIVE AND The Role of Coolant in Subgingival Sonic and PIEZOELECTRIC ULTRASONIC SCALERS Ultrasonic Scaling Safety and Efficacy of Oscillating Scalers Instrument Power Setting Principles of Sonic and Ultrasonic Instrumentation Instrument Grasp and Finger Rest Patient and Operator Positioning Systematic Approach Site Evaluation

ne of the central components of periodontal ther- scalers. Sonic scaler hand-pieces were invented during apy is the removal of the subgingival bacterial the 1960s (e.g., Densonic scaler, Titan S, KaVo Sonic- biofilm and calculus that act as reservoirs for peri flex)62 and operate by compressed air from the dental odontopathogenic microrganisms. Traditionally, root unit. A rotating cam within the instrument hand-piece surface debridement has been carried out with hand in- generates vibrations with frequencies in the range of struments such as curettes. Hand instrumentation is 6000 Hz to 9000 Hz (Fig. 43-2). The vibrations are con- technically demanding, time consuming, tiring, and un- ducted to the scaler tip, which then oscillates, depending comfortable for both the operator and the patient, and on the air pressure input, with an amplitude of up to as a result, numerous power-driven scalers have been de- 1000 j,m in an almost circular motion 20,29,34,59 (Fig. 43-3). veloped during the last decades. Until recently, their use Due to this oscillation pattern, irrespective of the adapta- was mostly limited to supragingival debridement due to tion of the tip to the root surface (i.e., mesial, distal, or bulky working tips. Technologic advances and new de- buccal), plaque and calculus are removed by a tapping signs of ultrasonic and sonic scalers have transformed motion, which is one of the major advantages of the the role of power-driven oscillating instruments in peri- sonic scalers over the ultrasonic scalers (Fig. 43-4). odontal therapy. The probelike, slender instrument tips Magnetostrictive ultrasonic scalers (e.g., Dentsply allow efficient instrumentation of deep periodontal Cavitron, Odontosson) were introduced in the 19505 62 pockets with increased patient comfort and less operator and are either driven by a metal stack consisting of fatigue'°•12,25,54 (Fig. 43-1). Consequently, power-driven nickel-iron alloy strips or a Ferrite Insert inserted into a instrumentation has now become an accepted treatment hand-piece (Figs. 43-5 and 43-6). Inside the hand-piece a modality in periodontal therapy. live coil generates an alternating electromagnetic field that leads to expansion or contraction of the ferromag- SONIC SCALERS AND MAGNETOSTRICTIVE netic material. The resulting vibrations are conducted to AND PIEZOELECTRIC ULTRASONIC SCALERS the scaler tip, causing oscillations with amplitudes of 13 to 72 Am and an elliptical motion pattern at frequencies Oscillating scaler systems can be divided into sonic of 20,000 Hz to 45,000 Hz. 34 Thus depending on the an- scalers and magnetostrictive and piezoelectric ultrasonic gulation of the scaler tip in relation to the root surface, a

607

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Fig. 43-1 Slender ultrasonic and sonic staler tips allowing subgin- Fig. 43-3 Photomicrograph of a sonic staler tip seen perpendicu- gival debridement with oscillating scalers. Top to bottom, Explorer lar to the very end of the tip. Left Tip at rest, showing distinct re- EXS 3A, Sonic Staler tip, Nabers furcation Probe. flections of a light beam. Right, Oscillating tip; reflections describe a circular motion pattern of the oscillation. (Courtesy Dr. B. Ehmke, University of Munster, Germany.)

Safety and Efficacy of Oscillating Sealers It is imperative to adjust the amount of substance removal and, consequently, the use of sonic and ultrasonic staler tips, according to the appropriate phase of periodontal therapy. In initial periodontal therapy an instrument needs to efficiently and rapidly remove tenacious calculus, whereas in maintenance therapy the instruments should efficiently remove bacterial biofilms while minimizing root substance removal . 9-35,12 In particular, during repeated maintenance visits, even minimal substance loss may accumulate over time and may lead to severe root damage. Factors influencing the amount of root substance removed during hand instrumentation have been well evaluated.11,61 Assuming a correct angula- Fig. 43-2 Sonic staler hand-piece fitted with slim staler tip (Type tion of the curette, the number of scaling strokes and the KaVo Sonicflex Lux 2000). lateral force applied represent the two main parameters influencing the efficacy of hand instruments. However, using power-driven oscillating scalers, the instruments' efficacy and safety also depends on instrumentation more or less pronounced hammering or scraping motion time, lateral force, sealer tip angulation, and instrument pattern will result (Fig. 43-4). power setting. In addition, the interactions of the work- Piezoelectric scalers (e.g., Amdent, EMS Piezon Master, ing parameters create a highly complex pattern of sub- Satellec Suprasson) also oscillate with frequencies of stance removal. More detailed information regarding the 20,000 to 45,000 Hz (Fig. 43-7). The vibration is gener- influence of certain working parameters root substance ated by changes in the dimension of a quartz crystal loss for different oscillating sealer systems was gained by caused by the application of an alternating current. The in vitro studies.17-19 For sonic scalers (KaVo Sonicflex Lux resulting oscillation mode of the piezoelectric staler tip 2000, KaVo, Biberach, Germany), lateral force showed is strictly linear with amplitudes up to 72 /_Lm.34 The the same impact on substance loss as staler tip angula- mode of action of the tip is either of a tapping or a scrap- tion. Assuming that a defect depth of 0.5 mm, resulting ing nature, depending on the direction of the sealer tip from repeated subgingival scaling over 10 years of main- toward the root surface (see Fig. 43-4). Instrument power tenance, is clinically acceptable and the same surfaces setting of magnetostrictive and piezoelectric ultrasonic are always scaled, the average defect depth per year scalers can be adjusted by the operator. A higher power should not exceed 50 p,m. With respect to instrument setting increases the amplitude of tip oscillation, how- safety, a resulting defect depth of 50 p,m after 40-second ever, with a constant and stable tip oscillation frequency instrumentation time (average time spent for debride- and motion pattern. ment of a root surface during maintenance within 1

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Fig. 43-4 Schematic drawing showing the differences between the different oscillation patterns of oscillating scaler systems. Left, Sonic scaler; center, Piezoelectric ultrasonic scaler; right, Magnetostrictive ultrasonic scaler. (Modified from Petersilka Gj, Flemmig TF: Subgingival root surface treatment using sonic and ultrasonic scalers. Parodontologie 1999; 3:233.)

Fig. 43-5 Insert used for magnetostrictive ultrasonic scalers. Top, Ferrite Insert (Odontosson) and metal alloy stack insert (Dentsply). Fig. 43-7 Piezoelectric ultrasonic scaler unit (EMS Piezon master 400. (Courtesy Electromedical Systems, Dallas, TX.)

year)' may be acceptable. Thus these instruments can be used safely if the scaler tip is angulated parallel to the root surface and the forces applied do not exceed 2N (Fig. 43-8). However, all other parameter combinations can lead to severe root damage. In magnetostrictive ultrasonic scalers, tip angulation and lateral force also have an almost identical influence on substance removal. For all instrument power settings, assessed higher angulations and lateral forces resulted in greater defect depths. By contrast, an increasing instrument power setting does not lead to a pronounced increase in defect depth. The critical defect depth of 50 p,m can only be maintained if the scaler tip is angulated absolutely parallel to the root surface and the forces used do not exceed 1N (see Fig. 43-8). Fig. 43-6 Magnetostrictive ultrasonic scaling unit (Type Dentsply As piezoelectric ultrasonic scalers show a linear os- Cavijet SLS. (Courtesy Dentsply International, Inc., York, PA). cillation pattern, root substance removal from these

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Fig. 43-8 Defect depth after 40-s instrumentation time with a piezoelectric scaler (right), sonic scaler (center) and magnetostrictive ultrasonic scaler (left). The critical defect depth of 50 Am is marked by the shaded area. (From Flemmig T, Petersilka G, Mehl A, et al: Working parameters of a sonic scaler influencing root substance removal in vitro. Clin Oral Invest 1997; 1:55.)

instruments is mostly influenced by scaler tip angula- In addition, the quality of root surfaces after debride- tion. The greatest increment in defect depth was found ment is of reduced importance, as are the clinical results of with increasing tip angulation from 45 degrees to 90 de- root surface instrumentation. Subgingival root surface grees. In contrast, lateral force and the instrument power roughness does not seem to interfere with healing after setting do not substantially influence substance loss. scaling and root planing. 39,56 Thus it does not appear useful However, if the tip is angulated parallel to the root sur- to reinstrument root surfaces with hand instruments after face, the critical defect depth can be maintained below a clinically detectable smooth surface has been created 50 gym, even if higher application forces up to 2N are with sonic or ultrasonic scalers. Complete instrumentation used (Fig. 43-9). of molar furcational aspects is difficult to achieve either Comparing the efficacy of oscillating scalers revealed with hand or power-driven scalers.16,28,42,43,16 This may be that magnetostrictive ultrasonic scalers remove a larger due to the fact that the average width of molar furcational amount of root substance at all power settings than the entrances is smaller than the working end of conventional piezoelectric ultrasonic scaler. The efficacy of the sonic curets.5 Additionally, even if access with small hand instru- scaler is comparable to the efficacy of a magnetostrictive ments is possible, it is difficult to implement proper work- scaler at low power setting or to the efficacy of the piezo- ing strokes within a furcation in the limited space avail- electric scaler at medium power settings . 44 able. Slim sonic or ultrasonic scaler tips allow access to the furcation and have been shown to be superior to hand instruments in cleaning furcation areas in vitro. 31,40 Principles of Sonic and Ultrasonic Instrumentation Sonic and ultrasonic scalers should not be used when Indications. Indications and contraindications for treating patients with transmissible diseases, since sonic and ultrasonic scaling do not substantially differ aerosol and splatter caused by sonic and ultrasonic from those given for the use of hand instruments in ini- scalers21 are a potential health hazard to the operating tial and supportive periodontal therapy. Clinical studies dental staff. 4,22 Although the amount of microbial con- have shown that achievable attachment gain and pocket tent in an aerosol generated during supragingival ultra- probing depth reduction after the use of hand instru- sonic scaling may be reduced by using a preprocedural ments and sonic or different types of ultrasonic scalers antiseptics rinse, 15,21 subgingival scaling procedures al- are identical.2-31,33 Numerous attempts have been made ways result in the dispersion of blood. Thus splatter and to investigate the quality-that is, the degree of rough- aerosol still might be contaminated with pathogenic mi- ness or root substance after different scaling modali croorganisms. A careful operative technique and the use ties. 1,14,23,24,26,32,36,41,48,55 However, results are equivocal of high volume evacuators aid in minimizing the aerosol and difficult to compare as study designs and results vary dispersion47 and therefore are of high importance for in- greatly. fection control. Since magnetostrictive ultrasonic scalers

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The Role of Coolant in Subgingival Sonic and Ultrasonic Scaling The high frequency oscillation of sonic and ultrasonic scaler tips generates heat which necessitates the application of a cooling irrigation fluid to keep the tissues surrounding the scaler tip within a physiologic temperature range . 37 A flow rate of at least 14 ml/min to 23 ml/min cooling agent22 appears to be sufficient to prevent thermal damages in periodontal pockets as the penetration of the coolant used correlates well with the depth of the pocket treated . 38 However, positioning of high volume evacuators close to the tip reduces the amount of coolant reaching the site being scaled and may lead to excessive heat generation. Since only little lateral dispersion of the irrigation fluid from the scaler tip occurs, bacterial biofilm removal Fig. 43-9 Schematic drawing of the different patterns of the in vivo is most likely caused by mechanical disruption cleaning action of hand instruments versus power-driven oscillating due to the oscillating tip. Possible cleaning mechanisms scalers. Left, Using a hand curette allows a sectionwide cleaning of due to microstreaming effects or cavitation caused by contaminated root surfaces. Right, Complete root surface debride- collapsing microbubbles formed within the coolant sur- ment with oscillating scalers is achieved by carrying out serpentine- rounding the oscillating ultrasonic scalers tip have been li ke, overlapping horizontal strokes in corono-apical direction. detected in vitro. 27,57-60 In addition, cell disruption due to (Modified from Petersilka GJ, Flemmig TF: Subgingival root surface ultrasonic scaling has been shown in filamentous and treatment using sonic and ultrasonic scalers. Parodontologie, 1999; 3:233.) rod-shaped bacteria . 3 However, these effects have not been proven to occur subgingivally, and cavitation is not likely to have an in vitro antimicrobial effect on periodontopathogenic bacteria such as Actinobacillus actinomycetemcomitans or Porphyromonas gingivalis.50 Several studies have evaluated the possible advanta- may interfere with some cardiac pacemakers, their use is geous effects of the use of antimicrobials as a coolant. Al- also not recommended in affected patients due to health though povidone-iodine solutions used as adjunctive ir- concerns. rigation liquid during ultrasonic scaling have been reported to have favorable clinical and microbiologic effects, there is a lack of clinically relevant attachment Patient and Operator Positioning gain.49 In addition, delivery of low concentration (0.1% Patient and operator positioning for sonic and ultrasonic to 0.2 %) chlorhexidine digluconate solutions as an irrig- instrumentation follow the same principles as for hand ant during ultrasonic or sonic scaling does not appear to instrumentation. For instrumentation of the upper arch, have relevant long-term benefits .7,46,51,53 Therefore the the patient is seated in a supine position with the chin use of antimicrobials cannot be considered as scientifi- slightly lifted up. The backrest of the dental chair should cally warranted at this time. be in approximately 45-degree angulation to the floor if treatment is carried out in the mandible. A slight lower- ing of the patient's chin allows good visibility to the lin- Instrument Power Setting gual aspects of the lower front teeth. Good patient posi- The power setting of sonic and ultrasonic scalers influ- tioning should allow the operator to be seated upright; ences the amplitude of tip oscillation. Therefore a high whenever necessary, indirect view or illumination by the instrument setting may generate pronounced aerosol use of dental mirrors should be used. and splatter formation and might reduce the volume of cooling agent that is delivered into the periodontal pocket. As treatment outcome is not significantly altered Site Evaluation by instrument power setting' and high instrument Before each scaling procedure, the clinician should carry power setting might facilitate unnecessary root sub- out a thorough evaluation of the sites to be treated. This stance removal,17-19 power setting should be reduced to a includes evaluation of pocket probing depth, root surface low or medium level whenever possible. anatomy, and morphology (i.e., detection of surface irregularities such as calculus, furcations, or invaginations), as well as an adequate interpretation of radiographic find- Instrument Grasp and Finger Rest ings. In combination with detailed anatomic knowledge, To allow maximum instrument stabilization the instru- the operator should be able to develop a three dimen- ment hand-piece should be held using a modified pen

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Fig. 43-11 Systematic approach of cleaning a root surface with sli m scaler tips. The tip is applied parallel to the long axis of the tooth. Additionally, an oblique insertion of the tip for cleaning the Fig. 43-10 Sample of scaler tip systems showing a left and right contralateral interdental surface is recommended. Irrespective of offset angulation. Note the correct application of the scaler tips to the orientation to the long axis of the tooth, the tip needs to be ap- the root surface as the convex part is applied to the root surface only. plied parallel to the root surface treated to avoid root surface damage. (Modified from Petersilka GJ, Flemmig TF: Subgingival root surface treatment using sonic and ultrasonic scalers. Parodontologie 1999; 3:233.)

grasp. With hand instrumentation an intraoral finger rest is recommended for instrumentation of teeth in the lower arch and in the upper front segment. An extraoral 43-11).41 Using the concave side as a working surface palm rest should be chosen while instrumenting maxil- bears the risk that the instrument tip will be applied per- lary posterior teeth, with the back of the hand in the right maxillary area or with the palm of the hand in the pendicular to the root surface leading to unnecessary left area respectively. gauging and root surface damage. The left bent tip is used for the instrumentation of the maxillary right posterior facial aspect, the maxillary front teeth palatal as- Systematic Approach pect and the maxillary left palatal aspect (Fig. 43-12). In addition, the contralateral approximal tooth surfaces Studies to date have failed to confirm that power- may be cleaned with the same left offset tip inserted in driven root instrumentation is much more rapid than an almost oblique/horizontal position (see Fig. 43-11). hand instrumentation .2,30,55 Experienced operators have The right offset tip is used to instrument the remaining been shown to instrument root surfaces more thor- areas to be treated (see Fig. oughly, 6,13.16.28 so a systematic approach in learning the 43-12). For instrumentation use of power-driven instruments is necessary to achieve in the mandible the left offset tip should be used for the the best clinical results. The application and implemen- right lingual molar area, the lower buccal frontal seg- tation of sonic and ultrasonic instruments is different ment, and the lower left buccal posterior area. As in the from that required for hand instrumentation. Plaque and maxilla, the right bent tip is used for the instrumenta- calculus removal with hand instruments is achieved by tion of the corresponding sites remaining to be treated (see Fig. 43-11). carrying out a series of overlapping vertical strokes around the circumference of the tooth. Because the con- By using this systematic approach, a complete and ef- tact surface between a rounded power-driven scaler tip ficient instrumentation of the entire dentition is attainable and both patient and operator will benefit from the and the spherical root surface is rather small, thorough use of sonic and ultrasonic scalers. mechanical debridement can only be attained by a series of overlapping horizontal serpentine-like strokes in a REFERENCES coronal-apical direction (Fig 43-10). Using the appropriate working parameters and instrument settings, roots 1. Allen E, Rhoads R: Effects of high-speed periodontal instru- should be instrumented with the scaler tip in constant ments on tooth surfaces. J Periodontol 1963; 34:352. motion until the surface feels smooth and clean. The use 2. Badersten A, Nilveus R, Egelberg J: Effect of nonsurgical pe- of an explorer helps detect residual calculus and prevents riodontal therapy. 1. J Clin Periodontol 1981; 8:57. inadvertent root overinstrumentation. To allow suffi- 3. Baehni P, Thilo B, Chapuis B, et al: Effects of ultrasonic and cient access to all tooth surfaces within the whole denti- sonic scalers on dental plaque microflora in vitro and in vivo. tion, most sonic and ultrasonic scaler systems operate J Clin Periodontol 1992; 19:455. with two different working tips showing a left and right 4. Barnes JB, Harrel SK, Rivera-Hidalgo F: Blood contamination offset angulation (Fig. 43-10). of the aerosols produced by in vivo use of ultrasonic scalers. For the use of these slim J Periodontol instruments it is of utmost importance that they be in- 1998; 69:434. 5. Bower RC: Furcation morphology relative to periodontal serted into the pocket in a manner in which the convex treatment. Furcation entrance architecture. J Periodontol working surface of the tip is in contact to the root (Fig. 1979; 50:23. Sonic and Ultrasonic Instrumentation • CHAPTER 43 613 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 43-12 Areas of the dentition to be debrided with area indicated by red line (left) or the area indicated by green line (right) offset angulated tips. The approximal areas indicated by arrows might be treated with the scaler tip inserted horizontally, but parallel to the root surface. (Modified from Petersilka Gi, Flemmig TF: Subgingival root surface treatment using sonic and ultrasonic scalers. Parodontologie 1999; 3:233.)

6. Brayer WK, Mellonig JT, Duinlap RM, et al: Scaling and root 17. Flemmig T, Petersilka G, Mehl A, et al: Working parameters planing effectiveness: The effect of root surface access and of a sonic scaler influencing root substance removal in vitro. operator experience. J Periodontol 1989; 60:67. Clin Oral Invest 1997; 1:55. 7. Chapple ILC, Walmsley AD, Saxby MS, et al: Effect of sub- 18. Flemmig T, Petersilka G, Mehl A, et al: The effect of working gingival irrigation with chlorhexidine during ultrasonic parameters on root substance removal using a piezoelectric scaling. J Periodontol 1992; 63:812. ultrasonic scaler in vitro. J Clin Periodontol 1998; 25:158. 8. Chapple ILC, Walmsley AD, Saxby MS, et al: Effect of in- 19. Flemmig T, Petersilka G, Mehl A, et al: Working parameters strument power setting during ultrasonic scaling upon of a magnetostrictive ultrasonic scaler influencing root sub- treatment outcome. J Periodontol 1995; 66:56. stance removal in vitro. J Periodontol 1998; 69:547. 9. Cheetham WA, Wilson M, Kieser JB: Root surface debride- 20. Gankerseer EJ, Walmsley AD: Preliminary investigation into ment: An in vitro assessment. J Clin Periodontol 1988; the performance of a sonic scaler. J Periodontol 1987; 8:780. 15:288. 21. Gross KB, Overman PR, Cobb C, et al: Aerosol generation by 10. Clifford LR, Needleman IG, Chan YK: Comparison of peri- two ultrasonic scalers and one sonic scaler. A comparative odontal pocket penetration by conventional and microul- study. J Dent Hyg 1992; 66:314. trasonic inserts. J Clin Periodontol 1996; 26:124. 22. Harrel SK, Barnes JB, Rivera-Hidalgo F: Reduction of aerosols 11. Coldiron NB, Yukna RA, Weir J, et al: A quantitative study produced by ultrasonic scalers. J Periodontol 1996; 67:28. of cementum removal with hand curettes. J Periodontol 23. Jones S, Lozdan J, Boyde A: Tooth surfaces treated in situ 1990; 61:293-299. with periodontal instruments. Scanning electron micro- 12. Dragoo M: A clinical evaluation of hand and ultrasonic in- scopic studies. Br Dent J 1972; 132:57. struments on subgingival debridement. I. With unmodified 24. Jotikashtira N, Lie T, Leknes K: Comparative in vitro studies and modified ultrasonic inserts. Int J Perio Res Dent 1992; of sonic, ultrasonic and reciprocating scaling instruments. J 12:311. Clin Periodontol 1992; 19:560. 13. Eaton KA, Kieser JB, Davies RM: The removal of root sub- 25. Kawanami M, Sugaya T, Kato S, et al: Efficacy of an ultra- stance deposits. J Clin Periodontol 1985; 12:141. sonic scaler with a periodontal probe-type tip in deep peri- 14. Ewen S, Scopp 1, Witkin R, et al: A comparative study of ul- odontal pockets. Adv Dent Res 1988; 2:405. trasonic generators and hand instruments. J Periodontol 26. Kerry G: Roughness of root surfaces after use of ultrasonic 1976; 47:82. instruments and hand curettes. J Periodontol 1967; 38:340. 15. Fine DH, Mendieta C, Barnett ML, et al: Efficacy of prepro- 27. Khambay BS, Walmsley AD: Acoustic microstreaming: De- cedural rinsing with an antiseptic in reducing viable bacte- tection and measurement around ultrasonic scalers. J Peri- ria in dental aerosols. J Periodontol 1992; 63:821. odontol 1999; 70:626. 16. Fleischer HC, Mellonig JT, Brayer WK, et al: Scaling and root 28. Kocher T, Ruhling A, Momsen H, et al: Effectiveness of sub- planing efficacy in multirooted teeth. J Periodontol 1989; gingival instrumentation with power-driven instruments in 60:402. the hands of experienced an inexperienced operators. A study on manikins. J Clin Periodontol 1997; 24:498.

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29. Kocher T, Plagmann HC: The diamond-coated sonic scaler 46. Reynolds MA, Lavigne CK, Minah GE, et al: Clinical effects tip. I. Oscillation pattern of different sonic scalers. Int J Peri- of simultaneous ultrasonic scaling and subgingival irriga- odont Rest Dent 1997; 17:393. tion with chlorhexidine. Mediating influence of periodontal 30. Laurell L, Petterson B: Periodontal healing after treatment probing depth. J Clin Periodontol 1992; 19:595. with the Titan-S sonic scaler or hand instruments. Swed 47. Rivera-Hidalgo F, Barnes JB, Harrel SK: Aerosol and splatter Dent J 1988; 12:187. production by focused spray and standard ultrasonic in- 31. Leon LE, Vogel RI: A comparison of the effectiveness of serts. J Periodontol 1999; 70:473. hand scaling and ultrasonic debridement in furcations as 48. Rosenberg R, Ash M: The effect of root roughness on plaque evaluated by differential dark-field microscopy. J Periodon- accumulation and gingival inflammation. J Periodontol tol 1987; 58:86. 1974; 45:146. 32. Lie T, Meyer K: Calculus removal and loss of tooth sub- 49. Rosling BG, Slots J, Christersson LA, et al: Topical antimi- stance in response to different periodontal instruments: A crobial therapy and diagnosis of subgingival bacteria in the scanning electron microscope study. J Clin Periodontol management of periodontal disease. J Clin Periodontol 1977; 4:340. 1986, 13:975. 33. Loos B, Kiger R, Egelberg J: An evaluation of basic periodon- 50. Schenk G, Flemmig TF, Lob S, et al: Lack of antimicrobial ef- tal therapy using sonic and ultrasonic scalers. J Clin Peri- fect on periodontopathogenic bacteria by ultrasonic and odontol 1987; 14:25. sonic scalers in vitro. J Clin Periodontol 1999; 27(2):116. 34. Menne A, Griesinger H, Jepsen S, et al: Vibration character- 51. Shiloah J, Patters MR: DNA probe analysis of selected peri- istics of oscillating scalers. J Dent Res 1994; 73:434. odontal pathogens following scaling, root planing, and in- 35. Moore J, Wilson M, Kieser JB: The distribution of bacterial trapocket irrigation. J Periodontol 1994; 65:568. lipopolysaccharide (endotoxin) in relation to periodontally 52. Smart GJ, Wilson M, Davies EH, et al: The assessment of ul- involved root surfaces. J Clin Periodontol 1986; 13:748. trasonic root surface debridement by determination of 36. Moskow B, Bressmann E: Cemental response to ultrasonic residual endotoxin levels. J Clin Periodontol 1990; 17:174. and hand instrumentation. J Am Dent Ass 1964; 68:698. 53. Taggart JA, Palmer RM, Wilson RF: A clinical and microbio- 37. Nicoll BK, Peters RJ: Heat generation during ultrasonic in- logical comparison of the effects of water and 0.02% chlor- strumentation of dentin as affected by different irrigation hexidine as coolants during ultrasonic scaling and root methods. J Periodontol 1998; 69:884. planing. J Clin Periodontol 1999; 17:32. 38. Nosal G, Scheidt M, O'Neal R, et al: The penetration of 54. Torfason T, Kiger R, Selvig A, et al: Clinical improvement of lavage solution into the periodontal pocket during ultra- gingival conditions following ultrasonic versus hand instru- sonic instrumentation. J Periodontol 1991; 62:554. mentation of periodontal pockets. J Clin Periodontol 1979; 39. Oberholzer R, Rateitschak K: Root cleaning or root smooth- 6:165. ing. An in vivo study. J Clin Periodontol 1996; 23:326. 55. Van Volkinburg J, Green E, Armitage G: The nature of root 40. Oda S, Ishikawa 1: In vitro effectiveness of a newly designed surfaces after curette, Cavitron and alpha-sonic instrumen- ultrasonic scaler tip for furcation areas. J Periodontol 1989; tation. J Periodont Res 1976; 11:374. 60:634. 56. Waerhaugh J: Effect of rough surfaces upon gingival tissues. 41. Pameijer C, Stallard R, Hiep N: Surface characteristics of Int Dent J 1956; 45:322. teeth following periodontal instrumentation: A scanning 57. Waerhaugh J: The furcation problem. Etiology, pathogene- electron microscope study. J Periodontol 1972; 43:628. sis, diagnosis, therapy and prognosis. J Clin Periodontol 42. Parashis AO, Anagnou-Vareltzides A, Demetriou N: Calculus 1980; 7:73. removal from multirooted teeth with and without surgical 58. Walmsley AD, Laird WRE, Williams AR: A model system to access. I. Efficacy on external and furcation surfaces in rela- demonstrate the role of cavitational activity in ultrasonic tion to probing depth. J Clin Periodontol 1993; 20:294. scaling. J Dent Res 1984; 63:1162. 43. Parashis AO, Anagnou-Vareltzides A, Demetriou N: Calculus 59. Walmsley AD, Laird WRE, Williams AR: Dental plaque re- removal from multirooted teeth with and without surgical moval by cavitational activity during ultrasonic scaling. access. 11. Comparison between external and furcation sur J Clin Periodontol 1988; 15:539. faces and effect of furcation entrance width. J Clin Peri- 60. Walmsley AD, Walsh TF, Laird WRE, et al: Effects of cavita- odontol 1993; 20:294. tional activity on the root surface of the teeth during ultra- 44. Petersilka GJ, Flemmig TF, Mehl A, et al: Comparison of root sonic scaling. J Clin Periodontol 1990; 17:306-312. substance removal by magnetostrictive and piezoelectric ul- 61. Zappa U, Smith B, Simona C, et al: Root substance removal trasonic and sonic scalers in vitro. J Clin Periodontol 1997; by scaling and root planing. J Periodontol 1991; 62:750-754. 24(abstr 70):864. 62. Zinner DD: Recent ultrasonic dental studies, including 45. Petersilka GJ, Flemmig TF: Subgingival root surface treat- periodontia, without the use of an abrasive. JADA 1955; ment using sonic- and ultrasonic scalers. Parodontologie 59:636-639. 1999; 3:233. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Supragingival and Subgingival Irrigation

Thomas F. Flemmig

CHAPTER

CHAPTER OUTLINE

I RRIGATOR DEVICES SUBGINGIVAL IRRIGATION SUPRAGINGIVAL IRRIGATION Subgingival Irrigation as a Monotherapy Supragingival Irrigation as a Monotherapy for Periodontitis Supragingival Water Irrigation and Toothbrushing Antimicrobial Agents and Scaling and Root Planing Antimicrobial Agents and Toothbrushing SAFETY OF IRRIGATION

n the treatment of periodontal diseases, irrigation is compression and may impair removal of bacteria. The used as a lavage to flush away the bacteria that are in majority of information available on the therapeutic contact with the periodontal tissues. Irrigation is a effects of supragingival irrigation are based on studies us- nonspecific reduction of plaque bacteria. The two types ing pulsating monojet irrigators, and multistreamed irri- of irrigation are supragingival and subgingival irrigation. gators have been insufficiently examined to date. For this They vary by the depth to which the irrigant is projected reason, pulsating monojet irrigators are preferred for into the gingival or periodontal pocket. In supragingival supragingival irrigation. irrigation, the irrigant penetrates 29% to 71% of shallow pockets, and 44% to 68% of moderately deep and deep pockets9,21 compared with 75% to 93% of the periodon- SUPRAGINGIVAL IRRI GATION tal pocket that is penetrated by subgingival irriga- Supragingival irrigation is usually performed once or tion.9,12,30 Mouth rinses penetrate only 4% of the pocket twice daily by the patient as an adjunct to toothbrushing depth and are therefore largely restricted to the supragin- and flossing. The irrigator's nozzle should be positioned gival area55 (Fig. 44-1). at some distance from the gingival margin and the jet stream lined perpendicular to the long axis of the teeth to achieve optimal subgingival penetration of an I RRIGATOR DEVICES irrigant" (Fig. 44-3). Irrigation pressures of 540 kPa to A number of irrigators offered today vary by irrigation 620 kPa (80 psi to 90 psi) can be tolerated without ad- pressure, water stream characteristics, and jet type design. verse effects.8,9 No histologic alteration of the gingiva has A syringe can also be used for delivering a solution to irri- been observed after supragingival irrigation at a pressure gate the pocket (Fig. 44-2). Monojet or multistreamed jet of 410 kPa (60 psi). 6 tips are available for supragingival irrigation, as well as blunted cannulae with end or side parts for subgingival irrigation. In most units the irrigation pressure is pro- Supragingival Irrigation as a Monotherapy duced by an electrical pump and is delivered in a contin- Supragingival irrigation with water alone does not suffi- uous or pulsating stream. The alternating compression ciently prevent plaque accumulation nor gingivitis. In and decompression phases in pulsating irrigators may fa- this respect, supragingival irrigation is clearly inferior to cilitate the displacement of plaque bacteria.7 A continu- mechanical plaque control such as using conventional ous flow of water during irrigation causes constant tissue oral hygiene measures . 33 Thus supragingival irrigation

615

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Fig. 44-1 Subgingival penetration of solutions delivered by supragingival or subgingival irrigation and rins- i ng in percent of pocket depth.

Fig. 44-2 Devices for supra- and subgingival irrigation. Fig. 44-3 Positioning of various irrigator tips for supragingival (extreme right) and subgingival irrigation (others).

cannot replace toothbrushing and should only be used strated that this method in conjunction with tooth- as an adjunct to toothbrushing and interdental cleaning. brushing can improve the periodontal health in patients with gingivitis and/or periodontitis, particularly for Supragingival Water Irrigation and Toothbrushing patients with clinical signs of gingival inflammation and/or poor oral hygiene 13,25,26,34,49 (Fig. 44-4). However, Although earlier studies concerning supragingival water patients with low plaque scores (i.e., good oral hygiene) irrigation as an adjunct to toothbrushing yielded contro- have no additional benefit from supragingival irriga- versial results, 18,22,32,33 recent studies have clearly demon- tion", 33 (Fig. 44-5).

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Fig. 44-4 Covariance adjusted mean plaque index scores (PLI) and percent of sites with bleeding on probing (BOP) in patients with naturally occurring gingivitis after 6 months of adjunctive irrigation. Supragingival irrigation was performed with 500 ml water (W-I) or 300 ml of water immediately followed by irrigation of 200 ml 0.06% chlorhexidine digluconate (CHX-I). Adjunctive rinsing with 15 ml of 0.12% chlorhexidine digluconate for 30 seconds twice daily (CHX-R) and toothbrushing alone (TB) were used as positive and negative controls, respectively. All groups performed regular tooth brushing .25

The therapeutic effects of supragingival irrigation with water on gingival inflammation is considerable and has been shown to be equivalent to twice daily mouth rinsing with 0.12% chlorhexidine digluconate solution in patients with gingivitis25 (see Fig. 44-4). Daily supragingival irrigation with water after initial therapy may also improve gingival health among patients with periodontitis.3 In patients receiving regular supportive periodontal therapy, daily supragingival irrigation with water can significantly reduce gingival inflammation and bleeding on probing. 26,49 Interestingly, supragingival irrigation with water has only limited effects on plaque scores-that is, supragingival plaque mass or the composition of the subgingival microflora. 17,20,25,26,48 Earlier reports of direct bactericidal effects from irrigation resulting in the reduction of bacterial cell contents" have not been confirmed. Thus it may be possible that supragingival irrigation reduces gingival inflammation without altering the supra- and subgingival plaque. Al- though the responsible mechanism for the antiinflammatory effect is not clearly known, it can be assumed that through supragingival irrigation, there is a dilution or a removal of bacterial toxins, an interference with Fig. 44-5 Correlation between the reduction of bleeding on prob- plaque maturation, or a possibility that the unattached ing by adjunctive supragingival irrigation with water and initial plaque may be washed away. One may also speculate bleeding on probing score. that the additional bacteremia caused by supragingival irrigation23,57 may stimulate the production of specific antibodies directed against periodontal pathogens . 62 Such antibodies have been shown to be protective and croflora compared to mouth rinsing. 9,21,55 The minimal reduce periodontal disease progression .5.29 effective dosage for once daily supragingival irrigation with chlorhexidine digluconate has been established to be 400 ml of a 0.02% solution.39 Antimicrobial Agents and Toothbrushing In patients with gingivitis using antimicrobials with Enhanced penetration of antimicrobials into the peri- supragingival irrigation (e.g., 200 ml of 0.06% chlorhexi- odontal pocket delivered by supragingival irrigation has dine digluconate), there is a greater reduction of gingival been speculated to better control the subgingival mi- inflammation compared to irrigation with only water" ,"

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or mouth rinsing with antimicrobials.25,38,54 The superior SUBGINGIVAL IRRIGATION antiinflammatory effects of supragingival irrigation with Numerous studies have assessed the potential benefit of 0.06% chlorhexidine digluconate is also accompanied subgingival irrigation using various irrigants in the treat- by a reduction of supragingival plaque and black-pig- ment of periodontitis; however, its benefit remains ques- mented bacteria, as well as other gram negative anaero- tionable due to controversial results . 27,59 To penetrate the bic rods in the subgingival plaque .48 However, not all periodontal pocket near its base by 75% to 93%,9,12,30 antimicrobial agents are beneficial as an irrigant. The rubber tip nozzles are positioned at the gingival margin 12 use of 0.00225% sanguinaria solution or a solution of or blunted cannulas with an end or side port are inserted thymol, menthol, eucalyptus, and methylsalicilate as an into the periodontal pocket30 (see Fig. 44-3). Ejection site irrigant did not improve the therapeutic effects of the pressures at the opening of various tip designs have been supragingival irrigation when compared with water or a demonstrated to range from 0.7 kPa to 35 kPa (0.1 psi to placebo irrigant. 16,5 4 5 psi) and were lowest in side port systems . 9,41 Care Gingival health, was significantly improved in pa- should be taken not to block the opening of the canula tients with periodontitis after scaling and supragingival to prevent excessive pressure buildup. Irrigating devices irrigation with 0.2% chlorhexidine digluconate or 0.02% similar to those employed for supragingival irrigation or stannous fluoride compared to only supragingival irriga- syringes have been used for the delivery of solutions. tion with water. 8,70 Lower concentrations of chlorhexi- Similar subgingival penetration can be achieved using dine digluconate (0.02%) or metronidazole (0.05%) solu- the side or end port cannulas .41 tion used over 4 weeks after initial therapy in patients Several factors limit the irrigant from reaching the with periodontitis demonstrated no differences in reduc- base of the pocket. The lateral dispersion of the subgingi- ing gingival inflammation compared with supragingival vally irrigated solution 51 and the presence of calculus de- irrigation with water.' posits impair the subgingival penetration into deep pock- The relatively high daily dosage of chlorhexidine ets of 7 to 10 mm. 41 To bring the irrigant into contact digluconate needed for supragingival irrigation is also with all root surfaces, scaling and root planing should financially more costly compared with mouth rins- precede subgingival irrigation, and irrigation should be ing.2,28,44 Thus the incremental benefit of using an an- performed circumferentially. Practical considerations, as timicrobial agent versus water for supragingival irrigation well as patient dexterity and compliance, dictate that the and delivering an antimicrobial agent by supragingival ir- use of cannulas be limited to professionals, whereas rub- rigation compared with application by mouth rinsing ber tip irrigators can be applied by the patient. However, should be weighed against the long-term costs. it has been reported that some instructed patients may be It is noteworthy that there is a significant elevation of able to successfully use a blunted canula for subgingival calculus formation, tooth and tongue staining, and taste irrigation. 1,74 Patient-applied subgingival irrigation can be impairment that occurs from the long-term use of performed on a daily basis, whereas professionally per- chlorhexidine digluconate25,40 (Fig. 44-6). In addition, formed irrigation requires the patient to visit the dentist few patients tolerate the esthetically compromising and is therefore limited to several applications per year. brown teeth stains that may appear over time with prolonged use. Although chlorhexidine digluconate may be safely applied long term ,44 its side effects have usually Subgingival Irrigation as a Monotherapy limited its use to short periods. for Periodontitis Several studies have demonstrated that subgingival irrigation with antimicrobial agents (e.g., 0.2% chlorhexidine digluconate solution, 1% chlorhexidine digluconate gel, 0.4% or 1.6% stannous fluoride, 0.5% tetracycline HCI, 7% tetrapotassium peroxydiphosphate, 3% hydrogen peroxide, or 0.5% metronidazole) resulted in a transient reduction of spirochetes, motile bacteria, and/or black-pigmented anaerobic rods in subgingival plaque. However, a rebound to pretreatment levels occurred within 1 to 8 weeks.31,37,42,43,47,58,60,72,73 Clinically, supragingival plaque scores were reduced and periodontal health was somewhat improved after subgingival irrigation.10,24,31,37,42,43,47,58,60,63,71,73 However, no difference was found between an antimicrobial agent or saline as the subgingival irrigant. 31,35,37,43,71,73 When compared with scaling and root planing, subgingival irrigation as a monotherapy had only limited effects on the subgingival microflora with low clinical benefits .42,43,58,71,73 Therefore applying subgingival irrigation with water or antimicrobial agents as the sole therapeutic method is insufficient Fig. 44-6 Extrinsic tooth staining after long-term application of to treat periodontitis and should not be performed in chlorhexidine digluconate. lieu of scaling and root planing.

Supragingival and Subgingival Irrigation • CHAPTER 44 61 9 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com Antimicrobial Agents and Scaling and Root Planing longer observation periods .25,26,49 In addition, no micro- It is well documented that mechanical debridement of morphologic changes of periodontal tissues after supra- deep pockets is often incomplete with residual subgingi- gingival irrigation have been found.' There has only val plaque and/or calculus remaining in the pocket.14.56,66 been one recent report on extensive tissue necrosis and The rationale for subgingival irrigation with an antimicro- permanent loss of alveolar bone after subgingival irriga- bial agent after scaling and root planing is based on the tion with 2% stannous fluoride . 62 assumption that bacteria left behind during mechanical It is important to know that the use of irrigators like debridement could be killed by the so-applied antimicro- toothbrushing and subgingival scaling 23,57 can cause bial solution. However, several factors impede the efficacy transient bacteremia. Although the incidence of tran- of antimicrobial agents delivered into the periodontal sient bacteremia after toothbrushing or subgingival scal- pocket. ing is not significantly increased by supragingival irriga- Due to the outwardly directed gingival crevicular fluid tion67,69 or subgingival irrigation,45 it may be prudent flow, antimicrobial agents irrigated subgingivally may not not to recommend irrigation for patients requiring pre- be in contact with the subgingival microflora long medication for bacterial endocarditis. 19 enough to be effective. The half-life time of subgingivally injected agents has been shown to be approximately 13 REFERENCES minutes .53 After subgingival irrigation for 5 minutes with 0.12% chlorhexidine, no chlorhexidine at antimicrobially 1. Asari AM, Newman HN, Wilson M, et al: 0.1%/0.2% com- effective levels remained in the periodontal pocket . 64 mercial chlorhexidine solution as subgingival irrigants in Chlorhexidine digluconate inhibits the majority of chronic periodontitis. J Clin Periodontol 1996; 23:320. 2. Axelsson P, Lindhe J: Efficacy of mouthrinses in inhibiting subgingival bacteria in vitro at concentrations attainable dental plaque and gingivitis. J Clin Periodontol 1987; 14:205. in vivo4,61 and may be inactivated when in contact with 3. Aziz-Gandour IA, Newman HN: The effects of a simplified blood components in the periodontal pocket . 52 A 0.5% oral hygiene regime plus supragingival irrigation with chlorhexidine digluconate solution required a longer chlorhexidine or metronidazole on chronic inflammatory contact time to eliminate periodontal pathogens in the periodontal disease. J Clin Periodontol 1986; 13:228. presence of serum . 52 Considering the biofilm structure of 4. Baker PJ, Coburn RA, Genco RJ, et al: Structural determi- subgingival plaque61 and its effect on the activity of an- nants of activity of chlorhexidine and alkyl bisbiguanides timicrobial agents, it becomes rather unlikely that sub- against the human oral flora. J Dent Res 1987; 66:1099. gingivally irrigated solutions have a profound effect on 5. Beikler T, Karch H, Ehmke B, et al: Protective effect of serum the subgingival microflora. For example, when Streptococ- antibodies against a 110-kilodalton protein of Actinobacil- lus actinomycetemcomitans following periodontal therapy. cus sanguis was exposed to 0.2% chlorhexidine diglu- Oral Microbiol Immunol 1999; 14:281. conate or 0.05% cetylpyridinium chloride, no viable 6. Bhaskar SN, Cutright DE, Frisch J: Effect of high pressure bacteria were detected after 5 minutes of exposure water jet on oral mucosa of varied density. J Periodontol of planktonic cells. However, the same bacterium was 1969; 40:593. shown to survive in biofilms even after exposure to 7. Bhaskar SN, Cutright DE, Gross A, et al: Water jet devices in chlorhexidine digluconate or cetylpyridinium chloride dental practice. J Periodontol 1971; 42:658. for 4 hours.75 Also, 50 to 5000 times higher concentra- 8. Boyd RL, Leggott P, Quinn R, et al: Effect of self-adminis- tions of antimicrobials are needed to kill bacteria that tered daily irrigation with 0.02% SnF2 on periodontal dis- are embeded in a biofilm compared with planktonic bac- ease activity. J Clin Periodontol 1985; 12:420. teria .36,5° These considerations may explain why Subgin- 9. Boyd RL, Hollander BN, Eakle WS: Comparison of a subgingivally placed cannula oral irrigator tip with a supragingi- gival irrigation with 0.12% chlorhexidine digluconate vally placed standard irrigator tip. J Clin Periodontol 1992; is of limited benefit as an adjunct to scaling and root 19:340. planing. 10,46,65,71,72 10. Braatz L, Garrett S, Claffey N, et al: Antimicrobial irrigation Only subgingival irrigation with 50 mg/ml to of deep pockets to supplement non-surgical periodontal 100 mg/ml tetracycline HCl for 5 minutes per tooth after therapy. 11. Daily irrigation. J Clin Periodontol 1985; 12:630. scaling and root planing results in an effective release of 11. Brady JM, Gray WA, Bhaskar SN: Electron microscopic study tetracycline HCl from root surfaces at antimicrobial con- of the effect of water jet lavage devices on dental plaque. centrations over 4 to 7 days due to the binding of tetra- J Dent Res 1973; 52:1310. cycline to the root surface. 15,64 Some improvements in 12. Braun RE, Ciancio SG: Subgingival delivery by an oral irriga- clinical attachment gain over scaling and root planing tion device. J Periodontol 1992; 63:469. 13. Brownstein CN, Briggs SD, Schweitzer KL, et al: Irrigation alone have also been reported. with chlorhexidine to resolve naturally occurring gingivitis. The preponderance of information available to date, A methodologic study. J Clin Periodontol 1990; 17:588. however, gives little evidence that suggests that adjunc- 14. Caffessee RG, Sweeny PL, Smith BA: Scaling and root plan- tive subgingival irrigation has a substantial long-term ing with and without periodontal flap surgery. J Clin Peri- benefit beyond its use in scaling and root planing. odontol 1986; 13:205. 15. Christenson LA, Norderyd OM, Puchalsky CS: Topical application of tetracycline-HCI in human periodontitis. J Clin SAFETY OF IRRIGATION Periodontol 1993; 20:88. Supragingival irrigation appears to be a safe method of 16. Ciancio SG, Mather ML, Zambon JJ, et al: Effect of chemo- treatment. Daily supragingival irrigation with water has therapeutic agent delivered by an oral irrigation device on shown no clinically significant adverse effects over plaque, gingivitis, and subgingival microflora. J Periodontol 1989; 60:310.

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17. Cobb CM, Rodgers RL, Killoy WJ: Ultrastructural examina- 38. Lang NP, Raber K: Use of oral irrigators as vehicles for the tion of human periodontal pockets following the use of an application of antimicrobial agents in chemical plaque con- oral irrigation device in vivo. J Periodontol 1988; 59:155. trol. J Clin Periodontol 1981; 8:177. 18. Covin NR, Lainson PA, Belding JH, et al: The effects of stim- 39. Lang NP, Ramseier-Grossman K: Optimal dosage of ulating the gingiva by a pulsating water device. J Periodon- chlorhexidine digluconate in chemical plaque control when tol 1973; 44:286. applied by the oral irrigator. J Clin Periodontol 1981; 8:189. 19. Dajani AS, Taubert KA, Wilson W: Prevention of bacterial 40. Lang NP, Catalanotto FA, Knopfli RU, et al: Quality-specific endocarditis. Recommendations by the American Heart As- taste impairment following the application of chlorhexi- sociation. JAMA 1997; 277:1794. dine gluconate mouthrinse. J Clin Periodontol 1988; 15:43. 20. Drisko GL, White CL, Killoy WJ, et al: Comparison of dark- 41. Larner JR, Greenstein G: Effect of calculus and irrigator tip field microscopy and a flagella stain for monitoring the ef- design on depth of subgingival irrigation. Int J Periodontics fect of a Water Pik on bacterial motility. J Periodontol 1987; Restorative Dent 1993; 13:288. 58:381. 42. Lazzaro AJ, Bissada NF: Clinical and microbiologic changes 21. Eakle WS, Ford C, Boyd RL: Depth of penetration in peri- following the irrigation of periodontal pockets with metro- odontal pockets with oral irrigation. J Clin Periodontol nidazole or stannous fluoride. Periodont Case Rep 1989; 1986; 13:39. 11:12. 22. Emslie RD: The value of oral hygiene. Br Dent J 1964; 43. Listgarten MA, Grossberg D, Schwimer C, et al: Effect of 117:373. subgingival irrigation with tetrapotassium peroxydiphos- 23. Felix J, Rosen S, App G: Detection of bacteremia after use of phate on scaled and untreated periodontal pockets. J Peri- an oral irrigation device in subjects with periodontitis. J Pe- odontol 1989; 60:4. riodontol 1971; 42:785. 44. Loe H, Schiott CR, Glavind L, et al: Two years oral use of 24. Fine JB, Harper DS, Gordon JM, et al: Short-term microbio- chlorhexidine in man. 1. General design and clinical effects. logical and clinical effects of subgingival irrigation with an J Periodont Res 1976; 17:135. antimicrobial mouthrinse. J Periodontol 1994; 65:30. 45. Lofthus JE, Waki MY, Jolkovsky DL, et al: Bacteremia follow- 25. Flemmig TF, Newman MG, Doherty FM, et al: Supragingival ing subgingival irrigation and scaling and root planing. irrigation with 0.06% chlorhexidine in naturally occurring J Periodontol 1991; 62:602. gingivitis. I. 6-month clinical observations. J Periodontol 46. MacAlpine R, Magnusson I, Kiger R, et al: Antimicrobial irri- 1990; 61:112. gation of deep pockets to supplement oral hygiene instruc- 26. Flemmig TF, Epp B, Funkenhauser Z, et al: Adjunctive supra- tion and root debridement. J Clin Periodontol 1985; 12:568. gingival irrigation with acetylsalicylic acid in periodontal 47. Mazza JE, Newman MG, Sims TN: Clinical and antimicro- supportive therapy. J Clin Periodontol 1995; 22:427. bial effect of stannous fluoride on periodontitis. J Clin Peri- 27. Greenstein G: Subgingival irrigations ability to enhance pe- odontol 1981; 8:203. riodontal status. J Periodontol 1987; 58:827. 48. Newman MG, Flemmig TF, Nachnanf S, et al: Irrigation 28. Grossman E, Meckel AH, Isaacs R, et al: A clinical compari- with 0.06% chlorhexidine in naturally occurring gingivitis. son of antibacterial mouthrinses: Effects of chlorhexidine, II. 6-month microbiological observations. J Periodontol phenotics, and sanguinarine on dental plaque and gingivi- 1990; 61:427. tis. J Periodontol 1989; 60:435. 49. Newman MG, Cattabriga M, Etienne D, et al: Effectiveness 29. Gunsolley JC, Burmeister JA, Tew JG, et al: Relationship of of adjunctive irrigation in early periodontitis: Multi-center serum antibody to attachment level patterns in young evaluation. J Periodontol 1994; 65:224. adults with juvenile periodontitis or generalized severe peri- 50. Nickel JC, Ruseka I, Wright JB, et al: Tobramycin resistance odontitis. J Periodontol 1987; 58:314. of Pseudomonas aeruginosa cells growing in a biofilm on 30. Hardy JH, Newman HN, Strhan JD: Direct irrigation and urinary catheter material. Antimicrob Agents Chemother subgingival plaque. J Clin Periodontol 1982; 9:57. 1985; 27:619. 31. Haskel F, Faquenasi J, Yussim I: Effects of subgingival 51. Nosal G, Scheidt MJ, O'Neal R, et al: The penetration of chlorhexidine irrigation in chronic moderate periodontitis. lavage solution into the periodontal pocket during ultra- J Periodontol 1986; 57:305. sonic instrumentation. J Periodontol 1991; 62:554. 32. Hoover DR, Robinson HB: The comparative effectiveness of 52. Oosterwaal PJ, Mikx FH, van den Brink ME, et al: Bacterici- a pulsating oral irrigator as an adjunct in maintaining oral dal concentrations of chlorhexidine-digluconate, amine flu- health. J Periodontol 1971; 42:37. oride gel and stannous fluoride gel for subgingival bacteria 33. Hugoson A: The effect of the Water Pik device on the devel- tested in serum at short contact times. J Periodont Res 1989; opment of plaque and gingivitis. J Clin Periodontol 1978; 24:155. 5:95. 53. Oosterwaal PJ, Mikx FH, Renggli HH: Clearance of a topi- 34. Jolkovsky DL, Waki MY, Newman MG, et al: Clinical and cally applied fluorescein gel from periodontal pockets. microbiological effects of subgingival and gingival marginal J Clin Periodontol 1990; 17:613. irrigation with chlorhexidine gluconate. J Periodontol 1990; 54. Parsons LG, Thomas LG, Southard GL, et al: Effect of san- 61:663. guinaria extract on established plaque and gingivitis when 35. Kalaitzakis CJ, Tynelius-Bratthall G, Attstrom R: Clinical supragingivally delivered as a manual rinse or under pres- and microbiological effects of subgingival application of a sure in an oral irrigator. J Clin Periodontol 1987; 14:381. chlorhexidine gel in chronic periodontitis. A pilot study. 55. Pitcher GR, Newman HN, Strahen JD: Access to subgingival Swed Dent J 1993; 17:129. plaque by disclosing agents using mouthrinsing and direct 36. Khoury AE, Lam K, Ellis B, et al: Prevention and control of irrigation. J Clin Periodontol 1980; 7:300. bacterial infections associated with medical devices. Am Soc 56. Rabbani GM, Ash MM, Caffesse RG: The effectiveness of Artif Intern Organs 1992; 38:M174. subgingival scaling and root planing in calculus removal. 37. Lander PE, Newcomb GM, Seymour GJ, et al: The antimi- J Periodontol 1981; 52:119. crobial and clinical effects of a single subgingival irrigation 57. Rahn R, Shah PM, Schafer V, et al: Endokarditis-risiko bei of chlorhexidine in advanced periodontal lesions. J Clin Pe- anwendung von mundduschen [Endocarditits risk follow- riodontol 1986; 13:74. ing use of irrigators]. ZWR 1990; 99:266.

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58. Schmid E, Kornman KS, Tinanoff N: Changes of subgingival 67. Tamimi H, Thomassen P, Moser Jr E: Bacteremia study using total colony-forming units and black-pigmented Bacteroides a water irrigation device. J Periodontol 1969; 40:424. after a single irrigation of periodontal pockets with 1.64% 68. Wade WG, Addy W: In vitro activity of a chlorhexidine- SnF2. J Periodontol 1985; 56:330. containing mouthwash against subgingival bacteria. J Peri- 59. Shiloah J, Hovious LA: The role of subgingival irrigations in odontol 1989; 60:521. the treatment of periodontitis. J Periodontol 1993; 64:835. 69. Waki MY, Jolkovsky DL, Lofthus JE, et al: Effects of subgin- 60. Silverstein L, Bissada N, Manouchehr-puor M, et al: Clinical gival irrigation on the incidence of bacteremia following and microbiological effects of local tetracycline irrigation of scaling and root planing. J Periodontol 1990; 61:405. periodontitis. J Periodontol 1988; 59:301. 70. Walsh TF, Glenwright HD, Hull PS: Clinical effects of pulsed 61. Singleton S, Treloar R, Warren P: Methods for microscopic oral irrigation with 0.2% chlorhexidine digluconate in pa- characterization of oral biofilms: analysis of colonization, tients with adult periodontitis. J Clin Periodontol 1992; microstructure, and molecular transport phenomena. Adv 19:245. Dent Res 1997; 11:133. 71. Wennstrom JL, Heijl L, Dahlen G, et al: Periodic subgingival 62. Sjostrom S, Kalfas S: Tissue necrosis after subgingival irriga- antimicrobial irrigation of periodontal pockets. 1. Clinical tion with fluoride solution. J Clin Periodontol 1999; 26:257. observations. J Clin Periodontol 1987; 14:541. 63. Southard S, Drisko CL, Killoy WF: The effects of 2% chlor- 72. Wennstrom JL, Dahlen G, Grondahl K, et al: Periodic sub- hexidine digluconate irrigation on the levels of Bacteroides gingival antimicrobial irrigation of periodontal pockets. gingivalis in periodontal pockets. J Periodontol 1989; 60:302. II. Microbiological and radiographical observations. J Clin 64. Stabholz A, Kettering J, Aprecio R, et al: Retention of an- Periodontol 1987; 14:573. timicrobial activity by human root surfaces after in situ sub- 73. Westling M, Tynelius-Bratthall G: Microbiological and clini- gingival irrigation with tetracycline HCl or chlorhexidine. cal short-term effects of repeated intracrevicular chlorhexi- J Periodontol 1993; 64:137. dine rinsings. J Periodontal Res 1984: 19(2):202. 65. Stabholz A, Nicholas AA, Zimmerman GJ, et al: Clinical and 74. Wiedes SG, Newman HN, Strahan JD: Stannous fluoride and antimicrobial effects of a single episode of subgingival irri- subgingival chlorhexidine irrigation in the control of gation with tetracycline HCl or chlorhexidine in deep peri- plaque and chronic periodontitis. J Clin Periodontol 1983; odontal pockets. J Clin Periodontol 1998; 25:794. 10:172. 66. Stambough RV, Dragoo M, Smith DM: The limits of subgin- 75. Wilson M, Patel H, Fletcher J: Susceptibility of biofilms of gival scaling, Int J Perio & Rest Dent 1981; 1:31. Streptococcus sanguis to chlorhexidine gluconate and cetylpyridinium chloride. Oral Microbiol Immunol 1996; 11:188.

Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com Treatment o f Periodontal Emergencies Henry H. Takei

Treatment of Acute Gingival Disease

Perry R. Klokkevold

CHAPTER

CHAPTER OUTLINE

TREATMENT OF ACUTE NECROTIZING TREATMENT OF ACUTE PERICORONITIS ULCERATIVE GINGIVITIS Pericoronitis and Necrotizing Ulcerative Gingivitis Treatment TREATMENT OF ACUTE HERPETIC Gingival Changes with Healing GINGIVOSTOMATITIS Additional Treatment Considerations Supportive Treatment Sequelae of Inadequate Treatment

'he treatment of acute gingival disease entails the where in the oral cavity, (2) alleviation of generalized alleviation of the acute symptoms and elimina- toxic symptoms such as fever and malaise, and (3) cor- tion of all other periodontal disease, chronic and rection of systemic conditions that contribute to the ini- acute, throughout the oral cavity. Treatment is not com- tiation or progress of the gingival changes. Chapter 51 plete as long as periodontal pathologic changes or fac- provides further information on the management and tors capable of causing them are present. treatment of NUG in patients with acquired immunodeficiency syndrome (AIDS). TREATMENT OF ACUTE NECROTIZING ULCERATIVE GINGIVITIS Treatment Necrotizing ulcerative gingivitis (NUG) can occur in a Treatment of NUG should follow an orderly sequence, as mouth essentially free of any other gingival involvement described in the following paragraphs. or be superimposed on underlying chronic gingival disease. Treatment should include the alleviation of the First Visit. At the first visit, the clinician should ob- acute symptoms and the correction of the underlying tain a general impression of the patient's background, chronic gingival disease. The former is the simplest part including information regarding recent illness, living of the treatment, whereas the latter requires more com- conditions, dietary background, type of employment, prehensive procedures. hours of rest, and mental stress. The patient's general ap- The treatment of NUG consists of (1) alleviation of pearance should be observed, as well as apparent nutri- the acute inflammation plus treatment of chronic dis- tional status and responsiveness or lassitude, and his or ease either underlying the acute involvement or else- her temperature should be taken. The submaxillary and

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submental areas should be palpated to detect enlarged 2. Rinse with a glassful of an equal mixture of 3% hydro- lymph glands. gen peroxide and warm water every 2 hours and/or The oral cavity is examined for the characteristic le- twice daily with 0.12 % chlorhexidine solution. sion of NUG (see Chapters 19 and 27), its distribution, 3. Pursue usual activities, but avoid excessive physical and the possible involvement of the oropharyngeal re- exertion or prolonged exposure to the sun as required gion. Oral hygiene is evaluated; the presence of pericoro- in golf, tennis, swimming, or sunbathing. nal flaps, periodontal pockets, and local irritants is deter- 4. Confine toothbrushing to the removal of surface de- mined. A bacterial smear may be made from the material bris with a bland dentifrice; overzealous brushing in the involved areas, but this is merely corroboratory and the use of dental floss or interdental cleaners and is not to be relied on for diagnosis. will be painful. Chlorhexidine mouth rinses are also The patient is questioned regarding the history of the very helpful in controlling plaque throughout the acute disease and its onset and duration. Is it recurrent? mouth. Are the recurrences associated with specific factors such as menstruation, particular foods, exhaustion, or mental Second Visit. At the second visit, 1 to 2 days later, stress? Has there been any previous treatment? When the patient's condition is usually improved; the pain is and for how long? One should also inquire as to the type diminished or no longer present. The gingival margins of treatment received and the patient's impression re- of the involved areas are erythematous, but without a su- garding its effect. perficial pseudomembrane. Treatment during this initial visit is confined to the Scaling is performed if sensitivity permits. Shrinkage acutely involved areas, which are isolated with cotton of the gingiva may expose previously covered calculus, rolls and dried. A topical anesthesia is applied, and after which is gently removed. The instructions to the patient 2 or 3 minutes the areas are gently swabbed with a cot- are the same as those given previously. ton pellet to remove the pseudomembrane and nonat- tached surface debris. Each cotton pellet is used in a Third Visit. At the next visit, 1 to 2 days after the small area and is then discarded; sweeping motions over second, the patient should be essentially symptom free. large areas with a single pellet are not recommended. Af- There may still be some erythema in the involved areas, ter the area is cleansed with warm water, the superficial and the gingiva may be slightly painful on tactile stimu- calculus is removed. Ultrasonic scalers are very useful for lation (Fig. 45-1). Scaling and root planing are repeated. this purpose, since they do not elicit pain, and the water The patient is instructed in plaque control procedures jet aids in the lavage of the area. (see Chapter 49), which are essential for the success of Subgingival scaling and curettage are contraindicated the treatment and the maintenance of periodontal at this time because of the possibility of extending health. The hydrogen peroxide rinses are discontinued, the infection to deeper tissues, and also of causing a but chlorhexidine rinses can be maintained for two or bacteremia. Unless an emergency exists, procedures such three weeks. as extractions or periodontal surgery are postponed until the patient has been symptom free for a period of 4 weeks, Subsequent Visits. In subsequent visits, the tooth to minimize the likelihood of exacerbating the acute symp- surfaces in the involved areas are scaled and smoothed, toms. and plaque control by the patient is checked and cor- The patient is also told to rinse the mouth every 2 rected if necessary. hours with a glassful of an equal mixture of warm water Unfortunately, treatment is often stopped at this time and 3% hydrogen peroxide. Twice-daily rinses with because the acute condition has subsided, but this is 0.12% chlorhexidine are also very effective. when comprehensive treatment of the patient's chronic Patients with moderate or severe NUG and local lym- periodontal problem should start. Appointments are phadenopathy or other systemic symptoms are placed scheduled for the treatment of chronic gingivitis, peri- on an antibiotic regimen of penicillin, 500 mg orally odontal pockets, and pericoronal flaps, as well as for the every 6 hours. For penicillin-sensitive patients, other an- elimination of all forms of local irritation. tibiotics, such as erythromycin (500 mg every 6 hours) Patients without gingival disease other than the are prescribed. Metronidazole (500 mg twice times daily treated acute involvement are dismissed for 1 week. If for 7 days), is also effective. Antibiotics are continued the condition is satisfactory at that time, the patient is until the systemic complications or the local lympha- dismissed for 1 month, at which time the schedule for denopathy have subsided. subsequent recall visits is determined according to the Patients are told to report back to the clinician in 1 to patient's needs. 2 days. The patient should be advised of the extent of total treatment the condition requires and warned that treatment is not complete when pain stops. He or she Gingival Changes with Healing should be informed of the presence of chronic gingival The characteristic lesion of NUG undergoes the follow- or periodontal disease, which must be eliminated to pre- ing changes in the course of healing in response to treat- vent recurrence of the acute symptoms. ment: INSTRUCTIONS TO THE PATIENT. The patient is discharged with the following instructions: 1. Removal of the surface pseudomembrane exposes the underlying red, hemorrhagic, craterlike depressions in 1. Avoid tobacco, alcohol, and condiments. the gingiva.

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Fig. 45-1 Initial response to treatment of acute necrotizing ulcerative gingivitis (NUG). A, Severe acute necrotizing ulcerative gingivitis. B, Third day after treatment. There is still some erythema, but the condition is markedly improved.

4. In the final stage the normal gingival color, consistency, surface texture, and contour are restored. Portions of the root exposed by the acute disease are covered by healthy gingiva (Figs. 45-2 and 45-3). When the men- strual period occurs in the course of treatment, there is a tendency toward exacerbation of the acute signs and symptoms, giving the appearance of a relapse. Patients should be informed of this possibility and spared unnecessary anxiety regarding their oral condition.

Additional Treatment Considerations Contouring of the Gingiva as an Adjunctive Pro- cedure. Even in cases of severe gingival necrosis, healing ordinarily leads to restoration of the normal gingival contour (Fig. 45-4). However, if the teeth are irregu- larly aligned, healing sometimes results in the formation of a shelflike gingival margin, which favors the retention of plaque and the recurrence of gingival inflammation. This can be corrected by reshaping the gingiva surgically or with electrosurgery (Fig. 45-5). Effective plaque control by the patient is particularly important to establish and maintain the normal gingival contour in areas of tooth irregularity.

Surgical Procedures. Tooth extraction or periodontal surgery should be postponed until 4 weeks after the acute signs and symptoms of NUG have subsided. If emergency surgery is required in the presence of acute symptoms, prophylactic chemotherapy with systemic Fig. 45-2 Treatment of acute NUG. A, Before treatment. Note the penicillin or other antibiotics is indicated to prevent characteristic interdental lesions. B, After treatment, showing worsening or spreading of the acute disease. restoration of healthy gingival contour. Role of Drugs. A large variety of drugs have been used topically in the treatment of NUG.2 Topical drug 2. In the next stage the bulk and redness of the crater therapy is only an adjunctive measure; no drug, when margins are reduced, but the surface remains shiny used alone, can be considered complete therapy. (see Fig. 45-1). Escharotic drugs such as phenol, silver nitrate, and 3. This is followed by the early signs of restoration of chromic acid should not be used. They are necrotizing normal gingival contour and color. agents that alleviate the painful symptoms by destroying

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the nerve endings in the gingiva. They also destroy the young cells necessary for repair and delay healing. Their repeated use results in the loss of gingival tissue, which is not restored when the disease subsides.' SYSTEMIC ANTIBIOTICS. Antibiotics are administered systemically only in patients with toxic systemic complications or local adenopathy. They are not recommended in NUG patients who do not have these complications. When used, systemic antibiotics also reduce the oral bacterial flora and alleviate the oral symptoms,10,11 but they are only an adjunct to the complete local treatment the disease requires. Patients treated by systemic antibiotics alone should be cautioned that the acute painful symptoms may recur after the drug is discontinued. SUPPORTIVE SYSTEMIC TREATMENT. In addition to systemic antibiotics, supportive treatment consists of copious fluid consumption and administration of analgesics for relief of pain. Bed rest is necessary for patients with toxic systemic complications such as high fever, malaise, anorexia, and general debility. NUTRITIONAL SUPPLEMENTS. The rationale for nutritional supplements in the treatment of NUG is based on the following:

1. Lesions resembling those of NUG have been produced experimentally in animals with certain nutritional deficiencies (see Chapter 12). 2. It is possible that difficulty in chewing raw fruits and vegetables in a painful condition such as NUG could Fig. 45-3 Physiologic contour and new attachment of gingiva af- lead to the selection of a diet inadequate in vitamins ter treatment of acute NUG. A, Acute NUG showing the character- B and C. istic punched-out eroded gingival margin with surface pseudo- 3. Isolated clinical studies4,6 report fewer recurrences membrane. B, After treatment. Note the restoration of physiologic when local treatment of NUG is supplemented with gingival contour and reattachment of the gingiva to the surfaces of vitamin B or vitamin C. the mandibular teeth, which had been exposed by the disease.

When the intake of water-soluble vitamins B and C has been severely curtailed because of pain in NUG, nutritional supplements may be indicated along with local treatment to ward off deficiencies of the aforementioned vitamins. Under such circumstances the patient may be given a standard multivitamin preparation combined with a therapeutic dose of vitamins B and C. The patient should be placed on a natural diet with the required detergent action and nutritional content as soon as the oral condition permits. Nutritional supplements may be discontinued after 2 months. Local procedures are the keystone of the treatment of necrotizing ulcerative gingivitis. Inflam- mation is a local conditioning factor that impairs the nutrition of the gingiva regardless of the systemic nutritional status. Local irritants should be eliminated to fos- ter normal metabolic and reparative processes in the gingiva. Persistent or recurrent NUG is more likely to be caused by the failure to remove local irritants and by inadequate plaque control than by nutritional deficiency.

Sequelae of Inadequate Treatment Fig. 45-4 Gingival healing after treatment. A, Before treatment. Persistent or "Unresponsive" Cases. If the clin- Severe acute necrotizing ulcerative gingivitis with crater formation. ician finds it necessary to change from drug to drug in B, After treatment. Note the restored gingival contour.

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Fig. 45-5 Reshaping the gingiva in the treatment of acute NUG. A, Before treatment, showing bulbous gingiva and interdental necrosis in the mandibular anterior area. B, After treatment. Gingival contours still undesirable. C, Final result. Physiologic contours obtained by reshaping the gingiva.

an effort to relieve a "stubborn" case of NUG, something Inadequate plaque control and heavy use o f tobacco are also is wrong with the overall treatment regimen that is not common causes of recurrent disease. likely to be corrected by changing drugs. When con- fronted with such a problem, the following should be TREATMENT OF ACUTE PERICORONITIS completed: The treatment of pericoronitis depends on the severity 1. All local drug therapy should be discontinued so that of the inflammation, the systemic complications, and the condition may be studied in an uncomplicated state. the advisability of retaining the involved tooth. All peri- 2. Careful differential diagnosis is undertaken to rule out coronal flaps should be viewed with suspicion. Persis- diseases that resemble NUG (see Chapter 12). tent symptom-free pericoronal flaps should be removed 3. A search is made for contributing local and systemic as a preventive measure against subsequent acute in- etiologic factors that may have been overlooked. volvement. 4. Special attention is given to instructing the patient in The treatment of acute pericoronitis consists of plaque control before undertaking comprehensive lo- (1) gently flushing the area with warm water to remove cal treatment. debris and exudate and (2) swabbing with antiseptic after elevating the flap gently from the tooth with a scaler. Recurrent Necrotizing Ulcerative Gingivitis. The underlying debris is removed, and the area is flushed The following factors should be explored in patients with warm water (Fig. 45-6). Antibiotics can be pre- with recurrent NUG: scribed in severe cases. If the gingival flap is swollen and fluctuant, an anteroposterior incision to establish drain- 1. Inadequate local therapy. Too often, treatment is dis- age is made with a #15 blade. continued when the symptoms have subsided, with- After the acute symptoms have subsided, a determina- out eliminating the chronic gingival disease and peri- tion is made as to whether the tooth is to be retained or odontal pockets that remain after the superficial acute extracted. The decision is governed by the likelihood of condition is relieved. Persistent chronic inflammation further eruption into a good functional position. Bone causes degenerative changes that predispose the gin- loss on the distal surface of the second molars is a hazard giva to recurrence of acute involvement. following the extraction of partially or completely im- 2. Pericoronal flap. Recurrent acute involvement in the pacted third molars,' and the problem is significantly mandibular anterior area is often associated with per- greater if the third molars are extracted after the roots sistent pericoronal inflammation arising from difficult are formed or in patients older than their early twenties. eruption of third molars.' The anterior involvement is To reduce the risk of bone loss around second molars, less likely to recur after the third molar situation is partially or completely impacted third molars should be corrected. extracted as early as possible in their development. 3. Anterior overbite. Marked overbite is often a contribut- If it is decided to retain the tooth, the pericoronal flap ing factor in the recurrence of disease in the anterior is removed using periodontal knives or electrosurgery region. When the incisal edges of the maxillary teeth (Fig. 44-6). It is necessary to remove the tissue distal to impinge on the labial gingival margin or the the tooth, as well as the flap on the occlusal surface. In- mandibular teeth strike the palatal gingiva, the resul- cising only the occlusal portion of the flap leaves a deep tant tissue injury predisposes the gingiva to recurrent distal pocket, which invites recurrence of acute pericoro- acute disease. Less severe overbite produces food im- nal involvement. paction and gingival trauma. Correction of the over- After the tissue is removed, a periodontal pack is ap- bite is necessary for the complete treatment of NUG. plied. The pack may be retained by bringing it forward

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Pericoronitis and Necrotizing Ulcerative Gingivitis Pericoronitis and NUG pericoronal flaps that are chronically inflamed may become the sites of NUG. The disease is treated in the same manner as elsewhere in the mouth; after the acute symptoms have subsided, the flap is removed. Pericoronal flaps are often referred to as primary incubation zones in NUG; their elimination is one of many measures required to minimize the likelihood of recurrent disease.

TREATMENT OF ACUTE HERPETIC GINGIVOSTOMATITIS Primary infection with herpes simplex virus in the oral cavity results in a condition known as acute herpetic gingivostomatitis, which is an oral infection often, accompanied by systemic symptoms (see Chapter 19). This infection typically occurs in children, but it can and does occur in adults as well. It runs a 7- to 10-day course and heals without scars. A recurrent herpetic episode may be precipi- tated in individuals with a history of herpes virus infections and by respiratory infections, sunlight exposure fever, trauma, exposure to chemicals, and emotional stress. Various medications have been used to treat herpes gingivostomatitis with little success; these have included local applications of escharotics, vitamins, radiation and antibiotics. Limited success was initially reported with the use of herpesvirus-specific drugs, such as acyclovir ointment.$ However, a recent clinical report has suggested good results using systemic acyclovir to prevent (or lessen the severity of) recurrent herpes virus infection associated with dental treatment." The patient, who was Fig. 45-6 Treatment of acute pericoronitis. A, Inflamed pericoro- known to have recurrent infections after dental treat- nal flap (arrow) in relation to the mandibular third molar. B, Ante- rior view of third molar and flap. C, Lateral view with staler in posi- ment, did not experience any recurrence when treated tion to gently remove debris under flap. D, Anterior view of staler with acyclovir. Most strains of herpes virus are suscepti- in position. E, Removal of section of the gingiva distal to the third ble to acyclovir, and it has been suggested that topical molar, after the acute symptoms subside. The line of incision is indi- application of acyclovir is useful in decreasing the spread cated by the broken line. F, Appearance of the healed area. G, In- and severity of the infection. correct removal of the tip of the flap, permitting the deep pocket Treatment consists of palliative measures to make the pa- to remain distal to the molar. tient comfortable until the disease runs its course. Plaque, food debris and superficial calculus are removed to reduce gingival inflammation, which complicates the acute herpetic involvement. Extensive periodontal therapy should The patient should be informed that the disease is be postponed until the acute symptoms subside to avoid contagious at certain stages such as when vesicles are the possibility of exacerbation (Fig. 45-7). For sympto- present (highest viral titer). All individuals exposed to an matic relief, especially before meals, topical local anes- infected patient should take precautions. Herpetic infec- thetic, such as lidocaine hydrochloride viscous solution tion of a clinician's finger, referred to as herpetic whitlow, can be applied to the affected areas. Before each meal the can occur if a seronegative clinician becomes infected patient should rinse with 1 tablespoon of this solution. If with a patient's herpetic lesions.8,9 the patient is experiencing pain of longer duration, aspirin or a nonsteroidal antiinflammatory agent can be given systemically. Supportive Treatment Local or systemic application of antibiotics is some- Supportive measures include copious fluid intake and times advised to prevent opportunistic infection of ulcer- systemic antibiotic therapy for the management of toxic ation'. This is especially true in the immune compro- systemic complications. For the relief of pain, aspirin is mised individual. If the condition does not resolve usually sufficient. A dosage of 325 mg to 650 mg every within a 2-week period, the patient should be referred to 4 hours may be prescribed for adults, with smaller doses a physician for medical consultation.' used for children. 628 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 45-7 Treatment of acute herpetic gingivostomatitis. A, Before treatment. Note diffuse erythema and surface vesicles. B, Before treatment, lingual view, showing gingival edema and ruptured vesicle on palate. C, One month after treatment, showing restoration of normal gingival contour and stippling. D, One month after treatment, lingual view.

RE FERENCES 7. Mitchell DF, Baker BR: Topical antibiotic control of necrotizing gingivitis. J Periodontol 1968; 39:81. 1. Ash Jr MM, Costich ER, Hayward JR: A study of periodontal 8. Regezi JA, Sciubba JJ: Oral Pathology: Clinical-Pathologic hazards of third molars. J Periodontol 1962; 33:209. Correlations. WB Saunders, Philadelphia, 1989. 2. Burket LW: Oral Medicine, ed 3. Philadelphia, JB Lippincott, 9. Snyder ML, Church DH, Rickles NH: Primary herpes infec- 1946. tion of right second finger. Oral Surg 1969; 27:598. 3. Glickman I, Johannessen LB: The effect of a six per cent so- 10. Wade AB, Blake GC, Manson JD, et al: Treatment of the lution of chromic acid on the gingiva of the albino rat-a acute phase of ulcerative gingivitis (Vincent's type). Br Dent correlated gross, biomicroscopic, and histologic study. J Am J 1963; 115:372. Dent Assoc 1950; 41:674. 11. Wade AB, Blake G, Mirza K: Effectiveness of metronidazole 4. King JD: Nutritional and other factors in "trench mouth" in treating the acute phase of ulcerative gingivitis. Dent with special reference to the nicotinic acid component of Pract 1966; 16:440. the vitamin B2 complex. Br Dent J 1943; 74:113. 12. Williamson RT. Diagnosis and management of recurrent 5. Langlais RP, Miller CS: Color Atlas of Common Oral Dis- herpes simplex induced by fixed prosthodontic tissue man- eases, ed 2. New York, Williams & Wilkins, 1998. agement: a clinical report. J Prosthet Dent 1999; 82:1. 6. Linghorne WJ, McIntosh WG, Tice JW, et al: The relation of ascorbic acid intake to gingivitis. J Can Dent Assoc 1946; 12:49.

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Treatment of the Periodontal Abscess

Henry H. Takei

CHAPTER

CHAPTER OUTLINE

THE ACUTE PERIODONTAL ABSCESS THE GINGIVAL ABSCESS Treatment THE CHRONIC PERIODONTAL ABSCESS

I eriodontal abscesses are commonly encountered Drainage through the Pocket. The area is anes- in patients with deep pockets. They are an acute thetized topically and, if necessary, local anesthesia is in- exacerbation of a preexisting pocket resulting jected around the periphery of the abscess. Care is taken from exudates and purulent material being entrapped in not to inject into the swelling itself. A flat instrument or the pocket with no pathway for drainage. Abscesses may a probe is carefully introduced into the pocket in an at- be acute or chronic. Acute abscesses are painful, edema- tempt to distend the pocket wall for drainage. A curette tous, red, shiny ovoid elevations of the gingival margin, can then be gently inserted into the pocket to further the attached gingiva, or both. After their purulent con- drain and gently curette the mass of tissue internally. tent is partially exuded, they become chronic. Chronic abscesses may produce a dull pain and may at times be- Drainage through an External Incision. The come acute (see Chapter 30). abscess is isolated and dried with gauze sponges. After the application of topical anesthesia, local anesthesia is injected around the periphery of the abscess. THE ACUTE PERIODONTAL ABSCESS A #15 blade is used to make a vertical incision To undertake the proper course of therapy, it is essential through the most fluctuant part of the swelling, extend- to establish the differential diagnosis between a peri- ing to an area just apical to the abscess (Fig. 46-1). A odontal and a pulpal abscess. Box 46-1 compares the curette or periosteal elevator is used to gently elevate the symptoms associated with the two lesions. tissue to create drainage and curette the granulomatous tissue in the internal aspect of the abscess. The external aspect of the abscess is gently pushed to drain the re- Treatment maining purulent material and approximate the wound The purpose of treatment of an acute abscess is to alleviate edges. Sutures are usually not required. the pain, control the spread of infection, and establish After the drainage stops, the area is dried and painted drainage! The patient's general systemic response should with an antiseptic. Patients without systemic complica- be evaluated. Rise in temperature, feverish appearance, tions are instructed to rinse often with a solution of 1 tsp and a feeling of malaise should be noted and a proper salt in a glass of warm water and to return for follow-up antibiotic regimen started if necessary. evaluation the next day. In addition to the rinses, peni- Drainage can be established through the pocket or by cillin or other antibiotics are prescribed for patients with means of an incision from the outer surface. The former elevated temperatures. The patient is also instructed to is preferable. avoid exertion and is placed on a copious fluid diet.

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Differences between Periodontal and Pulpal Abscesses

Fig. 46-1 Incision of an acute periodontal abscess. A, Fluctuant acute periodontal abscess. B, Abscess incised. C, After acute signs subside.

If necessary, bed rest is recommended. Analgesics are gauze pad. After bleeding stops, the patient is dismissed prescribed for pain. for 24 hours and instructed to rinse every 2 hours with a The next day, the swelling is generally markedly re- glassful of warm water. duced or absent and the symptoms should have sub- When the patient returns, the lesion is generally re- sided. If acute symptoms persist, the patient is instructed duced in size and free of symptoms. A topical anesthetic to continue the regimen prescribed the previous day and is applied, and the area is scaled. If the residual size of to return in 24 hours. The symptoms invariably disap- the lesion is too great, it is removed surgically. pear by this time, and the lesion is ready for the usual treatment of a chronic periodontal abscess. THE CHRONIC PERIODONTAL ABSCESS

THE GINGIVAL ABSCESS After adequate drainage, antibiotic treatment, or both, the acute abscess becomes chronic. Some cases have In contrast to the periodontal abscess, which involves drained spontaneously and the patient is then diagnosed the supporting tissues, the gingival abscess is a lesion of as having a chronic abscess. Further treatment is similar the marginal or interdental gingiva, usually produced by to that of a periodontal pocket. an impacted foreign object. It is treated as follows: Under topical and local infiltrative anesthesia, the REFERENCE fluctuant area of the lesion is incised with a #15 blade, and the incision is gently widened to permit drainage. 1. Manson JD: Periodontics, ed 3. Philadelphia, Lea & Febiger, The area is cleansed with warm water and covered with a 1975. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Scaling and Root Planing

Gordon L. Pattison and Anna M. Pattison*

CHAPTER

CHAPTER OUTLINE

PRINCIPLES OF SCALING AND ROOT PLANING Subgingival Scaling and Root Planing Technique Definitions and Rationale Ultrasonic Scaling Detection Skills Evaluation Supragingival Scaling Technique

PRINCIPLES OF SCALING AND that are compatible with health.16,68,77,97,100,108,110 After ROOT PLANING thorough scaling and root planing, a profound reduction of spirochetes, motile rods, and putative pathogens such Definitions and Rationale as Actinobacillus actinomycetemcomitans, Porphyromonas Scaling is the process by which plaque and calculus are gingivalis, and Prevotella intermedia and an increase in coc- removed from both supragingival and subgingival tooth coid cells occur. 68,97,103,108,120,127 These changes in the mi- surfaces. No deliberate attempt is made to remove tooth crobiota are accompanied by a reduction or elimination substance along with the calculus. Root planing is the of inflammation clinically. 9,31,37,49,52,67,92,93 This positive process by which residual embedded calculus and por- microbial change must be sustained by the periodic scal- tions of cementum are removed from the roots to pro- ing and root planing performed during supportive peri- duce a smooth, hard, clean surface. odontal therapy.', 14,64,67,90,108,124 The primary objective of scaling and root planing is to Scaling and root planing are not separate procedures. All restore gingival health by completely removing elements the principles of scaling apply equally to root planing. The that provoke gingival inflammation (i.e., plaque, calcu- difference between scaling and root planing is only a mat- lus, and endotoxin) from the tooth surface (see Color Fig. ter of degree. The nature of the tooth surface determines 48-1). Instrumentation has been shown to dramatically the degree to which the surface must be scaled or planed. reduce the numbers of subgingival microorganisms and Plaque and calculus on enamel surfaces provoke gin- produce a shift in the composition of subgingival plaque gival inflammation. Unless they are grooved or pitted, from one with high numbers of gram-negative anaerobes enamel surfaces are relatively smooth and uniform. to one dominated by gram-positive facultative bacteria When plaque and calculus form on enamel, the deposits are usually superficially attached to the surface and are not locked into irregularities. Scaling alone is sufficient * Material in this chapter was drawn freely from Pattison AM, to completely remove plaque and calculus from enamel, Pattison GL: Periodontal Instrumentation, ed 2. Upper Saddle River, leaving a smooth, clean surface. NJ. Prentice Hall, 1992. Root surfaces exposed to plaque and calculus pose a 631

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different problem. Deposits of calculus on root surfaces are with good lighting and a clean field. Light deposits of frequently embedded in cemental irregularities. 1,17,76,105,128 supragingival calculus are often difficult to see when When dentin is exposed, plaque bacteria may invade dentinal they are wet with saliva. Compressed air may be used to tubules.' Therefore scaling alone is insufficient to remove dry supragingival calculus until it is chalky white and them, and a portion of the root surface must be removed to readily visible. Air also may be directed into the pocket eliminate these deposits. Furthermore, when the root sur- in a steady stream to deflect the marginal gingiva away face is exposed to plaque and the pocket environment, from the tooth so that subgingival deposits near the sur- its surface is contaminated by toxic substances, notably face can be seen. 2,1,44 endotoxins. Recent evidence suggests that these Tactile exploration of the tooth surfaces in subgingival toxic substances are only superficially attached to the areas of pocket depth, furcations, and developmental de- root and do not permeate it deeply."',' 9,47,48,75,79,80,111 Re- pressions is much more difficult than visual examination moval of extensive amounts of dentin and cementum is of supragingival areas and requires the skilled use of a not necessary to render the roots free of toxins and fine-pointed explorer or probe. The explorer or probe is should be avoided. 35,67,90 However, where cementum is held with a light but stable modified pen grasp. This pro- thin, instrumentation may expose dentin. Although this vides maximal tactile sensitivity for detection of subgin- is not the aim of treatment, it may be unavoidable. 104,119 gival calculus and other irregularities. The pads of the Scaling and root planing should not be thought of as thumb and fingers, especially the middle finger, should separate procedures unrelated to the rest of the treat- perceive the slight vibrations conducted through the in- ment plan. They belong in the initial phase of an orderly strument shank and handle as irregularities in the tooth sequence of treatment. After careful analysis of a case, surface are encountered. the number of appointments needed to complete this After a stable finger rest is established, the tip of the phase of treatment is estimated. Patients with small instrument is carefully inserted subgingivally to the base amounts of calculus and relatively healthy tissues can be of the pocket. Light exploratory strokes are activated ver- treated in one appointment. Most other patients require tically on the root surface. When calculus is encoun- several treatment sessions. The dentist should estimate tered, the tip of the instrument should be advanced api- the number of appointments needed on the basis of the cally over the deposit until the termination of the number of teeth in the mouth, severity of inflammation, calculus on the root is felt. The distance between the api- amount and location of calculus, depth and activity of cal edge of the calculus and the bottom of the pocket pockets, presence of furcation invasions, patient's com- usually ranges from 0.2 to 1.0 mm. The tip is adapted prehension of and compliance with oral hygiene instruc- closely to the tooth to ensure the greatest degree of tac- tions, and need for local anesthesia. Recent research in- tile sensitivity and avoid tissue trauma. When a proxi- dicates that completing initial scaling and root planing mal surface is being explored, strokes must be extended in one or two long appointments rather than four at least halfway across that surface past the contact area shorter quadrant scaling appointments may be advanta- to ensure complete detection of interproximal deposits. geous. 74,94,95 This removes pathogens from the entire When an explorer is used at line angles, convexities, and mouth as quickly as possible so that they are not present concavities, the handle of the instrument must be rolled to reinfect previously instrumented areas. slightly between the thumb and fingers to keep the tip When the rationale for scaling and root planing is constantly adapted to the changes in tooth contour. thoroughly understood, it becomes apparent that mastery Although exploration technique and good tactile sen- of these skills is essential to the ultimate success of any sitivity are important, interpreting various degrees of course of periodontal therapy. Of all clinical dental proce- roughness and making clinical judgments based on these dures, subgingival scaling and root planing in deep pock- interpretations also require much expertise. The begin- ets are the most difficult and exacting skills to master. It ning student usually has difficulty detecting fine calculus has been argued that such proficiency in instrumentation and altered cementum. Such detection must begin with cannot be attained; therefore periodontal surgery is neces- the recognition of ledges, lumps, or spurs of calculus, sary to gain access to root surfaces. Others have argued then smaller spicules, then slight roughness, and finally that although proficiency is possible, it need not be de- a slight graininess that feels like a sticky coating or film veloped because access to the roots can be gained more covering the tooth surface. Overhanging or deficient easily with surgery. However, without mastering subgin- margins of dental restorations, caries, decalcification, gival scaling and root planing skills, the clinician will be and root roughness caused by previous instrumentation severely hampered and unable to treat adequately those are all commonly found during exploration. These and patients for whom surgery is contraindicated. other irregularities must be recognized and differentiated from subgingival calculus. Because this requires a great Detection Skills deal of experience and a high degree of tactile sensitivity, many clinicians agree that the development of detection Good visual and tactile detection skills are required for skills is as important as the mastery of scaling and root the accurate initial assessment of the extent and nature planing technique. of deposits and root irregularities before scaling and root planing. Valid evaluation of results of instrumentation depends on these detection skills. Supragingival Scaling Technique Visual examination of supragingival and subgingival Supragingival calculus is generally less tenacious and less calculus just below the gingival margin is not difficult calcified than subgingival calculus. Because instrumenta-

Scaling and Root Planing • CHAPTER 47 633 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com tion is performed coronal to the gingival margin, scaling Sickles, hoes, files, and ultrasonic instruments also are strokes are not confined by the surrounding tissues. This used for subgingival scaling of heavy calculus. Some small makes adaptation and angulation easier. It also allows di- files such as the Hirschfeld file may be inserted to the base rect visibility as well as a freedom of movement not pos- of the pocket to crush or initially fracture tenacious de- sible during subgingival scaling. posits. Larger files, hoes, sickles, and standard ultrasonic Sickles, curettes, and ultrasonic and sonic instruments are tips for supragingival use are too bulky and cannot easily most commonly used for the removal of supragingival calcu- be inserted into deep pockets or areas where tissue is firm lus. Hoes and chisels are less frequently used. To perform and fibrotic. Hoes and files are not able to produce as supragingival scaling, the sickle or curette is held with a smooth a surface as curettes. 12,104 Hoes, files, and standard modified pen grasp, and a firm finger rest is established large ultrasonic tips are all more hazardous than the on the teeth adjacent to the working area. The blade is curette in terms of trauma to the root surface and sur- adapted with an angulation of slightly less than 90 de- rounding tissues. 12,85,104 Although thin ultrasonic tips degrees to the surface being scaled. The cutting edge should signed for scaling of deep pockets and furcations can be engage the apical margin of the supragingival calculus inserted more easily subgingivally, they must be used on while short, powerful, overlapping scaling strokes are ac- low power.31,32,45 When low-power scaling is performed on tivated coronally in a vertical or an oblique direction. heavy calculus or tenacious sheets of calculus, thin ultra- The sharply pointed tip of the sickle can easily lacerate sonic tips are likely to burnish the calculus rather than marginal tissue or gouge exposed root surfaces, so careful thoroughly remove it. Therefore ultrasonic scaling should adaptation is especially important when this instrument be followed by careful assessment with an explorer and is being used. The tooth surface is instrumented until it is further instrumentation with curettes when necessary. visually and tactilely free of all supragingival deposits. If Subgingival scaling and root planing are accomplished the tissue is retractable enough to allow easy insertion of with either universal or area-specific (Gracey) curettes us- the bulky blade, the sickle may be used slightly below the ing the following basic procedure: The curette is held free gingival margin. If the sickle is used in this manner, with a modified pen grasp, and a stable finger rest is es- final scaling and root planing with the curette should al- tablished. The correct cutting edge is slightly adapted to ways follow. the tooth, with the lower shank kept parallel to the tooth surface. The lower shank is moved toward the tooth so that the face of the blade is nearly flush with the tooth Subgingival Scaling and Root Planing Technique surface. The blade is then inserted under the gingiva and Subgingival scaling and root planing are far more com- advanced to the base of the pocket by a light exploratory plex and difficult to perform than supragingival scaling, stroke. When the cutting edge reaches the base of the Subgingival calculus is usually harder than supragingival pocket, a working angulation of between 45 and 90 de- calculus and is often locked into root irregularities, mak- grees is established, and pressure is applied laterally ing it more tenacious and therefore more difficult to re- against the tooth surface. Calculus is removed by a series move. 17,76,105,128 The overlying tissue creates significant of controlled, overlapping, short, powerful strokes pri- problems in subgingival instrumentation. Vision is ob- marily using wrist-arm motion (Fig. 47-1). As calculus is scured by the bleeding that inevitably occurs during in- removed, resistance to the passage of the cutting edge di- strumentation and by the tissue itself. The clinician must minishes until only a slight roughness remains. Longer, rely heavily on tactile sensitivity to detect calculus and ir- lighter root planing strokes are then activated with less regularities, guide the instrument blade during scaling and lateral pressure until the root surface is completely root planing, and evaluate the results of instrumentation. smooth and hard. The instrument handle must be rolled In addition, the adjacent pocket wall limits the direc- carefully between the thumb and fingers to keep the tion and length of the strokes. The confines of the soft blade adapted closely to the tooth surface as line angles, tissue make careful adaptation to tooth contours impera- developmental depressions, and other changes in tooth tive to avoid trauma. Such precise adaptation cannot be contour are followed. Scaling and root planing strokes accomplished without a thorough knowledge of tooth should be confined to the portion of the tooth where cal- morphologic features. The clinician must form a mental culus or altered cementum is found. This zone is known image of the tooth surface to anticipate variations in as the instrumentation zone. Sweeping the instrument over contour, continually confirming or modifying the image the crown where it is not needed wastes operating time, in response to tactile sensations and visual cues such as dulls the instrument, and causes loss of control. the position of the instrument handle and shank. The The amount of lateral pressure applied to the tooth clinician then must instantaneously adjust the adapta- surface depends on the nature of the calculus and tion and angulation of the working end to the tooth. It whether the strokes are for initial calculus removal or final is this complex and precise coordination of visual, men- root planing. If heavy lateral pressure is continued after tal, and manual skills that makes subgingival instrumen- the bulk of calculus has been removed and the blade is re- tation one of the most difficult of all dental skills. The peatedly readapted with short, choppy strokes, the result curette is preferred by most clinicians for subgingival scaling will be a root surface roughened by numerous nicks and and root planing because of the advantages afforded by its de- gouges, resembling the rippled surface of a washboard.89 sign. Its curved blade, rounded toe, and curved back al- If heavy lateral pressure is continued with long, even low the curette to be inserted to the base of the pocket strokes, the result will be excessive removal of root struc- and adapted to variations in tooth contour with mini- ture, producing a smooth but "ditched" or "riffled" root mal tissue displacement and trauma. surface. To avoid these hazards of overinstrumentation,

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A common error in instrumenting proximal surfaces is failing to reach the midproximal region apical to the contact. This area is relatively inaccessible, and the technique requires more skill than instrumentation of buccal or lingual surfaces. It is extremely important to extend strokes at least halfway across the proximal surface so that no calculus or roughness remains in the interproximal area. With properly designed curettes, this can be accomplished by keeping the lower shank of the curette parallel with the long axis of the tooth (Fig. 47-3). With the lower shank parallel to the long axis, the blade of the curette will reach the base of the pocket and the toe will extend beyond the midline as strokes are advanced across the proximal surface. This extension of strokes beyond the midline ensures thorough exploration and instrumentation of these surfaces. If the lower shank is angled or tilted away from the tooth, the toe will move toward the contact area. Because this prevents Fig. 47-1 Subgingival scaling procedure. A, Curette inserted with the blade from reaching the base of the pocket, calculus the face of the blade flush against the tooth. B, Working angulation apical to the contact will not be detected or removed. (45 to 90 degrees) is established at the base of the pocket. C, Lat- Strokes will be hampered because the toe tends to be- eral pressure is applied, and the scaling stroke is activated in the come lodged in the contact. If the instrument is angled coronal direction. or tilted too far toward the tooth, the lower shank will hit the tooth or the contact area, preventing extension of strokes to the mid-proximal region (see Fig. 47-3). The relationship between the location of the finger a deliberate transition from short, powerful scaling rest and the working area is important for two reasons. strokes to longer, lighter root planing strokes must be First, the finger rest or fulcrum must be positioned to al- made as soon as the calculus and initial roughness have low the lower shank of the instrument to be parallel or been eliminated. nearly parallel to the tooth surface being treated. This When scaling strokes are used to remove calculus, parallelism is a fundamental requirement for optimal force can be maximized by concentrating lateral pressure working angulation. Second, the finger rest must be po- onto the lower third of the blade (see Fig. 42-19). This sitioned to enable the operator to use wrist-arm motion small section, the terminal few millimeters of the blade, to activate strokes. On some aspects of the maxillary is positioned slightly apical to the lateral edge of the de- posterior teeth, these requirements can be met only posit, and a short vertical or oblique stroke is used to with the use of extraoral or opposite-arch fulcrums. split the calculus from the tooth surface. Without with- When intraoral finger rests are used in other regions of drawing the instrument from the pocket, the lower third the mouth, the finger rest must be close enough to the of the blade is advanced laterally and repositioned to en- working area to fulfill these two requirements. A finger gage the next portion of the remaining deposit. Another rest that is established too far from the working area vertical or oblique stroke is made, slightly overlapping forces the clinician to separate the middle finger from the previous stroke. This process is repeated in a series of the fourth finger in an effort to obtain parallelism and powerful scaling strokes until the entire deposit has been proper angulation. Effective wrist-arm motion is possi- removed. The overlapping of these pathways or "chan- ble only when these two fingers are kept together in a nels" of instrumentation89 ensures that the entire instru- built-up fulcrum. Separation of the fingers commits the mentation zone is covered (Fig. 47-2). clinician to the exclusive use of finger flexing for the ac- Engaging a large, tenacious ledge or piece of calculus tivation of strokes. with the entire length of the cutting edge is not recom- As instrumentation proceeds from one tooth to the mended because the force is distributed through a longer next, the body position of the operator and the location section of the cutting edge rather than concentrated. Far of the finger rest must be frequently adjusted or changed more lateral pressure is required to dislodge the entire de- to allow parallelism and wrist-arm motion. Various ap- posit in one stroke. Although some clinicians may pos- proaches to instrumentation in different areas of the sess the strength to remove calculus completely in this mouth are illustrated here. The examples shown provide manner, the heavier forces required diminish tactile sen- maximal efficiency for the clinician and comfort for the sitivity and contribute to a loss of control that results in patient. For most areas, more than one approach is pre- tissue trauma. A single heavy stroke usually is not suffi- sented. Other approaches are possible and are acceptable cient to remove calculus entirely. Instead, the blade skips if they provide equal efficiency and comfort. The follow- over or skims the surface of the deposit. Subsequent ing approaches may be used: strokes made with the entire cutting edge tend to shave the deposit down layer by layer. When a series of these Maxillary right posterior sextant: facial aspect (Fig. 47-4). repeated whittling strokes is applied, the calculus may be Operator position: Side position. reduced to a thin, smooth, burnished sheet that is diffi- Illumination: Direct. cult to distinguish from the surrounding root surface. Visibility: Direct (indirect for distal surfaces of molars). Scaling and Root Planing • CHAPTER 47 635 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 47-2 Instrumentation for calculus removal, A, Calculus is removed by engaging the apical or lateral edge of the deposit with the cutting edge of a scaler; vertical movement of the instrument will remove the fragment of calculus engaged by the instrument, as seen in the shaded drawing, B, The instrument is moved laterally and again engages the edge of the calculus, overlapping the previous stroke to some extent; the shaded drawing shows further removal. C, The final portion of the deposit is engaged and removed. Note how in an interdental space the operation is performed by entering facially and lingually.

