216 Theories and techniques of oral implantology

odontal tissues, although they may occur in the mucosal tissues elsewhere in the mouth.

There is no specific single cause for periodontal diseases. Although the local irritants or environmental factors precipating the disease may be easily identified, the disease actually results from multiple and complex disturbances in even the best environment. Anything that alters a patient's resistance at the cellular level can affect the progress of the disease. The most conmionly implicated conditions include altered sugar metabolism and hormonal imbalances (including stress reactions, nutritional deficiency diseases, vascular diseases, antigen-antibody reactions, and hereditary factors). Any systemic diseases affecting the blood, as is the case with most diseases, can be reflected in the condition of the periodontium.

When complex conditions are present, special diagnostic procedures including biopsy, bacterial smears, dietary analyses, and other laboratory tests are in order. The treatment of periodontal disease should he based on understanding the causes of the disease. If the condition is a reflection of disease elsewhere in the body, naturally treatment of the underlying condition is necessary. If the condition is local, the situation that provoked the condition should be alleviated. No matter what its causes, several alternative methods of treatment can be instituted, depending upon the severity of the disease.

As an example, the treatment of an inflammatory periodontal disease usually involves instituting a means of locally controlling the disease process, reducing the damage to the periodontal tissues by corrective treatment, and establishing a system of preventive measures to lessen the chances of relapse and recurrence.

A number of periodontal surgical procedures may be utilized for treating advanced periodontal conditions. One of the most common objectives in periodontal surgery is the elimination of the pocket, or pathologic sulcus, that occurs when the gingival tissue is detached from the root of the tooth by periodontal infection. The complexity of the surgical procedures depends upon the extent of the condition.

The simplest surgical procedure is gingival curettage, or the removal of dental calculus and other pocket debris. With periodontal instruments the soft tissue comprising the pocket wall, either sulcular or crevicular, is removed.

A gingivectomy involves excising the soft tissue wall of the periodontal pocket. This is done when the pocket has not extended into the underlying

bone. A gingivectomy is often accompanied by gingivoplasty, the procedure by which enlargements and other gingival deformities are reshaped and reduced to recreate normal, functional form.

When the bone is involved, the treatment be-comes more complicated. Osseous surgery may involve modifying and reshaping defects and deformities iii the alveolar bone around the affected teeth. Bone grafts, curettage of infrabony defects, and other techniques may be necessary to encourage the re-generation of bone. Usually it is necessary to make a soft tissue flap in order to reach a bone defect.

Mucogingivoplastic surgery is used to correct and modify defects in the morphology and position of the soft tissues surrounding the teeth. These procedures can be done separately or in combination with osseous surgery.

A combination of periodontic and endodontic procedures, such as root canal therapy, may be necessary. Two conunon situations in which combined procedures must be used are when a pulp canal infection spreads into the periodontal tissues, coalescing with an existing periodontal infection, and when periodontal disease creates a deformity around a multirooted tooth that can only be managed by the removal of one or more roots and perhaps a portion of the crown. Subsequent endodontic and periodontic therapy can be accomplished on the remaining portion of the tooth.

Examining the oral cavity

An examination of the oral cavity should not be neglected when considering dental implants. The condition of the structures and tissues in the mouth may very well serve as an excellent diagnostic aid for dental conditions and conditions elsewhere in the body. Many of the disturbances of the gingival tissues manifest themselves in the surrounding anatomy of the oral cavity.

An examination of the soft tissues should include inspection of the lips, buccal mucosa, tongue, gingiva, floor of the mouth, openings of the salivary ducts, face musculature, and type of saliva (ropy, dry, or liquid). The size and shape of the tongue and the shape and depth of the palatal vault should also be noted.

Diseases of the oral cavity

When disease is present, the dentist will, of course, institute therapy. If the disease is not curable, he must then decide whether implant procedures would aggravate the condition; in many cases they