Scaling Cleaning (Detertrage / Curettage)
Ultrasonic and motorized cleaners and hand tools are used to clean the calculus. The process of cleaning the tooth parts above the gums is called detertrage, and the process of wiping the tooth surfaces is called polishing. It can be completed in a single session or an additional session may be needed. In cases where the removal process is insufficient to establish gingival health, further treatments are required.
The most important step in periodontal treatments is the elimination of the infection. The main factor causing the infection is the bacterial plaque, which we call microbial dental plaque. For this reason, in addition to the treatments performed by the physician in order to control the disease, it is essential for the patient to increase the existing oral hygiene and clean the teeth, gums and interdental areas.
Beginning gum disease is called gingivitis. Gingival recession or bone loss has not occurred yet. During this period of the disease, swelling, bleeding and redness of the gums can be seen. These symptoms are generally stable in gingival diseases. For the disease to progress to the next stage, bone loss must have started and this disease of the gums is called Periodontitis. After periodontitis occurs, a periodontal pocket develops, which may result in gingival recession and/or sagging in the teeth in the future. As a result of the decrease in the number of capillaries and the increase in the keratin structure of the gingiva in smokers, the gingival tissue that does not bleed, does not swell and remains tight seems to be healthy, which is usually a false picture and delays the patient’s time to consult a doctor. Although the patient has no complaints, the level of advanced gingival discomfort and bone loss can be easily determined as a result of radiographic and clinical examination.
After the gingival treatment, gingivitis will decrease and at the same time, the gingival pockets and tooth surfaces will be smoothed, which helps the bacterial plaque to adhere. Elimination of the infection will be possible by cleaning the bacterial plaque causing the disease, tartar and root surfaces where the tartar is attached by the physician. If the infection does not recur, it will be possible if the patient can regularly clean the bacterial plaque every day and maintain the current healthy condition. If the recommended treatment is not applied, gum disease will continue in the area of the teeth or may remain stable for a period of time without progression. However, depending on the progression of the disease, an increase in the mobility of the teeth, a decrease in chewing function and tooth loss may occur in the later period.
It has been reported in the literature that periodontal tissues with impaired health also negatively affect general health. The relationship between periodontal disease and many diseases such as cardiovascular diseases, diabetes, kidney diseases, increased risk of miscarriage in pregnancy, and rheumatoid arthritis has been revealed in the literature.
If the patient cannot provide the desired oral care, no improvement is observed in the treated areas. New bacterial plaque accumulating around the teeth and gums 2-4. It can form the initial stage of the disease on the first day of the disease, and on the 21st day it can reach the potential to cause bone destruction. If the patient’s oral care is sufficient, some recession may occur in the gingiva following the recovery after the operation. The amount of gingival recession depends on the initial depth of the gingival pocket and the degree of periodontitis. As a result of the treatment, depending on the position of the bone, some parts of the tooth root may be exposed, the clinical length of the tooth may be extended and the tooth may appear longer. In the early stages of treatment, teeth may become more sensitive to cold and heat. Although this situation is usually resolved with supportive fluoride applications in a short time, in some cases this period may take up to 2 months. An increase in mobility (mobility) of the teeth may occur following treatment, but after the healing process is complete, the mobility of the teeth is usually reduced and they become firmer than in their original state. Teeth with excessive bone loss, where the teeth are very mobile, may need to be fixed to adjacent teeth, which is called a splint.
Periodontal Flap Operation (Gum Surgery)
Clinical and radiographic evaluation is required to determine the level of existing gingival disease. Bone loss can be determined radiographically, as well as millimetric measurement of the gingival pocket depths with the periodontal probe during the clinical evaluation, and the stage of the disease and the need for treatment are determined. As the gingival pocket depth increases, it is understood that the bone destruction is more and the gingival disease has progressed. Flap operation is the appropriate treatment option in cases where the periodontal pocket depth is 5 mm or more.
The purpose of this operation; It is the detailed cleaning of root surfaces and granulation tissues (soft tissue formed as a result of inflammation) by providing direct and full access to the root surface and the deepest area of bone destruction. Periodontal flap operation is recommended in the presence of periodontal pockets deeper than 5 mm and especially in molars with two or three roots, since it has been reported that periodontal hand tools and ultrasonic tools that help to remove calculus are ineffective in the presence of periodontal pockets deeper than 5 mm.
Local anesthesia is applied before the procedure. The gingiva is separated from the root surface and a small amount of bone with an incision. Inflamed granulation tissues are cleaned from the top of the bone, around the root surface and from the areas adhered to the soft tissue. After this stage, as in the curettage process, basically root surface scraping and planning is done. The advantage of the procedure is that it provides direct vision and direct access to the deep areas where the disease is effective. In addition, it also allows the application of various biomaterials to ensure bone formation. However, for biomaterial applications (augmentation), it is important that bone destruction is suitable in terms of shape and that the patient can provide oral hygiene above a certain standard. After cleaning the soft and hard tissues, the area is washed and closed with a suture type suitable for the needs of the relevant area.
