Antibiotic therapy is the use of local and systemic agents to control the bacterial etiology of the inflammatory periodontal diseases. These agents include both locally and systemically delivered antibiotics and chemotherapeutic agents.

When Are Antibiotic therapy Indicated in Periodontal Therapy?

Indications for the use of antibiotic therapy in periodontal disease include the following:

• Periodontal abscess

Agressive periodontitis

Juvenile periodontitis

Rapidly progressive periodontitis

Prepubertal periodontitis

• Chronic periodontitis with persistent severe gingival inflammation

• Refractory forms of chronic or aggressive periodontitis

• Protection vs subacute bacterial endocarditis

• When surgical therapy is contraindicated

• To control local sites of inflammation

• As an adjunct to conventional mechanical therapy

• Subantimicrobial dose of doxycycline to stabilize collagenase activity

What Antibiotic therapy Are Commonly Used Systemically in Periodontal Therapy?

The most commonly used antibiotics in periodontal therapy are:

• Amoxicillin (with or without clavulanic acid – Augmentin)

• Metronidazole

• Ciprofloxacin

• Clindamycin

• Doxycycline

• Azithromycin

What Are Some of the Risks of Using Systemic Antibiotic therapy in Periodontal Therapy?

There are general and specific risks in the use of antibiotic therapy in periodontal therapy. These include:

• Allergic reactions (delayed or immediate hypersensitivity)

• Gastrointestinal problems

• Development of superinfections by unaffected organisms

• Development of resistant bacterial strains

How Is the Appropriate Antibiotic therapy Regimen Chosen?

It is preferable that the bacteria associated with the inflamed sites have been identified before the selection of antibiotic therapy. Bacterial identification may be accomplished by culturing the bacteria from within the pocket or by using DNA probe identification technology. The advantage of culturing is that sensitivity of the identified bacteria to specific antibiotics can also be reported. The major advantage of DNA probe technology is that viable bacteria are not needed to identify the penodontopathogens.

Antibiotics are prescribed without identifying the associated microorganisms and the patient is monitored for clinical success. The major risks in this approach are the selection of an antibiotic to which the pathogen is resistant or the development of a superinfection caused by an unidentified and unaffected bacterial strain.

What Are the Principles of Antibiotic therapy Dosing?

• Employ high doses for a short duration

• Use an oral antibiotic loading dose, especially with the tetracyclines or with an acute infection

• Achieve blood levels of the antibiotic at 2-8 times the minimal inhibitory concentration

• Use frequent dosing intervals, particularly with antibiotics with a relatively short half-life

• Determine the duration of therapy by the remission of disease

What Are the Potential Problems With Drug Interactions?

Depending on the mechanism of antibiotic action, combinations of antibiotics may have an additive, synergistic, or antagonistic effect Static antibiotics used in combination generally exhibit an additive effect, bacteriocidal antibiotics exhibit a synergistic effect, and the combination of bacteriocidal and bacteriostatic agents exhibit an antagonistic effect. Antibiotics may also react with other medications the patient may be taking or interact with certain foods (tetracycline chelating with calcium or other divalent cat ions). Individual drug interactions can be found in the section on specific agents below.

What Are Some Common Dosing Regimens for Systemic Antibiotic therapy Use in Periodontal Therapy?

Arriving at an appropriate antibiotic selection and dosing regimen is an inexact science. Individual antibiotics or combination therapy may be selected depending on whether or not the infection seems to be caused by one bacterial species or is a mixed infection, as most periodontal infections tend to be. Protocol selection may depend on the practitioner’s knowledge, previous experience, and perhaps by the most recent advertisement or sales representative to speak with the practitioner. The suggested regimens that follow are taken from recommendations of Dr. Thomas Rams, Director of the Oral Microbiology Testing Service at Temple University and a long-time researcher in the field of antibiotic therapy in the treatment of the periodontal diseases. While there are other suitable regimens, these recommendations are a good starting point for those practitioners in need of guidance.

