Professional Documents
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Perio Clinic Manual
Perio Clinic Manual
DIVISION OF PERIODONTOLOGY
CLINICAL MANUAL
Edition 2003 2004
TABLE OF CONTENTS
PAGE
Preface
Introduction
Patient Examination
The Odontogram
I.
Gingival Diseases
12
II.
Periodontitis
13
III.
14
IV.
14
V.
VI.
14
15
15
15
Phases of Treatment
15
Phase II Re-Evaluation
17
18
Case Presentation
20
21
PAGE
Appendix A: Periodontal Form 1
25
Periodontal Form 2
26
27
29
32
36
40
42
PREFACE
This manual has been written for the undergraduate students in the College of
Dentistry, King Saud University who will be Inshallah the next generation of dental
practitioners in the Kingdom. It is meant to guide the student through the procedures
to be followed in patient management in the undergraduate periodontal clinic. The
preventive basis underlying the management of periodontal diseases is highlighted
and great importance is placed on patient examination and treatment planning
objectives.
From this approach, a student dentist will achieve competence in the
techniques available to prevent the occurrence of diseases, treat the diseases should
they occur and finally to maintain the health of their patients and in that way to
minimize as much as possible the need for more radical and costly periodontal
surgical procedures.
The manual was prepared by Dr. basher J. Zulqarnain and Dr. Mohammed
Eid. Later on, it was reorganized by Dr. James E. Stakiw.
Thanks are due to the following current and past members of the Division of
Periodontology who contributed greatly in the preparation of this manual:
Thanks also for PDS Department Secretary Ms. Elizabeth Posadas for her
help in typing and organizing of this manual.
Last, it revisited and updated by Dr. Abdulaziz Al-Rasheed (9th September
2003G [1424H].
INTRODUCTION
This manual has been prepared to assist you, the student dentist, to gain
competence in clinical techniques and administrative procedures, which once
mastered can provide the basis for the successful management of the periodontal
patient in your practices.
A description of general protocol and performance standards expected in the
clinic is presented and the importance of this manual as the reference source on most,
if not all clinical matters cannot be overstated.
Students must be in the clinic on time and be ready to begin their work.
Students should wear clean clinic gowns/lab coats and appear wellgroomed and professional.
3.
4.
The patients file, evaluation forms etc. should be available with initial
entries already made before starting the actual procedures.
5.
6.
7.
The student should be prepared to discuss the treatment planned and the
rationale for the procedures drawing upon knowledge gained earlier
regarding etiology, progression of the disease, treatment planning, results
expected, prognosis of the dentition and other relevant topics.
8.
9.
10.
Do not call an instructor to check your work at the last minute you
should leave at least 20 minutes for a worthwhile teaching learning
evaluation process. It is important that you do not RUSH through your
clinical work. There is nothing wrong in having an incomplete on your
daily record this likely means you are aware of what your treatment
goals are and are in the process of logically achieving these. There is
nothing more frustrating to everyone concerned than to see you have
rushed through your work leaving calculus undetected, tissues in poor
shape, instruments in disarray and then expect to have a good grade. Be
mature and professional about your work.
11.
ALL
INFORMATION
PERTIENNT
TO
THE
CLINICAL
2.
periodontal management of the patient. By developing a keen use of all the students
relevant senses, a correct diagnosis and treatment plan for the patient is arrived at for
the benefit of all concerned.
instructor/student analysis of this form for most patient PLAN YOUR TIME
ACCORDINGLY. You may do odontogram charting at the first appointment
followed by completion of the remainder of the form at a subsequent appointments.
Take your time on this form. Haste makes waste.
The Perio Form 2 is hygiene form. This form is used to record bleeding on
probing and plaque score (percentage) on initial and subsequent visits for recall and
re-evaluation.
6
PATIENT EXAMINATION
Remember, your periodontal examination must of necessity include a general
assessment of the overall health and disease status of the patient and a relevant
dental/oral/facial examination.
comprehensive dental/oral health care and disease management. That is why your
instructor will stress that you do a general and dental examination in addition to the
periodontal examination of your patient.
