Periodontology (Gum) Treatments

Periodontal Diseases

Periodontology is a branch of dentistry that deals with gingival diseases and their treatments. The term “periodontal” means the surrounding area of the tooth. Gingiva means gums. The terms used for inflammation of the gum tissue are “gingivitis” and “periodontitis”.

1. Gingivitis

Gingivitis is the early stage of gum disease. The gums become red, swollen with oedema and bleeding occurs. There is no bone resorption on the alveolar bone which supports the tooth. Gingivitis is usually encountered when there is inadequate oral hygiene. By exercising proper dental care and treatments, gums are restored back to their original form.

The most prominent symptom is spontaneous bleeding as a result of a trigger (brushing, biting etc) or by itself. Because of the fact that smoking deteriorates the oral vascular structure, it may conceal the most important symptom by blocking the bleeding of the gums; therefore causing the disease to progress into more advanced stages on a patient outside of regular check-ups. The factors which increase the severity of the disease are diabetes, smoking, genetic disposition, systemic diseases, stress, malnutrition, hormonal changes, pregnancy, HIV infections and the use of certain medications.

2. What is Periodontitis?

Untreated gingivitis may progress to periodontitis. Over time, the toxins of the bacteria that exists on the accumulated bacterial plaque on teeth irritate the gums and these toxins cause chronic inflammatory response. Destruction begins on the supporting bone and tissues around the tooth. The gingiva is separated from the tooth and a periodontal pocket is formed. As the disease progresses, the pocket gets deeper and an increase is observed in the bone and gum tissue destruction. If there isn't an intervention to this process, the bone destruction will lead to a necessity for tooth extraction.

Periodontitis has many different forms. The most common ones are listed as follows;

a) Agressive Periodontitis: Rapid bone loss is the most commonly observed property and it is related to hereditary (genetic) factors.

b) Chronic Periodontitis: As mentioned above, the inflammation on the tooth-supporting tissue causes bone destruction and gingival recession. Clinically, this is observed with periodontal pocket formation and gingival recession. Commonly encountered in adults, it may occur at any age.

On patients with chronic periodontitis, bone loss is usually slow. However, there may be periods where bone destruction is occurring rapidly.

c) Periodontitis As A Symptom Of A Systemic Disease: Usually begins in younger ages. Some heart diseases, lung diseases and diabetes are associated with this type of periodontitis.

d) Necrotic Periodontal Disease: It is a contagious disease which is characterised by the necrosis of gums and surrounding tissues. These lesions are most commonly observed in HIV-positive immunosuppressed patients or due to malnutrition.

3. What Are The Risk Factors For Gingival Diseases?

Although the principal cause for periodontal diseases is bacterial plaque, the following other factors are also affecting gingival health.

a) Age: According to research, it has been established that the rate of periodontal disease occurrence on elderly people is higher.

b) Tobacco products: Smoking is connected with many diseases such as lung cancer and heart diseases. Cigarettes increase the risk of periodontal disease. As a result of conducted research, it has been discovered that smoking is the most important risk factor for periodontal disease occurrence and progression.

c) Genetics: According to research, it has been demonstrated that some people are more prone to gingival diseases than others. The evaluation of this tendency is possible with genetic tests. The patients belonging to this group are helped preserve their teeth by preventive treatments.

d) Stress: Stress is associated with cancer, high blood pressure and other health problems. It is also a risk factor for periodontal diseases. Research has shown that stress negatively affects the body's defense mechanism against infection and triggers periodontal disease.

e) Medications: Birth control pills, anti-depressants and some heart disease medication can affect oral health.

f) Tooth clenching and grinding: Due to the fact that these habits put extreme pressure on teeth, they may cause destruction on periodontal tissue or rapid progression of the existing disease.

g) Other systemic diseases: Immunosuppressive diseases also affect gingival health negatively. Coronary heart diseases, diabetes and romatoid arthritis are among these diseases.

h) Bad diet and obesity: Malnutrition is an important factor which negatively affects the body's immune system. Due to the fact that periodontal diseases begin as an infection, the weakness of the immune system and bad dietary habits adversely affect gingival health. In the recent studies, it has been found that obesity increases the risk of periodontal disease.