GUIDELINES IN THE SELECTION OF SYSTEMIC ANTIBIOTIC THERAPY IN PERIODONTAL THERAPY

Possible Antibiotic Recommendations for Specific Microbiological Test Findings

*For combinations of anaerobic and facultative periodontal pathogens:

1st choice: Metronidazole + amoxicillin or Augmentin@ (250 mg each TID for 5-7 days, or metronidazole 500 mg and Augmentin 875 mg each BID for 5-7 days)

2nd choice: Metronidazole ÷ ciprofloxacin (500 mg each BID for 5-7 days)

Note: Combination drug regimens are generally preferred to single antibiotic administration)

For Actinobacillus actinomycetemcomitans:

1st choice: Metronidazole + amoxicillin or Augmentin (250 mg each TID for 5-7 days, or metronidazole 500 mg and Augmentin 875 mg each BID for 5-7 days)

2nd choice: Ciprofloxacin (adults only) alone or with metronidazole (500 mg each BID for 5-7 days)

3rd choice: Azithromycin (500 mg/day for 3-5 days)

4th choice: Doxycycline (100 mg BID for 14-21 days)

*For anaerobic pathogens (Porphyromonas gingivalis, Prevotella intermedia, Sacteroides forsythus, Fusobacterium species, Peptostreptococcus micros, and Campylobacter species):

1st choice: Metronidazole + amoxicillin or Augmentin (250 mg each TID for 5-7 days, or metronidazole 500 mg and Augmentin (875 mg BID for 5-7 days)

2nd choice: Augmentin® (250-500 mg TID, or 875 mg BID for 7 days)

3rd choice: Metronidazole (500 mg BID for 7 days)

4th choice: Clindamycin (150 mg TID for 5-7 days)

5th choice: Azithromycin (500 mg/day for 3-5 days)

6th choice: Doxycycline (100 mg BID for 14-21 days)

(Note: Some Fusobacterium strains may metabolize metronidazole and reduce its efficacy; some Pepto- streptococcus micros strains are resistant to tetracydines, metronidazole, and azithromycin; Prevotella intermedia is often resistant to tetracycline antibiotics.)

*For enteric rods, Pseudomonads, Enterococci and/or Staphylococci:

1st choice: Ciprofloxacin (usually given with metronidazole – 500 mg each BID for 5-7 days)

2nd choice: Variable depending on strain susceptibility

*For beta-hemolytic Streptococci:

1st choice: Augmentin(250-500 mg TID or 875 mg BID for 7 days)

2nd choice: Clindamycin (150 mg TID for 5-7 days)

What Are Some Common Reasons for Antibiotic therapy Failure in Periodontal Therapy?

• Inappropriate choice of antibiotics (the microorganism is not susceptible to the antibiotic of choice)

• Incorrect / inadequate doses

• Emergence of antibiotic-resistant microorganisms

• Too low a blood concentration of the antibiotic

• Slow growth rate of the microorganisms

• Impaired host defenses

• Patient noncompliance

• Antibiotic antagonism (eg, using bacteriocidal and bacteriostatic antibiotics together)

• Inability of the antibiotic to penetrate to the site of infection

• Limited vascularity or decreased blood flow

• Unfavorable local factors

• Failure to eradicate the source of infection

What Is Subantimicrobial Antibiotic therapy Usage?

It has been demonstrated that tetracycline and the tetracycline derivative doxycycline (subantimicrobial dose of doxycycline – SDD) can reduce collagenase activity when used in doses too low to have any antimicrobial effect. The use of SDD has been shown to reduce the rate and amount of attachment loss associated with advancing periodontal disease. SDD is currently used as a 20 mg dose of doxycycline twice a day. Long-term studies have been for 9-month durations. There is little data on the manufacturers provide detailed instructions, there is an effectiveness of SOD therapy for longer periods of time, the learning curve to developing an efficient technique for the use of each product.

What Are the Indications for the Use of Locally Delivered Antibiotic therapy and Antimicrobial Therapy?

• Local site(s) with signs of inflammation that have not responded to conventional mechanical therapy

• Local site that has recurrent signs of inflammation at a maintenance visit

• Buying time for a so-called hopeless tooth before extraction

• Resolving marginal inflammation when oral hygiene has reached maximum effectiveness distributors.

What Therapeutic Mouthrinses Are Available to Reduce Plaque and Help Control Gingival Inflammation?

It should be remembered that a mouthrinse must not only reduce plaque but also have a therapeutic effect.

Currently; long-term antibiotic therapy like, 6-month studies support only the use of mouthrinses containing 0.12% chlorhexidine gluconate or the “essential oils” (phenolic compounds – thymol, menthol, eucalyptol, methyl salicylate) to reduce plaque and gingivitis. These mouthrinses are available to consumers through a variety of manufacturers. These mouthrinses must be used appropriately usually a 30-second rinse twice daily to be effective These rinses have an alcohol vehicle ranging from 17% to 26.7%.

What Are Other Periodontal Conditions That May Require Chemotherapeutic Treatment along with Antibiotic therapy ?

