Perio Sheet #2 By Lana Obeidat

by **Sura** 1/10/2012, 12:24 am

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by **Shadi Jarrar** 12/11/2012, 9:15 pm

- The most common cause of gingivitis and periodontitis is plaque

- If gingivitis is left untreated it turns to periodontitis

- We have different types of gingivitis: plaque induced chronic gingivitis, non-plaque induced gingivitis

- Signs and symptoms of gingivitis are: bleeding upon probing, redness and swelling

- Periodontitis has the same symptoms plus pocketing

- When you are talking about pocketing you have to be specific and talk about : true pocketing depth ( aka: true pocket) this is about periodontitis , not pseudo pockets

- Not every enlargement associated with gingivitis is resilient , because in long standing gingivitis the resilient tissues turn to fibrotic

- Some patients take certain types of drugs that cause the gingival enlargement to be fibrotic

- Treatment of gingivitis is scaling, polishing and oral hygiene instructions

- Treatment of periodontitis is same as gingivitis : scaling, polishing and OHI , then we reach the pocketing which needs certain measurements

- Treatment of periodontitis depends on the depth of the pocket , if the pocket depth is less than (5 mm) will resolve when treated with scaling and polishing and OHI and root planning , if more than that it indicates resorption of the bone

- Resilient means: amenable to treatment

Lecture topic : the treatment of tissues that had undergone enlargement and became Fibrotic

Patients may present with :

- Gingivitis with fibrotic tissues

- Drug induced enlargement

The fibrotic gingiva ( non-resilient ) cannot be treated with OHI, scaling and polishing only, the problem will not resolve after 2 weeks of this treatment so we turn into other options

Gingivectomy : the excision of excess gingiva from the gingival margin

once we do gingivectomy we have to restore the contour and shape of the gingiva into its original state so it cannot be done haphazardly

Gingivoplasty : restore shape and contour of the gingiva to its original state following the CEJ

Soft Tissue management

Indications: when to decide to do gingivectomy to the patient

1. Gingival enlargement or other gingival growth elicited by phenytoin as an example ( we have other drugs such as channel blockers such as nifedipine “adalap”, sodium dilantine “tegretol “ for epilepsy

Because tissues grow in fibrotic texture ( they do not change )

We have to treat those because it hampers on the esthetics, Oral hygiene..etc

2. Idiopathic gingival fibromatosis.

3. Pseudo-pockets; not all pseudo pockets have to be excised ( the resilient ones can be left without excision it can be treated with good oral hygiene )

Here we mean the pseudo pockets associated with fibrotic gingival enlargement

4. Shallow supra-bony pockets: shallow gingival enlargement not amenable to treatment

Such as cases with periodontitis with 5 mm pocket depth ( aka : does not have bone resorption ).

we treat it with OH, scaling, polishing and root planning, curettage but it does not resolve, we give the patient antibiotics for anaerobic the bacteria that is involved but it also does not resolve, we cannot leave it as a pocket because food will accumulate in it along with bacteria and cause infra bony pocket , ie. It will destruct the environment around it , so we have to eliminate it with gingivectomy

5. Areas with difficult access. Ex; class 5 caries extended beyond the marginal gingival ( sub-gingival) so we do gingivectomy to reach the unexposed area to treat the tooth

6. Minor connective procedure. ( pulp polyp removal)

Contra-indications:

- The attached gingival extends from muco-gingival line to the gingival margin

1. Narrow or absent attached gingiva. Mainly in the ant region.

If we didn’t have sufficient attached gingival ( width and height ) and we cut anyway the roots will be exposed! Highly unaesthetic and highly contraindicated

2. Infra-bony pockets, We’ll end up with exposing roots and alveolar bone

3. Thickening of marginal alveolar bone: when you see a thickened gingival and after palpating you notice that the reason behind the thickening is bone ( we will expose bone and this will cause alveolitis) : in this case we do not do gingivectomy, instead we do a flap > reduction of the thickness of the alveolar bone on a specific tooth where the gingiva appears thickened and we do osteoplasty with a bur , we remove bone until the area is similar to its adjacent areas and we close)

Advantages:

1. technically simple and good visual access , root planning where you don’t see the root is somewhat harder than doing a procedure where everything is exposed to you

2. Complete pocket elimination: if infra bony pocket is present and we do gingivectomy we remove the supra bony pocket completely

3. Predictable results: since we can see the whole defect then we are in total control of the outcome , ie. We reach every part that needs to be reached and excised and we don’t miss accidentally and area as what can be done with root planning

Principles of operation :

1. Continuous incision at 45 degree angle to the base of the pocket. The blade direction is apically along the long axis of the root to restore the contour ( the bevel ) of the gingiva.

