101. Principles of Periodontal Surgery

When should systemic antibiotics be prescribed after periodontal surgery? How will you choose the correct antibiotic to give a patient?

What anatomical considerations are important in periodontal surgery? What pre-operative information or findings are important in surgical management?

What are the different types of sutures? What are the important principles of suturing? Describe the different techniques for suturing.

What instructions should a patient be given following surgery? How should postoperative instructions be written and communicated?

What type and dosage of pain and or anti-inflammatory medications are effective?

When should systemic antibiotics be prescribed after periodontal surgery? How will you choose the correct antibiotic to give a patient?

Mueller, 1999 ARTICLE
P: to investigate if a single dose of Clindamycin 600mg IV preoperatively provides:

M: 31 pts. (19M-12F) with mean age of 40 and mean weight of 70 kg undergoing maxillofacial surgery (tumor sx, trauma sx, osteoplasty, orthagnathic sx, TMJ) received 600mg clindamycin i.v. immediately before surgery. Plasma samples taken at 15, 30 min, 1,2,4, and 8h after infusion. Tissue samples taken only if surgery indicated removal. Tissues were quantitatively measured by bioassay for clindamycin.
R: Clindamycin above MIC₉₀ (minimum inhibitory concentration of 90%) in all tissues investigated until 8h post-infusion. The MIC₉₀ of Clindamycin for endogenous pathogens (staphylococci,streptococci and anaerobic gram + and -) is .025 mg/l. The highest clindamycin plasma levels (12.73 +/- 4.52 mg/l) were reached immediately after finishing the infusion. Plasma levels fell continuously to 1.41 +/- 0.88 mg/l after 8 h. The highest concentration in muscles was 4.64 +/- 2.78 mg/l at 46-75minutes. Clindamycin levels in oral mucosa reached 4.27 +/- 1.45 mg/l at 15-45 min after infusion and remained relatively stable for 1.75 h. Concentration in skin was 11.05 mg/l 1.5 h after infusion. In bone 3.4 mg/l at 0.5 h after administration. Fatty tissue concentrations ranged from “non-detectable” to 4.32 mg/l.
-muscle tissue most sampled- 4X MIC level maintained 6h after infusion.
-oral mucosa- comparable values to muscles w/ last sample at 4h.
-Highest tissue levels of clindamycin seen in skin.
BL: From a pharmokinetic point of view, 600mg clindamycin i.v. is suitable for perioperative prophylaxis during oral and maxillofacial surgery w/ no additional doses required when procedures do not exceed 8hours.

Cummings, 2000 ARTICLE
BG: Studies have shown that Alveolar bone loss after full thickness flap elevation is 0.5-<1.0mm. Gingival recession and bone loss also occurs after endodontic surgery. Doxycycline has been reported to prevent alveolar bone loss and root resorption after full thickness flap reflection.
P: To observe the effect of systemic doxycycline on crestal alveolar bone loss after periradicular surgery in beagle dogs
M+M: 5 Beagle dogs used in 2 phases. Prior to either phase, RCT was performed on the 3^rd and 4^th premolars. The endodontic surgery consisted of osteotomies, root resection and retro-fill with amalgam or MTA.
1^st phase (controlled): FTF in one mandibular quadrant had, notches placed in enamel of 3^rd and 4^th premolars and notched distances from CEJ to cortical bone were recorded. After 8 weeks there was surgical reentry and measurement of bone loss.
2^nd phase (experimental sides): The same procedure as was previously mentioned, but dogs were given doxycycline 4.4 mg/Kg/day X 10 days. After 8 weeks surgical reentry was done to measure bone loss.
Animals were sacrificed after 60 days post surgery.
R: All dogs in experimental and control sides had some alveolar bone loss. Bone loss in control was 0.97 ± 0.19 mm, doxycycline experimental side was 0.57±0.34. Each experiment result was statistically significant.
D: Ability of doxycycline to prevent bone loss may be due to having the ability of blocking MMPs by binding Zn and Ca. Action on osteoblasts by maybe altering collagen and alkaline phosphatase synthesis. Action on osteoclasts by decreasing acid production and the ruffled border areas. Also could be altering neutrophil-mediated tissue damage by inhibiting migration, degranulation and synthesis of O2-free radicals; and by inhibiting collagenase activity better than other tetracyclines. Other antibiotics have been examined but none have the ability like the tetracyclines to inhibit bone resorption.
BL: Systemic doxycyline SS reduces the amount of bone loss after full thickness flaps in dogs models.

Zucchelli 1999 ARTICLE
BG: Neither systemic antibiotics nor local antimicrobial rinses have been proven effective in preventing bacterial colonization of either bioabsorbable or non-resorbable membranes used for GTR, indicating that either the drugs administered are not directed against the microorganisms responsible for the infection or that the drug does not reach the infected site at a concentration sufficiently high enough to inhibit the target microorganisms
P: To evaluate the effect of topical metronidazole gel on: 1) clinical outcomes of GTR using titanium reinforced (ePTFE) membrane; 2) bacterial colonization of membrane material; and 3) flap connective tissue-membrane integration; and to compare it with systemic antibiotic therapy.
M&M: 56 pts with

4mm IP bony defects (

8mm PD and NO furc involvement) were treated with GTR using titanium reinforced ePTFE membranes. Patients were randomly assigned to 1 of the 2 antimicrobial treatment groups; the test group (26pts) received topical application of 25% metronidazole gel along the gingival margin once a week for 5 wks (no systemic atb given), and the control group (30pts) received systemic antibiotics (augmentin 1g/day for 14 days). Both groups were prescribed CHX rinse, and had weekly SPT until membrane removal, then monthly. Clinical outcomes were assessed at 1 year; the amount of bacterial contamination and connective tissue integration on membrane material was evaluated at time of membrane removal (6 weeks post-op) by means of a morphological (SEM) method.
R: 17 membrane exposures in test (65%), 13 in control (43%). NSSD was found between test and control groups in terms of regenerating tissue at membrane removal. NSD at 1 yr b/w groups for PD reduction or CAL gain, but SS (0.6 mm) increase in gingival recession was found in the test group, and overall there was sig greater amount of tissue lost from time of membrane removal to 1 year in the test group. The SEM analysis revealed NSSD between the number of fields positive to integrated connective tissue, while the number of fields positive to bacteria was statistically higher (P < 0.001) in the control group. CT was highest in middle and apical portions; bacterial colonization highest in coronal aspect.
BL: Metronidazole gel is more effective than systemic antibiotics in preventing membrane contamination, but it possibly interferes with gingival healing, and overall has worse clinical outcomes.

Rollke 2012 ARTICLE
Purpose: To compare the clinical outcomes of regenerative periodontal therapy of infrabony defects with or without postsurgical administration of 200mg DOXY once a day for 7 days.
Materials and methods: Pts were categorized as smokers (quit smoking less than 5 years), or non-smokers (quit smoking more than 5 years). They were adults, had gone through phase I treatment, at least one infrabony defect of more than 4mm deep radiographically and 6mm or more PD and attachment loss and in good physical health. Clinical measurements were performed in 6 sites per tooth, at baseline and 6 months after surgery by two calibrated examiners. Standardized radiographs were also taken and evaluated by one blinded examiner. Immediately before surgery and 14±2 days after that sub-g plaque samples were obtained and analyzed by a PCR test.
Defects were treated either with bioabsorbable barrier membranes or application of EMD and both could be combined with the used of a filler (Bi-Oss collagen). Pts were given Chx mouthwash post-op, ibuprofen was prescribed and they were also given Doxy or placebo pills. 7-8 days post-op the wound healing was evaluated and patients were asked about the intensity and duration of pain at that time and at 14 and 21 days.

Results: 61 pts were included in the study. 3 pts failed to attend the 6 month re-eval. The majority of defects (54) were treated exclusively with EMD. In 3 defects EMD was combined with fillers. In one pt a membrane was used.
The difference between two groups in AL gain was not statistically significant. No difference was found between groups in flap closure, or microbiological analysis.

Conclusion: 200mg doxy for 7 days after regenerative therapy of infrabony defects using EMD failed to result in better PD reduction and AL gain compared to placebo in this study.

Lockhart 2007 ARTICLE
Purpose: A systemic review to determine evidence for antibiotic prophylaxis in dentistry and its efficacy in preventing distant site infections in patients
Materials and methods:

Discussion:
The AHA came up with guidelines for antibiotic prophylaxis in 1955 based on a proposed link b/w rheumatic heart dz and bacteremia from dental procedures.
When looking at those surveyed, 14-91% recommend prophylactic antibiotics for dental procedures in the questioned group of pts, but 24% recommend this for medicolegal not evidence based reasons. This literature review includes a classification scheme of recommendations based on level of evidence:
Class I: good evidence &/or general agreement for use
Class II: conflicting evidence or divergent opinions. Class IIa: evidence is in favor of use. Class IIb: weight of evidence is less well established.
Class III: Evidence or general agreement that txt is not useful or effective. In some cases might be harmful

BL: very little evidence to support antibiotic coverage. Recommendation for coverage for immunosuppressed patients on chemo and cardiac involvement (prosthetic valve or history of endocarditis) has some anecdotal evidence.

