DEN 150 final 1

Includes 54, 55 MISSING: 60, 58, 56, 59, 57

What can the dental assistant assist with during periodontal procedures?

periodontal charting

periodontal surgeries

provide home care instructions to the patient

The Periodontal Practice

Patients are referred by the general dentist or dental hygienist for treatment of a periodontal condition

*After the periodontal treatment, the patient will return to the general dentist for routine dental care

*Frequently, periodontal patients will alternate periodontal maintenance (cleaning) appointments between the periodontist’s office and the general dentist’s office

The Periodontal Examination

A periodontal examination includes:

Medical and dental history

Radiographic evaluations

Examination of the teeth

Examination of the oral tissues

Supporting structures

Periodontal charting

Periodontal charting includes pocket readings, furcation's,*tooth mobility, exudate (pus), and gingival recession

Medical and Dental History

Systemic diseases such as acquired immunodeficiency syndrome, human immunodeficiency virus infection, and diabetes can decrease resistance of the tissue to infection

Dental history used to gather information about conditions that could indicate periodontal disease

For example, patients with periodontal disease often complain

* of bleeding gums

* loose teeth

* bad taste in the mouth

Dental Examination

Mobility

• It is normal for teeth to have a slight amount of mobility (tooth movement) because of the cushioning effect of the periodontal membranes

• Excessive mobility important sign of periodontal disease

Oral Tissues and Supporting Structures

The periodontal examination includes:

• Assessment of the amounts of plaque and calculus

• Changes in gingival health and bleeding

• Assessment of the level of bone

• Detection of periodontal pockets

Supporting Structures

Periodontal Probing

A periodontal pocket results when the gingival sulcus becomes deeper than normal (<3 mm)

Periodontal probing measures how much epithelial attachment has been lost to disease

The greater the depth of the periodontal pocket results in

* the greater the loss of epithelial attachment

*the greater loss of bone

*more serious the periodontal disease

Periodontal pockets are very difficult, and sometimes impossible, for the patient to clean

Early Signs of Periodontal Disease

Changes in the gingiva (color, size, shape, texture)

Gingival inflammation

Gingival bleeding

Evidence of exudates

Development of periodontal pockets

Bleeding Index

The severity of gingival inflammation can be measured by the bleeding index

Several different systems of recording bleeding scores are used

Occlusal Adjustment

Patient’s bite is evaluated for areas of unequal pressure

Occlusal trauma can result if excessive biting pressure is noted in a specific area

Occlusal adjustment: Procedure that adjusts patient’s bite so that occlusal forces are equally distributed over all the teeth

Radiographic Analysis

Radiographs are a valuable aid for evaluating periodontal disease

Bitewing radiograph: Can accurately depict bone height along the root surface

Vertical bitewing radiographs are excellent for determining the extent of crestal bone loss

Periodontal Instruments

Periodontal therapy requires the use of specialized instruments

*to remove calculus,

*smooth root surfaces

* measure periodontal pockets,

*perform periodontal surgery

In general, the dentist or registered dental hygienist who uses these instruments takes responsibility for maintaining their sharpness

Periodontal Probes

Used to locate and measure the depth of periodontal pockets

On some types of probes, the tip is color-coded to make the measurements easier to read

Periodontal probe

* tapered to fit into the gingival sulcus

* shape is blunt or rounded tip

Six measurements are taken and recorded for each tooth

Scalers and Files

Sickle scalers are used primarily to remove large deposits of supragingival calculus

Chisel scalers are used to remove supragingival calculus in the contact area of anterior teeth

The blade on the chisel scaler is curved slightly to adapt to the tooth surfaces

Hoe Scalers are used to remove heavy supragingival calculus

Hoe Scalers are most effective when used on buccal and lingual surfaces of the posterior teeth

Curettes

Curettes are used to remove

*subgingival calculus,

*smooth rough root surfaces (root planning),

*remove the diseased soft tissue lining of the periodontal pocket (soft tissue curettage)

A curette has a rounded end, unlike a scaler, which has a pointed end

Two basic designs of curettes

• Universal

• Gracey

Types of Curettes

Universal curettes are designed so that one instrument can be used on all tooth surfaces

Gracey curettes have only one cutting edge and are area-specific

• They are designed for use on specific tooth surfaces (mesial or distal)

• Treatment of the entire dentition requires the use of several curettes

Pocket Markers

These perforations, which are referred to as bleeding points, are used to outline the area for an incision on the gingivae

Ultrasonic Scaler

Allows for rapid calculus removal and reduces hand fatigue for the operator

Works by converting very-high-frequency sound waves into mechanical energy in the form of very rapid vibrations

A spray of water at the tip prevents the buildup of heat and provides a continuous flushing of debris and bacteria from the base of the pocket

• Because of the spray of water at the tip, there is a large amount of potentially contaminated aerosol spray

• Highly desirable for the operator of an ultrasonic scaler to have the dental assistant help with using the high-volume evacuator to minimize aerosol contamination.

