Periodontal Disease: The Latest on Treating and Preventing Gingivitis and Periodontitis

Because gingivitis is a reversible inflammation of the gums, treatment is focused on removing the irritants that cause inflammation. These are often plaque (layers of soft bacterial deposits) and calculus (hardened bacterial deposits), also known as tartar.

The best way to prevent gingivitis is to brush and floss daily. These home care efforts will remove the plaque as it accumulates and if performed regularly and effectively, gingivitis should not form. Patients should also be seen every six months by the hygienist and dentist for preventive visits called prophylaxis appointments. During these visits, the teeth are scaled, polished and flossed. A periodic examination by your dentist should also be performed to examine your teeth and gum tissues for early signs of gum disease (as well as decay).

Once gingivitis has developed, a basic treatment called scaling is generally recommended. This is the scraping of calculus off the tooth surface. Plaque must also be removed by scaling and polishing. To reduce inflammation, irritants must be removed and then kept away. Therefore, proper oral hygiene efforts such as brushing, flossing, and rinsing with antibacterial agents are the road to regaining healthy gums.

Mild Periodontitis:

There are two primary differences between gingivitis and early periodontitis. First, early periodontitis causes slight loss of periodontal support. This results in development of a space between the gum and tooth called a periodontal pocket. Inside these pockets, early exposure of the root surface of the tooth will develop. Bacterial deposits and toxins that accumulate on the root surface may soften the root. Sometimes, the gums will shrink with the loss of bone and the root surface will be exposed. Receding gum lines can be unsightly at times and are associated with root sensitivity.

The dentist can diagnose this condition by taking a complete set of dental x-rays and a careful periodontal screening which includes measuring the depth of pockets around each tooth. Normal pocket depth measurements range from two to three millimeters, so increased measurements are a clear indication of periodontitis.

Treatment is very similar to the management of gingivitis. Plaque and calculus are removed through scaling. Then the roots must be smoothed through root planing. Local anesthetic (Novocaine) is given to prevent discomfort during this procedure. Most patients require mild pain medication after this treatment.

Moderate Periodontitis:

Treatment becomes more involved as more bone around the teeth is lost. The primary goal of treatment is to preserve the remaining support to the involved teeth. Factors other than plaque and calculus become involved with this disease. For example, traumatic biting forces and smoking can affect the progression of bone loss. To be effective, treatment must address these other factors.

Effective oral hygiene must be established over the long term for treatment to succeed. Hygiene instruction is usually the first part of treatment and may require constant reinforcement. Scaling and root planing are then performed to begin reducing inflammation in the gum tissues.

Teeth may be arranged in an unhealthy bite when one or more teeth are constantly subjected to heavy forces. A bite plate may be made to protect teeth from clenching or grinding during sleep. Occasionally, the dentist may adjust a tooth or teeth to reduce heavy forces in some patients.

Once these causes have been removed, a natural healing period over four to eight weeks is recommended. Inflammation in the gums will diminish. Loosened teeth may tighten up as a result of healing in the supporting tissues. Pocket depth measurements tend to shrink with the swollen gums and improve the patient's access to hidden plaque areas.

A reevaluation appointment is critical to determine that enough improvement has occurred. Once the tissues return to a relatively normal structure with shallow pocket depth measurements, the patient can be start on a preventive periodontal program. However, if there are areas in the mouth with residual deep pocket depths, the patient still has an obstacle to removing plaque on the root surface.

Pocket reduction procedures are examples of treatments that can be performed to improve gum structure and access to hidden plaque areas. Regenerative bone grafting procedures can be used on deeper areas of bone loss. These surgical procedures are now performed with a minimum of discomfort and a high level of success. Medications are usually used to prevent pain, swelling and infection.

Advanced Periodontitis:

When periodontitis has progressed to severe levels, teeth have suffered large amounts of bone loss. Teeth may become loose and uncomfortable, some may even need to be extracted. Loss of bone may have extended to expose separation between the roots of molars. Treatment is designed to stop periodontal disease from getting worse as well as stabilize the teeth for comfortable eating, speaking, and smiling.

Irritants or causes such as plaque, tartar and traumatic bites must be controlled as described for the management of moderate periodontitis. Treatment always begins with scaling and root planing to remove sources of inflammation. Oral hygiene must be effective to prevent the repopulation of bacteria into sites that scaling has removed. The advanced nature of this disease demands that each step be performed with the highest level of care as further periodontal breakdown is often accompanied by tooth loss.

It is more common for bite plates (night guards) to be used to protect teeth with compromised support. Adjustment of unhealthy bites may also be required to eliminate those forces that loosen teeth.

Once the early steps of treatment have been completed, additional steps may be taken to boost resistance to further periodontal breakdown. Newer technologies such as local antibacterial delivery systems have evolved over the past several years to improve the control of bacterial plaque under the gumline. These treatments have been shown to help stabilize and improve many areas of periodontitis when scaling and root planing alone could not. Doxycycline, an antibiotic that has been available for years, is now being prescribed at low doses under the name Periostat, to aid the body in resisting the enzymes that help to break down periodontal tissues.

Periodontal surgery is usually required to reduce pocket depths and to build bone support. Bone can often be added through grafting procedures. Pockets can be reduced by changing the shape of the gums and intentionally creating a receding gumline.

Ultimately, the success or failure of any periodontal treatment plan will primarily depend on consistent and effective plaque control. Plaque and tartar can be controlled with good daily oral hygiene and regular visits to the dental hygienist.