Blossom, 2008 ARTICLE
Background: Clostridium difficile is a gram-positive, spore- forming, toxin-producing, anaerobic bacillus that causes diseases of the gastrointestinal tract ranging from asymptomatic colonization to a life- threatening condition known as “toxic megacolon.” Antimicrobial agent exposure is an important risk factor for Clostridium difficile– associated disease (CDAD). Bacteria colonize the mucosal crypts and proliferate when the normal flora is disrupted. It is best known for its association with uncomplicated antimicrobial-agent-associated diarrhea.
Purpose: To present two previously published cases of Clostridium difficile-associated disease (CDAD) to highlight it’s varied clinical manifestations
M&M: A 48-year-old woman undergoing endodontic therapy was prescribed clindamycin and developed mild CDAD. Her symptoms were liquid brown diarrhea and a small amount of blood (8-10 movements a day). After a stool sample she took metronidazole, and her C. difficile infection resolved in 10 days. A 31-year-old pregnant woman developed severe CDAD after receiving antibiotics (trimethoprim-sulfamethoxazole) for a urinary tract infection. Her symptoms were 3 days of watery black stools. After a stool sample and unsuccessful tx with antibiotics, she underwent surgery to remove part of her colon, but her condition worsened, and she died.
Treatment: The most important element in managing CDAD is to discontinue the use of any inciting antimicrobial agents whenever possible. In addition, clinicians should prescribe to patients with CDAD a 10-day course of an appropriate oral antimicrobial agent to treat C. difficile. For mild-to-moderate CDAD, oral metronidazole usually is effective. For severe CDAD, oral vancomycin may be a better choice. Follow-up
C/BL: Clinicians should suspect C. difficile in patients who have diarrhea and have been exposed to antimicrobial agents within the previous two months.
Dentists often prescribe antimicrobial agents to treat infections. An important risk factor for CDAD and recurrent CDAD is antimicrobial agent exposure. Dentists should be aware of CDAD to help prevent its spread and facilitate early recognition and treatment to minimize severe outcomes.

Lopes, 2011 ARTICLE
Purpose: to compare 2 regimens of antimicrobial prophylaxis to prevent surgical site infection in dental-invasive procedures in immunosuppressed patients by chemotherapy for cancer or solid organ transplants.
M&M:, 414 patients who scheduled for exodontia or SRP were randomized to receive one po 500- mg dose of amoxicillin 2 hours before the procedure (1-dose group) or a 500-mg dose 2 hours before the procedure and an additional dose 8 hours later (2-dosegroup). 68 % pt had organ transplant and 32% had cancer. After 30min of procedure (exodontia/SRP), 20 ml of blood collected for culture. The first primary outcome was incisional surgical site infection( purulence, dehiscence, febrile, localized pain, positive culture; the second primary outcome was organ/space surgical site infection, which was diagnosed if the infection involved any part of the surgically accessed area except the incision. Secondary outcomes: (1) use of medication for pain after the third day after the procedure; (2) systemic use of an antimicrobial drug within 30 days after the procedure; (3) hospitalization for any reason within 15 days after the procedure; and (4) death by any reason within 15 days after the procedure. Outcomes were evaluated at each follow-up visit. Follow-up was 4 weeks. Patients returned for evaluation every 3 days during the first week and weekly after that.
Results: 63% pt had SRP and 37% had exodontia. No deaths or surgical site infections occurred. Six patients (1.4%) presented with use of pain medication > 3 days or hospitalization (non-dental related) during follow-up. Bacteremia occurred in 3 patients submitted to dental extraction and in 2 patients submitted to scaling. Blood for cultures was collected within 30 minutes of the dental procedure; thus, none of the patients assigned to 2 doses of amoxicillin had yet taken the second dose. There were no adverse events attributed to amoxicillin in either prophylaxis regimen
Conclusion: NSS occurred in outcome using 1 or 2 doses of prophylactic amoxicillin for invasive dental procedures in immunocompromised patients.

Putnins, 2001             ARTICLE
Background: Dental unit waterline contamination is a concern to clinical dentistry. This concern arises from the fact that bacteria sloughed from established biofilms in dental unit waterlines increase heterotrophic bacteria counts in water exiting these units.
P: To examine dental unit waterlines and water samples for the presence of sessile and planktonic bacterial biofilms respectively and to measure LPS levels in the samples.
M&M: Water samples from 11 dental units of an established dental clinic connected to municipal water supply. Scanning microscopy and bacterial viability staining were used to examine the biofilm present in dental unit waterlines and water samples. Endotoxin levels (LPS) in dental unit waterline samples were quantified with the limulus amebocyte lysate test (LAL).
R: All dental unit waterlines were covered with a continuous microbial biofilm. The surface layer of the biofilm consisted primarily of filamentous and bacillus-like microorganisms. Water samples contained high numbers of individual bacteria and bacterial aggregates. The staining technique identified significantly more bacteria in water than the amount that could be cultured in the laboratory. 64% of the total bacterial population stained as non-vital. Since the presence of gram-negative bacteria load was high, the LPS in water samples were examined. The mean LPS levels in water lines from high speed and air water lines were 480 and 1008 endotoxin units, significantly higher than the level found in the adjacent sinks (66). The differences between air/water and high-speed lines were not significant. The mean LPS levels at the start of the day (2560 EU/ml) was reduced by 70% with 1 minute of flushing (to 800 EU/ml). NSSD reduction was noticed after flushing 5-10 min compared to 1 min.
Conclusion: High bacterial numbers, bacterial aggregates and LPS were found in dental unit water samples. The risk of using this water on patients and its effects on periodontal wound healing have not yet clearly established but there is a lot of theoretical risk for increasing inflammation unnecessarily during periodontal surgery.
BL: Sterile water should be used during surgical procedures.

Rautemaa, 2006             ARTICLE
P: To study how far airborne micro-organisms are spread during dental surgery when modern high-speed rotating instruments are used.
M&M: 72 samples were collected from 6 rooms where high speed and/or ultrasonic instruments were used. 24 samples were collected from 4 rooms where dental services were provided that did not use high speed or ultrasonics. 3 rooms at rest were sampled for background contamination. All rooms had standardized ventilation and filtration. 6 Horse blood chocolate agar plates were placed in pairs between 0.5 and 2 m from the patient. The plates were open once treatment started and one set of plates was closed after 1.5 hr and the other set after 3.0 hr.. Samples were also collected with sterile cotton swabs from facial masks of providers and assistants, as well as from different surfaces from the dental chair, cabinets, keyboards, and door knobs. These samples were immediately plated and samples were taken before and after disinfecting between patients. Plates were then incubated and colonies were counted and bacteria classified by gram stain.
R: Significant contamination was found at all distances sampled when high speed instruments were used. Results are given in colony-forming unit CFU/m²/h with standard deviations. The bacterial density was 823 CFU/m²/h at <1m and 1120 CFU/m²/h at >1.5m. This increase in bacterial contamination with increased distance was not found to be statistically significant. Viridans streptococci and stayphylococci were the most common findings. Bacterial findings were 589 CFU/m²/h in rooms were no high speed or ultrasonics were used and gram positive cocci also dominated these samples. The difference in bacterial density between these rooms were not determined to be statistically significant. Contamination in the rooms at rest was 35 CFU/m²/h. Facial masks were equally contaminated as contaminated as the rooms. Surfaces in the room had high counts of gram positive cocci but were for the most part negative after disinfection between patients.
D: Aerosols containing microbes from the oral cavity are created when modern high speed rotating instruments are used in restorative dentistry. This can be problematic with the recent emergence of MRSA in healthcare settings. These microbes can contaminate surfaces stored on work surfaces. The contaminated area was thought to be 1-1.5m from the patient’s mouth. There is no current consensus regarding acceptable level of contamination in a dental practice setting.

BL: Instruments with increased rotating speeds increase the contaminated bacterial zone larger than had been previously though. Only necessary items should be on working surfaces and the rest should be stored in closed cupboards. Disinfection between patients should be easy and thorough. Dental operatories should be treated more as hospital settings than dental offices in order to minimize cross-infection. Protection of the face, hair, and personal hygiene of the work personnel should be emphasized to prevent spread of bacterial infections. Rubber dams and antiseptic mouth rinses before treatment can reduce the amount of aerosolized bacteria.

