So, now that you know the basics of periodontal (gum) disease (if not, please see
previous website section titled “What is Periodontal (Gum) Disease?”), I will now
explain the various methods dentists and hygienists have to treat it.
As mentioned in the previous section, periodontal disease is the progressive process
of bone loss around the circumference of the tooth leaving a “moat” or “periodontal
pocket” for further plaque to collect, calcify to tartar, harbor bacteria, and cause
further bone loss and pocket formation.
There are 3 major ways to treat Periodontal (Gum) Disease:
1. Scale and Root Planing or “Deep Cleaning”
2. Periodontal Surgery or “Gum Surgery”
3. Laser Therapy
Scale and Root Planing (Deep Cleaning)
Scale and Root Planing (Deep Cleaning) is the the traditional treatment. Its the
process of removing the calcified Tartar (or “Barnacles” as I like to call them)
from the base of the periodontal pocket. This can be done in two ways.
First, mechanically, hand instruments called “Scalers” and “Curettes” (see photo)
may be used to carefully slide into the perio pocket and physically wedge and pop
off the barnacles that are bonded to the tooth. Secondly, a device called an Ultrasonic
Scaler or “Cavitron” (see photo) is a valuable tool for knocking loose tartar. This
device emits a high frequency vibration and water spray that rattles the tartar from
the tooth and out of the pocket. This method is highly efficient but, in my opinion,
lacks the tactile sense used when using Scalers and Curettes. Working inside a periodontal
pocket is somewhat of a blind procedure and relies heavily on tactile sensation and
ultimately the skill of the clinician. I believe it is a combination of Cavitron
(for gross removal) and Scalers and Curettes (for detail work) that accomplishes
the best results when doing a deep cleaning.
And, by the way, any dentist or hygienist who views deep cleanings as an easy procedure
in dentistry (ie. they book only a small about of time to do it....), be very wary
that THEY ARENT DOING IT RIGHT... or they AREN’T BEING THOROUGH ENOUGH. I’ve heard
many stories of these large “fast food” dental places spending only 20 minutes on
a basic cleaning or only one hour to do multiple quadrants of deep cleaning. This
isn’t right. In a moment, I will go over appropriate times needed to accomplish these
Please keep in mind that it is very difficult to remove tartar. This is something
that can not be done with a toothbrush at home. I’ve tried to scale my own teeth
at home in a mirror, and its impossible... and I’m a dentist!! This hardened material
on the teeth is one of the biggest reasons why people should have regular dental
checkups every 6 months... And, if the person has periodontal disease, then the recall
interval should be tighter. I figure people can brush their own teeth. But, it’s
my job as a dentist (and the job of my hygienist) to remove the calcified tartar.
Furthermore, its my job to measure pockets and document them through time. My hygienist
will have the periodontal chart out at EVERY cleaning. The periodontal chart is our
blueprint or roadmap to cleaning teeth. My staff and I keep excellent records and
it is this meticulous monitoring and documenting of patients through time that keeps
people healthy and free of periodontal disease.
There is a wide spectrum of severity when it comes to periodontal disease. We measure
six periodontal pocket sites on a tooth and document them. Numbers (depth of pocket)
can range from zero to about twelve. (Please see previous section “What is Periodontal
(Gum) disease?” to understand what these numbers mean.) The number of teeth that
have numbers greater than three AND the numbers themselves that determine the severity
of periodontal disease. For example, cleaning a 4mm is much different from cleaning
a 10mm... AND, cleaning a mouth with one pocket is much different than cleaning a
mouth with 60 pockets.
So, you begin to see why a periodontal chart is so important when planning treatment
on a patient.
OK. Let’s say you’ve been told you have Periodontal Disease (either just one or
two pockets or a mouth full of pockets) and you’re freaking out. OR let’s say you’ve
been told you have some degree of periodontal disease at some time in your life and
you’ve been avoiding it. The “See No Evil, Hear No Evil Syndrome...”
Either way, DON’T WORRY!!!
One of my many mantras in dentistry is, “No matter how easy or complex a dental
case is... you can always break it down into bite size pieces; Anything can be figured
AND, We can treat it without you feeling pain in the dental chair!!
The following is how we do this:
1. If you’re a person with perfect gum health and no pockets, you get something
called a “prophy” which is, by definition, cleaning above the gum line/monitor for
future pockets type appointment. 1 Hour. 6 month recall.
1. If you’re a person with good gum health and maybe one or two localized pockets
on one or two teeth, it is broken down into 2 appointments. You get something called
a “prophy” plus “Localized Scale and Root Plane.” 1 Hour for prophy 40 minutes
for Localized Scale and Root Planing
* The reason why extra time is needed when pockets are present is because its uncomfortable
to remove tartar from a pocket and anesthesia is a good idea. My hygienist and I
strive to keep patients comfortable and pain free when in the chair. We also like
to use topical “gel” on the gums just to be extra nice ; ) !!! Also, it takes time,
determination, and skill on the part of the clinician to do this correctly. The anesthetized
patient experiences only light pressure from hand scaling and a cool vibration spray
from the ultrasonic scaler.
