Diagnosis and Treatment

Diagnosis and Treatment

Diagnosing Periodontal Disease

• Dental / Medical Histories
• Physical and Clinical Examination
• Photographs
• Dental Radiographs
• Diagnosis
• Consultation and Collaborative Treatment Plan

Treating Periodontal Disease

• Initial Preparation
• Re-evaluation
• Surgical Treatment
• Maintenance

Diagnosing Periodontal Disease

Before any periodontal intervention, a diagnosis must be made. To reach a diagnosis, the patient's dental and medical histories must be taken, a clinical examination must be performed, and dental X-rays (radiographs) must be reviewed. These steps are generally accomplished during the initial consultation appointment, although a second consultation appointment may be needed, particularly when additional information must be obtained.

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Biopsy

Biopsies are common procedures performed when there are findings detected that are suggestive of some sort of pathology that has taken place. After the area is numb, either a section (incisional biopsy) or the entire (excisional biopsy) pathological tissue is removed and sent for an oral pathologist to analyze microscopically. A definitive diagnosis of the pathological tissue can then be determined and appropriate treatment recommended thereafter.

For areas that are suggestive of pathology, a preliminary biopsy can be performed to assess whether or not there has indeed been unfavorable cellular changes within the area of concern. A brush biopsy is a procedure whereby a small scraping of the tissue from the area of concern can be performed (usually without any anesthetic required) to assess whether there has been any changes within the cells that make up the tissue in the area of concern that is suggestive of cancer. If the brush biopsy reports that there has been no cellular changes of concern, continued and periodic observation is usually all that is required. If there has been cellular changes suggestive of oral cancer, a more intimate analysis will be required, either in the form of an incisional or excisional biopsy.

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Dental / Medical Histories

For decades we have known that a prime indicator for future periodontal breakdown is a past history of periodontal disease. By taking a dental history and evaluating previous X-rays, we have a better understanding about the rate of disease progression, and can determine what must be done to prevent further breakdown. In the last decade periodontists have also begun to understand that periodontal disease is a result of bacteria interacting with the patient's defense systems. How the patient's body responds to the bacterial (plaque) assault depends on the "host" resistance. Some people are fortunate, and have minor periodontal disease even with poor oral hygiene. For others, the same amount of bacteria may cause advanced periodontal disease and bone loss.

In other words, certain patients are very susceptible to periodontal disease, and these patients must be particularly diligent with their oral hygiene and maintenance to reduce the bacteria challenge. By taking a complete medical history we can determine if the patient has certain risk factors and may modify treatment accordingly. Below are the most significant general health considerations that may affect periodontal disease susceptibility.

Smoking-A host risk factor that CAN be altered, and one that GREATLY increases the risk of disease.

Diabetes-Increases the risk of disease if not well controlled.

Stress-Long-term stress may adversely alter the way we fight periodontal disease.

Hormones-Increases in gingival inflammation is seen with increased levels of estrogen.

Medications-Dilantin and several common heart medications may cause medication-induced gum overgrowth.

Severe Osteopenia-May result in more jawbone loss, particularly in post-menopausal women.

Family History/Genetics-About one-fourth of the population is genetically more susceptible to periodontal disease.

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Clinical Examination

The periodontal examination gives us complete picture of the periodontal condition of your oral health. This information is needed before an accurate diagnosis can be made. The oral exam is supplemented with information gained from the dental X-rays. Sometimes, bacterial samples are obtained and evaluated to determine the presence of an aggressive disease pattern. Often adjunctive use of antibiotics in combination with periodontal treatments are necessary.

A major focus of the exam is to determine how much bone loss has occurred. When healthy, there is generally a 2-3 millimeter space (sulcus) between the tooth and the gum. This space deepens as bacterial plaque causes bone deterioration, and penetrates down the side of the tooth.This deepened space is called a pocket.

Each tooth is measured (probed) (See What is Periodontal Disease?) at six places, surrounding the tooth, to determine the pocket depth. Normally anesthesia is not needed for this charting, which gives the dentist a blueprint of periodontal changes.

