PERIODONTAL DEBRIDEMENT

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The Base Two Geometric Sequence describes the process of both periodontal infection and debridement in a highly reasonable manner. 1 - 2 - 4 - 8 - 16 - 32 etc. Eventually the infection reaches a high number, like a kilobyte ie 1024 or a megabyte 1048576. Or even a gigabyte ie 1073741824. At some point the tooth becomes so infested with calculus and biofilm it is toast, ie hopeless and needs to get extracted.

So... put this process in reverse. Let us say you only get 1/2 of the stuff per debridement. Then let the area recover and heal for a week or a month. Then whack it again. So Halving or Reverse Doubling lowers the amount of biofilm - 1/2 - 1/4 - 1/8 - 1/16 - 1/32 - 1/64 - So you can see by the 6th debridement the amount of debris left is only around 1-2% of the original amount of infection.

Will the tooth heal at this point? Maybe. But also consider that you are digging down too. So the lower layers may still be full of infection. So you can judge the degree of healing by the degree of the original infection. Plus to remember Winston Churchill's quote: "When you are going through hell keep going."

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PROGRESSIVE DEBRIDEMENT - The basic argument is whether a single scaling and root planing is adequate to debride the calculus from under the gumline. DIYPERIO says NO. Similarly roughly a thousand years ago a fairly up-to-date dentist said the same thing. Abu'l-Qasim from Cordoba:  "Scrape throughout... until the calculus is gone. It is possible that one scaling will suffice. If not begin a second, third or fourth time, until your purpose is completely attained."

Meanwhile it is generally agreed that: "Research studies also conclude that, despite our best efforts, calculus remains on tooth surfaces ranging from 17% to 64% after closed scaling and root planing and 7% to 24% after surgical intervention and open instrumentation by experienced operators."

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MODERN THEORY OF PERIODONTOLOGY - IMMUNE OR TOXIC RESPONSE IS THE CULPRIT - IE THE BONE ITSELF IS TO BLAME FOR ITS OWN DESTRUCTION - LOL - Modern standard periodontology hopey changey is based around the idea of becoming friends with the infection ie appeasement. To get the infection to stop being so toxic and become more friendly. Or to encourage the bone to become less intolerant of the infection.

CALCULUS IS NOT TOXIC - ?? - Really I am quite surprised about this claim. So it is the biofilm living inside the calculus that is toxic? But the calculus itself is friendly? Honestly I don't see how anyone can make this claim with a straight face and expect people to believe them. So that means it is okay to leave a lot of calculus behind then, eh? And if the gums keep bleeding then it turns into a true mystery, eh? Why not just round up the usual suspects? How about if we try that, eh?

Similarly even if the bone can be encouraged to not turn to mush in the presence of the infection the calculus still does occupy space and so does its accompanying biofilm. So the bone simply gets crowded out and a monolith of calculus then gets created that will untimately destroy the bone, the tooth, the jaw, the nearby teeth and your dentition. It is as simple as that.

What this means is the solution is also simple. Get rid of the calculus. Do what you have to do. Get better at it. Do not shirk your duty. BUT ... this is very important... If you get into a mud puddle of crud in way over your head swimming around in sinus and facial nerves and strange bizarre places with no hope... THEN WHAT??? - Basically you are in deep trouble, that is what. If the trouble is too bad then you can get the tooth pulled and go see an oral surgeon. Or still try to DIY and hope you win. Just try to remember to stick to the infection and dead stuff and technically you should not get into too much trouble. Since the living tissue does not co-reside with the dead. Nor with the infection.

NOTE - I have one super-abscess series on my upper right quad that I have been working on in a general way for the past 7 years. Then in a super-serious way for almost two years. It could blow open in a bad way anytime. But it hasn't. I still have some more super-serious stuff to do on it that gives me the willies just thinking about it. But in the meantime my ongoing debridement keeps at least two teeth alive and on an upward spiral. And when I do the dirty deal, again, They could come out of it okay. You never know.

BUT MAYBE YOUR TROUBLES WON'T BE SO BAD - HOW ABOUT THAT? - Yes, maybe you will be able to return most if not all of your teeth to pretty reasonable health and you will never have to face the serious troubles. Or maybe you will decide to face the serious troubles and you will win. OR pull the plug. You can't stop what is coming.

NO COUNTRY FOR OLD MEN - ELLIS - "Whatcha got ain't nothin new. This country's hard on people, you can't stop what's coming, it ain't all waiting on you. That's vanity."

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GENERAL NOTES ON THE DEBRIDEMENT PROCESS - INCLUDING BULLS-EYE THEORY AND PROGRESSIVE DEBRIDEMENT

NOTE - There are books on Dental Hygiene and Periodontal Hygiene that describe the basic debridement process. But more or less the idea is to stick the curette in and then try to catch it on something that is clearly calculus and then to try to pull it out and break off a piece of calculus.

BREAKING OFF VERSUS PEELING OFF PIECES - Peeling off pieces is generally described as negative. Since it can take many many layers of peeling to get to the lower layers. However... if you try to break off too much at once then the force necessary to break off the piece will be too great.

SO WHAT IS THE SOLUTION? - The general idea is to try to get to an edge of calculus that is small enough that the force applied against the curette is greater than the tensile strength of the piece of calculus. This can also be termed as out-flanking strategy.

OUT-FLANKING STRATEGY - The logic is very similar in debridement as it is in warfare. you can imagine attacking a wall that is just too strong. But if you can get to the end of the wall then you can apply a greater force against a smaller countering force. In warfare you would then "roll up the flank."

