Lauren Holvey

DH 271: Periodontology II

Periodontal Specialty Office Visit

3/15/2024

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 For this specialty office visit, I chose to shadow Dr. Andrew Dow’s office, Eugene

Periodontics & Implant Surgery. I was able to spend about three and a half hours shadowing and

was fortunate enough to watch a few different surgical procedures. Dr. Dow himself and his staff

were so kind and answered all my questions as they came. I am so appreciative of the knowledge

I gained from the shadow and glad I have a better insight into the role the periodontist plays in

the field of dentistry.

The first surgery I watched was a gingival flap and root planing surgery as well as the

placement of a subgingival graft. This surgery started at 5:30 a.m. and ended at 7 a.m. A gingival

flap and root planing procedure is performed on patients that are diagnosed with moderate to

severe periodontal disease or to determine presence of a fractured tooth, root, or external root

resorption. I arrived at 6:00 a.m. and did not get to see the preparation for this procedure as Dr.

Dow starts promptly at 5:30 a.m. This patient was on I.V. sedation when I arrived as well as

oxygen. When I showed up, Dr. Dow was working on tooth #8 and started out by probing the

area (8mm pocket on mesial of #8). The tissue was then flapped utilizing a scalloped inverse

bevel incision technique (modified Widman flap). After the tissue is reflected, he went in with

the piezo ultrasonic scaler followed by a Prichard curette, Back-Action chisel and Sugarman file

to clean up the area of any debris and calculus. He sutured this area back together using 4-0 PGA

sutures (which are absorbable), a needle, and Castroviejo needle holders. He then moved on to

the gingival graft portion of the surgery. This procedure is used to thicken the gingiva while

providing minor root coverage; this was done over the facial gingiva of #24 and #25. The donor

site for this procedure was the patient’s palate. Dr. Dow gave an inferior alveolar nerve block and

locally infiltrated at the recipient site as well as the donor site using articaine 4% 1:100,000

epinephrine. In this area he again went in with the piezo ultrasonic scaler and hand instruments

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to clean the affected area before placing the tissue graft. Dr. Dow initially placed the donor tissue

on the receptor site and sutured it into place using the same materials as he did for tooth #8.

After the completion of the surgery, post operation intraoral photos were taken for

documentation purposes. The patient was then taken off the I.V. sedation. When the use of I.V.

sedation is indicated for treatment, patients are instructed to have a responsible adult come to the

appointment and drive the patient home. Post-operative instructions are given to the patient

before they leave, which includes leaving the gums undisturbed for at least two weeks, avoiding

extremely hot foods and the use of straw for two weeks as well as commercial mouth rinses.

Patients are also told to not brush, floss or waterpik the area of tissue graft for two weeks. The

patient will be seen back in two to six weeks to observe healing.

The next two surgeries I watched were both surgical extractions. The first extraction was

scheduled from 6:30 a.m. to 7:30 a.m. and the second extraction was scheduled from 7:30 a.m. to

8:30 a.m. The procedure was first explained to the patient and then the assistant/phlebotomist

drew blood from the both the patient’s arm to mix later with the platelet-rich plasma bone to be

placed at the extraction site. The blood was then placed in a Salvin Speed Centrifuge to separate

the platelets from the rest of the blood to be used later. The first patient was under I.V. sedation

with the use of midazolam (Versed), dexamethasone (Decadron), and fentanyl. The second

patient was not under I.V. sedation. Regardless, local anesthesia was given to the patient

depending on the area as one extraction was performed on the maxilla and the other was

performed on the mandible. After the patient was numb, Dr. Dow went in with a set of elevators,

both small and large luxators and even had to go in with a surgical handpiece and 1558 surgical

bur to remove both teeth in separate pieces. After both the tooth and roots were removed, he

irrigated the area with saline water and then went in with a spoon excavator to remove any

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diseased tissue. For the first procedure Dr. Dow showed me the diseased tissue he was removing

from the extraction site. For both procedures he placed platelet-rich plasma bone (allograft from

cadaver) mixed with the patients’ blood (that was placed in centrifuge earlier) which Dr. Dow

stated eliminates preservatives that could be present in alternative materials. After the bone was

placed, the extraction site was then sutured using 4-0 PGA sutures, needle, and Castroviejo

needle holders. A post-operative intraoral photo was again taken (for both patients) for

documentation purposes. Post-operative instructions were given to both patients which includes

biting down firmly on gauze for 45 minutes after surgery, eating any nourishing foods that can be

eaten comfortably, avoid rinsing vigorously or probing the area with any objects, do not floss or

use a waterpik in area for six weeks and smoking, chewing tobacco, or vaping should be avoided

for six weeks. Both patients will be seen for tissue observation in two weeks.

