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A Conservative Method for the Treatment of Pyorrhea*, *
A CONSERVATIVE METHOD FOR THE TREATMENT OF PYORRHEA* By F. V . SIM O N TO N , D .D .S., San Francisco, California
HERE are two general clinical is a hygienic measure, preventing lodg methods employed at the present ment of food débris; but we believe that, time in the treatment of pyorrhea. by a conservative method, sufficiently One method involves the elimination of close apposition of the tissues and an pockets by excision of the overlying gum. adequate tonicity can be produced to The other method seeks to preserve all minimize this factor, provided, of course, tissue possible and at the same time effect that the patient cooperate. a restoration of health. An intermedi In strum en ts ate method comprises the laying back of We have perfected and adopted a set gum flaps to expose the roots for more of eight instruments, including the ready removal of accretions; and the sub periodontometers.3 These instruments, sequent suture of the incisions.1 which are of a spoon type, are all Of these three methods, the second based on the same plan. The larger mentioned, which we will term a conserv pair of scalers are duplicates of ative method, will be described herewith. We have learned as a result of our earlier the periodontometers with the gradua studies that it is possible, by scaling, to tions omitted, and the remaining pairs abort the destructive processes and to (Figs. 1 and 2) are precisely similar, place the tissues in a constructive physio only smaller. They are numbered on 3 logic condition.2 to eight, respectively. With these few I f we can accomplish this result by instruments, we find it possible to reach scaling, it seems unnecessary to excise any portions of any of the roots of the the gum for the purpose of eliminating teeth within the limits of rational treat the pathologic conditions. It may be ment. This type of instrument was argued, of course, that the elimination of selected after careful consideration of pockets by excision of the overlying gum the other forms in use, and we believe *From the California Stomatological Re that it is superior to the straight edge search Group (Dental Section). type. In the design of some of the pyor *Aided by grants from the Carnegie Corpo rhea instruments, the fact that a con ration of New York, the American Dental As siderable proportion of the area of the sociation and the Associated Radiograph Lab oratories of San Francisco. root surfaces is concave does not seem 1. Simonton, G. W .: Treatment of Py to have been recognized, and, in conse orrhea by Surgical Exposure of the Tissues quence, the blades of such instruments Involved; J.A.D.A. to be published. are even less adapted to scale concave
T
2. Hanford, W. H., et al: A Contribution to Our Knowledge of Pyorrhea from the Standpoint of Histopathology, Dental Cosmos, 65: 12-17 (Jan.) 1923. Jour. A. D .A ., February, 1925
197
3. Simonton, F. V. : Examination of the Mouth, with Special Reference to Pyorrhea; to be published.
198
The Journal o f the American Dental Association
Fig. 1.— Pyorrhea scalers.
Simonton— Treatment of Pyorrhea
Fig. 2.— Pyorrhea scalers.
199
200
The Journal o f the American Dental Association
surfaces than they are to scale convex and fails to reach the root between these ones. points. The objection to this instrument Figure 3 illustrates the result of at- in scaling convex surfaces lies in the fact In S T R Ü M E liT S C & G PÆ S f í r PO !M TS fJ .fír iP .B .: f í n o
rtt/ L S
to
# £ ftcn
Fig. 3.—Diagram illustrating the lack of adaptability of a straight blade to contours of a root.
tempting to scale a concave surface with a straight edge scaler. It is obvious that this instrument scrapes at points A and B,
Fig. 4.—Diagram illustrating adaptability of blades of spoon type to contours of root.
that it tends to cut flat surfaces, as shown in Figure 3. On the other hand, scalers of the spoon type may be adapted to contours exactly as a French curve is adapted to a curve by a draughtsman (Fig. 4 ). The working edge extends a considerable distance, as shown in Figure 1 at W, and, by proper inclination or rotation of the instrument, this edge can be fitted to the portion of the root being scaled. A further objection to the straight edge scaler lies in the fact that it will not reach entirely to the bottom of a pocket, as shown in Figure S. The application of a spoon type scaler is shown in Figure 6 . It cannot be denied that it requires
Simonton— Treatment o f Pyorrhea
201
great skill and care to use these spoon type instruments correctly, and it is probable that most novices would prefer the other type; but it has been our ex perience that persistent use of the former leads to increased appreciation of their possibilities and overcomes, the difficul ties. The statement that a technic is
changing curvature of the root. Each area passed over is to be scaled in two opposite directions and, when possible, in four directions. The first two direc tions are longitudinal and transverse and the other two should be oblique to these. It is essential that the operator begin at some definite point, stepping his instru-
Fig. 5.—Diagram showing failure of straight edge scaler to reach bottom of pocket.
