Initial Therapy

Initial therapy consists of all treatment carried out in advance of evaluation for the surgical phases of periodontal therapy. A number of procedures in each patient's treatment regimen may be accomplished before more definitive or invasive approaches are undertaken.

Control of Microbial Plaque. The most critical aspect of periodontal therapy is the control of mi-crobial flora in the sulcular area. If the patient does not maintain excellent oral hygiene and thereby the optimum condition of soft and hard tissues, subse-

Sulcular Brushing Technique
Fig. 5-11. Bass sulcular method of toothbrushing.

quent periodontal and restorative treatments will be jeopardized.

Bacterial plaque occurs on all surfaces of the teeth but is especially prevalent on the gingival third 25 It is strongly adherent to the tooth structure, which means that it is not removed by the chewing of fibrous foods . 26 The prevention of plaque accumulation, by either mechanical or chemical means, is critical to the prevention of hard and soft tissue pathosis. Although there are chemical means for removing plaque accumulation, only mechanical methods will be considered in this text. For excellent reviews of the subject of chemical plaque removal, refer to standard periodontal texts.

Toothbrushing. Plaque removal is accomplished with a toothbrush and other orophysiother-apy aids. Many types of toothbrushes can be used and are classified according to their size, shape, length, bristle arrangement, and whether they are manually or electrically powered. Reviews of the many types of brushes and alternate techniques can be reviewed in standard periodontal textbooks. The soft-bristle brush is particularly effective for cleaning in the gingival sulci and at buccal and lingual surfaces of interproximal areas without causing gingival damage and tooth abrasion that can result from a hard-bristle brush.29

Technique. In toothbrushing, effective placement of the bristles is more important than the amount of energy expended. The Bass sulcular method of brushing (Fig. 5-11) is preferred for most fixed prosthodontics patients because it cleans the sulci, where the margins of restorations are often placed.

The bristles are placed in the sulci at an angle of approximately 45 degrees to the tooth surface, directed gingivally, and moved back and forth with short scrubbing motions under light pressure. The brush is applied in a similar manner throughout the mouth on all buccal and lingual or palatal surfaces of the teeth. In the anterior area, where interproxi-mal spaces are small and where it may seem impossible to place the brush horizontally against the gingiva, the brush can be turned vertically for better access. After the sulcular areas have been cleansed, the occlusal surfaces are brushed, as is the dorsal surface of the tongue. For excellent descriptions and illustrations of toothbrush placement, refer to standard periodontal texts. 5-7

Flossing. Interproximal plaque can be controlled with dental floss.31 Both waxed and un-waxed types will clean proximal surfaces, but the unwaxed floss has several advantages 32 :

1. It is smaller in diameter and thus more easily passed through interproximal contact areas.

2. It flattens out under tension, and thus each separate thread effectively covers a larger surface area.

3. It makes a squeaking noise when applied to a clean tooth surface, which can be used as a guide to effective performance.

Technique. A generous length of floss is cut and wrapped around the middle fingers of each hand. The forefingers and thumbs are used for placement (Fig. 5-12). The floss is slipped past the contact area to the base of the sulcus and is moved up and down on each proximal tooth surface until both surfaces are free of plaque. The floss is then removed and inserted in the next proximal area, systematically progressing until all the proximal surfaces have been cleaned.

Other Aids. Plaque may also be controlled effectively by orophysiotherapy aids such as dental tape, yarn, rubber and wooden tips, toothpicks, interdental stimulators, interproximal brushes, and electric toothbrushes.

When plaque is removed around a fixed partial denture or a restoration involving splinted teeth, a floss threader may be needed. Alternatively, special

Effect Overhanging Margin Fpd

Fig. 5-12. Proper use of dental floss. A, Forefinger grip for positioning. B, Thumb grip for positioning. C, The floss is placed apical to the contact area and is gently worked to the base of the sulcus. D, After cleaning the mesial portion of the proximal sulcus, the floss is moved coronally and placed at the distal portion of the sulcus. E, Cleaning the distal portion of the proximal sulcus (i.e., mesial of the adjacent tooth).

Fig. 5-12. Proper use of dental floss. A, Forefinger grip for positioning. B, Thumb grip for positioning. C, The floss is placed apical to the contact area and is gently worked to the base of the sulcus. D, After cleaning the mesial portion of the proximal sulcus, the floss is moved coronally and placed at the distal portion of the sulcus. E, Cleaning the distal portion of the proximal sulcus (i.e., mesial of the adjacent tooth).

lengths of floss with stiffened ends are available and have been shown to be quite effective.

Disclosing agents may be used to provide better visualization of areas where plaque control is difficult or deficient. Erythrosin dye in tablet or liquid form stains plaque and is readily observable. Ultraviolet light has been used in combination with fluorescein dye to reveal plaque deposits, bypassing the undesirable red stain that remains after erythrosin use.

All the previously mentioned items are useful in removing and controlling inflammation-inducing microbial plaque. However, the most important aspect of plaque control is patient motivation. Without motivation, all orophysiotherapy aids and the knowledge to apply them are useless.