Timmerman 2004             ARTICLE
P: To determine the microbial atmospheric contamination during initial periodontal treatment using piezoelectric scaler in combination with either high volume evacuation (HVE) or conventional dental suction (CDS).
M&M: 6 patients, 43-69 years were included. They had at least 3 teeth in each quadrant and diagnosed as having generalized chronic periodontitis. Use of antibiotics or topical antiseptics was not allowed during a period of 30 days prior to the study. Treatment consisted of 17 sessions (2-4 sessions per patient), 40min episode of continuous plaque and calculus removal using an ultrasonic unit. The use of HVE and CDS was randomly assigned with each patient. Before each treatment, the operating room was not used for 15hr. At the start of each treatment, Petri dishes were placed in the middle of the operatory and exposed to the air for 10min to measure baseline air contamination. At the start of the actual treatment 4 plates were exposed, 2 were placed on a tray table over the patient’s chest , 40cm away from pt’s mouth and exposed to the air for 5 min. Another set of plates was placed on a cart approximately 150cm away from the pt’s mouth, behind the patient and the dentist, at a height of approximately 100cm. These plates were exposed for 20 min and then the procedure was repeated (2 plates at 40cm for 5 min and 2 plates at 150cm for 20min). The plates were cultured aerobically and anaerobically for 3 and 7 days respectively.
R: Mean colony forming units (CFU) before treatment never exceeded 0.6 colonies per plate. At 40cm, the mean CFU, when considering a period of 40min was 8 for HVE and 17 for CDS. The mean CFU during this period at 150cm was 8.1 for HVE and 10.3 for CDS. No differences were found between two types of suction. Comparable proportions of aerobic and anaerobic bacteria were found.
CON: With reference to the Air Microbial Index the operatory atmosphere was considered to be in good condition during 40min of continuous used of ultrasonic scaler in combination with HVE and CDS. Only limited atmospheric microbial contamination is produced when using a piezoelectric ultrasonic scaler

What anatomical considerations are important in periodontal surgery? What pre-operative information or findings are important in surgical management?

Clarke, 1971 ARTICLE
P: A detailed review of anatomic considerations pertinent to perio surgery
M+M: Dissections done on fresh and prepared specimens.
D: MANDIBLE: Anterior Facial - Mentalis muscle may prevent increasing the KG. Possibly have to detach coronal fibers if mucogingival defects exist. Prominent mental tuberosity may limit the depth of the vestibule.
Anterior Lingual - Possibly large or high genial tubercles to which several muscles attach that will limit osseous recontouring.
Post Facial - External oblique ridge limits deepening of the vestibule or may need extensive osseous recontouring if osseous defects are present. Buccinator also limits vestibular deepening. Facial artery can be severed along the inferior mandibular border. Mental foramen-should have careful dissection in this area.
Post Lingual – The mylohyoid ridge can extend prominently from 3^rd molar towards anterior. The lingual nerve and submandibular gland should be avoided.
MAXILLA: Anterior Facial - Infraorbital nerve and blood vessels can only be disturbed if caninus muscle attachment is lifted.
Anterior Palatal - Avoid sphenopalatine foramen in dissection and reflection. Since these vessels are smaller, if sever the artery passing through incisive foramen should not be of as much consequence.
Posterior Facial – Maxillary tuberosity- extent of keratinized tissue determines surgical access. Limitation of vestibular deepening by buccinator and zygoma.
Posterior Palatal - Avoid greater palatine vessels. For all maxillary posterior teeth, if pneumatization of sinus has occurred, this can limit extent of osseous recontouring.
Potential spaces to take into consideration for spread of infection: submental, sublingual, submandibular, buccal, pterygomandibular, and parapharyngeal.
Origin and path of arteries, veins and nerves also discussed.
BL: Frequently review the anatomy of the jaw prior to surgery. Need to be aware of the anatomical limitations when treatment planning periodontal surgery. “Never take a knife in your hand without picturing in your mind’s eye the structures in and adjacent to your operative field, however small that field may be.”-Heslop (1963)

Bavitz 1994 ARTICLE
P: To describe the blood supply to the mandibular lingual gingiva and floor of the mouth and delineate the relative contribution and importance of the sublingual vs. submental artery in humans.
M&M: 74 cadavers used to make 124 extra-oral dissections of submental & submandibular triangles. Submental artery traced to determine presence or absence of large branch perforating mylohyoid muscle. When located, the vessel and the point of perforation with respect to the menton were measured. Sublingual artery evaluated & divided into 2 groups: 1. normal or 2. Small, insignificant, or missing and measured.
R: Large branch of submental artery found perforating the mylohyoid muscle in only 60% of the cases. Of the 60%, 69 of the 74(93.2%) of the branch were larger than ½ of the diameter of parent submental artery and were considered the terminal branch. Average area of perforation of mylohyoid muscle was 37mm posterior to menton. Floor of the mouth revealed that 53% of dissections had small, insignificant, or missing sublingual artery (in these cases, a large perforating ranch from the submental artery was present).
BL: Submental artery has a more significant role in blood supply to floor of the mouth & lingual gingiva than described in textbooks. Submental artery can be considered main arterial blood supply to the area. This study demonstrates the need to change procedure of extra-oral ligation for hemorrhage control in the floor of mouth. The facial & submental arteries should be ligated first, then the lingual artery, to ensure hemostasis.

De Oliveira 2012 ARTICLE
Purpose: To assess the mandibular canal (MC) and its variations through CBCT images.
Materials and methods: 100 CBCT exams displaying the entire mandibular bone (200 hemimandibles) were observed by three examiners.
Diameter of MC in the 1^st molar region, corticalization of the MC in the 1^st molar region, trabeculation in the submandibular gland fossa (SGF) region, bifid MC, position of bifurcations, diameter and direction of bifid canals and measurement of anterior loops were recorded.
Results: No significant differences between genders, age groups, or left and right sides were observed for all parameters. (98/100 Caucasians)
Corticalization of MC: 59% present, 23% canal was not corticalized but could be visualized and 18% canal could not be detected.
SGF trabeculation: decreased in 53% and not visible in 27%. Absence of MC corticalization was significantly correlated with decrease in trabeculation pattern in SGF region.
Bifid MC were observed in 19%. 14/19 cases were associated with additional mental foramina. 6 of them had double mental foramina (diameter more than 50% of the corresponding mental foramina) and 8 had accessory mental foramina (diameter less than 50% of the corresponding mental foramina). For the remaining bifid MC cases the bifurcation was observed in the posterior region of the mandible, near the mandibular angle. Diameter of bifid MC was between 1 and 3.3mm.

Conclusion: Low dose CBCT prior to implant placement and other surgical procedures is necessary. Recommendations of safe fixed distances from anatomical landmarks are not reliable.

What are the most common postsurgical complications and their management?

Pack, 1983 ARTICLE
Purpose: To determine the incidence of infection after periodontal surgery and the effectiveness of prophylactic antibiotic therapy in preventing post-op infection.
Materials and methods:

BL: The overall incidence of post-op infection with or without antibiotics is about 1% so unless there is a medical indication, there is no basis for the use of prophylactic antibiotic therapy to prevent infection following periodontal surgery.

Malmquist 2008 ARTICLE
P: To evaluate the efficacy of HemCon DentalDressing (HDD) and determine whether early hemostasis affects post-op care and surgical healing outcomes following oral surgical procedures.
M&M: 17 pts 18-90 yrs of age that were not allergic to seafood were included in the study. All pts (nine) taking oral anti-coagulative therapy (OAT) were included without altering their anticoagulant regimens. There were 74 HDD sx sites and 52 control sites (pts bit on a gauze) evaluated. The amount of time needed for homeostasis of the extraction site or sx site was recorded. The HDD was not placed in closed sx wounds, because that would impair dissolution of the material (takes 2 days). Thus, the HDD was visible and not packed deeply into the extraction sockets. At one-week post-op the pain scores (reported 0-10 by the pt), alveolar osteitis and healing (compared to the control) were evaluated.
R: All pts, including those on OAT, achieved hemostasis in less than 1 minute. Controls achieved hemostasis on average in 9.5 minutes. This difference was SS. Using a scale comparing HDD to controls (better, equal, worse), 24/74 of HDD sites demonstrated SS improved healing. None of the control sites had better healing. There was NSSD between self-reported pain in the two groups. There was also NSSD between groups causing alveolar osteitis. No HDD material was found at the 1-week post-op visit. If it were to be found, it could be easily removed with irrigation.
BL: HDD provides much faster hemostasis than simply biting on a gauze, even in pts taking OAT.