Retraction: Mirror or index finger of the nonoperating hand. Finger rest. Extraoral, palm up. Backs of the middle and fourth fingers on the lateral aspect of the mandible on the right side of the face.

Maxillary right posterior sextant, premolar region only: facial aspect (Fig. 47-5). Operator position: Side or back position. Illumination: Direct. Visibility: Direct. Retraction: Mirror or index finger of the nonoperating hand. Finger rest. Intraoral, palm up, Fourth finger on the occlusal surfaces of the adjacent maxillary posterior teeth. Fig. 47-3 Shank position for scaling proximal surfaces. A, Correct Maxillary right posterior sextant: lingual aspect (Fig. 47-6). shank position, parallel with the long axis of the tooth, B, Incorrect shank position, tilted away from the tooth, C, Incorrect shank posi- Operator position: Side or front position. tion, tilted too far toward the tooth. Sextant: lingual aspect. Illumination: Direct and indirect. Visibility: Direct or indirect. Retraction: None. Finger rest. Extraoral, palm up. Backs of the middle and fourth fingers on the lateral aspect of the mandible on Maxillary anterior sextant: facial aspect, surfaces away the right side of the face. from the operator (Fig. 47-8). Operator position: Back position. Maxillary right posterior sextant: lingual aspect (Fig. 47-7). Illumination: Direct. Operator position: Front position. Visibility: Direct. Illumination: Direct. Retraction: Index finger of the nonoperating hand. Visibility: Direct. Finger rest. Intraoral, palm up. Fourth finger on the in- Retraction: None. cisal edges or occlusal surfaces of adjacent maxillary Finger rest: Intraoral, palm up, finger-on-finger. Index fin- teeth. ger of the nonoperating hand on the occlusal surfaces of the maxillary right posterior teeth; fourth finger of Maxillary anterior sextant: facial aspect, surfaces toward the operating hand or the index finger of nonoperat- the operator (Fig. 47-9). ing hand. Operator position: Front position.

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Fig. 47-4 Maxillary right posterior sextant: facial aspect. Fig. 47-5 Maxillary right posterior sextant, premolar region only: facial aspect.

Fig. 47-6 Maxillary right posterior sextant: lingual aspect, Fig. 47-7 Maxillary right posterior sextant: lingual aspect,

Fig. 47-8 Maxillary anterior sextant: facial aspect, surfaces away Fig. 47-9 Maxillary anterior sextant: facial aspect, surfaces toward from the operator. the operator.

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Illumination: Direct. Maxillary left posterior sextant: facial aspect (Fig. 47-11). Visibility: Direct. Operator position: Side or back position. Retraction: Index finger of the nonoperating hand. Illumination: Direct or indirect. Finger rest. Intraoral, palm down. Fourth finger on the in- Visibility: Direct or indirect. cisal edges or the occlusal or facial surfaces of adjacent Retraction: Mirror. maxillary teeth. Finger rest. Extraoral, palm down. Front surfaces of the middle and fourth fingers on the lateral aspect of the Maxillary anterior sextant: lingual aspect, surfaces away mandible on the left side of the face. from the operator (surfaces toward the operator are scaled from a front position) (Fig. 47-10). Maxillary left posterior sextant: facial aspect (Fig. 47-12). Operator position: Back position. Operator position: Back or side position. Illumination: Indirect. Illumination: Direct or indirect. Visibility: Indirect. Visibility: Direct or indirect. Retraction: None. Retraction: Mirror. Finger rest. Intraoral, palm up. Fourth finger on the incisal Finger rest. Intraoral, palm up. Fourth finger on the in- edges or occlusal surfaces of adjacent maxillary teeth. cisal edges or occlusal surfaces of adjacent maxillary teeth. Maxillary left posterior sextant: lingual aspect (Fig. 47-13). Operator position: Front position. Illumination: Direct.

Fig. 47-11 Maxillary left posterior sextant: facial aspect. Fig. 47-10 Maxillary anterior sextant: lingual aspect, surfaces away from the operator (surfaces toward the operator are scaled from a front postion).

Fig. 47-12 Maxillary left posterior sextant: facial aspect. Fig. 47-13 Maxillary left posterior sextant: lingual aspect,

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Fig. 47-14 Maxillary left posterior sextant: lingual aspect. Fig. 47-15 Maxillary left posterior sextant: lingual aspect.

Fig. 47-16 Mandibular left posterior sextant: facial aspect.

Fig. 47-17 Mandibular left posterior sextant: lingual aspect. Fig. 47-18 Mandibular anterior sextant: facial aspect, surfaces toward the operator.

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Visibility: Direct. Finger rest. Intraoral, palm down. Fourth finger on the in- Retraction: None, cisal edges or the occlusal surfaces of adjacent man- Finger rest: Intraoral, palm down, opposite arch, rein- dibular teeth. forced. Fourth finger on the incisal edges of the Mandibular anterior sextant: facial aspect, surfaces to- mandibular anterior teeth or the facial surfaces of the ward the operator (Fig. 47-18). mandibular premolars, reinforced with the index fin- Operator position: Front position. ger of the nonoperating hand. Illumination: Direct. Maxillary left posterior sextant: lingual aspect (Fig. 47-14). Visibility: Direct. Operator position: Front position. Retraction: Index finger of the nonoperating hand. Illumination: Direct and indirect. Finger rest: Intraoral, palm down. Fourth finger on the Visibility: Direct and indirect. incisal edges or the occlusal surfaces of adjacent Retraction: None. mandibular teeth. Finger rest: Extraoral, palm down. Front surfaces of the Mandibular anterior sextant: facial aspect, surfaces away middle and fourth fingers on the lateral aspect of the from the operator (Fig. 47-19). mandible on the left side of the face. The nonoperat- Operator position: Back position. ing hand holds the mirror for indirect illumination. Illumination: Direct. Maxillary left posterior sextant: lingual aspect (Fig. 47-15). Visibility: Direct. Operator position: Side or front position. Retraction: Index finger or thumb of the nonoperating Illumination: Direct. hand. Visibility: Direct. Finger rest. Intraoral, palm down. Fourth finger on the in- Retraction: None. cisal edges or the occlusal surfaces of adjacent man- Finger rest: Intraoral, palm up. Fourth finger on the oc- dibular teeth. clusal surfaces of adjacent maxillary teeth. Mandibular anterior sextant: lingual aspect, surfaces Mandibular left posterior sextant: facial aspect (Fig. 47-16). away from the operator (Fig. 47-20). Operator position: Side or back position. Operator position: Back position. Illumination: Direct. Illumination: Direct and indirect. Visibility: Direct or indirect. Visibility: Direct and indirect. Retraction: Index finger or mirror of the nonoperating Retraction: Mirror retracts tongue. hand. Finger rest. Intraoral, palm down. Fourth finger on the in- Finger rest. Intraoral, palm down. Fourth finger on the incisal edges or the occlusal surfaces of adjacent man- cisal edges or the occlusal or facial surfaces of adjacent dibular teeth. mandibular teeth. Mandibular anterior sextant: lingual aspect, surfaces to- Mandibular left posterior sextant: lingual aspect (Fig. ward the operator (Fig. 47-21). 47-17). Operator position: Front position. Operator position: Front or side position. Illumination: Direct and indirect. Illumination: Direct and indirect. Visibility: Direct and indirect. Visibility: Direct. Retraction: Mirror retracts tongue. Retraction: Mirror retracts tongue. Finger rest: Intraoral, palm down. Fourth finger on the incisal edges or the occlusal surfaces of adjacent mandibular teeth.

Fig. 47-19 Mandibular anterior sextant: facial aspect, surfaces Fig. 47-20 Mandibular anterior sextant: lingual aspect, surfaces away from the operator, away from the operator.

640 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com Mandibular right posterior sextant: facial aspect (Fig. Finger rest: Intraoral, palm down. Fourth finger on the in- 47-22). cisal edges or the occlusal surfaces of adjacent man- Operator position: Side or front position. dibular teeth. Illumination: Direct. Visibility: Direct. Retraction: Mirror or index finger of the nonoperating Ultrasonic Scaling hand. Ultrasonic Scaling Instruments. Ultrasonic in- Finger rest. Intraoral, palm down. Fourth finger on the instruments have been used as a valuable adjunct to con- cisal edges or the occlusal surfaces of adjacent man- ventional hand instrumentation for many years, Until dibular teeth. relatively recently, all ultrasonic tips were large and Mandibular right posterior sextant: lingual aspect (Fig. bulky, making them generally suitable only for supragin- 47-23). gival scaling or subgingival scaling where tissue was in- Operator position: Front position. flamed and retractable. However, newly designed, thin Illumination: Direct and indirect. ultrasonic tips have allowed better access to subgingival Visibility: Direct and indirect. areas previously accessible only with hand instru- Retraction: Mirror retracts tongue. ments.20 It is important to understand this historical perspective when attempting to interpret the literature comparing the effects of hand and ultrasonic instruments on root surfaces. Earlier studies using older tip designs generally showed that ultrasonic instruments left a rougher, more damaged surface than curettes . 4,22,35,36,51,53,114,119,126 More recent studies, especially those using the newer, thinner tips, show that ultrasonic instruments can produce root surfaces as smooth or smoother than can be produced by curettes. 30,31,34,98 Whether these relative degrees of smoothness are important has not been clearly established. 35,45,54,61,81,107 It is evident, however, that both methods of instrumentation are able to provide satisfactory clinical results as measured by removal of plaque and calculus, reduction of bacteria, reduction of inflammation and pocket depth, and gain in clinical attachment.6-10,28,37,65,83,92,114,1 v Ultrasonic instruments have been shown to be more effective than hand instruments at reducing spirochetes and motile rods in class II and III furcations. 62 Recently, two in vitro studies found that ultrasonic and sonic scalers do not kill periodontopathic bacteria by vibrational energy but rather suggest an antimicrobial effect from an increase in temperature . 82,106 Fig. 47-21 Mandibular anterior sextant: lingual aspect, surfaces Other in vitro studies found that Gracey Curvette curets toward the operator, were more effective than slim ultrasonic inserts in de-

Fig. 47-22 Mandibular right posterior sextant: facial aspect, Fig. 47-23 Mandibular right posterior sextant: lingual aspect.

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briding root trunks, furcation entrances, and furcation or overheating of the tooth.30 Using a lower-power setting areas of mandibular first molars . 86,87 and applying only slight pressure reduces the volume and The selection of either ultrasonic or hand instrumen- depth of tooth structure removal .22,91 The working end of tation should be determined by the clinician's preference the ultrasonic instrument must come in contact with the and experience and the needs of each patient. The suc- calculus deposit to fracture and remove it. As with hand cess of either treatment method is determined by the instruments, instrument adaptation to the tooth is critical time devoted to the procedure and the thoroughness of to success. The working tip must contact all aspects of the root debridement. In practice, clinicians commonly use a root surface to thoroughly remove plaque and toxins. Al- combination of both ultrasonic and hand instrumenta- though as much as 10 mm or more of the length of the tion to achieve thorough debridement. ultrasonic tip vibrates, only a small portion of it can be The vibrational energy produced by the ultrasonic in- adapted to contact the curved root surface at any one strument makes it useful for removing heavy, tenacious time or point. As with hand instruments, a series of rapid, deposits of calculus and stain. Such deposits can be re- overlapping strokes must be activated to ensure complete moved more quickly and with less effort ultrasonically root coverage .45 However, these rapid, light strokes with a than manually. When ultrasonic instruments are prop- blunt, vibrating working end impair tactile sensitivity, erly manipulated, less tissue trauma and therefore less and the constant water spray necessary for the operation postoperative discomfort occur. This makes ultrasonic in- of the instrument hampers visibility. For these reasons, strumentation useful for initial debridement in patients during ultrasonic instrumentation, the tooth surface with acute painful conditions such as necrotizing ulcera- should be frequently examined with an explorer to evalu- tive gingivitis. This same quality can be used to advan- ate the completeness of debridement. tage with the new, thin ultrasonic tips for subgingival The aerosol produced by sonic and ultrasonic instru- root debridement and deplaquing in maintenance pa- mentation may contain potentially infectious blood- tients with residual pocket depth. Ultrasonic scaling de- borne and airborne pathogens. 5,31-40,46,58,72,73,99,118 Pneu- vices also have been used for gingival curettage and to mococci, staphylococci, alpha hemolytic streptococci, remove overhangs and excess cement after cementing and Mycobacterium tuberculosis are among the bacteria orthodontic appliances. Opinions differ regarding the ef- that have been found in dental aerosols .50,63 Aerosols fectiveness of ultrasonic instruments for removing stain also subject dental personnel and patients to many compared with conventional polishing methods.', 16 viruses including herpes simplex virus, hepatitis virus, Some definite contraindications to the use of ultrasonic influenza virus, common cold viruses, Epstein-Barr virus, and sonic scaling devices exist. No one with a cardiac pace- and cytomegalovirus.20-26,69,116 Of additional concern are maker should be exposed to ultrasonic instruments.'° Pa- pathogens that do not originate from patients but are tients with known communicable diseases that can be from the contaminated waterlines of the dental unit or transmitted by aerosols should not be treated with ultra- the ultrasonic device .27,33,88 Putative pathogens such as sonic or sonic scaling devices. The water spray creates a Pseudomonas sp. and Legionella pneumophilia have been contaminated aerosol that fills the operating area, exposing isolated from dental unit water and can become personnel and surfaces. 58,78 Even when treating patients aerosolized by an ultrasonic scaler. 27,33,38,84 Aerosol from without known communicable diseases, it is especially im- ultrasonic instrumentation always contains blood11,71 portant that proper infection control measures be ob- and lingers in the air for 30 minutes or longer in the en- served (i.e., use of protective clothing, eyewear, masks, and tire operatory and in areas of the dental office outside gloves) and proper surface decontamination be performed the operatory. 58,60,72,73 Unprotected patients may be more afterward. Prerinsing for 1 minute with an antimicrobial susceptible to infection from the aerosol than dental per- mouthwash such as 0.12% chlorhexidine significantly re- sonnel who are wearing protective barriers such as duces the number of bacteria in the aerosol for approxi- masks, gloves, eyewear and clinical clothing. 13,20,109 High- mately 1 hour. 121 Patients at risk for respiratory disease speed evacuation, preprocedural rinsing with chlorhexi- should not be treated with ultrasonic or sonic devices; dine, flushing of the handpiece and waterlines or a self- these include patients who are immunosuppressed or suf- contained sterile water source, thorough disinfection of fer from chronic pulmonary disorders. 109,115 Finally, metal environmental surfaces, and adequate ventilation and ultrasonic and sonic inserts are contraindicated for tita- air filtration units with HEPA (High Efficiency Particulate nium implants, which can be etched or gouged, and for Air) filters (Honeywell Environmental Air Control Inc., porcelain or bonded restorations, which can be fractured Hagerstown, MD) are all important precautions to mini- or removed. 15,29,59,96,122 Plastic-tipped ultrasonic and sonic mize the potential hazards of ultrasonic aerosols .41-43,101 inserts that do not cause damage to titanium implants With these points in mind, the ultrasonic device is are available.'' Also, Teflon-coated sonic scaler tips have used in the following manner: been developed for titanium implants and for deplaque- ing and subgingival polishing of root surfaces .55,56,102 l. Thoroughly wipe the ultrasonic unit with a disinfectant. Use a sterile, autoclavable ultrasonic handpiece Ultrasonic Scaling Technique. Ultrasonic instru- or wipe the handpiece with disinfectant. Cover the ul- mentation is accomplished with a light touch and light trasonic unit or control knobs and the handpiece pressure, keeping the tip parallel to the tooth surface and with plastic or latex barriers. Flush the waterlines and constantly in motion. 31,45,91 Leaving the tip in one place handpiece for 2 minutes to decrease the number of for too long or using the point of the tip against the tooth microorganisms in the lines. 125 Use waterline filters or can produce gouging and roughening of the root surface sterile water whenever possible.

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2. Direct the patient to rinse for 1 minute with an an- wounds created during instrumentation takes 1 to 2 timicrobial mouthrinse such as 0.12% chlorhexidine weeks. 112,113 Until then, gingival bleeding on probing can to reduce the contaminated aerosol. 121,125 be expected even when calculus has been completely re- 3. The clinician and the assistant should wear protective moved because the soft tissue wound is not epithelialized. eyewear and masks and use high-speed evacuation to Any gingival bleeding on probing noted after this interval minimize inhalation of the contaminated aerosol pro- is more likely to be due to persistent inflammation pro- 41-43 duced during instrumentation. duced by residual deposits that were not removed during 4. Turn on the unit, select an insert, place it into the the initial procedure or inadequate plaque control. Posi- handpiece, and then adjust the water control knob to tive clinical changes after instrumentation often continue produce a light mist of water at the working tip. Ade- for weeks or months. For this reason, a longer period of quate aspiration is necessary to remove this water as it evaluation may be indicated before deciding whether to accumulates in the mouth. The power setting should intervene with further instrumentation or surgery. 21 begin on low and be adjusted no higher than neces- Occasionally the clinician may find that some slight sary to remove calculus. Medium- to high-power set- root roughness remains after scaling and root plan- tings have been shown to cause damage to roots ing. 53,114,126 If sound principles of instrumentation have when the tip is not parallel to the root surface. been followed, the roughness may not be calculus. Be- 5. The instrument is grasped with a light pen or modi- cause calculus removal, not root smoothness per se, has fied pen grasp, and a finger rest or extraoral fulcrum been shown to be necessary for tissue health, it might be should be established to allow a very light, featherlike more prudent in such a case to stop short of perfect touch. Extraoral hand rests should be used for the smoothness and reevaluate the patient's tissue response maxillary teeth. For the mandibular teeth, either in- after 2 to 4 weeks or longer. This avoids overinstrumen- traoral or extraoral fulcrums may be used. tation and removal of excessive root structure in the pur- 6. Use short, light, vertical, horizontal, or oblique over- suit of smoothness for its own sake. If the tissue is lapping strokes. Keep the working tip adapted to the healthy after an interval of 2 to 4 weeks or longer, no tooth surface as it is passed over the deposit. Heavy further root planing is necessary. If the tissue is inflamed, lateral pressure is unnecessary because the vibrational the clinician must determine to what extent this is due energy of the instrument dislodges the calculus. How- to plaque accumulation or the presence of residual calcu- ever, the working end must touch the deposit for this lus and to what degree further root planing is necessary. to occur. 7. The working end should be kept in constant motion, REFERENCES and the tip should be kept parallel to the tooth surface or at no more than a 15-degree angle to avoid 1. Adriaens P, Edwards C, DeBoever J, et al: Ultrastructural etching or grooving the tooth surface."' observations on bacterial invasion in cementum and radic- 8. The instrument should be switched off periodically to ular dentin of periodontally diseased human teeth. J Peri- allow for aspiration of water, and the tooth surface odontol 1988; 59:493. 2. Aleo J, DeRenzis F, Farber P: In vitro attachment of human should be examined frequently with an explorer. 9. gingival fibroblasts to root surfaces. J Periodontol 1975; Any remaining irregularities of the root surface may be 46:639. removed with sharp standard or mini-bladed curettes 3. Aleo J, DeRenzis F, Farber P, et al: The presence and biolog- if necessary. ical activity of cementum-bound endotoxin. J Periodontol 1974; 45:672. 4. Evaluation Allen EF, Rhoads RH: Effects of high-speed periodontal instruments on tooth surfaces. J Periodontol 1963; 34:352. The adequacy of scaling and root planing is evaluated 5. Ashimoto A, Chen C, Bakker I, et al: Polymerase chain re- when the procedure is performed and again later, after a action detection of 8 putative periodontal pathogens in period of soft tissue healing. subgingival plaque of gingivitis and advanced periodonti- Immediately after instrumentation, the tooth surfaces tis lesions. Oral Microbiol Immunol 1996; 11(4):266. 6. Axelsson P, Lindhe J: Effect of controlled oral hygiene pro- should be carefully inspected visually with optimal light- cedures on caries and periodontal disease in adults. Results ing and the aid of a mouth mirror and compressed air; after 6 years. J Clin Periodontol 1981; 8:239. they also should be examined with a fine explorer or 7. Baderstein A, Nilveus R, Egelberg J: Effect of nonsurgical probe. Subgingival surfaces should be hard and smooth. periodontal therapy. I. Moderately advanced periodontitis. Although complete removal of calculus is definitely nec- J Clin Periodontol 1981; 8:57. essary for the health of the adjacent soft tissue, 123 little 8. Baderstein A, Nilveus R, Egelberg J: 4-year observations of documented evidence that root smoothness is necessary basic periodontal therapy. J Clin Periodontol 1987; 14:438. 35,37,117 9. is available . Nevertheless, relative smoothness is Baderstein A, Nilveus R, Egelberg J: Scores of plaque, bleed- still the best immediate clinical indication that calculus ing, suppuration, and probing depth to predict probing at- has been completely removed.35 tachment loss. 5 years of observation following nonsurgical periodontal therapy. J Clin Periodontol 1990; 17:102. Although smoothness is the criterion by which scaling 10. Baehni P, Thilo P, Chapuis B, et al: Effects of ultrasonic and and root planing are immediately evaluated, the ultimate sonic scalers on dental plaque microflora in vitro and in 123 evaluation is based on tissue response. Clinical evalua- vivo. J Clin Periodontol 1992; 19:455. tion of the soft tissue response to scaling and root plan- 11. Barnes JB, Harrel SK, Rivera-Hidalgo F: Blood contamina- ing, including probing, should not be conducted earlier tion of the aerosols produced by in vivo use of ultrasonic than 2 weeks postoperatively. Reepithelialization of the scalers. 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12. Barnes JE, Schaffer EM: Subgingival root planing: A com- 34. Garnick JJ, Dent J: A scanning electron micrographical parison using files, hoes, and curets. J Periodontol 1960; study of root surfaces and subgingival bacteria after hand 31:300. scaling and ultrasonic instrumentation. J Periodontol 13. Basu MK, Browne RM, Potts AJ, et al: A survey of aerosol- 1989; 60:441. related symptoms in dental hygienists. J Soc Occup Med 35. Garrett JS: Effects of nonsurgical periodontal therapy on 1988; 38(1-2):23. periodontitis in humans. A review. J Clin Periodontol 14. Becker W, Berg LE, Becker BE: Long-term evaluation of pe- 1983; 10:515. riodontal treatment and maintenance in 95 patients. Int J 36. Green E, Ramfjord SR: Tooth roughness after subgingival Periodontics Restorative Dent 1984; 4:54. root planing. J Periodontol 1966; 37:396. 15. Bjornson EJ, Collins DE, Engler WO: Surface alteration of 37. 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57. Kwan J, Zablotsky MH, Meffert RM: Implant maintenance 80. Nyman S, Westfelt E, Sarhed G, et al: Role of "diseased" using a modified ultrasonic instrument. J Dent Hyg 1990; root cementum in healing following treatment of peri- 64:422. odontal disease: A clinical study. J Clin Periodontol 1988; 58. Larato DC, Ruskin PE Martin A: Effect of an ultrasonic 15:464. scaler on bacterial counts in air. J Periodontol 1967; 38:550. 81. Oberholzer R, Rateitschak KH: Root cleaning or root 59. Lee S-Y, Lai Y-L, Morgano SM: Effects of ultrasonic scaling smoothing. An in vivo study. J Clin Periodontol 1996; and periodontal curettage on surface roughness of porce- 23(4):326. lain. J Prothet Dent 1995; 73:227. 82. O'Leary R, Sved AM, Davies EH, et al: The bactericidal ef- 60. Legnani P, Checchi L, Pelliccioni GA, et al: Atmospheric fects of dental ultrasound on Actinobacillus actinomycetem- contamination during dental procedures. Quintessence Int comitans and Porphyromonas gingivalis. 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Muir KF, Ross PW, MacPhee IT, et al: Reduction of micro- bridement on the elimination of Actinobacillus actino- bial contamination from ultrasonic scalers. Br Dent J 1978; mycetemcomitans and Bacteroides gingivalis from periodon- 145:760. tal pockets. J Clin Periodontol 1990; 17:345. 79. Nakib NM, Bissada NF, Simmelink JW, et al: Endotoxin 98. Ritz L, Hefti AF, Rateitschak KH: An in vitro investigation penetration into root cementum of periodontally healthy on the loss of root substance in scaling with various in- and diseased human teeth. J Periodontol 1982; 53:368. struments. J Clin Peridontol 1991; 18:643.

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99. Rivera-Hidalgo F, Barnes JB, Harrel SK: Aerosol and splatter 113. Stahl SS, Weiner JM, Benjamin S, et al: Soft tissue healing production by focused spray and standard ultrasonic in- following curettage and root planing. J Periodontol 1971; serts. J Periodontol 1999; 70:473. 42:678. 100. Rosenberg ES, Evian CI, Listgarten M: The composition of 114. Stende GW, Schaffer EM: A comparison of ultrasonic and the subgingival microbiota after periodontal therapy. J Pe- hand scaling. J Periodontol 1961; 32:312. riodontol 1981; 52:435. 115. Suzuki JB, Delisle AL: Pulmonary Actinomycosis of peri- 101. Rutala WA, Jones SM, Worthington JM, et al: Efficacy of odontal origin. J Periodontol 1984; 55:581. portable filtration units in reducing aerosolized particles in 116. Ting M, Contreras A, Slots J: Herpesvirus in localized juve- the size range of Mycobacterium tuberculosis. Infect Control nile periodontitis. J Periodontal Res 2000; 35(1):17. Hosp Epidemiol 1995; 16(7):391. 117. Torfason T, Kiger R, Selvig KA, et al: Clinical improvement 102. Ruhling, A, Kocher T, Kreusch J, et al: Treatment of subgin- of gingival conditions following ultrasonic versus hand in- gival implant surfaces with Teflon-coated sonic and ultra- strumentation of periodontal pockets. J Clin Periodontol sonic scaler tips and various implant curettes. An in vitro 1979; 6:165. study. Clin Oral Implants Res 1994; 5(1):19. 118. Umeda M, Contreras A, Chen C, et al: The utility of whole 103. Sbordone L, Ramaglia L, Guletta E, et al: Recolonization of saliva to detect the oral presence of periodontopathic bac- the subgingival microflora after scaling and root planing teria. J Periodontol 1998; 69(7):828. in human periodontitis. J Periodontol 1990; 61:579. 119. Van Volkinburg J, Green E, Armitage G: The nature of root 104. Schaffer EM: Histologic results of root curettage on human surfaces after curette, cavitron, and alpha-sonic instrumen- teeth. J Periodontol 1956; 27:269. tation. J Periodont Res 1976; 11:374. 105. Selvig KA: Attachment of plaque and calculus to tooth sur- 120. van Winkelhoff AJ, van der Velden U, de Graaff J: Micro- faces. J Periodont Res 1970; 5:8. bial succession in recolonizing deep periodontal pockets 106. Schenk G, Flemmig TF, Lob S, et al: Lack of antimicrobial after a single course of supra- and subgingival debride- effect on periodontopathic bacteria by ultrasonic and ment. J Clin Periodontol 1988; 15:116. sonic scalers in vitro. J Clin Periodontol 2000; 27(2):116. 121. Veksler AE, Kayrouz GA, Newman MG: Reduction of sali- 107. Schlageter L, Rateitschak-Pluss EM, Schwarz JP: Root sur- vary bacteria by pre-procedural rinses with chlorhexidine face smoothness or roughness following open debride- 0.12%. J Periodontol 1991; 62:649. ment. An in vivo study. J Clin Periodontol 1996; 23(5):460. 122. Vermilyea SG, Prasanna MK, Agar JR: Effect of ultrasonic 108. Shiloah J, Patters M: Repopulation of periodontal pockets cleaning and air polishing on porcelain labial margin by microbial pathogens in the absence of supportive ther- restorations. J Prosthet Dent 1994; 71:447. apy. J Peridontol 1996; 67:130. 123. Waerhaug J: Healing of the dentoepithelial junction follow- 109. Shreve WB, Hoerman KC, Trautwein CA: Illness in patients ing subgingival plaque control. J Periodontol 1978; 49:1. following exposure to dental aerosols. J Public Health Dent 124. Westfelt E, Nyman S, Socransky SS, et al: Significance of 1972; 32(1):34. frequency of professional tooth cleaning following peri- 110. Slots J, Mashimo P, Levine MJ, et al: Periodontal therapy in odontal surgery. J Clin Periodontol 1983; 10:148. humans. I. Microbiological and clinical effects of a single 125. Wilkins EM: Clinical Practice of the Dental Hygienist, ed 7. course of periodontal scaling and root planing, and of ad- Philadelphia, Williams & Wilkins, 1994. junctive tetracycline therapy. J Periodontol 1979; 50:495. 126. Wilkinson RF, Maybury J: Scanning electron microscopy of 111. Smart GJ, Wilson M, Davis EH, et al: The assessment of ul- the root surface following instrumentation. J Periodontol trasonic root surface debridement by determination of 1973; 44:559. residual endotoxin levels. J Clin Periodontol 1990; 17:174. 127. Ximenez-Fyvie LA, Haffajee AD, Socransky SS: Comparison 112. Stahl SS, Slavkin HC, Yamada L, et al: Speculations about of the microbiota of supra- and subgingival plaque in gingival repair. J Periodontol 1972; 43:395. health and periodontitis. J Clin Periodontol 2000; 27(9):648. 128. Zander HA: The attachment of calculus to root surfaces. J Periodontol 1953; 24:16. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Phase I Periodontal Therapy

Dorothy A. Perry and Max O. Schmid

CHAPTER

CHAPTER OUTLINE

RATIONALE REEVALUATION RESULTS DECISION TO REFER FOR SPECIALIST TREATMENT

base I therapy is the first step in the chronologic shows the results of Phase I therapy for two different pe- sequence of procedures that constitute periodontal riodontal patients. treatment. The objective of Phase I therapy is to Phase I therapy is a critical aspect of periodontal alter or eliminate the microbial etiology and contribut- treatment. Data from clinical research indicate that the ing factors for gingival and periodontal diseases. The re- long-term success of periodontal treatment depends sult is the arresting of the progression of disease and predominantly on maintaining the results achieved preservation of the dentition in a state of health, com- with Phase I therapy and much less on any specific sur- fort, and function with appropriate esthetics.' Phase I gical procedures. In addition, Phase I therapy provides therapy is referred to by a number of names, including an opportunity for the dentist to evaluate tissue re- initial therapy,' nonsurgical periodontal therapy,'' cause- sponse and the patient's attitude toward periodontal related therapy,$ and the etiotropic phase of therapy.16 All care, both of which are crucial to the overall success of terms refer to the procedures performed to treat gingival treatment. and periodontal infections, up to and including tissue Phase I therapy has many specific goals that go well reevaluation. beyond the control of inflammation and pocket reduction by mechanical means. The American Academy of RATI ONALE Periodontology has included the following aspects in the Parameters of Care for Phase I Therapy': The reduction and elimination of etiologic and contributing factors in periodontal treatment is achieved by 1. Evaluation and alteration of patient systemic risk fac- complete removal of calculus, correction of defective tors. These include, among others, systemic diseases restorations, treatment of carious lesions, and institution and conditions, smoking, substance abuse, and use of of a comprehensive daily plaque control regimen .3.5,7,9,'4 medications. Consultation with the patient's physi- The initial phase of therapy is provided to all patients cian may be a necessary part of Phase I therapy. with periodontal pockets who later will be evaluated for 2. Plaque control performed by the patient (see surgical intervention and those with gingivitis or mild Chapter 49). chronic periodontitis who are unlikely to need surgical 3. Removal of microbial plaque and calculus from the treatment. The procedures included in Phase I therapy surfaces of the teeth (see Chapters 42 and 43). may be the only procedures required to solve the pa- 4. Appropriate use of antimicrobial agents and devices tient's periodontal problems, or they may constitute the including necessary plaque sampling and antibiotic preparatory phase for surgical therapy. Color Fig. 48-1 sensitivity testing (see Chapters 44 and 50).

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5. Control or elimination of contributing local factors group using antimicrobial adjuncts. As our understand- including the following: ing of the best use of antimicrobial agents increases, A. Treatment of poorly fitting restorations treatment plans undoubtedly will evolve to maximize B. Correction of poorly fitting prosthetic devices therapeutic results. C. Restoration of carious lesions A number of specific conditions need to be considered D. Odontoplasty in formulating the treatment plan for each patient. The E. Tooth movement individual patient considerations relating to the develop- F. Treatment of food impaction areas ment of the Phase I therapy treatment plan and se- G. Treatment of occlusal trauma quence include the following"15 H. Extraction of hopeless teeth • General health and tolerance of treatment Based on the knowledge that microbial plaque har- • Number of teeth present bors the primary pathogens of gingival inflammation, • Amount of supragingival calculus the specific aim of Phase I therapy for every patient is ef- • Amount of subgingival calculus fective plaque control. This is accomplished by establish- • Probing pocket depths (amount of attachment loss is ing an effective daily plaque control regimen for the pa- less significant than depth of pockets for determining tient, removing calculus, and eliminating rough and the treatment plan) irregular tooth surfaces, including treating carious le- • Furcation involvement sions. Effective plaque control is the key objective of • Alignment of teeth every therapeutic periodontal procedure, but it is best ac- • Margins of restorations complished if tooth surfaces are free of rough deposits • Developmental anomalies and irregular contours so that they are readily accessible • Physical barriers to access (i.e., limited opening or to oral hygiene aids. tendency to gag) Caries control and treatment of active carious lesions • Patient cooperation is an often-overlooked aspect of Phase I therapy. Caries is • Patient sensitivity (requiring use of anesthesia or anal- now recognized as an infection.' As such, carious must gesia) be temporized, with removal of the infectious process and improved tooth contours established to maximize the healing achieved during the scaling and root planing RESULTS treatment. Frank carious lesions, particularly Class V le- Phase I therapy is a complex and individualized treat- sions in the cervical areas of teeth and those on root sur- ment. It requires detailed analysis of each patient's dis- faces, provide a reservoir for bacteria and can contribute ease and contributing factors and customized therapy. to the repopulation of the periodontal plaque. The cavi- The treatments common to all Phase I therapy are pa- ties themselves are receptacles where plaque is sheltered tient plaque control, caries control, and scaling and root from even the most energetic mechanical plaque re- planing to remove supragingival calculus, subgingival moval. For these reasons it is imperative that caries con- calculus, and plaque deposits. Plaque control performed trol and at least temporization of carious lesions be by the patient at home is complex and requires chang- completed during Phase I therapy. ing lifelong habits. It is difficult to achieve and varies After careful analysis of the case and diagnosis of the among individual patients, but strategies for success ex- specific periodontal condition presented, the dentist de- ist. Plaque control education and motivation are pre- termines the treatment plan for the scaling and root sented in Chapter 49. planing portion of Phase I therapy. This is an estimate of Scaling and root planing therapy has been studied ex- the procedures and number of appointments needed to tensively to evaluate its effects on periodontal disease. A complete the initial phase of therapy after carious le- review of studies evaluating the effects of scaling and sions are controlled. Patients with small amounts of cal- root planing indicate that the treatment is both effective culus and relatively healthy tissues can be treated in one and reliable.6 Studies ranging from 1 month to 2 years in appointment. Most patients require several treatment length demonstrate up to 80% reductions in bleeding on sessions to complete debridement of tooth surfaces. The probing and mean probing depth reductions in the dentist should estimate the number of appointments range of 2 to 3 mm. Others have demonstrated that the needed on the basis of the conditions presented by each number of pockets 4 mm in depth or greater was re- individual patient. In addition to the number of times duced by 52% to 80%. Several of these studies also com- the patient must be seen, some consideration should be pared the relative healing result using hand instrumenta- given to control of infectious organisms during the pe- tion and ultrasonic or sonic instruments for scaling and riod of active Phase I treatment. One option for schedul- root planing. No difference in healing was identified ing appointments is one or two longer appointments on based on the type of instruments used to provide the consecutive days, while the patient is on an aggressive treatmennt6 Additional individual treatment such as prescribed regimen of antimicrobial agents, then follow- caries control and correction of ill-fitting restorations up appointments during healing. This treatment se- only augment the positive results of healing gained quence has been referred to as anti-enfective or disinfec- through good plaque control and scaling and root plan- tion treatment.lo,10,13 Data from these studies indicated ing. Fig. 48-1 shows the effects of an overhanging that improvements in probing depths and reduction of amalgam restoration on the gingiva. 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Fig. 48-1 Effect of an overhanging amalgam margin on the interproximal gingiva of a maxillary first molar. A, Clinical appearance of rough, irregular, and overcontoured amalgam. B, Gentle probing of the interproximal pocket. C, Extreme amount of bleeding elicited by gentle probing in the area is indicative of severe inflammation in the area. D, Clinical appearance of recontoured restoration (arrow).

conditions that retain plaque and provide reservoirs for uncomfortable consequences may result in distrust and repopulation of periodontal pathogens. loss of motivation to continue therapy, so it is important that patients be educated about the consequences at the outset of treatment. REEVALUATIO N The periodontal tissues must be carefully reexamined Reevaluation of the periodontal case should occur about 4 to determine the need for further therapy. Pockets must weeks after the completion of the scaling and root plan- be reprobed to decide whether surgical intervention in ing procedures. This permits time for both epithelial and indicated. However, additional improvement through connective tissue healing, correction of conditions such as surgery can be expected only if Phase I therapy has been overhanging margins, and sufficient practice with oral hy- successful. Therefore surgical treatment of periodontal giene skills so that the dentist can accurately assess the pe- pockets should be attempted only if the patient is exer- riodontal condition at the end of Phase I therapy. cising effective plaque control and the gingiva is free of Gingival inflammation is usually substantially re- overt inflammation. duced or eliminated within 3 to 4 weeks after removal of calculus and local irritants. Healing consists of the for- DECISION TO REFER FOR mation of a long junctional epithelium rather than new SPECIALIST TREATMEN T connective tissue attachment to the root surfaces. The attachment epithelium reappears within 1 to 2 weeks. The goal of this textbook is to prepare general dentists to Gradual reductions in inflammatory cell population, manage most periodontal care required in their practices. crevicular fluid flow, and repair of connective tissue re- The preface to the 8th edition of this textbook states: sult in reduction of the clinical signs of inflammation, with less redness and swelling.' The periodontal care of the public is primarily the con- Transient root hypersensitivity and recession of the cern o f the general dentist, and that the general dentist gingival margins frequently accompany the healing cannot disregard his or her responsibility to provide process. Patients should be warned at the outset of treat- periodontal care for all patients. The extremely high in- ment that these results may happen, otherwise it may cidence of periodontal problems in the population come as an unpleasant surprise. These unexpected and makes it impossible for the small number o f specialists

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In addition to the 5-mm standard, other factors must be considered in the decision to refer. These include the following:

1. Extent of disease: The deeper the pockets, the stronger the indication for referral. 2. Root length: Short roots are more seriously jeopardized by 5 mm of clinical attachment loss than long roots. 3. Hypermobility, which suggests a more guarded prognosis. 4. Difficulty of scaling and root planing: The presence of deep pockets and furcations make local treatment much more difficult. 5. Restorative work: Long-term prognosis of the tooth is an important consideration in planning extensive restorative work. 6. Age of the patient: The younger the patient with extensive attachment loss, the more aggressive the disease process is likely to be. 7. Resolution by shrinkage: Some tissue such as thick, fi- Fig. 48-2 The 5-mm standard for referral to a periodontist is brotic gingiva do not resolve as well as thinner, ede- based on root length, probing depth, and attachment loss. The matous gingiva when edema subsides, leaving deeper standard serves as a reasonable guideline to trigger further analysis probing depths. of the case and possible need for specialist care. (Redrawn from Ar- mitage G (ed): Periodontal Maintenance Therapy. Berkeley, CA, The success in treating advanced periodontal disease Praxis, 1974.) generally occurs in patients with 6- to 8-mm probing depths and/or attachment loss. Specialists have limited success when depths are 9 mm or greater, so early referral of advanced cases is likely to provide the best results. in periodontics to cope with them; in addition, the close Each patient is unique, and the decision process for each relationship between periodontal and restorative dental patient is complex. The considerations presented in this therapies makes it very important for the general dentist to have a thorough knowledge of periodontics. A section should give the reader some guidance in making well-trained group of periodontists who specialized in referral decisions. the diagnosis and treatment of severe or unusual prob- REFERENCES lems should serve only to supplement the general dental care available to our population.' 1. Ad Hoc Committee on the Parameters of Care: Phase I Ther- apy. American Academy of Peridontology. J Periodontol The question remains when to refer a patient for spe- 2000; 71(suppl):856. cialist periodontal care. With a few patients the disease is 2. Anderson MH, Bales DJ, Omnell K-A: Modern management so severe or unusual in presentation that referral to a pe- of dental caires: The cutting edge is not the dental bur. riodontist is obvious. Many cases are treatable in the J Amer Dent Assoc 1993; 124:37. general dentist's office and likely to heal sufficiently after 3. Axelsson P, Lindhe J: The effect of a preventive programme Phase I therapy so that no further treatment interven- on dental plaque, gingivitis and caries in school children. tion is required beyond routine maintenance. Any pa- Results after one and two years. J Clin Periodontol 1974; tient who does not clearly fall into either category has 1:126. 4. Carranza FA, Jr, Newman MG: Preface. In: Carranza FA, Jr, been called a candidate for referral." The 5-mm standard Newman MG (eds): Clinical Periodontology, ed 8. Philadel- has been proposed as a guideline for referral. If the pa- phia, Saunders, 1996. tient at reevaluation has apical migration of the epithe- 5. Chawla TN, Nanda RS, Kapoor KK: Dental prophylaxis pro- lial attachment, probing depths of greater than 5 mm, or cedures in control of periodontal disease in Lucknow both, then referral should be considered. The 5-mm (rural). Indian J Periodontol 1975; 46:498. standard has been suggested because the typical root 6. Cobb CM: Non-surgical pocket therapy: Mechanical. Ann length is about 13 mm (Fig. 48-2). The probe, when in- Periodontol 1996: 1:443. serted into the 5-mm pocket, rests near the epithelial at- 7. Lightner LM, O'Leary TJ, Drake RB, et al: Preventive peri- tachment, which is normally about 1 mm thick. The odontics treatment procedures: Results over 46 months. crest of the bone supporting the tooth would then be J Periodontol 1971; 42:555. 8. Lindhe J: Textbook of Clinical Periodontology. Philadelphia, 7 mm apical to the cementoenamel junction (CEJ), Saunders, 1983. demonstrating loss of approximately half the bone sup- 9. Lindhe J, Kock G: The effect of supervised oral hygiene on port for the tooth. Specialist care could help preserve the the gingiva of children. Progression and inhibition of gin- tooth in this situation by eliminating deep pockets and givitis. J Periodont Res 1966; 1:260. regenerating support for the tooth.

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10. Mongardini C, van Steenberghe D, Dekeyser C, et al: One chronic adult or generalized early-onset periodontitis. II. stage full- versus partial-mouth disinfection in the treat- Long-term impact on microbial load. J Periodontol 1999; ment of chronic adult or generalized early-onset periodonti- 70:646. tis. I. Long-term clinical observations. J Periodontol 1999; 14. Suomi JD, Greene JC, Vermillion JR, et al: The effect of con- 70:632. trolled oral hygiene procedures on the progression of peri- 11. Parr RW, Pipe P, Watts T. Shall I refer? In: Armitage G (ed): odontal disease in adults: Results after third and final year. Periodontal Maintenance Therapy, ed 2. Berkeley, CA, J Peridontol 1971; 42:152. Praxis, 1982. 15. Treatment planning for the periodontal patient. In: Perry 12. Perry DA, Beemsterboer PB, Taggart EJ: Periodontology for DA, Beemsterboer PB, Taggart EJ: Periodontology for the the Dental Hygienist. Philadelphia, Saunders, 2001. Dental Hygienist. Philadelphia, Saunders, 2001. 13. Quirynen M, Mongardini C, Pauwels M, et al: One stage 16. Wilkins EM: Clinical Practice of the Dental Hygienist. full- versus partial-mouth disinfection in the treatment of Philadelphia, Lea & Febiger, 1989. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Plaque Control for the Periodontal Patient

Dorothy A. Perry

CHAPTER

CHAPTER OUTLINE

THE TOOTHBRUSH CARIES CONTROL FOR THE PERIODONTAL PATIENT POWERED TOOTHBRUSHES CHEMICAL PLAQUE CONTROL DENTIFRICES Chlorhexidine TOOTHBRUSHING METHODS Essential Oil Mouthrinse The Bass Method Other Products The Modified Stillman Method Recommendations The Charters Method DISCLOSING AGENTS Methods of Cleaning with Powered Toothbrushes FREQUENCY OF PLAQUE REMOVAL INTERDENTAL CLEANING AIDS Recommendation Dental Floss PLAQUE CONTROL INSTRUCTION Interdental Cleaning Devices Motivation for Effective Plaque Control GINGIVAL MASSAGE Education ORAL IRRIGATION DEVICES I nstruction and Demonstration Supragingival Irrigation SUMMARY Subgingival Irrigation

I laque control is the removal of dental plaque on a resulting in the development of gingivitis in all subjects regular basis and the prevention of its accumula- within 7 to 21 days. The composition of bacteria also tion on the teeth and adjacent gingival surfaces. It shifted so that gram-negative organisms predominated is a critical component of dental practice, permitting in dental plaque associated with gingival inflammation. long-term success of periodontal and dental care. This In addition, it was shown that the gingivitis was re- widely held view is reflected in the following policy versible. Daily removal of dental plaque led to resolution statement adopted in 1998 European Workshop on Me- of the gingival inflammation in just a few days. Good chanical Plaque Control: "Forty years of experimental re- supragingival plaque control has also been shown to research, clinical trials, and demonstration projects in dif- tard calculus formation and affect the growth and com- ferent geographical and social settings have confirmed position of subgingival plaque. 121 Carefully performed that effective removal of dental plaque is essential to daily home plaque control, combined with frequent pro- dental and periodontal health throughout life.""' fessionally delivered plaque removal, has been demon- In 1965, Loe and co-workers conducted the classic strated to reduce supragingival plaque, decrease the total study demonstrating the relationship between plaque ac- number of microorganisms in moderately deep pockets, cumulation and the development of experimental gin- including furcation areas, and greatly reduce the number givitis in humans. Dental plaque was allowed to accu- of subgingival sites with Porphyromonas gingivalis, a sig- mulate in the absence of any plaque control procedures, nificant periodontal pathogen. Thus plaque control is

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an effective way of treating and preventing gingivitis keted and are commonly used as adjunctive agents to and is a critical part of all the procedures involved in the mechanical techniques. These medicaments, as with any treatment and prevention of periodontal diseases .as drug, should be recommended and prescribed according Although all patients need to adopt good plaque con- to the needs of individual patients. Chemical plaque trol practices, periodontal patients are considered more control is a rapidly growing field and will become even "at risk" than the general dental patient population. more significant for periodontal patients and practices Their plaque control is critical because they have active in the future as increasingly effective products become infections or have had previously treated disease. In ei- available. ther case, periodontal patients have demonstrated sus- Plaque control is one of the key elements of the prac- ceptibility to periodontal infections. The tissue destruc- tice of dentistry. It permits each patient to assume re- tion they experience creates sites and defects susceptible sponsibility for his or her own oral health on a daily ba- to further breakdown.$$ The role of other risk factors for sis. Without it, optimal oral health through periodontal periodontal infections, such as smoking, genetic predis- treatment cannot be attained or preserved. Every patient position, or systemic disease, also are very important but in every dental practice should be educated about plaque not easily quantified. In reality, the control of these control and encouraged to perform a personalized pro- other risk factors is often beyond the control of the clini- gram on a daily basis. Good plaque control facilitates the cian, requiring the focus on this one well-established return to health for patients with gingival and periodon- etiologic factor, dental plaque. Plaque control and pre- tal diseases, prevents tooth decay, and preserves oral ventive procedures can be relied upon to improve peri- health for a lifetime. odontal infections; however, the resolution of disease also depends on the type of periodontal infection and T the presence of additional risk factors. 55 HE TOOTHBRUSH The dental profession relies on mechanical plaque The bristle toothbrush appeared about the year 1600 in control (i.e., daily cleaning with a toothbrush and other China, was first patented in America in 1857, and has oral hygiene aids) as the most dependable way of achiev- since undergone little change. Generally, toothbrushes ing oral health benefits for all dental patients including vary in size and design as well as in length, hardness, periodontal patients. Plaque growth occurs within hours and arrangement of the bristles (Fig. 49-1).134 The Ameri- and must be completely removed at the very least every can Dental Association has described the range of di- 48 hours in periodontally healthy subjects to prevent in- mensions of acceptable brushes: a brushing surface 1 to flammation. 140 Toothbrushing is a completely accepted 1.25 inches (25.4 to 31.8 mm) long and 5/16 to 3/8 inch (7.9 part of daily life and good oral hygiene practice. How- to 9.5 mm) wide, 2 to 4 rows of bristles, and 5 to 12 tufts ever, plaque control by toothbrushing alone is not suffi- per row.2 A toothbrush should be able to reach and efficient to control gingival and periodontal diseases because ciently clean most areas of the teeth. periodontal lesions are predominantly interdental. 88 It Some toothbrush manufacturers claim superiority of has been demonstrated in healthy subjects that plaque design for such things as minor modifications of bristle formation begins on the interproximal surfaces where the placement, length, or stiffness. These claims are primar- toothbrush does not reach. Masses of plaque first develop ily based on demonstrations of plaque removal that are in the molar and premolar areas, followed by the proxi- shown to be statistically significantly superior to compa- mal surfaces of the anterior teeth and the facial surfaces rable toothbrushes in one or more clinical studies. How- of the molars and premolars. Lingual surfaces accumulate ever, the research does not show significant differences the least amount of plaque. In terms of removing plaque, in gingivitis scores or bleeding indices, the more impor- subjects consistently leave more plaque on the posterior tant measures of improved gingival health. It is ques- teeth than the anterior teeth, and interproximal surfaces tionable whether slight differences in measurements of retain the highest amounts of plaque. 140 The plaque con- plaque removal are in fact clinically significant because trol efforts of periodontal patients are further compli- no toothbrush and few toothbrushers remove all plaque. cated by defects in gingival architecture and long, ex- A recent study of four different commercially available posed root surfaces. toothbrush designs compared plaque removal at a single The optimal frequency for plaque removal by peri- brushing. All four toothbrushes removed plaque equally odontal patients has not been determined, but it is rea- and the authors concluded that no one design was supe- sonable to expect periodontal patients to completely re- rior to others.33 move plaque from the teeth at least once every 24 hours In terms of recommending a particular toothbrush, due to patient susceptibility to disease and complexity of superiority of clinical significance has not been demon- the task.' Taken together, these findings suggest plaque strated for any one type of toothbrush. Ease of manipu- control efforts must focus on more than simply improved lation by the patient is an important factor in brush se- toothbrushing. Periodontal patients must concentrate on lection, as is the patient's perception that the brush cleaning interproximal areas and be encouraged to adopt works well. The effectiveness of and potential injury significantly more difficult and time-consuming oral hy- from different types of brushes depend to a great degree giene habits that must be performed daily. on how the brushes are used.26 Data from in vitro studies Chemical inhibitors of plaque and calculus incorpo- of abrasion by different manual toothbrushes suggest rated in mouthwashes or dentifrices also play an impor- that differences in the brush design permitting the bris- tant role in plaque control. Fluorides are essential for tles to carry more toothpaste while brushing contribute caries control. These products have been highly mar- to abrasion more than brush bristles themselves." The Plaque Control for the Periodontal Patient • CHAPTER 49 653 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 49-1 Manual toothbrushes. A, Toothbrushes from the 1 9" and 20th centuries, two with ivory handles from about 1890 (left), one with a sterling silver handle (center), and an early travel brush with a plastic handle from about 1 930 (right). The ivory-handled brushes belonged to dental students who used the handles to practice cutting preparations and using filling materials. The designs are "filled" with either gold foil or amalgam. B, A variety of toothbrushes are available; note the variation in brush head and handle design. C, Close-up view of brush heads showing various bristle configurations. (Antique brushes from the UCSF School of Dentistry Historical Collection, courtesy Dean Charles N. Bertolami, San Francisco, Calif.) type of brush is largely a matter of individual preference. clusal/incisal surfaces at one time. This study also However, there is common agreement that use of a hard showed slight differences in plaque removal favoring the toothbrush, vigorous horizontal brushing, and possibly new design over a conventional brush and a powered use of very abrasive dentifrice may lead to cervical abra- toothbrush. It did not evaluate changes in gingival con- sions of teeth and recession of gingva" dition."' The notion of brushing all reachable surfaces Recently, some novel designs intended to make brush- of the teeth at one time is attractive, and these inventive ing easier and hard-to-reach areas more accessible have brush designs may be useful for some patients to achieve been described. One has curved bristles on both sides of better plaque control. There is no reason to discourage the brush head and shorter bristles running down the use of any particular device, especially if the patient likes center. It is designed to brush buccal, lingual, and oc- it and uses it more or better than a conventional brush. clusal/incisal surfaces of the teeth at one time. One study There may well be a truly better design in the hands of demonstrating its plaque removal ability showed statisti- any individual patient that results in better plaque re- cally significant differences between the curved bristles moval and improved gingival health. and a conventional brush, but absolute differences were Two kinds of bristle material are used in toothbrushes: slight.30 Another design featured a U-shaped head with natural bristles from hogs and artificial filaments made bristles that would also reach buccal, lingual, and oc- predominantly of nylon. Both types remove plaque, and

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nylon bristles vastly predominates in the market.21 How- weeks .36 Unfortunately, people tend to use toothbrushes ever, in terms of homogeneity of the material, unifor- as long as possible, often long after the bristles are quite mity of bristle size, elasticity, resistance to fracture, and worn. Toothbrushes with wear reminders (e.g., a blue dye repulsion of water and debris, nylon filaments are clearly on some of the bristles) are currently available. The dye superior. Because of their tubular form, natural bristles fades with use and can be helpful in reminding patients are significantly more susceptible to fraying, breaking, to replace their toothbrushes periodically. contamination with diluted microbial debris, softening, The preference of handle characteristics is a matter of and loss of elasticity. Patients accustomed to the softness individual taste. The handle should fit comfortably in of an older natural bristle brush can traumatize the gin- the palm of the hand; it may be straight or angled, thick giva when using a new brush with comparable vigor. It is or thin (see Fig. 49-1). Brushes with modest angulation helpful to point this out when a patient changes from between the head and the handle are available, and natural to nylon bristles. some clinical evidence supports the idea that these brush Toothbrush bristles are grouped in tufts that are usu- handles improve access for plaque removal under super- ally arranged in three or four rows. Multitufted tooth- vised brushing conditions. In fact, a recent study de- brushes contain more bristles and may clean more effi- scribed a toothbrush with a double angulation of the ciently than skimpier brushes. Rounded bristle ends neck of the handle and demonstrated significantly more cause fewer scratches on the gingiva than flat cut bristles plaque reduction, especially on the buccal and lingual with sharp ends .37.134 The question of the most desirable surfaces. The clinical significance of these findings has bristle hardness is not settled. Bristle hardness is propor- not been determined, but it is reasonable to surmise that tional to the square of the diameter and inversely pro- modifications improving access may help some patients portional to the square of bristle length . 70 Diameters of to brush more effectively. commonly used bristles range from 0.007 inch (0.2 mm) For most patients, short-headed brushes with straight- for soft brushes to 0.012 inch (0.3 mm) for medium cut, round-ended, soft to medium nylon bristles brushes and 0.014 inch (0.4 mm) for hard brushes. 76 Soft arranged in three or four rows of tufts are recommended. bristle brushes of the type described by Bass"' have However, if a patient perceives any benefit from a partic- gained wide acceptance. Bass recommended a straight ular brush design characteristic, use of that brush should handle and nylon bristles 0.007 inch (0.2 mm) in diame- be encouraged. ter and 0.406 inch (10.3 mm) long, with rounded ends, arranged in three rows of tufts, six evenly spaced tufts POWERED TOOTHBRUSHES per row, with 80 to 86 bristles per tuft. For children, the brush is smaller, with thinner (0.005 inch or 0.1 mm) Electrically powered toothbrushes were invented in 1939 and shorter (0.344 inch or 8.7 mm) bristles."$ and intended to make plaque control easier for patients Opinions regarding the merits of hard and soft bris- to master. The first powered toothbrushes were designed tles are based on studies carried out under differing con- to mimic hand toothbrushing techniques using back- ditions; these studies are often inconclusive and contra- and-forth motions. Some were subsequently designed dict one another.77 Soft bristles are more flexible, clean with circular or elliptic motions, and some with combi- beneath the gingival margin when used with a sulcus nations of motions. Today, many types of powered brushing technique,17 and reach further onto the proxi- toothbrushes designed for home use are available, some mal tooth surfaces.57 Use of hard-bristled toothbrushes is with reciprocating bristle tufts (Fig. 49-2) and brushes associated with more gingival recession, and frequent that use low-frequency acoustic energy to enhance brushers who use hard bristles have more recession than cleaning ability. Powered toothbrushes that have shaped those who use soft bristles . 86 However, the manner in tips designed for interproximal cleaning are also avail- which a brush is used and the abrasiveness of the denti- able (Fig. 49-3). frice affect the action and abrasion to a greater degree All powered toothbrushes rely on mechanical contact than the bristle hardness itself. 1,109 Bristle hardness does between the bristles and the tooth to remove plaque. not significantly affect wear on enamel surfaces.128 The addition of low-frequency acoustic energy generates Overzealous brushing can lead to gingival recession; dynamic fluid movement and provides cleaning slightly bacteremia, especially in patients with pronounced gin- away from the bristle tips. The vibrations have also been givitis, wedge-shaped defects in the cervical area of root shown to interfere with bacterial adherence to oral sur- surfaces56,127; and painful ulceration of the gingiva. 120 This faces. Neither the sonic vibrations nor the mechanical type of brushing should be identified and discouraged. motion of powered toothbrushes has been shown to af- To maintain cleaning effectiveness, toothbrushes must fect bacterial cell viability. 106 be replaced periodically. Wear patterns differ widely One review suggested that acoustic microstreaming, among individuals, but with conscientious, regular use, hydrodynamic shear forces that may disrupt plaque, are most brushes show signs of wear within a few months. If the likely mechanism of action for these powered all the bristles are flattened after 1 week, brushing is brushes. The authors noted that most comparison stud- probably quite vigorous; if the bristles are still straight af- ies between powered toothbrushes, manual tooth- ter 6 months, either the brushing is done very gently or brushes, or other powered devices demonstrate, at best, the brush has not been used every day. The amount of slightly improved plaque removal for the device of inter- force used to brush does not appear to be critical in est in short-term clinical trials. Although this permits ad- plaque removal. 144 Nor does the amount of visible bristle vertising claims of superiority, improved oral health for wear appear to affect plaque removal function for up to 9 all patients or all periodontal patients has not been

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Fig. 49-2 Powered toothbrush designs offer options in head shape Fig. 49-3 Powered toothbrush with shaped tips can be used for and size. i nterproximal cleaning and other difficult areas around the teeth.

demonstrated. Patient acceptance of powered tooth- improve gingival health,101,108 other authors have reported brushes is good. A recent study reported that 88.9% of that the same brushes failed to perform better than com- patients introduced to a powered toothbrush would con- parisons. 14,15,54,6o,112,145 Identified improvements tend to be tinue to use it. 148 Patients quit using powered tooth- slight and localized in terms of improved gingival health,' brushes after about 5 or 6 months, presumably when the but more plaque is typically removed from proximal sur- novelty has worn off." However, modern powered faces using the newer devices. 143 One interesting study toothbrushes with additional features such as sonic tech- demonstrated reductions in gingival fluid flow for pa- nology to reach further onto proximal surfaces and tients with moderate periodontal disease when the sonic timers to remind patients to brush longer are considered toothbrush was used over an 8-week period. The authors by some to be superior to manual brushes. 145 suggested the sonic toothbrush might have some effect Regardless of the type of device, the best plaque re- on inflammation beyond that achieved by manual tooth- moval results are obtained when the patient is instructed brushing."' Generally, powered toothbrushes are at least in its proper use. This assures that the moving bristles as good for plaque removal as manual brushes. If a pow- have to be placed correctly around the mouth. 11,145 in ered toothbrush can be helpful to a particular patient, it fact, instructional videos have been shown to be an ef- should be recommended and encouraged. fective way of educating patients on the proper use of No specific toothbrush can be singled out as clearly powered toothbrushes. 123 superior for the routine removal of dental plaque from Patients who can develop the ability to use a tooth- the teeth when measured by improvement in gingival brush properly usually do equally well with a manual or health. Requirements for a good toothbrush differ a powered toothbrush. Less diligent brushers do better greatly among individuals, and any toothbrush, includ- with powered toothbrushes, which generate stroke mo- ing powered toothbrushes, should be recommended af- tions automatically and require less operator effort . 6o ter considering factors such as patient interest, morphol- Powered toothbrushes have been shown to improve oral ogy of the dentition, periodontal health, and manual health for: (1) children and adolescents, (2) children dexterity. Because of the wide acceptance of oral hygiene with physical or mental disabilities, (3) hospitalized pa- principles first reported by Bass, 11,18 the one brush proba- tients, including older adults who need to have their bly most commonly recommended by dentists appears teeth cleaned by caregivers, and (4) patients with fixed to be the four-row, multitufted, soft, nylon, handheld orthodontic appliances. They have not been shown to toothbrush. This style of brush is certainly adequate but routinely provide benefits for patients with rheumatoid does not fit the needs or provide the best choice for arthritis, children who are well-motivated brushers, and every patient in every practice. patients with chronic periodontitis. 73 Powered toothbrushes can be valuable replacements Powered toothbrushes are not generally superior to for manual brushes if used regularly and properly. They manual ones. Although some researchers have reported are particularly useful for cleaning proximal surfaces and that powered toothbrushes remove more plaque than for people with limited dexterity, children who like manual toothbrushes, reduce calculus accumulation, and them, and caregivers of ill patients. Some patients simply

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DENTIFRICES Dentifrices aid in cleaning and polishing tooth surfaces. They are used mostly in the form of pastes, although tooth powders and gels are also available. Dentifrices are made up of abrasives such as silicon oxides, aluminum oxides, and granular polyvinyl chlorides; water; humec- tants; soap or detergent; flavoring and sweetening agents; therapeutic agents such as fluorides and pyrophosphates; and coloring agents and preservatives. Dentifrices should be sufficiently abrasive for satisfactory cleansing and polishing but should provide a margin of safety to protect the aggressive toothbrusher from wearing away root structure and soft restorative materials.130 Abrasives, commonly in the form of insoluble in- organic salts, Fig. 49-4 Vigorous tooth brushing with an abrasive dentifrice can make up 20% to 40% of a dentifrice. The result in trauma and wearing away of the tooth surfaces, especially proper use of a dentifrice can enhance the abrasive ac- root surfaces, and contribute to gingival recession. tion of a toothbrush as much as 40 times. 109 Tooth powders contain about 95% abrasives and are five times more abrasive than pastes. The abrasive quality of dentifrices affects enamel, but abrasion is more of a concern for patients with exposed roots because dentin is culus and does not affect the fluoride ion in the paste or abraded 25 times faster and cementum 35 times faster increase tooth sensitivity. This type of dentifrice has re- than enamel. This can lead to root surface abrasion and duced the formation of new supragingival calculus by root sensitivity. 139 Existing literature suggests that hard 30% or more .83,107,154 These pastes are beneficial only for tissue damage from oral hygiene procedures is mainly supragingival calculus. They do not affect subgingival due to abrasive dentifrices, whereas gingival lesions can calculus formation or gingival inflammation. To achieve be produced by the toothbrush alone 120,121 (Fig. 49-4). the greatest effect from anti-calculus toothpaste, the pa- Abrasions are more prevalent on maxillary than on tient's teeth must be cleaned and completely free of mandibular teeth and are found more frequently on the supragingival calculus when starting to use the product left than on the right half of the dental arch. This sug- daily. The inhibitory effect will only work against the de- gests that access and right- or left-handedness may also position of new calculus. contribute to the abrasion. Dentifrices that provide the effectiveness required for plaque control with a mini- TOOTHBRUSHIN G M ETHOD S mum of abrasion are preferable. There is considerable interest in improving dentifrices Many methods for brushing the teeth have been de- by using them as vehicles for chemotherapeutic agents scribed and promoted as being efficient and effective. to inhibit plaque, calculus, caries, or root hypersensitiv- These methods can be categorized primarily according to ity. The pronounced caries-preventive effect of fluorides the pattern of motion when brushing8 l: incorporated in dentifrices has been proved beyond 131 Roll: The roll method' or modified Stillman" technique question. To achieve this effect, free fluoride ions must Vibratory: The Stillman,"' Charters , 29 or Bass" techniques be available in the paste, not bound to the ingredients in Circular: The Fones 53 technique the abrasive system. The American Dental Association Vertical: The Leonard technique 96 (ADA) Council on Scientific Affairs3 (formerly the Coun- Horizontal: The scrub technique"o cil on Dental Therapeutics) has voluntarily evaluated fluoride dentifrices. Several toothpastes have been found to Controlled studies evaluating the effectiveness of the have fluoride available in the correct amount (1000 to most common brushing techniques have not demon- 1100 ppm), along with clinical studies documenting strated any clear superiority for any one method. The scrub their caries reduction effects. Toothpaste products that technique is probably the simplest and most common have been tested by the ADA and have been determined method of brushing. Patients with periodontal disease are to have fluoride ion available in the appropriate amount most frequently taught a sulcular brushing technique using carry the ADA seal of approval for caries control and can a vibratory motion to improve access in the gingival areas. be relied on to provide caries protection. The roll technique seems to be the least effective method, Substances such as chlorhexidine,45 penicillin, dibasic perhaps because it generates only intermittent pressure ammonium phosphate, vaccines, vitamins, chlorophyll, against the teeth compared with the sustained force ap- and formaldehyde have proved to be of little therapeutic plied with the sulcular and scrub techniques.22 value in toothpastes. Tartar control toothpastes with the Three common methods of brushing the teeth are active ingredient pyrophosphate are currently available. presented here, any of them, if properly performed, can This ingredient interferes with crystal formation in cal- provide excellent plaque control. The goal of brushing is

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Fig. 49-5 Bass method. A, Place the toothbrush so that the bristles are angled approximately 45 degrees from the tooth surfaces. B, Start at the most distal tooth in the arch and use a vibrating, back-and-forth motion to brush.

Fig. 49-6 Bass method. A, Proper position of the brush in the mouth aims the bristle tips toward the gingival margin. B, Diagrams shows the ideal placement, which could permit slight subgingival penetration of the bristle tips.

to remove as much plaque from the accessible tooth sur- gival sulcus area (Fig. 49-5) as well as partially into the faces as possible. The best brushing method for each pa- interproximal embrasures. The pressure should produce tient is determined when forming an individualized and perceptible blanching of the gingiva (Fig. 49-6). Com- complete plaque control program. It also should be re- plete approximately 20 strokes in the same position. This membered that brushing with a powered toothbrush is repeated motion cleans the tooth surfaces, concentrating an equally good alternative. on the apical third of the clinical crowns, the gingival sulci, and as far onto the proximal surfaces as the bristles can reach. Lift the brush, move it to the adjacent teeth, The Bass Method and repeat the process for the next three or four teeth. Technique. Place the head of a soft brush parallel Continue around the arch, brushing about three teeth with the occlusal plane, with the brush head covering at a time, then use the same method to brush the lingual three to four teeth, beginning at the most distal tooth in surfaces (Figs. 49-7 and 49-8). After completing the max- the arch. Place the bristles at the gingival margin, es- illary arch, move the brush to the mandibular arch and tablishing an angle of 45 degrees to the long axis of the brush in the same manner until the entire dentition is teeth. Exert gentle vibratory pressure, using short back- completed. To help reach the lingual surfaces of the an- and-forth motions without dislodging the tips of the terior teeth if the brush seems too large, insert the brush bristles. This motion forces the bristle ends into the gin- vertically (Figs. 49-9 and 49-10). Press the end of the

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Fig. 49-7 Bass method. The correct palatal position on molars and Fig. 49-9 Bass method. Adjusting the palatal position of the premolars is with the bristle tips at the gingival margin as shown in toothbrush on incisors, as shown in the diagram, may provide bet- the diagram, not on the occlusal surfaces. ter access for plaque removal.

Fig. 49-8 Bass method. Palatal position of the soft toothbrush on Fig. 49-10 Bass method. Placement of the bristles on the palatal the molars and premolars permits bristle tip penetration into the in- surfaces of the incisor teeth can be difficult and often requires this terproximal areas and possibly slightly subgingivally. modified approach.

brush into the gingival sulcus area and proximal surfaces The Bass technique is efficient and can be recom- at a 45-degree angle to the long axis of the teeth and mended for any patient with or without periodontal brush with multiple short vibratory strokes. involvement. Press the bristles firmly into the pits and fissures of the occlusal surfaces (Fig. 49-11) and brush with about 20 short back-and-forth strokes. Use this technique and The Modified Stillman Method brush a few teeth at a time until all posterior teeth in all The modified Stillman method137 requires that the four quadrants are cleaned. brush be placed with the bristle ends resting partly on The Bass technique requires patience and placement the cervical portion of the teeth and partly on the adja- of the toothbrush in many different positions to cover cent gingiva, pointing in an apical direction and at an the full dentition. Patients need to be instructed to brush oblique angle to the long axis of the teeth (Fig. 49-12). in a controlled and systematic sequence to optimize Apply pressure against the gingival margin to produce a plaque removal. perceptible blanching. Then move the brush about The Bass method has certain advantages over other 20 short back-and-forth strokes while simultaneously techniques, as follows: moving it coronally along the attached gingiva, the gingival margin, and the tooth surface. A soft or medium 1. The short back-and-forth motion is easy to master be- multitufted brush should be used with this technique to cause it is a simple movement familiar to most pa- minimize trauma to the gingiva. tients who brush using a scrub technique. This process must be repeated on all tooth surfaces, pro- 2. It concentrates the cleaning action on the cervical ceeding systematically around the mouth. To reach the and interproximal portions of the teeth, where micro- lingual surfaces of the maxillary and mandibular incisors, bial plaque is most likely to have accumulated. the handle of the brush can be held in a vertical position,

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Fig. 49-11 This brush position on occlusal surfaces of the teeth is used with any technique, including the Bass, Stillman, or Charters method.

Fig. 49-13 Charters method. The Charters method requires that the bristles be pressed against the sides of the teeth and gingiva. The brush is moved with short circular or back-and-forth strokes.

surfaces (see Fig. 49-11). The procedures are repeated systematically until all surfaces are cleaned. The Charters method provides gentle plaque removal. This technique can be recommended for cleaning in areas of healing wounds after periodontal surgery.

Fig. 49-12 Modified Stillman method. This method requires Methods of Cleaning with Powered Toothbrushes placement of the sides of the bristles against the teeth and gingiva The various mechanical motions built into powered while moving the brush with short, back-and-forth strokes in a toothbrushes do not require special techniques of appli- coronal direction. cation. The patient need only concentrate on placing the brush head next to the teeth at the gingival margin and proceeding systematically around the dentition. Addi- tional placement adjustments can be made to clean diffi- engaging the end of the brush. With this technique, the cult areas, such as the distal surfaces of the third molars, sides rather than the ends of the bristles do the work. The furcations, or gingival clefts. The methods described for bristles tend not to penetrate into the gingival sulcus. manual brushing are also suitable for application with The occlusal surfaces of molars and premolars are powered toothbrushes (Fig. 49-14). cleaned with the bristles placed perpendicular to the occlusal plane and penetrating into the grooves and interproximal embrasures (see Fig. 49-11). I NTERDENTAL CLEANING AIDS The modified Stillman method may be recom- Any toothbrush, regardless of the brushing method used, mended for cleaning in areas with progressing gingival does not completely remove interdental plaque. This is recession and root exposure to minimize abrasive tissue true both in individuals with healthy periodontal condi- destruction. tions and those with periodontal destruction resulting in open embrasures .58.63.131 Interdental plaque removal is The Charters Method crucial to augment the effects of tooth brushing because, as previously noted, the majority of dental and peri- The Charters method requires placement of a soft or odontal disease originates in interproximal areas. Other medium multitufted brush on the teeth with the bristles conditions found in periodontal and gingival diseases pointed toward the crown at a 45-degree angle to the also demand an emphasis on interproximal cleaning. long axis of the teeth (Fig. 49-13). The sides of the bris- The gingival tissues are swollen in the presence of gingi- tles should be flexed against the gingiva, and a back-and- val inflammation, rendering the self-cleansing mecha- forth vibratory motion used to brush. The technique was nisms of the mouth less effective than in a healthy peri- designed to gently massage the gingiva, so the bristle odontium. Also, tissue destruction associated with tips should not drag across the gingiva. The bristle tips periodontal disease may leave large open spaces between should be placed in the pits and fissures, and short back- teeth and long-exposed root surfaces with anatomical and-forth strokes should be used to clean the occlusal concavities and furcations. These are difficult areas to

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Fig. 49-15 Dental floss may be held securely in the fingers or tied in a loop.

Teflon-type material are preferred by some individuals because they are slick and do not fray. A variety of individual factors determine the choice of dental floss, such as the tightness of tooth contacts, roughness of proximal surfaces, and patient's manual dexterity, not the superiority of any one product. Clinical research so far has not been able to show any significant differences in the ability of the various types of floss to remove dental plaque; they all work equally well.' 1,75,84,85,128 In the past, waxed dental floss was thought to leave a waxy film on proximal surfaces, thus contributing to plaque accumulation Fig. 49-14 Positioning of the powered toothbrush head and bris- and gingivitis. It has been shown, however, that wax is 121 tle tips so that they reach the gingival margin is critical to achieving not deposited on tooth surfaces and that improve- the most effective cleaning results. A, Straight head placement. ment in gingival health is unrelated to the type of floss B, Round head placement. used." Therefore recommendations about type of floss should be based on ease of use and personal preference.

Technique. The floss must contact the proximal clean and only poorly accessible to the toothbrush . 88 In- surface from line angle to line angle to clean effectively. terdental cleaning should occur every day for the same It must also clean the entire proximal surface, not just be rationale as brushing daily.' slipped apical to the contact area. The following descrip- The purpose of interdental cleaning is to remove tion is a primer in floss technique: plaque, not to dislodge fibrous threads of food wedged between teeth. Although interdental cleaning does dis- • Start with a piece of floss long enough to grasp se- lodge food fragments, correcting proximal tooth con- curely; 12 to 18 inches is usually sufficient. It may be tacts and plunger cusps is required to stop chronic food wrapped around the fingers, or the ends may be tied impaction. together in a loop. The specific aids required for interproximal cleaning • Stretch the floss tightly between the thumb and fore- depend on various criteria such as the size of the inter- finger (Fig. 49-15), or between both forefingers, and dental spaces, the presence of furcations, tooth align- pass it gently through each contact area with a firm ment, and the presence of orthodontic appliances or back-and-forth motion. Do not snap the floss past the fixed prostheses. contact area, because this may injure the interdental Among the numerous aids available, dental floss and gingiva. In fact, zealous snapping of floss through interdental cleaners such as wooden or plastic tips and contact areas creates proximal grooves in the gingiva. interdental brushes are commonly recommended. • Once the floss is apical to the contact area between the teeth, wrap the floss around the proximal surface of one tooth, and slip it under the marginal gingiva. Dental Floss Move the floss firmly along the tooth up to the con- Dental floss is the most widely recommended tool for re- tact area and gently down into the sulcus again, removing plaque from proximal tooth surfaces." Floss is peating this up-and-down stroke several times (Fig. available as a multifilament nylon yarn that is twisted or 49-16). Then move the floss across the interdental nontwisted, bonded or nonbonded, waxed or unwaxed, gingiva and repeat the procedure on the proximal sur- and thick or thin. Monofilament flosses made of a face of the adjacent tooth.

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Fig. 49-16 Dental floss technique. The floss is slipped between the contact area of the teeth (in this case teeth #7 and #8), wrapped around proximal surface, and removes plaque by using several up-and-down strokes. The process must be repeated for the distal surface of tooth #8.

• Continue through the whole dentition, including the distal surface of the last tooth in each quadrant. When the working portion of the floss becomes soiled or begins to shred, move to a fresh portion of floss. Flossing can be made easier by using a floss holder (Fig. 49-17, A). Although use of such devices can be more time consuming than finger flossing, they are helpful for patients lacking manual dexterity and for nursing personnel assisting handicapped and hospitalized patients Fig. 49-17 Floss holders can simplify the manipulation of dental in cleaning their teeth. A floss holder should possess floss. A, Reusable floss tools require stringing the floss around a se- these features: (1) one or two forks that are rigid enough ries of knobs and grooves to secure it. B, Disposable floss tools have to keep the floss taut when penetrating into tight con- prestrung floss and are easy to use, but the floss may shred and break, requiring several tools to complete flossing the teeth. tact areas, and (2) an effective and simple mounting mechanism to hold the floss firmly in place. The disadvantage of floss tools is that they must be rethreaded whenever the floss becomes soiled or begins to shred. visited the dentist.'°s No information is available about Disposable, single-use floss holders with prethreaded the establishment of long-term flossing habits compar- floss are available and may be useful for some patients. ing the various tools to finger flossing. However, the Short-term clinical evidence suggests that plaque reduc- tools may be useful to help some individuals begin floss- tion and improvement in gingivitis scores are similar for ing or make flossing possible if they have limited dexter- individuals instructed in the use of disposable floss de- ity. The benefits of interproximal cleaning using dental vices when compared with scores for those instructed in floss are undisputed. Proper manipulation of floss re- finger flossing (see Fig. 49-17, B). quires good dexterity and repeated reinforcement. Powered flossing devices are also available (Fig. 49-18). These devices have a single bristle that moves in a circular motion. The devices have been shown to be interclental Cleaning Devices safe and effective but no better at plaque removal than Dental floss is probably the most effective dental hy- finger flossing. 34.64 giene aid for cleaning in narrow gingival embrasures that The establishment of a lifelong habit of flossing the are occupied by intact papillae and bordered by tight teeth is difficult to achieve for both patients and den- contact zones. Concave root surfaces and furcations that tists, regardless of whether one uses a tool or flosses with are often present in periodontal patients who have expe- the fingers. In fact, the daily use of floss is universally rienced significant attachment loss and recession are not low. It was recently reported that only about 8% of 12- as thoroughly cleaned with dental floss alone. A compar- to 16-year olds in Great Britain floss daily,'°s a number ison study of dental floss and interdental brushes used similar to other countries.$$ An analysis of the British by patients with moderate to severe periodontal disease adolescents showed that daily flossing was correlated to showed that the interproximal brushes removed slightly frequent hand washing and bathing and having recently more interproximal plaque. However, no difference was

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Fig. 49-20 A large variety of interproximal cleaning devices are available: wooden tips (A and B), interproximal brushes (C-F), and rubber tip stimulators (G).

Fig. 49-18 A powered flossing device can be easier to use than hand-held floss. The tip is inserted into the proximal space, and a bristle or wand comes out of the tip and moves in a circular motion when the device is turned on. The bristle mechanically removes the plaque.

Fig. 49-21 Triangular wooden tip. The tip is inserted between the Fig. 49-19 Cleaning of concave or irregular proximal tooth sur- teeth, with the triangular portion resting on the gingival papilla, faces. Dental floss (A) may be less effective than an interdental and is moved in and out. This device is popular but is very difficult brush (B) on long root surfaces with concavities. to use on posterior teeth and from the lingual aspect of all teeth.

seen in probe depth reductions or bleeding indices. In tal floss (Fig. 49-20). The most common types are small addition, the interdental brushes were considered by the conical or cylindric brushes, tapered wooden toothpicks subjects to be easier to use than dental floss. Therefore that are round or triangular in cross-section, and single- other cleaning aids that are easy to handle and adaptable tufted brushes. Many interdental devices can be attached to irregular and long, exposed root surfaces (Fig. 49-19) to a handle for convenient manipulation around the can be recommended for proximal cleaning of teeth teeth and in posterior areas. Clinical research has shown when interdental spaces permit access. This type of that the devices are effective on lingual and facial tooth gingival architecture and root exposure is commonly surfaces as well as on proximal surfaces.88,131,146 found in periodontal patients. A wide variety of interdental cleaning devices are Interdental Brushes. Interdental brushes are cone- available for removing soft debris from tooth surfaces shaped or cylindric brushes made of bristles mounted on that are not accessible to a full-size toothbrush and den- a handle (see Fig. 49-20, C and D), single-tufted brushes

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Fig. 49-22 Wooden toothpick. A, The tip is a common wooden toothpick held in a handle and broken off. It is used to clean subgingivally and reach into periodontal pockets. B, The tip can also be used to clean along the gingival margins of the teeth and reach under the gingiva.

(see Fig. 49-20, E), or small cylindric brushes (see Fig. Rubber tips should be placed into the embrasure space 49-20, F). Interdental brushes are particularly suitable for and used in a circular motion. They can be applied to in- cleaning large, irregular, or concave tooth surfaces adja- terproximal spaces and other defects throughout the cent to wide interdental spaces. mouth and are easily adaptable to lingual surfaces. Conventional toothpicks can also be used for inter- Technique. Interdental brushes of any style are in- proximal cleaning. They have the advantage of being a serted through interproximal spaces and moved back common device and readily available in most homes. and forth between the teeth with short strokes. For most Toothpicks can be attached to commercially available efficient cleaning, it is probably best to select the diame- handles for better access to posterior and lingual areas or ter of brush that is slightly larger than the gingival em- used as bought (Fig. 49-20, B). Once mounted on the brasures to be cleaned. This size permits bristles to exert handle, the toothpick is broken off so that it is only 6 or pressure on both proximal tooth surfaces, working their 7 mm long. The tip of the toothpick is used to trace way into concavities on the roots. Single-tufted brushes along the gingival margin and into the proximal areas are highly effective on the lingual surface of mandibular from both the facial and lingual surfaces throughout the molars and premolars, where the tongue often impedes a mouth. Plaque can also be removed by using the sides in regular toothbrush, and may provide access to furcation a manner similar to a wooden pick (Fig. 49-22, A) or the areas and isolated areas of deep recession. tip of the toothpick (Fig. 49-22, B). This device is particularly efficient for cleaning along the gingival margin Wooden or Rubber Tips. Wooden tips are used and into periodontal pockets and furcations. either with or without a handle (Fig. 49-20, A and B). Ac- cess is easier from the buccal surfaces for those tips with- Conclusions. A large and changing variety of inter- out handles, primarily in the anterior and bicuspid areas. dental cleaning aids are available for patients. Experience Rubber tips come mounted on handles or the ends of and patient preference will help you determine which toothbrushes and can easily be adapted to all proximal are best for any particular situation. It is important to re- surfaces in the mouth. Various plastic tips are also avail- member that brushing alone is not sufficient for plaque able and can be used in a manner similar to wooden tips. removal and that some interproximal device needs to be Both rubber and plastic tips can be rinsed and reused used routinely by the patient in the daily plaque control and easily carried in a pocket or purse, features that are regimen. In general, the largest brush or device that fits attractive to some patients. into a space will clean most efficiently, and obviously, the devices the patient likes will be most used. Technique. Soft, triangular wooden picks or plastic Embrasure spaces vary greatly in size and shape. A alternatives are placed in the interdental space in such a representation of three types of embrasures and the kind way that the base of the triangle rests on the gingiva and of interdental cleaner often recommended for each is the sides are in contact with the proximal tooth surfaces shown in Fig. 49-23. As a general rule, the larger the (Fig. 49-21). The pick is then repeatedly moved in and space, the larger the device that should be used. How- out of the embrasure, removing soft deposits from the ever, some devices are more difficult to assemble and use teeth and mechanically stimulating the papillary gin- than others, so a favorite tool of one individual may be giva. The disadvantage of the triangular toothpick is that impossible for another to use. It is useful to have a vari- it is very hard to access any surfaces other than the facial ety of aids available so that you and the patient can de- surfaces in the more anterior region of the mouth. cide what fits best and is easiest to use. Often the patient

664 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com ORAL IRRIGATION DEVICES requires three components to the plaque control routine; a brushing method, dental floss to clean subgingivally Supragingival Irrigation and tight embrasure spaces, and an interdental aid for larger interdental spaces and furcations. Typically, the Oral irrigators for daily home use by patients work by di- routine of complete plaque removal with the brush and recting a high-pressure, steady or pulsating stream of wa- required interproximal aids takes the periodontal patient ter through a nozzle to the tooth surfaces (see also Chap- up to 30 minutes every day. ter 44). Most commonly, a device with a built-in pump generates the pressure (Fig. 49-24, A), but other devices at- GING IVAL MASSAGE tach to the water faucet. Oral irrigators clean nonadherent bacteria and debris from the oral cavity more effectively Massaging the gingiva with a toothbrush or an interden- than toothbrushes and mouthrinses. They are particularly tal cleaning devices produces epithelial thickening, in- helpful for removing debris from inaccessible areas creased keratinization, and increased mitotic activity in around orthodontic appliances and fixed prostheses. the epithelium and connective tissue. 26,28,61,136 The in- When used as adjuncts to toothbrushing, these devices creased keratinization occurs on the oral gingiva and not can have a beneficial effect on periodontal health by re- on the areas more vulnerable to microbial attack, the sul- tarding the accumulation of plaque and calculus cular epithelium and the interdental areas where the gin- and by reducing inflammation and pocket depth . gival col is present. It has never been demonstrated that Oral irrigation has been shown to disrupt and detox- epithelial thickening, increased keratinization, and blood ify subgingival plaque and can be useful in delivering circulation provide protection against microorganisms antimicrobial agents into periodontal pockets. 114 Irriga- and other local irritants and thus are beneficial or neces- tion can be supragingival or subgingival. Daily supragin- sary for gingival health . 62 The improved gingival health gival irrigation with a dilute antiseptic, chlorhexidine, associated with interdental stimulation is far more likely for 6 months resulted in significant reductions in bleed- the result of plaque removal rather than gingival massage. ing and gingivitis compared with water irrigation and In addition, studies of chemotherapeutic mouthrinses chlorhexidine rinse controls. Irrigation with water alone containing chlorhexidine have shown that gingival also reduced gingivitis significantly but not as much as health can be maintained for periods of time in the ab- the dilute chlorhexidine.52 sence of any mechanical oral hygiene procedure. 102 These data underscore the importance of emphasizing altering Technique. The common home-use irrigator tip is or removing plaque rather than stimulating or thickening a plastic nozzle with a 90-degree bend at the tip (Fig. 49- the keratinized surface in the plaque control program. 24, B), attached to a pump providing pulsating beads of Toothbrushing methods designed to massage the gin- water at speeds regulated by a dial. Patients should be in- giva and devices such as the rubber tip stimulator (see structed to aim the pulsating jet across the proximal Fig. 49-21, G) result in plaque removal in addition to papilla, hold it there for 10 to 15 seconds, then trace massage. The plaque removal effect is likely far more im- along the gingival margin to the next proximal space portant to periodontal health. and repeat the procedure. By the time the patient has

Fig. 49-23 Interproximal embrasure spaces vary greatly in patients with periodontal disease. In general, embrasures with no gingival recession are adequately cleaned using dental floss (A); larger spaces with exposed root surfaces require the use of an interproximal brush (B); and single-tufted brushes clean efficiently in interproximal spaces with no papillae (C).

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irrigated all the proximal spaces in the full dentition, the planing has not been shown to improve clinical heal- irrigator reservoir will be empty. The irrigator should be ing. It was reported that the flushing of untreated peri- used from both the buccal surface and lingual surface. odontal pockets with stannous fluoride resulted in This cleaning must be done while leaning across the slowed regrowth of subgingival bacteria."' However, bathroom sink because water will drip down the pa- other studies have not confirmed this effect. Data from tient's arm. Patients with gingival inflammation usually clinical studies of flushing immediately after scaling and start at lower pressure and then can increase the pressure root planing do not show improved gingival healing comfortably to about medium as tissue health improves. and do not support its use as providing consistent thera- Some individuals like to use the device on the highest peutic results . pressure setting, with no reported harm. Patient comfort Subgingival irrigation performed with an oral irrigator should be the guide for pressure setting. using chlorhexidine diluted to one-third strength, performed regularly at home after scaling, root planing, and in-office irrigation therapy, has produced significant gin- Subgingival Irrigation gival improvement compared with controls. 82 These doc- Subgingival irrigation performed both in the dental of- umented improvements in gingival health, along with fice or by the patient at home, particularly employing other positive clinical results . suggest that patients antimicrobial agents, has been shown to provide some can and should use subgingival irrigation at least once site-specific therapy. It is performed by aiming or placing daily in difficult sites such as furcations and residual the irrigation tip into the periodontal pocket, attempting pockets. Currently available subgingival irrigation tips to insert the tip at least 3 mm. This is achieved by using have been shown to disrupt plaque about half the depth a soft rubber tip at home or a canula in the dental office of pockets, up to 7 mm, much further apically than a . 4° (Fig. 49-24, C and D) Irrigation performed in the den- toothbrush or floss can reach . 42 tal office, also called lavage or flushing of the periodontal Currently, two types of irrigator tips are useful for pocket, as a one-time treatment after scaling and root subgingival irrigation (see Fig. 49-24, C and D). One is

Fig. 49-24 Oral irrigation. A, The most common devices have a built-in pump and reservoir. B, Conven- tional plastic tips are used for daily supragingival irrigation at home by the patient. C, A soft rubber tip is used for daily subgingival irrigation by the patient at home. D, A canula tip is used for subgingival irrigation by the dentist or dental hygienist in the office.

