Table of Contents
How Gum Disease progresses
On the diagram at the head of this page, Type I periodontal disease is characterized by swollen and red gums. In fact, this condition is called gingivitis. The distance between the crest of the gingiva and the depth of the sulcus is greater than that found in healthy gums, but this is caused mostly by swelling of the gingival tissues. Increased sulcus depth caused by swelling of the gingiva, rather than by loss of bone is called pseudopocketing. If there is a substantial buildup of calculus in the sulcus, the treatment of choice is a full mouth debridement followed by a second prophylaxis visit (referred to as a fine scale). A debridement procedure (covered above) accomplishes two goals: It allows for initial healing of the pseudopockets so that the dentist/hygienist can do an accurate pocket charting at the next visit, and it allows the patient to clean to the base of the sulcus using ordinary toothbrush and floss. In most cases, serious gingivit
is responds well to this regimen and is permanently cured if the patient practices good daily dental hygiene. Swelling subsides and the depth of the pocket returns to normal. There is not yet any destruction of bone, and thus not much root is exposed, so the debridement procedure can usually be done without local anesthesia.
Type II (early or mild) Periodontal Disease (ADA code 4600)
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“. In early periodontal disease, the pockets tend to be localized to the areas between the teeth and are at most 3-4 mm deep. As with type I disease, the first line of treatment always involves a debridement visit followed by the thorough removal of all calculus and plaque from the root surfaces in several succeeding visits. Because of the bone loss, however, more root is exposed and local anesthesia may be 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.
Type III (moderate periodontitis) (ADA Code 4700)
The difference between early periodontal disease and moderate periodontal disease is the increased depth and distribution of the pocketing. In moderate periodontitis, pocket depths (or attachment loss) are 4 to 6 mm. There is generally bleeding upon probing, and sometimes slight tooth mobility.
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The model on the left shows the bone level in a state of health. The model on the right shows how the bone and teeth look in moderate to severe periodontaol disease. this type of damage can happen after twenty years of poor hygiene, or as quickly as a couple of years if the patient not only has poor hybiene, but lives a more destructive lifestyle of drugs or alcohol.
These cases are also treated with an initial debridement visit followed by several visits for scaling and root planing procedures. 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 (see next paragraph). 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, Doctor’s BrushPics and Proxabrushes. Water Picks can be useful, but they are not as effective as mechanical devices like good old fashioned toothpicks. “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 III periodontal disease will, sooner or later, find themselves with teeth showing more exposed root due to the gingival crest receding because of increasing gingival health, but with no active disease processes continuing to destroy the periodontal tissues. 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. These patients are now most often treated regularly with adjunctive antibiotic therapy and Arestin placed in the deeper pockets.
Type IV (severe) Periodontal Disease (ADA code 4800)
Type IV periodontal disease is much more serious than either of the other two types because the bone loss is so much more pronounced. It involves not only gingival (soft tissue) pocketing, but also “infrabony” pocketing which is diagramed in the type III schematic at the head of this page, and can be seen quite well on the image of the dentaform to below. The model on the right shows the difference between the healthy state and the diseased state.
The roots of many of the teeth are sitting in “wells” of bone. Consequently, much of the bone that surrounds the roots does not actually touch them and therefore lends no support. Patients suffering type IV periodontal disease are initially treated with an initial debridement visit followed by several visits (generally 4 visits, one for each quadrant) of root planing. After the root planing, the infra-bony pockets are sometimes treated with bone grafting to restore bony support to the teeth.
Even in severe cases like this, a thorough root planing followed by excellent oral hygiene can generally stop the progression of the disease. The major difficulty here is that the bony pockets will not rebuild, and it becomes very difficult to reach all the way to the bottom of the infrabony pockets to clean them. In most of these cases, patients are referred to a periodontist who is a “gum specialist” who will perform periodontal surgery to modify the shape of the gums so that good oral hygiene can be accomplished. These patients are are also treated regularly with adjunctive antibiotic therapy and Arestin placed in the deeper pockets.
Type V (refractory) periodontal disease (ADA code 4900)
Patients in this category may start out with mild to moderate periodontitis, follow through with treatment for each stage, carry out all home care procedures and get routine periodontal scaling every three or four months, but still suffer progressive bone loss into and through type IV periodontitis. We say they are refractory because the normal periodontal treatments may slow down the progression of the disease, but do not halt it, even with the best home and professional care.
Recent studies have found that this type of patient may have a genetic propensity toward periodontal disease, as well as coronary artery disease and cerebrovascular disease. Approximately 35% of all people possesses the genetic interlukin-1 marker. The IL-1 marker is a key regulator of the inflammatory process.
These people are best treated with a combination of regular periodontal root planings, periodontal surgery and adjunctive antibiotic therapy targeting the specific bacterial species which are initiating the inflammatory response. This is covered in more detail on page 6 of this section.