Jan Lindhe. Clinical Periodontology

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BREATH MALODOR • 515

Fig. 24-3. Nasal examination

should be done routinely when

the air expired through the nose is

malodorous.

Fig. 24-4. The oropharyngeal air is

sampled by an electronic appara-

tus which measures the volatile

sulfur components.

Clinical and laboratory examination

Organoleptic

Even though some instruments are now available, the

best method in the examination of breath malodor is

still the organoleptic assessment made by a judge,

who has been tested and calibrated for his/her smell-

ing acuity. This testing is done by determining the

threshold level for detecting a series of dilutions of a

malodorous compound such as isovaleric acid. The

discrimination power of the judge is evaluated by

presenting to him/her a series of odors for identifica-

tion (Doty et al. 1984).

The use of any fragance, shampoo or body lotion,

and smoking, alcohol consumption or garlic intake are

strictly forbidden 12 hours before the assessment is

made. This involves both the patient and the judge.

The judge will not wear rubber gloves, the odor of

which may interfere with the organoleptic assess-

ments. Assessments should be performed at several

appointments on different days, since breath odor

fluctuates dramatically from one day to the next. The

patient should be encouraged to bring a confidant to

the consultations to help him/her identify the odor

causing the problem. The judge will smell a series of

different air samples (Fig. 24-2):

•

Oral cavity odor:

the subject opens his/her mouth

and refrains from breathing; the judge places his

nose close to the mouth opening.

•

Breath odor:

the subject breathes out through the

mouth; the judge smells both the beginning (deter-

mined by the oral cavity and systemic factors) and

the end (originating from the bronchi and lungs) of

the expired air.

•

Tongue coating scraping:

the judge smells the tongue

scraping and also presents it to the patient or the

accompanying confidant to evaluate whether they

associate the smell from the scraping with the mal-

odor complaint.

•

Breath odor when breathing out through the nose: when

the air expired through the nose is malodorous, but

the air expired through the mouth is not, a na-

sal/paranasal etiology should be suspected.

In the oro-pharyngeal examination, the clinician must

look for inflammation of the gingiva, or in the mucosa

under a prosthesis. Fresh extraction wounds or inter-

516 • CHAPTER 24

dental food entrapment can cause breath malodor. The

pharynx should be thoroughly inspected for the pres-

ence of inflamed tonsils. The tonsils often present with

crypts which may harbor anaerobic bacteria, pus and

even calculus (tonsilloliths).

Less obvious for a dentist is the examination of the

nostrils, although this is essential if the breath mal-

odor is noticed more clearly when the subject breathes

out through the nostrils (Fig. 24-3).

Portable volatile sulfide monitor

This is an electronic device that aspirates the air of the

mouth or expired air through a straw and analyses the

concentration of H

S (hydrogen sulfide) and CH

(

methylmercaptan), without discriminating between

the

two (Fig. 24-4). It can also be used to measure the

headspace above incubated saliva (Rosenberg et al.

1991). The monitor is good for the detection of hydro-

gen sulfide but less good for methyl mercaptan. It

needs regular calibrations.

It should be stressed that this machine will not

detect malodorous components such as cadaverine,

putrescine, urea, indole, skatole and several others

which have been described in salivary headspace

(

Kostelc 1981). Cadaverine (produced by bacteria

through decarboxylation of lysine to counteract the

unfavorable acidic growth conditions during gly-

colysis) and putrescine (from decarboxylation of orni-

thine or arginine) are both diamines the level of which

in air expired from the mouth does not, evidence

shows, correlate with VSC scores (Goldberg et al.

1994) but does correlate to a certain extent with tongue

coating and/or periodontitis.

Gas

chromatography

This can analyse air or incubated saliva or crevicular

fluid for any volatile component (Goldberg et al.

1994).

Some hundred components were isolated, and

mostly

identified, from saliva and/or tongue coating,

from

ketones to alkanes and from sulfur-containing

compounds to phenyl compounds (Claus et al. 1996).

Gas chromatography is only available in specialized

centers and for identifying non-oral causes such as

intestinal (Suarez et al. 1999) or bronchial/pulmonary

causes.

