How is periodontal disease treated?

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Oral Hygiene
ADOH (RMIT)

How is periodontal disease treatedPeriodontal disease, or gum disease, can take one of two main forms: gingivitis and periodontitis.

Gingivitis

Gingivitis is inflammation of the gingival tissue (gum) and it presents as red, inflamed and easily bleeding gums. The longer plaque and tartar are left on the teeth, the more harmful that bacteria becomes. The patient typically reports “My gums are bleeding when I brush and/or floss” – this being the most common sign of gingivitis.

Gingivitis is a mild form of periodontal disease and is normally curable with the collaboration of the dental practitioner performing regular professional cleans and the patient being compliant with brushing two times a day and flossing. This form of gum disease does not involve any loss of the bone or tissue.

Periodontitis

Periodontitis is a more advanced form of periodontal disease, presenting as inflammation around the tooth. It affects the gingival tissue (gum) as well as the supporting structures holding the tooth in place, such as the fibres and bone. Advancement of the disease causes the gum to pull away from the teeth, forming a periodontal pocket that becomes infected.

The body’s immune system spontaneously fights the associated bacteria as it spreads below the gum line. Bacterial toxins and the body’s natural immune response to infection then cause a breakdown of the bone and connective tissue. If not treated, the bones, gums, and tissue that support the affected teeth are destroyed.

The teeth may eventually become loose and have to be removed. Once the disease has entered the supporting fibres and bone, the damage is irreversible. The only option is to manage and control progression of the disease; unfortunately the bone cannot grow back of its own accord.

Of greatest importance in the treatment of periodontal disease is the “team approach”. The patient must recognise that their dental practitioner cannot treat their active gum disease alone without the patient’s commitment and dedication at home.

Risk factors

There are many risk factors for periodontal disease. Some can be eliminated, reducing your risk; others cannot be eliminated.

Smoking

Smoking is one of the most significant risk factors associated with the development of periodontal disease. Additionally, continuing to smoke while undergoing gingivitis treatment or periodontitis treatment can significantly lower the chances of a successful outcome.

Hormonal changes (puberty, pregnancy, breast feeding, menopause)

These changes can exaggerate the body’s response to the bacteria present in the mouth.

Diabetes

There is a two-way relationship between diabetes and gum disease. People with diabetes are at higher risk for developing infections, including gum disease. Uncontrolled diabetes can also result in poor outcomes of gingivitis treatment and periodontitis treatment.

Other illnesses and their treatments

AIDS and its treatments can also impair gum health, as can treatments for cancer.

Prescription medication

There are hundreds of prescription and over-the- counter medications that can reduce the flow of saliva, causing xerostomia (dry mouth). Saliva has a protective effect on the teeth and tissues of the mouth. Without enough saliva, the mouth is vulnerable to infections such as periodontal disease.

Additionally, certain medicines can cause abnormal overgrowth of the gum tissue, which in turn makes it difficult to keep teeth and gums clean.

Genetic susceptibility

Some people are more susceptible to gum disease than others.

Gingivitis treatment and periodontitis treatment

The main goal of treatment is to control the infection/disease. The number and types of treatment will vary according to the extent of the disease. All treatments require the patient to keep up an excellent oral hygiene regime at home. The hygienist, periodontist or dentist may also suggest changing behaviours, such as quitting smoking, as a way to improve treatment outcome and the overall health of the oral cavity.

Deep periodontal cleaning

The dental practitioner (dentist, hygienist or periodontist) will remove the bacteria through a deep-cleaning method called scaling and root debridement. This process is completed by removing the tartar from above and below the gum line with instruments specifically designed for this process.

Medication

Medications such as specific antimicrobial mouth rinses may be used in conjunction with scaling and root debridement for a combination approach. Chlorhexidine is the antimicrobial of choice. Its most common form is a mouth rinse and it is best used after periodontal treatment, when the bacteria have been removed and disrupted. This mouth rinse is to be used for a course of ten days, twice a day, independently of brushing because the active ingredients in the toothpaste and mouthwash cancel each other out; they are best used at least 30 minutes apart. These mouth rinses should only to be used for the prescribed time and not over long periods.

In some cases, antibiotics are prescribed for the short-term treatment of an acute or locally persistent periodontal infection. Antibiotics are only to be prescribed by a specialist periodontist. However, they are not always the treatment option of choice. The most important aspect of treatment is the mechanical removal of the plaque/bacteria.

Surgical treatment by a specialist periodontist

In certain circumstances, surgical treatment may be required. There are two main surgical interventions: flap surgery, and bone and tissue grafts.

Flap surgery

In the cases where inflammation and deep pockets remain desoite deep cleaning, a specialist periodontist may need to perform flap surgery to remove tartar deposits. This can reduce the periodontal pocket and make it easier for the patient to keep the area clean in the future. This surgical approach involves lifting gingival tissue (gum) and removing the tartar. The gingival tissue is then stitched back in place so that the tissue fits snugly around the tooth again. After surgery the gums will heal and fit more tightly around the tooth. This sometimes results in the teeth appearing longer.

Bone and tissue grafts

In addition to flap surgery, your periodontist may suggest procedures to help regenerate any bone or gum tissue lost to periodontitis. Bone grafting, in which natural or synthetic bone is placed in the area of bone loss, can help promote bone growth. A technique that can be used with bone grafting is called guided tissue regeneration. In this procedure, a small piece of mesh-like material is inserted between the bone and gum tissue. This keeps the gum tissue from growing into the area where the bone should be, allowing the bone and connective tissue to regrow.

Growth factors (proteins that can help your body naturally regrow bone) may also be used. In cases where gum tissue has been lost, your periodontist may suggest a soft tissue graft, which involves taking tissue from another area of your mouth and using it to cover the exposed tooth roots.

Treatment results

Treatment outcomes depend on many things, including how far the disease has progressed, how well the patient keeps up oral care at home, and certain risk factors, such as smoking or uncontrolled diabetes, which may lower the chances of success. Your periodontist should be able to give you an indication of the expected level of success in your particular case.

In summary, the patient’s oral hygiene regime at home is as important as, if not more important than, the treatment any professional can perform. Even when the practitioner conducts all relevant treatments, the desired outcome is unlikely if no care is taken at home.

So, remember to:

  • brush your teeth twice a day (with a fluoride toothpaste);
  • floss regularly to remove plaque from between teeth;
  • visit your dentist/hygienist routinely for a check-up and professional cleaning; and
  • avoid smoking.

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