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Treatment versus overtreatment in the war
against periodontal disease.
In conservative perio treatment there are 2 kinds of appointments
... Don’t confuse them, or you may put your patient at risk.
by Larry Burnett, DDS
Imagine the typical perio patient at the initial appointment:* Teeth
encrusted with calculus ... Often substantial bleeding ... Perhaps
some exudate.
Restoring and maintaining the perio-prone patient involves two kinds
of hygiene appointments.
There are the initial therapeutic appointments, which usually require
hard-core calculus removal and debridement.
Then there are the maintenance appointments.
It’s very important that both hygienist and dentist have a
clear understanding of the difference between these two types of
appointments ... because procedures that are perfectly appropriate
at one type of appointment may actually exacerbate the patient’s
problems if applied at the other type of appointment.
The initial appointments ... definitive debridement
To grab the attention of my audience, I often start my lectures
by declaring that if you’re more than 30 years old, a lot of
what you learned about periodontal therapy in school is outdated.
Then I list things I used to teach when I was an instructor in hygiene
school: “Calculus is your primary enemy.” Wrong. “Bleeding
at recall is a sure sign that the treatment isn’t working.”
Wrong. “Ultrasonic scalers are appropriate only for gross calculus
removal.” Wrong. Wrong. Wrong.
In reality though, the initial appointments really don’t vary
all that much from the old-time “grunt-sweat-and-scale”
appointments we taught 30 years ago.
At the definitive appointment you’re usually addressing hard
... sometime VERY hard ... calculus. We all now recognize that it’s
the bacterial infection (not the calculus) that’s the real
cause of periodontal disease. Nevertheless, the first few definitive
appointments will inevitably involve substantial calculus removal.
Though calculus isn’t the enemy, it can provide safe harbor
to the enemy.
The easiest way to blast hard calculus
My primary tool for both definitive and maintenance therapy is the
ultrasonic scaler. But I use the device differently in the two types
of appointments.
The calculus-removing power of an ultrasonic insert is dependent
on the amplitude of the tip movement and the mass of the tip. You
control the amount of tip movement with the scaler’s Power
Control. The higher the power the greater the strength of the stroke
... and the greater the hammer blow to the accretion.
When I’m attacking industrial-strength calculus, I don’t
fool around. A traditional perio tip set at medium power won’t
even scratch old calculus. One of the most frequent mistakes at
definitive appointments is turning the power down too low.
So I turn the power up ... WAY up ... sometimes all the way to maximum.
Most thin tips that slip into the sulcus aren’t designed for
this kind of high-power calculus blasting. In fact, manufacturers
recommend against it. They frequently break, and because the thin
design has so little mass, it tends to bounce off the accretion
without delivering much power.
So a few years ago I asked Parkell to develop a thin insert that
could be used effectively at high power-settings. The Power-Tip
is longer than conventional slim inserts. In fact, it looks a lot
like a perio probe. It delivers a longer stroke, and though it’s
still slim enough to fit into the sulcus, it has slightly more mass.
Greater mass not only makes the Power-Tip more robust (less likely
to break), but also delivers more force to the calculus. In fact,
the Power-Tip is the most powerful calculus blaster I’ve used
(including the fatter supragingival tips.)
“But doesn’t high-power calculus scaling cause patient
discomfort?” you ask.
You bet it does! That’s why all my initial definitive appointments
are anesthetized. Some purists claim that they can deep scale a
quadrant of prehistoric calculus without numbing the patient. I
find it a lot easier to use anesthesia. I’m more relaxed knowing
I’m not going to hurt the patient, so I can devote all my attention
to the job at hand.
During these calculus-blasting appointments, I normally scale just
one quadrant at time.
While the patient is getting numb, I run a perio probe or explorer
over the roots to get a feeling for the topography. During this
exploration I refer frequently to the radiographs.
Then (and this is very important!) when I begin ultrasonic calculus
removal I let the tip do the work. Let those 25000 or 30000 cycles-per-second
hammer off the accretions, not your aching wrists. Exerting hand
pressure may stall the vibration or gouge the root.