1. If you’ve got multiple pockets in multiple corners of the mouth or “quadrants”
(ie. Upper right, Lower right, Upper left, Lower Left), then the treatment is broken
down into what’s called “Quadrant Deep Cleanings” or “Quadrant Scale and Root Plane”.
For this to be done correctly, EACH quadrant requires an HOUR to complete. This may
be done on four separate one hour appointments, two separate two hour appointments,
or one giant 4 hour appointment. This choice is left up to the patient. Sometimes,
in cases where the pockets aren’t severe or prevalent enough to warrant 4 quadrants,
we will clean four quads and charge for only two. I always try to be as fair as possible.
Again, it depends on the chart. But, you get the idea of how the pocket numbers determine
Periodontal Surgery or “Gum Surgery”
In many practices, moderate to severe periodontal conditions may warrant a referral
to a specialist called a “Periodontist” to perform a procedure called “Periodontal
Surgery”. Periodontal Surgery is when an incision is made along the gum line, the
tissue is filleted back (like you are peeling an orange) exposing the naked roots
and immediate bone surrounding the tooth, all tartar is cleaned from the roots using
methods explained above, bone is sometimes ground away to remove irregularities or
defects, then the tissue is sutured back to a higher level on the tooth, thus, reducing
the pocket and exposing the roots as so the patient may again clean them.
When the procedure is completed, the patient leaves with sutures and sometimes a
difficult post op recovery. Also, the teeth and roots will appear longer in the mouth
because the tissue has been essentially raised up into where the pocket used to be.
I used to refer patients for Periodontal Surgery as I have performed the procedure
myself many times. There is no question that it accomplishes the goal of pocket reduction,
but patients hate the idea of “cut and suture” and the post op recovery is extremely
So, about 8 years ago, I set out to find a better way. I kept hearing about Laser
Therapy and its success in reducing pocket numbers. After attending a number of courses,
I bought my first laser. Now, I am not exaggerating when I say that the purchase
of this laser was undoubtedly the BEST thing I have ever done for my patients and
my practice. I have been doing laser dentistry and laser periodontics now for over
8 years, have since bought a second laser for my hygienist, and I am astounded as
to why more dentists (and periodontists!!) aren’t tending more to this mode of treatment.
Lasers can be used in dentistry for a wide spectrum of modalities (see section titled
“Lasers”) But, for my purposes here, I will explain how I use it to fix periodontal
The Laser absorbs the wavelength of the color of red irritated gum tissue. Through
a photo-thermal reaction it dissolves this tissue and selectively removes it while
leaving healthy pink gum tissue. In addition, depending on how the laser is set,
it disinfects the site, cauterizes blood vessels, and leaves a healthy environment
for healing to take place. In other words, there is no need for cut and suture.
Logistically, performing laser periodontics is different from traditional deep cleaning.
I don’t break treatments into quadrant hour appointments. Instead, my hygienist
and I only work on about one or two teeth per hour appointment. The prevalence and
severity of the pockets determine the number of one hour laser appointments. This
is a much nicer situation for patients because they are not subjected to a full “periodontal
surgery” all at once and the post op recovery is MUCH more tolerable. Also, the patient
doesn’t leave with sutures.
Mechanically, Laser Therapy is doing the same thing as Periodontal Surgery. The
patient is numbed in the area to be worked on. Like Perio Surgery, we use the laser
to contour the tissue into a higher place on the tooth, eliminating the pocket, and
giving the patient (and hygienist) the ability to access these areas of the gums
and teeth. However, unlike Perio Surgery, there is the added benefit of disinfection/sterilization
by the laser, immediate cauterization, and a more controlled (ie. personalized) contouring
of the tissue around each individual tooth. This is in contrast to one giant incision
going across multiple teeth.
Following laser treatments, its important to stay on a tight 3 or 4 month recall
to follow pocket numbers. I often will schedule a “touch up” appointment 3 or 4 months
out to tidy up any residual pockets that aren’t behaving.
Overall, Laser Therapy is amazing. From my experience, and I have done multiple
hundreds (into thousands) of cases, I can achieve the same results (even better in
some respects) than Periodontal Surgery. One of the biggest advantages is LONG TERM
success. I’ve found that patients leave treatment with a positive experience rather
than the negative torture stories I so often hear with periodontal surgery. Patients
are more motivated to stay on their recall and maintain their perio condition into
the future. All too often, I’ve found post op perio surgery patients get discouraged
from their experience and don’t follow up. They disappear from dentistry for many
years only to find a recurrence of pockets down the road. Its an endless cycle of
chasing your tail.
Now, don’t get me wrong. I’m not knocking Periodontal Surgery in terms of results.
It gets results. Its the accepted and traditional way to treat this condition. And,
I entirely see why specialists love this procedure and are very successful with it.
But, often the general dentists are the ones who ultimately see these patients many
years down the road, especially if the patient never followed up due to a tough post
op experience. In my opinion, there is more to it than results. I can achieve comparable
results with a laser and, from my experience, patients are much more likely to follow
up and maintain a healthy perio condition into the future. Also, unlike perio surgery,
its not an “all or none” procedure. It can be broken down to individual teeth and
easy “touchups” can be done at any time in the future.