CURETAGE ON CHRONIC PERIODONTITIS CASE

CURETAGE  ON CHRONIC PERIODONTITIS CASE

Case Report

Dentistry Undergraduate Study Program and Dentist Profession

Faculty of Medicine

Udayana University

ABSTRACT

The problem of oral health in Indonesia is one that needs attention, it is characterized by a high prevalence of tooth and mouth damage such as caries and periodontal disease. Periodontal disease begins when plaque or calculus accumulates on the tooth surface. Calculus itself is a factor that has contributed as an etiological factor for periodontal disease. Periodontal disease is often marked with a pocket. The initial treatment for periodontal disease is to eliminate the etiological factors, namely scaling and root planning and curettage, however, periodontal pockets are not a diagnosis of a disease. The definition of periodontal pockets is the process of increasing gingival sulcus, and is one of the clinical features of periodontal disease. This case report will discuss the treatment management of scalling, root planning and curettage in cases of chronic periodontitis experienced by a 56-year-old woman in teeth 12 and 13.
Keywords: Chronic periodontitis, scalling, root planning, curettage

 

PRELIMINARY

The problem of oral health in Indonesia is one that needs attention. This is indicated by the prevalence of tooth and mouth damage such as caries and periodontal disease which is quite high. The disease is due to lack of attention and knowledge about oral health. Periodontal disease is used to describe a condition that can cause inflammation in the supporting tissues of the teeth, namely gingiva, periodontal ligament, cementum root teeth, and alveolar bone.

Periodontal disease is a dental and oral health problem that has a fairly high prevalence in the community. The prevalence of periodontal disease in all age groups in Indonesia is 96.58% .1 There are two forms of periodontal disease, namely gingivitis and periodontitis. Gingivitis is inflammation of the gingiva which is a reaction of gingival tissue to the accumulation of bacterial plaque. While peridontitis is inflammation of the tissue that covers the teeth and tooth roots. Periodontitis is divided into two types, namely marginal periodontitis which is a continuation of the development of untreated gingivitis, whereas apical periodontitis is inflammation that occurs in tissues around the apex of the teeth which is a continuation of infection or inflammation of the pulp. Periodontitis is inflammation of the tooth supporting tissue caused by specific microorganisms that produce damage to the periodontal ligament and alveolar bone.2,4

Chronic periodontitis is defined as slow progressive periodontitis, which is usually the initial therapy consisting of scaling and root planing, oral hygiene, and may even require occlusal adjustment, or slight tooth movement. Periodontal disease is often seen with a pocket. However, periodontal pockets are not a diagnosis of a disease. Definition of periodontal pockets is a process of increasing gingival sulcus, and is one of the clinical features of periodontal disease

Procedures for removing etiogenic factors in periodontal pockets can be performed with curettage to remove lesions. Periodontal pockets often accompany several periodontal diseases, for example in gingivitis or chronic periodontitis. Periodontal pockets containing pathogenic tissue and debris must be removed immediately so that they do not expand to become more severe. Alternative treatments for periodontal pockets include curettage. Curettage is based on indications in patients. Curettage can be carried out as part of a new attachment procedure in a medium-depth infrabony pocket that is on the accessible side. In addition, curettage is often carried out at regular visits in the context of the maintenance phase, as a method of maintenance in areas with recurrence / recurrence of inflammation and pocket deepening. 2 In this case report will be discussed about the treatment of curettage in cases of chronic periodontitis experienced by a woman aged 56 years on teeth 12 and 13.3

CASE REPORT

A 56-year-old female patient came to the Udayana University RSGM clinic with complaints that tartar was interfering with her appearance and bad breath. From the history it is known that the patient had never cleaned tartar before, the patient said his gums often bleed when brushing his teeth and often swelled, but had never been examined or treated.

In extra oral examinations, no abnormalities were found. Examination of right and left lymph nodes is soft and painless. Intra oral examination revealed calculus in all anterior and posterior teeth of the maxilla and mandible, as well as swelling in the gums of 12 and 13 labial teeth. The patient's oral hygiene score was 4.16 (poor).

