Subgingival Scaling with Root Planing and Curettage: Effects upon Gingival Inflammation: A Comparative Study

to compare these effects to those obtained when the same patients are submitted to subgingival curettage. In this study, a problem raised by other authors and which to date has not been answered, was considered: " A r e the results obtained in the initial preparation of periodontal treatment (oral hygiene, scaling and root planing) as effective as those obtained with the same procedures, though supplemented by curettage? In other words, is curettage justified to eliminate gingival inflammation so as to accomplish retraction of the gingiva? 4

by NESTOR J . LOPEZ*

MATERIALS AND METHODS

Thirteen patients from the Clinica of Periodontics of the University of Chile, School of Dentistry, were cho­ sen. The clinical histories of these patients did not show any systemic diseases and they all had marginal perio­ dontitis with suprabony pockets 3 to 4 mm deep. Complete radiographic examinations and study models were performed. Clinical histories were taken in each case and the depth of the gingival sulcus on all four sides of each tooth was measured using a G o l d ­ man-Fox Williams probe. The clinical crown was also measured on four sides of each tooth. A functional examination of the occlusion to preclude the existence of traumatogenic factors was performed. In each patient an ultrasonic dental unit (Ultrason model 880) was used to remove supragingival calculus, and the dental crowns were cleaned with rotary brushes and fine grain polishing paste. A l l patients were instructed to keep their teeth free from dental plaque by using Charter's brushing technique and a disclosing solution. A t this stage, three patients were excluded as they did not cooperate fully to accomplish adequate control of the formation of dental plaque. The study group was now down to 10 patients, eight women and two men. Their ages ranged between 24 and 51 years of age; the mean age was 32 years. A l l dental archs were divided into halves. The teeth in one half were treated with subgingival scaling and root planing alone whereas those in the other half were treated with root planing supplemented with gingival curettage. For both procedures M c C a l l numbers 13/14 and 17/18 curettes were used. The gingiva of the curet­ ted teeth was protected with periodontal pack for 7 days. Each individual patient was treated by one operator. In the teeth submitted to subgingival scaling and root planing alone, curettes with only one cutting edge were used (the other cutting edge had been worn out) in order not to inadvertently inflict any injury on the soft wall of the pocket. Curettes were sharpened prior to each use and not more than four teeth per patient were treated in each session. A total of 201 teeth were treated: 103 by curettage and 98 by root planing. Biopsies of the gingiva were taken inmediately after treatment and at various intervals following treatment: 2, 4, 5, 7, 10, 12 and 14 days. In each case, an effort

MARIO BELVEDERESSI† SUBGINGIVAL SCALING with root planing is designed to free the root surface from all dental deposits (calculus, dental plaque and necrotic cementum) which irritate the gingiva, so as to accomplish remission from inflam­ mation and gingival retraction along with the removal of the periodontal pocket. The term "gingival curettage" implies directing an operative instrument against the gingival wall of the periodontal pocket in order to remove the ulcerated epithelium covering the sulcus. Thus, curettage is the conversion of a chronic inflammatory ulcer to the gingi­ val wall of the pocket into a surgical wound. Actually, both procedures — subgingival scaling with root planing and curettage — are used in combination to eliminate the pocket. There are clinicians who under­ take both procedures simultaneously, while there are others who curette as a separate procedure, after root planing has been performed. Several a u t h o r s have conducted interesting studies to determine the response of gingival tissue both to the removal of calculus and other local irritants and to curettage. Due to the double-edged curettes used in subgingival scaling, some gingival lining is also removed while the root surface is being treated. In many if not most cases, the epithelial attachment is also removed with the same inadvertence. M o s k o w reported this side effect of the curette when he studied the response of gingival tissue to the action of subgingival scaling. In practically all the cases in his study, there was some damage to the crevicular epithelium. This two-fold effect of the curette makes it very difficult to evaluate the effect of subgingival scaling with root planing upon gingival inflammation, because to a certain extent, simultaneous curettage is per­ formed. 1

2,3

2,3,6,7,8-13

2

RESEARCH OBJECTIVES

This study was aimed at establishing the effects of scaling with root planing on gingival inflammation and * Associate Professor of Periodontology, School of Dentistry, Uni­ versity of Chile, Avda. Manuel Montt 051 Dpto. 104 Stgo. 9, Santiago, Chile, S.A. †Professor of Pathology, School of Dentistry, University of Chile, Santiago, Chile.