ROLL UP THE FLANK - It may not be so easy to actually find the flank to roll up. Similarly you may have to actually dig to find the flank. Similarly you can imagine the flank like some rounded object with smooth edges so it is hard to catch an edge on anything. Or like a large pipe at the top of a wall to keep people from climbing over. So certainly it is difficult to find anything practical to debride when you start. But once you find something that you can break off it becomes progressively easier.

Plus quite literally and well as figuratively you can imagine catching your curette on an edge, just like it is the end of a wall and then breaking off the edge. Then what will happen is the end of the "ledge" will break off at an angle, providing another weak point of an edge to break off. And to continue until you "roll up the flank."

LANDING STRIP - This is one way to help set up your edge to find the edge of the ledge to start the breaking off process to roll up the flank. Here what happens is you find a good location that is below the area you want to break off. You can imagine this similarly to some paratrooper landing and then preparing a landing strip for aircraft.

Here you smooth the "landing strip." Then at some point it will become easier to catch the edge of the ledge and break it off.

CONTINUATION OF PROCESS - Idea is then to continue the process until the area stops bleeding. Which means it is relatively clean.

SEVEN CITIES OF TROY - Just like the archeological discovery of ancient Troy the calculus first forms as biofilm on the surface of the tooth. That biofilm then dies and turns into calculus and a new layer of biofilm becomes the "living" portion of the construction. But the calculus is not really dead. It has channels throughout that function as energy transport routes. Plus it supports interior biofilm biology too. It also leap frogs its way down the tooth.

THE RESULT IS THE OLDER LEVELS ARE HARDER - So the debridement process will typically reach layers of calculus that are just too difficult to remove. Close to impossible. But once the upper layers are gone the lower levels become more biologically active. Hence they soften up. Then in a few weeks you can go back and attack these lower layers.

FIRST - SECOND - THIRD - FOURTH DEBRIDEMENTS ETC - Depending on how severe the situation is the debridements can usually be classified as first, second and third debridements. The first debridement cleans things out on a gross level. The second debridement more so. Then figuratively the third debridement gets the area more or less clean.

Likewise you can think of it as primary, secondary and definitive debridement. Or could call it tertiary. But to call a debridement "definitive" more often than not is really just a play of words. Alternately you can imagine the secondary debridment as going on for a series of debridements. Or can imagine the primary debridement as also going on for a series of debridements.

Alternately you can just count the debridements. But if the area is in bad enough shape you might be counting up to some pretty high numbers. Likewise you may only have time or opportunity to get a portion of the area at once. So in general can imagine "primary" as very dirty, "secondary" as still very dirty but not as bad as primary. Then can imagine "definitive" debridement, or maybe "teriary" would be better as a state where it has already been debrided a lot but there is still left to go.

Alternately rather than "definitive" or "tertiary" debridement perhaps there is a better term. Or could just go primary and secondary and think of definitive as more theoretical than real.

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SPECIAL NOTE ON PERIODONTAL MEMBRANE - If things start off really bad and go really deep then when you reach the "end of the line" what you are generally left with is dead periodontal ligament, which I call periodontal membrane. It is like leather and it does not want to come off. SO... after a pretty successful series of debridements you may easily get stuck in limbo with this dead membrane. Oftentimes too deep to get much of a meaningful angle on. So what you need to do is persist. My general feeling here would be to have a lot of short sessions in fairly quick succession, like a week or two apart. Also to use the DuoDerm and the Urea-Papain to try to soften the stuff.

The reason this is so important is that if you can actually debride the membrane then there is a reasonable chance your tooth bone will actually regenerate. Don't get your hopes up too high. But a milometer or two is a reasonable result.

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CASE FOR MARATHON DEBRIDEMENT SESSIONS - 11-02-13 - OBSERVATION - Took the entire day off yesterday to debride the gap between 31-32. Which has a super-deep abscess. Plus two serious bleed-outs so far. See - TOOTHPICK BLOBBAGE -  Plus to debride the lingual side of tooth 31. Including both corners. Which has a cup defect and deep furcation. Issues also include both buccal and alveolar nerve involvement. The buccal nerve seems fairly benign so far, but with past issues and likelihood of deep abscess proximity. The alveolar nerve tingling and numbness comes and goes and has been acting up more lately. Most likely due to proximity to deep infection and not likely due to injury, since have never roughed it up or even gotten too close for comfort. It does its thing and I do mine.

GUMS OPENING UP - SO... planned for long debridement session. Logic was to bleed-out deep sub-mandible abscess for third time. Which never happened. But nonetheless the logic is that the longer the debridement session the more and more the are will open up. So started debriding at roughly 1pm-5pm, or 4 hours. Then from roughly 8pm-5am pretty straight through, or another 8 hours with breaks for a total of 12 hours.

Got a lot done. In particular, after got mostly stymied after trying to open up the abscess again but while still clearing dozens upon dozens of pieces of crud, plus a fair amount of random blood and granulation tissue, I then turned my attention to the #31 Lingual and debrided the hell out of it over roughly a 5 hour stretch. Certainly didn't finish it off, but definitely got down to bone level and by the time I stopped had apparently gotten almost all the large chunks and was mostly down to small pieces.

SO WHAT IS THE POINT?? - That in the process of doing my nearby marathon session on the gap the gums opening up process apparently spread to the nearby deep lingual portion. Apparently. This saved the time of trying to open up that area separately. It also gave the gap additional time to continue bleeding-out. So even if the gap did not get a grand bleed-out it still got to bleed a lot.