666 PART 5 • Treatment of Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com the cannula type tip recommended for office use, and sions than the fluoride level of 1100 ppm found in con- the other is a soft rubber tip for patient use at home. ventional toothpastes. 19 Both reduce the pressure and flow of the pulsating jet of Periodontal patients require appropriate use of topical water. Effective penetration of irrigant of up to 70% in fluorides in the daily plaque control regimen to protect laboratory simulation has been shown when using the and remineralize both exposed root surfaces and coronal cannula tip for deeper pockets . 79 Similar results have surfaces of teeth. been reported for the soft rubber tip." The soft rubber tip, designed to irrigate at low pressure and reduced flow, CHEMICAL PLAQUE CONTROL is recommended for patient use at home . 32 One cautionary note must be considered. Transient Mechanical plaque removal remains the primary method bacteremia has been reported after water irrigation in pa- used to prevent dental diseases and maintain oral health. tients with periodontitiss and patients on periodontal However, an improved understanding of the infectious maintenance. 147 However, bacteremia has also been nature of dental diseases has dramatically revitalized in- found after toothbrushing118 and is known to occur in terest in chemical methods of plaque control. some significant number of patients after scaling alone. 117 The ADA Council on Scientific Affairs has adopted a According to the Council on Dental Therapeutics of the program for acceptance of plaque control agents. The ADA, bacteremia also can occur in the absence of dental agents must be evaluated in placebo-controlled clinical procedures .35 Therefore dentists should make every at- trials of 6 months or longer that demonstrate signifi- tempt to reduce gingival inflammation in susceptible pa- cantly improved gingival health compared with controls. tients by the use of toothbrushes, floss, and antiseptic To date, the ADA has accepted two agents for treatment mouthrinses. Subgingival irrigation at home is not the of gingivitis: prescription solutions of chlorhexidine oral hygiene procedure of choice for patients requiring digluconate mouthrinse and nonprescription essential oil antibiotic prophylaxis before dental treatment, particu- mouthrinse. larly if extensive inflammation is present .4° Supragingival irrigation used in combination with toothbrushing and other interdental cleaning aids is acceptable and can re- Chlorhexidine sult in improved clinical health. The agent that has shown the most positive results to date is chlorhexidine, a diguanidohexane with pronounced antiseptic properties. The initial finding that CARIES CONTROL FOR two daily rinses with 10 ml of a 0.2% aqueous solution THE PERIODONTAL PATIENT of chlorhexidine digluconate almost completely inhib- Dental caries, particularly root caries, can be a problem ited the development of dental plaque, calculus, and gin- for periodontal patients because of attachment loss asso- givitis in the human model for experimental gingivitis63 ciated with the disease process and periodontal thera- has been confirmed by several other clinical investiga- peutic procedures. Root caries develops through a tions. Clinical studies of several months' duration have process similar to coronal caries, involving the alternat- reported plaque reductions of 45% to 61% and, more im- ing cycle of demineralization and remineralization of the portantly, gingivitis reductions of 27% to 67%. 68'92 The surfaces. 149 The process requires the fermentation of car- 0.12% chlorhexidine digluconate preparation is an bohydrates in the plaque by oral bacteria, resulting in equally effective agent currently available in the U.S. for loss of mineral from the root surface. Lactobacilli and reducing plaque and gingivitis. Streptococci species are involved in the root caries process, Local, reversible side effects to chlorhexidine use may similar to coronal caries. The major difference is the occur, primarily brown staining of the teeth, tongue, and amount of organic material in the root surfaces is greater silicate and resin restorations92 and transient impairment than in enamel, so once the demineralization has of taste perception. 104 Chlorhexidine has very low sys- occurred, the organic matrix-mostly collagen-is ex- temic toxic activity in humans, has not produced any posed. Organic material is then further broken down by appreciable resistance of oral microorganisms, and has bacterial enzymes, resulting in destruction of the root not been associated with any teratogenic alterations. surface .47 The preparation contains 12% alcohol, which is of con- Fluoride works primarily by topical effects to prevent cern to clinicians and patients who know that regular and reverse the caries process, whether in enamel, ce- use of alcohol increases the risk of oropharyngeal cancer. mentum, or dentin. Low concentrations of topical fluo- However, an extensive review of the available epidemio- ride inhibit demineralization, enhance remineralization, logic evidence associating alcohol-containing mouth- and inhibit the enzyme activity in bacteria by acidifying rinse preparations with cancer concluded that existing the cells .48.49 data do not support this association . 44 Regardless, many Topical application of fluorides has been demon- patients continue to express this concern or simply do strated to prevent and reverse root surface carious lesions not wish to consume alcohol in any form. in vitro. 149 Adult patients benefit from the prevention and reversal of root caries provided by low-concentration topical fluoride delivered by toothpastes or other Essential Oil Mouthrinse topical applications .48 It also has been demonstrated that Essential oil mouthrinses contain thymol, eucalyptol, the use of fluoride dentifrice containing 5000 ppm fluo- menthol, and mythyl salicylate.7 They have been evalu- ride was more effective in reversing active root caries le- ated in three long-term clinical studies and demonstrate

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plaque reductions of 20% to 35% and gingivitis reduc- brushing rinses should not be discouraged if patients tions of 25% to 35%. 39,65,89 This type of mouthrinse has a perceive benefits from them, but they should not be long history of daily use and safety dating back to the used to replace proven mechanical and chemical means 19th century, and many patients have used the products of plaque removal. Active recommendation of the use of for decades. These products also contain alcohol (up to all adjunctive agents should be based on evidence of effi- 24% depending on the preparation), so some patients cacy and confirmed by clinical research on patients. and clinicians are reluctant to use them. DISCLOSING AGENTS Other Products Disclosing agents are solutions or wafers capable of stain- One preparation containing triclosan has shown some ing bacterial deposits on the surfaces of teeth, tongue, effectiveness in reducing plaque and gingivitis. It is and gingiva. They are excellent oral hygiene aids because available in toothpaste form, and the active ingredient is they can provide the patient with an educational and more effective in combination with zinc citrate or a motivational tool to improve the efficiency of plaque copolymer of methoxyethylene. 69 control procedures (Fig. 49-25). Several other mouthrinse products on the market have Solutions and wafers are available commercially. Solu- shown some evidence of plaque reduction, although long- tions are applied to the teeth as concentrates on cotton term improvement in gingival health has not been sub- swabs or diluted as rinses. They usually produce heavy stantiated. These include stannous fluoride, 98,152 cetylpyri- staining of bacterial plaque, gingiva, tongue, lips, and dinium chloride (quaternary ammonia compounds), 12,13 fingers, as well as the sink. Wafers are crushed between and sanguinarine.110,119 Evidence suggests that these and the teeth and swished around the mouth for a few sec- other available mouthrinse products do not possess the onds and then spit out. Either should be used in the of- antimicrobial potential of either chlorhexidine products fice for plaque control instruction and dispensed as or essential oil preparations. Also available are mouthrinse needed for home use to aid periodontal patients in eval- preparations with no alcohol content, which may be uating the effectiveness of their oral hygiene routines. preferable for some patients. However, any of these mouthrinse products can be useful for patients who perceive benefits from the preparations. FREQUENCY OF PLAQUE RE MOVAL One type of agent has been marketed as a prebrushing In the controlled and supervised environment of clinical mouthrinse to improve the effectiveness of toothbrush- research, where well-trained individuals remove all visi- ing. The active ingredient is sodium benzoate. Research ble plaque, gingival health can be maintained by one to support its effectiveness is contradictory, but the pre- thorough cleaning exercise with brush, floss, and tooth- ponderance of evidence suggests that using a prebrush- picks every 24 to 48 hours. 81,88,91 Most patients, however, ing rinse is no more effective than brushing alone . z°,21 fall far short of this goal. The average cleaning lasts less Chemical plaque control has been shown to be effec- than 2 minutes every day and removes only 40% of tive for both plaque reduction and improved wound plaque. Several studies report improved plaque removal healing after periodontal surgery. 129 Both chlorhexidine9 and therefore improved periodontal health associated and essential oil"' mouthrinses have significant positive with increasing the frequency of brushing up to twice effects when prescribed for use after periodontal surgery per day.81,113 Cleaning three or more times per day does for periods of 1 to 4 weeks. not appear to further improve periodontal conditions. Cleaning once a day with all necessary tools is sufficient Recommendations if it is performed meticulously. If plaque control is not adequate, a second brushing will help. Mechanical plaque control is necessary and not replace- able by chemical plaque control. Fluoride toothpastes are an essential part of any long-term plaque control pro- Recommendation gram. Appropriate topical preparations of fluoride such Emphasis must be placed on the efficiency of complete as mouthrinses and higher concentration gels should be plaque removal at least once per day, rather than the fre- used as needed for caries control. The addition of antimi- quency of brushing alone. However, poor performance crobial mouthrinses will likely reduce gingivitis in peri- of plaque removal can be improved by brushing twice odontal patients. Chlorhexidine rinses are very effective per day. agents and can be used to augment plaque control during Phase I therapy, for patients with recurrent problems, for ineffective plaque control for any reason, for some PLAQUE CONTROL INSTRUCTION uncommon oral mucous membrane diseases, and for use In periodontal therapy, plaque control has two impor- after periodontal or oral surgery. Essential oil mouth- tant purposes: to minimize gingival inflammation and to rinses are also effective but to a lesser degree . 69 They may prevent the recurrence or progression of periodontal dis- be advantageous because they have fewer side effects and ease. Daily mechanical removal of plaque by the patient, are available without a prescription. Oral irrigators used including the use of appropriate antimicrobial agents, with dilute solutions of effective antimicrobial agents appears to be the only practical means for improving can improve daily plaque control by patients. 43 The use oral hygiene on a long-term basis. The process requires of other agents such as cosmetic mouthrinses and pre- motivation on the part of the patient, education, and 668 PART 5 • Treatment of Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 49-25 Effect of a disclosing agent. A, Unstained. B, Plaque shows as dark-red particulate matter when stained with a disclosing dye. C, The absence of plaque is dramatically demonstrated by restaining the teeth after mechanical plaque control procedures.

instruction, followed by encouragement and reinforce- and co-workers followed 100 patients who had been ment. An example of a plaque control record that per- treated for moderate to severe periodontal disease.72 All mits repeated measures and comparison over time is pre- had been taught to use one or more interdental cleaning sented in Fig. 49-26. aids, but only 20% used the aids after 6 months. Of those who had started using three devices, one third had stopped all interdental cleaning at 6 months; the others Motivation for Effective Plaque Control used one or two of the aids. The situation is no better Undoubtedly, mechanical oral hygiene practices, whether when looking at patient willingness to return for office or not they are supplemented with chemical plaque con- visits. One study of private patients in a dental clinic trol, are key in the restoration of health and prevention showed very disappointing compliance with recall main- of disease in dentistry. This is true for the two major oral tenance, the long-term reinforcement and prevention of health diseases, dental caries and periodontal disease. recurrence aspects of periodontal care. Of 1280 patients, Although this chapter has focused on plaque control for most of whom had periodontal surgery in multiple sites patients with periodontal disease, appropriate use of fluo- after intensive scaling, root planing, and plaque control ride products to promote remineralization of tooth sur- instruction, 25% never returned for a follow-up visit. faces and deter demineralization are also essential ele- Only 40% returned regularly."' Wilson reported that ments in all individual plaque control programs. These 67% of periodontal patients were noncompliant with re- must be used along with appropriate mechanical imple- turn visits in a 20-year retrospective of a private peri- ments and disinfecting solutions. odontal practice. Once the patient and clinician have determined the ap- Yet motivating patients to adopt new habits and re- propriate regimen, changing and augmenting patient be- turn for office visits is not an impossible task. To be suc- havior remains a significant challenge. Motivating patients cessful, the patient must be: to perform effective plaque control is one of the most critical and difficult elements of long-term success in peri- 1. Receptive: Required to understand the concepts of the odontal therapy. It requires both the patient's commit- pathogenesis, treatment, and prevention of periodon- ment to adopting new habits of daily plaque control and tal disease. regular return visits for maintenance and reinforcement. 2. Willing to change the habits of a lifetime: Necessary Patient noncompliance with both prescribed oral hy- to adopt a successful, self-administered daily plaque giene regimens and regular return visits is a common oc- control regimen. currence in dental practice. To give a sense of the magni- 3. Able to make behavioral changes: Required to adjust tude of the problem with plaque control devices, it has the hierarchy of a person's beliefs, practices, and values been shown that patients stop using interproximal to accommodate the required new oral hygiene habits cleaning aids in a very short period of time. Heasman and return for regular periodontal maintenance visits. Plaque Control for the Periodontal Patient • CHAPTER 49 669 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 49-26 The plaque control record can be an effective motivator for patients. This form permits easy comparison of scores over time. (Courtesy Dean Charles N. Bertolami, UCSF School of Dentistry, San Francisco, Calif.)

The patient must understand what periodontal dis- dentist or dental hygienist once every few months are ease is, what its effects are, that he or she is susceptible sufficient for plaque removal and disease control. It must to it, and what his or her responsibility is in achieving be explained that dental visits two or three times a year and maintaining oral health. Manual skills must be de- are only part of the maintenance needed; effective daily veloped and used to establish an effective plaque control home plaque control is the rest. This information gives regimen. In addition, the benefits of a clean mouth must each patient responsibility for health care and control be understood. The patient must both learn and adopt over the disease process. Only the combination of regu- the required plaque control measures and return for peri- lar office visits with conscientious home care signifi- odic recall treatment to achieve long-term health bene- cantly reduces gingivitis and loss of supporting peri- fits."' If not, long-term success of treatment is far less odontal tissues over the long term. 99-141 likely and can lead to frustration for both the dentist The periodontal patient should be shown that peri- and the patient. Changes in the habits of individuals' odontal disease has manifested itself in his or her own entire lives are difficult to achieve but essential. This mouth. Stained dental plaque, the bleeding of inflamed process begins with educating the patient, developing an gingiva, and demonstrations of the periodontal probe in- acceptable plaque control strategy, and reinforcing posi- serted into pockets are impressive and convincing tive changes in behavior. demonstrations of the presence of pathogens and symptoms of disease. It also is of educational value to a patient to have his or her oral cleanliness and periodontal Education condition recorded periodically." The patient and the Many patients believe that visits to the dental office for dentist can use this as feedback information about the periodontal care will eliminate the disease process. It is in- level of performance and positive reinforcement for im- cumbent on the dentist to educate and inform the patient provement. The Plaque Control Record and the Bleeding to reinforce patient responsibility for long-term success of Points Index are simple indices and are commonly used therapy and cure. Patient-administered plaque control for patient reinforcement. currently is the most important preventive and therapeutic procedure in periodontal therapy. Our health-con- Plaque Control Record (the O'Leary Index)."' scious society is an advantage with regard to patient edu- Disclosing solution is applied to all supragingival tooth cation. Most patients know what gingivitis is because they surfaces. After the patient has rinsed to remove excess have heard about it on television or read about it in maga- dye, each tooth surface (except occlusal surfaces) is ex- zines. They are willing to spend time and money to try amined for the presence or absence of stained deposits at new products such as toothbrushes and mouthrinses. the dentogingival junction, four surfaces for each tooth. Each patient education experience must be individual- Plaque, if present, is indicated on the appropriate box in ized according to need and level of understanding. a diagram. After all teeth have been scored, the index is Patients must be informed that periodic assessment calculated by dividing the number of surfaces with and debridement of the teeth in the dental office are re- plaque by the total number of surfaces scored and then quired to prevent recurrence of periodontal diseases and multiplied by 100 to get a percentage of surfaces with identify problems that may arise. These procedures work plaque present. A reasonable goal for patients is 10% or best if combined with individualized oral hygiene proce- fewer surfaces with plaque, unless plaque is always pre- dures practiced daily at home. Therefore time spent in sent in the same areas. If so, special instructions should the dental office teaching the patient how to perform be directed toward improving performance in those ar- plaque control procedures is as central to ongoing care as eas. It is extremely difficult to achieve a perfect score of scaling the teeth. The purpose of the recall visit is not to 0, so patients should be rewarded for approaching it. remove plaque because plaque forms every day. Patients Some commonly used plaque indices do not require sometimes have the concept that "cleanings" by the staining the teeth, such as the Plaque Index of Silness

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and Loe.133 These may seem more convenient to use and that requires patient participation, careful supervision possibly more acceptable to patients, but they have some with correction of mistakes, and reinforcement during disadvantages for patient education. Identification of return visits until the patient demonstrates that he or plaque is not as quick and easy for the clinician's record she has developed the necessary proficiency. 8,97 making, and because plaque is not stained, it is not high- One useful strategy for introducing plaque control to lighted for the patient to see and remove. the periodontal patient includes several elements. At the first instruction visit, the patient should be given a new Bleeding Points Index.95 The Bleeding Points In- toothbrush, an interdental cleaner, and a disclosing dex provides an evaluation of bleeding gingiva around agent. The patient's plaque should be disclosed. Small each tooth in the patient's mouth. Retract the cheek, amounts of dental plaque are difficult for the patient to and place the periodontal probe 1 mm into the sulcus or see if not disclosed (see Fig. 49-25, A); heavier accumula- pocket at the distal aspect of the most posterior tooth in tions of plaque and debris may be visible as gray, yellow, the quadrant. Carry the probe lightly across the length or white material on the teeth, along the gingival mar- of the sulcus to the mesial interproximal area on the fa- gin, and in faciolingual embrasures. Then a disclosing cial aspect. Continue along all the teeth in the quadrant solution or wafer is used to stain the invisible plaque. Af- from the facial aspect. Wait 30 seconds, and record the ter a brief water rinse to remove excess dye and stained presence of bleeding on the distal, facial, and mesial sur- saliva, which would obscure the view of the teeth, the faces on the chart. Repeat on the lingual-palatal aspect, stained plaque and pellicle can be clearly demonstrated recording bleeding only for the direct lingual surface, to the patient (see Fig. 49-25, B). Polished dental restora- not for the mesial or distal surfaces. This results in four tions do not take up the stain, but the oral mucosa and separate scores for each tooth and does not score the the lips may retain it for up to several hours. Covering mesial and distal surfaces twice. Repeat the steps for each the lips lightly with petroleum jelly before using the dye quadrant. is helpful. The percentage of the number of bleeding surfaces is Toothbrushing should be demonstrated in the pa- then calculated to provide the patient's score. Divide the tient's mouth while he or she observes with a hand mir- number of surfaces that bled by the total number of ror. The patient then takes over and repeats the proce- tooth surfaces (4 per tooth) and convert the number to a dures on his or her own teeth with the instructor giving percentage by multiplying by 100. assistance, correction, and positive reinforcement. This index is designed to demonstrate bleeding gin- Repeat the demonstration and instruction process giva rather than the presence of plaque. Again, a goal of with dental floss and interdental cleaning aids according 10% or fewer bleeding points is good, but 0 is ideal. If a to the patient's needs. The teeth can be restained to eval- few bleeding points repeatedly occur in the same areas, uate the efficiency of plaque removal, but even after vig- plaque control for those areas should be reinforced or orous cleaning, some stain usually remains on proximal modified. surfaces (see Fig. 49-25, C). Teaching videos and pamphlets can be used to augment personalized instruction, Significance of Plaque Scores and Bleeding but they are not a substitute; reminder pamphlets may Scores. Plaque scores are helpful as indicators of pa- be useful for the patient to take home. tient compliance and success with daily plaque control The patient should be given the hygiene aids neces- procedures. They once were used as an educational tool sary to get started. He or she must be encouraged to to demonstrate improvement in patient technique and clean the teeth at least once a day, with thorough atten- give positive reinforcement. However, plaque levels tion to all areas. Home care procedures on a full denti- themselves do not necessarily reflect gingival health or tion take 5 to 10 minutes; in complex periodontal main- risk of disease progression, even though plaque is highly tenance cases, such procedures may require up to 30 correlated with the presence of gingivitis.103 In terms of minutes. The patient should set aside a convenient time predicting success in controlling inflammation and re- and place in his or her daily schedule to perform the ducing the chance of disease progression, bleeding is by procedures reliably every day. far the better indicator. Bleeding on probing is not the Subsequent instruction visits should be used to rein- most specific and sensitive of measures of health; how- force or modify previous instructions, periodically record- ever, it has a strong negative correlation to disease pro- ing the state of gingival health and amount of plaque. gression. If bleeding is absent at any given site in the In general, some strategies will help improve patient mouth, reflecting good plaque control and disease man- compliance. These include the following: agement, the chance that periodontal disease will progress is unlikely. • Providing clinician encouragement • Demonstrating how devices should work • Providing samples Instruction and Demonstration • Showing improvements 142 Patients can reduce the incidence of plaque and gingivi- • Generally using positive reinforcement tis with repeated instruction and encouragement far In addition, some strategies are sure not to work. more effectively than with self-acquired oral hygiene These include the following: habits .66,141 However, instruction in how to clean teeth must be more than a cursory chairside demonstration of • Showing insensitivity to patient needs and situation the use of a toothbrush. It is a painstaking procedure • Instructing at the end of the appointment, when the

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plaque has either been removed by the clinician or 2. Accepted Dental Therapeutics, ed 3. Chicago, American the patient is exhausted or sore Dental Association, 1969-1970. Failing to provide reinforcement at subsequent ap- 3. ADA Council on Scientific Affairs. 2001; www.ada.org. pointments 4. Addy M, Adriaens P: Consensus report of group A epidemiology and etiology of periodontal diseases and the role of Handing the patient too many tools plaque control in dental caries. In: Lang NP, Attstrom R, Relying only on a pamphlet to provide education Loe H (eds): Proceedings of the European Workshop on Reinforcement and encouragement should be given Mechanical Plaque Control. Chicago, Quintessence, 1998. often to help patients modify long-standing habits, 5. Ainamo J, Xie Q Ainamo A, et al: Assessment of the effect of an oscillating/rotating electric toothbrush on oral adopt new ones, and understand that their plaque con- health: A 12-month longitudinal study. J Clin Periodontol trol is also important to the clinician. 1997; 24:28. Sensitivity to patient needs, patience on the clini- 6. American Academy of Periodontology, Committee Report: cian's part, and positive reinforcement are the secrets of The tooth brush and methods of cleaning the teeth. Dent success in plaque control instruction. Items Int 1920; 42:193. 7. American Academy of Periodontology: Treatment of gingivitis and periodontitis position paper. J Periodontol SUMMARY 1997; 68:1246. 1. All patients require the regular use of a toothbrush, ei- 8. Anderson JL: Integration of plaque control into the prac- ther manual or electric, at least once per day. The tice of dentistry. Dent Clin North Am 1972; 16:621. 9. Anderson L, Sanz M, Newman MG, et al: Clinical effects of brushing method should include access to the gingi- a 0.12% chlorhexidine mouthrinse on periodontal surgical val margin of all accessible surfaces and extension as wounds without periodontal dressing. J Dent Res 1988; far onto the proximal surfaces as possible. 67:329(abst 1728). 2. Dental floss should be used in all interdental spaces 10. Arnim SS: The use of disclosing agents for measuring tooth that are filled with gingiva. The technique requires cleanliness. J Periodontol 1963; 34:227. wrapping the floss around the proximal surfaces and 11. Ash MM: A review of the problems and results of studies inserting the floss as far subgingivally as possible. on manual and power toothbrushes. J Periodontol 1964; Flossing may be accomplished either with a tool or by 35:202. using the fingers. 12. Ashley FP, Skinner A, Jackson P, et al: The effect of a 0.1% 3. Interdental aids such as interproximal brushes, cetylpyridinium chloride mouthrinse on plaque and gingivitis in adult subjects. Br Dent J 1984; 157:191. wooden tips, rubber tips, or toothpicks should be 13. Ashley FP, Skinner A, Jackson PY, et al: Effect of a 0.1% used in all areas where the toothbrush and floss tech- cetylpyridinium chloride mouthrinse on the accumulation niques cannot adequately remove the plaque. This in- and biochemical composition of dental plaque in young cludes large embrasure spaces and furcation areas. adults. Caries Res 1984; 18:465. 4. All periodontal patients should use some form of low- 14. Axelsson P, Lindhe J: The effect of a preventive programme concentration topical fluoride on a daily basis, a fluo- on dental plaque, gingivitis and caries in school children: ride containing dentifrice at the very least. Topical Results after one and two years. J Clin Periodontol 1974; rinses and gels may be required if the patient demon- 1:126. strates a risk of caries or history of root caries. 15. Barnes CM, Russell CM, Weatherford III TW: A comparison 5. Daily home-delivered subgingival irrigation may be a of the efficacy of 2 powered toothbrushes in affecting good choice for reduction of inflammation and main- plaque accumulation, gingivitis, and gingival bleeding. J Periodontol 1999; 70:840. tenance for patients with residual deep pockets and 16. Barrikman R, Penhall O: Graphing indexes reduce plaque. those who struggle with mechanical interproximal J Am Dent Assoc 1973; 87:1404. cleaning devices. The effectiveness of irrigation is en- 17. Bass CC: An effective method of personal oral hygiene. hanced by the addition of chlorhexidine or essential Part 11. J La State Med Soc 1954; 106:100. oil mouthrinse to the irrigation water. 18. Bass CC: The optimum characteristics of toothbrushes for 6. Chemical antimicrobial agents such as chlorhexidine personal oral hygiene. Dent Items Int 1948; 70:697. or essential oil mouthwashes can be prescribed to dis- 19. Baysan A, Lynch E, Ellwood R, et al: Reversal of primary infect the patient's mouth and control the infection. root caries using dentifrices containing 5000 and 1100 ppm They may be continued indefinitely, as no specific du- fluoride. Caries Res 2001; 35:41. 20. Beiswander BB, Mallott MC, Mau MS, et al: The relative ration of time for use of these products has been rec- plaque removal effect of a prebrushing mouthrinse. J Am ommended. In fact, many patients have used essential Dent Assoc 1990; 120:190. oil mouthrinses for years. The staining of teeth and 21. Binney A, Addy M, Newcombe RG: The plaque removal ef- taste alteration side effects may limit patient use of fects of single rinsings and brushings. J Periodontol 1993; these products. 64:181. 7. Reinforcement of daily plaque control practices and 22. 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26. Cantor MT, Stahl SS: The effects of various interdental 48. Featherstone JDB: Prevention and reversal of dental caries: stimulators upon the keratinization of the interdental col. Role of low level fluoride. Comm Dent Oral Epidemiol Periodontics 1965; 3:243. 1999; 27:31. 27. Carter-Hanson C, Gadbury-Amyot C, Killoy WJ: Compari- 49. Featherstone JDB: The science and practice of caries pre- son of the plaque removal efficacy of a new flossing aid vention. J Amer Dent Assoc 2000; 131:887. (Quik-Floss) to finger flossing. J Clin Periodontol 1996; 50. Felix JA, Rosen S, App GR: Detection of bacteremia after 23:873. the use of an oral irrigation device in subjects with peri- 28. Castenfelt T. Toothbrushing and Massage in Periodontal odontitis. J Periodontol 1971; 42:785. Disease. An Experimental Clinical Histologic Study. Stock- 51. Finkelstein P, Grossman E: The effectiveness of dental floss holm, Nordisk Rotegravyr, 1952. in reducing gingival inflammation. J Dent Res 1979; 29. 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Greenstein G: Effects of subgingival irrigation on peri- Evaluation of the epidemiologic evidence. Otolaryngol odontal status. J Periodontol 1987; 58:827. Head Neck Surg 1995; 113:253. 68. Grossman E, Reiter G, Sturzenberger OP, et al: Six-month 45. Eriksen HM, Gjermo P, Johansen JR: Results from two study of the effects of a chlorhexidine mouthrinse on gin- years' use of chlorhexidine (CH)-containing dentifrices. givitis in adults. J Periodont Res 1986; 21(Suppl):33. Hely Odontol Acta 1973; 17:52. 69. Hancock EP: Prevention. Ann Periodontol 1996; 1:223. 46. Ervin JC, Bucher ET: Prevalence of tooth root exposure and 70. Harrington JH, Terry IA: Automatic and hand toothbrush- abrasion among dental patients. Dent Items Int 1944; ing abrasion studies. J Am Dent Assoc 1964; 68:343. 66:7601. 71. Harris NO: Dentifrices, mouth rinses, and oral irrigators. 47. Featherstone JDB: Fluoride, remineralization and root In: Harris NO, Christen AG (eds): Primary Preventive Den- caries. 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72. Heasman PA, Jacobs DJ, Chapple IL: An evaluation of the 94. Lang NP: Preface. In: Lang NP, Attstrom R, Lbe H (eds): effectiveness and patient compliance with plaque control Proceedings of the European Workshop on Mechanical methods in the prevention of periodontal disease. J Clin Plaque Control. Chicago, Quintessence, 1998. Prev Dent 1989; 11:24. 95. Lenox JA, Kopczyk RA: A clinical system for scoring a pa- 73. Heasman PA, McCracken GI: Powered toothbrushes: A re- tient's oral hygiene performance. J Am Dent Assoc 1973; view of clinical trials. J Clin Periodontol 1999; 26:407. 86:849. 74. Hellstrom M-K, Ramberg P, Krok L, et al: The effects of 96. Leonard JF: Conservative treatment of periodontoclasia. supragingival plaque control on subgingival microflora in J Am Dent Assoc 1939; 26:1308. human periodontitis. J Clin Periodontol 1996; 23:934. 97. Less W: Mechanics of teaching plaque control. Dent Clin 75. 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Lobene RR: The effect of a pulsed water pressure cleaning givally placed cannula oral irrigator tip with a supragingi- device on oral health. J Periodontol 1969; 40:667. vally placed standard irrigator tip. J Clin Periodontol 1992; 101. Lobene RR: The effect of an automatic toothbrush on gin- 19:340. gival health. J Periodontol 1964; 35:137. 80. Hoover DR, Robinson HBG, Billingsley A: The comparative 102. Lbe H, Schiott CR: The effect of mouthrinses and topical effectiveness of the Water-Pik in a noninstructed popula- application of chlorhexidine on the development of dental tion. J Periodontol 1968; 39:43(abst). plaque and gingivitis in man. J Periodont Res 1970; 5:79. 81. Jepson S: The role of manual toothbrushes in effective 103. Lbe H, Theilade E, Jensen SB: Experimental gingivitis in plaque control; advantages and limitations. In: Lang NP, man. J Periodontol 1965; 36:177. Attstrom R, Lbe H (eds): Proceedings of the European 104. Lbe H: Does chlorhexidine have a place in the prophylaxis Workshop on Mechanical Plaque Control. Chicago, Quin- of dental disease? J Periodont Res 1973; 8(suppl 12):93. tessence, 1998. 105. Macgregor IDM, Balding JW, Regis D: Flossing behaviour 82. Jolkovsky DL, Waki MY, Newman MN, et al: Clinical and in English adolescents. J Clin Periodontol 1998; 25:291. microbiological effects of subgingival and gingival mar- 106. MacNeill S, Walter DM, Day A, et al: Sonic and mechanical ginal irrigation with chlorhexidine gluconate. J Periodon- toothbrushes an in vitro study showing altered microbial tol 1990; 61:663. surface structures but lack of effect on viability. J Clin Peri- 83. Kazmierczak M, Mather M, Ciancio S, et al: A clinical eval- odontol 1998; 25:988. uation of anticalculus dentifrices. J Clin Preventive Dent 107. Mallatt ME, Beiswanger BB, Stookey GK, et al: Influence of 1990; 12:13-17. soluble pyrophosphates on calculus formation in adults. J 84. Keller SE, Manson-Hing LR: Clearance studies of proximal Dent Res 1985; 64:1159. tooth surfaces. Part 11. In vivo removal of interproximal 108. Manhold JH: Gingival tissue health with hand and power plaque. Ala J Med Sci 1969; 6:266. brushing: A retrospective with corroborative studies. J Peri- 85. Keller SE, Manson-Hing LR: Clearance studies of proximal odontol 1967; 38:23. tooth surfaces. Parts III and IV. In vivo removal of inter- 109. Manly RS, Brudevold F: Relative abrasiveness of natural proximal plaque. Ala J Med Sci 1969; 6:399. and synthetic toothbrush bristles on cementum and 86. Khocht A, Simon G, Person P, et al: Gingival recession in dentin. J Am Dent Assoc 1957; 55:779. relation to history of hard toothbrush use. J Periodontol 110. Mauriello SM, Bader JD: Six-month effects of a sanguinar- 1993; 64:900-905. ine dentifrice on plaque and gingivitis. J Periodontol 1988; 87. Kieser J: Groeneveld H: A clinical evaluation of a novel 59:238. toothbrush design. J Clin Periodontol 1997; 24:419. 111. Mazza JE, Newman MG, Simms TN: Clinical and microbial 88. Kinane DF: The role of interdental cleaning in effective effect of stannous fluoride on periodontitis. J Clin Peri- plaque control: need for interdental cleaning in primary odontol 1981; 8:203. and secondary prevention. In: Proceedings of the Euro 112. McKendrick AJW, Barbenel LMH, McHugh WD: A two-year pean Workshop on Mechanical Plaque Control. Chicago, comparison of hand and electric toothbrushes. J Periodont Quintessence, 1998. Res 1968; 3:224. 89. Lamster IB, Alfano MC, Seiger MC, et al: The effect of Lis- 113. McKendrick AJW, Barbenel LMH, McHugh WD: The influ- terine antiseptic on reduction of existing plaque and gin- ence of time of examination, eating, smoking, and fre- givitis. J Clin Prev Dent 1983; 5:12. quency of brushing on the oral debris index. J Periodont 90. Lang NP, Brecx MC: Chlorhexidine digluconate-an agent Res 1970; 5:205. for chemical plaque control and prevention of gingival in- 114. Mueller-Joseph LM, Davis C, Jones B: Oral irrigation and flammation. J Periodont Res 1986; 21(Suppl):74. antimicrobial plaque control. In: Woodall IR (ed): Compre- 91. Lang NP, Cumming BR, Lbe H: Toothbrushing frequency hensive Dental Hygiene Care, ed 4. St Louis, Mosby, 1993. as it relates to plaque development and gingival health. 115. Novaes AB, Novaes AB Jr, Moraes N, et al: Compliance J Periodontol 1973; 44:396. with supportive periodontal therapy. J Periodontol 1996; 92. Lang NP, Hotz P, Graf H, et al: Effects of supervised 67:213. chlorhexidine mouthrinses in children. A longitudinal 116. O'Beirne G, Johnson RH, Persson GR, et al: Efficacy of a clinical trial. J Periodont Res 1982; 17:101. sonic toothbrush on inflammation and probing depth in 93. Lang NP, Joss A, Orsanic T, et al: Bleeding on probing: a adult periodontitis. 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118. O'Leary TJ, Shafer WG, Swenson HM, et al: Possible pene- 138. Stookey G: Are all fluoride dentifrices the same? In: Wei tration of crevicular tissue from oral hygiene procedures. SHY (ed): Clinical Uses of Fluorides. Philadelphia, Lea & II. Use of the toothbrush. J Periodontol 1970; 41:158. Febiger, 1985. 119. Parsons LG, Thomas LG, Southard GL, et al: Effect of san- 139. Stookey GK, Muhler JC: Laboratory studies concerning the guinaria extract on established plaque and gingivitis when enamel and dentin abrasion properties of common denti- supragingivally delivered as a manual rinse or under pres- frice polishing agents. J Dent Res 1968; 47:524. sure in an oral irrigator. J Clin Periodontol 1987; 14:381. 140. Straub AM, Salvi GE, Lang NP: Supragingival plaque for- 120. Pattison GA: Self-inflicted gingival injuries: Literature re- mation in the human dentition. In: Lang NP, Attstrom R, view and case report. J Periodontol 1983; 54:299. L6e H (eds): Proceedings of the European Workshop on 121. Perry DA, Pattison G: The investigation of wax residue on Mechanical Plaque Control. Chicago, Quintessence, 1998. tooth surfaces after the use of waxed dental floss. Dent Hy- 141. Suomi JD, Green JC, Vermillion JR, et al: The effect of con- giene 1986; 60:16. trolled oral hygiene procedures on the progression of peri- 122. Proceedings of the European Workshop on Mechanical odontal disease in adults: Results after two years. J Peri- Plaque Control (Lang NP, Attstrom R, Lbe H, eds.) odontol 1969; 40:416. Chicago, Quintessence, 1998. 142. Tedesco LA, Keffler MA, Davis EL, et al: Effect of a social 123. Renton-Harper P, Addy M, Warren P, et al: Comparison of cognitive intervention no oral health status, behavior re- video and written instructions for plaque removal by an ports, and cognition. J Periodontol 1992; 63:567. oscillating/rotating/reciprocating electric toothbrush. J Clin 143. Tritten CB, Armitage GA: Comparison of a sonic and a Periodontol 1999; 26:752. manual toothbrush for efficacy in supragingival plaque re- 124. Renvert S, Glavind L: Individualized instruction and com- moval and reduction of gingivitis. J Clin Periodontol 1996; pliance in oral hygiene practices: recommendations and 23:641. means of delivery. In: Lang NP, Attstrom R, L6e H, (eds): 144. van der Weijden GA, Timmerman MF, Danser MM, et al: Proceedings of the European Workshop on Mechanical Relationship between the plaque removal efficacy of a nat- Plaque Control. Chicago, Quintessence, 1998. ural toothbrush and brushing force. J Clin Periodontol 125. Robinson HBG, Hoover PR: The comparative effectiveness 1998; 25:413. of a pulsating oral irrigator as an adjunct in maintaining 145. van der Weijden GA, Timmerman ME Danser MM, et al: oral health. J Periodontol 1971; 42:37. The role of electric toothbrushes: advantages and limita- 126. Sanders WE, Robinson HBG: The effect of toothbrushing tions. In: Lang NP, Attstrom R, Loe H (eds): Proceedings of on deposition of calculus. J Periodontol 1962; 33:386. the European Workshop on Mechanical Plaque Control. 127. Sangnes G, Gjermo P: Prevalence of oral soft and hard tis- Chicago, Quintessence, 1998. sue lesions related to mechanical tooth cleaning proce- 146. Waerhaug J. The interdental brush and its place in opera- dures. Commun Dent Oral Epidemiol 1976; 4:77. tive and crown and bridge dentistry. J Oral Rehabil 1976; 128. Sangnes G: Traumatization of teeth and gingiva related to 3:107. habitual tooth cleaning procedures. J Clin Periodontol 147. Waki MY, Jolkovsky DL, Otomo-Corgel J, et al: Effects of 1976; 3:94. subgingival irrigation on bacteremia following scaling and 129. Sanz M, Herrera D: Role of oral hygiene during the healing root planing. J Periodontol 1990; 61:405. phase of periodontal therapy. In: Lang NP, Attstrom R, Loe 148. Warren PR, Ray TS, Cugini M, et al: A practice-based study H (eds): Proceedings of the European Workshop on Me- of a power toothbrush: assessment of effectiveness and ac- chanical Plaque Control. Chicago, Quintessence, 1998. ceptance. J Am Dent Assoc 2000; 131:389. 130. Saxton CA: The effects of dentifrices on the appearance of 149. Wefel JS: Root caries histopathology and chemistry. Am J the tooth surface observed with the scanning electron mi- Dent 1994; 7:261. croscope. J Periodont Res 1976; 11:74. 150. Wilkins EM: Oral disease control: toothbrushes and tooth- 131. Schmid MO, Balmelli O, Saxer UP: The plaque removing brushing. In: Clinical Practice of the Dental Hygienist, ed effect of a toothbrush, dental floss and a toothpick. J Clin 6. Philadelphia, Lea & Febiger, 1992. Periodontol 1976; 3:157. 151. Wilson TG Jr, Glover ME, Schoen J, et al: Compliance with 132. Shiloah J, Hovious LA: The role of subgingival irrigations maintenance therapy in a private dental practice. J Peri- in the treatment of periodontitis. J Periodontol 1993; odontol 1984; 55:468. 64:835. 152. Yankell SL: Toothbrushing and toothbrushing techniques. 133. Silness J, We H: Periodontal disease in pregnancy: II. Cor- In: Harris NO, Christen AG (eds): Primary Preventive Den- relation between oral hygiene and periodontal condition. tistry, ed 3. East Norwalk, CT, Appleton & Lange, 1991. Acta Odontol Scand 1964; 22:121. 153. Yukna RA, Broxson AW, Mayer ET, et al: Comparison of 134. Silverstone LM, Featherstone MJ: A scanning electron mi- Listerine mouthwash and periodontal dressing following croscope study of the end rounding of bristles in eight periodontal flap surgery. Clin Prev Dent 1986; 4:14. toothbrush types. Quint Int 1988;19:87. 154. Zacheri WA, Pheiffer HJ, Swancar JR: The effect of soluble 135. Spolsky VA, Perry DA, Meng Z, et al: Evaluating the effi- pyrophosphates on dental calculus in adults. J Am Dent cacy of a new flossing aid. J Clin Periodontol 1993; 20:490. 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Chemotherapeutic Agents in the Treatment of Periodontal Diseases

David L. Jolkovsky and Sebastian G. Ciancio

CHAPTER

CHAPTER OUTLINE

SYSTEMIC ADMINISTRATION OF ANTIBIOTICS HOST MODULATION Tetracyclines Doxycycline Hyclate Metronidazole Nonsteroidal Antiinflammatory Drugs Penicillins LOCAL DELIVERY OF ANTIBIOTICS Cephalosporins Tetracycline-Containing Fibers (Actisite) Clindamycin Subgingival Delivery of Doxycycline Ciprofloxacin (Atridox) Macrolides Subgingival Delivery System for Minocycline SERIAL AND COMBINATION ANTIBIOTIC THERAPY (Dentamycin and PerioCline) Rationale Subgingival Delivery of Metronidazole Clinical Use LOCAL DELIVERY OF AN ANTISEPTIC AGENT

he various periodontal diseases result from suscep- agent aids in attaining a clinical benefit. Clinical benefits tible hosts having their periodontal tissues colo- can be derived through antimicrobial actions or an in- nized by specific oral pathogens in numbers suffi crease in the host's resistance. An antimicrobial cient to overwhelm their tissue defenses. Clinical success agent is a chemotherapeutic agent that works by reduc- in the treatment of these diseases thus requires reduction ing the number of bacteria present. Antibiotics are a of the bacterial load or enhancement of the host tissues' naturally occurring, semisynthetic or synthetic type of an- ability to defend or repair itself. Traditionally, the foun- timicrobial agent that destroys or inhibits the growth of dations of clinical success include education of patients selective microorganisms, generally at low concentrations. in daily oral hygiene; surgical and nonsurgical mechani- Antiseptics are chemical antimicrobial agents that are cal root debridement to remove subgingival bacteria and applied topically or subgingivally to mucous membranes, their accretions from root surfaces; and supportive peri- wounds, or intact dermal surfaces to destroy microorgan- odontal therapy generally at 3- to 6-month intervals. In isms and inhibit their reproduction or metabolism.18 In certain types of periodontal disease including chronic dentistry, antiseptics are widely used as the active ingredi- advanced periodontitis, refractory periodontitis, aggres- ent in antiplaque and antigingivitis mouthrinses and den- sive periodontitis, and periodontitis as a manifestations tifrices. Disinfectants, a subcategory of antiseptics, are of systemic diseases, adjunctive chemotherapeutic agents antimicrobial agents that are generally applied to inani- may be necessary to control the disease process.' This mate surfaces to destroy microorganisms.18 chapter reviews the indications and use of chemothera- Chemotherapeutic agents can be administered locally, peutic agents in the treatment of periodontal disease. orally, or parenterally. In either case, their purpose is to re- Chemotherapeutic agent is a general term for a duce the number of bacteria present in the diseased peri- chemical substance that provides a clinical therapeutic odontal pocket. Systemic antibiotics may be a necessary benefit. This term does not specify in what way the adjunct in controlling bacterial infection because bacteria

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can invade periodontal tissues, making mechanical ther- marily in identifying specific etiologic microorganism(s) apy alone sometimes ineffective. 11,15,60 Local administration rather than microorganisms simply associated with vari- of antimicrobial agents, generally directly in the pocket, ous periodontal disorders.16,17 has the potential to provide greater concentrations di- The possible clinical benefits of administering antibi- rectly to the infected area and reduce possible systemic otics to help control periodontal disease must be side effects. weighed against possible adverse reactions. Some adverse A single chemotherapeutic agent can have a dual reactions include allergic/anaphylactic reactions, super- mechanism of action. For instance, tetracycline is a infections of opportunistic bacteria, development of re- chemotherapeutic agent that can reduce collagen and sistant bacteria, interactions with other medications, up- bone destruction through its ability to inhibit the en- set stomach nausea, and vomiting.38 Common and zyme collagenase. As an antibiotic agent, it also can re- indiscriminate use of antibiotics worldwide has con- duce periodontal pathogens in periodontal tissues.17,18 tributed to increasing numbers of resistant bacterial Additionally, tetracyclines have been shown to be effec- strains over the last 15 to 20 years, and this trend is tive when administered systemically and applied locally. likely to continue given the widespread use of antibiotics." The overuse, misuse, and widespread prophylactic application of antimicrobial drugs are some of the SYSTEMIC ADMINISTRATION factors that have led to the emergence of resistant mi- OF ANTIBIOTICS croorganisms. Increasing levels of resistance of subgingi- The treatment of periodontal diseases is based on the in- val microflora to antibiotics has been correlated with the fectious nature of these diseases (Table 50-1). Ideally, the increased use of antibiotics in individual countries. 73 causative microorganism(s) should be identified and the An ideal antibiotic for use in prevention and treat- most effective agent selected using antibiotic sensitivity ment of periodontal diseases should be specific for peri- tests. Although this appears simple, the difficulty lies pri- odontal pathogens, allogenic and nontoxic, substantive,

Antibiotics Used to Treat Periodontal Diseases: Their Major Features and Indications

Agent(s) Used to Treat Category/Family Periodontal Diseases Major Features Indications

Penicillin Amoxicillin Extended spectrum of antimicrobial activity, LAP, GAP, MRP, RP. excellent oral adsorption; used systemically. Augmentin Effective against penicillinase producing microorganisms; used systemically. Tetracycline Minocycline Effective against broad spectrum of microorganisms; used systemically and applied locally (subgingivally). Doxycycline Effective against broad spectrum of microorganisms; used systemically and applied locally (subgingivally); chemotherapeutically used in subantimicrobial dose for host modulation (Periostat). Tetracycline Effective against broad spectrum of microorganisms; applied locally (subgingivally) in fiber (Actisite). Quinolone Ciprofloxacin Effective against gram-negative rods, promotes health-associated microflora. Macrolide Azithromycin Concentrates at sites of inflammation; used systemically. Lincomycin Clindamycin Used in penicillin-allergic patients; derivative effective against anaerobic bacteria; used systemically. Nitroimidazole Metronidazole Effective against anaerobic bacteria; LAP, GAP, MRP, RP, used systemically and applied locally AP, NUG. (subgingivally) as a gel.

CP, Chronic periodontitis; LAP, localized aggressive periodontitis; GAP, generalized aggressive periodontitis; MRP, medically related periodontitis; NUG, necrotizing ulcerative periodontitis; RP, refractory periodontitis.

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not in general use for treatment of other diseases, and the deepest pocket(s) present to absorb bacteria in the inexpensive.26 Currently, an ideal antibiotic for the treat- loosely associated plaque. This endodontic point is ment of periodontal diseases does not exist.38 Although placed in reduced transfer fluid and sent overnight to oral bacteria are susceptible to many antibiotics, no sin- the laboratory. The laboratory will then send the re- gle antibiotic at concentrations achieved in body fluids ferring dentist a report that includes the pathogens inhibits all putative periodontal pathogens.81 Indeed, a present and any appropriate antibiotic regimen. combination of antibiotics may be necessary to elimi- 5. Plaque sampling can be performed at the initial exam- nate all putative pathogens from some periodontal pock- ination, root planing, reevaluation, or supportive pe- ets" (Table 50-2). riodontal therapy appointment. As noted previously, Guidelines for use of antibiotics in periodontal ther- clinical indications for microbial testing include ag- apy include the following: gressive forms of periodontal disease, diseases refractory to standard mechanical therapy, and periodonti- 1. The clinical diagnosis and situation dictate the need tis associated with systemic conditions (see Fig. 50-1). for possible antibiotic therapy as an adjunct in con- 6. Antibiotics have been shown to have value in reduc- trolling active periodontal disease (Fig. 50-1). The pa- ing the need for periodontal surgery in patients with tient's diagnosis can change over time. For instance, a chronic periodontitis.47 patient that presents with generalized slight chronic 7. Antibiotic therapy should not be used as a monother- periodontitis can return to a diagnosis of periodontal apy (Figs. 50-1 and 50-2). That is, it must be part of health after initial therapy. However, if this patient the comprehensive periodontal treatment plan. This has been treated appropriately and continues to have therapy should have debridement of root surfaces, op- active disease, the diagnosis can change to refractory timal oral hygiene, and frequent supportive periodon- periodontitis. tal therapy at the center of therapy. Other chemother- 2. Continuing disease activity, as measured by continu- apeutic adjuncts include locally placed subgingival ing attachment loss, purulent exudate, and/or contin- antimicrobial agents, subgingival ultrasonic irrigation uing periodontal pockets of >_5 mm43,44 that bleed on with iodophors during root debridement, chlorhexi- probing, is an indication for microbial analysis and dine rinse after debridement for 2 weeks, and home further periodontal therapy. intraoral irrigation with or without chemotherapeutic 3. When used to treat periodontal disease, antibiotics are agents.38 Chlorhexidine gluconate is effective as an selected based on the microbial composition of the antiplaque rinse, but its antimicrobial activity is plaque, the patient's medical status and the current greatly reduced in the presence of organic matter in medications.38 the subgingival periodontal pocket. However, povi- 4. Microbiologic sampling is performed according to the done-iodine (Betadine) is an effective antibacterial instructions of the reference microbiologic laboratory. agent when used directly into the periodontal pocket, Commonly, the samples are taken at the beginning of even at low concentrations. 38,59 Povidone-iodine must an appointment before instrumentation of the be used with caution in patients sensitive to iodine, pocket. Supragingival plaque is removed and an en- although the sensitization rate is low. 52 It also should dodontic paper point is inserted subgingivally into be used with caution in patients who are pregnant or lactating. 14 8. Slots and co-workers have described a series of steps using antimicrobial agents for enhancing regenerative healing. They recommend starting antibiotics 1 to Common Antibiotic Regimens Used in Treating 2 days before surgery and continuing for a total of at .38,54,62 Periodontal Diseases 38 least 8 days

Regimen Duration Tetracyclines Single Agent Tetracyclines have been widely used in the treatment of Metronidazole 250-500 mg 8 days periodontal diseases. They have been frequently used in 3 times daily treating refractory periodontitis, including localized ag- Ciprofloxacin 500 mg 2 times daily 8 days gressive periodontitis (see Table 50-1). Tetracyclines have Clindamycin 300 mg 2 times daily 8 days the ability to concentrate in the periodontal tissues and inhibit the growth of Actinobacillus actinomycetemcomi- Combination Therapy tans. In addition, they exert an anticollagenase effect Metronidazole/ 250 mg of each 8 days that can inhibit tissue destruction and may aid bone re- amoxicillin 3 times daily generation (see Host Modulation). Metronidazole/ 500 mg of each 8 days ciprofloxacin 2 times daily Pharmacology. The tetracyclines are a group of antibiotics produced naturally from certain species of Strep- These regimens are prescribed with a review of the patient's med- tomyces or derived semisynthetically. These antibiotics are ical history, periodontal diagnosis, and antimicrobial testing. Con- bacteriostatic and are effective against rapidly multiply- sult Mosby's GenRx61 or manufacturer's guidelines for contraindica- ing bacteria. They generally are more effective against tions and precautions. gram-positive bacteria than gram-negative bacteria.83

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Fig. 50-1 Guidelines for use of antimicrobial therapy.

Tetracyclines are effective in treating periodontal dis- tions of tetracycline-resistant, gram-negative rods (i.e., eases in part because their concentration in the gingival Fusobacterium nucleatum). After the antibiotic was discon- . 42 crevice is 2 to 10 times that in serum .2,5,31 This allows a tinued, the flora was characteristic of sites with disease high drug concentration to be delivered into periodontal Therefore it is not advisable to engage in long-term regi- pockets. In addition, several studies have demonstrated mens of tetracyclines because of the possible develop- that tetracyclines at a low gingival crevicular fluid con- ment of resistant bacterial strains. Although commonly centration (2 to 4 leg/ml) are very effective against many used in the past as antimicrobial agents, especially for lo- periodontal pathogens. 6,7,81 calized aggressive periodontitis and other types of aggressive periodontitis, tetracyclines now tend to be re- Clinical Use. Tetracyclines have been investigated placed by more effective combination antibiotics . 38,73 as adjuncts in the treatment of localized aggressive periodontitis (LAP). A. actinomycetemcomitans is a frequent Specific Agents. Tetracycline, minocycline, and causative microorganism in LAP and is tissue invasive. doxycycline-all semisynthetic members of the tetracy- Therefore mechanical removal of calculus and plaque cline group-have been used in periodontal therapy. from root surfaces may not eliminate this bacterium TETRACYCLINE. Tetracycline requires administra- from the periodontal tissues. Systemic tetracycline can tion of 250 mg qid. It is inexpensive, but compliance eliminate tissue bacteria and has been shown to arrest may be reduced by having to take four capsules per day. bone loss and suppress A. actinomycetemcomitans levels in MINOCYCLINE. Minocycline is effective against conjunction with scaling and root planing."M This a broad spectrum of microorganisms. In patients with combined form of therapy allows mechanical removal of adult periodontitis, it suppresses spirochetes and motile root surface deposits and elimination of pathogenic bac- rods as effectively as scaling and root planing, with sup- teria from within the tissues. Increased posttreatment pression remaining evident for up to 3 months after bone levels have been noted using this method . 25,61 therapy. Minocycline can be given twice a day, thus fa- Long-term use of low doses of tetracyclines has been cilitating compliance when compared with tetracycline. advocated in the past. One long-term study of patients Although it is associated with less photo- and renal toxi- taking low doses of tetracycline (250 mg per day for 2 to city than tetracycline, it may cause reversible vertigo. 7 years) showed persistence of deep pockets that did not Minocycline administered in a dosage of 200 mg per day bleed on probing. These sites contained high propor- for 1 week results in a reduction in total bacterial counts,

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Fig. 50-2 Sequencing of antimicrobial agents. (Adapted from Jorgensen MG, Slots J: Practical antimicrobial periodontal therapy. Compend Contin Educ Dent 2000; 21:111.)

complete elimination of spirochetes for periods of up to Metronidazole is also effective against anaerobes such as 2 months, and improvement in all clinical parameters . 2° Porphyromonas gingivalis and Prevotella intermedia.34 DOXYCYCLINE. Doxycycline has the same spectrum of activity as minocycline and may be equally as ef- Clinical Usage. Metronidazole has been used clini- fective." Because it can be given only once daily, pa- cally to treat gingivitis, acute necrotizing ulcerative gin- tients may be more compliant. Compliance is also givitis, chronic periodontitis, and aggressive periodonti- favored because its absorption from the gastrointestinal tis. It has been used as monotherapy and also in tract is not altered by calcium, metal ions, or antacids, as combination with both root planing and surgery or with is absorption of other tetracyclines. The recommended other antibiotics. Metronidazole has been used success- dosage when used as an antimicrobial agent is 100 mg fully for treating necrotizing ulcerative gingivitis." twice daily the first day, then 100 mg once daily. To re- Studies in humans46,47 have demonstrated the efficacy duce gastrointestinal upset, 50 mg can be taken twice of metronidazole in the treatment of gingivitis and daily. When used in a subantimicrobial dose to inhibit periodontitis. A single dose of metronidazole (250 mg collagenase, it is recommended in a 20-mg dose twice orally) appears in both serum and gingival fluid in suffi- daily" (see Host Modulation). cient quantities to inhibit a wide range of suspected periodontal pathogens. Administered systemically (750 to 1000 mg/day for 2 weeks), this drug reduces the growth Metronidazole of anaerobic flora, including spirochetes, and decreases Pharmacology. Metronidazole is a nitroimidazole the clinical and histopathologic signs of periodontitis.46 compound developed in France to treat protozoal infec- The most commonly prescribed regimen is 250 mg tid for tions. It is bactericidal to anaerobic organisms and is be- 7 days .4s Loesche and co-workers found that 250 mg of lieved to disrupt bacterial DNA synthesis in conditions metronidazole given three times daily for 1 week was of in which a low reduction potential is present. Metron- benefit to patients with a diagnosed anaerobic periodon- idazole is not the drug of choice for treating A. actino- tal infection. In this study, an infection was considered mycetemcomitans infections, but it may be effective at anaerobic when spirochetes composed 20% or more of therapeutic levels owing to its hydroxy metabolite. How- the total microbial count. Metronidazole used as a sup- ever, it is effective against A. actinomycetemcomitans plement to rigorous scaling and root planing resulted in a when used in combination with other antibiotics .56,57 significantly reduced need for surgery when compared

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with root planing alone. The bacteriologic data of this Amoxicillin may be useful in the management of pa- study showed that only the spirochete count was signifi- tients with aggressive periodontitis, both in the localized cantly reduced.47 Currently, the critical level of spiro- and generalized forms. Recommended dosage is 500 mg chetes needed to diagnose an anaerobic infection, the tid for 8 days . 38,39 appropriate time to give metronidazole, and the ideal dosage or duration of therapy are unknown .34 Amoxicillin-Clavulanate (Augmentin). The As monotherapy (no concurrent root planing), combination of amoxicillin with clavulanate potassium metronidazole is inferior and at best only equivalent to makes Augmentin resistant to penicillinase enzymes pro- root planing. Therefore if metronidazole is used, it duced by some bacteria. Augmentin may be useful in the should not be administered as monotherapy. management of patients with refractory or localized ag- Metronidazole offers some benefit in the treatment of gressive periodontitis.57 Bueno and co-workers reported refractory periodontitis, particularly when used in com- that Augmentin arrested alveolar bone loss in patients bination with amoxicillin. The existence of refractory with periodontal disease that was refractory to treatment periodontitis as a diagnostic category indicates that some with other antibiotics including tetracycline, metronida- patients do not respond to conventional therapy, includ- zole, and clindamycin.10 ing root planing, surgery, or both. Soder and co-workers showed that metronidazole was more effective than Cephalosporins placebo in the management of sites unresponsive to root planing. 65 Nevertheless, many patients still had sites that Pharmacology. The family of /3-lactams known as bled on probing despite metronidazole therapy. cephalosporins is similar in action and structure to peni- Studies have suggested that when combined with cillins. They are frequently used in medicine and are re- amoxicillin or amoxicillin-clavulanate potassium (Aug- sistant to a number of ß-lactamases normally active mentin), metronidazole may be of value in the manage- against penicillin. ment of patients with localized aggressive or refractory periodontitis (see later discussion). Clinical Usage. Cephalosporins are generally not used to treat dental-related infections. The penicillins are Side Effects. Metronidazole has an antabuse effect superior to cephalosporins in their range of action when alcohol is ingested. The response is generally pro- against periodontopathic bacteria. portional to the amount ingested and can result in severe cramps, nausea, and vomiting. Products containing Side Effects. Patients allergic to penicillins must be alcohol should be avoided during therapy and for at considered allergic to all ß-lactam products. Rashes, ur- least 1 day after therapy is discontinued. Metronidazole ticaria, fever, and gastrointestinal upset have been associ- also inhibits warfarin metabolism. Patients undergoing ated with cephalosporins.78 anticoagulant therapy should avoid metronidazole because it prolongs prothrombin time."34 It also should be Clindamycin avoided in patients who are taking lithium. Pharmacology. Clindamycin is effective against Penicillins anaerobic bacteria." It is effective in situations in which the patient is allergic to penicillin. Pharmacology. Penicillins are the drugs of choice for the treatment of many serious infections in humans Clinical Usage. Clindamycin has shown efficacy in and are the most widely used antibiotics. Penicillins are patients with periodontitis refractory to tetracycline ther- natural and semisynthetic derivatives of broth cultures apy. Walker and co-workers" have shown aid in stabiliz- of the Penicillium mold. They inhibit bacterial cell wall ing refractory patients. Dosage used in their studies was production and therefore are bactericidal. 150 mg qid for 10 days. Jorgensen and Slots have recommended a regimen of 300 mg twice daily for 8 days.39 Clinical Usage. Penicillins other than amoxicillin and amoxicillin-clavulanate potassium (Augmentin) Side Effects. Clindamycin has been associated with have not been evaluated, and their use in periodontal pseudomembranous colitis more often than other antibi- therapy does not appear to be justified . 82 otics, thereby limiting its use. When needed, however, it can be used with caution. Diarrhea or cramping that de- Side Effects. Penicillins may induce allergic reac- velops during the use of clindamycin may be indicative of tions and bacterial resistance; up to 10% of patients may cholitis, and clindamycin should be discontinued. If symp- be allergic to penicillin. toms persist, the patient should be referred to an internist.

Amoxicillin. Amoxicillin is a semisynthetic peni- Ciprofloxacin cillin with an extended antimicrobial spectrum that includes gram-positive and gram-negative bacteria. It Pharmacology. Ciprofloxacin is a quinolone ac- demonstrates excellent absorption after oral administra- tive against gram-negative rods, including all facultative tion. Amoxicillin is susceptible to penicillinase, a and some anaerobic putative periodontal pathogens. ß-lactamase produced by certain bacteria that breaks the penicillin ring structure and thereby renders penicillins Clinical Usage. Because it demonstrates minimal ineffective. 82 effect on Streptococcus species, which are associated with

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periodontal health, 56 ciprofloxacin therapy may facilitate microbial flora associated with the various periodontal the establishment of a microflora associated with peri- disease syndromes.80 These "mixed" infections can in- odontal health. At present, ciprofloxacin is the only an- clude a variety of aerobic, microaerophilic, and anaero- tibiotic in periodontal therapy to which all strains of bic bacteria, both gram negative and gram positive. In A. actinomycetemcomitans are susceptible. It also has been these instances, it may be necessary to use more than How- used in combination with metronidazole.56 one antibiotic, either serially or in combination.57 ever, before combinations of antibiotics are used, the pe- Side Effects. Nausea, headache, and abdominal riodontal pathogen(s) being treated must be identified discomfort have been associated with ciprofloxacin. and antibiotic susceptibility testing performed. Quinolones inhibit the metabolism of theophylline, and caffeine and concurrent administration can produce tox- Clinical Use icity. Quinolones have also been reported to enhance the effect of warfarin and other anticoagulants.' $ Antibiotics that are bacteriostatic (e.g., tetracycline) generally require rapidly dividing microorganisms to be effective. They do not function well if a bactericidal antibi- Macrolicles otic (e.g., amoxicillin) is given concurrently. When both Pharmacology. Macrolide antibiotics contain a types of drugs are required, they are best given serially, not in many-membered lactone ring to which one or more de- combination. oxy sugars are attached. They inhibit protein synthesis Rams and Slots reviewed combination therapy using by binding to the 50 S ribosomal subunits of sensitive systemic metronidazole along with amoxicillin, Augmen- microorganisms. They can be bacteriostatic or bacterici- tin, or ciprofloxacin.57 The metronidazole-amoxicillin dal, depending on the concentration of the drug and the and metronidazole-Augmentin combinations provided nature of the microorganism. excellent elimination of many organisms in adult and localized aggressive periodontitis that had been treated un- Clinical Usage. Erythromycin does not concen- successfully with tetracyclines and mechanical debride- trate in gingival crevicular fluid, and it is not effective ment. These drugs have an additive effect regarding against most putative periodontal pathogens. For these suppression of A. actinomycetemcomitans. Tinoco and co- reasons, it is not recommended as an adjunct to peri- workers" found metronidazole and amoxicillin to be clini- odontal therapy. Spiramycin is active against gram- cally effective in treating localized aggressive periodontitis, positive organisms; it is excreted in high concentrations although 50% of patients harbored A. actinomycetemcomi- in saliva. It is used as an adjunct to periodontal treat- tans one year later. Metronidazole-ciprofloxacin combina- ment in Canada and Europe but is not available in the tion is effective against A. actinomycetemcomitans. Metron- U.S. Several studies have shown benefits, as measured idazole targets obligate anaerobes, and ciprofloxacin by the Gingival Index, the Plaque Index, pocket depth, targets facultative anaerobes. This is a powerful combina- and crevicular fluid flows50,68 when spiramycin was pre- tion against mixed infections. Studies of this drug combi- scribed in advanced periodontal disease. In addition, it is nation in the treatment of refractory periodontitis have a safe, nontoxic drug with few and infrequent side ef- documented marked clinical improvement. This combina- fects and is not in general use for medical problems.28 tion may provide a therapeutic benefit by reducing or elimi- Azithromycin (Zithromax) is a member of the aza- nating pathogenic organisms and a prophylactic benefit by lide class of macrolides. It is effective against anaerobes giving rise to a predominantly streptococcal microflora.56 and gram-negative bacilli. After an oral dosage of 500 mg Systemic antibiotic therapy combined with mechani- once daily for three consecutive days, significant levels cal therapy appears valuable in the treatment of recalci- of azithromycin can be detected in most tissues for 7 to trant periodontal infections and localized aggressive 10 days.' The concentration of azithromycin in tissue periodontitis infections involving A. actinomycetemcomi- specimens from periodontal lesions is significantly tans. Antibiotic treatment should be reserved for specific higher than that of normal gingiva. 49 It has been pro- subsets of periodontal patients who do not respond to posed that azithromycin penetrates fibroblasts and conventional therapy. Selection of specific agents should phagocytes in concentrations 100 to 200 times greater be guided by the results of cultures and sensitivity tests than that of the extracellular compartment. The azithro- for subgingival plaque microorganisms. mycin is actively transported to sites of inflammation by phagocytes and then released directly into the sites of in- HOST MODULATION flammation as the phagocytes rupture during phagocyto- sis.27-36 Therapeutic use requires a single dose of 250 mg Doxycycline Hyclate per day for 5 days after an initial loading dose of 500.'8 The U.S. Food and Drug Administration recently granted marketing approval for doxycycline hyclate (Periostat) SERIAL AND COMBINATION for the adjunctive treatment of periodontitis. Periostat, ANTIBIOTIC THERAPY available as a 20-mg capsule of doxycycline hyclate, is prescribed for use by patients twice daily. The mecha- Rationale nism of action is by suppression of the activity of collage- Because periodontal infections may contain a wide di- nase, particularly that produced by polymorphonuclear versity of bacteria, no single antibiotic is effective against leukocytes. A schematic diagram of the role of matrix all putative pathogens. Indeed, differences exist in the metalloproteinases in the progression of periodontal

682 PART 5 • Treatment of Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com glandins, thromboxanes, and prostacycline by the enzyme cyclooxygenase. The lipoxygenase pathway can produce leukotrienes and hydroxyeicosatetraenoic acids from arachidonic acid. Strong evidence suggests that cyclooxygenase pathway products (e.g., prostaglandins) may be important mediators of some pathologic events occurring in periodontal diseases$ Therefore modulation of the host's inflammatory response to bacteria may alter the incidence and severity of periodontal disease. Nons- teroidal antiinflammatory drugs (NSAIDs) may be of therapeutic value in treating periodontal disease because of their ability to interfere with arachidonic acid metab- Fig. 50-3 Matrix metaIloproteinases in the progression of peri- olism and thereby inhibit the inflammatory process. odontal disease. This expectation has been validated in studies in both animals and humans. 23,55,75,86,88 Some NSAIDs have been shown to affect the response of polymorphonuclear neutrophils (PMNs) to inflammation not related to disease is seen in Fig. 50-3. Although this drug is in the prostaglandin inhibition."," Beneficial effects of NSAIDs antibiotic family, it does not produce antibacterial effects have also been found after topical application .11,74,85 because the dose of 20 mg twice daily is too low to affect Drugs such as flurbiprofen, ibuprofen, mefenamic acid, bacteria. As a result, resistance to this medication has and naproxen have been studied. not been seen. Flurbiprofen appears to be an NSAID worthy of fur- Four double-blind, clinical, multicenter studies of ther investigation. It inhibits PMN migration, reduces vas- more than 650 patients have demonstrated that doxycy- cular permeability, and inhibits platelet aggregation by in- cline hyclate improves the effectiveness of professional hibiting cyclooxygenase. 35 In a 3-year study, Williams and periodontal care and slows the progression of the disease co-workers reported that flurbiprofen significantly inhib- process. The results of the first three studies showed that ited radiographic alveolar bone loss when compared with doxycycline hyclate resulted in approximately a 50% im- placebo. Unfortunately, by 24 months, the difference in provement in clinical attachment levels in pockets with the rate of bone loss had disappeared. 14 This group also reprobing depths (PD) of 4 to 6 mm and a 34% improve- ported a return to baseline in the rate of bone loss after ment in pockets with probing depths >_ 7 mm. It was also treatment with flurbiprofen was discontinued. 87 noted that attachment loss was prevented in sites with normal probing depths (0 to 3 mm), whereas the placebo LOCAL DELIVERY OF ANTIBIOTICS groups lost 0.13 mm at 12 months (p = 0.05). 12,19 A recent study by Caton and co-workers has shown sta- The limitations of mouthrinsing and irrigation have tistically significant reductions in probing depths and in- prompted research for the development of alternative creases in clinical attachment levels with adjunctive Perio- delivery systems. Recently, advances in delivery technol- stat in conjunction with root planing at 3-, 6-, and ogy have resulted in the controlled release of drugs 9-month evaluations compared with placebo groups un- (Table 50-3). The requirements for treating periodontal dergoing root planing alone." Although statistically signif- disease include a means for targeting an antimicrobial to icant, the net changes were considered limited alterations infection sites and sustaining its localized concentration in patients with moderate to severe chronic periodontitis. 4 at effective levels for a sufficient time while concurrently Results of safety studies showed the use of 20-mg Pe- evoking minimal or no side effects. riostat BID either with or without mechanical therapy (SRP) did not exert an antimicrobial effect on the periodontal microflora and did not result in a detrimental Tetracycline-Containing Fibers (Actisite) shift in the normal flora. The colonization or overgrowth The first local delivery product available in the U.S., one of the periodontal pocket by bacteria resistant to doxycy- which has been extensively studied, is an ethylene/vinyl cline, tetracycline, minocycline, amoxicillin, erythromy- acetate copolymer fiber, diameter 0.5 mm, containing cin, or clindamycin has not been observed. In addition, tetracycline, 12.7 mg/9 inches (Actisite tetracycline fiber; no evidence of any tendency toward the acquisition of manufactured by Alza Corporation, Palo Alto, CA; distrib- multiantibiotic resistance was found. 21,76 uted by Procter & Gamble Co., Cincinnati, OH) (Fig. 50-4). When packed into a periodontal pocket, it is well tolerated by oral tissues, and for 10 days it sustains tetracycline con- Nonsteroidal Anti inflammatory Drugs centrations exceeding 1300 ltg/ml, well beyond the 32 to It is only relatively recently that the role of the host's in- 64 wg/ml required to inhibit the growth of pathogens iso- flammatory system in periodontal disease has begun to lated from periodontal pockets .70,79 In contrast, crevicular be understood. Following activation of inflammatory fluid concentrations of only 4 to 8 Ag/ml are reported after cells in the periodontium by bacteria, phospholipids in systemic tetracycline administration, 250 mg four times the plasma membranes of cells are acted on by phospho- daily for 10 days (total oral dose, 10 g). 32 lipase. This leads to the liberation of free arachidonic Studies demonstrate that tetracycline fibers applied acid,58 which then can be metabolized into prosta- with or without scaling and root planing reduce probing

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Currently Available or Investigational, Locally Delivered Antimicrobials for Periodontal Therapy

Product Antimicrobial Agent FDA Clearance Dosage Form Manufacturer Actisite Tetracycline Yes Nonresorbable fiber Alza Corp., Palo Alto, CA Arestin Minocycline No Biodegradable powder Orapharma Corp., i n syringe Warminster, PA Atridox Doxycycline Yes Biodegradable mixture Atrix Labs, Ft. Collins, CO in syringe Dentamycin, Minocycline No Biodegradable mixture Sunstar Corp., Tokyo, Japan Perio Cline in syringe Elyzol Metronidazole No Biodegradable mixture Dumex Corp., in syringe Copenhagen, Denmark PerioChip Chlorhexidine Yes Biodegradable device Dexcel Pharma, Inc., Jerusalem, Israel

depth, bleeding on probing, and periodontal pathogens and provide gains in clinical attachment level. Such effects are significantly better than those attained with scaling and root planing alone or with placebo fibers. In a 2-month study, compared with scaling and root planing, the fibers used alone have provided more than a 60% greater improvement in probing depth and clinical attachment level than scaling alone . 29 No change in antibiotic resistance to tetracycline has been found following tetracycline fiber therapy among the tested putative periodontal pathogens .3o Disadvan- tages of the fiber include the length of time required for placement (10 minutes or more per tooth), the consider- Fig. 50-4 Placement of Actisite fiber. able learning curve required to gain proficiency at placement, and the need for a second patient appointment 10 days after placement for removal of the fiber. Also, placement of fibers around 12 or more teeth has resulted in oral candidiasis in a few cases. Another study suggested that rinsing with 0.12% chlorhexidine (Peridex; Zila Pharmaceuticals, Inc., Phoenix, AZ) after fiber placement had a synergistic effect, enhancing the reduction of bacterial pathogens. 53 Evaluation of the effect of tetracycline fibers on root surfaces, using fluorescent light and scanning electron microscopy,51 showed superficial penetration of tetracycline, with minor penetration into dental tubules, and a few areas of demineralized root surface. Scanning electron microscopic observations made in this study also re- Fig. 50-5 Placement of Atridox gel. vealed reductions in the subgingival microbial flora on the root surfaces of teeth treated with the fibers versus the control specimens. other treatments at all time periods, with the exception of the 3-month clinical attachment level value. For the Subgingival Delivery of Doxycycline (Atridox) Atridox group, the reduction in clinical attachment level Atridox® (manufactured by Atrix Laboratories, Fort at 9 months showed a gain of 0.4 mm compared with Collins, CO; licensed for marketing by Block Drug, Inc., vehicle control, the reduction in probing depth was Jersey City, NJ) is a gel system that incorporates the antibi- 0.6 mm greater than vehicle control, and the reduction otic doxycycline (10%) in a syringeable gel system (Fig. of bleeding on probing was 0.2 units greater than vehicle 50-5). Atridox is cleared by the FDA for sale in the U.S. control. The differences were clinically small but statisti- In a 9-month multicenter study of 180 patients, treat- cally significant. Although resistance was not evaluated ment with Atridox alone was more effective than the in this study, the local application of doxycycline has

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measures, and the reduction in probing depth was significantly greater with minocycline gel. When sites with probing depth of at least 7 mm and significant bleeding at baseline were considered, the improvements were greater than with 5-mm pockets. The improvements with minocycline were statistically significantly better than the vehicle-control group. Applications of 2% minocycline were also evaluated in a 3-month study in 30 patients. -33 Active or placebo gel was placed subgingivally at planed sites in each subject according to a double-blind protocol, immediately after scaling and root planing and 2 and 4 weeks later. Fig. 50-6 Minocycline syringable gel. Differences between groups in mean probing depth did not reach statistical significance at any visit, but mean clinical attachment levels were different in favor of the minocycline group (p < 0.05) at both reassessments. A previously been reported to show transient increases in difference was found in the number of sites that bled af- resistance in oral microbes and no overgrowth of foreign ter deep probing at 12 weeks, favoring the minocycline pathogens . 4s group (p < 0.05). This product (2% minocycline) is not Data also has been reported from two multicenter clin- available in the U.S. ical trials, each studying 411 patients with moderate to severe periodontitis.24 At baseline, patients were randomized to one of four treatment groups: Atridox, vehicle Subgingival Delivery of Metronidazole control, oral hygiene only, and scaling and root planing. A topical medication (Elyzol; Dumex, Copenhagen, Den- Sites with probing depth >5 mm that bled on probing mark) containing an oil-based metronidazole 25% dental were treated at baseline and then again with the same gel (glyceryl mono-oleate and sesame oil) has been tested treatment at 4 months. Clinical assessments were made in a number of studies.' It is applied in viscous consis- for 9 months, measuring clinical attachment level, prob- tency to the pocket, where it is liquidized by the body ing depth, and bleeding on probing. All treatment groups heat and then hardens again forming crystals in contact in both studies showed clinical improvements from base- with water. As a precursor, the preparation contains line over the 9-month period. The results for all parame- metronidazole-benzoate, which is converted into the ac- ters measured were significantly better in the Atridox tive substance by esterases in the crevicular fluid. Two group compared with vehicle control and oral hygiene 25% gel applications at a 1-week interval have been used only. Compared with scaling and root planing, the effects in clinical studies.'' of Atridox as a monotherapy on clinical attachment level Studies of the metronidazole gel have shown it to be gain and probing depth reduction were equivalent. equivalent to scaling and root planing but have not shown adjunctive benefits in conjunction with scaling Subgingival Delivery System for Minocycline and root planing. For example, a recent 6-month study (Dentamycin and PerioCline) of 30 patients showed the following67: The treatment consisted of two applications of the dental gel in two A subgingival delivery system of 2% (w/w) minocycline randomly selected quadrants at 1-week intervals as well hydrochloride (Dentamycin, Cyanamid International, as simultaneous subgingival scaling of the remaining Lederle Division, Wayne, NJ; PerioCline, SunStar, Osaka, quadrants. Oral hygiene instructions were given on day Japan) is available in many countries for use as an ad- 21. Statistical analyses showed that both treatments were junct to subgingival debridement. This system is a sy- effective in reducing probing depth and bleeding on ringeable gel suspension delivery formulation (Fig. 50-6). probing over the 6-month period. At the end of the fol- In a four-center, double-blind, randomized trial, pa- low-up period, the mean reduction in probing depth was tients with periodontal pockets at least 5 mm deep were 1.3 mm after gel treatment and 1.5 mm after subgingival selected, and either 2% minocycline gel or vehicle were scaling. Bleeding on probing was reduced by 35% and applied once every 2 weeks for four applications follow- 42%, respectively. No significant differences between the ing initial scaling and root planing. '2 A total of 343 teeth two treatments were detected. Dark-field microscopy (976 sites) were included in the minocycline group, with showed a shift towards a seemingly more healthy mi- 299 teeth (810 sites) in the control group. croflora for both treatment modalities; this effect per- Reductions in P. gingivalis and P. intennedia at weeks 2, sisted throughout the 6-month period. 4, 6, and 12 and at weeks 6 and 12 for A. actinomycetem- A large, multicenter study of 206 subjects investigated comitans were statistically significant. These results demon- two applications of this gel in two randomly selected strated the advantages of supplementing standard subgin- quadrants versus two quadrants of scaling.' Probing gival debridement with minocycline gel application. depths were reduced by 1.2 mm in the gel and 1.5 mm The three primary clinical efficacy variables in this in the scaling group. At 6 months, the differences be- study were probing depth, clinical attachment level, and tween treatments were statistically but not clinically sig- bleeding index. There was a trend toward clinical im- nificant. Also, bleeding on probing was reduced by 88% provement in both the treatment groups for all three for both treatment groups. Chemotherapeutic Agents in the Treatment o f Periodontal Diseases • CHAPTER 50 685 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

LOCAL DELIVERY OF AN 4. American Academy of Periodontology Statement (Commit- ANTISEPTIC AGENT tee on Research, Science, and Therapy). October 1998. 5. Bader HI, Goldhaber P: The passage of intravenously ad- A resorbable delivery system (Periochip) has been tested ministered tetracycline into the gingival sulcus of dogs. for the subgingival placement of chlorhexidine glu- J Oral Ther Pharmacol 1968; 2:324. conate with positive clinical results. It is a small chip 6. Baker PJ, Evans RT, Slots J, et al: Antibiotic susceptibility of (4.0 x 5.0 x 0.35 mm) composed of a biodegradable anaerobic bacteria from the oral cavity. J Dent Res 1985; hydrolyzed gelatin matrix, cross-linked with glutaralde- 65:1233. 7. Baker PJ, Evans RT, Slots J, et al: Susceptibility of human hyde and also containing glycerin and water, into which oral anaerobic bacteria to antibiotics suitable for topical use. 2.5 mg chlorhexidine gluconate has been incorporated J Clin Periodontol 1985; 12:201. per chip. This delivery system releases chlorhexidine and 8. Blandizzi C, Tecla M, Lupetti A, et al: Periodontal tissue dis- maintains drug concentrations in the gingival crevicu- position of azithromycin in patients affected by chronic in- lar fluid greater than 100 hg/ml for at least 7 days,66 flammatory periodontal diseases. J Periodontol 1999; 70:960. concentrations well above the tolerance of most oral 9. Briner WW, Kayrouz GA, Chanak MX: Comparative antimi- bacteria.' Because the chip biodegrades in 7 to 10 days, a crobial effectiveness of a substantive (0.12% chlorhexidine) second appointment for removal is not needed. and a nonsubstantive (phenolic) mouthrinse in vivo and in Two multicenter, randomized, double-blind, parallel vitro. Compend Contin Educ Dent 1994; 15:1158. group, controlled clinical trials of this chip were con- 10. Bueno L, Walker C, Van Ness W, et al: Effect of augmentin on microbiota associated with refractory periodontitis. Ab- ducted in the U.S. with a total of 447 patients in 10 cen- stract 1064. J Dent Res 1988; 67:246. ters . 3 ' In these studies, patients received a supragingival 11. Carranza FA Jr, Saglie R, Newman MG, et al: Scanning and prophylaxis for up to 1 hour, followed by scaling and transmission electron microscopic study of tissue-invading root planing for 1 hour. Chips were placed in target sites microorganisms in localized juvenile periodontitis. J Peri- with probing depth of 5 to 8 mm at baseline that bled on odontol 1983; 54:598. probing and again at 3 and 6 months if probing depth re- 12. Caton J, Bleiden T, Adams D, et al: Subantimicrobial doxy- mained >_5 mm. Sites in control-group subjects received cycline therapy for periodontits (Abstract). J Dent Res 1997; either a placebo chip (inactive) with scaling and root 76:1307. planing or scaling and root planing alone. Sites in test- 13. Caton JG, Ciancio SG, Blieden TM, et al: Treatment with group subjects received either a chlorhexidine chip (ac- Subantimicrobial dose doxycycline improves the efficacy of scaling and root planing in patients with adult periodonti- tive) with scaling and root planing or scaling and root tis. J Periodontol 2000; 71:521. planing alone (to maintain the study blind). Examina- 14. Chanoine, J, Boulvain M, Bourdoux, D, et al: Increased re- tions were performed at baseline and again at 3, 6, and 9 call rate at screening for congenital hypothyroidism in months. At 9 months, significant decreases in probing breast fed infants born to iodine overloaded mothers. Arch depth from baseline favoring the active chip compared Dis Child 1988; 63:1207. with controls were observed: chlorhexidine chip with 15. Christenson LA, Slots J, Rosling BG, et al: Microbiological scaling and root planing, -0.95 ± 0.05 mm; placebo chip and clinical effects of surgical treatment of localized juve- with scaling and root planing, -0.69 ± 0.05 mm (p = nile periodontitis. J Clin Periodontol 1985; 12:465. 0.001); scaling and root planing alone, -0.65 ± 0.05 mm 16. Ciancio SG: Use of antibiotics in periodontal therapy. In: (p = 0.00001). Although statistically significant, the net Newman MG, Goodman A (eds): Antibiotics in Dentistry. Chicago, Quintessence, 1983. clinical changes were limited. The proportion of pocket 17. Ciancio SG: Antibiotics in periodontal therapy. In: Newman sites with a probing depth reduction of 2 mm or more MG, Kornman K (eds): Antibiotic/Antimicrobial Use in Den- was increased in the chlorhexidine chip group (30%) tal Practice. Chicago, Quintessence, 1990. compared with scaling and root planing alone (16%), a 18. Ciancio SG: Antiseptics and antibiotics as chemotherapeutic difference which was statistically significant on a per pa- agents for periodontitis management. Compend Contin tient basis (p < 0.0001). Educ Dent 2000; 21:59. No signs of staining were noted in any of the above 19. Ciancio SG, Adams D, Blieden T, et al: Subantimicrobial three studies as a result of the "chlorhexidine chip" dose doxycycline: A new adjunctive therapy for adult peri- treatment, as measured by a stain index. Adverse effects odontitis. Presented at the annual meeting of the American were minimal, with a few patients who complained of Academy of Periodontology, Boston, MA, September 1998. 20. Ciancio SG, Slots J, Reynolds HS, et al: The effect of short- slight pain and swelling in the first 24 hours after chip term administration of minocycline HCl administration on placement. gingival inflammation and subgingival microflora. J Peri- odontol 1982; 53:557. REFERENCES 21. Crout R, Adams D, Blieden T, et al: Safety of doxycycline hyclate 20 mg bid in patients with adult periodontitis. Pre- 1. Ainamo J, Lie T, Ellingsen BH, et al: Clinical responses to sented at the annual meeting of the American Academy of subgingival application of a metronidazole 25% gel com- Periodontology, Boston, MA, September, 1998. pared to the effect of subgingival scaling in adult periodon- 22. Edelson H, Kaplan H, Korchak H: Differing effects of nons- titis. J Clin Periodontol 1992; 19(Part II):723. teroidal anti-inflammatory agents on neutrophil functions. 2. Alger FA, Solt CW, Vuddhankanok S, et al: The histologic Clin Res 1982; 30:469A. evaluation of new attachment in periodontally diseased hu- 23. Feldman R, Szeto B, Chauncey H, et al: Nonsteroidal anti- man roots treated with tetracycline-hydrochloride and fi- inflammatory drugs in the reduction of human alveolar bronectin. J Periodontol 1990; 61:447. bone loss. J Clin Periodontol 1983; 10:131. 3. American Academy of Periodontology: Parameters of care. 24. Garrett S, Adams D, Bandt C, et al: Two multicenter clinical J Periodontol 2000; 71(suppl):847. trials of subgingival doxycycline in the treatment of periodontitis. J Dent Res 1997; 76:153(Abstr #1113).

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25. Genco RJ, Cianciola JJ, Rosling H: Treatment of localized ju- 48. Lozdan J, Sheiham A, Pearlman BA, et al: The use of nitrimi- venile periodontitis. Abstract 872. J Dent Res 1981; 60:527. dazine in the treatment of acute ulcerative gingivitis. A 26. Gibson W: Antibiotics and periodontal disease: A selective double-blind controlled trial. Br Dent J 1971; 130:294. review of the literature. J Am Dent Assoc 1982; 104:213. 49. Malizia T, Tejada MR, Ghelardi E, et al: Periodontal tissue 27. Gladue RP, Snyder ME: Intracellular accumulation of disposition of azithromycin. J Periodontol 1997; 68:1206. azithromycin by cultured human fibroblasts. Antimicrob 50. Mills WH, Thompson GW, Beagrie GS: Clinical evaluation Agents Chemother 1990; 34:1056. of spiramycin and erythromycin in control of periodontal 28. Gold SI: Combined therapy in the treatment of periodonto- disease. J Clin Periodontol 1979; 6:308. sis: Case report. Periodont Case Rep 1979; 1:12. 51. Morrison SL, Cobb CM, Kazakos GM, et al: Root surface 29. Goodson JM, Cugini M, Kent RL, et al: Multicenter evalua- characteristics associated with subgingival placement of tion of tetracycline fiber therapy: II. Clinical response. J Pe- monolithic tetracycline-impregnated fibers. J Periodontol riodont Res 1991; 26:371. 1992; 63:137. 30. Goodson JM, Tanner A: Antibiotic resistance of the subgin- 52. Neidner R: Cytotoxicity and sensitization of povidone- gival microbiota following local tetracycline therapy. Oral iodine and other frequently used anti-infective agents. Der- Microbiol Immunol 1992; 7:113. matology 1997; 195(suppl):89. 31. Gordon JM, Walker CB, Murphy JC: Concentration of tetra- 53. Niederman R, Holborow D, Tonetti M, et al: Reinfection of cycline in human gingival fluid after single doses. J Clin Pe- periodontal sites following tetracycline fiber therapy. J Dent riodontol 1981; 8:117. Res 1990; 69:277(Abstr 1345). 32. Gordon JM, Walker CB, Murphy CJ, et al: Tetracycline: lev- 54. Nowzari H, McDonald ES, Flynn J, et al: The dynamics of els achievable in gingival crevice fluid and in vitro effect on microbial colonization of barrier membranes for guided tis- subgingival organisms. Part 1. Concentrations in crevicular sue regeneration. J Periodontol 1996; 67:694. fluid after repeated doses. J Periodontol 1981; 52:609. 55. Offenbacher S, Braswell L, Loos A, et al: Effects of flur- 33. Grace MA, Watts TLP, Wilson RF, et al: A randomized con- biprophen on the progression of periodontitis in Macaca trolled trial of a 2% minocycline gel as an adjunct to non- mulatta. J Periodont Res 1987; 22:473. surgical periodontal treatment, using a design with multiple 56. Rams TE, Feik D, Slots J: Ciprofloxacin/metronidazole treat- matching criteria. J Clin Periodontol 1997; 24:249. ment of recurrent adult periodontitis. Abstract. J Dent Res 34. Greenstein G: The role of metronidazole in the treatment of 1992; 71:319. periodontal diseases. J Periodontol 1993; 1:1. 57. Rams TE, Slots J: Antibiotics in periodontal therapy: An up- 35. Heasam PA, Berm DK, Kelly PJ, et al: The use of topical flur- date. Compend Contin Educ Dent 1992; 13:1130. biprofen as an adjunct to non-surgical management of peri- 58. Research, Science and Therapy Committee: Pharmacologic odontal disease. J Clin Periodontol 1993; 20:457. blocking of host responses as an adjunct in the manage- 36. Hoepelman IM, Schneider MME: Azithromycin: The first of ment of periodontal diseases: A research update. Chicago, the tissue-selective azalides. Int J Antimicrob Agents 1995; American Academy of Periodontology, 1992. 5:145. 59. Rosling BG, Slots J, Christersson LA, et al: Topical antimi- 37. Jeffcoat M, Bray KS, Ciancio SG, et al: Adjunctive use of a crobial therapy and diagnosis of subgingival bacteria in the subgingival controlled-release chlorhexidine chip reduces management of inflammatory periodontal disease. J Clin probing depth and improves attachment level compared Periodontol 1986; 13:975. with scaling and root planing alone. J Periodontol 1998; 60. Saglie FR, Carranza FA Jr, Newman MG, et al: Identification 69:989. of tissue invading bacteria in human periodontal disease. 38. Jorgensen MG, Slots J: Practical antimicrobial periodontal J Periodont Res 1982; 17:452. therapy. Compend Contin Educ Dent 2000; 21:111. 61. Schrefer J (pub): Mosby's GENRx, ed 10. St Louis, Mosby, 2001. 39. Jorgensen MG, Slots J: Responsible use of antimicrobials in 62. Slots J, McDonald ES, Nowzari H: Infectious aspects of peri- periodontics. J Cal Dent Assoc 2000; 28:185. odontal regeneration. Periodontol 2000 1999; 19:164. 40. Kaplan H, Edelson H, Korchak H, et al: Effects of nons- 63. Slots J, Rams TE: Antibiotics and periodontal therapy: Advan- teroidal anti-inflammatory agents on neutrophil functions tages and disadvantages. J Clin Periodontol 1990; 17:479. in vitro and in vivo. Biochem Pharmacol 1984; 33:371. 64. Slots J, Rosling BG: Suppression of periodontopathic mi- 41. Klinge B, Attstrom R, Karring T, et al: 3 regimes of topical croflora in localized juvenile periodontitis by systemic tetra- metronidazole compared with subgingival scaling on peri- cycline. J Clin Periodontol 1983; 10:465. odontal pathology in adults. J Clin Periodontol 1992; 19 65. Soder P, Frithiof L, Wikner S, et al: The effects of systemic (Part Il):708. metronidazole after non-surgical treatment in moderate 42. Kornman KS, Karl EH: The effect of long-term low-dose and advanced periodontitis in young adults. J Periodontol tetracycline therapy on the subgingival microflora in refrac- 1990; 61:281. tory adult periodontitis. J Periodontol 1982; 53:604. 66. Soskolne WA, Heasman PA, Stabholz A, et al: Sustained local 43. Lang NP, Adler R, Joss A, et al: The absence of bleeding on delivery of chlorhexidine in the treatment of periodontitis: probing. An indicator of periodontal stability. J Clin Peri- a multi-center study. J Periodontol 1997; 68:32. odontol 1990; 17:714. 67. Stelzel M, Flores-De-Jacoby L: Topical metronidazole appli- 44. Lang NP, Joss A, Orsanic T, et al: Bleeding on probing. A pre- cation compared with subgingival scaling. A clinical and dictor for the progression of periodontal disease? J Clin Peri- microbiological study on recall patients. J Clin Periodontol odontol 1986; 13:590. 1996; 23:24. 45. Larsen T. Occurrence of doxycycline-resistant bacteria in 68. Sznajder N, Piovano S, Bernat MI, et al: Effect of spiramycin the oral cavity after local administration of doxycycline in therapy on human periodontal disease. J Clin Periodontol patients with periodontal disease. Scand J Infect Dis 1991; 1987; 22:255. 23:89. 69. Tinoco EM, Beldi M, Campedelli F, et al: Clinical and micro- 46. Lekovic V, Kenney EB, Carranza FA Jr, et al: Effect of biologic effects of adjunctive antibiotics in treatment of lo- metronidazole on human periodontal disease. A clinical calized aggressive periodontitis. A controlled clinical study. and microbiologic study. J Periodontol 1983; 54:476. J Periodontol 1998; 69:1355. 47. Loesche WJ, Giordano JR, Hujoel P, et al: Metronidazole in 70. Tonetti M, Cugini AM, Goodson JM: Zero order delivery periodontitis: Reduced need for surgery. J Clin Periodontol with periodontal placement of tetracycline loaded ethylene 1992; 19:103. vinyl acetate fibers. J Periodontal Res 1990; 25:243.