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was made to match the gingival samples of pieces sub­ mitted to root planing with gingival samples submitted to curettage on the same date and on the same patient so as to avoid, as far as possible, any individual varia­ tions in the process of tissue repair. In each biopsy, two neighboring papillae and the gingival tissue between them were taken as one single block thus ensuring that each sample contained the entire buccal gingiva of a tooth, including both the medial and distal papilla (Fig. l a ) . The incision to remove the gingiva was performed apically to the epi­ thelial attachment. HISTOLOGICAL PROCEDURE

For fixation, 1 0 % neutral formalin was used. T o facilitate the orientation of the samples when they were embedded in paraffin, they were cut macroscopically with a scalpel to secure adequate visualization of the internal and external gingival slopes. A previous study conducted by one of us established that the best ori­ entation is obtained through an oblique section of the interdental papilla, since a vertical section along the mayor axis of the papilla does not permit observation of both slopes.

355

a

b

F I G U R E l a . Illustrates the manner in which the biopsy of the buccal gingiva was performed, and F I G U R E lb shows the incisions performed in each gingival sample.

5

A s stated, each gingival sample consisted of two interdental papillae and the buccal interpapillar gin­ giva. Oblique sections of both interdental papillae and vertical sections of the buccal interpapillar gingiva were made. (Fig. l b ) . Before sectioning with scalpel, the entire sample was dried to facilitate identification of the surface to be sectioned with a coloring solution.* This coloring solution, which acts only on the sur­ face, helps to clearly identify the surface sectioned in orienting the sample when it is embedded in paraffin. Five sections were obtained from each gingival sam­ ple. A l l were embedded in a single paraffin block. For staining, six different histological techniques were used: (1) Hematoxylin and eosin (routine tech­ nique); (2) V a n Gieson-Ponceau (specially for collagen fibers); (3) Periodic Acid-Schiff (Mucopolysaccharides, keratin and glycogen); (4) Foot (reticulin fibers); (5) Ayub-Scklar, modified A z a n (collagen fibers); (6) Brown-Brenn (bacterial colonies). The combined use of all of these techniques was designed to detect all phases of repair from the granula­ tion tissue, and also to detect the presence of muco­ polysaccharides, reticulin fibers and mature collagen fibers. HISTOLOGICAL STUDY

Histological study was performed as follows: 1. The internal slope was studied to establish the presence or absence of bacterial colonies and of inflam­ matory exudate and to determine the condition of the crevicular epithelium (present, absent, partially ulcer­ ated, invaded by neutrophylic leucocytes, hyperplasia, evidence of regeneration, parakeratinization, etc.) * Merthiolate.

2. The subepithelial zone of the internal slope was examined from the summit to the terminal end of the crevicular epithelium. 3. A l l connective tissue between both slopes was examined. 4. The internal slope was studied and the type and extent of the inflammation and the characteristics of post-treatment tissue repair was recorded. 5. Finally, the condition of the crevicular epithelium was observed during the first 5 days following treat­ ment. A n extensive and detailed report was prepared for each sample and subequently a summary of the most significant traits of each one of them was recorded. A l s o , a comparative study was performed of the condi­ tion of the crevicular epithelium of the cases submitted to curettage and the cases submitted to root planing. The histological slides were studied jointly by the clinician and the pathologist. This is very interesting and must be undertaken once the pathologist has com­ pleted his study and evaluated all of the material in a report. It helps to improve the interpretation of the results of the techniques used. RESULTS

A total of 2132 histological sections from the gingival samples obtained were examined. From the 10 patients, 60 useful samples were ob­ tained. Four samples were not useful due to their scanty size. Thirty samples belonged to the gingiva of teeth submitted to subgingival scaling with root planing and 30 to teeth treated by curettage. The intent was to quantify the evolutive changes which followed treatment, but the evaluation of the results obtained with both procedures was difficult be­ cause almost no case was absolutely free from inflam­ mation. Despite the fact that the samples had been taken at different time periods, in many cases they

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displayed similar histological characteristics. In the sys­ tematic study of the samples, it became obvious for instance, that different areas studied in the same pa­ tient showed varying degrees of chronic inflammation, which could or could not be accompanied by exacerba­ tion. For the above reasons, the description of the results will be made in summary form. Only the most signifi­ cant aspects observed regarding inflammation, repair, presence of bacteria and the condition of the crevicular epithelium will be pointed out.

