What you need to know about Periodontology!

Believe it or not, our teeth and gums can be thought of as a separate entity. Did you know that you can

have a disease in your mouth? I know that probably sounds terrible but let me explain. Our teeth are

surrounded by that soft skin looking tissue that we know as gums. This is referred to as gingiva. Our

teeth also sit inside of a socket that is deep in the bone. This is called alveolar bone. This bone is very

important to the function of our teeth. We need our teeth to eat. If we do not have healthy bone or

gums, it can become difficult to chew which would compromise our ability to fuel our bodies with the

nutrition we need.

With a brief description of the anatomy of our mouths, let us dive into the disease process I was

discussing above. Periodontology is essentially the study of the bone and tissues that surround the

teeth. It looks at the diseases and conditions that can lead to periodontitis. Periodontal disease itself

causes receding gums, damage to the bone and connective tissue around teeth, and (in severe cases)

tooth loss.[CITATION htt \l 1033 ]. There are stages to gum disease. The earliest stage is known as

gingivitis. This happens with the bacteria grown on the teeth form what is called plaque. This is a sticky

substance that accumulates mainly along the gumline. If not removed, the tissues around the teeth

become red and inflamed, swollen, or may bleed. When plaque calcifies, it forms a hard-mineral deposit

called tartar or calculus. This can not be removed by only brushing or flossing. This hard deposit that

forms above and below the gumline can become a trap for bacteria. These bacteria can cause irritation

to the tissues even below the gumline. The gums will try to “pull away” from the bacteria which can lead

to recession. Destruction of the bone that lies under the effected tissues will start to become prominent.
Between the recession of gums tissue and bone destruction, the teeth will not be as secure in the socket

and can become loose with may lead to loss of a tooth.

There are some factors that can predispose a person to periodontal disease. Smoking, aging and some

general health issues can be a factor that may lead a person to develop periodontal disease. Tobacco

smoking can modify the host response to the challenge of bacteria in microbial plaque. Nicotine exerts

local vasoconstriction, reducing blood flow, edema, and clinical signs of inflammation [ CITATION

You14 \l 1033 ] . Another health issue that is a risk factor for developing periodontal disease is diabetes.

There are many studies that demonstrate an association between diabetes and an increased

susceptibility to oral infections including periodontal disease [ CITATION You14 \l 1033 ] . Other risk

factors that can predispose a person to periodontal disease is stress, obesity, cardiovascular disease, and

drug induced disorders. Interestingly, Osteoporosis can be a nonmodifiable risk factor. Osteoporosis was

significantly associated with severe alveolar crestal bone loss. Periodontitis and osteopenia may have

common etiological agents that may either directly influence or modulate both disease processes

[ CITATION You14 \l 1033 ].

Among the many bacteria present in the oral cavity, there are some that can be directly related

to periodontal disease. A classification system for bacteria present in plaque was formed and formed

into clusters knows as red, orange, yellow, green, blue, and purple. Actinomyces odontolyticus and

Veillonella parvula represented the purple form while species of Streptococci including S. sanguinis and

S oralis refer to the yellow form. Many other bacteria are mentioned that fit into the blue, green, yellow

and red clusters. Finally though, the red complex include bacteria such as P. gingivalis and T. denticola in

addition to Tannerella forsythia refer to the red cluster and are considered the prevalent pathogens in

periodontal progression [ CITATION Ahm18 \l 1033 ] .

surgical. Surgical treatments include flap surgery, soft tissue grafts, and bone grafting. Non-surgical

treatment includes scaling, root planning and antibiotics. It will be necessary to remove all plaque and

calculus. If not removed, harmful bacteria could be left behind, and infection can return. This can

continue to destroy the gum tissue and underlying bone. The effectiveness of scaling and root planning

depends upon factors such as: the progression of the disease, patient compliance with oral hygiene and

treatment schedules, depth of periodontal pockets, the unique shape and grooves in the roots of teeth,

which may limit the visibility of underlying deep calculus and debris [ CITATION Cou20 \l 1033 ]. Home

care will be extremely important because if not aiding in the removal of biofilm at home, it will continue

to accumulate and could potentially further the progression of the disease.

