Periodontal Specialty Observation Report

Paige Humphries
DH271 Periodontology
February 28th, 2024

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Introduction and Procedures
For the periodontal specialty office observation, I visited Dr. Daniel Harper at the Cal
Young Periodontics Center. Dr. Harper graduated from the University of Pennsylvania School
of Dental Medicine and then went on to obtain his certificate in periodontology from the Ohio
State University College of Dentistry. He owns his practice and works with three dental
assistants, one dental hygienist, a front office manager, and two front office receptionists. While
visiting this office, I had the opportunity to witness a periodontal (flap) surgery and a surgical
extraction.

Periodontology
Periodontology is a specialty of dentistry that focuses on severe oral disease surrounding
the supporting structures of the teeth, the periodontium. Procedures performed by periodontists
may include periodontal (flap) surgeries, scaling and root planing, periodontal maintenance,
frenectomies, gingivectomies, osseous and tissue grafts, guided bone and tissue regeneration,
crown lengthening procedures, simple and surgical extractions, and implant placement. All of
these listed procedures are provided at the Cal Young Periodontics Center by Dr. Harper. Some
procedures performed at Dr. Harper’s office can be accomplished with a diode laser, such as
frenectomies, biopsies, and gingivectomies. Diode lasers may also be used by the periodontist or
dental hygienist to perform gingival curettage or laser pocket disinfection (LPD); however, the
assistant informed me that the dental hygienist at the Cal Young Periodontics Center does not
utilize the diode laser for hygiene treatment. A dental hygienist’s duty within a periodontal office
may include providing nonsurgical periodontal therapy and periodontal maintenance procedures.
Overall, the procedures performed by periodontal specialty offices have a general goal of
returning the periodontium to a state of health.

Referral
Patients are often referred to a periodontist by a general dentist or dental hygienist. Dr.
Harper’s website has a link to an online referral form that can be filled out when a referral is
indicated for a patient. Referral may be necessary when advanced periodontal procedures are
required to treat conditions affecting the periodontium. Examples of these advanced periodontal
procedures include guided tissue regeneration and implant placement. A dental hygienist can
refer patients to a periodontist when the patient requires advanced scaling and root planing
procedures. Periodontists can perform open (flap) scaling procedures, which is advantageous for
treating severe periodontal conditions and furcation involvement. Also, when periodontal disease
is rapidly progressive and not controlled by nonsurgical periodontal therapy, a referral may be
indicated. Other indications for a referral to a periodontist include patient preference,
periodontal abscesses, vertical bony defects, furcation involvement, mobility, peri-implantitis,
increasing periodontal pocket depths (>5mm), and mucogingival involvement.

