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Periodontal Disease and Electrocoagulation
PERIODONTAL DISEASE AND ELECTRO COAGULATION By M . D .
W o lfs o h n ,
E R I O D O N T A L disease has been as sociated with mankind since the earliest records of medical literature. M a n y concoctions, potions and remedies have been used in its treatment during these years, with indifferent results. A s tringents and mouthwashes have been prescribed. Centuries ago, teeth were tied together and extruded teeth were filed down. In the latter part of the nineteenth century, John M . Riggs, of Hartford, Conn., first described a method of treat ing periodontal disease by surgery. The modern school of advocates of treating periodontoclasia by instrumentation is of comparatively recent origin. M a n y of the operators of this new era are still doing splendid work. M ost of them early realized that it requires more than a knowledge of treatment of the perio dontal pockets around a tooth to achieve successful end-results. In studying the books and published articles of this new school on this subject, one is impressed with the necessity of acquiring a fundamental knowledge of the histology and pathology of perio dontal disease as well as a thorough understanding of its etiology and diag nosis. A keen appreciation of the in tricacies of occlusion is surely a requisite. Stillman and M c C a ll have made a great contribution to modern dentistry in their “Textbook of Clinical Periodon tia.” In both editions of this book, they have stressed the important part that traumatic occlusion plays in the causation of periodontal disease.
P
Jour. A.D .A., Vol. 26, August 1939
D.D.S., Buffalo, N. Y.
A n understanding of the diagnosis and treatment of this important condition goes a long way toward the successful handling of a so-called pyorrheic tooth. DIAGNOSIS
M a n y cases of periodontoclasia are treated and finally discharged with ap parently good results without any attempt at diagnosis. The mere act of trying to make a diagnosis often helps the dentist to observe causative agents that would otherwise be overlooked. These factors are often fundamentally important sources of disturbance and their elimination tends to bring the case to a successful conclu sion. In other words, cases that are treated without a diagnosis turn out to be complete or partial failures. Conse quently, it is advisable, in handling a periodontal condition, to spend the time necessary to establish a diagnosis. Good x-ray pictures are of primary importance. PROGN OSIS
It is also requisite that much thought be given to the prognosis of the case. This pertains to the condition of the mouth in toto and to each tooth to be treated. Under this heading, I shall consider the status of the devitalized tooth. So much has been written about these pulpless teeth that there seems to be nothing new to record. However, there are cer tain important points to be contemplated. One is the retention of teeth having good root-canal fillings and which ap
1294
1295
W o ljso h n — Periodontal Disease and E lectrocoagulation
pear negative in the roentgenogram as to apical disease. It is true that cultures made from a pulpless tooth with negative x-ray find ings often yield Streptococcus viridans. It is also true that the same bacteria may often be obtained from vital teeth hav ing deep-seated fillings and from teeth containing pulp stones. It therefore seems reasonable to retain these pulpless x-ray negative teeth with mild perio-
to the normal functioning o f the occlusal surfaces. TREATM EN T
T h e latest contribution to the treat ment o f periodontoclasia is electrocoagu lation. M uch experimental work has been performed during the past few years in the adaptation o f the diathermy m a chine to the needs of dentistry. The greatest progress, in m y opinion, was
A B Fig. 1.— A , case before extraction. B, fixed bridge inserted after extraction.
Fig. 2.— Electrodes.
A B Fig. 3.— An apparently hopeless case treated by electro-coagulation. These teeth are firm and comfortable, and functioning normally.