The diagnosis of a patient's complaint is chronic periodontitis that is aggravated by migration. The treatment plan that will be carried out is scaling, root planning and curettage along with post operative control.

Case Management

1. First Visit (September 26, 2019)

• History

• Extra-oral, intra-oral examinations

• Scaling and root plaining

• DHE

Figure 1. Intra oral conditions before scaling and root planning

The results of the pocket examination at the first visit were periodontal pockets on 12 mm mesiolabial teeth by 4 mm, 4 mm labial, 4 mm distolabial and 13 mm mesiolabial 4 mm teeth, 4 mm labial, 4 mm distolabial 4 mm. During this visit scaling and root planning were carried out. Bleeding On Probing / BOP (+).

planning. Bleeding On Probing/ BOP (+).

Figure 2. After scaling and root planning.

2. Second Visit (3 October 2019)

• Patients come for scaling control and root planning

• Periodontal pocket examination

• Indications for curettage

• Indications for panoramic X-ray

The results of the pocket check on the first control post scaling and root planning are periodontal pockets on 12 teeth, the mesiolabial section was reduced from 4 mm to 3 mm, the labial portion was still 4 mm, the distolabial portion was reduced from 4 mm to 3 mm and the 13 teeth were reduced by mesiolabial 4 mm to 2 mm, labial 4 mm, distolabial 4 mm, distopalatal 4 mm

 

3. Third visit (October 16, 2019)

• Patients come for curettage

• Prepare tools and materials

• Asepsis of the work area with povidone iodine

• Perform infiltration anesthesia

• Scaling and root planning return to teeth 42 and 43

• Curettage with grace curette no. 1-4

• Irrigation with saline

• Control bleeding with sterile gauze for 10-15 minutes

• Manipulation of periodontal pack material

• Periodontal pack installation

• Amoxicillin and mefenamic acid prescribing, IEC patients

·          

Gambar 4. Anestesi infiltrasi

Gambar 5. Prosedur kuretase

Gambar 6. Irigasi dengan larutan saline dan povidon iodine

 

Gambar 7. Setelah kontrol perdarahan

Gambar 8. Pemasangan periodontal pack

Gambar 9. Kontrol 1 minggu setelah kuretase

 

Figure 10. Examination of the pocket during the second control post curettage.

 

4. Fourth visit (23 October 2019)

• Patients present for first control post curettage

• Periodontal packs are intact and the condition of the soft tissue around teeth 12 and 13 does not indicate inflammation

• Open the periodontal pack, re-irrigate the postoperative area

5. The fifth visit (30 October 2019)

• Pasen come for the second control post curettage

• Periodontal pocket examinations were performed on 12 teeth where the mesiolabial section was reduced from 4 mm to 1 mm, the labial portion was reduced from 4 mm to 2 mm, the distolabial portion was reduced from 4 mm to 2 mm and tooth 13 the mesiolabial part was reduced from 4 mm to 2 mm, the labial portion was reduced from 4 mm to 1 mm, the distolabial portion was reduced from 4 mm to 1 mm, the distopalatal portion was reduced from 4 mm to 3 mm. BOP (-)

• Treatment of teeth 12 and 13 is declared complete, IEC patients to maintain dental and oral hygiene and control every 6 months

• Treatment of other teeth with chronic periodontitis has been continued by other operators.

DISCUSSION

According to Newman et al. periodontitis is inflammation of the tooth supporting tissue caused by certain microorganisms or certain groups of microorganisms, which results in damage to the periodontal ligament and alveolar bone with increasing depth of the periodontal pocket.2 Clinical signs of periodontal pocket formation such as redness, thickening of the gingival edge, gingival bleeding and suppuration, oscillation teeth and the formation of gaps between teeth, local pain or pain in the bone

According to Carranza and Takei appropriate and appropriate periodontal care is an action taken to eliminate the existing disease and prevent the return of the disease. Scaling and root planing, curettage and good oral hygiene, will eliminate inflammation and reduce the depth of the pocket, even in many cases can eliminate all the symptoms of existing diseases. Curettage is a procedure in the treatment of periodontitis. The action of curettage is the cleansing of granulation tissue that experiences chronic inflammation that forms on the lateral wall of the periodontal pocket.4 Granulation tissue in the periodontal pocket contains tissue that has chronic inflammation, particles of calculus and bacterial colonies. Calculus and bacterial colonies that are still left in the periodontal pocket will aggravate periodontal disease and inhibit healing despite scaling and root planning.

