Treating Periodontal Disease

Periodontal disease is one of the biggest threats to dental health. It is the result of

infections and inflammation of the gums and the alveolar bone that supports the teeth. It is an

inflammatory process that results in destruction of the attachment apparatus, loss of supporting

alveolar bone and if untreated it can lead to tooth loss. The etiology of periodontal disease is

bacterial plaque, microbial by products and the host immune response. The main etiologic factor

is bacteria. The bacteria in the mouth cause infection of the tissue leading to inflammation that

results in periodontal disease.

There are typically two categories of periodontal disease, chronic periodontitis and

aggressive periodontitis. They can also be further characterized by the extent of bone loss and

severity of disease. Chronic periodontitis is what most patients are diagnosed with. The

destruction of bone is consistent with the presence of plaque and calculus. Aggressive

periodontitis results in rapid destruction of bone and attachment loss. The amount of destruction

is not typically comparable to the amount of microbial deposits. There are many predisposing

factors for periodontal disease including smoking, diabetes, poor oral hygiene, genetics,

immunocompromised patients, defective restorations, medications, hormonal changes and

malocclusion.

There are more than 500 different bacterial species that reside in the subgingival plaque.

Biofilm consists of gram positive, gram negative, aerobic, facultative and anaerobic

microorganisms. Bacteria continue to develop with congregation between other bacteria of the

same or different species. There is a shift between gram positive facultative bacteria to gram

negative anaerobic bacteria as the biofilm beings to mature. The reason for this shift is that the
bacteria colonize under the gingival surface. The subgingival bacteria are not affected by salivary

and masticatory influences like they are on supragingival bacteria. Subgingival plaque is either

tooth associated, or tissue associated. The plaque that is tooth associated primarily consists of

gram-positive rods and cocci. The plaque that is associated with the tissue consists of gram-

negative rods, filaments and spirochetes. Bacteria that may cause periodontal disease are

Treponema, Bacteroides, Porphyromonas, Actinobacillus and Eikenella.

Common treatment methods for periodontal disease are surgical intervention, mechanical

therapy and use of pharmacological agents. Treatment of periodontal disease is a challenge

because the infection occurs due to bacterial biofilm that is highly resistant to the antimicrobial

and host response. The severity of the disease depends on the bacterial components present and

the host response. Scaling and root planing is a treatment where plaque and calculus is removed

with manual instruments and ultrasonic instruments. Root planing entails leveling rough spots on

a tooth to eliminate bacteria. If the periodontal disease has become advanced, surgery may be the

only solution. Pocket reduction surgery (gingival flap surgery) is the most common surgical

periodontal disease treatment. The gums are flapped back and any disease-causing bacteria is

removed. Any defective bone can be smoothed by a process called osseous recontouring.

Afterwards the gum tissue is sutured back into place. Another surgical procedure that is

commonly done in cases with significant bone loss is called graft surgery. Bone grafting will

promote regrowth in areas where there is exposed tooth root.

Studies have shown the effectiveness of periodontal therapy. Surgical procedures have

been shown to be effective in treating periodontitis when followed by appropriate maintenance

care. Both surgical and non-surgical treatment methods have been proven to result in pocket

reduction. Literature also indicates that scaling and root planing combined with flap surgery
results in greater initial pocket reduction than does scaling and root planing alone. It also has

been shown that both methods result in decreased gingivitis, plaque and calculus. “For pockets 4-

6mm, both treatment procedures resulted in equal effective sustained pocket reduction. Deep

pockets (greater than or equal to 7 mm) were initially reduced more by the flap procedure”

(Pihlstrom, McHugh, Oliphant & Ortiz-Campost, 1983, p. 1).

Follow up care after treatment is essential in order to keep the periodontal disease stable.

Patients will return every 3 months for cleanings to ensure the bacteria are kept under control. It

is important that the patient has good home care afterwards to prevent the bacteria from

accumulating. Patients should be brushing twice a day, flossing regularly, using fluoridated

toothpaste and antibiotics to combat plaque. Periodontal maintenance will help prevent tooth loss

and prevent or delay the progression of periodontitis.