Examination Kit
This kit includes:
1.
Mouth mirror
2.
Periodontal probe
3.
Explorer #2
4.
Cotton pliers
5.
6.
A white plastic lined paper bag or plastic cup taped to the right side of the
bracket table to receive waste.
The instruments and materials should be neatly arranged from left to right on
your bracket table. The patients file, current radiographs and student evaluation form
must be neatly displayed and readily available for the instructors use.
The following may also be required during patient examination and should be
available:
1.
2.
3.
Dental floss
4.
5.
6.
Study casts
7.
Patient toothbrush (patients should bring their own toothbrushes for each
appointment).
Begin your professional relationship with your patient through completing the
oral hygiene section. You will want to determine your patients attitude to oral
hygiene since this will affect your management of the patient over the short and long
term.
Record your examination findings either:
1.
2.
General
A patient assigned to the periodontics clinic usually will have had much of the
dental chart completed by the screening/oral diagnosis divisions. It is important you
review this information. If this section is incomplete notify your instructor. It is
important you review the completed information at each visit asking the patient if
there have been any changes to their medical/dental status. Proceed on how to
complete the top part of the Perio Form 1. Any relevant medical history which may
compromise the patient on your treatment must be noted in the Medical Alert box.
Use red pencil for medical alert.
The next step is to complete the chief complaint, history of past treatment, and
summary of medical history sections particularly as to how the latter may affect the
clinical management of the patient. Under history of past treatment you will want to
know about history of the clinical complaint, when the patient last had dental
treatment, how long ago, what was done and were there any difficulties or
complications.
Call the instructor to obtain an approval to continue with patient examination.
General Appearance
Note the general appearance/personality of patient whether robust or sickly,
nervous, tense or relaxed and content. Approximate height and weight.
Extra-Oral
Examine the patient and record your findings regarding lymph nodes, TMJ
status and function, masticatory musculature etc.
Intra-Oral
Record if there is bad breath (foetid odor). This may alert you to possible
pathology being present. Begin your examination by recording any change of the
lips, commissures, then go on to alveolar/buccal mucosa, tongue, floor of mouth and
upper pharynx. Do a complete oral examination.
Describe all gingival surfaces including colour, contour, consistency etc.
Describe the worst areas first followed by those with decreasing pathology and
minimally describe normal tissue findings. At the beginning of your program you
may be asked to describe normal tissues in greater detail.
THE ODONTOGRAM
The Perio Form 1, Periodontal Assessment and Treatment Plan contains
portions of chief complaint, history oral, medical history, examination, extra-oral and
intra-oral. The odontogram provides space for writing sensitivity, pocket depth,
furcation, mobility, recession, and periodontal diagnosis.
Note: If bleeding on probing occurs, put a red dot in the square of the tooth where
bleeding occurred.
When you have completed the odontogram section of the chart, have an
instructor go over the information gathered so far.
Supplementary Tests
Indicate in this section tests which are indicated to confirm or verify the
potential problems discovered during examination of the patient.
Calculus Present
Indicate the presence of calculus in each sextant by the appropriate sign as
follows:
S
Supragingival calculus
SS
SG
Subgingival calculus
10
NOTE :
Missing sextant
You must have at least two (2) teeth in a sextant to be counted.
Etiologic Factors
Here you should list all of the factors which have and are accounting for the
periodontal pathology you have noted in the chart so far. These are discussed further
in your lecture series.
Periodontal Diagnosis
All the relevant and important facts regarding the patient have been collected
and neatly recorded in the chart. The CORRECT periodontal diagnosis must now be
arrived at by a process of reasoning and common sense.
You will note space has been allocated in the chart for a systemic/oral
diagnosis and above each tooth a square for periodontal diagnosis. Systemic diseases
having a direct/indirect bearing on the periodontium e.g. diabetes mellitus should be
included as well as oral diagnostic findings e.g. caries, multiple missing teeth (plus
tooth numbers) etc.