Tan, 2014 ARTICLE
P: To compare patient-reported outcome measures (PROMs) after different dental surgical procedures over a 1-week post-surgical period and in relation to duration of the surgery, and periosteal releasing incisions. To evaluate the prevalence of post-surgical complications.
M&M: 468 healthy dental patients requiring surgeries, such as crown lengthening (CL), open flap debridement (OFD) and implant installation (IMP) in the National Dental Centre, Singapore (2009–2011), were consecutively recruited. PROMs on bleeding, swelling, pain and bruising were obtained using Visual Analogue Scales (VAS) on days 0, 3, 5 and 7 post-operatively.
R: On the day of surgery, the IMP procedure gave the lowest median VAS for all four PROM parameters. After a week, OFD still had a significantly higher VAS for swelling, pain and bruising. Patients who underwent procedures lasting more than 60 min. had higher VAS for all parameters except bleeding. After considering other important confounders, type of surgery procedure was no longer associated with the VAS score for any of the parameters. Time after surgery, male gender and shorter surgery duration reduced post-operative VAS for one or more of the parameters. Longer surgeon experience helps reduce VAS scores only for bleeding. Prevalence for tenderness to palpation was 11.6%, 8.9% and 12.2% for IMP, CL and OFD, respectively, 1-week post-operatively. Swelling and suppuration occurred rarely.
C: The median VAS scores for all PROM parameters were generally low and reduced to near zero over a week following all three surgical procedures tested. Time after surgery and shorter surgery duration were associated with lower VAS scores in all the PROM parameters in this cohort of patients. Surgery type was not associated significantly with VAS after adjustment with other important confounders. Low prevalences of post-surgical complications were reported.
L: study didn’t differentiate between the types of CL procedure performed. The measurement of pain tends to be subjective and at most qualitative.
BL: the median VAS scores for all PROM parameters (bleeding, swelling, pain and bruishing) were generally low and reduced to near zero over a week following implant and periodontal surgical.BL: the median VAS scores for all PROM parameters (bleeding, swelling, pain and bruishing) were generally low and reduced to near zero over a week following implant and periodontal surgical.

What are the different types of sutures? What are the important principles of suturing? Describe the different techniques for suturing.

Dahlberg,1969. ARTICLE
Basic considerations of incisions and suturing in Periodontal Surgery:
1-Two principals reasons for surgical exposure: Access and change the position of underlying tissues.
2- Flap types: Full thickness: Includes the periosteum. Partial thickness: leaves connective tissue covering the bone.
3- Surgical principles: Aseptic technique, hemostasis, sharp dissection, gentle manipulation, fine suture, obliterate dead space, no tension, no torsion, adequate base for blood supply. Try to keep bulk of anesthetic away from the periphery of the flap to avoid trauma from localized vasoconstriction. Irrigate and aspirate any debris before wound closure. Avoid entrapment of air from air turbine. Use moist gauze to press area to prevent entrance of saliva.
4- Incisions:
Coronal incisions: Depend of amount of tissue. 1-Low KG and thin: split marginal gingiva to preserve external tissue and remove the sulcular elements. 2- Fibrotic: Thinned internally and removed from coronal if needed.
Lateral incisions: are needed for access, flap mobility, ensure maximum bone coverage. Try to avoid: 1- Lingual aspect of mandible has thin and fragile tissue complex. Vertical incision will open into the sublingual space, or submandibular space if extended beyond mylohyoid muscle. If extended pass the 2^nd molar an infection can extend to the pharyngeal space. Area with high vascularity. Incision heals slower over the dense bone on the lingual surface. If you need more lingual access extend mesially. If vertical incision in this area is needed do not extend over the mucogingival line. 2- Palate: It has an inside curve; usually it doesn’t require vertical incisions. The major concern is the palatal artery; avoid incision too deep and distal to the 1^st premolar. Vertical incisions are placed interdentally or in furcation areas (not in line angles)*.
Pedicle flap incisions: This flap shouldn’t make the vestibule shallower. Technique described below:

Supplementary releasing incisions: Incision to the periosteum, to give mobility to the flap.
5- Suturing: Use the smallest and least reactive suture material, leave a minimum amount of suture amount of material under the flap, maintain suture close to the tissue, remove as soon as they are not necessary (5-7d).
Interrupted suture: Good for areas where both sides require the same tension or one side is attached, tuberosity reduction and pedicle grafts.
The Sling Suture: For areas where different precise level position is needed b/w different teeth. For example: posterior buccal surface.

The Continuous Sling Suture: Time saving, especially in the lingual surface of both arches. Start it with a loose loop or with an interrupted suture.

The Anchor Suture: Delicate position of a single papilla.

Vertical Mattress Suture: Keep suture material from under the flap. Better if grasps the attached gingiva and not the mucosa.

Selvig, 1998             ARTICLE
P: To examine tissue reactions to different types of suture materials placed in densely fibrous gingiva and in oral mucosa.
M+M: 138 sutures made in edentulous ridges and oral mucosa of 8 beagle dogs. #4-0 Sutures used: silk (nonabsorbable organic multifilament), chromic gut (absorbable, organic monofilament), e-PTFE (Gore-Tex, nonabsorbable synthetic, monofilament), and coated vicryl (polyglactin, absorbable synthetic, multifilament). SRP done prior to surgery. Mandibular premolars extracted in four of the dogs 6 months earlier, up to 6 sutures (at least one from each category) were placed in dense fibrous tissue 10 mm apart in each mandibular quadrant with 5-6 mm bites. In four of the dogs, the mandibular first premolars were extracted 6 weeks earlier. In these dogs, 2 sutures placed in space between canine and second premolar. All dogs received additional sutures of similar size placed in a vertical direction in the apical mucosa over the maxillary premolars and first molar. Plaque control included 2% chlorhexidine spray every other day. Biopsy specimens included suture loop and surrounding tissues were obtained at 3, 7, and 14 days and processed for histological analysis.
R: Clinically: Silk, e-PTFE, and coated vicryl sutures were present at observation periods of 3 and 7 days. Several chromic gut sutures had disappeared at day 3 and none were seen clinically at day 7, however, the suture needle puncture wounds were seen. After 14 days, several sutures of all materials had been lost. At all time points and with all suture materials, swelling was more pronounced in the vestibular mucosa than in the edentulous mandibular ridge areas. At the ridge, swelling was minimal at 3 and 7 days, but more extensive at 14 days, some surfaces exhibited ulceration at the puncture site at 7 and 14 days as well.
Histo: Tissue response similar between ridge and mucosa and unrelated to fiber density of connective tissue, inflammatory reactions appeared more extensive in vestibular mucosa.
3 days: Fibrin clot containing neutrophils (PMN) and monocyte, plaque and leukocytes in suture track and between the threads of the braided sutures; some epithelial ingrowth into the connective tissue; chromic gut sutures undergoing degradation.
7 days: Disintegration of all sutures except e-PTFE. More extensive invasion of bacteria and leukocytes with multifilament (Vicryl and silk) than monofilament, some sutures completely lined by epithelium, chromic gut either partially or completely absorbed.
14 days: Epithelialization of suture channels, zone of granulation tissue replaced some inflammation cells. Silk had most bacteria, inflammatory cells, and areas of delayed healing indicated by poorly developed granulation tissue. Chromic gut was lost or absorbed. e-PTFE had limited inflammation and well-developed granulation tissue. Coated vicryl showed considerable inflammation but fibers were intact.
BL: Braided sutures conduct bacterial migration to a greater extent than monofilament sutures. e-PTFE showed less extensive bacterial ingrowth than the other materials. Although silk is commonly used because of its ease of handling, study demonstrated that silk elicits an extensive tissue reaction clinically and histologically. Chromic gut absorbs more quickly than other sutures. e-PTFE appears to be highly histocompatible. Vicryl is bioabsorbable but does not dissolve appreciably at 14 days.

Leknes 2005             ARTICLE
P: To evaluate clinically and histologically human tissue reactions to silk and expanded polytetrafluoroethylene (ePTFE) suture materials placed in pts scheduled for perio sx.
M&M: Twelve pts with moderate to advanced periodontitis that needed bilateral maxillary gingivectomies in the premolar and molar area were enrolled in the study. Each pt had an initial hygienic phase performed. All pts were systemically healthy and had PDs of at least 5mm. Silk 4-0 with a reverse cutting needle FS-2 and monofilamentous ePTFE CV-5 equipped with a comparable reverse cutting needle RT-16 were placed at 7 and 10 days prior to the gingivectomies. One quadrant received the silk sutures and the contralateral quadrant received ePTFE. Two clinical parameters were measured immediately after suture placement: the length of the suture embedded in tissue (the “bite”), the amount of slack if the suture loop was not properly tightened. Pts were instructed not to brush the maxilla and were given 0.2%CHX to rinse with twice daily. Prior to the gingivectomies, the bite of each suture and the slack were measured again. The tissue was excised and histology was performed.
R: Results from one pt were not included due to the loss of 4 sutures. The difference between change of slack was SS greater for silk at 7 days, but there was NSSD at 10 days. The range for the slack was 0.5mm-6.5mm for silk and 0.5-2.0mm for ePTFE at 10 days. The difference in bite was also greater for silk at 7 and 10 days, but there was NSSD. At ten days, epithelization of the suture channels was consistenetly present along the entire suture loop, except for one ePTFE suture. Inflammatory cells within the epithelial sleeve surrounding the sutures were found in 10 silk sutures and 9/10 ePTFE. The CT was characterized by the presence of granulation tissue, which seemed to have replaced the distinct zones of infiltration and inflammation seen at 7 days. Disintegration of some of the silk sutures was present to a certain extent. Thickness of the perisutural epithelial sleeve ranged from 0.03 – 0.16mm at 10 days and there was NSSD between groups. NSSD was present with respect to the proportion of inflammatory cells to epithelial cells between groups either (but there was a trend for silk sutures to present a higher proportion). At 10 days, the invasion of bacterial plaque along the suture track was found in 10/11 silk sutures and 4/10 ePTFE sutures.
BL: Braided silk sutures cause a greater inflammatory reaction, are more susceptible to bacteria, and are more prone to slack of the suture loop than ePTFE sutures.

