Nimisha Nagar

Periodontology

Shaunda Clark

Date: 10/9/2017
 Examination of Methods of Periodontal Disease

Periodontal disease ranges from simple gingival inflammation to sever oral disease that can

result in severe damage of soft tissues and the bone that supports the teeth. Everyone has bacteria in

the mouth. These bacteria along with mucus and other particles, constantly build up sticky, loosely

attached, colorless plaque in the oral cavity. If the plaque is not removed by regular brushing and

flossing, it will form calculus. Brushing and flossing does not clean calculus, only professional cleaning by

a dentist or a dental hygienist can clean the calculus. ("Periodontal (Gum) Disease: Causes, Symptoms,

and Treatments", 2017).

If the calculus is not removed and stays longer on the tooth, it can become harmful to the

gingival tissue. The bacteria cause inflammation of the gingiva known as ‘gingivitis’. Gingiva becomes

swollen, red and can bleed easily. It can be reversed with regular oral prophylaxis and regular dental

cleaning appointments.

If gingivitis is not treated, it can progress and cause Periodontitis. “Periodontitis is a set of

diseases characterized by inflammation of the supporting tissues of the teeth, specifically the

periodontal ligament, cementum and alveolar bone. Periodontal disease is an inclusive term describing

any disease of the tissues surrounding the teeth, including gingival diseases and diseases of the

supporting structures.” (Perry, Beemsterboer & Essex, 2014). Gingiva around the tooth starts to pull

away from the teeth and creates pockets. Pockets become infected and body’s immune system fights

against the bacteria that grows under the gumline as plaque spreads. Eventually, bone and connective

tissue starts to breakdown due to bacterial toxins and body’s defense mechanism to infection. If it is not

treated, the bones, tissue and gingiva can be destroyed, teeth may become loose and needs to be

removed. ("Periodontal (Gum) Disease: Causes, Symptoms, and Treatments").

 There are some warning signs of periodontal disease. Bad breath or bad taste that doesn’t go

away, red or swollen gums, tender or bleeding gums, painful chewing, loose teeth, sensitive teeth or any

change in the way your teeth fit together when you bite or any change in the fit of partial dentures.

Some of the risk factors for the periodontal disease include smoking, diabetes, poor oral hygiene, stress.

heredity, crooked teeth, underlying immuno-deficiencies—e.g., AIDS, fillings that have become

defective, taking medications that cause dry mouth, bridges that no longer fit properly, female

hormonal changes, such as with pregnancy or the use of contraceptives. ("Periodontal Disease | Division

of Oral Health | CDC", 2017)

In addition to the surface biofilm, there are several viable periodontal pathogens such as

Aggregatibacter actinomycetemcomitans, Treponema denticola and Porphyromonas gingivalis are the

microorganisms involved in periodontal disease. Persistence of Porphyromonas gingivalis in the

subgingival environment following periodontal therapy has been associated with progressive alveolar

bone loss. (Cobb, 2017). Other bacteria are Bacteroides Forsythus, Prevotella intermedia and

Camphylobacter rectus (Clark, 2017)

There are several treatment options for periodontal disease including non-surgical treatments,

gum graft surgery, laser treatment, regenerative procedures, dental crown lengthening, dental implants.

pocket reduction procedures and plastic surgery procedures. ("Periodontal Treatments and Procedures

| Perio.org", 2017).

Non-surgical treatment includes scaling and root planning and tray delivery systems.

“Scaling and root planning 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. Scaling

and root planning is sometimes followed by adjunctive therapy such as local delivery antimicrobials,

systemic antibiotics, and host modulation, as needed on a case-by-case basis.” Custom fit trays made
from impression of the patient’s mouth which they can take home. This procedure is approved by FDA.

According to the studies done by AAP – American Academy of Periodontology, tray delivery system is

done in adjunct to SRP and there is no evidence that adjustive use of tray delivery system is more

effective than doing SRP alone. ("Periodontal Treatments and Procedures | Perio.org").