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71. Tyler K, Walker CB, Gordon J, et al: Evaluation of clin- 80. Walker CB, Gordon JM, Magnusson 1, et al: A role for antibi- damycin in adult refractory periodontitis: Antimicrobial otics in the treatment of refractory periodontitis. J Peri- susceptibilities. Abstract 1667. J Dent Res 1985; 64 (special odontol 1993; 64:772. issue):360. 81. Walker CB, Gordon JM, Socransky SS: Antibiotic susceptibil- 72. Van Steenberghe D, Bercy P, Kohl J: Subgingival minocy- ity testing of subgingival plaque samples. J Clin Periodontol cline hydrochloride ointment in moderate to severe chronic 1983; 10:422. adult periodontitis: A randomized, double-blind, vehicle- 82. Weinstein L: Antimicrobial agents: Penicillins and cephalo- controlled, multicenter study. J Periodontol 1993; 64:637. sporins. In: Goodman LS, Gilman A (eds): The Pharmacho- 73. Van Winkelhoff AJ, Gonzales DH, Winkel EG, et al: Antimi- logical Basis of Therapeutics, ed 5. New York, Macmillan, crobial resistance in the subgingival microflora in patients 1975. with adult periodontitis. A comparison between the Nether- 83. Weinstein L: Antimicrobial agents: Tetracyclines and chlo- lands and Spain. J Clin Perio 2000; 27:79. ramphenicol. In: Goodman LS, Gilman A (eds): The Phar- 74. Vogel R, Schneider L, Goteinter D: The effects of a topical machological Basis of Therapeutics, ed 5. New York, nonsteroidal anti-inflammatory drug on ligature induced Macmillan, 1975. periodontal disease in the squirrel monkey. J Clin Periodon- 84. Williams RC, Jeffcoat MK, Howell T, et al: Altering the pro- tol 1986; 12:139. gression of human alveolar bone loss with the non-steroidal 75. Waite I, Saxon C, Young A, et al: The periodontal status of anti-inflammatory drug flurbiprofen. J Periodontol 1989; subjects receiving nonsteroidal anti-inflammatory drugs. 60:485. J Periodont Res 1981; 16:100. 85. Williams RC, Jeffcoat MK, Howell T, et al: Ibuprofen: An in- 76. Walker C, Thomas J: The effect of subantimicrobial doses of hibitor of alveolar bone resorption in beagles. J Periodont doxycycline on the microbial flora and antibiotic resistance Res 1988; 23:225. in patients with adult periodontitis. Presented at the annual 86. Williams RC, Jeffcoat MK, Howell T, et al: Indomethacin or meeting of the American Academy of Periodontology, flurbiprofen treatment of periodontitis in beagles: Compari- Boston, MA, September, 1998. son of effect on bone loss. J Periodont Res 1987; 22:403. 77. Walker CB: The acquisition of resistance of antibiotic resis- 87. Williams RC, Jeffcoat MK, Howell T, et al: Three year trial of tance in the periodontal microflora. Periodontol 2000 1996; flurbiprofen treatment in humans: Post-treatment period. 10:79. Abstract #1617. J Dent Res 1991; 70:448. 78. Walker CB: Selected antimicrobial agents: Mechanisms of 88. Williams RC, Jeffcoat MK, Wechter WJ, et al: Flurbiprofen: action, side effects and drug interactions. Periodontol 2000 A potent inhibitor of alveolar bone resorption in beagles. 1996; 10:12. Science 1985; 227:640. 79. Walker CB, Cordon JM, Mcquilkin SJ, et al: Tetracycline: Levels achievable in gingival crevice fluid and in vitro effect on subgingival organisms. Part II. Susceptibilities of periodontal bacteria. J Periodontol 1981; 52:613. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Periodontal Management of HIV-Infected Patients

Terry D. Rees

CHAPTER

CHAPTER OUTLINE

PERIODONTAL TREATMENT PROTOCOL BACILLARY (EPITHELIOID) ANGIOMATOSIS Health Status NONSPECIFIC ORAL ULCERATIONS AND Infection Control Measures RECURRENT APHTHAE Goals of Therapy PERIODONTAL DISEASE IN HIV-POSITIVE Supportive Periodontal Therapy I NDIVIDUALS Psychologic Factors Linear Gingival Erythema ORAL CANDIDIASIS Necrotizing Ulcerative Gingivitis ORAL HAIRY LEUKOPLAKIA Necrotizing Ulcerative Stomatitis KAPOSI'S SARCOMA Necrotizing Ulcerative Periodontitis

acquired immunodeficiency syndrome (AIDS) is a Health Status universal epidemic that significantly affects den- The patient's health status should be determined from tal practice, regardless of geographic location. the health history, physical evaluation, and consultation The oral cavity is a frequent site for clinical with his or her physician. Treatment decisions will vary manifestations of the disease. The ability to recognize depending on the patient's state of health. For example, and manage the oral manifestations of this disease is an delayed wound healing and increased risk of postopera- important part of dental practice. The dentist should be tive infection are possible complicating factors in AIDS prepared to assist human immunodeficiency virus (HIV)- patients, but neither concern should significantly alter infected patients in maintenance of oral health through- treatment planning in an otherwise healthy, asympto- out the course of their disease. matic, HIV-infected patient with a normal or near-normal The detection and diagnosis of oral lesions in HIV- CD4 count and a low viral bioload.21,29,36 It is important positive patients was described in Chapter 29. The clini- to obtain information regarding the patient's immune cal management of these conditions, with particular em- status. What is the CD4+ T4 lymphocyte level? What is phasis on periodontal conditions, is presented in this the current viral load? How do current CD4+ T4 cell and chapter. viral load counts differ from previous evaluations? How often are such tests performed? How long ago was the PERIODONTAL TREATMENT PROTOCOL HIV infection identified? Is it possible to identify the approximate date of original exposure? Is there a history of To safely and effectively provide periodontal therapy to drug abuse, sexually transmitted diseases, multiple infec- HIV-infected individuals, several treatment considerations, or other factors that might alter immune response? tions are important. For example, does the patient have a history of chronic 688

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hepatitis B, hepatitis C, neutropenia, thrombocytopenia, fluence the responsiveness of affected patients to dental nutritional deficiency, or adrenocorticoid insufficiency? treatment. However, psychologic factors are numerous in What medications is the patient taking? Does the patient virtually all HIV-infected patients, even in the absence of describe or present with possible adverse side effects from neuronal lesions. Patients may be greatly concerned with medications being taken? maintenance of medical confidentiality, and such confidentiality must be upheld. Coping with a life-threatening disease may elicit depression, anxiety, and anger in such Infection Control Measures patients, and this anger may be directed toward the den- Clinical management of HIV-infected periodontal pa- tist and the staff.' It is important to display concern and tients requires strict adherence to established methods of understanding for the patient's situation. Treatment infection control, based on guidance from the American should be provided in a calm, relaxed atmosphere, and Dental Association (ADA) and the Centers for Disease stress to the patient must be minimized.' Control and Prevention (CDC). 5 Compliance, especially The dentist should be prepared to advise and counsel with universal precautions, will eliminate or minimize patients on their oral health status. Dentists often en- risks to patients and the dental staff. 28-33 Immunocom- counter HIV-infected patients who are unaware of their promised patients are potentially at risk for acquiring as disease status. Early diagnosis and treatment of HIV in- well as transmitting infections in the dental office or fection can have a profound effect on the patient's life other health care facility.4.27,31,53 expectancy and quality of life, and the dentist should be prepared to assist the patient in obtaining testing. 41 Any patient with oral lesions suggestive of HIV infection Goals of Therapy should be informed of the findings and, if appropriate, A thorough oral examination will determine the pa- questioned regarding any previous exposure to HIV. If tient's dental treatment needs. The primary goals of den- HIV testing is requested, it must be accompanied by pa- tal therapy should be the restoration and maintenance tient counseling. For this reason, such tests might best of oral health, comfort, and function. At the very least, be obtained through medical referral. However, if the periodontal treatment goals should be directed toward dentist elects to request testing for HIV antibody, the pa- control of HIV-associated mucosal diseases such as tient must be informed. In most circumstances, written chronic candidiasis and recurrent oral ulcerations. Acute informed consent is desirable prior to testing. periodontal and dental infections should be managed, and the patient should receive detailed instructions in ORAL CANDIDIASIS performance of effective oral hygiene procedures.47 Con- servative, nonsurgical periodontal therapy should be a Early oral lesions of HIV-related candidiasis are usually treatment option for virtually all HIV-positive patients, responsive to topical antifungal therapy (Fig. 51-1). More and performance of elective surgical periodontal proce- advanced lesions, including hyperplastic candidiasis, may require systemic antifungal drugs; systemic therapy dures to include implant placement has been re- 42,51 ported. 15,30 Necrotizing ulcerative periodontitis (NUP) or is mandatory for esophageal candidiasis (Fig. 51-2). necrotizing ulcerative stomatitis (NUS) can be severely With any therapy, lesions tend to recur after the drug destructive to periodontal structures, but a history of is discontinued, and resistant strains of candidal organ- these conditions does not automatically dictate extrac- isms have been described, especially with the use of sys- tion of involved teeth unless the patient is unable to temic agents. 8,42,48,51 Box 51-1 identifies therapeutic maintain effective oral hygiene in affected areas. Deci- agents commonly prescribed for treatment of candidal sions regarding elective periodontal procedures should infections. Most oral topical antifungal agents contain be made with the informed consent of the patient and large quantities of sucrose, which may be cariogenic after after medical consultation, when possible. long-term use. For this reason, some authorities recommend oral use of vaginal tablets because they do not contain sucrose. However, such tablets are relatively low Supportive Periodontal Therapy in active units (100,000) versus usual oral dosages of It is imperative that the patient maintain meticulous 200,000 to 600,000 units. Sucrose-free nystatin is also personal oral hygiene. In addition, periodontal mainte- available in a powder form, which may be mixed extem- nance recall visits should be conducted at short intervals poraneously with water at each use (s tsp powder to (2 to 3 months) and any progressive periodontal disease 1/2 glass water). Recently, sucrose-free oral suspensions of treated vigorously. As mentioned earlier, however, sys- itraconazole and amphotericin B oral rinse have become temic antibiotic therapy should be administered with available. To date, no comparative studies have been per- caution. Blood and other medical laboratory tests may formed regarding the effectiveness of these products. be required to monitor the patient's overall health sta- Amphotericin B oral suspension is more effective against tus, and close consultation and coordination with the Candida albicans than other species. Patients should be patient's physician are necessary. instructed to rinse with the oral suspension for several minutes, then swallow.34 Fluconazole oral suspension has been reported to be more effective as an antifungal Psychologic Factors than liquid nystatin.35 Chlorhexidine and cetyl- HIV infection of neuronal cells may affect brain function pyridinium chloride oral rinses may also be of some and lead to outright dementia. This may profoundly in- prophylactic value against oral candidal infection. 10,14

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Fig. 51-1 Erythematous and pseudomembranous candidiasis. A, Before treatment. B, Resolution after 1 week of topical clotrimazole therapy.

Fig. 51-2 Marked hyperplastic candidiasis in corner of mouth. A, Before treatment. B, After 2 weeks of systemic fluconazole therapy.

Long-term prophylactic effectiveness of once-weekly sys- example, long-term use of ketoconazole may induce liver temic fluconazole also has been described. 10-42 damage in individuals with preexistent liver disease. The Systemic antifungal agents such as ketoconazole, flu- increased risk of chronic hepatitis B or hepatitis C infec- conazole, itraconazole and amphotericin B are effective tion in immunosuppressed individuals may put some pain treatment of oral candidiasis (see Box 51-1). Ketocona- tients at risk for ketoconazole-induced liver damage. If zole may be the agent of choice when systemic therapy ketoconazole is prescribed, patients should receive liver is required.'," As mentioned before, however, resistant function tests at baseline and at least monthly during strains of candidal organisms may develop with pro- therapy. The drug is contraindicated if the patient's as- longed use of any systemic agent, potentially rendering partate transaminase (AST) level is greater than 2.5 times the drugs ineffective against life-threatening candidal in- normal." Ketoconazole absorption also may be ham- fections in the later stages of immune suppression.' In pered by the gastropathy experienced by many HIV- addition, significant adverse side effects may occur. As an infected individuals .2s Periodontal Management o f HIV-Infected Patients • CHAPTER 51 691 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Commonly Prescribed Antifungal Therapeutic Agents for Oral Candidiasis

Fig. 51-3 Oral hairy leukoplakia of 2 years' duration. A, Before treatment. B, Unexpected remission after initiation of zidovudine therapy.

ORAL HAIRY LEUKOPLAKIA Clinical impressions suggest that the incidence of At present, there appears to be little advantage in treat- OHL has been markedly reduced since the advent of ing oral hairy leukoplakia (OHL) in most patients. Le- multidrug antiviral therapy for HIV infection. sions can be successfully removed, however, with laser or conventional surgery. Resolution has been reported KAPOSI'S SARCOMA after therapy with zidovudine (Fig. 51-3) or topical retinoids, but systemic antiviral agents such as acyclovir Although Kaposi's sarcoma (KS) has been the most com- may elicit remission more predictably (Fig. 51-4), mon tumor encountered in HIV-positive individuals, its although lesions reappear when antiviral therapy is incidence may be markedly decreasing since the advent discontinued. 2,38,40 of multidrug antiviral therapy. 49 Treatment of oral KS may 692 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 51-4 Oral hairy leukoplakia of left buccal mucosa. A, Before treatment. B, Remission after initiation of systemic acyclovir therapy.

Fig. 51-5 Kaposi's sarcoma of maxillary anterior region. A, Anterior facial gingiva before treatment. B, Palate before treatment. C, Partial resolution of facial gingival lesion after two vinblastine injections. D, Partial resolution of palatal lesion. Patient was satisfied with results and declined additional therapy.

include use of antiretroviral agents, laser excision, radia- peated at 2-week intervals until resolution or stabilization tion therapy, or intralesional injection with vinblastine of the lesions. Side effects included some posttreatment (Fig. 51-5), interferon a, or other chemotherapeutic pain and occasional ulceration of the lesions, but in gen- drugs. 11,12,13,40,43,49 Nichols et a132 described the successful eral the therapy was well tolerated. Total resolution was use of intralesional injections of vinblastine at a dosage of achieved in 70% of 82 intraoral KS lesions with one to 0.1 mg/cm2 using a 0.2 mg/ml solution of vinblastine sul- six treatments. Lesions tended to recur, however, thus fate in saline. In responsive patients, treatment was re- indicating that treatment probably should be reserved for

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Fig. 51-6 Major aphthae of soft palate in a 28-year-old HIV-positive man. A, Before treatment. B, Remis- sion of lesion 1 week after prescribing topical corticosteroids.

oral KS lesions that are easily traumatized or interfere with On occasion, large aphthae in HIV-positive individu- chewing or swallowing. On some occasions, treatment als may prove resistant to conventional topical therapy. may be indicated when KS lesions create an unsightly ap- In this event, systemic corticosteroids (prednisone 40 pearance on the lips or in the anterior oral cavity. to 60 mg daily) (Fig. 51-7) or alternative therapy Destructive periodontitis has also been reported in (thalidomide, levamisole, pentoxifylline, or others) must conjunction with gingival KS. In such instances, scaling be considered . 6,17,19,24,45 and root planing and other periodontal therapy may These agents may have significant side effects, however, be indicated in addition to intralesional or systemic and the clinician should remain alert for any evidence sug- chemotherapy. 43,48 gestive of an adverse drug reaction or adverse interaction with currently prescribed medications .22 It should be noted that virtually all antiviral agents used in treatment BACILLARY (EPITHELIOID) ANGIOMATOSIS of HIV infection have the potential for adverse side effects Treatment of bacillary angiomatosis consists of broad- or drug interactions. For these reasons, the dental clinician spectrum antibiotics such as erythromycin or doxycy- should consider topical therapy as long as it is effective. cline in conjunction with conservative periodontal therapy and possibly excision of the lesion. 16,18,30 PERIODONTAL DISEASE IN HIV-POSITIVE INDIVIDUALS NONSPECIFIC ORAL ULCERATIONS AND As described in Chapter 29, gingival and periodontal RECURRENT APHTHAE manifestations may be found in HIV-positive individu- Recent evidence indicates that many nonspecific oral als. The former include linear gingival erythema and ulcerations may be of viral origin with herpes simplex, necrotizing ulcerative gingivitis (NUG), both of which Epstein-Barr virus, and cytomegalovirus being most com- may develop into rapidly progressive necrotizing ulcera- mon." For this reason, the practitioner should consider tive stomatitis (NUS) or necrotizing ulcerative periodon- viral culturing of such lesions and the use of antiviral titis (NUP). 9 Management of these conditions should be agents in treatment where appropriate. preceded by a thorough medical evaluation, including Oral viral infections in immunocompromised individ- determination of the CD4 and viral load status, in con- uals are often treated with acyclovir (200 to 800 mg ad- sultation with the treating physician. ministered five times daily for at least 10 days). Subse- quent daily maintenance therapy (200 mg two to five Linear Gingival Erythema times daily) may be required to prevent recurrence. Re- sistant viral strains are treated with foscarnet, ganci- LGE is often refractory to treatment, but lesions may clovir, or valacyclovir hydrochloride. 48,50 undergo spontaneous remission. Recent evidence suggests Topical corticosteroid therapy (fluocinonide gel ap- that LGE may result from a chronic infection with C. al- plied three to six times daily) is safe and efficacious for bicans or other candidal strains .52 The recommended treatment of recurrent aphthous ulcer or other mucosal management of this condition is as follows: lesions in immunocompromised individuals (Fig. 51- 6). However, topical corticosteroids may predispose im- Step 1: Instruct the patient in performance of meticulous munocompromised individuals to candidiasis. Conse- oral hygiene. quently, prophylactic antifungal medications should be Step 2: Scale and polish affected areas, and perform sub- prescribed. gingival irrigation with chlorhexidine.

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Fig. 51-7 Persistent ulceration of soft palate. A, Lesion was refractory to topical corticosteroids. B, Healing after 1 week of systemic corticosteroid therapy (40 mg prednisone daily).

Step 3: Prescribe chlorhexidine gluconate mouthrinse. Necrotizing Ulcerative Stomatitis Step 4: Reevaluate the patient in 2 to 3 weeks. If lesions NUS may be severely destructive and acutely painful. It persist, evaluate for possible candidiasis. Consider em- is characterized by necrosis of significant areas of oral piric administration of a systemic antifungal agent soft tissue and underlying bone. It may occur separately such as fluconazole for 7 to 10 days. or as an extension of NUP9 and is commonly associ- Step 5: Re-treat if necessary. ated with severe depression of CD4+ immune cells and Step 6: Place the patient on 2- to 3-month recall. an increased viral load. Treatment may include prescription of an antibiotic Necrotizing Ulcerative Gingivitis such as metronidazole and use of an antimicrobial mouthrinse such as chlorhexidine gluconate. If osseous There is no consensus on whether the incidence of NUG necrosis is present, it is often necessary to remove the af- increases in HIV-positive patients.23 The treatment of fected bone to promote wound healing. this condition in these individuals does not differ from that in HIV-negative individuals (see Chapter 45). Basic treatment may consist of cleaning and debridement of Necrotizing Ulcerative Periodontitis affected areas with a cotton pellet soaked in peroxide af- Therapy for NUP includes local debridement, scaling and ter application of a topical anesthetic. Escharotic oral root planing, in-office irrigation with an effective antimi- rinses such as hydrogen peroxide should only rarely be crobial agent such as chlorhexidine gluconate or povi- used, however, for any patient and are especially con- done iodine (Betadine), and establishment of meticulous traindicated in immunocompromised individuals. The oral hygiene, including home use of antimicrobial rinses patient should be seen daily or every other day for the or irrigation20,26,39.s4 (Color Fig. 51-1 and Fig. 51-8). first week; debridement of affected areas is repeated at This therapeutic approach is based on reports involv- each visit, and plaque control methods are gradually in- ing only a small number of patients.39 In severe NUP, an- troduced. A meticulous plaque control program should tibiotic therapy may be necessary but should be used be taught and started as soon as the sensitivity of the with caution in HIV-infected patients to avoid an oppor- area allows it. tunistic and potentially serious localized candidiasis The patient should avoid tobacco, alcohol, and condi- or even candidal septicemia.' If an antibiotic is necessary, ments. An antimicrobial mouthrinse such as chlorhexi- metronidazole (250 mg, with two tablets taken immedi- dine gluconate 0.12% is prescribed. ately and then one tablet qid for 5 to 7 days) is the drug Systemic antibiotics such as metronidazole or amoxi- of choice. Prophylactic prescription of a topical or sys- cillin may be prescribed for patients with moderate to se- temic antifungal agent is prudent if an antibiotic is used. vere tissue destruction, localized lymphadenopathy or Conventional periodontitis should be managed based systemic symptoms, or both. The use of prophylactic an- on the considerations outlined in "Periodontal Treat- tifungal medication should be considered if antibiotics ment Protocol." are prescribed. The periodontium should be reevaluated 1 month REFERENCES after resolution of acute symptoms to assess the results of treatment and determine the need for further 1. Asher RS, McDowell JD, Winquist H: HIV-related neuropsy- therapy. chiatric changes: Concerns for dental professionals. J Am Dent Assoc 1993; 124:80. Periodontal Management of HIV-Infected Patients • CHAPTER 51 695

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Fig. 51-8 Localized necrotizing ulcerative periodontitis in a 43-year-old HIV-positive man. A, Facial view. B, Lingual view. C, Radiographic view of the mandibular anterior. D, Resolution 48 hours after initiation of periodontal therapy. Facial view. E, Resolution. Lingual view.

2. Brockmeyer NH, Kreugfelder E, Martins L, et al: Zidovudine 7. Clerici M, Piconi S, Balotta C, et al: Pentoxifylline improves therapy of asymptomatic HIV-1-infected patients and com- cell-mediated immunity and reduces human immunodefi- bined Zidovudine-acyclovir therapy of HIV-1-infected pa- ciency virus (HIV) plasma viremia in asymptomatic HIV- tients with oral hairy leukoplakia. J Infect Dermatol 1989; seropositive persons. J Infect Dis 1997; 175:1210. 92:647. 8. Dis Dios P, Hermida AO, Alvarez CM, et al: Fluconazole-re- 3. Casado JL, Quereda C, Oliva J, et al: Candidal meningitis in sistant oral candidosis in HIV-infected patients. AIDS 1995; HIV-infected patients: Analysis of 14 cases. Clin Infect Dis 9:809. 1997; 25:673. 9. European Community Clearinghouse on Oral Problems Re- 4. Centers for Disease Control: Case-control study of HIV sero- lated to HIV Infection and WHO Collaborating Centre on conversion in health-care workers after percutaneous expo- Oral Manifestations of the Immunodeficiency Virus: Classi- sure to HIV-infected blood-France, United Kingdom and fication and diagnostic criteria for oral lesions in HIV infec- United States. January 1988-August 1994. MMWR 1995; tion. J Oral Pathol Med 1993; 22:289. 44:929. Epstein JB: Antifungal therapy in oropharyngeal mycotic in- 5. Centers for Disease Control: Recommended infection-con- fections. Oral Surg Oral Med Oral Pathol 1990; 69:32. trol practices for dentistry, 1993. MMWR 1993; 42(RR-8):1. Epstein JB, Lozada-Nur F, McLeod A, et al: Oral Kaposi's sar- 6. Chandrasekhar J, Liem AA, Cox NH, et al: Oxypentifylline coma in acquired immunodeficiency syndrome: Review of in the management of recurrent aphthous oral ulcers. Oral management and report of the efficacy of intralesional vin- Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 87:564. blastine. Cancer 1989; 64:2424.

696 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com 12. Epstein JB, Scully C: HIV infection: Clinical features and 34. Pons V, Greenspan D, Lozada-Nur F, et al: Oropharyngeal treatment of 33 homosexual men with Kaposi's sarcoma. candidiasis in patients with AIDS: Randomized comparison Oral Med Oral Surg Oral Pathol 1991; 71:38. of fluconazole versus nystatin oral suspensions. Clin Infect 13. Ficarra G, Berson AM, Silverman S Jr, et al: Kaposi's sarcoma Dis 1997; 24:1204. of the oral cavity: A study of 134 patients with a review of 35. Physicians Desk Reference: Fungisone oral suspension. the pathogenesis, epidemiology, clinical aspects and treat- Health Care Series 1998; 97:1. ment. Oral Sung Oral Med Oral Pathol 1988; 66:543. 36. Porter SR, Scully C, Luker J: Complications of dental surgery 14. Giuliana G, Pizzo G, Milici ME, et al: In vitro activities of in persons with HIV disease. Oral Surg Oral Med Oral Pathol antimicrobial agents against Candida species. Oral Surg Oral 1993; 75:165. Med Oral Pathol Oral Radiol Endod 1999; 87:44. 37. Regezi JA, Eversole LR, Barker BF, et al: Herpes simplex and 15. Glick M: Clinical protocol for treating patients with HIV cytomegalovirus coinfected oral ulcers in HIV-positive pa- disease. Gen Dent 1990; 38:418. tients. Oral Sung Oral Med Oral Pathol Oral Radiol Endod 16. Glick M, Cleveland DB: Oral mucosal bacillary epitheloid 1996; 81:55. angiomatosis in a patient with AIDS associated with rapid 38. Reichart PA, Langford A, Gelderblom HR, et al: Oral hairy alveolar bone loss: A case report. J Oral Pathol Med 1993; leukoplakia: Observations in 95 cases and review of the lit- 22:235. erature. J Oral Pathol Med 1989; 18:410. 17. Glick M, Muzyka BC: Alternative therapies for major aph- 39. Robinson P: Periodontal diseases and HIV infection. J Clin thous ulcers in AIDS patients. J Am Dent Assoc 1992; 123:61. Periodontol 1992; 19:609. 18. Glick M, Holmstrop P: HIV infection and periodontal dis- 40. Saiag P, Pavlovic M, Clerici T, et al: Treatment of early AIDS- eases. Periodontal Medicine. In: Genco R, Mealey B, Rose L related Kaposi's sarcoma with oral all-trans-retinoic acid: Re- (eds): Hamilton, Canada, 2000, Decker. sults of a sequential non-randomized phase II trial. AIDS 19. Gorin I, Vilette B, Gehanno P, et al:. Thalidomide in hyper- 1998; 12:2169. algic pharyngeal ulceration of AIDS. Lancet 1990; 335:1343. 41. Schulman DJ: The dentist, HIV and the law. CDA J 1993; 20. Grassi M, Williams CA, Winkler JR, et al: Management of 21(9):45. HIV-associated periodontal diseases. In: Robertson PB, 42. Schuman P, Capps L, Peng G, et al: Weekly fluconazole for Greenspan JS (eds): Oral Manifestations of AIDS. Littleton, the prevention of mucosal candidiasis in women with HIV MA, PSG, 1988. infection. Ann Int Med 1997; 126:689. 21. Hammer SM: Advances in antiretroviral therapy and viral 43. Shibosky CH, Winkler JR: Gingival Kaposi's sarcoma and pe- load monitoring. AIDS 1996; 10(Suppl 3):Sl. riodontitis. Oral Med Oral Surg Oral Pathol 1991; 76:38. 22. Haslett P, Tramontana J, Burroughs M, et al: Adverse reac- 44. Shibosky CH, Winkler JR: Gingival Kaposi's sarcoma and pe- tions to thalidomide in patients infected with human im- riodontitis. Oral Surg Oral Med Oral Pathol 1993; 76:49. munodeficiency virus. Clin Infect Dis 1997; 24:1223. 45. Silverman S: Color Atlas of Oral Manifestations of AIDS. 23. Horning GM, Cohen ME: Necrotizing ulcerative gingivitis, Toronto, Decker, 1989. periodontitis and stomatitis: Clinical staging and predispos- 46. Silverman S Jr, Gallo JW, McKnight ML, et al: Clinical char- ing factors. J Periodontol 1995; 66:990. acteristics and management responses in 85 HIV-infected 24. Jacobson JM, Greenspan JS, Spritzler J, et al: Thalidomide patients with oral candidiasis. Oral Surg Oral Med Oral for the treatment of oral aphthous ulcers in patients with Pathol Oral Radiol Endod 1996; 82:402. human immunodeficiency virus infection. N Engl J Med 47. Stevenson GC: Removable prosthodontics and the HIV-in- 1997; 336:1487. fected patient: Assessment and treatment planning. Dental 25. Lake-Bakaar G, Tom W, Lake-Bakaar D, et al: Gastropathy Alliance AIDS/HIV Care 1996; 3(1):8. and ketoconazole malabsorption in the acquired immunod- 48. Tavitian A, Raufman JP, Rosenthal LE, et al: Ketoconazole- eficiency syndrome (AIDS). Ann Intern Med 1988; 109:471. resistant candida esophagitis in patients with acquired im- 26. Levine RA, Glick M: Rapidly progressive periodontitis as an mune deficiency syndrome. Gastroenterology 1986; 90:443. important clinical marker for HIV disease. Compend Contin 49. Tomlinson DR, Coker RJ, Fisher M: Management and treat- Educ Dent 1991; XII(7):478. ment of Kaposi's sarcoma in AIDS. Int J STD AIDS 1996; 27. Lot F, Seguier J-C, Fegueux S, et al: Probably transmission of 7:466. HIV from an orthopedic surgeon to a patient in France. Ann 50. United States Pharmacopeial Convention Inc: Drug infor- Intern Med 1999; 130:1. mation for the health care professional, ed 19. World Color 28. Mandel ID: Occupational risks in dentistry: Comforts and Book Services, Taunton. 1999. concerns. J Am Dent Assoc 1993; 124:41. 51. Ustianowski AP, Leake H, Evans S: Outpatient therapy of 29. Margiotta V, Campisi G, Mancuso S, et al: HIV infection: HIV-associated oral and oesophageal candidosis. Int J STD Oral lesions, CD4+ cell count and viral load in an Italian AIDS 1997; 8:592. study population. J Oral Pathol Med 1999; 28:173. 52. Velegraki A, Nicolatou O, Theodoridou M, et al: Pediatric 30. Mealey BL: Periodontal implications: Medically compro- AIDS-related linear gingival erythema: A form of erythema- mised patients. Ann Periodontol 1996; 1:256. tous candidiasis? J Oral Pathol Med 1999; 28:178. 31. Molinari JA: HIV, health care workers and patients: How to 53. Verrusio AC: Risk of transmission of the human immuno- ensure safety in the dental office. J Am Dent Assoc 1993; deficiency virus to health care workers exposed to HIV- 124:51. infected patients: A review. J Am Dent Assoc 1989; 118:339. 32. Nichols CM, Flaitz CM, Hicks MJ: Treating Kaposi's lesions 54. Winkler JR, Murray PA, Grassi M, et al: Diagnosis and man- in the HIV-infected patient. J Am Dent Assoc 1993; 124:78. agement of HIV-associated periodontal lesions. J Am Dent 33. Olsen RJ, Lynch P, Coyle MB, et al: Examination gloves as Assoc 1989; 120(suppl):S25. barriers to hand contamination in clinical practice. JAMA 55. Winkler JR, Murray PA, Hammerle C: Gangrenous stomatitis 1993; 270(3):350. in AIDS. Lancet 1989; 2(8454):108. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Occlusal Evaluation and Therapy in the Management of Periodontal Disease

Carol A. Bibb CHAPTER

CHAPTER OUTLINE

TERMINOLOGY INTERPRETATION AND TREATMENT PLANNING FUNCTIONAL ANATOMY OF THE TMD Screening MASTICATORY SYSTEM Occlusal Evaluation BIOLOGIC BASIS OF OCCLUSAL FUNCTION OCCLUSAL THERAPY CLINICAL EVALUATION PROCEDURES Occlusal Adjustment TMD Screening Examination I nterocclusal Appliance Therapy Intraoral Evaluation of Occlusion SUMMARY Role of Articulated Casts

n understanding of the principles of occlusion Contemporary definitions of occlusion reflect the im- and the relationship to oral health and disease portance of structure-function relationships in biologic is necessary for all dental clinicians. Unfortu- systems. For example, McNei11 29 defines occlusion as the nately, no other discipline in dentistry has been functional relationship between the components of the so complicated by confusion and controversy. Histori- masticatory system, including the teeth, supporting tis- cally, occlusal relationships have been considered largely sues, neuromuscular system, temporomandibular joints, from a morphologic rather than a biologic perspective. and craniofacial skeleton. An important corollary of this This approach has led to an overemphasis on occlusal definition is that the occlusion is a dynamic relationship scheme and jaw position without adequate considera- and must be defined physiologically as well as morpho- tion of the functional status of the patient's entire masti- logically. The clinical application of this definition is catory system. that the occlusion cannot be evaluated or treated in iso- The current resurgence of interest in occlusion18.19,27 lation. Instead, each component of the masticatory sys- coincides with the Institute of Medicine's recommenda- tem must be fully understood along with its potential for tion that the dental profession make use of scientific evi- adaptation and pathophysiology as well as interactions dence, outcomes research, and formal consensus processes with the other components. This chapter presents a bio- when devising practice guidelines. 12 As a result, we now logic rationale and practical guidelines for evaluating jaw have the opportunity and responsibility to move away function status and occlusion in the context of the man- from practice based on empiric experience toward prac- agement of periodontal disease. tice based on scientific evidence. Application of this approach to the field of occlusion has already begun to TERMINOLOGY have, and is expected to continue to have, a significant impact on clinical practice and an improved standard of The complexity surrounding occlusal concepts has been patient care, including for those patients undergoing pe- compounded by an abundance of heterogeneous termi- riodontal therapy. 14,19,20 nology requiring definition and clarification. The key

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FUNCTIONAL ANATOMY OF THE MASTICATORY SYSTEM An understanding of the biologic basis of occlusal function requires that the teeth, temporomandibular joints (TMJs), and muscles of mastication be considered as a functional unit (Fig. 52-1). These structures developed together during embryogenesis and postnatal growth, and perturbations to one component in the system would be expected to influence other components to undergo either adaptive or pathologic changes. Therefore the clinician must recognize that it is inappropriate to consider any component in isolation and instead must include all components of the system and their functional interactions as part of any evaluation.

BI OLOGIC BASIS O F OCCLUSAL FUNCTION Fig. 52-1 Functional anatomy of the masticatory system shown in sagittal view: the temporomandibular joint (circled), the masseter The ideal occlusal relationships depicted in textbook dia- and temporalis muscles, and the dental occlusion in ICP. grams and on typodont models have served as the primary focus of traditional dental education. In reality, such ideal tooth contact relationships are uncommon in natural dentitions,2,17,22,35,43 and a variety of occlusal schemes, including chronic excursive interferences,1,32,33,42 are clinically acceptable. In addition, it is now recognized that the occlusion is terms used in this chapter, along with common syn- a dynamic relationship reflecting an equilibrium between onyms, are defined as follows: the various components of the masticatory system . 29 Intercuspal position (ICP): The position of the man- Therefore the functional status of an individual's occlu- dible when there is maximal intercuspation between sion is more clinically significant than its morphology. the maxillary and mandibular teeth. Synonym: centric A widely accepted physiologic classification of occlu- occlusion. sion is as follows: Muscular contact position (MCP): The position of A physiologic occlusion is present when no signs of the mandible when lifted into contact from resting dysfunction or disease are present and no treatment is position. indicated. Excursive movement: Any movement of the man- A nonphysiologic (or traumatic) occlusion is asso- dible away from ICP. ciated with dysfunction or disease due to tissue injury, Laterotrusion: Movement of the mandible laterally and treatment may be indicated. In this text, the term to the right or left from ICP. Synonym: working trauma from occlusion is applied to periodontal tissue movement. injury due to occlusal forces. Laterotrusive side: The side of either dental arch cor- A therapeutic occlusion is the result of specific inter- responding to the side of the mandible moving away ventions designed to treat dysfunction or disease. from the midline. Synonym: working side. Mediotrusive side: The side of either dental arch cor- Maintenance of a physiologic occlusion requires fa- responding to the side of the mandible moving to- vorable structure-function relationships and optimal tis- ward the midline. Synonym: balancing side, nonwork- sue adaptation throughout the masticatory system. The ing side. anatomic features that contribute to a physiologic occlu- Protrusion: Movement of the mandible anteriorly sion and should be the goal in a therapeutic occlusion29 from ICP. include a stable end-point of mandibular closure, bilat- Retrusion: Movement of the mandible posteriorly from eral distribution of occlusal forces across many posterior ICP teeth, and axial loading of these teeth. When occlusal Retruded position: The most cranial position of the forces are distributed optimally, the occlusion will be sta- mandible along the retruded path of closure. Syn- ble by objective criteria and is likely to be subjectively onym: centric relation. comfortable for the patient. Guidance: Pattern of opposing tooth contact during ex- The signs and symptoms of a nonphysiologic occlu- cursive movements of the mandible. The teeth mak- sion include damaged teeth and restorations, abnormal ing such contact cause separation of the other teeth. mobility, fremitus, a widened periodontal ligament, Synonym: disclusion. pain, and a subjective sense of bite discomfort. As em- Interference: Any contact, in ICP or excursions, that phasized in Chapter 24, the criterion that determines prevents the remaining occlusal surfaces from achiev- whether an occlusion is traumatic is whether it produces peri- ing stable contact. Synonym: supracontact. odontal injury, not how the teeth occlude. Alternatively, many Occlusal Evaluation and Therapy in the Management o fPeriodontal Disease • CHAPTER 52 699 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com so-called malocclusions do not produce discomfort or injury and therefore are not traumatic occlusions by definition. Adverse tooth loading due to increased force or fre- TMD Screening Evaluation quency can result from many factors. One cause is missing or shifting teeth, leading to alterations in arch form 1. Maximal interincisal opening and alignment. This situation is frequently seen in pa- 2. Opening-closing pathway tients who have lost teeth due to untreated periodontal 3. Auscultation for TMJ sounds disease. In general, occlusal changes that occur gradually 4. Palpation for TMJ tenderness are more likely to give the tissue time to adapt, whereas 5. Palpation for muscle tenderness acute occlusal changes, including iatrogenic changes introduced by faulty restorative dentistry, are more likely to produce injury. Parafunctional habits such as bruxism are another potential cause of occlusal trauma. Bruxism is defined as di- urnal or nocturnal parafunctional activity including clenching, bracing, gnashing, and grinding of the teeth. approximately 5 minutes. The generally accepted compo- Although there is no association between bruxism and nents of this examination26 are shown in Box 52-1. bruxism def- gingival inflammation 7 or periodontitis,15,16 Interincisal opening. The patient is instructed to "open as initely has the potential to cause tooth wear, fracture, wide as possible" while a millimeter ruler is placed and periodontal and muscle pain and is a major cause of on the lower incisors. The interincisal distance is mobility." There is no significant evidence that maloc- recorded in millimeters (mm). clusions or interferences are causal factors in bruxism, 9 Opening pathway: The opening/closing pathway is ob- and occlusal adjustment has not proven to be an effec- served, and any deviations from a midline path are 3.21 tive means of treatment. Instead, the maxillary stabi- diagrammed. lization appliance is generally considered the most effec- TMJ sounds: Light finger pressure is applied bilaterally tive means of managing bruxism. 6 over the TMJs while the patient is asked to open and Chapter 24 provides a detailed description of the re- close. Joint sounds are classified as discrete clicks or sponse of the periodontium to occlusal forces and dis- diffuse grating sounds, termed crepitus. The location cusses the relationship of trauma from occlusion to the of the sound in the opening/closing cycle and any etiology and progression of periodontal disease. The liter- associated pain or mechanical disruption should be ature on this topic includes numerous experimental ani documented. mal model studies 10,11,23-25,30,31,39,43 in which the challenge TMJ tenderness: Light bilateral palpation over the lateral is to make clinically relevant extrapolations to human aspect of the condyles is used to elicit TMJ tenderness periodontal disease. The current consensus is that trauma if present. It should be recorded as mild, moderate, or from occlusion has the potential to alter disease severity severe. The patient should be asked to compare right and prognosis. However, the therapeutic priority is to and left sides for calibration purposes. control inflammation, and this must be successful for Muscle tenderness: The masseter (origin and insertion) healing of the periodontal tissues to occur. 14,30,31,36,37,43 and temporalis (anterior and middle) muscles are ex- Therefore it is recommended that occlusal interven- amined bilaterally using moderate finger pressure. tions be deferred until inflammation is controlled and Sites of muscle pain should be localized and described reevaluation determines that any residual mobility is as mild, moderate, and severe on an appropriate the result of adverse tooth loading rather than decreased anatomic diagram. The most common error is to ap- support .13,19,20 ply insufficient pressure, so the patient should be advised to expect some discomfort and instructed to dif- CLINICAL EVALUATION PROCEDURES ferentiate pressure from pain. It is also helpful to ask the patient to compare right and left sides for calibra- The current standard of care requires that a screening tion purposes. evaluation for temporomandibular disorders (TMD) be included in all routine dental examinations . 26 This screening should occur early in the physical evaluation Intraoral Evaluation of Occlusion of the patient to ensure that subsequent examination In addition to collecting standard data on static occlusal and treatment procedures will not have an adverse im- relationships, a functional evaluation of the occlusion pact on preexisting TMDs. In addition, a valid examina- (Box 52-2) should be carried out. This includes an assess- tion of the occlusion requires that the patient's jaw func- ment of ICP stability, the quality of mandibular move- tion status be within normal limits. ments, and tooth mobility and wear.

Intercuspal position: The patient should be able to close TMD Screening Examination into ICP consistently from MCP without searching for The recommended screening examination includes a stable or comfortable bite. The most efficient way to health history questions focused on jaw function status, a locate zones of ICP contact is to place mylar strips be- brief history, and a cursory examination expected to take tween the teeth and ask the patient to "close and

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Intraoral Occlusal Evaluation Requirements for Occlusal Stability

1. Identification of ICP zones of contact Intercuspal position 2. Guidance in excursive movements • Light or absent anterior contacts 3. Tooth mobility • Well-distributed posterior contacts 4. Attrition • Coupled contacts between opposing teeth • Cross tooth stabilization • Forces directed along long axis of each tooth 2. Smooth excursive movements without interferences 3. No trauma from occlusion hold." The presence or absence of contacts should be 4. Favorable subjective response to occlusal form and documented for the molars, premolars, canines, and function incisors. More detailed information on the specific sites of ICP contacts can be obtained by using occlusal indicator wax or marking ribbon. Excursive movements: The quality of tooth contact patterns during mandibular movements out of ICP are no significant joint or muscle tenderness, and mini- observed by asking the patient to move into protru- mal joint sounds. sion and right and left laterotrusion. Mylar strips are 2. Certain findings should alert the clinician to the po- useful for verifying tooth contact patterns during ex- tential for aggravating benign problems, especially cursions. with wide opening during long appointments. Exam- Tooth mobility: Mobility is recorded as part of the initial ples include a history of jaw problems after long ap- occlusal evaluation and to monitor any changes over pointments, several sites of mild to moderate muscle time. (See Chapter 30 for additional details.) tenderness, or a previously benign TMJ click. In these Attrition: Attrition is defined as wear due to tooth-to- cases the patients should be advised of the need to tooth contact. A certain amount of physiologic attri- notify the clinician if symptoms develop or progress. tion is normal. However, accelerated attrition should Use of a bite block, shortened appointments, and be noted, including the location of significant wear longer intervals between appointments may also be facets. indicated. 3. Significant findings indicate the need for a more comprehensive evaluation or referral prior to any non- Role of Articulated Casts emergency treatment. Examples include a restricted Articulated dental casts are not necessary for a functional interincisal opening, significant pain on jaw use, se- evaluation of the occlusion. In specific cases, they may vere joint or muscle pain, and progressive locking be required for pretreatment documentation of occlusal episodes, such as after wide opening. It should be ob- relationships, localization of wear facets, trial occlusal vious that continuing with nonemergency treatment adjustments, and monitoring of the progression of oc- would be difficult and likely to exacerbate these prob- clusal changes. lems. Furthermore, evaluation of the occlusion will not be valid unless the patient's jaw function status is INTERPRETATION AND determined to be within normal limits. TREATMENT PLANNING It is important to emphasize that the prevalence of TMD signs and symptoms in adult subjects ranges from TMD Screening 28% to 86% in various studies,40 but it has been esti- The goal of the TMD screening examination is to deter- mated that only 5% to 7% are in need of TMD treat- mine whether jaw function status is sufficiently within ment. 41 In triaging patients as described previously, the normal range to permit examination procedures and significant pain or dysfunction and progression of symp- treatment to proceed without provoking or exacerbating toms are the key determinants. Furthermore, clinicians symptoms. Therefore the clinical significance of the find- treating older adults should be aware that a high preva- ings will be considered in this context. lence of crepitus and jaw opening of less than 40 mm A suggested practical approach is to use the screening has been reported in older individuals compared with examination findings to place the patient in one of the young adults . 4 These signs were not associated with pain following three categories: or disability and do not contraindicate treatment . 4 How- ever, they may have an impact on providing dental care 1. The jaw function status is determined to be within to this age group. normal limits; there are no contraindications to proceeding with further examination and treatment procedures. A patient in this category will have no Occlusal Evaluation complaints or significant history of jaw pain or dys- The findings from the occlusal examination should be function, an interincisal opening of at least 40 mm, reviewed in the context of the definitions of physiologic Occlusal Evaluation and Therapy in the Management o f Periodontal Disease • CHAPTER 52 701

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Fig. 52-2 A, Sites of ICP contact on supporting cusps (solid circles) and corresponding vertical stops (open circles). Cross tooth stabilization is shown on proximal (B) and occlusal views (C). Note the direction of occlusal forces along the long axis of the teeth shown in B.

and nonphysiologic occlusions. The most significant Occlusal Adjustment concern is whether the occlusion meets the require- Occlusal adjustment, or coronoplasty, is the selective re- ments for occlusal stability (Box 52-3). Specific require- shaping of occlusal surfaces with the goal of establishing ments for stability of posterior teeth in ICP are illus- a stable, nontraumatic occlusion. The resulting occlusion trated in Fig. 52-2. should meet the requirements for occlusal stability described previously and would be termed a therapeutic occlusion. Many categories of occlusal adjustment exist, OCCLUSAL THERAPY ranging from the altering of contours of a single tooth to The purpose of occlusal therapy is to establish stable major full mouth equilibration to the retruded position. functional relationships favorable to the oral health of Occlusal adjustment procedures have been used ex- the patient, including the periodontium. A variety of tensively in the past for treating a variety of problems in- procedures could contribute to this objective: interoc- cluding occlusal trauma, TMD symptoms, bruxism, and clusal appliance therapy, occlusal adjustment, restorative headache. However, occlusal adjustment is an invasive, procedures, orthodontic tooth movement, and ortho- irreversible intervention. Therefore in the current cli- gnathic surgery. mate of evidence-based practice, the prudent clinician is Some overall guidelines apply to occlusal therapy in encouraged to question the scientific evidence in sup- general. First, there should be a sound biologic rationale port of such therapy. Specifically, does the evidence sup- for the intervention. Second, occlusal interventions port a causal relationship between occlusal factors and should be considered an adjunct to periodontal therapy. the condition being treated? What is the evidence that Third, significant irreversible occlusal changes should be occlusal adjustment is therapeutically beneficial for the considered in the context of the restorative care planned condition being treated? for the patient. Finally, it is imperative that a thorough, In the case of TMD, the evidence leads to the conclu- informed consent be provided to the patient. With re- sion that occlusal adjustment as an irreversible treat- spect to periodontal management, it is critical that the ment modality should rarely be considered as a primary patient understand that the goal of the occlusal inter- component of TMD treatment and never as a preventive vention is to increase stability and comfort, not to treat measure.26 Similarly, there is no evidence that occlusal the periodontal disease. adjustment is useful in the management of bruxism. The contributions of restorative dentistry and ortho- The role of occlusal adjustment in the management of dontic tooth movement to the management of the peri- periodontal disease is more complex because both periodontal patient are covered elsewhere in this book. There- odontitis and trauma from occlusion can lead to tooth fore the role of occlusal adjustment and interocclusal mobility. In one randomized clinical trial with a two-year appliance therapy is the primary focus of this discussion. follow-up, it was concluded that occlusal adjustment

702 PART 5 • Treatment of Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com resulted in a more favorable attachment level but no dif- 2. Anderson JR, Myers GE: Natural contacts in centric occlu- ferences in reduction of mobility or pocket depth. sion in 32 adults. J Dent Res 1971; 50:7. Clearly, additional well-designed outcome studies de- 3. Bailey JO Jr, Rugh JD: Effect of occlusal adjustment on brux- signed to evaluate the effects of occlusal adjustment on ism as monitored by nocturnal EMG recordings. Abstract healing after periodontal therapy are needed. These stud- 199. J Dent Res 1980; 59:317. 4. ies should include variables such as timing of the oc- Bibb CA, Atchison KA, Pullinger AG, et al: Jaw function status in an elderly community sample. Community Dent Oral clusal intervention in the therapeutic sequence, the re- Epidemiol 1995; 23:303. sponse of individual teeth rather than dentitions, and 5. Burgett FG, Ramfjord SP, Nissle RR, et al: A randomized trial long term follow-up. of occlusal adjustment in the treatment of periodontitis pa- Until these issues are resolved, it is recommended that tients. J Clin Periodontol 1992; 19:381. occlusal adjustment generally be deferred until inflam- 6. Clark GT. Interocclusal appliance therapy. In: Mohl ND, mation is controlled, time is allowed for tissue healing, Zarb GA, Carlsson GE, et al (eds): A Textbook of Occlusion. and reevaluation determines that any residual mobility Chicago, Quintessence, 1988. is the result of adverse tooth loading rather than de- 7. Clark GT, Love R: The effect of gingival inflammation on creased support. 13,19,20 Exceptions to this recommenda- nocturnal masseter muscle activity. J Am Dent Assoc 1981; tion include the need to address pain or dysfunction 102:319. 8. Clark GT, Mohl ND, Riggs RR: Occlusal adjustment therapy. clearly determined to be the result of occlusal trauma. In: Mohl ND, Zarb GA, Carlsson GE, et al (eds): A Textbook A major consideration prior to occlusal adjustment is of Occlusion. Chicago, Quintessence, 1988. the restorative needs of the patient. For example, the 9. Clark GT, Tsukiyama Y, Baba K, et al: Sixty-eight years of ex- benefits of placing provisional restorations with optimal perimental interference studies: what have we learned? contours and well-adjusted occlusal surfaces should not J Prosthet Dent 1999; 82:704. be overlooked. This approach offers the opportunity to 10. Ericsson I, Giargia M, Linde J, et al: Progression of periodon- restore occlusal stability by distributing forces as well as tal tissue destruction at splinted/non-splinted teeth: An to evaluate the response of the periodontium to the an- experimental study in the dog. J Clin Periodontol 1993; ticipated restoration of the patient's dentition. 10:693. For cases in which occlusal adjustment has been de- 11. Ericsson I, Lindhe J: Lack of effect of trauma from occlusion on the recurrence of experimental periodontitis. J Clin Peri- termined the best approach, the procedure must be pre- odontol 1977; 4:115. ceded by good informed consent,8 and trial adjustment 12. Field MJ (ed): Dental Education at the Crossroads. Washing- on accurately mounted diagnostic casts is recommended. ton, DC, National Academy Press, 1995. Clark and McNeill28 have provided detailed practical 13. Fleszar TJ, Knowles JW, Morrison EC, et al: Tooth mobility protocols for occlusal adjustment procedures. and periodontal therapy. J Clin Periodontol 1980; 7:495. 14. Gher ME: Changing concepts. The effect of occlusion on periodontitis. Dent Clin North Am 1998; 2:285. Interocclusal Appliance Therapy 15. Hanamura H, Houston F, Rylander H, et al: Periodontal sta- Interocclusal appliances, generally fabricated of hard tus and bruxism. A comparative study of patients with periodontal disease and occlusal parafunctions. J Periodontol acrylic resin, have the advantage of providing a reversible 1987; 58:173. means of redistributing occlusal forces and minimizing 16. Hellsing G: Functional adaptation to changes in vertical di- excessive force on individual teeth. A full-coverage, max- mension. J Prosthet Dent 1984; 52:867. illary stabilization appliance is particularly useful in man- 17. Hochman N, Ehrlich J: Tooth contact location in intercus- aging bruxism as part of an overall comprehensive treat- pal position. Quintess Int 1987; 18:193. ment plan for the patient. Providing such an appliance to 18. J Calif Dent Assoc 2000; vol 28 (entire issue). the periodontal patient is likely to contribute to an over- 19. Kao RT. The role of occlusion in periodontal disease. In: all sense of bite comfort in addition to minimizing the McNeill C (ed): Science and Practice of Occlusion. Chicago, destructive consequences of bruxism. Clark' has provided Quintessence, 1997. an excellent description of design, delivery, adjustment, 20. Kao RT, Chu R, Curtis D: Occlusal considerations in determining treatment prognosis. J Calif Dent Assoc 2000; 28:760. and postinsertion instructions for such an appliance. 21. Kardachi BJR, Bailey JO Jr, Ash MM Jr: A comparison of biofeedback and occlusal adjustment on bruxism. J Peri- odontol 1978; 49:367. 22. Korioth TWP: Number and location of occlusal contacts in Evaluation and management of the periodontal patient intercuspal position. J Prosthet Dent 1990; 64:206. must include a thorough examination of the masticatory 23. Lindhe J, Ericsson I: Effect of longstanding jiggling on ex- system, including a TMD screening exam and functional perimental marginal periodontitis in the beagle dog. J Clin evaluation of the occlusion. Occlusal interventions should Periodontol 1982; 9:497. be considered an adjunct to periodontal therapy, re- 24. Lindhe J, Ericsson I: The effect of elimination of jiggling versible when possible, and planned in the context of the forces on periodontically exposed teeth in the dog. J Peri- odontol 1982; 53:562. restorative needs of the patient. 25. Lindhe J, Svanberg G: Influence of trauma from occlusion on progression of experimental periodontitis in the beagle dog. J Clin Periodontol 1974; 1:3. 26. McNeill C (ed): Temporomandibular Disorders: Guidelines 1. Agerberg G, Sandstrom R: Frequency of occlusal interfer- for Classification, Assessment, and Management. Chicago, ences: A clinical study in teenagers and young adults. Quintessence, 1993. J Prosthet Dent 1988; 59:212. Occlusal Evaluation and Therapy in the Management of Periodontal Disease • CHAPTER 52 703 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

27. McNeill C (ed): Science and Practice of Occlusion. Chicago, 37. Polson AM, Adams RA, Zander HA: Osseous repair in the Quintessence, 1997. presence of active tooth hypermobility. J Clin Periodontol 28. McNeill C: Selective tooth grinding and equilibration. In: 1983; 10:370. McNeill C (ed): Science and Practice of Occlusion. Chicago, 38. Polson AM, Meitner SW, Zander HA: Trauma and progres- Quintessence, 1997. sion of marginal periodontitis in squirrel monkeys. 111. 29. McNeill C: Occlusion: What it is and what it is not. J Calif Adaptation of interproximal alveolar bone to repetitive in- Dent Assoc 2000; 28:748. jury. J Periodont Res 1976; 11:279. 30. Meitner S: Co-destructive factors of marginal periodontitis 39. Polson AM, Meitner SW, Zander HA: Trauma and progression and repetitive mechanical injury. J Dent Res 1975; 54:78. of marginal periodontitis in squirrel monkeys. IV Reversibil- 31. Miyata T, Kobayashi Y, Araki H, et al: The influence of con- ity of bone loss due to trauma alone and trauma superim- trolled occlusal overload on peri-implant tissue. Int J Oral posed upon periodontitis. J Periodont Res 1976; 11:290. Maxillofac Implants 1998; 13:677. 40. Rugh JD, Solberg WK: Oral health status in the United 32. Nilner M: Prevalence of functional disturbances and dis- States: Temporomandibular disorders. J Dent Educ 1985; eases of the stomatognathic system in 15-18 year-olds. 49:398. Swed Dent J 1981; 5:189. 41. Solberg WK: Epidemiology, Incidence, and Prevalence of 33. Nilner M, Lassing S-A: Prevalence of functional disturbances Temporomandibular Disorders: A Review. In: The President's and diseases of the stomatognathic system in 7-14 year- Conference on the Examination, Diagnosis, and Manage olds. Swed Dent J 1981; 5:173. ment of Temporomandibular Disorders. Chicago, American 34. Pavone BW: Bruxism and its effect on the natural teeth. Dental Association, 1983. J Pros Dent 1985; 53:692. 42. Tipton RT, Rinchuse DJ: The relationship between static oc- 35. Plasmans PJJM, Knipers L, Vollenbrock HR, et al: The occlusion and functional occlusion in a dental school popula- clusal status of molars. J Prosthet Dent 1988; 60:500. tion. Angle Orthodont 1991; 61:57. 36. Polson AM: The relative importance of plaque and occlu- 43. Zander HA, Polson AM: Present status of occlusion and oc- sion in periodontal disease. J Clin Periodontol 1986; 13:923. clusal therapy in periodontics. J Periodontol 1977; 48:540. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

The Role of Orthodontics as an Adjunct to Periodontal Therapy

Vincent G. Kokich CHAPTER

CHAPTER OUTLINE

BENEFITS OF ORTHODONTICS FOR Fractured Teeth/Forced Eruption A PERIODONTAL PATIENT Hopeless Teeth Maintained for PREORTHODONTIC OSSEOUS SURGERY Orthodontic Anchorage Osseous Craters ORTHODONTIC TREATMENT OF Three-Wall Intrabony Defects GINGIVAL DISCREPANCIES ORTHODONTIC TREATMENT OF OSSEOUS DEFECTS Uneven Gingival Margins Hemiseptal Defects Significant Abrasion and Overeruption Advanced Horizontal Bone Loss Open Gingival Embrasures Furcation Defects SUMMARY Root Proximity

O rthodontic tooth movement may be a substantial restorations. This chapter shows the ways in which ad- benefit to the adult periorestorative patient. Many junctive orthodontic therapy can enhance the periodon- adults who seek routine restorative dentistry have tal health and restorability of teeth. problems with tooth malposition that compromise their ability to adequately clean and maintain their dentitions. BENEFITS OF ORTHODONTICS FOR If these individuals also are susceptible to periodontal dis- A PERIODONTAL PATIE NT ease, tooth malposition could be an exacerbating factor that could cause premature loss of specific teeth. Ortho- Orthodontic therapy can provide several benefits to the dontic appliances have become smaller, less noticeable, adult periodontal patient. The following six factors and easier to maintain during orthodontic therapy. Many should be considered: adults are taking advantage of the opportunity to have their teeth aligned to improve the esthetics of their Aligning crowded or malposed maxillary or mandibu- smiles. If these individuals also have underlying gingival lar anterior teeth permits the adult patient better access or osseous periodontal defects, these defects often can be to adequately clean all surfaces of their teeth. This improved during orthodontic therapy if the orthodontist could be a tremendous advantage for patients who are is aware of the situation and designs the appropriate susceptible to periodontal bone loss or do not have the tooth movement. In addition, implants have become a dexterity to adequately maintain their oral hygiene. major part of the treatment plan for many adults with 2. Vertical orthodontic tooth repositioning can improve missing teeth. If adjacent teeth have drifted into edentu- certain types of osseous defects in periodontal pa- lous spaces, orthodontics is often helpful to provide the tients. Often, the tooth movement eliminates the ideal amount of space for implants and subsequent need for resective osseous surgery.

704 The Role o f Orthodontics as an Adjunct to Periodontal Therapy • CHAPTER 53 705 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com P REORTHODONTIC OSSEOUS SURGERY 3. Orthodontic treatment can improve the esthetic relationship of the maxillary gingival margin levels be- The extent of the osseous surgery depends on the type of fore restorative dentistry. Aligning the gingival mar- defect (i.e., crater, hemiseptal defect, three-wall defect, gins orthodontically avoids gingival recontouring, and/or furcation lesion). The prudent clinician knows which potentially could require bone removal and ex- which defects can be improved with orthodontic treat- posure of the roots of the teeth. ment and which defects require preorthodontic, peri- 4. The fourth benefit of orthodontics is for the patient odontal, surgical intervention. who has suffered a severe fracture of a maxillary anterior tooth, which requires forced eruption to per- Osseous Craters mit adequate restoration of the root. In this situation, erupting the root allows the crown preparation to An osseous crater is an interproximal, two-wall defect have sufficient resistance form and retention for the that does not improve with orthodontic treatment. final restoration. Some shallow craters (i.e., 4- to 5-mm pocket) may be 5. Orthodontic treatment allows open gingival embra- maintainable nonsurgically during orthodontic treat- sures to be corrected to regain lost papilla. If these ment. However, if surgical correction is necessary, this open gingival embrasures are located in the maxillary type of osseous lesion can easily be eliminated by re-

anterior region, they can be unaesthetic. In most pa- shaping the defect 12.15 and reducing the pocket depth tients, these areas can be corrected with a combina- (Fig. 53-1) (see Chapter 62). This in turn enhances the tion of orthodontic root movement, tooth reshaping, ability to maintain these interproximal areas during or- and/or restoration. thodontic treatment. The need for surgery is based on 6. Orthodontic treatment could improve adjacent tooth the patient's response to initial root planing, the pa- position before implant placement or tooth replace- tient's periodontal resistance, the location of the de- ment. This is especially true for the patient who has fect, and the predictability of maintaining defects non- been missing teeth for several years and has drifting surgically while the patient is wearing orthodontic and tipping of the adjacent dentition. appliances.

Fig. 53-1 This patient had a 6-mm probing defect distal to the maxillary right first molar (A). When this area was flapped (B), a cratering defect was apparent. Osseous surgery was used to alter the bony architecture on the buccal and lingual to eliminate the defect (C and D). After 6 weeks, the probing pocket defect had been reduced to 3 mm, and orthodontic appliances were placed on the teeth (E). By eliminating the crater before orthodontics, the patient could maintain the area during and after orthodontics (F).

706 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com Three-Wall Intrabony Defects quires any preorthodontic surgery. After the completion Three-wall defects are amenable to pocket reduction with of orthodontic treatment, these teeth should be stabi- regenerative periodontal therapy.' Bone grafts using either lized for at least 6 months and reassessed periodontally. autogenous bone from the surgical site or allografts along Often, the pocket has been reduced or eliminated and no with the use of resorbable membranes have been success- further periodontal treatment is needed. It would be in- ful in filling three-wall defects.14 If the result of periodon- judicious to perform preorthodontic osseous corrective tal therapy is stable (Fig. 53-2) 3 to 6 months after peri- surgery in such lesions if orthodontics is part of the over- odontal surgery, orthodontic treatment may be initiated. all treatment plan. In the periodontally healthy patient, orthodontic ORTHODONTIC TREATMENT brackets are positioned on the posterior teeth relative to OF OSSEOUS DEFECTS the marginal ridges and cusps. However, some adult patients may have marginal ridge discrepancies caused by Hemiseptal Defects uneven tooth eruption. When marginal ridge discrepancies are encountered, the decision as to where to place Hemiseptal defects are one- or two-wall osseous defects the bracket or band is not determined by the anatomy of that often are found around mesially tipped teeth (Fig. the tooth. In these situations, it is important to assess 53-3) or teeth that have supererupted (Fig. 53-4). Usually, these teeth radiographically to determine the interproxi- these defects can be eliminated with the appropriate or- mal bone level. thodontic treatment. In the case of the tipped tooth, up- If the bone level is oriented in the same direction as righting',' and eruption of the tooth levels the bony de- the marginal ridge discrepancy, then leveling the mar- fect. If the tooth is supererupted, intrusion and leveling ginal ridges will level the bone. However, if the bone of the adjacent cementoenamel junctions can help level level is flat between adjacent teeth (see Fig. 53-4) and the the osseous defect. marginal ridges are at significantly different levels, cor- It is imperative that periodontal inflammation be rection of the marginal ridge discrepancy orthodonti- controlled before orthodontic treatment. This usually cally produces a hemiseptal defect in the bone. This can be achieved with initial debridement and rarely re- could cause a periodontal pocket between the two teeth.

Fig. 53-2 This patient had a significant periodontal pocket (A) distal to the mandibular right first molar. A periapical radiograph (B) confirmed the osseous defect. A flap was elevated (C), revealing a deep, three- wall osseous defect. Freeze-dried bone (D) was placed in the defect 6 months after the bone graft. Ortho- dontic treatment was initiated (E). The final periapical radiograph shows that the preorthodontic bone graft helped regenerate bone and eliminate the defect distal to the molar (F). The Role o f Orthodontics as an Adjunct to Periodontal Therapy • CHAPTER 53 707 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com If the bone is flat and a marginal ridge discrepancy is patient to clean. As the defect is ameliorated through present, the orthodontist should not level the marginal tooth extrusion, interproximal cleaning becomes easier. ridges orthodontically. In these situations, it may be nec- The patient should be recalled every 2 to 3 months dur- essary to equilibrate the crown of the tooth (see Fig. ing the leveling process to control inflammation in the 53-4). For some patients, the latter technique may re- interproximal region. quire endodontic therapy and restoration of the tooth because of the required amount of reduction of the length of the crown. This approach is acceptable if the Advanced Horizontal Bone Loss treatment results in a more favorable bone contour be- After orthodontic treatment has been planned, one of tween the teeth. the most important factors that determine the outcome In some patients, a discrepancy may exist between of orthodontic therapy is the location of the bands and both the marginal ridges and the bony levels between brackets on the teeth. In a periodontally healthy individ- two teeth. However, these discrepancies may not be of ual, the position of the brackets is usually determined by equal magnitude. In these patients, orthodontic leveling the anatomy of the crowns of the teeth. Anterior brack- of the bone may still leave a discrepancy in the marginal ets should be positioned relative to the incisal edges. ridges (Fig. 53-5). In these situations, the crowns of the Posterior bands or brackets are positioned relative to the teeth should not be used as a guide for completing or- marginal ridges. If the incisal edges and marginal ridges thodontic therapy. The bone should be leveled ortho- are at the correct level, the cementoenamel junction dontically and any remaining discrepancies between the (CEJ) will also be at the same level. This relationship cre- marginal ridges should be equilibrated. This method pro- ates a flat, bony contour between the teeth. However, if a duces the best occlusal result and improves the peri- patient has underlying periodontal problems and signifi- odontal health. cant alveolar bone loss around certain teeth, using the During orthodontic treatment, when teeth are being anatomy of the crown to determine bracket placement is extruded to level hemiseptal defects, the patient should not appropriate (Fig. 53-6). be monitored regularly. Initially, the hemiseptal defect In a patient with advanced horizontal bone loss, the has a greater sulcular depth and is more difficult for the bone level may have receded several millimeters from

E F

Fig. 53-3 This patient was missing the mandibular left second premolar, and the first molar had tipped mesially (A). A pretreatment periapical radiograph (B) revealed a significant hemiseptal osseous defect on the mesial of the molar. To eliminate the defect, the molar was erupted and the occlusal surface was equilibrated (C). The eruption was stopped when the bone defect was leveled (D). The posttreatment intraoral photograph (E) and periapical radiograph (F) show that the periodontal health had been improved by correcting the hemiseptal defect orthodontically. 708 PART 5 • Treatment of Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 53-4 This patient showed overeruption of the maxillary right first molar and a marginal ridge defect between the second premolar and first molar (A). A pretreatment periapical radiograph (B) showed that the interproximal bone was flat. To avoid creating a hemiseptal defect, the occlusal surface of the first molar was equilibrated (C and D) and the malocclusion was corrected orthodontically (E and F).

the CEJ. As this occurs, the crown-to-root ratio becomes require special attention in the patient undergoing or- less favorable. By aligning the crowns of the teeth, the thodontic treatment. Often, the molars require bands clinician may perpetuate tooth mobility by maintaining with tubes and other attachments that impede the pa- an unfavorable crown-to-root ratio. In addition, by tient's access to the buccal furcation for home care and aligning the crowns of the teeth and disregarding instrumentation at the time of recall. the bone level, significant bone discrepancies occur Furcation lesions require special consideration be- between healthy and periodontally diseased roots. cause they are the most difficult lesions to maintain and This could require periodontal surgery to ameliorate the can worsen during orthodontic therapy. These patients discrepancies. need to be maintained on a 2- to 3-month recall sched- Many of these problems can be corrected by using the ule. Detailed instrumentation of these furcations helps bone level as a guide to position the brackets on the minimize further periodontal breakdown. teeth (see Fig. 53-6). In these situations, the crowns of If a patient with a Class III furcation defect will be the teeth may require considerable equilibration. If the undergoing orthodontic treatment, a possible method tooth is vital, the equilibration should be performed for treating the furcation is to eliminate it by hemisect- gradually to allow the pulp to form secondary dentin ing the crown and root of the tooth (Fig. 53-7). How- and insulate the tooth during the equilibration process. ever, this procedure requires endodontic, periodontal, The goal of equilibration and creative bracket placement and restorative treatment. If the patient will be undergo- is to provide a more favorable bony architecture as well ing orthodontic treatment, it is advisable to perform the as a more favorable crown-to-root ratio. In some of these orthodontic treatment first. This is especially true if the patients, the periodontal defects that were apparent ini- roots of the teeth will not be moved apart. In these pa- tially may not require periodontal surgery after ortho- tients, the molar to be hemisected remains intact during dontic treatment. orthodontics (see Fig. 53-7). This patient would require 2- or 3-month recall visits to ensure that the furcation defect does not lose bone during orthodontic treatment. Furcation Defects Keeping the tooth intact during the orthodontics sim- Furcation defects can be classified as incipient (Class I), plifies the concentration of tooth movement for the or- moderate (Class 11), or advanced (Class III). These lesions thodontist. After orthodontics, endodontic therapy is The Role of Orthodontics as an Adjunct to Periodontal Therapy • CHAPTER 53 709 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

A B

Fig. 53-5 Before orthodontic treatment, this patient had significant mesial tipping of the maxillary right first and second molars, causing marginal ridge discrepancies (A). The tipping produced root proximity between the molars (B). To eliminate the root proximity, the brackets were placed perpendicular to the long axis of the teeth (G). This method of bracket placement facilitated root alignment and elimination of the root proximity as well as leveling of the marginal ridge discrepancies (D, E, and F).

required (followed by periodontal surgery) to divide the of plan has been adopted, the timing of the extraction tooth. and placement of the implant can occur at any time rela- In some patients requiring hemisection of a man- tive to the orthodontic treatment. In some situations, dibular molar with a Class III furcation, pushing the the implant could be used as an anchor to facilitate pre- roots apart during orthodontic treatment may be advan- restorative orthodontic treatment (see Fig. 53-9). tageous (Fig. 53-8). If the hemisected molar will be used The implant must remain embedded in bone for 4 to as an abutment for a bridge after orthodontics, moving 6 months after placement before it can be loaded as an the roots apart orthodontically permits a favorable orthodontic anchor. It must be placed precisely so that it restoration and splinting across the adjacent edentulous not only provides an anchor for tooth movement but spaces. also may be used an eventual abutment for a crown or In the latter situation, hemisection, endodontic ther- fixed bridge. If the implant will not be used as an anchor apy, and periodontal surgery must be completed before for orthodontic movement, it may be placed after the or- the start of orthodontic treatment. After these procedures thodontic treatment has been completed. Considera- have been completed, bands or brackets can be placed on tions regarding timing are determined by the restorative the root fragments and coil springs used to separate the treatment plan. roots. The amount of separation is determined by the size of the adjacent edentulous spaces and the occlusion in the opposing arch. About 7 or 8 mm may be created be- Root Proximity tween the roots of the hemisected molar. This process When roots of posterior teeth are in close proximity, the eliminates the original furcation problem and allows ability to maintain periodontal health and accessibility the patient to clean the area with greater efficiency. for restoration of adjacent teeth may be compromised.' In some molars with Class III furcation defects, the However, if the patient were undergoing orthodontic tooth may have short roots, advanced bone loss, fused therapy, the roots can be moved apart and bone will be roots, or other problems that prevent hemisection and formed between the adjacent roots (see Fig. 53-5). crowning of the remaining roots. In these patients (Fig. This opens the embrasure beneath the tooth contact, pro- 53-9), extracting the root with a furcation defect and vides additional bone support, and enhances the pa- placing an implant may be more advisable." If this type tient's access to the interproximal region for hygiene.

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Fig. 53-6 Before orthodontic treatment, this patient had a significant Class III malocclusion (A). The maxil- l ary central incisors had overerupted (B) relative to the occlusal plane. A pretreatment periapical radiograph (C) showed that significant horizontal bone loss had occurred. To avoid creating a vertical periodontal defect by intruding the central incisors, the brackets were placed to maintain the bone height (D). The incisal edges of the centrals were equilibrated (E), and the orthodontic treatment was completed without intrud- i ng the incisors (F).

Fig. 53-7 This patient had a Class III furcation defect before orthodontic treatment (A and B). Orthodon- tic treatment was performed (C), and the furcation defect was maintained by the periodontist on 2-month recalls until after orthodontic treatment. After appliance removal, the tooth was hemisected (D), and the roots were restored, and splinted together (E). The final periapical radiograph (F) shows that the furcation defect has been eliminated by hemisecting and restoring the two root fragments.

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Fig. 53-8 Before orthodontic treatment, this patient had a Class III furcation defect in the mandibular left second molar (A and B). Because the patient had an edentulous space mesial to the molar, the tooth was hemisected (C), and the root fragments were separated orthodontically (D). After orthodontic treatment, the root fragments were used as abutments to stabilize a multiunit posterior bridge (E and F).

Fig. 53-9 This patient was missing several teeth in the mandibular left posterior quadrant (A). The mandibular left third molar had a Class III furcation defect and short roots (B). The third molar was extracted and two implants were placed in the mandibular left posterior quadrant (C). The implants were used as anchors to facilitate orthodontic treatment (D) and help reestablish the left posterior occlusion (E and F). 712 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 53-10 This patient had a severe fracture of the maxillary right central incisor (A) that extended apical to the level of the alveolar crest on the lingual (I3). To restore the tooth adequately and avoid impinging on the periodontium, the fractured root was extruded 4 mm (C). As the tooth erupted, the gingival margin followed the tooth (D). Gingival surgery was required to lengthen the crown of the central incisor (E) so that the final restoration had sufficient ferrule for resistance and retention and the appropriate gingival margin relationship with the adjacent central incisor (F).

This generally improves the periodontal health of this restored with light-cured composite or porcelain veneers. area. However, in some situations, the fracture may extend be- If orthodontic treatment will be used to move neath the level of the gingival margin and terminate at roots apart, this plan must be known before bracket the level of the alveolar ridge (Fig. 53-10). In these situa- placement. It is advantageous to place the brackets so tions, restoration of the fractured crown is impossible be- that the orthodontic movement to separate the roots cause the tooth preparation would extend to the level of will begin with the initial archwires (see Fig. 53-5). the bone. This overextension of the crown margin could Therefore brackets must be placed obliquely to facilitate result in an invasion of the biologic width of the tooth this process. To determine the progress of orthodontic and cause persistent inflammation of the marginal gin- root separation, radiographs are needed to monitor the giva. It may be beneficial in such cases to erupt the frac- status. Generally, 2 to 3 mm of root separation provides tured root out of the bone and move the fracture margin adequate bone and embrasure space to improve peri- coronally so that it can be properly restored.' However, if odontal health. During this time, the patient should be the fracture extends too far apically, it may be better to maintained to ensure that a favorable bone response oc- extract the tooth and replace it with an implant or curs as the roots are moved apart. In addition, these pa- bridge. Six criteria determine whether the tooth should tients need occasional occlusal adjustment to recontour be forcibly erupted or extracted. the crown because the roots are moving apart. As this occurs, the crowns may develop an unusual occlusal con- 1. Root length: Is the root long enough so that a one-to- tact with the opposing arch. This should be equilibrated one crown-root ratio will be preserved after the root to improve the occlusion. has been erupted? To determine the answer to this question, the clinician must know how far to erupt the root. If a tooth fracture extends to the level of the Fractured Teeth/Forced Eruption bone, it must be erupted 4 mm. The first 2.5 mm Occasionally, children and adolescents may fall and acci- moves the fracture margin far enough away from the dentally injure their anterior teeth. If the injuries are mi- bone to prevent a biologic width problem. The other nor and result in small fractures of enamel, these can be 1.5 mm provides the proper amount of ferrule for The Role o f Orthodontics as an Adjunct to Periodontal Therapy • CHAPTER 53 71 3 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

adequate resistance form of the crown preparation. erupted root requires crown lengthening to expose the Therefore if the root is fractured to the bone level and correct amount of tooth to create the proper ferrule, resis- must be erupted 4 mm, the periapical radiograph tance form, and retention for the final restoration. must be evaluated (see Fig. 53-10) and 4 mm sub- After the tooth root has been erupted, it must be sta- tracted from the end of the fractured tooth root. The bilized to prevent it from intruding back into the alveo- length of the residual root should be compared with lus. The reason for reintrusion is the orientation of the the length of the eventual crown on this tooth. The principal fibers of the periodontium. During forced erup- root-to-crown ratio should be about 1:1. If the root- tion, the periodontal fibers become oriented obliquely to-crown ratio is less than this amount, there may be and stretched as the root moves coronally. These fibers too little root remaining in the bone for stability. In eventually reorient themselves after about 6 months. Be- the latter situation, it may be prudent to extract the fore this occurs, the root can reintrude significantly. root and place a bridge or implant. Therefore if this type of treatment is performed, an ade- 2. Root form: The shape of the root should be broad and quate period of stabilization is necessary to avoid signifi- nontapering, rather than thin and tapered. A thin, ta- cant relapse and reintrusion of the root. pered root provides a narrower cervical region after As the root erupts, the gingiva move coronally with the tooth has been erupted 4 mm. This could com- the tooth. As a result, the clinical crown length becomes promise the esthetic appearance of the final restora- shorter after extrusion (see Fig. 53-10). In addition, the tion. The internal root form is also important. If the gingival margin may be positioned more incisally than root canal is wide, the distance between the external the adjacent teeth. In these situations, gingival surgery is root surface and root canal filling will be narrow. In necessary to create ideal gingival margin heights. The these situations, the walls of the crown preparation type of surgery varies depending on whether bone re- are thin, which could result in early fracture of the removal is necessary. If bone has followed the root during stored root. The root canal should not be more than eruption, a flap is elevated and the appropriate amount one third of the overall width of the root. In this way, of bone is removed to match the bone height of the ad- the root could still provide adequate strength for the jacent teeth. If the bone level is flat between adjacent final restoration. teeth, a simple excisional gingivectomy corrects the gin- 3. Level of the fracture: If the entire crown is fractured 2 gival margin discrepancy. to 3 mm apical to the level of the alveolar bone, it is After gingival surgery, an open gingival embrasure difficult, if not impossible, to attach to the root to may exist between the erupted root and adjacent teeth erupt it. (see Fig. 53-10). The space occurs because the narrower 4. Relative importance of the tooth: If the patient were 70 root portion of the erupted tooth has been moved into years of age and both adjacent teeth had prosthetic the oral cavity. This space may be closed in two different crowns, then it could be more prudent to construct a ways. One method involves overcontouring of the re- fixed bridge. However, if the patient is 15 years of age placement restoration. The other method involves re- and the adjacent teeth were unrestored, then forced shaping of the crown of the tooth and movement of the eruption would be much more conservative and ap- root to close the space. This latter method often helps propriate. improve the overall shape of the final crown on the re- 5. Esthetics: If the patient has a high lip line and displays stored tooth. 2 to 3 mm of gingiva when smiling, then any type of restoration in this area will be more obvious. In this situation, keeping the patient's own tooth would be Hopeless Teeth Maintained for much more esthetic than any type of implant or pros- Orthodontic Anchorage thetic replacement. Patients with advanced periodontal disease may have 6. Endo/perio prognosis: If the tooth has a significant peri- specific teeth diagnosed as hopeless, which would be ex- odontal defect, it may not be possible to retain the tracted before orthodontics (Fig. 53-11). However, these root. In addition, if the tooth root has a vertical frac- teeth can be useful for orthodontic anchorage if the peri- ture, the prognosis would be poor and extraction of odontal inflammation can be controlled. In moderate to the tooth would be the proper course of therapy. advanced cases, some periodontal surgery may be indicated around a hopeless tooth. Flaps are reflected for de- If all these factors are favorable, then forced eruption bridement of the roots to control inflammation around of the fractured root is indicated. The orthodontic me- the hopeless tooth during the orthodontic process. The chanics necessary to erupt the tooth can vary from elastic important factor is to maintain the health of the bone traction to orthodontic banding and bracketing. If a large around the adjacent teeth. Periodontal recall is impera- portion of the tooth is still present, then orthodontic tive during the process. bracketing is necessary. If the entire crown has fractured, After orthodontic treatment, there is a six-month pe- leaving only the root, then elastic traction from a bonded riod of stabilization before reevaluating the periodontal bar may be possible. The root may be erupted rapidly or status. Occasionally, the hopeless tooth may be so im- slowly. If the movement is performed rapidly, the alveolar proved after orthodontic treatment that it is retained. bone will be left behind temporarily and a circumferential However, in most cases, the hopeless tooth requires ex- fiberotomy may be performed to prevent bone from fol- traction, especially if other restorations are planned in lowing the erupted root. However, if the root is erupted the segment. Again, these decisions require reevaluation slowly, the bone follows the tooth. In this situation, the by the clinician. 71 4 PART 5 • Treatment of Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 53-11 This patient had an impacted mandibular right second molar (A). The mandibular right first molar was periodontally hopeless because of an advanced Class III furcation defect. The impacted second molar was extracted, but the first molar was maintained as an anchor to help upright the third molar orthodontically (B, C, and D). After orthodontic uprighting of the third molar, the first molar was extracted and a bridge was placed to restore the edentulous space (E and F).

ORTHODONTIC TREATMENT OF GINGIVAL DISCREPANCIES edges or delayed migration of the gingival margins. When gingival margin discrepancies are present, the Uneven Gingival Margins proper solution for the problem must be determined: orthodontic movement to reposition the gingival margins The relationship of the gingival margins of the six maxil- or surgical correction of gingival margin discrepancies. lary anterior teeth plays an important role in the esthetic To make the correct decision, it is necessary to evalu- appearance of the crowns. Four factors contribute to ate four criteria. First, the relationship between the gingi- ideal gingival form. val margin of the maxillary central incisors and the patient's lip line should be assessed when the patient 1. The gingival margins of the two central incisors smiles. If a gingival margin discrepancy is present but the should be at the same level. discrepancy is not exposed, it does not require correction. 2. The gingival margins of the central incisors should be If a gingival margin discrepancy is apparent, the sec- positioned more apically than the lateral incisors and ond step is to evaluate the labial sulcular depth over the at the same level as the canines.13 two central incisors. If the shorter tooth has a deeper sul- 3. The contour of the labial gingival margins should cus, excisional gingivectomy may be appropriate to mimic the CEJs of the teeth. move the gingival margin of the shorter tooth apically. 4. A papilla should exist between each tooth, and the However, if the sulcular depths of the short and long in- height of the tip of the papilla is usually halfway be- cisors are equivalent, gingival surgery does not correct tween the incisal edge and the labial gingival height the problem. of contour over the center of each anterior tooth. The third step is to evaluate the relationship between Therefore the gingival papilla occupies half of the in- the shortest central incisor and the adjacent lateral interproximal contact, and the adjacent teeth form the cisors. If the shortest central is still longer than the lat- other half of the contact. eral incisors, the other possibility is to extrude the longer central incisor and equilibrate the incisal edge. This However, some patients may have gingival margin moves the gingival margin coronally and eliminates the discrepancies between adjacent teeth (Fig. 53-12). These gingival margin discrepancy. However, if the shortest discrepancies could be caused by abrasion of the incisal central is shorter than the laterals, this technique would The Role of Orthodontics as an Adjunct to Periodontal Therapy • CHAPTER 53 71 5 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 53-12 This patient had a protrusive bruxing habit that had resulted in abrasion and overeruption of the maxillary right central incisor (A). The objective was to level the gingival margins during orthodontic therapy. Although gingival surgery was a possibility, the labial sulcular depth of the maxillary right central incisor was only 1 mm, and the CEJ was located at the bottom of the sulcus. Therefore the best solution involved positioning the orthodontic brackets to facilitate intrusion of the right central incisor (B, C, and D). This permitted the restorative dentist to restore the portion of the tooth that the patient had abraded (E), resulting in the correct gingival margin levels and crown lengths at the end of treatment (F).

produce an unaesthetic relationship between the gingi- achieve adequate retention and resistance form for the val margins of the central and lateral incisors. crown preparations. Two options are available. One op- The fourth step is to determine whether the incisal tion is extensive crown lengthening by elevating a flap, edges have been abraded. This is best accomplished by removing sufficient bone, and apically positioning the evaluating the teeth from an incisal perspective. If one flap to expose adequate tooth length for crown prepara- inaisal edge is thicker labiolingually than the adjacent tion. However, this type of procedure is contraindicated tooth, this may indicate that it has been abraded and the in the patient with short tapered roots because it could tooth has overerupted. In such cases, the best method of adversely affect the final root to crown ratio and poten- correcting the gingival margin discrepancy is to intrude tially open gingival embrasures between the anterior the short central incisor (see Fig. 53-12). This method teeth. moves the gingival margin apically and permits restora- The other option for improving the restorability of tion of the incisal edges .3.6,8-10 The intrusion should be these short abraded teeth is to orthodontically intrude accomplished at least 6 months before appliance re- the teeth and move the gingival margins apically (see Fig. moval. This allows reorientation of the principal fibers of 53-13). It is possible to intrude up to four maxillary in- the periodontium and avoids reextrusion of the central cisors by using the posterior teeth as anchorage during incisor(s) after appliance removal. the intrusion process. This process is accomplished by placing the orthodontic brackets as close to the incisal edges of the maxillary incisors as possible. The brackets Significant Abrasion and Overeruption are placed in their normal position on the canines and Occasionally, patients have destructive dental habits remaining posterior teeth. The patient's posterior occlu- such as a protrusive bruxing habit that could result in sion resists the eruption of the posterior teeth, and the significant wear of the maxillary and mandibular in- incisors gradually intrude and move the gingival margins cisors and compensatory overeruption of these teeth and the crowns apically. This creates the restorative space (Fig. 53-13). The restoration of these abraded teeth is of- necessary to temporarily restore the incisal edges of these ten impossible because of the lack of crown length to teeth and then eventually place the final crowns.

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Fig. 53-13 This patient had a protrusive bruxing habit that had caused severe abrasion of the maxillary anterior teeth, resulting in the loss of over half of the crown length of the incisors (A and B). Two possible options existed for gaining crown length to restore the incisors. One possibility was an apically positioned flap with osseous recontouring, which would expose the roots of the teeth. The less destructive option was to intrude the four incisors orthodontically, level the gingival margins (C and D), and allow the dentist to restore the abraded incisal edges (E and F). The orthodontic option was clearly successful and desirable in this patient.

Fig. 53-14 This patient initially had overlapped maxillary central incisors (A), and after initial orthodontic alignment of the teeth, an open gingival embrasure appeared between the centrals (B). A radiograph showed that the open embrasure was caused by divergence of the central incisor roots (C). To correct the problem, the central incisor brackets were repositioned (D), and the roots were moved together. This required restoration of the incisal edges after orthodontics (E) because these teeth had worn unevenly before orthodontic therapy. As the roots were paralleled (F), the tooth contact moved gingivally and the papilla moved incisally, resulting in the elimination of the open gingival embrasure. The Role of Orthodontics as an Adjunct to Periodontal Therapy • CHAPTER 53 71 7 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com When abraded teeth are significantly intruded, it is tooth contact, and the other is the papilla. The ratio of necessary to hold these teeth for at least 6 months in the papilla to contact is 1:1. Half of the space is occupied by intruded position with either the orthodontic brackets, papilla, and half is formed by the tooth contact. If the archwires, or both, or some type of bonded retainer. The patient has an open embrasure, the first aspect that must principal fibers of the periodontium must accommodate be evaluated is whether the problem is due to the papilla to the new intruded position, a process that could take a or the tooth contact. If the papilla is the problem, then minimum of 6 months in most adult patients. Ortho- the cause is usually a lack of bone support due to an un- dontic intrusion of severely abraded and overerupted derlying periodontal problem. teeth is usually a distinct advantage over periodontal In some situations, a deficient papilla can be improved crown lengthening unless the patient has extremely long with orthodontic treatment. By closing open contacts, and broad roots or has had extensive horizontal peri- the interproximal gingiva can be squeezed and moved in- odontal bone loss. cisally. This type of movement may help create a more esthetic papilla between two teeth despite alveolar bone loss. Another possibility is to erupt adjacent teeth when Open Gingival Embrasures the interproximal bone level is positioned apically. The presence of a papilla between the maxillary central Most open embrasures between the central incisors incisors is a key esthetic factor in any individual. Occa- are due to problems with tooth contact. The first step in sionally, adults have open gingival embrasures or lack the diagnosis of this problem is to evaluate a periapical gingival papillae between their central incisors. These radiograph of the central incisors. If the root angulation unaesthetic areas are often difficult to resolve with peri- is divergent, then the brackets should be repositioned so odontal therapy. However, orthodontic treatment can the root position can be corrected (Fig. 53-14). In these correct many of these open gingival embrasures. This situations, the incisal edges may be uneven and require open space is usually due to one of three causes: tooth restoration with either composite or porcelain restora- shape, root angulation, or periodontal bone loss.' tions. If the periapical radiograph shows that the roots The interproximal contact between the maxillary cen- are in their correct relationship, then the open gingival tral incisors consists of two parts. One portion is the embrasure is due to a triangular tooth shape (Fig. 53-15).

Fig. 53-15 This patient initially had triangular-shaped central incisors (A and B), which produced an open gingival embrasure after orthodontic alignment (C). Because the roots of the central incisors were parallel with one another, the appropriate solution for the open gingival embrasure was to recontour the mesial surfaces of the central incisors (D). As the diastema was closed (E), the tooth contact moved gingivally and the papilla moved incisally, resulting in the elimination of the open gingival embrasure (F).

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If the shape of the tooth is the problem, two solutions 3. Chiche G, Kokich V, Caudill R: Diagnosis and treatment are possible. One possibility is to restore the open gingi- planning of esthetic problems. In: Pinault A, Chiche G val embrasure. The other option is to reshape the tooth (eds): Esthetics in Fixed Prosthodontics. Chicago, Quintes- by flattening the incisal contact and closing the space sence, 1994. (see Fig. 53-15). This results in lengthening of the contact 4. Gould MSE, Picton DCA: The relation between irregularities of the teeth and periodontal disease. Br Dent J 1966; until it meets the papilla. In addition, if the embrasure 121:21. space is large, closing the space squeezes the papilla be- 5. Ingber J: Forced eruption: Part I. A method of treating iso- tween the central incisors. This helps create a 1:1 ratio lated one and two wall infrabony osseous defects; rationale between the contact and papilla and restores uniformity and case report. J Periodontal 1974; 45:199. to the heights between the midline and adjacent papillae. 6. Kokich V: Enhancing restorative, esthetic and periodontal results with orthodontic therapy, In: Schluger S, Youdelis R, Page R, et al (eds): Periodontal Therapy. Philadelphia, Lea & SUMMARY Febiger, 1990. This chapter has discussed and illustrated the benefits of 7. Kokich V, Nappen D, Shapiro P: Gingival contour and clini- integrating orthodontics and periodontics in the man- cal crown length: Their effects on the esthetic appearance of maxillary anterior teeth. Am J Orthod 1984; 86:89. agement of adult patients with underlying periodontal 8. Kokich V: Anterior dental esthetics: An orthodontic per- defects. The key to treating these types of patients is spective. I. Crown length. J Esthet Dent 1993; 5:19. communication and proper diagnosis before orthodontic 9. Kokich V: Esthetics and vertical tooth position: The ortho- therapy as well as continued dialogue during orthodon- dontic possibilities. Compendium Cont Ed Dent 1997; tic treatment. Not all periodontal problems are treated in 18:1225. the same way. This chapter has provided a framework for 10. Kokich V: Esthetics: The orthodontic-periodontic-restorative the integration of orthodontics to solve periodontal connection. Semin Orthod 1996; 2:21. problems. 11. Kramer GM: Surgical alternatives in regenerative therapy of the periodontium. Int J Periodont Rest Dent 1992; 12:11. REFERENCES 12. Ochsenbein C, Ross S: A re-evaluation of osseous surgery. Dent Clin North Am 1969; 13:87. 13. Rufenacht C: Structural esthetic rules. In: Rufenacht C (ed): 1. Becker W, Becker BE: Treatment of mandibular 3-wall intra- Fundamental of Esthetics. Chicago, Quintessence, 1990. bony defects by flap debridement and expanded polytetra- 14. Schallhorn R, McClain P: Combined osseous composite fluoroethylene barrier membranes. Long-term evaluation of grafting, root conditioning and guided tissue regeneration. 32 treated patients. J Periodontol 1993; 64:1138. Int J Periodont Rest Dent 1988; 8:9. 2. Brown IA: The effect of orthodontic therapy on certain 15. Schluger S: Osseous resection: A basic principle in periodon- types of periodontal defects. I. Clinical findings. J Periodon- tal surgery. Oral Surg 1949; 2:316. tol 1973; 44:742.

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The Surgical Phase of Therapy

Henry H. Takei and Fermin A. Carranza

CHAPTER

CHAPTER OUTLINE

OBJECTIVES OF THE SURGICAL PHASE CRITICAL ZONES IN POCKET SURGERY Surgical Pocket Therapy Zone 1: The Soft Tissue Wall Results of Pocket Therapy Zone 2: The Tooth Surface POCKET ELIMINATION VERSUS Zone 3: The Bone POCKET MAINTENANCE Zone 4: The Attached Gingiva REEVALUATION AFTER PHASE I THERAPY METHODS OF POCKET THERAPY INDICATIONS FOR PERIODONTAL SURGERY Criteria for Method Selection

lthough in a strict sense, all instrumental ther- OBJECTIVES OF TH E SURGICAL PHASE apy can be considered surgical, this chapter The surgical phase of periodontal therapy seeks the refers only to those techniques that include the following: intentional severing or incising of gingival tissue* with the following purposes: 1. Improvement of the prognosis of teeth and their replacements. • Controlling or eliminating periodontal disease. 2. Improvement of esthetics. • Correcting anatomic conditions that may favor periodontal disease, impair esthetics, or impede the place- The surgical phase consists of techniques performed ment of correct prosthetics. for pocket therapy and for the correction of related mor- • Placing implants to replace lost teeth and improving phologic problems, namely mucogingival defects. In the environment for their placement and function. many cases, procedures are combined so that one surgical intervention fulfills both objectives. The purpose of surgical pocket therapy is to eliminate the pathologic changes in the pocket walls; to create a stable, easily maintainable state; and, if possible, to pro- * Scaling and root planing are not included because these proce- mote periodontal regeneration. To fulfill these objec- dures do not intentionally act on the gingival tissue. tives, surgical techniques 1) increase accessibility to the

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Periodontal Surgery

Fig. 54-1 Accumulation of plaque leads to gingival inflammation and pocket deepening, which in turn increases the area of plaque accumulation.

Surgical Pocket Therapy Surgical pocket therapy can be directed toward 1) access surgery to ensure the removal of irritants from the tooth surface or 2) elimination, or reduction of the depth of, the periodontal pocket. The effectiveness of periodontal therapy is predicated on success in completely eliminating calculus, plaque, root surface, making it possible to remove all irritants; 2) and diseased cementum from the tooth surface. Numer- reduce or eliminate pocket depth, making it possible for ous investigations have shown that the difficulty of this the patient to maintain the root surfaces free of plaque; task increases as the pocket becomes deeper. The pres- and 3) reshape soft and hard tissues to attain a harmo- ence of irregularities on the root surface also increase the nious topography. Pocket reduction surgery seeks to re- difficulty of the procedure. As the pocket gets deeper, the duce pocket depth by either resective or regenerative surface to be scaled increases, more irregularities appear means or often by a combination of both methods. on the root surface, and accessibility is impaired" , "; the Chapters 60 to 64 describe the different techniques used presence of furcation involvements sometimes creates for these purposes. insurmountable problems (see Chapter 64). The second objective of the surgical phase of peri- All these problems can be reduced by resecting or odontal therapy is the correction of anatomic morpho- displacing the soft tissue wall of the pocket, thereby in- logic defects that may favor plaque accumulation and creasing the visibility and accessibility of the root sur- pocket recurrence or impair esthetics. It is important to face.3 The flap approach and the gingivectomy tech- understand that these procedures are not directed to nique attain this result. treat disease but aim to alter the gingival and mucosal The need to eliminate or reduce the depth of the tissues to correct defects that may predispose to disease. pocket is another important consideration. Pocket elimi- They are performed on noninflamed tissues and in the nation consists of reducing the depth of periodontal absence of periodontal pockets. pockets to that of a physiologic sulcus to enable cleans- Three types of techniques fall into this category: ing by the patient. By proper case selection, both resec- the plastic surgery techniques used to create or widen the tive techniques and regenerative techniques can be used attached gingiva by placing grafts of various types, the to accomplish this goal. The presence of a pocket pro- esthetic surgery techniques used to cover denuded roots duces areas that are impossible for the patient to keep and to recreate lost papillae, and the preprosthetic tech- clean, and therefore the vicious circle depicted in Fig. niques, the purpose of which is the adaptation of the pe- 54-1 is established. riodontal and neighboring tissues to receive prosthetic replacements and which include crown lengthening, ridge augmentation, and vestibular deepening. The Results of Pocket Therapy plastic and esthetic surgery techniques are presented A periodontal pocket can be in an active state or a period in Chapter 66 and the preprosthetic techniques in of inactivity or quiescence. An active pocket is one under Chapter 74. which bone is being lost (Fig. 54-2, top left). It often can In addition, periodontal surgical techniques for the be diagnosed clinically by bleeding, either spontaneously placement of dental implants are available. These in- or on probing. After Phase I therapy, the inflammatory volve not only the implant placement techniques but changes in the pocket wall subside, rendering the pocket also a variety of surgical procedures to adapt the neigh- inactive and reducing its depth (see Fig. 54-2, top center). boring tissues, such as the sinus floor or the mandibular The extent of this reduction depends on the depth be- nerve canal, for subsequent placement of the implant fore treatment and the degree to which the depth is the (Box 54-1). These methods are discusssed in Chapters 70 result of the edematous and inflammatory component of and 71. the pocket wall.

