GINGIVAL CURETTAGE
The word curettage is used in periodontics to mean the scraping of
the gingival wall of a periodontal pocket to remove diseased soft
tissue.
The term "gingival curettage" implies directing an operative
instrument against the gingival wall of the periodontal pocket in
order to remove the ulcerated epithelium covering the sulcus.
( Nestor & Lopez ,1977)
Terminology :-
Gingival curettage
Removal of the inflamed soft tissue lateral to the
pocket wall and the junctional epithelium.
Subgingival curettage
Procedure that is performed apical to the
junctional epithelium and severing the connective
tissue attachment down to the osseous crest.
Inadvertent curettage
Some degree of curettage is done unintentionally
when scaling and root planing is performed.
Rationale
Curettage accomplishes the removal of the chronically inflamed
granulation tissue that forms in the lateral wall of the periodontal
pocket.
This tissue, in addition to the usual components of granulation
tissues (fibroblastic and angioblastic proliferation), contains areas of
chronic inflammation and may also have pieces of dislodged
calculus and bacterial colonies.
This inflamed granulation tissue is lined by epithelium, and deep
strands of epithelium penetrate into the tissue.
The presence of this epithelium is construed as a barrier to the
attachment of new fibers in the area.
Curettage may also eliminate all or most of the epithelium that lines
the pocket wall and the underlying junctional epithelium.
Curettage and Esthetics
In the past, pocket elimination was the primary goal of therapy and
little regard was given to the esthetic result.
Currently, esthetics is a major consideration of therapy, especially in
the maxillary anterior area and every effort is made to minimize
gingival tissue shrinkage and the preservation of the interdental
papilla.
A compromise therapy is feasible in the anterior maxilla; this
therapy consists of thorough subgingival root planing.
Indications
1. Curettage can be performed as part of new attachment attempts in
moderately deep intrabony pockets located in accessible areas in
which a nonflap type of “closed” surgery is indicated.
2. Curettage can be attempted as a nondefinitive procedure to reduce
inflammation when aggressive surgical techniques (e.g., flaps) are
contraindicated in patients because of their age, systemic problems,
psychologic problems, or other factors.
3. Curettage is also frequently performed on recall visits as a method
of maintenance treatment for areas of recurrent inflammation and
pocket depth, especially where pocket reduction surgery has
previously been performed.
Contraindications
Firm, fibrotic tissue
ANUG
Thin, fragile gingival tissue
Procedure
Curettage should always be preceded by scaling and root planing.
Instruments:
Gracey curettes
Universal curettes
Isolation & Anesthetize :
Local infiltration is given to anesthetize the isolated selected site.
Insertion of Curette :
Gracey or Universal curette is inserted to engage the inner lining of
the pocket wall and is carried along the soft tissue, usually in a
horizontal stroke
In gingival curettage angulation should be greater
than 90 degrees.
The pocket wall may be supported by gentle finger
pressure on the external surface.
The curette is then placed under the cut edge of the
junctional epithelium to undermine it.
In subgingival curettage, the
tissues attached between the
bottom of the pocket and the
alveolar crest are removed
with a scooping motion of
the curette to the tooth
surface
Irrigation :
Irrigate the area to remove debris & press the tissue to the tooth
surface gently which enables the arrest of bleeding & adaptation of
soft tissue to the root surface
Suturing :
Indicated if the clot area has been disrupted & the papilla have been
separated.
Healing :
It will result in shrunken, firm well adapted & well contoured
tissue.
Other Techniques
Other techniques for gingival curettage include
the excisional new attachment procedure
ultrasonic curettage
the use of caustic drugs
LANAP
Excisional New Attachment Procedure (ENAP)
The excisional new attachment procedure (ENAP) has been
developed and used by the United States (US) Naval Dental
Corps.
After adequate anesthesia, make an internal bevel incision
from the margin of the free gingiva apically to a point below
the bottom of the pocket.
Carry the incision interproximally on both the facial and the
lingual side, attempting to retain as much interproximal
tissue as possible.
The intention is to cut the inner portion of the soft tissue wall
of the pocket, all around the tooth.
Remove the excised tissue with a curette, and carefully
perform root planing on all exposed cementum to achieve a
smooth, hard consistency.
Preserve all connective tissue fibers that remain attached to
the root surface.
Approximate the wound edges; if
they do not meet passively, recontour
the bone until good adaptation of the
wound edges is achieved.
Place sutures and a periodontal
dressing.
Ultrasonic Curettage
The use of ultrasonic devices has been recommended for gingival
curettage.
Ultrasound is effective for debriding the epithelial lining of
periodontal pockets.
It results in a narrow band of necrotic tissue (microcauterization),
which strips off the inner lining of the pocket
The Morse scaler-shaped and rod-shaped ultrasonic instruments are
used for this purpose.
Nadler H-1962 found ultrasonic instruments to be as effective as
manual instruments for curettage but resulted in less inflammation
and less removal of underlying connective tissue.
Caustic Drugs
Since early in the development of periodontal procedures, the use
of caustic drugs has been recommended to induce a chemical
curettage of the lateral wall of the pocket or even the selective
elimination of the epithelium.
Drugs such as :
1. sodium sulfide
2. alkaline sodium hypochlorite solution (Antiformin)
3. phenol
Disadvantages
The extent of tissue destruction with these drugs cannot be
controlled, and they may increase rather than reduce the amount of
tissue to be removed by enzymes and phagocytes.
These drugs were discarded after studies showed their
ineffectiveness.
Laser-assisted New Attachment Procedure
(LANAP)
Drs. Robert Gregg and Delwin McCarthy
Millennium Dental Technologies, Inc., developed the PerioLase
MVP-7 laser, (Nd: YAG), which operates at a wavelength of 1064
nm to deliver the LANAP therapeutic procedure.
Advantages
Less invasive and less traumatic
Minimal postoperative discomfort
Minimal recession and thermal sensitivity
Quicker healing
Equally successful results treating dental implants and natural teeth
Healing after Scaling and Curettage
Immediately after curettage, a blood clot fills the pocket area, which
is totally or partially devoid of epithelial lining.
This is followed by a rapid proliferation of granulation tissue with a
decrease in the number of small blood vessels as the tissue matures.
Restoration and epithelialization of the sulcus generally require 2 to
7 days and restoration of the junctional epithelium occurs in animals
as early as 5 days after treatment.
Immature collagen fibers appear within 21 days.
Healthy gingival fibers inadvertently severed from the tooth and
tears in the epithelium are repaired in the healing process.
Clinical Appearance after Scaling and Curettage
Immediately after scaling and curettage, the gingiva appears
hemorrhagic and bright red.
After 1 week, the gingiva appears reduced in height because of an
apical shift in the position of the gingival margin.
The gingiva is darker red than normal , but much less so than on
previous days.
After 2 weeks and with proper oral hygiene, the normal color,
consistency, surface texture, and contour of the gingiva are attained
and the gingival margin is well adapted to the tooth.
Present concept
Long term clinical trials have confirmed that gingival curettage
provides no additional benefits when compared to Scaling and Root
planing alone.
Ramfjord SP 1987
The American Dental Association has deleted that code from the
fourth edition Of current Dental Terminology(CDT-4).
In addition the American Academy of Periodontology in its
Guidelines for peiodontal therapy, did not include Gingival curettage
as a method of treatment
AAP Statement Regarding Gingival curettage (2002)
