Periodontal curettage
Reminder on the periodontal pocket:
2-4-1-Definition:
It is the pathological deepening of the gingivo-dental groove by apical migration of the junctional epithelium and bone destruction.
It is characterized by the transformation of the functional and sulcular epithelium into pocket epithelium which detaches from the root surface on which it can migrate apically towards the deep periodontal structures.
2-4-2-Description:
-The hard wall: This is the root wall (cementum) infiltrated by bacterial products, covered with tartar and bacterial plaque,
– The bottom: made up of the residual epithelial attachment which varies according to its length, its width and the state of the epithelial cells, these cells can be well formed and healthy, they also present a degeneration from slight to very marked. However, the degenerative transformations at the base of the pocket are usually less serious than those which appear in the epithelium of the lateral wall of the pocket.
– Content: Periodontal pockets contain debris which are mainly:
– Microorganisms and their products (enzymes, endotoxins, etc.)
– Bacterial plaque
– Gingival fluid
– Food debris
– Salivary mucin
– Desquamated epithelial cells
– Leukocytes
– Tartar covered with bacterial plaque usually projects from the hard surface.
When there is a purulent exudate, it consists of:
*live, degenerated and necrotic leukocytes
*live and dead bacteria *serum
*low amount of fibrin.
Periodontal curettage
The different periodontal curettage procedures:
1-Blind periodontal curettage:
1-1-Definition:
Periodontal curettage is defined as the removal of the inner surface of the soft tissue wall of the pocket using a curette (Lindhe 1986).
It is a long and meticulous intervention which must be carried out dial by dial.
1-2-Objectives:
The purpose of blind periodontal curettage is:
- To check and perfect under anesthesia:
-removal of soft and calcified deposits from the tooth surface;
-removal of infiltrated cement;
-root polishing (smooth and clean surface allowing reattachment of soft tissues).
- To eliminate:
-pathological epithelial tissue lining the base of the pocket;
-the infiltrated connective tissue of the attachment.
These 02 interventions result in:
-reduction of inflammation;
-the formation of a new connective and/or epithelial attachment at the root surface;
-the resulting tissue contraction contributes to the reduction of pocket depth and improvement of attachment level.
1-3-Indications:
-persistence of edema and erythema after initial therapy;
– blind periodontal curettage is indicated in the presence of edematous gingiva and a 0.5 mm pocket without infrabony lesion;
-curettage allows the assessment of scar tissue response;
-this is the preparatory step for periodontal surgery;
-in the case of severe and advanced periodontitis, periodontal curettage can constitute preparation for surgery and promote healing;
-in the case of furcation damage class 01 and 02 (conservative treatment).
1-4-Contraindications:
-local: unmotivated patients, presence of fibrous gum consistency.
-general: those of periodontal surgery.
1-5-The instrumentation:
Periodontal curettage is performed using manual instruments called curettes.
The following instrumentation will be recommended:
– a consultation platform;
– an anesthesia syringe, preferably with an aspirator;
– universal curettes are sharp on both edges, while Gracey curettes only have one;
-we can use scrapers, especially falciform ones;
-gingival scalpels: like Lagrange scalpels to thin the internal wall.
1-6-Operating protocol:
– asepsis of the operating field;
-anesthesia: will preferably be with vasoconstrictor, contact, followed by periapical anesthesia, supplemented by intrapapillary filtrations;
-Surfacing: we will preferably use a Gracey curette, held like a pen, with a support point provided by the ring finger or middle finger, the working part is brought to the bottom of the pocket until it meets resistance, we perform a traction movement in the occlusal direction, and which will be repeated several times until having a smooth surface, we wash with an antiseptic.
-Curetage: the curette is applied with the working part against the internal wall of the pocket, then moved continuously from the base of the pocket towards the gingival margin.
Then a thinning of the internal wall using a perfectly sharpened curette or a scalpel blade no. = 15, this action is often facilitated by light pressure with the finger on the surface of the gum opposite the instrument.
-washing with an antiseptic;
-very firm compression is carried out using a gas compress for 2 to 3 minutes in order to promote the adaptation of the superficial periodontal tissues to the root surface and the formation of an adequate blood clot;
-surgical dressing for proper soft tissue rehabilitation on the root surface , and helps to minimize clot between the gingiva and the root surface.
1-7-Post-operative care and advice:
-drug prescription based on anti-inflammatories;
– chlorhexidine-based mouthwashes, with 2 rinses for 1 minute per day for 10 days;
-avoid hot and spicy foods;
-recommendation to use soft toothbrushes;
-the patient will be informed of the possible consequences: slight gingival recession, hyperesthesia at the level of the dental surfaces, dental discoloration.
1-8-Healing:
There will be an epithelial-connective reattachment: in certain cases the epithelium adheres to the root by forming a long epithelial sleeve, this type remains fragile and under the effect of PB can disappear and allow microorganisms to recolonize the root.
Periodontal curettage
2-Periodontal curettage by flap (open):
2-1-Indications:
– pockets greater than 05mms;
-no improvement after blind curettage.
2-2-Operating protocol:
Several open curettage techniques have been developed, all with the essential aim of allowing direct vision of the roots, and thus facilitating cleaning by the declination of a flap.
Once anesthesia has been achieved, a vertical releasing incision is made at the end of the surgical site. This incision is not always essential, but it provides better access and easier flap replacement. Then an intrasulcular incision is made, and the muccoperiosteal flap is detached.
We start with manual root planing then chemical (phosphoric acid and tetracycline).
Then, the pocket epithelium and granulation tissue are removed, the internal face of the flap is refined and thinned with the Kirckland scalpel to promote its subsequent adaptation.
The flap is adapted, repositioned, then sutured.
2-3-Healing:
We are witnessing the formation of an epithelial-connective reattachment, that is to say that there is formation of a fairly rigid fibrous sleeve below a junctional epithelium to ensure adequate periodontal health.
Postoperative consequences will include bone resorption and gingival retraction that is much more pronounced than after blind curettage.
Periodontal curettage
Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.