Diagnosis and Treatment of Periodontal Disease
Diagnosing Periodontal Disease
Diagnosing Periodontal Disease
Before any periodontal treatment is undertaken, a diagnosis must be made. To reach a diagnosis, the patient's dental and medical histories must be taken, a clinical examination must be performed, and dental x-rays (radiographs) must be reviewed. These steps are generally accomplished during the initial consultation appointment, although a second consultation appointment may be needed, particularly when additional information must be obtained.
Dental / Medical Histories
For decades we have known that a prime indicator for future periodontal breakdown is a past history of periodontal disease. By taking a dental history and evaluating previous x-rays, we have a better understanding about the rate of disease progression, and can determine what must be done to prevent further breakdown. In the last decade periodontists have also begun to understand that periodontal disease is a result of bacteria interacting with the patient's defense systems. How the patient's body responds to the bacterial (plaque) assault depends on the "host" resistance. Some people are fortunate, and have minor periodontal disease even with poor oral hygiene. For others, the same amount of bacteria may cause advanced periodontal disease and bone loss.
In other words, certain patients are very susceptible to periodontal disease, and these patients must be particularly diligent with their oral hygiene and maintenance to reduce the bacteria challenge. By taking a complete Medical History we can determine if the patient has certain risk factors and may modify treatment accordingly (See Host Resistance). Below are the most significant general health considerations that may affect periodontal disease susceptibility. (Click any risk factor for a more detailed discussion).
Smoking - A host factor that CAN be altered, and one that GREATLY increases the risk of disease.
Diabetes - Increases the risk of disease if not well controlled.
Stress - Long-term stress may adversely alter the way we fight periodontal disease.
Hormones - Increases in gingival inflammation is seen with increased levels of estrogen.
Medications - Dilantin and several common heart medications may cause gum overgrowth.
Severe Osteopenia - May result in more jawbone loss, particularly in postmenopausal women.
Genetics - About one-fourth of the population is genetically more susceptible to periodontal disease. Today we are able to do a simple test for genetic susceptibility.
The periodontal examination gives the dentist a complete picture of the periodontal condition of the patient's mouth. This information is needed before an accurate diagnosis can be made. The oral exam is supplemented with information gained from the dental X-rays.
A major focus of the exam is to determine how much bone loss has occurred. When healthy, there is generally a 2-3 millimeter space (sulcus) between the tooth and the gum. This space deepens as bacterial plaque causes bone deterioration, and penetrates down the side of the tooth. This deepened space is called a pocket.
Bone loss leading
to pocket formation
Using a probe to measure
pocket depth and bone loss
Each tooth is measured (probed) (See What is Periodontal Disease?) at six places, surrounding the tooth, to determine the pocket depth. Normally anesthesia is not needed for this charting, which gives the dentist a blueprint of periodontal changes.
Probe next to healthy gum
Probe inserted sulcus bottom (green line measures 3mm )
Gum inflammation indicating periodontal disease
Probe 5mm into pocket
Periodontal charting showing pocket depths, with gum (red) and bone (blue) levels outlined on teeth. "X" indicates a missing tooth.
Please click for a larger view
- Gum recession - The amount of recession added to the pocket depth determines total bone loss.
- Furcations - Bone loss into the furcation of a tooth compromises the prognosis.
- Amount of attached gingiva - Without adequate attached gingiva, recession will occur.
- Occlusion (bite) - Excessive forces on teeth may increase the chances of bone loss.
- Tooth mobility (looseness) - Generally indicates inadequate bone support or a bite problem.
- Patient oral hygiene - Poor brushing and flossing will greatly compromise the long-term result.
Dental Radiographs (X-RAYS)
A good series of dental x-rays is mandatory to accurately evaluate periodontal disease. They help determine the amount and location of bone loss, the size and shape of the roots, the amount of root still embedded in bone, the relationship of the teeth to each other, whether the nerve in a tooth has died, the location of the sinus and mandibular nerve when placing implants, and oral pathologies, among other things. We are not able to treat a patient unless we have adequate x-rays. The exception is gingival grafting, which normally does not require x-rays.
There are a number of different types of dental x-rays, each with a specific purpose, but for periodontal treatment a full series of periapical films is generally required. Below is a list of the commonly taken x-ray views, and the indications for each. (Click for a more detailed discussion and examples of each type of x-ray).
- Full Mouth Periapicals - 16 - 18 detailed views of the teeth and surrounding bone, necessary for an accurate periodontal examination.
- Panograph - A single screening film showing an overview of the upper and lower jaws, sinus, temporomandibular joint, and other anatomic features.
- Bitewings - Four detailed views of the side and back teeth, primarily used to detect decay. Often used with the panograph by general dentists for routine new patient screenings.
- Vertical Bitewings - Four to seven detailed views of the teeth that can show both decay and bone levels when severe bone loss has not occurred.