Indications for Use of the Ultrasonic Scaler

Removal of supragingival calculus and difficult stains

Removal of subgingival calculus, attached plaque, and endotoxins from the root surface

Cleaning of furcation areas

Removal of deposits before periodontal surgery

Removal of orthodontic cements; debonding

Removal of overhanging margins of restorations

Contraindications to Use of the Ultrasonic Scaler

Communicable disease: transmitted by aerosols, such as tuberculosis, poses a risk to the operator

Immunocompromised: A compromised patient is open to infection

Respiratory problems: Materials can be aspirated into the lungs of a patient with respiratory problems

Swallowing difficulty: Problems with swallowing or a severe gag reflex

Cardiac pacemaker: Consultation with the patient’s cardiologist is necessary

Precautions for Children

Young tissues are very sensitive to ultrasonic vibrations

These vibrations and heat may damage the pulp tissue of primary and newly erupted permanent teeth

Nonsurgical Periodontal Treatment

Dental prophylaxis

Prophylaxis is the complete removal of

*calculus

* soft deposits

* plaque

*stains from all supragingival

* unattached subgingival tooth surfaces

Dentist and dental hygienist are licensed to perform this procedure

Scaling, Root Planing, and Gingival Curettage

Scaling and root planing are done as part of a periodontal debridement

In some cases, gingival curettage, a nonsurgical technique, may also be indicated

A local anesthetic is usually administered before these procedures

Scaling

Scalers

*supragingival calculus from the tooth surface

Curettes

*remove supragingival and subgingival calculus

Root Planing

Root planing is performed after scaling procedures to remove any remaining particles of calculus and necrotic cementum embedded in the root surface

After root planing, the surfaces of the root are smooth and glasslike

Anesthetic is usually required for this procedure

Gingival Curettage

Curettage means scraping or cleaning with a curette

Some patients also require gingival curettage in addition to scaling and root planing

Gingival curettage, also known as subgingival curettage, is the scraping of the gingival lining of a periodontal pocket

This is performed to remove necrotic (dead) tissue from the pocket wall

Antimicrobial and Antibiotic Agents

Tetracycline is an antibiotic that is particularly useful for the treatment of periodontitis

Penicillin

Fluoride mouth rinses

A twice-daily chlorhexidine rinse (Peridex) is the most effective means available for reducing plaque and gingivitis

Locally Delivered Antibiotics

New methods can be used to apply antibiotics directly into the periodontal pockets

In one technique, a fiber that contains tetracycline is packed into periodontal pockets

Other methods include using a syringe to insert dissolvable materials such as a gel into the pocket

A dissolvable chip that releases chlorhexidine is inserted into deep pockets

Surgical Periodontal Treatment

When nonsurgical treatment is ineffective in stopping the disease process, periodontal surgery is indicated to control the progress of periodontal destruction and loss of attachment.

Advantages of Periodontal Surgery

*Allows access to the root surface for scaling and root planing

*Makes it easier for the patient to clean difficult areas

*Results in better access to furcations and other areas that are very difficult to reach during traditional scaling and root planing

Disadvantages of Periodontal Surgery

The health status of the patient, age of the patient as well as limitations of the procedures

From the patient’s point of view: Time, cost, esthetics, and discomfort

Excisional Periodontal Surgery

This surgery is used to remove the excess tissue

It is the most rapid means of reducing periodontal pockets

Common Types of Excisional Surgeries:

*Gingivectomy

*Gingivoplasty

Gingivectomy

Gingivectomy is the surgical removal of diseased gingival tissues

Performed when it is necessary to reduce the depth of the periodontal pocket and when fibrous gingival tissue must be removed

Recently, the use of dental laser equipment in gingivectomy has become popular

Gingivoplasty

*surgical reshaping

*contouring of the gingival tissues

Incisional Surgery

Incisional surgery known as periodontal flap surgery or simply flap surgery

Performed when an excisional surgery is not recommended

Osseous (Bone) Surgery

Periodontal surgery that involves modification of the supporting bone

This surgery is performed to eliminate pockets, remove defects, and to restore normal contours in the bone

Two types of bone surgeries are:

Osteoplasty

Ostectomy

Osteoplasty

In osteoplasty, or additive surgery,

*bone is contoured and reshaped

In addition, bone may be added, either through bone grafting (taking bone from one area and placing it in another) or placement of bone substance.

