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Treatment of Periodontal Disease

Periodontal Scaling & Root Planing

The objective of scaling & root planing is to remove etiologic agents which cause inflammation to the gingival (gum) tissue and surrounding bone. Common etiologic agents removed by this conventional periodontal therapy include dental plaque and tartar (calculus).

These non-surgical procedures which completely cleanse the periodontium, work very effectively for individuals suffering from gingivitis (mild gum inflammation) and moderate/severe periodontal disease.

Reasons for scaling and root planing

Scaling and root planing can be used both as a preventative measure and as a stand-alone treatment. These procedures are performed as a preventative measure for a periodontitis sufferer.

Here are some reasons why these dental procedures may be necessary:

Disease prevention: The oral bacteria which cause periodontal infections can travel via the bloodstream to other parts of the body. Research has shown that lung infections and heart disease have been linked to periodontal bacteria. Scaling and root planing remove bacteria and, in mild cases, can prevent periodontal disease from progressing, thus preventing the bacteria from traveling to other parts of the body.
Tooth protection: When gum pockets exceed 3mm in depth, there is a greater risk of periodontal disease. As pockets deepen, they tend to house more colonies of dangerous bacteria. Eventually, a chronic inflammatory response by the body begins to destroy gingival and bone tissue which may lead to tooth loss. Periodontal disease is the number one cause of tooth loss in the developed world.
Aesthetic effects: Scaling and root planing help remove tartar and plaque from the teeth and below the gumline. As an added bonus, if superficial stains are present on the teeth, they will be removed in the process of the scaling and root planing procedure.
Better breath: One of the most common signs of periodontal disease is halitosis (bad breath). Food particles and bacteria can cause a persistent bad odor in the oral cavity which is alleviated with cleaning procedures such as scaling and root planing.

What do scaling and root planing treatments involve?

Scaling and root planing treatments are only performed after a thorough examination of the mouth. The dentist will take X-rays, conduct visual examinations and make a diagnosis before recommending or beginning these procedures.

Depending on the current condition of the gums, the amount of calculus (tartar) present, the depth of the pockets and the progression of the periodontitis, local anesthetic may be used.

Scaling: This procedure is usually performed with special dental instruments and may include an ultrasonic scaling tool. The scaling tool removes calculus and plaque from the surface of the crown and root surfaces. In many cases, the scaling tool includes an irrigation process that can also be used to deliver an antimicrobial agent below the gums that can help reduce oral bacteria.
Root Planing: This procedure is a specific treatment which serves to remove cementum and surface dentin that is embedded with unwanted microorganisms, toxins and tartar. The root of the tooth is literally smoothed in order to promote good healing. Having clean, smooth root surfaces helps bacteria from easily colonizing in future.

Following these deep cleaning procedures, the gum pockets may be treated with antibiotics. This will soothe irritation and help the gum tissues to heal quickly.

During the next appointment, the dentist will thoroughly examine the gums again to see how well the pockets have healed. If the gum pockets still measure more than 3mm in depth, additional and more intensive treatments may be recommended.

Antibiotic Treatment

Periodontal disease is a progressive condition which leads to severe inflammation and tooth loss if left untreated. Antibiotic treatments can be used in combination with scaling and root planing, curettage, surgery or as a stand-alone treatment to help reduce bacteria before and/or after many common periodontal procedures.

Antibiotic treatments come in several different types, including oral forms and topical gels which are applied directly into the gum pockets. Research has shown that in the case of acute periodontal infection, refractory periodontal disease, prepubertal periodontal disease and juvenile periodontal disease, antibiotic treatments have been incredibly effective.

Antibiotics can be prescribed at a low dose for longer term use, or as a short term medication to deter bacteria from re-colonizing.

Oral and Locally Delivered Antibiotics Oral antibiotics tend to affect the whole body and are less commonly prescribed than topical gel. Here are some specific details about several different types of oral antibiotics:

Tetracycline antibiotics: Antibiotics which include tetracycline hydrochloride, doxycycline, and minocycline are the primary drugs used in periodontal treatment. They have antibacterial properties, reduce inflammation and block collagenase (a protein which destroys the connective tissue).
Macrolide antibiotics: This group of antibiotics has proven effective at reducing inflammation, and can also reduce bacterial growth associated with periodontitis.
Metronidazole: This antibiotic is generally used in combination with amoxicillin or tetracycline to combat inflammation and bacterial growth in severe or chronic periodontitis.
Arestin®: This Minocycline antibiotic comes in mini capsules which are delivered into the gums after scaling and root planing.