Fig. 6.—Diagram showing possibility of reaching bottom of pocket with spoon type of scaler.
difficult is not a sound argument in den tistry, provided that technic can be shown to be superior. S c a l in g
T e c h n ic
The pocket is carefully explored in order that its outline may be vizualized in the mind of the operator. The larger, readily accessible deposits of calculus are then removed. The case is now ready for the finer and more careful scaling. The ideal method for this purpose consists in, first, so alining the instrument that the blade of the scaler fits the curve of the root, and altering the angle of appli cation as the instrument moves, in such manner as continually to adapt it to the
ment continuously and progressively, and not scaling here and there, haphazard. In this part of the operation, the por tion of the root immediately adjacent to the line of detachment is left untouched for a distance crownwise, approximately 1 mm. T o scale this zone, we begin at a given point, pass the scaler along the side of the root until the bottom of the pocket is reached and then, engaging the blade to remove débris or deposits, draw it crownwise. This is repeated until, mov ing along the line of detachment step by step, about 5 mm. of its length has been so treated. This 5 mm. length is then
202
The Journal of the American Dental Association
rescaled by a push or pull stroke parallel to it. It will be noted that the operator is enabled to judge the direction of this parallel stroke as a result of his previ ously seeking out the line of detachment (or line of attachment) in his longi tudinal strokes. The surface of the instrument toward the tooth is flat from side to side, and slightly concave along the blade. The back of the blade, which comes in con tact with the overlying soft tissues, is convex from side to side and slightly convex longitudinally. There is a uni form lessening in thickness as the tip of the blade is approached. There are no comers or thick edges to come in con tact with the soft tissue. These instru ments can be slipped between the hard and soft tissues completely to the attach ment of the periodontal membrane, with out lacerating, stretching or bruising the soft tissues. They are so thin that it is possible to scale approximating surfaces of teeth even though they are very close together, and to scale around contacts. The rounded backs prevent lacerations and, incidentally to the scaling of the roots, serve to massage and stimulate the soft tissues effectively. We believe in repeated scaling, to aid in the re
moval of any particles of deposit that have escaped attention; to free the wound from any fragments of dead tissue; to further surface the root, and finally to stimulate and massage the overlying soft tissues, relieve stasis and promote constructive physiologic activity. We believe that the beneficial effects of repeated careful instrumentation have not hitherto been sufficiently emphasized, especially as regards the stimulus result ing from the massaging effect of this in strumentation. We have undertaken to study technic by scaling a number of hopelessly in volved teeth and subsequently extracting them. Some of the results will be pre sented later. There is no question that the satis factory treatment of pyorrhea is difficult and tedious, requiring long experience and a high degree of skill, but we are convinced that the results justify the effort. I f the disease is not too far ad vanced, teeth can be saved and the in vesting tissues can be maintained in a reasonably healthy state for an indefinite period of time. Infection can be reduced and kept at a minimum. And all this can be accomplished without any inten tional sacrifice of tissue.
HERE are two general clinical is a hygienic measure, preventing lodg methods employed at the present ment of food débris; but we believe that, time in the treatment of pyorrhea. by a conservative method, sufficiently One method involves the elimination of close apposition of the tissues and an pockets by excision of the overlying gum. adequate tonicity can be produced to The other method seeks to preserve all minimize this factor, provided, of course, tissue possible and at the same time effect that the patient cooperate. a restoration of health. An intermedi In strum en ts ate method comprises the laying back of We have perfected and adopted a set gum flaps to expose the roots for more of eight instruments, including the ready removal of accretions; and the sub periodontometers.3 These instruments, sequent suture of the incisions.1 which are of a spoon type, are all Of these three methods, the second based on the same plan. The larger mentioned, which we will term a conserv pair of scalers are duplicates of ative method, will be described herewith. We have learned as a result of our earlier the periodontometers with the gradua studies that it is possible, by scaling, to tions omitted, and the remaining pairs abort the destructive processes and to (Figs. 1 and 2) are precisely similar, place the tissues in a constructive physio only smaller. They are numbered on 3 logic condition.2 to eight, respectively. With these few I f we can accomplish this result by instruments, we find it possible to reach scaling, it seems unnecessary to excise any portions of any of the roots of the the gum for the purpose of eliminating teeth within the limits of rational treat the pathologic conditions. It may be ment. This type of instrument was argued, of course, that the elimination of selected after careful consideration of pockets by excision of the overlying gum the other forms in use, and we believe *From the California Stomatological Re that it is superior to the straight edge search Group (Dental Section). type. In the design of some of the pyor *Aided by grants from the Carnegie Corpo rhea instruments, the fact that a con ration of New York, the American Dental As siderable proportion of the area of the sociation and the Associated Radiograph Lab oratories of San Francisco. root surfaces is concave does not seem 1. Simonton, G. W .: Treatment of Py to have been recognized, and, in conse orrhea by Surgical Exposure of the Tissues quence, the blades of such instruments Involved; J.A.D.A. to be published. are even less adapted to scale concave
T
2. Hanford, W. H., et al: A Contribution to Our Knowledge of Pyorrhea from the Standpoint of Histopathology, Dental Cosmos, 65: 12-17 (Jan.) 1923. Jour. A. D .A ., February, 1925
197
3. Simonton, F. V. : Examination of the Mouth, with Special Reference to Pyorrhea; to be published.
198
The Journal o f the American Dental Association
Fig. 1.— Pyorrhea scalers.
