Periodontal Disease

What is Periodontal Disease?
Periodontal disease (Gum Disease) is an infection of the gums and/or bone that surrounds the tooth. Generally the disease causes little discomfort, and most patients are not aware they have a problem until examined by a dentist.

With a healthy tooth, the root is anchored in the jawbone by a strong ligament, which keeps the tooth tightly attached to the bone. Gum covers the bone, and like skin, protects it from bacteria that are constantly present in the mouth. The gum connects to the neck of the tooth with a band of fibers, which insert just above the bone into the root. In a healthy situation, the gum margin is higher than the fiber attachment, forming a space around the tooth. This is similar to having a turtleneck sweater, and this sulcus should be 2-3 millimeters in depth. 

Everyone has bacteria in their mouth continuously. These bacteria collect on all surfaces, forming colorless, sticky colonies called plaque. Unfortunately, this plaque also forms in the space underneath the edge of the gum. If the plaque is not removed (something that takes careful brushing and flossing), it will start to cause inflammation in the gums. Plaque that remains on the tooth for a long period of time absorbs salts from the saliva, and becomes hard. This calculus, or tartar, can not be removed by brushing and flossing, and must be removed by a dental professional. 

The Stages of Periodontal Disease
The first stage of periodontal disease is gum inflammation, or gingivitis (from "gingiva", meaning gum, and "itis", meaning inflammation). The body responds to the bacteria by recruiting blood vessels, which carry cells to destroy the bacteria. This makes the tissue appear red, perhaps swollen, and patients may notice bleeding when brushing their teeth.

 At this stage there has been no bone destruction, and careful removal of all calculus, along with meticulous patient brushing and flossing, generally corrects the problem.

If the gingivitis is not corrected, the bacteria may destroy the fiber barrier, and start moving down the infected tooth surface. There is a battle between the advancing bacteria, and the body trying to defend against invasion. Some of the destruction is caused by the body itself, when attempts to destroy the bacteria also destroy healthy tissue in the area. There are many factors that influence how well your body reacts to the bacterial invasion .

As the bacteria advances down the tooth, the inside lining of the gum, and the bone, are destroyed. This penetration of bacteria forms a periodontal pocket, or deepened space between the gum and tooth. By measuring the depth of the space with a periodontal probe your dentist can see how much bone loss has occurred.

 Periodontal pocket with bone loss occurring

Treating Periodontal Disease
An Overview
There are two main objectives in treating periodontal disease. The first is to reduce and control the bacterial colonies that form under the gum. The second is to eliminate any known factors that cause the patient to be more susceptible to breakdown. Primary among these is poor oral hygiene.

In the early stages of periodontal disease (gingivitis), the gum is infected but the bone has not yet been damaged. The pocket depth is 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.

Scaling removes plaque & calculus

Root planing smoothes the root surface

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 access in debriding the bottom of the pocket. In these cases flap surgery is needed so the periodontist can gain access to clean the root effectively. With this procedure, an incision is made between the gum and tooth, and the gum is gently opened away from the tooth slightly exposing a small amount of bone. The surgeon can then easily remove 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 may not attach back to the tooth completely, this may 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-shaped bone. This pocket elimination procedure allows the patient to access and remove the bacterial plaque daily with brushing and flossing. If all plaque is eliminated daily, the disease can be kept under control.

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, perioscopy (endoscopically assisted scaling and root planing) may be preferred over surgery.

During surgery the periodontist can visualize and debride 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 warranted.

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 cleaned without reflecting the gum. The objective is to thoroughly clean 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 defects can benefit from these regeneration procedures. Your periodontist will tell you if you are a good candidate for 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 at home.

Periodontal disease may be considered a chronic disease, and for that reason a complete "cure" is usually not possible.  As periodontists we simply maintain the disease. 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 healthy. Even with the best care certain areas may lose ground, although the majority of patients who follow good maintenance can expect to have the majority of their teeth for a 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.

Diagnosis and Treatment of Periodontal Disease

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 to 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 cellular change. 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.

Diagnosing Periodontal Disease

Before any periodontal treatment is undertaken, a diagnosis must be made. To obtain 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.

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 (host) 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 bacterial 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 gum overgrowth.

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

Genetics - About one-fourth of the population is genetically more susceptible to periodontal disease. Today we are able to do a simple test for genetic susceptibility.

Clinical Examination
The periodontal examination gives the dentist a complete picture of the periodontal condition of the patient's mouth. 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 organism. Occasionally, adjuntive use of antibiotics in combination with periodontal treatments are neccessary.

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.
.

Healthy tooth

Bone loss leading
to pocket formation

Each tooth is measured (probed) 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 architecture. 

Other important information is collected during the examination, so an accurate diagnosis can be made (click a heading for a more detailed discussion).

• Gum recession - The amount of recession added to the pocket depth determines total 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 increase the chances of 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.

