Читать книгу Blackwell's Five-Minute Veterinary Consult Clinical Companion - Группа авторов - Страница 34
ОглавлениеChapter 5 Periodontal PocketTherapy
INDICATIONS
To remove deposits of plaque, calculus, and debris from the tooth surfaces in periodontal pockets and gently debride the inner lining of the pocket.
To further treat selected periodontal pockets with subgingival medicaments to enhance healing of the lesion.
To manage soft tissue associated with periodontal pockets or adjacent to teeth that have been extracted to provide optimal periodontal health to the remaining teeth.
EQUIPMENT (see Chapter 9)
Periodontal probe (Figure 5.1a)
Hand curette and other debridement instruments (serrated periodontal elevators)
W‐3 PFI (plastic filling instrument) – “beaver tail”
Doxirobe™ gel (if available, or similar human product)
Scalpel blade/handle
Gingivoplasty and soft tissue debridement implements: serrated periosteal elevator, crown and collar scissors, 12‐fluted burs (Figure 5.1b)
Figure 5.1 (a) Periodontal probe, hand curette (with round end), and W‐3 beaver tail for packing perioceutic. (b) Gingivoplasty and soft tissue debridement implements: serrated periosteal elevator, crown and collar scissors, 12‐fluted burs.
PROCEDURE
Provide preoperative and intraoperative (local) analgesia where appropriate.
Some soft tissue periodontal pockets may be due to chronic minor gingival enlargement, or bone loss with decreased attachment levels.If there is sufficient attached gingiva remaining, a simple gingivoplasty of excess or inflamed gingival margin can immediately reduce the pocket depth.A 12‐fluted bur (finishing bur) can be used to gently remove the excess tissue and provide a contoured feathered edge to the gingival margin (Figure 5.2).
Identify and select periodontal pockets of appropriate depth for additional therapy (3–5 mm) (Figure 5.3).These are moderate depth, supra‐bony, soft tissue pockets.Deeper soft tissue pockets (greater than 5 mm) would require performing a gingival flap to open the site for adequate cleaning (open root planning).Figure 5.2 Use of a 12‐fluted bur to recontour areas of mild gingival enlargement, surgically reducing the pocket depth.Figure 5.3 (a) Probe inserting into periodontal pocket (5 mm in depth). (b) Probe placed at the 5‐mm mark on top of the gingiva to indicate the depth of the pocket.Deeper infra‐bony pockets (with vertical bone loss) would require more advanced periodontal procedure with gingival flap for access, complete curettage of infra‐bony pocket, and placement of material to encourage bone regrowth.
Select appropriate hand curette: curettes have a round toe at the end and rounded back (in cross‐section, they have a half‐moon shape and a flat edge, which is the face of the instrument).Curettes are double‐ended: the two ends are mirror images of each other, as only one side will contact tooth surface for root planing.Curette working ends are numbered (e.g. 11/12), with varying angulations (designed in human dentistry to clean specific tooth surfaces). Some equipment companies have specialized veterinary curettes (feline).Size of working ends can also vary: some smaller types (mini) may be useful for instrumentation in periodontal pockets of small dogs and cats.
Insert curette head into depth of pocket, adjusting the cutting edge to contact the tooth surface (closed face) (Figure 5.4).
With a pull stroke, bring curette edge down the surface of the root, dislodging calculus and debris. Use this pull stroke in several different directions in a cross‐hatching pattern to effectively root plane the surface free from debris (Figure 5.5).Figure 5.4 (a) Working edge of the curette placed against the tooth surface. (b) Curette advanced into depth of the pocket.Figure 5.5 With a pull stroke down, calculus and debris in the pocket can be debrided (this is demonstrated in a specimen, so no bleeding is present, as would be the case in a patient).
As the surface is cleaned of debris, the tactile (and auditory) sensation will go from a rough feel to a smooth feel.
With light digital pressure on the external surface of the pocket, allow the opposite edge of the curette to gently debride the diseased soft tissue (subgingival curettage or debridement). There will be moderate hemorrhage.
