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Periodontal Disease Research Paper

By: Callan Meskimen
Periodontal disease is a very common disease but more often than not is

overlooked in today’s society. According to Centers for Disease Control and

Prevention, "1 in 2 Americans over the age of 30 has periodontitis”. As dental

hygienists it’s our job to educate our patients on the importance of good oral

hygiene, periodontal disease and how to maintain periodontal disease.

Periodontal disease is an irreversible chronic inflammation and infection

surrounding the tooth structures such as the periodontal ligament, alveolar bone

structure, cementum and gingival tissue. There are many different risk factors to

periodontal disease. Some of the most common factors are: the person’s life style,

poor dental hygiene, diabetes, certain medications, smoking, nutrition, stress,

systemic conditions and being immunocompromised. Diabetes is one of the most

common risk factors to periodontitis due to increasing the patient’s susceptibility to

contracting infections.

The main cause of periodontal disease is the bacteria formed in the dental

plaque. There are approximately 400 species of bacteria present in the oral cavity

and with insufficient removal the bacteria will start to accumulate. Immediately

after one brushes plaque starts to form called pellicle. Pellicle is the beginning stage

of biofilm and is composed of saliva and glycoproteins. Pellicle helps the bacteria

adhere to the supragingivial tooth structure and starts to layer and colonize. The

bacterium also mixes with the minerals in our mouth, our saliva, exudate and

polysaccharides to create an intrabacterial matrix. These bacteria organisms first

consist of gram-positive cocci and rods. Overtime the biofilm increases in mass and

changes in the microorganisms start to happen. If the plaque is not removed

sufficiently after one to two days Streptococcus mutans and Streptococcus sanguis

produce glucan that helps more bacteria stick to the colony and provides the colony

with energy. Next, gram-positive filamentous rods such as Corynebacterium or

Actinomyces, will start to increase in numbers and cover the cocci. In over a week

of insufficient cleaning filaments have increased and the formation gram-negative

spirochetes and vibrios are now starting to develop along the gingival margin,

becoming anaerobic. As the supragingival plaque matures and grows the gingiva

starts to become inflamed and allows the plaque to move apically beneath the gum

lines. This allows for more anaerobic gram- negative bacteria to form, such as

Veilonela, Fusobacterium and Prevotella intermedia. Around 10-21 days gingivitis,

which is inflammation of the gums, is seen. Gingivitis is reversible with good oral

hygiene, but if the bacterium is left untouched has the potential to lead to

periodontal disease. When the bacterium continues to grow it forms a periodontal

pocket and extends down into the structures around the tooth such as the

periodontal ligament, alveolar bone and cementum resulting in the loss of the bone

and gingiva. The start of periodontal disease is bleeding upon probing and deeper

probing depths of 4mm and up. Bacterium such as P. gingivalis is very prominent in

the pockets as well as P. intermedia, F. nucleatum and Bacteroides forsythus. The

body’s immune system works to remove the infection, but the bacterium has many

self-defense mechanisms to prevent the body from eliminating them. In the end the

body is unable to prevent the destruction of the bacterium and if left untreated may

result in tooth loss and systemic issues.

There are several different stages of periodontal disease. Periodontal disease

can be either localized and or generalized throughout the mouth. Different areas of

the mouth can be at different stages of periodontal disease at the same time and

other areas of the mouth may be relatively healthy. As stated earlier the start to

disease is gingivitis. Gingivitis is a reversible infection and is related to gingival

inflammation, redness of tissue, and no clinical attachment loss. Gingivitis may also

have bleeding upon probing, exudate and probing depths of 4mm or less. The next

stage is slight periodontitis. Slight periodontitis is related to clinical attachment loss

of 1-2mm, radiographic loss of the alveolar crest and probing depths of less than or

equal to 5mm. Following slight is moderate periodontitis. Moderate periodontitis is

related to clinical attachment loss of 3-4mm, furcations, bleeding upon probing and

pocket depths of less than or equal to 6mm. Patients may have either vertical or

horizontal bone loss and tooth mobility may be seen at this stage. The next stage is

advanced periodontitis. Advanced periodontitis is related to clinical attachment loss

of less than or equal to 5mm, suppuration, class 2 and 3 furcation and pocket depths

greater than or equal to 7mm. Patients may have suppuration and major horizontal

and or vertical bone loss and mobility. Lastly is refractory periodontal disease.