Silverstein, 2007             ARTICLE
P: This article talks about the rationale behind specific suturing techniques and suture materials to help the clinician with optimal wound closure.
D:
Proper dental suturing involves choosing the appropriate suture materials (suture thread, Needle), Knots, and user friendly technique to position and secure surgical flaps for optimal healing.
Suture Materials
Nonresorbable:
Silk- moderate to high tensile strength
Nylon- moderate to high tensile strength
Polypropylene- high tensile strength

Resorbable:
Gut (3-5 days)- mild tensile strength
Chromic gut (7-10 days)- mild to slightly moderate tensile strength
Polyglycolic acid (21-28 days)- high tensile strength
Suture thread

Nelson 1977 ARTICLE
P: To determine the efficacy of interrupted (IS) and continuous suturing (CS) techniques after apically positioned flap surgery with primary closure. They were evaluated from the standpoint of post-therapy gingival health status, residual pocketing, loss of soft tissue attachment and amount of recession.
M&M: 10 patients (5males/5females), mean age of 43.1 years, with moderate periodontal disease participated in the study. All were in good general health, except one that was controlled diabetic. 22 surgical sites were studied, continuous suturing was used to secure the flaps at 11 surgical sites and interrupted sutures on 11 contralateral sites in each patient. Second and third molars were not included in this study. After initial therapy, pictures were taken and impressions for diagnostic casts. Gingival index (GI) and plaque score (PS) were measured prior to osseous surgery. Acrylic stents were fabricated on the diagnostic casts to standardize the measurements (FGM, PD, AL) before and immediately after the suturing, and at 1,2,4 weeks and 3, 6 months. The distance from the base of the stent to the free gingival margin and to the base of the pocket were measured. Antibiotic was given 1 hour before surgery and continued for 5 days. Sutures were removed at 1 week and dressing was replaced. Results at 3 and 6 months after surgery were reported.
R: Gingival &oral hygiene indices: There was a progressive SS decrease in the gingival index scores from the pre-surgical to the 6-month post-surgical assessment for both groups. Six months after surgery, the oral hygiene index had decreased significantly for the continuous suture group from a pre-surgical level of 0.60

0.46 to 0.43

0.31. The interrupted suturing group had a smaller decrease in the oral hygiene index from a pre-op mean score of 0.71

0.46 to a mean score of 0.63

0.34. Pocket depth: The reduction in pocket depth at each treatment site was statistically significant for both groups. The mean overall pre-surgical pocket depth was 2.57mm in the continuous suturing group and 2.67 for the interrupted suturing group. There was no significant difference between the two groups. At 6 months after surgery, the mean pocket depth was 1.59mm for the continuous suturing group and 1.54mm for the interrupted suturing group. Recession: The differences from the pre-surgical levels were statistically significant. At 6 months, the mean recession score for the continuous suturing group was 1.35mm and for the interrupted suturing group it was 1.38mm. The difference was not statistically significant. Bone loss: Loss of supporting bone was considered to have occurred when the distance measured between the base of the stent and the base of the pocket (post-surgically) was equal to or greater to the distance measured between the base of the stent and the crest of the alveolar bone at the time of the surgery. The number of recordings indicating bone loss was greater for the continuous suturing group at 3 months after surgery than for the interrupted suturing group. At 6 months, they were almost identical. Postsurgical clinical assessment: Each of the suturing techniques resulted in primary closure. At 3 and 6 months after surgery it was not possible to distinguish one surgical site from the other.
BL: According to parameters evaluated in this study, NSSD was found between interrupted and continuous suturing techniques. However, the overall clinical impression was that interrupted suturing provided better flap adaptation.

Pini Prato 1987 ARTICLE
Background: Fibrin sealing system is a kit consisting of 5 units: 1) lyophilized Tissucol (fibrinogen, factor XIII, fibronectin , PDGF, plasminogen, antiplasmins) 2)aprotinin 3) thrombin 4) calcium chloride 5) distilled water. The combined effect o the substances contained in the kit provides prompt hemostasis, prolonged stability of the coagulum with firm and persistent adhesion and quicker wound healing.
Purpose: To test the fibrin glue vs silk sutures from biological and clinical standpoints.
Materials and methods: 51 patients 9-63 years, 22 males and 29 females took part in the study and had the same procedure performed in both sides (split mouth design).

At the time of the surgery the following data were collected: time needed for the preparation of the Tissucol including all phases (mixing, heating, preparation of the special syringe), time needed for the preparation, sterilization and storage of the instruments required for suturing, time needed to fix the flaps of grafts by using glue or sutures, persistence of bleeding after 1 and 5 min and amount of Tissucol used.
7 days later the time required to remove the sutures was measured and patients were examined for edema, color of tissues and were required to report differences in pain between two sides. 14 and 21 days post-op sites were re-evaluated.
Results: Time needed to prepare the fibrin-sealing system ranged from 10-16 minutes. Time needed for the sutures was 9-10 minutes. Sterilization of suturing instruments needed 20min while time to open or store the Tissucol kit was negligible.

Bleeding subsided quickly after application of Tissucol than after suturing. Tissues were always attached to the underlying layer 5min after the application of Tissucol but were still movable 5min after suturing completion.
Most patients did not notice any difference between two sides. Red halo arounf sutures was usually present at day 7.
No differences were observed at days 14 and 21.

Conclusions: 1) Fibrin glue is easier and quicker to use than sutures
2) Fibrin glue provides better early hemostasis and a complete adhesion of the whole surface of the tissues to the underlying layer.
3) Sutures cause inflammation around themselves and Tissucol enhances early wound healing.
4) Fibrin-sealing system is effective as a means of fixing tissues after periodontal surgery.

Tibbetts 1998 No ARTICLE
Periodontal microsurgery defined: refinements in existing basic surgical techniques made possible by use of surgical microscope. Why we need it: periodontal surgical procedures “demand clinical expertise that challenges the technical skills of periodontists to the limits of and beyond the range of visual acuity. Forms of Loupes: Simple, Compound, and Prism. Prism>Compound>Simple. Loupes vs. operating microscope: loupes are less cumbersome, expensive and have an easier learning curve. Microscopes have a greater operator eye comfort, variable magnification, excellent illumination and ability for still or video camera.
Mucogingival surgery Px’s are technique and operator sensitive and therefore tend to have varying therapeutic results. Microsurgery techniques and training allow for more consistent treatment outcomes. Microsurgery improves reliability of gingival grafting procedures- esp correction of Miller Type I and Type II defects- making them ‘extremely predictable.’
Flap margins and closure are best controlled with a uniform thickness flap w/ scalloped butt-joint margin- allows for precise adaptation of tissue to teeth or apposing flap.

What are the advantages and disadvantages of using surgical dressings?

Jones 1979             ARTICLE
P: To compare clinical and histological results after periodontal flap surgery with and without surgical dressing and to subjectively evaluate postoperative comfort.
M&M: 7 patients, ages 40-62, first went through initial therapy (OHI, root planning, occlusal equilibration) then 20 quads of external bevel FTAP flaps were performed. Quads were randomly selected to either have a non-eugenol dressing (Coe-Pak) or no dressing. GI, fluid index, inflammatory index, PD and pt comfort was evaluated at 16 weeks post op.
R: NSSD in the gingival fluid, GI, sulcus depth, and inflammatory index between the areas with dressing vs. the areas without dressing. 5/7 patients said they experienced more discomfort or pain when the dressing was used than when it was not used. One patient said he preferred no dressing because the dressing gave the feeling of having a foreign material in the mouth. When asked which the patients preferred, most stated that they preferred no dressing.
BL: Results showed no difference in parameters between quadrants where periodontal dressings were used or were not used following surgery. Pts reported more pain and discomfort when the dressing was used. Results suggest that surgical dressing serves no useful purpose when periodontal flap surgery is performed.

