The diagram above gives a simplified view of the three stages of the disease. 

The diagram at the top of the page shows the soft tissue (gums--the gingiva) as gray, the bone as the spongy looking white material underneath it, and the teeth as white.  The black material (on the diagram) encrusting the teeth is calculus, a hard, flinty buildup of hardened plaque which tends to act like a splinter when it is in chronic contact with the gingiva. 

 When a patient receives his/her initial oral examination at a dentist's office, it generally involves probing the depth of the pockets pictured in the diagram above.  This is done with a blunt instrument and is generally painless.  The measurement from the edge of the gums to the depth of the pocket is measured and recorded on a chart.   Each tooth is measured at six places around its circumference.  By examining the chart, the dentist and hygienist are able to categorize the patient into one of several periodontal classifications, and thus is able to determine the best course of treatment for that patient. 

It is important to understand that the hygienist is the professional who will be handling most of the patient's periodontal therapy.  The hygienist is a thoroughly trained specialist whose lifelong experience is recognizing and treating periodontal conditions.  Because of their training, and time spent with the patient, hygienists are generally better attuned to the patient's periodontal needs than the dentist him/herself.

Prophylaxis, Debridement and Root planing:  The categorization of periodontal condition and how patients are treated.

Until recently, when a patient called his general dentist to make an appointment for an exam and cleaning, he generally got exactly what he expected regardless of the seriousness of his periodontal disease.  If the patient had serious problems with his gums, and if the hygiene team thought the disease could not be halted with a simple cleaning, that patient was referred to a periodontist (gum specialist).  Things are beginning to change now, and not every new patient who schedules a "cleaning" will actually receive an "ordinary" prophylaxis, which is the type of cleaning he may be used to.  Indeed, that patient may not receive a cleaning at all on the first visit.  Moreover, the "cleaning" may involve as many as five separate appointments, often with numerous shots of local anesthetic to make the scraping of the teeth tolerable.  Each office will have its own categorization of hygiene patient.  For ease of discussion, I have listed the five classifications I use in my own office.

1. The prophylaxis patient

A prophylaxis is the type of cleaning that everyone expects when they get to the dentist's office.  It involves scaling calculus above the gum line followed by ordinary flossing, and pumice polishing using a rubber cup on a slow speed handpiece (drill).  Note that this procedure can be done only if the patient has little or no calculus below the gum line.  In other words, a prophylaxis is performed only on patients with little bone loss and only minor, localized pocketing.  When the dentist or hygienist probes the gums around the teeth in a "normal" patient, he finds the probe goes no deeper than two or three millimeters below the gum line.   A prophylaxis is not appropriate on patients who have periodontal problems beyond minor redness and bleeding.   A prophylaxis patient can expect a full dental exam, x-rays and his/her cleaning on the same initial visit.

2. The debridement patient

Sometimes, a new patient will present with so much plaque and calculus built up on their teeth that it is impossible to completely visualize the teeth, or to probe the depths of the patient's periodontal pockets without pain and bleeding.  When this is the case, A normal prophylaxis is not possible, and a more aggressive procedure called a full mouth debridement is necessary.  It involves a rough scaling to remove the bulk of the calculus and plaque from the teeth, and as far down on the roots as the patient can tolerate without anesthesia.  This will make it possible for the patient's gums to begin the process of healing, and just as importantly, it makes a thorough oral examination possible.  (Click on the image to enlarge and learn more about this "calculus bridge").

A debridement removes most of the calculus buildup.   It is quite labor intensive and is more expensive than a normal prophylaxis.  The full mouth debridement is accomplished on the initial office visit, and the official oral exam is deferred until a subsequent visit, after some healing has taken place.   If the patient's periodontal condition has improved to the point where bleeding has stopped, and minor periodontal pocketing has begun to resolve, then a second cleaning visit (called a fine scale and prophylaxis) and the initial oral examination is performed.  If the patient's periodontal condition remains grave, then the initial oral exam is performed, a treatment plan is outlined and the patient is scheduled for several  periodontal root planing visits in addition to appointments to repair or extract damaged teeth.