The functional portion of the tip is the last 2-3 mm, so that’s
what you want to apply to the calculus. If it’s particularly
tenacious, tap it from different directions till it succumbs.
A little practice with extracted
teeth ...
quickly demonstrates the reason for attacking the plaque from multiple
directions.
If you limit your practice sessions to perfect teeth mounted
in a plastic typodont, you won’t appreciate the curves Mother
Nature occasionally throws (pun intended.) So for my hands-on courses
I use extracted teeth set in plaster.
When you’re ultrasonically debriding apical to a protruberance,
a single angle of approach will always leave plaque. That’s
why you should lightly run your ultrasonic tip over the root from
different angles. The more angles, the greater the chance of reaching
bacteria lurking in those obscure areas.
The maintenance appointment.
Question: Once you have the teeth free of calculus,** how often
must the roots be scaled and planed?
a) Every two years
b) Every 3 years
c) As often as the insurance will pay for it
d) none of the above
In my opinion, once the patient is on a maintenance program the correct
answer is “NEVER.”
The confusion rises from confusion about the differences between definitive
and maintenance appointments. The thinking goes something like this:
If deep scaling is beneficial at the initial appointments, it must
be beneficial at maintenance appointments.
In fact, ritualistic root scraping during the maintenance appointment
is at best a waste of time. And at worst? At worst it may actually
CAUSE the bone destruction you’re dedicated to preventing.
But more of that in a minute.
Plaque... not calculus
Supragingival calculus begins reforming the instant you remove it.
But subgingival calculus is a different beast. In fact, it takes 9-12
months for attached subgingival plaque to calcify to the point it
appears on an X-ray.
This means that if the patient is on a 3 or 6-month recall schedule,
subgingival calculus doesn’t have time to form. Maintenance root
debridement is concerned primarily with plaque removal ... not calculus
removal.
If you discover a chunk of root calculus at a recall, know this: you
missed it at prior appointments. (Don’t feel bad, it happens
to all of us.) The only time I ever have to resort to heavy calculus
removal is when a maintenance patient suddenly reappears after a long
absence.
Though calculus rarely forms at the bottom of a 6mm pocket, plaque
is perfectly happy there. In fact, the most destructive periodontal
pathogens (the loosely-attached and free-swimming anaerobic bacteria)
simply thrive deep in the pocket.
So how do you remove sticky plaque at the apex of a pocket using a
hand instrument? Sure, you can do it. But because hand instruments
work from the bottom up, you’ll damage the periodontal attachment
when you position it below the apical plaque.
My favorite instrument for deplaquing roots is a long, thin ultrasonic
insert. Ultrasonic tips work from the top down, so I won’t damage
the periodontal membrane when I’m debriding the most apical recesses
of the pocket.
Setting the power and water for deplaquing
Even if you don’t run chlorhexidene or iodine through your scaler
like I do, that ultrasonically-charged water coming off your tip maybe
lethal to the pathogens. Several studies have suggested that ultrasonic
streaming and the energy in the millions of cavitation bubbles will
destroy bacterial plaque. (Not just loosen it. Not just wash it away.
KILL it!)
To the best of my knowledge there haven’t been any studies demonstrating
exactly how much energy must be in the water to create this bug-busting
effect. So I figure the greater the energy, the more lethal it should
be. I turn the scaler power as high as I can without creating discomfort.
(Since thresholds vary dramatically from patient to patient, I adjust
the power differently for each case. With the power set all the way
down, I insert the tip under the gum and gradually turn up the power
till the patient tells me he perceives it. Then I turn it slightly
beyond that point.)
I adjust the water till it makes an audible “SHHHSS” sound.
If the handpiece starts to get hot, I know I’m not using enough
water.
Finally, using just the lightest butterfly touch, I run the insert
over the root. I try to approach the root from many different angles,
especially around the CEJ, and I attempt to touch the entire surface.