Checchi, 1993             ARTICLE
P: To evaluate a patient’s pain experience and discomfort with and without the use of periodontal dressing in conjunction with 0.2% CHX after APF procedure.
M&M: 24 patients with mean age 44.2y, 2 bilateral sites with similar periodontal involvement. Pre-op OHI, SRP, Occlusal equilibration. Sx: osseous with APF when pt plaque control≤20%. Periodontal pack was either placed or not placed. All Pts rinsed t.i.d. with 0.2% CHX for the 1st post-op wk. No antibiotics. Pts instructed not to take analgesics unless absolutely necessary. Pain assessment was done after 1 wk and OH in area of sx started. After 1 month the second flap procedure was performed. The site in Pt’s previously Treated with dressing was left uncovered and vice versa. Pts filled a questionnaire at the completion of the study.
R: NSD between dressed and undressed sites. NSD in mean pain scores between CHX with dressed and undressed sites. NSD in total analgesic consumption. 2 pts reported not needing any analgesic for the whole period and most did not use any after day 2. Eating difficulty was reported by all Pts. 79% of the Pts reported a psychological feeling of protection and well being when the surgical site was packed.
BL: Pain with and without a dressing are statistically equal when 0.2% CHX is prescribed. Most patients reported a feeling of protection and well being when the pack was used.

Powell 2005:                 ARTICLE
P: Retrospective study on the prevalence of post-surgically infection and the relationship b/w diverse tx variables and infection rates.
Methods:
395 pts (ASA I, II) with 1,053 fully documented surgical procedures. Surgical techniques reviewed included Oss Sx, flap curettage, distal wedge, gingivectomy, root resection, GTR, DI, FGG, SCTG, CPF, sinus augmentations, ridge preservation and augmentation procedures. Infection was defined as increasing and progressive swelling with the presence of suppuration. The impact of various tx variables (like the use of bone grafts, membranes, soft tissue grafts, post-surgical CHX rinses, systemic antibiotics, and dressings) were analyzed.
R:
-22 infections developed out of 1053 surgeries, for an overall prevalence of 2.09%. 73% were in the mand and 27% in maxilla. (NSSD)
- Pts who received antibiotics (pre- and/or post-surgically) developed infection in 2.85% of the surgical sites vs. 1.81% of sites where antibiotics weren’t used.
-NSSD b/w infection rate and any specific treatment.
-NSSD b/w increased risk of infection using bone grafts or membranes vs. sites where weren’t used.
- Sx in which CHX was used during post-surgical care had a lower infection rate (1.89%) compared to procedures after which CHX was not used (3.27%). (NSSD).
- Use of post-surgical dressing showed a slightly higher rate of infection
(2.67%) vs. non-using a dressing (1.86%). (NSSD).
-Highest infection rate was after FGG (5.88%), followed by GBR (4.0%) and SCTG (3.66%). (NSSD).
C: Postoperative infection following perio sx is rare. Although perioperative antibiotics are commonly used when performing certain regenerative and implant surgical procedures, data from this and other studies suggest that there may be no benefit in using antibiotics for the sole purpose of preventing post-surgical infections.
BL: Use of antibiotics just to prevent post-sx infection may NOT be justified.

What instructions should a patient be given following surgery? How should postoperative instructions be written and communicated?

George, 1982             ARTICLE
P: to demonstrate the importance of psychological factors which can affect aspects of post-sx recovery
Discussion: A review of various studies from both in-pt & out-pt oral surgery that demonstrate that psychological factors are related to post-sx recovery.
Anxiety
- Phycological stress can have many physical consequences, ranging from increased sympathetic-adrenomedullary activity to increased susceptibility to disease
- Pts with higher levels of anxiety before surgery had more postsurgical pain
Coping behavior and style
- Refers to the way in which a pt copes or deals with the stress of surgery
- Avoiding or Vigilant coping behavior
- Vigilant behavior showed poorer recovery, probably due to greater stress
Locus of control
- Refers to the amount of control that people believe they have over events in their own lives.
- Internal (we control) or External (fate, luck, or powerful others)
- Internal locus of control did less well and had more interference with activities and slower healing, probably due to the feeling of lack of control producing more stress
Psychological interventions
- Hypnosis: pts who were hypnotized presurgically needed less pain medication and were discharged from the hospital sooner than the controls
- Information and coping techniques: Improvement through preoperative encouragement and instruction. Giving information alone was not found to be an effective preparation technique.
Dentists should give the sx a more positive meaning, improve pt’s acceptance of their condition, make pt expectations more positive, & reducing anxiety about recovery. The best preparation techniques include giving positive suggestions & teaching coping techniques. The literature is not conclusive on varying the type of preparation to fit the personality traits of pts.
BL: Dentists should give positive suggestions and teach coping techniques. If you make the surgery more positive then the patient will associate it with a more desirable outcome. Some pts may need more attention than others based on personality traits.

Croog 1994             No ARTICLE
Purpose: To describe the effects of two types of messages, control enhancement (CE) and positive affect enhancement (PAE), on post-surgical responses, including pain, psychological characteristics and life activity.
M&M: 42 female patients with moderate-severe periodontitis and scheduled for 2 or more sessions of periodontal surgery were included, but with no previous experience with this therapy. The effects of CE and PAE alone, and in combination were compared with a neutral control group. Patients were randomly assigned to one of the 4 groups. The intervention consisted of slide-tape materials presented to the patients in their own homes. CE is about talking to the patients regarding what they can do to prevent or reduce the pain. PAE is to emphasize on the benefits of the therapy, that actually overweigh any cost or trouble that the treatment itself may include.
R: The CE and the control group differed from the PAE group in reporting SSD of fewer days of pain. In regard to other indirect, postoperative pain measures, comparisons between the 4 groups showed NSSD in cross-sectional analysis after either surgery I or surgery II. The data in this study suggest that the CE messages in repetition and in combination with the previous experience of coping with discomfort after surgery may have more salutary effects than a single message before a 1st surgery.
Conclusion: The periodontist may help reduce discomfort in the post-Sx period through standardized preparatory messages and use of audiovisual methods. These methods were associated with reduction of pain after the 2^nd surgery and with no effect after the 1^st surgery.

Coulthard, 2000             ARTICLE
P: To investigate the validity of using behavioral measures to provide info about a patient’s experience of pain during early stages of recovery from oral surgery under general anesthesia, and to examine the relationship between pre-op anxiety and post-op pain measured immediately after the operation.
M+M: 64 patients (28M, 36F, ages 18-60) who were to have 2 impacted mandibular third molars removed. Operations were carried out under general anesthesia. All patients were ASA I or II. All patients completed an anxiety VAS(visual analogue scale), half completed a McGill Pain Questionnaire, half completed a pain VAS. All patients completed an anxiety VAS 2 hours post-op. Half completed pain VAS and half completed McGill pain questionnaire at 2 hours post-op or at time of request of analgesia.
R: Only weak associations were found between preop or post op anxiety and post operative pain. Preoperative anxiety and postoperative VAS pain, r=0.40; postoperative anxiety and postoperative VAS pain, r=0.29; preoperative anxiety and postoperative MPQ pain, r=0.17; and postoperative anxiety and postoperative MPQ pain, r=0.38.
Significantly more women than men showed signs of pain despite the little difference in self-rating pain scores. The quality of pain was described differently between the two sexes.
BL: While clinicians may build a better picture of a patient’s pain experience by including behavioral observations in their range of assessments of pain, they should not rely on behavior observations when making a judgment about the degree of a patient’s post op pain and need for analgesia.

Eli 2000             ARTICLE
P: To evaluate the effect of gender and anxiety on pain prediction and pain memory under periodontal surgical treatment.
M&M: 37 pts (15 men/22 women) that were under treatment by senior dental students participated in the study. Patients were scheduled for single tooth crown lengthening surgery by a periodontist (senior faculty member). Patients were evaluated during 4 consecutive appointments: at initial check-up, immediately pre-op, 1 week post-op, and at 4 week post-op follow-up. Pts completed questionnaires concerning their dental anxiety on a scale-DAS (rated from 5-20) as well as on a VAS of 0 (not afraid at all) to 100 (terrified). Also, at each appointment they completed evaluations concerning pain on a 100mm VAS ranging from 0 (no pain) to 100(worst pain imaginable). Evaluations concerning expectation to experience pain during the planned surgery (pain prediction) were made at the first two appointments and evaluations of the experienced pain as remembered from the surgery (pain memory) were made at the last two appointments.
R: Mean score on DAS was 8.9, while high dental anxiety is considered a score of 13 and up. There was a significant increase in anxiety between initial exam and immediate pre-op appointment. Women constantly scored higher in their state anxiety but no significant interaction between gender and the changes occurring in subjects’ anxiety over time could be detected. Significant correlation was found between anxiety and pain prediction and long-term pain memory (four weeks post-op). Gender had a significant effect on pain prediction and pain memory. Women predicted less pain than men prior to surgery, but reported remembering more pain post-surgery than men. Men expected to feel more pain at the consult and pre-op, but remembered less pain after surgery.
BL: Cognitive pain perception in clinical situations differs between genders.

