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Periodontal Disease

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of periodontal disease

Alternative Names

Gingivitis

Treatment

Studies support the effectiveness of active treatment combined with a strict maintenance program for patients with periodontal disease. In one 2002 study, for example, people with periodontal disease who were inconsistent in caring for their gums after treatment had 5.6 times the risk for tooth loss as those who were very vigilant. Some dentists have reported a success rate of 85% when professional treatment and good home maintenance are combined. Treatment helps nonsmokers more than smokers, particularly when pockets are deep and persistent. One study found that periodontal treatment in people with type 2 diabetes actually helped improve blood sugar levels. Whether treatment will help reduce other health risks, including heart attack and stroke, is unknown.

Treatment Goals. Once periodontal disease has been identified, the goals of treatment are the following:

  • To arrest and control the progress of the disease.
  • To leave the periodontal tissues in an easily maintainable state.
  • If possible, to restore the supporting structures, which include bone, gum tissue, and ligaments.

Treatment Phases. To achieve these goals, there are various approaches:

  • Initial Cleaning, Scaling, and Curettage.
  • Surgery (if needed). Surgery is indicated when deep pockets remain underneath the gum after extensive cleaning sessions. The depth of these pockets must be reduced.
  • Low-dose Oral or Topical Antibiotics.
  • Maintenance. After the active treatment is completed and the mouth is in a relative state of health, the patient should have regular cleanings lasting 45 minutes to an hour, approximately every three months. These may be done by the dental hygienist, the periodontist, or the general dentist. They patient may alternate between them. Home care, of course, must be continued.

Antibiotics Before Treatment. In cases where the individual has a mitral valve prolapse or history of rheumatic heart disease, pretreatment with an appropriate antibiotic is required before any dental work, including cleaning. This is necessary to prevent the possibility of bacterial endocarditis, which can be life threatening.

Deep Cleaning: Scaling and Root Planing

Scaling, polishing, and sometimes curettage are used to manage periodontal disease. They are usually accomplished in a series of three to four visits spaced about a week apart. (Patients might ask their dentist about the gas nitrous oxide, which is helpful for many patients and may reduce the visits to a single one.) The dental hygienist or practitioner generally uses both ultrasonic and manual instruments to remove calculus.

  • Calculus above the gum is easily seen. The dental professional usually detects calculus below the gum by careful probing with an instrument.
  • The hygienist or dentist may use an ultrasonic instrument for removal of the more accessible calculus. This probe-like device vibrates at a frequency range higher than is audible to the human ear. Some people with low tolerance for the ultrasonic probe may wish to request nitrous oxide.
  • A spray of water is used with ultrasound to prevent overheating and to flush out the debris that is dislodged. Povidone-iodine (PVP-I), a potent antiseptic, can reduce the level of gingivitis and may be more beneficial than water as the irrigant used during ultrasonic treatment. Further studies are needed.
  • The dental professional will scrape the plaque and from form above and below the gum line (called scaling). When the probe contacts the rock-like calculus, deposits fracture off the tooth fairly efficiently.
  • The hygienist or dentist will then smooth the rough spots on the tooth and helps remove bacteria that collect there (root planing) Smooth the surface also helps the gums reattach.
  • Polishing is the finishing procedure. It employs a rubber cup with an abrasive paste to remove plaque and stains on the crown portion of the tooth. It produces a smooth surface, making it harder for plaque to adhere. Its benefits are short lived, however.

After the cleaning procedure, the dentist will check the pocket depths around the teeth after the cleaning process has been completed. Further treatment needs are determined by the results of these initial sessions:

  • If the cleaning processes have reduced inflammation, observation only is needed.
  • If an abscess is present, surgery is often warranted. (One case study suggested that simply draining an abscess caused by deep pockets and allowing the periodontal pockets to improve and the gum tissue to return to health may avoid the need for surgery. If, in such cases, tissue health has not been achieved, and if the pocket depth is greater than 4 mm, surgery may be necessary.)

Finally, the dental hygienist or practitioner should offer thorough instructions on home care to insure the removal of bacteria on a daily basis. This includes proper use of the toothbrush, paste, mouth rinses, floss, floss threaders, and proxabrushes. Home care can effectively eliminate the plaque above the gums and down to 2 mm below the gums.

Gingival Curettage

Gingival curettage removes the soft tissue lining of the periodontal pockets in order to completely eliminate bacteria and diseased tissue. It may be used along with scaling and root planing, but achieves a deeper and more complete cleaning. Evidence indicates, however, that it does not contribute any additional benefits beyond simple scaling and planing.

