PERIODONTAL FLAP SURGERY

PERIODONTAL FLAP SURGERY:

When advanced gum disease (periodontitis) develops, your teeth are in danger: At this stage, the ligaments and bone tissue that surround them are being destroyed, and you could even begin losing teeth! If the disease can't be controlled by non-surgical treatments like cleaning and scaling, then periodontal flap surgery may be your best treatment option. 

 

Flap surgery is today's leading method for treating and repairing periodontal pockets. 


What are these “pockets?” They are areas below the gum line where gum tissue has detached from the teeth, resulting in an uncleansable space where harmful bacteria can proliferate. 


These bacteria cause inflammation of the tissues, resulting in sensitivity, bleeding, and pain. Left untreated, they can cause a host of problems including gum disease, loss of the tooth-supporting bone structure, and possibly even systemic (whole-body) problems.


 When periodontal pockets develop, the first step in treating them is usually via cleaning and scaling (also referred to as root debridement) with a manual or ultrasonic instrument. If this isn't effective, then periodontal surgery is considered. 


Flap surgery isn't a cure for periodontal disease — but it helps create an environment that makes it easier to maintain your periodontal health. And even if you're prone to gum disease, proper professional treatment and regular care at home can help keep your teeth healthy for as long as possible.

The Goals of Flap Surgery:

 One major objective of flap surgery is to eliminate or reduce the pocket itself. To access it, a flap-like incision is made in the gum tissue. 


This allows diseased tissue to be removed from inside the pocket, and provides access to the teeth's root surfaces for a thorough cleaning, which helps to eliminate harmful plaque and calculus (tartar). Afterward, the “flap” is closed, sealing the area. This begins the healing process, which takes place rapidly.


Another goal is the regeneration of periodontal ligament and bone tissue which may have been lost to the disease. 


A variety of techniques may be used to accomplish this, including high-tech methods of bone grafting and chemicals referred to as growth factors. 


These approaches help restore the gums to their normal form and function, and promote the healthy and secure anchoring of teeth.

The Flap Surgery Procedure:

 


Flap surgery is typically done under local anesthesia, sometimes accompanied by oral anti-anxiety medications; alternatively, it may be performed under intravenous conscious sedation. 

After anesthesia has taken effect, a small incision is made to separate the gums from the teeth. 


The outer gum tissue is gently folded back to give access to the roots and the supporting ligament and bone tissue.


 Next, the inflamed gum tissue can be removed, and the tooth roots can be cleaned; if needed, the area may also be treated with antibiotics or other medications. 

Bone defects can be repaired with grafting material, and proper regeneration of the periodontal ligament can be encouraged by physical (barrier membranes) and chemical (growth factors) methods. 


Finally, the incision is closed and the procedure is completed.
 Performed by an experienced hand, state-of-the-art flap surgery has an excellent track record and offers well-established benefits. It's often the treatment of choice for relieving periodontal disease and helping to maintain your oral health — and preserve your teeth.

EMERGENCIES IN DENTISTRY

Medical and dental emergencies and complications in dental practice and its management:

 

An emergency is a medical condition that demands immediate attention and successful management. 

These are the life-threatening situations of which every practitioner must be aware of so that needless morbidity can be avoided.

A survey of 4000 dental surgeons conducted by Fast and others revealed an incidence of 7.5% emergencies per dental surgeon over a 10-year period. 

Basic principles of management of medical emergencies:

The golden rule in managing any emergency is rendering basic life support (BLS) measures and cardiopulmonary resuscitation (CPR). 

This is done by following the basic principles: Position (P), Airway (A), Breathing (B), Circulation (C), and Definitive therapy (D),.

The primary positions to manage an emergency are supine position, Trendelenburg position, and semi-erect position.  

Maintaining a patent and functioning airway is the first priority in managing an emergency. This is achieved usually by the head tilt-chin lift manoeuvre. 

If clear airway is still not achieved, then invasive procedures like direct laryngoscopy and cricothyrotomy can be followed. 

The next priority is to check for the presence of adequate breathing which is assessed by the look-feel and listen technique^. 

If spontaneous breathing is not evident then rescue breathing should be accomplished immediately either by the mouth-to-mouth technique or the bag-valve-mask technique. 

After establishing a patent airway and breathing, circulation is assessed. The most rapid and reliable method is by palpating the carotid pulse at the region of the sternocleidomastoid muscle. 

If pulse is absent, then CPR is initiated immediately. Once airway, breathing, and circulation is maintained, definitive treatment is begun if the emergency is acute and cause is clear to the dental specialist. 

Definitive therapy involves administration of drug when indicated and contacting for emergency care.