Periodontal (Flap) Surgery

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 The first procedure that I witnessed was classified as a periodontal (flap) surgery, with
the intent to gain access to an edentulous area to remove necrotic bone. The treatment area was
distal to tooth #19, where the patient previously had an implant placed in the location of tooth
#18. After this implant was placed, the patient was prescribed oral bisphosphonates by their
primary care provider for the treatment of osteoporosis. The use of oral bisphosphonates caused
necrosis of the alveolar bone surrounding the implant, which led to inadequate healing and
implant failure. After implant removal, the patient was referred to Dr. Harper for evaluation and
treatment of the area. Upon initial observation, the patient had visible necrotic bone protruding
through the gingival tissue.
The first step in this procedure involved the assistant seating the patient, obtaining
informed consent, and taking vital signs. The assistant recorded the patient’s blood pressure and
heart rate. Following this, the dental assistant informed the patient of the treatment being
provided and then reviewed postoperative instructions with the patient. The patient was
provided with a copy of these instructions to review following treatment (see attached images).
When Dr. Harper entered the treatment room, he ensured that the patient understood the
treatment plan, and then he began the procedure.
For this procedure, the surgical site was on the left side of the mandible; therefore, Dr.
Harper used a left-sided inferior alveolar nerve block and a long buccal injection. Before
administering the injections, 20% benzocaine topical anesthetic was applied to the site of
penetration. Dr. Harper used 4% articaine (Septocaine) with 1:100,000 epinephrine setup in a
syringe with a 30-gauge short needle and another syringe with a 27-gauge long needle. The long
needle was used for the inferior alveolar nerve block and the short needle was used for the long
buccal injection. For the inferior alveolar nerve block, Dr. Harper had the dental assistant add
sodium bicarbonate to the local anesthetic solution with a device called the Onset by Onpharma.
The addition of sodium bicarbonate raises the pH of the anesthetic solution, which increases the
amount of free base form that is present in the tissue. An increase in the free base form of the
anesthetic solution allows for anesthesia to be achieved at a faster rate. Dr. Harper administered
one cartridge of articaine for the inferior alveolar nerve block and half a cartridge for the long
buccal injection. Once the injections were complete, Dr. Harper recapped the needles using a
Pro Tector Needle Sheath Prop (engineering control) with the one-handed recapping technique to
prevent a needle stick injury.
Once adequate anesthesia had been achieved, Dr. Harper utilized a scalpel with a
stainless-steel feather blade to make an incision. This incision extended from the center of the
edentulous area (area of #18) and continued along the distal, buccal, and lingual surfaces of tooth
#19. Once this area was incised and partially reflected, the assistant utilized a sterilizable
metallic surgical suction line to keep the surgical field clear of blood. Dr. Harper then used a
stainless-steel periosteal elevator to reflect the tissue, exposing the underlying alveolar bone.
During the entire procedure, the dental assistant used a Minnesota retractor for cheek retraction
and increased visibility.
Once the tissue was reflected and the bone was visible, Dr. Harper began scaling necrotic
bone from the area. Dr. Harper also scaled the distal root surface of tooth #19 during this
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procedure. The tool that he utilized to hand scale the necrotic bone and root surface was a solt
periodontal chisel. Following this, Dr. Harper utilized a size 4 carbamide round bur with a slow-
speed handpiece to carefully remove the remaining necrotic bone. Once the necrotic bone was
completely removed, Dr. Harper used a piezoelectric scaler with a 4R/4L type tip to flush the
debris from the area. After thorough debridement of the area, Dr. Harper used a slow-speed
handpiece with a ¼ round carbamide bur to drill small holes into the bone. Dr. Harper explained
to me that these small holes initiate blood flow through the bone and aid in the healing process.
He mentioned that this helps to ensure viable bone formation.
Next, the assistant used chlorhexidine gluconate 0.12% to irrigate and render the
treatment area more visible for Dr. Harper’s viewing. Dr. Harper evaluated the surgical site and
determined that the procedure was complete. Upon completion, Dr. Harper utilized a size 3-0
synthetic absorbable polyglycolic acid (PGA) surgical suture material to approximate the tissue.
This type of suture material is often slowly resorbed by enzymes in the oral cavity; however, if
the sutures remain at the re-evaluation appointment, they can be removed. For this procedure,
Dr. Harper placed four individual sutures using the single interrupted suturing technique. Suture
forceps were used to insert the swaged needle through the tissue and to aid in tying the suture
knots. The assistant used sterile scissors to carefully cut the remaining suture material ends after
each suture was placed.
Following the placement of the sutures, the patient was sat up in the chair and was
instructed to return in 7-10 days for a postoperative exam to evaluate the surgical site. As a part
of the postoperative instructions, the patient was prescribed chlorhexidine gluconate 0.12% and
instructed to use a cotton swab to gently apply the solution to the area twice daily. After this, the
patient was dismissed. Overall, the entire appointment lasted an hour and fifteen minutes, but
the procedure itself only lasted around 45 minutes.

Surgical Extraction
The second procedure that I witnessed was a surgical extraction. The initial steps of this
procedure included obtaining informed consent, taking vital signs, and reviewing postoperative
instructions. This patient presented with chronic pain in the area of tooth #19, which didn’t have
any clinically or radiographically identifiable defects or cavitations. Dr. Harper had performed
nonsurgical periodontal therapy as a form of initial treatment for this patient, but weeks later, the
patient still presented with severe pain. Due to this continued discomfort, Dr. Harper suspected a
possible root fracture. To determine if the tooth required an extraction, Dr. Harper conducted an
exploratory periodontal (flap) surgery to gain better subgingival access and visibility. Because
tooth #19 was being treated, a left-side inferior alveolar nerve block and long buccal injection
were used. As with the previous periodontal (flap) surgery, Dr. Harper requested the addition of
sodium bicarbonate to the anesthetic solution being used for the inferior alveolar nerve block
injection. The same anesthetic solution, dosage, and setups were utilized and are the setups that
Dr. Harper uses for the majority of his procedures. Once adequate anesthesia was achieved, Dr.
Harper used a stainless-steel feather scalpel blade and made an incision along the buccal and
lingual surface of the tooth, extending into the interproximal areas. Dr. Harper then used the
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periosteal elevator to reflect the tissue flap in a buccal and lingual direction. This allowed Dr.
Harper to visualize a fracture on the distal root, confirming the need for extraction.
While the tissue of the surgical site was reflected, Dr. Harper used the Younger-Good 7/8
to clean out a vertical bony defect that was on the distal surface of the root (in the area where the
root fracture was). Following this, Dr. Harper placed cowhorn forceps into the buccal and
lingual furcations of tooth #19 and attempted to remove the tooth by rocking in a forward and
backward direction. He also moved in a side-to-side direction trying to loosen the tooth from the
alveolus. In this case, the tooth was not releasing, and Dr. Harper had to use a high-speed
handpiece with a size 4 round carbide bur to remove enamel from the contact area. Once this
was complete, the cowhorn forceps were successfully used to extract the tooth.
Following the extraction of tooth #19, the solt chisel was used to scale debris from the
area. After this, a ¼ round carbide bur was used to place small holes in the alveolar bone to
increase blood flow to the area. For this patient, they decided to place a bone graft material into
the extraction socket so that an implant could be placed once healing was complete. Dr. Harper
used an OsteoGen Plug, which is a bone grafting material (xenograft) that is used to preserve the
extraction socket. This product “combines OsteoGen Bioactive Resorbable Calcium Apatite
with a bovine Achilles tendon collagen matrix to create a structure that mimics the organic and
inorganic components of physiologic bone” (Osteogen Plug Slim). Dr. Harper removed this
capsule-like material from its packaging and used sterile scissors to cut it roughly into the same
shape as mandibular molar roots. Dr. Harper then placed the plug directly into the extraction
socket (alveolus). After this, non-absorbable sutures were used to ensure the retention of the
plug. The suture used for this procedure were Monotex brand, size 3-0 polytetrafluoroethylene
monofilament swagged suture. Dr. Harper used four interrupted sutures to secure the plug under
the gingival tissue. After placement of the sutures, Periacryl oral tissue adhesive was applied
over the sutured surgical site. Periacryl is described as a “non-toxic and biocompatible
cyanoacrylate tissue adhesive that is useful in securing sutures, stabilizing membranes, covering
bone grafting material post-extraction, or dressing donor and recipient site” (Oral Tissue
Adhesives).
After completion of the surgical procedure, the patient was advised to return in two
weeks for suture removal and postoperative evaluation. This procedure was scheduled for an
hour and lasted the length of the appointment. Even with a challenging extraction, the
appointment did not run over on time.