Scaling and Polishing. Removal of supragingi-val calculus (scaling) and polishing of the coronal portion of the tooth are the first definitive steps in debridement of the teeth. Scaling consists of the removal of deposits and accretions from the crowns of teeth and from tooth surfaces slightly subgingival. This is accomplished with the use of sharp scalers or curettes. The gingiva responds to this removal of supragingival and slightly subgingival calculus with a decrease in inflammation and bleeding. Thus the patient is able to observe the first signs of therapeutic gain, especially when part or half of the mouth is instrumented at one appointment, and the remainder is done after a short amount of time has elapsed.

during the initial therapy phase of treatment by either replacement or reshaping and/or removal of the overhang (Fig. 5-14). Close cooperation and communication between the periodontist and the restorative dentist are essential during this treatment phase.

Root Planing. Root planing (Fig. 5-15) is the process of debriding the root surface with a curette. It is a more deliberate and more delicately executed procedure than scaling and requires the administration of a local anesthetic in most instances. At

The Structure Ofthe Central Incisor
Fig. 5-14. Recontouring of the interproximal space of the castings seen in Fig. 5-13 allows the patient to clean the area. Note the excellent gingival health between the central incisors as a result of good oral hygiene techniques.

Correction of Defective and/or Overhanging Restorations. Overhanging restorations, open interproximal contacts, and areas of food impaction contribute to local irritation of the gingiva and (of greater importance) impede proper plaque control. These deficiencies (Fig. 5-13) should be corrected

Chemical Plaque Control
Fig. 5-13. Overhanging splinted restoration connecting the mandibular right and left central incisors, with obliteration of the interproximal space by the castings. The patient's inability to clean this area properly has resulted in iatrogenic loss of attachment.
Mechanical Debridement With Root Planing

Fig. 5-15. Root planing. A, Curette placed in the sulcus to address calculus. B, The curette, initially placed apical to the calculus, moves coronally to dislodge the calculus. C, Accretions removed and the root planed to a smooth finish. CU, Curette; CA, calculus; S, sulcus; R, root surface. (Redrawn from Carranza FA Jr: Glickman's clinical periodon-tology, ed 7, Philadelphia, 1990, WB Saunders.)

Fig. 5-15. Root planing. A, Curette placed in the sulcus to address calculus. B, The curette, initially placed apical to the calculus, moves coronally to dislodge the calculus. C, Accretions removed and the root planed to a smooth finish. CU, Curette; CA, calculus; S, sulcus; R, root surface. (Redrawn from Carranza FA Jr: Glickman's clinical periodon-tology, ed 7, Philadelphia, 1990, WB Saunders.)

present it constitutes the primary mode of initial therapy in periodontiss, and evidence suggests that disease progression will continue without root planing, even with effective oral hygiene 33

The curette is a spoon-shaped instrument well suited to cleaning and smoothing root surfaces. It is applied apically on the root with respect to the accretion and is moved coronally to lift deposits off the root surface and to plane it to a glasslike smoothness. As the patient's plaque-control techniques improve, the changes observed when root planing is completed may necessitate changing or modifying the treatment plan, and further therapy may not be indicated.

Root planing and the incidental curettage of soft tissue that accompanies it may be an end point of active periodontal therapy. In many cases the combination of root planing and improved oral hygiene on the part of the patient leads to manageable probing depths, and no further treatment is necessary. For this reason the initial therapy requires careful evaluation.

Strategic Tooth Removal. An important part of treatment sequencing is the elimination of teeth that are hopelessly involved periodontally or are nonre-storable. Although no hard-and-fast rules exist regarding the timing of such extractions, removing teeth early in therapy is often more advantageous, when the patient has recently been informed of the prognosis and is prepared for treatment.

Extractions can be accomplished during initial therapy when the quadrant being instrumented is anesthetized. The operator can make an excellent determination of questionable teeth at this time by "sounding" the periodontium and can inform the patient of the verdict immediately. The patient is thus prepared psychologically (and also pharmacologically) for the removal. Teeth can also be removed during periodontal surgery, when the same conditions exist.

Early extraction of teeth and/or roots will allow the socket areas to heal and can provide better access for plaque control of adjacent tooth surfaces. A transitional or provisional RPD or FPD can also be fabricated and will stabilize the arch and potentially maintain or improve occlusion, function, and esthetics.

Stabilization of Mobile Teeth. Tooth mobility occurs when a tooth is subjected to excessive forces, especially when bony support is lacking. It is not necessarily a sign of disease, because it may be a normal response to abnormal forces, and it does not always need corrective treatment. However, it is sometimes a source of discomfort to the patient, and in these cases it should be treated by reduction of the abnormal forces after occlusal evaluation. Depending on the patient's need, the teeth may also be treated by splinting with provisional restorations (see Chapter 15) or an acid-etch resin technique (see Chapter 26) in conjunction with occlusal adjustment (see Chapter 6). Such restorations should be carefully designed so they do not impede plaque control or future periodontal treatment. Close communication between the periodontist and the restorative dentist is critical in this phase of treatment.

Minor Tooth Movement. Orthodontics can be of major benefit to periodontal therapy. Malposed teeth may be realigned to make them more receptive to periodontal treatment and to improve the efficacy of plaque-control measures. As seen in Chapter 6, restorative procedures can also be aided by minor tooth movement. Thus, for the best treatment of a patient with complex dental problems, good communication among consulting dentists is essential.

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