The bone and gum tissue should fit snugly around the teeth like a turtleneck around your neck. When the patient has periodontal disease, this supporting tissue and bone is destroyed, forming "pockets" around the teeth. Over time, these pockets become deeper, providing a larger space for bacteria to live. As bacteria develop around the teeth, they can accumulate and advance under the gum tissue. These deep pockets collect even more bacteria, resulting in further bone and tissue loss. Eventually, if too much bone is lost, the teeth will need to be extracted. Periodontitis, like any other chronic disease (i.e. 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. With careful assessment and treatment, it is usually possible to completely halt the progress of periodontitis.
STEPS OF THERAPY
1. PERIODONTAL EXAMINATION
During the first visit, the periodontist usually reviews the patient’s complete medical and dental histories. It is extremely important for the periodontist to know if any medications are being taken or if the patient is being treated for any condition that can affect periodontal care, such as heart disease, diabetes, or pregnancy.
The periodontist examines the gums, checks to see if there is any gum line recession, assesses how the teeth fit together when biting, and checks the teeth to see if any are loose. The periodontist will also take a small measuring instrument called a probe and place it between the teeth and gums to determine the depth of those spaces, known as periodontal pockets; this helps the periodontist assess the health of the gums. Full mouth X-rays are taken to observe the health of the bone below the gum line. After the exam, a detailed written report and a copy of the radiographs will be sent to your dentist.
2. NON-SURGICAL PERIODONTAL TREATMENT
Periodontal health should be achieved in the least invasive and most cost-effective manner. This is often accomplished through non-surgical periodontal treatment. Non-surgical periodontal treatment does have its limitations. When it does not achieve periodontal health, surgery may be indicated to restore periodontal health. This phase includes the following:
Personalized oral hygiene instruction and advice
The aim of the oral hygiene phase of treatment is to reduce the number of bacteria in the mouth and therefore reduce the level of inflammation. Your dental practitioner will first explain the causes of your periodontitis and explain exactly how to keep your teeth and gums clean. You will be given individual advice adapted to your needs on how to use the various cleaning techniques and tools most effectively; for example, the most appropriate tooth brushing technique and the correct use of dental floss and interdental brushes.
All soft deposits will be removed from accessible areas of the teeth and the teeth polished and treated with fluoride.
Scaling and root planning
Scaling and root planing is a careful cleaning of the root surfaces to remove plaque and calculus from deep periodontal pockets and to smooth the tooth root to remove bacterial toxins. Special instruments are used below the gum line to remove soft and hard deposits from the tooth surface. The irritants have to be removed from the root surface. Deep cleaning does not eliminate deep pockets and may have to be redone periodically. Scaling and root planing is often followed by adjunctive therapy such as local delivery antimicrobials and host modulation, as needed on a case-by-case basis. Most periodontists would agree that after scaling and root planing, many patients do not require any further active treatment. However, the majority of patients will require ongoing maintenance therapy to sustain health.
Evaluation of additional risk factors
Several risk factors, although incapable of starting periodontal disease on their own, can speed up its evolution and render it unstable when in the presence of inflammation.
In an effort to eliminate these factors, some of the following treatments may be required:
In some cases, with or without microbiological evaluation, antibiotics are prescribed to deal with active or persistent gum infections, which have not responded to oral hygiene measures.
Bite adjustment & making of a bite plane to control the trauma caused by teeth grinding (bruxism)
Splinting of weakened adjacent teeth
Extraction of untreatable teeth
Between 6 and 12 weeks after the initial phase is completed, your periodontist will reexamine your gums in order to evaluate the healing that has occurred, determine if additional treatment is recommended and plan the latter. A special instrument called a periodontal probe is used to record the depth of any periodontal pockets and check for bleeding from the gums. If periodontal pockets are still present and deeper than ≥5 mm, further treatment options may be suggested, including corrective periodontal surgery.
3. PERIODONTAL SURGERY
Periodontal Renerative Surgery
Periodontal surgery will be recommended if it is likely to improve the long-term stability of the gum condition. Surgical procedure is carried out to clean away plaque bacteria and deposits that are under the gum within periodontal pockets and on the root surfaces at the furcations (where the roots diverge). These areas are inaccessible to brushes and floss and inflammation will persist in these sites as long as bacteria are allowed to colonize them. Under local anaesthesia, the gum is lifted away and the root surfaces are cleaned under direct vision to ensure that all bacteria are removed. During this procedure, your periodontist folds back the gum tissue and removes the disease-causing bacteria. Sometimes, it is possible to treat bone loss at the same time using a special regenerative treatment. Membranes, bone grafts or tissue-stimulating proteins can be used to encourage your body's natural ability to regenerate bone and tissue. At the end of the procedure, the gums are sutured back into place around the teeth.