The medical and dental emergencies that are commonly encountered in dental practice involve syncope, airway obstruction, anaphylaxis, local anesthetic toxicity, asthmatic attack, chest pain, hemorrhage, and seizure. Myocardial infarction and cardiac arrest are extremely rare. Analysis of history and patient counseling and motivation also play a role in minimizing the emergencies.

Syncope:

 




Syncope is caused due to inadequate cerebral perfusion. Causes of sudden loss of consciousness and collapse include hypotension, adrenal crisis, anaphylaxis, cardiac arrest, diabetic collapse, hypoglycemia, epileptic seizure, fainting, or stroke. 


The early manifestations include nausea, warmth, perspiration, baseline blood pressure, and tachycardia. 


Late manifestations include hypotension, bradycardia, pupillary dilation, peripheral coldness, and visual disturbance. 


Most of the syncopal attacks can be prevented by ensuring that the patient has had their meal before treatment in case of systemic diseases like diabetes and also making the patient lie in the supine position before administering local anesthetics.




Management: 


The patient should be in the supine position 


Recovery is almost instantaneous if the patient has simply fainted. 


Then maintain airway, check pulse (if absent, indicates cardiac arrest), and start CPR immediately. 


If pulse is palpable and the patient has not completely lost consciousness, 


Four sugar lumps may be given orally or intravenous 20 ml of 20-50% sterile glucose. 


A hypoglycemic patient will improve with this regimen. But if there is still no improvement medical assistance should be summoned. 


Meantime, hydrocortisone sodium succinate 200 mg IV should be given.

Airway obstruction:

Airway obstruction is usually caused due to accidental slippage, aspiration of foreign objects, or laryngeal spasm. 


Patient manifests with inability to speak, grasps the throat (universal sign), coughs, inability to exchange air (in spite of respiratory movements), cyanosis, and loss of consciousness. 


These might eventually lead to cardiac arrest finally.


Management: 


Main priority is to clear the airway, but the method differs depending upon whether the patient is conscious or unconscious.

If the patient is conscious, then he/she must be made to sit straight, support chest with one hand, and deliver five sharp back blows between the shoulder blades with the heel of the other hand. 


But if the patient is choking, an attempt is made to expel the object with upward thrusts using Heimlich thrust(see Figure).


It acts as artificial cough that produces a rapid increase in intra-thoracic pressure thus helping to expel the foreign body out.


Anaphylaxis:

It is a hypersensitive state that results from exposure to an allergen. 


The most common allergen in a dental setup is latex^.. 


Manifestations vary from a mild form where the patient presents with erythematous rash, cyanosis, nausea, vomiting, tachycardia, utricaria, or angiodema to a severe form which leads to airway obstruction or inadequate blood pressure and blood flow to the brain which is a life-threatening situation. 


Management involves lying the patient in the supine position with legs raised. administer oxygen, and the drug of choice being 0.5 ml of 1:1000 adrenaline IM or SC.




Local anesthetic toxicity:

Local anesthetics are the most commonly used drugs in dentistry. 


Toxicity is usually either due to the local anesthetic itself or the vasoconstrictor which can be due to rapid infusion or failure to aspirate before injection. 


Generally, the reactions are self limiting. 


Toxicity presents with talkativeness, slurred speech, anxiety, confusion, drowsiness, or even seizure and cardiac arrhythmias in extreme cases.


Management: 


Sessate the administration of injection and monitor vital signs. Administer oxygen and in adverse cases administration of diazepam 5 mg slowly is advised^.

Asthmatic attack:

Anxiety, infection, exposure to an allergen or drugs can precipitate an asthmic attack. 


The goal of management during an acute asthmatic episode on a dental chair should be to relieve the bronchospasm associated with the attack.


Patient presents with thickness or heaviness in the chest, difficulty in breathing, spasmodic and unproductive cough, expiratory wheeze, and anxious behavior. 


Hence, the patient should primarily be relieved of irritants and all articles should be removed from oral cavity.


Drug of choice is 2 puffs of albuterol. 


If no improvement is seen in 15 seconds then administer 1:1000 adrenaline 0.5 ml SC/IM and if still no response is observed in 2-3 min then salbutamol slow IV injection is advised.

Chest pain:

Factors that precipitate chest pain include angina, acute myocardial infarction, gastrointestinal reflux disease, anxiety, costochondritis and paroxysmal supraventricular tachycardia.


Patients generally present with tightness, fullness, constriction, or heavy weight on the chest. 


Angina pectoris and acute myocardial infarction (AMI) are the two commonly occurring cardiac problems in a conscious patient. 


Patient's history is of prime concern here. 


If this is the first time patient has ever experienced a chest pain, then dental specialist should treat him or her as if it were an acute myocardial infarction and have emergency medical service transfer immediately. If not then it is an angina pectoris situation.


