PERIODONTAL THERAPY

Periodontics is a specialty of dentistry that deals with the maintenance of health and the diagnosis and treatment of gum disease, as well as the placement of dental implants. A periodontist is a dentist who has completed a university post-graduate specialty program in periodontics.

Periodontitis, like any other chronic disease (e.g., heart disease), will progress if untreated or inadequately treated. Moreover, it will recur if given the chance. Thus, it is very important to complete all the steps of the recommended treatment, from beginning to end.

The goals of the treatment are to control the cause (bacterial plaque) and the risk factors, repair the damage present (pockets) and restore and maintain a healthy environment.

DEFINITION OF PERIODONTITIS

In the broadest sense, periodontal disease can be considered any form of disease affecting the periodontium – the tissues that surround and support the teeth. Inflammation of the bone is called periodontitis.

The periodontium also includes the gums (or gingiva), the bone of the tooth socket, and the periodontal ligament – a thin layer of connective tissue that holds the tooth in its socket and acts as a cushion between tooth and bone.

Inflammation or infection of the gums is called gingivitis. If allowed to progress, gingivitis can turn into periodontitis, the invasion and destruction of the underlying bone that anchors the teeth in place. As that happens, the gums may recede, exposing the root surfaces and increasing sensitivity to heat and cold. Teeth may even loosen because of bone destruction.

CAUSES AND RISK FACTORS OF PERIODONTITIS

These conditions can arise for a variety of reasons. A severe deficiency of vitamin C can lead to scurvy and result in bleeding, spongy gums, and eventual tooth loss. And at least one periodontal disease – the uncommon but highly destructive juvenile periodontitis – is thought to have a strong genetic basis. But as the terms periodontal disease, gingivitis, and periodontitis are most commonly used, they refer to disease that is caused by the buildup of dental plaque.

Plaque is a combination of bacteria and sticky bacterial products that form on the teeth. Its source is the natural bacteria in the mouth, of which more than 300 different species have been identified. In small amounts and when newly formed, plaque is invisible and relatively harmless. But when left to accumulate, it increases in volume (in large amounts, plaque can be seen as a soft whitish deposit), and the proportion of bacteria in the plaque grows.

The role played by plaque in the development of gingivitis was demonstrated in the early 1960s. Dental researchers had people stop brushing their teeth and let the plaque in their mouths build up. Within two to three weeks, signs of inflammation appeared – redness, swelling, and an increased tendency to bleed – and when brushing resumed, the inflammation went away.

Some people with gingivitis do, nonetheless, develop periodontitis. The plaque that causes gingivitis is located at or above the gum line and is referred to as supragingival plaque. With time, areas of supragingival plaque can become covered by swollen gum tissue or otherwise spread below the gum line (where it is called subgingival plaque). In this airless environment, the harmful bacteria within the plaque proliferate. These bacteria can injure tissues through the direct secretion of toxins. However, they cause the greatest damage by stimulating a chronic inflammatory response in which the body in essence turns on itself, and the periodontal ligament and bone of the tooth socket are broken down and destroyed.

The bone destruction from periodontitis can be fairly even, resulting in receding gum lines. But more often, it causes deep crevices between an individual tooth and its socket. These crevices are called periodontal pockets, and just as it once was thought that gingivitis progressed to periodontitis, so it was once believed that shallow periodontal pockets inevitably deepen, eventually becoming deep enough to jeopardize the socket’s support of the adjacent tooth.

SYMPTOMS OF PERIODONTITIS

You can and should check yourself for the warning signs of gum disease. However, you may have gum disease that has spread into the bone and not have any of the symptoms. Most people do not experience any pain due to gum disease and therefore it often goes unnoticed. It is important to have regular dental checkups, including a periodontal examination.

The warning signs of gum disease include:

• bleeding gums during tooth brushing
• red, swollen or tender gums
• gums that have pulled away from the teeth
• persistent bad breath
• pus between the teeth and gums
• loose or separating teeth
• a change in the way your teeth fit together when you bite
• a change in the fit of partial dentures

You should contact your dentist if you notice any of these symptoms.

DIAGNOSIS OF PERIODONTITIS

The dentist or dental hygienist will inspect the color and firmness of the gums and test the teeth for looseness. They will also check the way your teeth fit together when you bite. X-rays may be taken to evaluate the bone supporting the teeth.

A technique called periodontal probing is the cornerstone of testing for gum disease. In this procedure, a small measuring instrument is gently inserted between the tooth and gum to measure the depth of the pocket.

TREATMENT OF PERIODONTITIS

In the earlier stages of the disease, most of the treatment involves root planing and curettage (cleaning) under the gum margins. It involves the removal of plaque and inflamed soft tissue in the pockets around the tooth with an instrument called a curette. Its purpose is to remove the bacterial colonies and the mechanical and chemical irritants that cause inflammation in hopes that the disease can be eradicated. The goal is that the gum will reattach itself to the tooth or will shrink enough to eliminate the pocket.

In most early cases, root planing, curettage, and proper daily plaque removal are all that are required for a satisfactory result.

In more advanced cases, the treatment may become more complex. If after removal of the deposits, fairly deep pockets remain, they can be eliminated by a minor surgical procedure called gingivectomy. This is done under local anesthesia, and a medicinal dressing is placed to cover the wound area for a week or so while it heals.

A similar procedure, called gingivoplasty, is used to remove excessive gum tissue and to provide a new and healthier shape for the gums.

In some cases, flap procedures are performed. The gum tissue in an area is lifted away from the teeth, all the underlying inflamed tissue and calculus are removed, the bone may then be reconstructed to a proper shape and the gum is then replaced to proper position and sutured. Healing of these procedures takes from seven to 21 days and is usually uneventful, although not without some expected post-operative discomfort.

Antibiotics are sometimes prescribed to treat gum inflammation.

PREVENTION OF PERIODONTITIS

The most effective nonprescription tool available is the toothbrush. Because a toothbrush’s ability to remove plaque is markedly reduced by splayed or matted bristles, toothbrushes need to be replaced at the first sign of wear.

Soft bristles are superior to hard for removing plaque, but the kind of brush you buy is less important than how well you use it. Several techniques have been developed for effective tooth brushing and it is advisable to be instructed in at least one by a dentist.

Flossing daily and brushing after meals will reduce the risk of developing plaque. Regular dental check-ups are important as well.

QUESTIONS TO ASK YOUR DOCTOR ABOUT PERIODONTITIS

Do any tests or procedures need to be done to diagnose periodontitis and to measure its severity?

What is the cause of the periodontitis?
How serious is the condition?
What treatment will you be recommending?
Will this treatment eliminate the disease?
Will the gums return to normal?
Will surgery be necessary?
Will you be prescribing any medication?
What are the side effects?