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Periodontal Procedures

Scaling and Root Planing


Scaling and root planing is the basis for treatment of periodontitis.  The objective of the procedure is to remove both hard and soft plaque (bacteria) that grow on the root surface underneath the gum tissue.  This results in a reduction of inflammation and reduction of pocket depth.  Scaling and root planing does not cure periodontal disease but is simply the preliminary procedure in the ongoing process to control the disease. Maintenance care every three months is the control.


Although scaling and root planing is sometimes performed by the periodontist, most of the time it is the dental hygienist.  Scaling and root planing is very difficult to accomplish well especially when the pockets become deeper.  Experience is the key.  Our hygienists each have over 20 years of clinical experience.


Scaling and root planing is only indicated for treatment of periodontitis- not for gingivitis.  Dr. Kaiser commonly sees second opinion consults where scaling and root planing have been recommended in cases of gingivitis and simple calculus accumulation. A correct diagnosis is essential.


Osseous Surgery/Open Flap Debridement


Osseous Surgery was “the bread and butter” of periodontists in the 1960s and ‘70s.  Then, researchers from the University of Michigan found that the less traumatic open flap debridement worked just as well with fewer postoperative problems.


Osseous surgery requires opening up the gum tissue and reshaping the jaw bone to try and eliminate the bone pockets.  The gum tissue is then repositioned further along the tooth, resulting in the long tooth look and sensitive teeth.


Open flap debridement, on the other hand, is simply scaling and rootplaning with visual access.  Lack of visual access is the limiting factor to effective scaling and root planing because the hygienist/dentist simply cannot see the root to clean it.  Open flap debridement is the solution to this problem because the gingival tissue is temporarily pulled away from the tooth to allow visual access. The root surface is scaled, and then the gum tissue is replaced.  Both scaling and root planing and open flap debridement have the same objective, clean the tooth root. 


Open flap debridement is Dr. Kaiser’s preferred procedure compared to osseous surgery which is almost never utilized in his office.


Guided Bone Regeneration and Bone Grafts


During periodontal disease and pocket formation a common misconception is the focus on bone loss.  Actually, the important thing to focus on is loss of the connection between the tooth root and the bone surface.  This connection is mediated by a ligament made up of collagen fibers inserted into the bone and tooth root, called the periodontal ligament.  Many periodontists are skeptical of our ability to regenerate the periodontal ligament and thus restore the connection which was present during health.  Although researchers sometimes document successful partial regeneration, it does not take place predictably in every day clinical practice. 



 Dr. Kaiser has found these procedures to be useful in selective situations, but routine scaling and rootplaning, or in advanced cases open flap debridement, remain the treatment of choice in almost every case.


Crown Lengthening


Sometimes a tooth becomes decayed or broken down below the gum line.  In these cases the gum and bone line need to be adjusted to allow the dentist to place a restoration, such as a crown or filling.  Also a dentist may have placed a restoration that extends too far under the gum line and is causing soreness and inflammation, which is another situation that may benefit from crown lengthening. 


Socket Preservation


When a tooth is extracted many times the gum tissue undergoes shrinkage because the underlying bone level changes.  This shrinkage may be a cosmetic problem in the front part of the mouth, but is often not a problem in the back, unless a dental implant is to be placed.


Socket preservation in the front of the mouth is usually a good idea. The benefit in the back of the mouth is questionable.


If an implant is to be placed, it is usually best to place the implant at the time of extraction which would eliminate the need for socket grafting and avoid unnecessary cost and delay in overall treatment time.  The exceptions are molar teeth which generally should be extracted and the socket allowed healing naturally before the implant is placed.  Usually a socket graft is not needed in a molar extraction site. 


Soft Tissue Grafts


Gingival recession is commonplace.  Most areas of gingival recession do not cause symptoms and are not pathologic.  Ultimately most recession, except that recession caused by periodontal disease, occurs because the gum and bone covering the root are too thin to stand the patient’s day to day function and brushing,or the tooth has been repositioned due to orthodontic treatment or due to function.  The result is that the gum line recedes until the point is reached where the gum is thick enough to resist. Therefore all most all recession is self limiting. 


Dr. Kaiser believes there are only two absolute indications to surgically intervene:


1.  Desire of the patient to improve the appearance.


2.  The presence of inflammatory disease, bleeding and or pus, that is not responsive to other routine periodontal procedures.   


This is not to say there are no other indications to consider a soft tissue graft.  It is just that fear of tooth loss is usually not one of them.  As an anecdotal observation in his 32 years of practice, Dr. Kaiser cannot remember ever seeing a tooth lost due to simple gum recession, meaning the recession was not caused by inflammation, or the presence of blood or pus. 

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