Gingival Curettage

 scraping of the gingival wall of a periodontal pocket to separate

diseased soft tissue.

Gingival curettage
 removal of the inflamed soft tissue lateral to the pocket wall.

Subgingival curettage
 procedure that is performed apical to the epithelial attachment,
severing the connective tissue attachment down to the osseous crest.

Inadvertent curettage
 curettage is done unintentionally when scaling and root planing is
performed.
 Rationale
 removal of the chronically inflamed granulation tissue that
forms in the lateral wall of the periodontal pocket.
 the need for curettage just to eliminate the inflamed granulation
tissue appears questionable.
 Indications
 as part of new attachment attempts in moderately deep intrabony
pockets located in accessible areas where a type of "closed“
surgery is deemed advisable.
 as a nondefinitive procedure to reduce inflammation prior to
pocket elimination using other methods.
 in patients in whom more aggressive surgical techniques (e.g.,
flaps) are contraindicated owing to age, systemic problems,
psychologic problems, and so forth.
 performed on recall visits as a method of maintenance treatment
for areas of recurrent inflammation and pocket depth.
 Procedure
 preceded by scaling and root planing.
 Under LA.
 The curette is selected so that the cutting edge will be against
the tissue.
 The instrument is inserted so as to engage the inner lining of the
pocket wall and is carried along the soft tissue, usually in a
horizontal stroke.
 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 functional
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.
 The area is flushed to remove debris, and the tissue is partly
adapted to the tooth by gentle finger pressure.
 Sometimes suturing of separated papillae and application of a
periodontal pack may be indicated.
 Other Techniques - Excisional
New Attachment Procedure (ENAP)
 Developed by the U.S. Naval Dental Corps.
 It is a definitive subgingival curettage procedure performed with
a knife.

Procedure
 After adequate anesthesia, an internal bevel incision is made from
the margin of the free gingiva apically to a point below the
bottom of the pocket.
 The incision is carried interproximally on both the facial and the
lingual sides, attempting to retain as much interproximal tissue
as possible.
 Remove the excised tissue with a curette, and carefully root
plane all exposed cementum to 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
 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.
 ultrasonic instruments are as effective as manual instruments
but resulted in less inflammation and less removal of underlying
connective tissue.
 The gingiva can be made more rigid for ultrasonic curettage by
injecting anesthetic solution directly into it.
Caustic Drugs
 chemical curettage of the lateral wall of the pocket or the
selective elimination of the epithelium.
 sodium sulfide, alkaline sodium hypochlorite solution
(Antiformin), and phenol.
 Disadvantages
 The extent of tissue destruction with these drugs cannot
be controlled.
 Increase the amount of tissue to be removed by enzymes
and phagocytes.
 HEALING AFTER SCALING AND CURETTAGE

 Immediately after curettage, a blood clot fills the pocket

area, which is totally or partially devoid of epithelial lining.
 Hemorrhage is also present in the tissues with dilated capillaries,
and abundant polymorphonuclear leukocytes appear shortly
thereafter on the wound surface.
 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
from 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.
 Several investigators have reported that healing results in the
formation of a long, thin junctional epithelium with no new
connective tissue attachment.
 Sometimes this long epithelium is interrupted by "windows" of
connective tissue attachment .
 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 owing to an
apical shift in the position of the gingival margin.
 The gingiva is also slightly redder than normal, but much less so
than on previous days.
 After 2 weeks and with proper oral hygiene by the patient, the
normal color, consistency, surface texture, and contour of the
gingiva are attained, and the gingival margin is well adapted to
the tooth.