In the appropriate square above each tooth, indicate the diagnostic code for
the American Academy of Periodontology (AAP) 1999 classification from the
following list:
Diagnosis (Modified from American Academy of Periodontology AAP
classification 1999).
This is a brief description lists of the classification and student need to return
back to the lectures in the periodontal courses and the recommended textbook
(Chapter 4, Clinical Periodontology, Carranza, 9th Edition, 2002) for more details.
11
I.
GINGIVAL DISEASES:
I-A.
There is
plaque accumulation around the teeth but the response of the gingival
tissue exaggerated due to presence of systemic factors such as
pregnancy, puberty and diabetic etc.
I-A3. Gingival diseases modified by medications:
response of
response of
I-B.
infections.
12
such as generalized
gingival candidosis.
I-B4. Gingival diseases of genetic origin:
such as Hereditary
gingival fibromatosis.
I-B5. Traumatic lesions of the gingiva: such as chemical, physical
and/or thermal injury to the gingival tissue.
I-B6. Foreign body reactions of the gingiva: such as changes of
gingival tissue as the result of introduction of amalgam into the
gingiva during the placement of a restoration.
II.
PERIODONTITIS:
It is an inflammatory disease of the supporting tissues of the teeth caused by
It include the
followings:
II-A. Chronic Periodontitis:
Most common form of perodontitis and it is associated with
accumulation of plaque and calculus and generally has a slow to moderate rate
of disease progression.
Extent:
-
Localized form:
Severity:
II-A1. Slight: 1-2 mm of clinical attachment loss.
II-A2. Moderate: 3-4 mm of clinical attachment loss.
II-A3. Severe: 5 mm or more of clinical attachment loss.
13
Note: Clinical attachment loss is measure from CEJ to the base of the pocket
i.e. recession + pocket depth.
Recession measure: from CEJ to gingival margin.
Pocket depth measure: from gingival margin to the base of the sulcus.
II-B. Aggressive periodontitis:
It is less frequent form of periodontitis.
III.
IV.
V.
Periodontal-Endodontic Lesion.
14
VI.
DEVELOPMENTAL
OR
ACQUIRED
DEFORMITIES
AND
CONDITIONS:
VI-A. Localized tooth-related factors that predispose to plaque induced
gingival diseases or periodontitis.
VI-B. Mucogingival deformities and conditions around teeth.
VI-C. Mucogingival deformities and conditions on edentulous ridges.
VI-D. Occlusal trauma.
Emergency treatment:
Abscess
Endodontic Therapy RCT
Extraction of hopeless tooth
Trauma etc.
Emergency treatment rendered as necessary.
Phase I:
Phase II:
Phase III:
Phase IV:
2.
b.
OHI: You should always what aids the patient is using before
giving him/her advise as to what to use. Mention what toothbrush and
brushing technique is used by the patient.
16
NOTE:
If the patient present with good hygiene bucally and lingually and an
acceptable hygiene interdentally, limit your instructions to interdental
cleaning. You must indicate and list all oral hygiene and teaching aids
you will prescribe to your patient. E.g. Butler 311 with modified Bass
technique, dental floss and proximal brush in molar areas.
c.
d.
e.
f.
g.
Occlusal adjustment.
h.
Orthodontic consultation.
Phase II Re-evaluation
Re-evaluation: 4-6 weeks after initial therapy.
At the time of initial treatment planning for areas having 6 mm or
more pockets, it might be necessary to treat them surgically. Identify all such
areas as needing periodontal surgery (this part is actually decided at the time
of Re-evaluation). After-re-evaluation you must specify the areas that need
surgery and the suggested procedure, e.g.:
a.
b.
c.
Surgery
Prosthesis
a. Full thickness mucoperiosteal flap #13 to 17 with possible ostectomy,
M16.
17
5.
Case Presentation
The importance of developing an ability to present the treatment plan to the
patient cannot be over emphasized for a number of reasons the main one being the
obtaining of informed consent from the patient for the treatment you are considering
doing for the patient. In addition, be enthusiastic about the treatment planned as being
of benefit to the patient and always seek to establish in the mind of the patient that
periodontal care is a primary treatment goal that for the long term success of all dental
treatment must be accomplished first in priority.
