Pyorrhea Pockets Must be Eradicated

By  W. V. Buck Stresses the Importance of Elimination of Diseased Tissues in

“A RATIONAL CONCEPT FOR THE TREATMENT OF PERIODONTAL  LESIONS” PART II

            I might use the word “pyorrhea” which commonly expresses the later stages of dental tissue involvement by the word “pyorrhea”. Let me quote from the Dental Survey “Pyorrhea as a name for a disease has been officially voted out of existence by the International Dental Congress. This action was take because the name “Pyorrhea” was voted out when the disease was not understood, and it only describes one symptoms of pockets around the teeth. In place of pyorrhea the Dental Congress voted for the names “Paradentosis” and “Paradentitis”, the former being the all inclusive name for the disease and the latter a name for a certain stage of the disease..

In the future pyorrhea may be used correctly only as a description of the symptoms of a late case of paradentosis. In other words paradentitis represents the acute stage. It includes gingivitis; gingivitis means only in inflammation of the gum together with the involvement of the epithelial and slight deepening of the gingival crevice. Paradentosis represents the chronic stage. There must be definite detachment of them together with pocket formation either with or without the presence of pus, also bone eruption, which may revert back to the acute stage of paradentititis.

At last there seems to be a uniform conception on the part of the pathologist and writers as to the general stages of this syndrome; the terminology however has not been universally adopted. Where one writer will describe a certain condition and call it one name and another will describe the same thing and call it by some other term. Such becomes very confusing to the average reader and unless he keeps in mind the various stages and thinks of them as each is place of by the many names, he is apt to think of the whole subject as a more complicated matter than he cares to read about.

Thus thru lack of reacting the general practitioner may have failed to acquire a sufficient knowledge of the treatment of periodontal lesions. The term “Periodontoclasia” is used extensively by the American Academy of Periodontology but even this term leaves some for the imagination since the suffix “clasia” means breaking down and the change involved in periodontal lesions are not always a true breaking down process. The writers on the west coast use the term “Paradontosis” quite extensively while the writers in the east use “periodontoclasia” Kronfeld in his recent book uses the term “periodontitis”. All of this serves to prove that nomenclature must be worked out more accurately in the future.

That most forms of milk inflammatory conditions can be properly treated by the simple removal of the irritating factors and the gums return to their natural pink color and healthy texture, nevertheless if such treatment is found to be insufficient or if the irritants are allowed to remain and continue their inflammatory effects until epithelium detachment and pocket formation has occurred, then the problem of treatment becomes more complicated. No longer is inflammation alone in need of treatment but super imposed thereon is the periodontal pocket which must be eliminated before treatment can be considered successful. Often the periodontal pocket is present without any seeming inflammation, treatment in which case is limited to obliteration of the pocket.

Normally the gingival crevice is approximately 1 mm in depth. When this depth has been increased beyond the normal it becomes a pathologic pocket which in its entirety a focus of infection and as such must be dealt with in one way or another.

Destruction of Pocket Brings Relief

Gottlieb (5) is quoted with the following statement which has a direct bearing on this problem “It is a well known fact that when we extract a pyorrhetic tooth, suppuration is checked at once. The inflammation was not in the tooth itself, and by extraction we have certainly not influenced the inflamed tissue or the microorganisms, yet the inflammation instantly disappears. By extraction there is only one thing which is certainly brought about and this is the destruction of the pocket. The pocket consists of two walls, the gingiva and the surface of the tooth. By the removal of the tooth, the pocket has stopped forming. From these considerations we may conclude that the presence of a pocket is the chief prerequisite for the existence of pyorrhea, the inflammation and the bacterial activity being of secondary importance.”

From this it is clear that the problem is not one of eliminating inflammation nor one of eliminating bacterial activity but primarily one of eliminating the pocket. Since the pocket is formed by its two walls, namely the tooth on the one side and the detached gingiva on the other, and since the pocket becomes a medium for the retention of pabulum and calculus and a nidus for pathogenic processes, and since the removal of either wall will obliterate the pocket, the choice of which to remove merits conservative judgment, based upon much clinical observation and personal management of many varying cases on the part of the dentist together with the patient’s attitude toward the prognosis as explained to him.

