General Principles of Periodontal Surgery Dr. Mohamed Elewa

Management of Postoperative Pain A common source of postoperative pain is overextension of the periodontal pack onto the soft tissue beyond the mucogingival junction or onto the frena. Overextended packs cause localized areas of edema, usually noticed 1 to 2 days after surgery. Removal of excess pack is followed by resolution in about 24 hours. Extensive and excessively prolonged exposure and dryness of bone also induce severe pain.

For most healthy patients Preoperative dose of ibuprofen (600 to 800 mg) followed by one tablet every 8 hours for 24 to 48 hours is very effective in reducing discomfort after periodontal therapy. Patients are advised to continue taking ibuprofen or change to acetaminophen if needed If pain persists, acetaminophen plus codeine can be prescribed. Caution should be used in prescribing Ibuprofen to patients with hypertension controlled by medications because it can interfere with the effectiveness of the medication.

When severe postoperative pain is present The patient should be seen at the office on an emergency basis. The area is anesthetized by infiltration or topically, the pack is removed, and the wound is examined. Postoperative pain related to infection is accompanied by a- localized lymphadenopathy & b- Slight elevation in temperature It should be treated with systemic antibiotics and analgesics

Treatment of Sensitive Roots. Common problem in periodontal practice. It may occur spontaneously when 1-the root becomes exposed as a result of gingival recession or pocket formation, or 2-After scaling and root planing and surgical procedures. It is manifested as pain induced by cold or hot temperature, more commonly cold; by citrus fruits or sweets; or by contact with a toothbrush or a dental instrument. Factor for reducing or eliminating hypersensitivity is adequate plaque control. The patient should be informed about the possibility of root hypersensitivity before treatment is undertaken.

DESENSITIZING AGENTS The following information on how to deal with the problem should also be given to the patient: 1. Hypersensitivity appears as a result of the exposure of dentin, which can be corrected if calculus and plaque and their products will be removed. 2. Hypersensitivity slowly disappears over a few weeks. 3. Plaque control is important for the reduction of hypersensitivity. 4. Desensitizing agents do not produce immediate relief. They have to be used for several days or even weeks to produce results.

DESENSITIZING AGENTS Desensitizing agents can be applied by the patient at home or by the dentist or hygienist in the dental office. The most likely mechanism of action is the reduction in the diameter of the dentinal tubules so as to limit the displacement of fluid in them. According to Trowbridge and Silver, this can be attained by 1) Formation of a smear layer produced by burnishing the exposed surface, 2) Topical application of agents that form insoluble precipitates within the tubules, 3) Impregnation of tubules with plastic resins, or 4) Sealing of the tubules with plastic resins

Agents used by the Patient The most common agents used by the patient for oral hygiene are dentifrices. Although many dentifrice products contain fluoride, additional active ingredients for desensitization are strontium chloride, potassium nitrate and sodium citrate. The following dentifrices have been approved by the American Dental Association for desensitizing purposes : Sensodyne, and Thermodent, which contain strontium chloride Crest Sensitivity Protection, Denquel, and Promise, which contain potassium nitrate and Protect,which contains sodium citrate. Fluoride rinsing solutions and gels can also be used after the usual plaque control procedures

Patients should be aware that several factors must be considered in the treatment of tooth hypersensitivity, including:- the history and severity of the problem as well as the physical findings of the tooth or teeth involved. A proper diagnosis is required before any treatment can be initiated so that pathologic causes of pain (caries, cracked tooth, pulpitis) can be ruled out before treating hypersensitivity. Desensitizing agents act via the precipitation of crystalline salts on the dentin surface,which block dentinal tubules. Patients must be aware that their use will not prove to be effective unless used continuously for a period of at least 2 weeks.

Agents used in the Dental Office These products and treatments aim to decrease hypersensitivity via blocking dentinal tubules with either a crystalline salt precipitation or an applied coating (varnish or bonding agent) on the root surface in an attempt to occlude the dentinal tubules. Fluoride solutions and pastes historically have been the agents of choice. In addition to their antisensitivity properties, they have the advantage of anticaries activity, which is particularly important for patients with a tendency to develop root caries. However, certain agents such as chlorhexidine, decrease the ability of fluoride to bind with calcium on the root surfaces. Thus it is important to advise patients not to rinse or eat for 1 hour after a desensitizing treatment.

A newer method of treatment for hypersensitive dentin is the use of varnishes or dentin bonding agents to occlude dentinal tubules. Newer restorative materials,such as and glass-ionomer cements dentine bonding agents, are still under investigation, but when the tooth needs recontouring or difficult cases do not respond to other treatments, the dentist may choose to use a restorative material. Resin primers alone could be promising, but the effects are not permanent and investigations are ongoing

Recently, attempts have been made to improve the success and longevity of these treatments using lasers. Low-level laser "melting" of the dentin surface appears to seal dentinal tubules without damage to the pulp. Nd:YAG laser has been used to coagulate fluoride varnish on root surfaces