Include the following in your case presentation:
1.
Discuss what you did in the examination procedure and explain your findings.
2.
3.
Discuss the sequential treatment plan step by step and indicate how much time
and how many visits it may take to complete the Phase I therapy.
Phase II Re-Evaluation
In the initial therapy, measures are taken to eliminate or bring as close to zero as
possible the etiologic factors for periodontal disease i.e. The BACTERIAL PLAQUE.
If the initial therapy is well done, only minimal amount of bacteria remain on the teeth
and the body is capable of dealing with the bacterial. The inflammatory reaction in the
periodontium will gradually diminish and the periodontal tissues will eventually return
to a healthy states. This will be a permanent result as long as bacterial masses are not
18
allowed to accumulate in the dentogingival region. The healing process will however
continue during a period of several months which a rebuilding of ground substances and
supporting collagen fibers in the gingiva takes place. The most superficial parts of the
periodontium, the gingiva, thereby regains a firm consistency and a pale pink color.
In our evaluation of the effects of initial therapy, we should therefore leave the
patient without intervention for a period of 6 weeks.
Re-evaluation appointment must, therefore, be scheduled at least 4-6 weeks after
the completion of Phase 1 Therapy.
The ability of the patient to keep his teeth clean during a prolonged period
without professional help.
appearance, (2) bleeding index, (3) plaque index (with disclosing solution).
2.
The capacity of the tissues of the periodontium to heal. This is assessed through
measuring pocket depth and bleeding on probing index.
3.
This is also an evaluation of the skill of the therapist to inform, motivate and
encourage the patients as well as give accurate and reasonable advice to the
patients about the cleaning of all surfaces of the teeth. It is also a test of the
dentist's skill to perform thorough scaling and root planning.
The information that is obtained must be analyzed before further
decisions are taken.
b.
c.
19
2.
3.
4.
5.
6.
b.
c.
This means that the patient is ready and you can proceed to the next step.
7.
8.
At this stage, you should be able to inform the instructor that the patient is ready
(or not) for re-evaluation procedure. If you are correct, the instructor will give
you the "go ahead" to complete the re-evaluation.
9.
If the patient is not ready, record your findings on the patient's chart. Re-instruct
your patient in OHI, re-scale and polish the teeth as needed and re-schedule the
patient after a week or two. The patient must leave your cubicle with a mouth
that is completely free of plaque.
You must be able to determine and explain to the instructor why the
patient is not ready for re-evaluation and what are you planning to do for
correcting this situation.
If you did not follow the step the instructor have the right to dismiss the
patient.
Phase III:
20
Phase IV:
21
The final two years of the student's clinical training are viewed by the
Division of Periodontics as a continuum of experience. Clinical components
form an essential part of all courses offered by the Division, but in grading, PDS
311 and 411 carry a heavy didactic weight.
22
Preparation
i.
ii.
Be punctual
iii.
iv.
Have the evaluation form properly complete and ready for appraisal.
v.
Have entered the details of the procedure performed on the patient in the
daily treatment record, for the instructor's signature.
Empathy toward patient, professional appearance and behavior and
Knowledge
The student should demonstrate his/her understanding of the rationale,
objective and indications for the planned procedure. Students are expected to
review material pertaining to the planned procedure prior to coming to the clinic
and will be expected to discuss all procedures and basic concepts pertaining to
the procedure with the instructor.
C.
Excellent (95%)
Will be awarded when the student performs at a satisfactory level
and does so independently. The work needs no improvement and no
faculty guidance or assistance.
VG.
G.
Good (85%)
Will be awarded when the student is able to perform at a
satisfactory level with little guidance and no assistance. The procedures
needed minimal improvement.
S.
Satisfactory (75%)
Will be give when the student needed considerable guidance or
instruction to complete the procedure satisfactorily.
The procedure
U.
Unsatisfactory (40%)
Will be given when the procedure could not be completed
satisfactorily by the student, or the patient was exposed to unnecessary
risk or had been inflicted unwarranted injury.
