Periodontology

Periodontitis is an inflammatory disease of the gums, much more serious than gingivitis. It is the next stage, in which the bone surrounding the teeth starts to get severely damaged. If the condition is left untreated, teeth gradually loose their bone support, start to move and, in advanced stages, may get automatically extracted with everyday biting movements.

A major clinical sign of periodontal disease is the existence of pockets around the teeth. A pocket is formed when gums start to get detached from the root surface, resulting in the creation of a space that works as a ‘pool’ for periopathogenic bacteria. In clinical conditions, the assessment of a patient’s periodontal health is based on the number and depth of periodontal pockets present.

Periodontal disease is classified according to its severeness in early, moderate and advanced periodontitis. It is also classified according to the pace of its progress, in chronic and aggressive periodontitis. Chronic periodontitis is the most usual type and it progresses slowly, with intermediate periods of outbreak. Aggressive periodontitis, on the contrary, is not so frequent, progresses rapidly, and usually affects younger patients. Other types of periodontitis are correlated to certain general diseases (i.e. diabetes), and therefore progress in accordance with them.

Periodontitis can be caused by localized factors, such as a poorly fitted crown, and in this case its progress stops when the factor is removed. Finally, periodontal disease’s progress is affected by the causative factors such as smoking, heredity, stress, diabetes, hormonal changes during puberty and pregnancy, as well as some types of medication, i.e. antidepressants, antihypertensives, contraceptives pills e.t.c.

According to the American Association of Periodontology, the goals of periodontal therapy are to preserve the natural dentition, periodontium and peri-implant tissues, as well as to maintain and improve periodontal and peri-implant health, comfort, esthetics and function.

During periodontal therapy, roots are thoroughly cleaned from bacteria, dental plaque and tartar with the use of special periodontal tools, ultrasonic or laser devices. The whole process is performed under local anesthesia, and is usually completed in 4 hourly sessions.

However, in-office treatment is not enough for keeping periodontal  tissues healthy. The factor that mainly determines the long term outcome of periodontal therapy is patient’s discipline in oral hygiene instructions. Even the best technique will not have any result, if the patient doesn’t follow the oral hygiene protocol for dental plaque removal. Therefore, a very important part of periodontal therapy is training and raising patient’s awareness in personal oral hygiene.

After completing periodontal therapy, the periodontist sets the date for the first recall  visit, usually 4-6 weeks later. At this very important session he  evaluates the treatment outcome and the patient’s discipline in oral hygiene instructions. Clinical signs of a healthy periodontium include the abscense of inflammatory signs of disease such as redness, swelling, suppuration, and bleeding on probing.  In case periodontal inflammation insists, the periodontist may decide to surgically complete the case.

Surgical periodontal therapy is usually the second phase of treatment in advanced types of periodontitis, where periodontal pockets are very deep and cannot be cleaned with the means of oral hygiene. With this procedure, gingiva are surgically flapped back to allow deep cleaning around the roots, and then gums are sutured back in a lower position. In this way, periodontal pockets are reduced in depth or even eliminated, and therefore can be reached and cleaned by the patient at home. The technique is performed under local anesthesia and is usually finished in 3-4 sessions.

Lasers have revolutionized multiple industries, and oral care is no exception. However, the use of laser in periodontal therapy is controversial; it shows promising results for eligible patients, but is still not considered a proven method of treatment by the American Association of Periodontology. Its major advantage is patient’s comfort during and after the treatment. Laser periodontal therapy is usually painless and performed without anesthesia, or with just a small amount of anesthetic gel. Surgical periodontal treatment is bloodless, with minor pain and swelling, and also doesn’t require stitches.

Periodontitis is a dynamic disease; it is treated with periodontal therapy, but its progress cannot be seized forever. Without adequate home care and maintenance, its signs and symptoms will always return and the patient’s periodontal health will deteriorate.

The ‘Periodontal Maintenance Program’ is a very important part of periodontal therapy, carefully designed for every periodontal patient, in order to maintain his treatment’s outcome. It is a 3-4 month recall program, aiming to control periodontal disease. It has been shown that the bacteria that cause periodontal-gum disease re-establish below the gum line 3 months after treatment. Therefore, a 3-4 month periodontal maintenance appointment is critically timed to disable the destructive process in its critical stage. This critical stage is when the bacteria and their poisons do most harm to the periodontal tissues. Waiting longer than 3-4 months for recare, may result in advanced inflammation and may require anesthesia to eliminate patient’s discomfort when treating. The frequency of the recall/recare appointments is determined by the initial type of periodontitis, as well as the patient’s general health and personal oral hygiene.

Periodontal plastic microsurgery is a relatively new and very promising field of  Periodontology. It grew due to modern cosmetic needs of the smile, following rapid development of Aesthetic Dentistry. The combination of these two specialties has given solutions in aesthetic dental problems that could not be treated in the past.

One such case is the correction of the outline of the gums in the so called ‘’gummy smile’’. In these cases, smile has an unpleasing appearance with an excessive display of the gums of the upper front teeth, that appear to be small and square. With gingivectomy, a periodontist removes the extra gum tissue and reshapes the gumline to expose more of the teeth, which are finally covered with ceramic veneers or crowns.

Another case where periodontal plastic surgery can be used is gingival recession. When gumline recedes, an unpleasing appearance of the roots of the teeth is created, that may also become sensitive to cold or hot stimuli. Roots can be covered by a small amount of tissue that is removed from the roof of the mouth (palate) and sutured on the affected sites.

Periodontal plastic microsurgery needs specialized knowledge, experience, special tools and equipment, and this is why it can be performed only by a periodontist. .

Daily removal of dental plaque from teeth surfaces is the key for maintaining oral health. Frequency of brushing and technique are really important factors.

1. Frequency : Brushing should be done at least twice a day, one necessarily before bedtime. Interdental cleaning with the use of dental floss and/or interdental brushes should be done at least once a day, preferably before night brushing. Daily use of mouthwash is optional, unless the instructions given by the periodontist are different.
2. Proper technique for brushing and interdental cleaning:

– The bristles of the toothbrush should form a 45-degree angle with the gums.

– Brushing should be done in small circular movements, without much force.

– All tooth surfaces should be brushed (including the chewing surface).

– The toothbrush should be soft, with a flat head. It should also be replaced every 3 months.

– Brushing should last 3-4 minutes.

– Flossing should be done once a day. A piece of floss should be wrapped between the middle fingers of the two hands, moved carefully up and down between each tooth, and make a C-shape as it reaches the gum line.

– Interdental cleaning should be done before brushing.

– The tongue should also be brushed with the toothbrush or a special tongue scraper, in order to remove bacteria that cause a bad breath.