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After performing the laboratory/clinical exercises in this chapter, the student will be able to do the following:
1. Remove a surgical dressing without damage to the oral tissues.
2. Debride both hard and soft tissues after dressing removal.
3. Remove all placed sutures without contamination of or damage to the tissues.
4. List the information recorded in the patient’s chart when removing a dressing or sutures.
5. Identify and name common suture patterns used in dentistry, and give an example of their application.
6. Describe the classification of suture materials.
Following periodontal surgery, the patient is frequently scheduled with the dental hygienist for a “post-op” appointment. Collagen deposition and primitive epithelium have usually repaired a surgical site by the end of the first postsurgical week. This provides enough strength to the wound to allow for dressing and suture removal. Therefore, the patient returns for a follow-up evaluation 7 to 10 days after the surgery. If the dressing has not been lost, the hygienist will remove the periodontal pack followed by suture removal and documentation of the healing state.
I. Removal of the Periodontal Dressing
A. A sturdy, blunt instrument, such as a surgical hoe, plastic instrument, or curet, is inserted under the edge of the dressing with a smooth surface against the tissue. Gentle lateral pressure is applied, and the pack is carefully loosened. Sutures that may have become incorporated into the dressing material must be detected and cut before each piece of pack can be removed. Remove the dressing pieces with forceps, being careful not to scratch the sensitive tissues. Suture removal is discussed later in this chapter, and the necessary items for removal of the periodontal dressing are listed in Table 34.1.
B. After the dressing has been removed, the teeth and tissues are swabbed gently with diluted disinfectant mouthwash or hydrogen peroxide on a cotton-tipped applicator to loosen food and bacterial debris, as shown in Figure 34.1. The area is then rinsed with warm water. This may need to be repeated to debride the area.
C. Inspect the surgical site for approximation of incision edges and absence of drainage, inflammation, and edema. The healing state is evaluated and noted in the patient’s chart. The tissues that had been surgically manipulated should be epithelialized (covered with epithelium); however, the epithelium will be friable at this early stage of healing. These tissues may appear redder than the surrounding tissues due to the greater vascularity and lesser degree of keratinization. Red, head-like projections of granulation tissue are an indication of residual calculus. If healing is delayed and the tissues are sensitive, another periodontal dressing may be placed for a 2nd week.
D. Residual dressing material and any visible calculus are removed, taking care not to disturb the fragile epithelium.
E. Assess periodontal pack removal by using the Skill Performance Evaluation sheet in Appendix 2.
TABLE 34.1. Armamentarium for Removal of the Periodontal Dressing and Sutures
FIGURE 34.1. Teeth and tissues are swabbed with a disinfectant.
II. Suture Removal
Sutures are stitches that are used to control bleeding and to hold body tissues in a desired position until healing has progressed to the point at which sutures are no longer needed. This healing normally takes place in 5 to 7 days for oral tissues. Removal of the sutures is usually performed at the 7- to 10-day postsurgical follow-up visit. All sutures that are not removed at this time act as a foreign body and promote inflammation to varying degrees. An infection at the sight of a suture is called a suture abscess or a stitch abscess.
A. Classifications of Suture Materials
Suture materials are discussed in Chapter 13. A typical suture package is shown in Figure 34.2A.
FIGURE 34.2. A. Silk suture material. B. Swaged suture needle.
Tips for Periodontal Dressing Removal (Laboratory Exercise)
- If the dressing is placed on a Dentoform for a laboratory exercise, prompt removal of the pack will facilitate cleaning of the Dentoform.
- Large pieces of retained material can be removed with a scaling instrument.
- The last traces of pack on the Dentoform can then be dissolved with orange solvent on a gauze square.
Precautions—Periodontal Dressing Removal
- Remove the surgical dressing with controlled force, checking for and cutting imbedded sutures.
- Loosened pieces of dressing are best removed with forceps to prevent scratching of the primitive epithelium.
1. Suture materials can be monofilaments (one strand of material) or multifilaments (multiple threads twisted or braided together in a strand). Greater capillary action, or “wicking effect,” is created by the multifilaments, which draw more bacteria into the tissues and create a greater inflammatory reaction than the monofilaments. Multifilament sutures are often coated and can elicit less tissue response. Sutures may also be dyed to make them easier to see.
2. Suture materials can be natural or synthetic. Natural suture materials elicit a strong inflammatory response because of the presence of foreign proteins.
3. Suture materials can be divided into two broad categories: absorbable and nonabsorbable. Absorbable sutures are broken down and absorbed by the body. They may not need to be removed at a following appointment. Those that have not been completely absorbed before the postsurgical evaluation visit are usually removed for patient comfort. A follow-up appointment is necessary to remove nonabsorbable sutures.
4. Absorbable Sutures
a. Natural absorbable sutures are absorbed by the process of phagocytosis and enzymatic resorption. Some synthetic materials are resorbed by hydrolysis, causing less inflammatory response.
i. Surgical gut or “gut” is a monofilament made from the connective tissue of sheep or cattle intestinal mucosa.
ii. Chromic gut is surgical gut that has been treated with chromic salts to inhibit enzymatic resorption. These sutures stay in place for 14 days or longer.
b. Synthetic, biodegradable sutures are commonly being used in dentistry today. These may be braided polymer fibers of polylactic acid or polyglycolic acid. Monofilaments of other polymers having more flexibility are also available.
5. Nonabsorbable Sutures
Nonabsorbable sutures can also be of natural or man-made materials. These materials will not be absorbed by the body; they must be removed at the postsurgical visit.
a. Silk sutures are braided fibers of protein excreted by the silkworm. Although made of a natural, biodegradable protein, the absorption of silk progresses much more slowly than does the healing process. Therefore, silk sutures are classified as nonabsorbable because they must be removed.
b. Synthetic, nonabsorbable sutures may be made of polypropylene, polyester, nylon, or Gore-Tex. Gore-Tex is made of polytetrafluoroethylene; the same polymer used for Teflon.
6. In the United States, sutures are sized according to diameter and are labeled numerically. As the number of zeros increases, the diameter decreases. For example, a “000” suture is larger in diameter than a “0000” suture. The “000” suture can also be expressed as “3-0” suture and is pronounced as “three ought” or “three zero.” The suture sizes used most commonly in dentistry are 3-0 to 5-0.
7. The European system of sizing simply states the metric diameter of the suture.
8. The suture material can be supplied separate from the suture needles, or it can be manufactured attached to the needle, creating a continuous unit of suture and needle. The latter option is termed swaged. A swaged needle with silk suture material is shown in Figure 34.2B.