J. Periodontol. June, 1977

Only those cases displaying all traits specific to an acute inflammatory process were ranked under exacer­ bation, as for instance: hyperemia, intravascular leucocytosis, edema and exudation. Acute inflammation was restricted in most cases to the subepithelial area of the internal slope. Scarcely ever did it invade other areas. The presence of regressive disturbances in some of

GINGIVAL INFLAMMATION

In general, the inflammatory phenomenon reached a greater concentration in the area beneath the crevicular epithelium from where it extended in clusters of inflammatory cells. These cells also may be locally arranged towards the center and the summit of the papilla. Chronic inflammation showed three degrees of in­ tensity: (a) severe, (b) moderate, and (c) mild. Macrofocal inflammation was deemed severe (Fig. 2); microfocal inflammation was deemed mild (Fig. 3); and those cases where the inflammatory elements had a band-like arrangement under the epithelium of the gingiva were deemed moderate (Fig. 4 ) . This gradation, which has been used already by oth­ ers authors, is subjective and consequently it has rela­ tive validity, all the more so if it is borne in mind that there exist variations in intensity in different areas of the same sample. 6

F I G U R E 2. Section of a gingival sample which displays macrofocal inflammation with dense fibrous connective tissue sur­ rounding two large inflammatory areas. The gingival sample was obtained 14 days after curettage (Ayub-Scklar, modified Azan stain, original magnification x 35).

F I G U R E 3. Section of gingival biopsy secured 14 days after root planing, which shows mild or microfocal inflammation with infiltration of small groups of inflammatory round cells (H & E, original magnification x 35).

F I G U R E 4. Section of a gingival sample from the central part of the buccal interpapillar gingiva taken 12 days after curettage and which displays a subepithelial band-like arrangement of inflammatory cells (H & E, original magnification x 35).

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Subgingival Scaling, Root Planing and Curettage

the macrofocal inflammatory zones afforded an inter­ esting histological trait. These disturbances were small necrotic areas in which the ground substance was disintegregated (depolimerization of mucopolysaccharides, fragmentation of fibers, etc.). Whenever these charac­ teristics were observed, the repair signs were absent to the extent that there did not even exist recognizable granulation tissue. This phenomenon was interpreted as a sign of a sustained turpid inflammatory process showing no repair trends. When root planing was used, pre-existing chronic inflammation continued as such, with variations in ex­ tent up to 10 days after treatment. Only in a small number of cases was there partial exacerbation of the inflammation following root planing (Fig. 5). A s of the 10th day treatment, chronic inflammation shows regression signs, manifested by an increasing fibropla­ sia observed in the samples of 10, 12 and 14 days and by a progressive decrease of the inflammatory elements in them (Fig. 6). When curettage was used in those cases in which the crevicular epithelium had been removed or at least damaged, there occurred an intense exacerbation of pre-existing inflammation, a reaction reaching its peak after 48 hours or so. Five days after there had occurred a noticeable decrease of neutrophylic leucocytes and of edema. In most cases of curettage, this exacerbation persisted, though to a lesser extent, up to the 14th day (Fig. 7). REPAIR

Repair was studied in the crevicular epithelium and in the connective tissue.

F I G U R E 5. Section of a gingival biopsy obtained 7 days after root planing, which shows exacerbation of preexisting chronic inflammation (H & E, original magnification x 35).

357

In the epithelium there was recognizable epithelial regeneration 4 or 5 days after curettage, in the manner of a very thin covering with an active basal stratum (Fig. 8). Healing manifested itself by a frankly positive P A S reaction, by the presence of small reticulin fibers and by fibroplasia (formation of collagen fibers). This cica-

F I G U R E 6. Section of a gingival sample taken 14 days after root planing displaying abundant collagen fibers and no inflamma­ tion at all (Ayub-Scklar, modified Azan stain, original magni­ fication x 35).

F I G U R E 7. Gingival biopsy obtained 14 days after curettage which shows a mild inflammation. Compare to sample in figure 6 which was obtained 14 days after root planing. (H & E, original magnification x 35).

