INITIAL THERAPY
I- Introduction:
Caries and periodontal diseases are the most common dental conditions. Until recently, they were treated mainly by symptomatic therapies (with a restorative aim). This treatment method could be considered appropriate since the etiology of these two conditions remained obscure.
Currently, important aspects of the etiology and pathogenesis of caries and periodontal disease are adequately understood, and therapeutic methods exist that can eradicate or control the etiological factors, as well as prevent the recurrence of periodontal disease.
Results from animal experiments and longitudinal studies in humans have conclusively shown that treatment involving the elimination or control of plaque infection and the introduction of rigorous plaque control measures results in most, if not all, cases in the restoration of dental and periodontal health.
The term “initial treatment” refers to the various techniques used to achieve this goal.
II- Etiological reminder of periodontal disease:
The main causes of periodontal disease were described by WESKI in 1836 in the form of a triad:
1- Local etiology:
– Local triggering factor: bacterial plaque according to LOE “dental plaque is a soft, non-calcified deposit that forms on insufficiently cleaned teeth”
– Local contributing factor: these are all the dental and iatrogenic anatomical factors which promote the retention and accumulation of bacterial plaque.
– Indirect local factor: represented by traumatic occlusal forces.
2- Constitutional etiology:
– Age
– Sex
– Breed
– Heredity
3- General etiology:
– Hormonal factors
– Nutritional factors
– Endocrine disorders: diabetes….
– Periodontal disease symptom of general illness: Lefèvre butterfly syndrome, Down syndrome…
– Blood factors
– Drug factors
– risk factors:
- Stress
- tobacco
III- Place of initial therapy in the treatment plan:
Periodontal treatment follows the establishment of a clinical file and a diagnosis.
The complete treatment of patients with periodontal disease can be divided for educational purposes into 4 phases, which, however, frequently overlap.
1- Etiological therapy:
Its goal is to stop the progression of periodontal disease by eliminating bacterial plaque and plaque retention factors.
2- The re-evaluation phase:
It will be carried out between 3 and 6 months following the initial treatment and will analyse the control of BP, bleeding, probing and radiography.
Different decisions result from this: strengthening of PB control, supportive care.
3- Corrective therapy:
The main objective is the restoration of function and aesthetics: either by non-surgical therapy or by surgical therapy and occlusal rehabilitation; which can only be considered as a complement to etiological therapy.
The various surgical methods should be judged on the basis of their ability to contribute to the control of bacterial plaque and thereby the long-term preservation of the periodontium.
4- The maintenance phase:
It aims to maintain the results obtained and prevent the recurrence of periodontal disease. The aim is to support the patient in his daily work of eliminating PB through periodic check-ups during which the bacterial deposits still present will be systematically eradicated.
IV- Definition of initial therapy:
Initial therapy is considered the most important phase of periodontal treatment. It is an etiological therapy that consists of eliminating all the causes of periodontal disease. It is based on several approaches: psychological, chemical and practical (motivation, control of bacterial plaque, scaling, surfacing, etc.), the main goal of which is the elimination of bacterial biofilm, a triggering factor for gingivitis and periodontitis.
V- Objectives of initial therapy:
– Inform the patient about his periodontal disease and its treatment , motivate him to control his disease.
– Teaching oral hygiene.
-stop the progression of periodontal disease.
– Elimination of bacterial plaque retention factors.
– Elimination of signs of inflammation.
– Stabilize bone lysis
-stop attachment losses.
– Creation of functional occlusal reports
– Stabilization of mobile teeth.
VI- The different stages of initial therapy:
1- Motivation:
This consists of raising awareness and informing the patient. For this, the practitioner must bring together a large number of qualities: patience, perseverance, psychology and teaching skills.
The dental surgeon is required to solicit active participation from the patient. This management constitutes an essential part of the treatment which determines its success, the whole problem of motivation consists of convincing the patient of the need to control PB and learn this behavior; it is a question of informing and instructing.
a- Motivation outside the dental office:
→ School hygiene: nursery school, primary school .
→ Parental motivation: they must learn that they are responsible for their children’s dental future.
→ General public information:
– Action by hygiene equipment manufacturers to increase product sales.
– Communication vehicles or mass media (press, displays, radio, television, etc.)
→ Diet: reduce foods rich in sugar and favor a hard and fibrous diet, rich in proteins and vitamins.
b- Motivation in the dental office:
→ In the waiting room:
– Books, magazines, posters
– Video cassettes, learning manuals
→ The assistant’s role is more spontaneous, the patient asks questions to the assistant more easily.