The Surgical Phase o f Therapy • CHAPTER 54 721 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com Whether the pocket remains inactive depends on its depth and the individual characteristics of the plaque components and the host response. Recurrence of the initial activity is likely. Inactive pockets can sometimes heal with a long junctional epithelium (see Fig. 54-2, top right). However, this condition also may be unstable, and the chance of recurrence and reformation of the original pocket is always present because the epithelial union to the tooth is weak. However, one study in monkeys has shown that the long junctional epithelial union may be as resistant to plaque infection as a normal connective tissue attachment. Studies have shown that inactive pockets can be maintained for long periods with little loss of attachment by means of frequent scaling and root planing procedures. A more reliable and stable result is obtained, however, by transforming the pocket into a healthy sulcus. The bottom of the healthy sulcus can be located either where the bottom of the pocket was localized or coronal to it. In the first case, there is no gain of attachment (see Fig. 54-2, bottom left) and the area of the root that was previously the tooth wall of the pocket becomes exposed. This does not mean that the periodontal treatment has caused recession, but rather that it has un- covered the recession previously induced by the disease. The healthy sulcus can also be located coronal to the bottom of the preexistent pocket (Fig. 54-2, bottom center and right). This is conducive to a restored marginal periodontium; the result is a sulcus of normal depth with gain of attachment. The creation of a healthy sulcus and a restored periodontium is termed regeneration and entails a total restoration of the status that existed before periodontal disease began. This is, of course, the ideal result of treatment.

POCKET ELIMINATION VERSUS Fig. 54-2 Possible results of pocket therapy. An active pocket can POCKET MAINTENANCE become inactive and heal by means of a long junctional epithe- li um. Surgical pocket therapy can result in a healthy sulcus, with or Pocket elimination (depth reduction to gingival sulcus without gain of attachment. Improved gingival attachment pro- levels) has traditionally been considered one of the main motes restoration of bone height, with reformation of periodontal goals of periodontal therapy. It was considered vital be- li gament fibers and layers of cementum. cause of the need to improve accessibility to root surfaces for the therapist during treatment and for the patient after healing. It is now the prevalent opinion that while in general the presence of deep pockets after therapy represents a greater risk of disease progression than shallow examined with a thin periodontal probe, but no pain, sites, individual probing depths per se are not good pre- exudate, or bleeding results; this appears to indicate that dictors of future clinical attachment loss.' The absence of no plaque has formed on the subgingival root surfaces. deep pockets in treated patients is, on the other hand, an These findings do not alter the indications for peri- excellent predictor of a stable periodontium. odontal surgery because the results obtained are based Longitudinal studies of different therapeutic modali- on surgical exposure of the root surfaces for a thorough ties, carried out in the last quarter century, have given and complete elimination of irritants. They do, however, somewhat conflicting results, 7,16 probably because of in- emphasize the importance of the maintenance phase herent problems created by the "split-mouth" design. In and the close monitoring of both level of attachment general, however, after surgical therapy, pockets that re- and pocket depth, together with the other clinical vari- bound to a shallow or moderate depth can be main- ables (bleeding, exudation, and tooth mobility). The tained in a healthy state and without radiographic evi- transformation of the initial deep, active pocket into a shal- dence of advancing bone loss by maintenance visits lower, inactive, maintainable one requires some form of defin- consisting of scaling and root planing, with oral hygiene itive pocket therapy and constant supervision thereafter. reinforcement performed at regular intervals of not more Pocket depth is an extremely useful and widely em- than 3 months. In these cases the residual pocket can be ployed clinical determination, but it must be evaluated

722 PART 5 • Treatment of Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com Zone 2: The Tooth Surface together with level of attachment and the presence of bleeding, exudation, and pain. The most important variable The presence of deposits and alterations on the cemen- for evaluating whether a pocket (or deep sulcus) is progres- tum surface and the accessibility of the root surface to sive is the level of attachment, which is measured in mil- instrumentation should be identified. Phase I therapy limeters from the cementoenamel junction; it is the apical should have solved many, if not all, of the problems on displacement of the level of attachment that places the the tooth surface. Evaluation of the results of Phase I tooth in jeopardy, not the increase in pocket depth, which therapy should determine the need for further therapy may be due to coronal displacement of the gingival margin. and the method to be used. Pocket depth remains an important clinical variable on which decisions about treatment selection can be Zone 3: The Bone based in part. Lindhe and colleagues compared the effect of root planing alone and in conjunction with a modified The shape and height of the alveolar bone next to the Widman flap on the resultant level of attachment and in pocket wall should be established by careful probing and relation to initial pocket depth.' They reported that scal- clinicoradiographic examination. Bony craters, horizon- ing and root planing procedures induce loss of attach- tal or angular bone losses, and other bone deformities ment if performed in pockets shallower than 2.9 mm, are important criteria for the selection of the treatment whereas gain of attachment occurs in deeper pockets. The technique. modified Widman flap induces loss of attachment if done in pockets shallower than 4.2 mm but results in a greater gain of attachment than root planing in pockets deeper Zone 4: The Attached Gingiva than 4.2 mm. The loss is a true loss of connective tissue The presence or absence of an adequate band of attached attachment, whereas the gain can be considered a false gingiva is a factor to be considered when selecting the gain owing to reduced penetrability of connective tissues pocket treatment method. Diagnostic techniques for apical to the bottom of the pocket after treatment.9,17 mucogingival problems are described in Chapter 66. An Furthermore, probing depths established following ac- inadequate attached gingiva may be due to a high tive therapy and healing (approximately 6 months after frenum attachment, marked gingival recession, or a deep treatment) can be maintained unchanged or reduced pocket that reaches the level of the mucogingival junc- even further during a maintenance care period involving tion. All of these possible conditions should be explored careful prophylaxis once every 3 months.' and their influence on pocket therapy determined. Ramfjord and associates and Rosling and colleagues13 showed that, regardless of the surgical technique used for I pocket therapy, a certain pocket depth recurs. Therefore NDICATIONS FOR PERIODONTAL SURGERY maintenance o f this depth without any further loss of attach- The following findings may indicate the need for a surgi- ment becomes the goal. cal phase of therapy: 1. Areas with irregular bony contours, deep craters, and REEVALU ATION AFTER PHASE I THERAP Y other defects usually require a surgical approach. 2. Pockets on teeth in which a complete removal of root The longitudinal studies mentioned previouslys have irritants is not considered clinically possible may call noted that all patients should be treated initially with for surgery. This occurs frequently in molar and pre- scaling and root planing and that a final decision on the molar areas. need for periodontal surgery should be made only after a 3. In cases of furcation involvement of Grade II or III, a thorough evaluation of the effects of Phase I therapy. surgical approach ensures the removal of irritants; The assessment is generally made no less than 1 to 3 any necessary root resection or hemisection also re- months and sometimes as much as 9 months after the quires surgical intervention. completion of Phase I therapy.' This reevaluation of the 4. Intrabony pockets on distal areas of last molars, fre- periodontal condition should include reprobing the en- quently complicated by mucogingival problems, are tire mouth, with rechecking for the presence of calculus, usually unresponsive to nonsurgical methods. root caries, defective restorations, and all signs of persis- 5. Persistent inflammation in areas with moderate to tent inflammation. deep pockets may require a surgical approach. In areas with shallow pockets or normal sulci, persistent in- CRITICAL ZONES IN POCKET SU RGERY flammation may point to the presence of a mucogingival problem that needs a surgical solution. Criteria for the selection of one of the different surgical techniques for pocket therapy are based on clinical findings in the soft tissue pocket wall, tooth surface, underly- METHODS OF POCKET THERAPY ing bone, and attached gingiva. The methods for pocket therapy can be classified under three main headings: Zone 1: The Soft Tissue Wall 1. New attachment techniques offer the ideal result The morphologic features, thickness, and topography of because they eliminate pocket depth by reuniting the the soft tissue pocket wall and persistence of inflamma- gingiva to the tooth at a position coronal to the tory changes in it should be determined. bottom of the preexisting pocket. New attachment is

The Surgical Phase o f Therapy • CHAPTER 54 723 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com usually associated with filling in of bone and regener- wall and 2) the pocket accessibility. The pocket wall can ation of periodontal ligament and cementum. be either edematous or fibrotic. Edematous tissue shrinks 2. Removal of the pocket wall is the most common after the elimination of local factors, thereby reducing or method. The wall of the pocket consists of soft tissue totally eliminating pocket depth. Therefore scaling and and may also include bone in the case of intrabony root planing is the technique of choice in these cases. pockets. It can be removed by the following: Pockets with a fibrotic wall are not appreciably re- • Retraction or shrinkage, in which scaling and duced in depth after scaling and root planing. They root planing procedures resolve the inflammatory therefore are eliminated surgically. Until recently, gin- process and the gingiva therefore shrinks, reducing givectomy was the only technique available, it solves the the pocket depth. problem successfully, but in cases of marked gingival en- • Surgical removal performed by the gingivectomy largement (e.g., severe phenytoin enlargement), it may technique or by means of an undisplaced flap. leave a large wound that goes through a painful and pro- • Apical displacement with an apically displaced longed healing process. In these cases, a modified flap flap. technique can adequately solve the problem with fewer 3. Removal of the tooth side of the pocket, which postoperative problems (see Chapter 59). is accomplished by tooth extraction or by partial tooth extraction (hemisection or root resection). Therapy for Slight Periodontitis. In slight or incipient periodontitis, bone loss has occurred to a small de- The techniques, what they accomplish, and the fac- gree and pockets are shallow to moderate. In these cases, a tors governing their selection are presented in Chapters conservative approach and adequate oral hygiene gener- 58 to 64. ally suffice to control the disease. Incipient periodontitis occurring as recurrence in previously treated sites may require a thorough analysis of the causes for the recurrence Criteria for Method Selection and, on occasions, a surgical approach to correct them. Scientific criteria to establish the indications for each technique are difficult to determine. Longitudinal stud- Therapy for Moderate to Severe Periodontitis in ies following a significant number of cases over a num- the Anterior Sector. The anterior teeth are impor- ber of years, standardizing multiple factors and many tant esthetically; therefore the techniques that induce variables, would be needed. Clinical experience, how- the least amount of visual root exposure should be con- ever, has suggested the criteria for selecting the method sidered first. However, the importance of esthetics may to be used to treat the pocket in individual cases. The se- be different for different patients, and nonelimination of lection of a technique for treatment of a particular peri- the pocket may place the tooth in jeopardy. The final de- odontal lesion is based on a number of considerations. cision may have to be a compromise between health and esthetics, not attaining ideal results in either respect. 1. Characteristics of the pocket: depth, relation to bone, and configuration. Anterior teeth offer some advantages to a conservative 2. Accessibility to instrumentation, including presence approach. First, they are all single rooted and easily accessible; second, patient's compliance and thoroughness of furcation involvements. in plaque control are easier to attain. Therefore scal- 3. Existence of mucogingival problems. ing and root planing is the technique of choice 4. Response to Phase I therapy. for the anterior teeth. 5. Patient cooperation, including ability to perform ef- Sometimes, however, a surgical technique may be fective oral hygiene and, for smokers, willingness to necessary owing to the need for improved accessibility stop their habit at least temporarily (i.e., a few weeks). for root planing or regenerative surgery of osseous de- 6. Age and general health of the patient. fects. The papilla preservation flap can be used for 7. Overall diagnosis of the case: various types of gingival both purposes and also offers a better postoperative re- enlargement and types of periodontitis (chronic mar- sult with less recession and reduced soft tissue crater for- ginal periodontitis, localized aggressive periodontitis, mation interproximally. 14 It is the first choice when generalized aggressive periodontitis, and so forth). a surgical approach is needed. 8. Esthetic considerations. When the teeth are too close interproximally, the 9. Previous periodontal treatments. papilla preservation technique may not be feasible, and a Each of these variables is analyzed in relation to technique that splits the papilla will have to be used. the pocket therapy techniques available, and a specific The sulcular incision flap offers good esthetic results technique is selected. Of the many techniques, the one and is the next choice. that would most successfully solve the problems with When esthetics are not the primary consideration, the the fewest undesirable effects should be chosen. Clini- so-called modified Widman flap can be chosen. This cians who adhere to one technique to solve all technique uses an internal bevel incision about 1 to problems do not use to the advantage of the pa- 2 mm from the gingival margin without thinning the tient the wide repertoire of techniques at their flap and may result in some small recession. disposal. In some infrequent cases, bone contouring may be needed despite the resultant root exposure. The tech- Therapy for Gingival Pockets. Two factors are nique of choice is the apically displaced flap with taken into consideration: 1) the character of the pocket bone contouring.

724 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com Therapy for Moderate to Severe Periodontitis in 2. Bower RC: Furcation morphology relative to periodontal the Posterior Area. Treatment for premolars and treatment. Furcation root surface anatomy. J Periodontol molars usually poses no esthetic problem but frequently 1979; 50:366. involves difficult accessibility. Bone defects are more 3. Caffesse RG, Sweeney PL, Smith BA: Scaling and root plan- frequent than in the anterior sector, and root morpho- ing with and without periodontal flap surgery. J Clin Peri- odontol 1986; 11:205. logic features, particularly in relation to furcations, may 4. Gher ME, Vernino AR: Root morphology-Clinical signifi- offer unsurmountable problems for instrumentation in a cance in pathogenesis and treatment of periodontal disease. close field. Therefore surgery is frequently indicated in J Am Dent Assoc 1980; 101:627. this region. 5. Greensteifl G: Contemporary interpretation of probing The purpose of surgery in the posterior area is either depth assessment: Diagnostic and therapeutic implications. enhanced accessibility or the need for definitive pocket A literature review. J Periodontol 1997; 68:1194. reduction requiring osseous surgery. Accessibility can be 6. Hill RW, Ramfjord SP, Morrison GC, et al: Four types of peri- obtained by either the undisplaced or apically displaced odontal treatment compared over two years. J Periodontol flap. 1981; 52:655. 7. Kaldahl WB, Kalkwarf KL, Patil KD: A review of longitudinal Most cases of moderate to severe periodontitis have studies that compared periodontal therapies. J Periodontol developed osseous defects that require some degree of 1993; 64:243. osseous remodeling or regenerative procedures. When 8. Lindhe J, Socransky SS, Nyman S, et al: Critical probing osseous defects amenable to regeneration are present, depths in periodontal therapy. J Clin Periodontol 1982; the papilla preservation flap is the technique of 9:323. choice because it better protects the interproximal areas 9. Magnusson 1, Runstad L, Nyman S, et al: A long junctional where defects are frequently present. Second and epithelium-A locus minoris resistentiae in plaque infec- third choices are the sulcular flap and the modi- tion. J Clin Periodontol 1983; 10:333. fied Widman flap, maintaining as much of the 10. Pihlstrom BL, Ortiz Campos C, McHugh RB: A randomized papilla as possible. four-year study of periodontal therapy. J Periodontol 1981; 52:227. When osseous defects with no possibility of reconstruc- 11. Rabbani GM, Ash MM, Caffesse RG: The effectiveness of tion, such as interdental craters, are present, the technique subgingival scaling and root planing in calculus removal. of choice is the flap with osseous contouring. J Periodontol 1981; 52:119. 12. Ramfjord SP, Knowles JW, Nissle RR, et al: Results following Surgical Techniques for Correction of Morpho- three modalities of periodontal therapy. J Periodontol 1975; logic Defects. The objectives and rationale for the 12:522. techniques performed to correct morphologic defects 13. Rosling B, Nyman S, Lindhe J, et al: The healing potential of (mucogingival, esthetic and preprosthetic) are given in the periodontal tissues following different techniques of pe- Chapter 66. riodontal surgery in plaque-free dentitions. A 2-year clinical study. J Clin Periodontol 1976; 3:233. 14. Takei HH, Han T J, Carranza FA Jr, et al: Flap technique for Surgical Techniques for Implant Placement and periodontal bone implants-The papilla preservation tech- Related Problems. The objectives and rationale nique. J Periodontol 1985; 56:204. for these techniques are described in Chapter 70. 15. Waerhaug J: Healing of the dentoepithelial junction following subgingival plaque control. 11. As observed on extracted REF ERENCES teeth. J Periodontol 1978; 40:119. 16. Weeks PR: Pros and cons of periodontal pocket elimination 1. Badersten A, Nilveus R, Egelberg J: Effect of nonsurgical pe- procedures. J Western Soc Periodontol 1980; 28:4. riodontal therapy. 11. Severely advanced periodontitis. J Clin 17. Westfelt E, Bragd L, Socransky SS, et al: Improved periodon- Periodontol 1984; 11:63. tal conditions following therapy. J Clin Periodontol 1985; 12:283.

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General Principles of Periodontal Surgery

Perry R. Klokkevold, Fermin A. Carranza, and Henry H. Takei

CHAPTER

CHAPTER OUTLINE

OUTPATIENT SURGERY The First Postoperative Week Preparation of the Patient Removal of the Periodontal Pack and Return Visit Emergency Equipment Care Measures to Prevent Transmission of Infection Care of the Mouth between Periodontal Sedation and Anesthesia Surgery Procedures Tissue Management Management of Postoperative Pain Scaling and Root Planing HOSPITAL PERIODONTAL SURGERY Hemostasis Indications Periodontal Dressings (Periodontal Packs) The Operation Instructions for the Patient after Surgery Postoperative Instructions

ll surgical procedures should be very carefully tissues more firm and consistent, thus permitting a more planned. The patient should be adequately pre- accurate and delicate surgery; and 3) acquaint the pa- pared medically, psychologically, and practically tient with the office and the operator and assistants, for all aspects of the intervention. This chapter thereby reducing the patient's apprehension and fear. covers the preparation of the patient and the general The reevaluation phase consists of reprobing and re- considerations common to all periodontal surgical tech- examining all the pertinent findings that previously in- niques. Complications that may occur during or after dicated the need for the surgical procedure. Persistence surgery are also discussed. of these findings confirms the indication for surgery. The Surgical periodontal procedures are usually performed number of surgical procedures, expected outcome, and in the dental office. Hospital periodontal surgery is dis- postoperative care necessary are all decided beforehand. cussed at the end of this chapter. These are discussed with the patient and a final decision is made, incorporating any necessary adjustments to the original plan. OUTPATIENT SURGERY Premeditation." For patients who are not med- Preparation of the Patient ically compromised, the value of administering antibi- Reevaluation after Phase I Therapy. Almost otics routinely for periodontal surgery has not been every patient undergoes the so-called initial or preparatory phase of therapy, which basically consists of thorough scaling and root planing and removing all irritants responsible for the periodontal inflammation. These pro- * Precautions to be taken with medically compromised patients can cedures 1) eliminate some lesions entirely, 2) render the be found in Chapter 38.

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clearly demonstrated,27 although some studies have re- Measures to Prevent Transmission of Infection ported reduced postoperative complications including In recent years, the danger of transmitting infections to reduced pain and swelling when antibiotics are given be- the dental team or other patients has become apparent, fore periodontal surgery and continuing for 4 to 7 days particularly with the threat of acquired immune defi- after surgery. 4,12,20,10 ciency syndrome (AIDS) and hepatitis B. Universal pre- The prophylactic use of antibiotics in patients who cautions, including protective attire, and barrier tech- are otherwise healthy has been advocated for bone-graft- niques are strongly recommended and often required ing procedures and has been claimed to enhance the by law. They include the use of disposable sterile chances of new attachment. Although the rationale for gloves, surgical masks, and protective eyewear. All sur- such use appears logical, no research evidence is avail- faces possibly contaminated with blood or saliva that able to support it. In any case, the risks inherent in the cannot be sterilized (such as light handles and unit sy- administration of antibiotics should be evaluated to- ringes) must be covered with aluminum foil or plastic gether with the potential benefits. wrap. Aerosol-producing devices, such as the Cavitron, Other presurgical medications include administration should not be used on patients with suspected infec- of a nonsteroidal, antiinflammatory drug such as ibupro- tions, and their use should be kept to a minimum in all fen (Motrin) 1 hour before the procedure and one oral other patients. Special care should be taken when using rinse with 0.12% chlorhexidine gluconate (Peridex or and disposing of sharp items such as needles and PerioGard). scalpel blades.

Smoking. The deleterious effect of smoking on healing of periodontal wounds has been amply docu- Sedation and Anesthesia mented (see also Chapter 14). Patients should be Periodontal surgery should be performed painlessly. The clearly informed of this fact and requested to quit or patient should be assured of this at the outset and stop smoking for a minimum of 3 to 4 weeks after the throughout the procedure. The most reliable means of procedure. For patients who are unwilling to follow this providing painless surgery is the effective administration advice, an alternate treatment plan not including highly of local anesthesia. The area to be treated should be thor- sophisticated techniques such as regenerative procedures oughly anesthetized by means of regional block and lo- and mucogingival and esthetic techniques should be cal infiltration injections. Injections directly into the in- considered. terdental papillae may also be helpful. Apprehensive and neurotic patients require special man- Informed Consent. The patient should be in- agement with antianxiety or sedative hypnotic agents. formed at the time of the initial visit about the diagno- Modalities for the administration of these agents include sis, prognosis, the different possible treatments with inhalation, oral, intramuscular, and intravenous routes. their expected results, and all pros and cons of each ap- The specific agents and modality of administration se- proach. At the time of surgery, the patient should again lected is based on the desired level of sedation, antici- be informed, verbally and in writing, of the procedure to pated length of the procedure, and overall condition of be performed, and he or she should indicate agreement the patient. Specifically, the medical history and physical by signing the consent form. and emotional status of the patient should be taken into consideration when selecting agents and techniques to be employed. Emergency Equipment Perhaps the simplest, least invasive method to allevi- The operator, all assistants, and office personnel should ate anxiety in the dental office is nitrous oxide and oxy- be trained to handle all the possible emergencies that gen inhalation sedation. For many individuals, this is may arise. Drugs and equipment for emergency use quite effective. Advantages include a quick onset of ac- should be readily available at all times. tion, the ability to adjust the level of sedation through- The most common emergency is syncope or a transient out the procedure, a rapid recovery, and little or no con- loss of consciousness due to a reduction in cerebral cern for postoperative impairment of sensory or motor blood flow. The most common cause is fear and anxiety. function. Disadvantages are few. A small percentage of Syncope is usually preceded by a feeling of weakness, patients will not achieve the desired effect. This is espe- and then the patient develops pallor, sweating, coldness cially true for the mentally impaired individual because of the extremities, dizziness, and slowing of the pulse. nitrous oxide and oxygen sedation requires some level of The patient should be placed in a supine position with patient cooperation. Overall, inhalation sedation with the legs elevated; tight clothes should be loosened, and a nitrous oxide and oxygen is a safe, effective and reliable wide-open airway ensured. Administration of oxygen is means of reducing mild anxiety. also useful. Unconsciousness persists for a few minutes. For individuals with mild to moderate anxiety, oral ad- A history of previous syncopal attacks during dental ap- ministration of a benzodiazepine can be effective in de- pointments should be explored before treatment is be- creasing anxiety and producing a level of relaxation. Oral gun, and, if these are reported, extra efforts to relieve the administration of a sedative agent can be more effective patient's fear and anxiety should be made. The reader is than inhalation anesthesia because the level of sedation referred to other texts' for a complete analysis of this im- achieved may be more profound. Disadvantages of oral portant topic. sedative administration include incomplete recovery, an

General Principles o f Periodontal Surgery • CHAPTER 55 727

Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com inability to control the level of sedation, and a prolonged surfaces should be carefully explored and planed as period of impaired sensory and motor skills. A variety of needed as part of the surgical procedure. In particular, ar- benzodiazepine agents are available for oral administra- eas of difficult access such as furcations or deep pockets tion. See Table 55-1 for a brief description of commonly often have rough areas or even calculus that was unde- used benzodiazepine agents, including dosage, onset of tected during the preparatory sessions. The assistant who action, and duration of effect (half-life). is retracting the tissues and using the aspirator should Intravenous (IV) administration of a benzodiazepine, also check for the presence of calculus and the smooth- alone or in combination with other agents, can be used ness of each surface from a different angle. to achieve a greater level of sedation in individuals with moderate to severe levels of anxiety. Furthermore, the Hemostasis onset of action of intravenous sedation is almost immediate and the level of sedation can be titrated, on an in- Hemostasis is an important aspect of periodontal surgery dividual basis, to the desired effect. The recovery period because good intraoperative control of bleeding permits depends on the half-life of the agent used and the an accurate visualization of the extent of disease, pattern amount given. The operator should receive formal train- of bone destruction, and anatomy and condition of the ing in the techniques of sedation; this often is required root surfaces. It provides the operator with a clear view by law. A thorough understanding of the indications, of the surgical site, which is essential for wound debride- contraindications, and risks of these agents is required .3 ment and scaling and root planing. In addition, good The reader is referred to other texts for a more detailed hemostasis also prevents excessive loss of blood into the discussion of conscious sedation techniques . 25 mouth, oropharynx, and stomach. Periodontal surgery can produce profuse bleeding, especially during the initial incisions and flap reflection. Tissue Management After flap reflection and removal of granulation tissue, 1. Operate gently and carefully. In addition to being most bleeding disappears or is considerably reduced. Typically, considerate to the patient, this is also the most effec- control of intraoperative bleeding can be managed with tive way to operate. Tissue manipulation should be aspiration. Continuous suctioning of the surgical site precise, deliberate, and gentle. Thoroughness is essen- with an aspirator is indispensable for performing peri- tial, but roughness must be avoided because it pro- odontal surgery. Application of pressure to the surgical duces excessive tissue injury, causes postoperative dis- wound with moist gauze can be a helpful adjunct to con- comfort, and delays healing. trol site specific bleeding. Intraoperative bleeding that is 2. Observe the patient at all times. It is essential to pay care- not controlled with these simple methods may indicate ful attention to the patient's reactions. Facial expres- a more serious problem and require additional control sions, pallor, and perspiration are some distinct signs measures. that may indicate the patient is experiencing pain, Excessive hemorrhaging following initial incisions anxiety, or fear. The doctor's responsiveness to these and flap reflection may be due to laceration of venules, signs can be the difference between success and failure. arterioles, or larger vessels. Fortunately, the laceration of 3. Be certain the instruments are sharp. Instruments must medium or large vessels is rare because incisions near be sharp to be effective; successful treatment is not highly vascular anatomic areas such as the posterior possible without sharp instruments. Dull instruments mandible (lingual and inferior alveolar arteries), and the inflict unnecessary trauma due to poor cutting and posterior, mid-palatal regions (greater palatine arteries) excessive force applied to compensate for their inef- are avoided in incision and flap design. Proper design of fectiveness. A sterile sharpening stone should be avail- the flaps, taking into consideration these areas, avoids able on the operating table at all times. accidents (see Chapter 56). However, even when all anatomic precautions are taken, it is possible to cause bleeding from medium or large vessels because anatomic Scaling and Root Planing variations do occur and may result in inadvertent lacera- Although scaling and root planing has been performed tion. If a medium or large vessel is lacerated, a suture previously as part of Phase I therapy, all exposed root around the bleeding end may be necessary to control

Oral Benzodiazepine Agents Commonly Used for Perioperative Antianxiety and Sedation

Generic Proprietary Adult Dose (mg) Onset (Hours) Half-Life (Hours) Alprazolam Xanax 0.25-0.5 1 -2 12-15 Diazepam Valium 2-10 0.5-2 30-70 Lorazepam Ativan 1 -4 1 -6 10-18 Triazolam Halcion 0.125-0.5 1 -2 1.5-5.5

728 PART 5 • Treatment o f Periodontal Disease

Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com hemorrhage. Pressure should be applied through the tis- scribes available, absorbable hemostatic agents useful in sue to determine the location that will stop blood flow the control of bleeding. in the severed vessel. Then a suture can be passed Absorbable gelatin sponge (Gelfoam), oxydized cellu- through the tissue and tied to restrict blood flow. lose (Oxycel), oxidized regenerated cellulose (Surgicel It is also possible to have excessive bleeding from a Absorbable Hemostat), and microfibrillar collagen hemo- surgical wound due to incisions across a capillary plexus. stat (Collacote, Collatape, Collaplug) are useful hemosta- Minor areas of persistent bleeding from capillaries can be tic agents for the control of capillaries, small blood ves- stopped by applying cold pressure to the site with moist sels, and deep wound bleeding. gauze (soaked in sterile ice water) for several minutes. Absorbable gelatin sponge is a porous matrix prepared The use of a local anesthetic with a vasoconstrictor may from pork skin that helps stabilize a normal blood clot. also be useful in controlling minor bleeding from the pe- The sponge can be cut to the desired dimensions and ei- riodontal flap. Both of these methods act via vasocon- ther sutured in place or positioned within the wound striction, thus reducing the flow of blood through in- (e.g., extraction socket). It is absorbed in 4 to 6 weeks. cised small vessels and capillaries. This action is Oxydized cellulose is a chemically modified form of sur- relatively short lived and should not be relied on for gical gauze that forms an artificial clot. The material is long-term hemostasis. It is important to avoid the use of friable and can be difficult to keep in place. It absorbs in vasoconstrictors to control bleeding prior to sending a 1 to 6 weeks. patient home. If a more serious bleeding problem exists Oxydized regenerated cellulose is prepared from cellulose or a firm blood clot is not established, bleeding is likely by reaction with alkali to form a chemically pure, more to reoccur when the vasoconstrictor has metabolized uniform structure than oxidized cellulose. The material and the patient is no longer in the office. is prepared in a cloth or thin gauze form that can be cut For slow, constant blood flow and oozing, hemostasis to the desired size and sutured or layered on the bleed- may be achieved with hemostatic agents. Table 55-2 de- ing surface. It can be used as a surface dressing because it

Absorbable Hemostatic Agents

Generic Name Brand Name Directions Adverse Effects Precautions Absorbable gelatin Gelfoam May be cut into various May form nidus for Should not be over- sponge sizes and applied to infection or abscess. packed into extraction bleeding surfaces. site or wound-may interfere with healing. Oxidized cellulose Oxycel Most effective when May cause foreign body Extremely friable and applied to wound reaction. difficult to place; dry as opposed to should not be used moistened. adjacent to bone- impairs bone regeneration; should not be used as a surface dressing-inhibits epithelialization. Oxidized Surgicel May be cut to various Encapsulation, cyst Should not be placed in regenerated Absorbable shapes and positioned formation, and foreign deep wounds-may cellulose Hemostat over bleeding sites; body reaction possible. physically interfere thick or excessive with wound healing amounts should not and bone formation. be used. Microfibrillar Collacote, May be cut to shape and May potentiate abscess May interfere with wound collagen Collatape, applied to bleeding formation, hematoma, healing; placement in hemostat Collaplug surface. and wound dehiscence; extraction sockets has possible allergic been associated with reaction or foreign increased pain. body reaction. Thrombin Thrombostat May be applied topically Allergic reaction can Must not be injected intc to bleeding surface. occur in patients with tissues or vasculature known sensitivity to because it can cause bovine materials. severe (possibly fatal) clotting.

General Principles o f Periodontal Surgery • CHAPTER 55 729

Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com does not impair epithelialization, and it is bactericidal immediately before use until a uniform color is obtained. against many gram-negative and gram-positive microor- One tube contains zinc oxide, an oil (for plasticity), a ganisms, both aerobic and anaerobic. Caution should be gum (for cohesiveness), and lorothidol (a fungicide); the used when wounds are infected or have an increased po- other tube contains liquid coconut fatty acids thickened tential to becoming infected (e.g., immunocompromised with colophony resin (or rosin) and chlorothymol (a patients) because the absorbable hemostatic agents can bacteriostatic agent). This dressing does not contain serve as a nidus for infection. asbestos or eugenol, thereby avoiding the problems asso- Thrombin is a drug capable of hastening the process of ciated with these substances. blood clotting. It is intended for topical use only because Other noneugenol packs include cyanoacrylates6.8 ,21 is applied as a liquid or powder. Thrombin should never and tissue conditioners (methacrylate gels) . 2 However, be injected into tissues because it can cause serious, even these are not commonly used. fatal intravascular coagulation. Also, because thrombin is a bovine-derived material, caution should be used for any Retention of Packs. Periodontal dressings are usu- patient with known allergic reaction to bovine products. ally kept in place mechanically by interlocking in inter- Finally, it is imperative to recognize that excessive dental spaces and joining the lingual and facial portions bleeding may be due to systemic disorders, including but of the pack. not limited to platelet deficiencies, coagulation defects, In isolated teeth or when several teeth in an arch are medications, and hypertension. As a precaution, all sur- missing, retention of the pack may be difficult. Numer- gical patients should be asked about current medications ous reinforcements and splints and stents for this pur- that may contribute to bleeding, any family history of pose have been described. 16,17,44 Placement of dental floss bleeding disorders, and hypertension. All patients, re- tied loosely around the teeth enhances retention of the gardless of health history, should have their blood pres- pack. sure evaluated prior to surgery, and anyone diagnosed with hypertension must be advised to see a physician be- Antibacterial Properties of Packs. Improved fore surgery. Patients with known or suspected bleeding healing and patient comfort with less odor and taste' deficiencies or disorders must be carefully evaluated be- have been obtained by incorporating antibiotics in the fore any surgical procedure. A consultation with the pa- pack. Bacitracin,5 oxytetracycline (Terramycin),13 neomy- tient's physician is recommended and laboratory tests cin, and nitrofurazone have been tried, but all may pro- should be done to assess the risk of bleeding. It may be duce hypersensitivity reactions. The emergence of resis- necessary to refer the patient to a hematologist for a tant organisms and opportunistic infection have been reported. comprehensive work-up. Incorporation of tetracycline powder in Coe-Pak is generally recommended, particularly when long and Periodontal Dressings (Periodontal Packs) traumatic surgeries are performed. In most cases, after the surgical periodontal procedures are completed, the area is covered with a surgical pack. Allergy. Contact allergy to eugenol and rosin has In general, dressings have no curative properties; they as- been reported .32 sist healing by protecting the tissue rather than providing "healing factors." The pack minimizes the likelihood Preparation and Application of the Periodontal of postoperative infection and hemorrhage, facilitates Dressing. Zinc oxide packs are mixed with eugenol healing by preventing surface trauma during mastica- or noneugenol liquids on a wax paper pad with a tion, and protects against pain induced by contact of the wooden tongue depressor. The powder is gradually incor- wound with food or the tongue during mastication. For porated with the liquid until a thick paste is formed. a complete literature review on this subject, the reader is Coe-Pak is prepared by mixing equal lengths of paste referred to the work by Sachs et alas from tubes containing the accelerator and the base until the resulting paste is a uniform color. A capsule of tetra- Zinc Oxide-Eugenol Packs. Packs based on the cycline powder can be added at this time. The pack is reaction of zinc oxide and eugenol include the Wondr- then placed in a cup of water at room temperature. In 2 Pak developed by Ward in 1923 and several others that to 3 minutes, the paste loses its tackiness (Fig. 55-1) and modified Ward's original formula. The addition of accel- can be handled and molded; it remains workable for 15 erators such as zinc acetate gives the dressing a better to 20 minutes. Working time can be shortened by working time. adding a small amount of zinc oxide to the accelerator Zinc oxide-eugenol dressings are supplied as a liquid (pink paste) before spatulating. and a powder that are mixed prior to use. Eugenol in this The pack is then rolled into two strips approximately type of pack may induce an allergic reaction that pro- the length of the treated area. The end of one strip is duces reddening of the area and burning pain in some bent into a hook shape and fitted around the distal sur- patients. face of the last tooth, approaching it from the distal surface (Fig. 55-2, A). The remainder of the strip is brought Noneugenol Packs. The reaction between a forward along the facial surface to the midline and gen- metallic oxide and fatty acids is the basis for Coe-Pak, tly pressed into place along the gingival margin and which is the most widely used dressing in the U.S. This is interproximally. The second strip is applied from the lin- supplied in two tubes, the contents of which are mixed gual surface. It is joined to the pack at the distal surface 730 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 55-1 Preparing the surgical pack (Coe-Pak). A, Equal lengths of the two pastes are placed on a paper pad. B, Pastes are mixed with a wooden tongue depressor for 2 or 3 minutes until the paste loses its tackiness (C). D, Paste is placed in a paper cup of water at room temperature. With lubricated fingers, it is then rolled into cylinders and placed on the surgical wound.

of the last tooth, then brought forward along the gingival margin to the midline (Fig. 55-2, B). The strips are joined interproximally by applying gentle pressure on the facial and lingual surfaces of the pack (Fig. 55-2, C. For isolated teeth separated by edentulous spaces, the pack should be made continuous from tooth to tooth, covering the edentulous areas (Fig. 55-3). When split flaps have been performed, the area should be covered with tin foil to protect the sutures before placing the pack (see Chapter 60). The pack should cover the gingiva, but overexten- sions onto uninvolved mucosa should be avoided. Excess pack irritates the mucobuccal fold and floor of the mouth and interferes with the tongue. Overextension also jeopardizes the remainder of the pack because the excess tends to break off, taking pack from the operated area with it. Pack that interferes with the occlusion should be trimmed away before the patient is dismissed (Fig. 55-4). Failure to do this causes discomfort and jeopardizes retention of the pack. The operator should ask the patient to move the tongue forcibly out and to each side, and the cheek and lips should be displaced in all directions to mold the pack while it is still soft. After the pack has set, it should be trimmed to eliminate all excess. As a general rule, the pack is kept on for 1 week after surgery. This guideline is based on the usual timetable of healing and clinical experience. It is not a rigid require- Fig. 55-2 Inserting the periodontal pack. A, A strip of pack is ment; the period may be extended, or the area may be hooked around the last molar and pressed into place anteriorly. repacked for an additional week. B, The lingual pack is joined to the facial strip at the distal surface Fragments of the surface of the pack may come off of the last molar and fitted into place anteriorly. C, Gentle pressure during the week, but this presents no problem. If a por- on the facial and lingual surfaces joins the pack interproximally. tion of the pack is lost from the operated area and the

General Principles o f Periodontal Surgery • CHAPTER 55 73 1 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com ually diminishing severity is a favorable sign. The pack should be removed and the gingiva checked for localized areas of infection or irritation, which should be cleaned or incised to provide drainage. Particles of calculus that may have been overlooked should be removed. Relieving the occlusion is usually helpful. Sensitivity to percussion may also be caused by excess Fig. 55-3 Continuous pack covers the edentulous space. pack, which interferes with the occlusion. Removal of the excess usually corrects the condition. 3. Swelling. Sometimes within the first 2 postoperative days, patients report a soft, painless swelling of the cheek in the area of operation. Lymph node enlargement may occur, and the temperature may be slightly elevated. The area of operation itself is usually symptom free. This type of involvement results from a localized inflammatory reaction to the operative procedure. It generally subsides by the fourth postoperative day, without necessitating removal of the pack. If swelling persists, becomes worse, or is associated with increased pain, then amoxyicillin, 500 mg should be taken every 8 hours for 1 week, and the patient should also be instructed to apply moist heat intermittently over the area. The antibiotic should also be used as a prophylactic measure after the next opera- Fig. 55-4 The pack should not interfere with the occlusion. tion, starting before the surgical appointment. 4. Feeling of weakness. Occasionally, patients report having experienced a "washed-out," weakened feeling for patient is uncomfortable, it is usually best to repack the about 24 hours after the operation. This represents a area. The clinician should remove the remaining pack, systemic reaction to a transient bacteremia induced wash the area with warm water, and apply a topical anes- by the operative procedure. It is prevented by premed- thetic before replacing the pack, which is then retained ication with amoxycillin, 500 mg every 8 hours, be- for 1 week. Again, patients may develop pain from an ginning 24 hours before the next operation and con- overextended margin that irritates the vestibule, floor of tinuing for a 5-day postoperative period. the mouth, or tongue. The excess pack should be trimmed away, making sure that the new margin is not Removal of the Periodontal Pack and rough, before the patient is dismissed. Return Visit Care When the patient returns after 1 week, the pack is taken Instructions for the Patient after Surgery off by inserting a surgical hoe along the margin and exerting gentle lateral pressure. Pieces of pack retained in- After the pack is placed, printed instructions are given to terproximally and particles adhering to the tooth surfaces the patient to be read before he or she leaves the chair are removed with scalers. Particles may be enmeshed in (Box 55-1). the cut surface and should be carefully picked off with fine cotton pliers. The entire area is rinsed with peroxide The First Postoperative Week to remove superficial debris.

Properly performed, periodontal surgery presents no seri- The following are ous postoperative problems. Patients should be told Findings at Pack Removal. to rinse with 0.12% chlorhexidine gluconate (Peridex, usual when the pack is removed: PerioGard) immediately after the surgical procedure and If a gingivectomy has been performed, the cut surface is twice daily thereafter until normal plaque control tech- covered with a friable meshwork of new epithelium, . 28-36,42 The following complica- nique can be resumed which should not be disturbed. If calculus has not tions may arise in the first postoperative week, although been completely removed, red, beadlike protuber- they are the exception rather than the rule: ances of granulation tissue will persist. The granula- 1. Persistent bleeding after surgery. The pack is removed, the tion tissue must be removed with a curette, exposing bleeding points are located, and the bleeding is the calculus so that it can be removed and the root stopped with pressure, electrosurgery, or electrocautery. can be planed. Removal of the granulation tissue After the bleeding is stopped, the area is repacked. without removal of calculus is followed by recurrence. 2. Sensitivity to percussion. Sensitivity to percussion may After a flap operation, the areas corresponding to the inci- be caused by the extension of inflammation into the sions are epithelialized but may bleed readily when periodontal ligament. The patient should be ques- touched; they should not be disturbed. Pockets tioned regarding the progress of the symptoms. Grad- should not be probed.

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Patient Instructions after Surgery

Instructions for (Patient's Name) give up smoking. In addition to all other well-known health The following information on your gum operation has been risks, smokers have more gum disease than nonsmokers. prepared to answer questions you may have about how to Do not brush over the pack. Brush and floss the areas of the take care of your mouth. Please read the instructions care- mouth not covered by the pack, as normal. Use chlorhexi- fully; our patients have found them very helpful. dine (Peridex, PerioGard) mouthrinses after brushing (the Although there will be little or no discomfort when the prescription for this mouthrinse has been given to you). anesthesia wears off, you should take two acetaminophen During the first day, apply ice intermittently on the face (Tylenol) tablets every 6 hours for the first 24 hours. After over the operated area. It is also beneficial to suck on ice that, take the same medication if you have some discom- chips intermittently during the first 24 hours. These methods fort. Do not take aspirin, as this may increase bleeding. will keep tissues cool and reduce inflammation and swelling. We have placed a periodontal pack over your gums to You may experience a slight feeling of weakness or chills protect them from irritation. The pack prevents pain, aids during the first 24 hours. This should not be cause for alarm healing, and enables you to carry on most of your usual ac- but should be reported at the next visit. Follow your regular tivities in comfort. The pack will harden in a few hours, after daily activities, but avoid excessive exertion of any type. Golf, which it can withstand most of the forces of chewing with- tennis, skiing, bowling, swimming, or sunbathing should be out breaking off. It may take a little while to become accus- postponed for a few days after the operation. tomed to it. Swelling is not unusual, particularly in areas that required The pack should remain in place until it is removed in the extensive surgical procedures. The swelling generally begins office at the next appointment. If particles of the pack chip 1 to 2 days after the operation and subsides gradually in 3 off during the week, do not be concerned as long as you do or 4 days. If this occurs, apply moist heat over the operated not have pain. If a piece of the pack breaks off and you are area. If the swelling is painful or appears to become worse, in pain, or if a rough edge irritates your tongue or cheek, please call the office. please call the office. The problem can be easily remedied Occasional blood stains in the saliva may occur for the by replacing the pack. first 4 or 5 hours after the operation. This is not unusual and For the first 3 hours after the operation, avoid hot foods to will correct itself. If there is considerable bleeding beyond permit the pack to harden. It is also convenient to avoid hot this, take a piece of gauze, form it into the shape of a U, liquids during the first 24 hours. You can eat anything you hold it in the thumb and index finger, apply it to both sides can manage, but try to chew on the nonoperated side of of the pack, and hold it there under pressure for 20 min- your mouth. Semisolid or finely minced foods are sug- utes. Do not remove it during this period to examine it. If gested. Avoid citrus fruits or fruit juices, highly spiced foods, the bleeding does not stop at the end of 20 minutes, please and alcoholic beverages; these will cause pain. Food supple- contact the office. Do not try to stop bleeding by rinsing. ments, or vitamins are generally not necessary. After the pack is removed, the gums most likely will Do not smoke. The heat and smoke will irritate your gums, bleed more than they did before the operation. This is per- and the immunologic effects of nicotine will delay healing fectly normal in the early stage of healing and will gradually and prevent a completely successful outcome of the proce- subside. Do not stop cleaning because of it. dure performed. If at all possible, use this opportunity to If any other problems arise, please call the office.

General Principles of Periodontal Surgery • CHAPTER 55 733 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com The facial and lingual mucosa may be covered with a showed that mucogingival procedures result in six times grayish-yellow or white granular layer of food debris more discomfort and osseous surgery in 3.5 times more that has seeped under the pack. This is easily removed discomfort than plastic gingival surgery. In the few cases with a moist cotton pellet. The root surfaces may be in which severe pain may be present, its control then be- sensitive to a probe or to thermal changes, and the comes an important part of patient management.27 teeth may be stained. A common source of postoperative pain is overexten- Fragments of calculus delay healing. Each root surface sion of the periodontal pack onto the soft tissue beyond should be rechecked visually to be certain that no cal- the mucogingival junction or onto the frena. Overex- culus is present. Sometimes the color of the calculus is tended packs cause localized areas of edema, usually no- similar to that of the root. The grooves on proximal ticed 1 to 2 days after surgery. Removal of excess pack is root surfaces and the furcations are areas in which cal- followed by resolution in about 24 hours. Extensive and culus is likely to be overlooked. excessively prolonged exposure and dryness of bone also induce severe pain. Repacking. After the pack is removed, it is usually For most healthy patients, a preoperative dose of not necessary to replace it. However, it is advisable to ibuprofen (600 to 800 mg) followed by one tablet every repack for an additional week for patients with 1) a low 8 hours for 24 to 48 hours is very effective in reducing pain threshold who are particularly uncomfortable when discomfort after periodontal therapy. Patients are advised the pack is removed, 2) unusually extensive periodontal to continue taking ibuprofen or change to aceta- involvement, or 3) slow healing. Clinical judgement minophen if needed thereafter. If pain persists, aceta- helps in deciding whether to repack the area or leave the minophen plus codeine (Tylenol #3) can be prescribed. initial pack on longer than 1 week. Caution should be used in prescribing or dispensing ibuprofen to patients with hypertension controlled by Tooth Mobility. Tooth mobility is increased im- medications because it can interfere with the effective- mediately after surgery,' but it diminishes below the pre- ness of the medication. treatment level by the fourth week.24 When severe postoperative pain is present, the patient should be seen at the office on an emergency basis. The area is anesthetized by infiltration or topically, the pack is Care of the Mouth between Periodontal removed, and the wound is examined. Postoperative pain Surgery Procedures related to infection is accompanied by localized lym- Care of the mouth by the patient between the treatment phadenopathy and a slight elevation in temperature. It of the first and the final areas, as well as after surgery is should be treated with systemic antibiotics and analgesics. completed, is extremely important . 45 These measures should begin after the pack is removed from the first op- Treatment of Sensitive Roots. Root hypersensi- eration. The patient has been through a presurgical pe- tivity is a relatively common problem in periodontal riod of instructed plaque control and should be rein- practice. It may occur spontaneously when the root be- structed at this time. comes exposed as a result of gingival recession or pocket Vigorous brushing is not feasible during the first week formation, or it may appear after scaling and root plan- after the pack is removed. However, the patient is in- ing and surgical procedures.* It is manifested as pain informed that plaque and food accumulation retard heal- duced by cold or hot temperature, more commonly cold; ing and is advised to try to keep the area as clean as pos- by citrus fruits or sweets; or by contact with a tooth- sible by the gentle use of soft toothbrushes and light brush or a dental instrument. water irrigation. Rinsing with a chlorhexidine mouth- Root sensitivity occurs more frequently in the cervical wash or its topical application with cotton-tipped appli- area of the root, where the cementum is extremely thin. cators (Q-tips) is indicated for the first few postoperative Scaling and root planing procedures remove this thin ce- weeks, particularly in advanced cases. Brushing is intro- mentum, inducing the hypersensitivity. duced when healing of the tissues permits it; the vigor of Transmission of stimuli from the surface of the dentin the overall hygiene regimen is increased as healing pro- to the nerve endings located in the dental pulp or in the gresses. Patients should be told that there be more gingi- pulpal region of the dentin could occur through the val bleeding will most likely occur than before the opera- odontoblastic process or owing to a hydrodynamic mech- tion, that it is perfectly normal and will subside as anism (displacement of dentinal fluid). The latter process healing progresses, and that it should not deter them seems more likely and would explain the importance of from following their oral hygiene regimen. burnishing desensitizing agents to obturate the dentinal tubule. An important factor for reducing or eliminating hy- Management of Postoperative Pain persensitivity is adequate plaque control. However, hy- Periodontal surgery performed following the basic prin- persensitivity may prevent plaque control, and therefore ciples outlined here should produce only minor pain a vicious circle of escalating hypersensitivity and plaque and discomfort.38 One study of 304 consecutive peri- accumulation may be created. odontal surgical interventions revealed that 51.3% of the patients reported minimal or no postoperative pain, and only 4.6% reported severe pain. Of these, only 20.1% * For a complete review of the literature, see Curro FA: Tooth took five or more doses of analgesic.11 The same study hypersensitivity. Dent Clin North Am 1990; 34(3):403.'°

73 4 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com DESENSITIZING AGENTS. A number of agents coating (varnish or bonding agent) on the root surface. have been proposed to control root hypersensitivity. The reader is again referred to the Towbridge and Silver" Clinical evaluation of the many agents proposed is diffi- for a more detailed consideration of these methods. cult because 1) measuring and comparing pain between Several agents have been used to precipitate crys- different persons is difficult, 2) hypersensitivity disap- talline salts on the dentin surface in an attempt to oc- pears by itself after a time, and 3) desensitizing agents clude the dentinal tubules. Fluoride solutions and pastes usually take a few weeks to act. historically have been the agents of choice. In addition The patient should be informed about the possibility to their antisensitivity properties, they have the advan- of root hypersensitivity before treatment is undertaken. tage of anticaries activity, which is particularly impor- The following information on how to cope with the tant for patients with a tendency to develop root caries. problem should also be given to the patient: However, certain agents such as chlorhexidine, decrease 1. Hypersensitivity appears as a result of the exposure of the ability of fluoride to bind with calcium on the root dentin, which is inevitable if calculus and plaque and surfaces.' Thus it is important to advise patients not to their products, buried in the root, are to be removed. rinse or eat for 1 hour after a desensitizing treatment. 2. Hypersensitivity slowly disappears over a few weeks. Currently, potassium and ferric oxalate solutions are the 3. Plaque control is important for the reduction of hy- preferred agents. They form insoluble calcium oxalate persensitivity. crystals that occlude the dentinal tubules.26,28 Potassium Protect 4. oxalate is available under the name and ferric ox- Desensitizing agents do not produce immediate relief. alate under the name They have to be used for several days or even weeks to Sensodyne Sealant. Special applica- produce results. tors have been developed for their use. A newer method of treatment for hypersensitive Desensitizing agents can be applied by the patient at dentin is the use of varnishes or dentin bonding agents home or by the dentist or hygienist in the dental office. to occlude dentinal tubules. Newer restorative materials, The most likely mechanism of action is the reduction in such as glass-ionomer cements and dentine bonding the diameter of the dentinal tubules so as to limit the agents, are still under investigation, but when the tooth displacement of fluid in them. According to Trowbridge needs recontouring or difficult cases do not respond to and Silver,40 this can be attained by 1) formation of a other treatments, the dentist may choose to use a smear layer produced by burnishing the exposed surface, restorative material. Resin primers alone could be 2) topical application of agents that form insoluble pre- promising, but the effects are not permanent and inves- cipitates within the tubules, 3) impregnation of tubules tigations are ongoing.14 with plastic resins, or 4) sealing of the tubules with plas- Despite some successes in decreasing dentin hyper- tic resins. sensitivity, it is important to note that these "dental of- Agents used by the Patient. The most common fice" treatments have not been a predictable means of agents used by the patient for oral hygiene are denti- solving hypersensitivity and the success achieved is of- frices. Although many dentifrice products contain fluo- ten short lived. The crystalline salts and/or varnishes and ride, additional active ingredients for desensitization are strontium chloride, potassium nitrate and sodium citrate. The following dentifrices have been approved by the American Dental Association for desensitizing purposes: Sensodyne, and Thermodent, which contain strontium Office Treatments for Dentinal Hypersensitivity chloride Crest Sensitivity Protection, Denquel, and Promise, which contain potassium nitrate1-9; and Protect, which contains sodium citrate. Fluoride rinsing solutions and gels can also be used after the usual plaque control procedures. 39 Patients should be aware that several factors must be considered in the treatment of tooth hypersensitivity, including the history and severity of the problem as well as the physical findings of the tooth or teeth involved. A proper diagnosis is required before any treatment can be initiated so that pathologic causes of pain (e.g., caries, cracked tooth, pulpitis) can be ruled out before attempting to treat hypersensitivity. Desensitizing agents act via the precipitation of crystalline salts on the dentin surface, which block dentinal tubules. Patients must be aware that their use will not prove to be effective unless used continuously for a period of at least 2 weeks. Agents used in the Dental Office. Box 55-2 lists various office treatments for the desensitization of hypersensitive dentin. These products and treatments aim to From Trowbridge HO, Silver DR: A review of current approaches to decrease hypersensitivity via blocking dentinal tubules i n-office management of tooth hypersensitivity. Dent Clin North with either a crystalline salt precipitation or an applied Am 1990; 34(3):566.

General Principles o f Periodontal Surgery • CHAPTER 55 735 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com sealants can be washed away over time, and hypersensi- dressing applications. For a variety of other reasons, pa- tivity may return. When this occurs, patients can have tients may desire to attend to their surgical needs in one sensitive root surfaces treated again. session under optimal conditions. Recently, attempts have been made to improve the success and longevity of these treatments using lasers. Patient Protection. Some patients have systemic Low-level laser "melting" of the dentin surface appears conditions that are not severe enough to contraindicate to seal dentinal tubules without damage to the pulp. elective surgery but may require special precautions best Finally, in a combined treatment modality, the Nd:YAG provided in a hospital setting. This includes some pa- laser has been used to congeal fluoride varnish on root tients with cardiovascular disease, abnormal bleeding surfaces. This in vitro study demonstrated that the laser tendencies, or hyperthyroidism; those undergoing pro- treated fluoride varnish resisted removal by electric longed steroid therapy; and those with a history of toothbrushing, with 90% of tubules remaining blocked rheumatic fever. while in the controls (no laser treatment) the fluoride The purpose o f hospitalization is to protect patients by an- varnish was almost completely brushed away.22 Despite ticipating their special needs, not to perform periodontal these convincing preliminary results, more research is surgery when it is contraindicated by the patient's general needed before laser treatment can be considered an ef- condition. For some patients, elective surgery is con- fective and predictable means of desensitization. Further- traindicated regardless of whether it is performed in the more, laser treatment is expensive and has the potential dental office or hospital. When consultation with the pa- to cause pulp damage. tient's physician leads to this decision, palliative periodontal therapy, in the form of scaling and root planing if permissible, is the necessary compromise. HOSPITAL PERIODONTAL SURGERY Ordinarily, periodontal surgery is an office procedure Premedication. Patients should be given a seda- performed in quadrants or sextants, usually at biweekly tive the night before surgery. Benzodiazepines work well or longer intervals. Under certain circumstances, how- for most patients, allowing the patient to sleep well the ever, it is in the best interest of the patient to treat the night before surgery. If the patient is extremely nervous mouth in one operation with the patient treated in a about the procedure, it is also helpful to advise them to hospital operating room under general anesthesia. Indi- take a benzodiazepine on the morning of surgery. This cations for hospital periodontal surgery include optimal ensures that they will be rested and as relaxed as possible control and management of apprehension, convenience before surgery. for individuals who cannot endure multiple visits to Patients with systemic problems (history of rheumatic complete surgical treatment, and patient protection. fever, cardiovascular problems, etc.) are premedicated as needed (see Chapter 38).

I ndications Anesthesia. Local or general anesthesia25 may be The Apprehensive Patient. Gentleness, under- used. Local anesthesia is the method of choice, except standing, and preoperative sedation usually suffice to for especially apprehensive patients. It permits unham- calm the fears of most patients. For some patients, how- pered movement of the head, which is necessary for op- ever, the prospect of a series of surgical procedures is suf- timal visibility and accessibility to the various root sur- ficiently stressful to trigger disturbances that jeopardize faces. Local anesthesia is used in the same manner as for the well-being of the patient and hamper treatment. Ex- routine periodontal surgery. plaining that the treatment at the hospital will be per- When general anesthesia is indicated, it is administered formed painlessly and that it will be accomplished by a by an anesthesiologist. It is important that the patient also level of anesthesia that is neither practical nor safe for receive local anesthesia, administered as for routine peri- patients in a dental office is an important step in allay- odontal surgery, to ensure comfort for the patient and ing their fears. The thought of completing the necessary reduced bleeding during the procedure. The judicious surgical procedures in one session rather than in re- use of local anesthetics to block regional nerves allows peated visits is an added comfort to the patient because the level of sedation or general anesthesia to be lighter. it eliminates the prospect of repeated anxiety in antici- Hence the entire operation is performed with a wider pation of each treatment. margin of safety.

mouth Patient Convenience. With complete The Operation surgery, there is less stress for the patient and less time involved in postoperative care. For patients whose occu- Surgery in the operating room is performed on the oper- pation entails considerable contact with the public, ating table with the patient lying down and the table ei- surgery performed at biweekly intervals sometimes pre- ther positioned flat or with the head inclined up to 30 sents a special problem. It means that for a period of sev- degrees. Some operating rooms are equipped with dental eral weeks, some area of the mouth will be covered by a chairs that can be used either flat or up to 30 degrees. periodontal pack. With the complete mouth technique, When general anesthesia is used, it is advisable to delay the pack is ordinarily retained for only 1 week. Patients placing the periodontal dressing until the patient has re- find this an acceptable alternative to several weeks of dis- covered sufficiently to have a demonstrable cough reflex. comfort in different areas of the mouth and multiple Periodontal dressings placed before the end of general

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anesthesia can be displaced during the recovery period 20. Kidd EA, Wade AB: Penicillin control of swelling and pain and pose serious risks of blocking the airway. after periodontal osseous surgery. J Clin Periodontol 1974; 1:52. 21. Lan WH, Liu HC: Treatment of dentin hypersensitivity by Postoperative Instructions Nd:YAG laser. J Clin Laser Med Surg 1996; 14:89. After a full recovery from general anesthesia, most pa- 22. Lan WH, Liu HC, Lin CP: The combined occluding effect of sodium fluoride varnish and Nd:YAG laser irradiation on tients can be discharged home with a responsible adult. human dentinal tubules. J Endod. 1999; 25:424. The effects of general anesthesia and sedative agents 23. Levin MP, Cutright DE, Bhaskar SN: Cyanoacrylate as a peri- make the patient drowsy for hours, recommending adult odontal dressing. J Oral Med 1975; 30:40. supervision at home for up to 24 hours after surgery. The 24. Majewski I, Sponholz H: Ergebnisse nach parodonal thera- typical postoperative instructions should be given to the peutischen Massnahmen unter besonderer Berucksichtigung responsible adult and the patient should be scheduled der Zahnbeweglichkeitssung mit dem Makroperiodontome- for a postoperative visit in 1 week. ter nach Muhlemann. Zahnaerztl Rundsch 1966; 75:57. 25. Malamed SF: Sedation. A Guide to Patient Management, ed REFERENCES 7. St Louis, Mosby, in press. 26. Miller JT, Shannon KL, Kilyore WG, et al: Use of water-free 1. ADA Guide to Dental Therapeutics, ed 1. Chicago, ADA, stannous fluoride-containing gel in the control of dental 1998. hypersensitivity. J Periodontol 1969; 40:490. 2. Addy M, Douglas WH: A chlorhexidine-containing metha- 27. Murphy NC, DeMarco TJ: Controlling pain in periodontal crylic gel as a periodontal dressing. J Periodontol 1975; patients. Dent Survey 1979; 55:46. 46:465. 28. Newman MG, Sanz M, Nachnani S, et al: Effect of 0.12% 3. Allen GD: Dental Anesthesia and Analgesia (Local and Gen- chlorhexidine on bacterial recolonization after periodontal eral), ed 3. Baltimore, Williams & Wilkins, 1984. surgery. J Periodontol 1989; 60:577. 4. Ariaudo AA: The efficacy of antibiotics in periodontal 29. Pack PO, Haber J: The incidence of clinical infection after surgery. J Periodontol 1969; 40:150. periodontal surgery. A retrospective study. J Periodontol 5. Baer PN, Goldman HM, Scigliano J: Studies on a bacitracin 1983; 54:441. periodontal dressing. Oral Surg 1958; 11:712. 30. Pendrill K, Reddy J: The use of prophylactic penicillin in pe- 6. Baer PN, Summer CF III, Miller G: Periodontal dressings. riodontal surgery. J Periodontol 1980; 51:44. Dent Clin North Am 1969; 13:181. 31. Preber H, Bergstrom J: Effect of cigarette smoking on peri- 7. Blitzer B: A consideration of the possible causes of dental odontal healing following surgical therapy. J Clin Periodon- hypersensitivity: Treatment by a strontium ion dentifrice. tol 1990; 17:324. Periodontics 1967; 5:318. 32. Romanow 1: Allergic reactions to periodontal pack. J Peri- 8. Burch J, Conroy CW, Ferris RT: Tooth mobility following odontol 1957; 28:151. gingivectomy. A study of gingival support of the teeth. Peri- 33. Romanow 1: Relationship of moniliasis to the presence of odontics 1960; 6:90. antibiotics in periodontal packs. Periodontics 1964; 2:298. 9. Collins JF, Gingold J, Stanley H, et al: Reducing dentinal hy- 34. Ross MR: Hypersensitive teeth: Effect of strontium chloride persensitivity with strontium chloride and potassium ni- in a compatible dentifrice. J Periodontol 1961; 32:49. trate. Gen Dent 1984; 32:40. 35. Sachs HA, Fanroush A, Checchi L, et al: Current status of 10. Curro FA: Tooth hypersensitivity. Dent Clin North Am periodontal dressings. J Periodontol 1984; 55:689. 1990; 34(3):403. 36. Sanz M, Newman MG, Anderson L, et al: Clinical enhance- 11. Curtis JW Jr, McLain JB, Hutchinson RA: The incidence and ment of post-periodontal surgical therapy by 0.12 per cent severity of complications and pain following periodontal chlorhexidine gluconate mouthrinse. J Periodontol 1989; surgery. J Periodontol 1985; 56:597. 60:570. 12. Dal Pra DJ, Strahan JD: A clinical evaluation of the benefits 37. Smith DC: A materialistic look at periodontal packs. Dent of a course of oral penicillin following periodontal surgery. Pract Dent Rec 1970; 20:273. Aust Dent J 1972; 17:219. 38. Strahan JD, Glenwright HD: Pain experience in periodontal 13. Fraleigh CM: An evaluation of topical Terramycin in post- surgery. J Periodont Res 1967; 1:163. gingivectomy pack. J Periodontol 1956; 27:201. 39. Tarbet WJ, Silverman G, Stolman JW, et al: A clinical evalua- 14. Gangarosa LP Sr: Current strategies for dentist-applied treat- tion of a new treatment for dentinal hypersensitivity. J Peri- ment in the management of hypersensitive dentine. Arch odontol 1980; 51:535. Oral Biol 1994; 39(Suppl):101S. 40. Tonetti MS, Pini Prato G, Cortellini P: Effect of cigarette 15. Gerschman JA, Ruben J, Gebart-Eaglemont J: Low-level laser smoking on periodontal healing following GTR in in- therapy for dentinal tooth hypersensitivity. Aust Dent J frabony pockets. A preliminary retrospective study. J Clin 1994; 39:353. Periodontol 1995; 22:229. 16. Hirschfeld AS, Wassermen BH: Retention of periodontal 41. Trowbridge HO, Silver DR: A review of current approaches packs. J Periodontol 1958; 29:199. to in-office management of tooth hypersensitivity. Dent 17. Holmes CH: Periodontal pack on single tooth retained by Clin North Am 1990; 34:583. acrylic splint. J Am Dent Assoc 1962; 64:831. 42. Vaughan ME, Garnick JJ: The effect of 0.125 per cent 18. Javelet J, Torabinejad M, Danforth A: Isobutyl cyanoacry- chlorhexidine rinse on inflammation after periodontal late: A clinical and histological comparison with sutures in surgery. J Periodontol 1989; 60:704. closing mucosal incisions in monkeys. Oral Surg 1985; 43. Ward AW: Inharmonious cusp relation as a factor in peri- 59:91. odontoclasia. J Am Dent Assoc 1923; 10:471. 19. Jones JK, Triplett RG: The relationship of cigarette smoking 44. Watts TAP, Combe EC: Adhesion of periodontal dressings to to impaired intraoral wound healing: A review of evidence enamel in vitro. J Clin Periodontol 1980; 7:62. and implications for patient care. J Oral Maxillofac Surg 45. Westfelt E, Nyman S, Socransky SS: Significance of fre- 1992; 50:237. quency of professional cleaning for healing following periodontal surgery. J Clin Periodontol 1983; 10:148. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Surgical Anatomy of the Periodontium and Related Structures

Fermin A. Carranza CHAPTER

CHAPTER OUTLINE

MANDIBLE MUSCLES MAXILLA ANATOMIC SPACES

- sound knowledge of the anatomy of the peri- The mental foramen, from which the mental nerve and odontium and the hard and soft structures that vessels emerge, is located on the buccal surface of the surround it is essential to determine the scope mandible below the apices of the premolars, sometimes and possibilities of surgical periodontal proce closer to the second premolar and usually halfway be- dures and minimize their risks. Bones, muscles, blood tween the lower border of the mandible and the alveolar vessels, and nerves, as well as the anatomic spaces lo- margin (Fig. 56-2). The opening of the mental foramen cated in the vicinity of the periodontal surgical field, are faces upward and distally, with its posterosuperior border particularly important. Only those features of periodon- slanting gradually to the bone surface. As it emerges, the tal relevance are mentioned in this chapter; the reader is mental nerve divides into three branches. One branch of referred to books on oral anatomy 4 for a more compre- the nerve turns forward and downward to supply the hensive description of these structures. skin of the chin. The other two branches course anteriorly and upward to supply the skin and mucous membrane of the lower lip and the mucosa of the labial alve- MANDIBLE olar surface. The mandible is a horseshoe-shaped bone connected to Surgical trauma to the mental nerve can produce the skull by the temporomandibular joints. It presents paresthesia of the lip, which recovers slowly. Familiarity several landmarks of great surgical importance. with the location and appearance of the mental nerve re- The mandibular canal, occupied by the inferior alveolar duces the likelihood of injury (Fig. 56-3). nerve and vessels, begins at the mandibular foramen on In partially or totally edentulous jaws, the disappear- the medial surface of the mandibular ramus and curves ance of the alveolar portion of the mandible brings the downward and forward, becoming horizontal below the mandibular canal closer to the superior border. When apices of the molars (Fig. 56-1). The distance from the canal these patients are evaluated for placement of implants, to the apices of the molars is shorter in the third molar area the distance between the canal and the superior surface and increases as it goes forward. In the premolar area, the of the bone must be carefully determined to avoid surgi- canal divides in two: the incisive canal, which continues cal injury to the nerve. horizontally to the midline, and the mental canal, which The lingual nerve, along with the inferior alveolar turns upward and opens in the mental foramen. nerve, is a branch of the posterior division of the mandibular nerve and descends along the mandibular ramus medial to and in front of the inferior alveolar The author is grateful to Dr. Andrew D. Dixon for his constructive nerve. It lies close to the surface of the oral mucosa in analysis of this chapter. the third molar area and goes deeper as it goes forward

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Fig. 56-1 Mandible, lingual surface view. Note the lingual or Fig. 56-3 Mental nerve emerging from the foramen in the premo- mandibular foramen (open arrow) where the inferior alveolar nerve lar area. enters the mandibular canal and the mylohyoid ridge (solid arrows).

Fig. 56-2 Mandible, facial surface view. Note the location of the Fig. 56-4 Lingual view of the mandible showing the pathway of mental foramen (open arrow), slightly distal and apical to the apex of the lingual nerve, which goes near the gingiva in the third molar the second premolar, and the shelflike area in the region of the molars area and then continues forward, going deeper and medially. (curved solid arrows), created by the external oblique ridge. Note also the fenestration present in the second premolar (straight solid arrow).

(Fig. 56-4; see also Fig. 56-18). It can be damaged during therapy may be difficult or impossible in this area owing anesthetic injections and during oral surgery procedures to the amount of bone that would have to be removed. such as third molar extractions. 7 Less commonly, it may Distal to the third molar, the external oblique ridge be injured when a periodontal partial thickness flap is circumscribes the retromolar triangle (see Fig. 56-6). This raised in the third molar region or releasing incisions are region is occupied by glandular and adipose tissue cov- made. ered by unattached nonkeratinized mucosa. If sufficient The alveolar process, which provides the supporting space exists distal to the last molar, a band of attached bone to the teeth, has a narrower distal curvature than gingiva may be present; only in such a case can a distal the body of the mandible (Fig. 56-5), creating a flat sur- wedge operation be performed. face in the posterior area between the teeth and the an- The inner side of the body of the mandible is tra- terior border of the ramus. This results in the formation versed obliquely by the mylohyoid ridge, which starts of the external oblique ridge, which runs downward and close to the alveolar margin in the third molar area and forward to the region of the second or first molar (Fig. continues anteriorly, increasing its distance from the os- 56-6), creating a shelflike bony area. Resective osseous seous margin as it goes forward (Fig. 56-7). The mylohy- Surgical Anatomy o f the Periodontium and Related Structures • CHAPTER 56 739 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 56-5 Occlusal view of mandible. Note the shelf created in the Fig. 56-7 Mandible: lingual view showing the inferior alveolar facial molar areas by the external oblique ridge. Arrows on the right nerve entering the mandibular canal (A), the lingual nerve travers- show the attachment of the buccinator muscle. ing near the lingual surface of the third molar (8), and inferiorly, the attachment of the mylohyoid muscle (C).

Fig. 56-6 Mandible: occlusal view of ramus and molars. Note the Fig. 56-8 Occlusal view of maxilla and palatine bone. Note the retromolar triangle area distal to the third molar (arrows). opening of the incisive canal or anterior palatine foramen (straight arrow) and the greater palatine foramen (curved arrows).

old muscle, inserted at this ridge, separates the sublin- zygomatic process, which extends laterally from the area gual space, located more anteriorly and superiorly, from of the first molar and determines the depth of the the submandibular space, located more posteriorly and vestibular fornix; and the frontal process, which extends inferiorly (see Fig. 56-18). in an ascending direction and articulates with the frontal bone at the frontomaxillary suture. MAXILLA The terminal branches of the nasopalatine nerve and vessels pass through the incisive canal, which opens in The maxilla is a paired bone that is hollowed out by the the midline anterior area of the palate (Fig. 56-8). The maxillary sinus and has four processes: the alveolar mucosa overlying the incisive canal presents a slight pro- process, which contains the sockets for the upper teeth; tuberance called the incisive papilla. Vessels emerging the palatine process, which extends horizontally to meet through the incisive canal are of small caliber, and their its counterpart from the other maxilla at the midline in- surgical interference is of little consequence. termaxillary suture, and posteriorly with the horizontal The greater palatine foramen opens 3 to 4 mm anterior plate of the palatine bone to form the hard palate; the to the posterior border of the hard palate (Fig. 56-9). The

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Fig. 56-11 Radiograph of upper molars and premolars, with the maxillary sinus apparently near the apices.

Fig. 56-9 Occlusolateral view of palate showing nerves and vessels emerging from the greater palatine foramen and continuing anteriorly on the palate.

Fig. 56-12 Radiograph of edentulous molar maxillary area, with the sinus very close to the surface.

The mucous membrane covering the hard palate is firmly attached to the underlying bone. The submucous layer of the palate posterior to the first molars contains the palatal glands, which are more compact in the soft palate and extend anteriorly, filling the gap between the mucosal connective tissue and the periosteum and protecting the underlying vessels and nerve (see Fig. 56-17). The area distal to the last molar is called the maxillary tuberosity and consists of the posteroinferior angle of the Fig. 56-10 Histologic frontal section of human palate at the level infratemporal surface of the maxilla; medially it articulates of the first molar, showing the location of vessels and nerve, surrounded by adipose and glandular tissue. with the pyramidal process of the palatine bone. It is covered by fibrous connective tissue and contains the terminal branches of the middle and posterior palatine nerves. Excision of the area for distal wedge surgery may reach greater palatine nerve and vessels emerge through this medially to the tensor palati muscle, which comes from foramen and run anteriorly in the submucosa of the the greater wing of the sphenoid bone and ends in a ten- palate, between the palatal and alveolar processes (Fig. don that forms the palatine aponeurosis, which expands, 56-10). Palatal flaps and donor sites for gingival grafts fanlike, to attach to the posterior border of the hard palate. should be carefully performed and selected to avoid The body of the maxilla is occupied by the maxillary invading these areas, as profuse hemorrhages may en- sinus or antrum, which is a hollow pyramidal area with sue, particularly if vessels are damaged at the palatine its base toward the nose and lined by respiratory epi- foramen. thelium. The inferior wall of the maxillary sinus is Surgical Anatomy of the Periodontium and Related Structures • CHAPTER 56 741 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 56-13 Clinical photograph of mandibular torus. Fig. 56-15 Clinical photograph after flap elevation, showing a palatal torus located near the osseous margin. Note also the circumferential bone loss around the second molar.

Fig. 56-14 Clinical photograph of palatal torus, located in the midline of the palate.

Fig. 56-16 Muscle attachments that may be encountered in mucogingival surgery. 7, Nasalis; 2, levator anguli oris; 3, buccina- frequently separated from the apices and roots of the tor; 4, depressor anguli oris; 5, depressor labii inferioris; 6, mentalis. maxillary posterior teeth by a thin, bony plate (Fig. 56- 11). In edentulous posterior areas the maxillary sinus bony wall may be only a thin plate in intimate contact with the alveolar mucosa (Fig. 56-12). Adequate determination of the extension of the maxillary sinus into the MUSCLES surgical site is important to avoid creating an oroantral Several muscles may be encountered when performing communication, particularly in relation to the place- periodontal flaps, particularly in mucogingival surgery. ment of implants. In edentulous jaws, determining the These are the mentalis, incisivus labii in ferioris, depressor amount of available bone in the anterior area, below the labii inferioris, depressor anguli oris (triangularis), incisivus floor of the nasal cavity, is also critical. labii superioris, and buccinator. Their bony attachment is Both the maxilla and the mandible may have exos- shown in Fig. 56-16, and they provide mobility to the toses or tori, which are considered to be within the nor- lips and cheeks. mal range of anatomic variation. Sometimes they may hinder the removal of plaque by the patient and may have to be removed to improve the prognosis of neigh- ANATOMIC SPACES boring teeth. The most common location of a mandibu- Several anatomic spaces or compartments are found lar torus is in the lingual area of canine and premolars, close to the operative field of periodontal surgery. These above the mylohyoid muscle (Fig. 56-13). Maxillary tori spaces contain loose connective tissue but can be easily are usually located in the midline of the hard palate (Fig. distended by inflammatory fluid and infection. 56-14); smaller tori may be seen over the palatal roots of Surgical invasion of these areas may result in danger- the molars (Fig. 56-15). ous infections and should be carefully avoided. Some of 742 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 56-17 Diagram of a frontal section of the human head at the level of the first molars, depicting the most important structures in relation to periodontal surgery. Note the location of the sublingual space, submandibular space, and greater palatine nerve and vessels.

these spaces are briefly described here. For further infor- abscess occupies the deepest part of this compartment, mation, the reader is referred to other sources .2,6,9,10 facial swelling may not be obvious but the patient may The canine fossa contains varying amounts of connec- complain of pain and trismus. Patients may also have tive tissue and fat and is bounded superiorly by the difficulty and discomfort when moving the tongue and quadratus labii superioris muscle, anteriorly by the orbic- swallowing. ularis oris, and posteriorly by the buccinator. Infection of The sublingual space is located below the oral mucosa this area results in swelling of the upper lip, obliterating in the anterior part of the floor of the mouth and con- the nasolabial fold, and of the upper and lower eyelids, tains the sublingual gland and its excretory duct, the sub- closing the eye. mandibular or Wharton's duct, and is traversed by the The buccal space is located between the buccinator lingual nerve and vessels and hypoglossal nerve (Fig. and the masseter muscles. Infection of this area results in 56-17). Its boundaries are the geniohyoid and genioglos- swelling of the cheek but may extend to the temporal sus muscles medially and the lingual surface of the space or the submandibular space, with which the buccal mandible and below the mylohyoid muscle laterally and space communicates. anteriorly (Fig. 56-18). Infection of this area raises the The mental or mentalis space is located in the region floor of the mouth and displaces the tongue, resulting in of the mental symphysis, where the mental muscle, de- pain and difficulty in swallowing but little facial swelling. pressor muscle of the lower lip, and depressor muscle of The submental space is found between the mylohyoid the corner of the mouth are attached. Infection of this area muscle superiorly and the platysma inferiorly. It is results in large swelling of the chin, extending downward. bounded laterally by the mandible and posteriorly by The masticator space contains the masseter muscle, the hyoid bone, and it is traversed by the anterior belly pterygoid muscles, tendon of insertion of the temporalis of the digastric muscle. Infections of this area arise muscle, and mandibular ramus and posterior part of the from the region of the mandibular anterior teeth and re- body of the mandible. Infection of this area results in sult in swelling of the submental region; they become swelling of the face and severe trismus and pain. If the more dangerous as they proceed posteriorly. Surgical Anatomy o f the Periodontium and Related Structures • CHAPTER 56 743 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

sult in swelling that obliterates the submandibular line and pain when swallowing. Ludwig's angina is a severe form of infection of this space that may extend to the sublingual and submental spaces; it results in hardening of the floor of the mouth and may lead to asphyxiation from edema of the neck and glottis. Although the bacte- riology of these infections has not been completely determined, they are presumed to be mixed infections with an important anaerobic component.

REFERENCES

1. Bartlett JG, Gorbach SL: Anaerobic infections of the head and neck. Otolaryngol Clin North Am 1976; 9:655. 2. Clarke MA, Bueltmann KW: Anatomical considerations in periodontal surgery. J Periodontol 1971; 42:610. 3. Dixon AD: Anatomy for Students of Dentistry, ed 5. New York, Churchill Livingstone, 1986. 4. DuBrul EL: Sicher and DuBrul's Oral Anatomy, ed 8. St Louis, Fig. 56-18 Posterior view of mandible, showing the attachment of Ishiyaku EuroAmerica, 1988. the mylohyoid muscles (A); geniohyoid muscles (8); sublingual 5. Gregg JM: Surgical anatomy. In: Laskin DM: Oral and Max- gland (C); submandibular gland (D), which extends below and illofacial Surgery. Vol 1. St Louis, Mosby, 1980. also to some extent above the mylohyoid muscle; and sublingual 6. Hollinshead WH: Anatomy for Surgeons. Vol 1: The Head (E) and inferior alveolar (F) nerves. and Neck. New York, Hoeber-Harper, 1954. 7. Kiesselbach JE, Chamberlain JG: Clinical and anatomic observations on the relationship of the lingual nerve to the mandibular third molar region. J Oral Maxillofac Surg 1984; 42:565. The submandibular space is found external to the sub- 8. Mulligan ME: Ear, nose, throat, and head and neck infec- lingual space, below the mylohyoid and hyoglossus mus- tions. In: Finegold SM, George WL (eds): Anaerobic Infec- cles (see Figs. 50-17 and 50-18). This space contains the tions in Humans. San Diego, Academic Press, 1989. submandibular gland, which extends partially above the 9. Spilka CJ: Pathways of dental infections. J Oral Surg 1966; mylohyoid muscle, thus communicating with the sub- 24:111. lingual space, and numerous lymph nodes. Infections of 10. Topazian RG, Goldberg MH: Oral and Maxillofacial Infec- this area originate in the molar or premolar area and re- tions, ed 3. Philadelphia, Saunders, 1994. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Gingival Curettage

Fermin A. Carranza and Henry H. Takei

CHAPTER

CHAPTER OUTLINE

RATIONALE HEALING AFTER SCALING AND CURETTAGE Curettage and Esthetics CLINICAL APPEARANCE AFTER SCALING AND INDICATIONS CURETTAGE PROCEDURE Basic Technique Other Techniques

ne wora curettage is usea m periociontics to mean enhancing gingival shrinkage, new connective tissue at- the scraping of the gingival wall of a periodontal tachment, or both. pocket to separate diseased soft tissue. Scaling refers to the removal of deposits from the root surface, RATIONALE whereas planing means smoothing the root to remove infected and necrotic tooth substance. Scaling and root Curettage accomplishes the removal of the chronically planing may inadvertently include various degrees of inflamed granulation tissue that forms in the lateral wall curettage. However, they are different procedures, with of the periodontal pocket. This tissue, in addition to the different rationales and indications, and should be con- usual components of granulation tissues (fibroblastic and sidered separate parts of periodontal treatment. angioblastic proliferation), contains areas of chronic in- A differentiation has been made between gingival and flammation and may also have pieces of dislodged calcu- subgingival curettage (Fig. 57-1). Gingival curettage con- lus and bacterial colonies. The latter may perpetuate the sists of the removal of the inflamed soft tissue lateral to pathologic features of the tissue and hinder healing. the pocket wall, whereas subgingival curettage refers to the This inflamed granulation tissue is lined by epithe- procedure that is performed apical to the epithelial at- lium, and deep strands of epithelium penetrate into the tachment, severing the connective tissue attachment tissue. The presence of this epithelium is construed as a down to the osseous crest. barrier to the attachment of new fibers in the area. It should also be understood that some degree of When the root is thoroughly planed, the major source curettage is done unintentionally when scaling and root of bacteria disappears and the pocket pathologic changes planing is performed. This is called inadvertent curettage. resolve with no need to eliminate the inflamed granula- This chapter refers to the purposeful curettage performed tion tissue by curettage. The existing granulation tissue during the same visit as scaling and root planing or as a is slowly resorbed; the bacteria present, in the absence of separate operation; its aim is to reduce pocket depth by replenishment of their numbers by the pocket plaque,

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Gingival Curettage • CHAPTER 57 745 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com esthetic result. Maximal, rapid shrinkage of gingival tissue was the aim to eliminate the pocket. Currently, esthetics is a major consideration of therapy, particularly in the anterior maxilla (teeth #6 to 11), and requires preservation of the interdental papilla. When regenerative therapy is not possible, every effort should be made to minimize shrinkage or loss of the interdental papilla. A compromise therapy that is feasible in the anterior maxilla, where access is not difficult, consists of thorough subgingival root planing, attempting not to detach the connective tissue beneath the pocket and avoiding gingival curettage. The granulation tissue in the lateral wall of the pocket, in an environment free of plaque and calculus, becomes connective tissue, thereby minimizing shrinkage. Thus although complete pocket elimination is not accomplished, the inflammatory changes are reduced or eliminated while the interdental papilla and the esthetic appearance of the area are preserved. Fig. 57-1 Extent of gingival curettage (white arrow) and subgingi- Surgical techniques specially designed to preserve the val curettage (black arrow). interdental papilla, such as the papilla preservation technique (see Chapter 60), result in better esthetic appearance of the anterior maxilla than do aggressive scaling and curettage of the area. are destroyed by the defense mechanisms of the host. Another important precaution refers to root planing Therefore the need for curettage just to eliminate the inflamed apical to the base of the pocket. The removal of the junc- granulation tissue appears questionable.* It has been shown tional epithelium and disruption of the connective tissue that scaling and root planing with additional curettage attachment exposes the nondiseased portion of the does not improve the condition of the periodontal tis- cementum. Root planing in this area of nondiseased ce- sues beyond the improvement caused by scaling and mentum may result in excessive shrinkage of the gin- root planing alone. giva, increasing recession or requiring "new attachment" Curettage may also eliminate all or most of the ep- where no disease previously existed. ithelium that lines the pocket wall and the underlying junctional epithelium. This purpose of curettage is still I NDICATIONS valid, particularly when an attempt is made at new attachment, as occurs in intrabony pockets. However, Indications for curettage are very limited. It can be used opinions differ regarding whether scaling and curettage after scaling and root planing for the following purposes: consistently remove the pocket lining and the junctional epithelium. Some investigators report that scaling and 1. Curettage can be performed as part of new attach- root planing tear the epithelial lining of the pocket with- ment attempts in moderately deep intrabony pockets out removing either it or the junctional epithelium, 15 located in accessible areas where a type of "closed" but both epithelial structures, 3-4-14 sometimes including surgery is deemed advisable. However, technical diffi- underlying inflamed connective tissue, 16 are removed by culties and inadequate accessibility frequently con- curettage. Other investigators report that the removal of traindicate such surgery. the pocket lining and junctional epithelium by curettage 2. Curettage can be done as a nondefinitive procedure to is not complete . 23,21,26 reduce inflammation prior to pocket elimination using other methods or in patients in whom more aggressive surgical techniques (e.g., flaps) are contraindi- Curettage and Esthetics cated owing to age, systemic problems, psychologic The awareness of esthetics in periodontal therapy has be- problems, and so forth. It should be understood that come an integral part of care in the modern practice of in these patients, the goal of pocket elimination is periodontics. In the past, pocket elimination was the pri- compromised and prognosis is impaired. The clinician mary goal of therapy, and little regard was given to the should resort to this approach only when the indicated surgical techniques cannot be performed, and both the clinician and the patient must have a clear understanding of its limitations. * This should not be confused with elimination of granulation tissue during flap surgery. The reason for the latter is to remove 3. Curettage is also frequently performed on recall vis- the bleeding tissue that obstructs the view and does not allow the its20 as a method of maintenance treatment for areas necessary examination of the root surface and the bone morphol- of recurrent inflammation and pocket depth, particu- ogy. Thus removal of granulation tissue during surgery is done for larly where pocket reduction surgery has previously technical rather than biologic reasons. been performed. Careful probing should establish the

746 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com Other Techniques extent of the required root planing and curettage to avoid unnecessary shrinkage, pocket formation, or Other techniques for gingival curettage include the exci- both. sional new attachment procedure, ultrasonic curettage, and the use of caustic drugs: PROCEDURE Excisional New Attachment Procedure (ENAP). ENAP has been developed and used by the U.S. Naval Basic Technique Dental Corps. 19,29,10 It is a definitive subgingival curet- Curettage does not eliminate the causes of inflammation tage procedure performed with a knife. The technique is (i.e., bacterial plaque and deposits). Therefore it should alas follows: ways be preceded by scaling and root planing, which is the basic periodontal therapy procedure. 1. After adequate anesthesia, an internal bevel incision Scaling and root planing is described in detail in is made from the margin of the free gingiva apically Chapters 42 and 47. The use of local infiltrative anesthe- to a point below the bottom of the pocket (Fig. 57-4). sia for this procedure is optional. However, gingival The incision is carried interproximally on both the fa- curettage always requires some type of local anesthesia. cial and the lingual sides, attempting to retain as The curette is selected so that the cutting edge will be much interproximal tissue as possible. The intention against the tissue (e.g., the Gracey No. 13-14 is used for is to cut the inner portion of the soft tissue wall of the mesial surfaces and the Gracey No. 11-12 for distal sur- pocket, all around the tooth. faces). Curettage can also be performed with a 4R-4L 2. Remove the excised tissue with a curette, and care- Columbia Universal curette. The instrument is inserted fully root plane all exposed cementum to a smooth, so as to engage the inner lining of the pocket wall and is hard consistency. Preserve all connective tissue fibers carried along the soft tissue, usually in a horizontal that remain attached to the root surface. stroke (Fig. 57-2). The pocket wall may be supported by 3. Approximate the wound edges; if they do not meet gentle finger pressure on the external surface. The passively, recontour the bone until good adaptation curette is then placed under the cut edge of the func- of the wound edges is achieved. Place sutures and a tional epithelium to undermine it. periodontal dressing. In subgingival curettage, the tissues attached between the bottom of the pocket and the alveolar crest are re- Ultrasonic Curettage. The use of ultrasonic de- moved with a scooping motion of the curette to the vices has been recommended for gingival curettage. 17 tooth surface (Fig. 57-3). The area is flushed to remove When applied to the gingiva of experimental animals, debris, and the tissue is partly adapted to the tooth by ultrasonic vibrations disrupt tissue continuity, lift off ep- gentle finger pressure. Sometimes suturing of separated ithelium, dismember collagen bundles, and alter the papillae and application of a periodontal pack may be morphologic features of fibroblast nuclei." Ultrasound is indicated. effective for debriding the epithelial lining of periodontal pockets'°; it results in a narrow band of necrotic tissue (microcauterization), which strips off the inner lining of the pocket.

Fig. 57-2 Gingival curettage performed with a horizontal stroke of Fig. 57-3 Subgingival curettage. A, Elimination of pocket lining. the curette. B, Elimination of junctional epithelium and granulation tissue. C, Procedure completed.

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The Morse scaler-shaped and rod-shaped ultrasonic in- severed from the tooth and tears in the epithelium 1-5,21 struments are used for this purpose. Some investigators are repaired in the healing process. Several investigators

found ultrasonic instruments to be as effective as manual have reported that in monkeys 8,29 and humans27 treated instruments for curettage 17,22,11 but resulted in less in- by scaling procedures and curettage, healing results in flammation and less removal of underlying connective the formation of a long, thin junctional epithelium with tissue. The gingiva can be made more rigid for ultrasonic no new connective tissue attachment. Sometimes this curettage by injecting anesthetic solution directly into it. 7 long epithelium is interrupted by "windows" of connective tissue attachment . 8 Caustic Drugs. Since early in the development of periodontal procedures, 24,28 the use of caustic drugs has been recommended to induce a chemical curettage of the CLINICAL APPEARANCE AFTER SCALING lateral wall of the pocket or even the selective elimina- AND CURETTAGE tion of the epithelium. Drugs such as sodium sulfide, al- Immediately after scaling and curettage, the gingiva ap- kaline sodium hypochlorite solution (Antiformin),1 1,12 pears hemorrhagic and bright red. and phenol have been proposed and then discarded af- After 1 week, the gingiva appears reduced in height ter studies showed their ineffectiveness. 2,9,12 The extent of owing to an apical shift in the position of the gingival tissue destruction with these drugs cannot be controlled, margin. The gingiva is also slightly redder than normal, and they may increase rather than reduce the amount of but much less so than on previous days. tissue to be removed by enzymes and phagocytes. After 2 weeks and with proper oral hygiene by the patient, the normal color, consistency, surface texture, and HEALING AFTER SCALING AND CURETTAGE contour of the gingiva are attained, and the gingival margin is well adapted to the tooth. Immediately after curettage, a blood clot fills the pocket area, which is totally or partially devoid of epithelial lin- REFERENCES ing. Hemorrhage is also present in the tissues with di- lated capillaries, and abundant polymorphonuclear 1. Barkann A: A conservative technique for the eradication of leukocytes appear shortly thereafter on the wound sur- a pyorrhea product. J Am Dent Assoc 1939; 26:61. face. This is followed by a rapid proliferation of granula- 2. Beube FE: An experimental study of the use of sodium sul- tion tissue, with a decrease in the number of small blood phide solution in treatment of periodontal pockets. J Peri- odontol 1939; 10:49. vessels as the tissue matures. 3. Beube FE: Treatment methods for marginal gingivitis and Restoration and epithelialization of the sulcus gener- periodontitis. Texas Dent J 1953; 71:427. 13,16,18,26 ally require from 2 to 7 days, and restoration of 4. Blass JL, Lite T. Gingival healing following surgical curet- the junctional epithelium occurs in animals as early as tage: A histopathologic study. NY Dent J 1959; 25:127. 5 days after treatment. Immature collagen fibers appear 5. Box KF: Periodontal disease and treatment. J Ontario Dent within 21 days. Healthy gingival fibers inadvertently Assoc 1952; 29:194. 6. Bunting RW: The control and treatment of pyorrhea by subgingival surgery. J Am Dent Assoc 1928; 15:119. 7. Burman LR, Alderman LE, Ewen SJ: Clinical application of ultrasonic vibrations for supragingival calculus and stain removal. J Dent Med 1958; 13:156. 8. Caton JC, Zander HA: The attachment between tooth and gingival tissues after periodic root planing and soft tissue curettage. J Periodontol 1979; 50:462. 9. Glickman J, Patur B: Histologic study of the effect of An- tiformin on the soft tissue wall of periodontal pockets in humans. J Am Dent Assoc 1955; 51:420. 10. Goldman HM: Histologic assay of healing following ultrasonic curettage versus hand instrument curettage. Oral Med Oral Pathol 1961; 14:925. 11. Hunter HA: A study of tissues treated with Antiformin citric acid. J Can Dent Assoc 1955; 21:344. 12. Johnson RW, Waerhaug J: Effect of Antiformin on gingival tissue. J Periodontol 1956; 27:24. 13. Kon S, Novaes AB, Ruben MP, et al: Visualization of microvascularization of the healing periodontal wound. 11. Curet- tage. J Periodontol 1969; 40:96. 14. Morris ML: The removal of the pocket and attachment epithelium in humans: A histological study. J Periodontol 1954; 25:7. 15. Moskow BS: The response of the gingival sulcus to instrumentation: A histologic investigation. 1. The scaling proce- Fig. 57-4 Excisional new attachment procedure. A, Internal bevel dure. J Periodontol 1962; 33:282. incision to point below bottom of pocket. B, After excision of tis- 16. Moskow BS: The response of the gingival sulcus to instru- sue, scaling and root planing are performed.