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trization was located as a rule in the area of the internal slope and its extension was rather restricted, with varia­ tions for the different cases. Healing of the connective tissue was more outstanding in curetted teeth and not as remarkable in root planed teeth. Condition of Crevicular

Epithelium

The systematic study of the cases of 0, 2, 4 and 5 days permitted the observation of some interesting facts. In order to assess whether the removal of the crevicular epithelium had been accomplished, only those cases having an evolution within 0 and 5 days were examined, because previous studies had shown that on the 7th day after curettage in the human being there has taken place a total regeneration of the crevi­ cular epithelium. A total of 28 cases met the above requirement. Basically three different patterns were observed: (1) 7,8

T A B L E 1. Time Distribution of Cases

Days

Cases treated with root planing

Cases treated with root planing and curettage

Total

0 2 4 5 7 10 12 14

3 5 6 2 4 2 3 5

3 5 4 2 4 3 4 5

6 10 10 4 8 5 7 10

30

30

60

Total

F I G U R E 8. Section of a gingival sample secured 5 days after curettage, in which there exists recognizable epithelial regener­ ation (H & E, original magnification x 35).

Crevicular epithelium present. (2) N o crevicular epi­ thelium as a result of curettage. (3) N o crevicular epithelium owing to removal with scalpel during bi­ opsy. When curettage was performed, the crevicular epi­ thelium was not removed completely in most of the cases. In several cases, the histological sections at dif­ ferent depths in the same sample showed that the crevicular epithelium had been removed only in some areas (Fig. 9 and 10). Thus, curettage did not accom­ plish removal of the crevicular epithelium in all cases and when it did so it was not uniform in the different areas of the gingiva. In some areas, there were signs of deep incision into the crevicular epithelium, though it had not been removed; in others the epithelium which lines the marginal gingiva and even the internal epithe­ lium of the external slope were damaged. Regarding the relationship between the condition of the crevicular epithelium and inflammation, it was pos­ sible to observe that in those cases treated by curettage, when the removal of the epithelium was more com­ plete, the exacerbation of inflammation was more acute and lasted slightly longer than in the cases in which removal was more incomplete. There is, then, an ob­ vious relationship between exacerbation of the inflam­ mation and damage to the crevicular epithelium. This is confirmed by the fact that in those cases treated by root planing where there was damage to the crevicular epi­ thelium, there also was exacerbation of the inflamma­ tion. In the samples of gingiva treated by root planing, and with an evolution between 0 and 5 days, it was ob­ served that, in most of the cases, the crevicular epithe-

F I G U R E 9. Gingival sample secured immediately after curet­ tage, which shows how the crevicular epithelium has been partially removed through curettage (H & E, original magnifi­ cation x 35).

Volume 48 Number 6

Hum and the epithelial attachment were present (Fig. 11). In the very limited number of cases in which there was no crevicular epithelium and epithelial attachment, their absence was imputed to removal when the biopsy was performed (Fig. 12). This was concluded from the

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neatness of the incision of the gingiva and the absence of exacerbation of the inflammation of the connective tissue neighboring the surgical incision. These results show that root planing with curettes (one of the cutting edges of which had been worn out previously) is an excellent method to determine the effects of root plan­ ing upon gingival inflammation. These effects were not easy to determine heretofore as previous studies showed that the curette damaged the gingival wall of the pocket, despite the fact that the instrument is directed only against the hard wall of the pocket. 2,

3

PRESENCE OF BACTERIAL COLONIES

Bacterial colonies were observed in five samples only. They were coccus and bacilar forms, usually in the neighborhood of clusters of extra gingival neutrophylic leucocytes. PRESENCE OF CEMENTUM OR OF CALCIFIED MATERIAL

In 11 of the 60 samples, it was possible to observe calcified material in the connective tissue beneath the internal slope or at a greater depth. Six of these samples had been curetted and five root planed. The fact that these fragments, which seemed to correspond to root cementum, did not produce any inflammatory reaction deserves mentioning (Fig. 10). CLINICAL RESULTS F I G U R E 10. Another gingival biopsy obtained immediately after curettage, which also shows partial removal of crevicular epithelium. The presence of calcified material (cementum?) in the connective tissue is to be observed. There are no signs of inflammation reaction around the calcified material.

Clinical observation of the cases treated showed that after the 7th day the group treated by curettage had a gingiva displaying more inflammation and less normal

F I G U R E 11. Intact crevicular epithelium in a section of a gingival sample from a patient submitted to root planing with curettes, one of the cutting edges of which had been worn out. The sample was obtained immediately after instrumentation. (H & E, original magnification x 35).

