DEFINITION
The term curettage is used in periodontics to mean the scraping of gingival wall of a periodontal pocket to separate diseased soft tissue.
Whereas scaling refers to removal of deposits from tooth/root surface and root planing means smoothening the root to remove infected and necrotic tooth surface.
TYPES
1. Gingival curettage: Consists of removal of inflamed soft tissue lateral to pocket wall.
a. Subgingival curettage: It is a procedure that is performed apical to epithelial attachment.
b. Inadvertant curettage: Curettage that is done unintentionally during scaling and root planing.
II. Surgical curettage, chemical curettage, ultrasonic curettage.
RATIONALE
The main accomplishment of curettage is the removal of chronically-inflamed granulation tissue that forms in the lateral wall of the periodontal pocket. This tissue apart from having its usual components like fibroblastic and angioblastic proliferations, also contains areas of chronic inflammation, pieces of dislodged calculus and bacterial colonies (Justification to curettage is more so from the fact that this granulation tissue which is lined by epithelium may hamper or act as a barrier for the attachment of new fibers).
The dilemma now is that, is it justified to do curettage, just to eliminate the inflamed granulation tissue? Because when the root is thoroughly planed, the major source of bacteria disappears and the pathologic changes in the periodontal pocket disappears without any need for curettage. Due to this existing granulation tissue also disappears, if any bacteria is present, is destroyed by defence mechanism due to their less number.
On the other hand curettage may also eliminate all or most of epithelium that lines the pocket wall and underlying junctional epithelium, though there are differing opinions regarding this, the purpose of curettage is still valid particularly in presurgical phase where there is persistant gingival inflammation even after repeated scaling and root planing.
INDICATIONS
1. Can be performed as a part of new attachment in moderately deep infrabony pockets located in accessi-
ble areas where a type of “closed surgery” is advised. 2. Can be done as a non-definite procedure to reduce inflammation prior to pocket elimination procedures like flap surgeries.
3. It can also be performed in patients where extensive surgical procedures are contraindicated like aging. systemic complications, etc. where the treatment is compromised and prognosis is impaired.
4. Curettage is frequently performed on recall visits as a method of maintenance treatment for areas of recurrent inflammation and pocket depth, particularly where pocket reduction surgery has previously been performed.
PROCEDURE
• Basic technique.
• Other techniques.
Curettage as such does not eliminate local factors like plaque and calculus, therefore it should always be followed by scaling and root planing procedures.
Basic Technique
After adequate local anesthesia, the correct curette is selected and adapted in such a way that the cutting edge is against the tissues. The instrument is inserted so as to engage the inner lining of the pocket wall and is carried along the soft tissue wall usually in a horizontal stroke. The pocket wall may be supported by gentle finger pressure on external surface.
In subgingival curettage, the tissue attached between the bottom of pocket and the alveolar crest is removed with a scooping motion of the curette to the tooth surface. The area is flushed to remove debris. If necessary sometimes sutures and a pack may be indicated. Other Techniques
ENAP (Excisional New Attachment Procedure)
It was developed by United States Naval Corps. It is a definitive subgingival curettage procedure performed with a knife.
The technique is:
1. After adequate local anesthesia, an internal bevel incision is made from margin of free gingiva apically below the base of pocket, it is carried all around the tooth surface, attempting to retain as much interdental tissue as possible.
2. The excised tissue is then removed with a curette and the root surface is planed to a smooth hard consistency.
3. Approximate wound edges if necessary, place sutures and a periodontal-dressing.
Ultrasonic Curettage
Ultrasonic scalers are used for ultrasonic curettage, here the ultrasonic vibrations disrupt tissue continuity, and the epithelium is lifted off. It also alters the morphologic features of fibroblast nuclei. This method has proved to be as effective as the manual method but results in decreased inflammation and less removal of connective tissue.
Caustic Drugs
Drugs such as sodium sulfide, Antiformin and phenol have been used to induce chemical curettage of the lateral wall of the pocket. Disadvantage is the extent of tissue destruction with these drugs cannot be controlled.
HEALING AFTER SCALING AND CURETTAGE
Immediately after curettage, a blood clot fills the pocket area, hemorrhage is also present in tissues with dilated capillaries and increase in polymorphonuclear leukocytes appear on wound surface. Rapid proliferation of granulation tissue occurs shortly thereafter with a decrease in the number of blood vessel. Restoration and epithelialization of sulcus takes place in 2 to 7 days.
CLINICAL APPEARANCE AFTER SCALING AND CURETTAGE
Immediately after curettage, the gingiva appears hemorrhagic and bright-red. After one week, the gingiva appears reduced in height with apical shift. The redness is slightly reduced. After two weeks, with proper oral hygiene the gingiva comes back to normal.