(Obviously, due to the irregular morphology of the root, I’ll
never really hit every square millimeter, but the more surface area
I can touch, the better.)
As I mentioned, when I’m treating perio patients, I often supplement
this ultrasonic deplaquing by running an antimicrobial agent through
the scaler. That way I’m irrigating while I’m debriding.
A study recently conducted at SUNY Buffalo and Niagara College and
presented at the 1999 session of the International Association for
Dental Research showed that when 2% chlorhexidene was applied ultrasonically,
its antimicrobial effects lasted longer (4-5 days.) Furthermore, the
chlorhexidene seemed to chemically penetrate the hydroxyapatite and
bond to it.1
Research into “transdermal ultrasonic delivery” at MIT suggests
that when medication is applied ultrasonically to soft tissue, the
vibrations cause the cells to loosen slightly, so the medication is
absorbed directly through the skin.2
If these two studies are applicable to the periodontal pocket, my
ultrasonic scaler may be helping the chlorhexidene reach those microbes
entrenched within the cementum and the soft crevicular tissue.
Removing an amalgam overhang
If the protuberance is due to an overhanging fin of amalgam (figure
3), I use the ultrasonic scaler tip to shave the excess.
Unlike deplaquing, here you have to apply some pressure. You want
to recontour the restoration without damaging the root. (Incidentally,
that’s why I like the Power-Tip for this application. A conventional
thin tip would probably stall at the pressures required to remove
amalgam.)
If there’s no proximal tooth, you can approach the overhang
from the occlusal (figure 4). More commonly, however, you’ll
have to place the tip parallel to the gingival seat just apical
to the restoration (figure 5) and then move it up and down to shave
the excess amalgam (figure 6). Final finishing should be done with
hand instruments.
The periodontal-endodontic lesion.
Just scratching the surface of perio disease
When you discover sudden, deep vertical bone loss in an otherwise
healthy mouth, there are two things you should immediately ask yourself
1) Are there any overhangs?
2) Is the pocket adjacent to an endodontically-treated tooth?
If you’re lucky, a defective amalgam will be acting as a plaque
trap. Remove the overhang (For me, the easiest way is with a Power-Tip
ultrasonic insert at maximum power. See figures 3-6), debride the
pocket, flush it with an antimicrobial agent ... and the pocket
will generally resolve.
Much, much more troublesome is the endo problem. In fact, the perio-endo
lesion (or “endo-perio” lesion depending on how you look
at it) may be the most complex, recalcitrant localized problem we
encounter.
Over the years, a number of studies have observed that the bugs
inhabiting a noncarious, non-vital pulp, bear a suspicious similarity
to the microflora in an inflamed pocket.3,4
Researchers are increasingly speculating that pathogens pass through
the tooth via cracks, accessory canals or open tubules. This cross-infection
would explain why endodontically-treated teeth with periapical lesions
are particularly susceptible to localized bone loss.5
And it may also explain why severe periodontal lesions may be followed
by chronic pulpitis or inexplicable death of the pulp.6,4
In fact, some research has suggested that a sharp, angular periodontal
defect is a more reliable indicator of pulpal pathlogy than any
of the traditional pulp tests.7
Incidentally, if valid, this endo-perio model would also explain
why the lesion is so hard to treat. It’s a complex lesion that
involves a 2-way septic highway of mutual reinfection.
Resolving the perio-endo lesion is outside the realm of conservative
periodontics. It usually requires retreatment of the canal ... often
flaps ... bone grafts ... and sometimes even root amputation or
extraction.
The reason I’m bringing it up in this article, is that old-time
periodontal therapy (scraping and planing) may play a role in initiating
this type of lesion.
Remember, the hypothesis is that the endo-perio lesion involves
noxious communication through the tooth.
Now historically, what have hygienists and dentists been taught
to do when they encountered bleeding associated with bone loss?
That’s right. They sharpen those currettes, and commence scaling
and planing to remove the offending calculus and smooth those roots.
