Initial Treatment 1—
• Creating Conditions that Enhance Oral Hygiene
Tooth Cleaning—Supragingival Scaling
Creation of Hygiene Capability
Active professional treatment by the dentist or dental hygienist should begin even as oral hygiene instruction, patient motivation and monitoring of home care are ongoing. The patient cannot be expected to improve her/his oral hygiene if the preconditions for optimum home care are not simultaneously created (creation of hygiene capability). Professional prophylaxis is particularly important in this regard, as well as elimination of any plaque-retentive areas (niches) that represent harbors for bacterial accumulation.
The procedures described below are part of the first phase of initial therapy. Together with oral hygiene by the patient, these procedures comprise the only treatment necessary for gingivitis, and are important prerequisites in periodontitis therapy as well.
The following pages provide details concerning:
Instruments and materials, and their uses
Supragingival tooth cleaning and calculus removal
Removal of iatrogenic irritants (niches)
Reduction of naturally-occurring plaque-retentive areas
Subgingival plaque and calculus removal from pseudopockets and shallow periodontal pockets
The various treatments performed during the first phase of initial therapy cannot be strictly separated from each other, either in the presentations that follow in this book, or in the practice of dentistry. At a single appointment, for example, calculus removal, elimination of amalgam overhangs, minor odontoplasty and occlusal equilibration may all be accomplished.
The subgingival treatment of root surfaces (second phase of initial therapy) may also intersect with the first phase. In clinical situations that represent the indistinct transition from gingivitis to incipient periodontitis, i.e., when pockets are shallow, supra- and subgingival scaling often can be performed simultaneously.
On the other hand, scaling and definitive root planing in deep pockets and eventual soft tissue curettage must be relegated to the second phase of initial therapy. These procedures are often categorized as actual surgical therapy.
Supragingival Tooth Cleaning—Power-driven Instruments … and their Use
The removal of all stains, deposits and concrements comprises the first phase initial therapy. It is also an important preventive measure in the healthy periodontium, and the most significant post-operative measure following completion of periodontitis therapy. Thorough tooth cleaning is performed during each recall appointment (maintenance phase, p. 309).
The prevention/treatment/maintenance therapy trio “without end” is the sole responsibility of the dental hygienist. It also demands rationalization, standardization and work simplification, as well innovation in the development of new instruments (ultrasonic devices, Air-Scaler etc.).
Difficult-to-remove stains resulting from medicaments (e.g., chlorhexidine), tobacco, beverages (tea, wine) and foodstuffs as well as dental plaque can be removed using instruments that provide a water-powder spray (e.g., Cavitron-Jet). The powder that is used in the water spray must be minimally abrasive for dentin and restorative materials (Iselin et al. 1989). Furthermore, the spray should never be directed perpendicular to the tooth surfaces, and should usually be used only on enamel, with constant movement of the tip. Such devices do not guarantee perfect cleaning in interdental spaces or niches. The spray with normal abrasive powder should not be directed into pockets. With the new, “mild,” minimally abrasive agents and fine tips, effective cleansing can be achieved, in certain circumstances, even subgingivally (e.g., glycine powder from Espe, with the EMS Airflow Handy 2; p. 282; Petersilka et al. 2002).
After the removal of soft deposits, calculus becomes visible. Calculus is an excellent substrate for plaque accumulation and must be completely removed. Numerous power-driven instruments are available: Ultrasonic apparatus (e.g., Cavitron) as well as Air-Scaler that can be attached to the air-water supply of the dental unit (e.g., Titan-S, Satelec; Sonicflex KaVo etc.; Hermann et al. 1995).
However, the most important and most precise means for removal of concrements remains: hand instruments (p. 242).
Supragingival Tooth Cleaning—Hand Instruments, Prophy Pastes … and Their Use
In addition to ultrasonic devices, hand scalers and curettes remain the most important instruments for periodontal therapy and prophylaxis. For the removal of soft deposits and stains, hand instruments are enhanced by the use of brushes, rubber cups and polishing strips along with cleaning and polishing pastes.
It is not the manufacturer that is critical for successful treatment, rather the shape of the instrument, especially its degree of sharpness, and above all the manual dexterity of the dental hygienist (scaling technique)!
For the removal of supragingival deposits, chisels, straight and angled scalers and also lingual scalers are effective. In premolar and molar segments, also on difficult-to-reach areas, grooves and depressions on the crown, as well as exposed root surfaces, the removal of supragingival concrements may require curettes in addition to scalers, usually without anesthesia.
For the first phase of initial therapy, the classical universal curettes are indicated. The slender Gracey curettes, which are sharpened on only one edge, are used almost exclusively for subgingival scaling and root planing in periodontitis patients (p. 259). Today, ultrasonic and sonic devices are being used more and more often, in addition to hand instruments.
If supragingival calculus is covered with thick soft deposits, these should be removed with brushes and coarse prophy paste before mechanical debridement.
Whenever calculus is removed, the teeth should be polished afterwards with a rubber cup and polishing paste. This polish of the teeth and any exposed root surfaces is performed with fluoride-containing prophy pastes, which are classified according to their dentin abrasiveness (radioactive dentin abrasion = RDA; p. 234).
Contact points and the interdental areas can be cleaned using fine polishing strips (see p. 244).