• Gum recession-The amount of recession added to the pocket depth determines total attachment (bone) loss.
• Furcations-Bone loss into the furcation of a tooth compromises the prognosis.
• Amount of attached gingiva-Without adequate attached gingiva, recession will occur.
• Occlusion (bite)-Excessive forces on teeth may accelarte bone loss.
• Tooth mobility (looseness)-Generally indicates inadequate bone support or a bite problem.
• Patient oral hygiene-Poor brushing and flossing will greatly compromise the long-term result

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Dental Radiographs (x-rays)

A good series of dental x-rays is mandatory to accurately evaluate and diagnose your oral health. They help determine the amount and location of bone loss, the size and shape of the roots, the amount of root still embedded in the bone, the relationship of the teeth to each other, whether the nerve in a tooth has died, the location of the sinus and mandibular nerve when placing implants, and oral pathologies, among other things. We are not able to treat a patient unless we have adequate x-rays, that are of diagnostic quality. On occasion this way we necessitate that we secure our own x-rays for you. The exception is gingival grafting, which normally does not require x-rays.

There are a number of different types of dental x-rays, each with a specific purpose, but for periodontal treatment a full series of periapical films is generally required. Below is a list of the commonly taken x-ray views, and the indications for each. (Click for a more detailed discussion and examples of each type of x-ray).

Full Mouth Periapicals-18-21 detailed views of the teeth and surrounding bone, necessary for an accurate periodontal examination.
Panograph-A single screening film showing an overview of the upper and lower jaws, sinus, temporomandibular joint, and other anatomic features.
Vertical Bitewings-Four to seven detailed views of the teeth that can show both decay and bone levels when severe bone loss has not occurred.
Digital x-rays-Any x-ray that is stored digitally, on a computer. Generally available in periapical and bitewings only.
CAT Scan-Detailed three-dimensional digital x-ray stored on a computer for implant treatment planning.

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Diagnosis

Once the clinical data is gathered and correlated with the x-ray findings, your periodontist is able to organize and systematically evaluate the results to make a diagnosis. This is critical, for while there may be various approaches to treat a problem, there can be only one correct diagnosis. Once the diagnosis is determined, various treatment options can be formulated. With this information the periodontist and the patient can determine which treatment plan to follow.

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Treating Periodontal Disease

The steps to treating periodontal disease

The treatment of periodontal disease involves these main steps:

• Step One
• Step Two
• Step Three
• Step Four

I: Initial Preparation (click for detailed information)

The first step of treatment is to eliminate all of the known causes of the periodontal disease. Mouth bacteria found in saliva forms colonies on the teeth and tissues, which is called plaque. This clear film of bacteria is the primary cause of periodontal inflammation and breakdown. Calculus (also known as tartar) is formed when salts from the saliva precipitate into the plaque. This forms a hard substance, which adheres tightly to the tooth, similar to barnacles on a boat's hull. Both the calculus and the plaque must be removed to achieve a successful result. The patient is taught to remove the plaque, while the dental professional must remove the calculus. Initial preparation also includes creating an environment that makes plaque removal by the patient as easy as possible. The following outline lists factors that may be addressed during initial preparation.

• Bacterial culture to determine the benefit of antibiotic therapy (combined therapy)
• Demonstration of proper oral hygiene procedures to remove surface plaque
• Scaling and root planing to remove calculus and deep plaque – typically performed in two sessions with half mouth treated per session and done with local anesthetic
• Smoothing or replacement of fillings that do not fit well and thus retain plaque
• Removal of hopeless teeth that may jeopardize good teeth
• Adjustment of bite (occlusal equilibration) if needed
• Minor orthodontics to better align teeth
• Placement of a night guard to prevent clenching at night

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II: Perioscopy-endoscopically assisted root planing

Following Initial Preparation, the tissues are re-evaluated after they have a chance to heal to determine if more periodontal therapy is needed. If the disease has been arrested, the optimal periodontal maintenance (cleaning) schedule is determined for the patient. If the disease persists, further non-surgical treatment may be performed. If surgery is needed to eliminate pockets that persist, a surgical treatment plan is formulated. The re-evaluation appointment is similar to the initial consultation appointment and is generally at no charge.

