perio

1. Submitted by:
B.Tejolatha
Internee

2. Introduction
 The “General principles of periodontal Surgery” covers the
preparation of the patient and the general considerations
common to all periodontal surgical techniques. Here
complications which occur during or after surgery are also
discussed.
 Surgical periodontal procedures are usually performed in the
dental office and Hospital periodontal surgery is also been
performed for some patients which are discussed at the end of
this topic. Hence periodontal surgery usually performed as
a. Out patient surgery and
b. Hospital periodontal surgery.

3. Outpatient Surgery
 A. Preparation of the Patient :-
 Preparation of the patient for periodontal
surgery includes
a. Re-evaluation after phase -1 therapy
b. Premedication
c. Smoking
d. Informed consent

4. Re-evaluation of the patient after
phase -1 therapy
 Almost every periodontal surgery patient must
undergo the so called “Initial or Preparatory
phase of therapy” which basically consists of
a. Thorough scaling and root planning and
b. Removal of all irritants responsible for the
periodontal disease.

5. These “preparatory phase of therapy”
 a. Eliminates some lesions entirely.
 b. Render the tissue more firm and consistent,
thus permitting a more accurate and delicate
surgery.
 c. Acquaint the patient with the office and the
operator and assistants, thereby reducing the
patients apprehension and fear.

6. The reevaluation phase consists of
 a. Reprobing and
 b. Re-examining all the pertinent findings that
previously indicated the need for the surgical
procedure. And persistence of these findings
confirm the indication for surgery.

7. Premedication
 The patients who are not medically compromised, the
value of administering antibiotics routinely for
periodontal surgery has not been clearly demonstrated,
although some studies have reported reduced post-
operative complications including reduced pain and
swelling when antibiotics are given before periodontal
surgery and continuing for 4 – 7 days after surgery.

8.  The prophylactic use of antibiotics in patients who are
otherwise healthy has been advocated for bone grafting
procedures and has been claimed to enhance the
chances of new attachment.
 Other presurgical medications include administration
of a non steroidal anti-inflammatory drug such as
Ibuprofen 1-hour before the procedure and one oral
rinse with 0.2% chlorhexidine gluconate

9. Smoking
 The deleterious effect of smoking on healing of
periodontal wounds has been amply documented.
Patients should be clearly informed of this fact and
requested to quit or stop smoking for a minimum of 3-
4 weeks after the procedure.
 For patients who are unwilling to follow this advice, an
alternative treatment plan not including highly
sophisticated techniques, such as regenerative
procedures and mucogingival and esthetic techniques
should be considered.

10. Informed Consent
 The patient should be informed at the time of initial
visit about the diagnosis, prognosis, the different
possible treatments with their expected results and all
pros and cons of each approach.
 At the time of surgery, the patient should again be
informed, verbally and in writing of the procedure to
be performed and he/she should indicate agreement by
signing the consent form.

11. Emergency Equipment
 The operator, all assistants and office personnel
should be trained to handle all the possible
emergencies that may arise. Drugs and
equipment for emergency use should be readily
available at all times.
 The most common emergency is syncope or a
transient loss of consciousness due to a
reduction in cerebral blood flow. The most
common cause is fear and anxiety.

12.  The patient should be placed in a supine position with
the legs elevated; tight clothes should be loosened, and
a wide-open airway ensured. Administration of oxygen
is also useful. Unconsciousness persists for a few
minutes.
 A history of previous syncopal attacks during dental
procedure should be explored before treatment is
began and if these are reported, extra efforts to relieve
the patients fear and anxiety should be made

13. Measures to prevent Transmission of
Infection
 In recent years, the danger of transmitting infections to
the dental team or other patients has become apparent,
particularly with the threat of AIDS and Hepatitis-B.
 Universal precautions include the use of
a. Disposable sterile gloves
b. Surgical masks
c. Protective eyewear.

