PERIODONTALMAITENANCE PHASE Preservation of the periodontal health of the treated patient requires as positive a program as that required for the elimination of periodontal disease. After Phase I therapy is completed, patients are placed on a schedule of periodic recall visits for maintenance care to prevent recurrence of the disease.REEVALUATION Transfer of the patient from active treatment status to a maintenance program is a definitive step in total patient care that requires time and effort on the part of the dentist and staff. Patients must be made to understand the purpose of the maintenance program, and the dentist must emphasize that preservation of the teeth is dependent on it. Patients who are not maintained in a supervised recall program subsequent to active treatment show obvious signs of recurrent periodontitis. The more often patients present for recommended supportive periodontal treatment, the less likely they are to lose teeth. Motivational techniques and reinforcement of the importance of the maintenance phase of treatment should be considered prior to performing definitive periodontal surgery. It is meaningless simply to inform patients that they are to return for periodic recall visits without clearly explaining the significance of these visits and describing what is expected of patients between visits. RATIONALE FOR SUPPORTIVE PERIODONTAL TREATMENT Studies have shown that even with appropriate periodontal therapy, some progression of disease is possible due to: Incomplete subgingival plaque removal. Bacteria are present in the gingival tissues in chronic and aggressive periodontitis cases Bacteria associated with periodontitis can be transmitted between spouses and other family members. Subgingival scaling alters the microflora of periodontal pockets In conclusion, there is a sound scientific basis for recall maintenance because subgingival scaling alters the pocket microflora fro variable but relatively long periods. MAINTENANCE PROGRAM Examination and Evaluation The recall examination is similar to the initial evaluation of the patient discussed in Clinical Diagnosis. Since the patient is not new to the office, the dentist primarily looks for changes that have occurred since the last evaluation. Analysis of the current oral hygiene status of the patient is essential. Updating of changes in the medical history and evaluation of restorations, caries, prostheses, occlusion, tooth mobility, gingival status, and periodontal pockets are important parts of the recall appointment. The oral mucosa should be carefully inspected for pathologic conditions. Radiograpic examination must be individualized depending on the initial severity of the case and the findings at the recall visit. These are compared with findings on previous radiographs to check the bone height and look for repair of osseous defects, signs of trauma from occlusion, periapical pathologic changes, and caries. Part I: Examination(approximate: 17 minutes) Medical history changes Oral pathologic examination Oral hygiene status Gingival changes Pocket depth changes Mobility changes Occlusal changes Dental caries Restorative and prosthetic status Part II: Treatment (approximate time: 35 minutes) Oral hygiene reinforcement Scaling Polishing Chemical irrigation Part III: Schedule next procedure (approximate time: 1 minute) Schedule next recall visit Schedule further periodontal treatment Schedule or refer for restorative or prosthetic treatment Checking of Plaque Control To assess the effectiveness of their plaque control, patients should perform their hygiene regimen immediately before the recall appointment. Plaque control must be reviewed and corrected until the patient demonstrates the necessary proficiency, even if additional instruction sessions are required Patients instructed in plaque control have less plaque and gingivitis than uninstructed patients, and the amount of supragingival plaque affects the number of subgingival anaerobic organisms Treatment The required scaling and root planing are performed, followed by an oral prophylaxis. Care must be taken not to heavily instrument normal sites with shallow sulci (1-3mm deep) because studies have shown that repeated subgingival scaling and root planing in initially normal periodontal sites result in significant loss of attachment. Irrigation with antimicrobial agents is performed in maintenance patients with remaining pockets. Recurrence of Periodontal Disease CAUSES: Inadequate or insufficient treatment that has failed to remove all the potential factors favoring plaque accumulation. Incomplete