Gum Disease - Treatment and Management

Treatment and Management of Periodontitis

The goal of periodontal treatment is to eliminate plaque, biofilm and calculus, from the tooth surface and establish an environment that can be maintained in health. Treatment of periodontitis can be non-surgical or surgical. The optimal treatment is based on the patient, site and systemic factors.

Non-Surgical
Non-surgical treatment is the professional removal of supragingival and subgingival bacterial plaque or biofilm and calculus, which provides a biologically acceptable root surface, as well as patient adoption of a comprehensive daily plaque or biofilm control routine.
Non-surgical therapy includes:

• Patient education and oral hygiene instruction

• Complete removal of supragingival calculus

• Restoration or temporization of carious lesions

• Treatment of areas where plaque and food debris can collect, including orthodontic treatment and removal of plaque retentive factors.

According to ADA clinical practice guidelines on non-surgical treatment, derived from a 2015 systematic review, scaling and root planing without adjuncts is the treatment of choice for patients who have periodontitis. The guidelines go on to endorse use of systemic sub-antimicrobial dose doxycycline along with scaling and root planing for patients with moderate-to-severe periodontitis. Specifically, the guidelines recommend oral doxycycline (20 mg twice a day) for 3 to 9 months following scaling and root planing for these patients.
Patients often require several treatment sessions for complete debridement of the tooth surfaces. After scaling, root planing, and other adjunctive treatment approaches such as use of antibiotic therapy, the periodontal tissues require approximately 4 weeks to demonstrate optimal effects of nonsurgical therapy.

Surgical
Many moderate to advanced cases require surgical access to the root surface for root planing and reducing pocket depth, which will allow the patient to achieve successful home care.
Surgical treatment entails:

• Correction of anatomic conditions that predispose the patient to periodontitis, impair aesthetics, or impede placement of prosthetic appliances

• Extraction of teeth that cannot be successfully treated

• Placement of implants when teeth are lost

Surgical treatment options include:

• Gum Graft Surgery: Gum graft surgery is intended to prevent further gingival (gum) recession and bone loss and to reduce sensitivity. During this procedure, tissue is taken from the palate or another donor source to cover exposed roots.

• Periodontal Pocket Reduction Procedures: In this approach, gingival tissue is folded back to allow for removal of disease-causing bacteria, after which the tissue is sutured back in place. This is intended to allow gingival tissue to reattach to the bone.

• Regenerative Procedures: These are procedures that are performed when there is bone destruction. Once again, the gingival tissue is folded back and the disease-causing bacteria are removed, after which membranes, bone grafts, or tissue-stimulating proteins are used to help promote regeneration of supporting periodontal tissues.

Maintenance
A patient with gingivitis can revert to a state of health with a reduced periodontium, but due to the host-related disease susceptibility, a periodontitis patient remains a periodontitis patient, even following successful therapy, and requires life‐long supportive care to prevent recurrence of disease. Further, patients with more severe periodontitis Stage and Grade have been found to be more likely to experience disease recurrence and tooth loss without regular periodontal maintenance visits.
Much of the literature agrees that, after non-surgical and/or surgical periodontal treatment, patients could benefit from more frequent visits, possibly every 3-6 months. These appointments could include a review of home oral hygiene behaviors, ascertainment of exposure to risk factors such as tobacco use, professional plaque removal, and subgingival debridement, as needed. Patients also could be assessed to determine if active therapy is needed to treat recurrent periodontal disease.
Researchers generally agree the maintenance phase is key to allow for close monitoring of the attachment level and pocket depth along with the other clinical variables, such as bleeding, exudation, tooth mobility.