Periodontitis is inflammation of the tooth supporting tissue, caused by microorganisms and can cause progressive damage to the periodontal ligament, alveolar bone and accompanied by pocket formation. Periodontitis causes permanent tissue destruction characterized by chronic inflammation, fused epithelium to apical migration, connective tissue loss and alveolar bone loss.3

The clinical picture of periodontitis is the change in gingival color to bright red, accompanied by swelling margins. Bleeding on probing and probing depths of ≥ 4 mm are caused by fused epithelial to apical migration. Alveolar bone loss and tooth swaying occur. Periodontitis is divided into two, namely chronic periodontitis and aggressive periodontitis.

Chronic periodontitis is associated with plaque and calculus accumulation and generally develops slowly, but a period of rapid destruction appears. Increased development of periodontitis can be caused by the impact of local, systemic and environmental factors that can affect plaque accumulation. Systemic diseases such as diabetes mellitus and HIV

can affect host defense; environmental factors such as smoking and stress can also affect the response of the host to plaque accumulation. The following characteristics are found in patients with chronic periodontitis, namely:

 More prevalent in adults but can also occur in children

 The amount of damage is consistent / in accordance with local factors

 Related to the pattern of microbial variables

 Subgingival calculus was discovered

 The rate of disease progression is slow to moderate with the possibility of a period of rapid development

 Can be modified or related to: systemic diseases such as diabetes mellitus and HIV infection environmental factors such as smoking and emotional stress.

Chronic peridontitis can be sub-classified into localized and generalized forms. While based on the severity and appearance are divided into mild, moderate or severe categories, as follows:

- Localized: <30% of the area involved

- Generalized:> 30% of the area involved

 Light: clinical attachment loss (CAL) 1-2 mm

 Moderate: clinical attachment loss (CAL) 3-4 mm

 Weight: clinical attachment loss (CAL) ≥ 5 mm

The main cause of periodontal disease is the presence of colonizing microorganisms in dental plaque. Dental plaque is a structured substance, soft, yellow in color, which is attached to the surface of a tooth. The content of dental plaque is various types of microorganisms, especially the remaining bacteria are fungi, protozoa and viruses. Plaque containing these pathogenic microorganisms plays an important role in exacerbating periodontal infections. Increasing the number of Gram-negative organisms in subgingival plaques such as the bacteria Porphiromonas gingivalis, Actinobacillus actinomycetemcomitans, Tannerela forsythia and Treponema denticola can initiate periodontal tissue infections.

In the treatment of curettage scaling and root planning are performed to ensure that no calculus particles are left behind. The removal of the pocket epithelium was performed by manual curettage technique and using the gracey curette instrument no. 1- The curette was inserted into the pocket to the bottom of the pocket, the sharp side was exposed to soft tissue, the outer surface of the gingiva was lightly held using the fingers that did not hold the instrument. Curettage of teeth 12 and 13 is performed with horizontal stroke stroke on the lateral wall of the pocket. Repeat several times, until the granulation tissue is lifted marked by fresh blood. Then the area is irrigated after it is dried, followed by periodontal pack application. After the curettage, the area around the wound is often painful due to tissue damage. Acute pain often causes unfavorable conditions for sufferers such as anxiety, hemodynamic changes, respiratory problems, urinary retention, and others5. Therefore given Dental Health Education (DHE) regarding complications that can occur after the action of curettage, drugs that must be taken, the amount and time of taking medication. Then the patient was prescribed an analgesic drug in the form of mefenamic acid 500 mg tablets and amoxicillin 500 mg tablet antibiotics for 5 days, and both drugs were taken 3 times a day after meals.