4. The Symptoms of Gingival Diseases

Gingival diseases often progress without presenting any symptoms, and the symptoms won't appear until later stages of the disease. However, the warning symptoms of gingival disease are as follows:

• Blushing, swelling, sensitiviy and pain on the gingiva
• Gingival bleeding when brushing, flossing or chewing something rough
• Gingival recession, teeth having a longer appearance than usual
• Tooth loss or diastema formation
• Pus discharge from the gingiva
• Mouth sores that appear in the mouth
• Permanent bad breath
• Compatibility issues with existing partial dentures

5. Prevention of Gingival Diseases

Also known as gingival diseases, periodontal diseases are caused by the bacterial plaque accummulated between teeth and the gingiva.

When the gingival disease isn't treated, the inflammation impairs the structure of the bone and the gingiva and causes gingival recession and tooth loss. In addition, as demonstrated by research, it leads to tooth loss. In other respects, research has also shown that gum disease is associated with many diseases including diabetes and heart disease. The patients are lucky in terms of the fact that gingival disease is a preventable and treatable disease.

Preventive habits listed below should be exercised daily and regularly.

a) Brushing: Toothbrushing facilitates the elimination of bacterial plaque and food particles between the tooth and the gingiva. It is important to keep in mind that the tongue also needs to be brushed.

b) Flossing: Daily flossing facilitates the elimination of food particles and plaque between the teeth. Because of the fact that toothbrush can not enter the tooth and gum line, these areas need to be cleaned with dental floss.

c) Mouthwash: Mechanical cleaning in dental care with brushing and flossing is essential. Mouthwash is supplementary for plaque removal.

d) Knowing the risk factors: Smoking, diabetes and genetic factors increase the risk of periodontal disease. Dental visit frequencies are adjusted considering these factors.

e) Going to the dentist: Regular dental check-ups every 6 months are necessary for maintaining the continuity of oral and dental health.

6. Gingival Diseases and Systemic Diseases

As a result of research, periodontal diseases are shown to be associated with many other diseases. The inflammation caused due to periodontal disease amplifies the manifestation of other diseases in the body. The treatment of inflammation aids with periodontal disease treatment as well as the treatment of other chronic inflammatory issues.

a) Diabetes and Gingival Diseases: On diabetic patients, the chance of periodontal disease is high. The periodontal diseases on diabetic patients are observed with blood sugar and diabetic complications. The connection between diabetes and periodontal diseases is bilateral. Severe periodontal disease increases blood sugar; consequently causing diabetic complications related to this condition. Diabetics have a higher chance of periodontal disease than other people.

b) Heart Disease and Periodontal Disease: The connection between these diseases are demonstrated in various research. While the cause-effect relationship is not fully proven yet, it has been established that the inflammation caused by periodontal disease increases the risk of heart disease. Periodontal disease may worsen pre-existing heart conditions. In the conducted research, it has been determined that Acute Cerebrovascular ischemia patients have oral infections and there is an association between periodontal disease and strokes. However, more research is needed.

c) Osteoporosis: It has been shown in various scientific research that jawbone loss and osteoporosis have a connection. Osteoporosis may cause tooth loss by causing loss of jawbone density.

d) Respiratory Disease: It has been discovered that oral bacteria can enter the lungs by breathing and nest there, consequently causing diseases such as pneumonia.

e) Cancer: According to scientific research, it is demonstrated that there is 49% more kidney cancer risk, 54% pancreatic cancer risk and 30% leukemia risk on males with gingival disease.

7. Gingival Diseases and Systemic Illnesses

The first step in gingivitis and periodontitis treatment is tartar scaling and maintaining oral hygiene. Oral hygiene involves utilizing the correct brushing technique and timing; dental floss and interdental brushes for interdental spaces cleaning.