F I G U R E 12. Section of a gingival biopsy obtained 5 days after curettage, in which the absence of crevicular epithelium and of epithelial attachment could be accounted for by removal with the scalpel upon performing biopsy (H & E, original magnifi­ cation x 35).

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clinical characteristics than the group treated by root planing only. After 14 days the clinical appearance of the gingiva was similar in both groups, and it was no longer possible to tell which procedure had been used in a given group (Figs. 13 to 16). A comparison of the measurements of the clinical crown and depth of the gingival sulcus recorded prior to treatment and 4 and 6 weeks following treatment, sug­ gests that curettage accomplishes a greater retraction of the gingiva than subgingival scaling and root planing. However, the data furnished by these measurements cannot be deemed definitive owing to variables which are difficult to evaluate, as for instance, damage during biopsy and the effects of the periodontal pack used to protect those areas where biopsy was performed. DISCUSSION

A careful review of existing literature avails us of an opportunity to make some relevant comments on di­ verse aspects. Obviously, none of the authors reviewed explains how the histological procedure was performed and they do not state whether step serial sectioning was per­ formed. In our research, several areas from the same sample were studied. This enabled us to observe that in the same sample there could be two areas free from inflammation with mild, moderate or severe exacerba­ tion (Figs. 4, 17 and 18). In our opinion there is still a need for further study involving semiserialized sectioning, at least on this subject.

F I G U R E 13. Clinical aspect of the gingiva of a patient affected by incipient marginal periodontitis, prior to treatment. The buccal pockets were 3 mm in depth. The interproximal pockets measured 4 mm.

F I G U R E 14. Photograph taken immediately after treatment. Teeth 1 , 2 , and 3 were submitted to subgingival scaling and root planing using single-end curettes. Teeth 1, 2 and 3 were submitted to both techniques complemented by curettage. Ob­ serve that the gingiva of curetted teeth is in a more traumatic condition owing to the action of the instrument.

The quantification of the extent of the inflammation also deserves attention. In this paper, as in previous authors, this quantification is altogether subjective and, therefore, very relative. Stahl et a l . aware of these limitations made an at­ tempt to design a procedure which would preclude the subjective element and resorted to statistical proce­ dures. It seems that these procedures were applied on the basis of histological reports containing subjective eval­ uations. In our opinion an objective quantification is possible if semiserialized sectioning followed by a cell count is used before applying statistical methods. The importance of chronic inflammation which per­ sists up to 14 days after treatment also deserves atten­ tion. In all the cases studied, histological examination revealed varying degrees of inflammation, even in those cases in which the gingiva from which the sample had been taken did not display any clinical evidence of inflammation. The extent of the inflammation observed is not related to the time elapsed between treatment and biopsy. Some gingival samples obtained 7 and 10 days after treatment showed less inflammation than samples obtained 12 and 14 days after treatment. This finding agrees with the results of several other investi­ gators in the f i e l d . The gingival samples from root planed teeth were less inflamed than the samples from curetted gingiva. We feel that as yet it is not possible to clearly inter­ pret the importance of inflammation in gingival sam6

2,6,7

FIGURE 15. Seven days after treatment. A certain degree of inflammation which can be clinically detected on the gingiva still persists. The gingiva of curetted teeth shows considerably more inflammation.

F I G U R E 16. Fourteen days after treatment. The gingiva offers a normal clinical aspect not only in curetted teeth but also in noncuretted teeth. The histological study from this gingiva showed a persistence of inflamation after both types of treat­ ment, though the inflammation in curetted gingiva was more intense under microscope.