PLUS... in the process of doing general debridements certainly most of the attention is given to the upper areas, since they certainly need the work, and the lower areas are not immediately accessible. BUT... when the lower areas open up it becomes imperative to go to town. Since this could be the only opportunity.

SUMMARY - Access to the lower deeper areas of crud down at the bone level can be so hit-and-miss sporadic that every opening-up opportunity should be exploited. Though obviously can't do everything at once. BUT... if commit to a super-marathon session of like 8-10 hours or more then deep access becomes normal. And get many hours to go after the worst stuff. THEN... if somehow area can be brought to resolution then have genuine opportunity to achieve close to definitive debridement leading to close to definitive healing. On a relative basis even 5 hours is just scratching the surface. Likewise the 8-10 hours can reasonably stretch to even 12-13 hours or some crazy amount.

NOTE - In particular, on tooth 16, which was close to toast, ended up doing two marathon sessions. Way back in 1997. Almost 7 years ago. Both debridement sessions were over 12 hours long. The second one resulting in buckets upon buckets of bloody crud, more than I could even believe could possibly exist. Even then had to go back several times to fix up my handiwork. But the result was that the tooth resolved itself. And even has a thin layer of bone in the gap. Have never had any recurring problems. WHY? Because I spent so much time debriding it, and when it finally opened up completely I kept going and didn't stop for like 10-12 hours. I did what I had to do. Plus if I stopped then the area would have closed right back up again and the leftover infection would have been so deep it would have been difficult to get to it. But instead I finished the job and got the benefits of a resolved tooth.

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BACK OFF JACK - NOTE ON DEBRIDEMENT STRATEGY - My general experience has been that calculus does not like to give up. Neither does periodontal membrane. So certainly a lot of time is spent nudging it to give up. But what if you really need it to come loose? Also, what if you have a good mental picture of where it is located and where its "drop-off point" is located? Meaning its edge? Well, obviously what to do there is to back off the curette until it actually drops off. Then to go back and to back off the curette again, but just not quite to the drop off point. So what will typically happen? You will break off a piece! WHY? Because the only reason why the piece breaks off at all it because the force of the curette is greater than the tensile strength of the particular section of calculus holding it both together and to the tooth.

SO WHAT WOULD THE IDEA STRATEGY BE? - Apparently it would be to start off slightly ambitiously, where the calculus is stronger than the force of the curette. Then to shift the curette to it progressively gets applied to a smaller and smaller weaker and weaker area until the piece breaks off. Then to repeat this process until the piece is gone.

EASIER SAID THAN DONE? - YES - ALSO CONSIDER THE LANDING STRIP STRATEGY - Much of the time the calculus is sensed as a monolith. Where no particular area seems weaker than the rest. But certainly where the curette "drops-off" must be weaker, right? Sounds so. Likewise if you can set up so-called landing strips, ie a smooth area, then you will get areas you know are tooth to use as bases of operations into forays against the calculus.

IS THERE A TRICK? - YES - Think the trick is to get used to micro-movements of the curette, of 1mm or less. Or roughly the thickness of a few sheets of paper. That way you can move from an area of high resistance to low resistance very very gradually. So that the moment you have the potential to overpower the calculus you take the opportunity. But don't move so far as to go past the opportunity point.

IS THIS EASY? - NOT REALLY - Certainly this is something I have known for a long time. But do I practice it religiously? The answer is no. Most of the time I am simply opportunistic. Which might explain why I take so many hours and hours to make decent progress and have to mostly be satisfied with a series of small pieces and "getting lucky" with the large chunks. BUT... when I am faced with something that does not want to give up no way no how then I do tend to concentrate. And in particular think if I concentrated more and more on certain particular pieces of calculus that have proved so close to impossible to remove, even after months and months of trying, then it could reasonably be possible to get even the most tenacious piece of calculus to give up. - AND WHY? - Because rather than a random strategy for attack the attack was super-deliberate and executed in fine detail.

IS THIS BS? - Well yes, at least a little. "Oh I have some grand new strategy that is going to save the world." When what you are really doing is committing to a large force effort being applied to a small area in a strategic way, including a time commitment just for that one special thing. Rather than to mostly rely on opportunism. But certainly going to go after the areas of greater opportunity. Once those areas are cleaned then will tend to go after the hardest stuff. Plus tenacious may really mean tenacious, like really, not just imaginary. Meaning that could reasonably just have to be satisfied getting off part of it one time then going back another time and getting more.  

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ORDER OF BUSINESS - How far is far, how deep is deep depends on how bad. Think of it as a mud puddle. Is it shallow, deep or really really deep? Likewise can categorize the stuff to debride. For simplicity, new calculus is not so old and not so tough. Old calculus can be close to impossible. The flat portions of the teeth are not so tough. The corners, especially the sharp corners can be close to impossible. Then comes biofilm, which liberates all by itself. Then comes granular tissue. Which is actually immature and never-to-happen regeneration. Finally comes dead periodontal membrane-ligament and dead cementum. Which doesn't want to give up and which is the final thing that has to get debrided before the area can start to regenerate itself.

OPEN FOR BUSINESS - STOCKHOLM SYNDROME - OPEN WIDE - SPREAD THOSE GUMS FOR ME WOULD YOU? - And let me just stick that curette right in. This is a very important principle. Basically what happens is that it takes roughly 1/2 hour to 1 full hour of stimulation or even longer before the gums open up enough to reach the deepest layers of crud. But once they do then even the deepest layers of all will open up to curettage, even right down to the tooth nerves - and down to the facial nerves too - danger-danger. What this means is that longer debridement sessions of 2+ hours and even 5+ hours make a lot of sense. Since if it takes an hour or more just for things to open up then doesn't it make sense to get as much bonafide debridement time as possible? Also doesn't it make sense to get all the way to the bottom as much as possible? Within guidelines of reasonable safety.

