DescriptionAn in-depth report on the causes, diagnosis, treatment, and prevention of periodontal disease
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:
Treatment Phases. To achieve these goals, there are various approaches:
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.
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:
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 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:
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:
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:
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.
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.