dontal conditions provided the age and general health are favorable. T h e extraction of this type of tooth, as shown in Figure 1, A , necessitated a fixed bridge, as shown in B. It is highly improbable that the inlays and dummy occlusal surfaces show such harmonious articulating surfaces as did the occlusal surfaces o f the natural teeth. T he health of the periodontol tissues is in proportion
the designing o f the Webb electrode. Its flexibility marks the first real improve ment in the use of diathermic energy to coagulate periodontal pockets and to de stroy excess and unnecessary tissue. T he silver points as furnished by the manufacturer can be filed to a smaller diameter, and thus be made more slender and therefore more adaptable for smaller pockets. T h e electrode shown in Figure
The Journal of the American Dental Association 2, A, can be used to reach most surfaces on all teeth, the exception being the lingual surfaces of the lower molars. For these surfaces, I use an electrode with the points placed opposite so that they can be readily inserted alongside the lingual aspect of the molar teeth. This electrode is shown in Figure 2, B. The first step, before applying the elec trode points, is the equilibration of the occlusion. This restores functional oc clusion, and it is a painstaking task, playing an important part in the success ful finishing of the work. Next, all scaling is performed. The apoxemena may be removed from all or from as many teeth as are to be treated by coagulation at one time. The number to be treated at one time varies with the individual. Some patients are more sensitive than others, but the range varies from four to eight teeth at one sitting. Local and topical anesthesia can be used, but, in many cases, anesthesia is unneces sary. A cross-section of a pus pocket shows an epithelial covering that has grown down from the crevicular surface. Thoma and Goldman have shown this condition in photomicrographs. It is necessary to remove the epithelium as well as the inflammatory tissue present in the pocket before closure can be accom plished. M y technic for treating periodontal pockets is somewhat different from the generally accepted method. The differ ence lies in the fact that I do not destroy the periodontium. I confine my efforts to desiccating the tissues of the perio dontal pocket. The only exception is the removal of the hypertrophied marginal gingiva or tissue at the bifurcation of a tooth. This method of using the electro coagulation points offers an ideal proce dure for attacking these tissues. No alveolar bone will be destroyed. The de calcified bone reticulum will be retained if care is exercised in the handling of these
points. All pus products that are present in the cavity are destroyed. This is es pecially important in focal infection as it prevents a bacterial shower. These slender silver points can be made to slide into the deepest pocket in any position, with the applicator for which the situa tion of the tooth calls. A shorter time application of the points under higher power is recom mended rather than the use of a longer placement under lower power. This makes for a less painful operation, es pecially where a local anesthetic is not used. The electrode points are bent so that they will be 1.5 mm. apart for use in the lower anterior teeth. In the rest of the mouth, they can be from 2 to 3 mm. apart, this depending on the area. They are also bent lengthwise to fit the case at hand. Then they are carefully inserted in the pocket alongside the root until the bottom has been reached. Pres sure is placed on the gum with the points away from the tooth. A short flash of current is turned on until the tissue is coagulated and the points are stepped over. The act is repeated until the entire pocket has been covered. The coagulated material can be carefully curetted at this time and nothing further is done to the pocket. The teeth should be examined a week later. I f any pockets have failed to close entirely, the teeth should be rechecked for the presence of any untoward condi tions, such as occlusal trauma that may not have been previously eliminated. These conditions are corrected and the pockets again treated with the coagulator. In very deep pockets, coagulation may have to be performed several times at intervals of two weeks. M O U T H H Y G IE N E
After the entire mouth has been treated and the teeth have been polished, in struction should be given to the patient on tooth-brushing technic and the home care of the oral cavity.
Easlìck—Teaching of Children’s Dentistry to Undergraduate Students C O N CLU SIO N
It is advisable to endeavor to determine the etiology in all cases of periodonto clasia. Diagnosis should be made and the prognosis of the case be determined. The occlusion should be carefully stud ied and corrected if found faulty. Treat ment of the teeth should then begin. The electrocoagulation unit is a great aid in the treatment of the periodontal pocket. Diathermic energy should be
1297
used to desiccate the epithelium and in flammatory tissues in the pocket and not to destroy the marginal or cementai gingiva. B IB L IO G R A P H Y
T h o m a , K . H ., and G o ld m an , H. M .: Paro
dontal Disease. J.A .D .A ., 2 4 :19 15, December 1937S t il l m a n , P. R ., and M c C a l l , J. D. : T ex t book of Clinical Periodontia. New York: M ac millan Company, 1922; Ed. 2, 1937. 131 Linwood Avenue.