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III: Surgical Treatment

Initial preparation generally produces shrinkage of the inflamed gum, and thus a reduction of the pocket depth. Often, if the patient has excellent oral hygiene habits and keeps regular maintenance appointments, this is enough to stabilize a case. However, with pockets that continue to bleed when probed, or with pockets deeper than 5mm, there is a high probability the disease process will continue. In those cases, elimination of the remaining pockets is the best treatment.

There are three primary surgical procedures that may be used to treat remaining disease after Initial Preparation (Click any heading for a more detailed discussion and clinical examples).

• Osseous Surgery-The most common surgical procedure, giving the periodontist access to the jawbone. In most advanced periodontal cases, the bone has been altered by infection and smoothing irregularities is needed. The goal is to correct the disease and create a maintainable situation long-term for the patient and the hygienist.
• Regeneration Surgery-Ideally, periodontal therapy would regenerate bone and tissue back to its original form. While this is not always possible, new techniques are allowing for more predictable regeneration of tissues.

The goal of periodontal surgery is to give the periodontist access for treatment, and to reduce pocket depth. The ideal surgical result is pocket elimination, giving the patient the ability to remove plaque from the sulcus daily. In some cases the pockets are so deep that complete elimination is not possible, and some depth remains even after surgery. Some of these teeth may be considered questionable, and their long-term prognosis guarded. However, as long as these teeth do not jeopardize surrounding dentition, are functional, and do not cause discomfort, they are maintained. Many questionable teeth are kept for years, if the patient is able to perform a high level of oral hygiene and stay on a good maintenance program.

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IV: Periodontal Maintenance (click for more information) 

The two most important factors in determining long-term success are patient home care, and compliant frequent periodontal maintenance (cleanings). It has been shown that without routine maintenance there is a 20-fold increase in the chance of recurrent disease. Most patients who are susceptible to periodontal disease must be seen for periodontal maintenance appointments every three months, rather than the typical twice yearly cleanings. Often, maintenance appointments are alternated between the general dentist and the periodontist. There is nothing a patient can do that is more important to maintaining a healthy mouth than daily flossing and brushing along with consistent periodontal maintenance.

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Initial Preparation (STEP ONE)

The first step of periodontal treatment is the removal of all known and recognizable causative factors. When these are removed, the body has a chance to heal, and the tissue will tend to shrink and tighten against the teeth. This reduces pocket depth, and may be all the treatment needed. Initial preparation may include some or all of the following:

1. Oral Hygiene Instruction
2. Scaling and Root Planing (Deep Cleaning)
3. Removal of Faulty Fillings/Crowns
4. Endodontics (Root Canals)
5. Removal of Hopeless Teeth (Extraction)
6. Removal of Hopeless Roots (Root Resection)
7. Occlusal Equilibration (Bite Adjustment)
8. Minor Tooth Movement (Orthodontics)
9. Stabilization
10. Night Guard
11. Re-evaluation

1.Oral Hygiene Instruction

Personal oral hygiene is the foundation to long-term periodontal health. Few people know how to adequately brush and floss, and home care instruction is important to a successful case. Essentially all periodontal treatment is directly or indirectly focused on plaque reduction, and the more proficient patient plaque control, the better the case result. Remember that learning proper brushing and flossing techniques takes some time and effort, but after several weeks of practice they will become second nature. There is no way to over-emphasize the importance of learning home care skills. The use of an automated toothbrush is recommended since it simplifies brushing and improves efficiency.