Five Methods Available for Pocket Removal

Having determined upon the elimination of the pocket by removal of the gum tissue and not the extraction of the tooth, it becomes necessary to select one of several methods of procedure. Some of these are new and have not been generally accepted while others have been time tried and tested and have proven very satisfactory when applied to the proper type of case.

These methods might be enumerated as follows:

  1. Ultra violet therapy.
  2. Direct electric current therapy.
  3. Medicinal therapy.
  4. Subgingival curettage.
  5. Surgery.

Of the first three methods I have but little to say since no cases have been treated in my office by any of these methods. Some claim to have had good results by them and if so the scientific and clinical proof of same will be most interesting. The last two methods have been quite universally accepted and much can be said for both.

The subgingival curettage method seeks first to eliminate all irritants, such as calculus and overhangs by sealing and polishing following which the pocket is packed with a cotton wick saturated with sodium sulphide. This is intended to dissolve the epithelium lining the pocket until the connective tissue is reached, this dissolved epithelium is then curetted away and a good firm blood clot is allowed to form, then coated with copal varnish which seals in the blood clot for about two weeks. The attempt is to secure reattachment of the tissue to the tooth surface or at least such a tight adaptation as to render access by probing quite difficult.

From a histological and scientific standpoint there is a question as to whether reattachment is possible. Herman Becks (6) has said “Up to the present time, it has not been possible in any case known to me to obtain reattachment by means of instrumental treatment. Scientific proof must be demanded from those authors who claim the possibility of reattachment.”

Kronfeld (7) has said “In order to prove beyond doubt that the tissue has actually become reattached to the root surface, it would be necessary to measure the exact distance to the bottom of the crevice, before and after the treatment, from a fixed point on the tooth surface, as, for instance, from the gingival margin of a filling; reattachment may be claimed only if such measurements show that the distance from the bottom of the pocket to the margin of the filling has actually become smaller. To the author’s knowledge such measurements have not yet been reported.

The second reason for the author’s scepticism is the consideration that the root surface, once it has become denuded and exposed over a long period of time, is in a biological sense a dead surface. Reattachment is performed by deposition upon the root surface of new layers of cementum in which new periodontal fibers have been embedded. Since the denuded root surface inside the pocket represents a necrotic, macerated and infected hard tissue surface, deposition of new layers of cementum, without which a functional reattachment is impossible, it unlikely and up to this time has not been demonstrated.

Another complication is the presence of the epithelial attachment to the root surface. As long as the wall of the pocket is covered by epithelium, reattachment of connective tissue is impossible. But even if it were possible to remove all epithelium to the very bottom of the pocket, there is still present beyond this point the epithelial attachment from which new epithelium can proliferate and interfere with cementum formation and connective tissue reattachment.

All of these factors contribute to make the conditions for reattachment relatively unfavorable. Therefore, the author believes that even though there might be theoretically a certain possibility reattachment, the practical value of the therapeutic methods based upon this possibility is rather questionable.”

Reattachment Not Permanent

If at any time someone might be able to demonstrate a physiologic reattachment, such a union could be only very weak because the intermediary epithelium has degenerated, the cementum surface has been made very smooth and the supporting alveolar process has been resorbed. All these three are necessary, inversely, to normal attachment, to afford strength against the strain of mastication.

Such a weak attachment would soon tend to break down and recreate the same pocket as before. As viewed in the light of these findings, any effort toward completely obliterating the pocket by the sub-gingival curettage method with any degree of reasonable permanency so far as reattachment is concerned, will in all probability, terminate in limited satisfaction and most likely failure.