O.
Zero
This grade will be given when the performance and the
professionalism of the student is unacceptable and the patient or the
student has to be dismissed.
A student found ignorant in "knowledge" and is not prepared to perform
Subjective Evaluation
While every attempt is made to insure that the clinical evaluations and
grading system is objective, it must be recognized that it may be difficult
sometimes to design a perfect system.
As such, there must be a high value placed on the individual and
cumulative judgement and experience of the Division of Periodontics faculty.
Therefore, each students' grade will be reviewed by the faculty at the end of the
grading period. Grading policy and evaluative procedures may vary from year
to year and will be presented to the student at the beginning of each academic
calendar year.
D.
Grades
This is filled only by the faculty. A grade may or may not be
given at the end of the appointment at the discretion of the faculty. If the
grade for a procedure has been left blank, it means that the faculty did
not feel there was sufficient opportunity to evaluate the treatment done.
This will not affect the student's final grade. A grade however, is given
for all procedures checked as complete.
24
25
26
Appendix B:
Examine the C.M.S radiographs in an orderly sequence so that you do not miss
any significant findings. Start with tooth #18 and work your way clockwise to tooth
#48. Assess, identify and record the following:
1.
2.
3.
Resorption Patterns
Observe the general pattern of bone resorption. Note whether it is
horizontal, vertical or a mixture with significant amounts of both. Always
generalize to report your findings by quadrant or by arch.
4.
27
1.
0% Bone Loss
2.
3.
20%-50% Bone Loss bone level more than 4 mm but <6 mm apical to
the CEJ, it suggests Moderate bone loss.
4.
Note: Bone loss may exhibit different severity in different areas of the mouth. This
must be taken into consideration while making individual tooth diagnosis.
5.
Vertical Defects
Note the location, type (angular or true vertical) and extent of the defects.
You will find that when you correlate the clinical findings with the radiographic
findings, it will be easier to interpret vertical defects more accurately.
6.
Furcation Involvement
Note the location and extent of any apparent furcation involvements.
Simply record the tooth number of teeth with furcation involvement. Later try to
correlate this information with the clinical data.
7.
8.
9.
28
Appendix C:
Initial therapy or phase I is the first step in the sequence of procedures that
constitute periodontal treatment. The objective of initial therapy is the reduction or
elimination of gingival inflammation. This is achieved by complete removal of all
factors responsible for gingival inflammation such as plaque, calculus, correction of
defective restorations, obturation of carious lesions, etc.
The long term success of periodontal treatment is principally dependant on
maintaining the results achieved with phase I therapy. In addition, initial therapy
provides an opportunity for the therapist to evaluate tissue response as well as the
patient's attitude toward periodontal care, both of which are crucial to the prognosis of a
periodontal condition.
Based on the concept that microbial dental deposits (plaque) produce the
primary pathogens of gingival inflammation, the specific aim of phase I therapy is to
facilitate the daily removal of such accretions from the teeth by eliminating rough and
irregular contours from the tooth surfaces and then establishing a suitable plaque control
regimen.
Removal of all etiologic factors may eliminate the need for periodontal surgery.
2.
Oral hygiene techniques can be instituted and the patient's willingness and ability
to accomplish plaque control are evaluated.
3.
It permits the dentist to evaluate the patient's tissue response to the removal of
local factors and subsequent healing.
4.
5.
Surgery can be performed with greater ease, because bleeding will be reduces
during surgery and tissue tags can be avoided.
6.
29
Patient Education
Since dental plaque and calculus formation associated with inadequate
oral hygiene are by far the most common causes of periodontal diseases, it seems
natural to start the therapy by eliminating these active irritants. The concept of
plaque control as well as the rationale for other aspects of the treatment plan
should be understood by the patient before the active treatment is initiated. It is
very important of the success of the treatment plan.
2.
Preliminary Scaling
The next step should be gross scaling and polishing of the teeth, followed
by specific instruction in oral hygiene.
3.
Deep Caries
Carious lesions should be excavated and temporary restorations placed.