PROBLEMS THAT ARE MET IN THE TEACHING OF CHILDREN’S DENTISTRY TO UNDERGRADU ATE AND POSTGRADUATE DENTAL STUDENTS By
K e n n e th E a s lìc k ,
M .A ., D .D .S., Ann Arbor, Mich.
U R IN G the past year, an anony mous dentist mailed to me three extracted deciduous teeth which came from the left side of the upper jaw of a 7-year-old boy. These teeth were the cuspid, the first molar and the sec ond molar. The four interproximal cav ities in them had been filled by two silver amalgam fillings. One filling, packed without a matrix in each set of two in terproximal cavities, made a veritable, three-tooth silver amalgam bridge. All three teeth had abscessed; and the note that accompanied them stated that the dentist who inserted the fillings had never taken a course in children’s den tistry. One who has an appreciation for the proper care of the mouths of young pa-
D
From the School of Dentistry, University of Michigan. Read before the Section on Children’s Den tistry and O ral Hygiene at the Eightieth A n nual Session of the American Dental Associa tion, St. Louis, Mo., October 27, 1938. Jour. A .D .A ., Vol. aG, August 1939
tients, but finds “amalgam bridges” and evidence of even worse dental practice in children’s mouths, may be tempted to comment on the preventive dentistry of 1938. No teacher of children’s dentistry in the dental schools of the United States or Canada and none of the numerous papers that have been published on chil dren’s dentistry during the past five years advocate the insertion of a single amal gam filling in two adjoining deciduous teeth or the retention of untreated in fected deciduous teeth in any child’s mouth; yet evidence of both practices is found during every school examination. Does the poor practice of dentistry for children mean that the younger gradu ates are ill taught, that the older dentists are not keeping abreast of modern prac tice, that parents are not educated as to the importance of young children’s teeth, that fees are too low for the adequate practice of children’s dentistry, that den tists are afraid of preschool children or that the wrong type of men have entered
W o lfs o h n ,
E R I O D O N T A L disease has been as sociated with mankind since the earliest records of medical literature. M a n y concoctions, potions and remedies have been used in its treatment during these years, with indifferent results. A s tringents and mouthwashes have been prescribed. Centuries ago, teeth were tied together and extruded teeth were filed down. In the latter part of the nineteenth century, John M . Riggs, of Hartford, Conn., first described a method of treat ing periodontal disease by surgery. The modern school of advocates of treating periodontoclasia by instrumentation is of comparatively recent origin. M a n y of the operators of this new era are still doing splendid work. M ost of them early realized that it requires more than a knowledge of treatment of the perio dontal pockets around a tooth to achieve successful end-results. In studying the books and published articles of this new school on this subject, one is impressed with the necessity of acquiring a fundamental knowledge of the histology and pathology of perio dontal disease as well as a thorough understanding of its etiology and diag nosis. A keen appreciation of the in tricacies of occlusion is surely a requisite. Stillman and M c C a ll have made a great contribution to modern dentistry in their “Textbook of Clinical Periodon tia.” In both editions of this book, they have stressed the important part that traumatic occlusion plays in the causation of periodontal disease.
P
Jour. A.D .A., Vol. 26, August 1939
D.D.S., Buffalo, N. Y.