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Post-treatment inflammation may be related to inmunological phenomena which are not determined as yet and are activated or originated by tissue destruction which results from manipulation when performing cur­ ettage and subgingival scaling. It is also possible that the inflammation observed in gingival sections of teeth treated by subgingival scaling and with curettage, and in gingiva, even several weeks after gingivectomy, may be caused by endotoxins from Gram-negative bacteria which might have seeped into the tooth cementum during the period when the pocket is developing and could be released from the cemen­ tum up to several weeks after treatment. Stahl et a l . have stated that "there are severe limita­ tions in properly controlling a histologic evaluation of the effects of soft tissue curettage." It would seem that this statement could be extended to the evaluation of the results of root planing using histological methods. Regarding the validity of curettage, O r b a n con­ tends that it is almost impossible to accomplish com­ plete removal of the sulcus epithelium from the pocket; Waerhaug states that such removal is altogether im­ possible; M o r r i s indicates that it is difficult to remove the epithelium in the coronal half; Wertheimer was able to accomplish complete removal only in three cases out of the 30 he studied. Sanderson observed the presence of epithelium in the surface of the pocket in only 4 7 % of hand-curetted cases. In a second series of samples, in the same research project, Sanderson found that epithelium persisted in 4 0 % of the cases. Stahl et a l . studied suprabony pockets and found that "the removal of crevicular epithelium using curettage was not always accomplished in all cases." 9

10

6

11

12

F I G U R E 17. Section of gingival papilla (taken 12 days after curettage) which displays macrofocal inflammation (H & E, original magnification x 35). Hematoxylin and eosin stain. 35

x.

13

14

15

6

F I G U R E 18. Another section of the same gingival sample shown in figure 17 in which there is no inflammation at all. The sections shown in figures 4, 17 and 18 all belong to the same gingival sample taken 12 days after curettage.

ples obtained 14 days after treatment. Some authors suggest that this inflammation is produced by the dental plaque which develops after treatment. In our cases the Brown-Brenn bacterial stain was negative in practically all the samples, a fact which is congruent with the clinical tests for the detection of dental plaque with disclosing solution effected immediately before biopsy, and which did not reveal the presence of bacterial plaque in any case. Therefore, the inflammation ob­ served after treatment cannot be attributed in our cases to the presence of a detectable dental plaque. Stahl recorded a great similarity in distribution and degree of intensity of inflammation in both untreated controls and samples obtained 8 weeks after curettage. 6

Our experience indicates that there are areas in which the removal of the crevicular epithelium is easier or more likely. These areas are in the vestibular or buccal gingiva of the central part of the tooth, and differ from the papillary gingiva where removal of the crevicular epithelium is more difficult to accomplish. It has been stated already that the crevicular epithelium persisted in different areas of the samples studied. Finally, it would seem that, as regards obtaining the sample, the different authors reviewed have either overlooked the possibility of removing the crevicular epithelium with the scalpel when performing biopsy or have not been explicit enough to indicate whether they have done so. SUMMARY

In a joint clinical and histological research, carried out in humans of both sexes, it was attempted to estab­ lish some of the differences between the effects of curettage and root planing as procedures to accomplish remission of gingival inflammation. In 10 patients, 210 teeth were treated (103 curetted and 98 root planed). Sixty useful samples and 2132 histological sections were obtained. Six different stain­ ing techniques were used to study the samples. Clinical

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and histological evaluations were made of the results obtained with both procedures. CONCLUSIONS

(1) The histological method used was not adequate enough to evaluate the effects of both procedures. (2) In the cases studied, curettage did not accomplish com­ plete removal of the crevicular epithelium. (3) In all those cases in which partial removal was accomplished or in which the crevicular epithelium was damaged, there occurred an exacerbation of the preexisting chronic inflammation. (4) The use of curettes with only one cutting edge is useful to determine the effects of subgingival scaling and root planing upon gingival in­ flammation, because they do not produce damage to the sulcus epithelium. ACKNOWLEDGMENTS

We wish to express our thanks to Miss María Luisa Canales for her technical assistance, and to Mr. Santiago Smith, who translated this paper. REFERENCES

1. Goldman H . , Schluger S., Fox L . , and Cohen D.: Periodontal Therapy, ed 3, p 385. St. Louis, The C. V. Mosby Co., 1964. 2. Moskow B.: The response of the gingival sulcus to instrumentation: a histological investigation. I. The scaling procedure.JPeriodontol 33: 282, 1962. 3. Moskow B.: The response of the gingival sulcus to instrumentation: a histological investigation. II. Gingival cur-

ettage.7. Periodont 35: 112, 1964. 4. Cohen W.: Role of periodontal surgery. J Dent Res (suppl. II) 50: 211, 1971. 5. Fernandez I., Belvederessi M . , Villavicencio J., and Canales M.: Contribución al estudio clínico e histopatológico de los resultados del pulido radicular. Terceras Jornadas Na­ y Oclusión, Julio, 1973. Santiago, Chile. 6. Stahl S., Weiner J. M., Benjamin S., and Yamada L.: Soft tissue healing following curettage and root planing. J