3. Incipient periodontitis

When a patient comes to the dental office with the beginnings of periodontal disease, he may present with pockets between the teeth, measuring 4 to 5 mm deep.  The pockets bleed when the dentist probes them. These patients have actually begun to lose the bone between their teeth.  If this is allowed to continue, the bone loss will progress over the course of several years until the bony support of the teeth has been undermined.   Patients who fit into this category are generally not given a normal prophylaxis on their initial visit.  The first visit is spent doing a thorough examination, including taking measurements of the pocket depths, getting a full series of x-rays, making a correct diagnosis and then explaining the diagnosis and proposed treatment with the patient.  This patient is generally brought back to the office for two separate "cleaning" visits.  The type of cleaning these patients receive is called a root planing.   During this procedure, the patient is thoroughly anesthetized and then the teeth are planed (think of a carpenter's wood plane) using scalers and curettes.  For incipient periodontitis, half the mouth is root planed on each of two visits.  After this procedure, there is a good possibility that the pockets will shrink provided that the patient institutes good home care, cleaning carefully between the teeth.  This is most easily done with Stimudents (toothpicks) or Proxabrushes.

4. Moderate periodontal disease

Periodontal disease most frequently starts between the teeth because it is between the teeth that patients are most likely to neglect to clean.  Left alone, the bone loss continues until the pockets become deeper and deeper, eventually fanning around the tooth to effect the bone on the outside and inside of the teeth.  When pockets measure 6 to 7 mm between the teeth, then the patient fits into a more severe classification of periodontal disease.  He is said to have moderate periodontal disease.  The treatment for moderate periodontal disease is root planing, the same as is done for incipient periodontal disease.  But since there is more root exposed above bone line to plane, the patient's mouth is done in four separate visits, one quarter of the mouth per visit.  Once the initial periodontal treatment has been carried out, these patients are frequently placed on a three or four month recall schedule to receive periodontal maintenance prophylaxis rather than the normal six months prophylaxis that non-periodontal patients are placed on.

5. Severe periodontal disease

Patients who have lost so much bone that they present with a generalized condition of 7 mm or greater pocketing are often treated at the general dentist's office with four quadrants of root planing, similar to the patient with moderate periodontal disease.  However, root planing alone is generally not sufficient to halt the disease, and these patients are often referred to a gum specialist (periodontist) for follow-up gum surgery.  These patients most often are seen twice a year by their periodontist alternating with twice a year visits to their general dentist for their periodontal maintenance prophylaxis treatments. 

6. Periodontal maintenance patients

Once patients with periodontal disease have had their initial periodontal treatment, and if their periodontal disease has been halted, and they are able to maintain their teeth in a disease free state, they become more like a normal prophylaxis patient.  However, since they have much more exposed root surface to scale, their "prophylaxis" is more complicated than a regular prophylaxis done on a patient without periodontal disease.  These patients receive a type of cleaning called a periodontal maintenance prophylaxis which is somewhat more expensive than a regular prophylaxis, and is generally done three or four times a year instead of twice a year as is done for patients without periodontal disease. 

Note to dentists A number of dentists have written to me asking exactly how periodontally involved patients are handled in my office.  The standard of care has changed significantly in the area of periodontal treatment, and general dentists have been assuming more responsibility for the treatment of their periodontally involved patients.   If you would like to know how I triage my periodontal patients when they present for general dental treatment, then please click here.

The difference between scaling and root planing

Treatment for all stages of periodontal disease involves the thorough removal of all plaque and calculus that has adhered to the teeth.  Even for patients who fit into the "prophylaxis patient" category above, calculus may build up very slightly below the gum line.  This can be removed during a normal prophylaxis without too much discomfort on the part of the patient.  When the damage from gum disease is slight,  this can be done without local anesthesia.  The process is called  "scaling" and is pictured at the right.   When the damage from periodontal disease is more pronounced, exposing more root structure above bone, the process is called "root planing".  Think of a carpenter's wood plane.  It is like smoothing the surface of a piece of wood, except it is done on the root of a tooth.  Root planing always requires local anesthesia.  The figure on the left shows the full extent of  the area scaled.  The root of a tooth is naturally sensitive, and that is why local anesthesia may be needed when working in this area.  It is apparent that there is also a great deal more root available to scale, which means more work for the hygienist or dentist to do.  This accounts for the greater cost of a periodontal cleaning.

Whenever the condition of the gums requires root planing or surgical procedures, the treatment is usually accompanied by a course of antibiotics, such as special forms of tetracycline,  which have an affinity for teeth and gums.  The hygienist may also apply localized antibiotics or other medicaments beneath the gum line in deep pockets after finishing the root planing procedure.  Because periodontal disease is the body's response to what is essentially a bacterial attack on the gums, the use of antibiotics, along with the drastically altered conditions around the teeth brought about by the root planing procedure can give the body a great boost in its fight against the disease.  