NOTE - I don't know the best answer about what to do if things open up all the way to the nerve. Or if you are swimming around in facial nerves or in your sinuses or in mysterious parts of your jawbone or sinuses and other uppers in the middle of a pile of crud. Since it sounds like you would be taking an area that is essentially unhealthy and exposing your most delicate bodily assets and parts of your mouth to the infection.

One theory here is Bullseye Theory - Which says STOP, let the area recover, then go back. This would be "conservative." The opposite theory - Eye of the Tiger - would say to go ahead. But this sounds really dumb and dangerous. Compromise is - Don't Freak! - Slow Down - Go in close but know when to quit. Also known as getting off the bus one stop before it crashes. Or go in deep, yes, but not too deep. Or get aggressive, yes, but not too aggressive... ALSO, if you do freak, then GET OUT!! Then let the area recover for days and days, weeks and weeks, or months and months. However long it takes for it to recover.

ALSO... Sickles and pointy things are basically knives. So they are very very dangerous. But Graceys don't really have anything pointy or sharp. So they are less likely to damage things. ALSO... Sticking things in moves the infection inward, nest's pas? But not so much when you pull something out, right? So... can go in a little bit... get an area clean... then go in a little more, in case you are dealing with infections that have broken through your inner perimeter into your inner body. Sound scary? Well it should sound scary because it is dangerous. But the alternative is basically to lose the teeth. Because once the perimeter is broken there is no turning back. It just goes and goes. So your only choice is to win. No matter how deep the mud puddle. Or just lose the teeth and forget about it. But even here the deep infection can still persist. Bottom line is there is trouble any way. And no easy answers.

More or less the logic of going in deep is that the accessibility becomes available. So might as well go for it. The logic of holding back, besides avoiding doing anything stupid, is that the deeper you get typically the harder and more resistant it gets too. So if you know when to quit and go back with full commitment then you will eventually open up the area again, even if it takes you an hour to do so, and then the area will tend to be softer, so what might have been impossible a month prior will just give itself up like that.

My developing philosophy is to get more aggressive than I might be comfortable with, but not to freak out until I really do freak out. Try to chill first. Then stop. Since even if you are freaking out there is almost always some latent not so dangerous areas you can trim off and can just stay away from the most dangerous area while still giving things a chance to bleed out some more without too much undue risk.

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SUMMARY - If the periodontal infection is serious enough and if the calculus has infiltrated a significant distance down the side of the tooth then periodontal debridement can turn into a very long process involving up to dozens of hours per tooth. Indeed to attempt to transition and rehabilitate and transform an entire set of seriously infected teeth into a set of teeth that is relatively healthy, even though still seriously highly damaged may take hundreds of hours. Yes, hundreds of hours.

WHY SO LONG? - ROCKPILE IMAGERY -  Largely the process takes a large time because removing each piece of calculus is a very slow process. Also because virtually all of the calculus has to be removed to bring the infection to a temporary halt so the gums can heal. You can imagine the process as similar to lifting heavy rocks away from a giant rockpile. Where the underlying rocks are being blocked by the rocks piled on top of them. So you remove one rock and then another in a long process that keeps going until you get to the bottom of the rockpile.

WHY SO LONG? - SCENARIO IMAGERY - Image a single tooth (or two teeth next to each other). Figure the tooth will have four corners and four flat portions. But each corner has two approaches. So you really have eight corners. Plus you have areas that are relatively shallow and areas that are relatively deep. So if each corner on each tooth takes 3 hours then the gap will take 12 hours. For just one debridement! If the second debridement also takes 12 hours the total is 24 hours of debridement just for one gap. Wow! That's a lot of time. Yes indeed it is. Will it really take that long? Maybe not THAT long. But if you think you can get even one tooth clean in an hour, or if you take the attitude that an hour is enough you are wrong. Simply wrong. A better approach is to keep cleaning an area until it is clean. Commonly I used to stop after two hours, complaining of some imaginary "trauma." Nowdays I just keep going. Often spending 5 or more hours on a single area, usually including opposite corners.

 SIMPLE SCENARIO  - In my experience for an area that is fairly filthy it will take me roughly three hours to get one corner of one tooth fairly clean. Similarly if the entire tooth is filthy it might take me ten or so hours in several separate sessions to get the area fairly clean. BUT that is only one debridement. Will typically have to wait a few weeks for the area to recover and then spend more time.  So let's say two more series of debridements with a total of five hours per series in multiple sessions. So now we are up to 20 hours to get the one tooth fairly clean. Multiply this times say ten bad teeth in total adds up to 200 hours. That is just the way it is. You can spend less time and do a pretty good job. But some crud will still be there left behind. Indeed, even with meticulous cleaning there will still be some stuff left behind.

ABSCESS SCENARIO - The defining issue of periodontal abscesses is that they are deep, very deep. Sometimes even approaching the tooth nerve. Or the other nerves. So as a general guideline I figure two to three hours to get to the gates of the gates of the abscess. Then another two or three hours to break through the gates. Then another two or three hours to bleed out the abscess.  For the first debridement. After that comes more debridement and typically will also include secondary abscesses. Adding up to many many hours. For my tooth #29, the first lower right bicuspid, which had roughly four fairly separate readily identifiable abscesses, I figured that just the basic debridement took over 30 hours to do. Plus I spent at least another ten hours on secondary debridement to get it fairly clean. And another 10 hours or so in an attempt to rehabilitate the tooth. But the tooth is quite wobbly and the lower alveolar nerve is also affected. So may lose the tooth anyway. And if I can't rehabilitate the nerve I may have to sacrifice the tooth for the sake of the nerve.

