Periodontal Treatment

Periodontal treatment or gum disease treatment involves thorough diagnosis and comprehensive treatment of the single largest cause of tooth loss in older people. There are several types of periodontal disease, and all of them are caused by bacterial infections, which attack the gums, jawbone and the ligaments that hold the teeth in the jaw. Periodontal disease usually starts silently, painlessly and without any significant symptoms. It can make slow or rapid progress depending on its severity.

Periodontal Disease and Your Health

Periodontal disease is an infection of the tissues that support your teeth. It begins with plaques, an invisible, sticky film form on the teeth created when starch and sugar in food intracts with bacteria in the mouth. It easily gets removed by brushing. Plaques that stays on the teeth more than 2-3 days can become tartar which is hard to remove and can only be removed by professional cleaning. Tartar can damage part of the gum around the base of the teeth and cause gingivitis, the mildest form of periodontal disease. If the issue not address early, gingivitis may lead to more serious, destructive forms of periodontal disease called periodontitis. The inflation causes developments of pockets between gum and teeth that gets filled with plaques and bacteria. The pockets gradually become deeper and progress under the gum line. The deep infection cause damage to the integrity of the gum tissue and eventually loses of teeth.

Although normally the cycle starts with poor maintenance and hygiene there are other factors that contribute to the condition:

Heredity –There is a heredity element to periodontal disease. If you are doing everything to maintain a good oral health and still suffer from gum disease you might have inherited a pre-disposition to periodontal problems.

Drugs – Oral application of drugs, such as cold medicine,oral contraceptives and antidepressants damage production of saliva which has cleansing effect. Lack of saliva production cause the plaque and tartar build up. Drugs such as anti epileptics, especially phonation (Dilantin) and the immune suppressants are among the medicines that can cause gingival overgrowth.

Hormonal changes – Changes in hormones during pregnancy can make the gums more prone to gum disease.

Smoking /Tobacco use – Tobacco Use in any form, smoked or chewed has a significant contribution to periodontal disease. Tobacco damages the immune system, putting the gum in greater risk of infection. Research shows even passive smoking contribute to gun disease. Smoking disguise the sings of gum disease and are less likely to respond to treatments then non-smokers.

Diabetes – Diabetic people are more likely to develop gum disease due to being more susceptible to infections. Gum disease is considered one of the complication of diabetes.Diabetes thickens the blood vessels, which carry oxygen and nutrition to body tissues and remove waste. Diabetes by thickening the blood vessels slows down the flow of blood and delivery of nutrition and removal of waste. This gradually damage the gum and increase the risk of infection.

Diet– poor diet can damage body’s immune system and impair body’s capability to fight infection. Lack of vitamin C and Calcium has been found to contribute to periodontal disease. Calcium strengthens the bone that supports the teeth while Vitamin C maintains the integrity of supporting tissues.

Stress– stress has been linked to many health conditions such as cancer and hypertension. Research has shown that stress can contribute to periodontal disease by making it more difficult for the body to fight infections.

Complications

Having periodontal disease may put you at greater risk of a number of serious medical conditions:

Heart disease and stroke

Gum disease can increase the risk of heart attack and stroke. Research suggests that inflammation caused by periodontal disease may be responsible for the connection. The bacteria responsible for gum disease can travel through bloodstreams to the heart where they initiate inflammation and arterial narrowing that cause hear attack. Oral bacteria can make the body more prone to develop blood clots and increased risk of stroke.

Complications of pregnancy

Pregnant women with gum disease, moderate to sever are more likely to give birth to premature baby in compare with women with healthy gum. Although the connection is not clear but having gum disease appears to limit the growth of the fetus in the womb and trigger the production of the substances that initiate labour. This is more apparent in cases of sever gum disease that gets worse during pregnancy. The problem gets worse for women with diabetes who are already considered at high risk of pregnancy problems.

Uncontrolled blood sugar

Diabeters puts whole body including the mouth at the risk developing complications. By developing periodontal disease and other infections the body's ability to use insulin is effected, making blood sugar level harder to control.