Touyz 1998             ARTICLE
Purpose: To determine wether telephone consultation influenced patients’ perception of and reaction to pain after periodontal surgery.
Materials and methods: 118 patients who presented the McGill University Division of Periodontology between 1991-1995 were admitted to the study. Inclusion criteria: moderate to severe periodontal disease, periodontal surgery for pocket reduction or preprosthetic surgery, systemic health, no history of mental disease, 30-70 years of age, no medication for at least 1 month prior to the procedure. Patients in the control group (59) were not called (NC) and in the experimental group patients (59) were called (PC).
Written post-op instructions were the same for all patients. An antiseptic mouthwash 12 analgesic tablets were prescribed. Patients were ignorant as to whether they would be called the next day, and they were unaware the a phone call was part of a clinical research.
Patients were called no later than 24 hours after surgery. The telephone interviewer inquired about 10 points: well being of patient, return to normal and loss of analgesia, jaw swelling, wound bleeding, pain, acquisition and use of th mouthwash and analgesics, need for a soft balanced diet, necessity of sustained oral hygiene, confirmation of next week’s apt ad reassurance with consolation about the reaction and pain. 1 week later at the post-op visit patients completed a form about the pain level and how many pain tablets were used.
Results: Groups were age- and sex-matched. Number of teeth involved in the procedure and the types of operations performed in each group were not statistically different. Subjective report of pain intensity scores was significantly reduced in the PC group. Number of pills used was significantly higher in the NC group. There was a significant positive correlation between pain intensity and the number of analgesics tablets consumed in both groups.
Conclusion: Post-op pain can be attenuated and made more tolerable thourgh psychologic support and communication with patients after surgical procedures.

Alexander, 1999             ARTICLE
Purpose: To examine the patient comprehension and need for written reinforcement of verbal instructions and to present ideas about a “more ideal” post-op instructions form to better serve the surgery patient.
Discussion:

BL: Patient education after surgery improves patient satisfaction and reduces morbidity. Providing only oral instructions is relatively ineffective. Using both verbal & written communications is the most effective way to increase patient understanding and compliance, and assure the optimal outcome. Materials should be written in a way that even a 6^th- to 8^th-grade level patient can understand.

What type and dosage of pain and or anti-inflammatory medications are effective?

Pearlman 1997 ARTICLE
Purpose: To test the efficacy of a non-steroidal anti-inflammatory agent, ibuprofen in pain control following periodontal surgery, when administered pre- and post-operatively.
Materials & Methods: 127 patients participated in a multi-center study. Patients who were to undergo periodontal surgery were randomly given either 2 tablets of 200 mg ibuprofen or 2 matching placebo tabs at least 30 minutes before administration of local anesthesia. The procedure was double blind: neither the patient nor the clinician was aware of the tablet identity. Post-op, all patients were given labeled ibuprofen for pain relief, but were randomly divided into 2 groups: As directed, who were instructed to take the drug regularly (1 tab every 4hours) for two days post-op, and As required, who were instructed to take the drug only if needed for pain relief. All patients completed a diary recording quantity and time of medication, and regular assessment of pain experience utilizing the Visual Analogue Scale (VAS), (First onset pain, Time when medications was taken, at 1, 2, 5, 9 hours after surgery, and at bed time). Age, sex and mass of patients were of normal distribution. Time for each surgery was recorded.
Results: The As directed group showed no significant difference in pain experience between pre-op and post-op only medication. The “As required” group experienced significantly less pain and requirement for medication if the ibuprofen was administered pre-op. 62% of the placebo group required medication at first onset of pain vs. 28% of the ibuprofen group. Some adverse effects were gastro-intestinal disturbance or headache.
BL: Ibuprofen appears to be more effective in limiting pain following periodontal surgery if administration is begun some time prior to procedure.

Tucker, 1996 ARTICLE
P: To compare the therapeutic utility of a typical etodolac regimen (NSAID) to a typical regimen using acetaminophen with hydrocodone for relief of postoperative periodontal discomfort.
M&M: 24 patients needing osseous surgery were randomly assigned to etodolac or the combination product group. The surgeon was unaware of the regimen assigned to the subjects. A questionnaire was given to each patient that asked to rate discomfort present at hourly intervals for the first 8 hours after the start of the surgery as well as side effects hourly for the first 8 hours and throughout the week. In addition subjects were requested to indicate the time when post-surgical medication was taken as well as the number of medications taken. The surgical procedures were similar for all patients. Local anesthesia was given via infiltration and nerve blocks, inverse bevel incision, reflection of FTF, removal of granulation tissue, osseous recontouring, apical positioning of the flap, suturing with 4-0 silk sutures and placement of periodontal surgical dressing were performed. The subjects were given either etodolac 300mg (10 tabs) or acetaminophen with hydrocodone (10 tabs) and were instructed to take the medications as needed for post-op discomfort. Patients receiving etodolac received a 600mg oral dose 30min prior to surgery and were told they could take 1 tab every 6-8 hrs. Those taking acetaminophen were not premedicated and were told they could take 1 or 2 tabs every 4 to 6 hours. A post-op appointment was scheduled one week after surgery to remove dressing and sutures and collect the reporting forms.
R: All patients response ranged from 1-4 score (1=no pain, 2=mild, 3=discomforting, 4=distressing). No subjects reported 5 (horrible).The time span from 30 min prior to the beginning of the surgery to the first postsurgical dose was greater for etolodac (358

77min) than for the combination drug (269

46). However, the total number of medication taken for both regimens was similar (0-10). Only 5 patients experienced side effects. 3 under the combination drug regimen had one complaint each: headache, constipation and lightheadedness. The headache was not due to the drug regimen since it was reported hours prior to the first dose of the combination drug.Two patients in the etodolac group complained of drowsiness.
BL: The analgesic regimen of etodolac was comparable to acetaminophen with hydrocodone, with minimum side effects in uncomplicated periodontal osseous surgery. Studies with larger numbers of patients are needed to evaluate if they are truly equivalent.
Cr: Not equal study design. Patients in the group with etodolac were premedicated.

Ahmad, 1997             ARTICLE
P: To examine the evidence for the efficacy of non-opioid analgesics in the dental pain model by conducting a meta-analysis.
M+M: A literature search from 1975 to 1996 using the terms: pain, analgesics, and dentistry. 294 articles were reviewed, 32 articles on 33 studies met the inclusion criteria: placebo control, randomized, double-blind trial, third molar extraction pain model, pain scales similar to Cooper and Beaver, at least one nonopioid (acetaminophen or NSAID) administered orally only, postoperative use of at least one nonopiod only, no steroid, no slow or controlled release administration, single-dose data, moderate to severe baseline pain, results reported for at least 6 hours post-op in numerical format and side effects reported. Pain scale results (pain intensity / pain relief) were transformed into a common percent scale and converted to N-weighted means. This allowed calculation of the mean effect of a treatment from several studies and weighed each study according to its sample size.
R: Therapeutic doses of the nonsteroidal anti-inflammatory drugs (NSAIDs) were significantly more efficacious than the combination of acetaminophen (600 or 650 mg) with codeine (60 mg). Specific doses of the NSAIDs – diflunisal (500-1000mg), flurbiprofen (100mg), ibuprofen (400mg), and ketorolac (10-20mg) were significantly more efficacious than the commonly used acetaminophen-codeine combination.
C: Support the validity of the recommendations advocating the use of NSAIDs. NSAIDs may be more efficacious than the acetaminophen-codeine combination for relief of postoperative dental pain.

What are the advantages and disadvantages of local anesthesia?

Buckley 1984             ARTICLE
Background: The safe arbitrary max dose of epi in a healthy pt is 0.2 mgs which is 10 ml of 1:50.000 (5.5 carpules) or 20ml of 1:100.000 (11.1 carpules).
P: To compare lidocaine 2% with 1:50,000 epi and 1:100,000 epi on blood loss in perio flap sx.
M&M: 10 pts after phase one treatment, 20 sx sites treated w/ lidocaine HCL (Xylocaine) 2% (10 sites w/1:50,000 & 10 w/ 1:100,000). B/f sx: bleeding time, baseline BP, PD & gingival index of Loe were obtained. Blood was collected using a portable suction unit and 2X2 sterile gauze. Gauze was rinsed a minimum of at least three times to retrieve absorbed blood. Blood loss was determined by cyanmethemoglobin comparison technique within 6 hours of the surgery. Blood pressure was taken again after the procedure.
R: The longer the sx procedure was the more blood that was lost. Pt’s who received 1:50k epi had considerably less blood loss.
50% of the 1:100,000 grp lost >140ml of blood.
None of the 1:50,000 grp lost >140ml of blood.
D: bleeding clotting and prothrombin times should be routine in pts w/ suspect of bleeding tendencies, even though these times can be w/in normal limits in a person who bleeds profusely. Heparin or aspirin could impair platelet function and prothrombin formation. Caution should also be taken when using epi on patients with heart conditions as well as hyperthyroidism patients.
BL: 1:50,000 epi causes less blood loss than 1:100,000 epi in perio flap sx.