Due to the severity of the disease and many other factors, there are surgical and non-surgical periodontal treatment methods. The purposes in periodontal treatments are eliminating periodontal pockets and maintaining gingival health.

* Non-Surgical Periodontal Treatment (Subgingival Curettage)

In this treatment method, the bacterial plaque and tartar in the pocket and root surface is cleaned, bacterial toxins are eliminated and root surface is smoothened out. This procedure is performed under local anesthesia. Sometimes, local antibiotics, systemic antibiotics, host modulation and dental lasers can be used as a supplement for this procedure.

* Surgical Periodontal Treatments

For the elimination of periodontal pocket, the gingiva is lifted with surgery, all the inflammatory tissue is cleaned, the tartar and bacterial leftovers located in the pocket on the root surface are removed. If necessary, the damaged bone surface is remedied and regenerative procedures may be performed according to the severity of bone destruction.

* Regenerative methods

These are surgical periodontal treatment methods. The gingiva is surgically lifted, the root surface and the surrounding inflammatory tissues are cleaned. Bone grafts and membranes or tissue-stimulating proteins are utilized.

Surgical and non-surgical treatment methods are of utmost importantce in the reduction of periodontal pockets and bacteria elimination for stopping the progression of periodontal disease. Pocket elimination will not be solely enough for establishing gingival health. In order to keep the disease from recurring, it is essential to carry on maintaining oral hygiene daily and attending periodontal dental check-ups.

8. Gingival Recession and Treatment Methods

Gingival recession due to periodontal diseases is caused by the existing inflammation, leading to the loss of connective tissue attachment in the gingiva and bone destruction. It is the most common cause in cases of gingival recession.

In some cases, the gingiva is healthy but there is gingival recession. This condition is more related to incorrect brushing technique, habits such as tooth grinding, occlusal rest or edge incompatibilities on prostheses, teeth crowding or misalignments, smoking and increasing age.

In addition to the causes of gingival recession, the gingiva being thin or thick is another factor which defines the severity of recession.

Because of the fact that the treatment of the periodontal diseases have been discussed in another title, gingival recession treatment methods will be discussed in this section. The first stage in gingival recession treatment is establishing the cause. According to the severity of the recession, conservative methods, elimination of causes and surgical treatment of the open root surface are performed. These mucogingival surgical methods involve either grafting gum tissue from the neighboring area, grafting from the patient's hard tissue or using artificial graft and similar materials for treatment.

9. Gingival Enlargement

Gingival enlargement may develop due to the inflammation caused by bacteria as well as hormones (pregnancy or puberty), medications (nifedipine, cyclosporine A and phenytoin drug family), tumoral (benign or malignant) and some systemic illnesses. The treatment of enlarged gingival tissue involves removal of enlarged tissue and correcting the gingiva to healthy margins as well as eliminating the factors.

10. Periodontal Plastic Surgery

Periodontal plastic surgery is the procedures performed in smile design and other prothetic restorations. Correction of the excessively exposed gum line, the reverse smile line, treatment of gum recession, crown length extension, extensive muscle attachment removal, reshaping of the gingival papilla and boosting the edentulous space are among this group of surgical procedures.

Gummy smile procedure, which is one of the periodontal plastic surgical methods and crown lengthening procedures can be solely based on gingival scaling as well as performed supplementally along with bone surgery.

11. Peri-implant Diseases

Peri-implant diseases are inflammatory conditions which affect the soft and hard tissues on the surrounding area of the dental implant. Just like natural tooth, bacteria nests beneath the gingiva on the implant, irritating the gingival tissue over time and causing inflammation and tissue damage. If it is not diagnosed early, bone destruction occurs and the implant gets damaged or even lost.