TREATMENT

An etiologic treatment is to be preferred. The treat-

ment of oral malodor consists of the elimination of the

pathology present, such as deepened and inflamed

periodontal pockets and/or tongue coating. If another

underlying disease is suspected, or if clinical experts

in the different disciplines (internal medicine, perio-

dontology, ENT, psychology, etc.) are not available, it

is possible to rapidly (within 1-2 weeks) make a dif-

ferential diagnosis by performing a full-mouth one-

stage disinfection of the oro-pharynx, including the

use of chlorhexidine spray to deal with the pharynx

(

Quirynen et al. 2000). Since all oral diseases which

cause malodor relate to microorganisms, this one-

stage professional approach reinforced by stringent

home care will dramatically reduce the oro-pharyn-

geal microbiota and the putrefraction they cause and

thus the malodour (Quirynen et al. 1998). If the symp

toms do not disappear, the patient should be referred

to a specialized multidisciplinary center where gas

chromatography can help in the differential diagnosis.

Masking of breath malodor should be distin-

guished from etiological treatment. It is well establ-

ished that zinc-containing mouthrinses have the prop

erty to complex the divalent sulfur radicals, reducing

this important cause of malodor. Thus it appears that

the application of a zincchloride/triclosan-containing

toothpaste on the tongue dorsum reduces the oral

malodor for some 4 hours (Hoshi & van Steenberghe

1996). Baking soda containing dentifrices (> 20%) con

fers a significant odor-reducing benefit for up to 3

hours (Brunette et al. 1998). The use of hydrogen

peroxide rinse also offers positive perspectives

(Suarez

et al. 2000). To deal with the tongue coating it

appears

that tongue brushing with chlorhexidine, be-

sides

oral rinses with the same antiseptic, reduces the

organoleptic scores significantly (Loesche & De Bo-

ever 1996). Whether the beneficial effect of tongue

brushing is related to the removal of bacteria and/or

to the reduction of their substratum, remains an open

question.

Hardly efficient are mints and other short acting

anti-breath" odor components. Most of them have

not

been properly tested in a blind way against a

placebo.

A recent review compared the efficiency of

oral rinses,

toothpastes and cosmetics for breath odor

therapy (

Quirynen et al. 2002).

When dryness is at stake, any measure to increase

the salivary flow may be beneficial. This can mean a

proper fluid intake or the use of chewing gum to

trigger the periodontal-parotid reflex, which origi-

nates from the mechanoreceptors in the periodontal

ligament of molar teeth (lower) and has the parotid

gland as a target (Hector & Linden 1987). The presence

of these molars is therefore crucial before advocating

the use of chewing gum to enhance salivary secretion.

The pH of the saliva can also be reduced to increase

the solubility of malodorous components (Re-

ingewirtz et al. 1999). Evidence shows that the effect

is short-lived.

CONCLUSIONS

Breath malodor has important socio-economic conse-

quences. A proper diagnosis and determination of the

etiology allows the proper etiological treatment to be

instituted quickly. Although gingivitis, periodontitis

and tongue coating are by far the most common

causes, other more challenging diseases should not be

BREATH MALODOR • 5

overlooked. This can be dealt with either by a trialfull-mouth one-stage disinfection) or by a multidisci-

therapy to deal quickly with intra-oral causes (the

plinary consultation.

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CHAPTER 25

Periodontal Surgery:

Access Therapy

JAN L. WENNSTROM, LARS HEIJL AND JAN LINDHE

Techniques in periodontal pocket surgery

Gingivectomy

Flap procedures

Regenerative procedures

Distal wedge procedures

Osseous surgery

General guidelines for periodontal surgery

Objectives, indications, contraindications Local

anesthesia

Instruments

Selection of surgical technique

Root surface instrumentation

Root surface conditioning/biomodification

Suturing

Periodontal dressings

Postoperative pain control

Postsurgical care

Outcome

Since most forms of periodontal disease are plaque-

associated disorders, it is obvious that surgical access

therapy can only be considered as adjunctive to cause

related therapy (see Chapter 20). Therefore, the vari-

ous surgical methods described below should be

evaluated on the basis of their potential to facilitate

removal of subgingival deposits and self-performed

plaque control and thereby enhance the long-term

preservation of the periodontium.

The decision concerning what type of periodontal

surgery should be performed and how many sites

should be included is usually made after the effect of

initial cause-related measures has been evaluated. The

time lapse between termination of the initial cause-re

lated phase of therapy and this evaluation may vary

from 1 to 6 months. This routine has the following

advantages:

•

The removal of calculus and bacterial plaque will

eliminate or markedly reduce the inflammatory cell

infiltrate in the gingiva (edema, hyperemia, flabby

tissue consistency), thereby making assessment of

the "true" gingival contours and pocket depths pos

sible.

