1. General principles of periodontal surgery
Dr. Malek Abdulmatlob B.D.S., M.D.S.

2. OUTLINE
Patient preparation Emergency Equipment Measures to Prevent Transmission of Infection Sedation and Anesthesia Tissue Management Scaling and Root Planning Hemostasis Periodontal Dressings (Periodontal Packs) Postoperative Instructions Treatment of Sensitive Roots Desensitizing agent

3. Patient preparation 1- re-evaluation after phase 1 therapy
2-Premedication
3- smoking
4-Informed Consent

4. Patient preparation
1- Re-evaluation after phase 1 therapy:
The patient should be re-evaluated after phase 1 therapy for the persistance of any findings that would make surgical procedures necessary.
e.g. pocket depth more than 5 mm that bleed on probing, gingival enlargement, vertical bone loss, recession , furcation involvement etc

5. 2-Premedication:
Some studies have reported reduced postoperative complications including reduced pain and swelling when antibiotics are given before periodontal surgery and continuing for 4 to 7 days after surgery.
Other presurgical medications include administration of a nonsteroidal, antiinflammatory drug such as ibuprofen 1 hour before the procedure and one oral rinse with 0.12% chlorhexidine gluconate

6. 3- smoking:
Has effect on healing of periodontal wounds.
Patients should be clearly informed of this fact and requested to stop smoking for a minimum of 3 to 4 weeks after the procedure.

7. 4-Informed Consent:
The patient should be informed at the time of the initial visit about the diagnosis, prognosis, the different possible treatments with their expected results.
At the time of surgery, the patient should again be informed, verbally and in writing, of the procedure to be performed, and he or she should indicate agreement by signing the consent form.

8. Emergency Equipment
The operator, all assistants, and office personnel should be trained to handle all the possible emergencies that may arise.
Drugs and equipment for emergency use should be readily available at all times.
The most common emergency is syncope or a transient loss of consciousness due to a reduction in cerebral blood flow.

9. Measures to Prevent Transmission of Infection:
Universal precautions, including protective attire, and barrier techniques are strongly recommended and often required.
They include the use of disposable sterile gloves, surgical masks, and protective eyewear.
All surfaces possibly contaminated with blood or saliva that cannot be sterilized (such as light handles and unit syringes) must be covered with aluminum foil or plastic wrap.

10. Aerosol-producing devices, such as the Cavitron, should not be used on patients with suspected infections.
Special care should be taken when using and disposing of sharp items such as needles and scalpel blades.

11. Sedation and Anesthesia:
Periodontal surgery should be performed painless
The area to be treated should be anesthetized by means of regional block and local infiltration injections.
Apprehensive and neurotic patients require special management with antianxiety or sedative hypnotic agents.

12. the simplest, least invasive method to alleviate anxiety in the dental office is nitrous oxide and oxygen inhalation sedation
For individuals with mild to moderate anxiety, oral administration of a benzodiazepine can be effective in decreasing anxiety and producing a level of relaxation.
(e.g. Alprazolam 0.5mg or Diazepam 5mg can be given 1 hour before the procedure).

13. Tissue Management: Operate gently and carefully:
Tissue manipulation should be precise, and gentle.
Thoroughness is essential, but roughness must be avoided because it produces excessive tissue injury, causes postoperative discomfort, and delays healing.

14. 2. Observe the patient at all times:
It is essential to pay careful attention to the patient's reactions.
Facial expressions, pallor, and perspiration are some distinct signs that may indicate the patient is experiencing pain, anxiety, or fear.
The doctor's responsiveness to these signs can be the difference between success and failure.

15. 3. Be certain the instruments are sharp:
Instruments must be sharp to be effective.
Dull instruments inflict unnecessary trauma due to poor cutting and excessive force applied to compensate for their ineffectiveness.
A sterile sharpening stone should be available on the operating table at all times.