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mentation: A histologic investigation. 11. Gingival curettage. of tooth in the treatment of pyorrhea alveolaris. Dent Cos- J Periodontol 1964; 35:112. mos 1899; 41:617. 17. Nadler H: Removal of crevicular epithelium by ultrasonic 25. Stone S, Ramfjord SP, Waldron J: Scaling and gingival curet- curettes. J Periodontol 1962; 33:220. tage-A radioautographic study. J Periodontol 1966; 37:415. 18. O'Bannon JY: The gingival tissues before and after scaling 26. Waerhaug J: Microscopic demonstration of tissue reaction the teeth. J Periodontol 1964; 35:69. incident to removal of subgingival calculus. J Periodontol 19. Periodontics Syllabus: NAVED P5110. US Naval Dental 1955; 26:26. Corps, 1975, pp 113-115. 27. Waerhaug J: Healing of the dentoepithelial junction follow- 20. Ramfjord SP, Ash MM Jr: Periodontology and Periodontics. ing subgingival plaque control. 1. As observed in human Philadelphia, Saunders, 1979. biopsy material. J Periodontol 1978; 49:1. 21. Ramfjord SP, Kiester G: The gingival sulcus and the peri- 28. Younger WJ: Some of the latest phases in implantations and odontal pocket immediately following scaling of the teeth. other procedures. Dent Cosmos 1893; 35:102. J Periodontol 1954; 25:167. 29. Yukna RA: A clinical and histological study of healing fol- 22. Sanderson AD: Gingival curettage by hand and ultrasonic lowing the excisional new attachment procedure in rhesus instruments-A histologic comparison. J Periodontol 1966; monkeys. J Periodontol 1976; 47:701. 37:279. 30. Yukna RA, Bowers GM, Lawrence JJ, et al: A clinical study of 23. Sato M: Histopathological study of the healing process after healing in humans following the excisional new attach- surgical treatment for alveolar pyorrhea. Bull Tokyo Dent ment procedure. J Periodontol 1976; 47:696. College 1960; 1:71. 31. Zach L, Cohen G: The histologic response to ultrasonic 24. Stewart H: Partial removal of cementum and decalcification curettage. J Dent Res 1961; 40:751. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

The Gingivectomy Technique

Fermin A. Carranza

CHAPTER

CHAPTER OUTLINE

I NDICATIONS AND CONTRAINDICATIONS Disadvantages SURGICAL GINGIVECTOMY Technique Gingivoplasty Healing after Electrosurgery Healing after Surgical Gingivectomy LASER GINGIVECTOMY GINGIVECTOMY BY ELECTROSURGERY GINGIVECTOMY BY CHEMOSURGERY Advantages

ingivectomy means excision of the gingiva. By re- 3. Esthetic considerations, particularly in the anterior moving the pocket wall, gingivectomy provides maxilla visibility and accessibility for complete calculus re The gingivectomy technique may be performed by moval and thorough smoothing of the roots (Fig. 58-1), means of scalpels, electrodes, laser beams, or chemicals. creating a favorable environment for gingival healing All these techniques will be reviewed, although the sur- and restoration of a physiologic gingival contour. The gingivectomy technique was widely performed in gical method is the only one recommended. the past. Improved understanding of healing mechanisms and the development of more sophisticated flap SURG I CAL G I NGIVECTOMY methods have relegated the gingivectomy to a lesser role Step 1: The pockets on each surface are explored with a in the current repertoire of available techniques. How- periodontal probe and marked with a pocket marker ever, it remains an effective form of treatment when indicated (Fig. 58-2). (Figs. 58-3 and 58-4). Each pocket is marked in several areas to outline its course on each surface. Step 2: Periodontal knives (e.g., Kirkland knives) are used I NDICATIONS AND CONTRAINDICATIONS for incisions on the facial and lingual surfaces and those distal to the terminal tooth in the arch. Orban The gingivectomy technique may be performed for: periodontal knives are used for supplemental interden- 1. Elimination of suprabony pockets, regardless of their tal incisions, if necessary, and Bard-Parker knives #11 depth, if the pocket wall is fibrous and firm and 12 and scissors are used as auxiliary instruments. 2. Elimination of gingival enlargements The incision is started apical to the points marking 3. Elimination of suprabony periodontal abscesses' the course of the pockets27,31 and is directed coronally to a point between the base of the pocket and the Contraindications include the following: crest of the bone. It should be as close as possible to 1. The need for bone surgery or examination of the the bone without exposing it to remove the soft tissue bone shape and morphology coronal to the bone. Exposure of bone is undesirable. 2. Situations in which the bottom of the pocket is apical If it occurs, healing usually presents no problem if the to the mucogingival junction area is adequately covered by the periodontal pack.

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Fig. 58-1 Visibility and accessibility of calculus. A, Gingival enlargement. B, Removal of diseased gingiva exposes calculus. (Phase I therapy is sometimes omitted when the indication for a gingivectomy is obvious. It can never be omitted when a flap appears to be indicated.)

Fig. 58-2 Results obtained by treating suprabony pockets of different depths with gingivectomy. Left, Before treatment. Right, After treatment.

Discontinuous or continuous incisions may be Step 4: Carefully curette out the granulation tissue used. Fig. 58-5 shows the design of each of these two and remove any remaining calculus and necrotic incisions. The incision should be beveled at approximately cementum so as to leave a smooth and clean sur- 45 degrees to the tooth surface and should recreate, as far face. as possible, the normal festooned pattern of the gingiva. Step 5: Cover the area with a surgical pack (see Chap- Failure to bevel leaves a broad, fibrous plateau that ter 55). takes more time than is ordinarily required to develop a physiologic contour. In the interim, plaque and food accumulation may lead to recurrence of pockets. Gingivoplasty Step 3: Remove the excised pocket wall, clean the area, Gingivoplasty is similar to gingivectomy, but its purpose and closely examine the root surface. The most apical is different. Gingivectomy is performed to eliminate pe- zone consists of a bandlike light zone where the tis- riodontal pockets and includes reshaping as part of the sues were attached, and coronally to it some calculus technique. Gingivoplasty is a reshaping of the gingiva remnants, root caries, or root resorption may be to create physiologic gingival contours, with the sole found. Granulation tissue may be seen on the excised purpose of recontouring the gingiva in the absence of soft tissue (Fig. 58-6). pockets.

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Fig. 58-3 Pocket marker makes pinpoint perforations that indicate Fig. 58-5 A, Discontinuous incision apical to bottom of the pocket depth. pocket indicated by pinpoint markings. B, Continuous incision begins on the molar and extends anteriorly without interruption.

Fig. 58-4 Marking the depth of suprabony pocket. A, Pocket Fig. 58-6 Field of operation immediately after removing pocket marker in position. B, Beveled incision extends apical to the perfo- wall. 1, Granulation tissue; 2, calculus and other root deposits; ration made by the pocket marker. 3, clear space where bottom of the pocket was attached.

Gingival and periodontal disease often produce defor- thinning the attached gingiva, and creating vertical in- mities in the gingiva that interfere with normal food ex- terdental grooves and shaping the interdental papillae to cursion, collect plaque and food debris, and prolong and provide sluiceways for the passage of food. aggravate the disease process. Gingival clefts and craters, shelflike interdental papillae caused by acute necrotizing ulcerative gingivitis, and gingival enlargement are exam- Healing after Surgical Gingivectomy ples of such deformities. The initial response is the formation of a protective sur- Gingivoplasty may be done with a periodontal knife, face clot; the underlying tissue becomes acutely in- a scalpel, rotary coarse diamond stones,6 or electrodes.' flamed, with some necrosis. The clot is then replaced by It consists of procedures that resemble those performed granulation tissue. By 24 hours, there is an increase in in festooning artificial dentures; namely, tapering the new connective tissue cells, mainly angioblasts, just be- gingival margin, creating a scalloped marginal outline, neath the surface layer of inflammation and necrosis; by

752 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com the third day, numerous young fibroblasts are located in Technique the area . 26 The highly vascular granulation tissue grows The removal of gingival enlargements and gingivo- coronally, creating a new free gingival margin and sul- plasty21 is performed with the needle electrode, supple- cus.22 Capillaries derived from blood vessels of the peri- mented by the small ovoid loop or the diamond-shaped odontal ligament migrate into the granulation tissue, electrodes for festooning. A blended cutting and coagu- and within 2 weeks they connect with gingival vessels .32 lating (fully rectified) current is used. In all reshaping After 12 to 24 hours, epithelial cells at the margins of procedures, the electrode is activated and moved in a the wound start to migrate over the granulation tissue, concise "shaving" motion. separating it from the contaminated surface layer of the In the treatment of acute periodontal abscesses, the clot. Epithelial activity at the margins reaches a peak in incision to establish drainage can be made with the nee- 24 to 36 hours'; the new epithelial cells arise from the dle electrode without exerting painful pressure. The inci- basal and deeper spinous layers of the wound edge ep- sion remains open because the edges are sealed by the ithelium and migrate over the wound over a fibrin layer current. After the acute symptoms subside, the regular that is later resorbed and replaced by a connective tissue procedure for the treatment of the periodontal abscess is bed." The epithelial cells advance by a tumbling action, followed (see Chapter 46). with the cells becoming fixed to the substrate by For hemostasis, the ball electrode is used. Hemorrhage hemidesmosomes and a new basement lamina." must be controlled by direct pressure (via air, compress, Surface epithelization is generally complete after 5 to 14 or hemostat) first; then the surface is lightly touched days. During the first 4 weeks after gingivectomy, kera- with a coagulating current. Electrosurgery is helpful for tinization is less than it was prior to surgery. Complete ep- the control of isolated bleeding points. Bleeding areas lo- ithelial repair takes about 1 month.29 Vasodilation and vas- cated interproximally are reached with a thin, bar- cularity begin to decrease after the fourth day of healing shaped electrode. and appear to be almost normal by the 16th day.19 Com- Frenum and muscle attachments can be relocated to plete repair of the connective tissue takes about 7 weeks.29 facilitate pocket elimination using a loop electrode. For The flow of gingival fluid in humans is initially in- this purpose, the frenum or muscle is stretched and sec- creased after gingivectomy and diminishes as healing tioned with the loop electrode and a coagulating cur- progresses.1-28 Maximal flow is reached after 1 week, co- rent. For cases of acute pericoronitis, drainage may be inciding with the time of maximal inflammation. obtained by incising the flap with a bent needle elec- Although the tissue changes that occur in postgin- trode. A loop electrode is used to remove the flap after givectomy healing are the same in all individuals, the the acute symptoms subside. time required for complete healing varies considerably, depending on the area of the cut surface and interference from local irritation and infection. In patients with Healing after Electrosurgery physiologic gingival melanosis, the pigmentation is di- Some investigators report no significant differences in minished in the healed gingiva. gingival healing after resection by electrosurgery and resection with periodontal knives; other researchers find GINGIVECTOMY BY ELECTROSURGERY delayed healing, greater reduction in gingival height, and more bone injury after electrosurgery. 25 There ap- Advantages pears to be little difference in the results obtained after shallow gingival resection with electrosurgery and that Electrosurgery permits an adequate contouring of the tis- with periodontal knives. However, when used for deep re- sue and controls hemorrhage P,21 sections close to bone, electrosurgery can produce gingival recession, bone necrosis and sequestration, loss o f bone height, Disadvantages furcation exposure, and tooth mobility, which do not occur with the use ofperiodontal knives .2,9 Electrosurgery cannot be used in patients who have noncompatible or poorly shielded cardiac pacemakers. The treatment causes an unpleasant odor. If the electro- LASER GINGIVECTOMY surgery point touches the bone, irreparable damage can The lasers most commonly used in dentistry are the be done 2,9,12.25; furthermore, the heat generated by inju- carbon dioxide (CO2) and the neodymium:yttrium- dicious use can cause tissue damage and loss of peri- aluminum-garnet (Nd:YAG), which have wavelengths of odontal support when the electrode is used close to 10,600 nm and 1064 nm, respectively, both in the in- bone. When the electrode touches the root, areas of ce- frared range; they must be combined with other types of mentum burn are produced.33 Therefore the use o f electro- visible lasers for the beam to be seen and aimed. surgery should be limited to superficial procedures such as re- The CO2 laser beam has been used for the excision of moval of gingival enlargements, gingivoplasty, relocation of gingival growths, 3.23 although healing is delayed when frenum and muscle attachments, and incision of periodontal compared with healing after conventional scalpel gin- abscesses and pericoronal flaps; extreme care should be exer- givectomy.11,17,24 The use of laser beam for oral surgery cised to avoid contacting the tooth surface. It should not be requires precautionary measures to avoid reflecting the used for procedures that involve proximity to the bone, such beam on instrument surfaces, which could result in in- as flap operations, or mucogingival surgery. jury to neighboring tissues and the eyes of the operator.

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At present, the use of lasers for periodontal surgery is 12. Henning F: Healing of gingivectomy wounds in the rat: not supported by research and is there fore discouraged. Reestablishment of the epithelial seal. J Periodontol 1968; The use oflasers for other periodontal purposes, such as sub- 39:265. gingival curettage is equally unsubstantiated and is also not 13. Henning F: Epithelial mitotic activity after gingivectomy. recommended. Relationship to reattachment. J Periodont Res 1969; 4:319. 14. Innes PB: An electron microscopic study of the regeneration of gingival epithelium following gingivectomy in the dog. GINGIVECTOMY BY CHEMOSURGERY J Periodont Res 1970; 5:196. 15. Krawczyk WS: A pattern of epithelial cell migration during Techniques to remove the gingiva using chemicals, such as wound healing. J Cell Biol 1971; 49:247. 5% paraformaldehyde20 or potassium hydroxide,16 have 16. Loe H: Chemical gingivectomy. Effect of potassium hydrox- been described in the past but are not currently used. They ide on periodontal tissues. Acta Odontol Scand 1961; are presented here to provide a historical perspective. 19:517. The chemical gingivectomy has the following disad- 17. Loumanen M: A comparative study of healing of laser and vantages: scalpel incision wounds in rat oral mucosa. Scand J Dent Res 1987; 95:65. 1. The depth of action cannot be controlled, and there- 18. Malone WF, Eisenmann D, Kusck J: Interceptive periodon- fore healthy attached tissue underlying the pocket tics with electrosurgery. J Prosthet Dent 1969; 22:555. may be injured. 19. Novaes AB, Kon S, Ruben MP, et al: Visualization of the 2. Gingival remodeling cannot be accomplished effec- microvascularization of the healing periodontal wound. tively. III. Gingivectomy. J Periodontol 1969; 40:359. 20. Orban B: New methods in periodontal treatment. Bur 1942; 3. Epithelialization and reformation of the junctional 42:116. epithelium and reestablishment of the alveolar crest 21. Oringer MJ: Electrosurgery for definitive conservative mod- fiber system are slower in chemically treated gingival ern periodontal therapy. Dent Clin North Am 1969; 13:53. wounds than in those produced by a scalpel . 3o 22. Persson PA: The healing process in the marginal periodontium after gingivectomy with special regard to the regenera- of The use chemical methods therefore is not recommended. tion of epithelium (an experimental study on dogs). Odon- tol T 1959; 67:593. REFERENCES 23. Pick RM, Pecaro BC, Silberman CJ: The laser gingivectomy: The use of CO 2 laser for the removal of phenytoin hyperpla- 1. Arnold R, Lunstad G, Bissada N, et al: Alterations in crevicu- sia. J Periodontol 1985; 56:492. lar fluid flow during healing following gingival surgery. 24. Pogrel MA, Yen CK, Hanser LS: A comparison of carbon J Periodont Res 1966; 1:303. dioxide laser, liquid nitrogen cryosurgery and scalpel 2. Azzi R, Kenney EB, Tsao TF, et al: The effect of electro- wound in healing. Oral Surg Med Pathol 1990; 69:269. surgery upon alveolar bone. J Periodontol 1983; 54:96. 25. Pope JW, Gargiulo AW, Staffileno H, et al: Effects of electro- 3. Barak S, Kaplan H: The CO2 laser in the surgical excision of surgery on wound healing in dogs. Periodontics 1968; 6:30. gingival hyperplasia caused by nifedipine. J Clin Periodon- 26. Ramfjord SP, Engler WD, Hiniker JJ: A radiographic study of tol 1988; 15:633. healing following simple gingivectomy. II. The connective 4. Eisenmann D, Malone WF, and Kusek J: Electron micro- tissue. J Periodontol 1966; 37:179. scopic evaluation of electrosurgery. Oral Surg 1970; 29:660. 27. Ritchey B, Orban B: The periodontal pocket. J Periodontol 5. Engler WO, Ramfjord S, Hiniker JJ: Healing following sim- 1952; 23:199. ple gingivectomy. A tritiated thymidine radioautographic 28. Sandalli P, Wade AB: Alterations in crevicular fluid flow dur- study. 1. Epithelialization. J Periodontol 1966; 37:289. ing healing following gingivectomy and flap procedures. 6. Fisher SE, Frame JW, Browne RM, et al: A comparative histo- J Periodont Res 1969; 4:314. logical study of wound healing following CO 2 laser and 29. Stanton G, Levy M, Stahl SS: Collagen restoration in healing conventional surgical excision of the buccal mucosa. Arch human gingiva. J Dent Res 1969; 48:27. Oral Biol 1983; 28:287. 30. Tonna E, Stahl SS: A polarized light microscopic study of rat 7. Flocken JE: Electrosurgical management of soft tissues and periodontal ligament following surgical and chemical gingi- restoration dentistry. Dent Clin North Am 1980; 24:247. val trauma. Helv Odontol Acta 1967; 11:90. 8. Glickman I: The results obtained with the unembellished 31. Waerhaug J: Depth of incision in gingivectomy. Oral Surg gingivectomy technique in a clinical study in humans. 1955; 8:707. J Periodontol 1956; 27:247. 32. Watanabe Y, Suzuki S: An experimental study in capillary 9. Glickman 1, Imber LR: Comparison of gingival resection vascularization in the periodontal tissue following gingivec- with electrosurgery and periodontal knives: a biometric and tomy or flap operation. J Dent Res 1963; 42:758. histologic study. J Periodontol 1970; 41:142. 33. Wilhelmsen NR, Ramfjord SP, Blankenship JR: Effects of 10. Goldman HM: The development of physiologic gingival electrosurgery on the gingival attachment in Rhesus mon- contours by gingivoplasty. Oral Surg 1950; 3:879. keys. J Periodontol 1976; 47:160. 11. Gottsegen R, Ammons WF Jr: Research in Lasers in Peri- odontics. Position Paper. Chicago, American Academy of Periodontology, May 1992. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Treatment of Gingival Enlargement

Paulo M. Camargo and Fermin A. Carranza

CHAPTER

CHAPTER OUTLINE

TREATMENT OF CHRONIC INFLAMMATORY TREATMENT OF LEUKEMIC GINGIVAL ENLARGEMENT ENLARGEMENT The Flap Operation TREATMENT OF GINGIVAL ENLARGEMENT TREATMENT OF PERIODONTAL AND I N PREGNANCY GINGIVAL ABSCESSES When to Treat TREATMENT OF DRUG-ASSOCIATED TREATMENT OF GINGIVAL ENLARGEMENT GINGIVAL ENLARGEMENT IN PUBERTY Treatment Options RECURRENCE OF GINGIVAL ENLARGEMENT

Treatment of gingival enlargement is based on an Selection of the appropriate technique depends on the understanding of the cause and underlying patho- size of the enlargement and character of the tissue. When logic changes (see Chapter 18). Gingival enlarge the enlarged gingiva remains soft and friable even after ments are of special concern to the patient and the den- scaling and root planing, a gingivectomy is used to re- tist because they pose problems in plaque control, move it because a flap requires a firmer tissue to ade- function (including mastication, tooth eruption and quately perform the incisions and other steps in the tech- speech), and esthetics. Because gingival enlargements nique (Fig. 59-1). However, if the gingivectomy incision differ in cause, treatment of each type is best considered removes all the attached gingiva, creating a mucogingival individually. problem, then a flap operation is indicated. Tumorlike inflammatory enlargements are treated by gingivectomy as follows: Under local anesthesia, the TREATMENT OF CHRONIC INFLAMMATORY tooth surfaces beneath the mass are scaled to remove cal- ENLARGEMENT culus and other debris. The lesion is separated from the Chronic inflammatory enlargements, which are soft and mucosa at its base with a #12 Bard-Parker blade. If the le- discolored and are caused principally by edema and sion extends interproximally, the interdental gingiva is cellular infiltration, are treated by scaling and root plan- included in the incision to ensure exposure of irritating ing, provided the size of the enlargement does not inter- root deposits. After the lesion is removed, the involved fere with complete removal of deposits from the in- root surfaces are scaled and planed and the area is volved tooth surfaces. cleansed with warm water. A periodontal pack is applied When chronic inflammatory gingival enlargements in- and removed after a week, at which time the patient is clude a significant fibrotic component that does not un- instructed in plaque control (Fig. 59-2, A and B). dergo shrinkage after scaling and root planing or are of such size that they obscure deposits on the tooth surfaces The Flap Operation and interfere with access to them, surgical removal is the treatment of choice. Two techniques are available for this See Chapters 60 and 61 and the following discussion of purpose: gingivectomy and flap operation. the flap technique for drug-induced enlargements.

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Fig. 59-1 Gingivectomy incision for gingival enlargement. A, Chronic inflammatory gingival enlargement with tumorlike area. Pinpoint markings outline the extent of the enlargement. Note the amount of attached gingiva remaining. B, Enlarged gingiva removed. Note the beveled incision.

Fig. 59-2 A, Chronic inflammatory gingival enlargement associated with mouth breathing. B, Appearance after treatment.

TREATMENT OF PERIODONTAL AND clinical and microscopic features, and pathogenesis of GINGIVAL ABSCESSES gingival enlargement induced by the above-mentioned The reader is referred to Chapter 46, "Treatment of the drugs is provided in Chapter 18. Periodontal Abscess," for a more complete discussion of Examination of cases of drug-induced gingival en- this topic. largement reveals the overgrown tissues to have two components: a fibrotic one, which is caused by the drug, TREATMENT OF DRUG-ASSOCIATED and an inflammatory one that is induced by bacterial GINGIVAL ENLARGEMENT plaque. Although the two components (fibrotic and inflammatory) present in the enlarged gingiva are the re- Gingival enlargement has been associated with the ad- sult of distinct pathologic processes, they almost always ministration of three different types of drugs: anticon- are observed in combination. The role of bacterial vulsants, calcium channel blockers, and the immunosu- plaque in the overall pathogenesis of drug-induced gin- pressant cyclosporine. A comprehensive review of the gival enlargement is not clear. Some studies indicate

756 PART 5 • Treatment of Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com that plaque is a prerequisite for gipgival enlargement,$ is usually not a practical option, but its substitution for whereas others suggest that the presence of plaque is a another medication might be. If any drug substitution is consequence of its accumulation due to the enlarged attempted, it is important to allow for a 6- to 12-month gingiva. period of time to elapse between discontinuation of the offending drug and the possible resolution of gingival enlargement before a decision to implement surgical Treatment Options treatment is made. Treatment of drug-induced gingival enlargement should Alternative medications to phenytoin include carba- be based on the medication being used and the clinical mazepine5 and valproic acid, both of which have been features of the case. reported to have a lesser impact in inducing gingival en- First, consideration should be given to the possibility largement. of discontinuing the drug or changing medication. For patients on nifedipine, which has a reported These possibilities should be examined with the patient's prevalence of gingival enlargement of up to 44%, other physician. Simple discontinuation of the offending drug calcium channel blockers such as diltiazem or verapamil

Fig. 59-3 Decision tree for treatment of drug-induced gingival enlargements.

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may be viable alternatives, and their reported prevalence Gingivectomy has the advantage of simplicity and of gingival enlargement is 20% and 4%, respectively. 3, 7. 11 quickness but presents the disadvantages of more post- Also, consideration may be given to the use of another operative discomfort and increased chance of postopera- class of antihypertensive medications rather than cal- tive bleeding. It also sacrifices keratinized tissue and does cium channel blockers, none of which are known to in- not allow for osseous recontouring. The clinician's deci- duce gingival enlargement. sion between the two surgical techniques available must Drug substitutions for cyclosporine are more limited. consider the extension of the area to be operated, the Recently, it has been shown that cyclosporine-induced presence of periodontitis and osseous defects, and the lo- gingival enlargement can spontaneously resolve if the cation of the base of the pockets in relation to the drug is substituted by tracolimus.10 There is also prelimi- mucogingival junction. nary evidence that the antibiotic azithromycin may aid In general, small areas (up to 6 teeth) of drug-induced in decreasing the severity of cyclosporine-induced gingi- gingival enlargement with no evidence of attachment val enlargement. 17 loss (and therefore no anticipated need for osseous Second, the clinician should emphasize plaque control surgery) can be effectively treated with the gingivectomy as the first step in the treatment of drug-induced gingi- technique. An important consideration is the amount of val enlargement. Despite the fact that the exact role keratinized tissue present, remembering that at least played by bacterial plaque is not well understood, there 3 mm in the apicocoronal direction should remain after is evidence that good oral hygiene and frequent profes- the surgery is completed. sional removal of plaque decreases the degree of gingival The gingivectomy technique is described in detail in enlargement present and improves overall gingival Chapter 58. Fig. 59-4 depicts diagrammatically the pro- health. 6,8.16 The presence of drug-induced enlargement is cedure, and Fig. 59-5 illustrates a case of cyclosporine- associated with pseudo-pocket formation, frequently induced gingival enlargement treated with the gingivec- with abundant plaque accumulation, which raises the tomy technique. possibility of periodontitis to develop; meticulous plaque Gingivectomy/gingivoplasty can also be performed control therefore helps maintain attachment levels. Also, via electrosurgery or a laser device. The advantages adequate plaque control may aid in preventing or retard- and disadvantages of these techniques are presented in ing the recurrence of gingival enlargement in surgically Chapter 58. treated cases. Third, in some cases, gingival enlargement persists af- The Flap Technique. Larger areas of gingival enter careful consideration of the above-mentioned ap- largement (more than 6 teeth) or areas where attach- proaches. These cases need to be treated by surgery, either ment loss and osseous defects are present should be gingivectomy or the periodontal flap. A decision tree out- treated by the flap technique, as should any situation in lining the sequence of events and options in the treat- which the gingivectomy technique may create a muco- ment of gingival enlargement is presented in Fig. 59-3. gingival problem. The periodontal flap technique used for the treatment of gingival enlargements is a simple variation of the one used to treat periodontitis, described in Chapters 60 and 61. Fig. 59-6 shows the basic steps in the technique, described as follows:

1. After anesthetizing the area, sounding of the underlying alveolar bone is performed with a periodontal probe to determine the presence and extent of osseous defects. 2. With a #15 Bard-Parker blade, the initial scalloped internal bevel incision is made at least 3 mm coronal to the mucogingival junction, including the creation of new interdental papillae. 3. The same blade is used to thin the gingival tissues in a buccolingual direction to the mucogingival junction. At this point the blade establishes contact with the alveolar bone, and a full-thickness or a split-thickness flap is elevated. 4. Using an Orban knife, the base of each papilla connecting the facial and the lingual incisions is incised. 5. The excised marginal and interdental tissue are removed with curettes. Fig. 59-4 The gingivectomy technique as used in treating drug-induced gingival enlargement cases. The dotted line represents the 6. Tissue tabs are removed, the roots are thoroughly external bevel incision, and the shaded area corresponds to the tis- scaled and planed, and the bone is recontoured as sue to be excised. Gingivectomy incision may not remove the en- needed. tire hyperplastic tissue (shaded area) and may leave a wide wound 7. The flap is replaced and, if necessary, trimmed to ex- of exposed connective tissue. actly reach the bone-tooth junction. The flap is then

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sutured with an interrupted or a continuous mattress Fig. 59-7 illustrates a case treated with the flap technique. technique, and the area is covered with periodontal Recurrence of drug-induced gingival enlargements is a dressing. reality in surgically treated cases. 14 As stated previously, meticulous home care 4,12 chlorhexidine gluconate Sutures and pack are removed after 1 week, and the rinses, and professional cleanings can decrease the patient is instructed to start plaque control methods. speed and the degree to which recurrence occurs. A hard, Usually it is convenient to have the patient use chlorhex- natural rubber, fitted bite guard worn at night sometimes idine mouthrinses once or twice daily for 2 to 4 weeks. assists in the control of recurrence. 1,2

Fig. 59-5 Surgical treatment of cyclosporin-induced gingival enlargement using the gingivectomy technique on a 16-year-old girl who had received a kidney allograft 2 years previously. A, Presence of enlarged gingival tissues and pseudo-pocket formation; no attachment loss or evidence of vertical bone loss existed. B, Initial external bevel incision performed with a Kirkland knife. C, Interproximal tissue release achieved with an Orban knife. D and E, Gingivoplasty performed with tissue nippers and a round diamond at high speed with abundant refrigeration. F, Aspect of the surgical wound at the conclusion of the surgical procedure. G, Placement of noneugenol periodontal dressing. H, Surgical area 3 months postoperatively. Note the successful elimination of enlarged gingival tissue, restoration of a physiologic gingival contour, and maintenance of an adequate band of keratinized tissue.

Treatment o f Gingival Enlargement • CHAPTER 59 759 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com TREATMENT OF GINGIVAL ENLARGEMENT Recurrence may occur as early as 3 to 6 months after I N PREGNANCY the surgical treatment, but in general, surgical results are maintained for at least 12 months. One study" examined Treatment requires elimination of all local irritants re- the recurrence of cyclosporine-induced gingival enlarge- sponsible for precipitating the gingival changes in preg- ment after treatment with the periodontal flap or gin- nancy. Elimination of local irritants early in pregnancy is givectomy and determined that increased pocket depth a preventive measure against gingival disease, which is return is slower with the flap as revealed by 6-month preferable to treatment of gingival enlargement after it postsurgical examination. Recurrence of periodontal tis- occurs. Marginal and interdental gingival inflammation sue increased thickness, however, has not been objec- and enlargement are treated by scaling and curettage tively evaluated. (see Chapters 42 and 47). Treatment of tumorlike gingival enlargements consists of surgical excision and scaling and planing of the tooth surface. The enlargement recurs TREATMENT OF LEUKEMIC unless all irritants are removed. Food impaction is fre- GINGIVA L ENLARGEMENT quently an inciting factor. Leukemic enlargement occurs in acute or subacute leu- kemia and is uncommon in the chronic leukemic state. When to Treat The medical care of leukemic patients is often complicated by gingival enlargement with superimposed painful Gingival lesions in pregnancy should be treated as soon as acute necrotizing ulcerative gingivitis, which interferes they are detected, although not necessarily by surgical with eating and creates toxic systemic reactions. Bleeding means. Scaling and root planing procedures and adequate and clotting times and platelet count of the patient oral hygiene measures may reduce the size of the enlarge- should be checked and the hematologist consulted before ment. Gingival enlargements do shrink after pregnancy, periodontal treatment is instituted (see Chapter 38). but they usually do not disappear. After pregnancy, the Treatment of acute gingival involvement is described entire mouth should be reevaluated, a full set of radi- in Chapter 45. After acute symptoms subside, attention ographs taken, and the necessary treatment undertaken. is directed to correction of the gingival enlargement. The Lesions should be removed surgically during pregnancy rationale is to remove the local irritating factors to con- only if they interfere with mastication or produce an es- trol the inflammatory component of the enlargement. thetic disfigurement that the patient wishes removed. The enlargement is treated by scaling and root plan- In pregnancy, the emphasis should be on 1) preventing carried out in stages under topical anesthesia. The ing gingival disease before it occurs and 2) treating exist- initial treatment consists of gently removing all loose ac- ing gingival disease before it worsens. All patients should cumulations with cotton pellets, performing superficial be seen as early as possible in pregnancy. Those without scaling, and instructing the patient in oral hygiene for gingival disease should be checked for potential sources plaque control, which should include, at least initially, of local irritation and should be instructed in plaque daily use of chlorhexidine mouthwashes. Oral hygiene control procedures. Those with gingival disease should procedures are extremely important in these cases and be treated promptly, before the conditioning effect of should be performed by the nurse if necessary. pregnancy on the gingiva becomes manifest. Precautions Progressively deeper scalings are carried out at subse- necessary for periodontal treatment of pregnant women quent visits. Treatments are confined to a small area of the are presented in Chapter 37. mouth to facilitate control of bleeding. Antibiotics are ad- Every pregnant patient should be scheduled for peri- ministered systemically the evening before and for 48 odic dental visits, the importance of which in the pre- hours after each treatment to reduce the risk of infection. vention of serious periodontal disturbances should be stressed.

TREATMENT OF GINGIVAL ENLARGEMENT IN PUBERTY

Gingival enlargement in puberty is treated by performing scaling and curettage, removing all sources of irritation, and controlling plaque. Surgical removal may be required in severe cases. The problem in these patients is recurrence due to poor oral hygiene.

RECURRENCE OF GINGIVAL ENLARGEMENT

Recurrence after treatment is the most common problem Fig. 59-6 Diagram representative of the periodontal flap for the in the management of gingival enlargement. Residual lo- treatment of drug-induced gingival enlargement. A, Initial reverse bevel incision followed by thinning of the enlarged gingival tissue; cal irritation and systemic or hereditary conditions caus- dotted lines represent incisions and the shaded area represents the ing noninflammatory gingival hyperplasia are the re- tissue portion to be excised. B, After flap elevation, the enlarged sponsible factors. portion of the gingival tissue is removed. C, The flap is placed on Recurrence of chronic inflammatory enlargement im- top of the alveolar bone and sutured. mediately after treatment indicates that all irritants have 760 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 59-7 Treatment of a case of a combined cyclosporin- and nifedipine-induced gingival enlargement with a periodontal flap on a 35-year-old female who had received a kidney allograft 31/2 years previously. A, Presurgical clinical aspect of the lower anterior teeth, showing severe gingival enlargement. B, Initial scalloped reverse bevel incision, including maintenance of keratinized tissue and creation of surgical papillae. C, Elevation of a full thickness flap and removal of the inner portion of the previously thinned gingival tissue; after scaling and root planing, osseous recontouring can be performed if necessary. D, The flap i5 positioned on top of the alveolar crest. E, Postsurgical aspect of the treated area at 12 months; note the reduction of enlarged tissue volume and acceptable gingival health.

not been removed. Contributory local conditions, such use is currently not recommended. The destructive action as food impaction and overhanging margins of restora- of the drugs is difficult to control; injury to healthy tis- tions, are commonly overlooked. If the enlargement re- sue and root surfaces, delayed healing, and excessive curs after healing is complete and normal contour is at- postoperative pain are complications that can be avoided tained, inadequate plaque control by the patient is the when the gingiva is removed with periodontal knives most common cause. and scalpels or by electrosurgery. Recurrence during the healing period is manifested as red, beadlike, granulomatous masses that bleed on slight REFERENCES provocation. This is a proliferative vascular inflammatory response to local irritation, usually a fragment of 1. Aiman R: The use of positive pressure mouthpiece as a new calculus on the root. The condition is corrected by re- therapy for Dilantin gingival hyperplasia. Chron Omaha moving the granulation tissue and scaling and planing Dent Soc 1968; 131:244. the root surface. 2. Babcock JR: The successful use of a new therapy for Dilantin gingival hyperplasia. Periodontics 1965; 3:196. Familial, hereditary, or idiopathic gingival enlargement 3. Barclay S, Thomason JM, Idle JR, et al: The incidence and recurs after surgical removal, even if all local irritants have severity of nifedipine-induced gingival overgrowth. J Clin been removed. The enlargement can be maintained Periodontol 1992; 19:311. at minimal size by preventing secondary inflammatory 4. Ciancio SG, Yaffe SJ, Catz CC: Gingival hyperplasia and involvement. diphenylhydantoin. J Periodontol 1972; 43:411. The use o f escharotic drugs has been recommended in 5. Dahilof G, Preber H, Eliasson S, et al: Periodontal condition the past for the removal of gingival enlargements, but its of epileptic adults treated with phenytoin or carbamazepine. Epilepsia 1993; 34:960.

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6. Dongari A, O'Donnell HT, Langlais RP: Drug-induced gingi- 12. Nishikawa S, Tada H, Hamasaki A, et al: Nifedipine-induced val overgrowth. Oral Surg Oral Med Oral Path 1993; 76:543. gingival hyperplasia: A clinical and in vitro study. J Peri- 7. Fattore L, Stablein M, Bredfelt G, et al: Gingival hyperplasia: odontol 1991; 62:30. A side effect of nifedipine and diltiazem. Spec Care Dent 13. Pilloni A, Camargo PM, Carere M, et al: Surgical treatment 1991; 11:107. of cyclosporine A- and nifedipine-induced gingival enlarge- 8. Hall WB: Dilantin hyperplasia: A preventable lesion. J Peri- ment. J Periodontol 1998; 69:791. odont Res 1969; 4:36. 14. Rees TD, Levine RA: Systemic drugs as a risk factor for peri- 9. Harel-Raviv M, Eckler M, Lalani K, et al: Nifedipine-induced odontal disease initiation and progression. Compend Cont gingival hyperplasia. A comprehensive review and analysis. Educ Dent 1995; 16:20. Oral Surg Oral Med Oral Path Oral Radiol Endod 1995; 15. Saravia ME, Svirsky JA, Friedman R: Chlorhexidine as an 79:115. oral hygiene adjunct for cyclosporine-induced gingival hy- 10. Hernandez G, Arriba L, Lucas M, et al: Reduction of severe perplasia. J Dent Child 1990; 57:366. gingival overgrowth in a kidney transplant patient by re- 16. Seymour RA, Jacobs DJ: Cyclosporin and the gingival tis- placing cyclosporin A with tracolimus. J Periodontol 2000; sues. J Clin Periodontol 1992; 19:1. 71:1630. 17. Wahlstrom E, Zamora JU, Teichman S: Improvement in cy- 11. Nery EB, Edson RG, Lee KK, et al: Prevalence of nifedipine- closporin-associated gingival hyperplasia with azithromycin induced gingival hyperplasia. J Periodontol 1995; 66:572. therapy. N Eng J Med 1995; 332:753. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

The Periodontal Flap

Henry H. Takei and Fermin A. Carranza

CHAPTER

CHAPTER OUTLINE

CLASSIFICATION OF FLAPS SUTURING TECHNIQUES DESIGN OF THE FLAP Technique I NCISIONS Ligation Horizontal Incisions Types of Sutures Vertical Incisions HEALING AFTER FLAP SURGERY ELEVATION OF THE FLAP

-periodontal flap is a section of gingiva and/or the split thickness flap. The partial thickness flap is indi- mucosa surgically separated from the underlying cated when the flap is to be positioned apically or when tissues to provide visibility of and access to the the operator does not desire to expose bone. bone and root surface. The flap also allows the There are conflicting data regarding the advisability gingiva to be displaced to a different location in patients of uncovering the bone when this is not actually with mucogingival involvement (Color Fig. 60-1). needed. When bone is stripped of its periosteum, a loss of marginal bone occurs, and this loss is prevented when the periosteum is left on the bone. 4 The differ- CLASSIFICATION OF FLAPS ences, however, are usually not clinically significant,' Periodontal flaps can be classified based on the following: although sometimes they may be (Fig. 60-2). The par- • Bone exposure after flap reflection tial thickness flap may be necessary in cases in which • Placement of the flap after surgery the crestal bone margin is thin and is exposed when • Management of the papilla the flap is placed apically, or when dehiscences or fenestrations are present. The periosteum left on the bone Based on bone exposure after reflection, the may also be used for suturing the flap when it is dis- flaps are classified as either full thickness (mucope- placed apically. riosteal) or partial thickness (mucosal) flaps (Fig. 60-1). Based on flap placement after surgery, flaps are classi- In full thickness flaps, all the soft tissue, including the fied as 1) nondisplaced flaps, when the flap is returned and periosteum, is reflected to expose the underlying bone. sutured in its original position; or 2) displaced flaps that This complete exposure of, and access to, the underly- are placed apically, coronally, or laterally to their original ing bone is indicated when resective osseous surgery is position. Both full thickness and partial thickness flaps contemplated. can be displaced, but to do so, the attached gingiva has The partial thickness flap includes only the epithe- to be totally separated from the underlying bone, thereby lium and a layer of the underlying connective tissue. The enabling the unattached portion of the gingiva to be bone remains covered by a layer of connective tissue, in- moveable. However, palatal flaps cannot be displaced ow- cluding the periosteum. This type of flap is also called ing to the absence of unattached gingiva.

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Fig. 60-1 A, Diagram of the internal bevel incision (first incision) to reflect a full thickness (mucoperiosteal) flap. Note that the incision ends on the bone to allow for the reflection of the entire flap. B, Diagram of the internal bevel incision to reflect a partial thickness flap. Note that the incision ends on the root surface to preserve the periosteum on the bone.

Fig. 60-2 Loss of marginal bone as a result of uncovering the osseous crest. A, Mucoperiosteal flap elevated as part of a clinical study. B, Reentry performed 6 months later reveals loss of marginal bone facial to second premolar (arrow). (Courtesy Dr. Silvia Oreamuno; San Jose, Costa Rica.)

Apically displaced flaps have the important advantage papilla in one of the flaps by means of crevicular inter- of preserving the outer portion of the pocket wall and dental incisions to sever the connective tissue attach- transforming it into attached gingiva. Therefore they ac- ment and a horizontal incision at the base of the papilla, complish the double objective of eliminating the pocket leaving it connected to one of the flaps. and increasing the width of the attached gingiva. Based on management of the papilla, flaps can be conventional or papilla preservation flaps. In the con- DESIGN OF THE FLAP ventional flap the interdental papilla is split beneath the The design of the flap is dictated by the surgical judge- contact point of the two approximating teeth to allow ment of the operator and may depend on the objectives reflection of buccal and lingual flaps. The incision is usu- of the operation. The degree of access to the underlying ally scalloped to maintain gingival morphology with as bone and root surfaces necessary and the final position much papilla as possible. The conventional flap is used of the flap must be considered in designing the flap. when 1) the interdental spaces are too narrow, thereby Preservation of good blood supply to the flap is an im- precluding the possibility of preserving the papilla, and portant consideration. 2) when the flap is to be displaced. Two basic flap designs are used. Depending on how Conventional flaps include the modified Widman the interdental papilla is dealt with, flaps can either split flap, the undisplaced flap, the apically displaced flap, the papilla (conventional flap) or preserve it (papilla and the flap for regenerative procedures. These tech- preservation flap). niques are described in detail in Chapter 61. In the conventional flap operation, the incisions for The papilla preservation flap incorporates the entire the facial and the lingual or palatal flap reach the tip of 764 PART 5 • Treatment of Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 60-3 Flap design for the conventional or traditional flap technique. A, Design of the incisions: the internal bevel incision, splitting the papilla, and the vertical incisions are drawn in interrupted lines. B, The flap has been elevated, and the wedge of tissue next to the tooth is still in place. C, All marginal tissue has been removed, exposing the underlying bone (see defect in one space). D, Tissue returned to its original positron. Proximal areas are not totally covered.

Fig. 60-4 Flap design for a sulcular incision flap. A, Design of the incisions: the sulcular incisions and the vertical incisions are depicted by interrupted lines. B, The flap has been elevated, exposing the underlying bone (see defect in one space). C, Tissue returned to its original position covers the entire interdental spaces.

the interdental papilla or its vicinity, thereby splitting INCISIONS the papilla into a facial half and a lingual or palatal half (Figs. 60-3 and 60-4). Horizontal Incisions The entire surgical procedure should be planned in Periodontal flaps use horizontal and vertical incisions. every detail before the intervention is begun. This Horizontal incisions are directed along the margin of the should include the type of flap, exact location and type gingiva in a mesial or a distal direction (Fig. 60-5). Two of incisions, management of the underlying bone, and types of horizontal incisions have been recommended: final closure of the flap and sutures. Although some de- the internal bevel incision ,6 which starts at a distance tails may be modified during the actual performance of from the gingival margin and is aimed at the bone crest, the procedure, detailed planning allows for a better clini- and the crevicular incision, which starts at the bottom cal result. of the pocket and is directed to the bone margin. In

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Fig. 60-5 A to C, The first (internal bevel), second (crevicular), and third (interdental) incisions are the three incisions necessary for flap surgery.

Fig. 60-7 A, The internal bevel (first) incision can be made at varying locations and angles according to the different anatomic and pocket situations. B, An occlusal view of the different locations where the internal bevel incision can be made. Note the scalloped shape of the incisions.

of the gingiva left around the tooth contains the epithelium of the pocket lining and the adjacent granu- Fig. 60-6 Position of knife in performing internal bevel incision. lomatous tissue. It is discarded after the crevicular (second) and interdental (third) incisions are performed (see Fig. 60-5). The internal bevel incision starts from a designated addition, the interdental incision is performed after the area on the gingiva and is directed to an area at or near flap is elevated. the crest of the bone (Fig. 60-6). The starting point on The internal bevel incision is basic to most periodontal the gingiva is determined by whether the flap is apically flap procedures. It is the incision from which the flap is displaced or not displaced (Fig. 60-7). reflected to expose the underlying bone and root. The The crevicular incision, also termed the second inci- internal bevel incision accomplishes three important ob- sion, is made from the base of the pocket to the crest of jectives: 1) it removes the pocket lining; 2) it conserves the bone (Fig. 60-8). This incision, together with the ini- the relatively uninvolved outer surface of the gingiva, tial reverse bevel incision, forms a V-shaped wedge end- which, if apically positioned, becomes attached gingiva; ing at or near the crest of bone; this wedge of tissue con- and 3) it produces a sharp, thin flap margin for adapta- tains most of the inflamed and granulomatous areas that tion to the bone-tooth junction. This incision has also constitute the lateral wall of the pocket, as well as the been termed the first incision because it is the initial inci- junctional epithelium and the connective tissue fibers sion in the reflection of a periodontal flap, and the re- that still persist between the bottom of the pocket and verse bevel incision, because its bevel is in reverse direc- the crest of the bone. The incision is carried around the tion from that of the gingivectomy incision. The #11 or entire tooth. The beak-shaped #12D blade is usually used #15 surgical scalpel is used most commonly. That portion for this incision.

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Fig. 60-10 Incorrect (A) and correct (B) locations of a vertical incision. This incision should be made at the line angles to prevent splitting of a papilla or incising directly over a radicular surface.

Flaps can be reflected using only the horizontal incision if sufficient access can be obtained by this means Fig. 60-8 Position of knife in performing crevicular incision. and if apical, lateral, or coronal displacement of the flap is not anticipated. If no vertical incisions are made, the flap is called an envelope flap.

Vertical Incisions

Vertical or oblique releasing incisions can be used on one or both ends of the horizontal incision, depending on the design and purpose of the flap. Vertical incisions at both ends are necessary if the flap is to be apically displaced. Vertical incisions must extend beyond the mucogingival line, reaching the alveolar mucosa, to allow for the release of the flap to be displaced (see Chapter 61). In general, vertical incisions in the lingual and palatal areas are avoided. Facial vertical incisions should not be made in the center of an interdental papilla or over the radicular surface of a tooth. Incisions should be made at Fig. 60-9 After the flap has been elevated, a wedge of tissue re- the line angles of a tooth either to include the papilla in mains on the teeth, attached by the base of the papillae. An inter- the flap or to avoid it completely (Fig. 60-10). The verti- dental incision along the horizontal lines seen in the interdental spaces will sever these connections. cal incision should also be designed so as to avoid short flaps (mesiodistal) with long, apically directed horizontal incisions because these could jeopardize the blood supply to the flap. A periosteal elevator is inserted into the initial inter- Several investigators 1,2,11,12 proposed the so-called in- nal bevel incision, and the flap is separated from the terdental denudation procedure, which consists of hori- bone. The most apical end of the internal bevel incision zontal, internal bevel, nonscalloped incisions to remove is more exposed and visible. With this access, the sur- the gingival papillae and denude the interdental space. geon is able to make the third or interdental incision to This technique completely eliminates the inflamed inter- separate the collar of gingiva that is left around the dental areas, which heal by secondary intention, and re- tooth. The Orban knife is usually used for this incision. sults in excellent gingival contour. It is contraindicated The incision is made not only around the facial and lin- when bone grafts are used. gual radicular area but also interdentally, connecting the facial and lingual segments, to completely free the gingiva around the tooth (Fig. 60-9; see Fig. 60-5). ELEVATION OF THE FLAP These three incisions allow the removal of the gingiva When a full thickness flap is desired, the reflection is ac- around the tooth (i.e., the pocket epithelium and the ad- complished by blunt dissection. A periosteal elevator is jacent granulomatous tissue). A curette or a large scaler used to separate the mucoperiosteum from the bone by (U15/30) can be used for this purpose. After removal of moving it mesially, distally, and apically until the desired the large pieces of tissue, the remaining connective tis- reflection is accomplished (Fig. 60-11). sue in the osseous lesion should be carefully curetted out Sharp dissection is necessary to reflect a partial so that the entire root and the bone surface adjacent to thickness flap. A surgical scalpel (#11 or #15) is used (Fig. the teeth can be observed. 60-12). The Periodontal Flap • CHAPTER 60 767 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 60-11 Elevation of the flap with a periosteal elevator to ob- Fig. 60-12 Elevation of the flap with a Bard-Parker knife to obtain tain a full thickness flap. a split thickness flap.

A combination of full and partial thickness flaps can often be indicated to obtain the advantages of both. The flap is started as a full thickness procedure, and then a Sutures for Periodontal Flaps partial thickness flap is made at the apical portion. In this way the coronal portion of the bone, which may be subject to osseous remodeling, is exposed while the remaining bone remains protected by its periosteum.

SUTURING TECHNIQUES After all the necessary procedures are completed, the area is reexamined and cleansed, and the flap is placed in the desired position, where it should remain without tension. It is convenient to keep it in place with light pressure with a piece of gauze so that a blood clot can form. The purpose of suturing is to maintain the flap in the desired position until healing has progressed to the point where sutures are no longer needed. There are many types of sutures, suture needles, and materials.5,10 Suture materials may be either nonresorbable or resorbable, and they may be further categorized as braided or monofilaments. The resorbable sutures have gained popularity since they enhance patient comfort and eliminate suture removal appointments. The monofilament type of suture alleviates the "wicking effect" of braided sutures that may allow bacteria from the oral cavity to be drawn through the suture to the deeper areas of the wound. Box 60-1 is a classification of Technique the sutures available today: The needle is held with the needle holder and should en- The nonresorbable, braided silk suture was the most ter the tissues at right angles and no less than 2 to 3 mm commonly used in the past due to its ease of use and low from the incision. The needle is then carried through the cost. The expanded polytetrafluoroethylene synthetic tissue, following the needle's curvature. The knot should monofilament is an excellent nonresorbable suture not be placed over the incision. widely used today. The periodontal flap is closed either with indepen- The most commonly used resorbable sutures are the dent sutures or with continuous, independent sling natural, plain gut and the chromic gut. Both are sutures. The latter method eliminates the pulling of the monofilaments and are processed from purified collagen buccal and lingual or palatal flaps together and instead, of either sheep or cattle intestines. The chromic suture is uses the teeth as an anchor for the flaps. There is less a plain gut suture processed with chromic salts to make tendency for the flaps to buckle, and the forces on the it resistant to enzymatic resorption, thereby increasing flaps are better distributed. the resorption time. The synthetic resorbable sutures are Sutures of any kind placed in the interdental papillae also often used. should enter and exit the tissue at a point located below

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the imaginary line that forms the base of the triangle of the interdental papilla (Fig. 60-13). The location of sutures for closure of a palatal flap depend on the extent of flap elevation that has been performed. The flap is divided in four quadrants as depicted in Fig. 60-14. If the elevation of the flap is slight or moderate, the sutures can be placed in the quadrant closest to the teeth. If the flap elevation is substantial, the sutures should be placed in the central quadrants of the palate. One may or may not use periodontal dressings. When Fig. 60-13 Placement of suture in the interdental space below the the flaps are not apically displaced, it is not necessary to base of an imaginary triangle in the papilla. use dressings other than for patient comfort.

Ligation Interdental Ligation. Two types of interdental ligation can be used: the director loop suture (Fig. 60-15) and the figure-eight suture (Fig. 60-16). In the figure- eight suture, there is thread between the two flaps. This suture is therefore used when the flaps are not in close apposition because of apical flap position or nonscalloped incisions. It is simpler to perform than the direct ligation. The direct suture permits a better closure of the interdental papilla and should be performed when bone grafts are used or when close apposition of the scalloped incision is required.

Sling Ligation. The sling ligation can be used for a flap on one surface of a tooth that involves two inter- Fig. 60-14 Placement of sutures for closing a palatal flap. For dental spaces (Fig. 60-17). slightly or moderately elevated flaps, the sutures are placed in shaded areas; for more substantial elevation of the flap, they are placed in the central (unshaded) area of their palate.

Fig. 60-15 A simple loop suture is used to approximate the buccal and lingual flaps. A, The needle penetrates the outer surface of the first flap. B, The undersurface of the opposite flap is engaged, and the suture is brought back to the initial side (C), where the knot is tied (D).

The Periodontal Flap • CHAPTER 60 769 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com Types of Sutures mal papilla against the bone. Two sutures are often nec- Horizontal Mattress Suture. This suture is often essary. The horizontal mattress suture can be incorpo- used for the interproximal areas of diastemata or for rated with continuous, independent sling sutures, as wide interdental spaces to properly adapt the interproxi- shown in Fig. 60-18.

Fig. 60-16 An interrupted figure-eight suture is used to approximate the buccal and lingual flaps. The needle penetrates the outer surface of the first flap (A) and the outer surface of the opposite flap (B). The suture is brought back to the first flap (C), and the knot is tied (D).

Fig. 60-17 A single, interrupted sling suture is used to adapt the flap around the tooth. A, The needle engages the outer surface of the flap and encircles the tooth (B). C, The outer surface of the same flap of the adjacent interdental area is engaged. D, the suture is returned to the initial site and the knot tied.

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Fig. 60-18 A, Continuous, independent sling suture using a horizontal mattress suture around diastemata or wide interdental areas (B and C). This mattress suture is utilized on both the buccal (D) and the lingual (E and F) surfaces. Continuation of suture on lingual surfaces (G to I) and completed suture (1).

The penetration of the needle is performed in such a Continuous Independent Sling Suture. This is way that the mesial and distal edges of the papilla lie used when there is both a facial and a lingual flap in- snugly against the bone. The needle enters the outer sur- volving many teeth. The suture is initiated on the facial face of the gingiva and crosses the undersurface of the papilla closest to the midline, because this is the easiest gingiva horizontally. The mattress sutures should not be place to position the final knot (Fig. 60-19). A continu- close together at the midpoint of the base of the papilla. ous sling suture is laced for each papilla on the facial sur- The needle reappears on the outer surface at the other face. When the last tooth is reached, the suture is an- base of the papilla and continues around the tooth with chored around it to prevent any pulling of the facial the sling sutures. sutures when the lingual flap is sutured around the teeth Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 60-19 The continuous, independent sling suture is used to adapt the buccal and lingual flaps without tying the buccal flap to the lingual flap. The teeth are used to suspend each flap against the bone. It is important to anchor the suture on the two teeth at the beginning and end of the flap so that the suture will not pull the buccal flap to the lingual flap. 771

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Fig. 60-20 A to D, Distal wedge suture. This suture is also used to close flaps that are mesial or distal to a lone-standing tooth.

Fig. 60-21 The closed anchor suture, another technique to suture distal wedges.

in a similar fashion. The suture is again anchored around the tooth, anchored around the tooth, passed beneath the last tooth before tying the final knot. the opposite flap, and tied. The anchor suture can be re- This type of suture does not produce a pull on the lin- peated for each area that requires it (Fig. 60-20). gual flap when the latter is sutured. The two flaps are completely independent of each other owing to the an- Closed Anchor Suture. Another technique to choring around both the initial and the final tooth. The close a flap located in an edentulous area mesial or distal flaps are tied to the teeth and not to each other because to a tooth consists of tying a direct suture that closes the of the sling sutures. proximal flap, carrying one of the threads around the This type of suturing is especially appropriate for the tooth to anchor the tissue against the tooth, and then maxillary arch because the palatal gingiva is attached tying the two threads (Fig. 60-21). and fibrous, whereas the facial tissue is thinner and mobile. Periosteal Suture. This type of suture is used to hold in place apically displaced partial thickness flaps. Anchor Suture. The closing of a flap mesial or dis- There are two types of periosteal sutures: the holding su- tal to a tooth, as in the mesial or distal wedge proce- ture and the closing suture. The holding suture is a hori- dures, is best accomplished by the anchor suture. zontal mattress suture placed at the base of the displaced This suture closes the facial and lingual flaps and adapts flap to secure it into the new position. Closing sutures them tightly against the tooth. The needle is placed at are used to secure the flap edges to the periosteum. Both the line angle area of the facial or lingual flap adjacent to types of periosteal sutures are shown in Fig. 60-22.

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results in areas of bone necrosis with reduction in bone height, which is later remodeled by new bone formation. Therefore the final shape of the crest is determined more by osseous remodeling than by surgical reshaping. This may not be the case when osseous remodeling does not include excessive thinning of the radicular bone.' Bone repair reaches its peak at 3 to 4 weeks." Loss of bone occurs in the initial healing stages both in radicular bone and in interdental bone areas. How- ever, in interdental areas, which have cancellous bone, the subsequent repair stage results in total restitution without any loss of bone; whereas in radicular bone, par- Fig. 60-22 Periosteal sutures for an apically displaced flap. Hold- ticularly if thin and unsupported by cancellous bone, ing sutures, shown at the bottom, are done first, followed by the bone repair results in loss of marginal bone. closing sutures, shown at the coronal edge of the flap. REFERENCES

1. Barkann L: A conservative surgical technique for the eradication of pyorrhea pockets. J Am Dent Assoc 1939; 26:61. HEALING AFTER FLAP SURGERY 2. Beube FE: Interdental tissue resection: An experimental Immediately after suturing (0 to 24 hours), a connection study of a surgical technique which aids in repair of the pe- between the flap and the tooth or bone surface is estab- riodontal tissues to their original contour and function. lished by a blood clot, which consists of a fibrin reticu- Oral Surg 1947; 33:497. lum with many polymorphonuclear leukocytes, erythro- 3. Caffesse RG, Ramfjord SP, Nasjleti CE: Reverse bevel periodontal flaps in monkeys. J Periodontol 1968; 39:219. cytes, debris of injured cells, and capillaries at the edge 4. Carranza Jr FA, Carraro JJ: Effect of removal of periosteum of the wound. A bacteria and an exudate or transudate on postoperative result of mucogingival surgery. J Periodon- also result from tissue injury. tol 1963; 34:223. One to 3 days after flap surgery, the space between the 5. Dahlberg WH: Incisions and suturing: Some basic consider- flap and the tooth or bone is thinner, and epithelial cells ations about each in periodontal flap surgery. Dent Clin migrate over the border of the flap, usually contacting North Am 1969; 113:149. the tooth at this time. When the flap is closely adapted 6. Friedman N: Mucogingival surgery: The apically reposi- to the alveolar process, there is only a minimal inflam- tioned flap. J Periodontol 1962; 33:328. matory response . 3 7. Hoag PM, Wood DL, Donnenfeld OW, et al: Alveolar crest reduction following full and partial thickness flaps. J Peri- One week after surgery, an epithelial attachment to the odontol 1972; 43:141. root has been established by means of hemidesmosomes 8. Lobene RR, Glickman 1: The response of alveolar bone to and a basal lamina. The blood clot is replaced by granu- grinding with rotary stones. J Periodontol 1963; 34:105. lation tissue derived from the gingival connective tissue, 9. Matherson DG: An evaluation of healing following peri- the bone marrow, and the periodontal ligament. odontal osseous surgery in monkeys. Int J Periodont Restor Two weeks after surgery, collagen fibers begin to appear Dent 1988; 8:9. parallel to the tooth surface.' Union of the flap to the 10. Morris ML: Suturing techniques in periodontal surgery. Peri- tooth is still weak, owing to the presence of immature odontics 1965; 3:84. collagen fibers, although the clinical aspect may be al- 11. Prichard JF: Present state of the interdental denudation pro- most normal. cedure. J Periodontol 1977; 48:566. 12. Ratcliff PA, Raust GT. Interproximal denudation: A conserv- One month after surgery, a fully epithelialized gingival ative approach to osseous surgery. Dent Clin North Am crevice with a well-defined epithelial attachment is pre- 1964; 8:121. sent. There is a beginning functional arrangement of the 13. Staffileno H, Wentz FE, Orban BJ: Histologic study of heal- supracrestal fibers. ing of split thickness flap surgery in dogs. J Periodontol Full-thickness flaps, which denude the bone, result 1962; 33:56. in a superficial bone necrosis at 1 to 3 days; osteoclastic 14. Wilderman MN: Exposure of bone in periodontal surgery. resorption follows and reaches a peak at 4 to 6 days, de- Dent Clin North Am 1964; 8:23. clining thereafter." This results in a loss of bone of about 15. Wilderman MN, Pennel BM, King K, et al: Histogenesis of re- 1 mm3,16 ; the bone loss is greater if the bone is thin .14,11 pair following osseous surgery. J Periodontol 1970; 41:551. Osteoplasty (thinning of the buccal bone) using diamond burs, included as part of the surgical technique, Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

The Flap Technique for Pocket Therapy

Fermin A. Carranza and Henry H. Takei

CHAPTER

CHAPTER OUTLINE

THE MODIFIED WIDMAN FLAP FLAPS FOR REGENERATIVE SURGERY THE UNDISPLACED FLAP The Papilla Preservation Flap The Palatal Flap Conventional Flap for Regenerative Surgery THE APICALLY DISPLACED FLAP DISTAL MOLAR SURGERY

everal techniques can be used for the treatment of The undisplaced (unrepositioned) flap, in addition to im- periodontal pockets. The periodontal flap is one of proving accessibility for instrumentation, removes the the most commonly employed procedures, particu pocket wall, thereby reducing or eliminating the pocket. larly for moderate and deep pockets in posterior areas This is essentially an excisional procedure of the gingiva. (see Chapter 54). The apically displaced flap also improves accessibility Flaps are used for pocket therapy to accomplish the and eliminates the pocket, but does the latter by apically following: positioning the soft tissue wall of the pocket.' Therefore it preserves and/or increases the width of the attached 1. Increase accessibility to root deposits gingiva by transforming the previously unattached kera- 2. Eliminate or reduce pocket depth by resection of the tinized pocket wall into attached tissue. This increase in pocket wall width of the band of attached gingiva is supposedly 3. Expose the area to perform regenerative methods based on an apical shift of the mucogingival junction, which includes apical displacement of the muscle attach- To fulfill these purposes several flap techniques are ments. A study made before and 18 years after apically available and in current use. displaced flaps failed to show a permanent relocation of The modified Widman flap facilitates instrumentation the mucogingival junction.' All three techniques use the but does not attempt to reduce pocket depth. Two flap tech- basic incisions described in Chapter 60: the internal niques have as their main purpose the reduction or elimina- bevel incision, the crevicular incision, and the interden- tion of pocket depth: the now-displaced flap and the api- tal incision. However, there are important variations in cally displaced flap. The decision of whether to perform one the way in which these incisions are performed for the or the other depends on two important anatomical land- different types of flaps. marks: pocket depth and the location of the mucogingival The modified Widman flap does not intend to remove junction. These landmarks establish the presence and width the pocket wall, but it does eliminate the pocket lining. of the attached gingiva, which is the basis for the decision. Therefore the internal bevel incision starts close (no The modified Widman flap has been described for ex- more than 1 to 2 mm apically) to the gingival margin posing the root surfaces for meticulous instrumentation and follows the normal scalloping of the gingival margin and for removal of the pocket lining'; it is not intended (Figs. 61-1 and 61-2). to eliminate or reduce pocket depth, except for the re- For the apically displaced flap, the pocket wall also duction that occurs in healing by tissue shrinkage. must be preserved to be positioned apically while its

774

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lining is removed. The purpose of this surgical technique is to preserve the maximum amount of keratinized gingiva of the pocket wall to displace it apically and trans- form it into attached gingiva. For this reason, the internal bevel incision should be made as close to the tooth as possible (0.5 to 1.0 mm) (see Fig. 61-1). There is no need to determine where the bottom of the pocket is in relation to the incision, as one would for the undisplaced flap; the flap is placed approximately at the tooth-bone junction by apically displacing the flap. Its final position is not determined by the placement of this first incision. For an undisplaced flap, however, the internal bevel incision is initiated at or near a point just coronal to the projection of the bottom of the pocket on the outer surface of the gingiva (see Fig. 61-1). This incision can be accomplished only if there is sufficient attached gingiva remaining apical to the incision. Therefore the two Fig. 61-1 Locations of the internal bevel incisions for the different types of flaps. anatomic landmarks, pocket depth and location of the mucogingival junction, must be considered to evaluate the amount of attached gingiva that remains. Because the pocket wall is not displaced apically, the initial incision should also eliminate the pocket wall. If the incision is made too close to the tooth, it will not eliminate the pocket wall and may result in the recre- ation of a soft tissue pocket. If the tissue is thick it should also be thinned by the initial incision to cover the bone properly during flap closure. Proper placement of the flap during closure is essential to prevent either recurrence of pockets or bone exposure; placement is determined by where this first incision is placed. The internal bevel incision should be scalloped to preserve, as much as possible, the interdental papilla (see Fig. 61-2). This allows better coverage of the bone at both the radicular and the interdental areas. Fig. 61-2 Scallopings required for the different types of flaps. If the surgeon contemplates osseous surgery, the first incision should be placed in such a way as to compensate for the removal of bone tissue so that the flap ends at the tooth-bone junction. The techniques used for regenerative purposes are the papilla preservation flap and the flap using only crevicular or pocket incisions, to retain the maximum amount of gingival tissue, including the papilla, for graft or membrane coverage.

THE MODIFIED WIDMAN F LAP In 1965, Morris revived a technique described early in this century in the periodontal literature; he called it the unrepositioned mucoperiosteal flap. 4 Essentially the same procedure was presented in 1974 by Ramfjord and Nissle who called it the modified Widman flap (Fig. 61-3) .6 This technique offers the possibility of establishing an intimate postoperative adaptation of healthy collagenous connective tissue to tooth surfaces5,6 and provides access for adequate instrumentation of the root surfaces and immediate closure of the area. The following is an outline of this technique: Fig. 61-3 The modified Widman flap technique. A, Facial view before surgery. Probing of pockets revealed interproximal depths Step 1: The initial incision is an internal bevel incision ranging from 4 to 8 mm and facial and palatal depths of 2 to to the alveolar crest starting 0.5 to 1 mm away from 5 mm. B, Radiographic survey of area. Note generalized horizontal the gingival margin (see Fig. 61-3, C). Scalloping bone loss. Continued

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Fig. 61-3, cont'd The modified Widman flap technique. C, Internal bevel incision. D, Elevation of the flap, leaving a wedge of tissue still attached by its base. E, Crevicular incision. F, Interdental incision sectioning the base of the papilla. G, Removal of tissue. H, Exposure of root surfaces and marginal bone; root planing and removal of remaining calculus. 1, Replacement of flap in its original position. J, Interdental sutures in place. (Courtesy Dr. Raul G. Caffesse, Houston, TX.)

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Fig. 61-4 A patient before (A) and after (B) treatment by means of Widman flaps. Note the reduction in gingival height and concomitant pocket depth. (Courtesy Dr. Raul G. Caffesse, Houston, TX.)

follows the gingival margin. Care should be taken to insert the blade in such a way that the papilla is left with a thickness similar to that of the remaining facial flap. Vertical relaxing incisions are usually not needed. Step 2: The gingiva is reflected with a periosteal elevator (Fig. 61-3, D). Step 3: A crevicular incision is made from the bottom of the pocket to the bone, circumscribing the triangular wedge of tissue containing the pocket lining (Fig. 61-3, E). Step 4: After the flap is reflected, a third incision is made in the interdental spaces coronal to the bone with a curette or an interproximal knife, and the gingival collar is removed (Fig. 61-3, F and G). Fig. 61-5 Diagram showing the location of different areas where the internal bevel incision is made in an undisplaced flap. The inci- Step 5: Tissue tags and granulation tissue are removed sion is made at the level of the pocket to discard the tissue coronal with a curette. The root surfaces are checked, and to it if there is sufficient remaining attached gingiva. then scaled and planed if needed (Fig. 61-3, H). Resid- ual periodontal fibers attached to the tooth surface should not be disturbed. Bone architecture is not corrected except if it pre- Step 6: THE UNDISPLA CED FLAP vents good tissue adaptation to the necks of the teeth. Every effort is made to adapt the facial and lingual in- Currently, the undisplaced flap is perhaps the most com- terproximal tissue adjacent to each other in such a monly performed type of periodontal surgery. It differs way that no interproximal bone remains exposed at from the modified Widman flap in that the soft tissue the time of suturing (Fig. 61-3, 1). The flaps may be pocket wall is removed with the initial incision; thus it thinned to allow for close adaptation of the gingiva may be considered an internal bevel gingivectomy. The around the entire circumference of the tooth and to undisplaced flap and the gingivectomy are the two tech- each other interproximally. niques that surgically remove the pocket wall. To per- Step 7: Interrupted direct sutures are placed in each inter- form this technique without creating a mucogingival dental space (Fig. 61-3, 1) and covered with tetracy- problem it should be determined that enough attached cline (Achromycin) ointment and with a periodontal gingiva will remain after removal of the pocket wall. The surgical pack. following is an outline of this technique: Ramfjord and colleagues performed an extensive lon- Step 1: The pockets are measured with the periodontal gitudinal study comparing the Widman procedure, as probe, and a bleeding point is produced on the outer modified by them, with the curettage technique and the surface of the gingiva to mark the pocket bottom. pocket elimination methods that include bone contour- Step 2: The initial, internal bevel incision is made (Fig. ing when needed.6 The patients were assigned randomly 61-5) after the scalloping of the bleeding marks on to one of the techniques, and results were analyzed the gingiva (Fig. 61-6). The incision is usually carried yearly up to 7 years posttherapy. They reported approxi- to a point apical to the alveolar crest, depending on mately similar results with the three methods tested. the thickness of the tissue. The thicker the tissue, the Pocket depth was initially similar for all methods but more apical is the ending point of the incision (see was maintained at shallower levels with the Widman Fig. 61-5). In addition, thinning of the flap should flap (Fig. 61-4); the attachment level remained higher be done with the initial incision because at this time, with the Widman flap. it is easier to accomplish than later with a loose 778 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 61-6 The undisplaced. A and B, Preoperative facial and palatal views. C and D, Internal bevel incisions in the facial and palatal aspects. Note the deeper scalloping palatally for the replaced flap. E and F, After the necessary osseous surgery, the flaps have been sutured. The facial flap is apically displaced, whereas the palatal flap is replaced. G and H, Ten-week postoperative results. (Courtesy Dr. Silvia Oreamuno, San Jose, Costa Rica.)

reflected flap that is difficult to manage. (Use of this Step 4: The flap is reflected with a periosteal elevator technique in palatal areas is considered in the follow- (blunt dissection) from the internal bevel incision. ing discussion.) Usually there is no need for vertical incisions because Step 3: The second or crevicular incision is made from the flap is not displaced apically. the bottom of the pocket to the bone to detach the Step 5: The interdental incision is made with an interdental connective tissue from the bone. knife, separating the connective tissue from the bone.

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Fig. 61-7 Examples of two methods for eliminating a palatal pocket. One incision is an internal bevel incision made at the area of the apical extent of the pocket. The other procedure uses a gin- Fig. 61-8 Diagrams illustrating the angle of the internal bevel inci- givectomy incision, which is followed by an internal bevel incision. sion in the palate and the different ways to thin the flap. A, The usual angle and direction of the incision. B, The thinning of the flap after it has been slightly reflected with a second internal incision. C, The beveling and thinning of the flap with the initial incision if the position and contour of the tooth allow. D, The problem encountered in thinning the flap once it has been reflected. The flap Step 6: The triangular wedge of tissue created by the is too loose and free for proper positioning and incision. three incisions is removed with a curette. Step 7: The area is debrided, removing all tissue tags and granulation tissue using sharp curettes. Step 8: After the necessary scaling and root planing, the flap edge should rest on the root-bone junction. If this changes in the location, angle, and design of the is not the case, due to improper location of the initial incision. incision or to the unexpected need for osseous surgery, The initial incision for a flap varies with the anatomic the edge of the flap is rescalloped and trimmed to al- situation. As shown in Fig. 61-7, the initial incision may low the flap edge to end at the root-bone junction. be the usual internal bevel incision, followed by crevicu- Step 9: A continuous sling suture is used to secure the fa- lar and interdental incisions. If the tissue is thick, a hori- cial and the lingual or palatal flaps. This type of su- zontal gingivectomy incision may be made, followed by ture, using the tooth as an anchor, is advantageous to an internal bevel incision that starts at the edge of this position and hold the flap edges at the root-bone incision and ends on the lateral surface of the underly- junction. The area is covered with a periodontal pack. ing bone. The placement of the internal bevel incision must be done in such a way that the flap fits around the tooth without exposing the bone. The Palatal Flap Before the flap is reflected to the final position for The surgical approach to the palatal area differs from that scaling and management of the osseous lesions, its thick- for other areas because of the character of the palatal tis- ness must be checked. Flaps should be thin to adapt to sue and the anatomy of the area. The palatal tissue is all the underlying osseous tissue and provide a thin, knife- attached, keratinized tissue and has none of the elastic like gingival margin. Often flaps, particularly palatal properties associated with other gingival tissues. There- flaps, are too thick; they may have a propensity to sepa- fore the palatal tissue cannot be apically displaced, nor rate from the tooth and may delay and complicate heal- can a partial (split) thickness flap be accomplished. ing. It is best to thin the flaps before their complete re- The initial incision for the palatal flap should be such flection, because a free, mobile flap is difficult to hold for that when the flap is sutured, it is precisely adapted at thinning (Fig. 61-8). A sharp, thin papilla positioned the root-bone junction. It cannot be moved apically or properly around the interdental areas at the tooth-bone coronally to adapt to the root-bone junction, as can be junction is essential to prevent recurrence of soft tissue done with the flaps in other areas. Therefore the location pockets. of the initial incision is important for the final place- The purpose of the palatal flap should be considered ment of the flap. before the incision is made. If the intent of the surgery is The palatal tissue may be thin or thick, it may or may debridement, the internal bevel incision is planned so not have osseous defects, and the palatal vault may that the flap adapts at the root-bone junction when su- be high or low. These anatomic variations may require tured. If osseous resection is necessary, the incision

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THE APICALLY DISPLACED FLAP This technique with some variants can be used for one or both of the following purposes: pocket eradication or widening the zone of attached gingiva. Depending on the purpose, it can be a full thickness (mucoperiosteal) or a split thickness (mucosal) flap. The split thickness flap requires more precision and time, and a gingival tissue thick enough to split, but it can be more accurately positioned and sutured in an apical position using a periosteal suturing technique, as follows: Step 1: An internal bevel incision is made (Fig. 61-10). To preserve as much of the keratinized and attached gingiva as possible, it should be no more than about 1 mm from the crest of the gingiva and directed to the crest of the bone (see Fig. 61-1). The incision is made after the existing scalloping, and there is no need to mark the bottom of the pocket in the external gingival surface because the incision is unrelated to pocket depth. It is also not necessary to accentuate the scallop interdentally, as the flap is displaced apically and not placed interdentally. Step 2: Crevicular incisions are made, followed by initial elevation of the flap, and then interdental incisions are performed and the wedge of tissue that contains Fig. 61-9 A, A distal view of incisions made to eliminate a pocket distal to the maxillary second molar. B, Two parallel incisions and the pocket wall is removed. the removal of the intervening tissue. C, Thinning of the flap and Step 3: Vertical incisions are made extending beyond the contouring of the bone. D, Approximation of the buccal and mucogingival junction, if the objective is a full thick- palatal flaps. ness flap it is elevated by blunt dissection with a periosteal elevator. If a split thickness flap is required, it is elevated using sharp dissection with a Bard-Parker knife to split it, leaving a layer of connective tissue, including the periosteum, on the bone. should be planned to compensate for the lowered level Step 4: After removal of all granulation tissue, scaling and of the bone when the flap is closed. Probing and sound- root planing, and osseous surgery if needed, the flap ing of the osseous level and the depth of the intrabony is displaced apically. It is important that the vertical pocket should be used to determine the position of the incisions, and consequently, the flap elevation, reach incision. past the mucogingival junction to provide adequate The apical portion of the scalloping should be nar- mobility to the flap for its apical displacement. rower than the line angle area because the palatal root Step 5: If a full thickness flap was performed, a sling su- tapers apically. A rounded scallop results in a palatal flap ture around the tooth prevents the flap from sliding that does not fit snugly around the root. This procedure to a position more apical than that desired, and the should be done before the complete reflection of the periodontal dressing can avoid its movement in a palatal flap, as a loose flap is difficult to grasp and stabi- coronal direction. A partial thickness flap is sutured to lize for dissection. the periosteum using a direct loop suture or a combi- It is sometimes necessary to thin the palatal flap after nation of loop and anchor suture. A dry foil is placed it has been reflected. This can be accomplished by hold- over the flap before covering it with the dressing to ing the inner portion of the flap with a mosquito hemo- prevent the introduction of pack under the flap. stat or Adson forceps as the inner connective tissue is carefully dissected away with a sharp #15 scalpel blade. After 1 week, dressings and sutures are removed. The Care must be taken not to perforate or overthin the flap. area is usually repacked for another week, after which The edge of the flap should be thinner than the base; the patient is instructed to use chlorhexidine mouth therefore the blade should be angled toward the lateral rinse or to apply chlorhexidine topically with cotton- surface of the palatal bone. The dissected inner connec- tipped applicators for another 2 or 3 weeks. tive tissue is removed with a hemostat. As with any flap, the triangular papilla portion (Fig. 61-9) should be thin FLAPS FOR REGENERATIVE SURGERY enough to fit snugly against the bone and into the interdental area. In current regenerative therapy, either bone grafts, The principles for the use of vertical releasing incisions membranes, or a combination of these with or without are similar to those for using other incisions. Care must other agents, are used for a successful outcome (see be exercised so that the length of the incision is minimal Chapter 63). The flap design should therefore be set up to avoid the numerous vessels located in the palate. so that the maximum amount of gingival tissue and

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Fig. 61-10 Apically displaced flap. A and B, Facial and lingual preoperative views. C and D, Facial and lingual flaps elevated. E and F, After debridement of the areas. G and H, Sutures in place. 1 and 1, Healing after 1 week. K and L, Healing after 2 months. Note the preservation of attached gingiva displaced to a more apical position.

782 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com papilla are retained to cover the material(s) placed in The Papilla Preservation Flap the pocket. The technique for employing a papilla preservation flap Two flap designs are available for regenerative surgery: is as follows: the papilla preservation flap and the conventional flap with only crevicular incisions. The flap design of choice is Step 1: A crevicular incision is made around each tooth the papilla preservation flap, which retains the entire with no incisions across the interdental papilla. papilla covering the lesion. However, to use this flap, Step 2: The preserved papilla can be incorporated into there must be adequate interdental space to allow the in- the facial or lingual/palatal flap, although it is most tact papilla to be reflected with the facial or lingual/palatal commonly integrated into the facial flap. In these flap. When the interdental space is very narrow, making it cases the lingual or palatal incision consists of a semi- impossible to perform a papilla preservation flap, a con- lunar incision across the interdental papilla in its ventional flap with only crevicular incisions is made. palatal or lingual aspect; this incision dips apically from the line angles of the tooth so that the papillary incision is at least 5 mm from the crest of the papilla. Step 3: An Orban knife is then introduced into this incision to sever one-half to two-thirds of the base of the interdental papilla. The papilla is then dissected from the lingual or palatal aspect and elevated intact with the facial flap. Step 4: The flap is reflected without thinning the tissue. These incisions are illustrated in Fig. 61-11 and Color Fig. 60-1.

Conventional Flap for Regenerative Surgery The technique for employing a conventional flap for regenerative surgery is as follows:

Step 1: Using a #12 blade, incise the tissue at the bottom Fig. 61-11 Flap design for a papilla preservation flap. A, Incisions of the pocket and to the crest of the bone, splitting for this type of flap are depicted by interrupted lines. The preserved the papilla below the contact point. Every effort papilla can be incorporated into the facial or the lingual-palatal flap. should be made to retain as much tissue as possible to B, The reflected flap exposes the underlying bone. Several os- subsequently protect the area. seous defects are seen. C, The flap returned to its original position covering the entire interdental spaces. Step 2: Reflect the flap maintaining it as thick as possible, not attempting to thin it as is done for resective surgery. The maintenance of a thick flap is necessary to prevent exposure of the graft or the membrane due to necrosis of the flap margins.

Fig. 61-12 A, The impaction of a third molar distal to a second Fig. 61-13 A, Removal of a pocket distal to the maxillary second molar with little or no interdental bone between the two teeth. molar may be difficult if there is minimal attached gingiva. If the B, Removal of the third molar creates a pocket with little or no bone ascends acutely apically, the removal of this bone may make bone distal to the second molar. This often leads to a vertical os- the procedure easier. B, A long distal tuberosity with abundant seous defect distal to the second molar (C). attached gingiva is an ideal anatomic situation for distal pocket eradication.

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Fig. 61-14 A, A distal pocket eradication procedure with the incision distal to the molar. B, The scalloped incision around the remaining teeth. C, The flap reflected and thinned around the distal incision. D, The flap in position prior to suturing. It should be closely approximated. E, The flap sutured both distally and over the remaining surgical area.

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Fig. 61-15 A typical incision design for a surgical procedure distal to the maxillary second molar.

Fig. 61-17 Incision designs for surgical procedures distal to the mandibular second molar. The incision should follow the areas of greatest attached gingiva and underlying bone.

Operations for this purpose were described by Robinson7 and Braden' and modified by several other investigators. Fig. 61-16 A, Pocket eradication distal to a mandibular second Some representative procedures are discussed here. molar with minimal attached gingiva and a close ascending ramus is anatomically difficult. B, For surgical procedures distal to a Maxillary Molars. mandibular second molar, abundant attached gingiva and distal The treatment of distal pockets space are ideal. on the maxillary arch is usually more simple than the treatment of a similar lesion on the mandibular arch because the tuberosity presents a greater amount of fibrous attached gingiva than does the area of the retromolar DISTAL MOLAR SURGERY pad. In addition, the anatomy of the tuberosity extending distally is more adaptable to pocket elimination than Treatment of periodontal pockets on the distal surface of is that of the mandibular molar arch, where the tissue terminal molars is often complicated by the presence of extends coronally. However, the lack of a broad area of bulbous fibrous tissue over the maxillary tuberosity or attached gingiva and the abruptly ascending tuberosity prominent retromolar pads in the mandible. Deep verti- sometimes complicates therapy (Fig. 61-13). cal defects are also commonly present in conjunction The following considerations determine the location with the redundant fibrous tissue. Some of these osseous of the incision for distal molar surgery: accessibility, lesions may result from incomplete repair after the ex- amount of attached gingiva, pocket depth, and available traction of impacted third molars (Fig. 61-12). distance from the distal aspect of the tooth to the end of The gingivectomy incision is the most direct approach the tuberosity or retromolar pad. in treating distal pockets that have adequate attached gingiva and no osseous lesions. However, the flap approach is Technique. Two parallel incisions, beginning at the less traumatic postsurgically, because it produces a pri- distal portion of the tooth and extending to the muco- mary closure wound rather than the open secondary gingival junction distal to the tuberosity or retromolar wound left by a gingivectomy incision. In addition, it re- pad, are made (Fig. 61-14). The faciolingual distance be- sults in attached gingiva and provides access for examina- tween these two incisions depends on the depth of the tion and, if needed, correction of the osseous defect. pocket and the amount of fibrous tissue involved. The

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deeper the pocket, the greater the distance between the areas. The retromolar pad area does not usually present two parallel incisions. It should be noted that when the as much fibrous attached gingiva. The keratinized gin- tissue between the two incisions is removed and the giva, if present, may not be found directly distal to the flaps are thinned, the two flap edges must approximate molar. The greatest amount may be distolingual or disto- each other at a new apical position without overlapping. facial and may not be over the bony crest. The ascending When the depth of the pocket cannot be easily esti- ramus of the mandible may also create a short horizontal mated, it is better to err on the conservative side, leaving area distal to the terminal molar (Fig. 61-16). The shorter overlapping flaps rather than too short flaps that result this area, the more difficult it is to treat any deep distal in exposure of bone. When the two flaps overlap after lesion around the terminal molar. the surgery is completed, they should be placed one over The two incisions distal to the molar should follow the other and the overlapping portion of one of them is the area with the greatest amount of attached gingiva grabbed with a hemostat. Then a sharp knife or scissors (Fig. 61-17). Therefore the incisions could be directed is used to cut the excess. distolingually or distofacially, depending on which area A transversal incision is made at the distal end of the has more attached gingiva. Before the flap is completely two parallel incisions so that a long, rectangular piece of reflected, it is thinned with a #15 blade. It is easier to tissue can be removed. These incisions are usually inter- thin the flap before it is completely free and mobile. Af- connected with the incisions for the remainder of the ter the reflection of the flap and the removal of the re- surgery in the quadrant involved. The parallel distal inci- dundant fibrous tissue, any necessary osseous surgery is sions should be confined to the attached gingiva because performed. The flaps are approximated similarly to those bleeding and flap management become problems when in the maxillary tuberosity area. the incision is extended into the alveolar mucosa. If access is difficult, especially if the distance from the distal REFERENCES aspect of the tooth to the mucogingival junction is short, a vertical incision can be made at the end of the 1. Ainamo A, Bergenholtz A, Hugoson A, et al: Location of the mucogingival junction 18 years after apically repositioned parallel incisions. flap surgery. J Clin Periodontol 1992; 19:49. In treating the tuberosity area, the two distal incisions 2. Braden BE: Deep distal pockets adjacent to terminal teeth. are usually made at the midline of the tuberosity (Fig. Dent Clin North Am 1969; 13:161. 61-15). In most cases, no attempt is made to undermine 3. Matelski DE, Hurt WC: The corrective phase: The modified the underlying tissue at this time. These incisions are Widman flap. In: Hurt WC (ed): Periodontics in General made straight down into the underlying bone where ac- Practice. Springfield, IL, Charles C Thomas, 1976. cess is difficult. A #12B blade is generally used. It is easier 4. Morris ML: The unrepositioned mucoperiosteal flap. Peri- to dissect out the underlying redundant tissue when the odontics 1965; 3:147. flap is partially reflected. When the distal flaps are placed 5. Ramfjord SP: Present status of the modified Widman flap back on the bone, the two flap margins should closely procedure. J Periodontol 1977; 48:558. approximate each other. 6. Ramfjord SP, Nissle RR: The modified Widman flap. J Peri- odontol 1974; 45:601. 7. Robinson RE: The distal wedge operation. Periodontics Mandibular Molars. Incisions for the mandibular 1966; 4:256. arch differ from those used for the tuberosity, owing to differences in the anatomy and histologic features of the Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Resective Osseous Surgery

Thomas N. Sims and Williams Ammons, Jr.

CHAPTER

CHAPTER OUTLINE

SELECTION OF TREATMENT TECHNIQUE Vertical Grooving RATIONALE Radicular Blending NORMAL ALVEOLAR BONE MORPHOLOGY Flattening Interproximal Bone TERMINOLOGY Gradualizing Marginal Bone FACTORS IN THE SELECTION OF RESECTIVE FLAP PLACEMENT AND CLOSURE OSSEOUS SURGERY POSTOPERATIVE MAINTENANCE EXAMINATION AND TREATMENT PLANNING WITH SPECIFIC OSSEOUS RESHAPING SITUATIONS RESECTIVE SURGERY SUMMARY METHODS OF OSSEOUS RESECTIVE SURGERY THE OSSEOUS RESECTION TECHNIQUE Instruments Used Technique

he damage resulting from periodontal disease reveals itself in variable destruction of the tooth- supporting bone. Generally, bony deformities are not uniform. They are not indicative of the alveolar housing of the tooth before the disease process, nor do they reflect the overlying gingival architecture. Bone loss has been classified as either horizontal or vertical, but in fact, bone loss is most often a combination of horizontal Osseous surgery can be either additive or subtractive and vertical loss. Horizontal bone loss generally results in in nature. Additive osseous surgery includes proce- a relative thickening of the marginal alveolar bone, since dures directed at restoring the alveolar bone to its origi- bone tapers as it approaches its most coronal margin. nal level, whereas subtractive osseous surgery is de- The effects of this thickening and the development of signed to restore the form of preexisting alveolar bone to vertical defects leave the alveolar bone with countless the level existing at the time of surgery or slightly more combinations of bony shapes. If these various topo- apical to this level (Fig. 62-1). graphic changes are to be altered to provide a more Additive osseous surgery brings about the ideal result physiologic bone pattern, a method for osseous recon- of periodontal therapy; it implies regeneration of lost touring must be followed. bone and reestablishment of the periodontal ligament,

786

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RATIONALE Osseous resective surgery necessitates following a series of strict guidelines for proper contouring of alveolar bone and subsequent management of the overlying gingival soft tissues. The specifics of these techniques are discussed later in this chapter. They are quite technique sensitive. The techniques discussed here for osseous resective surgery have limited applicability in very deep intrabony or hemiseptal defects, which could be treated with a different surgical approach, are discussed in Chapter 63. Osseous surgery provides the purest and surest method for reducing pockets with bony discrepancies that are not overly vertical and also remains one of the principal periodontal modalities because of its long- term success and predictability. Osseous resective surgery is the most predictable pocket reduction technique. 10,12,13 However, more than any other surgical technique, osseous resective surgery is performed at the expense of bony tissue and attachment level. Thus its value as a surgical approach is limited by the presence, quantity, and shape of the bony tissues and by the amount of attachment loss that is acceptable. The major rationale for osseous resective surgery is cen- tered on the tenet that discrepancies in level and shapes of the bone and gingiva predispose patients to the recurrence of pocket depth postsurgically.6 Although this concept is Fig. 62-1 Additive and subtractive osseous surgery. A, Before and not universally accepted 3,5 and despite the fact that the B, immediately after subtractive osseous surgery; the osseous wall procedure induces loss of radicular bone in the healing of the two adjoining infrabony pockets has been removed. C, Be- phase, there are cases in which recontouring of bone is the fore and D, 1 year after additive osseous surgery; the area has been only logical treatment choice. The goal of osseous resective flapped and thoroughly instrumented, resulting in regeneration of therapy is to reshape the marginal bone to resemble that the interdental and periapical bone. (Courtesy Drs. E. A. Albano of the alveolar process undamaged by periodontal disease. and B. O. Barletta; Argentina.) The technique is performed in combination with apically positioned flaps, and the procedure eliminates periodontal pocket depth and improves tissue contour to provide a more easily maintainable environment. The relative merits of pocket reduction procedures are discussed in Chapters gingival fibers, and junctional epithelium at a more 33 and 54; this chapter discusses the osseous resective coronal level. This type of osseous surgery is discussed in technique and how and where it may be accomplished. Chapter 63. It is proposed that the conversion of the periodontal Subtractive osseous surgery procedures provide an al- pocket to a shallow gingival sulcus enhances the pa- ternative to additive methods and should be resorted to tient's ability to remove plaque and oral debris from the when the latter are not feasible. They are discussed in dentition. Likewise, the ability of dental professionals to this chapter. maintain the periodontium in a state free of gingivitis and periodontitis is more predictable in the presence of shallow sulci. The more effective the periodontal mainte- SELECTION OF TREATMENT TECHNIQUE nance therapy, the greater is the longitudinal stability of The morphology of the osseous defect largely determines the surgical result. The efficacy of osseous surgery there- the treatment technique to be used. One-wall angular fore is dependent on its ability to affect pocket depth defects usually have to be recontoured surgically. Three- and to promote periodontal maintenance. 11,23,24 The wall defects, particularly if they are narrow and deep, merits of resection vs. other treatment procedures are can be successfully treated with techniques that aim at discussed in Chapter 54 of this text. new attachment and bone regeneration. Two-wall angular defects can be treated with either method, depending NORMAL ALVEOLAR B ONE MORPHOLOGY on their depth, width, and general configuration. There- fore except for one-wall defects, wide and shallow two- Knowledge of the morphology of the bony periodon- wall defects, along with interdental craters, osseous de- tium in a state of health is required to correctly perform

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resective osseous surgery (Fig. 62-2). The characteristics the anterior. This "scalloping" of the bone on the fa- of a normal bony form are as follows: cials and linguas/palatals is related to tooth and root 1. The interproximal bone is more coronal in position form, as well as tooth position, within the alveolus. than the labial or lingual/palatal bone and pyramidal Teeth with prominent roots or that are displaced to in form. the facial or lingual may also have fenestrations or de- 2. The form of the interdental bone is a function of the hiscences (Fig. 62-3). The molar teeth have less scal- tooth form and the embrasure width. The more ta- loping and a more flat profile than bicuspids and in- pered the tooth, the more pyramidal is the bony form. cisors. Although these general observations apply to The wider the embrasure, the more flattened is the in- all patients, the bony architecture may vary from pa- terdental bone mesiodistally and buccolingually. tient to patient in the extent of contour, configura- 3. The position of the bony margin mimics the contours tion, and thickness. These variations may be both of the cementoenamel junction. The distance from normal and healthy. the facial bony margin of the tooth to the interproximal bony crest is more flat in the posterior areas than TER MI NOLOGY Numerous terms have been developed to describe the topography of the alveolar housing, the procedure for its removal, and the resulting correction. These terms should be clearly defined. Procedures used to correct osseous defects have been classified in two groups: osteoplasty and ostectomy. Osteoplasty refers to reshaping the bone without removing tooth-supporting bone. Ostectomy (or osteoectomy) includes the removal of tooth-supporting bone. One or both of these procedures may be necessary to produce the desired result. Terms that describe the bone form after reshaping can refer to morphologic features or to the thoroughness of the reshaping performed. Examples of morphologically descriptive terms include negative, positive, flat, and ideal. These terms all relate to a preconceived standard of ideal osseous form. Fig. 62-2 Photograph of a healthy bony periodontium in a skull. Positive or negative architecture refer to the rela- Although a slight amount of attachment may have been lost, this tive position of interdental bone to radicular bone (Fig. skull demonstrates the characteristics of normal form. 62-4). The architecture is said to be positive if the radicu-

Fig. 62-3 The effects of tooth position on facial bony contours. A, Bony fenestration; B, bony dehiscence. These deformities can and should be detected by palpation, probing and sounding prior to flap surgery.

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lar bone is apical to the interdental bone. The bone is remain at the facial, lingual/palatal line angles of the said to have negative architecture if the interdental bone teeth (so-called widow's peaks). During healing, the soft is more apical than the radicular bone. Flat architec- tissue tends to bridge the embrasure from the most coro- ture is the reduction of the interdental bone to the nal height of the bone on one tooth to the most coronal same height as the radicular bone. heights on the adjacent teeth. The result therefore is the Osseous form is considered to be ideal when the bone tendency to replicate the attachment contour on the is consistently more coronal on the interproximal surfaces than on the facial and lingual surfaces. The ideal form of the marginal bone has similar interdental height, with gradual, curved slopes between interdental peaks (Fig. 62-5). Terms that relate to the thoroughness of the osseous reshaping techniques include definitive and compromise. Definitive osseous reshaping implies that further osseous reshaping would not improve the overall result. Compromise osseous reshaping indicates a bone pattern that cannot be improved without significant osseous removal that would be detrimental to the overall result. References to compromise and definitive osseous architecture can be useful to the clinician, not as description of morphologic feature, but as terms that express the expected therapeutic result.

FACTORS IN THE SELECTION OF RESECTIVE OSSEOUS SURGERY The relationship between the depth and configuration of the bony lesion(s) to root morphology and the adjacent teeth determines the extent that bone and attachment is removed during resection. Bony lesions have been classified according to their configuration and number of bony walls.' The technique of ostectomy is best applied to patients with early-to-moderate bone loss (2 to 3 mm) with moderate-length root trunks 19 that have bony defects with one or two walls. These shallow-to-moderate bony defects can be effectively managed by osteoplasty and osteoectomy. Patients with advanced attachment loss and Fig. 62-4 Diagram of types of bony architecture. A, a positive deep intrabony defects are not candidates for resection to bony architecture; B, a flat bony architecture; and C, a reversed or produce a positive contour. To simulate a normal archi- negative bony form. tectural form, so much bone would have to be removed that the survival of the teeth could be compromised. Two-walled defects/craters occur at the expense of the interseptal bone. As a result, they have buccal and lingual/palatal walls that extend from one tooth to the adjacent tooth. The interdental loss of bone exposes the proximal aspects of both adjacent teeth. The buccal- lingual interproximal contour that results is opposite to the contour of the cementoenamel junction of the teeth (Fig. 62-6, A and B). Two-walled defects (craters) are the most common bony defects found in patients with periodontitis.15.21 If the facial and/or lingual plates of this bone are resected, the resultant interproximal contour would become more flattened or ovate (Fig. 62-6, C and D). However, confining resection only to ledges and the interproximal lesion results in a facial and lingual bone form in which the interproximal bone is located more apically than is the bone on the facial or lingual aspects of the tooth. This resulting anatomic form is reversed or negative architecture18,19,23 (see Fig. 62-6, C and D). Fig. 62-5 Skull photograph of a healthy periodontium. Note the Although the production of a reversed architecture shape of the alveolar bone housing. This bone is considered to have minimizes the amount of ostectomy that is performed, it ideal form. It is more coronal in the interproximal areas, with a is not without consequences.' Peaks of bone commonly gradual slope around and away from the tooth.