Some (not all) ultrasonic units are made to allow subgingival cleaning, which allows cavitation of bacteria in addition to scaling.Other ultrasonic scalers should not be used below the gumline, as once the tip is buried the water spray cannot adequately cool the tip, potentially causing overheating and damage to tooth.
Polish the crown surface and gently splay the foot of the prophy cup to polish a millimeter or two of the root surfaces (Figure 5.6).
Irrigate then air dry the area thoroughly to remove any remnants of calculus, debris, or prophy paste (Figure 5.7).Figure 5.6 The prophy cup foot is splayed to polish the root surface of the pocket.Figure 5.7 After irrigating all debris and prophy paste off the tooth, a gentle blast of air into the sulcus helps dry the area and shows clean surfaces.
Prepare the perioceutic according to manufacturer’s recommendations.
Introduce the material into the pocket, following manufacturer’s instructions.
Note: there are other perioceutics used in human dentistry and other products with clindamycin.
Homecare: oral solutions or gels may be used initially, but the owner should not brush for 14 days. Recheck at two weeks to assess healing and start brushing at that time.
Prescribe antibiotics and pain medication postoperatively as appropriate.
Recheck and re‐treat in five months.
Treat interdental periodontal pockets with planned extraction(s) of one of the teeth. For example, mandibular third incisor extraction to treat canine; mandibular fourth premolar or second molar extraction to treat first molar.
Removal of persistent or redundant tissue that is forming pockets (mandibular canines).For descriptive purposes, images are provided to show how excess or redundant tissue will be excised from the mesial aspect of a mandibular canine tooth to manage the soft tissue and reduce the pocket depth (Figure 5.8).Make a reverse bevel incision into the interdental or mesial/proximal tissue, extending from the mesial aspect of 304, through the redundant tissue both buccally/labially and lingually, preserving a collar of attached gingiva (Figure 5.9). This would extend to the mesial aspect of third incisor for its extraction flap. If this incision is made to incorporate the extraction of 301, 302, 303, it can be termed a “wedge” excision.Use a blade to make a sulcular incision around the tooth/teeth to be extracted (403 plus), and at the mesial aspect of 304 if the pocket affects the canine (second incision).Using crown and collar scissors, curettes, or serrated periosteal elevator, debride the pocket lining and redundant tissue as the 403 is elevated or excess tissue removed (Figures 5.10 and 5.11).Further debride the now accessible area adjacent to 304, including open root planing and ultrasonic scaling of the tooth/root surface. If an infra‐bony pocket between 304 and bone is present, a bone graft material can be used.Suture the healthy gingival margins, with care at the mesial aspect of 404; this closure may be located further apically on the tooth, with resultant root exposure, but the pocket will be minimized (Figure 5.12).Figure 5.8 Area of redundant tissue between mandibular canines after incisors have been lost; deep pockets are present.Figure 5.9 Make a reverse bevel incision into the proximal tissue, extending from the mesial aspect of 304, through the redundant tissue both buccally/labially and lingually, preserving a collar of attached gingiva.Figure 5.10 Using crown and collar scissors or curettes, debride the pocket lining and redundant tissue.Figure 5.11 Further debride the now accessible area adjacent to 304, using a serrated periosteal elevator to remove granulation tissue, and including open root planing and ultrasonic scaling of the tooth/root surface.Figure 5.12 Suture the healthy gingival margins with care at the mesial aspect of 304. This closure may be located further apically on the tooth, with resultant root exposure, but the pocket will be minimized.
COMMENTS
Blunt or dull curettes will be ineffective in root planing; keep instruments sharpened.
Using the perioceutic without effective root planing will have poor results.
Attempting to root plane or treat a pocket deeper than 5 mm without using a gingival flap will be ineffective.
Excessive pressure when root planing can damage the root surface.
Appropriate preoperative diagnostics when indicated prior to procedure.
Appropriate antimicrobial and pain management therapy when indicated.
Appropriate patient monitoring and support during anesthetic procedures.
See also the following chapters:
Abbreviation
PFI = plastic filling instrument or W‐3
Author: Heidi B. Lobprise, DVM, DAVDC
Consulting Editor: Heidi B. Lobprise, DVM, DAVDC