Pneumonia

If you have gum disease and lung problems, the travelling bacteria from your mouth yourlungs may cause aspiration pneumonia, a condition that is common in hospitals where patientsare sedated or have tracheal tubes.

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What is Gingivitis?

To understand gingivitis, it is important to have an idea of the anatomy of the tooth and its supporting structure.

When a tooth is clean, the gums around it are usually pink and healthy.
01-When a tooth is clean, the gums around it are usually pink and healthy
If the tooth is not properly cleaned, plaque forms and accumulates on its surface. Plaque is a sticky layer of bacteria (very small germs) that grows on any tooth surface, even between the teeth.
02-If the tooth is not properly cleaned, plaque forms and accumulates on its surface
Plaque causes irritation of the gums. The gums usually become red and slightly swollen. This condition is called gingivitis.
03-Plaque causes irritation of the gums
When gingivitis is present:

  1. Pocket depth may increase due to swelling
  2. The gums may bleed more easily when touched
  3. The bone level does not change around the tooth

Almost all advanced periodontal diseases start with gingivitis.

04-When gingivitis is present

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Periodontal Treatment overview

Following the initial examination and radiographs, the goals of the periodontal treatment are to control the cause (bacterial plaque) and the risk factors, repair the damage present (pockets), and restore and maintain a healthy environment.

In order to attain these objectives, there are 5 main steps:

09-The Periodontic Process

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Periodontal disease examination

To perform periodontal disease examination dentist utlizies a metal prob to measure the depth of the gingival sulcus, the gap between your gums and your teeth. The prob is inserted under gum line at several points in the mouth. If the gum is healthy the depth of the gum is expected to be 2-3 millimeters. A depth beyond 3 millimeters indicates that a pocket has been formed between your gums and your teeth which is a sign of serious gum disease.

Periodontal Disease Examination

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Clinical Crown Lengthening

Clinical crown lengthening procedure is required when the tooth is fractured or has very large filling to restore the tooth to normal function.

Clinical crown lengthening procedure involves the removal and re-contouring of the gum and bone surrounding the tooth. This provides your dentist with sufficient tooth to work with in order to place the crown so that it will have a better chance of being retained on the tooth and to allow the gum tissues to be healthy.

Example of a healthy tooth.
30-Clinical crown-lengthening - Example of a healthy Tooth
Example of a tooth fracture below the gum line, into the jaw bone. The restorative dentist cannot access the remaining tooth structure and restore this tooth adequately.
31-Clinical crown-lengthening - Example of a tooth fracture below the gum line, into the jaw bone
A periodontal procedure is required to remove some bone and expose the remaining tooth structure.
32-Clinical crown-lengthening - Periodontal procedure is required to remove some bone and expose the remaining tooth structure
Final bone and gum level after healing. The remaining tooth structure is accessible to the restorative dentist.
33-Clinical crown-lengthening - Final bone and gum level after healing. The remaining tooth structure is accessible to the restorative dentist
The tooth is restored with a filling. Depending on the remaining tooth structure, a crown may also be required to restore the tooth.
34-Clinical crown-lengthening - The tooth is restored with a filling

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Aesthetic crown lengthening

Aesthetic crown lengthening is a procedure similar to conventional crown-lengthening. Its goal is to establish proper gingival contours while exposing the complete crown of the tooth.

It is possible that during normal growth and development, too much gum tissue forms around the teeth. This is often referred to as a "gummy" smile. Teeth will appear shortened and the gum margin where the gum contacts the tooth may appear to have a ledge as opposed to a fine contour line.

 

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Gum Graft

A gum graft (also called free gingival graft) increases the attached tissue and stops the progression of recessions. It is placed at the base of the tooth and does not cover the already exposed root surface. The success rate of this procedure is excellent and its benefits should last a lifetime. Healing can be compromised with smokers.