Periodontal Plastic Surgery
Exposed tooth roots are the result of gum recession. Gum graft surgery will repair the defect and help to prevent additional recession and bone loss. Gum grafts are designed to cover exposed roots, to reduce further gum recession and to protect vulnerable roots from decay. This may reduce tooth sensitivity and improve esthetics of your smile. During gum graft surgery, the periodontist takes gum tissue from your palate or another donor source to cover the exposed root. This can be done for one tooth or several teeth to even your gum line and reduce sensitivity. Whether you have a gum graft to improve function or esthetics, patients often receive the benefits of both: a beautiful new smile and improved periodontal health – your keys to smiling, eating and speaking with comfort and confidence.
Periodontal Resective Surgery
You may have asked your periodontist about procedures to improve a "gummy" smile because your teeth appear short. Your teeth may actually be the proper lengths, but they're covered with too much gum tissue. To correct this, your periodontist performs a dental crown lengthening procedure. During the dental crown lengthening procedure, excess gum and bone tissue is reshaped to expose more of the natural tooth. This can be done to one tooth, to even your gum line, or to several teeth to expose a natural, broad smile.Your dentist or periodontist may also recommend dental crown lengthening to make a restorative or cosmetic dental procedure possible. Perhaps your tooth is decayed, broken below the gum line, or has insufficient tooth structure for a restoration, such as a crown or bridge. Crown lengthening adjusts the gum and bone level to expose more of the tooth so it can be restored.
Some patients’ implant therapy needs can be managed by the general dentists. However, as more and more patients are exhibiting signs of periodontal disease, coupled with research that suggests a relationship between periodontal disease and other chronic diseases of aging, implant treatment may necessitate a greater understanding and increased level of expertise by a trained specialist. In patients who present with moderate or severe levels of periodontal disease, or patients with more complex cases, implant therapy will be best managed by a partnership between the dentist and periodontist. The ideal candidate for a dental implant is in good general and oral health. Adequate bone in your jaw is needed to support the implant, and the best candidates have healthy gum tissues that are free of periodontal disease. A dental implant is an artificial tooth root that is placed into your jaw to hold a replacement tooth or bridge. Dental implants may be an option for people who have lost a tooth or teeth due to periodontal disease, an injury, or some other reason.
In peri-implant mucositis, gum inflammation is found only around the soft tissues of the dental implant, with no signs of bone loss. Generally peri-implant mucositis is a precursor to peri-implantitis. Evidence suggests that peri-implant mucositis may be successfully treated and is reversible if caught early.
In peri-implantitis, gum inflammation is found around the soft tissue and there is deterioration in the bone supporting the dental implant. Signs of peri-implant diseases are similar to symptoms of gum disease: red or tender gums around the implants, or bleeding when brushing. Other risks factors for developing peri-implant disease include previous periodontal disease diagnosis, poor plaque control, smoking, and diabetes. Peri-implantitis usually requires surgical treatment.
4. PREVENTIVE MAINTENANCE PHASE
Successful periodontal treatment requires your full co-operation in regard to daily oral hygiene practices and attendance at regular follow-up appointments. The long-term success of periodontal treatment depends both on your own efforts with oral hygiene and those of the practice team who provide your regular care and ongoing assessment. In order to maintain the high level of periodontal health obtained with the treatment rendered thus far, it is of utmost importance to meticulously follow the recommended home care instructions daily. The frequency of your follow-up appointments will depend on the severity of disease and your individual risk of disease progression. Usually, follow-up visits are scheduled for every 3 to 6 months. Regular follow-up appointments are vitally important to determine the stability of your periodontal health, ensure that the disease process does not recur, causing further destruction of the gums and supporting bone. If there are signs of continuing disease, your dentist will be able to identify new or recurring sites of inflammation and treat them at an early stage. You will also be given advice on how to modify your oral hygiene practices to tackle the inflammation. When treated and maintained properly, long lasting and predictable results are expected.
European Federation of Periodontology
Canadian Academy of Periodontology
American Academy of Periodontology