General principles of periodontal instrumentation

This chapter focuses on the principles of periodontal instrumentation including scaling and root planing. Effective instrumentation is governed by a number of general principles that are common to all periodontal instruments. Proper position of the patient and the operator, illumination and retraction for optimal visibility and sharp instruments are the fundamental prerequisites. This chapter covers the accessibility (positioning of patient and operator), visibility, illumination and retraction, condition of instruments (sharpness), maintaining a clean field, instrument stabilization, instrument activation, principles of scaling and root planing, ultrasonic instruments, and aerosol production. Scaling is the process by which plaque and calculus are removed from both supragingival and subgingival tooth surfaces. Root planing is the process by which residual embedded calculus and portions of cementum are removed from the roots to produce a smooth, hard, clean surfaceThis chapter focuses on the principles of periodontal instrumentation including scaling and root planing. Effective instrumentation is governed by a number of general principles that are common to all periodontal instruments. Proper position of the patient and the operator, illumination and retraction for optimal visibility and sharp instruments are the fundamental prerequisites. This chapter covers the accessibility (positioning of patient and operator), visibility, illumination and retraction, condition of instruments (sharpness), maintaining a clean field, instrument stabilization, instrument activation, principles of scaling and root planing, ultrasonic instruments, and aerosol production. Scaling is the process by which plaque and calculus are removed from both supragingival and subgingival tooth surfaces. Root planing is the process by which residual embedded calculus and portions of cementum are removed from the roots to produce a smooth, hard, clean surfaceThis chapter focuses on the principles of periodontal instrumentation including scaling and root planing. Effective instrumentation is governed by a number of general principles that are common to all periodontal instruments. Proper position of the patient and the operator, illumination and retraction for optimal visibility and sharp instruments are the fundamental prerequisites. This chapter covers the accessibility (positioning of patient and operator), visibility, illumination and retraction, condition of instruments (sharpness), maintaining a clean field, instrument stabilization, instrument activation, principles of scaling and root planing, ultrasonic instruments, and aerosol production. Scaling is the process by which plaque and calculus are removed from both supragingival and subgingival tooth surfaces. Root planing is the process by which residual embedded calculus and portions of cementum are removed from the roots to produce a smooth, hard, clean surfaceThis chapter focuses on the principles of periodontal instrumen

1. PRINCIPLES OF PERIODONTAL SURGERY

2. CONTENTS INTRODUCTION OUTPATIENT SURGERY HOSPITAL PERIODONTAL SURGERY SURGICAL INSTRUMENTS CONCLUSION REFERENCES

3. INTRODUCTION Main objective of the periodontal surgery is to contribute to the long term preservation of the periodontium by facilitating plaque removal and its control. All the surgical procedures should be carefully planned. The patient should be adequately prepared medically, psychologically, and practically, for all the aspects of innervation.

4. OUTPATIENT SURGERY

5. Outpatient Surgery Re-evaluation After Phase I Therapy :- Almost every patient undergoes the so-called initial or preparatory phase of therapy, which basically consists of thorough scaling and root planing and the removing of all irritants responsible for the periodontal inflammation

6. PREMEDICATION Ariaudo & Pendrill have reported reduced postoperative complications, including reduced pain and swelling, when antibiotics are given before periodontal surgery and continued for 4 to 7 days after surgery. The prophylactic use of antibiotics in patients who are otherwise healthy has been advocated for regenerative procedures.

7. SMOKING The deleterious effect of smoking on the healing of periodontal wounds has been amply documented. Patients should be clearly informed of this fact and asked to quit smoking completely or to stop smoking for a minimum of 3 to 4 weeks after the procedure. For patients who are unwilling to follow this advice, an alternate treatment plan that does not include complicated techniques (e.g., regenerative, mucogingival, aesthetic)

8. INFORMED CONSENT The patient should be informed at the initial visit regarding the diagnosis, prognosis, and recommended treatment options including explanations about expected outcomes. The pros and cons of each approach should be discussed, and the patient should be encouraged to ask questions. Should sign the written consent form.

9. Emergency Equipment The clinician, all assistants, and office personnel should be trained to handle all possible emergencies that may arise. Drugs and equipment for emergency use should be readily available at all times.

10. Basic principles of management of medical emergencies The golden rule in managing any emergency is rendering basic life support (BLS) measures and cardiopulmonary resuscitation (CPR)

11. PREVENTION OF MEDICAL EMERGENCIES The physical examination of the patient and assessment of previous medical history are essential to prevent emergencies. With careful planning of emergency protocol with team approach and theoretical and practical training in effective expired air resuscitation….

12. Measures to Prevent Transmission of Infection The danger of transmitting infections to the dental team or to other patients is an important precaution that must be a part of every appointment in the dental office….AIDS and hepatitis B virus infection. Universal precautions (e.g., protective attire ) and barrier techniques must be incorporated into the surgical protocol of every procedure.

