2. All surgical procedures must be
carefully planned.
The patient should be adequately
prepared medically, psychologically,
and practically for all aspects of the
intervention.
3. Patient Preparation
Every patient must do scaling and root planning and the removing of
all irritants responsible for the periodontal inflammation.
When these procedures ended, the results will:
(1) Eliminate some lesions entirely;
(2) render the tissues firm and consistent
(3) reducing the patient’s fear from the office, the clinician, and the
assistants
4. The reevaluation phase consists of re-probing and reexamining all of
the associated findings that previously indicated the need for the
surgical procedure.
The persistence of these findings confirms the indication for surgery.
The number of surgical procedures, the expected outcome, and the
postoperative care necessary are all determined before therapy and are
explained to the patient After all of the important information
regarding the surgery is discussed.
5. Premedication
For patients who are not medically compromised, administration of
antibiotics routinely for periodontal surgery has not been clearly
demonstrated.
Additional presurgical medications that may be administered include a
non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (e.g.,
Motrin) 1 hour before the procedure and an antimicrobial mouth rinse
such as 0.12% chlorhexidine gluconate.
6. Smoking
The effect of smoking on the healing of periodontal wounds has been
documented.
Patients should be clearly informed of this fact and asked to quit
smoking completely or to stop smoking for a minimum of 3 to 4 weeks
after the procedure.
For patients did not follow this advice, an alternate treatment plan that
does not include complicated techniques (e.g., regenerative,
mucogingival, aesthetic) should be considered.
7. Informed Consent
The patient should be informed at the initial visit regarding the
diagnosis, prognosis, and recommended treatment options including
explanations about expected outcomes.
At the time of surgery, the patient should again be informed both
verbally and in writing of the procedure to be performed, including the
expected outcomes.
After that they should indicate their agreement to undergo the
procedure by signing the informed consent form.
8. Emergency Equipment
The most common emergency is syncope, which is a transient loss of
consciousness caused by a reduction in cerebral blood low, which are
due to fear and anxiety.
Syncope is usually preceded by a feeling of weakness, and then the
patient experiences pallor, sweating, coldness of the extremities,
dizziness, and a slowing of the pulse.
The patient should be placed in a supine position with the legs elevated;
tight clothes should be loosened, and a wide-open airway should be
ensured.
9. The administration of oxygen should be started. Unconsciousness
may persist for a few minutes. A previous history of syncope
during dental appointments should be explored before the
treatment is started.
If the patient has had other experiences with syncope, every effort
should be made to minimize the patient’s fear and anxiety, as well
as considering the use of oral sedatives.
10. Measures to Prevent Transmission of Infection
The danger of transmitting infections to the dental team or to other
patients is an important precaution, especially with the threat of AIDS and
hepatitis B virus infection.
Universal precautions which include the use of disposable sterile gloves,
surgical masks, and protective eyewear.
All surfaces that may be contaminated with blood or saliva and cannot be
sterilized.
Aerosol producing devices (scalers) should not be used on patients with
suspected infections, and their use should be kept to a minimum in all
other patients.
11. Sedation and Anesthesia
Pain control in periodontal surgery is important. Most procedures should
either be painless or minimally painful.
The area to be treated should be thoroughly anesthetized by means of
regional block and local infiltration. Injections directly into the interdental
papillae may also be helpful.
Apprehensive and neurotic patients may require special management
with antianxiety or sedative–hypnotic agents.
12. Hospital Periodontal Surgery
For most patients, periodontal surgical procedures are managed well in
the dental office with local anesthesia only or with some form of
sedation.
Certain patients and procedures warrant treatment in the hospital
operating room with general anesthesia.
These include patients who are not well enough to undergo treatment
in a dental office and procedures that are more extensive and difficult
for patients to endure.
13. Tissue Management
1. Operate gently and carefully. Traumatic instrumentation must be
avoided because it produces excessive tissue injury, causes
postoperative discomfort, and delays healing.
2. Facial expressions, pallor, and perspiration are distinct signs that may
indicate when a patient is experiencing pain, anxiety, or fear.
3. Instruments must be sharp to be effective; successful treatment is
not possible without sharp instruments.