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I could sing you a tune and promise you the moon
But if that's what it takes to hold you I'd just as soon let you go
But there's one thing I want you to know
You'd better look before you leap still waters run deep
And there won't always be someone there to pull you out
And you know what I'm talking about
So smile for a while and let's be jolly love shouldn't be so melancholy
Come along and share the good times while we can

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- www.diyperio.com
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TOOTHPICK AS DEBRIDEMENT TOOL - In any bad area a toothpick is likely to dislodge a lot of crud and blood. Is this debridement? Most certainly yes. Issue is whether the toothpick will dislodge the underlying calculus. Answer here is yes, it will get the easy pickings and will also work well as a finishing tool. But mid-layer so-called tenacious calculus will well resist the toothpick. BUT technically according to halfway acceptable general theory calculus is housing, not the infection itself. Go figure. So if the calculus is hard enough the amount of present highly active infection might not be so much. So somebody might figure to use the toothpick to get everything as clean as possible and to dislodge major free-floating  blobs and any available monstrosities and in fact can do a major debridement just with the toothpicks alone. While accepting that for the present time the tenacious calculus is left behind. Especially if the infection is more moderate than severe. Or there are areas that are severe but otherwise hard to reach. Since the toothpick can go in very deep and provide both a hard flexible point and resiliancy and rough surface.

TOOTHPICK AS FINISHING TOOL - I am well waking up to this. After serious curettage most certainly want to irrigate with the irrigator to dislodge anything still loose. Both with the needle and with the waterpick. Can include brush-picks too. But also rub the toothpick all around the debrided pocket to help smooth the surface and help leftover calculus to liberate itself. In fact the toothpick makes a great finishing tool and should be part of the plan. To finish off with the toothpick and irrigator.

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HOW CAN DEBRIDEMENTS BE CLASSIFIED? - The simplest model would seem to be 1st, 2nd and 3rd debridements. etc. Which do refer to the actual number of times the area has been worked on. But also refers to stages of activity, ongoing bacteriological destruction and healing. Or can just count the numbers. As in some action being a 10th debridement. But mostly the terms refer to the stages and are meant to be generally instructive and observing. As a guide for future action.

SIMPLE MODEL FOR DEBRIDEMENT? - YES - Can imagine your house or apartment got completely trashed but not completely destroyed in a hurricane or flood or mudslide. And you have to clean it out. SO the first debridement would be with a shovel, clearing out the debris and detritus. The second debridement would again most likely be with a shovel, depending on the completeness of the first debridement. Then can presumably figure goal of the third debridement would be to get the area broom clean.

BUT BEST LAID PLANS FALL VICTIM TO THE FORTRESS - Anyway, this idea is that the calculus has natural layers of depth. And that the upper layers tend to block access to the lower layers. So debridement will tend to take place in a series of waves, separated by healing. Where person goes down to one level, waits for healing and then goes in deeper. In fortress terms can imagine a castle of calculus hidden deep within the forest. SO HOW TO ATTACK? - Figure can destroy the forest protecting the castle. And then use siege weapons to attack the fortress. And if the nerve is getting held hostage then to figure on a long term strategy to get to the bottom and metaphorically destroy the fortress. Or series.

FIRST DEBRIDEMENT - This is the initial attack with arrows and spears and knives and bludgeons on the calculus and biofilm colonial and colonizing infrastructure. In addition is separating the wheat from the chaff. Plus recognition and appropriate action and respect towards all of the different entities involved in the debridement. Besides the actual physical biofilm and calculus are parts of the body, both living and dead. What is the answer here?

REALITY OR MYTH OF ZOMBIE BONE - (NEO-FRANKENSTEIN) - This boils down to two issues. First is what actually happens to the bone. Does it have to die or can it recover? Second is the fact that dead bone can come back to life! Like magic. Under certain circumstances. But if two adjacent teeth both have calculus infiltrated down the sides do not see how the bone in between can survive. If this is true than largely zombie bone is a myth. Alternately there might be deep bone where an attack when the area is in the throes of infection would tend to lead to the cutting out or free liberation destruction of that bone. Which would quite literally be throwing out the baby with the bathwater.

ZOMBIE BONE REHABILITATION IDEA - IF IT EXISTS - Alternately using Bulls-Eye-Big-O strategy, if a person works their way down at a steady rate, sort of like the aliens did to the humans in the Matrix, then possibly enough of the bacterial load can be eliminated to take some of the pressure off the zombie bone. Additionally the area above would get a chance to heal and get stronger etc. Plus the tissue below still held hostage by the infection may be be able to shrug it off a little bit and created isolated islands of neo-healthy tissue. Realistically the zombie bone, if it exists could obviously not yet be able to rehabilitate itself back to life. But the more healthy area around it might tend to give it better support. Then let us just say that we might suppose on the next round of debridement or after that that the healthy tissue will start to dominate. And that the infection can indeed be rejected. At that point it may be possible for bone cells to invade the zombie bone and capture it and use the zombie bone to build new bone. Is this true? Possibly yes. But this is still not an excuse to go aggressively against readily available infection. Though perhaps it is an argument against super-aggressiveness. And it is highly likely it is a complete myth.


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BRIGHT IDEAS vs DUMB IDEAS - Idea is that person does not know what they are doing. But simply moving along from one bright idea to the next. Which is an accurate portrayal. Object is to slow down time to its absolute minimum to focus attention on a particular piece of calculus sticking to the tooth that needs to get removed. Then moving on to the next. Piece by piece. Like moving a Rockpile.

