Periodontal disease is a destructive process (infection) of the supporting structures of the teeth. The supporting structures of the teeth include the gums (called gingiva – the soft tissue surrounding the teeth), the ligaments that connect the roots of the teeth to the jaw bone, and most importantly, the jaw bone itself that holds the teeth in place. There are several specific types of periodontal diseases currently recognized. Periodontal disease is usually considered to progress as a gradual process, but is also known to advance at different rates during different times. Different people exhibit individual susceptibility to periodontal breakdown. Heredity has been shown to play a role in an individual’s susceptibility to periodontal disease. There is usually no pain associated with the disease, although warning signs can include bleeding and swollen gums, unpleasant taste and breath, and loose and shifting teeth.
Technically speaking, the most compelling evidence now suggests that periodontitis is not a conventional infectious disease, but rather an inflammatory disease triggered by the patient’s own host-immune response to a broad range of oral bacteria. Simply put, there are two major underlying causes of periodontal disease. By far the most important cause is bacteria. Although we can not eliminate all the bacteria in the mouth, the most important component in the treatment of periodontal disease is the reduction of disease-causing (pathogenic) bacteria. A second contributing factor to the cause of periodontal disease is the way the teeth come together when you bite (called occlusion). Systemic factors (hormonal, immunological, generalized bodily diseases – such as diabetes) can also play a major role. Extensive research has shown that smoking causes alveolar (jaw) bone loss. This association is believed to involve inhibition of one’s systemic immune response. In addition, the condition of one’s dental restorations (crowns or fillings) can sometimes influence disease progression as well.
Although individual bacteria are invisible to the naked eye, they make their presence known through the formation of plaque. Plaque is a soft, sticky colorless bacterial film found above and below the gum line that continuously forms on the teeth. When plaque has been allowed to remain on the teeth for a period of time (in as little as a few days) it can mineralize, producing a hard substance termed dental calculus, or tartar.
The cornerstone of periodontal therapy is the significant reduction or elimination of plaque and calculus. Since plaque forms daily, our goal is not only to remove it during active therapy, but to teach you how to control it on a daily basis as well. Since daily home care is so important, successful periodontal disease therapy is rarely accomplished without the patient and the doctor working as a team.
Treatment of periodontal disease is usually initiated by determining the exact nature and extent of the disease. This is done during the appointment we term a “workup.” During this workup appointment, a thorough history is taken, the X-rays are read to aid in the evaluation of the extent of any jaw bone changes, a thorough clinical examination is performed, a definitive diagnosis is made, and a detailed and individualized treatment plan is formulated. If necessary, the periodontist also works closely with the general dentist to devise a prosthetic (tooth replacement) treatment plan. Also during this appointment, measurements of periodontal pockets are done. Pockets are formed when the gums separate from the necks of the teeth, and most always represent (jaw) bone loss.
The next step in the treatment of periodontal disease may be a series of appointments which we term scaling and root planing. Although plaque can be removed by tooth brushing and flossing, calculus can only be professionally scraped away. (It is possible that this step has already been completed in the general dentist’s office.) The doctor or dental hygienist will be removing plaque, calculus, and stain from above and below the gum line. This is most often done with local anesthetic (“Novocain”) provided by the periodontist. Also during these appointments, we will be making sure that you are brushing and flossing correctly. This is a very important step, because without your daily cooperation and help, successful control of periodontal disease is not possible.
After finishing with the scaling and root planing, you will likely notice a big improvement in your gums. The gums will be less red and swollen, and will not bleed so much. After waiting a few weeks, you will likely return to see the periodontist for a re-evaluation appointment. Several goals are planned for this visit as we re-evaluate your progress. The periodontist will re-measure the pockets, he will evaluate your home care, and he will then decide if further treatment is needed.
Gum surgery is usually only necessary in advanced cases. If gum surgery is needed, the periodontist will discuss the specifics with you at the re-evaluation appointment. There are many different types of gum surgery. Specific techniques have changed dramatically even in the last several years. The most common and basic surgical procedure is flap surgery. Flap surgery serves three major functions:
- It allows visual access for the removal of calculus that lies deep in the pockets, or put another way, allows access to the root of the infection.
- It allows for the reduction / elimination of infected periodontal pockets.
- It allows for changes to be made to the supporting bone, either by smoothing irregularities of the bone, or by adding new bone.
Sometimes bone can be replaced by grafting new bone to areas where it has been previously lost. The source for the grafted bone can be from other areas of the mouth, or more commonly from a bone bank. (The potential of disease transmission with bone from a bone bank is zero.) Sometimes new bone and tooth ligament can actually be grown. The regeneration of alveolar (jaw) bone is an exciting concept in periodontics and is an area of much investigative research. One technique involves the temporary placement of special “membranes” beneath the gums. This technique is called guided bone regeneration (GBR). Other techniques involve the introduction of different genetic and tissue engineered products to enhance bone repair.
Other types of gum surgery involve adding or transplanting new gum to areas with deficient amounts. (Once again, the source of this gum can be from the patient’s mouth, or from a tissue bank, although soft tissue grafts are usually taken from the roof of the patient’s mouth.)
Sometimes gum surgery is required even when there is no gum disease, for instance when the general dentist requires more exposure of the tooth root in order to place a crown.
In cases where a tooth cannot be saved, or to replace a tooth lost years earlier, tooth replacement is often possible with dental implants. Dental implants are now a proven technology (>95% long term success), and have been part of this practice since 1986. (The topic of dental implants is beyond the scope of this information sheet, but Dr. Orr or Dr. Naghieh will be happy to discuss this subject further if needed.)
Periodontal surgery is usually done in the dental chair with local anesthetic (“Novocain”). Other than the annoyance of anesthetic injections, the patient shouldn’t feel any discomfort during the procedure. Most often a quarter, or sometimes half, of the mouth is done at one time. Sutures are placed in the gums and sometimes a dressing is placed around the teeth. Detailed post-operative instructions are given. After having had periodontal surgery, the overwhelming majority of people go to work the next day. Even though a prescription for a painkiller is often provided, most people do not even need them. (In special cases, periodontal surgery is performed in the hospital.)
One week after surgery, the sutures are removed and the surgical site is checked for healing. Detailed instructions are again given at this time to show the patient how to take care of the surgical site as it further heals.
The risks of periodontal surgery are minor. The most common side affect from surgery is a transient increase in sensitivity of the roots of the teeth to cold. This is usually only a problem for the most severe cases, however, even in the most severe cases, the sensitivity usually goes away completely in a few months. In situations involving severe bone loss, the surgical reduction of the pockets can result in spaces between the teeth where the papilla (triangle) of gum used to be. Fortunately, this new gum architecture allows for more effective plaque control.
Other than scaling and root planing, there are other non-surgical treatment modalities. These treatment regimens include systemic antibiotic use, local delivery of antimicrobial agents (placed under the gums in the periodontal pockets), and irrigation under the gum with anti-microbial solutions. Sometimes these options are utilized in conjunction with surgical therapy. Dr. Orr or Dr. Naghieh will discuss with you what they feel will be best for your particular case.
The final step in the successful treatment of periodontal disease is the maintenance phase. Maintenance is usually scheduled every three months and is most often shared with the referring general dentist’s office. This scheduling is based on scientific studies that show this to be the optimum interval to maintain existing gum attachment levels. The maintenance appointment consists of a periodontal prophylaxis (periodontal cleaning), an examination for areas of further breakdown, and a check of effectiveness (and reinforcement) of the patient’s daily home care.