16. Scaling and Root Planing:
Although scaling and root planing has been performed previously as part of Phase I therapy, all exposed root surfaces should be carefully explored and planed as needed as part of the surgical procedure.
In particular, areas of difficult access such as furcations or deep pockets often have rough areas or even calculus that was undetected during the phase 1 therapy.

17. Hemostasis:
good intraoperative control of bleeding permits an accurate visualization of the extent of disease, pattern of bone destruction, and anatomy and condition of the root surfaces.
Periodontal surgery can produce profuse bleeding, especially during the initial incisions and flap reflection.
After flap reflection and removal of granulation tissue, bleeding disappears or is considerably reduced.
Continuous suctioning of the surgical site with an aspirator is indispensable for performing periodontal surgery.

18. Application of pressure to the surgical wound with moist gauze can be a helpful adjunct to control site specific bleeding.
Excessive hemorrhaging following initial incisions and flap reflection may be due to laceration of venules, arterioles, or larger vessels.
Pressure should be applied through the tissue to determine the location that will stop blood flow in the severed vessel. Then a suture can be passed through the tissue and tied to restrict blood flow.
Minor areas of persistent bleeding from capillaries can be stopped by applying cold pressure to the site with moist gauze (soaked in sterile ice water) for several minutes.
For slow, constant blood flow and oozing, hemostasis may be achieved with hemostatic agents.

19. Some hemostatic agents:
Absorbable gelatin sponge (Gelfoam)-from pork skin
oxydized cellulose (Oxycel)- chemically modified form of surgical gauze
oxidized regenerated cellulose (Surgicel)-like a gauze.
Thrombin (Thrombostat): from bovin, liquid/powder

20. Periodontal Dressings (PeriodontalPacks):
In most cases, after the surgical periodontal procedures are completed, the area is covered with a surgical pack.
Dressings have no curative properties; they assist healing by protecting the tissue rather than providing "healing factors."

21. Advantages of using a periodontal pack:
pack minimizes the likelihood of postoperative infection and hemorrhage.
facilitates healing and protects against pain by preventing surface trauma and contact of the wound with food or the tongue during mastication.

22. Types of periodontal packs:
Zinc Oxide-Eugenol Packs:
e.g. Wondr-Pak.
Eugenol in this type of pack may induce an allergic reaction that produces reddening of the area and burning pain in some patients.
Not used anymore.

23. 2. Noneugenol Packs:
e.g. Coe-pak, cyanoacrylates, and tissue conditioners (methacrylate gels) .
Is the most widely used dressing.
supplied in two tubes, the contents of which are mixed immediately before use until a uniform color is obtained.
One tube contains zinc oxide , the other tube contains liquid coconut fatty acids.
The reaction between a metallic oxide and fatty acids is the basis for Coe-Pak.

24. Preparation and Application of the Periodontal Dressing:
Take equal lengths of the two pastes on a paper pad.
Mix them with a wooden tongue depressor for 2 or 3 minutes and place it in a cup of water at room temperature until the paste loses its tackiness

25. With lubricated fingers, roll it into cylinders and then place it on the surgical wound

26. Trim away excess pack: it should not extend into the vestibule or floor of the mouth.
It should not interfere with occlusion.

27. The pack is usually kept on for 1 week after surgery.
The pack is taken off by inserting a surgical hoe (or sickle scaler) along the margin and exerting gentle lateral pressure.
The area is rinsed with saline to remove superficial debris.

28. Postoperative Instructions
The First Postoperative Week:
Properly performed, periodontal surgery presents no serious postoperative problems.
Patients should be told to rinse with 0.12% chlorhexidine gluconate immediately after the surgical procedure and twice daily thereafter until normal plaque control technique can be resumed

29. Avoid hot, spicy food and drinks for the first 24 hours.
Eat soft, semisolid or minced foods.
Do not drink alcohol or smoke.
Do not brush over the pack / healing area for at least a week.
On the first day, apply ice intermittently on the face over the operated area.
If there is any swelling 1-2 days after the surgery, apply moist heat over the area and call your doctor if it become worse
Avoid excessive exertion

30. Complications may arise in the first postoperative week:
1. Persistent bleeding after surgery: The pack is removed, the bleeding points are located, and the bleeding is stopped with pressure, electrosurgery, or electrocautery. After the bleeding is stopped, the area is repacked.