Ostectomy

In ostectomy, or subtractive surgery, bone is removed

This procedure is necessary when the patient has large exostoses (bony growths)

For example, ostectomy is performed if a patient needs a denture and the bony growth would interfere with the comfort and fit of the denture

Crown Lengthening

A surgical procedure that is designed

* to expose more tooth structure for the placement of a restoration such as a crown

Crown lengthening is becoming a very common procedure for esthetic anterior restorations

Soft Tissue Grafts

Pedicle graft

The pedicle graft is “freed” on three sides but remains attached on one side and retains its blood supply

Free gingival soft tissue graft

Has a donor site that is located away from the grafted site

Postsurgical Patient Instructions

After surgery, the periodontist will most likely prescribe an analgesic and possibly an antibiotic

Many periodontists recommend the use of an antibacterial rinse twice a day to help with plaque control

A chlorhexidine mouthwash may also be used during the first week to freshen the mouth and inhibit plaque formation during the early stages of healing

Postoperative instructions should be given to the patient to ease discomfort and promote healing

Periodontal Surgical Dressings

Periodontal dressings, also known as periopacks, are used to:

Hold the flaps in place

Protect the newly forming tissues

Minimize postoperative pain, infection, and hemorrhage

Protect the surgical site from trauma during eating and drinking

Support mobile teeth during the healing process

Types of Periodontal Surgical Dressings

The most commonly used materials are:

Zinc oxide–eugenol (ZOE) dressing

Noneugenol dressing

ZOE Dressing

Patient may experience redness and burning pain in the area of the dressing

ZOE dressings are supplied as a powder and a liquid that are mixed before use

Material may be mixed ahead of time, wrapped in waxed paper, and frozen for future use

ZOE has a slow set time, which allows for a longer working time

Sets to a firm, heavy consistency and provides good protection for tissues and flaps

Some patients are allergic to the eugenol

Noneugenol Dressing

Most widely used type of periodontal dressing

Supplied in two tubes: One of base material and the other of the accelerator

Easy to mix and place and has a smooth surface for patient comfort

Has a rapid setting time if exposed to warm temperatures

Cannot be mixed in advance and stored

Lasers in Periodontics

The term laser is an acronym for light amplification by simulated emission of radiation

A laser beam is a highly concentrated beam of light

Power of this beam can be adjusted to enable it to cut, vaporize, or cauterize tissue

The use of lasers is a promising new technology in dentistry

Use of Lasers on Soft Tissue

*Removal of tumors and lesions

*Vaporization of excess tissues, as in gingivoplasty, gingivectomy, and frenectomy

*Removal of or reduction in hyperplastic tissues

*Control of the bleeding of vascular lesions

*Aid in the removal of cold sores on the lip

Advantages of Laser Surgery over Conventional Surgery

Laser incisions heal faster than incisions made with electrosurgery

*Hemostasis (control of bleeding) is rapid

*The surgical field is relatively dry

*The opportunity for bloodborne contamination is reduced

*There are fewer traumas to adjacent tissues

*There is less postsurgical swelling, scarring, and pain

*Some procedures can be performed more quickly

*Patients who are afraid of “surgery” may accept this method

Laser Safety

Precautions must be taken to protect both the patient and dental staff during laser procedures

Any person who operates a laser or assists during a laser operation must be thoroughly trained in the use of this powerful instrument

Guidelines for Laser Safety

*Shielded eyeglasses: Protect the eyes; dental staff and patient must wear special shielded eyeglasses

*Matte-finished instruments: Reflective surfaces such as instruments, mirrors, and even polished restorations can reflect laser energy

*Protection of nontarget tissues: Nontarget oral tissue (tissues not being treated with the laser) should be shielded with the use of wet gauze packs

*High-volume evacuation: High-volume evacuation should be used to draw off the plume (cloud) created when tissue vaporizes

This plume should be considered infectious

Endodontics

The specialty of dentistry that manages the prevention, diagnosis, and treatment of the dental pulp and the perio radicular tissues surrounding the root of the tooth