 

 

Surgical Removal of Tissue

The next method is Surgery either by the flap technique or by excision. Quoting Hermann Becks (8) “Whether or not the pocket is inflamed or discharges pus is not important. The therapeutic measures should consist of eliminating the pathologic pocket by normal surgical procedure.” Again quoting Kronfeld (9) “In a deep pocket a vicious circle develops; the existing inflammation and suppuration destroy the tissue attachment and cause deepening of the pocket, which in turn if followed by an increase in inflammation and discharge of pus. The therapy in such a case consists in the removal of the entire outer wall to the bottom of the pocket. All tissue would have to be removed in order to re-establish clean conditions and to prevent progressive destruction. The removal of the flap that overlies the pocket can be done by surgical excision.

If properly carries out, such therapy will result in the establishment of a crevice of zero depth. This is the only safe way to eliminate inflammation and suppuration and reestablish hygienic conditions. Any etiological factors involved, such as occlusal conditions, will of course, have to be remedied at once to prevent recurrence of the pocket.”

The surgical flap method is confined largely to the upper anterior areas especially where the mucoperiosteum is very dense and the pockets are more than 3 mm in depth. With a slender lancet, the interproximal tissue is severed as near the center, labiolingually and mesiodistally, to the full depth of the lesion. One half the papilla is retracted labially and one half lingually. The gingiva is pushed back far enough to expose about 2 mm of process and at the same time, the mass of diseased granulation tissue filling the lesion is exposed, as well as the entire field of operation.

With suitable instruments the pathologic or granulation tissue is removed from the pocket surface, the tartar is scaled from the pocket surface, the tartar is scaled from the root surface and cementum is smoothed and any sharp spicules and rough edges of process are rounded over. The labial and lingual flaps are trimmed to fit closely when brought together and then sutured. Surfaces are dried and painted with a warm mixture of resin and wax applied with a camel hair brush and allowed to so remain for six days, when with normal healing and repair, light massage may be started followed in another week by tooth brushing.

The drawbacks of this procedure lie in the possibility of the non-collapse of the gingiva due to hypertrophying tendencies in healing. In this way the gingival crevice, although in most cases will be somewhat reduced, will not be reduced sufficiently to ultimately make the desired shallow gingival crevice. Also in retracting the gum tissue from the alveolar process and keeping same exposed during the operation until closed by suturing, the way is paved for possible infection being sealed within the enclosure and thus disturb normal healing.

Surgery by excision or as is called by some Gingivoectomy, is the last method to be here discussed. To prelude a description of this technique let me quote Harold Keith Box (10) “In stagnation zones like primary incubation zones associated with the gingival flaps of partly or perfectly erupted third molars, the mucous membrane changes in character as it passes backwards from the dense gum which is bound down to the bone, to the lax and loosely attached tissue behind the tooth. With inflammation and swelling, common to this region, deep thin pockets are formed which create long capillary spaces and the bacteria instead of being swept away remain in situ and their toxins cause necrosis of the underlying epithelium and an ulcer results, so that there is now provided a suitable medium for growth of bacteria in the damaged tissue and an entrance into the body.

Eliminate Infected Zones

Therefore as a prophylactic measure, the elimination of this zone is of extreme importance. This primary zone is of greatest significance and examples are present where with excision of the overlying gingival flap and consequent tissue contraction, the pocket is made shallow to permit establishment of hygienic conditions. As an aid in the excision of the tissues, the author has found extremely valuable the instrument known as the “guillotine.”

Here with the free gingival margin elongated to almost the level of the occlusal surface, forming the one wall of this third molar pocket, and the distal enamel surface of the third molar informing the other wall, reattachment is physiologically impossible as the enamel surface will not so permit; shrinkage of so much gum tissue is also impossible by any known method. Therefore excision by surgery becomes of necessity the only means of safety and efficiently eliminating this pocket.

