Laxity Should Not be Permitted in Management

Laxity Should Not be Permitted in Management of Pyorrhea
Careful Manipulation of Instruments and Consideration of Gingival Tissues of Utmost Importance
W. V. Buck, D.D.S., Discusses
“A RATIONAL CONCEPT FOR THE TREATMENT OF PERIODONTAL LESIONS,” PART I
(Vincent’s Infection not included)
So long as dental procedures follow along lines of reason and safety just so long may they be considered rational and acceptable. It is the departure from such that leads to fields of trouble and reflects without credit on both the operator and his profession.
Only with a clear understanding of the normal relation of the various dental structures to each other, can there be an appreciation of what is necessary to change pathologic conditions back to the normal.
Gingival Crevice
When it is clearly understood that ordinarily the gingival crevice is less than 1 mm in depth, that the bottom of this crevice is found somewhere on the middle or gingival third of the enamel in youth, and not until between the 20th and 30th year is this crevice found at the cemento-enamel junction and after that age there is a tendency to migrate root wise beyond the cemento-enamel junction, that the epithelium is attached intimately and organically to the enamel as a band and this epithelium has a tendency to proliferate apically during the process of tooth eruption, gum recession and pocket formation, that the normal gingiva is thin and pink and hard, then and only then is the operator fortified with the right concept of normal structures to proceed with the treatment of periodontal lesions.
Prevention of disease is universally accepted as the best policy and when applied to the dental structures, nothing could be more proper than to adopt and use right methods of tooth brushing and gum massage.
The toothbrush therefore is the first instrument to use in combating periodontal lesions. This common yet ultra useful instrument when selected carefully and used in the right manner and at the proper times can do more to prevent gum inflammation and thus maintain healthy dental conditions, than any other instrument of the catalogue. Massage of the gums is not a new idea nor will its benefits ever cease to be paramount. Especially can we appreciate its value now that we have a new and improved conception of the gingival attachment to the enamel.
Bodecker and Applebaum (1) have said “Frequent massage of the gum tissue results in firm, normal, pink gingivae, highly resistant to injury and infection. The more the gingivae are massage, the thicker will be the protective, hornified layer, and the more firmly will the gum tissue be attached to the tooth. Disuse is one reason given by investigators to account for the fact that the gingivae in man are so prone to inflammation. The diet of civilized people seems to require too little mastication; hence the gingivae receive insufficient massage.
This results in a lack or hornification of the epithelium and a consequent loosening of the gum tissue from the tooth, allowing infection to penetrate more readily to the underlying connective tissue. Brushing of the gum therefore seems necessary under our civilized conditions in order to maintain a shallow gingival crevice. The fact that inflammatory conditions attack the interproximal gingivae more readily than they affect the labia, buccal or lingual areas may be explained by the seclusion the gingival papillae.
Massaging Benefits Gingivae
Hence the advantage of forcing the bristles of the toothbrush with a rotary motion into the approximal areas of the teeth, giving these areas the necessary massage and stimulating the hornification of the gingival papillae. This results in a firmer attachment of the epithelium and a reduction of the depth of the gingival crevice.”
If a real stiff bristle brush is used, then only the sides of the bristle tufts should be applied to the gums (Charter’s method). If for any reason the principle is not and cannot be utilized then it would be better to use a softer bristle brush without the sharp pointed tufts, so that when the ends of the bristles, in place of the sides, are applied to the gums there would not be the usual tearing away of gum tissue causing recession and possible erosion together with exposing sensitive dentine. The majority of patients show a willingness to learn and using the sides of the bristle and not the end of the revert back to the other method, namely, brushing with the ends of the bristle; now if these bristles are especially hard there will be serious injury done, and regularly maintained it would be better to guide the patient into the best results possible with whatever method he persists in using.

Education Needed in Method of Brushing
After questioning 1000 users of the toothbrush during the past year, over 98% stated they used the ends of the bristle and not the sides in brushing their teeth. If these findings are any kind of a representative cross section, you might ask the question –has the Charter’s method made headway? I would say, there is much work yet to be done.