Refractory periodontal disease is a disease that is unresponsive to dental treatment

and continues to show attachment loss despite attempts to slow the progression.

Periodontal disease is irreversible, but with good oral hygiene and

professional treatment it can be maintained and prevented from progressing.

Treatment methods dental hygienists provide are nonsurgical treatments such as

the removal of biofilm, scaling and root planning and antimicrobial therapy
(local/systemic). Treatment such as removing biofilm will help reduce the amount

of plaque build up in the mouth and will prevent the supragingival gram-positive

bacteria from moving into the periodontal pockets and becoming gram-negative. A

study was done in 2004 on 20 different college students by conducting three

different treatments of biofilm removal. They collected the microbe samples and

their plaque score. After the third treatment the results showed the mean of the

plaque score decreased from 72% to 0%, the mean of gingival index decreased from

.82 to .77 and the total number of bacteria reduced one-third of the original number.

Scaling and root planning includes removal of both subgingival and supragingivial

plaque and calculus as well as smoothing the root surface to prevent biofilm buildup

and restore the health of the peridontium.

Antimicrobial therapy can be either systemic or localized. Systemic therapy

is taking an antibiotic orally to help kill or prevent the growth of gram-

negative/positive bacteria in the mouth. Common systemic antibiotics used are

tetracycline, doxycycline and penicillin. A study was conducted in 2016 by

MEDLINE-Pub med database comparing scaling and root planning alone and scaling

and root planning with antibiotics. They measured clinical attachment level,

bleeding on probing and probing depths. All of the patients were classified as

generalized moderate. They tested amoxicillin, doxycycline, azithromycin and

metronidazole for 3,6,9 and 12 months. The research showed that combination of

SRP and antibiotics amoxicillin and metronidazole achieved the best outcome for

Localized antibiotic therapy includes a dental professional applying a

bactericidal chlorhexidine chip, a bactericidal doxycycline gel or a bacteriostatic gel

minocycline. The local antibiotic when used in combination with scaling and root

planning helps to decrease the amount of bacteria left after SRP by either killing the

bacteria and or inhibiting the growth of the bacteria. The localized antibiotic

chemotherapeutics are clinically proven to reduce periodontal pockets up to 2mm.

A study was conducted in 2015 to compare the effectiveness of the chlorhexidine

chip to minocycline on periodontal disease and according to Indian Journal of

Dentistry, “From the present study, it can be concluded that both the drugs were

equally effective in reducing the plaque scores as well as gingival scores. It was

further observed that Arestin resulted in better results at 6 weeks while Periochip

showed better results at 3 months, with respect to probing depth reduction”.

At times nonsurgical treatment may not be sufficient enough for a patient

with an advancing periodontal disease. Patients may need to be sent to a

Periodontist for surgical treatment. These treatments may include gingivectomy,

gingivoplasty, periodontal flap surgery and soft tissue grafts. Whichever treatment

the clinician and the patient agree on the treatment wont work or be beneficial if the

patient isn’t having good homecare. We must teach the patient that the only way

they are going to maintain their periodontal status is to have excellent oral hygiene.

By us removing the biofilm and scaling and root planning we are allowing their body

to heal, but if they aren’t doing their part and keeping the bacteria out of the

periodontal pockets the bacteria will accumulate and their periodontal condition

will only continue to get worse. The same thing goes systemic and local antibiotic
therapy. If they aren’t working to keep their mouths free of plaque the antibiotics

wont be able to keep up with the biofilm. Any type of treatment weather its

nonsurgical or surgical cannot and will not work unless the patient is willing to

change their lifestyle and habits. We must stress how crucial it is for them brush at

least twice a day, floss daily and follow our home care instructions.

