Nonsurgical care of Periodontal disease is both possible and often very successful. it requires assiduous removal of subgingival calculus and a compliant, well-instructed dental patient.
The removal of calculus via scaling is time, skill and instrument dependent.
I'll elaborate more about the time referenced in #2, later in this narrative, but let me just relate a study done involving Periondontists with more than 10 years of experience. A study done on single-rooted teeth that had not undergone periodontal treatment with pocket depth of 5-8mm revealed the following:
- Periodontists who did the scaling spent an average of 10 minutes per tooth
Let's return to the issue of time.
The concept of the 10-minute tooth evolved after our experience, both surgically and with the perioscope as well. For those of you not familiar with the Perioscope, learn more here. Perioscopic guided scaling is a technique employed using a probe and a light to actually project the subgingival environment on a screen so we can visualize the root surface as it is scaled to both see the calculus during and the root surface after scaling to ensure complete removal. Because of perioscopy, the results of our nonsurgical scaling have improved significantly with pocket depth reductions up to an exceeding 5 mm once the calculus is completely removed. However, even with direct visualization, these procedures require a significant investment of time.
The issue of instrumentation and particularly the sharpness of curettes and the viability of the blade have also proven to be very important parameters in terms of the effectiveness of scaling. Since our nonsurgical scaling, without the perioscope, involves the use of curettes, our experience has proven that using a new or nearly-new curette with a sharp blade is the sine qua non of effective scaling since it is necessary to remove not only what appears to be calculus but to smooth the root surface as well to ensure calculus is removed. Calculus is often embedded in the root surface and does not come off easily. [ The earlier philosophy of root planing which was utilized to remove diseased cementum should be looked at rather as a method for removing calculus by planing the root surface. Calculus is often burnished into a root, making its perception often impossible hence root planing becomes critical to the removal of calculus and the imbedded bacteria.
Inevitably when we have patients who we have previously treated and they subsequently develop progressive peridontal disease, upon either perioscopic visualization or surgical exposure, we find calculus universally present in the pockets that have recurrent disease. Because of this, a protocol has been developed called the 10-minute tooth. We are going to use this as a procedure as it relates to teeth on recall patients and for patients who have recurrent and/or progressive periodontal disease or have been treated in the past. The 10-minute procedure often involves 10 minutes on one or two surfaces in the following manner:
Using a sharp curette, the area is root planed with approximately 100 strokes. Instrumenting the root with different instruments will ensure not only calculus removal but planing of the root to remove spicules embedded in the root surface. This is followed by a similar number of strokes also coming at it from different angles with an ultrasonic instrument to hopefully augment the scaling with a curette. A new curette or a continually sharpened one is indispensable.
When this approach is employed, we have observed a marked improvement in sites that have been resistant to previous routine maintenance. Significant pocket reduction, elimination of bleeding upon probing, and a tight adaption of the tissue to the tooth is obtained in a vast majority of the cases.
The 10-minute tooth is obviously meant more figuratively than literally but it is a direction in terms of how to approach tissues that heretofore have been unsuccessfully treated or referred for surgical procedures and/or subgingival antibiotic medication.
This is not to say that all areas can be treated nonsurgically. Lack of attached gingiva, intrabony defects, furcation involvements, and root concavities all represent challenges that cannot always be dealt with successfully in all patients in a nonsurgical manner. However, it is an excellent starting point and often ending point for many teeth that can be treated noninvasively.
Ultimately, it is imperative that the clinician be able to step back and re-evaluate patients after scaling has been performed in order to assess outcomes and then take an action which would include either a further commitment to nonsurgical debridement or surgical exposure if perioscopy is not available.
I am most interested in hearing your thoughts regarding this issue. Please don’t hesitate to share by sending me an email, note or calling to talk with me personally. I look forward to hearing from you
Feel free to share your thoughts with me.
Dr. Victor M. Sternberg, D.M.D.
PDF File for hygienists