Diet analysis and modification is another aspect of optimizing the status of the patients oral cavity. This is particularly relevant in relation to caries control. Although many foodstuffs can act as a substrate for the plaque forming microbes, our main concern would be diets high in refined forms of carbohydrates and sugars.
The form in which these are ingested is significant. Sugars ingested in a tough sticky form (e.g. a toffee) take about four times as long or more to be cleared from the oral cavity than that ingested in a liquid form. This allows the oral microbiota that much longer to utilize these sugars as a substrate for their metabolism. This can lead to an increase in plaque by- product formation and population growth, both undesirable sequelae.
The erosive effect of excessive dietary acid (such as citric acid found in citrus fruit and juices) on dental tissues has been well documented. If erosion lesions are noted and dietary analysis can identify the etiology, counseling in this regard can help prevent or reduce further loss of tooth structure this way.
It should always be remembered that, although rare in the United States, a number of dietary deficiency / malnutrition conditions exist that have oral manifestations (e.g. scurvy, beri-beri, pellagra).
During the process of root debridement, all hard and soft deposits are removed from the radicular and coronal surfaces(scaling) as well as a thin layer of diseased cementum leaving the root surface healthy and smooth (root planing). Additionally, a thin layer of diseased pocket epithelium may be removed at the time of subgingival scaling and root planing (currettage). The soft deposits are materia alba and plaque and the hard deposits are sub and supragingival calculus. The inflammatory effect of calculus, once thought to be due to mechanical irritation of the tissue, is now known to be due to its endotoxin content and the layer of plaque retained around it. The importance of removing bacterial endotoxin from the oral cavity (plaque: calculus: diseased cementum and tissue) lies in its ability it initiate a host inflammatory response and prevent periodontal reattachment occurring. It goes without saying that calculus removal must be as thorough as possible and that the most important piece of calculus to remove is the last one.
According to the extent of the hard and soft deposits on the tooth surface as well as the degree of periodontal disease present, a number of appointments are scheduled to remove these deposits. The complete removal of subgingival calculus, however is not easily accomplished and becomes more difficult and less attainable as pocket depth increases. Increasing pocket depth, multi rooted teeth, furcation involvement, tooth crowding, root proximity and intra-bony defect morphology are all factors that complicate subgingival root debridement.
A pocket probing up to 5mm is regarded by conventional wisdom as the maximum pocket depth in which an acceptable level of root debridement can be achieved by "closed" scaling and root planing techniques. Initial therapy debridement must be regarded as a vital and specialized field of our work requiring extensive skills, knowledge, manual dexterity, patience and persistance.
All teeth deemed to have a hopeless prognosis due to periodontal and/or restorative considerations should be extracted during initial therapy This not only allows healing at these sites but removes deep pockets and/or carious lesions from the oral cavity which are inaccessible to oral hygiene measures and act as foci of infection which can reinfect other areas of the mouth. The strategic extraction of healthy teeth for orthodontics and/or restorative considerations should also be done at this stage so that the healing process can begin. For esthetic considerations, one or more teeth slated for extraction may be retained until an esthetic replacement can be provided. It is important to discuss the possible need for a transitional, removable partial denture with the patient.
Endodontically involved teeth should be appropriately treated during initial therapy to remove the infected pulpal tissue debride and obturate the canals and facilitate resolution of any periapical or "endo-perio" lesions. It is best to perform endodontic therapy early in the treatment plan as this allows for healing of bone defects associated with pulpal disease and often results in complete restoration of lost or demineralized bone.
Any teeth requiring intentional endodontics for restorative needs may also be treated at this stage.
Any teeth requiring intentional endodontics for restorative needs may also be treated at this stage.
All carious lesions should be completely removed and the teeth restored with provisional or final restorations depending on the complexity of the case and what the situation allows. This will prevent progression of the caries to the pulpal tissues, eliminate an area of plaque retention and facilitate better plaque control. This therapy can be supplemented with fluoride treatment which will strengthen the mineralized tissues and decrease susceptibility to carious involvement. The application of fissure sealants can also be included as part of caries control.