How Gum Disease progresses

Type II (incipient and moderate ) Periodontal Disease

In type II periodontal disease, some bone loss has occurred.  The sulcus depth is now increased due to both swollen gingiva and the loss of the bone.  Whenever the depth of the sulcus is increased due to the loss of bone, the term "sulcus" is replaced with the term "pocket".  The difference between incipient periodontal disease (gingivitis) and moderate periodontal disease is the increased depth and distribution of the pocketing.  In incipient periodontal disease, the pockets tend to be localized to the areas between the teeth and are at most 5 mm deep, while in moderate periodontal disease, the pocketing is more widespread and somewhat deeper, up to 7 mm deep.  As with type I disease, the first line of treatment always involves the thorough removal of all calculus and plaque from the root surfaces.  Because of the bone loss, however, more root is exposed and local anesthesia is needed.  This type of scaling is called a root planing.  Once again, with good continued hygiene, the pocket depth will subside due to the reduction in swelling of the gingiva.  Patients suffering type II periodontal disease are generally treated with root planing. 

Unfortunately, because of the loss of the bone, the pockets may not subside all the way back to normal. Floss may not be able to reach all the way down to the base of the pocket between the teeth (where most of the problem generally starts).   The key to cure is good hygiene, and that means cleaning the plaque all the way to the bottom of the pocket.  At this point, the disease may be kept permanently at bay by taking special measures to be sure to clean to the depth of the pocket around each and every tooth.  

These measures include the use of the rubber tips frequently found on the ends of the handle of toothbrushes, Stimudents, and Proxabrushes.  Water Picks can be useful, but they are not as effective as mechanical devices like good old fashioned toothpicks.  The new "sonic" electric toothbrushes are fairly effective at cleaning deeply on the outside and inside surfaces, but they will not reach completely between the teeth.  If good hygiene is practiced all the time, the pocket depths will continue to decrease over time, and patients who have had type II periodontal disease will, sooner or later, find themselves without a trace of the disease.   If the disease continues due to some remaining deep pocketing which prevents complete cleaning with good home care, the patient is often referred to a specialist for surgery to eliminate the pockets. 

The periodontist will generally assess the patient for surgical procedures to reduce the pockets to make it possible to maintain the hygiene himself. There are three general categories of pocket elimination surgeries performed by periodontists, over and above scaling and root planing which also is always done during these surgeries.

1. Gingivectomy

Gingivectomy is used mostly in the treatment of Type II periodontal disease.  In this case, the level of the bone is ascertained, and the gingiva are simply cut off at that level.  By eliminating the top of the gingiva, the sulcus is reduced to manageable depth, and oral hygiene can resume at normal levels.  This type of surgery used to be the gold standard in the treatment of periodontal disease, but patients were left with long teeth and irregular gum lines. Also, simple gingivectomies did nothing to correct the bony defects seen in more severe type III disease.  This type of surgery still has its place, but it has been eclipsed by other more modern forms.

Dilantin (phenytoin)--A drug used to treat seizures in epileptics--can cause overgrowth of the gums (gingival hyperplasia), especially in persons who do not brush their teeth regularly.  The image to the right shows what the combination of poor oral hygiene and Dilantin can do to a patient's gums. Certain other commonly used medications can also cause this condition, although to a lesser extent.  They include blood pressure medications in the calcium channel blocker category (Cardizem), birth control and hormone replacement drugs (Progestogen) and immunosupressive agents such as cyclosporine.  Better oral hygiene generally reduces likelihood of this complication.  This type of gingival enlargement can be prevented by good hygiene, but once it occurs, the only way to eliminate it is through surgical removal of the excess tissue--in other words, a  gingivectomy.

In an Apically repositioned flap procedure, a pair of vertical incisions are made at either end of a scalloped incision around the necks of the teeth.  The gingiva are then retracted exposing the bone and roots underneath.  Once exposed, the bone is reshaped. and sometimes augmented with bone-graft material to eliminate bony pockets and to even out the gum line.  After the bone has been resculpted, the gingiva are replaced back into a position which is closer to the bone line.  This results in an even, and well scalloped gum line.  Because of the care taken in reshaping the underlying bone, this surgery technique produces much more esthetic results than gingivectomy and allows for the treatment of the bony defects seen in type III disease.

