Introduction

Periodontal diseases affect a significant proportion of the population. The most prevalent periodontal disease is chronic periodontitis, although it should be remembered that this condition is only one of a number of diseases that can affect the periodontal tissues (Table 1).1 Chronic periodontitis is a plaque-induced inflammatory disease resulting from interactions between plaque bacteria and the immune system. These interactions result in loss of attachment to the root surface and pocket formation, allowing more bacteria to accumulate beneath the gingival margin. If left untreated, loss of supporting alveolar bone occurs, which can lead to increased mobility and tooth loss.2 This process may be exacerbated by various systemic factors such as smoking, diabetes and some rare disorders of the immune system.

Table 1 1999 International Workshop Classification of Periodontal Diseases
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Common signs and symptoms of periodontitis include bleeding gums, halitosis, receding gums, tooth sensitivity and tooth mobility (Fig. 1). Unfortunately, periodontal diseases often don't cause obvious symptoms until the teeth begin to move or feel loose. Many patients think that it's perfectly normal to have bleeding gums when brushing!

Figure 1
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Chronic periodontitis case showing plaque accumulation, marked gingival inflammation and bleeding after probing

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There is emerging evidence of a significant association between periodontitis and other diseases, most notably cardiovascular disease.3 Although a causal link has not been proven, the common risk factors between the two conditions are now well established and are subject to ongoing research activity. Some of this discussion has been published in the news media and many patients are becoming concerned over the possible link between periodontitis and their overall general health.

Diagnosis of periodontal diseases

Since periodontitis is often asymptomatic, it is essential to screen all patients for periodontal diseases to allow early diagnosis and treatment. A simple and effective way of screening patients in general dental practice is to carry out a Basic Periodontal Examination (Table 2) using a WHO periodontal probe (Fig. 2). Patients who have signs of significant periodontitis will require a more comprehensive examination including pocket charting, bleeding scores and radiographs in order to assess the extent of the disease and periodontal bone levels (Fig. 3).4

Table 2 The Basic Periodontal Examination (BPE)
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Figure 2
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A WHO periodontal probe used to carry out a Basic Periodontal Examination (BPE). All sites (excluding third molars) are examined and each sextant given a code depending on the worst site in that sextant (as described in Table 2)

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Figure 3
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Radiograph showing advanced bone loss resulting from severe chronic periodontitis

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Initial periodontal therapy

Maintaining excellent oral hygiene on a daily basis is critical for successful treatment. This is an excellent opportunity to involve the whole dental team in providing educational materials and oral hygiene advice.

The conventional approach to periodontal treatment is to remove bacterial deposits from the teeth and root surfaces by scaling and root planing. This traditionally involves thorough subgingival debridement to remove all plaque and calculus using a combination of hand and ultrasonic instruments over a series of appointments.

Contemporary treatment places less emphasis on mechanical scaling of the root surface and a greater focus on subgingival decontamination and disruption of the subgingival biofilm, usually with ultrasonic instrumentation and often over fewer appointments. In the presence of adequate supragingival plaque control, this initial therapy allows resolution of inflammation and a reduction in probing pocket depths (Figs 4, 5).5 Full-mouth treatment protocols typically involve instrumentation within a very short timescale (usually within 24 hours) and often require significant adjunctive chlorhexidine application. The concept of ‘full-mouth disinfection’ has been very popular in recent times, although new research suggests that conventional staged treatment may be just as effective.6

Figure 4
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Chronic periodontitis case before initial periodontal therapy

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Figure 5
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Chronic periodontitis case (seen in Fig. 4) after initial periodontal therapy

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Once the disease has been brought under control, most periodontal patients will require supportive periodontal treatment at regular intervals in order to monitor their oral hygiene, remove any deposits and re-instrument any residual sites that the patient is unable to access.7 Much of this treatment may be carried out by a dental hygienist or therapist working under the guidance of a dentist or periodontist.

Various types of locally delivered antimicrobials are available to place into periodontal pockets and these can be useful to manage non-responding sites or areas of disease recurrence. Antibiotics are rarely indicated in the management of periodontitis except in exceptional circumstances, such as in cases of aggressive periodontitis.

Surgical treatment

Further treatment may occasionally be necessary to deal with residual pockets or difficult anatomical features. This can involve periodontal surgery to allow better access to the root surface, eliminate periodontal pockets and re-shape the periodontal tissues to aid oral hygiene procedures by the patient.8 In certain circumstances, it is possible to regenerate some of the periodontal tissues that have been lost due to destructive periodontal diseases by using specialist techniques and biomaterials.9

Rehabilitation of the periodontally compromised dentition

Periodontitis is a major cause of tooth loss and many patients will require replacement of missing teeth due to the effects of periodontitis. This requires careful treatment planning and often requires multi-disciplinary management with input from periodontists, prosthodontists and dental technicians. Dental implants are becoming more widely available to replace missing teeth and are often the treatment of choice in the rehabilitation of the periodontally compromised dentition.10 Since periodontitis results in the loss of alveolar bone, placement of implant fixtures in patients who have suffered periodontitis may be quite complex, sometimes requiring bone grafts or augmentation to provide sufficient bone for implant placement.

Peri-implant disease (peri-implantitis) is also becoming an increasing problem and can be difficult to manage.11 It is very important to thoroughly treat any existing periodontal disease prior to implant treatment and arrange frequent review appointments to carry out any necessary supportive periodontal treatment.

Cosmetic periodontal treatment

There has been a significant growth in the market for cosmetic dental treatment in recent years. Many patients are requesting ‘smile makeovers’ involving tooth whitening, orthodontics or the provision of porcelain crowns or veneers. It is important that the soft tissue aesthetics are not overlooked when planning and discussing cosmetic dental treatment. Common problems include gingival asymmetry, excess gingival display and recession.12

Excess gingival display can be treated using crown-lengthening surgery to reduce the amount of soft tissue around the teeth and recreate a more natural gum line (Figs 6, 7). Osseous recontouring is usually required to ensure maintenance of the biologic width and a stable outcome. This technique can also be helpful when restoring posterior teeth with subgingival restoration margins or when insufficient coronal tissue remains to provide a satisfactory restoration.

Figure 6
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Gingival asymmetry case prior to cosmetic treatment

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Figure 7
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Gingival asymmetry case (seen in Fig. 6) after crown lengthening surgery to improve gingival contours and provision of anterior veneers (restorations by Dr Darren Cannell)

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Gingival recession can be treated with soft tissue surgery using locally repositioned flaps or soft tissue grafts taken from elsewhere in the mouth to cover recession defects.13 Soft tissue grafting may also be necessary to recreate a better soft tissue profile beneath bridge pontics or adjacent to implant fixtures to improve the aesthetic outcome.

Conclusions

Periodontology has evolved over the years to address not only the treatment of periodontitis, but also the functional and cosmetic rehabilitation of patients who have suffered periodontal diseases. Our approach to treating periodontitis has also changed to reflect a greater understanding of the disease process and the response to therapy.

The whole dental team can play an important role in managing periodontitis by becoming involved with patient education, providing oral hygiene advice, co-ordinating treatment and carrying out some of the initial non-surgical therapy. Most periodontal diseases are preventable with good oral hygiene and we should therefore strive to promote excellent periodontal health for all of our patients.boxed-text

Further reading

Lindhe J, Lang P L, Karring T. Clinical periodontology and implant dentistry, 5th ed. Blackwell Munksgaard, 2008.