Georgia Periodontics, P.C.

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

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

(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.
[Back to top]

STEP FOUR: Periodontal Maintenance

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.

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. (See Oral Hygiene)

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 (See Periodontal Maintenance).

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.

1. 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.
2. 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.
3. 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.