#9 Periodontal Procedures – Part 2

In topic #8, the den­tal pro­ce­dure of scal­ing ( clean­ing ) to remove plaque and cal­cu­lus above the gums and in shal­low spaces below the gums was dis­cussed. Now den­tal pro­ce­dures for remov­ing plaque and cal­cu­lus in mod­er­ate and deep spaces below the gums will be discussed.

To remove plaque and cal­cu­lus in mod­er­ate depth spaces below the gums, a den­tal pro­ce­dure called scal­ing and root plan­ning is used. In sim­ple terms, this pro­ce­dure can be thought of as a deep clean­ing. How­ever this pro­ce­dure is dif­fer­ent than scal­ing in a num­ber of ways. First, some form of local anes­the­sia is com­monly used so that the patient can tol­er­ate the pro­ce­dure as the instru­ments go fur­ther under the gums than in the scal­ing pro­ce­dure. This pro­ce­dure is more inten­sive and more time con­sum­ing than scal­ing as the root are planned smooth in addi­tion to the removal of plaque and calculus.

How­ever the scal­ing and root plan­ning pro­ce­dure is only designed to remove plaque and cal­cu­lus in mod­er­ate depth spaces below the gums. Its lim­i­ta­tion is that this pro­ce­dure will not remove all plaque and cal­cu­lus in deep spaces below the gums regard­less of the den­tist or hygien­ist per­form­ing this pro­ce­dure. This risk of this pro­ce­dure is the same as scal­ing when it comes to areas with deep spaces below the gums.

The scal­ing and root plan­ning pro­ce­dure will improve the super­fi­cial lay­ers of the gums and result in less bleed­ing, how­ever the con­tin­ued increased risk of bone loss in the areas where the plaque and cal­cu­lus remain in the deep spaces under the gums is still present. Bone loss will often con­tinue dur­ing the fol­low­ing years in the areas with deep spaces while the super­fi­cial lay­ers of the gums will appear improved, there­fore giv­ing the patient a false impres­sion of improve­ment in their peri­odon­tal condition.

The rea­son for this lim­i­ta­tion of scal­ing and root plan­ning is the same as for scal­ing, being that the den­tist or hygien­ist is work­ing only by feel to remove the plaque and cal­cu­lus. The full extent of the plaque and cal­cu­lus below the gums can not be seen with the scal­ing and root plan­ning pro­ce­dure alone and that is the rea­son why plaque and cal­cu­lus will be left in deep spaces using this procedure.

For removal of plaque and cal­cu­lus in deep spaces below the gums, the den­tal pro­ce­dure of peri­odon­tal surgery is used. There are dif­fer­ent vari­a­tions of peri­odon­tal surgery for this pur­pose; how­ever what the dif­fer­ent types of surg­eries have in com­mon is access and vis­i­bil­ity. In surgery the gums are lifted up and moved to the side to expose the entire roots and the bone under the gums. This expo­sure cre­ates the access and vis­i­bil­ity needed by the den­tist or peri­odon­tist to reach, see and remove the remain­ing plaque and cal­cu­lus on the roots of the teeth. This expo­sure also cre­ates the access and vis­i­bil­ity to the bone to remove infected soft tis­sue above the bone, to smooth sharp edges of bone, to add bone grafts if pos­si­ble and to add mem­branes and other mate­ri­als if pos­si­ble to regen­er­ate bone and improve gum attach­ment to the roots of the teeth. At the end of the surgery, the gums are replaced to cover the roots and bone and on heal­ing the gums reat­tach to the roots and the bone.

There are a few lim­i­ta­tions of the peri­odon­tal surgery pro­ce­dure. In some cases, it is best not to do this pro­ce­dure due to the gen­eral med­ical con­di­tion of the patient and only do the scal­ing and root plan­ning pro­ce­dure with or with­out local antibi­otic deliv­ery. In other cases, cost may be a fac­tor in lim­it­ing this pro­ce­dure. In cases where the oral hygiene of the patient is not good and where the patient is not fully com­mit­ted to reg­u­lar main­te­nance vis­its, peri­odon­tal surgery in the long term will not be suc­cess­ful as the plaque and cal­cu­lus will return deep under the gums after a few years. Also this pro­ce­dure for the pur­pose of plaque and cal­cu­lus removal is designed only for deep spaces below the gums.

In cases of gum inflam­ma­tion, when plaque and cal­cu­lus is removed by scal­ing, scal­ing and root plan­ning, surgery or any com­bi­na­tion of these pro­ce­dures, the inflam­ma­tion in the gums will decrease or dis­ap­pear often expos­ing more of the tooth roots as the gums move closer to the bone. Actu­ally the gums mov­ing closer to the bone means that the spaces below the gums in that area has become more shal­low, which is a desired goal of any of these pro­ce­dures. How­ever due to the increased root expo­sure, some­times root sen­si­tiv­ity devel­ops. Whether root sen­si­tiv­ity devel­ops or not is not pre­dictable as many peo­ple have many areas of exposed roots with no sen­si­tiv­ity whereas other peo­ple have a small area of root expo­sure with root sen­si­tiv­ity. This root sen­si­tiv­ity if it devel­ops is often treated by desen­si­tiz­ing tooth pastes or other chem­i­cals and is usu­ally temporary.

In future top­ics, other aspects of gin­givi­tis, peri­odon­tal dis­ease or related top­ics will be discussed.