Simonton— Treatment of Pyorrhea
Fig. 2.— Pyorrhea scalers.
199
200
The Journal o f the American Dental Association
surfaces than they are to scale convex and fails to reach the root between these ones. points. The objection to this instrument Figure 3 illustrates the result of at- in scaling convex surfaces lies in the fact In S T R Ü M E liT S C & G PÆ S f í r PO !M TS fJ .fír iP .B .: f í n o
rtt/ L S
to
# £ ftcn
Fig. 3.—Diagram illustrating the lack of adaptability of a straight blade to contours of a root.
tempting to scale a concave surface with a straight edge scaler. It is obvious that this instrument scrapes at points A and B,
Fig. 4.—Diagram illustrating adaptability of blades of spoon type to contours of root.
that it tends to cut flat surfaces, as shown in Figure 3. On the other hand, scalers of the spoon type may be adapted to contours exactly as a French curve is adapted to a curve by a draughtsman (Fig. 4 ). The working edge extends a considerable distance, as shown in Figure 1 at W, and, by proper inclination or rotation of the instrument, this edge can be fitted to the portion of the root being scaled. A further objection to the straight edge scaler lies in the fact that it will not reach entirely to the bottom of a pocket, as shown in Figure S. The application of a spoon type scaler is shown in Figure 6 . It cannot be denied that it requires
Simonton— Treatment o f Pyorrhea
201
great skill and care to use these spoon type instruments correctly, and it is probable that most novices would prefer the other type; but it has been our ex perience that persistent use of the former leads to increased appreciation of their possibilities and overcomes, the difficul ties. The statement that a technic is
changing curvature of the root. Each area passed over is to be scaled in two opposite directions and, when possible, in four directions. The first two direc tions are longitudinal and transverse and the other two should be oblique to these. It is essential that the operator begin at some definite point, stepping his instru-
Fig. 5.—Diagram showing failure of straight edge scaler to reach bottom of pocket.
Fig. 6.—Diagram showing possibility of reaching bottom of pocket with spoon type of scaler.
difficult is not a sound argument in den tistry, provided that technic can be shown to be superior. S c a l in g
T e c h n ic
The pocket is carefully explored in order that its outline may be vizualized in the mind of the operator. The larger, readily accessible deposits of calculus are then removed. The case is now ready for the finer and more careful scaling. The ideal method for this purpose consists in, first, so alining the instrument that the blade of the scaler fits the curve of the root, and altering the angle of appli cation as the instrument moves, in such manner as continually to adapt it to the
ment continuously and progressively, and not scaling here and there, haphazard. In this part of the operation, the por tion of the root immediately adjacent to the line of detachment is left untouched for a distance crownwise, approximately 1 mm. T o scale this zone, we begin at a given point, pass the scaler along the side of the root until the bottom of the pocket is reached and then, engaging the blade to remove débris or deposits, draw it crownwise. This is repeated until, mov ing along the line of detachment step by step, about 5 mm. of its length has been so treated. This 5 mm. length is then
202
The Journal of the American Dental Association
rescaled by a push or pull stroke parallel to it. It will be noted that the operator is enabled to judge the direction of this parallel stroke as a result of his previ ously seeking out the line of detachment (or line of attachment) in his longi tudinal strokes. The surface of the instrument toward the tooth is flat from side to side, and slightly concave along the blade. The back of the blade, which comes in con tact with the overlying soft tissues, is convex from side to side and slightly convex longitudinally. There is a uni form lessening in thickness as the tip of the blade is approached. There are no comers or thick edges to come in con tact with the soft tissue. These instru ments can be slipped between the hard and soft tissues completely to the attach ment of the periodontal membrane, with out lacerating, stretching or bruising the soft tissues. They are so thin that it is possible to scale approximating surfaces of teeth even though they are very close together, and to scale around contacts. The rounded backs prevent lacerations and, incidentally to the scaling of the roots, serve to massage and stimulate the soft tissues effectively. We believe in repeated scaling, to aid in the re
moval of any particles of deposit that have escaped attention; to free the wound from any fragments of dead tissue; to further surface the root, and finally to stimulate and massage the overlying soft tissues, relieve stasis and promote constructive physiologic activity. We believe that the beneficial effects of repeated careful instrumentation have not hitherto been sufficiently emphasized, especially as regards the stimulus result ing from the massaging effect of this in strumentation. We have undertaken to study technic by scaling a number of hopelessly in volved teeth and subsequently extracting them. Some of the results will be pre sented later. There is no question that the satis factory treatment of pyorrhea is difficult and tedious, requiring long experience and a high degree of skill, but we are convinced that the results justify the effort. I f the disease is not too far ad vanced, teeth can be saved and the in vesting tissues can be maintained in a reasonably healthy state for an indefinite period of time. Infection can be reduced and kept at a minimum. And all this can be accomplished without any inten tional sacrifice of tissue.