The treatment method of choice for periodontal disease is scaling and root

planning. Over 90% of patient’s main treatment is scaling and root planning while

7%-9% have advanced to surgical treatment. According to The Journal of Dental

Hygiene,” thorough scaling and root planing (SRP) is still considered the gold

standard in periodontal therapy”.

Scaling and root planning is preformed by a dental hygienist, dentist or a

periodontist. Periodontists specialize in the treatment, prevention and diagnosis of

periodontal disease. They have an additional three years of schooling after dental

school and provide nonsurgical and surgical treatments. Dental hygienists are

registered professionals that are trained in preventive and therapeutic procedures

such as scaling and root planing. The professional preforming the treatment will

have a treatment plan that is specific to the patient and their needs. Treatment is

determined by the overall health status of the patient and the severity of their

disease. SRP is done with a periodontal pocket depth greater than 3mm and

depending on the patient may take one appointment to 4 appointments. Ideal

candidates are patients that have bleeding upon probing, clinical attachment loss,

furcactions, pocket depths of 4mm and above, inflammation of the gums and are

diagnosed with a periodontal case type of generalized/localized slight and above.

Patients that are in an advanced periodontal case or refractory may need surgical

treatment if scaling and root planning is not helping maintain the patient.

The process of scaling and root planning is first determining the diagnosis of

the patient and planning the treatment plan. Patients diagnosed with slight

periodontal case type may not need anesthesia and may only take one appointment

to finish the treatment. They also may not need to be on a three-month recall and

only visit the dentist twice a year if their periodontal diagnosis is maintained.

Patients with moderate and advanced diagnosis may need anesthesia and several

appointments either one quad per visit or one side per visit. These patients may also

need to be on a three-month recall and may require other nonsurgical treatment

methods. Before treatment a dental professional will administer anesthesia for

patient comfort and complete biofilm and deposit removal. Then the dental

professional will use an ultrasonic to remove biofilm and flush out the periodontal

pockets of debris and bacteria. Ultrasonics also provides assistance in removing

thick calculus sub and supragingivally. The dental professional then will use hand

instruments to scale the rest of the deposits of calculus on the teeth and the

periodontal pockets. Root planning is the process of removing cementum or rough

dentin containing calculus and bacteria and creating a smooth hard surface free of

periodontal causing endotoxins. According to Periodontology for the Dental

Hygienist, “root planing involves a specific effort to instrument every portion of the

root surfaces, not simply identifiable calculus deposits”. The main goal of SRP is to

produce deposit free surfaces and allow the periodontum to heal.

The cost of scaling and root planing treatment ranges from $140-$300 per

quadrant depending on the patients’ needs and treatment plan. Many factors come

into play with the pricing of SRP such as the patient’s insurance, if the treatment is

done by a specialist, number of appointments required, and if other treatment

methods are required. Patients with a more advanced or aggressive diagnosis may

need more SRP treatments and maintenance appointments resulting in higher costs

and possible surgical treatment costs.

There are many benefits to SRP such as removing harmful plaque and

bacteria from the periodontal pockets and gums to allow for proper healing and

decreased probing depths. This procedure helps the patient maintain their

periodontal diagnosis and helps aid in the prevention of disease progression. As

well as prevention in gum disease SRP also aids in preventing bad breath and dental

decay by the removal of bacteria and tarter removal. SRP is the treatment of choice

by many because the patient only benefits from the removal of bacteria. By

smoothing the surfaces of the roots bacteria is less likely to attach and grow and

disrupting the bacteria gives the body a break from constantly fighting off the

infection. SRP aids in eliminating harmful bacteria, which is a factor in preterm

babies and heart disease. A study was conducted in 2013 on the effects of SRP and

reducing preterm birth. Results found a significant reduction in preterm birth rate

in patients whom were considered high risk. But, for the other women not

considered high risk SRP failed at producing enough evidence to aiding in reducing

preterm birth. Another study that was conducted in 2016 on the comparison of SRP

treatment and none between patients with aggressive periodontitis. Results

concluded with treatment of SRP provided the clinical attachment gain of .5mm with

a 95% success rate compared to no treatment.