79 0 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com technique is properly applied to appropriate patients, the mean reduction in attachment circumferentially around the tooth has been determined to be 0.6 mm at six probing sites . 23 Practically, this means that the technique is best applied to interproximal lesions 1- to 3-mm deep in patients with moderate to long root trunks. 18 Patients with deep, multiwalled defects are not candidates for resective osseous surgery. They are better treated with regenerative therapies or by combining osteoplasty to reduce bony ledges and to facilitate flap closure with new attachment/regeneration procedures.

EXAMINATION AND TREATMENT PLANNING WITH RESECTIVE SURGERY The potential for the use of resective osseous surgery is usually identified during a comprehensive periodontal examination. Suitable patients display the signs and symptoms of periodontitis (see Chapter 30). The gingiva may be inflamed and deposits of plaque, calculus, and oral debris may be present. An increased flow of crevicular fluid may be detected, and bleeding on probing and exudation are commonly observed. Periodontal probing and exploration are key aspects of the examination. Careful probing reveals the presence of (1) pocket depth greater than that of a normal gingi- Fig. 62-6 Effect of correction of craters. A and B, Diagram of facial and interproximal bony contours after flap reflection. Note the val sulcus, (2) the location of the base of the pocket rela- loss of some interproximal bone and cratering. C and D, Line an- tive to the mucogingival junction and attachment level gles; this is only osteoplasty and has resulted in a reversed architec- on adjacent teeth, (3) the number of bony walls, and ture. E and F, Ostectomy on the facial and lingual bone and the re- (4) the presence of furcation defects. Transgingival moval of the residual widow's peaks to produce a positive bony probing, or sounding, under local anesthesia confirms architecture. the extent and configuration of the intrabony component of the pocket or offurcation defects . 6,11 Routine dental radiographs do not identify the presence of periodontitis, nor do they accurately document tooth. The interproximal soft tissues invest these peaks of the extent of bony defects. The number of bony walls bone, which may subsequently resorb with a tendency to and the presence or extent of bony lesions on the facial/ rebound without gain in attachment over time. A recur- buccal or lingual/palatal walls cannot be accurately de- rence of interproximal pocket depth can occur. Z3,25 termined by radiographs. Well-made radiographs provide Ostectomy to a positive architecture requires the re- useful information about the extent of interproximal moval of the line angle inconsistencies (widow's peaks), bone loss, the presence of angular bone loss, caries, root as well as some of the facial, lingual and palatal and in- trunk length, and root morphology. They also facilitate terproximal bone. The result is a loss of some attach- the identification of other dental pathoses that require ment on the facial and lingual root surfaces but a topog- treatment. In addition, a properly made radiographic raphy that more closely resembles normal bone form survey serves as a means of evaluating the success of before disease (Fig. 62-6, E and F). Proponents of osseous therapy and of documenting the longitudinal stability of resection to create a positive contour believe that this ar- the patient . 2° chitecture, devoid of sharp angles and spines, is con- Treatment planning should provide solutions for ac- ducive to the formation of a more uniform and reduced tive periodontal diseases and correction of deformities soft tissue dimension postoperatively.18,22 The therapeu- that result from periodontitis, and it should facilitate the tic result is less pocket depth and increased ease of peri- performance of other dental procedures included in a odontal maintenance by the patient, dental hygienist or comprehensive dental treatment plan. The extent of pe- dentist. riodontal involvement can vary significantly from tooth The amount of attachment lost from the use of ostec- to tooth in the same patient. The response to therapy tomy varies with the depth and configuration of the os- from patient to patient may also vary, as may the treat- seous defects that are treated. Osseous resection applied ment objectives for the patients. Therefore a treatment to two-wall intrabony defects (craters), the most com- plan may encompass a number of steps and/or combina- mon osseous defects, results in attachment loss at the tions of procedures in the same surgical area. proximal line angles and the facial and lingual aspects of After oral hygiene instruction, scaling, and root plan- the affected teeth without affecting the base of the ing, along with other disease control procedures, the re- pocket. The extent of attachment loss during resection sponse of the patient to these treatment procedures is to a positive architecture has been measured. When the evaluated by reexamination and recording the changes

Resective Osseous Surgery • CHAPTER 62 791 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com that have occurred in the periodontium. Because the ex- can be exposed for restoration, fractured roots of abutment tent of periodontal involvement can vary significantly teeth can be exposed for removal, and bony exostoses from tooth to tooth in the same patient, the local re- and ridge deformities can be altered in contour to im- sponse to therapy is also variable. The resolution of in- prove the performance of removable or fixed prostheses flammation and decrease in edema and swelling may (Fig. 62-7, A to D). Severely decayed teeth or teeth with have resulted in a return to normal depth and configura- short anatomic crowns can be lengthened by resection tion of some pockets and additional therapy beyond pe- or by a combination of orthodontic tooth extrusion and riodic maintenance is not required. osseous resection. Such procedures allow the therapist to The patient with moderate to advanced periodontitis expose more tooth for restoration, prevent an invasion and bony defects, although the overt signs of periodonti- of the biologic width of attachment, and create a peri- tis may be reduced, may display a persistence of pocket odontal attachment of normal dimension.8,16 Resection depth bleeding on probing and suppuration. These signs can also provide a means of producing optimal crown may indicate the presence of residual plaque and calcu- length for cosmetic purposes. lus attributable to the difficulty of instrumentation in these deep pockets or an inability or unwillingness of METHODS OF OSSEOUS the patient to perform adequate oral hygiene in these RESECTIVE SURGERY sites. Patients with inadequate oral hygiene are not good candidates for periodontal surgery. If the supragingival The reshaping process is fundamentally an attempt to plaque control is good, and the residual pocket depths gradualize the bone sufficiently to allow soft tissue struc- are 5 mm or more, such areas may be candidates for peri- tures to follow the contour of the bone. The soft tissue odontal surgery. 14 predictably attaches to the bone within certain specific Resective osseous surgery is also used to facilitate cer- dimensions. The length and quality of connective tissue tain restorative/prosthetic dental procedures. Dental caries and junctional epithelium that reforms in the surgical

Fig. 62-7 Reduction of bony ledges and exposure of caries by osteoplasty. A, Buccal preoperative photograph showing two crowns, exostoses, and caries. B, Flap reflected to reveal caries on both molars at the restoration margins, interdental cratering, and a facial exostosis. C, Postosseous surgery; the bulk of the bony removal was by osteoplasty with minor ostectomy between the two molars. The caries is now exposed and the crowns lengthened for restoration. D, Six weeks postoperative photograph. The plaque control is deficient but the teeth should be readily restorable at this time. (Courtesy Dr. Joseph Schwartz; Portland, Ore.) 79 2 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 62-8 Instruments often used in osseous surgery. A, Rongeurs: Friedman (top) and 90-degree Blumen- thal (bottom). B, Carbide round burrs (left to right): friction grip, surgical-length friction grip, and slow- speed hand-piece. C, Diamond burrs. D, Interproximal files: Schluger and Sugarman. E, Back-action chisels. F, Ochsenbein chisels.

site are dependent on numerous factors, including the direct knowledge as possible from soft tissue palpation, health of the tissue, the condition of the root surface radiographic assessment, and transgingival probing, or and the topography, as well as the proximity of the bone sounding. surrounding the tooth. Each of these factors must be Radiographic examination can reveal the existence of controlled to the best of the clinician's ability to obtain angular bone loss in the interdental spaces; these usually the optimal result, making osseous resective surgery an coincide with intrabony pockets. The radiograph does extremely precise technique. not show the number of bony walls of the defect, nor It is assumed in this chapter that the gingival tissue does it determine with any accuracy the presence of an- has been reflected by the apically positioned flap de- gular cone defects on facial or lingual surfaces. Clinical scribed in Chapter 60. Reshaping of the bone may ne- examination and probing determines the presence and cessitate selective changes in gingival height. These depth of periodontal pockets on any surface of any tooth changes must be calculated and accounted for in the and can also give a general sense of the bony topography, initial flap design. For this reason, it is important for the but intrabony pockets can go undetected by probing. clinician to know about the underlying bone tissue be- Both clinical and radiographic examinations can indicate fore flap reflection. The clinician must gain as much in- the presence of intrabony pockets when (1) angular bone Resective Osseous Surgery • CHAPTER 62 79 3 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 62-9 A, Drawing representing the bony topography in moderate periodontitis with interdental craters. B, Vertical grooving, the first step in correction by osseous reshaping. C, Radicular blending and flattening of interproximal bone. D, Gradualizing the marginal bone. Note the area of the furcation on the first molar where the bone is preserved.

loss, (2) irregular bone loss, or (3) pockets of irregular depth in adjacent areas of the same tooth or adjacent teeth are found. The experienced clinician can use transgingival probing to predict many features of the underlying bony topography. The information thus obtained can change the treatment plan. For example, an area that had been selected for osseous resective surgery may be found to have a narrow defect that was unnoticed in the initial probing and radiographic assessment and is ideal for augmentation procedures. Such findings can and do change the flap design, osseous procedure, and results expected from the surgical intervention. Transgingival probing is extremely useful just before flap reflection. It Fig. 62-10 Diagrammatic representation of bone irregularities in is necessary to anesthetize the tissue locally before in- periodontal disease. The thick line is the proposed correction of serting the probe. The probe should be "walked" along the defect. Note the flattening of the interproximal bone between the tissue-tooth interface so that the operator can feel the molars and the protection of the furcal bone on the first molar. Facial crest height is reduced in both interproximal areas to the the bony topography. The probe may also be passed hor- depth of the defect. izontally through the tissue to provide three-dimen- sional information regarding bony contours (i.e., thickness, height, and shape of the underlying base). It must be remembered, however, that this information is still The situations that can be encountered after peri- "blind," and although it is undoubtedly better than odontal flap reflection vary greatly. When all soft tissue probing alone, it has significant limitations. Neverthe- is removed around the teeth, there may be larger exoto- less, this step is recommended immediately before the ses, ledges, troughs, craters, vertical defects, or combina- surgical intervention. tions of any of these. For this reason, each osseous situa- Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 62-11 Compromise osseous surgery. A and B, Preoperative views of the buccal and lingual surfaces. C and D, Pre- and postoperative view of the buccal osseous recontouring class I buccal furcation defects, a moderate crater between the two molars, and a deep 1-2-3 walled defect at the mesial of the first involvements. D, The buccal aspects of these lesions were corrected with osteoplasty and a small amount of ostectomy. E and F, Pre- and postoperative views of the lingual osseous management. E, Notice the combination 1-2-3 wall defect between the second bicuspid and first molar, as well as the irregular pattern of bone loss with ledging. F, These defects were corrected by osteoplasty and ostectomy with the exception of the deep defect at the mesial of the molar. This area was resected until the residual defect was of two and three walls only and left to repair. G and H, Buccal and lingual 5-year postoperative views of tissue configuration. Note the residual soft tissue defect between the bicuspid and first molar.

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Fig. 62-12 Osteoectomy and osteoplasty to a positive contour with flap placement at the newly created bony crest for minimal pocket depth. A and B, Buccal and lingual preoperative views. C and D, Buccal pre-and postosseous correction. Osteoplasty and osteoectomy used to produce a positive contour. Note the osteoplasty into the buccal furcation of the first molar. This is about the extent of craters that can be corrected to a positive contour in teeth with moderate root trunk length. E and F, Lingual pre- and postosseous correction. Osteoplasty and osteoectomy to produce a positive contour. Note the lingual ledge, which was reduced. Such ledges are common in this area. G and H, Buc- cal and lingual flaps sutured with continuous sling sutures to allow placement of the flaps to cover the bony margins. Continued

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Fig. 62-12, cont'd Osteosectomy and osteoplasty to a positive contour with flap placement at the newly created bony crest for minimal pocket depth. I and 1, Buccal and lingual 1 week postoperative views. There is a minimal soft tissue thickness, and the interdental areas are granulating in over the positive bony form. Minimal pocket depth results from such management. tion presents uniquely challenging problems, especially step of the resective process, because it can define the gen- if reshaping to the optimal level is contemplated. eral thickness and subsequent form of the alveolar housing. This step is usually performed with rotary instruments THE OSSEOUS RESECTION TECHNIQUE such as round carbide burrs or diamonds. The advantages of vertical grooving are most apparent with thick, bony I nstruments Used margins; shallow crater formations; or other areas that require maximal osteoplasty and minimal ostectomy. Verti- A number of hand and rotary instruments have been cal grooving is contraindicated in areas with close root used for osseous resective surgery. Some excellent clini- proximity or thin alveolar housing. cians use only hand instruments and rongeurs, whereas others prefer a combination of hand and rotary instruments. Rotary instruments are useful for the osteoplastic Radicular Blending steps outlined previously, whereas hand instruments Radicular blending, the second step of the osseous re- provide the most precise and safe results with ostectomy shaping technique, is an extension of vertical grooving procedures. Nevertheless, care and precision are required (see Fig. 62-9, C). Conceptually, it is an attempt to gradu- each step of the way to prevent excessive bone removal alize the bone over the entire radicular surface to provide or root damage, both of which are irreversible. Fig. 62-8 the best results from vertical grooving. This provides a illustrates some of the instruments commonly used for smooth, blended surface for good flap adaptation. The osseous resective techniques. indications are the same as for vertical grooving (i.e., thick ledges of bone on the radicular surface, where se- Technique lective surgical resection is desired). Naturally, this step is not necessary if vertical grooving is very minor or if To handle the multitude of clinical situations, the fol- the radicular bone is thin or fenestrated. Both vertical lowing sequential steps are suggested (Fig. 62-9, A to D): grooving and radicular blending are purely osteoplastic 1. Vertical grooving techniques that do not remove supporting bone. In most 2. Radicular blending situations, they compose the bulk of osseous resective 3. Flattening interproximal bone surgery. Classically, shallow crater formations, thick os- 4. Gradualizing marginal bone seous ledges of bone on the radicular surfaces, and class I and early class II furcation involvements are treated al- Not all steps are necessary in every case, but the se- most entirely with these two steps. quencing of the steps in the order given is necessary to expedite the reshaping procedure, as well as to minimize the removal of bone. Flattening Interproximal Bone Flattening of the interdental bone requires the removal Vertical Grooving of very small amounts of supporting bone (Fig. 62-10). It is indicated when interproximal bone levels vary hori- Vertical grooving is designed to reduce the thickness of the zontally. By definition, most of the indications for this alveolar housing and to provide relative prominence to step are one-walled interproximal defects or so-called the radicular aspects of the teeth (see Fig. 62-9, B) and hemiseptal defects. The omission of flattening in such Color Fig. 62-1). It also provides continuity from the inter- cases results in increased pocket depth on the most proximal surface onto the radicular surface. It is the first apical side of the bone loss. This step is typically not

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Fig. 62-13 Interproximal craters. The shaded areas illustrate different techniques for the management of such defects. The technique that reduces the least amount of supporting bone is preferable.

necessary in class crater formations or flat interproximal defects. It is best used in defects that have a coronally placed one-walled edge of a predominantly three-walled angular defect, and it can be helpful in obtaining good flap closure and improved healing in the three-walled defect. The limitation of this step, as with osseous resective surgical therapy in general, is in the treatment of advanced lesions. Large hemiseptal defects would require removal of inordinate amounts of bone to provide a flattened architecture, and the operation would be too costly in terms of bony support. Compromised osseous architecture is the only logical solution (Fig. 62-11).

Gradualizing Marginal Bone The final step in the osseous resective technique is also Fig. 62-14 Reduction of a one-wall angular defect. A, Angular an ostectomy process. Bone removal is minimal but nec- bone defect mesial to the tilted molar. B, Defect reduced by essary to provide a sound, regular base for the gingival "ramping" angular bone. tissue to follow. Failure to remove small bony discrepancies on the gingival line angles (often called widow's peaks) allows the tissue to rise to a higher level than of altering the width of the gingiva (denudation). the base of the bone loss in the interdental area (see Fig. However, such flap placement results in more postsurgi- 62-9, C and D). This may make the process of selective cal resorption of bone and patient discomfort than if the recession and subsequent pocket reduction incomplete. newly created bony margin were covered by the flap. Po- This step of the procedure also requires gradualization sitioning the flap to cover the new margin results in a and blending of the radicular surface (see Fig. 62-10 and minimum of postoperative complications and optimal Color Fig. 62-1, C. The two ostectomy steps should be postsurgical pocket depths' (Fig. 62-12, I and J). performed with great care so as not to produce nicks or Suturing may be accomplished using a variety of differ- grooves on the roots. When the radicular bone is thin, it ent suture materials and suture knots' (see Chapter 60). is extremely easy to overdo this step, to the detriment of The sutures should be placed with minimal tension to co- the entire surgical effort. For this reason, various hand apt the flaps, prevent their separation, and maintain the instruments, such as chisels and curettes, are preferable position of the flaps. Sutures placed with excessive ten- to rotary instruments for gradualizing marginal bone. sion rapidly pull through the tissues.

FLAP PLACEMENT AND CLOSURE POSTOPERATIVE MAINTENANCE Following the performance of resection, the flaps are po- Sutures may be removed at varying periods. Nonre- sitioned and sutured. Flaps may be replaced to their orig- sorbable sutures such as silk are usually removed after inal position, to cover the new bony margin, or they 1 week of healing, although some of the newer synthetic may be apically positioned. Replacing the flap in areas materials may be left for periods of up to 3 weeks or that previously had deep pockets may result initially in longer without adverse consequences. Resorbable sutures greater postoperative pocket depth, although a selective maintain wound approximation for varying periods or recession may diminish the depth over time. Positioning 1 to 3 weeks or more, depending on the material of the flap apically to expose marginal bone is one method which they are made. At the suture removal appointment 798 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 62-15 Correction of exotoses by osseous surgery. A, Periodontal disease in a patient with bulbous gingival contour in the mandible. B, Reflected flap reveals exostoses. C, Exostoses reduced, interdental grooves established, and interdental bone tapered inward and toward the crest. D, (1) Lateral view, showing exostosis; (2) exostosis reduced and bone recontoured to provide interdental grooves. E, After 10 weeks, pockets are eliminated, and physiologic gingival contour is restored. Compare with A. (Courtesy of Dr. Charles A. Palioca; Homosassa, Fla.)

the periodontal dressing, if present, is removed, and After suture removal the surgical site is examined the surgical site is gently cleansed of debris with a cot- carefully, and any excessive granulation tissue is re- ton pellet dampened with saline. Nonresorbable sutures moved with a sharp curette. The patient is provided with are then cut and removed. If sutures of a resorbable ma- postsurgical maintenance instructions and the instru- terial were used, then the area should be inspected care- ments needed to maintain the surgical site in a plaque- fully to insure that no suture fragments remain. Suture free state. These instruments should not produce addi- removal should be accomplished without dragging cont- tional trauma to the healing tissues. Many therapists aminated portions of the suture through the periodon- find the use of a plaque-suppressive agent such as tal tissues. This may be accomplished by lightly com- chlorhexidine digluconate to be a valuable adjunct to pressing the soft tissue immediately adjacent to the postsurgical maintenance. A second postoperative visit is suture. This exposes (extrudes) a portion of the suture often performed at the second or third week, and the that was previously under the gingival tissues and less surgical site is lightly debrided for optimal results. A pro- likely to be contaminated by plaque. The suture is then fessional prophylaxis for complete plaque removal cut at the gingival surface. Removal of the pressure from should be done every 2 weeks until healing is complete the site results in the cut surface being slightly sub- and the patient is maintaining appropriate levels of merged in the tissue. The sutures are then removed with plaque control. cotton pliers by pulling the suture from its contami- Healing should proceed uneventfully, with the at- nated end. tachment of the flap to the underlying bone being Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Color Fig. 51-1 Necrotizing ulcerative peridontitis (NUP) in a 28-year-old woman with a CD4 count of 48. A, NUP of mandibular anterior region. B, Necrotizing stomatitis in mandibular left molar area. C, Radiograph of sequestra in mandibular left molar area. D, Sequestrae removed in conjunction with extraction of teeth #17 and 18. E, Mandibular anterior area 1 week posttreatment. F, Mandibular left molar region 2 months postoperatively. Note the uneventful healing. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Color Fig. 60-1 The periodontal flap technique. A, Facial view and B, palatal view of case preoperatively. A thorough scaling and root planing had been performed 6 weeks before. Five- to six-millimeter pockets persisted in palatal areas. C, Facial incisions (internal bevel and crevicular) performed. D, Palatal incisions performed. Note the scalloping. E and F, Facial and palatal flaps elevated. Wedge of marginal tissue not yet removed in the palate. After thorough debridement, the root is examined for any remaining accretions and the bone is examined to determine the need for osseous surgery. G and H, Continuous mattress suture in place. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Color Fig. 60-2 The papilla preservation flap. A, Facial view after sulcular incisions have been made. B, Straight line incision in the palatal area about 3 mm from gingival margins. This incision is then connected to the margins with vertical incisions in the mid- part of each tooth. C, The papillae are reflected with the facial flap. D, Lingual view after reflection of the flap. E, Lingual view after the flap is brought back to its original position. It is then sutured with independent sutures. F, Facial view after healing. G, Palatal view after healing. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Color Fig. 62-1 Bone contouring in flap surgery. A-C, Bone contouring in interdental craters. D and E, Bone contouring in exotoses. F and G, Bone contouring in one-wall vertical defect. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Color Fig. 63-1 A, Pretreatment photograph of lower left posterior teeth with marked recession and tissue inflammation. B, Underlying extensive crestal bone loss, dehiscence, and intrabony osseous defects. C, Bone graft in position approximating the cementoenamel junction of the posterior teeth. D, Barrier membranes over the bone grafts. E, Flaps coronally positioned and secured over the barrier membranes. F, Membrane removal revealing new alveolar bone. G, Pretreatment radiograph. H, One-year postoperative radiograph depicting new alveolar bone apposition. (From McClain P: Dental Economics 1996; 4:92.)

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Color Fig. 63-2 Reconstructive periodontics: use of decalcified freeze-dried bone allografts (DFDBA) and porous hydroxyapatite. Facial view (A) and lingual view (B) of deep vertical lesions mesial and distal to lower first molar, exposed by a flap and debridement. Furcation is not involved. C and D, Facial and lingual views, respectively, of lesions filled with DFDBA (mesial defect) and porous hydroxyapatite (distal defect). This case was part of a study comparing both types of bone grafts. E and F, Facial and lingual views, respectively, of reentry at 6 months postoperatively, showing total fill of distal defect and partial fill of mesial defect. G, Preoperative radiograph. H, Radiograph immediately after placement of grafts. Continued Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Color Fig. 63-2, cont'd 1, Radiograph 6 months later. (From Oreamuno S, Lekovic V, Kenney EB, et al: Comparative clinical study of porous hydroxyapatite and decalcified freeze- dried bone in human periodontal defects. J Periodontol 1990; 61:399.)

Color Fig. 66-1 Technique for free gingival grafts. A, Lack of attached gingiva and the beginning of recession on the lower second premolar. B, Surgical bed prepared and the border of the wound sutured to the periosteum. C, Donor site in the palatal area immediately after removal of tissue for grafting. Note the presence of periosteum. D, Donor tissue placed on the surgical bed and sutured with catgut. E, Recipi- ent site 1 month postoperatively. F, Recipient site 3 months postoperatively. Compare with A. (Courtesy Dr. Agusti Marfany, St. Julian, Andorra.) Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Color Fig. 66-2 Mucogingival defects. A, Irregular gingival contours, pocket furcations, and recession with severe gingival inflammation. B, Gingival recession and inflammation. Bottom of pocket is beyond mucogingival junction. C, Recession on mesiobuccal root of lower first molar. Probe indicates presence of shallow pocket with absence of attached gingiva. D, Gingival recession and cleft on upper cuspid. E, Ad- vanced gingival recession and inflammation. F, After scaling and root planing and adequate plaque control, gingival condition has improved markedly.

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Fig. 62-16 Photographs taken A, before osseous surgery and B, after osseous management. C, Results 3 weeks after surgery.

800 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com of the bony lesion begins with reduction of the interdental walls of craters and the one-walled component of angular defects and wells (moats) and grooving into sites of early involvement." The walls of the crater may be reduced at the expense of the buccal, lingual, or both walls (Fig. 62-17). The reduction should be made to remove the least amount of alveolar bone required to produce a satisfactory form, prevent the therapeutic invasion of furcations, and blend the contours with the adjacent teeth. The selective reduction of bony defects by "ramping" the bone to the palatal or lingual to avoid involvement of the furcations has been advocated by Ochsen- bein and Bohannan19 and Tibbetts, Ochsenbein, and Loughlin24 (Fig. 62-18). One-walled or hemiseptal defects usually require the removal of some bone from the tooth with the greatest coronal bony height. This removal of bone may result in a significant reduction in attachment on relatively unaf- fected adjacent teeth to eliminate the defect (see Fig. 62- Fig. 62-17 Diagram of crater reduction patterns. A, Preoperative 16, A and B). However, if a tooth in the surgical field has bony form after flap reflection. B, Reduction of craters to the facial. C, Reduction of craters to the lingual. D, Reduction of craters to one-walled defects on both its mesial and distal surfaces both buccal and lingual. and this is recognized during examination, the severely affected tooth may be extruded by orthodontics during disease control treatment to minimize or eliminate the need for resection of bone from the adjacent teeth. In the presence of heavy ledges of bone, it is usually wise to do osteoplasty first to eliminate any exostoses or completed by 14 to 21 days. Maturation and remodeling reduce the buccal/lingual bulk of the bone (Fig. 62-19). It can continue for up to 6 months. It is usually advisable is common to incorporate a degree of vertical grooving to wait a minimum period of 6 weeks after the comple- during the reduction of bony ledges, since it facilitates tion of the last surgical area before beginning dental the process of blending the radicular bone into the inter- restorations. For those patients with a major cosmetic proximal areas at the next step. concern, it is wise to wait as long as possible to achieve a postoperative soft tissue position and sulcus that is stable. SUMMARY Though osseous surgical techniques cannot be applied to every single bony abnormality or topographic modifi- SPECIFIC OSSEOUS RE SHAPING SITUATION S cation, clearly it has been demonstrated that properly The osseous corrective procedure that has been described used osseous surgery can eliminate and modify defects, is classically applied to shallow craters with heavy faci- as well as gradualize excessive bony ledges, irregular olingual ledges (Fig. 62-13). The correction of other os- alveolar bone, early furcation involvement, excessive seous defects is also possible; however, careful case selec- bony exostosis, and circumferential defects. When prop- tion for definitive osseous surgery is very important. erly performed, osseous resective surgery achieves a Correction of one-walled hemiseptal defects requires physiologic architecture of marginal alveolar bone that the bone be reduced to the level of the most apical conducive to gingival flap adaptation with minimal portion of the defect. Therefore great care should be probing depth. The advantages of this surgical modality taken to select the adequate case. If one-walled defects include a predictable amount of pocket reduction that occur next to an edentulous space, the edentulous ridge can enhance oral hygiene and periodic maintenance. It is reduced to the level of the osseous defect (Fig. 62-14). also preserves the width of the attached tissue, while re- Other situations that complicate osseous correction moving granulatous tissue and providing access for are exostoses (Fig. 62-15; see Color Fig. 62-1, D and E), debridement of the radicular surfaces. Additionally, re- malpositioned teeth, and supraerupted teeth. Each of contouring of bony abnormalities, including hemiseptal these situations is best controlled by following the defects, tori, and ledges, is permitted. Proper assessment four steps previously outlined. In most situations, the for restorative procedures such as crown lengthening unique feature of the bony profile is well managed by and assessment of restorative overhangs and tooth ab- prudently applying the same principles. (Fig. 62-16; normalities such as enamel projections, enamel pearls, see Color Fig. 62-1). However, some situations require perforations, and fractures is also a substantial benefit deviation from the definitive osseous reshaping tech- of osseous resective surgery. All factors lead to the nique; examples include dilacerated roots, root proxim- conclusion that osseous resective surgery can be an ity, and furcations that would be compromised by os- important technique in the armamentarium necessary seous surgery. to provide a maintainable periodontium for periodon- In the absence of ledges or exostoses, the elimination tal patients. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 62-18 Correction of osseous defects largely to the palatal. A and B, Buccal and palatal preoperative views. The patient is 6 weeks post- completion of scaling and root planing. C and D, Buccal preosseous and postosseous views. C, Note the ledging on the facial of the molars, and one wall defects on both molars. D, The postosseous view shows the elimination of these defects by osteoplasty on the ledges and ostectomy of the one wall defects to produce a positive buccal architecture. E and F, Palatal preosseous and postosseous views. E, Note the pattern of bony loss, which is more severe on the palatal. In addition to the facial one-wall defects, there is an incipient furcation defect at the mesial of the first molar and a class II furcation at the mesial of the second molar. F The configuration of the defects was such that ostectomy was performed on the palatal roots of both molars to produce a compromised architecture. G and H, Ten-year postoperative views of the buccal and palatal areas displaying the pattern of soft tissue adaptation to the surgically produced bony form. 801 802 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 62-19 Reduction of bony ledges by osteoplasty before correction of interdental defects. A, Buccal preoperative view. B, Buccal flap reflection. Note the buccal ledge and the class II buccal furcation. C, Buccal correction largely by osteoplasty with minor ostectomy over the root prominence to produce a positive architecture. D, Ten-year postoperative view of soft tissue form. Minimal pocket depth is present.

REFERENCES 10. Kaldahl WB, Kalkwarf KL, Patin KD, et al: Evaluation of four modalities of periodontal therapy: Mean probing depth, 1. Black GV: Surgical treatment of pockets. In Black AD: Spe- probing attachment level and recession changes. J Peri- cial Dental Pathology, ed 3. Chicago, Medico Dental, 1917. odontol 1988; 59:783. 2. Carranza FA, Carranza FA Jr: The management of the alveo- 11. Kaldahl WB, Kalkwarf KL, Patil KD, et al: Long-term evalua- lar bone in the treatment of the periodontal pocket. J Peri- tion of periodontal therapy. 1. Response to four therapeutic odontol 1956; 27:29. modalities. J Periodontol 1996; 67:93. 3. Caton J, Nyman S: Histometric evaluation of periodontal 12. Kaldahl WB, Kalkwarf KL, Patil KD, et al: Long-term evalua- surgery. III. The effect of bone resection on the connective tion of periodontal therapy: 1. Response to four therapeutic tissue attachment level. J Periodontol 1981; 52:405. modalities. J Periodontol 1996; 67:103. 4. Dahlberg WH: Incisions and suturing: Some basic consider- 13. Knowles J, Burgett F, Nissle R, et al: Results of periodontal ations about each in periodontal surgery. Dent Clin N Amer treatment related to pocket depth and attachment level. 1969; 13(1):149. Eight years. J Periodontol 1979; 50:225. 5. Donnenfeld OW, Hoag PM, Weissman DP: A clinical study 14. Lindhe J, Socransky S, Nyman S, et al: Critical probing of the effects of osteoplasty. J Periodontol 1961; 32:131. depths in peridontal therapy. J Clin Periodontol 1982; 6. Easley J: Methods of determining alveolar osseous form. 9:323. J Periodontol 1967; 38:112. 15. Manson JD, Nicholson K: The distribution of bone defects 7. Friedman N: Periodontal osseous surgery: Osteoplasty and in chronic periodontitis. J Periodontol 1974; 45:88. osteoectomy periodontol 1955; 26:257. 16. Maynard JG, Wilson RDK: Physiologic dimensions of the 8. Garguilo AW, Wentz FM, Orban B: Dimensions and rela- periodontium significant to the restorative dentist. J Peri- tions of the dentogingival junction in humans. J Periodon- odontol 1979; 50:170. tol 1961; 32:261. 17. Mealey BL, Beybayer MF, Butzin CA, et al: Use of furcal 9. Goldman HM, Cohen DW: The infrabony pocket: Classifi- bone sounding to improve the accuracy of furcation diag- cation and treatment. J Periodontol 1958; 29:272. nosis. J Periodontol 1994; 65:649.

Resective Osseous Surgery . CHAPTER 62 803 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com 18. Ochsenbein C: A primer for osseous surgery. Int J Perio Rest 22. Schluger S, Yuodelis RA, Page RC, et al: Resective periodon- Dent 1986; 6(1):9. tal surgery in pocket elimination. In Periodontal Diseases. 19. Ochsenbein C, Bohannan HM: The palatal approach to os- Philadelphia, Lea & Febiger, 1990. seous surgery. II. Clinical application. J Periodontol 1964; 23. Selipsky HS: Osseous surgery. How much need we compro- 35:54. mise? Dent Clin N Amer 1976; 20(1):79. 20. Prichard JF: The roentgenographic depiction of periodontal 24. Tibbetts L, Ochsenbein C, Loughlin D: The lingual ap- disease. Periodontics 1973; 3(2). proach to osseous surgery. J Periodontol 1976; 20(1):61. 21. Schluger S: Osseous resection: A basic principle in periodon- 25. Townsend-Olsen C, Ammons WF, Van Belle C: A longitudi- tal surgery. Oral Surg Oral Med Oral Path 1949; 2:316. nal study comparing apically repositioned flaps, with and without osseous surgery. Int J Periodontics Restorative Dent 1985; 5(4):11. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Regenerative Osseous Surgery

Fermin A. Carranza, Pamela McClain, and Robert Schallhorn

CHAPTER

CHAPTER OUTLINE

EVALUATION OF NEW ATTACHMENT AND BONE REGENERATIVE SURGICAL TECHNIQUES REGENERATION Non-Graft-Associated New Attachment Clinical Methods Graft Materials and Procedures Radiographic Methods Combined Techniques Surgical Reentry FACTORS INFLUENCING A SUCCESSFUL OUTCOME Histologic Methods SUMMARY

ew attachment with periodontal regeneration is Clinical Methods the ideal outcome of therapy because it results in obliteration of the pocket and reconstruction Clinical methods consist of comparison of pre- and of the marginal periodontium (Color Fig. 63-1; Fig. 63-1). posttreatment pocket probings and determinations of However, the techniques available are not totally depend- clinical gingival findings. The probe can be used to de- able, and the following other results of therapy may be termine pocket depth, attachment level, and bone level seen (Fig. 63-2): (see Chapter 30) (Fig. 63-3). Clinical determinations of attachment level are more useful than strict pocket 1. Healing with a long junctional epithelium, which can depths because the latter may change as a result of dis- occur even if filling in of bone has occurred. placement of the gingival margin. Several studies have 2. Ankylosis of bone and tooth with resultant root re- determined that the depth of penetration of a probe in sorption. a periodontal pocket varies according to the degree of 3. Recession. inflammatory involvement of the tissues immediately 4. Recurrence of the pocket. beneath the bottom of the pocket (Fig. 63-4). Therefore 5. Any combination of the above. even though the forces used may be standardized with pressure-sensitive probes, there is an inherent margin of error in this method that is difficult to overcome. EVALUATION OF NEW ATTACHMENT Fowler and colleagues 54 have calculated this error to be AND BONE REGENERATION 1.2 mm, but it is even greater when furcations are It is sometimes difficult in clinical and experimental situ- probed."' ations to determine whether new attachment has oc- Bone probing performed under anesthesia is not curred and the extent to which it has occurred. Evi- subject to this error and has been found to be as accu- dences of reconstruction of the marginal periodontium rate as bone height measurements made on surgical can be obtained by clinical, radiographic, surgical reen- reentry.'° 144,186 try, or histologic procedures.28-99 All these methods have Measurements of the defect should be made before advantages and shortcomings that should be well under- and after treatment from the same exact point within stood and considered in individual cases and when criti- the defect and with the same angulation of the probe. cally evaluating the literature. This reproducibility of probe placement is difficult and

804

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Fig. 63-1 Bone regeneration after closed scaling, root planing, and curettage. Before (A) and after (B) radiographs are shown. (From Carranza FA Sr: A technique for reattachment. J Periodontol 1954; 25:272.)

Fig. 63-3 Different types of probings in an interdental space.

Fig. 63-4 Left, Arrow pointing downward depicts penetration of a probe in an untreated periodontal pocket. The probe tip goes past the junctional epithelium and the inflamed tissue and is stopped by the first intact, attached collagen fibers. Right After thorough scaling and root planing, the location of the bottom of the pocket has not changed, but the probe penetrates to only about one third the length of the junctional epithelium (see Chapter 30). The reduction Fig. 63-2 Possible outcomes of therapy. in probing depth may not reflect a change in attachment level.

may be facilitated in part by using a grooved stent to Radiographic Methods guide the introduction of the probe (Fig. 63-5). Preopera- Radiographic evaluation of bone regeneration also re- tive and postoperative comparability of probing mea- quires carefully standardized techniques for reproducible surements that do not use this standardized method may positioning of the film and the tube. 128,148 Even with be open to question. standardized techniques (see Chapter 34), the radiograph

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Fig. 63-5 Grooved acrylic stent used in clinical research to stan- dardize the direction of introduction of the probe. Fig. 63-7 A, Periodontal pocket preoperatively. B, Periodontal pocket immediately after scaling, root planing, and curettage. C, New attachment. The arrow indicates the most apical part of the junctional epithelium. Note regeneration of bone and periodontal ligament. D, Healing by long junctional epithelium. Again, the arrow indicates the most apical part of the junctional epithelium. Note that the bone is new but the periodontal ligament is not.

radiographic analysis significantly underestimates pretreatment bone loss and posttreatment bone fill."' Studies with subtraction radiography have enhanced the usefulness of radiographic evaluation .43.44,190 A comparative study between linear measurement, computer assisted densitometric analysis (CADIA) (see Chapter 34), and a method combining the two reported that the linear-CADIA method offers the highest level of accuracy. 179

Surgical Reentry The surgical reentry of a case after a period of healing can give a good view of the state of the bone crest that can be compared with the view taken during the initial surgical intervention and can also be subject to measurements (Fig. 63-6). Models from impressions of the bone taken at the time of the initial surgery and later at reentry can be used to assess the results of therapy. This method is very useful but has two shortcomings: it requires a frequently Fig. 63-6 Reentry evidence of bone apposition following regener- unnecessary second operation, and it does not show the ative therapy. A, Surgical exposure of facial bone dehiscence and type of attachment that exists (i.e., new attachment or furcation defects. B, Two-year reentry with tip of probe on new coronal bone height. (From McClain P, Schallhorn RG: The use of long junctional epithelium (Fig. 63-7).31 combined periodontal regenerative techniques (guest editorial). Int j Periodont Restorative Dent 1993; 13:15.) Histologic Methods The type of attachment can be determined only by histologic analysis of tissue blocks obtained from the healed does not show the entire topography of the area before or area. Although this method can offer clear evidence of after treatment. Furthermore, thin bone trabeculae may regeneration of the attachment apparatus, it is not with- exist before treatment and go undetected radiographi- out problems. The need to remove a tooth with its peri- cally because a certain minimal amount of mineralized odontium after successful treatment limits this method tissue must be present to register on the radiograph. Sev- to volunteers who need the extraction for prosthetic or eral studies have demonstrated that radiographs, even other reasons and agree to the procedure. those taken with standardized methods, are less reliable Animal studies can be used to clarify some aspects than clinical probing techniques . 91,178 A comparative study of the tissue response to different materials. However, of pretreatment bone levels and posttherapy bone fill with species differences should always be remembered when 12-month reentry bone measurements showed that linear extrapolations to humans are attempted. The compati-

Regenerative Osseous Surgery • CHAPTER 63 807 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com REG ENERATIVE SURGICAL TECHNIQUES Regenerative periodontics can be subdivided into two major areas: non-graft-associated new attachment and graft-associated new attachment. Many techniques combine both approaches. All recommended techniques include careful and complete removal of all irritants. Although this can be done in some cases as a closed procedure, in the great majority of cases it should be done after exposure of the area with a flap. Flap design and incisions should follow the description given in Chapter 60 for regenerative flaps. Trauma from occlusion may impair posttreatment healing of the supporting periodontal tissues, reducing the likelihood of new attachment. Occlusal adjustment, if needed, is therefore indicated. Systemic antibiotics are generally used after regenerative periodontal therapy, although definitive information on the advisabilitty of this measure is still lacking. Case reports have been presented showing extensive regeneration of the periodontal lesions after scaling, root planing, and curettage combined with systemic and local treatment with penicillin or tetracycline in combina- Fig. 63-8 For future histologic reference, notches can be placed clinically at the most apical part of the calculus (1) or at the level tion with other forms of therapy.25,120 of the osseous crest (3). However, the real landmark that determines whether new attachment has taken place is the base of the Non-Graft-Associated New Attachment pocket (2). Periodontal reconstruction can be attained without the use of grafts in meticulously treated three-wall defects bility of a material with the tissues can be shown by im- (intrabony defects) and in periodontal and endodontal planting the substance into the long bones or calvaria of abscesses.21,66,79,122,138 New attachment is more likely to rats or other rodents, but this does not prove the regen- occur when the destructive process has occurred very eration of periodontal attachment. rapidly (e.g., after treatment of pockets complicated by Studies of the reconstruction of periodontal structures the formation of acute periodontal abscesses and after have been performed in dogs, monkeys, and pigs. Be- treatment of acute necrotizing ulcerative gingivitis). cause it is difficult to find naturally occurring periodon- The following section covers the rationale and tech- tal osseous defects that would be adequate for a study, nique for the removal of the junctional and pocket epi- experimentally induced bone defects must be used. Sur- thelium and the prevention of their migration into the gically produced bone defects can simulate the shape of healing area after therapy. It also covers the so-called osseous periodontal lesions but lack their chronicity and bio-conditioning of the root surface and the use of self-sustaining features. They are not exactly similar to growth factors and enamel matrix proteins to enhance naturally occurring disease. They can be allowed to be- or direct healing. come chronically infected, and then their similarity to chronic natural lesions improves, but they are never Removal of junctional and Pocket Epithelium. identical.192 However, these studies are useful to establish Since the earliest attempts at periodontal new attach- healing sequences and mechanisms. ment, the presence of junctional and pocket epithelium In addition, the exact location of the bottom of the has been perceived as a barrier to successful therapy be- pocket must be determined prior to the procedure because its presence interferes with the direct apposition of cause the surgical technique opens tissues beyond the connective tissue and cementum, thus limiting the bottom of the pocket, and healing below this point does height to which periodontal fibers can become inserted not constitute new attachment. Notches on the root sur- to the cementum. 76,118,141,193 Several methods have been face must be used to indicate this important point. Be- recommended to remove junctional and pocket epithe- cause the exact coronal point of the junctional epithelia. These include curettage, chemical agents, ultrasonic lium is lost when surgically opening the area, a decision methods, and surgical techniques. must be made as to whether to place the notch at the CURETTAGE. Results of removal of epithelium by bottom of the calculus or on the crest of the alveolar means of curettage vary from complete removal to per- bone (Figs. 63-8 and 63-9). The former is slightly coronal sistence of as much as 50%.165 It therefore is not a reli- and the latter slightly apical to the real bottom of the able procedure. Ultrasonic methods and rotary abrasive pocket. The bottom of the calculus is a better landmark, stones have also been used, but their effects cannot be but obviously the presence of calculus is required. controlled because of the clinician's lack of tactile sense Numerous pitfalls are therefore inherent in histologic when using these methods studies, and their accuracy and reliability should always CHEMICAL AGENTS. Chemical agents have also be very carefully considered. been used to remove pocket epithelium, in most cases in

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conjunction with curettage. The most commonly used SURGICAL TECHNIQUES. Surgical techniques drugs have been sodium sulfide, phenol camphor, an- have been recommended to eliminate the pocket and tiformin, and sodium hypochlorite. However, the effect junctional epithelia. The excisional new attachment proce- of these agents is not limited to the epithelium, and dure consists of an internal bevel incision performed their depth of action cannot be controlled. They are with a surgical knife, followed by removal of the excised mentioned here for their historical interest. tissue. 194 No attempt is made to elevate a flap. After care-

Fig. 63-9 A, Notch being placed through the apical extent of the calculus into the root surface as a histologic marker. B, Six-month postoperative histologic block section of control site depicting no regeneration coronal to the reference notch (arrow). C, Six-month postoperative histologic block section of experimental site using a demineralized freeze-dried bone allograft depicting regeneration coronal to the crestal bone notch (calculus notch 7 mm apical to crestal notch). D, High power of reference notch through calculus at base of defect with new cementum (artifactual split during histologic preparation), bone, and periodontal ligament. (Courtesy Dr. Gerald Bowers, University of Maryland.)

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ful scaling and root planing, interproximal sutures are of different types to cover the bone and periodontal liga- used to close the wound (see Chapter 57). ment, thus temporarily separating them from the gingi- Glickman and Prichard have advocated performing a val epithelium (see Chapter 36). Excluding the epithe- gingivectomy to the crest of the alveolar bone and debriding lium and the gingival connective tissue from the root the defect.65,137 Excellent results have been obtained with surface during the postsurgical healing phase not only this technique in uncontrolled human studies . 8,138 prevents epithelial migration into the wound but also fa- The modified Widman flap, as described by Ramfjord vors repopulation of the area by cells from the periodon- and Nissle, is similar to the excisional new attachment tal ligament and the bone. procedure but is followed by elevation of a flap for better Initial animal experiments using Millipore filters and exposure of the area."' It eliminates the pocket epithe- Teflon membranes resulted in regeneration of cementum lium with the internal bevel incision (see Chapter 61). and alveolar bone and a functional periodontal liga- Another approach to delaying epithelial migration ment. 29,30,33,116 Clinical case reports showed that guided into the healing pocket area has been the use of coronal tissue regeneration results in a gain in attachment level, displacement of the flap, which increases the distance be- which is not necessarily associated with a buildup of tween the epithelium and the healing area. This tech- alveolar bone.9,10 Histologic studies in humans provided nique is particularly suitable for the treatment of lower evidence of periodontal regeneration in most instances, molar furcations and has been used mostly in conjunc- even in cases of horizontal bone losses. 69,170,174 61,10' tion with citric acid treatment of the roots . Peri- The use of polytetrafluoroethylene membranes (Gore- odontal regeneration after the use of this technique has Tex periodontal material, Gore-Tex, Flagstaff, AZ) has been demonstrated histologically in humans.'" been tested in controlled clinical studies in lower molar furcations and has shown statistically significant de- Prevention of Epithelial Migration. Elimina- creases in pocket depths and improvement in attach- tion of junctional and pocket epithelia may not be suffi- ment levels after 6 months; bone level measurements cient because the epithelium from the excised margin have been inconclusive .94,136 A study on upper molar fur- may rapidly proliferate to become interposed between cations did not result in significant gain in attachment the healing connective tissue and the cementum. or bone levels.''' Several investigators have analyzed in animals and The initial membranes developed were nonresorbable humans the effect of excluding the epithelium by ampu- and therefore required a second operation, albeit frequently tating the crown of the tooth and covering the root with very simple, to remove it. This second operation was done the flap (root submergence). 12,13,17 This experimental tech- after the initial stages of healing, usually 3 to 6 weeks after nique not only excludes the epithelium but also pre- the first intervention. This second operation was a signifi- vents microbial contamination of the wound during the cant obstacle in the utilization of the procedure, and reparative stages. Successful repair of osseous lesions in therefore resorbable membranes were developed. 189 the submerged environment was reported, but obviously The expanded polytetrafluoroethylene membrane this method has little or no clinical application. (nonresorbable) can be obtained in different shapes and Another method proposed to prevent or retard the sizes to suit proximal spaces and facial/lingual surfaces of migration of the epithelium consists of total removal of furcations (Fig. 63-10). The technique for its use is as fol- the interdental papilla covering the defect and its re- lows (Figs. 63-11): placement with a free autogenous graft obtained from the palate. 46 During healing, the epithelium necroses, and its 1. Raise a mucoperiosteal flap with vertical incisions, ex- migration is retarded. tending a minimum of two teeth anteriorly and one GUIDED TISSUE REGENERATION. The method tooth distally to the tooth being treated. for the prevention of epithelial migration along the ce- 2. Debride the osseous defect and thoroughly plane the mental wall of the pocket that has gained wide attention roots. is the so-called guided tissue regeneration (GTR). This 3. Trim the membrane with sharp scissors to the approx- method derives from the classic studies of Nyman, imate size of the area being treated. The apical border Lindhe, Karring, and Gottlow and is based on the as- of the material should extend 3 to 4 mm apical to the sumption that only the periodontal ligament cells have margin of the defect and laterally 2 to 3 mm beyond the potential for regeneration of the attachment appara- the defect; the occlusal border of the membrane tus of the tooth . 68,69,125,126 It consists of placing barriers should be placed 2 mm apical to the cementoenamel junction. 10 4. Suture the membrane tightly around the tooth with a sling suture. 5. Suture the flap back in its original position or slightly coronal to it, using independent sutures interdentally and in the vertical incisions. The flap should cover the membrane completely. 6. The use of periodontal dressings is optional, and the patient is placed on antibiotic therapy for 1 week.

After 4 to 6 weeks, the margin of the membrane be- Fig. 63-10 Different shapes and sizes of expanded polytetrafluo- comes exposed. The membrane is removed with a gentle roethylene membranes marketed by Gore-Tex (Flagstaff, AZ). tug 5 weeks after the operation. If it cannot be removed

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Fig. 63-11 Patient treated according to the principles of guided tissue regeneration. A, Deep osseous defect on the distal root of a lower molar. B, After thorough instrumentation, the Gore-Tex membrane is placed. C, Reentry after 9 months, showing the defect fill. Before (D) and after (E) radiographs of patient. (Courtesy Drs. Burton Becker and William Becker, Tucson, Ariz.)

easily, the tissues are anesthetized and the material is dura mater. 14,11,24,32,52,53,60,100,101,131-133,189,196 Clinical stud- surgically removed using a miniflap. ies with a mixture of copolymers derived from polylactic The results obtained with the guided tissue regenera- acid and acetyl tributylcitrate resorbable membranes tion technique are enhanced when the technique is (Guidor membrane, no longer on the market) and a combined with grafts placed in the defects (see Com- poly-D,L-lactide-co-glycolide (Resolut membrane, also bined Technique).', 16,92,103 no longer on the market) have shown significant gains in clinical attachment and bone fill. 34,61,180 The Use of Biodegradable Membranes. The Resorbable membranes marketed in the U.S. as of this search for resorbable membranes included tests with rat writing include: OsseoQuest, Gore Co. (polyglycolic acid, collagen, bovine collagen, Cargile membrane derived polylactic acid and trimethylene carbonate; resorbs at from the cecum of an ox, polylactic acid, Vycril (poly- 6 to 14 months); BioGuide, OsteoHealth Co. (bi-layer glactin 910), synthetic skin (Biobrane), and freeze-dried porcine-derived collagen); Atrisorb, Block Drug Co.

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(polylactic acid gel); and BioMend, Calcitech Co. (bovine ter root planing, the acid produces a 4-mm-deep dem- Achilles tendon collagen, resorbs in 4 to 18 weeks). ineralized zone with exposed collagen fibers . 64 The potential of using autogenous periosteum as a 3. Root-planed, non-acid-treated roots are left with a sur- membrane and also to stimulate periodontal regenera- face smear layer of microcrystalline debris; citric acid tion has been explored in two controlled clinical studies, application not only removes the smear layer, exposing one of grade II furcation involvements in lower molars the dentinal tubules, but also makes the tubules appear and another of interdental defects .90,93 The periosteum wider and with funnel-shaped orifices. 134 was obtained from the patient's palate by means of a 4. Citric acid has also been shown in vitro to eliminate window flap. Both studies reported that autogenous pe- endotoxins and bacteria from the diseased tooth riosteal grafts can be used in guided tissue regeneration surface .39,51 and result in significant gains in clinical attachment and 5. An early fibrin linkage to collagen fibers exposed by osseous defect fill. the citric acid treatment prevents the epithelium from migrating over treated roots."' Clot Stabilization, Wound Protection, and Space Creation. Some investigators have attributed the This technique has been extensively investigated in successful results reported with graft materials, barrier animals and humans. Studies in dogs have given encour- membranes, and coronally displaced flaps to the fact aging results, especially for the treatment of furcation that all protect the wound and create a space for undis- lesions, but the results in humans have been contra- 7, 124,143,145,168 turbed and stable maturation of the clot. 62,74,11 This hy- dictory.3 pothesis suggests that preservation of the root surface- The recommended technique is as follows: fibrin clot interface prevents apical migration of the gin- 1. Raise a mucoperiosteal flap. gival epithelium and allows for connective tissue attach- 2. Thoroughly instrument the root surface, removing ment during the early wound healing period .62,192 calculus and underlying cementum. The importance of space creation for bone repair has 3. Apply cotton pledgets soaked in a saturated solution long been recognized in orthopedic and maxillofacial of citric acid (pH 1), and leave on for 2 to 5 minutes. surgery. Transference of this concept to periodontal ther- 4. Remove pledgets, and irrigate root surface profusely apy has been explored for regeneration techniques and with water. root coverage and treatment of periimplant bone defects. 5. Replace the flap and suture. The space is created by using a titanium-reinforced ePTFE membrane to prevent its collapse. For the study of regen- The use of citric acid has also been recommended in erative techniques, these membranes were placed over conjunction with coverage of denuded roots using free experimentally created supraalveolar bone defects in dogs gingival grafts (see Chapter 66). and considerable bone regeneration was reported. 164 FIBRONECTIN. Fibronectin is the glycoprotein that fibroblasts require to attach to root surfaces. The ad- Biomodification of the Root Surface. Changes dition of fibronectin to the root surface may promote in the tooth surface wall of periodontal pockets (e.g., de- new attachment . 21,50, "1 However, increasing fibronectin generation of remnants of Sharpey's fibers, accumulation above plasma levels produces no obvious advantages. of bacteria and their products, and disintegration of the Adding fibronectin and citric acid to lesions treated with cementum and dentin) interfere with new attachment. GTR in dogs did not improve the results. 22,166 However, these obstacles to new attachment can be elim- The effect of a fibrin-fibronectin sealing system on inated by thorough root planing. healing of periodontal surgical wounds, particularly in Several substances have been used in attempts to bet- reconstructive procedures, has been investigated. 130 This ter condition the root surface for attachment of new material is commercially available in Europe as Tissucol. connective tissue fibers. These include citric acid, fibro- It is a biologic mediator that enhances the tissue re- nectin, and tetracycline. sponse in the early phases of wound healing, prevents CITRIC ACID. Studies by Urist showed that the separation of the flap, and favors hemostasis and con- implantation of demineralized dentin matrix into mus- nective tissue regeneration. Clinical trials have been cle tissue in animals induced mesenchymal cells to dif- promising, but further research is necessary. 35 ferentiate into osteoblasts and started an osteogenic TETRACYCLINE. In vitro treatment of the dentin process. 183-185 Following up on this concept, a series of surfaces with tetracycline increases binding of fibronectin, studies applied citric acid to the roots to demineralize which in turn stimulates fibroblast attachment and growth the surface, thus inducing cementogenesis and attach- while suppressing epithelial cell attachment and migra- ment of collagen fibers. tion.1" It also removes an amorphous surface layer and ex- The following actions of citric acid have been re- poses the dentin tubules. 191 In vivo studies, however, have ported: not shown favorable results.191 A human study showed a trend for greater connective tissue attachment after tetra- 1. Accelerated healing and new cementum formation cycline treatment of roots, tetracycline alone gave better occur after surgical detachment of the gingival tissues results than when combined with fibronectin . 2 and demineralization of the root surface by means of citric acid. 143 Polypeptide Growth Factors. Growth factors are 2. Topically applied citric acid on periodontally diseased polypeptide molecules released by cells in the inflamed root surfaces has no effect on nonplaned roots, but af- area that regulate events in wound healing. They can be

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considered hormones that are not released into the lowed for 3 years.'$ They found a statistically significant bloodstream but have only a local action. Growth sub- radiographic bone gain of 2.6 mm. Additional studies are stances regulate connective tissue cell migration and pro- needed to assess its potential use in various defects and liferation and synthesis of proteins and other compo- possible enhancing effect in combined techniques. nents of the extracellular matrix. 98 These factors, primarily secreted by macrophages, en- dothelial cells, fibroblasts, and platelets, include platelet- Graft Materials and Procedures derived growth factor (PDGF), insulin-like growth factor Numerous therapeutic grafting modalities for restoring (IGF), basic fibroblastic growth factor (bFGF), and trans- periodontal osseous defects have been investigated. Mate- forming growth factor (TGF)-a and -ß. Growth factors rial to be grafted can be obtained from the same person could be used to control events during periodontal (autografts), from a different person of the same species wound healing (e.g., promoting proliferation of fibrob- (allografts), or from a different species (xenografts). lasts from the periodontal ligament and favoring bone Bone graft materials are generally evaluated based on formation) .187 Howell and co-workers reported that a sin- their osteogenic, osteoinductive, or osteoconductive po- gle application in human periodontal defects of IGF-I re- tential. Ostegenesis refers to the formation or develop- sulted in significant improvement in bone fill above that ment of new bone by cells contained in the graft; os- obtained in controls, while another growth factor tested teoinduction is a chemical process by which molecules (PDGF-BB) was not effective . 82 contained in the graft (bone morphogenetic proteins or BMPs) convert the neighboring cells into osteoblasts, Enamel Matrix Proteins. Enamel matrix pro- which in turn form bone; and osteoconduction is a physi- teins, mainly amelogenin, are secreted by Hertwig's ep- cal effect by which the matrix of the graft forms a scaf- ithelial root sheath during tooth development and in- fold that favors outside cells to penetrate the graft and duce acellular cementum formation. Based on these form new bone. observations, they are believed to favor periodontal Periodontal defects as sites for transplantation differ regeneration. '2 from osseous cavities surrounded by bony walls. Saliva One enamel matrix protein derivative obtained from and bacteria may easily penetrate along the root surface, developing porcine teeth has been approved by the Food and epithelial cells may proliferate into the defect, re- and Drug Administration (FDA) and marketed under the sulting in contamination and possible exfoliation of the trade name Emdogain. The material is a viscous gel ob- grafts. Therefore the principles established to govern tained by mixing 1 ml of a vehicle solution with a pow- transplantation of bone or other materials into closed os- der and applied with a syringe into the site. seous cavities are not fully applicable to transplantation The technique, as described by Mellonig, is as of bone into periodontal defects. follows, lo: The considerations that govern the selection of a ma- 1. Raise a flap for regenerative purposes (see Chapter 60). terial have been defined as follows"': 2. Remove all granulation tissue and tissue tags, expos- Biologic acceptability ing the underlying bone, and remove all root deposits Predictability by hand, ultrasonic scaling, or both. Clinical feasibility 3. Completely control bleeding within the defect. Minimal operative hazards 4. Demineralize the root surface with citric acid pH 1, or Minimal postoperative sequelae preferably with 24% ethylenediaminetetracetic acid Patient acceptance (EDTA Biora) pH 6.7 for 15 seconds. This removes the smear layer and facilitates adherence of the Emdogain. It is difficult to find a material with all these character- 5. Rinse the wound with saline and apply the gel to fully istics, and to date there is no ideal material or technique. cover the exposed root surface. Avoid contamination Graft materials have been developed and tried in with blood or saliva. many forms. To familiarize the reader with various types 6. Close the wound with sutures. Perfect abutment of of graft material, as defined by either the technique or the flaps is necessary; if this cannot be obtained, cor- the material used, a brief discussion of each is provided. rect the scalloping of the gingival margin or perform All grafting techniques require presurgical scaling, oc- a slight osteoplasty. Although placement of the dress- clusal adjustment as needed, and exposure of the defect ing is optional, it may protect the wound. with a full-thickness flap. The flap technique best suited for grafting purposes is the papilla preservation flap be- Systemic antibiotic coverage for 10 to 21 days is rec- cause it provides complete coverage of the interdental ommended (Doxycycline, 100 mg daily). area after suturing. (See Chapter 60 for a description of In a histologic study of 10 defects in 8 patients, Yukna the technique.) The use of antibiotics after the procedure and Mellonig report evidences of regeneration (new is generally recommended. cementum, new bone, and new periodontal ligament) in 3 specimens, new attachment (connective tissue Auto enous Bone Grafts attachment/adhesion only) in 3 specimens, and a long BONE FROM INTRAORAL SITES. In 1923, junctional epithelium in 4 specimens.198 No evidence of Hegedus attempted to use bone grafts for the reconstruc- root resorption or ankylosis was found. tion of bone defects produced by periodontal disease. Heijl et al have compared the use of enamel matrix de- The method was revived by Nabers and O'Leary in 1965, rivatives with a placebo in 33 patients with 34 paired test and numerous efforts have been made since that time to and control sites, mostly one and two wall defects, fol- define its indications and technique. 121

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Sources of bone include bone from healing extraction Bone Blend. Some disadvantages of osseous coag- wounds, bone from edentulous ridges, bone trephined ulum derive from the inability to use aspiration during from within the jaw without damaging the roots, newly accumulation of the coagulum; another problem is the formed bone in wounds especially created for the pur- unknown quantity and quality of the bone fragments in pose,tomy.2 and7,7 bone1,78,80,147 removed during osteoplasty and ostec- the collected material. To overcome these problems, the so-called bone blend technique has been proposed . 4o Osseous Coogulum. Robinson described a tech- The bone blend technique uses an autoclaved plastic nique using a mixture of bone dust and blood that he capsule and pestle. Bone is removed from a predeter- termed osseous coagulum. 146 The technique uses small mined site, triturated in the capsule to a workable, plastic- particles ground from cortical bone. The advantage of like mass, and packed into bony defects. Froum and the particle size is that it provides additional surface area co-workers have found osseous coagulum-bone blend pro- for the interaction of cellular and vascular elements. cedures to be at least as effective as iliac autografts and Sources of the implant material include the lingual open curettage .s6-s8 ridge on the mandible, exostoses, edentulous ridges, the Intraoral Cancellous Bone Marrow Transplants. bone distal to a terminal tooth, bone removed by osteo- Cancellous bone can be obtained from the maxillary plasty or ostectomy, and the lingual surface of the tuberosity; edentulous areas, and healing sockets. The mandible or maxilla at least 5 mm from the roots. Bone maxillary tuberosity frequently contains a good amount of is removed with a carbide bur #6 or #8 at speeds between cancellous bone, particularly if the third molars are not 5000 and 30,000 rpm, placed in a sterile dappen dish or present; also, foci of red marrow are occasionally observed. amalgam cloth, and used to fill the defect (Fig. 63-12). After a ridge incision is made distally from the last molar, The obvious advantage of this technique is the ease of bone is removed with a curved and cutting rongeur. Care obtaining bone from already exposed surgical sites, and should be taken not to extend the incision too far distally its disadvantages are its relatively low predictability and to avoid sectioning the tendons of the palatine muscle; inability to procure adequate material for large defects.55 also, the location of the maxillary sinus has to be analyzed Although notable success has been reported by many in- on the radiograph to avoid cutting into it. dividuals, studies documenting the efficacy of the tech- Edentulous ridges can be approached with a flap, and nique are still inconclusive .36,56,51,146 cancellous bone and marrow are removed with curettes. Healing sockets are allowed to heal for 8 to 12 weeks, and the apical portion is used as donor material. The particles are reduced to small pieces (Figs. 61-13 and 61-14). Bone Swaging. This technique requires the existence of an edentulous area adjacent to the defect from which the bone is pushed into contact with the root surface without fracturing the bone at its base .48.149 Bone swaging is technically difficult, and its usefulness is limited.

Fig. 63-12 Bone defect on the distal root of a first molar treated Fig. 63-13 A, Bone being removed from the maxillary tuberosity with osseous coagulum implants. A, Before treatment. B, One year (creating a "socket") to be used as an intraoral osseous cancellous after treatment. (Courtesy Dr. R. Earl Robinson.) bone and marrow graft. B, Graft materal placed in dappen dish prior to transfer to the graft site.

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Fig. 63-14 Autogenous bone transplant obtained with trephine. A, Trephines: top, manual trephine; center, different sized power trephines (#2, #4, and #6); bottom, orifices of trephines. B, Mucoperiosteal flap elevated, showing osseous defect on the mesial surface of the first molar. The trephine is inserted into bone distal to the second molar. C, Bone separated by a trephine. D, Bone transplant; the cancellous portion is used and the cortical layer is removed. E, Radiograph showing an osseous defect on mandibular first molar. F, Six months after treatment, showing the osseous defect partially filled with the implant. The radiolucent area in the interdental bone is the donor site of the transplant.

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Fig. 63-15 A, Cancellous bone and marrow being procured from the posterior iliac crest with a Westerman- Jensen bone marrow biopsy needle. B, One of the cores obtained, approximately 3 x 25 mm in size. C, Five cores removed through the same 1/4-inch incision site through different cortical punctures and placed in a transfer storage media prior to direct placement of frozen storage if periodontal surgery is delayed/staged.

Fig. 63-16 A, November 1 973. Radiograph of a patient immediately prior to the placement of a fresh iliac autograft. B, Two months later, bone repair is evident. Note the early radiolucent areas on the mesial aspect of the canine. C, After 7 months, "bone fill" is occurring, but obvious root resorption is present. D, April 1975. Root resorption is apparent on all grafted teeth. Note the obvious degree of fill of the original bone defects. E, February 1976. Further involvement. F, October 1977. Four years later, root resorption has progressed into the pulp of the lateral incisor, causing a periosteal-endosteal complication.

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BONE FROM EXTRAORAL SITES surgical removal of donor material from the patient. Iliac Autografts. The use of fresh or preserved iliac However, both allografts and xenografts are foreign to cancellous marrow bone has been extensively investi- the organism and therefore have the potential to provoke gated. This material has been used by orthopedic sur- an immune response. Attempts have been made to sup- geons for years. Data from human and animal studies press the antigenic potential of allografts and xenografts support its use, and the technique has proved successful by radiation, freezing, and chemical treatment. 19 in bony defects with various numbers of walls, in fur- Bone allografts are commercially available from tissue cations, and even supracrestally to some extent (Fig. banks. They are obtained from cortical bone within 63-15).11,20,38,41,42,154,155,151 However, owing to problems 12 hours of the death of the donor, defatted, cut in associated with its use, such as postoperative infection, pieces, washed in absolute alcohol, and deep frozen. The exfoliation, sequestration; varying rates of healing; root material may then be demineralized, and subsequently resorption; and rapid recurrence of the defect (Fig. ground and sieved to a particle size of 250 to 750 mm 63-16), in addition to increased patient expense and dif- and freeze dried. Finally, it is vacuum sealed in glass ficulty in procuring the donor material, the technique is vials. no longer in use. 20.42,'56,157 Numerous steps are also taken to eliminate viral infec- tivity. These include exclusion of donors from known Allografts. Obtaining donor material for autograft high-risk groups and various tests on the cadaver tissues to purposes necessitates inflicting surgical trauma on an- exclude individuals with any type of infection or malig- other part of the patient's body. Obviously, it would be to nant disease. The material is then treated with chemical the patient's and therapist's advantage if a suitable substi- agents or strong acids to effectively inactivate the virus, if tute could be used for grafting purposes that would offer still present. The risk of human immunodeficiency virus similar potential for repair and not require the additional (HIV) infection has been calculated as 1 in 1 million to 8 million and is therefore characterized as highly remote. UNDECALCIFIED FREEZE-DRIED BONE ALLOGRAFT (FDBA). Several clinical studies by Mellonig, Bowers, and co-workers reported bone fill exceeding 50% in 67% of the defects grafted with FDBA and in 78% of the defects grafted with FDBA plus autogenous bone. 113,150,162 FDBA, however, is considered an osteoconductive material, whereas decalcified FDBA (DFDBA) is considered an

Fig. 63-17 A, Combined mesial two-wall, three-wall intrabony and facial dehiscence osseous defects on tooth #23. B, Demineralized freeze-dried bone allograft in place after root and site preparation is completed. C, Three-year posttreatment photo of site, depicting slight gingival recession and a 2-mm probing depth. D, Preoperative radiograph of site. E, Three-year postoperative radiograph suggesting bone fill and stability, which correlates with probing attachment level improvement.

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osteoinductive graft. Laboratory studies have found that fibrils, that have been termed bone morphogenetic protein DFDBA has a higher osteogenic potential than FDBA and (Figs. 63-17 and 63-18).185 is therefore preferred. 109,111,112 In 1975, Libin et al reported three patients with 4 to DECALCIFIED FREEZE-DRIED BONE ALLOGRAFTS. 10 mm of bone regeneration in periodontal osseous de- Experiments by Urist and co-workers have established fects.97 Subsequent clinical studies were made with can- the osteogenic potential of DFDBA. 183,184 Demineraliza- cellous DFDBA and cortical DFDBA. 129,139 The latter re- tion in cold, diluted hydrochloric acid exposes the com- sulted in more desirable results (2.4 mm versus 1.38 mm ponents of bone matrix, closely associated with collagen of bone fill).

Fig. 63-18 A, Facial aspect of tooth #34 with 9-mm pocket. B, Mesial one-wall/hemiseptal intrabony defect and facial dehiscence osseous defect exposed and site debrided. G, Bone replacement graft (DFDBA) in position. D, Barrier membrane (ePTFE) over bone graft. E, Appearance of new tissue at time of membrane removal (6 weeks after surgery) suggestive of new alveolar bone slightly apical to the cementoenamel junction. F, Pretreatment radiograph of site. G, Two-year postoperative radiograph depicting favorable bone regeneration in the site.

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Bowers and associates, in a histologic study in hu- the bone regenerative results of the matrix alone in peri- mans, showed new attachment and periodontal regener- odontal defects. 199 ation in defects grafted with DFDBA. 1 7 Mellonig and associates tested DFDBA against autogenous materials in Nonbone Graft Materials. In addition to bone the calvaria of guinea pigs and showed it to have similar graft materials, many nonbone graft materials have been osteogenic potential."',' 12 tried for restoration of the periodontium (Fig. 63-19). These studies provided strong evidence that DFDBA Among them are sclera, dura, cartilage, cementum, in periodontal defects results in significant probing dentin, plaster of Paris, plastic materials, ceramics, and depth reduction, attachment level gain, and osseous re- coral-derived materials . 21,47,95,96,123,1S2 None offers a reli- generation (Color Fig. 63-2); the combination of DFDBA able substitute to bone graft materials; some of these ma- and guided tissue regeneration has also proven very suc- terials are briefly presented here to offer a complete pic- cessful.5,170 However, limitations of the use of DFDBA in- ture of the many attempts that have been made to solve clude the possible, albeit remote, potential of disease the crucial problem of periodontal regeneration. transfer from the cadaver. SCLERA. Sclera was originally used in periodontal A bone-inductive protein isolated from the extracellu- procedures because it is a dense fibrous connective tissue lar matrix of human bones, termed osteogenin, has been with poor vascularity and minimal cellularity. 87-89 This tested in human periodontal defects and seems to en- affords a low incidence of antigenicity and other unto- hance osseous regeneration. 18 ward reactions.83 In addition, sclera may provide a barrier to apical migration of the junctional epithelium and Xenografts. Calf bone (Boplant), treated by deter- serve to protect the blood clot during the initial healing gent extraction, sterilized, and freeze dried, has been used period. for the treatment of osseous defects .7,160,161 Kiel bone is Although some studies show that sclera is well ac- calf or ox bone denatured with 20% hydrogen peroxide, cepted by the host and is sometimes invaded by host cells dried with acetone, and sterilized with ethylene oxide. and capillaries and replaced by dense connective tissue, it Anorganic bone is ox bone from which the organic mater- does not appear to induce osteogenesis or cementogene- ial has been extracted by means of ethylenediamine; it is sis.49,119,127,182 The available scientific research does not then sterilized by autoclaving. 106,107 These materials have warrant the routine use of sclera in periodontal therapy. been tried and discarded for various reasons; they are CARTILAGE. Cartilage has been used for repair mentioned here to provide a historical perspective. studies in monkeys and treatment of periodontal defects Recently, however, Yukna and co-workers have in humans. It can serve as a scaffolding; when so used a natural, anorganic, microporous, bovine-derived used, new attachment was obtained in 60 of 70 case hydroxyapatite bone matrix, in combination with a cell- studies. 1-53 However, cartilage has received only limited binding polypeptide that is a synthetic clone of the 15 evaluation. amino acid sequence of type I collagen. 199 The addition PLASTER OF PARIS. Plaster of Paris (calcium sul- of the cell binding polypeptide was shown to enhance fate) is biocompatible and porous, thereby allowing fluid

Fig. 63-19 A, Surgical exposure of the lower first molar, depicting a deep intrabony defect on the mesial and distal. B, Enamel matrix protein placement in site after root preparation. C, Preoperative radiograph. D, Two-year postoperative radiograph suggesting bone fill.

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exchange, which prevents flap necrosis. Plaster of Paris Clinical studies on these materials showed pocket re- resorbs completely in 1 to 2 weeks. One study in surgi- duction, attachment gain, and bone level gain .81,84,15 The cally created three-wall defects in dogs showed signifi- materials have also been studied in conjunction with cant regeneration of bone and cementum. 86 It was found membranes, with good results . 92,172 Both materials have to be useful in one uncontrolled clinical study, but other demonstrated microscopic cementum and bone forma- investigators have reported that it does not induce bone tion, but their slow resorbability or lack thereof has hin- formation. 1,163 One report suggested its use in combina- dered clinical success in practice .21,169 tion with DFDBA and a Gore-Tex membrane. 167 Its usefulness in human cases, however, has not been proven. Combined Techniques PLASTIC MATERIALS. HTR polymer is a nonresorbable, microporous, biocompatible composite of poly- The combination of barrier techniques with bone methylmethacrylate and polyhydroxylethylmethacry- grafts and other methods has been suggested and proce- late.195 A clinical 6-month study showed significant dures following these ideas proposed by several au defect fill and improved attachment level."' Histologi- thors.5,73,92,104,108,188 The following technique has been cally, this material is encapsulated by connective tissue described by Schallhorn and McClain 103,159: fibers, with no evidence of new attachment. 173 CALCIUM PHOSPHATE BIOMATERIALS. Several 1. Perform a regenerative type flap. If recession has calcium phosphate biomaterials have been tested since occurred and/or coronal flap positioning is required the mid-1970s and are currently available for clinical for membrane coverage, periosteal separation is use. Calcium phosphate biomaterials have excellent tis- performed. sue compatibility and do not elicit any inflammation or 2. The defect is debrided of all granulation tissue and foreign body response. These materials are osteoconduc- the root surface is planed to remove all remnants of tive, not osteoinductive, meaning that they will induce plaque, accretions and other root surface alterations bone formation when placed next to viable bone but not (grooves, notches, caries) employing ultrasonic/ when surrounded by non-bone-forming tissue such as sonic, hand, and/or rotary instrumentation. skin. 3. Odontoplasty and/or osteoplasty are performed if Two types of calcium phosphate ceramics have been required for adequate access to the defect including used: intraradicular or furcation fundus concavities and/or reduction of enamel projections. 1. Hydroxyapatite (HA) has a calcium-to-phosphate ratio 4. The bone graft (typically DFDBA) is prepared in a dap- of 1.67, similar to that found in bone material. HA is pen dish, hydrating it with sterile saline or local anes- generally nonbioresorbable. thetic solution, and if there is no contraindication, is 2. Tricalcium phosphate (TCP), with a calcium-to- combined with tetracycline (125 mg/0.25 g of DFDBA). phosphate ratio of 1.5, is mineralogically B-whitlockite. After mixing, the dappen dish is covered with a sterile, TCP is at least partially bioresorbable. moistened gauze to prevent drying of the graft. 5. The appropriate membrane (usually ePTFE) is se- Case reports and uncontrolled human studies have lected and trimmed to fit the desired position and shown that calcium phosphate bioceramic materials are placed on a sterile gauze. Care is taken to prevent perfectly tolerated and can result in clinical repair of contamination by contact with soft tissues or saliva. periodontal lesions. Several controlled studies were con- 6. The area is thoroughly cleansed and isolated, and ducted on the use of Periograf and Calcitite; clinical re- the regenerative site root surface is treated with cot- sults were good, but histologically these materials ap- ton pellets soaked in citric acid pH 1 for 3 minutes, peared to be encapsulated by collagen.59,105,140,197 taking care that the solution does not go beyond the BIOACTIVE GLASS. Bioactive glass consists of root and bone surface. The pellets are removed and sodium and calcium salts, phosphates, and silicon diox- the site inspected for any residual cotton fibers prior ide; for its dental applications it is used in the form of to flushing the site with sterile water or saline. irregular particles measuring 90 to 170 b,m (PerioGlas, 7. If a sclerotic bone surface exists in the graft site, intra- Block Drug Co., Jersey City, NJ) or 300 to 355 N,m marrow penetration is performed with a 1/4 round bur. (BioGran, Ortho Vita, Malvern, PA). When this material 8. The ligament surface is "scraped" with a periodontal comes into contact with tissue fluids, the surface of the probe to remove any eschar and stimulate bleeding. particles becomes coated with hydroxycarbonateapatite, 9. The DFDBA is packed firmly in the defect using an incorporates organic ground proteins such as chondroitin overfill approach, covering the root trunk and com- sulfate and glycosaminoglycans, and attracts osteoblasts bination or confluent vertical dehiscence or horizon- that rapidly form bone.' tal osseous defects. This material may have potential, and clinical studies 10. The custom-fitted membrane is placed over the graft are needed to establish its real usefulness. and secured as appropriate. CORAL-DERIVED MATERIALS. Two different 11. The area is rechecked to ensure that adequate graft coralline materials have been used in clinical periodon- material remains in the desired area, and the flap is tics: natural coral and coral-derived porous hydroxyap- positioned to cover the membrane and secured with atite. Both are biocompatible, but whereas natural coral nonabsorbable sutures. is resorbed slowly (several months), porous hydroxyap- 12. A periodontal dressing is passively applied over the atite is not resorbed or takes years to do so. surgical area, with Surgicel covering the sutures.

820 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com Typical peri- and postoperative medication regimens REFEREN CES include, if not contraindicated, 7 to 10 days of antibiotic coverage, which is subsequently extended with doxycy- 1. Alderman NE: Sterile plaster of Paris as an implant in the cline, 100 mg daily for 2 to 7 weeks; steroid therapy such infrabony environment: A preliminary study. J Periodontol as methylprednisolone dosepak; and analgesic agents. 1969; 40:11. Sutures are removed if and when they become loose 2. Alger FA, Solt CW, Vuddahanok S, et al: The histologic or no longer aid in tissue position or wound closure. evaluation of new attachment in periodontally diseased human roots treated with tetracycline-hydrochloride and The patient is seen for monitoring and local debride- fibronectin. J Periodontol 1990; 61:447. ment as needed every 1 to 2 weeks. If a nonresorbable 3. American Academy of Periodontology: Glossary of Peri- membrane has been used, it is removed 6 to 8 weeks af- odontal Terms, ed 3. Chicago, American Academy of Peri- ter the operation. odontology, 1992. Several studies and case reports have shown excellent 4. American Dental Association, Council on Scientific Affairs: results with the combined technique. 5,16,18,92,103,108,159,188 Products designed to regenerate periodontal tissues: Accep- tance Program Guidelines. The American Dental Associa- tion, July 1997, pp. 1-7. FACTORS INFLUENCING A 5. Andereeg CR, Martin SJ, Gray JL, et al: Clinical evaluation SUCCESSFUL OUTCOME of the use of decalcified freeze-dried bone allograft with guided tissue regeneration in the treatment of molar furca- Factors adversely affecting outcomes were assessed in tion invasions. J Periodontol 1991; 62:264. the 1996 evidence-based World Workshop in Periodon- 6. Andereeg CR, Alexander DC, Freidman M: A bioactive 6,139 tics. These included the following: glass particulate in the treatment of molar furcations. • Inadequate plaque control J Periodontol 1999; 70:384. 7. • Poor compliance with supportive periodontal therapy Arrocha R, Wittwer J, Gargiulo A: Tissue response to het- • Smoking erogenous bone implantation in dogs. J Periodontol 1968; 39:162. • Other factors such as flap design, defect and root mor- 8. Becker W, Becker BE, Berg L, et al: Clinical and volumetric phology, material employed, flap position, and post- analysis of three-wall intrabony defects following open operative management flap debridement. J Periodontol 1986; 57:277. 9. Becker W, Becker BE, Berg L, et al: New attachment after Other factors possibly influencing outcomes but treatment with root isolation procedures: Report for which lack conclusive evidence at this time include: age, treated class III and class II furcations and vertical osseous systemic conditions, and use of membranes in patients defects. Int J Periodont Restor Dent 1988; 8(3):9. requiring prophylactic medication. 10. Becker W, Becker BE, Prichard JF, et al: Root isolation for Other reports have also attempted to delineate vari- new attachment procedures-A surgical and suturing ables for case/site selection and management. 3,4 These method: Three case reports. J Periodontol 1987; 58:819. included: therapist considerations (training and experi- 11. Bierly JA, Sottosanti JS, Costley JM, et al: An evaluation of ence), patient factors (systemic conditions, stress level, the osteogenic potential of marrow. J Periodontol 1975; smoking habits, plaque control, patient compliance, tis- 46:277. sue response to presurgical therapy, and age), defect fac- 12. Bjorn H: Experimental studies on reattachment. Dent Pract 1961; 11:351. tors (bone height, access, tooth/defect anatomy, space 13. Bjorn H, Hollender L, Lindhe J: Tissue regeneration in pa- maintenance of membranes employed, and tooth stabil- tients with periodontal disease. Odont Rev 1965; 16:317. ity), surgical considerations (flap design/management, 14. Blumenthal NM: The use of collagen materials in bone root preparation and possible biomodification, regenera- grafted defects to enhance guided tissue regeneration. Peri- tive materials employed, infection control, etc.), postsur- odont Case Rep 1987; 9:16. gical management, and supportive periodontal therapy 15. Blumenthal NM: The use of collagen membranes to guide after completion of active therapy. regeneration of new connective tissue attachment in dogs. J Periodontol 1988; 59:830. 16. Blumenthal NM, Steinberg J: The use of collagen mem- SUMMARY brane barriers in conjunction with combined demineralized bone-collagen gel implants in human infrabony de- The subject of new attachment has received a great deal fects. J Periodontol 1990; 61:319. of attention because of its obvious importance in im- 17. Bowers GM, Chadroff B, Carnevale R, et al: Histologic eval- proving the results of therapy. On the basis of available uation of new attachment apparatus formation in hu- information, reconstruction of human supporting peri- mans. Part III. J Periodontol 1989; 60:683. odontal tissues is possible in selected sites and patients 18. Bowers G, Felton F, Middleton F, et al: Histologic compari- with the use of autogenous bone grafts and/or freeze son of regeneration in human intrabony pockets when os- dried bone allografts and resorbable or nonresorbable teogenin is combined with demineralized freeze-dried barrier membranes. bone allograft and with purified bovine collagen. J Peri- The clinician should make an effort to differentiate odontol 1991; 62:690. between those techniques that have been studied in 19. Buring K, Urist MR: Effects of ionizing radiation on the bone induction principle in the matrix of bone implants. depth and with acceptable results and others that, al- Clin Orthop 1967; 55:225. though promising, are still experimental. Research pa- 20. 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22. Caffesse RG, Nasjleti CE, Anderson GB, et al: Periodontal 45. Ellegaard B: Bone grafts in periodontal attachment proce- healing following guided tissue regeneration with citric dures. J Clin Periodontol 1976; 3:5. acid and fibronectin application. J Periodontol 1991; 62:21. 46. Ellegaard B, Karring T, Loe H: Retardation of epithelial mi- 23. Caffesse RG, Smith BA, Nasjleti CE, et al: Cell proliferation gration in new attachment attempts in intrabony defects after flap surgery, root conditioning and fibronectin appli- in monkeys. J Clin Periodontol 1976; 3:23. cation. J Periodontol 1987; 58:661. 47. Ellegaard B, Nielsen IM, Karring T. Lyodura grafts in new 24. Card SJ, Caffesse RG, Smith BA, et al: New attachment attachment procedures. J Dent Res 1976; 55(special issue following the use of a resorbable membrane in the treat- B):B-304. ment of periodontitis in dogs. Int J Periodont Restor Dent 48. Ewen SJ: Bone swaging. J Periodontol 1965; 36:57. 1989; 9:59. 49. 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69. Gottlow J, Nyman S, Lindhe J, et al: New attachment for- conjunction with a polytetrafluoroethylene membrane. mation in human periodontium by guided tissue regenera- J Periodontol 1990; 61:575. tion. J Clin Periodontol 1986; 13:604. 93. Lekovic V, Kenney EB, Carranza FA Jr, et al: The use of au- 70. Greenberg J, Laster L, Listgarten MA: Transgingival prob- togenous periosteal grafts as barriers for the treatment of ing as a potential estimation of alveolar bone level. J Peri- grade 11 furcation involvements in lower molars. J Peri- odontol 1976; 47:514. odontol 1991; 62:775. 71. Halliday DG: The grafting of newly formed autogenous 94. Lekovic V, Kenney EB, Kovacevic K, et al: Evaluation of bone in the treatment of osseous defects. J Periodontol guided tissue regeneration in class lI furcation defects. A 1969; 40:511. clinical study. J Periodontol 1989; 60:694. 72. Hammarstrom L: Enamel matrix, cementum development 95. 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113. Mellonig JT, Bowers GM, Bright RW, et al: Clinical evalua- 135. Polson AM, Proye MP: Fibrin linkage: A precursor for new tion of freeze-dried bone allografts in periodontal osseous attachment. J Periodontol 1983; 54:141. defects. J Periodontol 1976; 47:125. 136. Pontoriero R, Lindhe J, Nyman S, et al: Guided tissue re- 114. Mellonig JT, Prewett AB, Moyer MP: HIV inactivation in a generation in degree 11 furcation-involved mandibular mo- bone allograft. J Periodontol 1992; 63:979. lars. A clinical study. J Clin Periodontol 1988; 15:247. 115. Metzler DG, Seamoons BC, Mellonig JT, et al: Clinical eval- 137. Prichard JF: The intrabony technique as a predictable pro- uation of guided tissue regeneration in the treatment of cedure. J Periodontol 1957; 28:202. maxillary class 11 molar furcation invasions. J Periodontol 138. Proceedings of the 1996 World Workshop in Periodontol- 1991; 62:353. ogy, Consensus Report: Periodontal regeneration around 116. 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Younger WJ: Some of the latest phases in implantations logic responses to the placement of HTR polymer particles and other operations. Dent Cosmos 1893; 25:102. in 11 intrabony lesions. J Periodontol 1990; 61:269. 194. Yukna RA: A clinical and histological study of healing fol- 174. Stahl SS, Froum SJ, Tarnow D: Human histologic responses lowing the excisional new attachment procedure in rhesus to guided tissue regenerative techniques in intrabony le- monkeys. J Periodontol 1976; 47:701. sions. J Clin Periodontol 1990; 17:191. 195. Yukna RA: HTR polymer graft in human periodontal os- 175. Takei HH, Han TJ, Carranza FA Jr, et al: Flap technique for seous defects. I. 6-months clinical results. J Periodontol periodontal bone implants. Papilla preservation technique. 1990; 61:633. J Periodontol 1985; 56:204. 196. Yukna RA: Clinical human comparison of expanded poly- 176. Terranova VP, Martin GR: Molecular factors determining tetrafluoroethylene barrier membrane and freeze-dried gingival tissue interaction with tooth structure. J Peri- dura mater allografts for guided tissue regeneration of lost odont Res 1982; 17:530. periodontal support. I. Mandibular molar class II furca- 177. Terranova VP, Franzetti LC, Hic S, et al: A biochemical ap- tions. J Periodontol 1992; 63:431. proach to periodontal regeneration: Tetracycline treatment 197. Yukna RA, Mayer ET, Brite DV: Longitudinal evaluation of of dentin promotes fibroblast adhesion and growth. J Peri- Durapatite ceramic as an alloplastic implant in periodontal odont Res 1986; 21:330. osseous defects after three years. J Periodontol 1984; 178. Theilade J: An evaluation of the reliability of radiographs 55:633. in the measurement of bone loss in periodontal disease. 198. Yukna RA, Mellonig JT: Histologic evaluation of periodon- J Periodontol 1960; 31:143. tal healing in humans following regenerative therapy with 179. Topback GA, Brunsvold MA, Nummikoski PV, et al: The ac- enamel matrix derivative. A 10-case series. J Periodontol curacy of radiographic methods in assessing the outcome 2000; 71:752. of periodontal regenerative therapy. J Periodontol 1999; 199. Yukna RA, Krauser JT, Callan DP, et al: Multi-center clinical 70:1479. comparison of combination anorganic bovine-derived hy- 180. Tonetti MS, Cortellini P, Suvan JE, et al: Generalizability of droxyapatite matrix (ABM)/cell binding peptide (P-15) and the added benefits of guided tissue regeneration in the ABM in human periodontal osseous defects, 6-month re- treatment of deep intrabony defects. Evaluation in a multi sults. J Periodontol 2000; 71:1671. center randomized controlled clinical trial. J Periodontol 1998; 69:1183. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Furcation: The Problem and Its Management

William F. Ammons, Jr. and Gerald W. Harrington

CHAPTER

CHAPTER OUTLINE

ETIOLOGIC FACTORS OF FURCATION PROBLEMS Therapy for Furcation Involvement: Class II DIAGNOSIS AND CLASSIFICATION OF Therapy for Advanced Furcation Defects: FURCATION DEFECTS Classes II-IV CLASSIFICATION OF FURCATION INVOLVEMENT SURGICAL THERAPY FOR FURCATION INVOLVEMENT LOCAL ANATOMIC FACTORS IN TREATMENT Root Resection OF FURCATIONS HEMISECTION The Tooth THE ROOT RESECTION/HEMISECTION PROCEDURE THE ANATOMY OF THE BONY LESIONS REGENERATION Pattern of Attachment Loss EXTRACTION OTHER DENTAL FINDINGS PROGNOSIS FOR ROOT RESECTION/HEMISECTION TREATMENT OF FURCATION DEFECTS Therapy for Early Furcation Defects: Class I

he progress of inflammatory periodontal disease, cation defect is variable and related to local anatomic if unabated, ultimately results in attachment loss factors such as root trunk length, root morphology, 11,27 sufficient enough to affect the bifurcation or tri and local developmental anomalies such as cervical furcation of multirooted teeth. The furcation is an area enamel projections . 21,27 Local factors may affect the rate of complex anatomic morphology5,6,10 that may be diffi- of plaque deposition or complicate the performance of cult or impossible to be debrided by routine periodontal oral hygiene procedures thereby contributing to the de- instrumentation.28,33 Routine home care methods may velopment of periodontitis and attachment loss. Studies not keep the furcation area free of plaque . 17,22 The pres- indicate that prevalence and severity of furcation in- 2 1 33 ence of furcation involvement is one clinical finding volvement increase with age . 20, Dental caries and pul- that can lead to a diagnosis of advanced periodontitis pal death may also affect a tooth with furcation involve- and potentially to a less favorable prognosis for the af- ment or even the area of the furcation. All of these fected tooth or teeth. Furcation involvement therefore factors should be considered during the diagnosis, treat- presents both diagnostic and therapeutic dilemmas. ment planning and therapy of the patient with furcation defects. ETIOLOGIC FACTORS OF FURCATION PROBLEMS DIAGNOSIS AND CLASSIFICATION OF FURCATION DEFECTS The primary etiologic factor in the development of furcation defects is bacterial plaque and the inflammatory A thorough clinical examination is the key to diagnosis consequences that result from its long-term presence. and treatment planning. Careful probing is required to The extent of attachment loss required to produce a fur- determine the presence and extent of furcation involve- 825

82 6 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com CLASSIFICATION OF FURCATION ment, the position of the attachment relative to the INVOLVEMENT furca, and the extent and configuration of the furcation defect.35 Transgingival sounding may further define the The extent and configuration of the furcation defect are anatomy of the furcation defect.28 The goal of this exam- factors in both diagnosis and treatment planning. This ination is to identify and classify the extent of furcation has led to the development of a number of indices to involvement and to identify factors that may have con- record furcation involvement. These indices are based on tributed to the development of the furcation defect or the horizontal measurement of attachment loss in the that could affect treatment outcome. Among these fac- furcation, 13- 1 7 on a combination of horizontal and verti- tors are 1) the morphology of the affected tooth, 2) the cal measurements, 14 or a combination of these findings position of the tooth relative to adjacent teeth, 3) the lo- with the localized configuration of the bony deformity.' cal anatomy of the alveolar bone, 4) the configuration of Glickman" graded furcation involvement into the fol- any bony defects, and 5) the presence and extent of lowing four classes (Fig. 64-1, A-D): other dental diseases such as caries and pulpal necrosis. The dimension of the furcation entrance is variable but Grade I: A Grade I furcation involvement is the incipient usually quite small. Eighty-one percent of furcations have or early stage of furcation involvement (see Fig. 64-1, an orifice of 1 mm or less, and 58% are 0.75 mm or less.5 ,6 A). The pocket is suprabony and primarily affects the These dimensions, along with the local anatomy 1 0,11,12 soft tissues. Early bone loss may have occurred with of the furcation area, should be kept in mind in the selec- an increase in probing depth, but radiographic tions of instruments for probing. A probe of small cross changes are not usually found. section is required if one is to detect early furcation Grade II: Grade II furcation can affect one or more of the involvement. furcations of the same tooth. The furcation lesion is

Fig. 64-1 Glickman's classification of furcation involvement. A, Grade I furcation involvement. Although the periodontal ligament is visible at the entrance to the furcation, no horizontal component of the furcation is evident on probing. B, Grade II furcation in a dried skull. Note both the horizontal and the vertical component of this cul-de-sac. C, Grade III furcations on maxillary molars. Probing confirms that the buccal furcation connects with the distal furcation of both of these molars, yet the furcation is filled with soft tissue. D, Grade IV furcation. The soft tissues have receded sufficiently to allow direct vision into the furcation of this maxillary molar.

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essentially a cul-de-sac (see Fig. 64-1, B) with a definite horizontal component. If multiple defects are present, they do not communicate with each other, since a portion of the alveolar bone remains attached to the tooth. The extent of the horizontal probing of the furcation determines whether the defect is early or advanced. Vertical bone loss may be present and represents a therapeutic complication. Radiographs may or may not depict the furcation involvement. This is particularly true of maxillary molars because of the radiographic overlap of the roots. Although in some views the presence of furcation arrows indicate possible furcation involvement (see Chapter 31). Grade III. In grade III furcations the bone is not attached to the dome of the furcation. In early grade III involvement the opening may be filled with soft tissue and may not be visible. Indeed one may not be able to pass a periodontal probe completely through the furcation because of interference with the bifurcational ridges or facial/lingual bony margins. However, if one adds the buccal and lingual probing dimensions and obtains a cumulative probing measurement that is equal to or greater than the buccal/lingual dimension of the tooth at the furcation orifice, it must be concluded that a grade III furcation exists (see Fig. 64-1, C. Properly exposed and angled radiographs of early class III furcations display the defect as a radiolucent area in the crotch of the tooth (see Chapter 32). Grade IV: In grade IV furcations the interdental bone is destroyed and the soft tissues have receded apically so that the furcation opening is clinically visible. A tunnel therefore exists between the roots of such an affected tooth. The periodontal probe therefore passes readily from one aspect of the tooth to another (see Fig. 64-1, D). Other classification indices: Hamp, Nyman, and Lindhe17 modified a three-stage classification system by attach- ing a millimeter measurement to separate the extent of horizontal involvement. Easley and Drennan, 9 and Tarnow and Fletcher" have described classification systems that consider both horizontal and vertical attachment loss in classifying the extent of furcation involvement. Consideration of defect configuration and the vertical component of the defect provides additional Fig. 64-2 Different degrees of furcation involvement in radi- information that may be useful in planning therapy. ographs. A, Grade I furcation on the maxillary first molar and a Grade III furcation on the mandibular second molar. The root approximation on the second molar may be sufficient to impede ac- LOCAL ANATOMIC FACTORS IN curate probing of this defect. B, Multiple furcation defects on a TREATMENT OF FURCATIONS maxillary first molar. There is a class I buccal furcation involvement Clinical examination of the patient should allow the and grade II mesiopalatal and distopalatal furcations. Deep devel- therapist to identify not only furcation defects but many opmental grooves on the maxillary second molar simulate furcation involvement in this molar with fused roots. C, Grade III and IV fur- of the local anatomic factors that may affect the result of cations on mandibular molars. therapy (prognosis). Well-made dental radiographs, while not allowing a definitive classification of furcation involvement, provide additional information vital for treatment planning (Fig. 64-2, A-C. Important local factors are described in the following section.