Peri-implant illnesses are classified in two categories.

a) Peri-implant Mucositis: This condition is limited to the soft tissue around the dental implant. No bone destruction is observed at this stage. It is usually the precursor for perio-implantitis. If this early stage is promptly and successfully treated, recovery is possible and healthy tissue around the implant starts to form again.

b) Peri-implantitis: This condition is observed when the inflammation around the soft tissue harms the implant-supporting bone. Peri-implantitis usually requires surgical treatment.

The symptoms for peri-implant diseases are similar to the symptoms of gum disease. These are:

- Blushing on gums

- Bleeding when brushing.

As with natural teeth, implants also need to be brushed and flossed and regular dental check-ups are required.

In addition to inflammation, other risk factors which cause peri-implant diseases to develop are the past presence of periodontal disease, lack of oral hygiene, smoking and uncontrolled diabetes.

12. Laser applications in Dentistry

Laser is discovered in USA on 1960. The abbreviation (LASER) derives from "Light Amplification by Stimulated Emission of Radiation". However, the word is used in Turkish as "Lazer". After approximately 20 years of its discovery, the technology made its way to the world of medicine and started being used in dentistry later. Initially, it was used in the treatment options involving soft tissues. Surgical procedures are simplifed thanks to the application of laser technology in dentistry. Due to the fact that there is minimal damage to the tissue, laser technology is becoming widespread in various stages of the surgical procedures. The most important advantages of the technology are bleeding-free operations on soft tissue, fast healing rate and sterilisation on the area of operation thanks to laser technology. Having no vibration on hard tissue and no need for anesthesia when performing minimal procedures, it has become a solid alternative for any patient who has dentophobia. Laser procedures for soft and hard tissue are applied with different power levels and frequencies. Each procedure has different conditions. After selecting the type of procedure, the wavelength exclusive to that particular procedure is only applied on the tissue which is going to be operated on. Today, there are laser types with different wavelengths such as Nd YAG laser, Diode laser, Erbium laser, CO2 laser and KTP laser. Each laser differentiates from one another in terms of tissues they can have an impact upon. When operating the Laser devices, it is mandatory to take the necessary protective precautions. The dentist, the assistant and the patient all must absolutely wear protective glasses especially during the procedure.

Laser application on Soft Tissue

Soft tissue lasers with special wavelength are mainly used in 3 types of procedures such as biostimulation, regional infection control and oral soft tissue incisions. Lasers are utilized in dealing with the conditions of gum tissue after oral surgeries and reducing the number of microorganisms which cause inflammation on gums. Gingivectomy, gingioplasty and frenectomy procedures can be performed without bleeding, stitching and less anesthesia thanks to laser technology. The technology also allows to proceed with other procedures without waiting thanks to no bleeding. In cases where scaling and root planning of periodontal pockets, in order to change the microbial contents of the periodontal pocket, it is possible to utilize sterilizing effect of the laser technology. Eliminating oral tumoral formations, avoiding stitches and faster healing rate is all possible with utilizing laser technology. During the early stages of aphtous ulcers, laser application will remove patient's pain and prevents the wound from opening, thus eliminating the difficulties when eating and speaking. Additionally, the procedure also diminishes the potential chance of aphtous ulcers or herpes to appear again. It is also reported that stimulating the tissue (biostimulation) with laser can promote and control the healing process.

Laser application on Hard Tissue

Laser technology can be used for cleaning the surface decay on teeth without the need for anesthesia. During surgical procedures involving the jawbone, it is also possible to lift the bone without vibration. Although successful in hard tissue procedures, the disadvantage of laser is the prolonged length of the operation. It can also be used for sterilizing the root canals during root canal therapy. Treatment of the inflamed regions surrounding the area of implants can be handled without any need for antibiotics. In addition to tooth paste and clinic flourine when treating teeth sensitivity, it is alternatively possible to plug the dentine canals with the utilization of laser technology.

Teeth Whitening and Laser Technology

It is possible to activate the whitening agents with later technology to achieve whitening as an alternative to the traditional whitening techniques.