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Treating Periodontal Disease

How to Treat Periodontal (Gum) Disease

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 procedures.

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 out!!!”

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.

2. 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.

3. 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 treatment.

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.

Laser Therapy

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 difficult.

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 disease.

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.

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