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Periodontics |
Periodontics is the study of clinical aspects of the supporting structures of
the teeth (i.e the periodontium), which includes the gingiva (gums), alveolar
bone (jaw), root cementum, and the periodontal ligament. The word comes from the
Greek words peri meaning around and odons meaning tooth. Literally taken, it
means study of that which is "around the tooth". A periodontist is a dentist
that specialises in treating diseases of the periodontium. Periodontal diseases
take on many different forms, but is usually a result of bacterial infection of
the gums. Untreated, it often leads to tooth loss and alveolar bone loss.
Periodontitis is an infection of tissues that support the teeth in the mouth. If
untreated, periodontitis causes progressive bone loss around teeth, looseness
and eventual tooth loss. Periodontitis is a very common disease affecting
approximately 50% of U.S. adults over the age of 30 years. Periodontitis is
thought to occur in people who have preexisting gingivitis - an infection that
is limited to the soft tissues surrounding the tooth and does not cause bone
loss. The cause of gingivitis is the accumulation of bacteria at the gum line
which is called dental plaque. In some people, gingivitis progresses to
periodontitis - the gum tissues separate from the tooth and form a periodontal
pocket. Bacteria under the gum line in periodontal pockets cause further
inflammation in the gum tissues and bone loss. If left undisturbed, bacterial
plaque calcifies to form dental calculus. Dental calculus above and below the
gum line must be removed completely by the dental hygienist or dentist to treat
gingivitis and periodontitis. Although the primary causes of gingivitis and
periodontitis are the bacteria that adhere to the tooth surface, there are many
other modifying factors. One of the strongest of these is tobacco use. Another
very strong factor is one's inherited or genetic susceptibilty. Several diseases
including diabetes, Down syndrome and diseases that affect one's resistance to
infection also increase susceptibility to periodontitis. Patients should realize
that the gingival inflammation and bone destruction are largely painless. Hence
people may wrongly assume that painless bleeding after teeth cleaning is
unimportant, although this may be a symptom of periodontitis progressing in that
patient. Most patients must prove the Daily oral hygiene measures to prevent
periodontal disease which include: brushing properly on a regular basis (2 times
a day), with the patient attempting to direct the toothbrush bristles underneath
the gum-line, so as to help disrupt the bacterial and plaque growth that may
occur there, flossing daily and using interdental brushes if there is sufficient
space between teeth and behind the last tooth in each quarter, using an
antiseptic mouthwash, Chlorhexidine gluconate based mouthwash or hydrogen
peroxide in combination with careful oral hygiene may cure gingivitis, although
they cannot reverse any bone loss due to periodontitis. (Alcohol based
mouthwashes may aggravate the condition), regular dental check-ups and
professional teeth cleaning as required. Dental check-ups serve to monitor the
person's oral hygiene methods and levels of bone around teeth, identify any
early signs of periodontitis, and monitor if it has responded to treatment.
Typically dental hygienists (or dentists) use special instruments to clean (debride)
teeth below the gumline and disrupt any plaque growing below the gum line. This
is a standard treatment to prevent any further progress of established
periodontitis. Studies show that after such a professional cleaning (periodontal
debridement), bacteria and plaque tend to grow back to pre-cleaning levels after
about 3-4 months. Hence, in theory, cleanings every 3-4 months might be expected
to also prevent the initial onset of periodontitis. However analysis of
published research has reported little evidence either to support this or the
intervals at which this should occur. Instead it is advocated that the interval
between dental check-ups should be determined specifically for each patient
between every 3 to 24 months. Nonetheless, the continued stabilization of a
patient's periodontal state depends largely, if not primarily, on the patient's
oral hygiene at home if not on the go too.
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Without daily oral hygiene, periodontal disease will not be overcome, especially
if the patient has a history of extensive periodontal disease. 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. 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 durring 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 bio-films 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. 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 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. | |
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