A graft is a thin piece of gum tissue usually taken from the roof of the mouth. Its main purpose is to stop the progression of the recession.
20-Gum graft-A graft is a thin piece of gum tissue usually taken from the roof of the mouth
The graft is usually placed at the base of the recession, to strengthen the attached tissue and prevent further recession.
21-The graft is usually placed at the base of the recession
This is a picture showing some recession and thin attached tissue.
22-This is a picture showing some recession and thin attached tissue
This is the same tooth after a graft successfully increased the attached tissue.
23-This is the same tooth after a graft successfully increased the attached tissue

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Root coverage graft

Root covering graft (also called connective tissue graft) is placed over the root to cover the already exposed root surface. It also increases the attached tissue and stops the progression of gingival recessions. The success rate of this procedure is variable depending on the shape and extent of the recession. Healing will be compromised with smokers.

A graft is a thin piece of gum tissue usually taken from the roof of the mouth. Its main purpose is to stop the progression of the recession.
24-Root coverage graft-A graft is a thin piece of gum tissue usually taken from the roof of the mouth
The graft is usually placed over the recession (outlined), to strengthen the attached tissue, improve the aesthetics and reduce root sensitivity. The amount of root coverage may vary depending on local factors.
25-Root covered graft-The graft is usually placed over the recession (outlined), to strengthen the attached tissue
This is a picture showing some recession and thin attached tissue.
26-Root covered graft-This is a picture showing some recession and thin attached tissue
This is the same tooth after a graft successfully covered the root surface and increased the attached tissue. It is not always possible to cover all the root surface.
27-Root covered graft-This is the same tooth after a graft successfully covered the root surface and increased the attached tissue
This is another example of gum recession.
28-This is another example of gum recession
The same area after the graft.
29-The same area after the graft

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Why Gums Recede?

Gum recedes and to understand why it happens it is important to have an idea of the anatomy of the tooth and its supporting structures.

A healthy tooth is surrounded by two types of gum tissue. The attached tissue (1), a leather-like solid tissue bound to the jaw and tooth. A minimum amount of attached tissue is crucial for the stability of your gums. A loose fragile tissue, called mucosa (2), which is not bound to the tooth or the jaw.
17-Receding gums - shows an ideal healthy gum
When the attached tissue is very thin (1), the area becomes more susceptible to breakdown. Brushing too hard in this area may sometimes speed up the breakdown.
15-Receding gum-When the attached tissue is very thin the area becomes more susceptible to breakdown
Gum tissue breakdown, called recession, results in exposure of the root surface. This process can be progressive and gradually expose more root surface. Severe recessions can jeopardize the long-term survival of the tooth.
18-Receding gum-Gum tissue breakdown, called recession, results in exposure of the root surface
The recessions can create areas that are difficult to clean. If the areas are not brushed properly, plaque deposits will cause gingivitis. Gingivitis can speed up the breakdown in the area. These areas can also be more sensitive to cold.
19-Receding gum-The recessions can create areas that are difficult to clean

Untreated progressive recessions can lead to tooth loss.

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Periodontal treatment maintenance

Periodontal treatment maintenance phase is of utmost important. In order to maintain the high level of periodontal health obtained with the treatment rendered thus far, it is crucial to meticulously follow the recommended home-care instructions daily.

A maintenance recall frequency will be recommended, depending on your specific needs. Preventive maintenance appointments allow us to determine the stability of your periodontal health and intercept any minor problems before they become major ones.

When treated and maintained properly, long-lasting and predictable results are expected.

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What Is Periodontitis?

Periodontitis can be understood better when we have an idea of the anatomy of the tooth and its supporting structure.

