Treating Periodontal Disease

Treating Periodontal Disease

An Overview

There are two main objectives in treating periodontal disease. The first goal is to reduce and control the bacterial colonies that form under the edge of the gum. The second goal is to eliminate any known factors that cause the patient to be more susceptible to breakdown. Primary among these is smoking.

In the early stages of periodontal disease (gingivitis), the gum is infected but the bone has not yet been altered. The pocket depth is generally only slightly deepened, to 4-5 mm. Scaling and root planing ("deep cleanings") is performed to remove any calculus that has formed. If the pockets are tender, numbing the gums is often necessary so there will be no discomfort during the procedure. There is little or no pain afterward. The patient must keep plaque from reforming by daily brushing and flossing. The healing gum will snug back up around the root, and health will return. Daily plaque removal with regular dental cleanings will prevent a reoccurrence.

In a few cases, the swollen gums may not shrink back to normal after the infection is removed, and must be trimmed by the dentist with a gingivectomy. Otherwise the swollen gum makes removal of plaque by the patient impossible, and the problem starts again.

In more moderate cases, there is actual bone loss, and the pockets may be 5-7mm in depth. Scaling and root planing will not predictably remove all the calculus from these deeper pockets, because of limited and difficult access in reaching the bottom of the pocket. In these cases flap surgery is needed so the periodontist can gain access to clean the root. With this procedure, an incision is made between the gum and tooth, and the gum is peeled back away from the neck of the tooth and the edge of the bone. The surgeon can then easily see the deep calculus, and adequately debride the tooth.

After flap surgery the tissue may be returned to its former position, which minimizes cosmetic changes. However, because the gum cannot connect back to the tooth, this does not eliminate the pocket. With the pocket remaining, the patient cannot remove all the bacteria, and must rely on frequent hygienist cleanings to help control reoccurrence of the infection.

The ideal flap surgery, pocket elimination surgery, is achieved when the periodontist surgically removes the pocket by repositioning the gum down to the new bone level. Any irregularities or pitting of the bone that was caused by the infection is first corrected, and the gum is sutured tightly down to the re-contoured bone. This pocket elimination allows the patient to access and remove the bacterial plaque daily with brushing and flossing. If all plaque is eliminated daily, the disease is completely arrested.

Pocket elimination surgery can cause cosmetic changes around the upper front teeth, and the periodontist may avoid pocket elimination surgery in this area to minimize any changes that could be seen. In these areas, different approaches of disease resolution may be preferred over surgery.

During surgery the periodontist can see and reach all areas, allowing for better tooth cleansing. However, each case is treated according to need and in cases where the need for surgery is not certain, the non-surgical scaling and root planing is performed first. The patient is then re-evaluated to see if further treatment is required.

In advanced cases, there has been extensive bone loss, and pocket depth may be 7mm or more. In these cases complete removal of the pocket is often not possible, due to limitations on how far the gum can be moved. However, surgery is necessary for the periodontist to access and clean the deeper areas, which cannot be effectively scaled without reflecting the gum. The objective is to thoroughly cleanse the roots, and to reduce the pockets as much as possible. Antibiotics may be prescribed to help eliminate very aggressive bacteria.

In the last decade there has been much research in actually re-growing the bone destroyed by periodontal disease. While not effective in all cases, today many periodontal lesions can benefit from these regeneration procedures. Your periodontist will tell you if you are a good candidate for regeneration. (See Regeneration)

In cases where surgery is not, or cannot, be performed, or in very advanced cases, there are often residual pockets after treatment. The deeper these pockets, the more guarded the long-term results will be. We try to reduce pockets as much as we can. As a rule of thumb, the shallower the pocket, the better the chances of maintaining the tooth. With a shallower pocket, the hygienist is able to clean more thoroughly at recall appointments, and the patient is able to remove a greater percentage of the plaque that forms.

Periodontal disease may be considered a chronic disease, and for that reason a complete "cure" is usually not possible. Patient susceptibility may continue to be high, and the cause of infection, plaque, is always present in the mouth. Daily vigilance is needed to control the disease and keep the gums in good health. Even with the best care certain areas may lose ground, although the vast percentage of patients who follow good maintenance can expect to have their teeth for their lifetime.

In summary, the treatment of periodontal disease focuses on removing bacterial plaque and calculus that forms under the gums. In more severe cases surgery is used to provide access for scaling, and to reduce pocket depth so the patient can more effectively access and remove plaque from their teeth at home. Good oral hygiene along with regular periodontal maintenance appointments (recalls) will help preserve the teeth for a lifetime.

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Scaling and Root Planing

The heart of all periodontal therapy is removal of calculus and plaque from the tooth. Removing debris from the crown of the tooth is often referred to as scaling, while root planing (debridment) refers to cleaning the root below the gum. This procedure is also referred to as deep cleaning. To successfully treat periodontal disease it is necessary to adequately debride the periodontal pocket. This is generally accomplished using curettes and/or ultrasonic scalers, although rotary instruments may be useful. Adequately cleaning a periodontal pocket takes time and skill, and many feel it is the most technically demanding procedure performed by dentists. Often a local anesthetic is used to assure patient comfort. In certain instances, the local anesthetic can be applied without a conventional needle, making it truly painless.

With early and moderate pockets, up to 5 mm in depth, adequate pocket debridement may be possible. However, with pockets over 5 mm, much of the root calculus is missed. Many studies have shown that deeper pockets are cannot be adequately cleaned with any technique, unless the gum is reflected to improve access. This minor surgical procedure consists of making a small incision to push back the gum edge, allowing access to deeper areas. This is known as open flap surgery, and is done under local anesthesia. Dissolvable sutures are generally used, but there is little post-operative discomfort.