As for a dentifrice it might be said that any substance when used on the brush as a harmless aid in cleansing tooth surfaces and massaging gums, may be considered an all-sufficient dentifrice. Special emphasis should be placed upon those products which have been accepted by the Council on Dental Therapeutics of the American Dental Association. These manufacturers are cooperating with our dental organizations in keeping the standards high and in removing from our profession and the public in general the tendency to make dishonest claims and irrational statements about products supposed to be cure-alls.
Although much can be said for the use of the toothbrush in combating dental infection especially within the field of prevention nevertheless there are inflammatory conditions of the gums which require a different procedure.
Often certain teeth are not in functional occlusion-a high spot on an inlay or filling or bridge or denture or a high cusp of a tooth due to extrusion or drifting or rotation may persist in traumatising that particular tooth. Here is where the most comprehensive knowledge of occlusal grinding fits into the program. The mounted stone now becomes the second useful instrument in the treatment of periodontal lesions.
If any operator would take just the time required to play 18 holes of golf, and devote same to the careful reading of Dr. Sidney Sorrin’s articles on “Occlusion” in the May and June, 1935 issues of The Dental Digest, he perhaps would acquire such a respect for the needs of this field as to encourage him to go much father until he would be able to properly grind all such high spots into functional comfort and occlusion.
This field also embraces the building in of correctly designed restorations, fillings, inlays, bridges and dentures. These replacements must be built to balance and the technique for arriving at such has been worked out in no finer and better way than by Dr. Fred S. Meyer. The remarkable results he has been able to obtain in balanced and functional occlusion, permitting the gum tissue to return to healthy condition and remain so , is worthy of sincere consideration.
Not until balanced functional occlusion and comfort has been established and all excessive strain removed from each tooth can it be expected that in inflammatory conditions will disappear from the surrounding gum tissue, when and after thorough tooth brushing has been adopted, there are no other causes of inflammation present.
Quoting Dr. G. V. Black (2) “The insidiousness of periodontal disease is such that many dentists have a regular habit of not noticing them during their early stages. A little redness here or there seems to be of no consequence, and after a time when the case has gone too far for remedies to be effective, the dentist will find the disease very serious, and incorrectly suppose that it is comparatively recent in its beginning. The dentist should make a careful examination of the gingivae of every patient, and if there are inflammations, they should have immediate and most painstaking treatment. No matter what may be the cause of such inflammation, it should be searched out to the limit, found and removed. In this way, I am persuaded, from past experience, that the vast majority of these cases can be prevented by removing the danger in its inception.”
These inflammatory conditions are varied and many. First there is tartar, both serumul and salivary calculus. Willman (3) is quoted as stating that of all the marginal irritants which are responsible for periodontal lesions, the accumulated tartar around the gingival tissues far outnumbers all other causes.
Instruments Used in Treatment
Since the beginning of dentistry there have been instruments devised for the removal of this substance and even today there are new designs claimed to do such work more efficiently than can be done by any other. All credit must be given to those who are diligently and thoughtfully studying the various structures and substances involved, in the hope of furnishing a better technique for freeing the teeth of these accumulations with the least possible injury to the attached epithelium. I doubt if there ever will come a time when any one set of scalers will be universally accepted by all operators.
Scalers might be classified into three groups:
1. Hoes 2. Sickles 3. Curettes
Hoes are the type with a turned edge, examples being the Blacks scaler, the Carr, the McCall, the Hartzell, the Pycope, the Rose, the Tompkins and many other sets. These are designed to reach beyond the deposit and by a pull stroke, the substance is removed. If the calculus approximates the gingival crevice and the scaler is carried carelessly and forcefully beyond, there is apt to be considerable injury done to the attached tissue forming the bottom of the crevice. Such an injury may open into the sub-epithelial structures and pave the way for a locus minoris resistentiae and thus become the first step toward the mechanical formation of the pyorrhea pocket.
Sensitivity May Result from Over Instrumentation
Scaling too often may injure the tooth surface causing much sensitiveness and in place of having a satisfied and cooperating patient he will avoid the operator and the dental office. Thus it becomes necessary to exercise the greatest care and skill in the use of this type of instrument. Files are included in this classification since a file is just a multiple hoe.