Dental Radiographs (X-RAYS)
A quality series of dental x-rays is mandatory to accurately evaluate periodontal disease. They help determine the amount and location of bone loss, the size and shape of the roots, the amount of root still embedded in 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. The exception is soft tissue 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. Full Mouth Periapicals - 18 - 21 detailed views of the teeth and surrounding bone, necessary for an accurate periodontal examination.
 periapical showing bone loss around teeth

• Panograph - A single screening film showing an overview of the upper and lower jaws, sinus, temporomandibular joint, and other anatomic features.
• Bitewings - Four detailed views of the side and back teeth, primarily used to detect decay. Often used with the panograph by general dentists for routine new patient screenings.
• 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.

Many people have a legitimate concern about the amount of radiation they receive with dental x-rays. It's un-nerving to watch the technician set the machine and run out of the room to expose the film! However, recent advances in dental x-rays make this an unnecessary concern. The film "speed" has improved dramatically, meaning that very little radiation is needed to expose the film. In fact, it is estimated that the amount of body radiation received with a full mouth series is much less than one would receive at a day at the beach.
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Diagnosis
Once the clinical data is gathered and compared with the x-ray findings, we are 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 a treatment plan to follow.

 Treating Periodontal Disease

The Steps to Treating Periodontal Disease
The treatment of periodontal disease involves these main steps:

• Initial Preparation
• Surgical Treatment
• Maintenance

The following is an overview of the components of each treatment step.

STEP ONE: Initial Preparation (click for detailed information)

The first step of treatment is to eliminate all of the known causes of the 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 bonds tightly to the tooth, similar to barnacles on a boat's hull. Both the calculus and the plaque must be removed to achieve health. 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
• 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/grinding at night

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. [back to top]

STEP Two: Surgical Treatment

Initial Preparation generally produces shrinkage of the inflamed gum tissues, 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 the periodontal status. 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 reduce or eliminate pockets that remain after Initial Preparation (Click any heading for a more detailed discussion and clinical examples).

• Gingivectomy - Trimming excess tissue when the bone contour has not been altered.
• Flap 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.
• 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 teeth, 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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STEP FOUR: Periodontal Maintenance (click for more information)

The two most important factors in determining long-term success are patient home care, and regular 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 bi-annual 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. [Back to top]

The Patient's Role in Therapy
No matter how successful the periodontal treatment has been, the patient is the most important part in maintaining periodontal health. For maximum results, the patient must accept this role as a "co-therapist".

The first responsibility of the patient is to eliminate factors that increase susceptibility to periodontal disease. The prime culprit is smoking, which increases the odds of losing teeth 700%! Diabetic patients are also more susceptible, although this effect is negligible if the blood sugar remains stable. Healthy diets promote healing, but don't be misled by vitamin claims. Periodontal disease is NOT affected by high doses of Vitamin C or calcium supplements, if the patient has a normal diet.

The second responsibility of the patient is to maintain daily plaque control, with brushing and flossing. Brushing is easy for most of us, but flossing is more demanding. Most periodontal disease, however, starts between the teeth, where the brush can not reach. "Floss is the Boss", and the time spent in learning proper technique will pay large dividends. Lastly, the patient is responsible for scheduling regular periodontal maintenance appointments. The frequency is determined by your periodontist and dentist, and is critical! Most patients with moderate and advanced cases should have periodontal maintenance appointments every three months for their lifetime, and staying faithful to this schedule is very important.

What to Expect from Surgery

In the past, periodontal surgery was considered an ordeal. Things have changed! Today there should be no pain involved during surgery, and the postoperative discomfort is minimal.  At our office, we use conscious sedation to better help our patients relax.  New and sophisticated medications ensure you a smooth procedure. Most patients prefer light sedation for surgical procedures. Research has shown that light sedation improves surgical safety, improves the outcome and contributes to a more pleasant post-operative course. All doctors are licensed by the States of Georgia to perform IV/IM sedation.

For surgeries that last an hour or longer, most patients prefer a light sedation. The medications we use routinely are Versed, Demerol, and/or Halcion, and/or Phenergan. This is not general anesthesia, and we do all our procedures in the office of your first consultation.  The procedure is extremely safe. We have done thousands of sedations without incident. Your heart rate and blood oxygen levels are monitored during the procedure to ensure your safety. With sedation, an hour procedure seems like 5 minutes, and you are not even aware of the local anesthetic when it is given. Of all the additions to modern periodontics, this is the most significant for patient comfort. If sedation is used, you must have a driver. If your driver does not stay for the surgery, he/she must be back 15 minutes before the scheduled appointment end.

Postoperative discomfort has been dramatically reduced with the use of NSAIDS (non-steroid anti-inflammatant drugs). These pain prevention drugs, such as Naprosyn and Motrin, stop the formation of the chemicals the body normally produces that cause elevated pain. NSAIDS are not narcotics, so you can function normally when taking them. Generally, NSAIDS are started the morning before surgery, and taken for three to five days postoperatively. After this time no prescription medications are normally needed. In addition to the NSAIDS, a narcotic may be recommended for the first or second day.

Patients are occasionally given antibiotics to take after surgery. It is important to take the prescriptions as directed, to optimize healing.

A prescription mouthwash is often prescribed after surgery, and may be used for 2 weeks. It is much more effective than any over-the-counter mouthwash, and kills bacteria throughout the mouth. During the first 7 days there is generally a periodontal dressing over the operated area (similar to kids silly putty), and using the mouthwash keeps the dressing clean.