13. These include the use of disposable sterile gloves, surgical masks, and protective eyewear. Gloves are used during any dental work, for a single patient only and, afterwards, they are removed and discarded. In patients with confirmed HIV or HBV and HCV infection, it is recommend that double gloves are used for the protection of the surgeon.

14. During the examination or any dental work, an appropriate mask and eye protectors are necessary. In case the dental patient suffers from an airborne disease (tuberculosis), the mask must be enhanced and fully adaptable to the wearer’s face. Eye protectors may include various types of glasses or plastic masks or shields made of transparent material.

15. All surfaces that may be contaminated with blood or saliva and cannot be sterilized (e.g., light handles, unit syringes) must be covered with sterile aluminum foil or plastic wrap.

16. Aerosol-producing devices (e.g., ultrasonic scalers) should not be used on patients with suspected infections, and their use should be kept to a minimum in all other patients. Special care should be taken when using of sharp items. Used needles must not .. . . The 'one hand ' technique to recap the needle or a mechanical means designed to hold the cap should always be used.

17. SEDATION AND ANESTHESIA Pain control in periodontal surgery is important. Most procedures should either be painless or minimally painful Painless surgery [local anesthesia]

18. The area to be treated should be thoroughly anesthetized by means of regional block and local infiltration. Injections directly into the interdental papillae may also be helpful

19. Apprehensive and neurotic patients may require special management with antianxiety or sedative–hypnotic agents The simplest, least invasive method to alleviate anxiety in the dental office is nitrous oxide and oxygen inhalation sedation. For individuals with mild to moderate anxiety, oral administration of a benzodiazepine .

20. Oral administration of a sedative agent can be more effective than inhalation anesthesia because the level of sedation achieved may be more profound.

21. Tissue Management 1. Operate gently and carefully 2. Observe the patient at all times 3. Be certain that the instruments are sharp

22. SCALING AND ROOT PLANING Although scaling and root planing have been performed previously as part of phase I therapy, all exposed root surfaces should be carefully explored and planed as needed during the surgical procedure. In particular, areas of difficult access, such as furcations or deep pockets.

23. HEMOSTASIS Hemostasis is an important aspect of periodontal surgery Good intraoperative control of bleeding permits accurate visualization of the extent of disease, the pattern of bone destruction, and the anatomy and condition of the root surfaces.

24. Excessive hemorrhaging after initial incisions and flap reflection may be caused by the laceration of venules , arterioles, or larger vessels. Proper design of the flaps that takes these areas into consideration will help avoid these accidents. Minor areas of persistent bleeding from capillaries can be stopped by applying cold pressure to the site with moist gauze for several minutes

25. The use of a local anesthetic with a vasoconstrictor (epinephrine) may also be useful for controlling minor bleeding from the periodontal flap. For a slow, constant blood flow and for oozing, hemostasis may be achieved with hemostatic agents. Absorbable gelatin sponge ( Gelfoam ) Oxidized cellulose ( Oxycel ) Oxidized regenerated cellulose ( Surgicel Absorbable Hemostat) Microfibrillar collagen hemostat ( Avitene , CollaCote , CollaTape , CollaPlug )

26. Finally, it is imperative to recognize that excessive bleeding may be caused by systemic disorders. . . All patients, regardless of health history, should have their blood pressure evaluated before surgery, and anyone who is diagnosed with hypertension must be advised to see a physician before surgery. Patients with known or suspected bleeding deficiencies or disorders must be carefully evaluated before any surgical procedure

27. PERIODONTAL DRESSINGS The Periodontal Dressing is a physical barrier that is placed in the surgical site to protect the healing tissues from the forces produced during mastication for comfort and close adaptation.

28. Eugenol dressings The Wondrpak was the first periodontal dressing introduced containing eugenol. It was a 2-component system comprising :- POWDER & LIQUID . Mixing… The dressing may be used immediately or wrapped in aluminum foil and refrigerated for use for up to 1 week

29. Role of Eugenol : - Eugenol-based dressings were formerly popular, especially following gingivectomy , due to their property of obtunding pain and rendering sites less sensitive. Waerhaug & Loe commented . . . However, eugenol was found to irritate oral mucosal tissues, induce allergic reactions and cause tissue necrosis, particularly of bone, which led to delay in healing ( Sarrami et al) Kreth & Rivera- Hidalgo et al based on the Histological evidence has also shown that eugenol-containing dressings produce greater tissue destruction, with more inflammatory cell infiltration and connective tissue response.

30. Noneugenol dressings :- Noneugenol dressings are currently the most widely used periodontal dressings. COE-PAK : -Coe-Pak is the most widely used noneugenol intraoral dressing manufactured by Coe Laboratories (Alsip, IL, USA).