Control after curettage treatment, subjective examination was not seen There were no complaints and objective examination was no periodontal pockets and inflammation of the gingiva around tooth 12 and tooth 13 mesiolabial section reduced from 4 mm to 1 mm, labial portion decreased from 4 mm to 2 mm, the distolabial portion was reduced from 4 mm to 2 mm and tooth 13 the mesiolabial portion was reduced from 4 mm to 2 mm, the labial portion was reduced from 4 mm to 1 mm, the distolabial portion was reduced from 4 mm to 1 mm, the distopalatal portion was reduced from 4 mm to 3 mm. and does not indicate bleeding on probing. This shows the prognosis of curettage treatment in this case is good. Healing obtained after curettage is the formation of blood clots that fill the pocket area. Root planning can reduce pocket depth, increase tissue clinical attachment and inhibit disease progression. Increased tissue clinical attachment leads to the formation of new connective tissue attachments, ie new periodontal fibers that are in the cementum.

CONCLUSION

Chronic periodontitis is defined as slow progressive periodontitis, which is usually the initial therapy consisting of scaling and root planing, curettage. Periodontal disease is often characterized by a pocket. However, periodontal pockets are not a diagnosis of a disease. The definition of a periodontal pocket is the process of increasing gingival sulcus, and is one of the clinical features of periodontal disease.

Curettage is a procedure to get rid of inflammatory granulation tissue that is in the periodontal pocket wall is one periodontal surgical technique that is very limited in its indications. Curettage is needed especially if new attachments between the cementum and alveolar bone are expected in the pocket by cleaning the damaged periodontal tissue, necrotic cementum, and tissue that can irritate the gingiva that is the wall of the tooth pocket concerned. Curettage can only be done if after scaling and root planning treatments are still found signs of inflammation such as edema, redness and pocket with a depth of 4-5 mm in the gingiva.

REFERENCES

1.      Astoeti, T.E, Boesro, S., Pengaruh Tingkat PCURETAGE  ON CHRONIC PERIODONTITIS CASE

Case Report

Dentistry Undergraduate Study Program and Dentist Profession

Faculty of Medicine

Udayana University

ABSTRACT

The problem of oral health in Indonesia is one that needs attention, it is characterized by a high prevalence of tooth and mouth damage such as caries and periodontal disease. Periodontal disease begins when plaque or calculus accumulates on the tooth surface. Calculus itself is a factor that has contributed as an etiological factor for periodontal disease. Periodontal disease is often marked with a pocket. The initial treatment for periodontal disease is to eliminate the etiological factors, namely scaling and root planning and curettage, however, periodontal pockets are not a diagnosis of a disease. The definition of periodontal pockets is the process of increasing gingival sulcus, and is one of the clinical features of periodontal disease. This case report will discuss the treatment management of scalling, root planning and curettage in cases of chronic periodontitis experienced by a 56-year-old woman in teeth 12 and 13.
Keywords: Chronic periodontitis, scalling, root planning, curettage

 

PRELIMINARY

The problem of oral health in Indonesia is one that needs attention. This is indicated by the prevalence of tooth and mouth damage such as caries and periodontal disease which is quite high. The disease is due to lack of attention and knowledge about oral health. Periodontal disease is used to describe a condition that can cause inflammation in the supporting tissues of the teeth, namely gingiva, periodontal ligament, cementum root teeth, and alveolar bone.

Periodontal disease is a dental and oral health problem that has a fairly high prevalence in the community. The prevalence of periodontal disease in all age groups in Indonesia is 96.58% .1 There are two forms of periodontal disease, namely gingivitis and periodontitis. Gingivitis is inflammation of the gingiva which is a reaction of gingival tissue to the accumulation of bacterial plaque. While peridontitis is inflammation of the tissue that covers the teeth and tooth roots. Periodontitis is divided into two types, namely marginal periodontitis which is a continuation of the development of untreated gingivitis, whereas apical periodontitis is inflammation that occurs in tissues around the apex of the teeth which is a continuation of infection or inflammation of the pulp. Periodontitis is inflammation of the tooth supporting tissue caused by specific microorganisms that produce damage to the periodontal ligament and alveolar bone.2,4

