Principles of periodontal surgery (Pre-operative evaluation of the patient, informed consent and pre-medication)

Introduction

Similar to the general principles of surgery, there are three primary objectives which should be achieved during periodontal surgery, including inflicting the wound without pain, adequate control of bleeding during the procedure and adequate healing of the wound following the procedure. Adequate asepsis and gentle handling of the tissue during the procedure ensure appropriate post-operative healing. Asepsis, sterilization, as well as aseptic conduct by the operator, are the fundamental requirements of periodontal surgical procedures. The surgical procedure should be carried out in an environment which is conducive to patient comfort and appropriate post-operative healing.

Rationale for periodontal surgical therapy

Access to root surfaces and alveolar bone:

Surgical periodontal therapy is primarily done to get access to the root surfaces of the teeth and alveolar bone defects. It facilitates the removal of hard deposits from the root surfaces and allows appropriate root surface treatment. Surgical intervention facilitates access to the bone defects and allows execution of appropriate resective or regenerative procedures. Bony recontouring is done to achieve physiologically acceptable bone architecture, conducive for the maintenance of periodontal health.

Periodontal pocket reduction:

Periodontitis is characterized by the formation of periodontal pockets, thereby resulting in the loss of periodontal support. One major rationale for surgical periodontal therapy is to eliminate or reduce periodontal pockets. Elimination of the pocket lining and granulation tissue can be done effectively by the surgical intervention. Furcation involvement due to the progression of the inflammatory periodontal disease is a poor prognostic factor for a tooth. Various surgical procedures are intended to eliminate or manage furcation involvement.

Regenerative periodontal therapy:

Regeneration of the lost periodontal tissue is one major objective of the periodontal treatment. Various periodontal regenerative therapies can be executed only by getting access to the periodontal bone defects.

Correction of mucogingival problems:

Loss of soft tissue around the teeth such as in the case of recession can be effectively treated by periodontal esthetic surgeries. Surgical intervention is required to increase the width of attached gingiva in the areas with minimal attached gingiva.

To prepare for restorative dentistry:

Teeth with insufficient crown length are prepared for restorations by recontouring of the alveolar bone. If the biological width around the tooth is not maintained, it can result in persistent inflammation in that area.

Fundamental principles of periodontal surgery

The clinicians should have a thorough knowledge of the principles followed during periodontal surgery so that any unwanted event during or after the surgery can be avoided. The following principles are followed during surgical periodontal therapy,

Pre-operative evaluation of the patient.
Informed consent.
Pre-medication.
Asepsis and disinfection.
Preparation of the operating room, operating team and the patient.
Local anesthesia.
Management of emergencies.
Intra-operative management of the patient,
Soft tissue management.
Hemostasis.
Bone reshaping.
Suturing.
Periodontal dressing.
Post-operative instructions to the patient.

Let us now discuss these principles in detail,

Pre-operative evaluation of the patient

Plaque accumulation in the area to be operated can severely jeopardize healing. The preparation of the patient for surgical periodontal therapy is primarily aimed at the removal of all local factors and patient education regarding the maintenance of good oral hygiene. In other words, we can say that it is the re-evaluation of phase I periodontal therapy. Before operating on the patient, it must be made sure that the patient is maintaining an adequate oral hygiene. There should be minimal gingival inflammation so that tissue handling is easy and bleeding is minimal during the surgical procedure. The oral hygiene status and gingival inflammation can be assessed by quantifying plaque accumulation ^{1, 2} and the presence of bleeding on probing, respectively. Tonetti et al. (1995) ³ and Lang (1996) ⁴ have recommended that full-mouth bleeding score should be less than 20% to ensure an acceptable pre-surgical oral hygiene condition. It has been demonstrated that poor oral hygiene adversely affects the regenerative procedures in intrabony defects ⁵. To reduce the bacterial load prior to surgery, it is recommended to let the patient rinse with a 0.1 or 0.2% chlorhexidine digluconate solution for 1 min ^{6, 7}.

     Although smoking is not an absolute contraindication for periodontal surgery, if the patient is a smoker; he/she should be asked to stop smoking 2-4 weeks before surgery. It has been shown that smoking can adversely affect the outcome of the periodontal treatment ^{3, 8}. If the patient is unwilling or unable to stop smoking, alternative treatments should be considered.