The Tooth During treatment planning, the following anatomic features of the affected teeth should be considered:

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Root trunk length: This is a key factor in both the development and treatment of furcation involvement. The distance from the cementoenamel junction to the entrance of the furcation can vary extensively. Teeth may have very short root trunks, moderate length trunks or roots than may be fused to a point near the apex (Fig. 64-3). The combination of root trunk length with the number and configuration of the roots affects both the ease and success of therapy. The shorter the root trunk, the less attachment has to be lost before the furcation is involved. Once the furcation is exposed, teeth with short root trunks may be more accessible to maintenance procedures and the short root trunks may facilitate some surgical procedures. Alternatively teeth with unusually long root trunks or fused roots may not be appropriate candidates for treatment once Fig. 64-4 Furcation involvement by grade III cervical enamel the furcation has been affected. projections. Root length: Root length is directly related to the quantity of attachment supporting the tooth. Teeth with long roots trunks and short roots may have lost a majority of their support by the time that the furcation becomes affected. 12,19 Teeth with long roots and short to moderate root trunk length are more readily treated as suffi- Classification of Cervical Enamel Projections cient attachment remains to meet functional demands. Root form: The mesial root of most mandibular first and second molars and the mesiofacial root of the maxillary first molar are commonly curved to the distal in the apical third. In addition, the distal aspect of this root is usually heavily fluted. The curvature and fluting may increase the potential for root perforation during endodontics or complicate postplacement during restoration. 1.24 These anatomic features may also result in an increased incidence of vertical root fracture. The size of the mesial radicular pulp may result in removal of the Masters DH, Hoskins SW: Projection of cervical enamel into molar majority of the portion of the tooth during preparation. furcations. J Periodontol 1964; 35:49. Interradicular dimension: The degree of separation of the roots is also an important factor in treatment planning. Closely approximated or fused roots can preclude ade- toplasty to reduce or eliminate these ridges may be re- quate instrumentation during scaling, root planing, quired during surgical therapy for an optimum result. and surgery. Teeth with widely separated roots present Cervical enamel projections: Cervical enamel projections more treatment options and are more readily treated. (CEPS) are reported to occur on 8.6% to 28.6% of mo- Anatomy of the furcation: The anatomy of the furcation is lars . 25.21,32 The prevalence is highest for mandibular complex. The presence of bifurcational ridges, a con- and maxillary second molars. The extent of CEPs was 16 cavity in the dome," and possible accessory canals classified by Masters and Hoskins27 in 1964 (Box 64-1). complicates not only scaling, root planing, and surgi- An example of a grade III CEP is shown in Fig. 64-4. cal therapy, 26 but also periodontal maintenance. Odon- These projections can affect plaque removal, complicate scaling and root planing, and may be a local factor in the development of gingivitis and periodontitis. They should be removed to facilitate maintenance.

THE ANATOMY OF THE BONY LESIONS

Pattern of Attachment Loss

The form of the bony lesions associated with the furcation can vary significantly. Horizontal bone loss can expose the furcation as thin facial/lingual plates of bone Fig. 64-3 Different anatomic features that may be important in that may be totally lost during resorption. Alternatively, prognosis and treatment of furcation involvement. A, Widely sepa- areas with thickened bony ledges may persist and predis- rated roots. B, Roots are separated but close. C, Fused roots sepa- pose to the development of furcations with deep vertical rated only in their apical portion. D, Presence of enamel projection components. The pattern of bone loss on other surfaces that may be conducive to early furcation involvement. of the affected tooth and adjacent teeth must also be

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considered during treatment planning. The treatment re- tooth represents the same problem that exists in furca- sponse in deep multiwalled bony defects is different tions without adequate root separation. Such a finding from that in areas of horizontal bone loss. Complex mul- may dictate the removal of the most severely affected tiwalled defects with deep interradicular vertical compo- tooth or the removal of a root or roots (Fig. 64-5). nents may be candidates for regenerative therapies. Al- The presence of an adequate band of gingiva and a ternatively, molars with advanced attachment loss on moderate to deep vestibule will facilitate the perfor- only one root may be treated by resective procedures. mance of a surgical procedure should it be indicated.

OTHER DENTAL FINDINGS TREATMENT OF FURCATION DEFECTS The dental and periodontal condition of the adjacent The objectives of furcation therapy are to 1) facilitate teeth must be considered during treatment planning for maintenance, 2) prevent further attachment loss, and furcation involvement. The combination of furcation in- 3) obliterate the furcation defects as a periodontal mainte- volvement and root approximation with an adjacent nance problem. The selection of therapeutic mode varies with the class of furcation involvement, the extent and configuration of bone loss, and other anatomic factors.

Therapy for Early Furcation Defects: Class I Incipient or early furcation defects (class I) are amenable to conservative periodontal therapy. As the pocket is suprabony and has not entered the furcation, oral hygiene, scaling, and root planing are effective." Any thick overhanging margins of restorations, facial grooves, or cervical enamel projections should be eliminated by odontoplasty, recontouring, or replacement. The resolution of inflammation and subsequent repair of the periodontal ligament and bone is usually sufficient to restore periodontal health.

Therapy for Furcation Involvement: Class II Once a horizontal component to the furcation has devel- Fig. 64-5 Advanced bone loss, furcation involvement, and root oped (class II), therapy becomes more complicated. Shal- approximation. Note the buccal furcation, which communicates with the distal furcation of a maxillary first molar that also displays low horizontal involvement without significant vertical advanced attachment loss on the distal root and approximation bone loss usually responds favorably to localized flap op- with the mesial of the maxillary second molar. The patient with eration with odontoplasty and osteoplasty. Isolated deep such teeth may benefit from root resection of the distobuccal root class II furcations may respond to flap procedures with of the first molar or extraction of the molar. osteoplasty and odontoplasty (Fig. 64-6, A and B). This

Fig. 64-6 Treatment of a grade II furcation by osteoplasty and odontoplasty. A, This mandibular first molar has been treated by endodontics and an area of caries in the furcation repaired. A class II furcation is present. B, Five year postoperative picture of the results of flap debridement, osteoplasty, and severe odontoplasty. Note the adaptation of the gingiva into the furcation area. (Courtesy Dr. Ronald Rott; Sacramento, Calif.)

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Fig. 64-7 Resection of a root with advanced bone loss. A, Facial terproximal and interradicular zones, unless the le- osseous contours. There is an early grade II furcation on the facial of sions have three bony walls, are not candidates for the mandibular first molar and a class III furcation on the mandibu- root amputation. lar second molar. B, Lingual osseous contours. Note the early grade 3. Teeth for which there is no more predictable or cost- II lingual furcation on the first molar and the deep circumferential effective method of therapy. Examples are teeth with bony lesion on the mesial root of the mandibular second molar. furcation defects that have been treated successfully C, Resection of the mesial root. The mesial portion of the crown was retained to prevent mesial drift of the distal root during heal- with endodontics but now present with a vertical root ing. The grade II furcations were treated by osteoplasty. D, Buccal fracture, advanced bone loss or caries on bone root. flaps adapted and sutured. E, Lingual flaps adapted and sutured. 4. Teeth in patients with good oral hygiene and low ac- F, Three-month postoperative view of the buccal aspect of this re- tivity for caries are suitable candidates. Patients un- section. New restorations were subsequently placed. G, Three- able or unwilling to perform good oral hygiene and month postoperative view of the lingual aspect of this resection. preventive measures are not suitable candidates for root resection or hemisection. Root-resected teeth require endodontic treatment 14 and commonly require cast restorations. These therapies can represent a sizeable financial in- vestment on the part of the patient in an effort to save reduces the dome of the furcation and alters gingival the tooth. Alternative therapies and their impact on the contours to facilitate the patient's plaque removal. overall treatment plan should always be considered and presented to the patient. Therapy for Advanced Furcation Defects: Class II-IV Root Resection: Which Root to Remove and The development of a significant horizontal component Why? A tooth with an isolated furcation defect in to one or more furcations of a multirooted tooth (late an otherwise intact dental segment may present few di- class II, class III or IV") and/or the development of a agnostic problems. However, the existence of multiple deep vertical component to the furca poses additional furcation defects of varying severity when combined problems. Nonsurgical treatment is commonly ineffec- with generalized advanced periodontitis can be a treat- tive as the ability to instrument the tooth surfaces ade- ment planning challenge. Careful diagnosis usually al- quately is compromised . 30-36 Periodontal surgery, en- lows the therapist to determine the feasibility of root re- dodontics, and restoration of the tooth may be required section and the identification of which root to remove to retain the tooth. before surgery (Fig. 64-7, A-G). The following is a guide to determining which root should be removed in these cases: SURGICAL THERAPY FOR FURCATION INVOLVEMENT 1. Remove the root(s) that will elliminate the furcation and allow the production of a maintainable architec- Root Resection ture on the remaining roots. 2. Remove the root with the greatest amount of bone Root resection may be indicated in multirooted teeth and attachment loss. It is obvious that sufficient peri- with grade II to IV furcation involvements. Root resec- odontal attachment must remain after surgery for the tion may be performed on vital'$ or endodontically tooth to withstand the functional demands placed on treated teeth. It is preferable, however, to have en- it. Teeth with uniform advanced horizontal bone loss dodontic therapy completed before resection of a are not candidates for root resection. root(s).14If this is not possible, then the pulp should be 3. Remove the root that best contributes to the elimina- removed, the patency of the canals determined, and the tion of periodontal problems on adjacent teeth. For pulp chamber medicated before resection. It is distress- example, a maxillary first molar, with a class III buc- ing to perform a vital root resection and to subse- cal-to-distal furcation is adjacent to a maxillary sec- quently have an untoward event occur such as perfora- ond molar with a two-walled intrabony defect be- tion, fracture of the root, or an inability to instrument tween the molars and an early class II furcation on the canal. the mesial furcation of the second molar. There may The indications and contraindications for root resec- or may not be local anatomic factors affecting the tion were well summarized by Bassaraba.1 In general, teeth. The removal of the distobuccal root of the first teeth planned for root resection should include the molar allows the elimination of the furcation and following: management of the two-walled intrabony lesion and 1. Teeth that are of critical importance to the overall also facilitates access for instrumentation and mainte- dental treatment plan . 4 Examples are teeth serving as nance of the second molar (Fig. 64-8). abutments of fixed or removable restorations for 4. Remove the root with the greatest number of which the loss of the tooth would result in the loss of anatomic problems such as severe curvature, develop- the prosthesis and entail major prosthetic retreat- mental grooves, root flutings, or accessory and multi- ment. ple root canals. 2. Teeth that have sufficient attachment remaining for 5. Remove the root that least complicates future peri- function. Molars with advanced bone loss in the in- odontal maintenance.

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Fig. 64-8 Advanced bone loss on one root with furcation involvement. The majority of the attachment has been lost on the distal surface of this maxillary first molar. A buccal grade I and a deep grade II distal furcation defect is present. A shallow two-walled defect, correctable by osteoplasty and osteoectomy, is present at the mesial of the second molar. Treatment options are root amputation or extraction.

HEMISECTION Hemisection is the splitting of a two-rooted tooth into two separate portions. This process has been called bicus- pidization or separation as it changes the molar into two separate roots. It is most likely to be performed on mandibular molars with buccal and lingual class II or III furcation involvements. As with root resection, molars with advanced bone loss in the interproximal and interradicular zones are not good candidates for hemisection. After sectioning of the teeth, one or both roots can be retained. This decision is based on the extent and pattern of bony loss, root trunk and root length, ability to eliminate the osseous defect, and endodontic and restorative considerations. The anatomy of the mesial roots of mandibular molars often leads to their extraction and the retention of the distal root to facilitate both endodontics and restorative dentistry. The interradicular dimension between the two roots of Fig. 64-9 Hemisection. a tooth to be hemisected is also important. Narrow interradicular zones can complicate the surgical procedure. The retention of both molar roots can complicate the restoration of the tooth, since it may be virtually impossi- tion is diagramed in Fig. 64-11, A-F. After appropriate ble to finish margins or to provide an adequate embra- local anesthesia, a full-thickness mucoperiosteal flap is sure between the two roots for effective oral hygiene and elevated. Root resection or hemisection of teeth with ad- maintenance (Fig. 64-9). Therefore orthodontic separa- vanced attachment loss usually requires opening both fa- tion of the roots is commonly required to allow restora- cial and lingual/palatal flaps. Chapter 60 of this text de- tion with adequate embrasure form (Fig. 64-10, A-D). scribes the process of flap elevation. It is uncommon to The result can be the need for multiple procedures and be able to resect a root without elevation of a flap. The extensive interdisciplinary therapy. In such patients the flap should provide adequate access for visualization and availability of other treatment alternatives such as guided instrumentation and to minimize trauma during the op- tissue/guided bone regeneration or replacement by os- eration. seointegrated dental implants should be considered. After debridement the resection of the root begins with the exposure of the furcation on the root to be removed (see Fig. 64-11, A). The removal of a small amount THE ROOT RESECTION/ HE M I of facial or palatal bone may be required to provide ac- SECTION PROCEDU RE cess for elevation and facilitate root removal (see Fig. 64- The most commonly performed root resection is the dis- 11, B). A cut is then directed from just apical to the con- tobuccal root of the maxillary first molar.3 This resec- tact point of the tooth, through the tooth, to the facial Furcation: The Problem and Its Management • CHAPTER 64 833 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 64-10 Hemisection and interradicular dimension. A, Buccal preoperative view of a mandibular right second molar with a deep grade II buccal furcation and root approximation. B, Buccal view of bony lesions with flaps. Note the mesial and distal one-wall bony defects. The lingual furcation was similarly affected. C, The molar has been hemisected and partially prepared for temporary crowns. Observe the minimal dimension between the two roots. D, Buccal view 3 weeks postoperative. As the embrasure space is minimal, these roots will be separated with orthodontics to facilitate restoration. (Courtesy Dr. Louis Cuccia; Roseville, Calif.) and distal orifices of the furcation, (see Fig. 64-11, C. (see Fig. 64-11, E). Care should be taken not to trauma- This cut is made with a high-speed surgical length fissure tize bone on the remaining roots or to damage an adja- or cross-cut fissure carbine bur. The placement of a cent tooth. Removal of the root provides visibility to the curved periodontal probe into or through the furcation furcation aspects of the remaining roots and simplifies aids in orienting the angle of the resection. For hemisec- the debridement of the furcation with hand, rotary, or tion a vertically oriented cut is made faciolingually ultrasonic instruments. If necessary, odontoplasty is per- through the buccal and lingual developmental grooves of formed to remove portions of the developmental ridges the tooth, through the pulp chamber, and through the and prepare a furcation that is free of any deformity that furcation. If the sectioning cut passes through a metallic would enhance plaque retention or adversely affect restoration, the metallic portion of the cut should be plaque removal (see Fig. 64-11, F). made before flap elevation. This prevents the contamina- Patients with advanced periodontitis commonly have tion of the surgical field with metallic particles. root resection performed in conjunction with other sur- If a vital root resection is to be performed a more hor- gical procedures. An example of combining root resec- izontal cut through the root is advisable (see Fig. 64-11, tion and periodontal osseous surgery is shown in Fig. 64- D). An oblique cut exposes a large surface area of the 12, A-I. The bony lesions that may be present on radicular pulp and/or dental pulp chamber. This can lead adjacent teeth are then treated using resective or regen- to postoperative pain and can complicate the perfor- erative therapies. After resection the flap(s) are then ap- mance of endodontics. A horizontal cut, although it may proximated to cover any grafted tissues or to slightly complicate root removal, has less postoperative compli- cover the bony margins around the tooth. Sutures are cations. This root stump can be removed by odonto- then placed to maintain the position of the flaps. The plasty after the completion of endodontic therapy or at area may or may not be covered with a surgical dressing. the time of tooth preparation. The removal of a root alters the distribution of oc- After sectioning, the root is elevated from its socket clusal forces on the remaining roots. Therefore it is wise 834 PART 5 • Treatment of Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 64-11 Diagram of a distobuccal root resection of a maxillary first molar. A, Pre-operative bony contours with grade II buccal furcation and a crater between the first and second molar. B, Removal of bone from the facial of the distobuccal root and exposure of the furcation for instrumentation. C, Oblique section that separates the distal root from the mesial and palatal roots of the molar. D, More horizontal section that may be used on a vital root amputation as it exposes less of the pulp of the tooth. E, Areas of application of instruments to elevate the sectioned root. F, Final contours of the resection.

to evaluate the occlusion of teeth from which roots have ical success with these techniques, 23 whereas others have been resected and if necessary to adjust the occlusion. suggested that the use of these materials in class II, III, or Centric holds should be maintained, but eccentric forces IV furcations offers little advantage compared with surgi- should be eliminated from the area over the root that cal controls . 3-8,29 was removed. Patients with advanced attachment loss Furcation defects with deep two-walled or significant may benefit from temporary stabilization of the resected three-walled components may however be candidates for tooth to prevent movement (Fig. 64-13, A-1). regeneration procedures. These vertical bony deformities respond favorably to a variety of other surgical proce- REGENERATION dures such as debridement with or without membranes and bone grafts. Therapies designed to induce new at- The periodontal literature has well-documented thera- tachment or reattachment are addressed in Chapter 63. peutic efforts designed to induce new attachment and/or regeneration on molars with furcation defects. Many surgical procedures using a variety of grafting materials EXTRACTION have been tested on teeth with different classes of furca- The extraction of teeth with through and through furcation involvement. Some investigators have reported clin- tion defects (class III and IV) and advanced attachment

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Fig. 64-12 Hemisection combined with osseous surgery to treat furcation defects. A, Buccal preoperative view with provisional bridge. B, Lingual view with provisional bridge in place. C, Radiograph of bony defects. Note the deep mesial bony defect that is largely of one wall and the radiolucent area in the furcation of the first molar indicating a grade II furcation. D, Buccal preosseous surgery view. In addition to the furcation involvement there is a root separation problem between the two roots of the first molar. Class II furcations are present on the second molar. E, Buccal view postosseous surgery. Mesial root hemisected and removed. The other defects were treated by osteoplasty and osteosectomy. F, Lingual pre-osseous view. Note the heavy bony ledging at the lingual of these first and second molars.

(Continued)

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Fig. 64-12 (Cont'ed) G, Lingual view postosseous surgery. The mesial root has been resected, the bony ledging recontoured, and the grade II furcations treated by osteoplasty. H, Buccal view, 10 years posttreatment. I, Lingual view, 10 years posttreatment. (Courtesy Dr. Louis Cuccia; Roseville, Calif.)

Fig. 64-13 Mesial root resection in the presence of advanced bone loss. A and B, Buccal and lingual preoperative views. Note the soft tissue contours that are predictive of the bony defects.

(Continued)

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Fig. 64-13 (Cont'ed) C, Radiograph of extent of furcation involvement of the first and second molars. D and E, Buccal pre- and postosseous surgery views. The mesial root of the second molar was resected and the interproximal craters treated by osteoplasty and minor ostectomy. F and G, Lingual pre- and postresection views. The heavy ledges and horizontal bone loss on the lingual was managed by osteoplasty. H and I, Six-week postoperative views of the buccal and lingual. A temporary wire splint has been bonded to the molars to prevent tipping of the distal root of the mandibular second molar. (Courtesy Dr. Louis Cucci; Roseville, Calif.)

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loss may be the most appropriate therapy for some pa- 7. Carnevale G, DiFebo G, Toyelli MP, et al: A retrospective tients. This is particularly true for individuals who can- analysis of the periodontal-prosthodontic treatment of mo- not or will not perform adequate plaque control, have a lars with interradicular lesions. Int J Periodontics Restora- high level of caries activity, will not commit to a suitable tive Dent 1991; 11:188. 8. Demolon IA, Person GR, Ammons WF, et al: Effects of maintenance program, or have socioeconomic factors antibiotic treatment on clinical conditions with guided tis- that may preclude more complex therapies. Some pa- sue regeneration: one-year results. J Periodontol 1994; tients are reluctant to accept periodontal surgery or even 65:713. allow the removal of a tooth with advanced furcation in- 9. Easley JR, Drennan GA: Morphological classification of the volvement even though the long-term prognosis is poor. furca. J Canada Dent Assn 1969; 35(2):104. The patient may elect to forego therapy, opt to treat the 10. Everett F, Jump E, Holder T, et al: The intermediate bifurca- area with scaling and root planing or site-specific anti- tional ridge: a study of the morphology of the bifurcation of bacterial therapies, and delay removal of the tooth until the lower molar. J Dent Res 1958; 37:162. the tooth becomes symptomatic. Although additional at- 11. Gher ME, Vernino AR: Root morphology: clinical signifi- tachment loss may occur, it is not uncommon for such cance in pathogenesis and treatment of periodontal disease. J Amer Dent Assn 1980; 101:627. teeth to last a significant number of years .20,31 12. Gher ME Jr, Dunlap RW: Linear variation of the root surface The advent of osseointegrated dental implants as an area of the maxillary first molar. J Periodontol 1985; 56:39. alternative abutment source has had a major impact on 13. Glickman I: Clinical Periodontology, ed 1. Philadelphia, the retention of teeth with advanced furcation problems. Saunders, 1953. The high level of predictability of osseointegration may 14. Harrington GW: The perio-endo question: differential diag- motivate the therapist and patient to consider removal nosis. Dent Clin N Amer 1979; 23(4):673. of teeth with a guarded or poor prognosis and to seek an 15. Goldman HM: Therapy of the incipient bifurcation involve- implant-supported prosthetic treatment plan. ment. J Periodontol 1958; 29:112. 16. Gutmann JL: Prevalence, location and patency of accessory canals in the furcation region of permanent molars. J Peri- PROGNOSIS FOR ROOT odontol 1978; 49:21. RESECTION/H EM [SECTION 17. Hamp S-E, Nyman S, Lindhe J: Periodontal treatment of multirooted teeth. Results after 5 years. J Clin Periodontol For many years the presence of significant furcation in- 1975; 2:126 volvement was deemed to give a tooth a hopeless long- 18. Haskell EW, Stanley HR: A review of vital root resection. Int term prognosis. Clinical research, however, has indicated J Periodont Restorative Dent 1982; 2(6):29. that furcation problems are not as severe a complication 19. Hermann DW, Gher ME Jr, Dumlap RM, et al: The potential as originally suspected if one can prevent the develop- attachment area of the maxillary first molar. J Periodontol ment of caries in the furcation. Relatively simple peri- 1983; 54:431. odontal therapy is sufficient to maintain these teeth in 20. Hirschfeld L, Wasserman B: A long-term survey of tooth loss function for long periods .20.31 Other investigators have in 600 treated periodontal patients. J Periodontol 1978; defined the reasons for clinical failure of root-resected or 49:225. 21. Hou GL, Tasai CC: Relationship between periodontal furca- hemisected teeth .2,24 Their data indicate that recurrent tion involvement and molar cervical enamel projection. periodontal disease is not a major cause of the failure of J Periodontol 1978; 58:715. these teeth. Investigations of root-resected or hemisected 22. Kalkwarf K, Kaldahl W, Patil K, et al: Evaluation of furcation teeth have provided evidence that such teeth can func- region response to periodontal therapy. J Periodontol 1988; tion successfully for long periods .2, The keys to long- 59:794. term success appear to be thorough diagnosis, selection 23. Kenney EB, Lekovic V, Elbaz JJ, et al: The use of porous hy- of patients with good oral hygiene, and careful surgical droxylapatite implants in periodontal defects. II. Treatment and restorative management. of class II furcation lesions in lower molars. J Periodontol 1988; 59:67. REFERENCES 24. Langer B, Stein SD, Wagenberg B: An evaluation of root re- sections. A ten-year study. J Periodontol 1981; 52:719. 1. Bassaraba N: Root amputation and tooth hemisection. Dent 25. Larato DC: Some anatomical factors related to furcation in- Clin N Amer 1969; 13(1):121. volvement. J Periodontol 1975; 46:608. 2. Basten CHJ, Ammons WF, Persson R: Long-term evaluation 26. Matia JB, Bissada NF, Maybury JE, et al: Efficiency of scaling of root resected molars. A retrospective study. Int J Peri- of the molar furcation area with and without surgical ac- odontics Restorative Dent 1996; 16(3):207. cess. Int J Periodont Restorative Dent 1986; 6(6):25. 3. Becker W Becker BE, Berg L, et al: New attachment after 27. Masters DH, Hoskins SW: Projection of cervical enamel into treatment with root isolation procedures. Report for treated molar furcations. J Periodontol 1964; 35:49. class III and class II furcations and vertical osseous defects. 28. Mealy BL, Beybayer MF, Butzin CA, et al: Use of furcal bone Int J Periodont Restorative Dent 1988; 8(3):9. sounding to improve accuracy of furcation diagnosis. J Peri- 4. Black GV: The American System of Dentistry. (Ed: W Litch.) odontol 1994; 65:649. Philadelphia, Lea Brothers, 1886. 29. Metzler DG, Seamons BC, Mellonig JT, et al: Clinical evalua- 5. Bower RC: Furcation morphology relative to periodontal tion of guided tissue regeneration in the treatment of max- treatment. Furcation root surface anatomy. J Periodontol illary class II molar furcation. J Periodontol 1991; 62:353. 1979; 50:366. 30. Parashis AO, Anognou-Vareltzides A, Demetrious N: Cal- 6. Bower RC: Furcation morphology relative to periodontal culus removal from multirooted teeth with and without treatment: Furcation entrance architecture. J Periodontol surgical access. 1. Efficacy on external and furcation surfaces 1979; 50:23. in relation to probing depth. J Clin Periodontol 1993; 20:63.

Furcation: The Problem and Its Management • CHAPTER 64 839 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com 31. Ross 1, Thompson RH: A long-term study of root retention 34. Tarnow D, Fletcher P: Classification of the vertical compo- of maxillary molars with furcation involvement. J Periodon- nent of furcation involvement. J Periodontol 1984; 55:283. tol 1978; 49:238. 35. Tibbetts LF: Use of diagnostic probes for detection of peri- 32. Tal H: Furcal bony defects in dry mandibles. 1. Biometric odontal disease. J Amer Dent Assn 1969; 78:549. study. J Periodontol 1982; 53:360. 36. Wylam JM, Mealey B, Mills MP, et al: The clinical effective- 33. Tal H, Lemmer J: Furcal defects in dry mandibles. 11. Severity ness of open versus closed scaling and root planing on of furcal defects. J Periodontol 1982; 53:364. multi-rooted teeth. J Periodontol 1993; 64:1023. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

The Periodontic-Endodontic Continuum

William F. Ammons, Jr. and Gerald W. Harrington

CHAPTER

CHAPTER OUTLINE

ETIOLOGIC FACTORS OF PULPAL DISEASE THERAPEUTIC MANAGEMENT OF PULPAL AND CLASSIFICATION OF PULPAL DISEASE PERIODONTAL DISEASE EFFECTS OF PULPAL DISEASE ON THE ENDODONTIC LESION PRIMARY PERIODONTIUM I NDEPENDENT PERIODONTAL AND EFFECT OF PERIODONTITIS ON THE DENTAL PULP ENDODONTIC LESIONS DIFFERENTIATION OF PERIODONTAL AND COMBINED LESIONS (PERIO-ENDO) PULPAL LESIONS PROGNOSIS OF COMBINED LESIONS The Signs and Symptoms of Periodontitis POTENTIAL COMPLICATIONS TO The Signs and Symptoms of Pulpal Disease ENDODONTIC THERAPY DIFFERENTIATION BETWEEN PULPAL AND RESTORATIVE IMPLICATIONS OF PERIODONTAL ABSCESSES ENDODONTIC THERAPY

he simultaneous existence of pulpal problems and minish in the deepest layers of the dentin, the ability inflammatory periodontal disease can complicate of microorganisms and their by-products to penetrate diagnosis and treatment planning and affect the through the dentinal tubules and to provoke pulpal in- sequence of care to be performed. This is particularly flammation is well documented. Direct exposure of the true for the patient with advanced periodontitis, tooth pulp by caries21 or sealing infected pulps may alter the loss and pulpal disease. process of infection if the pulp is unable to eliminate the bacteria . 6.20 The dynamics of the pulpal reaction is dic- ETIOLOGIC FACTORS OF PULPAL DISEASE tated by the virulence of the bacteria, the host response, the effectiveness of pulpal circulation, and the degree of The major causes of pulpal inflammation are 1) instru- vascular and lymphatic drainage . 42 mentation during periodontal, restorative or prosthetic Pulpal infection is a polymicrobial process. Although dentistry; 2) the progression of dental caries; and 3) di- a correlation between causation and any species of bacte- rect, local trauma such as tooth fracture. The extent of ria is not currently possible , 2 studies based on culturing inflammation of the pulp and the signs and symptoms suggest that a mean of five bacterial strains may be cul- that result vary with the severity of the insult and the tured from infected root canals.2 The organisms cultured ability of the host to ameliorate the inflammation that are predominately gram-negative anaerobes .2.3.10.13.38 As results. the infective process proceeds the proportion of strict Of these, dental caries is the most common cause of anaerobic-to-facultative organisms and the total number pulpal disease. Bacteria are present in carious enamel of bacteria increases. The most common organisms asso- and dentin. Although the numbers of bacteria may di- ciated with pulpitis are listed in Table 65-1.

840

The Periodontic-Endodontic Continuum • CHAPTER 65 841 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com the deposition of reparative dentin if odontoblasts are destroyed. The reversibility of inflammation and symp- Bacteria Associated with Pulpitis toms, without permanent pulpal damage, has led to a classification of this condition as reversible pulpitis. Number of If the pulp is so affected that the inflammatory lesion Bacteria Strains Gram Stain cannot be resolved, even though the source of the trauma is eliminated, a progressive degeneration of the Eubacterium ssp. 59 Gram-positive, pulp results. This progression has been described as be- nonmotile ing an irreversible pulpitis. Irreversible pulpitis may be Peptostreptococcus ssp. 54 Gram-positive, void of symptoms or it may be associated with intermit- nonmotile tent or continuous episodes of spontaneous pain. The Fusobacterium ssp. 50 Gram-negative, application of heat to a tooth with irreversible pulpitis nonmotile can lead to an immediate painful response that can per- Prophyromonas ssp. 32 Gram-negative, sist for a prolonged period. Cold may also provoke such nonmotile a response, although occasionally, the application of Prevotella spp. 45 Gram-negative, cold may provide relief from the pain. A reduced respon- nonmotile siveness of teeth with irreversible pulpitis to thermal Streptococcus spp. 28 Gram-positive, stimuli has been claimed, but Mumford found similar nonmotile pain thresholds in both inflamed and noninflamed Lactobacillus spp. 24 Gram-positive, pulps. nonmotile Irreversible pulpitis ultimately leads to loss of pulpal Wolinella spp. 18 Gram-negative, vitality (necrosis). Necrosis usually results from the same motile factors that induced the irreversible pulpitis and may lead Actinomyces spp. 1 4 Gram-positive rod, to an alteration in the patient's symptoms. Not all nonvi- nonmotile tal teeth display signs and symptoms of pulpal disease and necrotic pulps are commonly asymptomatic. When Modified from Sundqvist G, Johansson E, Sjogren U: Prevalence symptoms do occur, they may be manifested as episodes of black-pigmented bacteroides species in root canal infections. of spontaneous pain. Testing the pulp with heat may be J Endodon 1989; 15(1):13; and Baumgartner JC, Falkler WA: inconclusive, and a response to cold stimuli is rare. Bacteria in the apical 5 mm of infected root canals. J Endodon 1 991; 17(8):380. EFFECTS OF PULPAL DISEASE ON THE PERIODONTIUM Pulpal tissue may be significantly inflamed and yet exert CLASSIFICATION OF PULPAL DISEASE little or no effect on the periodontium. As long as the The correlation between the histology of pulpal disease pulp remains vital it is unlikely that significant changes and the patient's symptoms is poor. Therefore pulpal dis- will occur in the periodontium. Necrosis of the pulp, ease is generally classified based on clinical signs and however, can result in bone resorption and the produc- symptoms rather than on histologic changes. Such a tion of radiolucency at the apex of the tooth, in the fur- classification is illustrated in Box 65-1. cation or at points along the root2 5.34,41,43 (Fig. 65-1). Minor injury such as periodontal root planing or the Dental radiographs usually document the presence of conservative preparation of a tooth for a restoration may apical or lateral lesions. lead to pulpal symptoms. A transient hypersensitivity to The lesion that results may be an acute apical lesion thermal stimuli is the most common symptom noted. or abscess, a more chronic periradicular lesion (cyst or The application of a thermal stimulus results in a brief, granuloma); or a lesion associated with a lateral or acces- painful response that varies in intensity from mild to se- sory canal. The lesion may remain small, or it can ex- vere. The response rapidly disappears after removal of pand sufficiently to destroy a substantial amount of the the stimulus. Although permanent pulpal damage may attachment of the tooth and/or to communicate with a not occur, a transient inflammatory response can lead to lesion of periodontitis. A classification of periradicular lesions is found in Box 65-2. The histopathologic structure of the periapical inflammatory lesion is usually a highly vascularized granulation tissue infiltrated to varying degrees by inflammatory cells. Neutrophils may be present near the apical fora- Classification of Pulpal Disease men, whereas plasma cells, macrophages, lymphocytes and fibroblasts are increased in the periphery of the lesion.5,28,39,44 This cellular infiltrate may vary with the nature and intensity of the irritants to the tissues. Similar lesions may develop adjacent to accessory or lateral canals. These canals form when the epithelial root sheath breaks down before root formation or anasto-

842 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com cidence is unknown .9,12,43 The majority of these canals occur in the apical portion of the root, with decreased numbers in the furcation area. They are more common in posterior teeth and in the apical portion of the root. 9,22,33 The prevalence of lateral canals in the middle and cervical areas of the root and the prevalence of endodontic- derived lesions in the marginal periodontium via lateral or accessory canals are low. The clinical significance of accessory or lateral canals in spreading infection from the necrotic pulp to the periodontium is therefore unclear. Necrotic pulps apparently exert no effect through the dentinal tubules on the cementum.'

EFFECT OF PERIODONTITIS ON THE DENTAL PULP Although the effects of pulpal disease on the periodontium are well documented, a clear-cut relationship between periodontitis and pulpal involvement is less evident. One may postulate that bacterial and the inflammatory products of periodontitis could gain access to the pulp via accessory canals, apical foramina, or dentinal tubules. This process, the reverse of the effects of a necrotic pulp on the periodontal ligament, has been 31,35 Fig. 65-1 Diagrammatic representation of different types of en- referred to as retrograde pulpitis. doperiodontal problems. A, An originally endodontic problem with However, although inflammatory changes have been fistulization from the apex and along the root to the gingiva. Pulpal reported adjacent to accessory canals exposed by infection can also spread through accessory canals to the gingiva or periodontitis, periodontitis rarely produces significant to the furcatioh. B, A long-standing periapical lesion draining changes in the dental pulp. Neither irreversible pulpitis through the periodontal ligament can become secondarily compli- or pulpal necrosis has been consistently found in histo- cated, leading to a retrograde periodontitis. C, A periodontal pocket logic studies of teeth extracted because of severe peri- can deepen to the apex and secondarily involve the pulp. D, A periodontal disease . 8,20,40 It has been suggested that the pres- odontal pocket can infect the pulp through a lateral canal, and this, ence of an intact layer of cementum may protect the in turn, can result in a periapical lesion. E, Two independent le- pulp from injurious elements produced by plaque micro- sions, periapical and marginal, can coexist and eventually fuse with each other. (Redrawn and modified from Simon JHS, Glick DH, biota. 1 Severe breakdown of the pulp apparently does Frank AL: The relationship of endodontic-periodontic lesions. J Peri- not occur until periodontitis has reached a terminal odontol 1972; 43:202.) state-that is, when bacterial plaque has involved the main apical foramina.20 The pulp has a good capacity for defense as long as the blood supply via the apical foramina is intact. Therefore retrograde periodontitis, if it occurs, is exceedingly rare. 14,15,40 Classification of Periradicular Lesions DIFFERENTIATION OF PERIODONTAL AND PULPAL LESIONS

The Signs and Symptoms of Periodontitis The signs and symptoms of periodontitis are described in Chapters 26 to 28 of this text. Periodontitis is a chronic inflammatory lesion, which begins in the marginal gingiva and extends apically causing attachment loss and moses between the dental papilla and the dental sac per- periodontal pocket formation In general the progression sist. Although many of the anastomoses are blocked or rate of attachment loss is slow, unless an acute incident reduced by the formation of dentin or the depositing of such as a periodontal abscess occurs. cementum, some of the communications between the Teeth with chronic periodontal lesions are commonly pulp and periodontium may remain patent in the adult free of acute symptoms. The patient may indeed be un- dentition. Lateral canals are usually not visible on x-rays aware of the condition, with the exception of bleeding and are most commonly identified only when the root on brushing and flossing, or bad breath, until sufficient and lateral canal has been filled with a radiopaque mate- attachment is lost, resulting in increased tooth mobility. rial during endodontic therapy The pocket may be tender to probing and extensive de- The incidence of accessory and/or lateral canals has posits may be present on the root(s) of the tooth/teeth. been quoted as ranging from 2% to 27%, but the true in- Probing is usually accompanied by bleeding and in

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deeper pockets with suppuration. However, significant point into the fistula and then making a radiograph. The discomfort is not elicited by percussion or thermal stim- point communicates with and stops within the peri- uli. Increased tooth mobility may occur if sufficient at- odontal pocket. Careful probing confirms the presence tachment has been lost. Dental radiographs usually dis- of the pocket, and dilation of the sulcus commonly re- close the extent of attachment loss, which should sults in drainage. correlate with clinical probing data. Acute apical abscesses commonly communicate directly with the external soft tissue surface by a sinus tract and a stoma through the oral mucosa or gingiva The Signs and Symptoms of Pulpal Disease (Fig. 65-2). Before the completion of the tract, the pa- The pulp has the ability to respond to stimulation tient commonly experiences acutely painful symptoms through enamel or dentin, or directly to the pulp. Higher as a result of the involvement of the periodontal liga- nerve centers interpret these sensations as pain. There is ment. The tract may exit through the periodontium and some evidence that the pulp may also sense temperature dissect along the root to empty into the gingival sulcus and touch,27 although the ability to discriminate between and the interfurcal area. It then goes through the peri- hot and cold may be affected by age." The character of odontal ligament of an adjacent tooth or into an exist- the pain may vary with its source. Pulpal sensation initia- ing periodontal pocket (see Fig. 65-1). When the latter tion by the stimulation of dentin is usually fast, sharp, occurs, the resulting defect is a true combined lesion.",' 1,35 and severe and is mediated by A-delta myelinated fibers. Acute apical abscesses can extend to involve the adja- Sensation from the core of the pulp is initiated by smaller cent periodontium. The sinus tract that forms usually ex- unmyelinated C fibers. This pain has been described as tends from the apex of the tooth to the buccal [word being slower, duller, and more diffuse.27 missing]; hence, the mandible and maxillary curvature The only symptom a patient with reversible pulpitis results in thin plates of bone at these sites. Although may report is a sensitivity to hot or cold fluids. The pe- palatal or lingual tracts do occur, they occur at a much riod of discomfort is usually brief. Teeth in which the in- lower frequency than buccal tracts. During formation of flammation is confined to the pulp chamber respond a sinus tract, the patient may experience extreme pain normally to percussion and palpation. Thermal stimuli because of involvement of the periodontal ligament and or percussion applied to teeth with irreversible pulpitis the elevation of the periosteum. Perforation of the plate can provoke severe pain. This pain may be intense and is is accompanied by swelling, pus formation, and collec- commonly described as bright or throbbing. When pro- tion under the periosteum. The swelling that results can voked, a significant period and/or the use of medications lead to substantial alterations in the appearance of the may be required before the pain is ameliorated. The pro- face, as substantial volumes of pus may be confined in gression of inflammation alters the response of the tooth the lesion. Ultimately, drainage is established via a to pulp testing. If the inflammatory process extends to stoma. As long as the sinus remains open and drainage involve the periodontal ligament, then the affected occurs, the symptoms and signs may be diminished. The tooth can become tender to pressure, biting, or light tap- acute inflammatory response may then take on the char- ping with an instrument. Necrosis of the pulp can result acteristics of a chronic lesion. in bony resorption. Thus pulp death may result in radi- The endodontic sinus tract is usually a narrow, con- olucency at the apex of the tooth, in the furcation, 15,41 or stricted lesion directed from the apex of the tooth later- at points along the root (see Fig. 65-1). The ability of in- ally. In the absence of inflammatory periodontal disease, flammatory periodontal disease to affect the pulp is a tract emptying into the sulcus exerts little effect on the much less certain .8.40 Dental radiographs usually document the presence of apical or lateral lesions. However, it should be remembered that some inflamed and/or necrotic pulps are asymptomatic and the patient is unaware of their existence.

DIFFERENTIATION BETWEEN PULPAL AND PERIODONTAL ABSCESSES Periodontal abscesses (see Chapter 22) are not usually severely painful lesions. They occur in the pocket or sulcus at the level of the connective tissue attachment, so there is little or no elevation of the periosteum to cause significant pain. The patient becomes aware of a sore or tender area in the gingiva and may notice swelling of the tissues to form a lump. This area may be sensitive to touch, mastication, or toothbrushing and/or flossing. Any stimulus to the site can indeed be painful. The formation of a fistula is less common than with apical periodontitis. If a fistula does form, it may be found in both Fig. 65-2 Gutta percha point inserted into a stoma located near the gingiva and mucosa. The path of the sinus tract can the junction of the gingiva and oral mucosa on a mandibular first be determined by carefully placing a fine gutta percha molar. This molar tested nonvital.

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remainder of the sulcus. Prichard stated that the "pulpal Occasionally, an abscess of pulpal origin, through an lesion does not change its character and become mar- apical or lateral canal, may establish drainage through ginal periodontitis when it reaches the bony crest or gin- the periodontal ligament and erupt into the furcation or gival margin, and the pulp does not immediately or in- the gingival sulcus. 12,15,31,34 The signs and symptoms of evitably become infected when bone resorption from this process are identical to the initial signs and symp- marginal periodontitis reaches the apex." 31 Both en- toms of abscesses establishing a path in a more horizon- dodontic and periodontal lesions may, however, result in tal direction, with the exception that a fistula is not evi- attachment loss that affects the furcation" ,31 and/or the dent. Therefore it becomes necessary to separate the apex of the tooth. signs and symptoms of pulpal disease from those associated with a periodontal abscess. The patient's history, pe- THERAPEUTIC MANAGEMENT OF PULPAL riodontal probing, radiographs, and pulpal testing are AND PERIODONTAL DIS EASE therefore consistent with pulpal disease. Root canal treatment resolves any tract or stoma that is present. Patients with pulpal disease may have a healthy periodontium, gingivitis, or varying amounts of attachment loss (periodontitis) on the affected or adjacent teeth. A INDEPENDENT PERIODONTAL AND host of other dental problems may also exist. Therefore, ENDODONTIC LESIONS appropriate treatment varies with the presence, nature, Patients with pulpal disease may also present with in- and extent of involvement of the diseases. flammatory periodontal disease. Gingivitis or early periodontitis, other than tenderness, bleeding on brushing, ENDODONTIC LESION PRIMARY or probing, commonly results in little discomfort. Pulpal disease, however, is associated with more noxious signs Patients with pulpal disease present only diagnostic and and symptoms. The progress of periodontitis is slow, treatment decisions relative to the endodontic lesion. with the exception of acute disease such as periodontal Debridement of the pulp chamber and canal, as well as abscesses or necrotizing ulcerative gingivitis. Therefore the completion of appropriate endodontic therapy, are the prompt management of the pulpal lesion is the pri- sufficient to result in healing of the lesion (Fig. 65-3, A mary concern. Pulpal extirpation and filling of the and B). Pulpal abscesses and apical lesions generally re- canals is the proper course of therapy, since extirpation solve with conventional therapy, although apical surgery of the pulp usually leads to the elimination of the pa- may be required in certain instances. Periodontal treat- tient's acute symptoms. Although residual sensitivity to ment is not required in the absence of any periodontal percussion or movement of the tooth may persist for a involvement. period, therapy for gingivitis or early periodontitis may

Fig. 65-3 Radiographs of suspected combined lesion (pero-endo lesion) on a maxillary cuspid and lateral incisor. A, Notice the advanced bone loss on the distal of the lateral incisor and the possible extension of the apical lesion to involve the maxillary canine. B, Posttreatment response. This canine was treated by a root canal procedure only. The lesion was of pulpal origin, and repair occurred following pulp extirpation and treatment.

The Periodontic-Endodontic Continuum • CHAPTER 65 845 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com be delayed until the acute symptoms of pulpal disease sults in the resolution of the endodontic lesion. It will, are alleviated. however, have little or no effect on the periodontal pocket A different scenario may result if a patient with (see Fig. 65-5, C), and appropriate periodontal therapy chronic periodontitis experiences a loss of pulpal vitality. will be required for a successful result. 16.17.31 Such a patient may simultaneously have the clinical signs and symptoms of both periodontitis and apical pe- COMBINED LESIONS (PERIO-ENDO riodontitis. The extent to which each can affect the tooth is both independent and variable. The involve- The true combined lesion results from the development ment of the apical periodontium by a pulpal lesion may and extension of an endodontic lesion into an existing obscure the symptoms of periodontitis. Therefore the periodontal lesion (pocket) .14.31 Such lesions may present ability to determine the independence of the two lesions with the characteristics of both diseases, which may on any tooth or area is a key consideration in the se- complicate diagnosis and treatment sequencing (Fig. quence of therapy. Most commonly the lesions are inde- 65-6, A and B). A thorough history and careful clinical pendent and do not communicate (Fig. 65-4, A -D). and radiographic examinations are required to identify Rarely a patient may present with abscesses of both and accurately assess the contribution of each lesion to pulpal and periodontal origin (Fig. 65-5, A-C). As the api- the patient's dental problems and to derive a treatment cal lesion tends to be the most painful lesion, endodontic sequence that is likely to produce an optimal therapeutic therapy is normally initiated before or at the same ap- result. Usually the developing periapical lesion extends pointment at which the periodontal abscess is drained. coronally to connect with a preexisting, chronic, wide- Again, the patient's history and thorough probing allows based periodontal pocket. On rare occasions a develop- a determination of the extent of each problem and the in- ing periodontal lesion, associated with a developmental dependence of the two defects. Endodontic therapy re- groove, may extend apically to connect with an apical or

Fig. 65-4 Independent periodontal and endodontic lesions. A, Radiograph of the mandibular left molars. Note the radiographic appearance of bone loss on the first and second molars, a possible cervical enamel projection on the first molar, and a large interradicular area of reduced bone density. B, Periodontal probe inserted in buccal furcation of no. 19. Note the adjacent stoma. Observe that the sulcus depth is 3 mm at this site. C, Gutta percha point inserted into the facial stoma. D, Note the gutta percha point enters the furcation defect and extends to the apex of the mesial root of the molar. Although the molar displays signs consistent with periodontitis, the interradicular defect is purely of endodontic origin. 846 PART 5 ' Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 65-5 Independent period ontal-endodontic abscesses. A, Radiograph of a mandibular left cuspid-bicuspid area. The patient presented with a large abscess involving all three teeth. Note the signs of marginal bone loss on the teeth, along with the area of decreased bone density-at the mesial of the mandibular left first bicuspid and the apparent calcification of the pulp canals. B, Radiograph with periodontal probe inserted into the mesio-lingual sulcus. There was, however, no communication with the mesial radiolucent area. C, Radiograph taken 6 months postendodontic treatment. Note the resolution of the mesial radiolucent area. The periodontal abscess was debrided, but the residual bony deformities remain.

lateral endodontic lesion. It also has been suggested that tion of the defect commonly has plaque, calculus, if periodontitis progresses to involve a lateral canal or and/or root roughness as a finding. This contaminated the apex of a tooth, then a secondary pulpal infection root surface and the associated osseous defect is the ma- may be induced. This is referred to as retrograde pulpitis. jor complication to treatment of combined lesions. Retrograde pulpitis, if it exists, is quite rare.', 14,15,35,40 The extent to which the periodontal lesion con- The pain from the loss of pulpal vitality is the most tributes to the loss of bone is a key consideration in diag- common presenting complaint of patients with com- nosis and treatment planning. Endodontic treatment is bined lesions. The symptoms reported are those most highly predictable, and when appropriately performed, commonly found with pulpal disease. Thermal pulp test- the alterations in radiographic appearance and clinical ing provides information relative to the status of the probing disappear (Fig. 65-3). The periodontal compo- pulp, and dental radiographs can confirm the presence nent of a combined lesion is a more difficult problem. It of apical changes and the extent of bone loss. Careful cannot resolve as long as the endodontic lesion is pres- probing confirms the presence and morphology of any ent, yet effective endodontic treatment cannot elimi- periodontal pocket and permits the location of the com- nate the periodontal pocket. Even with periodontal munication with the apical lesion. The periodontal por- treatment, the periodontal defect commonly does not

The Periodontic-Endodontic Continuum • CHAPTER 65 847 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com resolve to the same extent that the endodontic lesion fect, the success of therapy likely depends on the ability does (Fig. 65-6, A and B). The ability to eliminate the pe- to fill or regenerate attachment to obliterate the defect. riodontal component of the defect ultimately dictates Therefore the decision to treat and retain teeth with treatment of the tooth. If the majority of the bony sup- combined periodontal and endodontic lesions should be port has been lost from periodontitis, regardless of the carefully considered in regard to the overall dental treat- predictability of endodontic therapy, the tooth may have ment plan as the time and cost of combined defect treat- a hopeless prognosis. ment may be considerable. Once the decision to retain the tooth is made, endodontic therapy should precede attempts at periodontal pocket elimination. 14 After successful endodontics, the POTENTIAL COMPLICATIONS TO residual periodontal pocket that remains can be more pre- ENDODONTIC THERAPY dictably treated. The periodontal therapeutic objectives As with any therapeutic modality, complications may vary with the extent and configuration of the residual pe- arise during endodontic treatment. Some are of an iatro- riodontal lesion. The elimination of etiologic factors, al- genic nature such as perforations of the floor of the pulp terations in the depth and configuration of the pocket, chamber or the root during access, canal instrumenta- and the facilitation of restorative dentistry may all be le- tion or preparation for a post (Fig. 65-7). These accidents gitimate objectives. Thus periodontal treatment may in- may result in periodontal defects, and treatment should clude scaling and root planing, as well as various surgical be instituted as soon as the perforation occurs. The heal- treatments. If the endodontic lesion requires apical ing of the lesion that occurs in the periodontium de- surgery, then the surgical treatment of both apical and pe- pends on whether bacterial infection can be excluded riodontal lesions may be accomplished simultaneously. from the wound area by obturation of the site of perforation.', " If the perforation occurs in the cervical area of PROGNOSIS OF COMBINED LESIONS the tooth, a surgical flap approach may provide sufficient access to expose the perforation and allow a suc- With proper treatment the healing of an endodontic le- cessful seal. However, because of the difficulty in sealing sion is highly predictable. However, the prognosis for a lateral perforation of the root, a guarded prognosis teeth with combined lesions varies with the extent that should be given to such a tooth. each lesion contributes to the loss of attachment. Le- Additional problems are root resorption and vertical sions resulting from pulpal disease tend to resolve with root fracture. Resorption may be of an internal or exter- endodontic therapy, whereas the repair/regeneration of nal nature. External resorption may follow impact in- attachment loss from periodontitis is less predictable. juries such as luxation or tooth avulsion and is most The long-term prognosis for a tooth with a combined le- commonly seen after reimplantation. sion is therefore closely related to the extent and config- Vertical root fractures are fractures oriented more or uration of the periodontal attachment loss. With ad- less longitudinally toward the apex of the tooth. The vanced horizontal attachment loss, even an optimal cause and prevalence of such fractures is not clearly estab- endodontic result may not be sufficient to retain the lished. However, such fractures may result during canal tooth as a functioning member of the dentition. If the obturation, pin or post placement, or cementation of in- periodontal lesion is an advanced, multiwalled bony de- tracoronal restorations.23,24 In some cases, they appear to

Fig. 65-6 Period ontal-endodontic lesion on a mandibular second molar. A, Pretreatment radiograph of a deep combination one- and two-walled bony defect on the mesial root of the second molar. Note the apparent involvement of the apex of the mesial root. B, Postendodontic therapy. The performance of the root canal has resulted in repair of the endodontic component of the defect. The periodontal component of the defect shows little change. The residual bony defect will require periodontal therapy. This is a "true" perio- endo lesion.

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Fig. 65-7 Radiograph of mandibular right molar area. Endodontic perforation into the furcation area on the mesial root of a mandibular second molar. The curvature and deep distal fluting on the mesial root of mandibular molars increases the risk of inadvertant root perforation.

Fig. 65-9 Radiographs of vertical root fracture. A, Radiograph of the mandibular right second molar in the same patient as Fig. 65-8. The bicuspid, supporting a cantilevered pontic, has an endodontic post in the root. It also has radiographic evidence of loss of periodontal attachment and widening of the periodontal ligament space. Note the apical halolike radiolucency. B, Radiograph of no. 29 taken 10 months later showing advanced attachment loss around the apical area of the root and evidence of vertical root fracture. This tooth also required extraction.

occur spontaneously. They appear to occur more commonly in teeth treated with endodontics than in nonen- dodontically treated teeth. It has been postulated that endodontic treatment may result in the teeth becoming more brittle and less resistant to forces of mastication. These fractures may occur years after endodontic treatment23 and are not readily visible in radiographs unless the fragments are separated (Fig. 65-8, A and B). It has been suggested that a thin, halolike apical radiolucency is an indication of vertical root fracture 30 (Fig. 65-9, A and B). Fractures are often inferred from symp- Fig. 65-8 Vertical root fractures. A, Radiograph of mandibular left toms of pain or tenderness on mastication or the devel- second bicuspid with a cantilevered pontic. This tooth shows evi- opment of a localized periodontal defect or sinus tract dence of periodontal attachment loss at the mesial and distal surfaces and an apparent widening of the periodontal ligament space. that cannot be explained by other clinical findings. Both B, Radiograph of the same bicuspid six months later. Note the ad- the application of an iodine stain or plaque-disclosing vanced loss of attachment and the radiographic signs of a vertical solution and indirect illumination are also useful diag- root fracture (separation of fragments). The sectioning of the nostic measures. However surgical exposure and direct bridge and removal of the tooth was required. visual examination is sometimes required to confirm the

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fracture. Vertical root fracture generally results in a hope- 15. Harrington G, Steiner D: Endodontic and periodontal inter- less prognosis for the affected root. relationships. In: Walton RE, Torabinejad M (eds): Principles and Practice of Endodontics, ed 3. Philadelphia, Saunders, 2002. RESTORATIVE IMPLICATIONS OF 16. Hiatt W: Periodontal pocket elimination by combined en- ENDODONTIC THERAPY dodontic-periodontic therapy. Periodontics 1963; 1:152. 17. Hiatt WH, Amen C: Periodontal pocket elimination by com- Ultimately, most root canal-treated teeth require restora- bined therapy. Dent Clin N Amer 1964; 9(1):133. tions. Although the initial success rate for endodontics is 18. Johnson J, Schwartz H, Blackwell R: Evaluation and restora- quite high, 36 the long-term retention and function is de- tion of endodontically treated posterior teeth. J Am Dent pendent on, to a great extent, the ability to adequately Assn 1976; 93:597. restore the tooth. Restoration is complicated by the ex- 19. Kollman W, Mijatovic E: Age dependent changes in ther- tent of crown loss from caries, fracture, and the size and moperception in human anterior teeth. Arch Oral Biol placement of the access to the pulp chamber." Addi- 1985; 30:711. tional factors are the type of restoration to be used, the 20. Langeland K, Rodriques H, Dowden W: Periodontal disease, configuration and number of the pulp canals, root form, bacteria and pulpal histopathology. Oral Surg Oral Med Oral Pathol 1974; 37(2):257. and the need for a post and core. 7,11,24,32,31 Although se- 21. Lin LB, Langeland K: Light and electron microscopic study verely decayed and/or fractured teeth can often be suc- of teeth with carious pulp exposures. Oral Surg Oral Med cessfully treated endodontically, such teeth may require Oral Pathol 1981; 51(3):292. periodontal surgery and yet be difficult or impossible to 22. Lowman JV, Burke RS, Pelleu GB: Patent accessory canals: restore. Complex interdisciplinary treatment should be incidence in moral furcation region. Oral Surg Oral Med confined to teeth that are of critical importance to the Oral Pathol 1973; 36(4):580. overall treatment plan after due consideration of alter- 23. Meister F, Lommel TJ, Gerstein H: Diagnosis and possible nate treatment methods. causes of vertical root fracture. Oral Sung Oral Med Oral Pathol 1980; 49(3):243. 24. Milot P, Stein R: Root fracture in endodontically treated REF ERENC ES teeth related to post selection and crown design. J Prosthet Dent 1992; 68:428. 1. Armitage GC, Ryder MI, Wilcox SE: Cemental changes in 25. Moller AJR, Fabricius L, Dahlen G, et al: Influence on peri- teeth with heavily infected root canals. J Endodon 1983; 9(2):127. apical tissues of indigenous oral bacteria and necrotic pulp tissue in monkeys. Scand J Dent Res 1981; 89:475. 2. Baumgartner JC: Endodontic microbiology. In: Walton RE, 26. Mumford JM: Pain perception threshold on stimulating hu- Torabinejad M (eds): Principles and Practice of Endodontics, man teeth and the histological condition of the pulp. Br ed 3. Philadelphia, Saunders, 2002. Dent J 1967; 123:427. 3. Baumgartner JC, Falkler WA: Bacteria in the apical 5 mm of 27. Nahri MVO: The characteristics of interdental sensory infected root canals. J Endodon 1991; 17(8):380. units and their responses to stimulation. J Dent Res 1985; 4. Beavers RA, Bergenholtz G, Cox CF: Periodontal wound 54:654. healing following intentional root perforation in perma- 28. Nilsen R, Johannessen AC, Skaug N, et al: In situ characteri- nent teeth of Macaca mulatta. Int J Endodont 1986; zation of mononuclear cells in human dental periapical in- 19:36. flammatory lesions using monoclonal antibodies. Oral Surg 5. Bergenholtz G, Lekholm U, Liljenberg B, et al: Morphomet- Oral Med Oral Pathol 1984; 58(2):160. ric analysis of chronic inflammatory periapical lesions in 29. Petersson K, Hasselgren G, Tronstad L: Endodontic treat- root-filled teeth. Oral Surg Oral Med Oral Pathol 1983; ment of experimental root perforations in dog teeth. Endod 55(3):295. 6. Bergenholtz G, Lindhe J: Effect of soluble plaque factors on Dent Traumatol 1986; 1:22. 30. Pitts DL, Natkin E: Diagnosis and treatment of vertical root inflammatory reaction in the dental pulp. Scand J Dent Res fractures. J Endodon 1983; 9(8):338. 1975;83:153. 31. Prichard JF, Simon P: Combined periodontal pulpal prob- 7. Brannstrom M, Lind PO: Pulpal response to early dental lems. In: Prichard JF (ed): The Diagnosis and Treatment of caries. J Dent Res 1965; 44:1045. Periodontal Disease in General Dental Practice. Philadel- 8. Czarnecki R, Schilder H: A histological evaluation of the human pulp in teeth with varying degrees of periodontal dis- phia, Saunders, 1979. ease. J Endodon 1979; 5(8):242. 32. Ross R, Nicholls J, Harrington G: A comparison of strains generated during placement of five endodontic posts. J En- 9. DeDeus QD: Frequency, location, and direction of the lateral, secondary and accessory canals. J Endodon 1975; 1:361. dodont 1991; 17(9):450. 10. Gharbia S, Haapasalo M, Shah HN, et al: Characterization of 33. Seltzer S, Bender IB, Ziontz M: Interrelationship of the pulp and periodontal disease. Oral Surg Oral Med Oral Pathol Prevotella intermedia and Prevotella nigrescens isolates from periodontal and endodontic lesions. J Periodontol 1994; 65:56. 1963; 16:1474. 34. Simon JHS, Glick DH, Frank AL: The relationship of 11. Gutmann JL: Preparation of endodontically treated teeth to receive a post-core restoration. J Prosthet Dent 1977; endodontic-periodontic lesions. J Periodontol 1972; 43:202. 38:413. 35. Simring M, Goldberg M: The pulpal pocket approach: Retro- 12. Gutmann JL: Prevalence, location and patency of accessory grade periodontitis. J Periodontol 1964; 35:22. canals in the furcation region of permanent molars. J Peri- 36. Sjogren U, Hagglund B, Sundqvist G, et al: Factors affecting odontol 1978; 49:21. the long-term results of endodontic treatment. J Endodont 13. Haapasalo M: Bacteroides spp in dental root canal infec- 1990; 16:498. tions. Endodont Dent Traumatol 1989; 5:1. 37. Sorenson J, Englemen M: Ferrule design and fracture resis- 14. Harrington GW: The perio-endo question: differential diag- tance of endodontically treated teeth. J Prosthet Dent 1990; nosis. Dent Clin N Amer 1979; 23(4):673. 63:529.

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38. Sundqvist G, Johansson E, Sjogren U: Prevalence of black RE, Torabinejad M (eds): Principles and Practice of En- pigmented Bacteroides species in root canal infections. J En- dodontics, ed 3. Philadelphia, Saunders, 2002. dodon 1989; 15(1):13. 42. Van Hassel HJ: Physiology of the human dental pulp. Oral 39. Walton RE, Garnick JT. The histology of periapical inflam- Surg Oral Med Oral Pathol 1971; 32:126. matory lesions in permanent molars in monkeys. J En- 43. Vertucci TJ, Williams RG: Furcation canals in the human dodon 1986; 12(2):49. mandibular first molar. Oral Surg Oral Med Oral Pathol 40. Torabinejad M, Kiger RD: A histologic evaluation of dental 1974; 38(2):308. pulp tissue of a patient with periodontal disease. Oral Surg 44. Yanagisawa S: Pathologic study of periapical lesions. 1. Peri- Oral Med Oral Pathol 1985; 59(2);198. apical granulomas: clinical histopathologic and immuno- 41. Torabinejad M: Pulp and periradicular pathosis. In: Walton histopathologic studies. J Oral Path 1980; 9:288. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Periodontal Plastic and Esthetic Surgery

Henry H. Takei and Robert A. Azzi

CHAPTER

CHAPTER OUTLINE

TERMINOLOGY TECHNIQUES FOR INCREASING OBJECTIVES ATTACHED GINGIVA Problems Associated with Attached Gingiva Gingival Augmentation Apical to Recession Problems Associated with a Shallow Vestibule Gingival Augmentation Coronal to Recession Problems Associated with an Aberrant Frenum (Root Coverage) ETIOLOGIC FACTORS OF MARGINAL TECHNIQUES TO DEEPEN THE VESTIBULE TISSUE RECESSION TECHNIQUES FOR THE REMOVAL OF FACTORS THAT AFFECT THE OUTCOME OF THE FRENUM PERIODONTAL PLASTIC SURGERY Frenectomy or Frenotomy Irregularity of Teeth CRITERIA FOR SELECTION OF TECHNIQUES The Mucogingival Line (Junction) SUMMARY

TERMINOLOGY Reconstruction of papillae he term mucogingival surgery was initially intro- Esthetic surgical correction around implants duced in the literature by Friedman30 to describe Surgical exposure of unerupted teeth for orthodontics surgical procedures for the correction of relation Periodontal plastic surgery is defined as the sur- ships between the gingiva and the oral mucous mem- gical procedures performed to correct or eliminate brane with reference to three specific problems: those anatomic, developmental, or traumatic deformities of associated with attached gingiva, shallow vestibules, the gingiva or alveolar mucosa. The term mucogingival and a frenum interfering with the marginal gingiva. therapy is a broader one, since it also includes nonsurgi- With the advancement of periodontal surgical tech- cal procedures such as papilla reconstruction by means niques, the scope of nonpocket surgical procedures in- of orthodontics or restorative dentistry. Periodontal plas- creased, encompassing now a multitude of areas that tic surgery includes only the surgical procedures of were not addressed in the past. Recognizing this, the mucogingival therapy. 1996 World Workshop renamed mucogingival surgery as This chapter deals only with the periodontal plastic periodontal plastic surgery, 2 a term originally proposed by surgical techniques that were traditionally included in Miller in 1993, and broadened to include the following areas1-2. the definition of mucogingival surgery-that is, widening attached gingiva, deepening of shallow vestibules; Periodontal-prosthetic corrections and resection of aberrant frena. Other aspects of peri- Crown lengthening odontal plastic surgery such as periodontal-prosthetic Ridge augmentation surgery, esthetic surgery around implants, and surgical Esthetic surgical corrections exposure of teeth for orthodontics are covered in Chap- Coverage of the denuded root surface ters 53, 70, and 74.

851

852 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com OBJECTIVES gival recession displaces the gingival margin apically, thus The three objectives of periodontal plastic surgery to be reducing vestibular depth, which is measured from the addressed in this chapter are as follows: gingival margin to the bottom of the vestibule. With minimal vestibular depth, proper hygiene procedures are jeop- 1. Problems associated with attached gingiva ardized. The sulcular brushing technique requires the 2. Problems associated with shallow vestibule placement of the toothbrush at the gingival margin, 3. Problems associated with aberrant frenum which may not be possible with reduced vestibular depth. Minimal attached gingiva with adequate vestibular depth Problems Associated with Attached Gingiva may not require surgical correction if proper atraumatic hygiene is practiced with a soft brush. Mini- The ultimate goal of mucogingival surgical procedures is mal amounts of keratinized attached gingiva with no the creation and/or widening of attached gingiva around vestibular depth usually benefit from mucogingival cor- teeth and implants .z The width of the attached gingiva rection. Adequate vestibular depth may also be necessary varies in different individuals and on different teeth of for proper placement of removable prostheses. the same individual (see Chapter 31). Attached gingiva is not synonymous with keratinized gingiva because the latter also includes the free gingival margin. Problems Associated with an Aberrant Frenum The width of the attached gingiva is determined by The final objective of periodontal plastic surgery is to cor- subtracting the depth of the sulcus or pocket from the rect frenal or muscle attachments. If there is adequate gin- distance between the crest of the gingival margin to the giva coronal to the frenum, there is usually no need to mucogingival junction. surgically remove it. A frenum that encroaches on the The original rationale for mucogingival surgery was margin of the gingiva may interfere with plaque removal predicated on the assumption that a minimal width of at- and tension on this frenum may tend to open the sulcus. tached gingiva was required for optimal gingival health to In these cases, surgical removal of the frenum is indicated. be maintained. However, several studies have challenged the view that a wide attached gingiva is more protective against the accumulation of plaque than a narrow or a ETIOLOGIC FACTORS OF MARGINAL nonexistent zone. No minimum width of attached gingiva TISSUE RECESSION has been established as a standard necessary for gingival The most common cause for these defects is abrasive and health. Persons who practice excellent oral hygiene may traumatic toothbrushing habits. Teeth positioned buccally maintain healthy areas with almost no attached gingiva. tend to have greater recession. Recession of the gingival However, those individuals whose oral hygiene prac- tissue and bone exposes the cemental surface, which al- tices are less than optimal can be helped by the presence lows abrasion and "ditching" of the cervical area. of keratinized gingiva and vestibular depth, which pro- Periodontal inflammation and the resultant loss of at- vide room for easier placement of the toothbrush and to tachment results in reduced attached gingiva. Advanced avoid brushing on mucosal tissue. To improve esthetics, periodontal involvement in areas of minimal attached the objective is the coverage of the denuded root surface. gingiva result in the base of the pocket extending close The maxillary anterior area, especially the facial aspect of to, or apical to, the mucogingival junction. the canine, often presents extensive recession. In an indi- Frenal and muscle attachments that encroach on the vidual with a high smile line, this recession may create an marginal gingiva distend the gingival sulcus, fostering esthetic defect. The coverage of the denuded root for es- plaque accumulation, increasing the rate of progression thetic purposes also widens the zone of attached gingiva. of periodontal recession, and causing their recurrence There is also a need for a wider zone of attached gingiva after treatment (Fig. 66-1, A-C). The problem is more around teeth that serve as abutments for fixed or remov- common on facial surfaces, but it may also occur on the able partial dentures, as well as in ridge areas in relation to lingual surface' (see Fig. 66-1, D). dentures. Teeth with subgingival restorations and narrow Orthodontic tooth movement through a thin buccal zones of keratinized gingiva have higher gingival inflam- osseous plate leading to a dehiscence beneath a thin gin- mation scores than teeth with similar restorations and gival tissue can cause recession and/or loss of the gingiva wide zones of attached gingiva." Therefore, in such cases, (Fig. 66-2).36,80 techniques for widening the attached gingiva are considered preprosthetic periodontal surgical procedures. Widening the attached gingiva accomplishes the fol- FACTORS THAT AFFECT THE OUTCOME OF lowing three objectives: PERIODONTAL PLASTIC SURGERY

1. Enhances plaque removal around the gingival margin Irregularity of Teeth 2. Improves esthetics Abnormal tooth alignment is an important cause of gin- 3. Reduces inflammation around restored teeth gival deformities that require corrective surgery and likewise, an important factor in determining the outcome of treatment. The location of the gingival margin, Problems Associated with a Shallow Vestibule width of the attached gingiva, and alveolar bone height Another objective of periodontal plastic surgery is the cre- and thickness are all affected by tooth alignment. On ation of some vestibular depth when this is lacking. Gin- teeth that are tilted or rotated labially, the labial bony

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Fig. 66-1 High frenum attachments. A, Frenum between maxillary central incisors. B, Frenum on the mesial surface of the maxillary second premolar. C, Frenum attached to a pocket wall on a mandibular first premolar. D, Frenum attached to a pocket wall on the lingual surface of an incisor.

plate is thinner and located farther apically than on the adjacent teeth; therefore the gingiva is recessed so that the root is exposed.$° On the lingual surface of such teeth, the gingiva is bulbous, and the bone margins are closer to the cementoenamel junction (CEJ). The level of gingival attachment on root surfaces and the width of the attached gingiva after mucogingival surgery are affected as much by tooth alignment as by variations in treatment procedures. Orthodontic correction is indicated when mucogingival surgery is performed on malposed teeth in an attempt to widen the attached gingiva or to restore the gingiva over denuded roots. If orthodontic treatment is not feasible, the prominent tooth should be reduced to within the borders of the alveolar bone, with special care taken to avoid pulp injury. Roots covered with thin bony plates present a hazard in mucogingival surgery. Even the most protective type of flap, a partial-thickness flap, creates the risk of bone resorption on the periosteal surface.38 Resorption in amounts that ordinarily are not significant may cause loss of bone height when the bone plate is thin or tapered at the crest.

The Mucogingival Line (junction) Fig. 66-2 A, Gingival recession and extreme inflammation around Normally, the mucogingival line in the incisor and ca- a lower central incisor. B, Advanced recession of mesiobuccal root nine areas is located approximately 3-mm apical to the of a first lower molar.

854 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com crest of the alveolar bone on the radicular surfaces and sired width of the attached gingiva, allowing for 50% 5-mm interdentally.69 In periodontal disease and on mal- contraction of the graft when healing is complete. The posed, disease-free teeth, the bone margin is located far- amount of contraction depends on the extent to which ther apically and may extend beyond the mucogingival the recipient site penetrates the muscle attachments. The line. The distance between the mucogingival line and deeper the recipient site, the greater is the tendency for the CEJ before and after periodontal surgery is not neces- the muscles to elevate the graft and reduce the final sarily constant. After inflammation is eliminated, there is width of the attached gingiva. The periosteum along the a tendency for the tissue to contract and draw the apical border of the graft is sometimes penetrated in an mucogingival line in the direction of the crown . 23 effort to prevent postoperative narrowing of the attached gingiva. Insert a #15 blade along the cut gingival margin and TECHNIQUES FOR INCREASING separate a flap consisting of epithelium and underlying ATTACHED GINGIVA connective tissue without disturbing the periosteum. Ex- To simplify and to better understand the techniques and tend the flap to the depth of the vertical incisions. the result of the surgery, the following classifications are If a narrow band of attached gingiva remains after the presented: pockets are eliminated, it should be left intact, and the recipient site should be started by inserting the blade at Gingival augmentation apical to the area of recession. A the mucogingival junction instead of at the cut gingival graft, either pedicle or free, is placed on a recipient bed margin. apical to the recessed gingival margin. No attempt is Suture the flap where the apical portion of the free made to cover the denuded root surface where there is graft will be located. Three to four independent gut su- gingival and bone recession. tures are placed. The needle is first passed as a superficial Gingival augmentation coronal to the recession (root cover- mattress suture perpendicular to the incision and then age). A graft (either pedicle or free) is placed covering on the periosteum parallel to the incision (Fig 66-4). the denuded root surface. Both the apical and coronal Make an aluminum foil template of the recipient site widening of attached gingiva enhance oral hygiene to be used as a pattern for the graft (see Fig. 66-3, C procedures, but only the latter can correct an esthetic and D). problem. For preprosthetic purposes, the combination Grafts can also be placed directly on bone tissue. For of widening keratinized gingiva apical and coronal to this technique, the flap should be separated by blunt dis- the recession would satisfy this objective. Considera- section with a periosteal elevator. Reported advantages of tion of the objectives as apical, coronal, or both pro- this variant are less postoperative mobility of the graft, vides a better understanding of the techniques re- and 1.5 to 2 times less quired to achieve the goals. less swelling, better hemostasis,24 shrinkage . 41,42 However, a healing lag is observed for the Widening of the keratinized attached gingiva (apical first 2 weeks. 12,15,28 or coronal to the area of recession) can be accomplished Step Two: Obtain the Graft from the Donor Site. by numerous techniques such as the free gingival auto- The classic or conventional-free gingival graft technique graft, free connective tissue autograft, and lateral pedicle consists of transferring a piece of keratinized gingiva of flap, which can be used for either objective. approximately the size of the recipient site. To avoid the large wound that this procedure sometimes leaves in the donor site, some alternative methods have been pro- Gingival Augmentation Apical to Recession posed. The original technique is described first, followed Techniques for this procedure include the following: free by several of the most common variants. For the classic gingival autograft, free connective tissue autograft, 3 and technique (see Fig. 66-3 and Color Figs. 66-1 and 66-2), a apically positioned flap partial thickness graft is used. The palate is the usual site from which donor tissue is removed. The graft should Free Gingival Autografts. Free gingival grafts are consist of epithelium and a thin layer of underlying con- used to create a widened zone of attached gingiva. They nective tissue. Place the template over the donor site (see were initially described by Bjorn' in 1963 and have been Fig. 66-3, D), and make a shallow incision around it with extensively investigated since that time. a #15 blade. Insert the blade to the desired thickness at THE CLASSIC TECHNIQUE one edge of the graft. Elevate the edge and hold it with Step One: Prepare the Recipient Site. The purpose tissue forceps. Continue to separate the graft with the of this step is to prepare a firm connective tissue bed to blade, lifting it gently as separation progresses to provide receive the graft. The recipient site can be prepared by visibility. Placing sutures at the margins of the graft incising at the existing mucogingival junction with a helps control it during separation and transfer and sim- #15 blade to the desired depth, blending the incision on plifies placement and suturing to the recipient site . 3 both ends with the existing mucogingival line (Color Proper thickness is important for survival of the graft. Figs. 66-1 and 66-2). Periosteum should be left covering It should be thin enough to permit ready diffusion of the bone. nutritive fluid from the recipient site, which is essential Another technique consists of outlining the recipient in the immediate posttransplant period. A graft that is site with two vertical incisions from the cut gingival too thin may necrose and expose the recipient site. If margin into the alveolar mucosa (Fig. 66-3). the graft is too thick, its peripheral layer is jeopardized Extend the incisions to approximately twice the de- because of the excessive tissue that separates it from new Periodontal Plastic and Esthetic Surgery • CHAPTER 66 855 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 66-3 Free gingival graft. A, Before treatment; sulcus extends into alveolar mucosa. B, Recipient site prepared for free gingival graft. C, Aluminum foil template of the desired graft. D, Template used to outline the graft in the donor site. E, Graft transferred. F, After 2 weeks. G, After 1 year, showing widened zone of attached gingiva. circulation and nutrients. Thick grafts may also create a The submucosa in the posterior region is thick and deeper wound at the donor site, with the possibility of fatty and should be trimmed so that it will not interfere injuring major palatal arteries." The ideal thickness of a with vascularization. Grafts tend to reestablish their orig- graft is between 1.0 and 1.5 mm.53 After the graft is inal epithelial structure so that mucous glands may oc- separated, remove loose tissue tabs from the undersur- cur in grafts obtained from the palate. face. Thin the edge to avoid bulbous marginal and inter- A thick graft can be thinned by holding it between dental contours. Special precautions must be taken with two wet wooden tongue depressors and slicing it longi- grafts from the palate. tudinally with a sharp #15 blade.

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cover the entire length of the recipient site (Fig. 66-5). These strips are placed side by side to form one donor tissue and sutured on the recipient site. The area is then covered with aluminum foil and surgical pack. The advantages of this technique are the rapid healing of the donor site. The epithelial migration of the close wound edges (3 to 5 mm) allows rapid epithelization of the open wound. The donor site usually does not require any suturing and heals uneventfully in 1 week. In some cases, a combination technique can be performed as follows. Remove a strip of tissue from the palate, about 3- to 4-mm thick, place it between two wet tongue depressors, and split it longitudinally with a sharp #15 blade. Both will be used as free grafts. The superficial portion consists of epithelium and connective tissue and the deeper portion consists only of connective Fig. 66-4 Diagram of graft bed suture. tissue. These donor tissues are placed on the recipient site as in the strip technique. The minimal donor site wound by obtaining two donor tissues from one site is the advantage of this technique. Step Three: Transfer and Immobilize the Graft. HEALING OF THE GRAFT. The success of the Remove the sponge from the recipient site; reapply it, graft depends on survival of the connective tissue (see with pressure if necessary, until bleeding is stopped. Re- Fig. 66-3 and Color Fig. 66-1). Sloughing of the epithe- move the excess clot. A thick clot interferes with vascu- lium occurs in most cases, but the extent to which the larization of the graft.54 connective tissue withstands the transfer to the new lo- Position the graft and adapt it firmly to the recipient cation determines the fate of the graft. Fibrous organiza- site. A space between the graft and the underlying tissue tion of the interface between the graft and the recipient (dead space) retards vascularization and jeopardizes the bed occurs within 2 to several days .67 graft. Suture the graft at the lateral borders and to the pe- The graft is initially maintained by a diffusion of fluid riosteum to secure it in position (see Fig. 66-3, E and from the host bed, adjacent gingiva, and alveolar mu- Color Figs. 66-1 and 66-2). Before suturing is completed, cosa.32 The fluid is a transudate from the host vessels and elevate the unsutured portion and cleanse the recipient provides nutrition and hydration essential for the initial bed beneath it with an aspirator to remove clots or loose survival of the transplanted tissues. During the first day, tissue fragments. Press the graft back into position and the connective tissue becomes edematous and disorga- complete the sutures. The graft must be immobilized. nized and undergoes degeneration and lysis of some of Any movement interferes with healing. Avoid excessive its elements. As healing progresses, the edema is resolved tension, which can distort the graft from the underlying and degenerated connective tissue is replaced by new surface. Every precaution should be taken to avoid granulation tissue. trauma to the graft. Tissue forceps should be used deli- Revascularization of the graft starts by the second 6 or cately, and a minimum number of sutures used to avoid third day." Capillaries from the recipient bed proliferate unnecessary tissue perforation. into the graft to form a network of new capillaries and Step Four. Protect the Donor Site. Cover the anastomose with preexisting vessels . 43 donor site with a periodontal pack for 1 week and repeat Many of the graft vessels degenerate and are replaced if necessary. Retention of the pack on the donor site can by new ones, and some participate in the new circula- be a problem. If facial attached gingiva was used, the tion. The central section of the surface is the last to vas- pack may be retained by locking it through the inter- cularize, but this is complete by the tenth day. proximal spaces onto the lingual surface. If there are no The epithelium undergoes degeneration and sloughing, open interdental spaces, the pack can be covered by a with complete necrosis occurring in some areas .13-56 It is re- plastic stent wired to the teeth. A modified Hawley replaced by new epithelium from the borders of the recipi- tainer is useful to cover the pack on the palate and over ent site. A thin layer of new epithelium is present by the edentulous ridges. fourth day, with rete pegs developing by the seventh day. VARIANT TECHNIQUES. The following variants The fact that heterotopically placed grafts maintain to the classic technique are described in this section: ac- their structure (keratinized epithelium), even after the cordion technique, strip technique, or a combination of grafted epithelium has become necrotic and has been re- both. All are modifications of the free grafts: placed by neighboring areas of nonkeratinized epithe- The accordion technique has been described by lium, suggests that there exists a genetic predetermina- Rateitschak and colleagues.61 It attains expansion of the tion of the specific character of the oral mucosa that is graft by alternate incisions in opposite sides of the graft. dependent on stimuli that originate in the connective The strip technique developed by Han and associ- tissue .44 This is the basis for the technique that uses ates37 consists of obtaining two or three strips of gingival grafts composed only of connective tissue obtained from donor tissue about 3- to 5-mm wide and long enough to areas where it is covered by keratinized epithelium. 10,22,28

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Fig. 66-5 Free gingival graft: strip technique. A-D, Mucosal tissue around implants. E and F, Recipient site prepared. G, Donor site with strips of free graft removed. H, Donor strips of free graft. I and J, Strips placed side by side on recipient site. K, Donor area one week after graft removal. L, Healing of recipient site after three months. Note good keratinized, attached gingiva.

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As seen microscopically, healing of a graft of interme- FREE CONNECTIVE TISSUE AUTOGRAFTS. The diate thickness (0.75 mm) is complete by 10.5 weeks; connective tissue technique was originally described by thicker grafts (1.75 mm) may require 16 weeks or Edel28 and is based on the fact that the connective tissue longer.33 The gross appearance of the graft reflects the carries the genetic message for the overlying epithelium tissue changes within it. At the time of transplantation, to become keratinized. Therefore only connective tissue the graft vessels are empty, and the graft is pale. The pal- from a keratinized zone can be used as a graft. lor changes to an ischemic grayish white during the first This technique has the advantage that the donor tis- 2 days until vascularization begins and a pink color ap- sue is obtained from the undersurface of the palatal flap, pears. The plasmatic circulation accumulates and causes which is sutured back in primary closure; therefore heal- softening and swelling of the graft, which are reduced ing is by first intention. There is less discomfort for the when the edema is removed from the recipient site by patient postoperatively at the donor site. In cases where the new blood vessels. Loss of epithelium leaves the graft resective flap surgery is planned for the palate, the con- smooth and shiny. New epithelium creates a thin, gray, nective tissue removed to thin the palatal flap can be veil-like surface that develops normal features as the ep- used as the graft tissue to augment areas of recession. ithelium matures. Fig. 66-6 shows a case in which the free connective tissue Functional integration of the graft occurs by the sev- graft technique was used. enteenth day, but the graft is morphologically distin- Another advantage is that better esthetics can be guishable from the surrounding tissue for months. The achieved because of a better color match of the grafted graft eventually blends with adjacent tissues, but some- tissue to adjacent areas. times, although pink, firm, and healthy, it is somewhat bulbous. The Apically Positioned Flap. This technique This ordinarily presents no problem, but if the graft uses the apically positioned flap, either partial thickness traps plaque or is esthetically unacceptable, thinning of or full thickness, to increase the zone of keratinized gin- the graft may be necessary. giva. A step-by-step description of the surgical technique Thinning the surface of the grafted tissue does reduce for apically positioned flaps is given in Chapter 61, and the bulbous condition, because the surface epithelium the procedure is shown in Fig. 66-7. tends to proliferate again. The graft should be thinned ACCOMPLISHMENTS OF THE APICALLY POSI- by making the necessary incisions to elevate it from the TIONED FLAP. The apically positioned flap opera- periosteum, removing tissue from its undersurface, and tion increases the width of the keratinized gingiva but suturing it back in place. cannot predictability deepen the vestibule with attached ACCOMPLISHMENTS OF FREE GINGIVAL GRAFTS. gingiva. Free gingival grafts effectively widen the attached gin- Adequate vestibular depth must be present before the giva. Several biometric studies have analyzed the width surgery to allow apical positioning of the flap. The edge of the attached gingiva after the placement of a free gin- of the flap may be located in three positions in relation gival graft. After 24 weeks, grafts placed on de- to the bone: nuded bone shrink 25%; whereas grafts placed on periosteum shrink 50%. 49 The greatest amount of shrinkage 1. Slightly coronal to the crest of the bone. This location at- occurs within the first 6 weeks. tempts to preserve the attachment of supracrestal The placement of a gingival graft does not, per se, im- fibers; it may also result in thick gingival margins and prove the status of the gingiva.26,27,75 Therefore the indi- interdental papillae with deep sulci and may create cation for a free gingival graft should be based on the the risk of recurrent pockets. presence of progressive gingival recession and inflamma- 2. At the level of the crest (see Fig. 66-7, C). This results in tion. When recession continues to progress after a period a satisfactory gingival contour, provided that the flap of a few months with good plaque control, a graft can be is adequately thinned. placed to prevent further recession and loss of attached 3. Two millimeters short of the crest (see Figs. 66-7, D; Fig. gingiva. 66-8). This position produces the most desirable gingi- Other materials have been used to replace gingival tis- val contour and the same posttreatment level of gin- sue in gingival extension operations. Attempts with gival attachment, as is obtained by placing the flap at lyophilized dura mater 66 and sclerall have not been satis- the crest of the bone .31 New tissue covers the crest of factory. The use of irradiated free gingival allografts the bone to produce a firm, tapered gingival margin. showed satisfactory results, 64 but further research is nec- Placing the flap short of the crest increases the risk of a essary before they can be considered for clinical use. slight reduction in bone height,21 but this is compensated Free autogenous gingival grafts have been found to be for by the advantages of a well-formed gingival margin. useful for covering nonpathologic dehiscences and fen- OTHER TECHNIQUES. The following techniques estrations. Nonpathologic refers to openings of the bone are briefly presented only because of their historical inter- through the tooth surface not previously exposed to the est. The vestibular extension technique, originally de- oral environment and found in the course of flap surgery.25 scribed by Edlan and Mejchar," produces statistically significant widening of attached nonkeratinized tissue. This The use of free gingival autografts to cover denuded increase in width in the mandibular area reportedly per- roots is described in the section entitled "Gingival Aug- sists in patients observed for periods of up to 5 years .29,65 , 76 mentation Coronal to the Recession." Currently, this technique is of historical interest only. Periodontal Plastic and Esthetic Surgery • CHAPTER 66 859 Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 66-6 Free connective tissue graft. A, Lack of keratinized, attached gingiva buccal to central incisor. B, Vertical incisions to prepare recipient site. C, Recipient site prepared. D, Palate from which connective tissue will be removed for donor tissue. E, Removal of connective tissue. F, Donor site sutured. G, Connective tissue for graft. H, Free connective tissue placed at donor site. 1, Ten days postoperative healing. 1, Final healing at 3 months. Note wide keratinized, attached gingiva.

The fenestration operation was designed to widen the tion. Its purpose is to create a scar that is firmly bound to zone of attached gingiva with a minimum loss of bone the bone." It prevents separation from the bone and height.62.63 It has also been called periosteal separation. 19 it postsurgical narrowing of the attached zone. Results ob- used a partial thickness flap, except in a rectangular area tained with this technique are not as predictable as with at the base of the operative field, where the periosteum is the free gingival graft; therefore it is not widely per- removed, exposing the bone. This is the area of fenestra- formed except for small, isolated areas. 860 PART 5 • Treatment o f Periodontal Disease Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 66-7 Apically positioned partial-thickness flap. A, Internal bevel incision (1) separates inner wall of periodontal pocket. MG, Mucogingival junction; V, vestibular fornix. B, Partial-thickness flap (F) separated, leaving periosteum and a layer of connective tissue on the bone. The inner wall of the periodontal pocket (I) is removed, and the tooth is scaled and planed. C, Partial-thickness flap (F) positioned apically with the edge of the flap at the crest of the bone. Note that the vestibular fornix is also moved apically. D, Partial-thickness flap (F) displaced apically with the edge of the flap several millimeters below the crest of the bone.

Gingival Augmentation Coronal to Recession the outcome of therapy. The predictability of root cover- (Root Coverage) age can be enhanced by the presurgical examination and the correlation of the recession by using the classifica- The understanding and knowledge of the different stages tion proposed by Miller." The following is his classifica- and condition of gingival recession is necessary for tion (Fig. 66-9): predictable root coverage. Several classifications of denuded roots have been proposed. In the 1960s, Sullivan Class I. This includes marginal tissue recession that does and Atkins" classified gingival recession into four mor- not extend to the mucogingival junction. There is no phologic categories: 1) shallow-narrow, 2) shallow-wide, loss of bone or soft tissue in the interdental area. This 3) deep-narrow, and 4) deep-wide. type of recession can be narrow or wide. This early classification was helpful to better catego- Class II. Class II consists of marginal tissue recession that rize the lesion but did not enable the clinician to predict extends to or beyond the mucogingival junction.

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Fig. 66-8 Apically positioned partial-thickness flap. A, Before treatment, the base of pocket extends to the mucogingival line. B, Mucosal flap separated from the periosterum; teeth scaled and smoothed. C, Flap replaced below the crest of the bone. D, Eight months after treatment. Note the shallow sulcus and the widened zone of attached gingiva. Compare with A.

There is no loss of bone or soft tissue in the interden- Some of the techniques used for widening the at- tal area. This type of recession can be subclassified tached gingiva apical to the area of recession can also be into wide and narrow. used for root coverage. Both the free gingival and con- Class III. In Class III, there is marginal tissue recession nective tissue autografts used for apical widening can be that extends to or beyond the mucogingival junction; used for coronal augmentation by incorporating some in addition, there is bone and/or soft tissue loss inter- modifications. In using the free grafts for root coverage, dentally or there is malpositioning of the tooth. the recipient bed surrounding the denuded root surface Class IV. There is marginal tissue recession that extends must be extended wider to allow for better blood supply to or beyond the mucogingival junction with severe to the donor free graft since a portion of the donor tissue bone and soft tissue loss interdentally and/or severe overlies the root surface that has no blood supply. tooth malposition. Prognosis. In general, the prognosis for Classes I and II is Free Gingival Autograft. In the last decade, suc- good to excellent; whereas for Class III, only partial cessful and predictable root coverage has been reported coverage can be expected. Class IV has a very poor using free gingival autografts.51 prognosis with present-day techniques. THE CLASSIC TECHNIQUE. Miller52 applied the classic free gingival autograft described previously with a The following is a list of techniques used for gingival few modifications. The technique is as follows: augmentation coronal to the recession (root coverage): Step One: Root Planing. Root planing is performed, with application of saturated citric acid for 1. Free gingival autograft 5 minutes with a cotton pledget, burnishing it on the 2. Free connective tissue autograft root. The advantage of citric acid application has not 3. Pedicle autografts been confirmed by other studies." • Laterally (horizontally) positioned Step Two: Prepare the Recipient Site. Make a horizon- • Coronally positioned tal incision in the interdental papillae at right angles to cre- • Semilunar pedicle (Tarnow) ate a margin against which the graft may have a butt joint 4. Subepithelial connective tissue graft (Langer) with the incision. Vertical incisions are made at the proxi- 5. Guided tissue regeneration mal line angles of adjacent teeth, and the retracted tissue is 6. Pouch and tunnel technique excised. Maintain an intact periosteum in the apical area.

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Fig. 66-10 Laterally positioned flap for coverage of denuded root. Top, Incisions removing the gingival margin around the exposed root and outlining flap. Bottom, After the gingiva around exposed root is removed, flap is separated, transferred, and sutured.

Step Four: Obtaining the Graft. From the palate, obtain a connective tissue graft. The donor site is sutured after the graft is removed. Step Five: Transferring the Graft. Transfer the graft to the recipient site and suture it to the periosteum with gut suture. Good stability of the graft must be attained with adequate sutures. Fig. 66-9 P. D. Miller's classification of denuded roots. Step Six: Covering the Graft. Cover the grafted site with dry aluminum foil and periodontal dressing.

Pedicle Autograft Steps Three and Four. Refer to the step-by-step LATERALLY (HORIZONTALLY) DISPLACED. This technique described for the classic gingival graft earlier technique, originally described by Grupe and Warren in in this chapter. 1956,35 was the standard technique for many years and is This technique results in predictable coverage of the still indicated in some cases. The laterally positioned flap denuded roots but may present esthetic color discrepan- can be used to cover isolated, denuded roots that have cies with the adjacent gingiva due to a lighter color. adequate donor tissue laterally and vestibular depth. The following is a step-by-step procedure for this technique. Free Connective Tissue Autograft. This tech- Step One: Prepare the Recipient Site. Make an in- nique was described by Levine in 1991. 46 The difference cision, resecting the gingival margin around the exposed between this technique and the previous one is that the roots (Figs. 66-10 and 66-11). Remove the resected soft tis- donor tissue is connective tissue. It consists of the fol- sue and scale and plane the root surface (see Fig. 66-11, C). lowing steps (see Fig. 66-6). Step Two: Prepare the Flap. The periodontium of CONNECTIVE TISSUE TECHNIQUE the donor site should have a satisfactory width of at- Step One: Divergent Vertical Incisions. Divergent tached gingiva and minimal loss of bone and without vertical incisions are made at the line angles of the tooth dehiscences or fenestrations. A full-thickness or partial- to be covered, creating a partial-thickness flap to at least thickness flap may be used, but the latter is preferable 5 mm apical to the receded area. because it offers the advantage of more rapid healing in Step Two: Suturing. Suture the apical mucosal the donor site and reduces the risk of loss of facial bone border to the periosteum using gut suture. height, particularly if the bone is thin or the presence of Step Three: Scaling and Planing. Thoroughly a dehiscence or a fenestration is suspected. However, if scale and plane the root surface, reducing any promi- the gingiva is thin, partial thickness may not be suffi- nence of the root surface. cient for flap survival. Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com

Fig. 66-11 Horizontally displaced flap combined with relocation of frenum attachment. A, Gingival defect of central incisor. B, Defect incised. C, Gingiva removed and tooth scaled and planed. D, Vertical incision on the canine for sliding flap. E, Sliding flap detached. Note high frenum attachment between the central incisors. F, Frenum detached and resected to level of vestibular fornix. G, Sliding flap positioned laterally on central incisor and fixed lateral and suspensory suture. H, One week after operation. Sutures to be removed. I, Five weeks after operation. j, Seven years after treatment. Note the preservation of gingival position and contour.