3. Functional and esthetic grafting techniques

The ability to replace bone and gum tissues lost to periodontal disease has made slow but steady progress over the last twenty years.  Where once the non supporting bone surrounding the "wells" of the infrabony pockets could only be shaved down to allow for better healed contours of soft tissue around the roots of teeth, now it has become possible to replace some of the missing bone with bone graft material.  The use of bone graft material generally requires the use of a collagen membrane to help hold it place.  The use of bone graft material and a collagen membrane is called guided tissue regeneration (GTR).

Sometimes, it is advantageous to use grafting procedures to improve the appearance of the teeth and gums.  This is frequently done by moving gum tissue from places where it can rebuild itself, such as from the roof of the mouth, to areas where it is needed for esthetic repair.  In fact, these repairs have functional value as well, and may make quite an improvement in the overall health of the teeth and gums.

4. Laser-assisted new attachment procedure (LANAP), is a therapy designed for the "effective treatment of periodontitis" through regeneration rather than resection.  In other words, it is claimed to be a relatively simple way to root plane the teeth, as well as to perform curettage, which means removing diseased soft tissue from the lining of the periodontal pocket.   In this procedure, a special laser (variable pulsed neodymium:yttrium-aluminum-garnet) is used to debride the periodontal pocket, removing the diseased epithelial tissue from the lining of the pocket, as well as calculus and diseased cementum from the tooth root.  This allows regeneration of both soft tissue epithelium and the cementum.   It is claimed that this procedure creates a new periodontal attachment which is supposed to be more resistant to further disease.

The studies and claims for this procedure come nearly exclusively from Millennium Dental Technologies, Inc., the manufacturer of the laser, or from academics closely associated with the company.  I can make no claims about LANAP except to say that the American Academy of Periodontology (the premier mainstream organization representing periodontists in the United States) has issued this statement: "The Academy [has] urged Millennium to withdraw its marketing claims due to insufficient evidence."

Antibiotics and antibiotic delivery systems

Recently, something of a "revolution" has happened in the treatment of periodontal disease.  The fact that the basic cause of all Periodontal disease is bacterial infection from plaque buildup has spawned a great deal of research into antibiotic therapies that can help to eliminate the disease, (preferably without the necessity of root planing, surgery or, preferably, even brushing the teeth).  

Most dentists, especially periodontists (gum specialists) have found that antibiotic therapy has been helpful as an adjunctive therapy in addition to root planing and good daily hygiene, but has been less successful (the effects being quite temporary) when used by itself without proper debridement, or if the patient does not perform meticulous home care.  

The most obvious reason for the futility of the use of antibiotic therapies without professional help and daily hygiene is that the antibiotics cannot be kept up indefinitely due to cost and side effects, and any benefit gained from their use is lost soon soon after the antibiotics are stopped.  Another reason is that the bone lost from the disease is never replaced, and the ill formed anatomy of the gums combined with the continued presence of the splinter-like calculus adhering to the roots continues to harbor bacteria regardless of the antibiotic dose applied. Good hygiene can overcome these obstacles.  Chemicals cannot.

Doxycycline [and metronidazole (Flagyl)]

Doxycycline (minocycline) is a long acting form of tetracycline.  Even though it is taken orally, it has an affinity for dermal structures so it tends to concentrate in the skin, teeth and gingiva.  Doxycycline has both antibiotic properties and the ability to block the action of collagenase which is an enzyme that is produced by plaque organisms and is partly responsible for the dissolution of the connective tissue which makes up gum tissue.  Many dentists who treat gum disease use it in conjunction with root planing for a period of ten days after each session to help the body recover from the procedure and to reduce the population of plaque organisms around the tooth roots during healing.  If the patient reciprocates with very good daily hygiene, the root planing, combined with the doxycycline can bring about excellent healing.  Total elimination of the disease may result provided that the patient is willing and able to clean all areas around each tooth.  The regimen used is Doxycycline 100 mgm.; two capsules the first day, then one capsule once a day for another nine days.  Some dentists prescribe one capsule twice a day instead.  The patient must be aware that the use of any of the tetracyclines will make him or her very sensitive to sunburn for as long as he takes the drug plus several days thereafter.  Some patients experience severe gastrointestinal upset from this drug.  Doxycycline is often used in combination with metronidazole (Flagyl) to further increase its effectiveness.