Caries in the vicinity of the gingiva interferes with plaque removal and
consequently with gingival health, even in absence of adjacent calculus or
defective restorations. Any teeth needing endodontic therapy should also be
treated at this time since further periodontal treatment would be meaningless if
endodontic treatment cannot be completed successfully.
4.
Hopeless Teeth
If some teeth have been diagnosed as "hopeless" and they are not in a
strategic or vital position for temporary maintenance of occlusal relations, such
teeth should be extracted at this time. Partially impacted third molars with
communication to the oral cavity, or teeth with advanced periodontal disease or
deep caries without functional or esthetics value, should also be extracted.
5.
Temporary Splinting
Although temporary splinting for hyper mobile teeth have not proved to
be useful in promoting periodontal healing during therapy, their use, however,
may expedite such treatment procedures as scaling, occlusal therapy, and
surgical periodontal therapy.
6.
7.
few
exceptions
rough,
overcontoured,
overhanging,
or
31
Appendix D:
Gingival/Plaque Index
1.
Dental Indices
The Gingival index (G.I.) by Le and Silness (1963) should be used .
The criteria are as follows:
0=
healthy gingiva
1=
2=
3=
P1.I.% record the percent of plaque covered surfaces in the mouth. This
means that you divide the number of plaque covered surfaces with the total
number of surfaces and multiply that with 100. Exclude occlusal surfaces. Use
Oral Hygiene Form No. 2 for average plaque score (%) in mouth.
32
2.
Registration of Plaque
First of all, fill in the Hygiene status No., the patient's name and date.
Then x-out the missing teeth so that the chart coincides with the actual number
of teeth in the mouth (in original form and in the duplicate) by black or blue ink.
Please note that all four surfaces of each tooth are to be examined for
plaque: the facial, lingual and proximal surfaces. Hence, the total number of
surfaces is equal to the number of teeth present multiplied by four.
The plaque is then registered following disclosure by staining solution or
tablets. Always use the disclosing agent in accordance with instructions given
by the manufacturer.
continuously for one minute, then the patient may rinse once. Disclosing
solutions are to be applied directly a with cotton pallet. Wait one minute and let
the patient rinse once.
Inspect all tooth surfaces (proximal surfaces must be inspected from both
the lingual and the facial sides). Mark the plaque-covered surfaces in red on the
tooth diagram. If you are in doubt whether plaque is present or not, use the side
of the probe. soft material adhering to the probe indicates plaque. Fill-in the
number of plaque-covered surfaces on the right-hand side of the form, and
calculate the plaque percentage (as mentioned above).
instructions (demonstrations) given to the patient that day in the lower right-hand
part of the form.
3.
Registration of Bleeding
Bleeding on probing should be noted by a short red dot () outside the
probe surface area. If bleeding is found in two neighboring proximal areas, be
aware that the two dots () must be separate and distinct.
Bleeding on probing is registered within 30 seconds following the
insertion of the probe in the periodontal pockets in exactly the same way as
during probing for periodontal pockets. It may therefore be convenient to probe
three teeth and then go back to register the bleeding areas before continuing with
the pocket depth measurements on the remaining teeth.
33
reach problem areas. Also, patients with physical or mental impairment will
often require a modification of OHI regimen, as well as a modification of our
expectations concerning their level of performance.
Despite our most conscientious efforts at OHI, there are a number of
patients who will not be motivated to maintain a satisfactory daily level of
plaque control. Not all patients have the same values as we do. It is important,
therefore, to document your activities with respect to OHI, and the patient's level
of performance that the treatment plan can be modified accordingly.
The
patients in this category are difficult to detect but usually are those who brush
and floss well only on the day of the appointment and thus, present with
persistent, generalized inflammation and little or no plaque. Role of miswak and
its effective method of use should be highlighted to patient with the message for
cleanliness.
b.
The practitioner may assume a level of knowledge which the patient does not
posses and therefore provides incomplete or insufficient instruction.
c.
Failure to recognize that the patient's reported behavior and actual behavior may
differ.
d.
e.
f.
g.