31. 2. Sensitivity to percussion:
Sensitivity to percussion may be caused by the extension of inflammation into the periodontal ligament. The patient should be questioned regarding the progress of the symptoms. Gradually diminishing severity is a favorable sign.
The pack should be removed and the gingiva checked for localized areas of infection or irritation, which should be cleaned or incised to provide drainage.

32. Particles of calculus that may have been overlooked should be removed.
Relieving the occlusion is usually helpful.
Sensitivity to percussion may also be caused by excess pack, which interferes with the occlusion. Removal of the excess usually corrects the condition.

33. 3. Swelling:
Sometimes within the first 2 postoperative days, patients report a soft, painless swelling of the cheek in the area of operation. Lymph node enlargement may occur, and the temperature may be slightly elevated. The area of operation itself is usually symptom free.
This type of involvement results from a localized inflammatory reaction to the operative procedure. It generally subsides by the fourth postoperative day, without necessitating removal of the pack.

34. If swelling persists, becomes worse, or is associated with increased pain, then amoxyicillin, 500 mg should be taken every 8 hours for 1 week, and the patient should also be instructed to apply moist heat intermittently over the area.

35. 4. Feeling of weakness:
Occasionally, patients report having experienced a "washed-out," weakened feeling for about 24 hours after the operation.
This represents a systemic reaction to a transient bacteremia induced by the operative procedure.
It is prevented by premedication with amoxycillin, 500 mg every 8 hours, beginning
24 hours before the next operation and continuing
for a 5-day postoperative period.

36. Removal of the Periodontal Pack and Return Visit Care:
When the patient returns after 1 week, the pack is taken off by inserting a surgical hoe along the margin and exerting gentle lateral pressure.
Pieces of pack retained interproximally and particles adhering to the tooth surfaces are removed with scalers.
The entire area is rinsed with saline / peroxide
to remove superficial debris.

37. Treatment of Sensitive Roots:
Root hypersensitivity is a relatively common problem in periodontal practice.
It may occur spontaneously when the root becomes exposed as a result of gingival recession or pocket formation, or it may appear after scaling and root planing and surgical procedures.

38. 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.
Root sensitivity occurs more frequently in the cervical area of the root, where the cementum is extremely thin.
Scaling and root planing procedures remove this thin cementum, inducing the hypersensitivity.

39. Transmission of stimuli from the surface of the dentin to the nerve endings located in the dental pulp results from a hydrodynamic mechanism (displacement of dentinal fluid).

40. hydrodynamic mechanism
The theory describes how the fluid within the dental tubules shift in the canals when the tooth receives a stimuli of some form, which then causes the pulp to send out a signal to the brain which it is interpreted as pain.

41. DESENSITIZING AGENTS:
They can be classified into:
Agents used by the Patient.
Agents used in the dental office.

42. 1. Agents used by the Patient:
They are usually in the form of toothpaste, mouthwashes and gels.
Active ingredients for desensitization include fluorides (Sodium/ stannous fluoride) in combination with:
Strontium chloride: Sensodyne.
Potassium nitrate: crest sensitivity protection.

43. 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.

44. 2.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
2. an applied coating (varnish or bonding agent) on the root surface.

45. Fluoride solutions and pastes historically have been the agents of choice.
Currently, potassium oxalate (protect) and ferric oxalate (sensodyne sealant) are the preferred agents. They form insoluble calcium oxalate crystals that occlude the dentinal tubules.
Cavity varnishes or dentin bonding agents can be applied to the root surface to occlude dentinal tubules

46. When cases do not respond to other treatments, the dentist may choose to use a restorative material such as:
˃ GIC or
˃ Composite resins (with dentin bonding agents)
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.

47. THANK YOU