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Flap Surgery

By far the most common surgery used in periodontal therapy is flap surgery. Moderate to advanced periodontal disease involves gum pockets (See What Is Periodontal Disease?) that are too deep to clean without reflecting back the gum tissue for access. Without this access, deep calculus and plaque cannot be removed from the root, and the disease will progress.

Once the pocket is cleaned, the gum may be returned to its original level. This results in a clean root, but the deepened space is still present. Frequent cleanings by the hygienist are necessary to remove the plaque in the residual pocket that the patient cannot reach with flossing and brushing (See Periodontal Maintenance). Even when there is good oral hygiene and regular quarterly recalls, the bacteria may still continue to cause the pocket to become reinfected. When cosmetics are not a concern (on the lower teeth, the inside of the upper teeth, and the outside of the upper back teeth), the surgeon may elect to suture the gum down to where the bone has resorbed, reducing the depth of the space. If the space is reduced to 3 millimeters or less, the patient can be more effective with keeping the disease stable and non-progressive (in recession).

In the majority of moderate to advanced cases, the bacterium has caused the bone to resorb and become pitted. In these cases, flap surgery gives access not only for root cleansing, but allows for recontouring of the bone itself. The technique of osseous surgery, along with professional maintenance is performed whereby the bone is recontoured to its natural scalloped shape, and eliminating the “pockets.”

The patient is then able to prevent recurrence of the disease by keeping the shallow space clean with brushing and flossing.

Bone recontoured after flap reflected.	Tissue sutured down to smooth bone to eliminate pocket.

Flap surgery is also needed if regeneration procedures are to be performed. Here the gum is reflected back to allow insertion of a bone graft for guided tissue regeneration purposes (See Regeneration Surgery).

In summary, for most moderate and advanced cases, it is impossible to be able to reach under the gum to treat the infection and diseased tissues. By using flap surgery, the periodontist is able to access these areas to provide the optimal care holting the disease. With today's medications, surgery should be painless with only a minimal amount of post-operative discomfort (See What to Expect from Surgery).

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Regeneration Surgery

The ideal outcome in the treatment of periodontal disease is to return the tissues to their original state, as they were before the infection started. While we cannot do this with all cases, today more and more pockets can be restored, at least partially, with regenerative surgery. There are three primary types of regenerative surgery:

1. Bone Grafting
The oldest technique used in regeneration surgery calls for placing various materials in the bone defect, to stimulate the patient's bone to re-grow. Bone grafting has been used for over 75 years, but today's materials are much superior in stimulating new bone to form. The implanted material is resorbed by the body, and after 6-12 months has completely disappeared, replaced by new bone. Various materials are available, with the selection made on a case by case basis.

Placing synthetic bone Synthetic bone placed in defect

Synthetic bone stimulates patient's natural bone to regenerate

2. Guided Tissue Regeneration
A more recently developed type of regenerative surgery depends on guiding the proper tissue to heal the periodontal lesions. Gum tissue heals very quickly, and after surgery migrates down into the bone pocket quickly. Unfortunately, this does not allow time for the bone to refill the pocket, so the defect persists. With guided tissue regeneration, the gum tissue is excluded from the bone defect with a resorbable membrane, allowing time for the bone to fill back in. This technique has been available for 18 years, and in certain areas is extremely predictable. Click here to see a Clinical Case.

3. Cell Stimulation
The most recent development in periodontal regeneration is the use of proteins to induce the formation of tooth supporting structures lost to periodontal disease. Available since 1999, the procedure calls for placing embryonic cells into the defect, which in turn stimulate production of new bone and tissue cells which reform the normal periodontal complex. These cells are porcine (pig), and carry no risk of disease transmission. While long-term studies are not yet available, the research to date warrants use of this approach under certain circumstances. (www.perio.org)

The periodontist must decide in each case whether the chances of improvement warrant the added expense of bone regeneration. However, restoring bone and the periodontal complex is the gold standard, and periodontal regeneration is being used more and more.

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Emdogain

Emdogain is a recently introduced product that fools the body into forming new bone, cementum, and attachment fibers. Technically, it is enamel matrix proteins (amelogenins) that are taken from developing teeth in pigs. These proteins are similar in all mammals, and humans do not recognize them as foreign. There is also no chance of transmission of any bacteria or virus by the proteins. In tooth development, the secretion of these proteins onto the developing root surface precedes the formation of tooth attachment. A similar action occurs when the proteins are placed on a root surface that has lost bone and attachment from disease. When applied to the root surface during surgery, these proteins assemble into an insoluble matrix layer that promotes the attachment of mesenchymal cells. These cells produce new matrix components and growth factors that participate in the regain of tooth attachment. Emdogain also inhibits epithelial cell growth that could interfere with proper tissue and bone reformation.

Please click on the images for a larger view.

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Guided Tissue Regeneration - Clinical Case

When any surgery is performed in the mouth, gum heals over the wound very quickly. This is a defense mechanism, as the body tries to re-establish a protective "skin" to prevent outside infection. This healing also occurs after treating a periodontal pocket, and the gum quickly fills any void created by the deterioration of infected bone (See What is Periodontal Disease). Unfortunately, this does not give the slower healing bone a chance to regenerate, which would restore the pocket back to its original healthy form. With guided tissue regeneration, the gum is excluded from the "wound" by placing a barrier between the gum and the defect, thus keeping the gum out. This allows time for cells in the periodontal ligament and surrounding bone to form new bone. While complete bony regeneration is rare, there are certain types of pockets that can be predictably restored to a remarkable degree. Your periodontist can tell you if you are a candidate for this procedure.

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Click here for more information on treating periodontal disease from the American Academy of Periodontology Consumer Page.