     A complete medical and dental history of the patient should be thoroughly reviewed before making a treatment plan for surgical intervention. The radiographs should be re-evaluated and periodontal probing should be done to accurately assess the present status of the patient. If the patient is suffering from conditions like uncontrolled diabetes or has hypertension, such conditions should be addressed first and then surgical treatment should be planned. A careful medical history should be recorded for patients who had congestive heart failure in the past. Patients with bleeding disorders should be evaluated for their condition, and if required, the patient should be referred to a physician. A written consent should be taken from the patient’s physician regarding the surgical procedure.

     In addition to this, the patient with medical problems may be taking numerous medicines that may affect dental procedures and have oral manifestations. Medically compromised patients are commonly on medications like anticoagulants, beta-blockers, calcium channel blockers, diuretics, etc. Any potential drug interaction should be taken into consideration during treatment planning.

Informed consent

An informed consent should be taken from the patient before the treatment. The patient should be clearly explained the benefits and possible risks/complications of any proposed procedure. The patient should also be explained the alternatives to surgical procedures so that after knowing the benefits of the surgical procedure over other procedures, the patient gives the consent to the surgical procedure. The informed con-sent should be in a language, the patient can understand. The informed consent should be attached to the patient’s record and a copy of the signed document should be given to the patient.

Pre-medication

Antibiotics:

Medically compromised patients, such as patients at a risk of developing bacterial endocarditis or patients with joint replacement surgery, need to be given antibiotic prophylaxis before any periodontal treatment that may cause bacteremia. Premedication with antibiotics needs to be provided for the following conditions,

Congenital heart disease.
Bacterial endocarditis.
Mitral valve prolapse syndrome with mitral insufficiency.
Prosthetic heart valves.
Cardiac transplantation recipients who develop cardiac valvulopathy.
Patients who have undergone joint replacement surgery.
Immunocompromised patients (along with physician’s consultation).

     A detailed description of antibiotic prophylaxis required for the above conditions has been discussed in detail in “Periodontal treatment of medically compromised patients”.

     In patients, who are not medically compromised, using antibiotics as premedication has been recommended in bone grafting procedures. It has been proposed to enhance the chances of new attachment. However, no scientific evidence is available to support it ⁹.

Anxiolytics:

For patients who are not medically compromised, the most common pre-medication drugs given are sedatives to reduce anxiety. These drugs are indicated in apprehensive and neurotic patients to reduce the level of anxiety. The anxiolytic drugs used include sedatives, hypnotics, tranquilizers or barbiturates. These may be given through oral, intramuscular or intravenous routes. 5-10 mg of diazepam the night before and 1-2 hours before the treatment is commonly prescribed anxiolytic drug. Some authors use inhalatory sedation in the form of nitrous oxide/oxygen ¹⁰.

Commonly used oral benzodiazepines as pre-medication.
Drug	Adult dose (mg)	Onset of action (Hours)	Half-life (Hours)
Alprazolam	0.25-0.5	1-2	12-15
Diazepam	2-10	0.5-2	30-70
Lorazepam	1-4	1-6	10-18
Triazolam	0.12- 0.5	1-2	1.5-5.5

Antiseptics:

Chlorhexidine gluconate is the drug of choice for pre-surgical mouth rinses. It reduces the bacterial load and is continued postoperatively for plaque control.

Non-steroidal anti-inflammatory drugs (NSAIDs):

The rationale for using NSAIDs as pre-medication before periodontal surgery is focused on the reduction of chemical inflammatory mediators (PGs) involved in pain. Ibuprofen, ketorolac, aceclofenac etc. are the commonly used NSAIDs as pre-medication.

Conclusion

Periodontics is a surgical field and like any other field, the principles of periodontal surgery are the same as followed during general surgery. We should have a deep understanding of these principles and they should be strictly followed during periodontal surgery. In this article we discussed only few of these principles. In the upcoming articles, we shall read about remaing principles of periodontal surgery.

References

References are available in the hard-copy of the website.

Suggested reading

Antibiotic Prophylaxis Prior to Dental Procedure.

Antibiotic prophylaxis for dental procedures

Antibiotic Prophylaxis for Dental Patients at Risk for Infection

Which Antibiotic Prophylaxis Guidelines for Infective Endocarditis Should Canadian Dentists Follow?