Show the patient evidence of dental disease in his/her own mouth. With the use
of a hand mirror show:
2.
a.
b.
c.
d.
e.
Explain that the bacteria on the teeth are the main cause of the above diseases
and point out that they (bacteria) are usually invisible to the naked eye.
3.
Ask the patient to rinse for at least one minute with disclosing solution.
4.
While the patient is rinsing, explain that the solution contains a harmless
vegetable dye which stains only that part of the tooth which is "dirty" or has
bacteria on it.
5.
After patient rinses a couple of times with clear water, determine the Plaque
Index (PlI) and record this in the treatment record.
6.
Show relationship of red dye to areas of disease. Re-emphasize the point that the
red dye represents bacteria.
7.
Ask the patient to show what tooth brushing technique he/she is currently using.
If the patient did not bring the toothbrush, open a new toothbrush pack, moisten
the bristles and ask the patient to show you his/her brushing technique.
8.
Re-examine the mouth and point out areas which were missed.
9.
Correct the technique where indicated. Make sure that the patient shows you the
correct technique in his/her mouth.
10.
Be sure to emphasize that the main objective of using the brush is to "brush the
red off" or remove the bacteria.
11.
Remind the patient to bring the toothbrush for each subsequent session.
36
Second Appointment
This is the suggested procedure when seeing your patient for the first time
following the introduction of oral hygiene instructions. Careful attention must be given
to the sequence outlined below:
1.
2.
past performance
b.
c.
d.
Greet the patient in your usual friendly manner and ask how he/she managed
with the use of the disclosing tablets. If he replies that they have not been used,
determine the reason. It is important to do this because somewhere along the
line you failed to convince the patient of the importance of visualizing the
plaque. It may be that they find something objectionable about the taste or the
coloration of the dye in the tablet. Nevertheless, it is important to determine why
they were not used and an effort should be made to correct this.
3.
If the patient replied that they worked well but that several areas were difficult to
reach, ask the patient to show you where these areas are. Ask the patient when
they last brushed their teeth. This is important because the amount of debris or
plaque on the teeth may give you an idea of how efficiently the patient is
cleansing his teeth. For example, if the patient states that they brushed their
teeth several hours before the dental appointment and the disclosing stain reveals
extensive dental plaque, not only in covering the tooth but also in bulk and/or
thickness, this would indicate that the patient is not properly performing oral
hygiene.
4.
Ask the patient to present their toothbrush. If they say they forgot it, do not
supply them with another but re-emphasize the point that it is necessary for the
instructional session for them to bring their toothbrush. They may buy a new
toothbrush from the pharmacy.
37
5.
Examine the patient's mouth for any deposits, materia alba or food debris. If any
of these are present, it should be pointed out to the patient and emphasize that the
accumulation of these materials is the result of improper cleansing.
The
presence of visible plaque and/or materia alba and food debris is indicative of a
poor response to oral hygiene training.
6.
7.
b.
distribution of plaque.
c.
"Record of Treatment".
8.
38
9.
b.
c.
10.
Review the OHI lecture notes given in 211 PDS for more details.
2.
3.
Use toothbrush, with toothpaste and dental floss (or suitable interdental cleaning
aid) to remove the red bacterial plaque.
4.
After brushing, chew another tablet and see if any other areas were missed.
5.
Teeth must be
thoroughly cleaned.
6.
7.
8.
When you are satisfied that your teeth are clean, then chew a disclosing tablet.
9.
10.
After that, use the tablets once a week, to check yourself (always use after tooth
cleaning).
39
Appendix E:
Now that you have completed your session of introduction to Oral Hygiene
Instruction, and coronal scaling (where indicated) you are ready to begin scaling, root
planning and polishing.
The instruments should be arranged in the order that they will be used. (left to
right). In addition to routine examination instruments, the scaling kit contains the
following scaler and curette:
Towner U15/30
Taylor 2/3
Columbia 4L/4R
Before beginning debridement (i.e. scaling and root planing), check with a
faculty member and tell him/her how much you intend to accomplish during this session
and how you intend to mange the case overall. The faculty will then either agree with
your plan or suggest alterations in your approach. (e.g. sextant by sextant handling vs
quadrant by quadrant treatment).
