[MUSIC] Hello. Today we're going to discuss some general aspects of periodontal treatment. The treatment of periodontitis ranges from a very simple approach requiring one or two visits, to a more complex and prolonged therapy in more advanced cases. In order to better understand the rational for periodontal therapy, let us use an analogy of a house which is being destroyed by fire. In case of such an event, you would first have to extinguish the fire. Secondly, you would have to remove all the hazardous material which may have contributed to the fire, clean the debris, and then assess the resulting damage. After assessing the damage, you would then decide to reconstruct the house by choosing the appropriate building materials. And lastly, you will be designing a long-term maintenance meant to prevent future disasters. Let us now compare periodontal therapy to the above scenario. In any dental treatment plan, the dentist has to first address any emerging problems, such as infection, pain, abscesses, hemorrhage and so forth. If no emergent problems are present, the treatment will be proceeding in three distinct phases. The first phase is referred to as initial therapy. This is essentially a non-surgical approach which is aimed in the elimination of causative, otherwise known as ecologic factors. It is similar to removing the debris after the fire on the house. This approach is generally used prior to a more complicated treatment, or in instances when the complicated treatment is not recommended. What are then the aspects of initial therapy? The dentist always has to start with oral hygiene instructions, teaching the patient techniques and effective plaque removal, such as good brushing techniques, flossing, ending smoking, consultation, and tobacco cessation. The second phase is scaling and root planing, which is designed to remove the bacterial biofilms covering the teeth, as well as the outer layer of infected cement and covering the roots. These slides demonstrate patients' tissue before and following calculus removal. Please note that the gum swelling has been considerable reduced, and the color of the gums has changed from red, indicating inflammation, to coral pink, more consistent with health. This scaling may be accomplished either via using hand instruments such as curettes, or ultrasonic cleaners, which are particularly effective in breaking large chunks of calculus and removing extrinsic stain from coronal surfaces of teeth. Initial therapy also involves a removal of contributing factors which may facilitate bacterial plaque accumulation, and prevent the patient from exercising effective oral hygiene. Those would include removal of poorly fitted restoration, which create ledges beneath the gum lines. Reshaping over-bulky crowns. These two images illustrate the removal of overhanging margins of a crown, and the shortening of a pontic in a bridge. In both cases, the objective is to facilitate an effective plaque removal by the patient. The initial therapy also includes possible anti-microbial therapy such as mouth rinses containing fluoride, cetylpyridinium chloride or chlorhexidine, and possibly short term antibiotics treatment intended to reduce periopathogens. Many patients wonder why antibiotics cannot be used routinely in the treatment of periodontal disease. Since periodontal disease is a chronic condition, it would require a prolonged treatment with antibiotic therapy, and that could lead to other problems, such as overgrowth of fungal infections or other pathogens. So generally speaking, indications for antibiotic therapy are for short term therapy. And they include prophylactic coverage prior to treatment to prevent post operative infection in immunocompromised patients, or patient with prosthetic heart valves. Acute infection such as acute abscesses, they include refractory periodontitis, aggressive periodontitis, dental implant replacement, guided tissue regenerations also use grafts. And short-term antibiotic therapy can also be used in treatment as an adjunctive to treatment of advanced periodontitis with severe bone loss. Initial therapy may also include bite adjustment to equalize the biting forces so that the occlusal pressure is evenly distributed on both the right and left sides. Cases where such forces are not equally distributed, or where excessive forces are applied to a single or small group of teeth, can result in occlusal trauma. In cases where occlusal trauma is caused by a patient's excessive clenching or grinding, a night guard may be recommended. This treatment may also include splinting of loose teeth, and this may be accomplished with wires or resins. Such splinting is indicated where occlusal forces act on teeth with compromised bone support. Once the initial therapy is accomplished, the periodontist will then be able to reassess the results, and evaluate the extent of lingering damage to the periodontal tissues. In cases where the periodontal disease is not very severe, this phase will be quite sufficient. The outcome of this phase is then evaluated, and at times this approach alone may be sufficient to treat the condition. However, frequently the surgical approach may become necessary. One of the main advantages of periodontal surgery is the ability of the clinician to gain adequate access to the two supporting structures beneath the gum margin. By retracting a flap of gum tissue, demonstrated in this picture, the dentist is then able to directly visualize and remove the tartar covering the root surface, as well as the outer layer of infected cementum in a more effective manner. The images illustrate the dark tartar on root surfaces, which becomes more accessible to its removal when a flap of tissue has been removed. Another objective of surgical approach is the elimination of deep spaces which are found between the teeth and the gums. These spaces, known also as periodontal pockets, are found in the course of periodontal disease due to gum detachment from the root, as well as bone loss. The problem with deep pockets, generally defined as those spaces five millimeters or more, is that they become reservoirs for pathogenic anaerobic bacteria, which are inaccessible to either the toothbrush or dental floss. The elimination of these pockets is often accomplished by the atypical repositioning of the gum tissue, thereby exposing more of the two structure. It is, therefore, not unusual for patients to experience a transient increase to thermal sensitivity following such a surgery. Furthermore, retracting flaps of gum tissue enables the dentist to recontour jagged areas of bone from doing bone resorption in periodontal disease. Sites where bony defects have formed may be augmented with various forms of bone grafts taken from human, or animal, or synthetic materials to recreate the loss, or compensate the loss, of periodontal support. This phase is equivalent to rebuilding the destroyed portion of the house which we have discussed earlier. In these images, hopeless teeth have been extracted and the remaining bony sockets have been filled with bone graft material. The graft material helps in bony ridge preservation, thereby leaving adequate bone to accommodate subsequent implant placement. Some periodontal conditions result in damage to soft tissue, without affecting the periodontal ligament or other tooth supporting structures. These conditions are collectively referred to as mucogingival problem. An example of a mucogingival problem in a case of a gingival recession, where the zone of keratinized tissues surrounding the tooth is insufficient to dissipate the massive pull in speech and mastication. In such instances, the receded areas augmented by a gum graft generally taken from the palate of animal tissues. Last but not least, we now have the ability to place implants to replace unsalvageable lost teeth. Implant placement is usually a two-step procedure. The first part involves the surgical placement of the implant inside the bone, which subsequently osseointegrates with it. This part essentially becomes the root of the tooth. The second part of the treatment involves recreating the crown of the tooth by placing a post and core inside the implant, and manufacturing a porcelain crown which is fitted and cemented on top of the core. The maintenance phase is perhaps the most important aspect of therapy. It requires regular visits by the patient to a dentist following an active treatment at regular intervals, involving reinforcement of good oral hygiene habits, performing dental prophylaxis, and addressing any potential emerging problems in a timely manner. Research both in the US and Scandinavian countries has indicated that regular maintenance is required for sustaining good oral health, as well as keeping positive outcome of previous periodontal therapy. In some instances, yearly visit by patients to the dental office will suffice. But in others, with history of more severe periodontitis, a three month interval may be required. These visits are meant to reinforce good oral hygiene, remove plaque and calculus, and intervene in a timely fashion in instances of disease recurrence. Multiple studies have proven that without such frequent and regular visits, periodontal condition, especially in patients with high susceptibility, will continue to deteriorate.