A n understanding of the diagnosis and treatment of this important condition goes a long way toward the successful handling of a so-called pyorrheic tooth. DIAGNOSIS
M a n y cases of periodontoclasia are treated and finally discharged with ap parently good results without any attempt at diagnosis. The mere act of trying to make a diagnosis often helps the dentist to observe causative agents that would otherwise be overlooked. These factors are often fundamentally important sources of disturbance and their elimination tends to bring the case to a successful conclu sion. In other words, cases that are treated without a diagnosis turn out to be complete or partial failures. Conse quently, it is advisable, in handling a periodontal condition, to spend the time necessary to establish a diagnosis. Good x-ray pictures are of primary importance. PROGN OSIS
It is also requisite that much thought be given to the prognosis of the case. This pertains to the condition of the mouth in toto and to each tooth to be treated. Under this heading, I shall consider the status of the devitalized tooth. So much has been written about these pulpless teeth that there seems to be nothing new to record. However, there are cer tain important points to be contemplated. One is the retention of teeth having good root-canal fillings and which ap
1294
1295
W o ljso h n — Periodontal Disease and E lectrocoagulation
pear negative in the roentgenogram as to apical disease. It is true that cultures made from a pulpless tooth with negative x-ray find ings often yield Streptococcus viridans. It is also true that the same bacteria may often be obtained from vital teeth hav ing deep-seated fillings and from teeth containing pulp stones. It therefore seems reasonable to retain these pulpless x-ray negative teeth with mild perio-
to the normal functioning o f the occlusal surfaces. TREATM EN T
T h e latest contribution to the treat ment o f periodontoclasia is electrocoagu lation. M uch experimental work has been performed during the past few years in the adaptation o f the diathermy m a chine to the needs of dentistry. The greatest progress, in m y opinion, was
A B Fig. 1.— A , case before extraction. B, fixed bridge inserted after extraction.
Fig. 2.— Electrodes.
A B Fig. 3.— An apparently hopeless case treated by electro-coagulation. These teeth are firm and comfortable, and functioning normally.
dontal conditions provided the age and general health are favorable. T h e extraction of this type of tooth, as shown in Figure 1, A , necessitated a fixed bridge, as shown in B. It is highly improbable that the inlays and dummy occlusal surfaces show such harmonious articulating surfaces as did the occlusal surfaces o f the natural teeth. T he health of the periodontol tissues is in proportion
the designing o f the Webb electrode. Its flexibility marks the first real improve ment in the use of diathermic energy to coagulate periodontal pockets and to de stroy excess and unnecessary tissue. T he silver points as furnished by the manufacturer can be filed to a smaller diameter, and thus be made more slender and therefore more adaptable for smaller pockets. T h e electrode shown in Figure
The Journal of the American Dental Association 2, A, can be used to reach most surfaces on all teeth, the exception being the lingual surfaces of the lower molars. For these surfaces, I use an electrode with the points placed opposite so that they can be readily inserted alongside the lingual aspect of the molar teeth. This electrode is shown in Figure 2, B. The first step, before applying the elec trode points, is the equilibration of the occlusion. This restores functional oc clusion, and it is a painstaking task, playing an important part in the success ful finishing of the work. Next, all scaling is performed. The apoxemena may be removed from all or from as many teeth as are to be treated by coagulation at one time. The number to be treated at one time varies with the individual. Some patients are more sensitive than others, but the range varies from four to eight teeth at one sitting. Local and topical anesthesia can be used, but, in many cases, anesthesia is unneces sary. A cross-section of a pus pocket shows an epithelial covering that has grown down from the crevicular surface. Thoma and Goldman have shown this condition in photomicrographs. It is necessary to remove the epithelium as well as the inflammatory tissue present in the pocket before closure can be accom plished. M y technic for treating periodontal pockets is somewhat different from the generally accepted method. The differ ence lies in the fact that I do not destroy the periodontium. I confine my efforts to desiccating the tissues of the perio dontal pocket. The only exception is the removal of the hypertrophied marginal gingiva or tissue at the bifurcation of a tooth. This method of using the electro coagulation points offers an ideal proce dure for attacking these tissues. No alveolar bone will be destroyed. The de calcified bone reticulum will be retained if care is exercised in the handling of these
points. All pus products that are present in the cavity are destroyed. This is es pecially important in focal infection as it prevents a bacterial shower. These slender silver points can be made to slide into the deepest pocket in any position, with the applicator for which the situa tion of the tooth calls. A shorter time application of the points under higher power is recom mended rather than the use of a longer placement under lower power. This makes for a less painful operation, es pecially where a local anesthetic is not used. The electrode points are bent so that they will be 1.5 mm. apart for use in the lower anterior teeth. In the rest of the mouth, they can be from 2 to 3 mm. apart, this depending on the area. They are also bent lengthwise to fit the case at hand. Then they are carefully inserted in the pocket alongside the root until the bottom has been reached. Pres sure is placed on the gum with the points away from the tooth. A short flash of current is turned on until the tissue is coagulated and the points are stepped over. The act is repeated until the entire pocket has been covered. The coagulated material can be carefully curetted at this time and nothing further is done to the pocket. The teeth should be examined a week later. I f any pockets have failed to close entirely, the teeth should be rechecked for the presence of any untoward condi tions, such as occlusal trauma that may not have been previously eliminated. These conditions are corrected and the pockets again treated with the coagulator. In very deep pockets, coagulation may have to be performed several times at intervals of two weeks. M O U T H H Y G IE N E
After the entire mouth has been treated and the teeth have been polished, in struction should be given to the patient on tooth-brushing technic and the home care of the oral cavity.