Quality of pain can also indicate whether the patient is having an angina or acute myocardial infarction. 


In angina pectoris pain is significant but not severe whereas an acute myocardial infarction pain generally radiates to left side of the body-left shoulder, left mandible, left arm.

Management: 


For angina pectoris, drug of choice is a nitrate, commonly nitroglycerine, sublingual tablet, translingual or transmucosal spray. 


Management of a patient with suspected acute myocardial infarction involves administration of morphine, oxygen, nitroglycerine, and aspirin (MONA) in addition to emergency medical service. 


If morphine is unavailable, the specialist can also substitute nitrous oxide/oxygen in a 50:50 concentration.

Haemorrhage:

Haemorrhagic disorders, though uncommon, should always be considered, as dental specialists deal with blood routinely and there are instances when significant bleeding could lead into an emergency. 





Emergency management begins by gently cleaning the mouth and locating the source of bleeding and the application of cold compress, pressure packs, or styptics. 



Suture the area under L.A when necessary. 


Tranexamic acid -500 mg in 5 ml by slow IV injection is the drug of choice.

Seizures:

Patients who convulse in dental office generally have a seizure history and are often characterized as having epilepsy.


Management: If the patients experiencing seizure is unconscious, they should primarily be placed in the supine position and the head tilt-chin lift manoeuvre is performed. 


Dental specialist should remove all instruments from patient's mouth and protect the patient. Clear airway, loosen clothing and help patient breath adequately.


If seizure continues for long, then the condition is known as status epilepticus. 


This is a life-threatening emergency and is best managed with I.V. diazepam 5 mg IV/IM or by maintaining BLS till patient is shifted to emergency medical care.

IN CONCLUSION:

Emergencies cannot be totally prevented but can be managed appropriately with thorough knowledge of the signs, symptoms, and accurate treatment of the emergencies. 

Accomplishing this depends on the combined effort of the dental specialist, staff, and immediate availability of the critical drugs and equipments for the procedure. 

However, no drug can replace an efficiently trained health care professional in managing an emergency but an emergency drug kit and equipment does play an integral role in the course and outcome of management of emergencies and complications in interdisciplinary dental practice.


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Dental Crowns:

A dental crown is a tooth-shaped cap that is placed directly over a tooth in order to restore its shape, strength, or size. In addition, crowns are able improve the appearance of the tooth, making it an attractive treatment for many patients. 


From the top of the tooth to the bottom of the gum line, the dental crown encloses the entire visible portion of the tooth. These serve to treat teeth that are badly decayed, cracked, or broken.


Many patients are intimidated by the concept of a dental crown. During the initial dentist visit, examination and preparation are the main goals. 


The dentist will take an impression of the teeth to be sent to a dental laboratory for construction and development. As the crown is being created, usually between 2 to 3 weeks, a temporary crown will be given to the patient.



Upon the second dentist visit, the dentist will remove the temporary crown in order to fit the permanent crown. After making sure that the fit and color are both appropriate, the crown will be permanently cemented.

When do I need a dental crown:

There are a wide variety of situations that may require a dental crown. Dependent upon personal preference, specific dental issue, and severity of the problems, all patients are encouraged to speak with a dental professional in order to determine the best treatment plan. 


Due to the permanent nature of dental crowns, it is imperative that patients fully understand the procedure and results that are entailed in this oral procedure.
The following are the most common situations that may require crown treatment.

• A tooth is broken or very worn down and needs to be restored.
• A tooth has weakened (often from decay) and requires crowning to avoid breaking or cracking of the tooth.
• Teeth that have been treated with a root canal.
• Holds the dental bridge in place
• Covering a dental implant.
• A large filling is given to a tooth with minimal area left in order to cover and/or support what is left of the tooth.
• Improve appearance of discolored or deformed teeth.
• Cosmetic adjustments.

Types of Crowns:

Temporary crowns are typically constructed using acrylic or stainless steel. Permanent crowns, on the other hand, must be fabricated in a dental laboratory. The following are the most common types of permanent crowns.


All-Ceramic or All-Porcelain: 

 As the name implies, these crowns are composed of ceramic and/or porcelain and most accurately match the coloring of surrounding normal teeth. Porcelain crowns were previously used only for the front teeth due to their potential to wear down. Due to advancing technology in the strength and appearance of these materials, porcelain crowns can now be a great choice for any tooth.


 Porcelain-Fused-to-Metal: 

 
These crowns are able to match the color of neighboring teeth. These are often used for front or back teeth and look very similar to the normal teeth surrounding it. Unlike a Ceramic or Porcelain crown, these have a metal substrate under them that over time can show through appearing like a black line under the gums. 