calculus removal in areas of difficult access is a common source of problems. Inadequate restorations placed after periodontal treatment was completed. Failure of the patient to return for periodic checkups. Presence of some systemic diseases that may affect host resistance to previously acceptable levels of plaque. A failing case can be recognized by the following: Recurring inflammation revealed by gingival changes and bleeding of the sulcus on probing. Increasing depth of sulci, leading to the recurrence of pocket formation. Gradual increases in bone loss as determined by radiographs. Gradual increases in tooth mobility as ascertained by clinical examination. Symptoms and Causes of Recurrence of Disease Increased mobility Increased inflammation Poor oral hygiene Subgingival calculus Inadequate restorations Deteriorating or poorly designed prostheses Systemic disease modifying host response to plaque Recession Toothbrush abrasion Inadequate keratinized gingiva Frenum pull Orthodontic therapy Increased mobility with no change in pocket depth and no radiographic change Occlusal trauma due to lateral occlusal interference Bruxism High restoration Poorly designed or worn-out prosthesis Poor crown-to-root ratio Increased pocket depth with no radiographic change Poor oral hygiene Infrequent recall visits Subgingival calculus Poorly fitting partial denture Mesial inclination into edentulous space Failure or new attachment surgery Cracked teeth Grooves in teeth New periodontal disease Increased pocket depth with increased radiographic bone loss Poor oral hygiene Subgingival calculus Infrequent recall visits Inadequate or deteriorating restorations Poorly designed prostheses Inadequate surgery Systemic disease modifying host response to plaque Cracked teeth Grooves in teeth New periodontal diease The decision to retreat a periodontal patient should not be made at the preventive maintenance appointment but should be postponed for 1 to 2 weeks. CLASSIFICATIONS OF POSTTREATMENT PATIENTS 1. First year First year patient routing therapy and uneventful healing Recall interval : 3 months First year patient difficult case with complicated prosthesis, furcation involvement, poor crown-to-root ratios, or questionable patient cooperation Recall interval: 1 to 2 months2. Class A Excellent results well maintained for 1 year or more Patient displays good oral hygiene, minimal calculus, no occlusal problems, no complicated prostheses, no remaining pockets, and no teeth with less than 50% of alveolar bone remaining Recall interval: 6 months to 1 year3. Class B Generally good results maintained reasonably well for 1 year or more, but patient displays some of the following factors:1. Inconsistent or poor oral hygiene2. Heavy calculus formati0n3. Systemic disease that predisposes to periodontal breakdown4. Some remaining pockets5. Occlusal problems6. Complicated prostheses7. Ongoing orthodontic therapy8. Recurrent dental caries9. Some teeth with less than 50% of alveolar bone support10. Smoking11. Positive genetic test12. Recall interval: 3 to 4 months (decide on recall interval on the basis of the number and severity of negative factors)4. Class C Generally poor results following periodontal therapy and/or several negative factors from the following list:1. Inconsistent or poor oral hygiene2. Heavy calculus formation3. Systemic disease that predispose to periodontal breakdown4. Remaining pockets5. Occlusal problems6. Complicated prostheses7. Recurrent dental caries8. Periodontal surgery indicated but not performed for medical, psychologic, or financial reasons9. Many teeth with less than 50% of alveolar bone support10. Condition too far advanced to be improved by periodontal surgery11. Smoking12. Positive genetic test13. More than 20% of pockets bleed on probing14. Recall interval: 1 to 3 months (decide on recall interval on the basis of the number and the severity of negative factors; consider retreating some areas or extracting the severly involved teeth) In summary, maintenance care is a critical phase of therapy. The long-term preservation of the dentition is closely associated with the frequency and quality GINGIVAL CURETTAGE SCALING Refers to the removal of deposits from root surface PLANING Means smoothing the root to remove infected and necrotic tooth substance. Scaling and root planing may inadvertently include various degrees of curettage. They are different procedures with different rationales and indications, and should be considered separate parts of periodontal treatment. CURETTAGE Used in periodontics to mean the scraping