At 7-10 days any dressing is removed, along with sutures which may not have dissolved. The area is cleaned, and postoperative care of the area is reviewed. This appointment generally lasts 15-30 minutes, and should not cause discomfort.

With most cases it is important to keep all bacteria away from the surgical site for 8-10 weeks. To help ensure optimal plaque control, polish appointments are often scheduled every 3-4 weeks. The prescription mouthwash may also be continued during this time. We have found that careful control of plaque during the healing phase greatly enhances surgical results.

SURGICAL POST-OPERATIVE INSTRUCTIONS

The post-operative instructions listed below should be followed accurately in order to speed your recovery.

1. SWELLING - The first 24 hours is the most critical phase for swelling control. Most swelling does not visibly appear until 24-48 hours after surgery. It is therefore important to apply (on and off) ice at 20 minutes intervals. Ice application after 48 hours slows healing and prevents swelling reduction.
2. EATING - The rule of thumb is "C.S.S." (cooler, softer, smaller). Avoid spicy or hot foods. Any food that is cool, easy to chew, and soft is O.K. to eat (ie. Jello, yogurt, sliced soft fruit, cereal, potato, fish, eggs, applesauce, etc.). DO NOT eat or drink anything hot during the first 24 hours.
3. EXERCISING - Aerobic activities and heavy lifting should be avoided for the first 72 hours. Let common sense prevail.
4. SMOKING - The less you smoke, the faster things heal and few complications arise. A better result will also be obtained.
5. CLEANING - Areas not included in the surgery can be cleaned as normal. Warm salt rinses (1/2 tsp. salt per 8 oz. glass of water) can be used after eating for the first week. NO brushing of surgical site until directed to do so.
6. PAIN CONTROL - Pain management begins immediately after surgery. The medication MUST be taken whether you experience pain or not. Proper blood levels are necessary in order to reduce pain and swelling.
7. MEDICATIONS - Use only the medications below that your doctor has checked.
   (Prescriptions will vary depending upon the circumstance warranting medication. Please follow you doctor's orders for each medication as they were discussed with you). Examples of medication regimens are listed below. Please consult your individual prescription instructions prior to taking ordered medications.
   • Decadron 1.5 mg: one pill taken after 6 pm the first day of surgery. Then one pill twice daily until entire amount is used.
   • Peridex: The day after surgery, begin twice daily oral rinses until the bottle is used up (approximately 2 weeks). A 30 second rinse in the morning and again in the evening will control bacteria that can delay healing. In special situations, extended use of Peridex may be suggested.
   • Apply Peridex topically with a Q tip to surgical site beginning on second day.
   • Motrin 600 mg and 1000 mg Extra Strength Tylenol. Alternate every 2 hours for the first day. Then take as needed for discomfort.
   • Other medications, as listed.

8. BLEEDING - Normally there will be some bleeding following surgery. The application of pressure from a damp, cool cloth or ice in these areas will usually hasten clotting. Continued bleeding can be controlled by firm pressure on a dampened tea bag placed directly on the area. However, should you become concerned about excess bleeding, please call the office for further instructions.
9. WEARING YOUR DENTURE OR BRIDGE for days. Before wearing your prosthesis, it must be modified and a medicated soft liner applied. This soft liner must be replaced every 4-6 weeks. Failure to do so could jeopardize healing.
10. PERIODONTAL SURGERY ONLY - PERIODONTAL DRESSING: The pinkish casts, when applied to the surgical area, should remain until your next appointment. These were applied to provide greater comfort. Should they loosen, do not force them back to place. Call your doctor.

When NO PERIODONTAL DRESSING is used, the following precautions should be observed:

1. No vigorous rinsing or spitting for the first 24 hours. This tends to promote bleeding.
2. Floss may be used to remove food should it collect between teeth.
3. Begin twice daily rinses with Peridex until the bottle is used up.
4. Avoid cold & hot beverages since the teeth may be sensitive to thermal stimuli.
5. If sutures become loose or stringy, do not pull on them.

If you are uncertain as to what to do, please call your doctor or our office.

Sinus Augmentation/Sinus Lift - In addition to the general post surgical instructions that should be followed (described in detail above), there are specific instructions that need to be followed for those patients who have had sinus lift surgery. The following post surgical instructions are in addition to those which should be followed for routine periodontal surgery/dental implant related surgery and include:

PRE-OPERATIVE PHASE:

1. Begin antibiotic medication 48 hours prior to surgery.
2. Prior to surgery, inform the office if you are having a sinus infection.

POST-OPERATIVE PHASE:

1. Continue the antibiotics until the entire prescription is completed.
2. Please use a nasal decongestant for the first 72 hours after surgery (e.g. Afrin nasal spray). Follow the pharmaceutical manufacturer instructions.
3. Do not hold your sneeze or blow your nose. The associated increase in pressure can damage the surgical site.
4. Nasal bleeding after surgery is common for the first 24 hours. Excessive bleeding should be reported to our office.
5. Any discharge, which smells or is discolored should be reported promptly.

Please note that smoking interferes with post-surgical healing.

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