•

The reduction of gingival inflammation makes the

soft tissues more fibrous and thus firmer, which

facilitates surgical handling of the soft tissues. The

propensity for bleeding is reduced, making inspec-

tion of the surgical field easier.

•

A better basis for a proper assessment of the prog-

nosis has been established. The effectiveness of the

patient's home care, which is of decisive importance

for the long-term prognosis, can be properly evalu-

ated. Lack of effective self-performed care will often

mean that the patient should be excluded from

surgical treatment.

TECHNIQUES

PERIODONTAL

POCKET SURGERY

Over the years, several different surgical techniques

have been described and used in periodontal therapy.

A superficial review of the literature in this area may

give the reader a somewhat confusing picture of the

specific objectives and indications relevant for various

surgical techniques. It is a matter of historical interest

that the first surgical techniques used in periodontal

therapy were described as means of gaining access to

diseased root surfaces. Such access could be accom-

plished without excision of the soft tissue pocket

open-view operations"). Later, procedures were de-

scribed by which the "diseased gingiva" was excised

(

gingivectomy procedures).

The concept that not only inflamed soft tissue but

also "infected and necrotic bone" had to be eliminated

called for the development of surgical techniques by

520 • CHAPTER 25

Fig. 25-1.

Gingivectomy.

The straight incision technique

(Robicsek 1884).

Fig. 25-2.

Gingivectomy.

The scalloped incision tech

nique (Zentler 1918).

Fig. 25-3.

Gingivectomy.

Pocket marking. (a) An ordinary periodontal probe is used to identify the bottom of the

deepened pocket. (b) When the depth of the pocket has been assessed, an equivalent distance is delineated on the

outer aspect of the gingiva. The tip of the probe is then turned horizontally and used to produce a bleeding point at

the level of the bottom of the probeable pocket.

which the alveolar bone could be exposed and re-

sected (flap procedures). Other concepts such as (1) the

importance of maintaining the mucogingival com

plex

(i.e. a wide zone of gingiva) and (2) the possibility

for

regeneration of periodontal tissues have also

prompted

the introduction of "tailor-made" surgical

techniques.

In the following, surgical procedures will be de-

scribed which represent important steps in the devel-

opment of the surgical component of periodontal ther-

apy.

Gingivectomy procedures

The surgical approach as an alternative to subgingival

scaling for pocket therapy was already recognized in

the latter part of the nineteenth century, when Robic-

sek (1884) pioneered the so-called

gingivectomy

proce-

dure. Gingivectomy was later defined by Grant et al.

(

1979) as being "the excision of the soft tissue wall of a

pathologic periodontal pocket". The surgical proce-

dure, which aimed at "pocket elimination", was usu-

ally combined with recontouring of the diseased

gingiva to restore physiologic form.

Robicsek (1884) and, later, Zentler (1918) described

the gingivectomy procedure in the following way: The

line to which the gum is to be resected is determined

first. Following a straight (Robicsek; Fig. 25-1) or scal-

loped (Zentler; Fig. 25-2) incision, first on the labial

and then on the lingual surface of each tooth, the

diseased tissue should be loosened and lifted out by

means of a hook-shaped instrument. After elimination

of the soft tissue, the exposed alveolar bone should be

scraped. The area should then be covered with some

kind of antibacterial gauze or be painted with disin-

fecting solutions. The result obtained should include

eradication of the deepened periodontal pocket and a

local condition which could be kept clean more easily.

Technique

The gingivectomy procedure as it is employed today

was described in 1951 by Goldman.

• When the dentition in the area scheduled for sur-

gery has been properly anesthetized, the depths of

the pathologic pockets are identified with a conven-

PERIODONTAL SURGERY: ACCESS THERAPY • 521

Fig. 25-4.

Gingivectomy.

(a) The primary incision. (b) The incision is terminated at a level apical to the

botto

the pocket and is angulated to give the cut surface a distinct bevel.

Fig. 25-6.

Gingivectomy.

The detached gingiva is re

moved with a scaler.

Fig. 25-5.

Gingivectomy.

The secondary incision through

the interdental area is performed with the use of a

Waerhaug knife.

Fig. 25-7.

Gingivectomy.

Probing for residual pockets.

Gauze packs have been placed in the interdental spaces

to control bleeding.

Fig. 25-8.

Gingivectomy.

The periodontal dressing has

been applied and properly secured.

tional periodontal probe (Fig. 25-3a). At the level of

the bottom of the pocket, the gingiva is pierced with

the probe and a bleeding point is produced on the

outer surface of the soft tissue (Fig. 25-3b). The

pockets are probed and bleeding points produced

several location points around each tooth in the

area. The series of bleeding points produced de-

scribes the depth of the pockets in the area sched-

uled for treatment and is used as a guideline for the

incision.