of the gingival wall of a periodontal pocket to removed inflamed soft tissue. Gingival curettage Consists of the removal of inflamed soft tissues lateral to the pocket wall. Subgingival curettage Refers to the procedure that is performed apical to the junctional epithelium, in which the connective tissue attachment is severed down to the osseous crest RATIONALE Curettage accomplishes removal of chronically inflamed granulation tissue in the lateral wall of the periodontal pocket Tissue contains areas of chronic inflammation and may have also pieces of dislodge calculus and bacterial colonies Calculus and bacterial colonies may perpetuate the pathologic features of the tissue and hinder healing. Curettage may also eliminate all or most of epithelium that lines the pocket wall, epithelial extensions that penetrate the granulation tissue, and the underlying junctional epithelium. CURETTAGE AND AESTHETICS Awareness of aesthetics in periodontal therapy has become an integral part of care in the modern practice of periodontics In the past, pocket elimination was the primary goal of the therapy Currently aesthetics is a major consideration of therapy, particularly in the anterior maxilla and require preservation of the interdental papilla. Surgical techniques specially designed to preserve the interdental papilla, such as the papilla preservation technique, result in a better aesthetic apperance of the anterior maxilla than do aggressive scaling and curettage of the area. INDICATIONS Indications for curettage are very limited. It can be used after scaling and root planing for the following purposes: 1. Curettage can be performed as part of new attachment attempts in moderately deep infrabony pockets located in accessible areas where a type of closed surgery is deemed advisable. However, technical difficulties and inadequate accessibility frequently contraindicate such surgery 2. Curettage can be done as non-definitive procedure to reduce inflammation prior to pocket elimination using other methods or in patients in whom more aggressive surgical techniques are contraindicated owing to age, systemic problems, psychologic problem, and so forth. 3. Curettage is also frequently performed on recall visits as a method of maintenance treatment for areas of recurrent inflammation and pocket deepening, particularly where pocket reduction surgery has previously been performed. PROCEDURES BASIC TECHNIQUE Curettage does not eliminate the causes of inflammation. Therefore, it should always be preceded by scaling and root planing, which is the basic periodontal therapy procedure. Gingival curettage always requires some type of local anesthesia. (scaling and root planing are optional) Curette is selected so that the cutting edge will be against the tissue Gracey curette no. 13-14 is used for mesial surface and the gracey curette no. 11-12 for distal surfaces. Curettage can also be performed with a 4R-4L Columbia universal curette. Instrument is inserted so as to engage the inner lining of the pocket wall and is carried along the soft tissue, usually in horizontal stroke. The pocket wall may be supported by gentle finger pressure on external surface. Curette is the placed under the cut edge of the junctional epithelium to undermine it. In subgingival curettage, the tissues attached between the bottom of the pocket and the alveolar crest are removed with a scooping motion of the curette to the tooth surface. The area is flushed to removed debris, and the tissue is partly adapted to the tooth with gentle finger pressure. sometimes, suturing of separated papillae and application of a periodontal pack may be indicated. OTHER TECHNIQUES Other techniques for gingival curettage include the excisional new attachment procedure, ultrasonic curettage, and the use of caustic drugs. EXCISIONAL NEW ATTACHMENT PROCEDURE (ENAP) Developed and used by U.S Naval Dental Corps. A definitive subgingival curettage procedure performed with a knife. The technique as follows: 1. After adequate anesthesia, an internal bevel incision is made with surgical blade from the margin of the free gingiva apically to a point below the bottom of the pocket. The incision is carried interproximally on both the facial and the lingual sides, attempting to retain as much interproximal tissues as possible. The in tention is to cut the inner portion of the soft tissue wall of the pocket, all around the tooth. 2. remove the excised tissue with a curette, and carefully root plane all exposed cementum to a smooth, hard consistency. Preserve all connective tissue fibers that remain attached to the root surface. 