In almost all cases, periodontitis starts with gingivitis.
05-In almost all cases, periodontitis starts with gingivitis
In susceptible patients, plaque and tartar will cause irritation of the gums and bone loss. This condition is called periodontitis.
06-In susceptible patients, plaque and tartar will cause irritation of the gums and bone loss
Bone loss means that the support of the tooth is reduced. Uncontrolled bone loss leads to tooth loss.
07-Bone loss means that the support of the tooth is reduced
When periodontitis is present:

  1. 1. Pocket depth increases due to swelling and bone loss.
  2. 2. The gums may bleed more easily when touched.
  3. 3. The supporting bone level is reduced around the tooth.Uncontrolled periodontal disease is a common cause of tooth loss in the adult population.
08-When periodontitis is present

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Initial or sanative phase | deep cleaning

Deep cleaning:

This first step is to reduce the gingival inflammation and thus allow the supporting bone to partially recover. For an optimal result, the oral hygiene must be excellent. This step includes the following:

  • Personalized oral hygiene instructions using techniques and tools adapted to your needs.
  • Scaling and root planing (deep cleaning) to remove the plaque and tartar buildup which adheres to the root surface below the gum line. This procedure is not a surgery, but rather a very thorough cleaning (compared to the habitual more superficial cleanings). It is done mainly under local anesthesia (freezing) and usually requires 2 to 4 appointments.
Special instruments are used below the gum line to remove soft and hard deposits from the tooth surface.
10-Special instruments are used below the gum line to remove soft and hard deposits from the tooth surface
The irritants have been removed from the root surface. Deep cleaning does not eliminate deep pockets and may have to be redone periodically.
11-The irritants have been removed from the root surface

Once the freezing has worn off, there is usually no pain. However some patients may experience the following side effects :

  • Tooth sensitivity (especially to cold, although temporary, it may last up to 2 months)
  • Contraction of the healing gums (as the inflammation decreases). This may create some spaces between certain teeth.

However, the benefits of the treatment significantly outweigh the potential side effects, especially considering that without the treatment, the teeth would be eventually lost.

Risk factors:

Several risk factors, although incapable of starting periodontal disease on their own, can speed up its evolution and render it unstable when in the presence of inflammation.

In an effort to eliminate these factors, some of the following treatments may be required :

  • Making of a bite plane to control the trauma caused by teeth grinding (bruxism)
  • Occlusal adjustment
  • Splinting of weakened adjacent teeth
  • Extraction of untreatable teeth
  • Antibiotics
  • Smoking cessation

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Periodontal re-evaluation

Periodontal re-evaluation must be done between 6 and 12 weeks after the sanative phase is completed. Your periodontist will re-examine your gums in order to evaluate the healing that has occurred, determine if additional treatment is recommended and plan the latter.

Treatment may consist of corrective periodontal surgery, non-surgical treatment and preventive maintenance visits. This important phase confirms the short-term improvement in your periodontal condition and determines the long-term potential that can be obtained with further treatment.

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Periodontal surgery

Periodontal surgery will be recommended if it is likely to improve the long term stability of the gum condition.

The objectives of the surgical phase are:

  • Removal of the plaque and tartar buildup (surgical techniques allow better access to deep tartar deposits)
  • Correction of the gingival and bony deformities
  • Reduction or elimination of the residual pockets to allow proper access for an efficient daily home-care regimen
  • To regenerate the supporting bone if possible

Two surgical approaches are possible:

1. Resective treatment: Consists of reducing the pocket depth by reducing the thickness of the gingiva (gums).

Before the surgical phase.
12-Resective treatment-before the surgical phase
After resective surgical treatment.
13-Resective treatment- after resective surgical treatment

2. Regenerative treatment: It consists in regenerating (rebuilding) the bony support and gum attachment to the tooth root. Although this technique is preferable to the resective approach, it requires several prerequisites that are seldom present. Furthermore, its outcome is less predictable.

Before the surgical phase.
14-Regenerative treatment - Before the surgical phase
At the time of surgery, various materials can be placed in the bone defect to enhance or promote bone regeneration.
15-Regenerative treatment at the time of surgery
Ideal goal of the regenerative surgical treatment. (Due to limitations in current materials and variations in local and host factors, complete regeneration is seldom achieved.)
16-Regenerative treatment - the ideal goal

Although the benefits of surgical treatment outweigh the side effects, these may include :

  • Gingival recession (longer teeth)
  • Spaces between teeth secondary to the bone loss
  • Aesthetic change and increased cold sensitivity, which is usually of short duration.

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