Along with benefits of scaling and root planing drawbacks are often

accompanied with the treatment. One draw back of thorough SRP is the necessity of

several appointments. For the dental professional to perform effective SRP they may

need several appointments to focus on each and every tooth surface. Maintenance

therapy also will need to be conducted resulting in the patient needing to have a

three month recall. Another drawback on SRP is the necessity for local anesthesia.

Some patients dislike the numbing feeling, the injection all-together and the risk of

the patient injuring themselves by cheek/tongue biting. After SRP treatment

patients may have discomfort from the removal of the biofilm and calculus deposits

causing the tooth to be more vulnerable for time being. Lastly, scaling and root

planing may not be enough to treat the patient and they may possibly need

adjunctive treatment or surgical treatment.

The failure rate for SRP is quite low, but with comparison of SRP alone and

SRP with other adjunctive treatment results have shown more progress with

adjunctive therapy. A study was done in 2016 by, The Journal of Evidence Based

Dental Practice, comparing SRP alone and SRP with adjunctive therapies. Results

concluded that with doxycycline there was a clinical attachment gain of .35mm and

chlorhexidine chips added .40mm clinical attachment gain. The conclusion of the

study was adjunctive treatments provide additional benefits of clinical attachment

loss by .2mm to. 6mm.

For the maintenance of periodontal disease both the clinician and the patient

need to work together and communicate about what is expected. Both have their

own set of responsibilities and guidelines they need to follow. Success will only be

possible if both participants hold up their end. The patient’s responsibilities are

maintaining a good oral hygiene regiment, which includes brushing 2x a day,

flossing daily or using floss aids, irrigating chemotherapeutics (if Dr. permitted), and

regularly visiting the dentist to monitor their progress. The patient may also need

to change their life style such as adjusting their diet to less cariogenic foods, and

cessation of smoking. The clinician is expected to adjust the treatment plan to the

patients needs. They need to know when scaling and root planning isn’t enough and

adjust the treatment plan accordingly whether it’s applying localized antibiotic

chemotherapeutics or surgical treatment. Clinicians also need to educate their

patients on what the best oral hygiene regime is for their patients and show them

the correct way to brush and floss. It is also important for the clinician to fully

educate their patient on their disease and the importance of compliance and the

consequences of progression if the patient doesn’t. Clinicians also need to provide

nutritional counseling and discuss lifestyle changes. Treatment may need to be

altered to the patients needs. Scaling and root planning is a multiple appointment

process and includes anesthetizing the patient for comfort and complete removal of

biofilm and calculus. The patient will also need to be brought back in for

reevaluation in 2-3 months to evaluate the patient’s status and periodontal

maintenance. Home care alterations that patients need to incorporate are brushing

their teeth for at least two minutes twice a day and follow the dental hygiene
instructions their clinical gave them. If a local antibiotic was administered the

patient may also need to avoid brushing and flossing in areas where the antibiotic

was placed. If the patient is prescribed with a systemic antibiotic they will need to

remember to take it for the allotted amount of time. To help reduce the bacterial

uptake the hygienist may have also included in the home care regiment of a

chlorohexidine rinse/irrigate. Patient compliance plays a crucial role in the health of

the patient. They may not show up for their three-month appointments, they may

continue to have bad oral hygiene, forget to take the antibiotics, ignore the advice of

good nutrition and continue with bad habits such as smoking and drinking.

Periodontal disease is an irreversible disease that affects the periodontum

and surrounding tooth structures. With treatment such as scaling and root planing

and adjunctive therapies periodontal disease can be maintained. It is important for

the clinician and the patient to work together to prevent the disease from

progressing. Patient home care is one of the most important factors for scaling and

root planing to be beneficial.

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