Documentation
At Cal Young Periodontics Center, the periodontist (Dr. Harper) is responsible for the
documentation. Between patients, while the dental assistant cleaned the operatory and prepared
for the next patient, Dr. Harper went to his office to complete the chart notation. The assistant
mentioned that they are allowed to review the chart notes and add pertinent information as
necessary. At the Cal Young Periodontics Center, they use Dentrix software and write their
chart notes in the SOAP format. The “S” stands for subjective, “O” stands for objective, “A”
stands for assessment, and “P” stands for plan. The periodontist documented information such as
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medical history findings, procedures that were completed that day, and any complications that
occurred.

Reflection
During the office visit, I noticed that the Cal Young Periodontics Center had nitrous
oxide systems built into each of the dental units. I could see how this system may be more
practical and user-friendly than separate nitrous oxide units. This addition could save time
during patient treatment and operatory preparation. Dr. Harper explained to me that he uses a
nitrous oxide technique called rapid induction. This nitrous oxide technique involves first
administering 100% oxygen through the nasal hood for several minutes. Then, the periodontist
administers a 70% nitrous oxide/oxygen concentration and asks the patient to take several deep
breaths through their nose. After this, the periodontist reduces the concentrations to around 30-
35% nitrous oxide/oxygen. This technique is called rapid induction because it works very
quickly and doesn’t require the extended time needed to titrate the patient up to the desired
concentration. Pre and postoperative vital signs are required any time nitrous oxide is used, as
well as the use of 100% oxygen for 5 minutes after nitrous oxide analgesia.
Overall, this experience was very interesting and beneficial to me. Observing this
periodontal specialty office allowed me to learn what it looks like when we refer our patients to a
periodontist and reminded me of the available treatment options. The capabilities of the
periodontist extend beyond what can be accomplished in a general dental practice.
I enjoyed the atmosphere of Dr. Harper's office. It was a calm, yet efficient and fast-
paced environment. Dr. Harper made his patients feel comfortable, created relationships with
them, and didn’t forget to smile and enjoy what he was doing. The procedures he was
performing seemed so complex, yet he completed them efficiently and at ease. After this office
visit, Dr. Harper and his team are people whom I would be confident and comfortable referring
my patients to.

Contact
Office visit: 12/14/2023 from 7:45am – 11:15am
Dr. Harper at Cal Young Periodontics Center
Website: https://www.drdanielharper.com
Phone: 541-485-6888
Email: calyoungperiocenter@mydentalmail.com
Citations
Osteogen Plug Slim. Avtec Surgical. (n.d.). https://www.bonegrafting.com/collections/plugs-
tape-cote/products/osteogen-plug-large-10-x-20mm-5-bx-1466016501

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Oral Tissue Adhesives. AD Surgical. (n.d.). https://ad-surgical.com/periacryl-oral-tissue-
adhesives/?sku=Glu-
Peri50&gad_source=1&gclid=Cj0KCQiA7OqrBhD9ARIsAK3UXh0LGpsrbE1n8aFVww
qsFm2o20dSVP6wrk1QFXtxKTpJjK3_rjBHSsQaAnxfEALw_wcB