Noticeable periodontal improvements are usually seen after systemic or oral antibiotic treatment. Your Periodontist or dentist will incorporate and recommend the necessary antibiotic treatments as necessary for the healing of your periodontal condition.

Periodontal Surgery

Pocket reduction surgery (also known as gingivectomy, osseous surgery and flap surgery) is a collective term for a series of several different surgeries aimed at gaining access to the roots of the teeth in order to remove bacteria and tartar (calculus).

The human mouth contains dozens of different bacteria at any given time. The bacteria found in plaque (the sticky substance on teeth) produce acids that lead to demineralization of the tooth surface, and ultimately contribute to periodontal disease.

Periodontal infections cause a chronic inflammatory response in the body that literally destroys bone and gum tissues once they invade the subgingival area (below the gum line). Gum pockets form and deepen between the gums and teeth as the tissue continues to be destroyed.

Periodontal disease is a progressive condition which, if left untreated, causes massive bacteria colonization in gum pockets can eventually lead to teeth falling out. Pocket reduction surgery is an attempt to alleviate this destructive cycle, and reduce the depth of the bacteria-harboring pockets.

Bone Grafts and GBR

During both periodontal and dental implant surgery, it may be necessary to perform bone grafting. The bone graft supplements the bone around existing teeth or in the case of implants, in the recipient site of the implant. The goal of the graft is to strengthen bone support for the existing tooth or to create a more stable base for the dental implant.

Ridge Preservation

Careful management of extraction sockets after tooth extraction prevents unsightly bone loss and provides a better cosmetic outcome for tooth replacement. The photos below illustrate what teeth look like without and with bone and soft tissue preservation.

Reasons for the pocket reduction surgery

Pocket reduction surgery is a common periodontal procedure which has been proven effective at eliminating bacteria, reducing inflammation and saving teeth. The goals of pocket reduction surgery are:

Reducing bacterial spread: Oral bacteria has been connected to many other serious conditions such as diabetes, heart disease and stroke. Oral bacteria can travel to various parts of the body from inside the bloodstream and begin to colonize. It is important to decrease bacteria in the mouth in order to reduce the risk of secondary infection.
Halting bone loss: The chronic inflammatory response induced by oral bacteria leads the body to destroy bone tissue. As the jawbone becomes affected by periodontal disease, the teeth lose their rigid anchor. When the teeth become too loose, they may require extraction.
Facilitate home care: As the gum pockets become progressively deeper, they become incredibly difficult to clean by the patient. The toothbrush and dental floss cannot reach to the bottom of the pockets, increasing the risk of further periodontal infections.
Enhancing the smile: An oral cavity that is affected by periodontal disease is not attractive to the eye. In fact, smiles may be marred by brown gums, rotting teeth and ridge indentations. Pocket reduction surgery halts the progression of gum disease and improves the aesthetics of the smile.

What does pocket reduction surgery involve?

Before recommending treatment or performing any procedure, the dentist will perform thorough visual and x-ray examinations in order to assess the condition of the teeth, gums and underlying bone. Pocket reduction surgery may be performed under local or general anesthetic depending on the preferences of the patient.

The gums will be gently pulled back from the teeth and bacteria and calculus (tartar) will be eliminated. Scaling and root planing will generally be required to fully remove the ossification (tartar) from the surface of the tooth root. If the root is not completely smooth, a planing procedure will be performed to ensure that when the gums do heal, they will not reattach to rough or uneven surfaces.

The final part of the surgery is usually the administration of an antimicrobial liquid to eliminate any remaining bacteria and promote healing. The gum is then sutured with tiny stitches that are left in place for 5-10 days.

Though the gums will be more sensitive immediately following the procedure, there will be a significant reduction in pocket depth and a vast improvement in the condition of the teeth and gums.

Illustrations courtesty of patient education materials from Osteohealth Co.

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