ROCKPILE THEORY - Logic here is to accept experience as valid. What does dislodging calculus feel like? It feels like moving a rockpile. With one rock blocking another rock. With many of the rocks close to impossible. So moving the rockpile is like that. Removing one piece of known calculus. Then removing another. Oblivious of the fact that the entire process is taking long periods of time, like even more than three hours or up to six hours or even more, like up to ten hours in a single location. Huh? Yes, correct. It makes no sense, but given the materials and tools at hand it just takes as long as it takes. Even if those hours are like crazy long - You mean to say you just spent six hours on a tooth? - Not exactly. All the time was spent on one face of the tooth. Plus the corners. It just takes a long time. That is just the way it is. WHY? Because the areas are very deep and very difficult. That is why. And the calculus refuses to give up. So have to dismantle it one small piece at a time. Until there are no more pieces. ALSO - ONE THING LEADS TO ANOTHER - which means that the six hours of dislodging the rockpile is then followed up by another six hours of releasing and bleeding out any periodontal abscess that just happens to be there.

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BIG DILEMMA - The big issue is "layers." Which is how calculus is formed. Object is NOT to remove in layers. Object is DO TRY to remove in big chunks. If you remove the calculus in layers it will peel off with great difficulty one layer at a time. With dozens upon dozens of layers. Endlessly. SEE - CALCULUS HAUL - The progress will be very slow and most of the calculus will remain on the tooth. But if you want you can try again later and after months and months and dozens and dozens of hours may eventually get the tooth fairly clean.

REMOVE CALCULUS IN LARGE CHUNKS - NOT IN LAYERS - But removing the calculus in large chunks, especially if the calculus is deep, is close to impossible. So what are you going to do? If you don't have a plan you can live with then it is not a good idea to proceed. Since you will be doomed to remove the calculus one layer at a time. Which as said is ill-advised.

JOSTLE THE CENTER & BREAK FROM THE SIDE - What I generally try to do, at least most recently, is to try to jostle the big calculus ledges from the center. Then to try to break from the side. Plus to find weak spots. Plus to clean the area around the ledge to getting a starting surface of clean tooth to work from. Then once I get one piece off it will become easier to break off the other pieces. Also I try to catch edges and then just hold on and jostle it patiently for even up to a minute or two. Like a label. Peel it off or crack it off in various places along its edge. Then work into one area deep enough to peel off the entire calculus ledge.

DO BEST CAN TO GET CHUNKS - ACCEPT LAYERS AS THE COMMON THOUGH LESS IDEAL REALITY -  Plus there is no way to eliminate the problem of only removing a layer of calculus and not the entire chunk. Just do the best you can. And also think the way to go might be with more use of the Universal Curettes. And don't just get comfortable with the Graceys and forget to use the Universals.

HOW DEEP IS DEEP? DEEP - And also including here the issue of "depth." Which is that people can and will discover deep pockets that defy imagination. Perhaps even leading into sinuses or major nerves. What to do then? Stop or continue? Clearly stopping will allow the disease to continue. Could also just tell the dentist to pull the tooth. But if you want to save the tooth on your own then this becomes the moment of truth. Or rather the three-month, six-month or year long moment of truth. If it is a mildly severe pocket it will give up and heal after three months. But if it is deep and particularly treacherous it could take a year or more to get the pocket clean. And it will feel like you are floating through an underwater city in a submarine.

THE DILEMMA OF DEEP - THIS IS NOT WHAT I BARGAINED FOR - THIS HOLE JUST KEEPS ON GOING AND GOING AND IT IS STARTING TO GET VERY VERY SCARY AND PAINFUL TO SCRAPE -  But how deep is deep? And how deep is too deep? This is a dilemma. What to do? There are no easy answers here. So what this means is that people would simply have to accept the fact that they may be called upon to go in deep. And they should have strategies about what to do. With the classic being to at least do something. Then give it a chance to heal. Then to go back and do some more.

WHAT DOES AGGRESSIVE MEAN - IS A CURETTE REALLY JUST A MORE ADVANCED TOOTHPICK? - At a most modest level this means toothpicks. At the more agressive levels this means at least aspiration needles. And really means curettes. Then either you quit or the disease quits. There is no other way. But if you can ever achieve anything resembling the mythical 100% Hygiene then your teeth will heal. Like magic. Unless they fail in the meantime. Such as tooth nerve issues or nasty abscess. Which will then be your fault. Unless the tooth was doomed anyway. Or the tooth was going to blow up anyway and all you did was fail to stop it in time. Take your pick.

PAINFUL AREA OF TOOTH - WHAT IS IT? - NERVE OR TOOTH? - DILEMMA - PRIMARY BOTCH - KILL THE NERVE MEANS KILL THE TOOTH - HOW TO DEBRIDE? - This is a big dilemma. To start the overriding principle is Bulls-eye strategy. What this means is to never directly attack or get too close to centers of either what is obviously the nerve, or what you suspect might be the nerve. Generally speaking will get lots of warning from extreme pain.

IN CASE OF PAIN CUT SPEED TO EXTREME SLOW MOTION - TO POINT WHERE HARDLY EVEN MOVE CURETTE AT ALL - WHERE CURETTE JUST HANGS OUT UNDER GUMS -  IMAGINE EVERY SECOND LASTING FOR FIVE SECONDS - This makes it much less likely that you will accidently jam the curette into the nerve, screw the pooch and severely injure or kill the nerve. Meanwhile leaving a wounded nerve in the presence of infection. You might as well kiss the tooth goodbye. Though obviously would still hope to be able to recover from this. Which is still possible. Though it sounds unlikely if there is any infection around the nerve. Which there obviously is if you were able to jam the curette into the nerve. Common sense is the nerve would have a hard time recovering in the presence of infection.

