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Periodontitis

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Periodontitis, which is erroneously called periodontosis by many, is the official term used to describe an abnormal inflammation of the periodontal apparatus. This inflammation invariably and, in most cases, painlessly leads to the loss of bone over a period of many years; the end result is tooth loss.

Not only do plaque and bacteria initiate caries, but they also cause inflammation of the periodontal apparatus; i.e., the periodontium. First, inflammation of the gingiva occurs with the formation of a gingival pocket. If plaque and bacteria are not removed, then this inflammation leads to bone loss with the formation of bony pockets.

Eventually, the disease develops its own momentum even if brushing habits are changed and plaque is thoroughly removed. It reaches a stage where one can no longer stop or slow down the progression of the disease because thorough cleaning of the bony pockets is no longer possible. Therefore, it is important to remove plaque from tooth surfaces as soon as it is formed and detected.

In cases of protruding crown margins, protruding fillings, and malocclusions, plaque removal becomes difficult or even impossible. Even if an optimal cleaning technique is employed, all the plaque will never be eliminated in such cases, eventually leading to periodontitis.

Genetically caused periodontitis, in which patients frequently lose their teeth at a very young age, is rare. In these patients, periodontitis is caused by a defect in the immune system. Dysfunctions in the masticatory system, disorders of the general metabolism, stress, alcohol and tobacco abuse, and mechanical trauma (e.g., high fillings) can also affect the course of the disease in a negative way. As a rule, periodontitis is a chronic disease.

However, it can also flare up intermittently. Acute symptoms such as severe pus formation are rare and recognized more easily by the affected patient. Thorough questioning and various tests regarding oral hygiene, brushing, and the status of the gingiva are indispensable for developing a treatment plan. These tests provide the dentist with information about plaque colonization, brushing quality, loss of supporting tissue, and the severity of the inflammation.

All these data must be documented accurately, because only then can the course of the disease be predicted. With the aid of special radiological techniques, bone deterioration can be better assessed. Furthermore, areas of disturbance underneath the mucous membrane, such as deposits or protruding crown margins, can be identified. Based on the data obtained, a diagnosis is made and the required treatment is initiated.

Periodontal treatment should not be confused with common oral prophylaxis, which is mostly employed for esthetics and damage prevention and is usually performed on healthy individuals. Thorough explanations of the disease and the chosen treatment plan are very important because healing is only possible if the inter-relationship between the various involved factors is understood. At the beginning of periodontal treatment, teeth that cannot be preserved must be extracted and necessary root canal treatments must be performed or repeated where required.

Then, an intensive cleaning phase with special periodontal instruments is undertaken. During this cleaning phase, calculus and pockets are eliminated. Furthermore, root surfaces are smoothened or planed. This is done painlessly under local anesthesia. Because such thorough cleaning is time consuming (all the root surfaces must be cleaned), this so-called initial treatment usually takes two to three sessions.

Eight weeks after the last cleaning session, a re-evaluation takes place. The dentist waits eight weeks in order to give the gingiva enough time to regenerate. During re-evaluation, data are collected again and compared with the initial values. This enables the dentist to judge the progression of the disease.

The plaque and bleeding values should be around 20% at this stage, and tooth mobility that was initially present should have decreased. Furthermore, the probing depths should be clearly reduced. However, a complete re-evaluation only makes sense if the patient’s hygiene indices are around 20%. When poor oral hygiene is at play, the patient will not experience optimal healing.

The patient’s basic treatment and motivation must continue as long as required in order to achieve necessary plaque control. The patient must demonstrate initiative and adjust his/her dental care at home in order to control the disease. Most periodontal diseases are chronic and will accompany affected patients throughout their lives.

A saliva test that determines the presence of bacterial flora in the gingival pockets should only be performed after the re-evaluation concludes that the initial treatment objective has not been achieved. Before that, it is baseless to perform this test because it is quite clear before treatment that bacteria are present in the pockets; otherwise, there would be no inflammation.

Laser/phototoxic treatment is not a scientifically proven option for periodontal treatment.Surgical interventions such as flap surgeries should also be performed only after conventional periodontal treatment and achievement of acceptable hygiene indices, because if there is no change in brushing behavior on behalf of the patient, a renewed flare-up of the disease is guaranteed.

If probing depth is not reduced and there are still signs of bacterial activity in the gingival pockets despite improved routine oral hygiene practices, the physician should ask himself the following questions:

Was the quality of the cleaning sufficient?
Was the initial diagnosis correct?
Are there any undetected systemic problems (latent diabetes, chronic infection, intake of specific medications, etc.)?
Are there any local factors, such as severe malocclusions/tooth anomalies or protruding filling and crown margins, which are adversely affecting the results?
Do specific periodontal bacteria require a different systemic antibiotic treatment?

The prognosis must be tailored to the individual patient, and can only be beneficial if the respective disease is recognized early and the necessary treatment actions are taken on time. However, well-performed dental and oral care on a daily basis combined with regular dental checkups will definitely ensure a positive result.

Video periodontitis.

Periodontitis