Scaling removes the bacteria from the surface of the teeth and beneath the gums. Hand instruments in

conjunction with an ultrasonic device may be used. Hand instruments that are used have specificity to

adapt to tooth anatomy to easily reach the areas needed for effective removal of debris. An ultrasonic

device uses a combination of vibration and water to essentially “shake” off the hard deposit from the

tooth surface. If a patient has sensitivity or experiences any pain during the hand scaling or ultrasonic

use may merit the use of a local anesthesia in certain areas to help alleviate any pain and to make the

patient more comfortable. This will also help the clinician be more effective with the debris removal.

With areas of deep deposits on the root surface and especially in areas of furcations, which are areas

where the bone level has dropped low enough to expose the area at which the roots branch off, root

planning may be necessary. This involves using special hand instruments that again are designed to

adapt and angle into the areas where you will need to remove the debris along the root surface. An

indication for anesthesia will almost always be necessary in this case. Always make sure to cross
reference any medical conditions and medications to check for any contraindications for the use of a

local anesthetic with the use of a vasoconstrictor.

Good candidates for scaling and root planning are patients that have deeper probing depths,

horizontal bone loss and/or another periodontal diagnosis such as slight, moderate, or advanced. In

healthy gum tissue, the probing depths are anywhere between 1-3mm. Once we start seeing

measurements 4mm and above, we need to take the periodontal classifications into account as a patient

would be a good candidate for scaling and root planning. Your dental hygienists or general dentist can

preform scaling and root planning. You may need to see specialist called a Periodontist to treat more

advanced or complex cases. A periodontist receives an additional three years of post-dental school

education which includes specialized gum training and treatment methods [ CITATION You \l 1033 ]6.

The cost for scaling and root planning can range between $140-300 per quadrant. Periodontal

maintenance costs after undergoing active therapy average $115. [ CITATION You \l 1033 ].

There are many benefits to scaling and root planning. Treatment can remove traces of plaque

and tartar below the gum line and near the roots, reduces or eliminates the risk of developing gum

disease and tooth loss, prevents the progression of gum disease to its more advanced form by getting

rid of the symptoms as early as possible. Other benefits include the patient comfort because usually

local anesthesia will be used, and this will prevent any pain [ CITATION axi \l 1033 ].

A few drawbacks for treatment would be pain. It is not unusual for patients to have discomfort

while assessing the periodontal condition, especially if they have some deeper pockets where bacteria is

trapped. This contributes to bleeding and inflammation of the gum tissue. Because of this disease and

inflammation, pain could be associated with treatment. This is where local anesthesia comes into play.

The patient will be able to tolerate treatment well therefore allowing the clinician to effectively perform

the treatment. Another drawback to treatment is that you may introduce harmful bacteria into the
blood stream. This can be especially dangerous for patients who have serious medical conditions such as

heart disease. Another issue could be with an artificial joint replacement. These patients are at risk for

infective endocarditis, a condition in which bacteria is introduced into the bloodstream and settles into

the lining of the heart. It will be important for a dental hygienist to pay close attention to medical

conditions and all medications a patient may have.

What is the difference between a cleaning and treatment for a disease? Sometimes patients do

not understand the difference. They seem to have the expectation they are getting their teeth cleaned

and going about their day. They are often unaware if they have a periodontal disease. It will be up to us

to accurately assess their periodontal condition and educate the patient. By looking at them and talking

to them, it may seem as though we are getting through to them, but we are not. It might be “in one ear,

out the other”. We have so many visuals at our disposal to help educate the patient. We can use our

periodontal probe to show readings and radiographs to demonstrate bone levels and diseased bone. It

would not be taboo to show the patient the plaque or calculus you are pulling off their teeth. It is our

duty to have the patient come to a place of acceptance before we decide to explain any treatment

needs. We want the patient to be aware of the expectations of time in the chair, number of

appointments, and the post-operative care[ CITATION Deb18 \l 1033 ].

After scaling and root planing, the dentist and dental hygienist will check the healing of the

gums and check the status of the periodontal pockets. In most cases, redness and any swollen or red

gum tissue becomes firm and pink again. Bleeding is reduced or eliminated, and pockets get smaller.

Periodontal maintenance at more frequent intervals such as every 3,4 months may be necessary and

consist of routine cleanings and careful examination of the gum tissue, as well as measurements of your

pocket depths. It will be recommended to brush at least twice a day with a fluoride toothpaste, floss
daily to clean between your teeth and any major dental work such as bridges, crowns, or

implants[ CITATION Don20 \l 1033 ]

With the right education and acceptance of treatment by the patient, together we can help stop

the progression of periodontal disease.

References
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