Gum graft surgery can be useful to cover the roots and it helps to reduce further recession and

bone loss. Periodontist takes gingival tissue from the patient’s palate or another donor source to cover

the exposed root. It can be done on one or several teeth. Laser treatment can be done instead of

traditional scaling and root planning but there is no sufficient evidence that the laser treatment is not

harmful. Also, it is unknown that laser treatment can be as effective as SRP. During regenerative

procedure, periodontist folds back the gingival tissue and removes the disease-causing bacteria which

helps to reduce pocket depth and repairs the damage caused by the progression of periodontal disease.

Dental crown lengthening procedure reshapes excess gingival and bone tissue to expose more of the

natural tooth. This can be done to one tooth or on several teeth. A dental implant is a titanium post (like

a tooth root) that is placed into jawbone 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. Deep pockets collect even more bacteria, resulting in further bone and tissue loss. During pocket

reduction procedure, the periodontist will fold back gingival tissue and removes the disease-causing

bacteria. Plastic surgery can also be done for uneven gingival margin, exposed teeth root or for

indentation due to tooth loss caused by periodontal disease. ("Periodontal Treatments and Procedures |

Perio.org").

Although all these options are available, homecare in treatment is significantly important. After

receiving extensive periodontal disease treatment, routine prophylaxis at home should be followed to

maintain the health of periodontium.

 Scaling and root planning(SRP) followed by use of antimicrobial agent is what I think would be a

better choice than any other treatments for periodontal disease.

SRP is a deep cleaning below the gingival margin. It can be done in two parts. The American

academy of Periodontology (AAP) defines scaling as “instrumentation of the crown and root surfaces of

the teeth to remove plaque, calculus and stains from these surfaces.” However, subgingival scaling is

also referred to as simply the removal of subgingival calculus or deposits. Associated plaque biofilm

deposits are also removed during the procedure. The focus while using the instrument is to remove

calculus and biofilms. Success of treatment will be assessed by explorer to evaluate smoothness after

scaling procedure to ensure calculus removal. (Perry)

Root planning is defined by the AAP as “a treatment procedure designed to remove cementum

or surface dentin that is rough, impregnated with calculus, or contaminated with toxins or

microorganisms.” This procedure focuses on the calculus on the root surface associated with the

periodontal pocket. The goal is to remove the surface layer of cementum or dentin that is affected by

bacteria or calculus to create a glassy, hard surface. The difference between scaling and root planning is

a matter of degree. Root planning involves a specific effort to instrument every portion of the root

surface, not simply identifiable calculus deposits. (Perry)

Scaling and root planning can be successfully performed by hand instrumentation or powered

scaling devices. The right candidate for the scaling and root planning will be based on the classification

and extent of the disease. A patient with slight periodontitis (1-2 mm CAL), moderate periodontitis (3-4

mm CAL), severe periodontitis (>=5 mm CAL) or aggressive periodontitis will be an ideal candidate for

the scaling and root planning. (Perry) This procedure may also require local anesthesia to make the

treatment painless. It may take more than one appointment to complete the SRP considering

completing one or two quads at each appointment. Antimicrobial agents should be used for full mouth
disinfection especially on severe and aggressive periodontal disease. This includes use of periochip,

atridox gel or arestin. Chlorhexidine rinse for 2 moths twice a day is strongly recommended for 2 months

following the scaling and root planning. (Perry)

Scaling and root planning may cost $400-$4,000 for your whole mouth. Local anesthetic may

add $300 per tooth or nitroxide may tack on an additional $50-100. Antibiotic injections at a cost of $30-

90 per tooth to help speed the healing process. Depending on the insurance plan, dental insurance may

cover 50% or more of the cost of scaling and root planning and some part of local anesthesia and

antimicrobial treatment. (Zach, 2017).