• The primary incision (Fig. 25-4), which may be made

by a scalpel (blade No. 12B or 15; Bard-

Parker

) in either a Bard-Parker handle or an angu-

lated handle (e.g. a Blake's handle), or a Kirkland

knife No. 15/16, should be planned to give a thin

and

properly festooned margin of the remaining

gingiva.

Thus, in areas where the gingiva is bulky, the

incision must be placed at a level more apical to

the

level of the bleeding points than in areas with a

thin

gingiva, where a less accentuated bevel is

needed.

The beveled incision is directed towards the base of

the pocket or to a level slightly apical to

the apical

extension of the junctional epithelium. In

areas

where the interdental pockets are deeper than

522 • CHAPTER 25

the buccal or lingual pockets, additional amounts of

buccal and/or lingual (palatal) gingiva must be

removed in order to establish a "physiologic" con-

tour of the gingival margin. This is often accom-

plished by initiating the incision at a more apical

level.

•

Once the primary incision is completed on the buc-

cal and lingual aspects of the teeth, the interproxi-

mal soft tissue is separated from the interdental

periodontium by a secondary incision using an Or-

ban knife (No. 1 or 2) or a Waerhaug knife (No. 1 or

2; a saw-toothed modification of the Orban knife;

Fig. 25-5).

•

The incised tissues are carefully removed by means

of a curette or a scaler (Fig. 25-6). Remaining tissue

tabs are removed with a curette or a pair of scissors.

Pieces of gauze packs often have to be placed in the

interdental areas to control bleeding. When the field

of operation is properly prepared, the exposed root

surfaces are carefully scaled and planed.

•

Following meticulous debridement, the den-

togingival regions are probed again to detect any

remaining pockets (Fig. 25-7). The gingival contour

checked and, if necessary, corrected by means of

knives or rotating diamond burs.

•

To protect the incised area during the period of

healing, the wound surface must be covered by a

periodontal dressing (Fig. 25-8). The dressing

should be closely adapted to the buccal and lingual

wound surfaces as well as to the interproximal

spaces. Care should be taken not to allow the dress

ing to become too bulky, since this is not only un-

comfortable for the patient, but also facilitates dis-

lodgement of the dressing.

•

The dressing should remain in position for 10-14

days. After removal of the dressing, the teeth must

be cleaned and polished. The root surfaces are care

fully checked and remaining calculus removed with

a curette. Excessive granulation tissue is eliminated

with a curette. The patient is instructed to properly

clean the operated segments of the dentition, which

now have a different morphology as compared to

the preoperative situation.

Flap procedures

The original

Widman flap

One of the first detailed descriptions of the use of a

flap procedure for pocket elimination was published

in 1918 by

Leonard Widman.

In his article "The opera-

tive treatment of pyorrhea alveolaris" Widman de-

scribed a mucoperiosteal flap design aimed at remov-

ing the pocket epithelium and the inflamed connec-

tive tissue, thereby facilitating optimal cleaning of the

root surfaces.

Technique

•

Sectional releasing incisions were first made to de-

marcate the area scheduled for surgery (Fig. 25-9).

These incisions were made from the mid-buccal

gingival margins of the two peripheral teeth of the

treatment area and were continued several millime-

ters out into the alveolar mucosa. The two releasing

incisions were connected by a gingival incision

which followed the outline of the gingival margin

and

separated the pocket epithelium and the inflamed

connective tissue from the non-inflamed gingiva.

Simi-

lar

releasing and gingival incisions were, if needed,

made on the lingual aspect of the teeth.

•

A mucoperiosteal flap was elevated to expose at

least

2-3 mm of the marginal alveolar bone. The

collar of

inflamed tissue around the neck of the teeth

was

removed with curettes (Fig. 25-10) and the exposed

root surfaces were carefully scaled. Bone

recontouring was recommended in order to achieve

an ideal anatomic form of the underlying alveolar

bone (Fig. 25-11).

•

Following careful debridement of the teeth in the

surgical area, the buccal and lingual flaps were laid

back over the alveolar bone and secured in this

position with interproximal sutures (Fig. 25-12).

Widman pointed out the importance of placing the

soft tissue margin at the level of the alveolar bone

crest, so that no pockets would remain. The surgical

procedure resulted in the exposure of root surfaces.