14.  All surfaces possibly contaminated with blood or saliva
that cannot be sterilized (such as light handles and unit
syringes) must be covered with aluminum foil or plastic
wrap.
 Aerosol producing devices, such as the cavitron,
should not be used on patients with suspected
infections, and their use should be kept to a minimum
in all other patients. Special care should be taken when
using and disposing of sharp items such as needles and
scalpel blades

15. Sedation and Anesthesia
 Periodontal surgery should be performed
painlessly. The patient should be assured of this
at the outset and throughout the procedure.
 The area to be treated should be thoroughly
anesthetized by means of nerve block and local
infiltration injections.

16.  Preanesthetic medication is given for relief of
apprehension and reduction of oral secretions and they
are given 30- 45 minutes before injection of local
anesthetic agent.
 Anxiety can alter certain drug effects, it often makes a
larger dose than normal necessary for satisfactory
results.
 Preanesthetic medication should also include an
anticholinergic drug such as atropine or hyoscine
(scopolamine) to reduce salivary and bronchial
secretions.

17.  The apprehensive and neurotic patients require
special management with antianxiety or sedative,
hypnotic agents.
 Modalities for the administration of these agents
include
a. Inhalation
b. Oral
c. Intramuscular and
d. Intravenous routes.

18.  The specific agents and modality of administration
selected is based on
a. The desired level of sedation
b. Anticipated length of the procedure
c. Overall condition of the patient.
 Specifically, the medical history, the physical status and
emotional status of the patient should be taken into
consideration when selecting agents and techniques
should be employed.

19.  Perhaps the simplest, least invasive method to alleviate anxiety
in the dental office is “Nitrous oxide and oxygen inhalation”
sedation. For many individuals this is quite effective.
 Advantages of Nitrous oxide sedation include
a. A quick onset of action
b. The ability to adjust the level of sedation
throughout the procedure
c. A rapid recovery and
d. little or no concern for post-operative impairment
of sensory or motor function.

20.  Disadvantages are very few. They include a small
percentage of patients will not achieve the desired
effect. This is especially true for the mentally impaired
individual because nitrous oxide and oxygen sedation
requires some level of patient cooperation.
 Overall inhalation sedation with nitrous oxide and
oxygen is safe, effective and reliable means of reducing
mild anxiety.

21.  For individuals with mild to moderate anxiety oral administration
of a Benzodiazepine can be effective in decreasing anxiety and
producing a level of relaxation.
 Oral administration of a sedative agent can be more effective
than inhalation anesthesia because the level of sedation achieved
may be more profound. Disadvantages of oral sedative
administration include
a. Incomplete recovery
b. An inability to control the level of sedation and
c. A prolonged period of impaired sensory and
motor skills.

22. Tissue management
 A maxim of the principles of surgery is that living
tissue must be handled gently. For post operative
patient comfort, uneventful healing and satisfactory
final result of any technique, tissue must be
manipulated as gently and atraumatically as possible.
 3 – steps should be considered for Tissue management,
during periodontal surgery are

23.  a. Operate gently and carefully:-
Tissue manipulation should be precise, deliberate and
gentle. Thoroughness is essential but roughness is
avoided because it produces excessive tissue injury,
cause post operative discomfort and delays healing.
 b. Observe the patient at all times:-
It is essential to pay careful attention to the patients
reaction. Facial expression, pallor and perspiration are
some distinct signs that may indicate the patient is
experiencing pain, anxiety or fear.

24.  c. Be certain the instruments are sharp:-
The cutting surfaces of the instruments should
be sharp so they will cut the tissue effectively
without crushing the tissues. Dull instruments
inflict unnecessary trauma due to poor cutting
and excessive force applied to compensate for
their ineffectiveness.

25. Scaling and Root Planing
 “Scaling” is the process by which plaque and
calculus are removed from both supragingival
and subgingival tooth surface.
 “Root Planing” is the process by which residual
embedded calculus and portions of cementum
are removed from the roots to produce a
smooth, hard, clean surface.

26. Hemorrhage Control (Hemostasis)
 Hemostasis is an important aspect of periodontal
surgery because good intraoperative control of
bleeding permits an accurate visualization of the extent
of the disease, pattern of bone destruction and an
anatomy and condition of the root surfaces.
 Hemostasis provides the operator with a clear view of
the surgical site, which is essential for wound
debridement and scaling and root planning.