Gold: 

 

These are amongst the most durable of crowns and are able to withstand daily use without cracking or chipping. In addition, minimal tooth structure needs to be eliminated for metal crowns. The biggest disadvantage, however, is the gold color. Therefore many patients choose metal crowns for back teeth that are not visible. 



Stainless Steel: 

This type of crown is used predominately as a temporary measure, but can make permanent crowns. Stainless steel crowns are typically used for children; as they are cost-effective and do not usually entail multiple visits to the dentist. 




All-Resin: 

 These are the least expensive types of crowns. All-resin crowns are vulnerable to fractures and typically wear down in a year.


Sometimes after a crown is cemented, there is some sensitivity to the tooth which usually subsides within a few weeks. 

However, once the patient becomes accustomed to the crown, they are likely to enjoy all of the benefits that this dental treatment offers. With proper care and consistent cleaning, the patient’s overall health and confidence in their smile will improve significantly with dental crowns.





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DENTURES IN DENTISTRY

Dentures:

There are a variety of different reasons that a dentist may suggest the necessity of dentures. 


For instance, when most or all of a patient’s teeth are severely decayed, the dentist may suggest dentures or a combination of dentures and dental implants. 


Methods such as root canals or bridges may not be adequate to address the severity of the problem at hand. Contrary to popular belief, dentures are no longer a solution for just elderly people. 


Patients of all ages may require dentures.
 The social stigma regarding dentures and old people is a perception of the past. Athletes, for instance, are often involved in accidents which result in dental injury. 


In the United States today, more than 15 million athletes suffer from some form of dental injury each year. 


The National Youth Sports Foundation for the Prevention of Athletic Injuries, Inc. estimates that these sports injuries result in more than 5 million lost teeth. 


Clearly, the use of dentures is widespread, encompassing all different ages and walks of life.

The use of dentures may be required when a patient suffers from severe tooth decay, looses teeth in an accident, or has advanced periodontal disease. 


As such, the denture is quite literally a removable replacement for the missing teeth and surrounding tissue. 


Dentures not only improve one’s appearance, but they also play a role in improving health by allowing patients to eat nutritious foods again.

Complete Dentures vs. Partial Dentures:

Patients who are considering dentures or patients who have been instructed by their dentist that dentures will eventually be required will have to consider two types of available dentures: complete or partial. 


The most significant difference between the two types is that complete dentures are used for those missing all of their teeth, as opposed to partial dentures which are used for those who have some natural teeth remaining.

Complete Dentures(C.D):

Complete dentures may be either immediate or conventional. Immediate dentures are made while the patient still has some teeth remaining. 


Once the teeth are removed, the dentures can be given to the patient on the same day. 


This method makes sure that the denture wearer does not have to deal with no teeth throughout the healing phase. Because the gums and bone shrink as they heal after teeth extractions, additional adjustments are needed for immediate dentures over the course of 6 months to a year after the teeth are extracted. 


Conventional dentures, on the other hand, are made after the removal of the teeth. Once the gums heal, the conventional dentures are delivered.

Partial Dentures:

 If the patient has one or more remaining teeth in either the lower or upper jaw, a partial denture can be an option. 


These dentures are removable and ensure that the surrounding natural teeth stay in the correct position. A crown is often placed on the teeth that surround the missing tooth in order to serve as an anchor for the partial denture itself.


All patients must understand that the decision to get dentures is one which must be made in conjunction with a dentist’s approval. The patient and dentist must both agree on a plan of action in order for the denture treatment to be successful.

Taking Care of the Dentures:

When a patient receives their dentures, the first few weeks can be challenging. The dentures are typically a bit loose and may feel odd, but this is normal as the tongue and cheek muscles begin to adjust to having new teeth. 


Many patients may experience a bit of soreness or irritation in these first few weeks and will need to return to their dentist for a adjustment of the dentures. These sore spots will slowly subside once the mouth is able to acclimate itself with the new dentures. 


Most patients find that they are able to eat just about anything with dentures. However, it is important to note that this is not the case in the beginning. It is important to start with soft foods preferably cut into tiny pieces. 


Eventually the patient will be able to return to a normal diet, however, they are advised to stay away from hard or sticky foods, especially gum chewing. The following advice should be taken while caring for your dentures.

• Always handle dentures with care, they can break very easily if dropped.
• Use denture cleansers or warm / cool water to wash the denture, making sure to get rid of any food particles adhering to it.
• Make sure to use a moistened denture brush and denture cleaning paste.
• Always handle with extreme care while brushing and washing off the dentures after the cleaning.
• Use a dentures cleanser recommended by the dentist to soak overnight.
• Be sure to brush your tongue, gums, and palate prior to reinserting the dentures.

 

Advancements in dental technology have truly changed the landscape of dentures and denture care. With the ability to achieve what looks like a natural smile, people of all ages have turned to dentures to address their missing teeth.



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