Often the interproximal areas were left without soft

tissue coverage of the alveolar bone.

The main advantages of the

"original Widman flap"

procedure in comparison to the gingivectomy proce-

dure included, according to Widman (1918):

•

less discomfort for the patient, since healing oc-

curred by primary intention and

•

that it was possible to reestablish a proper contour

of the alveolar bone in sites with angular bony

defects.

The Neumann flap

Only a few years later,

Neumann

(1920, 1926) sug-

gested the use of a flap procedure which in some

respects was different from that originally described

by Widman.

Technique

•

According to the technique suggested by Neumann,

an intracrevicular incision was made through the

base of the gingival pockets, and the entire gingiva

(

and part of the alveolar mucosa) was elevated in a

mucoperiosteal flap. Sectional releasing incisions

were made to demarcate the area of surgery.

•

Following flap elevation, the inside of the flap was

curetted to remove the pocket epithelium and the

granulation tissue. The root surfaces were sub-

sequently carefully "cleaned". Any irregularities of

the alveolar bone were corrected to give the bone

crest a horizontal outline.

•

The flaps were then trimmed to allow both an opti-

mal adaptation to the teeth and a proper coverage

Fig. 25-9.

Original Widman flap.

Two releasing incisions

demarcate the area scheduled for surgical therapy. A

scalloped reverse bevel incision is made in the gingival

margin to connect the two releasing incisions.

Fig. 25-10.

Original Widman flap.

The collar of inflamed

gingival tissue is removed following the elevation of a

mucoperiosteal flap.

Fig. 25-11.

Original Widnian flap.

By bone recontouring,

"physiologic

contour of the alveolar bone may be

reestablished.

Fig. 25-12.

Original Widman flap.

The coronal ends of

the buccal and lingual flaps are placed at the alveolar

bone crest and secured in this position by interdentally

placed sutures.

of the alveolar bone on both the buccal/lingual

(

palatal) and the interproximal sites. With regard to

pocket elimination, Neumann (1926) pointed out

the importance of removing the soft tissue pockets,

i.e. replacing the flap at the crest of the alveolar

bone.

PERIODONTAL SURGERY: ACCESS THERAPY • 523

524 • CHAPTER 25

Fig. 25-13.

Modified flap operation (The Kirkland flap).

tracrevicular incision.

Fig. 25-14.

Modified flap operation (The Kirkland flap).

The

gingiva is retracted to expose the "diseased" root sur-

face.

Fig. 25-15.

Modified flap operation (The Kirkland flap).

The

exposed root surfaces are subjected to mechanical de-

bridement.

Fig. 25-16.

Modified flap operation (The Kirkland flap).

The

flaps are replaced to their original position and sutured.

The modified

flap

operation

In a publication from 1931

Kirkland

described a surgi-

cal procedure to be used in the treatment of "periodon-

tal pus pockets". The procedure was called the

modi

fied

flap operation,

and is basically an access flap for proper

root debridement.

Technique

•

In this procedure incisions were made intracrevicu-

larly through the bottom of the pocket (Fig. 25-13)

on both the labial and the lingual aspects of the

interdental area. The incisions were extended in a

mesial and distal direction.

•

The gingiva was retracted labially and lingually to

expose the diseased root surfaces (Fig. 25-14), which

were carefully debrided (Fig. 25-15). Angular bony

defects were curetted.

•

Following the elimination of the pocket epithelium

and granulation tissue from the inner surface of the

flaps, these were

re-placed

to their original position

and secured with interproximal sutures (Fig. 25-16).

Thus, no attempt was made to reduce the preopera-

tive depth of the pockets.

In contrast to the

original Widman flap

as well as the

Neumann flap,

the

modified flap operation

did not in

clude (

1) extensive sacrifice of non-inflamed tissues and (2)

apical displacement of the gingival margin.

Since the

root surfaces were not markedly exposed

thereby, the

method could for esthetic reasons be use

ful in the

anterior regions of the dentition. Another

advantage of

the

modified flap operation

was the poten

tial for bone

regeneration in intrabony defects which,

according to

Kirkland (1931), in fact frequently oc

curred.

The main objectives of the flap procedures so far

described were to:

•

facilitate the debridement of the root surfaces as

well as the removal of the pocket epithelium and the

inflamed connective tissue,

•

eliminate the deepened pockets (the

original Wid

man

flap

and the

Neumann flap)

and

•

cause a minimal amount of trauma to the periodon-

tal tissues and discomfort to the patient.