27.  In addition, good hemostasis also prevents
excessive loss of blood into the mouth,
oropharynx and stomach.
 Periodontal surgery can produce profuse
bleeding, especially during the initial incisions
and flap reflection. After flap reflection and
removal of granulation tissue, bleeding
disappears or is considerably reduced.

28.  Typically control of intra operative bleeding can be
managed with aspiration. Continuous suctioning of the
surgical site with an aspirator is indispensable for
performing periodontal surgery.
 Primary hemorrhage is rarely severe, but occasionally it
must be controlled. A strip of gauge moistened with
topical epinephrine solution and held against the
bleeding surface for a few minutes usually is adequate.

29.  The guage should be moist but not dripping wet
because a systemic reaction can be caused by careless
use of topical epinephrine.
 Additional infiltration of local anesthetic agent into the
bleeding area often will reduce the hemorrhage because
of the epinephrine in the solution.
 Bleeding should be stopped before the surgical dressing
is applied. Proper precautions taken at this time will
make post operative or secondary hemorrhage unlikely.

30.  The hemorrhage which is constant and oozing,
hemostasis may be achieved with haemostatic agents.
There are a variety of haemostatic agents available
which are used in the past and still continuing their
usage and new recently tried agents which are classified
based on their mode of administration, they are
a. Local haemostatic agents
b. Systemic haemostatic agents

31.  Some of the available locally administered absorbable
haemostatic agents which are commonly used in
periodontal surgery to control bleeding include
a. Absorbable gelatin sponge (Gelfoam)
b. Oxidized cellulose (oxycel)
c. oxidized regenerated cellulose (Surgicel
absorbable hemostat)
d. Microfibrillar collagen hemostat (collatape,
collaplug, collacote).
e. Thrombin (Thrombostat)

32. Absorbable gelatin sponge
 “Absorbable gelatin sponge” is a porous matrix
prepared from pork skin that helps stabilize a
normal blood clot. The sponge can be cut to
the desired dimensions and either sutured in
place or positioned within the wound (extraction
socket). It is absorbed in 4-6 weeks.

33. Oxidized cellulose
 “Oxidized cellulose” is a chemically modified
form of surgical gauze that forms an artificial
clot. The disadvantage is that the material is
“friable” and is difficult to keep in place. It is
absorbed in 1-6 weeks.

34. Oxidized regenerated cellulose
 “Oxidized regenerated cellulose” is prepared from cellulose by
reaction with alkali to form a “chemically pure, more uniform
structure than oxidized cellulose.
 The material is prepared in a thin cloth or thin gauge form that
can be used as surface dressing because it does not impair
epithelialization and it is bactericidal against many gram-negative
and gram–positive microorganisms.
 Caution should be used when wounds are infected or have an
increased potential to becoming infected (e.g.:
Immunocompromised patients) because the absorbable
haemostatic agents can serve as a nidus for infection.

35. Thrombin
 “Thrombin” is a drug capable of hastening the
process of blood clotting.
 It is intended for topical use only because is
applied as a liquid or powder.
 Thrombin should never be injected into tissues
because it can cause serious, even fatal
intravascular coagulation.
 It is a bovine derived material and those who are
allergic to bovine products it is contraindicated.

36. Periodontal Dressings (periodontal packs)
 In most cases after periodontal surgical procedures are
completed, the area is covered with a surgical pack. The
surgical dressing is applied over the wound to provide
“patient comfort” and to “protect the wound from
further injury while it is healing”.
 The action of this dressing material is to “avoid
mechanical irritation” and it does not increase the rate
of healing. But it assist healing by protecting the tissue
rather than providing “healing factors”.

37.  The dressing is adapted around and between the teeth
for retention and it is placed apical to the height of
contour of the teeth to prevent interference with
occlusion.
 The incisal relationship is observed to be sure that the
mandibular incisors will not displace the dressing when
the patient closes in centric occlusion.
 If intrabony type deformities present, they are covered
with a “tent” of adhesive fail to prevent any dressing
material from entering the defect.