Any licensed dental hygienist can perform scaling and root planning and they do not require any

extra training for that. Licensed dental hygienist gets a special training during their education for SRP.

(Perry)

I recommend scaling and root planning with antimicrobial agents for the treatment of

periodontal disease because I feel that it is the better way to treat without any surgical need. Patient

has less discomfort after SRP compare to the level of pain and discomfort after surgery.

A study done by National center for biotechnology information in 2001 indicates 95.1% success

rate in achieving no further loss of alveolar bone following scaling and root planning. (Lundgren D,

2017). No data has been found about any disadvantages of scaling and root planning. No data found on

any disadvantages of using antimicrobial agents after scaling and root planning. According to NCBI,

antimicrobial agents such as atridox, arresting and periochip are considered superior drug delivery

system because of low cost, greater stability, non-toxicity, biocompatibility, non-immunogenicity, and

are biodegradable in nature. (Sreeja C. Nair, 2012).

A dental hygienist plays a major role in treating a patient with periodontal treatment. A patient

would expect reduction in periodontal disease by some extent after extensive treatment of scaling and
root planning. RDH would expect reduction in probing depth and reduction in periodontal disease. A

hygienist plays a major role in evaluation of therapy and to determine the maintenance program for the

patient. Most patients with severe to chronic periodontal disease may require a maintenance visit at

every 3 months. Patient needs to be counseled about oral home care very thoroughly and it should

include discussion about patient’s own risk factors associated with the progression of the periodontal

disease. Alterations may require in routine dental hygiene care considering patient needs. For example,

patient with systematic disease or who refuse or delay treatment may require more counselling. There

are other patient compliance issues such as failure to follow oral hygiene routine or keeping

maintenance appointments. The hygienist should establish best possible periodontal health in such

patients.

References:

1. Periodontal (Gum) Disease: Causes, Symptoms, and Treatments. (2017). Nidcr.nih.gov. Retrieved

18 September 2017, from

https://www.nidcr.nih.gov/OralHealth/Topics/GumDiseases/PeriodontalGumDisease.htm

2. Perry D., Beemsterboer P., Essex G., (2014). Periodontal Diseases. Periodontology for the Dental

Hygienist (4th ed.). St. Louis, Missouri. Elsevier Saunders. Oct. 5, 2017

3. Periodontal Disease | Division of Oral Health | CDC. (2017). Cdc.gov. Retrieved 6 October 2017,

from https://www.cdc.gov/oralhealth/periodontal_disease/index.htm.

4. Clark, S. (2017). Talon.kirkwood.edu. Retrieved 9 October 2017, from

https://talon.kirkwood.edu/d2l/le/content/60629/viewContent/1784895/View

5. Cobb, C. (2017). Microbes, Inflammation, Scaling and Root Planning, and the Periodontal

Condition. http://jdh.adha.org/. Retrieved 5 October 2017, from

http://jdh.adha.org/content/82/suppl_2/4.full.pdf
6. Periodontal Treatments and Procedures | Perio.org. (2017). Perio.org. Retrieved 24 September

2017, from https://www.perio.org/consumer/periodontal-treatments-and-procedures.

7. Zach, B. (2017). How Much Periodontal Scaling and Root Planning Cost? Authority Dental.

Retrieved 5 October 2017, from https://www.authoritydental.org/scaling-and-root-planing-

costs.

8. Lundgren D, e. (2017). Success rates in periodontal treatment as related to choice of evaluation

criteria. Presentation of an evaluation criteria staircase for cost-benef... - PubMed - NCBI.

Ncbi.nlm.nih.gov. Retrieved 5 October 2017, from

https://www.ncbi.nlm.nih.gov/pubmed/11142663.

9. Sreeja C. Nair, K. (2012). Intraperiodontal pocket: An ideal route for local antimicrobial drug

delivery. PubMed Central (PMC). Retrieved 5 October 2017, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312733/.