Periodontitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Periodontal disease
This x-ray shows significant bone loss between the two roots of a tooth. The spongy bone has receded due to infection under tooth, reducing the bony support for the tooth.

Treatment of established disease

This section from a panoramic X-ray film depicts the teeth of the lower left quadrant, exhibiting generalized severe bone loss of 30-80%. The red line depicts the existing bone level, whereas the yellow line depicts where the bone was originally, prior to the patient developing periodontal disease. The pink arrow, on the right, points to a furcation involvement, or the loss of enough bone to reveal the location at which the individual roots of a molar begin to branch from the single root trunk; this is a sign of advanced periodontal disease. The blue arrow, in the middle, shows up to 80% bone loss on tooth #21, and clinically, this tooth exhibited gross mobility. Finally, the peach oval, to the left, highlights the aggressive nature with which periodontal disease generally affects mandibular incisors. Because their roots are generally situated very close to each other, with minimal interproximal bone, and because of their location in the mouth, where plaque and calculus accumulation is greatest because of the pooling of saliva, mandibular anteriors suffer excessively. The split in the red line depicts varying densities of bone that contribute to a vague region of definitive bone height.

If good oral hygiene is not yet already undertaken daily by the patient, then twice daily brushing with daily flossing, mouthwashing and use of an interdental brush needs to be started. Technique with these tools is very important. Aged persons may find that use of these interdental devices more necessary and easier, since the gaps between the teeth may become larger.

A dental hygienist or a periodontist can use professional scraping instruments, such as scalers and currettes to remove bacterial plaque and calculus (formerly referred to as tartar) around teeth and below the gum-line. There are devices that use a powerful ultra-sonic vibration and irrigation system to break up the bacterial plaque and calculus. Local anesthetic is commonly used to prevent discomfort in the patient during this process.

It is difficult to induce the body to repair bone that has been destroyed due to periodontitis. Much depends on exactly how much bone was lost and the architectural configuration of the remaining bone. Vertical defects are those instances of bone loss where the height of the bone remains somewhat constant except in the localized area where there is a steep, almost vertical drop. Horizontal defects are those instances of more generalized bone loss, resulting in anywhere from mild to severe loss of initial bone height. Sometimes bone grafting surgery may be tried, but this has mixed success. Bone grafts are more reliable in instances of vertical defects, where there might be a sufficient "hole" within which to place the added bone. Horizontal defects are rarely if ever able to be grafted properly, as there is nowhere to secure the bone.

Dentists sometimes attempt to treat patients with periodontitis by placing tiny wafers dispensing antibiotics underneath the gumline in affected areas. However, the general scientific consensus is that antibiotic treatment is of minimal value in treating bone loss due to periodontitis. It may help to recover about one millimeter of bone, but it is questionable if this is of significant therapeutic value.

Alternatively, regular subgingival flushing with an anti-calculus composition can dissolve subgingival calculus (tartar) thus facilitating natural healing without surgery. This process is widely used for supragingival tartar via tartar-control toothpastes. Subgingival application of an anti-calculus composition requires a subgingival syringe or an oral irrigator.

One such anti-calculus composition (Periogen) contains Sodium Tripolyphosphate, Tetrapotassium Pyrophosphate, sodium bicarbonate, Citric Acid and sodium fluoride.

In the composition, tetrapotassium pyrophosphate (TKPP) is a cleaning agent designed to clear away biofilms in order to facilitate chemical access to calculus. sodium tripolyphosphate (STPP) acts as the anti-calculus agent, activated by Sodium Fluoride (.04%), providing a chelating action on the structure of the calculus.

Sodium Bicarbonate and Citric Acid are product activators which assist in dissolving the composition in water for periodontal delivery via a subgingival syringe or oral irrigator with a periodontal tip.

Assessment and prognosis

Dentists or dental hygienists "measure" periodontal disease using a device called a periodontal probe. This is a thin "measuring stick" that is gently placed into the space between the gums and the teeth, and slipped below the gum-line. If the probe can slip more than 3 millimetres length below the gum-line, the patient is said to have a "gingival pocket" around that tooth. This is somewhat of a misnomer, as any depth is in essence a pocket, which in turn is defined by its depth, i.e., a 2 mm pocket or a 6 mm pocket. However, it is generally accepted that pockets are self-cleansable (at home, by the patient, with a toothbrush) if they are 3 mm or less in depth. This is important because if there is a pocket which is deeper than 3 mm around the tooth, at-home care will not be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach 5, 6 and 7 mm in depth, even the hand instruments and cavitrons used by the dental professionals cannot reach deeply enough into the pocket to clean out the bacterial plaque that cause gingival inflammation. In such a situation the pocket or the gums around that tooth will always have inflammation which will likely result in bone loss around that tooth. The only way to stop the inflammation would be for the patient to undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so that they become 3 or less mm in depth and can once again be properly cleaned by the patient at home with his or her toothbrush.

If a patient has 5 mm or deeper pockets around their teeth, then they would risk eventual tooth loss over the years. If this periodontal condition is not identified and the patient remains unaware of the progressive nature of the disease then, years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain.

According to the Sri Lankan Tea Labourer study, in the absence of any oral hygiene activity, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment (>2 mm/year). 80% will suffer from moderate loss (1-2 mm/year) and the remaining 10% will not suffer any loss.

Related Chapters

• Actinomyces naeslundii (a kind of bacterium)
• Calculus (dental)
• Campylobacter
• Dental plaque
• Gingivitis
• Gum graft
• Head and neck anatomy
• Osteoimmunology

Further reading

• Pihlstrom, BL (2005). "Periodontal diseases". Lancet. 366 (9499): 1809–20. ISSN 0140-6736. PMID 16298220.

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