38.  Commercially available periodontal packs
include
(a) Zinc-Oxide eugenol packs
(b) Non-eugenol packs
(c) Peripack – premixed dressing
(d) Tissue conditioners
(f) Chemical adhesives (Cyanoacrylates)

39. Zinc-Oxide eugenol packs
 Packs based on the reaction of Zinc-oxide and Eugenol include
the “Wonder pack” developed by ward in 1923 and several
others modified “Wards” original formula, but they all consists
primarily of a
a. Powder – containing zinc oxide, powdered rosin and tannic acid
flaxes in various proportions.
b. Liquid – containing Eugenol and either almond,
Peanut or Mineral oil.
 Addition of accelerators such as zinc acetate gives the dressing a
better working time.
 Use of Eugenol dressings has been largely discontinued because
of the unpleasant taste and rough surface.

40. Non eugenol packs
 The reaction between a metallic oxide and fatty acids is the basis
for development of “Non eugenol packs”
 commercially available as ‘Coe-pak” which is the most widely
used dressing in the U.S.
 “Coe-Pak” is supplied in two tubes
a. One tube contains – zinc oxide, an oil (plasticity), a
gum (for cohesiveness) and Lorothidol (a fungicide).
b. The other tube contains – Liquid “coconut fatty acids
thickened with colophony resin (or rosin) and
chlorothymol (a bacteriostatic agent).
 This dressing doesnot contain asbestos or eugenol, thereby
avoiding the problems associated with these substances.

41. Retention of the pack
 1. Periodontal dressings are usually kept in place
mechanically by interlocking in interdental spaces and joining the
lingual and facial portions of the pack.
 2. When several teeth in an arch are missing or there is
wide interdental spaces where retention of pack seems to be
difficult, can take reinforcements with
a. Splints
b Stents
c. Placement of dental floss loosely around the teeth
enhances the retention of the pack.

42. Antibacterial Properties of the Pack
 Improved healing and patient comfort with less odour
and taste have been obtained by incorporating
antibiotics in the pack.
 The antibiotics that have been tried in periodontal pack
are
a. Bacitracin
b. Oxytetracycline
c. Neomycin and
d. Nitrofurazone.
 But all may produce hypersensitivity reactions. The
emergence of resistant organisms and opportunistic
infections have been reported.
 Incorporation of Tetracycline powder in Coe-Pak is
generally recommended in long and traumatic surgeries
when performed

43. Preparation and Application of the
Periodontal Dressing
 Zinc oxide packs are mixed with eugenol or non
eugenol liquids on a wax paper pad with a wooden
tongue depressor.
 “Coe – Pak” is prepared by mixing equal lengths of
pastes from tubes containing the accelerator and the
base until a uniform colour of paste is obtained.

44. Preparing the surgical pack

45.  A capsule of Tetracycline powder can be added at this
time. The pack is then placed in a cup of water at
room temperature. In 2-3 minutes the paste looses its
tackiness, and can be handled and moulded. It remains
workable for 15-20 minutes.
 Working time can be shortened by adding a small
amount of Zinc oxide to the accelerator before
spatulation.

46.  The pack is then rolled into two strips approximately
the length of the treated area. The end of one strip is
bent into a hock shape and fitted around the distal
surface of the last tooth, approaching it from the distal
surface.
 The remainder of the strip is brought forward along
the facial surface to the midline and gently pressed into
place along the gingival margin and interproximally.

47. Inserting the periodontal pack

48.  The second strip is applied from the lingual
surface and is joined to the pack at the distal
surface of the last tooth, then brought for ward
to the midline along the gingival margin.
 The strips are joined interproximally by applying
gentle pressure on the facial and lingual surfaces
of the pack.

49.  For isolated teeth separated by edentulous
spaces, the pack should be made continuous
from tooth to tooth covering the edentulous
area.
 The over extension of the pack on to the
uninvolved mucosa should be avoided. Excess
pack irritates mucobuccal fold and floor of the
mouth and interferes with the tongue.