Easlìck—Teaching of Children’s Dentistry to Undergraduate Students C O N CLU SIO N
It is advisable to endeavor to determine the etiology in all cases of periodonto clasia. Diagnosis should be made and the prognosis of the case be determined. The occlusion should be carefully stud ied and corrected if found faulty. Treat ment of the teeth should then begin. The electrocoagulation unit is a great aid in the treatment of the periodontal pocket. Diathermic energy should be
1297
used to desiccate the epithelium and in flammatory tissues in the pocket and not to destroy the marginal or cementai gingiva. B IB L IO G R A P H Y
T h o m a , K . H ., and G o ld m an , H. M .: Paro
dontal Disease. J.A .D .A ., 2 4 :19 15, December 1937S t il l m a n , P. R ., and M c C a l l , J. D. : T ex t book of Clinical Periodontia. New York: M ac millan Company, 1922; Ed. 2, 1937. 131 Linwood Avenue.
PROBLEMS THAT ARE MET IN THE TEACHING OF CHILDREN’S DENTISTRY TO UNDERGRADU ATE AND POSTGRADUATE DENTAL STUDENTS By
K e n n e th E a s lìc k ,
M .A ., D .D .S., Ann Arbor, Mich.
U R IN G the past year, an anony mous dentist mailed to me three extracted deciduous teeth which came from the left side of the upper jaw of a 7-year-old boy. These teeth were the cuspid, the first molar and the sec ond molar. The four interproximal cav ities in them had been filled by two silver amalgam fillings. One filling, packed without a matrix in each set of two in terproximal cavities, made a veritable, three-tooth silver amalgam bridge. All three teeth had abscessed; and the note that accompanied them stated that the dentist who inserted the fillings had never taken a course in children’s den tistry. One who has an appreciation for the proper care of the mouths of young pa-
D
From the School of Dentistry, University of Michigan. Read before the Section on Children’s Den tistry and O ral Hygiene at the Eightieth A n nual Session of the American Dental Associa tion, St. Louis, Mo., October 27, 1938. Jour. A .D .A ., Vol. aG, August 1939
tients, but finds “amalgam bridges” and evidence of even worse dental practice in children’s mouths, may be tempted to comment on the preventive dentistry of 1938. No teacher of children’s dentistry in the dental schools of the United States or Canada and none of the numerous papers that have been published on chil dren’s dentistry during the past five years advocate the insertion of a single amal gam filling in two adjoining deciduous teeth or the retention of untreated in fected deciduous teeth in any child’s mouth; yet evidence of both practices is found during every school examination. Does the poor practice of dentistry for children mean that the younger gradu ates are ill taught, that the older dentists are not keeping abreast of modern prac tice, that parents are not educated as to the importance of young children’s teeth, that fees are too low for the adequate practice of children’s dentistry, that den tists are afraid of preschool children or that the wrong type of men have entered