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2. Scaling and Root Planing (Deep Cleaning)

Scaling and root planing is the removal of all hard and soft deposits from the teeth. Scaling usually refers to removal of deposits above the gum line, while root planing refers to removal of deposits on the root itself, below the gum line. Deep cleaning is a lay term generally referring to root planing (under the gum). The soft bacterial deposits that form on tooth surfaces will become hard over time, attaching to the root like a barnacle to a boat hull. These deposits must be removed to eliminate the infection in the gum. Complete scaling and root planing is generally done with local anesthetic ("Novacaine"), and takes from 2 to 6 hours, depending on the case. The deeper the pocket, the harder it is to remove all deposits because of difficulty in seeing and reaching deeper deposits. With deep pockets, surgery is the only way to effectively clean the root surfaces.

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3. Removal of Faulty Fillings/Crowns
Smoothing or removing faulty fillings is needed to prevent shredding of floss, and to remove nooks and crannies where bacteria can hide. Poor restorations can make adequate oral hygiene an impossible task.

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4. Endodontics (Root Canals)

At times it is difficult to tell whether an abscess that forms on the gum's edge is originating from a periodontal pocket, or from an endodontic (root canal) problem. In the latter, the nerve of the tooth has died and infection is draining from the tooth tip out through the gum. If the source of the abscess is a dying nerve, then the gum problem will be corrected by performing a root canal. If the tooth also needs periodontal work, the root canal is usually performed first to help with the periodontal healing. In addition, if a tooth is going to have a root resection, endodontics must be performed before or soon after the procedure.

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5. Removal of Hopeless Teeth (Extraction)

Our purpose and commitment to you is to save your teeth. However, if a tooth is very weak, and cannot be saved, extraction may be recommended. This is particularly true if leaving that tooth in may cause an adjacent tooth to be lost from the enlargement of the pocket, or if leaving the tooth will mean less bone support later for partial dentures or implants.

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6. Removal of Hopeless Roots (Root Resection)
At times one root of a multi-rooted tooth (upper molars have 3 roots, and lower molars have two roots) is hopeless, but the rest of the tooth is healthy. In these cases a root resection may be appropriate, and the hopeless root is removed, while retaining the tooth. Endodontics is always necessary with this procedure, and a crown is generally needed later to strengthen the tooth.

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7. Occlusal Equilibration (Bite Adjustment)

If teeth do not hit evenly, some teeth will be subjected to more forces than they can tolerate. Over time these teeth are more susceptible to bone loss. Bite adjustment (occlusal equilibration) smoothes off the high spots and spreads normal chewing forces evenly over all the teeth, so they may function in health.

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8. Minor Tooth Movement (Orthodontics)

Teeth that are mal-aligned are difficult to keep clean, cannot take their share of the biting load, and may be unsightly. Minor tooth movement may correct these problems, and create a healthy environment. In some cases, orthodontically moving a tooth may actually reduce pocket depth and lessen the need for periodontal surgery. Using another orthodontic technique, forced tooth eruption, teeth with decay near the bone may be extruded so the decay is visible, helping preserve a cosmetic result by reducing the need for bone recontouring. Generally, these small orthodontic procedures take only a few months to complete.

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9. Stabilization

After minor tooth movement, or if teeth are loose due to bone loss, stabilization may be performed to help tighten the teeth. Two or more teeth are connected together so they may support one another, using crowns, bonding, or other methods.

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10. Night Guard Occlusal Splint Therapy

Some patients clench their teeth unconsciously when they sleep. This causes enormous stress on the teeth, and if they are already weakened from periodontal bone loss, can lead to tooth loss. A plastic mouthpiece (night guard - also known as occlusal splint therapy) may be worn at night to prevent these excessive forces from harming the teeth.

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11. Re-evaluation

The last, and most important, step of initial preparation is the re-evaluation. Only then can we (Drs. Rosenfeld and Mandelaris and the patient) determine if the procedures have eliminated or stabilized the disease. During this phase, together we decide if further work is needed, and if so, what treatment would be best. If the case is stable, a maintenance (periodontal cleaning) schedule (usually every 3 months) is determined to keep the periodontal tissue in good health.