Remember that:
1.
Patients with subgingival calculus always require more than one appointment to
complete the procedure. 4-6 appointments may be needed.
2.
Avoid long appointments. It is better to have three, one hour session than one
three hour session. Progressive resolution of inflammation due to scaling and
root planing, combined with oral hygiene efforts of the patient, result in greater
visibility of calculus (shrinkage) and less bleeding.
3.
One must try to be systematic. Do not instrument all areas of the mouth in the
first session (unless you are doing GROSS scaling). You may do coronal (gross)
scaling and polishing and then thoroughly scale and root plan individual
sextants/quadrants. This will depend on the amount of supragingival calculus
and on the complexity of the case. Local anesthesia should not be used unless
permission is given by an instructor.
40
4.
5.
procedure but especially when you are encountering difficulties or have any
questions. It is better to seek help when you experience a problem rather than
wait until the end of the clinic session or waiting until the instructor is checking
and grading the procedure.
6.
The Pl.I. as
41
Appendix F:
Surgical Treatment
42
1.
It is, therefore, safe to say that the main purpose for doing
periodontal surgery is to afford both the therapist and the patient better
accessibility to plaque removal.
Probably the most important criterion used over time in determining
whether periodontal surgery is necessary is the depth of the periodontal pocket.
Other than pocket depths there are also clinically recognized physical
characteristics of the gingival tissue, such as color, size and consistency, which
must be considered.
demonstrated a high correlation between the volume of GCF flow and severity
of inflammation. GCF can be used, therefore, as an indicator of early as well as
advanced gingival disease.
Propensity of hemorrhage
b.
Pocket depth
c.
Crevicular fluid
d.
periodontal health should be used as a criteria used disease elimination and control as a
goal, rather than pocket elimination by itself. However, once the need for surgical
therapy has been established, various techniques can be utilized. This will be briefly
discussed in the following section.
The objectives of periodontal surgery can thus be summarized in the following
list:
a.
b.
c.
d.
e.
f.
g.
44
Such
information is important in selecting the type of periodontal surgery that will yield the
best results. It must be emphasized that periodontal surgery may do more harm than
good if adequate cooperation and plaque control cannot be established.
Technically, it is easier to perform accurate surgery when the initial incisions can
be made in fibrotic gingival tissues than in gingival tissues that are soft, edematous, and
hemorrhagic. Surgical management of the tissue including precise suturing is facilitated
by its firmness. The chances for harmful sequel such as loss of attachment associated
with periodontal surgery, are reduced when the surgery is done on fibrous, firm, gingival
tissues and teeth that are plaque-free. Performing periodontal surgery on teeth that have
been scaled and root planed and are devoid of plaque, will create a local environment
that is favorable for tissue regeneration.
45
Bleeding disorders
Periodontal surgery involves a traumatic disruption of the tissues and
necessarily causes some bleeding. Any hemorrhagic disorder of severe nature,
such as hemophilia, thrombocytopenic purpura and so forth usually constitutes a
contraindication to periodontal surgery, unless bleeding can be controlled.
2.
3.
Specific considerations
Patients with a short-life expectancy are candidates for palliative
periodontal procedures rather that periodontal surgery.
4.
Gingival Curettage
2.
Gingivectomy/Gingivoplasty
3.
4.
Osseous Surgery
Bone Grafts
Ostectomy/Osteoplasty
46
B.
Mucogingival Surgery
Pedicle Grafts
Shrinkage
b.
Resection
c.
Reattachment
d.
Apical positioning
Obtaining reattachment to the tooth by formation of new bone "fillingin" of the defect (induction).
b.
c.
Tissue State
Therapy
3 mm
4mm
4-5 mm
Periodontitis
Inflamed
Edematous
Fibrous
Sc & Rp
Sc & Rp
Scaling & gingivectomy
4 mm
5 mm
5-8 mm
edematous
horizontal bone loss
infrabony pockets
Gingivitis
47