→ During the consultation:
You have to visualize the enemy to
Fight it better
↓ ⇓ ↓
Revealers – Awareness of the Clues
Patient
– The possibility of control
by the patient himself
– Take photographs, x-rays, models.
– If good hygiene is not practiced, he will not be entitled to restorative treatment.
The revealers:
These are solutions applied with a cotton ball or tablets that are kept in the mouth for 1 minute.
INITIAL THERAPY
c- Means of PB elimination:
→ Mechanical means:
∙ Brushing:
It is the action of brushing the teeth using a brush to remove soft deposits and food debris.
⮞Benefits of brushing:
– Elimination of soft deposits, bacterial plaque, food fragments and at the same time reduce and delay the formation of tartar.
– Massage the gum to promote keratinization of the epithelium and stimulate blood circulation.
– Eliminate bad breath of oral origin.
⮞Frequency and duration of brushing:
– Duration: 3 mins.
– Frequency: 3 times a day after meals
⮞Toothbrushes:
They consist of a handle, a neck, and a head which carries the bristles, this represents the active part of the brush and varies according to 3 parameters:
– Their nature: natural bristles (real reservoirs of germs), synthetic bristles (do not lose their elasticity when wet and wear out less quickly)
– Their flexibility: which depends on the diameter and sometimes the length of the bristles (extra-soft brush, soft brush, medium brush, hard and extra-hard brush)
– Their implantation: either perpendicular to the support, which gives a homogeneous surface of the end of the bristles, or in V which gives an irregular surface which allows better penetration into the inter-dental spaces.
The number of tufts is also variable:
– Single-tuft brush: comprising a single tuft of bristles implanted perpendicular to the head, this tuft is cut to a point, it is indicated for cleaning interdental spaces and the distal surfaces of molars.
– Brush with 2 rows of 6 tufts.
– Brush with 3,4,6 rows of 10 tufts.
There are several types of toothbrush:
– Manual toothbrush.
– Electric toothbrush: horizontal or rotating movement.
– Ultrasonic toothbrush: equipped with a lighting system.
Qualities required for a toothbrush:
– Grip handle.
– Possibility of curvature of the neck.
– Easy to clean.
– Durable and inexpensive.
– Able to differentiate itself from other brushes in the family.
⮞Contraindications to brushing:
– Acute phase of GUN.
– Inflammatory reaction in irradiated patients.
– After surgery or tooth extraction.
– Within the first few days following a traumatic injury.
⮞Brushing methods:
Horizontal method:
🢂Indication: children up to 3 years old.
🢂Technique: with the arches in occlusion, place the brush perpendicular to the vestibular or occlusal surface, and perform a back and forth movement.
This method is very widespread and yet it is the most traumatic and the least effective, it is only justified on the occlusal surfaces.
INITIAL THERAPY
Fones circular method:
🢂Indication: children and patients with healthy periodontium.
🢂Technique: the brush is positioned at 90° to the dental surface, with the patient in occlusion. The rotational movements concern the vestibular faces then the lingual faces, the occlusal surfaces will be brushed with a rotary back and forth movement.
Rolling method:
🢂Indication: adolescents and adults with healthy periodontium.
🢂Brush position: parallel at 45° to the dental axis, pressing lightly on the gum with the mouth open.
🢂Technique: stroke the brush from the gum to the tooth, the bristles bend, thus stimulating the gum and at the end of the movement allow the removal of marginal and inter-dental PB.
INITIAL THERAPY
Bass Method:
🢂Indication: adults with healthy periodontium but also patients suffering from gingivitis or periodontitis.
🢂Brush position: tilt the brush at 45° relative to the dental axis, the end of the bristles is in the gingival sulcus and the interdental space while maintaining the position of the brush.
🢂Technique: open mouth, discreet vibrating movements.
Simplified Bass Method:
In addition to the vibrating movement, a sweeping movement is added.
Stillman method:
🢂Indication: recessions, edematous gingivitis.
🢂Brush position: parallel to the axis of the tooth, with the subject in an open mouth, the end of the bristles must extend 2mm beyond the edge of the marginal gum, while exerting pressure on it.
🢂Technique: after tilting the brush at 45°, light movements are made in the mesio-distal direction, which allows, in addition to a gingival massage, an elimination of the PB.
INITIAL THERAPY
Modified Stillman method:
It is the combination of the vibratory action of the bristles and the stroke movement of the brush along the longitudinal axis of the teeth.