Scaling/planing removes tooth structure. First it removes the protective
cementum. Then when that’s gone, it starts removing the dentin
itself.
The proposed endo/perio mechanism. An infected canal reinfects the
pocket, while the infected pocket reinfects the canal. Root planing
won’t help and may make the root even more permeable.
A sharp angular defect in an otherwise healthy mouth should trigger
an alarm.
One possibility - The pulp may be infected or necrotic and serving
as a source of infection.
But, of course, the real problem in an endo-perio lesion isn’t
the calculus or the irregular surfaces. It’s bacterial communication
through the root. So when we root-plane we’re “treating”
the problem by opening even more tubules and making the tooth even
more permeable. The harder we try, the worse things get.
Attempting to treat a complex perio lesion by scaling may be like
trying to put out a fire by dousing it with gasoline. It just makes
matters worse.
Several recent studies in Australia and Scandinavia have suggested
the danger of routinely scaling endodontically-treated teeth.
If the direction hinted in these studies is substantiated by others,
we may soon be reading that root-planing of non-vital teeth at recall
appointments should be avoided. (And I would add “And so should
routine planing of most other teeth as well.”)
Knowing when to stop.
Treating the periodontal patient is a bit like restoring an old
“fixer-upper” house.
At first the work is heavy-duty labor: structural repair, scraping
the peeling paint, clearing overgrowth out of the yard. This corresponds
to the therapeutic appointments.
But once you have the house in relatively good shape, it doesn’t
take all that much work to keep it up: mowing the lawn, occasionally
trimming the hedges ... walking around the foundation checking for
termites. At the perio maintenance appointments you’re primarly
deplaquing and looking for flare-ups.
If you find yourself repeatedly scraping paint (or calculus) during
the maintenance phase, you’re doing something wrong.
Of course, both kinds of appointment are important, but in my opinion
maintenance is by far the more important.
*By “initial” I mean the first therapeutic
appointment. Not the preliminary diagnostic appointments.
** Okay, okay. You never get the root surfaces absolutely free of
calculus. Studies have shown that even the most conscientious scaling
always leaves some accretions.
References
1 Goulding MJ, et al. Ultrasonic augmentation of chlorhexidine substantivity
to surface characterized dense hydroxyapatite. Jour Dent Res. 78:Spec,
Abstr #1298, p268, Mar 99
2 Langer R et al. Science August 1995 - As quoted in Washington
Associated Press Release, August 12, 1995
3 Kipioti A,et al. Microbiological findings of infected root canals
and adjacent periodontal pockets in teeth with advanced periodontitis.
Oral Surg Oral Med Oral Pathol. 58:213-9, 84)
4 Kobayashi T, et al. The microbial flora from root canals and periodontal
pockets of non-vital teeth associated with advanced periodontitis.
Int End J. 23:100- 6, 90
5 Jansson L, et al. The influence of endodontic infection on progression
of marginal bone loss in periodontitis. J Clin Periodontol. 10:729-34,
Oct 95
6 Wong R, Hirsh RS, Clarke NG. Endodontic effects of root planing
in humans. Endo Dent Traumatol. 5(4):193-6, Aug 89
7 Hirsch RS, et al. Pulpal pathosis and severe alveloar lesions:
a clinical study. Endo Dent Traumatol. 5:48-54, 89
About the author ...
A graduate of the Medical College of Virginia School of Dentistry,
Dr. Burnett has authored numerous articles and lectured extensively
on conservative periodontal therapy throughout the US and Canada.
A frequent speaker at both the ADA annual scienific session (1995,
1996, 1997, 1998) and AGD meetings (1994, 1995), he is featured
in the new video-based program “Advanced Ultrasonics in General
Practice”
Dr. Burnett also conducts hands-on courses for dentist and hygienists.
He can be contacted at: Dr. Larry Burnett, 2221 SW First Ave #1224,
Portland, OR 97201 Tel: 503-221-4237, lburnett2@msn.com.
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