Surgery (Open Flap Curettage)

Surgery allows access for deep cleaning of the root surface, removal of diseased tissue, and repositioning and shaping of the bones, gum, and tissues supporting the teeth. Surgical procedures vary depending on the individual diagnosis and needs of the patient. The basic procedure is known as open flap curettage. It involves the following:

  • The periodontal surgeon lifts, or flaps, the gums away from the tooth and surrounding bone.
  • The diseased root surfaces are cleaned and curetted (scraped) to remove deposits.
  • Gum tissue is replaced into positions to minimize pocket depth.
  • The periodontist may also contour the remaining bone and attempt to regenerate lost bone and gingival attachment through bone grafts and guided tissue regeneration or the use of enamel matrix protein derivatives.

There is some debate about whether this procedure is any more effective in preventing disease progression than non-surgical therapies, such low-dose doxycycline, short-term antibiotics, or antibiotic gels. Some studies have reported that although surgical treatment reduced pocket depth more than non-surgical therapies for at least one year after the procedure, benefits from surgery do not persist beyond five years, except in very deep pockets.

Postsurgery Pain and Discomfort. Post-surgery discomfort is usually managed easily with over-the-counter medications, such as ibuprofen. If discomfort is severe, stronger analgesics may be prescribed. Some patients experience sensitivity to hot or cold temperatures from exposed roots; these problems can be managed with topical fluoride treatments or, in severe cases, with dental restoration.

Techniques and Materials for Restoring Gum Tissue and Bone

Guided Tissue Regeneration. A more advanced technique is called guided tissue regeneration, which is being used to stimulate bone and gum tissue growth:

  • First the root surfaces and diseased bone are meticulously cleaned out. Preventing bacterial contamination is very important; the more residual bacteria, the greater the chance that the treatment will fail.
  • A specialized piece of fabric is sewn around the tooth to cover the crater in the bone left after the cleaning. It is either absorbable or nonabsorbable. (Studies are reporting highly beneficial results with new absorbable materials, including one that is coated with the antibiotic doxycycline.)
  • The gum is then sewn over the fabric. The fabric prevents the gum tissue from growing down into the bone defect and allows the bone and the attachment to the root to regenerate.
  • After four to six weeks the nonabsorbable fabric must be removed using a minor surgical procedure. The absorbable membrane may be left in. In general, there is little difference in outcome between absorbable and nonabsorbable procedures. The absorbable fabric may not be as effective as standard grafts if gum tissue is thin, although newer materials may prove to produce better results.

One 1999 study found that guided tissue regeneration techniques surpassed open flap curettage alone in improving pocket depth and attachment gain. In one study of patients who were followed for four to seven years after guided tissue regeneration, the general failure rate was 41%. In smokers, however, the failure rate was 80%.

Bone Grafting. In some cases of severe bone loss, the surgeon may attempt to encourage regrowth and restoration of bone tissue that has been lost through the disease process. This involves bone grafting:

  • The surgeon places bone graft material into the defect.
  • The material may be either bone from the same patient or a substance called decalcified freeze-dried bone allografts (DFDBA) which is obtained from a donor. In one study, bone gain from freeze-dried bone was still maintained after three years, although another study indicated that commercial batches of DFDBA varied in their ability to induce new bone growth. Bone from older donors appears to be less effective for restoring new bone.
  • This material then stimulates new bone growth in the area.

Enamel Matrix Protein Derivative. Amelogenin is a derivative of a major protein in the structure (the matrix) of enamel that helps stimulate gum tissue growth. A gel containing amelogenin (Emdogain) is applied during surgery and forms a coat over the roots of the teeth. The gel itself dissolves after two days, leaving the active substance behind. Studies are reporting that it is safe and may significantly reduce the effects of periodontal disease. A 2001 study suggested that the benefits, as indicated by bone attachment, can persist for at least four years. (Results were similar to guided tissue regeneration.)

Cosmetic and Gum Grafting Treatments

Gum grafting techniques can also be very useful for improving the looks of the gum as well as adding support to the teeth. During this procedure, the periodontist takes gum tissue from the palate or another donor source to cover the exposed root in order to even the gum line and reduce sensitivity. Other procedures are available to improve the look of the gums and teeth. The gum line can be sculpted to improve uneven or excess gums and to cover exposed roots as gums recede.

Implants

Periodontists report that they are achieving greater success with tooth implants in patients who have lost teeth due to periodontal disease. The average cost for a single implant is high, however, and one implant requires five to seven months for completion.

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