Rationale of Periodontal

Treatment

by
Dr. Marcel Hallare
 

The effectiveness of periodontal

therapy is made possible by the
remarkable healing capacity of the
periodontal tissue
 

Properly performed, periodontal

treatment can be relied on to
accomplish the following:

1. eliminate pain
2. el
elim
imin
inat
ate
e gi
ging
ngiv
ival
al in
infl
flam
amma
mati
tion
on an
and
d
gingival bleeding
3. re
redu
duce
ce pe
peri
riod
odon
onta
tall p
poc
ocke
kets
ts an
and
d
eliminate infection
 

4. stop pus formation

5. ar
arre
rest
st th
the
e dest
destru
ruct
ctio
ion
n of
of soft
soft ti
tiss
ssue
ue

and bone
6. re
red
duc
uce
e ab
abno
norrma
mall mobil
iliity
7. es
esta
tabl
blis
ish
h opti
optima
mall occl
occlus
usal
al fun
funct
ctio
ion
n
8. rest
restor
ore
e tis
tissu
sue
e des
destr
troy
oyed
ed by dis
disea
ease
se
in some instances
 

9. re
rees
esta
tabl
blis
ish
h th
the
e ph
phys
ysio
iolo
logi
gic
c gi
ging
ngiv
ival
al
contour necessary for preservation
of periodontal health
10.prevent the recurrence of disease
11. redu
reductio
ction
n of tooth loss
 

Local Therapy
 

The cause of periodontitis and

gingivitis is bacterial plaque
accumulation on the tooth surface in
close proximity to gingival tissue
 

The accumulation of plaque can be

favored by a variety of local factors:

1. calculus
2. ov
over
erha
hang
ngin
ing
g ma
marg
rgin
ins
s of re
rest
stor
orat
atio
ions
ns

3. food impaction
 

The removal of plaque and all the

factors that favor its accumulation
is therefore the primary
consideration in local therapy
 

Systemic Therapy
 

Systemic therapy may be employed

as an adjunct to local measures
and for specific purposes such as:

1. the
the co
fromcont
ntro
roll of
acute syst
system
emic
infectionsic co
comp
mplilica
cati
tion
onss
2. ch
chem
emot
othe
hera
rapypy to pr
prev
even
entt har
harmf
mfulul ef
effe
fect
cts
s
of posttreatment bacteremia nutritional
3. sup
suppo
port
rtiv
ive
e nunutr
trit
itio
iona
nall the
hera
rapy
py
4. th
the
e cont
contro
roll of sy
syststem
emicic di
dise
seas
ases
es th
that
at
aggravate the patient’s periodontal
condition
 

Systemic therapy for treatment of the

periodontal condition and in conjunction
with local therapy is indicated in localized

and generalized aggressive periodontitis

In these diseases, systemic antibiotics are

used to completely eliminate the bacteria
that invade the gingival tissues and can
repopulate the pocket after scaling and root
planing
 

In studies,
drugs suchNonsteroidal
as flubiprofenanti-inflammatory
and ibuprofen
can slow down the development of 
experimental gingivitis, as well as the loss
of alveolar bone in periodontitis
These drugs are propionic acid derivatives
and act by inhibiting the cyclooxygenase

pathway of anachidonic acid metabolism,

thereby reducing prostaglandin formation
 Administered orally or applied topically
 

Future treatment modalities may

attempt not to control the bacterial
cause of disease, but also suppress
the self-destructive components of the
host inflammatory response.
 

FACTORS THAT
 AFFECT HEALING
 

In the periodontium, as elsewhere in

the body, healing is affected by local
and systemic factors
 

Local Factors
 

Systemic conditions that impair 

healing may reducetreatment

of local periodontal the effectiveness
and
should be corrected before, or along

with, local procedures

 

Healing may be delayed by:

1. exce
excess
ssiv
ive
e ti
tiss
ssue
ue ma
mani
nipu
pula
lati
tion
on
during treatment
2. trauma to the tissues
3. pr
pre
esen
ence
ce of for
ore
eign bo
bod
die
ies
s
4. repe
repeti
titi
tive
ve tr
trea
eatm
tmen
entt pr
proc
oced
edur
ures
es th
that
at
disrupt the orderly cellular activity in
the healing process
 

 An adequa
adequatete blood supply is needed
for the increased cellular activity

during healing

If this is impaired or insufficient, areas

of necrosis will develop and delay the
healing process
 

Healing is improved
immobilization of theby debridement,
healing area,
and pressure on the wound
 

Systemic Factors
 

Healing capacity diminishes with age,

probably due to atherosclerotic
vascular changes, which is common
in aging and result in reduction of 
blood circulation

Healing is delayed in patients with

generalized infections and in those
with diabetes and other debilitating
diseases
 

Healing is retarded by insufficient

food intake; bodily conditions that
interfere with the use of nutrients
nutrients;; and
deficiencies in vitamin C, proteins,
and other nutrients
 