The brush is positioned at the mucogingival line, the bristles are placed away from the crown and moved along the attached gingiva, marginal gingiva and tooth surface.
The handle is turned towards the crown and vibrated by moving the brush.
Charters Method:
🢂Indication: patient with periodontal disease, recessions, diastemas.
🢂Brush position: the edges of the bristles form an angle of 45° along their entire length with respect to the axis of the tooth, pressing on the gum, the mouth is open, the bristles directed towards the occlusal plane.
🢂Technique: in this position we make small oscillations in the interdental spaces.
∙ Brushing aids:
⮞Silk thread: The thread is wrapped around the middle fingers and is stretched with the thumb and index finger. The thread is recommended for cleaning proximal surfaces.
It is passed gently under the contact point until reaching the gingival line and then raised, pressing the wire against the proximal surface of the tooth.
INITIAL THERAPY
⮞Toothpick: interdental stick.
⮞Interdental stick:
INITIAL THERAPY
⮞Stimulators:
are made of a rubber cone
or plastic material mounted on a handle,
It is inserted into the interdental space with a
⮞Interdental brushes:
INITIAL THERAPY
⮞Water flossers: allow for jet rinsing with water or an antiseptic solution.
→Chemical means:
∙Antibiotics: Almost all antibiotics have been tested. Long-term use of antibiotics is contraindicated because the dose contained in toothpastes is quite likely to create antibiotic-resistant strains.
∙Enzymes: mutanase and other enzymes showing short-term efficacy but side effects are common.
– Dextranase.
∙Vitamins: vitamin C and zinc mouthwash, vitamin A, vitamin D.
∙Antiseptics:
⮞Chlorhexidine: This is one of the best BP inhibitors, and as such this bactericidal and bacteriostatic agent has been widely tested in the form of gels and toothpastes.
⮞Sanguinarine: considered a good anti-plaque agent.
⮞Fluoride:
– fluoride toothpastes: it is advisable to prescribe toothpastes with a truly medicinal action.
2- Descaling and surfacing:
a- Definition: Scaling is an intervention which consists of eliminating PB and tartar from the surface of the teeth.
Depending on the location of the deposits, scaling will be supra- or subgingival.
The aim of supragingival scaling is the removal of deposits located on the clinical crown of the teeth.
Root planing involves the removal of the “softened” cementum, leaving the root surface hard and smooth.
b- Purposes of scaling and surfacing:
The aim is to obtain smooth, hard and clean surfaces, thus making it possible:
– Elimination of subgingival bacterial and tartaric mass.
– Easier cleaning of root surfaces by the patient and the practitioner during professional prophylaxis sessions, which allows the pockets to heal and prevents recurrence.
– Reduction of gingival inflammation and stopping the destruction process.
c- Indication of scaling and surfacing:
– Presence of supra- and subgingival tartar on the dental surface in the context of gingivitis and periodontitis.
– Scaling and resurfacing are an essential part of initial therapy in the context of non-surgical and surgical therapy.
– Represents the only treatment in unmotivated patients and in patients whose general condition contraindicates more elaborate interventions.
d- Contraindications for scaling and resurfacing:
→Relatives:
– Kidney disease.
– High blood pressure, Acute rheumatic fever.
– Unbalanced diabetes.
– Heart diseases that are not life-threatening.
→Absolute:
– White line disorders (Leukemia, Hemophilia)
– Sick on anticoagulants.
– Patient on corticosteroid therapy.
e- Instrumentation used:
– Manual: Scraper (sickle-shaped, hoe-shaped, scissors), curettes, files.
– Ultrasonic: the Cavitron operating at 25,000 vibrations/second dislodges tartar by fragmentation.
f- Descaling and surfacing technique:
→Preparation of the operating field:
– A broad irrigation using a spray of the surgical field is performed to remove food debris.
– Local anesthesia is sometimes necessary in cases of significant hypersensitivity.
– First, supragingival scaling is carried out to facilitate access to the subgingival area.
⇒ Certain rules must be strictly observed when descaling and resurfacing:
– The support point which must be close to the area to be descaled to ensure stability of the movement.
– The grip of the instrument in a standard pen holder.
→Technique itself:
– After supragingival scaling: the root surface is first explored with a probe to determine the depth of the pocket and the position of the calcified deposits.
– The curette is inserted up to the base of the pocket, its smooth side facing the gum, the curette is turned into the working position then a traction movement is performed in the apico-coronal direction while maintaining an angle of 60° to 80° with the root, this movement is repeated until a smooth and hard surface is obtained, controlled using the probe.