3. approximate the wound edges; if they do not meet passively, recontour the bone until good adaptation of the wound edges is achieved. Place sutures and a periodontal dressing. ULTRASONIC CURETTAGE Used of electronic devices has been recommended for gingival curettage Ultrasound is effective for debriding the epithelial lining of periodontal pockets; it results in a narrow band of necrotic tissue which strips off the inner lining of the pocket Some investigators found ultrasonic instruments to be as effective as manual instrument for curettage but resulting in less inflammation and less removal of underlying connective tissue than manual instruments. CAUSTIC DRUGS Since early in the development of periodontal procedures, use of caustic drugs has been recommended to induce the chemical curettage of lateral wall of the pocket or even selective elimination of the epithelium. Drugs such as sodium sulfide, alkaline sodium hypochlorite solution (Antiformin), and phenol have been proposed and then discarded after studies shows ineffectiveness. The extent of tissue destruction with these drugs cannot be controlled, and they may increase rather than reduce the amount of tissue to be removed by enzymes and phagocytes. Healing after scaling and curettage Immediately after curettage, a blood clot fills the gingival sulcus, which is totally or partially devoid of epithelial lining. Hemorrhage is also present in the tissues with dilated capillaries, and abundant polymorphonuclear leukocytes appear shortly thereafter on the wound surface. Restoration and epithelialization of the sulcus generally require 2 to 7 days. Immature collagen fibers appear within 21 days Healthy gingiva in advertently severed from the tooth and tears in the epithelium are repaired in healing process. Several investigators have reported that in monkeys and humans treated by scaling and curettage procedures, healing results in the formation of a long, thin junctional epithelium with no new connective tissue attachment. CLINICAL APPEARANCE AFTER CURETTAGE Immediately after scaling and curettage, the gingiva appears hemorrhagic and bright red. After 1 week, the gingiva appears reduced in height owing to an apical shift in the position of the gingival margin. The gingiva is also redder than normal, but much less so than on previous days. After 2 weeks, and with proper oral hygiene by the patient, normal color, consistency, surface texture, and contour of the gingiva are attained, and the gingival margin is well adapted to the tooth. of recall maintenance.

THE GINGIVECTOMY TECHNIQUE GINGIVECTOMY Means excision of the gigngiva. By removing the diseased pocket wall that obscures the tooth surface, gingivectomy provides the visibility and accessibility necessary for complete removal of surface deposits and thorough smoothing of the roots. It also creates favorable environment for gingival healing and the restoration of a physiologic gingival contour. GINGIVECTOMY TECHNIQUE Was widely performed in the past. Improved understanding of healing mechanisms and the development of more sophisticated flap methods have relegated the gingivectomy technique to a lesser role in the current repertoire of available techniques. INDICATIONS The gingivectomy technique may be performed for1. Elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous or firm2. Elimination of gingival enlargements3. Elimination of suprabony periodontal abscess CONTRAINDICATIONS 1. The need for bone surgery or even for examination of the bone shape and morphologic features2. The bottom of the pocket located apical to the mucogingival junction3. Aesthetic considerations, particularly in the anterior maxilla SURGICAL GINGIVECTOMY STEP 1 The pockets on each surface are explored with a periodontal probe and marked with a pocket marker. Each pocket is marked in several areas to outline its course on each surface STEP 2 Periodontal knives are used for incision on the facial and lingual surfaces and those distal to the terminal tooth in the arch. The incision is started apical to the points marking the course of the pockets and is directed coronally to the point between the base of the pocket and the crest of the bone. Discontinuous or continuous incisions may be used. The incision should be beveled at approximately 45 degrees to the tooth surface and should re-create, as far as possible, the normal festooned pattern of the gingiva. STEP 3 Removed the excised pocket wall, clean the area, and closely examine the root surface. The most apical zone will consist of band-like light zone where