The last surgery I was able to watch was a pocket reduction surgery (also known as

osseous surgery). This surgery started at 8:30 a.m. and ended at 10 a.m. This patient had

furcation defects that made it difficult for the patient to keep clean. Again, the procedure was

explained prior to the start of the induction. This procedure is performed while the patient is

under I.V. sedation using the same medications mentioned above. When a patient is under I.V.

sedation, they are also on oxygen through the span of the whole procedure and all vitals are

being monitored throughout the entirety of the surgery. The osseous surgery was performed on

three out of the four quadrants and started with anesthetic. Due to Dr. Dow working in three

different quadrants, it felt as though he would give an according nerve block

(PSA/MSA/ASA/IA/LB) and then would give a handful of other tissue infiltrations; he went

very fast! He used articaine 4% 1:100,000 epinephrine as well as lidocaine 2% 1:100,000

epinephrine as the anesthetics of choice (depending on injection). Dr. Dow first started by

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removing the collar of tissue using a 15c scalpel blade. He then flapped the gingiva also using

periosteal elevators to gain access to the furcation perforation. Once access was gained to the

appropriate area, Dr. Dow went in with a high-speed handpiece and carbide burs to smooth the

roots of the teeth, as well as remove the furcation perforations. Dr. Dow also used a Prichard

curette, Back-Action chisel, Sugarman file and Piezo ultrasonic scaler. He finally sutured the

surgical area and repeated this process in the other two quadrants. Post-operative instructions for

this procedure were both explained and sent hone with the patient. Instructions include limiting

any vigorous physical activity for about two weeks, to avoid the use of a straw for two weeks as

well as commercial mouth rinses. It is best to use a soft bristle toothbrush in the surgical site and

to not smoke or vape for six weeks to improve the chances of success. This patient will be seen

in two weeks to observe healing and remove the sutures placed. At the end of procedure intraoral

photos were taken for documentation purposes.

In terms of documentation software, Dr. Dow’s office uses Eaglesoft for all

administrative needs. This includes anything from scheduling appointments to uploading signed

forms and any front office notes. Other than these few features, Dr. Dow’s office uses a software

system called PANDA Perio. In essence, this software is similar to Eaglesoft but is more geared

towards periodontics specifically. PANDA Perio is used for dental charting, periodontal charting,

and treatment notes. There are multiple note templates for the clinical staff to use depending on

the procedure being performed. PANDA Perio has a multitude of interesting features that aid in

the use of the system, particularly from a periodontal standpoint. The periodontal chart includes

over 200 point and click chartable findings all on one screen. This includes biological width

impingement, food impaction, mobility, and occlusal information, to name a few. PANDA Perio

also offers personalized treatment planning features including ways the professional describes

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their own cases. As the treatment is being created, PANDA Perio automatically transfers the

information with codes to be used by the financial coordinator in the office. These features seem

especially beneficial to this practice of dentistry.

The field of periodontics in dentistry deals with advanced and complex diseases that

affects the surrounding periodontium. Common procedures that are performed in this scope of

practice include implant placement, gingivectomies and frenectomies, periodontal flap surgeries,

osseous recontouring surgeries, tissue and bone grafting, crown lengthening, guided tissue and/or

bone regeneration. A general dentist may suggest a referral to a periodontist for periodontal

conditions outside of a general dentist’s scope of practice or of his team’s experience and that are

too severe to treat without surgical means. Such conditions could include chronic, aggressive

periodontitis, periodontal abscesses, severe furcation involvement, vertical bony defects, severe

root exposure, peri-implant disease, unresolved inflammation, deep periodontal pockets, and

tooth mobility. Dr. Dow has a unique route for patient referrals through his website via an online

form. This virtual form requires a referring Doctor’s name, patient’s name and phone number,

tooth or area of concern and for what evaluation (bone graft, extraction, peri-implantitis, etc).

Radiographs and other patient records may be sent directly to Dr. Dow or with the patient. The

use of written paper referral may be satisfactory as well.

The field of periodontics in dentistry is a very interesting one and seems to be an

extremely rewarding field of work. Dr. Dow’s office was very clean, organized and ran like a

well-oiled machine. The staff from treatment coordinators to the dental assistants to Dr. Dow

himself, were all so kind and welcoming. Everyone at Dr. Dow’s exuded a great passion for the

field of periodontics and worked very hard to treat each patient with the upmost care, this was

extremely refreshing to see. This specialty office visit showed me the importance a hygienist can

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play in the field of prevention and identification of conditions for referral. It is so important as

dental hygienists to help our patients maintain proper oral hygiene and removing any diseased

tissue, dental plaque biofilm and calculus. While not all patients at Dr. Dow’s are referred for

procedures to address attachment loss, some are, and this only reiterated the importance

prevention can serve in maintaining optimum oral health. As dental hygienists, we very well

could be the first to see a patient’s condition worsening as we do see patients on a routine basis.

This demonstrates the importance in identifying circumstances that may indicate a referral to a

periodontist.

Eugene Periodontics & Implant Dentistry: https://eugeneperio.com/

Phone Number: 541-654-5482