• Scaling in 2 appointments within 24 hours
• Tongue brushing with 1% chlorhexidine gel
• 0.2% chlorhexidine rinse
• 1% chlorhexidine pocket irrigation

Oral Hygiene Tools

Toothbrush Bristle Diameter:

• Soft: 0.007" (0.2 mm)
• Medium: 0.012" (0.3 mm)
• Hard: 0.014" (0.4 mm)

Brushing Techniques:

• Roll: Modified Stillman
• Circular: Fones
• Vertical: Leonard
• Horizontal: Scrub

Scaling Instruments

• Gracey curettes: Only outer cutting edge
• Universal curettes: Both edges cutting
• Langer curettes: Gracey shank + Universal blade
• Best grasp: Modified pen grasp (tripod effect)
• Scaling angle: 45 – 90°

Ultrasonic Scaling

• Vibration frequency: 18,000 – 50,000 cycles/sec

Stroke Types

• Exploratory: Light feeling (with probes)
• Scaling: Short powerful pull
• Root planing: Moderate to light pull

Concentration Requirements

• Minimum Effective: 0.12%
• Optimum Concentration: 0.2%
• Duration: Typically used for 2-4 weeks

Side Effects

• Staining: Yellowish-brown stains on teeth and restorations
• Taste Alteration: Temporary metallic taste
• Soft Tissue Irritation: Rare but possible

Delivery Systems

• Chip Degradation: 7-10 days for chlorhexidine chips
• Sustained Release: Provides extended antimicrobial effect

Classification of Cementum According to Schroeder

Cementum is a specialized calcified tissue that covers the roots of teeth and plays a crucial role in periodontal health. According to Schroeder, cementum can be classified into several distinct types based on its cellular composition and structural characteristics. Understanding these classifications is essential for dental professionals in diagnosing and treating periodontal conditions.

Classification of Cementum

1. Acellular Afibrillar Cementum:

   • Characteristics:
     • Contains neither cells nor collagen fibers.
     • Present in the coronal region of the tooth.
     • Thickness ranges from 1 µm to 15 µm.
   • Function:
     • This type of cementum is thought to play a role in the attachment of the gingiva to the tooth surface.

2. Acellular Extrinsic Fiber Cementum:

   • Characteristics:
     • Lacks cells but contains closely packed bundles of Sharpey’s fibers, which are collagen fibers that anchor the cementum to the periodontal ligament.
     • Typically found in the cervical third of the roots.
     • Thickness ranges from 30 µm to 230 µm.
   • Function:
     • Provides strong attachment of the periodontal ligament to the tooth, contributing to the stability of the tooth in its socket.

3. Cellular Mixed Stratified Cementum:

   • Characteristics:
     • Contains both extrinsic and intrinsic fibers and may contain cells.
     • Found in the apical third of the roots, at the apices, and in furcation areas.
     • Thickness ranges from 100 µm to 1000 µm.
   • Function:
     • This type of cementum is involved in the repair and adaptation of the tooth root, especially in response to functional demands and periodontal disease.

4. Cellular Intrinsic Fiber Cementum:

   • Characteristics:
     • Contains cells but no extrinsic collagen fibers.
     • Primarily fills resorption lacunae, which are areas where cementum has been resorbed.
   • Function:
     • Plays a role in the repair of cementum and may be involved in the response to periodontal disease.

5. Intermediate Cementum:

   • Characteristics:
     • A poorly defined zone located near the cementoenamel junction (CEJ) of certain teeth.
     • Appears to contain cellular remnants of the Hertwig's epithelial root sheath (HERS) embedded in a calcified ground substance.
   • Function:
     • Its exact role is not fully understood, but it may be involved in the transition between enamel and cementum.

Clinical Significance

• Importance of Cementum:

  • Understanding the different types of cementum is crucial for diagnosing periodontal diseases and planning treatment strategies.
  • The presence of various types of cementum can influence the response of periodontal tissues to disease and trauma.

• Cementum in Periodontal Disease:

  • Changes in the thickness and composition of cementum can occur in response to periodontal disease, affecting tooth stability and attachment.

Keratinized Gingiva and Attached Gingiva

The gingiva is an essential component of the periodontal tissues, providing support and protection for the teeth. Understanding the characteristics of keratinized gingiva, particularly attached gingiva, is crucial for assessing periodontal health.

Keratinized Gingiva

1. Definition:

   • Keratinized gingiva refers to the gingival tissue that is covered by a layer of keratinized epithelium, providing a protective barrier against mechanical and microbial insults.

2. Areas of Keratinized Gingiva:

   • Attached Gingiva:
     • Extends from the gingival groove to the mucogingival junction.
   • Marginal Gingiva:
     • The free gingival margin that surrounds the teeth.
   • Hard Palate:
     • The roof of the mouth, which is also covered by keratinized tissue.

Attached Gingiva

1. Location:

   • The attached gingiva is the portion of the gingiva that is firmly bound to the underlying alveolar bone.

2. Width of Attached Gingiva:

   • The width of attached gingiva varies based on location and can increase with age and in cases of supraerupted teeth.

3. Measurements:

   • Greatest Width:
     • Found in the incisor region:
       • Maxilla: 3.5 mm - 4.5 mm
       • Mandible: 3.3 mm - 3.9 mm
   • Narrowest Width:
     • Found in the posterior region:
       • Maxillary First Premolar: 1.9 mm
       • Mandibular First Premolar: 1.8 mm

Clinical Significance

• Importance of Attached Gingiva:

  • The width of attached gingiva is important for periodontal health, as it provides a buffer zone against mechanical forces and helps maintain the integrity of the periodontal attachment.
  • Insufficient attached gingiva may lead to increased susceptibility to periodontal disease and gingival recession.

• Assessment:

  • Regular assessment of the width of attached gingiva is essential during periodontal examinations to identify potential areas of concern and to plan appropriate treatment strategies.

• Chlorhexidine:
  • Minimum: 0.12%; Optimum: 0.2%.
  • Chip degrades in 7 – 10 days.
• Floss & Brushes:
  • Preferred floss: Unwaxed thin.
  • Floss length: 12 – 18 inches.
  • Toothbrush: 2 – 4 rows, 5 – 12 tufts per row.
  • Soft bristle diameter: 0.2 mm.
• Powered Brushes: Invented in 1939; use oscillating/rotating motion.
• Fones Technique: Circular brushing method.
• Antiplaque Agents:
  • Bisbiguanides: 2nd generation.
  • Pyrophosphate: Inhibits calculus formation.

• Bence Jones Proteins: Mostly gamma chains
• Commonest lytic lesion site: Vertebral column
• Russell bodies: Found in plasma cells
• Bone scan not useful
• No ALP elevation
• High ESR: Often seen
• Prognostic marker: Beta-2 microglobulin