Periodontology (gum treatment)

Periodontal disease, or periodontosis (a common but incorrect term), is the most prevalent disease in the oral cavity. Its consequences are the gradual loss of jawbone and consequently the loss of otherwise healthy teeth. The disease begins with bleeding gums or gingivitis (acute inflammation of the gums), caused by poor oral hygiene, and continues with the deterioration of the gums and jawbone. Treatment comprises procedures that remove dental deposits and damaged root surfaces: scaling and root planing.

Periodontal disease, or disease of the tissues surrounding the teeth, is a problem encountered daily in dental practices. Most of us are not even aware that we have the disease because, particularly at the beginning, it generally progresses without significant subjective problems that would alert the patient to its presence. The disease is multifactorial, meaning that it is influenced by many different factors. The factors over which people themselves have control—hygiene, smoking and stress—contribute substantially to the development of the disease. The diagram shows the main factors and the mechanism by which the disease develops.

The diagnosis is established by means of a clinical examination, during which dental deposits are usually found. Dental calculus can be seen or detected with probes below the gumline. Gums that bleed upon contact indicate the constant presence of soft dental plaque, which contains numerous bacteria that cause gum inflammation. X-rays form the basis for diagnosing the disease. They provide information about the amount of alveolar bone lost (the bone surrounding the tooth roots), which is crucial for determining the severity and complexity of the disease. The amount of bone lost and the depth of the periodontal pockets are measured using special graduated periodontal probes. The depth of the periodontal pockets is the main piece of information determining the method of treatment and the prognosis of the disease.

The treatment of the disease primarily comprises measures that reduce or eliminate the disease factors that we can also influence ourselves. First and foremost, patients must understand the importance of oral hygiene, the dangers of smoking and the impact of a stressful lifestyle. Establishing and maintaining appropriate oral hygiene, including the use of interdental brushes, dental floss, electric toothbrushes, etc., is essential for treating periodontal disease. Treatment would be completely unsuccessful without compliance with hygiene instructions. Once patients understand and carry out the first phase of treatment—oral hygiene instruction—the treatment can continue. The objective is to remove dental plaque and calculus that patients cannot remove themselves. The following therapeutic procedures are distinguished:

The procedures described are performed using manual or powered instruments. The best-known and most commonly used manual instruments are the so-called Gracey curettes. Their concavely shaped blades adapt exceptionally well to the contours of tooth roots. Differently shaped curettes are available for individual groups of teeth. They allow deposits, both hard and soft, located below the gumline to be scaled effectively and quickly. In addition to conventional steel instruments, we also use plastic and titanium instruments to treat peri-implant mucositis and peri-implantitis. Inflamed tissues around dental implants are the principal cause of implant loss. Curettes are also used to plane root areas that have been exposed to periodontal pockets and damaged by pathogenic bacteria.

Powered instruments, with which we seek to achieve the same objectives as with manual instruments, are divided into sonic and ultrasonic instruments. The working tips, which enable access to difficult-to-reach areas of periodontal pockets, vibrate at a frequency of 8,000 Hz in sonic instruments. The magnitude of the vibrations, or their amplitude, is 1,000 µm. Ultrasonic instruments oscillate considerably faster, at a frequency of 40,000 Hz, while their vibrations are considerably smaller. The oscillation amplitude is only 100 µm. Powered instruments facilitate and accelerate our work, but their precision in removing deposits is not as high as that achieved with manual instruments. The force used during cleaning is lower because the device is merely placed against the surface of the tooth neck and root, which is not the case with curettes.

Ultrasonic instruments must not be used in patients with implanted cardiac pacemakers. The electrical impulses that cause the tip to oscillate could interfere with the pacemaker’s operation. For our own safety, we do not use ultrasonic instruments in patients with HIV or hepatitis. Microscopic droplets or aerosols generated by ultrasonic vibrations are dispersed through the air far beyond the working area despite the use of powerful suction instruments. These devices may also pose a risk to certain fixed prosthetic restorations, such as ceramic crowns or aesthetic veneers. In the cases listed, sonic devices are used instead of ultrasonic instruments; these use compressed air rather than electrical impulses to vibrate their working tips.

Both manual and powered treatment cause greater or lesser bleeding from the gums and consequently allow pathogenic bacteria present in dental deposits to enter the bloodstream. Bacteraemia could be fatal for patients with endocarditis, so they must receive antibiotic prophylaxis before the procedure. It is also beneficial for patients to rinse their mouths with mild antiseptics containing chlorhexidine before procedures. This additionally reduces the concentration of bacteria in the treatment area. In practice, we most commonly use a combination of manual and powered sonic removal of deposits.

Recently, the laser has also appeared in periodontal disease treatment. The treatment is expensive and demanding and, if performed carelessly, can cause the treatment area to overheat. The results are comparable to those achieved with conventional manual treatment using the curettes described above.

The use of systemic antibiotics to treat periodontal disease is limited to certain groups of patients for whom local mechanical treatment alone, which reduces local gum inflammation, would not be sufficient. This group includes patients with certain systemic diseases and specific destructive forms of periodontal disease. In practice, the combination of amoxicillin/clavulanic acid and metronidazole has proved effective.

Pregnancy is not an absolute contraindication to treatment. Women should nevertheless become pregnant with healthy gums, as some internationally recognised studies have results indicating that the disease in pregnant women could affect the reduced birth weight of newborns. If a pregnant woman requires treatment, it is best performed at the beginning of the second trimester.

After treatment, approximately half of patients report tooth hypersensitivity. This most commonly increases between the first and third weeks after treatment. It usually decreases after the third week. Sensitivity to stimuli is considerably lower in patients who consistently follow oral hygiene instructions. Patients are informed of the possibility of this complication before treatment begins. After treatment, patients are scheduled for check-ups, during which particular attention is paid to evaluating oral hygiene. We draw attention to sites where plaque accumulates. Repeating treatment to the same extent as already performed does not provide any substantial improvement in the condition.

The procedures described produce very good results in periodontal pockets no deeper than 6 mm. Severe forms of periodontal disease, particularly affecting teeth in the transcanine sector (premolars and molars), are an indication for an open or surgical approach to removing deposits and irreversibly damaged dental and periodontal tissues. Surgical procedures are always combined with non-surgical procedures. Non-surgical procedures (scaling and root planing) are a prerequisite for the success of surgical procedures and always constitute the introductory phase of treatment.

The objective of treatment is to reduce the depth of periodontal pockets and tooth mobility. Patient cooperation through compliance with oral hygiene instructions, together with professional treatment, ensures success.