| | Cleaning, Scaling, and Curettage |
| | Scaling, polishing, and sometimes curettage are used to manage periodontal disease. They are usually accomplished in a series of three to four visits spaced about a week apart. |
| | Cleaning and Scaling. The dental hygienist or practitioner generally uses both ultrasonic and manual instruments to remove calculus. |
| | Calculus above the gum is easily seen. The dental professional usually detects calculus below the gum by careful probing with a dental instrument. |
| | The hygienist or dentist may use an ultrasonic instrument for removal of the more accessible calculus. This probelike device vibrates at a frequency range higher than is audible to the human ear. Some people with low tolerance for the ultrasonic probe may wish to request nitrous oxide. |
| | A spray of water is used with ultrasound to prevent overheating and to flush out the debris that is dislodged. |
| | When the probe contacts the rock-like calculus, deposits fracture off the tooth fairly efficiently. |
| | Povidone-iodine (PVP-I), a potent antiseptic, can reduce the level of gingivitis and may be more beneficial than water as the irrigant used during ultrasonic treatment. Further studies are needed. |
| | Curettage. Curettage removes the diseased soft tissue lining the periodontal pockets. It is a manual procedure and permits a deeper and more complete cleaning than ultrasound. It does not add any significant benefits for shallow pockets. Local anesthesia is often used. Fine scaling instruments, called curettes, serve two functions: |
| | They scrape and clean the root surfaces. |
| | They also plane the surfaces in an attempt to smooth and remove the outer layer of diseased material. |
| | Repeated scaling and root planing with steel instruments may cause loss of the tooth surface and increased sensitivity of the teeth over time. Newer plastic instruments may be just as effective without damaging the hard structure of the tooth. |
| | Polishing. Polishing is the finishing procedure. It employs a rubber cup with an abrasive paste to remove plaque and stains on the crown portion of the tooth. It produces a smooth surface, making it harder for plaque to adhere. Its benefits are short lived, however. |
| | Instructions for Home Care. Finally, the dental hygienist or practitioner should offer thorough instructions on home care to insure the removal of bacteria on a daily basis. This includes proper use of the toothbrush, paste, mouth rinses, floss, floss threaders, and proxabrushes. Home care can effectively eliminate the plaque above the gums and down to 2 mm below the gums. |
| | Follow-Up. The dentist will check the pocket depths around the teeth after the cleaning and curettage process has been completed. Further treatment needs are determined by the results of these initial sessions: |
| | If the cleaning processes have reduced inflammation, observation only is needed. |
| | If an abscess is present, surgery is often warranted. (One case study suggested that simply draining an abscess caused by deep pockets and allowing the periodontal pockets to improve and the gum tissue to return to health may avoid the need for surgery. If, in such cases, tissue health has not been achieved, and if the pocket depth is greater than 4 mm, surgery may be necessary.) |
| | Surgery |
| | Surgery allows access for deep cleaning of the root surface, removal of diseased tissue, and repositioning and shaping of the bones, gum, and tissues supporting the teeth. (Some studies have reported that although surgical treatment reduced pocket depth more than non-surgical therapies for at least one year after the procedure, benefits from surgery do not persist beyond five years, except in very deep pockets.) Surgical procedures vary depending on the individual diagnosis and needs of the patient. |
| | Open Flap Curettage . The basic procedure is known as open flap curettage. It involves the following: |
| | The periodontal surgeon lifts, or flaps, the gums away from the tooth and surrounding bone. |
| | The diseased root surfaces are cleaned and curetted (scraped) to remove deposits. |
| | Gum tissue is replaced into positions to minimize pocket depth. |
| | The periodontist may also contour the remaining bone and attempt to regenerate lost bone and gingival attachment through bone grafts and guided tissue regeneration [ see below ]. |
| | Guided-Tissue Regeneration. A more advanced technique is called guided tissue regeneration, which is being used to stimulate bone and gum tissue growth: |
| | First the root surfaces and diseased bone are meticulously cleaned out. Preventing bacterial contamination is very important; the more residual bacteria, the greater the chance that the treatment will fail. |
| | A specialized piece of fabric is sewn around the tooth to cover the crater in the bone left after the cleaning. It is either absorbable or nonabsorbable. (Studies are reporting highly beneficial results with new absorbable materials, including one that is coated with the antibiotic doxycycline.) |
| | The gum is then sewn over the fabric. The fabric prevents the gum tissue from growing down into the bone defect and allows the bone and the attachment to the root to regenerate. |
| | After four to six weeks the nonabsorbable fabric must be removed using a minor surgical procedure. The absorbable membrane may be left in. In general, there is little difference in outcome between absorbable and nonabsorbable procedures. The absorbable fabric may not be as effective as standard grafts if gum tissue is thin, although newer materials may prove to produce better results. |
| | One 1999 study found that guided tissue regeneration techniques surpassed open flap curettage alone in improving pocket depth and attachment gain. In one study of patients who were followed for four to seven years after guided tissue regeneration, the general failure rate was 41%. In smokers, however, the failure rate was 80%. |
| | Bone Grafting. In some cases of severe bone loss, the surgeon may attempt to encourage regrowth and restoration of bone tissue that has been lost through the disease process. This involves bone grafting: |
| | The surgeon places bone graft material into the defect. |
| | The material may be either bone from the same patient or a substance called decalcified freeze-dried bone allografts (DFDBA) which is obtained from a donor. In one study, bone gain from freeze-dried bone was still maintained after three years, although another study indicated that commercial batches of DFDBA varied in their ability to induce new bone growth. Bone from older donors appears to be less effective for restoring new bone. |
| | This material then stimulates new bone growth in the area. |