14. Scaling and Root Planning
Although scaling and root planning have been performed previously
as part of phase I therapy, all exposed root surfaces should be carefully
explored and planed as needed during the surgical procedure.
In particular areas of difficult access (e.g., furcation's, deep infra bony
pockets) often have rough areas or even calculus that was undetected
during the preparatory sessions.
The assistant should also check for the presence of calculus and the
smoothness of each surface from a different angle.
15. Hemostasis
Hemostasis is an important aspect of periodontal surgery because
good intraoperative control of bleeding permits accurate
visualization of the extent of disease.
It provides the operator with a clear view of the surgical site, which is
essential for wound debridement and scaling and root planning.
Also good hemostasis prevents excessive loss of blood into the
mouth, oropharynx, and stomach.
16. Periodontal surgery can produce profuse bleeding, especially during the
initial incisions and lap reflection. The application of pressure to the
surgical wound with moist gauze can be a helpful adjunct to control site-
specific bleeding.
If a medium or large vessel is lacerated, a suture around the bleeding end
may be necessary to control the hemorrhage.
Pressure should be applied through the tissue to determine the location
that will stop blood low in the severed vessel.
17. The use of a local anesthetic with a vasoconstrictor (epinephrine) is
useful to control minor bleeding from the periodontal flap.
It is important to avoid the use of vasoconstrictors to control bleeding
before sending a patient home.
Bleeding is likely to recur when the vasoconstrictor has metabolized
and the patient is no longer in the office.
18. Thrombin is a drug that is intended for topical use only, and it is applied
as a liquid or powder.
Thrombin should never be injected into tissues because it can cause
serious or even fatal intravascular coagulation.
All surgical patients should be asked about any current medications that
may contribute to bleeding, any family history of bleeding disorders, and
hypertension.
19. Periodontal Dressings (Periodontal Packs)
At completion of the periodontal surgical procedure, clinicians may
elect to cover the area with a surgical dressing.
The dressing minimizes the likelihood of postoperative infection,
facilitates healing by preventing surface trauma during mastication.
Zinc oxide and eugenol dressings was developed by Ward in 1923.
Other non-eugenol dressings include cyanoacrylates and tissue
conditioners.
20. Retention of Dressing
Periodontal dressings are usually kept in place mechanically by
interlocking the dressing in interdental spaces and joining the
lingual and facial portions of the dressing.
In isolated teeth or when several teeth in an arch are missing,
retention of the dressing may be difficult.
The placement of dental floss tied loosely around the teeth
enhances retention of the dressing.
21. Postoperative Instructions
Patients instructed to rinse with 0.12% chlorhexidine gluconate
immediately after the surgical procedure and twice daily. Complications
may arise during the first postoperative week:
1. Persistent bleeding after surgery.
2. Sensitivity to percussion due to extension of inflammation into the
periodontal ligament.
3. Swelling, Feeling of weakness During the first 2 postoperative days. If
swelling persists, amoxicillin (500 mg) should be taken every 8 hours
for 1 week.
22. Removal of the Dressing and Return Visit
When the patient returns in 1 week, the periodontal dressing is
removed.
Particles of dressing and debris may be enmeshed in the surgical
surfaces and should be carefully removed with cotton pliers.
The entire area is irrigated with peroxide to remove the superficial
debris.
23. Redressing
After the dressing is removed, it is usually not necessary to replace it.
However, redressing for an additional week is advised for the following
types of patients:
(1) those with a low pain threshold;
(2) those with unusually sensitive root surfaces post-surgically
(3) those with an open wound where the flap edges have necrosed.
24. Tooth Mobility
Tooth mobility usually increases immediately after surgery. This
results from edema in the periodontal ligament space from the
inflammation that occurs post surgically.
The mobility diminishes to the pretreatment level by the fourth
week.
The patient should be reassured before surgery that the
mobility is temporary.
25. Management of Postoperative Pain
For most healthy patients, a preoperative dose of ibuprofen (600 to
800 mg) followed by 1 tab. every 8 hours for 24 to 48 hours is very
effective.
If pain persists, acetaminophen plus codeine can be prescribed.
Caution should be used when prescribing ibuprofen to patients with
hypertension that is controlled by medications.
