Therapy - Periodontology
A diagnosis of the periodontal abnormalities can be made on the basis of the history and the findings from the clinical and X-ray examinations. Once the diagnosis has been made, a prognosis can be made. This is a forecast for the future of the state of the periodontium.
The main cause of periodontal disease is dental plaque. After examining and explaining to the patient, work is first done on reducing the plaque through extensive dental cleaning and oral hygiene instruction. In addition, acute problems are treated and a start is made with the elimination of plaque retention sites. This first phase usually consists of several treatment sessions. The initial treatment consists of the components described below.
- Treatment of acute complaints (eg periodontal abscess or an endodontic problem).
- Removal of overhanging restoration edges. Overhang of fillings and crowns increases plaque retention. These areas can often be corrected by grinding. Sometimes a new restoration must be made.
- Caries, where acute, is treated.
- Extraction of teeth to be considered as lost. If the prognosis of an element is very poor, it is often better to extract it in advance.
- Oral hygiene instruction tailored to the individual patient. The periodontal treatment stands or falls with the extent to which the patient manages to control the plaque himself. The patient is taught a brushing method and aids are recommended for interdental cleaning. This also includes the cleaning of removable prostheses.
- Plaque index and bleeding index to motivate the patient.
- Cleaning of teeth. This involves the mechanical removal of tartar and plaque and the polishing of the teeth.
For the removal of tartar, an ultrasonic tartar removal device or manual instrumentation can be used.
With ultrasonic tartar removal, the tip of the instrument is brought into a high-frequency vibration. As a result, the tartar is knocked off the tooth surface as it were. This causes a vibrating feeling in the patient. A lot of heat is released by the vibrations. The instrument is therefore water cooled. This has the advantage that the work site is always cleaned and kept clear. The cooling water is extracted. Large quantities of tartar can be removed quickly with ultrasonic equipment.
For precise removal of tartar, in particular subgingival, manual instruments are usually used. With scalers and curettes, tartar and plaque are scraped from the tooth surface (see images below).
Hand tools for tartar removal: a scaler; b curette for the front; c curette for lateral parts.
Cross sections of the leaf of a scaler (left) and of a curette (right).
The following terms are important when cleaning teeth.
- Scaling is the removal of supra and subgingival tartar. Scaling is a difficult and time-consuming treatment that must be done systematically and efficiently. Small residues of tartar that serve as the basis for a new deposit must also be removed from both the crown surface and the root surface. Scalers are used for the removal of supragingival tartar, curettes especially for subgingival cleaning.
- Rootplaning is the smoothing of the root surface and rid this surface of necrotic (dead) cement. A smooth root surface reduces the retention of dental plaque and a new gingiva attachment can occur. Furcations that are accessible through or are accessible are also cleaned as well as possible using curettes and / or furcation files.
- Polishing the teeth. The glaze and the surface of the root, which may be exposed by the gingiva defect, are smoothly polished. Polishing removes small irregularities, such as smoke or tea deposits and leftover plaque. The retention for plaque is therefore reduced. Polishing pastes use polishing pastes, pumice or a fluoride paste. These are applied to the element with a rubber cup or brush, which is mounted in a slowly rotating corner piece.
Tartar instruments must have the correct blade angles and be sharp to be able to clean effectively and not to damage the tooth surface. This is checked before treatment. If necessary, the instruments can be sharpened with a flat Arkansas stone or with a grinder. When using an Arkansas brick, some paraffin oil is applied to the flat brick and the curettes and scalers are ground by grinding the lateral parts (and sometimes also the top) of the blade. It is important that the original shape of the instrument does not change. The instrumentation can be fixed in a vice during grinding. The instruments can be sharpened easily with an electric grinder. The instrument is fixed in the device, the correct sharpening angle is set and the instrument can then be sharpened (see images below).
Synthetic resin rod for testing the sharpness of instruments, flat sharpening stone and bottle of oil for sharpening tartar instruments (and enamel knives).
Sharpening a curette with an Arkansas stone.
A reassessment takes place after the initial treatment. A definitive treatment plan can be drawn up following the reassessment. The effect of dental cleaning and oral hygiene of the patient is examined. Depending on the oral hygiene and the depth of the pockets, the final plan can consist of three, four or six-month inspection appointments. During these sessions, dental cleaning by the dentist or dental hygienist takes place and oral hygiene is evaluated. If this is necessary, the restorative or prosthetic follow-up treatment can now also start.
If it appears during the initial treatment that the dental hygienist has not been able to clean the pockets sufficiently, periodontal surgery may be advised. This is for example the case with furcation problems, large depth of the pockets, an unfavorable shape of the element or poor restorations deep under the gums. In these situations it is of course impossible for the patient to keep his mouth clean.
The purpose of periodontal surgery is:
- Make subgingivally located root surfaces accessible for professional dental cleaning;
- Creating a situation in the mouth that the patient can maintain.
The two most commonly used surgical techniques for the treatment of periodontal disease are gingivectomy and flap surgery, possibly combined with bone correction.
Gingivectomy is applied to supra-alveolar and pseudopockets. The gingiva is cut away to the bottom of the pocket. The amount of gums to be removed is indicated with a pocket marker. The pocket marker is brought to the bottom of the pocket with one leg, while the other leg makes a marker point in the gingiva at the same height. The excess gingiva tissue is cut away with special gingivectomy knives or with a scalpel knife. After this, the visible root surface can be freed from plaque, tartar and inflammatory tissue. A better view of the work area can therefore be obtained through surgical treatment. It is sometimes difficult to get into deep pockets with curettes.
A wound dressing is applied after cleaning the root surface. This is a putty-like material that hardens somewhat after application and protects the wound during the first few days. It is then deleted. After a week, the gums are usually completely recovered. The teeth have become longer, but there are no more pockets and the whole is now easier to maintain (see image below).
Gingivectomy, only possible with a supra-alveolar pocket. Gums that are not supported by jaw bone are cut away at an angle of 45 °. With a pocket marker the depth of the pocket on the gingiva is made visible.
The flap operation is used to reduce deep inflamed pockets. The technique is used in particular in infra-alveolar pockets, in bone craters and in advanced furcation disorders. During the flap operation, a tissue patch is detached from the underlying bone on the buccal and / or lingual (palatinal) side of a dental element and the patch is shifted to apical. The tissue patch is held in place with a gauze or breed paratorium. Shearing gives a good view of the periodontium. Any bone craters and tartar, plaque, inflammatory tissue on deeper root portions become visible. If bone craters are present, they can be corrected with a nibbling pliers, with a small cutter or with a round steel drill mounted in a slowly rotating corner piece with water cooling. The root surface can be made clean and smooth with a scaler or curette. The tissue flaps are either shortened or thinned, put back against the bone surfaces and sutured. A wound dressing is then applied, which must remain in place for a few days. Healing usually occurs within two weeks.
General contraindications in periodontal surgery are smoking and poor oral hygiene. When surgery is started in a non-plaque-free mouth, increased tissue breakdown occurs.
There is an increasing tendency in dentistry to limit the treatment of periodontal disorders in the first instance to good patient motivation and optimum dental cleaning by removing retention factors such as tartar and so on. Good results are achieved with this. Periodontal surgery is only used to a limited extent. Mainly to get a better overview of the operating area and to eliminate deep inflamed pockets or bone craters (see image below).
Flap operation: a vertical incision; b folding and sliding the mucosa; c removal of inflamed gums and bone, rootplaning; d the shortened piece has been folded back and a wound dressing has been applied.