– Polishing.
– Post-operative advice.
3-Drug treatment:
Mechanical therapies may be insufficient for the treatment of certain advanced forms of periodontal diseases (PJ, PPR, PPP)
Thus the concept of bacterial plaque control represents the very essence of therapy whatever the treatment philosophy, and the new etiopathogenic data associated with a better knowledge of the bacterial profile of periodontal pockets fully justify the use of antibacterial substances capable of potentiating the mechanical control of plaque, among them we have:
a- Antiseptics:
→Chlorhexidine:
Thanks to its cationic properties it has an affinity for the cell wall of microorganisms and depending on its concentration it can be bactericidal or bacteriostatic.
→Hexetidine:
It has a broad spectrum antibacterial property, anti-plaque effect.
→Sanguinarine:
Alkaloid extracted from Sanguinaria Canadensis, it has broad-spectrum antibacterial properties.
→Hydrogen peroxide:
It is an antiseptic with a foaming effect which allows O2 to be transported to the bottom of the pocket.
⇒ Antiseptics are used as mouthwash or with a water flosser
b- Antibiotics:
Indicated during the active phase of the disease, general illness (or there is the risk of infection; RAA, heart disease, unbalanced diabetes), active periodontal treatment after bacteriological confirmation (bacterial specificity
4- Elimination of iatrogenic factors and contributing factors:
a- Correction of overflows:
→Overflowing obstruction:
INITIAL THERAPY
→Crowns clearly subgingival or overhanging:
If cervical correction proves impossible or unsightly, they are removed and replaced by temporary restorations.
→Inadequate intermediate elements:
Bridge correction or replacement.
b- Extractions:
Teeth with insufficient bone support will be extracted otherwise they will cause functional discomfort and represent a reservoir of bacteria.
During a difficult extraction, various techniques can often prevent damage to the periodontium.
⇒ Monoradicular: – elevation of a vestibular flap.
– Elimination of part of the vestibular bone table.
– Preservation of the interdental septum.
⇒ Molars: separation of the roots.
c- Orthodontics:
Multi-band appliances are a formidable plaque trap (especially at the level of molar bands)
Wires located close to the gum raise the question of reconciling the imperatives of biomechanics and periodontology; professional prophylaxis during treatment often proves essential.
5- Functional treatment:
a-Temporary prosthesis:
The missing teeth will be replaced later by definitive prosthetic restorations, but during the initial therapy in order to restore function and aesthetics a provisional prosthesis will be made in order to prevent further resorption, dental malpositions and reduce occlusal overloads on the remaining teeth.
b- The restraint:
The word “retention” means “to hold with”, this translates to the temporary or permanent immobilization of mobile teeth in the best anatomical and functional position.
INITIAL THERAPY
→ Removable temporary restraint:
– The Howley plate: this is an acrylic resin plate with a headband and bite plane.
– The SVED plate: resin plate with a support on the palate
→ Temporary restraint fixed:
– Figure-eight metal ligature.
– Ladder metal ligature.
– Sewing machine stitch binding.
VII- Special case:
People with general illnesses will have to be satisfied with the initial therapy since surgery is contraindicated for them, however they present an infectious risk, antibiotic prophylaxis will be established:
– For unbalanced diabetics: Spiramycin 6M / day for 8 days.
– Heart disease: Amoxicillin 3g 1 hour before the procedure
child: 75mg/kg
In case of allergy to B-lactams: Clindamycin 600mg 1 hour before the procedure
child: 15mg/kg
Or Prestinamycin 1g 1 hour before the act
Child: 25mg/kg
– Renal insufficiency: an ATB with elimination other than renal is given, ½ dose.
– Liver failure: ATBs to avoid are Tetracycline, Spiramycin, Clindamycin.
VIII- Conclusion:
Currently, most authors agree that the elimination and control of bacterial plaque, followed by scaling and root planing, as well as the so-called “iatrogenic” factors that will either have to be eliminated or corrected, constitute the most important stage of periodontal treatment since they allow to reduce gingival inflammation and the depth of pockets, and therefore stop the process of destruction of periodontal disease, which constitutes the goal of modern dental care.
Good oral hygiene is essential to prevent cavities and gum disease.
Regular scaling at the dentist helps remove plaque and maintain a healthy mouth.
Dental implant placement is a long-term solution to replace a missing tooth.
Dental X-rays help diagnose problems that are invisible to the naked eye, such as tooth decay.
The dentist uses local anesthesia to minimize pain during dental treatment.