Healing is also affected by hormones

Systemically administered
glucocorticoids such as cortisone
hinder repair by depressing the

inflammatory
the growth of reaction orthe
fibroblast, by inhibiting
production of collagen, and the
formation of endothelial cells
 

Systemic stress, thyroidectomy,

testosterone, adrenocorticotropic
hormone, and large doses of estrogen
suppress the formation of granulation

tissue and retard

Progesterone healingand
increases
accelerates the vascularization of 
immature granulation tissue and
appears to increase the susceptibility
of the gingiva to mechanical injury by
causing dilation of the marginal
vessels
 

HEALING AFTER
PERIODONTAL
THERAPY
 

The basic healing processes are the

same following all forms of 
periodontal therapy
They consist of the removal of 
degenerated tissue debris and the
replacement of tissue destroyed by
disease
Regeneration, repair, and new
attachment are aspects of periodontal
healing
 

Regeneration
 

Regenerati on is the growth and

Regeneration
differentiation
differentiatio n of new cells and
intercellularr substances to form
intercellula
new tissues or parts

It takes place by growth from the

same type of tissue that has been
destroyed or from its precursor 
 

In the periodontium, gingival

epithelium is replaced by epithelium,

and the underlying connective tissue
and periodontal ligament are derived

from connective tissue

 

Bone and cementum are not replaced

by existing bone or cementum but by
connective tissue, which is the
precursor of both
 

Undifferentiated connective tissue

cells develop into osteoblasts and
cementoblasts, which form bone and
cementum
 

Regeneration of the periodontium is a

continuous physiologic process

Under normal conditions new cells

and tissues are constantly being
formed to replace those that mature
and die

This is termed wear and tear repair 

 

It is manifested by mitotic activity in

the epithelium of the gingiva and the

connective tissue of the periodontal
ligament, by the formation of new

bone, and by
deposition the continuous
of cementum
 

Regeneration is also going on

during destructive periodontal
disease

Most gingival and periodontal

diseases are chronic inflammatory
processes and, as such, are healing
lesions

Regeneration is part of the healing

 

However, bacteria and bacterial

products that perpetuate the disease
process and the inflammatory
exudate they elicit are injurious to the
regenerating cells and tissues and

prevent the healing from proceeding

to completion
 

By removing bacterial plaque and

creating the conditions to prevent its
new formation, periodontal treatment
removes the obstacles to
regeneration and enables the patient
to benefit from the inherent
regenerative capacity of the tissue
 

Repair 
 

Repair simply restores

of the diseased thegingiva
marginal continuity
and
reestablishes a normal gingival sulcus
at the same level on the root as the
base of the preexistent periodontal
pocket

This process, called healing by scar,

arrests bone destruction without
necessarily increasing bone height
 

Restoration of the destroyed

periodontium involves mobilization of 
epithelial and connective tissue cells
into the damaged area and increased
local mitotic divisions to provide
sufficient number of cells
 

New Attachment
 

It is the embedding of new periodontal

ligament fibers into new cementum
and the attachment of the gingival
epithelium to a tooth surface
previously denuded by disease

Epithelial
apposition adaptation is the
of the gingival close
epithelium
to the tooth surface without complete
obliteration of the pocket
 

The pocket space does not permit

passage of the probe

These deep sulci lined by long, thin

epithelium may be as resistant to
disease as true connective tissue
attachment
 

The absence of bleeding or secretion

on probing, the absence of clinically
visible inflammation, and the absence
of stainable plaque on the tooth
surface when the pocket wall is
deflected from the tooth may indicate
that the “deep sulcus” persists in an
inactive state, causing no further loss
of attachment
 

Post-therapy depth of 4 or even 5mm

may therefore be acceptable in these
cases

New attachment and osseous

regeneration have been a constant
but elusive goal of periodontal therapy
 

Melcher pointed out that the

regeneration of the periodontal
ligament is the key to new attachment
because it “provides
between the alveolarcontinuity
bone and the
cementum and also because it
contains cells that can synthesize and
remodel the three connective tissues
of the alveolar part of the
periodontium”  
periodontium”
 

During the healing stage of a

periodontal pocket, the area is
invaded by cells from four different
sources: oral epithelium, gingival
connective tissue, bone,
periodontal ligament and

The final outcome of periodontal

pocket healing depends on the
sequence of events during the healing
stages
 

If the epithelium proliferates along the

tooth surface before other tissues
reach the area, the result will be a
long junctional epithelium
 

If the cells from the gingival

connective tissue
tissue are the first to
populate the area, the result will be
fibers parallel to the tooth surface are
remodeling of the alveolar bone with
no attachment to the cementum
 

If bone cells arrive first, root

resorption and Ankylosis may occur 
 

Only when cells from the periodontal

ligament proliferate coronally is there
new formation of cementum and
periodontal ligament
 

The End