Periodontal Abscess Treatment
Periodontal abscess can be acute or chronic. In the acute state, severe pain, swelling, lymphadenopathy, fever and malaise are seen. In this case, the patient is given antibiotics and treatment is started. After the use of antibiotics, the abscess is drained. For this, local anesthesia is applied to the area and subgingival curettage (root surface scraping and planning) is performed. Flap surgery is performed when necessary. If the abscess is chronic, antibiotic treatment is often not required. The aim of the treatment is primarily to eliminate the patient’s complaints such as pain and swelling. It is aimed to recover the tissues lost as a result of abscess, but it may not always be possible. If the recommended treatment is not followed, the periodontal abscess may progress to deeper tissues and threaten the root tip or all-around root. As a result of bone loss, increased mobility of the teeth, decreased chewing function and tooth loss in later periods may occur.
Treatments of Gingival Recessions
In soft tissue losses or insufficiency, soft tissue grafts are transferred from the appropriate tissues in the oral cavity of the patients to the needed areas and fixed. Soft tissue transfer may be necessary to compensate for the loss of tissues after the surgical procedure, to reduce the tension in the gingiva, to make the tissues suitable for the prosthesis or to prevent gingival recession. Generally, soft tissue grafts are obtained from the appropriate palate regions of the patient’s mouth. If the patient does not want a second wound area to be created on the palate, ready-made grafts obtained from other sources and sterilized can also be preferred. However, if the patient’s own tissue is used, a much more harmonious healing process will be experienced as the body recognizes its own tissue.
Among the mucogingival surgical methods, the supply of suitable soft tissue from adjacent and/or close areas to the areas of gingival loss and the use of the relevant tissue by changing its position (shifting) have been reported as methods that can benefit the patient without creating a second wound area. The most commonly used method of mucogingival surgery is “Connective Tissue Graft”. Free gingival graft and (subepitalial) connective tissue graft create an additional surgical field in the palate region. Applications such as lateral/coronal position flap and double papillary shift technique aim to close recessions with a single surgical field, but for these operations, some criteria such as gingival phetontype, thickness, and position of teeth should be considered and may not be suitable for every case.
Gingival Growths and Treatment
The healthy appearance of the gingiva is pale pink, called coral pink. The gingiva is tight and has tiny indentations and protrusions similar to the structure on the orange peel. In gingival enlargements, this appearance usually changes from pink to red, from a tight and thin appearance to a swollen, shiny appearance. It is often accompanied by gingival bleeding. In acute cases such as gingival abscess, patients may notice that the top of the tooth is covered with the gingiva. The main element of gingival enlargement is considered to be bacterial plaque. However, gingival enlargement may occur due to hormonal changes (age of growth, pregnancy, etc.), some drugs (nifedipine, phenytoin, cyclosporine A) or idiopathic causes. In addition to these, tumoral growths, growths due to continuous chronic traumas can also be seen. Mouth breathing, dry mouth, severe vitamin C deficiency (if scurvy occurs if no fresh fruit and vegetables are eaten) are listed as predisposing factors for gingival enlargement. Tumor-like rapid gingival enlargement that occurs during pregnancy is called pregnancy tumor. For gingival enlargements that do not improve with simple interventions like this, a minor surgical procedure called gingivectomy is applied.
Gingivectomy
Gingivectomy is a resective treatment method. With this procedure, it is aimed to remove the part of the gingiva that is more than normal and to restore the healthy gingival structure to the patient. If the physician deems it necessary, he can send the removed tissue for biopsy.
Gingivectomy can also be applied for aesthetic procedures. In line with the aesthetic needs of the patient with a gingival smile (Gummy Smile), the most visible parts of the gingiva are removed with a manicure-like procedure. This procedure is applied to all teeth that include the patient’s smile. Traditionally, the gingiva can be shaped using a scalpel or electro-cautery, today it is possible to shape the gingiva using dental lasers. The term “Pink Aesthetics” has been widely used to describe gingivectomy procedures performed for aesthetic purposes. In some cases of gingivectomy for aesthetic purposes, removing only the excess gingival may not allow the existing gingival smile to be completely removed. In such cases, gingival surgery (flap operation) should be performed and the bone under the gingiva should be shaped and adapted to the new position of the gingiva (more apical), which usually exposes the roots of the tooth to some extent. For this reason, lamina and so on in the related teeth. restorations may be needed. As another method, patients can have the relevant specialists perform alternative methods such as botox.