Sickles. This type has a thin taper shaped triangular blade, bent to a short or long curve are the Bates and Morse sets. Here again the purpose is to reach beyond the deposit and remove same with a drawing stroke. Being thin, narrow and small in all dimensions, this instrument with its sharp angular point, in the hands of a skillful operator will slide around between calcareous deposits and epithelium, without much distortion and injury to tissue, and has become a most favored instrument to many practitioners in removing tartar and smoothing the roughened surface. The danger of this type lies in its sharp tapered point. Unless this point is dexterously guided it will tear the epithelium away from its attachment and such lacerations will be just as potentially harmful as those caused by the first mentioned group of scalers.
Curettes. This type of scaler somewhat resembles the spoon excavator. Examples are the Younger set and the Gracey set. The principles here involved is that of both push and pull. The blades are thin, narrow, sharpened on both edges and shaped to fit the contour of the tooth. By the push stroke it is intended to loosen the tartar and when so loosened can be flushed out with irrigation. Having the two edges sharp, both push and pull strokes will serve in smoothing any roughness of tooth surface and thus leave the enamel and cementum free from all minute accumulations.
Even where there are depressions and concavities, their curved design will reach in and adapt themselves to the otherwise inaccessible places. Once again care must be cautioned since the lack of complete control in scaling, curetting and smoothing will cause the instrument to cut and injure the crevice and enamel epithelium unnecessarily.
With these three general types of scalers available to examination in any dental supply house, surely any operator can make a suitable selection. In determining upon any one set it would seem advisable to study the several types carefully and when a set has been chosen, to study all the instructions of the designer, then proceed with a case and use every instrument as intended, becoming thoroughly familiar with the limitations and possibilities of each, continuing the same procedure with other cases until complete mastery of the usage of the entire set has been acquired. Though many months may be so required it will pay in dividends of satisfaction to be able to do the work as it ought to be done with a well designed set of instruments.
After the operator has completely familiarized himself with his first choice of instruments, he should plan to purchase another set from a different group. Here again he should do as before both in selection and usage until complete mastery of technique has been acquired. In this manner the dentist will learn with which instruments he can expedite the best results in the most satisfactory manner.
It is highly advisable in purchasing instruments to purchase every instrument of the set, not one or two which seem most attractive. Each number is designed to meed a specific purpose, for had not the designer been confronted with the need of such an instrument he never would have included it in the set and as such a need arose in his office so it will reoccur in the office of any operator. Therefore being properly equipped with right instruments for every occasion, there should be no excuse for doing any other than satisfactory work.
The need for scaling of teeth will always be present in every dental office, from simple prophylaxis to the difficult removal of tenacious calculus; always this department of dental practice must be adequately cared for, so it behooves every dentist to treat this need most seriously. The cost of equipment is minor compared with the returns, only a few prophylaxis appointments are necessary to pay for the best set of scalers available and perhaps several sets can be purchased from such a return.
Scaling Requires Careful Manipulation
Lest there be some who might think lightly of the exacting requirements of the right scaling and polishing of tooth surfaces, let me quote Dr. Austin F. James, (4) “I wish to emphasize the fact that there is no operation in dentistry that requires finer skill or a more delicate manipulation of instruments stroke and method, than in smoothing tooth surfaces.” If this be true it is easy to reason than an unlimited amount of damage can be done to tooth and tissue, in scaling and polishing teeth, unless the operator is especially skillful.
Besides tartar there are other causes of inflammatory conditions of gums, namely, over extension of the edges of amalgam and synthetic fillings, inlays, three quarter crowns and full crowns. These irritating extensions must be trimmed away to a smooth flush joint and proper contour before inflammation will have a chance to disappear. The sandpaper strip, the trimming knife, the mounted stone, the tapered bur and the file have all proven very useful in removing these irritants.
All Irritants Must be Removed
Sometimes it is necessary to remove the fillings and restorations entirely and put in new and correctly designed replacements, but in either event the tissues must be relieved of all such imposters or a chronic state of pocket formation will develop. In this manner the scaler in one form or another together with the above group just mentioned, becomes the third type of instrument, namely irritant removers, for the treatment of periodontal lesions.
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