cionales de Parodoncia

Periodontol 42: 678,

1971

7. Ramfjord S., Caffeese R.: Reacción tisular y cicatriza­ ción periodontal. Técnicas de raspaje, curetaje y gingivectomía. Rev Asoc Odontol Argentina 56: 303, 1968. 8. Stone S., Ramfjord S.: Scaling and gingival curettage. A radioautographic study. J Periodontol 37: 415, 1966. 9. Stahl S., Witkin G. J., Heller A., and Brown R.: Gingival healing. II. Clinical and histologic repair sequences following gingivectomy. J Periodontol 39: 109, 1968. 10. Morris M.: An inhibitory principle in the matrix of periodontally diseased roots. J Periodontol 46: 33, 1975. 11. Orban B.: Pocket elimination or reattachment. N Y State Dent J 14: 227,

1948.

12. Waerhaug J.: The gingival pocket. Odontol Tskr 60 (suppl. I) 156, 1952. 13. Morris M.: The removal of pocket and attachment epithelium in humans: a histological study. J Periodontol 25: 7, 1954. 14. Wertheimer F.: Effectiveness of "Berliner epithelial scalpel" in removing the epithelial lining in periodontal pock­ ets. J Periodontol

25: 264,

1954.

15. Sanderson A.: Gingival curettage by hand and ultra­ sonic instruments, a histologic comparison.JPeriodontol 37: 279, 1966.

Announcements BOSTON UNIVERSITY S C H O O L O F G R A D U A T E DENTISTRY announces the following courses in its continuing education program

October 21-22, 1977 Fee: $160 III.

CLINICAL PERIODONTAL SURGERY

May 5-7, 1977 (Course filled) Next Available Dates: December 1-3, 1977 (filled); May 4-6, 1978 (filled); November 30-December 2, 1978 (open) Fee: $250 G E R A L D M . KRAMER, D . M . D . , Professor and Chairman, Depart­ ment of Periodontology J. DAVID K O H N , Associate Professor of Periodontology PERIODONTAL PROSTHESIS

May 8-10, 1977 (Course filled) Next Available Date: December 5-7, 1977 Fee: $240 G E R A L D M . KRAMER, D . M . D . , Professor and Chairman, Depart­ ment of Periodontology MYRON NEVINS, D . D . S . , Associate Professor of Periodontology HOWARD M . SKUROW, D . D . S . , Assistant Clinical Professor of Pros­ thetic Dentistry PERIODONTICS FOR THE G E N E R A L PRACTITIONER

A Six-Course Series with Participation HENRY M . G O L D M A N , Dean of the School I.

UNDERSTANDING PERIODONTAL DISEASE A N D ITS TREATMENT

June 17-18, 1977 Fee: $160 II.

PREPARATION OF A C A S E FOR TREATMENT

DEFINITIVE PERIODONTAL THERAPY

December 1-3, 1977 Fee: $240 IV.

M A N A G E M E N T OF THE A D V A N C E D PERIODONTAL DISEASE C A S E

March 3-4, 1978 Fee: $160 V

THERAPY OF T H E O C C L U S A L TRAUMATIC LESION

May 12-13, 1978 Fee: $160 VI.

PARTICIPATION COURSE IN PERIODONTAL THERAPY

June 9-10, 1977 Fee: $200 For further information contact: Program Coordinator, Division of Continuing Education, Boston University School of Graduate Dentistry, 100 E . Newton St., Boston, Mass. 02118; (617) 2476354. UNIVERSITY O F F L O R I D A , G A I N E S V I L L E , F L O R I D A Applications are now being accepted for a postgraduate program leading to certification in both Periodontics and Dental Education. The duration of this program is 36 months. A 24-month certificate program in Periodontics is also available. Contingent on approval in May by the Commission on Accreditation of the Council on Dental Education, both programs will commence July 1, 1977. For further information, please contact Dr. Paul J . Heins, Chair­ man, Department of Periodontics, or Dr. William B . Shreve, Assist­ ant Dean for Advanced Education, College of Dentistry, University of Florida, Gainesville, F L 32610.

Subgingival scaling with root planing and curettage: effects upon gingival inflammation: a comparative study.

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