50. The pack should not
Interfere with
occlusion

51.  Over extension also jeopardizes the remainder
of the pack because the excess tends to break
off, taking pack from the operated area with it.
 Pack that interferes with occlusion should be
trimmed away before the patient is dismissed.
Failure to do this causes discomfort and
jeopardizes the retention of the pack.

52. Re-evaluation of the patient after
periodontal surgery
The First-Post Operative week:
 Properly performed periodontal surgery presents no
serious post operative problems. The following
complication may arise in the first post operative week,
although they are the exceptions rather than the rule,
they include
(a) Persistent bleeding after surgery.
(b) Sensitivity to percussion
(c) Post operative swelling
(d) Feeling of weakness

53. Removal of the periodontal pack and
return visit care
 When the patient returns after 1-week, the pack is taken
off by inserting a “surgical hoe” along the margin and
exerting gentle lateral pressure.
 Pieces of pack retained interproximally and particles
adhering to the tooth surfaces are removed with scalers.
 Particles may be enmeshed in the cut surface and
should be carefully picked off with fine cotton pliers.
 The entire area is rinsed with peroxide to remove
superficial debris.

54. Findings at pack removal
 If “gingivectomy” has been performed the cut surface
is covered with a “friable mesh work of new
epithelium”, which should not be disturbed.
 If calculus has not been completely removed, red, bead
like granulation tissue will persists.
 The granulation tissue must be removed with a curette,
exposing the calculus so that it can be removed and
root planed. “Removal of the granulation tissue
without removal of calculus is followed by recurrence”.

55.  After a “Flap Operation” the areas corresponding to
incisions are epithelialised but may bleed readily when
touched, they should not be disturbed and pockets
should not be probed. The facial and lingual mucosa
may be covered with a “grayish-yellow or white
granular layer of food debris” that has seeped under
the pack. This is easily removed with a moist cotton
pellet.
 Each root surface should be checked visually to be
certain that no calculus is present. The grooves on
proximal root surfaces and the furcations are areas in
which calculus is likely to be overlooked.

56. Repacking
 After pack is removed it is usually not necessary to
replace it. However it is advisable to repack for an
additional week for patients with
(a) “low pain threshold” who are “apparently
uncomfortable when the pack is removed”.
(b) “Usually extensive periodontal involvement”
(c) After grafting procedures and mucogingival
surgeries
 “Clinical judgment” helps in deciding whether to repack
the area or leave the initial pack longer than 1-week.

57. Tooth mobility
 Tooth mobility is increased immediately after
surgery but it diminishes below the pretreatment
level by the ‘4th week”.

58. Care of the mouth between
periodontal surgical procedures
 Care of mouth by the patient between the treatment of
the first and the final areas, as well as after surgery is
completed is extremely important.
 These measures should begun after the pack is removed
from the first operation.
 The patient has been through a presurgical period of
instructed plague control and should be reinstructed at
this time.

59.  “Vigorous tooth brushing is not feasible” during
the first week after the pack is removed and is
advised to try to keep the area as clean as
possible by the “gentle use of soft tooth brushes
“ and “rinsing with chlorhexidine mouth wash
for the first few weeks post operatively”.
 Brushing is introduced “when healing of the
tissues permit it”, the vigor of the overall
performance is increased as healing progresses.

60. Treatment of sensitive roots
 Root hypersensitivity occurs spontaneously when the
root becomes exposed as a result of gingival recession
or pocket formation or it may appear after scaling and
root planning and surgical procedures.
 It is manifested as pain induced by cold, hot
temperature but more commonly cold, by citrus fruits
or sweets or by contact with toothbrush or a dental
instrument.

61. Desensitizing agents
 A number of agents have been proposed to control
root hypersensitivity but “clinical evaluation of these
agents is difficult because
(a) Measuring and comparing pain between different
persons is difficult.
(b) Hypersensitivity disappears by itself after a time
and
(c) Desensitizing agents take few weeks to act.
 The patient should be informed about the possibility of
root hypersensitivity before treatment is undertaken.