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Forced Tooth Eruption

One way orthodontics is used in treating periodontal disease is forced tooth eruption. When a tooth is moved orthodontically, the bone will follow the tooth as long as there is no inflammation. Thus, if there is a bone pocket next to the tooth, it may be possible to erupt the tooth out of the defect. In the illustration below, there is a 4mm bone pocket next to the tooth. If pocket elimination surgery were used to correct the pocket, much of the adjacent bone would have to be ground away to allow the gum to again connect to the tooth next to the bone. However, if the tooth is extruded 4 mm, the bone will follow it up until it is level with the adjacent bone. The pocket is now gone, without bone surgery. Also, because the height of the tooth must remain the same so the patient's bite won't be affected, the top of the tooth is reduced as the eruption progresses. This normally can be done without causing the tooth to need a filling or crown. By shortening the part of the crown out of the bone, the ratio of tooth in bone to that out of bone (the crown/root ratio) improves. This stabilizes the tooth, and makes it stronger. In this example, the crown/root ratio has improved from 10/6 to 6/6.

Another common use for forced eruption is to allow better access to deep decay. While the gum and bone can be surgically removed until the decay is seen (See Crown Lengthening), this may create a high gum line and a cosmetic problem with front teeth. By erupting the decayed tooth, the adjacent teeth are not affected when exposing the decay. In the example below, the deep decay is clearly seen on the pre-operative x-ray. After orthodontically extruding the tooth, the new x-ray shows the decay much nearer the gum surface. When the gum is reflected, the decay is easily seen. Note that the bone erupted along with the tooth, and is now too high on the extruded tooth. That bone is leveled with the adjacent bone, and the gum closed. Note that no bone on the adjacent teeth needed to be moved higher. The final x-ray shows the bone level the same as with the pre-operative x-ray, while access for a crown has been achieved.

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Types of X-Rays

Full Mouth Periapicals

The most complete periodontal x-ray exam is the full mouth periapical exam. Each film shows the entire tooth and surrounding bone, in detail, and allows Drs. Rosenfeld and Mandelaris to see subtle change occurring in the bone support. Root canal problems around the root tips are also easily seen. Generally 16-18 films are exposed. It is recommended that patients who have had moderate or advanced periodontal disease have full periapical x-rays every three years. In addition, bitewings are suggested every 6-12 months to check for decay.

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Panographs

A common screening film is the panograph, which gives an overview of both upper and lower arches and the surrounding anatomic structures. When taking this x-ray, no film is placed in the patient's mouth, and the x-ray machine circles around the head. While a useful screening tool, and important for implant placement, it lacks the detail needed for a complete periodontal exam. We generally do not use the panorex x-ray to assess a patient's periodontal health.

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Bitewings

The bitewing x-ray is commonly used to detect decay  and may be used in the general dentist's screening in conjunction with the panograph. It shows the crowns of the upper and lower teeth at the same time and shows good detail. Normally 4 films are taken. Unfortunately, the bone is often not visible, which limits the usefulness of bitewings in periodontics. Bitewings are generally recommended every 6-12 months to check for decay

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Vertical Bitewings

Vertical bitewings are films that show both upper and lower teeth, but the view extends farther down the root, generally giving an excellent image of the bone. Normally 4-7 views are taken. In cases of severe bone breakdown, the film will not show all the bone, and root canal lesions also do not show. We also request that vertical bitewings be taken on periodontal patients, not horizontal bitewings.

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Digital x-Rays

Digital x-rays don't use conventional x-ray film, but rather the image is stored in a computer and projected on a monitor. There are a number of advantages to digital x-rays, including even less radiation needed for exposure, and having the ability to manipulate the image on the computer to optimize the view. Since our office is fully computerized, we can input your digital x-rays to our x-ray software system if taken at another office. If we take your x-rays, they may or may not be taken using digital technology. If not, a conventional x-rays or x-ray series will be taken, scanned into your computerized record, and the original copy sent to your dentist.

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