2. Sharp dissection of tissues in the inter dental area

3. smoothening of the incision edge ( no one has an artistic hand that can allow him to do one cut , elevations, stopping and irregularities are bound to happen)

4. scaling and root planning : once the area is exposed it is called scaling even if it is a root , when it’s closed it’s called root planning

5. periodontal wound dressing with zinc oxide non-eugenol

Instruments for Gingivectomy :

- Marker tweezer: it has a sharp needle edge from one side and a calibrated other side in mm , it punctures the tissues when the ends are brought up together and that’s to know how much to cut

It makes bleeding points to determine from where the cutting is to be started

We insert the probe looking end on the area that has thickening ( fibrotic tissues ) once it stops we puncture it ( this is the depth that we need to excise at) , we keep doing that along the tissues

Knifes:

- Kirkland knife; named after its inventor , found as left and right ( 2 instruments ) , after we have multiple bleeding points that gave me a layout on the area that needs to be excised , we bring the Kirkland knife with a 45 angle and we cut under the bleeding point , that is because if it’s above the bleeding point it will leave some of the supra bony pocked not excised , so we need to eliminate the pockets completely

- Urban knife; used to cut the inter dental papilla and release the tissue

Smoothening:

- Electro-surgery apparatus : has loops , depends on the area you’re working on and makes smoothening on the area where the gingivectomy was done

Any surgical procedure we put a dressing on it to eliminate the discomfort of the patient , here we put periodontal dressing ( we protect the area from the surrounding environment , thus lowering the discomfort) , some say it enhances healing ( that is not wrong but it has to be explained that the only way it enhances it is by protecting it from outer environments)

First dressing to be used in history is the asbestos: a chemical material used for gingivectomy at the beginning

Then zinc oxide eugenol was used , until they figured that eugenol is tissue irritant , so they removed the eugenol from it and we got the ZONE : zinc oxide non- eugenol

- Those were catalyst and base

- Then became light cure > that is put on the tissues and cured by light > making a mechanical Lock, not chemically !

- Some impregnate a disinfectant (antibiotics ) material into dressings and it’s released over a period of time making a disinfection for the surgical sight

- The maximum time for dressings is one week : and that’s because of the healing process that needs a week

Procedure :

A patient came with fibrotic tissues because of drugs with severe plaque : meaning no matter how much you do scaling and polishing the issue will not resolve : this indicates for gingivectomy

The reason we do scaling before is to remove the plaque that was a cofounder of the enlargement : it’s known that the main cause behind the enlargement is the drugs but the plaque also causes it to enlarge as well

- So we remove plaque by scaling, polishing and oral hygiene, and we wait until the gingiva becomes healthy then we do gingivectomy on the next visit

- Measuring : we insert the marking probe and measure the depth , to determine whether it’s only enlargement or enlargement associated with a pocket , to know if the pocket is supra or infra bony pocket . if it’s infra it’s contraindicated to do gingivectomy, if supra the we go ahead and continue with the procedure

- Detachment of the inter dental papilla (it has to be fibrotic ) to be indicated for gingivectomy , not all detachments are fibrotic, some are resilient and are not indicated for gingivectomy , instead OHI and scaling and polishing is done for the resilient type

- Minimum amount of anaesthesia is given by infiltration for the areas of the problem and it becomes blanched due to anaesthesia indicating that it’s working

- Bring the marker tweezer and insert it until resistance is felt meaning it’s the maximum depth , the puncturing of the tissues follows , multiple bleeding points give us the guidelines of the excision area

- To make it more visible; the probe is re-inserted to each point when cutting in that area

- Kirkland knife is brought in a 45 degree ( so that at the end of the cutting the gingival margin looks normal and original ) under the bleeding point ( but it has to be distal to the bleeding point ) to include a WHOLE inter dental papillae , once the knife is inserted hard tissues should be touched to cut all structures and then with a steady hand move from one side to another.

- the base is free after cutting , but the interdental papillae is still attached

- Urban knife : looks like a sickle , it is inserted interdentally , and then it’s pushed beneath and it splits the labial interdental papillae from the lingual one and the gingiva now is completely detached

- It is not necessary to remove the tissue as a whole piece , it is ideal to do so

- A curette is then brought to do scaling to the area , to detoxify the area mechanically

- Electro-surge is brought to do gingivoplasty to smoothen the area around it , the instrument is chosen depending on the thickness of the tissue and type of the tissue , those instruments do cutting with clotting ( some surgeons do the whole procedure of gingivectomy with this instrument only) the motion from one side to another is called sweeping , as it moves it gives heat, the movement should be continuous to avoid burning the area and depressing it , to achieve uniform thickness

- For the burnt/necrotic tissues , any flat scraping knife ( as Kirkland ) is used to remove them

- The area is clean , the enlargement is gone, the supra bony pocket is removed , now the area is left for healing , but since we’re cutting a wide area , the healing will be by 2^nd intention , so periodontal dressing is recommended to close the area, better than that is to use an antibiotic gel to disinfect the area chemically and eliminate the bacteria and the healing becomes normal

The best antibiotic gel is (doxycycline gel , agrimycin gel )

- After the gel , a dressing is applied ( catalyst and base ) , normal setting or fast setting , it’s better use the normal setting for the patient to go home with no bleeding , Vaseline is applied to the hands to prevent the dressing from sticking to them , an equal amount is mixed , then the tissues are dried , the dressing is applied to them , and a pressure is put on the dressing to cause the dressing to extend in that area and make mechanical interlocking

- The seal of the tissues will not be 100% meaning micro leakage will occur but it’s still better than complete leakage without the dressing , especially if it’s a 2^nd healing process

- The dressing is left on the tissues for a week , because the healing takes one week

- Patient returns after a week, the dressing is removed and polishing is made to the area

Remember : an indication for gingivectomy and gingivoplasty is un-accessible areas , ( class 5 carious teeth ) , it is done, then the caries are treated , healing is given its time , and then it all returns to its prior state ( the tissues that are removed are only in the areas where it’s needed )

Done by: Lana Obeidat

Perio lec. No. 2

Perio Sheet #2 By Lana Obeidat

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