Causes of Pulpal Nerve Damage

Physical irritation

• Extensive decay moving into the pulp

Trauma

• Blow to a tooth or jaw

Signs and Symptoms of Pulpal Nerve Damage

Pain when occluding

Pain during mastication

Sensitivity to hot or cold beverages

Facial swelling

Fever

Tenderness of surrounding gums

Cracked or discolored teeth

Endodontic Diagnosis: Subjective Examination – Patient Describes

Chief complaint

Painful stimuli

Character and duration of pain

Sensitivity to biting and pressure

Endodontic Diagnosis: Objective Examination – Dentist Findings

Extent of decay

Periodontal conditions

Extensive restoration

Tooth mobility

Swelling or discoloration

Pulp exposure

Percussion Test

Determines whether the inflammatory process has extended into the periapical tissues

The dentist taps on the incisal or occlusal surface with the end of the mouth-mirror handle held parallel to the long axis of the tooth

Palpation Test

Determines whether the inflammatory process has extended into the periapical tissues

The dentist applies firm pressure to the mucosa above the apex of the root

Thermal Sensitivity

Necrotic pulp will not respond to cold or heat

1. Cold test

• Ice, dry ice, or carbon dioxide is used to determine the response of a tooth to cold

2. Heat test

• A piece of gutta-percha or an instrument handle is heated and applied to the facial surface of the tooth

Electric Pulp Testing

A small electrical stimulus is delivered to the pulp-determine if tooth is vital or nonvital.

Factors that may influence readings include:

• The patient has extensive restorations

• The patient has teeth with more than one canal

• Failing pulp produces a variety of responses

• Control teeth don’t respond as anticipated

• There is moisture on the tooth during testing

• The batteries in the tester weaken over time

Five (5) Radiographic Imaging Taken for Endodontic Treatment

Initial radiograph: Diagnosis

Working length image: To determine the length of the canal

Final instrumentation image: Final size files in all canals

Root canal completion image: Taken after the tooth has been temporized

Recall image: Taken at posttreatment evaluations

Requirements of Radiographic Images

Must show apex of the tooth and the surrounding bone or pathologic condition

Must present an accurate image

Must exhibit good contrast so that all pertinent structures are readily identifiable

A. Good contrast around apex

B. Poor Contrast around apex

Diagnostic Conclusions

Normal pulp

• No subjective symptoms or objective signs are noted

• The tooth responds normally to sensory stimuli, and a healthy layer of dentin surrounds the pulp

Pulpitis

• The pulp tissues have become inflamed

Reversible pulpitis

• The pulp is irritated, and the patient is experiencing pain in response to thermal stimuli

Irreversible pulpitis

• The tooth displays symptoms of lingering pain (pulp incapable of healing)

Diagnostic Conclusions: Periradicularor Periapical Abscess

This inflammatory reaction surrounding the tip of the root has pulpal infection which can be chronic or acute onset with pain, tenderness of the tooth due to pressure, pus(exudate), and swelling of the tissues.

Tooth has experienced bone loss and bacteria having access along the root.

• Chronic-presence of a draining sinus tract

• Acute-pain, tenderness, swelling because of the necrosis (dying)

Diagnostic Conclusions: Periodontal Abscess

Inflammatory reaction caused by bacteria trapped in the periodontal sulcus

A patient will experience rapid onset of pain, tenderness of the tooth in response to pressure, pus formation, and swelling

• Chronic

• Acute

Diagnostic Conclusions: Periradicular or Perioapical Cyst

This type of cyst develops at or near the root of a necrotic tooth

The cyst develops as an inflammatory response to pulpal infection and necrosis of the pulp

Diagnostic Conclusions: Pulp Fibrosis

A decrease in living cells within the pulp causes fibrous tissue to take over the pulpal canal

(Mostly seen in older patients.

Patients with recent trauma to a tooth may be susceptible)

Diagnostic Conclusions: Necrosis

The tooth may also be referred to as nonvital

• The term is used to describe a tooth that does not respond to sensory stimulus

Endodontic Procedures: Pulp Capping

Pulp capping is an attempt to save the tooth.