the tissues were attached, and coronally to it some calculus remnants, root caries, or root resorption may be found. Granulation tissue may be seen on the excised soft tissue. STEP 4 Carefully curette out the granulation tissue and remove any remaining calculus and necrotic cementum, so as to leave a smooth and clean root surface. STEP 5 Cover the area with surgical pack. GINGIVOPLASTY Similar to gingivectomy, but its purpose is different It is reshaping of the gingiva to create physiologic gingival contours, with the sole purpose of recontouring the gingiva in the absence of pockets. May be done with periodontal knife, a scalpel, rotary course diamond stones, or electrodes. It consists of procedures that resemble those performed festooning artificial dentures HEALING AFTER SURGICAL GINGIVECTOMY Initial response after gingivectomy is the formation of a protective surface clot; the underlying tissue becomes acutely inflamed, with some necrosis. By 24 hours, there is an increase in new connective tissue cells, mainly angioblasts, just beneath the surface layer of inflammation and necrosis; by the 3rd day, numerous young fibroblasts are located in the area. After 12 to 24 hours, epithelial cells at the margins of the wound start to migrate over the granulation tissue, separating it from the contaminated surface layer of clot. Epithelial activity at the margins reaches a peak in 24 to 36 hours; the new epithelial cells arise from the basal and deeper spinous layers of the wound edge epithelium and migrate over the wound over a fibrin layer that is later resorbed and replaced by a connective tissue. Surface epithelialization is generally complete after 5 to 14 days. During the first 4 weeks after gingivectomy, keratinization is less than it was prior to surgery. Complete epithelial repair takes about 1 month. Vasodilation and vascularity begin to decrease after the fourth day of healing and appear to be almost normal by the 16th day. Complete repair of the connective tissue takes about 7 weeks. GINGIVECTOMY BY ELECTROSURGERY ADVANTAGES Electrosurgery permits adequate contouring of the tissue and controls hemmorhage DISADVANTAGES electrosurgery cannot be used in px who have a non-compatible or a poorly shielded cardiac pacemaker. Treatment causes an unpleasant odor. If the electrosurgery point touches the bone, irreparable damage can be done. Heat generated by injudicious uses can cause tissue damage and loss of periodontal support when the electrode is used to close the bone. When the electrode touches the root, areas of cementum burn are produced. TECHNIQUE The removal of gingival enlargements and gingivoplasty is performed with the needle electrode, supplemented by the small ovoid loop or the diamond-shaped electrodes for festooning. A blended cutting and coagulating current is used. In all reshaping procedures the electrode is activated and moved in a concise shaving motions. In the tx of acute periodontal abscesses, the incision to establish drainage can be made with the needle electrode without exerting painful pressure. For hemostasis, the ball electrode is used. Hemorrhage must be controlled by direct pressure first; then the surface is lightly touched with a coagulating current. Frenum and muscle attachments can be relocated to facilitate pocket elimination using a loop electrode. HEALING AFTER ELECTROSURGERY Some investigations report no significant differences in gingival healing after resection with periodontal knives. Others have reported delayed helaing, greater reduction in gingival height, and more bone injury after electrosurgery. LASER GINGIVECTOMY Lasers most commonly used in dentistry are carbon dioxide (CO2), and the neodymium;ytrium-aluminumgarnet (Nd:YAG) lasers, which have wavelengths of 10,600 nm and 1064 nm respectively. At present the use of lasers of periodontal surgery is not supported by research and is therefore discouraged. The use of lasers for other periodontal purposes, such as gingival curettage, is equally unsubstantiated and its also recommended. GINGIVECTOMY BY CHEMOSURGERY Several techniques using chemicals (5% paraformaldehyde or potassium hydroxide) to remove the gingiva has been described. ADVANTAGES:1. Their depth of action cannot be controlled, and therefore, healthy attached tissue underlying the pocket may be injured.2. Gingival remodelling cannot be accomplished effectively3. Epithelialization and reformation of the junctional epithelium and re-establishment of the alveolar crest fiber system are slower in chemically treated gingival wounds than in those produced by a scalpel.