Treating Gum Disease
Treating Periodontal Disease
There are two main objectives in treating gum disease. The first goal is to reduce and control the bacterial colonies that form under the edge of the gum. The second goal is to eliminate any known factors (such as smoking) that cause the patient to be more susceptible to breakdown. The procedure(s) used for treating gum disease can vary based upon the severity of the disease and other considerations.
In the early stages of periodontal disease (gingivitis), the gum is infected but the bone has not yet been altered. The pocket depth is generally only slightly deepened, to 4-5 mm. Scaling and root planing (“deep cleanings”) is performed under local anesthesia to remove any calculus that has formed. If the pockets are tender, numbing the gums is often necessary so there will be no discomfort during the procedure. There is little or no pain afterward. The patient must keep plaque from reforming by daily brushing and flossing. The healing gum will snug back up around the root, and gum health will return. Daily plaque removal with regular dental cleanings will prevent a reoccurrence.
In more moderate cases of periodontal disease there is actual bone loss, and the pockets may be increased to a level that is not manageable by non-surgical means alone. Scaling and root planing will not predictably remove all the calculus from these deeper pockets, because of limited and difficult access in reaching the bottom of the pocket. Treating these cases of gum disease requires periodontal surgery so the periodontist can gain access to clean the root. With this procedure, an incision is made between the gum and tooth, and the gum is moved back away from the neck of the tooth and the edge of the bone. The surgeon can then see the calculus (tartar), and adequately debride the tooth of diseased tissue.
The ideal flap surgery for treating gum disease is known as pocket elimination surgery. It is achieved when the periodontist surgically removes the pocket by repositioning the gum down to the new bone level. The periodontist first corrects any irregularities or pitting of the bone that was caused by the infection, and the gum is sutured tightly down to the re-contoured bone. This pocket elimination allows the patient to access and remove the bacterial plaque daily with brushing and flossing. If all plaque is eliminated daily, the disease is completely arrested.
Pocket elimination surgery can cause cosmetic changes around the upper front teeth, and the periodontist may avoid pocket elimination surgery in this area to minimize any changes that could be seen. In these areas, different types of gum disease treatment may be preferred over surgery. During surgery the periodontist can see and reach all areas, allowing for better tooth cleansing. However, each case is treated according to need and in cases where the need for surgery is not certain, the non-surgical scaling and root planing is performed first. The patient is then re-evaluated to see if further gum disease treatment is required.
In advanced cases of periodontal disease, there has been extensive bone loss, and pocket depth may be 7mm or more. In these cases complete removal of the pocket is often not possible due to limitations on how far the gum can be moved. However, surgery is necessary for the periodontist to access and clean the deeper areas, which cannot be effectively scaled without reflecting the gum. As with other methods of treating gum disease, the objective is to thoroughly cleanse the roots, and to reduce the pockets as much as possible.
There has been much research in actually re-growing the bone destroyed by gum disease. While not effective in all cases, today many periodontal lesions can benefit from “periodontal regeneration” procedures. Your periodontist can tell you if you are a candidate for regeneration. (See Regeneration)
In cases where surgery is not – or cannot be – performed, or in very advanced cases, there are often residual pockets, which remain after treating the gum disease. The deeper these pockets, the more guarded the long-term results may be. We try to reduce pockets as much as we can. A rule of thumb: the shallower the pocket, the better the chances of maintaining the tooth. With a shallower pocket, a hygienist is able to clean the patient’s tooth more thoroughly, and the patient is able to remove a greater percentage of the plaque that forms.
Treating gum disease can be an ongoing process for many patients. Periodontal disease may be considered a chronic disease, and for that reason a complete “cure” is usually not possible. Patient susceptibility may continue to be high, and the cause of infection, plaque, is always present in the mouth. Daily vigilance is needed to control the disease and keep the gums in good health. Even with the best care and expert treatment, certain areas may lose ground, although the vast majority of patients who follow good maintenance can expect to have their teeth for their lifetime.
In summary, the treatment of periodontal disease focuses on removing bacterial plaque and calculus that forms under the gums. In many cases, periodontal surgery is used to provide access for scaling, and to reduce pocket depth so the patient can more effectively access and remove plaque from their teeth at home. Good oral hygiene along with regular periodontal maintenance appointments (recalls) will help preserve the teeth for a lifetime.
Scaling and Root Planing
The heart of all periodontal therapy is removal of calculus and plaque from the tooth. Removing debris from the crown of the tooth is often referred to as scaling, while root planing (debridment) refers to cleaning the root below the gum. This procedure is also referred to as deep cleaning. To successfully treat periodontal disease it is necessary to adequately debride the periodontal pocket. This is generally accomplished using curettes and/or ultrasonic scalers, although rotary instruments may be useful. Adequately cleaning a periodontal pocket takes time and skill, and many feel it is the most technically demanding procedure performed by dentists. Often a local anesthetic is used to assure patient comfort. In certain instances, the local anesthetic can be applied without a conventional needle, making it truly painless.
With early and moderate pockets, up to 5 mm in depth, adequate pocket debridement may be possible. However, with pockets over 5 mm, much of the root calculus is missed. Many studies have shown that deeper pockets cannot be adequately cleaned with any technique, unless the gum is reflected to improve access. This minor surgical procedure consists of making a small incision to push back the gum edge, allowing access to deeper areas. This is known as open flap surgery, and is done under local anesthesia. Dissolvable sutures are generally used, but there is little post-operative discomfort.
Depending on the severity of periodontal disease – in particular the degree of damage to the surrounding tissue – there are different types of gum surgery that can be performed.
By far the most common gum surgery used in periodontal therapy is surgery. Moderate to advanced gum disease involves gum pockets (See What Is Gum Disease?) that are too deep to clean without moving (“reflecting”) back the gum tissue for access to the root. Without this access, deep calculus and plaque cannot be removed from the root, and the disease will progress. So during flap surgery, the gum is reflected so the periodontist can remove the calculus (hardened plaque) and manage any irregularities to the bone.
After periodontal surgery for management of periodontitis, frequent cleanings by the hygienist are necessary to remove the plaque in the residual pocket that the patient cannot reach with flossing and brushing (See Periodontal Maintenance). Even when there is good oral hygiene and regular cleanings, the bacteria may still continue to cause the pocket to become re-infected. When appearance is not a concern (i.e., on the lower teeth, the inside of the upper teeth, and the outside of the upper back teeth), the surgeon may elect to suture the gum down to where the bone has resorbed, reducing the depth of the space. If the space is reduced to 3 millimeters or less, the patient can be more effective with keeping the disease stable and non-progressive (in recession).
In the majority of moderate to advanced cases, the bacterium has caused the bone to resorb (dissolve) and become pitted. In these cases, flap surgery gives access not only for root cleansing, but allows for recontouring (reshaping) of the bone itself. The technique of osseous surgery, is performed by recontouring the bone to its natural scalloped shape and eliminating the “pockets.”
This creates a natural architecture that can be adequately cleaned by the patient with brushing and flossing. Good daily hygiene and professional maintenance are then usually enough to prevent recurrence of the disease.
Periodontal surgery is also needed if regeneration procedures are to be performed. Here the gum is reflected back to allow insertion of a bone graft for guided tissue regeneration purposes (Periodontal Regeneration).
In summary, the management of periodontal disease is not the same for everyone. We employ a personalized, preventative, predictable and proven methodology and treatment strategy in the management of periodontal disease for each individual patient. Your periodontist will develop a customize and individual treatment plan for you based on your unique situation with the goal of retainin your natural teeth for a lifetime.