BUT DEEP TOOTH COVERED IN CALCULUS CAN HURT A LOT TOO - WHY? - I am guessing because the tooth starts to taper off. Putting the surface of the tooth closer and closer to the nerve. SUMMARY - If you have this problem you have an extreme problem tooth and a difficult dilemma. Thick layers of calculus right next to the nerve. Both hurt a lot. Who is to say which is which. WHAT IS THE ANSWER? - The answer obviously is not to try to dislodge the calculus in big pieces and to avoid the area right around the nerve.

DO NOT TRY TO DISLODGE CALCULUS RIGHT NEXT TO THE NERVE IN ONE PIECE - ONLY DISLODGE IN FAIRLY SMALL PIECES -  WHY? - Because part of the piece might damage the nerve when you are pulling it free. Think it is probably best to work from the sides and avoid the center closest to the nerve. Also pull away at a steep angle so the calculus gets pulled up, not sideways, which again could damage the nerve.

WHAT WILL HAPPEN IN A WISHFUL THINKING WORLD? -  WHERE THE NERVE IS THE CENTER OF THE BULLS-EYE - RIGHT NEXT TO CALCULUS - A few things are just common sense. One is that the outer areas will tend to get healthier and stronger. Also that the center area right around the nerve will also get at least a little healthier if the area all around it except for the center was adequately debrided. WHAT DOES THIS MEAN? What this means is that after the area has had a chance to heal that you can go in closer to the center. Which is the most vulnerable and dangerous area right around the nerve.

WILL THE CENTER EVER SPONTANEOUSLY REJECT ITS INFECTION? - SELF-FIX SO TO SPEAK? - THINK THE ANSWER IS YES - BUT NOT READILY LIKELY - This is a complicated subject surrounded by wishful thinking. The general idea of any chronic wound is that you debride until the wound "quits the field." What does this mean? What it means is that if an infection is removed progressively at some point when there is almost no infection left anyway the infection basically just gives up. It loses its spirit so to speak. The body then takes the upper hand. So we wishfully imagine the body casting off that last nagging piece of calculus right next to the nerve. Or in some inaccessible area. Is this just a pipe dream.

DO NOT THINK THAT THE BODY SHRUGGING OFF THE END OF THE INFECTION IS A PIPE DREAM - WHY? - Well, to start if you look at the shape of the tooth right around the nerve there are two planes both rounding themselves off at the same time. Almost like part of a ball. So reasonably a little bit of jostling might do the trick without having to get too close. Also have to figure that the nerve largely does a pretty good job trying to protect itself. So it is not unreasonable to figure that even in some pretty nasty infection that the nerve somehow managed to keep itself surrounded with fairly decent protection. Leading to hopeful thinking that the calculus ONLY SEEMS TO BE RIGHT ON THE NERVE AND REALLY ISN'T??

ANYWAY I DON'T KNOW WHY THE BODY CAN SHRUG OFF THE LAST BIT BUT IT CAN - Think it might be relation to liquification - which is a process where the body takes dead organic matter and turns it into a liquid. Which it can do for a small amount but not for a big amount. Following this logic you can imagine a small piece of calculus attached to the tooth right next to the nerve which perhaps already got jostled. So some of the liquifying serum the body produces manages to get between the calculus and the tooth. So next time around a little bit more jostling, plus perhaps a gush of bloody detritus or a good blast of a water jet or toothpick or whatever is just enough to get it to come loose. HURRAY! YIP YIP HURRAY! - But is this true?  ANSWER - IF EVERYTHING HAPPENS JUST RIGHT THEN YES. OTHERWISE NO.

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DANGER - ADDITIONAL NOTE - THE PRIMARY REASON WHY DIY PERIO IS DIFFICULT AND DANGEROUS IS BECAUSE TEETH LACK SELF-LOCATION-AWARENESS.  What this means is that the brain will fill in the missing information and possibly convince the person they are in a different location than they really are. Which is obviously potentially dangerous. But if a person consistently checks where the curette really is and not be so enamored by where they think it is then problems here can largely be averted. The worst possible mistake would be to think you were tugging on teeth when in fact you were tugging on weakened but still possible viable bone. Thereby losing bone unnecessarily. But would think this would hurt a lot. So hard to say how great this actual risk is.

ADDITIONAL NOTE ON SELF-LOCATION-AWARENESS - For most teeth this is not much of a problem since there are not too many possibilities for your brain to fill-in. But for molars this can turn into a more serious problem. Since there are so many possible places you could be. Especially with furcations. For me personally I have given up on trying to figure out where I am and instead rely on "walking the line."

WALK THE LINE - WALK THE DOG - FOLLOW THE CIRCLE - WHAT DOES THAT MEAN? - What it means is that since it is difficult to be able to figure out where you are while under the gumline than try to be content to just run the curette from some reasonble starting point to some ending point. Hence outlining the pocket. Even though you may not know just where in the pocket you are at any particular time. Do it enough times and you will cover all the ground one way or another.

THE BALANCE OF TRAUMA - Now it is true that a slow leisurely debridement provides more time for trauma to set in. But certainly over-aggressiveness speeds up the time for trauma to set in. But if you are not overly aggressive you should be able to manipulate the curette for quite some time, even up to several hours, in the same location, with only a slow buildup in trauma. So there is usually no reason to quit soon.