62. Agents used by patient
 The most common agents used by the patient for oral
hygiene are dentifrices. Although many dentifrice
products contain additional active ingredients for
desensitization, which include
(a) Strontium chloride
(b) Potassium nitrate
(c) Sodium citrate.
 Desensitizing agents act via “the precipitation of
crystalline salts on the dentin surface, which block
dentinal tubules”. Patients must be made aware that
their use will not prove to be effective unless used
continuously for a period of 3-weeks.

63. Agents used in the dental office
 Lists of various office treatments for the
desensitization of hypersensitive dentin- are
(a) Cavity varnishes
(b) Burnishing of dentin
(c) Fluoride compounds 1. Sodium fluoride
2. Stannous fluoride
(d) Iontophoresis
(e) Strontium chloride
(f) Potassium oxalate
(g) Restorative resins
(h) Dentin bonding agents.

64. Hospital periodontal surgery
 Usually periodontal surgery is an office procedure performed in
quadrants or sextants usually at biweekly or longer intervals.
 Under certain circumstances, it is in the best interests of the
patient to treat the mouth in one operation with the patient
treated in a hospital operating room under general anesthesia.
 Indications for hospital periodontal surgery include
(a) Optimal control and management of apprehensive
patients.
(b) Convenience for individuals who cannot endure multiple
visits.
(c) Patient protection

65. The Apprehensive patient
 Gentle approach, understanding patient needs and pre
operative sedation usually suffice to calm the fears of
most patients.
 For some patients the prospects of series of surgical
procedures is sufficiently stressful to trigger disturbance
that jeopardize the well-being of the patient and
hamper treatment.
 Completing the surgical procedure in one session rather
than in repeated visits is an added comfort to the
patients because it eliminates the prospects of repeated
anxiety in anticipation of each treatment.

66. Patient Convenience
 With complete mouth surgery, there is less stress
for the patient and less time involved in post
operative care.
 With the complete mouth technique, the pack is
ordinarily retained for one week only. Patients
find this an acceptable alternative to several
weeks of discomfort in different areas of mouth
and multiple dressing applications.

67. Patient protection
 Some patients have systemic condition that are
not severe enough to contraindicate elective
surgery but may require special precautions best
provided in hospital settings.
 This includes some patients with
(a) Cardiovascular disease
(b) Abnormal bleeding tendencies
(c) Hyperthyroidism
(d) Those undergoing prolonged steroid therapy
(e) With a history of rheumatic fever.

68. Premedication
 Patients should be given a sedative the night before
surgery. Benzodiazepines work well for most patients,
allowing them to sleep well the night before surgery.
 If the patient is extremely nervous about the
procedure, advise them to take a benzodiazepine on the
morning of surgery also. This ensures that they will be
rested and as relaxed as possible before surgery.

69. Anesthesia
 Local or general anesthesia may be used but local
anesthesia is the method of choice, except for severe
apprehensive patients. It permits unhampered
movements of the head, which is necessary for optimal
visibility and accessibility.
 When general anesthesia is indicated, it is administered
by an anesthesiologist. It is important that patient
should also receive local anesthesia, administered for
routine periodontal surgery to ensure comfort of the
patient and reduced bleeding during the procedure.
 The judicious use of local anesthesia should be avoided
which reduces the level of sedation or general
anesthesia. Hence the entire operation is performed
with a wider margin of safety

70. The Operation
 Surgery in the operating room is performed on the
operating table with patient lying down and the table
either positioned flat or the head position inclined up to
30-degrees.
 When general anesthesia is used, it is advisable to decay
placing periodontal dressing until the patient had
recovered – sufficiently, demonstrated by cough reflex.
 Periodontal dressing placed before the end of general
anesthesia can be displaced during the recovery period
and poses serious risks of blocking the airway.

71. Post Operative Instructions
 After full recovery from general anesthesia, most
patients can be discharged home with a responsible
adult.
 The effects of general anesthesia and sedation make the
patient drowsy for hours, recommending adult
supervision for 24 hours after surgery.
 The typical post – operative instructions should be
given to the responsible adult and the patient should be
scheduled for a post operative visit in 1-week.