Chronic periodontitis is defined as slow progressive periodontitis, which is usually the initial therapy consisting of scaling and root planing, oral hygiene, and may even require occlusal adjustment, or slight tooth movement. Periodontal disease is often seen with a pocket. However, periodontal pockets are not a diagnosis of a disease. Definition of periodontal pockets is a process of increasing gingival sulcus, and is one of the clinical features of periodontal disease

Procedures for removing etiogenic factors in periodontal pockets can be performed with curettage to remove lesions. Periodontal pockets often accompany several periodontal diseases, for example in gingivitis or chronic periodontitis. Periodontal pockets containing pathogenic tissue and debris must be removed immediately so that they do not expand to become more severe. Alternative treatments for periodontal pockets include curettage. Curettage is based on indications in patients. Curettage can be carried out as part of a new attachment procedure in a medium-depth infrabony pocket that is on the accessible side. In addition, curettage is often carried out at regular visits in the context of the maintenance phase, as a method of maintenance in areas with recurrence / recurrence of inflammation and pocket deepening. 2 In this case report will be discussed about the treatment of curettage in cases of chronic periodontitis experienced by a woman aged 56 years on teeth 12 and 13.3

CASE REPORT

A 56-year-old female patient came to the Udayana University RSGM clinic with complaints that tartar was interfering with her appearance and bad breath. From the history it is known that the patient had never cleaned tartar before, the patient said his gums often bleed when brushing his teeth and often swelled, but had never been examined or treated.

In extra oral examinations, no abnormalities were found. Examination of right and left lymph nodes is soft and painless. Intra oral examination revealed calculus in all anterior and posterior teeth of the maxilla and mandible, as well as swelling in the gums of 12 and 13 labial teeth. The patient's oral hygiene score was 4.16 (poor).

The diagnosis of a patient's complaint is chronic periodontitis that is aggravated by migration. The treatment plan that will be carried out is scaling, root planning and curettage along with post operative control.

Case Management

1. First Visit (September 26, 2019)

• History

• Extra-oral, intra-oral examinations

• Scaling and root plaining

• DHE

Figure 1. Intra oral conditions before scaling and root planning

The results of the pocket examination at the first visit were periodontal pockets on 12 mm mesiolabial teeth by 4 mm, 4 mm labial, 4 mm distolabial and 13 mm mesiolabial 4 mm teeth, 4 mm labial, 4 mm distolabial 4 mm. During this visit scaling and root planning were carried out. Bleeding On Probing / BOP (+).

planning. Bleeding On Probing/ BOP (+).

Figure 2. After scaling and root planning.

2. Second Visit (3 October 2019)

• Patients come for scaling control and root planning

• Periodontal pocket examination

• Indications for curettage

• Indications for panoramic X-ray

The results of the pocket check on the first control post scaling and root planning are periodontal pockets on 12 teeth, the mesiolabial section was reduced from 4 mm to 3 mm, the labial portion was still 4 mm, the distolabial portion was reduced from 4 mm to 3 mm and the 13 teeth were reduced by mesiolabial 4 mm to 2 mm, labial 4 mm, distolabial 4 mm, distopalatal 4 mm

 

3. Third visit (October 16, 2019)

• Patients come for curettage

• Prepare tools and materials

• Asepsis of the work area with povidone iodine

• Perform infiltration anesthesia

• Scaling and root planning return to teeth 42 and 43

• Curettage with grace curette no. 1-4

• Irrigation with saline

• Control bleeding with sterile gauze for 10-15 minutes

• Manipulation of periodontal pack material

• Periodontal pack installation

• Amoxicillin and mefenamic acid prescribing, IEC patients

·          

Gambar 4. Anestesi infiltrasi

Gambar 5. Prosedur kuretase

Gambar 6. Irigasi dengan larutan saline dan povidon iodine

 

Gambar 7. Setelah kontrol perdarahan