- Digital x-rays - Any x-ray that is stored digitally, on a computer. Generally available in periapical and bitewings only.
Many people have a legitimate concern about the amount of radiation they receive with dental x-rays. It's un-nerving to watch the technician set the machine and run out of the room to expose the film! However, recent advances in dental x-rays make this an unnecessary concern. The film "speed" has improved dramatically, meaning that very little radiation is needed to expose the film. In fact, it is estimated that the amount of body radiation received with a full mouth series is much less than one would receive at a day at the beach.
Once the clinical data is gathered and correlated with the x-ray findings, your periodontist is able to organize and systematically evaluate the results to make a diagnosis. This is critical, for while there may be various approaches to treat a problem, there can be only one correct diagnosis. Once the diagnosis is determined, various treatment options can be formulated. With this information the periodontist and the patient can determine which treatment plan to follow.
The following is an overview of the components of each treatment step.
STEP ONE: Initial Preparation (click for detailed information)
The first step of treatment is to eliminate all of the known causes of the periodontal disease. Mouth bacteria found in saliva forms colonies on the teeth and tissues, which is called plaque. This clear film of bacteria is the primary cause of periodontal inflammation and breakdown. Calculus (also known as tartar) is formed when salts from the saliva precipitate into the plaque. This forms a hard substance, which adheres tightly to the tooth, similar to barnacles on a boat's hull. Both the calculus and the plaque must be removed to achieve a successful result. The patient is taught to remove the plaque, while the dental professional must remove the calculus. Initial preparation also includes creating an environment that makes plaque removal by the patient as easy as possible. The following outline lists factors that may be addressed during initial preparation.
- Demonstration of proper oral hygiene procedures to remove surface plaque
- Scaling and root planing to remove calculus and deep plaque
- Smoothing or replacement of fillings that do not fit well and thus retain plaque
- Removal of hopeless teeth that may jeopardize good teeth
- Adjustment of bite (occlusal equilibration) if needed
- Minor orthodontics to better align teeth
- Placement of a night guard to prevent clenching at night
Following Initial Preparation, the tissues are re-evaluated after they have a chance to heal to determine if more periodontal therapy is needed. If the disease has been arrested, the optimal periodontal maintenance (cleaning) schedule is determined for the patient. If the disease persists, further non-surgical treatment may be performed. If surgery is needed to eliminate pockets that persist, a surgical treatment plan is formulated.
STEP TWO: Surgical Treatment
Initial Preparation generally produces shrinkage of the inflamed gum, and thus a reduction of the pocket depth. Often, if the patient has excellent oral hygiene habits and keeps regular maintenance appointments, this is enough to stabilize a case. However, with pockets that continue to bleed when probed, or with pockets deeper than 5mm, there is a high probability the disease process will continue. In those cases elimination of the remaining pockets is the best treatment. If it is obvious during the examination that surgery is needed to obtain the best result, parts of the Initial Preparation may be abbreviated or by-passed completely. Scaling and root planing may be done during surgery, when access is the most ideal. This approach avoids repeating steps of Initial Preparation that would be performed during surgery, saving time and reducing costs.
There are three primary surgical procedures that may be used to reduce or eliminate pockets that remain after Initial Preparation (Click any heading for a more detailed discussion and clinical examples).
- Gingivectomy - Trimming excess tissue when the bone contour has not been altered.
- Flap Surgery - The most common surgical procedure, giving the periodontist access to the jawbone. In most advanced periodontal cases, the bone has been altered by infection and smoothing irregularities is needed.
- Regeneration Surgery - Ideally, periodontal therapy would regenerate bone and tissue back to its original form. While this is not always possible, new techniques are allowing for more predictable regeneration of tissues.
The goal of periodontal surgery is to give the periodontist access for treatment, and to reduce pocket depth. The ideal surgical result is pocket elimination, giving the patient the ability to remove plaque from the sulcus daily. In some cases the pockets are so deep that complete elimination is not possible, and some depth remains even after surgery. Some of these teeth may be considered questionable, and their long-term prognosis guarded. However, as long as these teeth do not jeopardize surrounding dentition, are functional, and do not cause discomfort, they are maintained. Many questionable teeth are kept for years, if the patient is able to perform a high level of oral hygiene and stay on a good maintenance program.
STEP THREE: Periodontal Maintenance (click for more information)
The two most important factors in determining long-term success are patient home care, and regular periodontal maintenance (cleanings). It has been shown that without routine maintenance there is a 20-fold increase in the chance of recurrent disease. Most patients who are susceptible to periodontal disease must be seen for periodontal maintenance appointments every three months, rather than the typical twice yearly cleanings. Often, maintenance appointments are alternated between the general dentist and the periodontist. There is nothing a patient can do that is more important to maintaining a healthy mouth than daily flossing and brushing along with consistent periodontal maintenance.