Linden, 1986             ARTICLE
Purpose: To compare the use of 0.5% bupivacaine with epi 1:200,000 to 2% lidocaine with epi 1:100,000 during and following perio surgery and to evaluate differences in postoperative (PO) pain, PO analgesics needed, and total time of numbness experience by the patient.
M&M: Double blind split-mouth study. 20 patients included. Periodontal surgeries were standardized with 1 operator to minimize differences in difficulty, extent and time. Patients told to take no pain medications until absolutely needed. Post op pain measured on VAS at 0, 2, 4, 6, 8, 10, 12, and 24 hours during the observation period following surgery.
Results: When bupivacaine was used there was less perception of post-op pain (SS), fewer number of analgesics tablets taken (bupivacaine group took 2.8 tablets compared to 4.3 for the Lidocaine group and this was also SS), and a longer period of “numbness” (mean time of 5.9 hrs for the bupivacaine group. as compared to 3.9 hours for the lidocaine group, this represents 51% increase in the duration of “numbness” and was also SS). There was NS correlation between “numbness” and pain perception and NSD in the onset of anesthesia. Clinically, the bupivacaine group demonstrated more bleeding during surgery, thus less visualization. 74% of the patients preferred bupivacaine for future surgeries.
BL: Use of bupivacaine results in less post op pain and a “greater length of time of numbness”, and less use of post-op analgesics compared to lidocaine with epi 1:100,000. However, more bleeding during perio procedure was observed.

Ahn, 1998             ARTICLE
BG: The dental pulp is a low-compliant system which is a terminal channel and particularly sensitive to insults. Gingival tissue has more collateral circulation so will probably be less affected by the effects of vasoconstrictor.
P: To monitor pulpal and gingival blood flow changes using laser Doppler flowmetry after injection of 2% lidocaine with 1:100,000 epinephrine.
M+M: 10 subjects (8M, 2F, 23-36 years of age) with 1 healthy, unrestored maxillary 1^st premolar. Pulpal and gingival blood flow was measured at baseline, 5, 10, 20, 30, 45, 60 min (pulp) and 8, 15, 25, 35, 50, 65 min (gingival) after injection using the Doppler flowmeter. Negative controls: endodontically treated teeth, Controls: 3 volunteers with 1 vital central incisor and 1 endo treated central.
R: After injection, there was significant reduction in pulpal (73%) and gingival (51%) blood flow in all patients. Although it did steadily increase over time, blood flow had not returned to baseline at 1 hour. Pulpal reaction was more rapid and profound than gingival.
BL: 2% lidocaine with 1:100,000 epi, SS reduced both pulpal and gingival blood flow. The pulpal blood was reduced to a greater degree, which may have adverse effects on pulps under certain conditions.

Ganzberg 2001             No ARTICLE
P: To review Local Anesthetics (LA) and vasoconstrictors (VC).
D: Primary intention of local anesthetic is to interrupt neural transmission reversibly, minimizing CNS recognition of noxious stimulus. The blockage of the Na⁺ channels inhibits nerve conduction.
The most commonly used local anesthetics belong to two main categories: Esters and Amides. Esters are metabolized by plasma esterase, while amides are hepatically metabolized .
Adverse effects:
1. CNS: Low concentrations of LA can cause drowsiness, whereas high blood levels can cause excitation, dizziness, visual and auditory disturbances, and muscle twitching. Possible to have seizures.
2.Cardiovascular: LA exert variable effects on the peripheral vasculature and the cardiac conduction system. Lidocaine is used to treat and prevent ectopic ventricular impulses. Highly lipophilic agents (etidocaine and bupivacaine) are cardiotoxic and can cause depression of myocardial contractibility.
Drug interactions:
1) lidocaine + cimetidine (Tagament): decrease of lidocaine metabolism, so high doses of LA can induce toxic level of lidocaine in the blood
2) lidocaine or etidocaine + B-blockers: decrease of LA metabolism with the same results.
Allergic reaction may be accounted for the addition of an antibacterial agent or sulfites to some solutions. There are some patients at risk: those that have shown sensitivity to sulfites; patients with asthmatic symptoms with sulfites, or poorly controlled asthma patients.
Vasoconstrictors: are added to LA solutions to retard diffusion of LA away from the site of injection and to cause local VC, which increases LA concentration and efficacy by retarding diffusion.
Drug interactions with vasoconstrictors:.
1.Tricyclic and non-tricyclic antidepressants: Unwanted hypertension
2. Adrenergic neuron blocking drugs: Hyper-dynamic CV responses.
3. Patients with CV diseases: The degree and type of CV disease are as important as the type and quantity of VC used, if any. The increase of epinephrine plasma levels can last up to 30 minutes and may cause an increase in myocardial oxygen demand. Current recommendations suggest administering no more than the equivalent of 2 dental cartridges of LA with 1:100,000 epinephrine or 1:20,000 levonordefrin to a patient with CV compromise.
-This article explains in depth the mechanism of action of local anesthetics

Pre Surgical Evaluation

Nery 1987             ARTICLE
Purpose: To investigate the prevalence of medical problems in the periodontal patients.
Materials and methods: Four periodontists collected data from their files (2 private practice, 1 from Marquett Uni dental school and 1 from VA Medical Center). Age, sex and medical problems were recorded.
Results: Medical – dental records from 581 patients were obtained.
Prevalence of medical problems was 27.6% for patients in private practice, 46.3% in the Dental School and 74.1% in the VA Hospital. There were more patients with medical problems (52.8%) than without but the difference was not statistically significant.
Cardiovascular disease (HTN, hypotension, congenital heart defects, mitral valve prolapse) was the most prevalent condition (26%).
Orthopedic problems were the 2^nd most common condition (10.8%).

No difference was observed between genders but age was a highly significant factor. Private practice had more patients in the 41-60 age range and fewer in the 60-90 age group.

Ho, 1997 ARTICLE
Purpose: To determine the reliability of a self-reported health questionnaire (SRHQ) and examine the potential response bias, if any, from 2 separate subjects reports of the same questionnaire.
Materials and methods:

BL: The overall substantial level of agreement and correlation b/t the 2 reports indicated that reliable info can be obtained from SRHQ.

Thompson, 1999 ARTICLE
P: to compare the findings of a self-reported medical history with laboratory results of 39 patients reporting to a dental office.
M&M: 39 consecutive patients (21M and 18F with an age range 30-69 years) were referred for a periodontal evaluation. Patients completed a medical questionnaire and an oral interview and were sent to a hospital laboratory for urinalysis, complete blood count (CBC), and a standard blood chemistry panel. Results were compared to the normal ranges reported by the hospital laboratory.
R: The self-reported medical history responses were compared with the laboratory data and several abnormalities were noted. The results of self-reported questionnaire showed: 21/39 patients (56%) reported a positive history in at least one medical category. Patients reported 9 entries for both cardiovascular disease and drug allergies, 6 in musculoskeletal system, 4 in respiratory and systems, 2 in the renal/urinary and liver system, 1 in the endocrine category and 0 in the central nervous system or substance abuse areas. 17/39 patients (44%) were smokers. The laboratory results showed several unexpected findings and one was in blood glucose levels. None of the patients reported a history of abnormal blood glucose values but 6 (15%) abnormal values were found. Another unexpected result was that only 2 (5%) of the patients reported a history of abnormal cholesterol, while the laboratory results demonstrated that 26 (67%) of the patients had elevated cholesterol levels. In addition 33% of the patients had increased triglyceride levels. Also, the results showed increased percentage of eosinophils (18/39, 46%) and monocytes (10/39, 26%). Smokers (17/39, 44%) had a higher number of abnormal levels or percentages of cholesterol, triglycerides, basophils, lymphocytes, eosinophils, and monocytes. Gender differences were seen in elevated triglyceride levels (10 males-2 females), the few patients with abnormal levels of AST and ALT were men, monocytes tended to be elevated more in males (7) than females (3) and females tended to have more eosinophil abnormalities (10 females, 8 males). In the section for self-reported medical history all 9 of positive entries for cardiovascular disease were men.
CL: This study demonstrated that many patients are unaware of their current medical status and a significant number had undiagnosed abnormalities. This is particularly true with those medical conditions which may produce minimal symptoms in the early stages.

Rapid Search Terms
Antibiotic coverage for periodontal surgery	Infection control
Anatomic considerations	preop information to consider before surgery
Common post surgical complications and management	Sutures and suturing techniques
Surgical dressings- advantages and disadvantages	Post operative instructions- what and how to give them
Postoperative analgesics and anti-inflammatory agents	Local anesthesia
Pre Surgical Evaluation