31. Preparation and Application of Dressing The Coe-Pak is prepared by mixing equal lengths of paste from tubes that contain the accelerator and the base until the resulting paste is a uniform color.

32. Continuous pack covers the edentulous space.

33. The dressing should cover the gingiva, but overextension onto uninvolved mucosa should be avoided. Excess dressing irritates . . . . Dressing that interferes with the occlusion should be removed before the patient is dismissed. If the dressing is lost from the operated area and the patient is uncomfortable, it is usually best to redress the area

34. POST OPERATIVE INSTRUCTIONS :- We have placed a periodontal pack over your gums to protect them from irritation. The pack should remain in place until it is removed in the office at the next appointment. For the first 3 hours after the operation, avoid hot foods to permit the pack to harden. Do not smoke. Do not brush over the pack. During the first day, apply ice intermittently on the face over the operated area.

35. Findings at the Time of Dressing Removal If gingivectomy has been performed, the incised surface is covered with a friable meshwork of new epithelium. This tissue should not be disturbed. After a flap operation , the areas that correspond to the incisions are epithelialized, but they may bleed readily if irritated.

36. Redressing After the dressing is removed, it is usually not necessary to replace it. However, redressing for an additional week is advised for the following types of patients:- (1) Those with a low pain threshold who are particularly uncomfortable when the dressing is removed (2) Those with unusually sensitive root surfaces postsurgically (3) Those with an open wound where the flap edges have necrosed

37. TREATMENT OF SENSITIVE ROOTS Dentin or root hypersensitivity is a relatively common problem in periodontal practice. It may occur spontaneously when the root becomes exposed as a result of gingival recession or pocket formation, or it may appear after scaling and root planing and other periodontal surgical procedures.

38. Desensitizing Agents Numerous agents have been proposed to control root hypersensitivity. According to Trowbridge and Silver this can be attained in the following ways: (1) By the formation of a smear layer produced by burnishing the exposed surface (2) The topical application of agents that form insoluble precipitates within the tubules (3) With the impregnation of tubules with plastic resins, or (4) By sealing the tubules with plastic resins

39. CLASSIFICATION OF DESENSITIZING AGENTS I. Mode of administration At home desensitizing agents In-office treatment II. On the basis of mechanism of action i) Nerve desensitization Potassium nitrate ii) Protein precipitation Gluteraldehyde Silver nitrate Zinc chloride Strontium chloride hexahydrate

40. Plugging dentinal tubules Sodium fluoride Stannous fluoride Dentine adhesive sealers Fluoride varnishes Oxalic acid and resin Glass ionomer cements Composites Dentin bonding agents Lasers Neodymium:yttrium aluminum garnet ( Nd –YAG) laser GaAlAs ( galium – aluminium –arsenide laser) Erbium–YAG laser Homeopathic medication Propolis

41. The American Dental Association : Sensodyne and Thermodent , which contain strontium chloride; Crest Sensitivity Protection, Denquel , and Promise, which contain potassium nitrate; and Protect, which contains sodium citrate.( Blitzer & Collins et al) Low-level laser “melting” of the dentin surface appears to seal dentinal tubules without damage to the pulp. Mc Carthy et al proposed that lasers coagulate the proteins inside the dentinal tubules and block the movement of fluid

42. MANAGEMENT STRATEGY Take a detailed clinical and dietary history. Differentially diagnose the condition from other dental pain conditions such as caries, cracked tooth, and other pulpal problems Identify and manage etiological and predisposing factors In case of mild-to-moderate sensitivity . . . If there is no relief or in case of severe sensitivity. . . . In extreme cases . . . .

43. Hospital Periodontal Surgery For most patients, periodontal surgical procedures are managed well in the dental office with local anesthesia only or with some form of sedation and are performed in quadrants or sextants, usually at biweekly or longer intervals. However, certain patients and procedures warrant treatment in the hospital operating room with general anesthesia

44. Indications (1) Optimal control and management of patients with severe anxiety and apprehension (2) Optimal safety for individuals who cannot endure multiple or extensive visits to complete surgical treatment, and perhaps most importantly (3) Optimal medical management of older and severely debilitated or medically compromised patients

45. SURGICAL INSTRUMENTS 1. Excisional and incisional instruments 2. Surgical curettes and sickles 3. Periosteal elevators 4. Surgical chisels 5. Surgical files 6. Scissors 7. Hemostats and tissue forceps

46. Periodontal Knives:- 1) The Kirkland knife Interdental Knives:- The Orban knife & Merrifield knife Surgical Blades:-

47. Surgical Curettes and Sickles :- The Prichard curette and the Kirkland surgical instruments are heavy curettes, whereas the Ball scaler is a popular heavy sickle. Periosteal Elevators :- The Woodson and Prichard elevators are well-designed periosteal instruments.

48. Surgical Chisels :- Scissors and Nippers :- Needle Holders :-