Scaling and root planing otherwise known as a “deep cleaning” is a procedure that is

done to remove etiologic agents which cause inflammation to the gingival tissue and surrounding

bone. Etiologic agents removed by periodontal therapy are dental plaque and calculus. Scaling

and root planing halts periodontal disease from progressing and preventing the bacteria from

traveling to other parts of the body. The oral bacteria can travel through the bloodstream to other

parts of the body. When patients have gum pockets that exceed 3 mm in depth, there is greater

risk for periodontal disease. As the pockets become deeper, they house more colonies of

dangerous bacteria. A chronic inflammatory response begins to destroy gingival and bone tissue

which may lead to tooth loss. Candidates for treatment depend on the current conditions of the

gums, the amount of calculus present, depth of the pockets and progression of periodontitis.

The process of scaling and root planing starts with local anesthetic to help alleviate any

discomfort. Scaling is done with special instruments and may include an ultrasonic scaler. The
instruments remove calculus and plaque from the surfaces of crowns and root surfaces. Root

planing consists of removing cementum that is embedded with unwanted microorganisms, toxins

and calculus. The root of the tooth is smoothed in order to promote good healing. Having smooth

root surfaces helps bacteria from easily colonizing in the future. The pockets may also be treated

with antibiotics to help with any irritation and help the gum tissues to heal. After treatment is

completed, the hygienist will throughly examine the gums and see how well the pockets have

healed. Dentists and periodontists offer scaling and root planing. The procedure is typically done

by a dental hygienist who has gone through schooling and training. The cost of the procedure

varies widely depending on how extensive the procedure needs to be, who performs it and

geographical location. Costs can range from $100 to over $1,000. It can be partially covered

through insurance and there are financing options available as well.

The benefits of scaling and root planing are stopping the advancement of disease, treating

the current infection and promoting healing, eliminating halitosis caused by periodontitis and

cleaning teeth above and below the gum line. I feel like scaling and root planing is the treatment

of choice because there is research showing that is halts the progression of periodontal disease

and infection. If patients return for 3-month periodontal maintenance appointments and have

good home care, then I believe that they can prevent the disease from progressing. Numerous

studies have confirmed the significant reduction of subgingival bacteria following scaling and

root planing. A study was done in from 2013 to 2016 in the Netherlands on 1,118 patients with

adult periodontitis needing non-surgical periodontal therapy. The results were that overall, 39%

of patients reached the successful treatment objective. Bleeding on probing was 14%. The

success of treatment was dependent on the tooth type. Single rooted from teeth were successful

at 85%, premolar teeth successful at 78% and molar teeth successful at 47%. In 55% of the cases
furcation involvement at molars was associated with absence of success in 8-11% of the cases.

Endodontic treatment was associated with absence of success in 8-11% of the cases. The study

showed that one third of the cases were successful. Outcomes were dependent on tooth type,

furcation involvement, severity of periodontal disease and smoking status.

The downsides of scaling and root planing are nerve damage, the procedure doesn’t

guarantee the reattachment of your gums to your teeth, can cause infections if your immune

system if compromised and pain and sensitivity after the procedure. The main drawback is pain

after treatment is completed. The risks from the procedure are very minimal, lasting for five to

seven days. Studies evaluating SRP effectiveness indicate that many teeth exhibit residual

subgingival biofilm and calculus. Deeper probing depths, root concavities, grooves, restorative

contours, and furcation involvements reduce efficacy. No treatments can completely remove all

bacteria. Limited visibility, restricted access, tissue invasion of microbes and inaccessible biofilm

retained in surface irregularities all impact the effectiveness of treatment.

We expect the patient to return to the dentist after the scaling and root planing a few

weeks after. The hygienist will touch up any areas, polish and remeasure the gum pockets to see

if the tissues have reattached in any areas. A plan will be made for ongoing maintenance.

Sometimes the disease can be so severe that the patient will have to see a periodontist to perform

additional surgical procedures. To help with sensitivity, it is recommended to avoid hot food for a

few days, stick to a soft diet and use over the counter pain medication to reduce inflammation

and manage the pain between. Regular brushing and flossing with a soft bristled toothbrush

twice a day and flossing once a day is recommended to overcome the inflammation and to avoid

future scaling and root planning procedures. A waterpik is highly recommended because floss

can't reach down into the deeper pockets. It can reach several millimeters below the gum line,
flushing plaque and food particles out of the periodontal pockets. If patients are not returning for

periodontal maintenance appointments and improving their home care, the likely hood that they

need to be retreated with scaling and root planing or even surgical periodontal therapy is high.

Patient compliance is essential to stabilize periodontal disease and prevent further progression.
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