Hypertrophied Tissue Forms Pockets

Another common condition-when the lower first molar has been extracted for a long period and the second molar has drifted and tipped mesially, due to the extensive hypertrophy of the tissue, a deep pocket has been created mesial to the second molar. Here again no reattachment is possible to the enamel, nor is shrinkage of this heavy tough tissue possible. Excision by surgery becomes the only rational means of pocket elimination.

Third case –when the edge of a gold crown has been irritating the surrounding gum tissue either because the edge has been pushed too far in to the crevice epithelium or because it is too large and not closely adapted around the tooth surface, there is caused a deepening of the crevice by degeneration of crevice epithelium or by hypertrophy of the gingiva. In this event no reattachment is possible because the only surface here concerned is the gold crown. Once more excision by surgery becomes the only rational means for reduction of such a pathological pocket.

Having cited three pathologic pocket formations commonly found in many mouths where elimination by surgery seems to be the only rational treatment to obtain satisfactory results and since these three are considered the most difficult of all periodontal pockets to eradicate, would it not be reasonable to apply this same rational procedure to the elimination of all other types of periodontal pocket and when properly done, expect the same kind of satisfaction to follow?

Surgical Technique Not New

The principle of the surgical technique was known centuries ago and was then practiced largely as an abortive measure in what was termed “suppuration of the gingivae.” During the last twenty years the medical and dental profession have come to realize the value of its efficacy in definitely combating periodontal infection. Such men as Black, Pickerill, Morningstar, Nodine, Ziesel, Ward, Crane, Kaplan, Blanquie and other have all written up this subject most completely in our journals and what I am writing is based upon their articles together with personal experience and the use of newly designed instruments which are aimed to reach the more inaccessible areas with greater ease and permit of more accurate operating. The whole procedure is simple and direct and can be followed by any skillful operator.

There are four stages:

  1. The diagnosis. This includes a full set of roentgenograms, study models, examination of all areas by exploring to depth of pockets, determining which teeth should be retained and which should be extracted, studying the occlusion and making certain corrections at the time, taking history of patient’s health diet and habits, consultation with physicians, studying possibilities for restorative dental work following periodontal treatment, quoting fee together with discussion of terms of payment with patient, and last but not least determining so far as is possible the prognosis of the case.
  2. The operation proper. This includes the usual precautions and preparations for clean surgical operating, premedication of patient, infiltration and back anesthesia, and selection of instruments. In the majority of cases, all areas are operated at the same appointment. Each pocket is marked at its bottom with a pocket marker, to guide in determining how far to operate. All upper areas are operated first, then the lowers. With properly designed lancets and curettes, the loose detached gum is trimmed away to the depth of the pocket or level with the alveolar process; often time it is necessary to reduce certain parts of the alveolar crest of the edges of the buccal and lingual alveolar crest or the edges of the buccal and lingual alveolar plates and when so necessary there is used the interproximal bone curettes, bone file and bone hoe. With clear vision now afforded, the majority of scaling and smoothing can be quickly done at this same time.
  3. The packing and protecting of all operated areas. This stage is exceedingly important since it is necessary to permit healing to take place as free as possible from every oral disturbance and at the same time to prevent the hypertrophying of the new granulation tissue. This packing consists of any one of the proprietary packs such as Dentopack, Surgopak or Wondrpak, or of a mixture of Zinc Oxide, resin, eugenol, and olive oil in balanced proportions. A matrix of long strand cotton is spatulated into a soft mix of the above pack and pressed interproximally and around all of the operated areas. This pack sets in about five minutes as a hard putty and is left on at least ten days, during which time there is accomplished the following:
    1. Protection to the cut areas in healing.
    2. Sedative action by the zinc oxide and eugenol.
    3. Enables patient to eat nearly 90% of ordinary diet.
    4. Controls the thickness of the new epithelium.
    5. Last stage –post operative care. It now becomes important to maintain the mouth in good health. All constitutional factors underlying the paradentosis must, as far as possible, be eliminated in cooperation with the physician. Such local causes as malocclusion, overhangs of crowns and fillings and all other irritants should be removed.

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