Calcium hydroxide is placed over an exposed or nearly exposed pulp to encourage the formation of dentin at the site of injury

2 types of capping:

• Indirect pulp capping (IPC) is indicated when a thin portion of dentin is still intact

• Direct pulp capping (DPC) is indicated when the pulp has been slightly exposed

Endodontic Procedures: Pulpotomy

This procedure involves removal of the coronal portion of an exposed vital pulp

It is used to preserve the vitality of the remaining portion of the pulp within the root of the tooth

The procedure is commonly indicated for vital primary teeth, teeth with deep carious lesions, and emergency situations

Endodontic Procedures: Pulpectomy

This procedure involves the complete removal of the dental pulp

Also referred to as root canal therapy

Instruments and Accessories for Endodontic Procedures

Hand instruments

Explorer

Endodontic spoon excavator

Spreaders and pluggers

Glick Number 1-used to remove excess gutta

percha

ORDER OF INSTRUMENTS USED IN ENDO

TREATMENT

1. Endo Explorer

2. Files

3.Paper Points

4.Gutta Percha

5. Glick Number 1

Hand-operated files

K-type file- cleaning of canal initially

Hedstrom file- spiral edges, cutting occurs only in the pulling stroke

Reamer file- remove dentin, to smooth and increase size of canal

Broaches- remove necrotic pulp tissue from canal

Rotary-operated files and burs

Gates-Glidden burs-first instrument used to enlarge

the cervical portion of the root canal.

Pesso files-to prepare canal for endodontic post

Auxiliary instruments

Rubber stops

Paper points-used to dry canal

Microscopic Endodontics

Medicaments and Dental Materials in Endodontics

Irrigation solutions

• Sodium hypochlorite (Bleach)

• Ethylenediaminetetraacetic acid (EDTA)

• Chlorhexidine (Peridex)

Intracanal medicaments

• Calcium hydroxide

• Chlorhexidine gel

Root canal sealers

Root canal filling materials

• Gutta-percha points

Overview of Root Canal Therapy

Anesthesia and pain control

Isolation and disinfection of the operating field(rubber dam)

Access preparation

Estimated working length (files)

Electronic apex locator

Debridement and shaping of the canal

Obturation (filling and sealing a tooth with root canal material)

Surgical Endodontics

Indications for surgical intervention

Endodontic failure

• Persistent infection, severely curved roots, perforation of the canal, fractured roots, extensive root resorption, pulp stones, or accessory canals that cannot be treated

Exploratory surgery

• To determine why healing did not occur

Biopsy

Apicoectomy and Apical Curettage

To surgically remove the apical portion of the root with the use of a high-speed handpiece and bur

To evaluate the following:

• Inadequate sealing of the canal

• Accessory (extra)canals

• Fractures of the root

• Pathologic tissue around the root apex

Retrograde (root-end filling) Restoration

This procedure is undertaken when an apical seal is not adequate

A small class I preparation is made at the apex and sealed with filling materials such as gutta-percha, amalgam, or composite

Root Amputation and Hemisection

Root amputation

• This surgery is performed to remove one or more roots of a multirooted tooth without removing the crown

Hemisection

• The root and the crown are cut lengthwise and removed

abscess

a localized infected area with accumulating pus

acute

sudden or onset illness or pain with a short duration

apical curettage

a surgical procedure that involves the removal of tissue surrounding the apex of a tooth

apicoectomy

a surgical procedure to remove the apex of a tooth's root, usually to treat infection.

chronic

a long-lasting condition or illness that persists over time.

control tooth

A tooth that is used as a reference for comparison in dental studies or treatments.

debridement

The process of removing decayed or infected tissue from a tooth or surrounding area and cleaning out the pulpal canal

direct pulp cap

application of a dental material with an exposed or nearly exposed dental pulp

endodontist

A dental specialist who diagnoses and treats dental pulp and root canal issues, focusing on saving teeth with advanced procedures.

gutta-percha

A biocompatible material used to fill and seal the pulpal canal during root canal treatment.

indirect pulp cap

placement of a sedative material when pulp tissue is close to the surface but not completely exposed

irreversible pulpitis

A painful condition occurring when the dental pulp becomes inflamed and irreversibly damaged, often requiring root canal therapy.

nonvital

dead

obturation

The process of filling a root canal space after endodontic therapy to seal it and prevent reinfection.

palpatation

The act of applying pressure to a specific area of the body to assess for pain, swelling, or other abnormalities.

percussion

The act of tapping on a surface to elicit sounds or vibrations in order to assess underlying structures or conditions.

periodontal abscess

localized infection within the periodontal sulcus

periradicular

refers to the area of nerves, blood vessels, and connective tissue surrounding the apex of a tooth root.

periradicular abscess

inflammatory reaction to pulpal infection

pulpectomy

a dental procedure that involves the removal of the pulp tissue from the tooth to treat infection or decay.