TRAUMA - ALSO CONSIDER THE TRAUMA OF INFECTION - When coming to the end of debridement it is usually common sense to keep going until you can no longer liberate significant sized pieces or chunks of debris. Additionally the length of time the chronic wound will continue to deliver large chunks is sometimes surprising. The wound will typically be most willing to give up its "crown jewels" at the end of a long debridement process.

TRAUMA - DEBRIDEMENT PROCESS PER SESSION USUALLY COMES TO A NATURAL CONCLUSION - PER FORTRESS WITHIN FORTRESS THINKING - Typically there is more calculus at deeper layers. If you wanted to go after that for a few more hours presumably you could. But it is not a good idea. WHY? The reason is the outer layers, shorn of infection, will tend to heal. Making the area stronger. So the new trauma caused to the deeper layers will be less extensive. So rather than create a huge ugly lengthy mess the idea is to stop, let it heal and get stronger, and then go back and go for the deeper layers. But you can also do marathon sessions to cut to the chase if you are willing to put up with a more extensive open pit. Which could also be worse for the gums. Hard to say. Or maybe it doesn't make a difference. Who knows.


OTHER NOTE - My personal issue against large layers or ledges of calculus is I don't seem to let myself use obvious logic to determine that something is calculus and there is no possible way it can be bone. So I might be swimming between gum and calculus and the calculus is obviously calculus ie it is sticking to the tooth and I am thinking "How can I be sure this is not bone?" - Which is obviously stupid. Since if it is sticking to the tooth it is obviously calculus. But as described, since I do not completely trust my senses and since bone could possibly feel like tooth then can't really know? Hard to say. Depends on situation. So I always try to go for blood and to work from the edges. But if I were more aggressive I am sure there are a lot of calculus ledges I could have gone after more aggressively. Rather than break off in smaller chunks or in layers. So what in reality took a long time might have gone much quicker.

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DANGER - ADDITIONAL NOTE - THE PRIMARY REASON WHY DIY PERIO IS DIFFICULT AND DANGEROUS IS BECAUSE TEETH LACK SELF-AWARENESS.  What this means is that the brain will fill in the missing information and possibly convince the person they are in a different location than they really are. Which is obviously potentially dangerous. But if a person consistently checks where the curette really is and not be so enamored by where they think it is then problems here can largely be averted. The worst possible mistake would be to think you were tugging on teeth when in fact you were tugging on weakened but still possible viable bone. Thereby losing bone unnecessarily. But would think this would hurt a lot. So hard to say how great this actual risk is.

OTHER NOTE - My personal issue against large layers or ledges of calculus is I don't seem to let myself use obvious logic to determine that something is calculus and there is no possible way it can be bone. So I might be swimming between gum and calculus and the calculus is obviously calculus ie it is sticking to the tooth and I am thinking "How can I be sure this is not bone?" - Which is obviously stupid. Since if it is sticking to the tooth it is obviously calculus. But as described, since I do not completely trust my senses and since bone could possibly feel like tooth then can't really know? Hard to say. Depends on situation. So I always try to go for blood and to work from the edges. But if I were more aggressive I am sure there are a lot of calculus ledges I could have gone after more aggressively. Rather than break off in smaller chunks or in layers. So what in reality took a long time might have gone much quicker.

WEASELS RIPPED MY FLESH - SOME CALCULUS LEDGES SUGGEST IT WOULD BE EXTREMELY PAINFUL TO ATTEMPT TO REMOVE ANY LARGE PIECES ALL AT ONCE - What happens is the calculus is laying itself over the tooth. Which is in close proximity to TOOTH TUBULES -

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APICAL PERIODONTITIS - WHAT IS THE ANSWER? What I call Tin Woodsman. Clean, heal, clean, heal, clean heal so eventually an entire field of crud is progressively replaced by healthy tissue. But not so much is removed that the entire area is compromised. This is also a normal variation on the general concept of Progressive Debridement.

WHAT ABOUT 3MIX? - HOLDING OUT FOR BETTER TIMES - Think 3MIX can also play a part. If the tooth nerve is in process of being infected then it might not last long enough for you to get to the last bit of infection. Likewise it could also be suffering from root resorption or a periodontal abscess. So the antibiotic can help keep the tooth alive in the meantime. What happens is the 3MIX penetrates into the dentinal tubules, slipping past the grit in the slim layer blocking the tubules. From there it helps to keep the tooth nerve disinfected and sterile so it can maintain a fighting chance against the onslaught of the constant infection.


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VIDEO - TOOTH 31 - POST ABSCESS DEBRIDEMENT - MANDIBLE SECOND MOLAR - DISTAL LINGUAL - Debridement w PDT QUEEN OF HEARTS - 54:34 - 1 of 7 videos in series - Shows 2nd debridement roughly 10 days after second primary debridement of area that had original primary debridement several months before. Original debridement in interproximal periodontal abscess was in December 2012. Tooth has received multiple series of ongoing debridement ever since. But without much focus on this particular area until now.
- LARGE DOWNLOAD - 136mb -   www.diyperio.com/video-89-31dl-QH-01.wmv

VIDEO - TOOTH 31 - POST ABSCESS DEBRIDEMENT - MANDIBLE SECOND MOLAR - DISTAL LINGUAL - Debridement w Toothpick & Langer 1-2 AE Mini - 2 of 7 videos in series - Continuation...
- LARGE DOWNLOAD - 65 mb -  www.diyperio.com/video-91-31dl-TP-Langer-02.wmv

www.diyperio.com

tom@diyperio.com

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