• Vesiculobullous diseases

— Benign mucous membrane (pemphigous)

— Lichen planus

— Pemphigus vulgaris

• Viral infections

— Herpes simplex

— Human immunodeficiency virus

As defined in the Glossary of Periodontal Terms, occlusal trauma is the functional loading of teeth (force is primary etiologic factor), usually off-axis, that is of sufficient magnitude (excess of the adaptive capacity) to induce changes to the teeth (eg, fractures, occlusal wear) or supporting structures (inflammation in the periodontal ligament and alveolar bone, also known as the lesion of trauma from occlusion). The changes may be temporary (reversible) or permanent (irreversible).

What is Adaptive Capacity? What Factors Affect the Adaptive Capacity?

Adaptive capacity is the ability of the teeth and tissues of the periodontium to sustain the effects of, or adapt to, forces acting on the periodontium without injury. The adaptive capacity is affected quantitatively and qualitatively by local and systemic contributing factors. When it is exceeded, occlusal traumatism occurs.

The etiologic forces that produce occlusal traumatism may not always be occlusal in nature, but they may be generated by orthodontic or prosthodontic appliances and/or habits of compulsion, such as pipe smoking or lingernail biting. The more inclusive designation, periodontal trauma tism, is preferred by some over occlusal traumatism because it allows for nonocclusal forces and ocolusal forces as etiologic factors.

What Is the Nature of the Injury to the Periodontal Attachment Apparatus Produced by Forces Acting on Teeth? What Is Primary Occlusal Trauma and Secondary Occlusal Trauma?

The injury to the periodontium caused by forces acting on teeth is called the lesion of trauma from occlusion or more simply, occlusal trauma.

• The lesion of occlusal trauma is located within the periodontal ligament in areas where the ligament is either under pressure (crushed) or under tension (torn). The crush or tear produces a physical injury resulting in local necrosis of the periodontal ligament and a typical inflammatory response. The histologic appearance of the periodontal ligament is described as hyalinization, or a decrease in the cellular component of the tissue. Resorption of nearby alveolar bone also occurs as an outcome of the inflammation. The resorption will occur on the periodontal ligament side of the alveolar bone proper with mild injury (frontal resorption) and/or on the marrow surfaces of the supporting alveolar bone (rear resorption). The degree of necrosis, inflammation, and resorption will depend upon the amount of force acting on the teeth and the adaptive capacity of the periodontium.

• Primary occlusal trauma is the injury resulting in tissue changes (injury to the attachment apparatus) from excessive (in excess of the normal adaptive capacity of the periodontium) occlusal (and other) forces to a tooth or teeth with a healthy, anatomically normal, periodontium in a systemically well patient. Primary occlusal trauma is usually reversible once the forces that produced it are controlled.

• Secondary occlusal trauma is the injury resulting in tissue changes (injury to the attachment apparatus) from normal or excessive (in excess of the reduced adaptive capacity of the periodontium) occlusal (and other) forces to a tooth or teeth with reduced support. Because these same contributing factors that reduced the adaptive capacity of the periodontium may be difficult to control or change, secondary occlusal trauma is difficult to reverse following force control.

Does the Injury in the Periodontium Produced by occlusal trauma on Teeth Contribute in Any Way to Periodontal Attachment Loss?

The marginal inflammatory lesion of periodontitis and the lesion of occlusal trauma were believed to be separate processes. However, it has been hypothesized that the two processes become co-destructive in the transseptal and alveolar crestal fiber region of the marginal periodontium. The suggestion that the marginal inflammation of periodontitis could be then spread into the periodontal ligament along fiber realignment caused by occlusal forces was supported in animal studies. This concept of periodontal pathogenesis conflicted critically with the classic periodontitis model where marginal inflammation was depicted as following perivascular connecfive tissue directly into alveolar bone marrow, and where the periodontal ligament was typically free of inflammation. The projected outcome of this “co-destructive” process was the formation of angular bony defects and infrabony pockets seen commonly in periodontitis.

Studies in both animals and humans have not been able to completely demonstrate the role of occlusal trauma in periodontitis. While it is unclear whether potentially destructive occiusal contacts have any impact on the severity of periodontitis, there is agreement that two of the recognized signs of occlusal trauma (eg, mobility and widened PDL spaces) are associated with greater amounts of attachment loss, pocket depth, and bone loss.

What Are the Clinical Signs and Symptoms of Occlusal Trauma?

The clinical signs and symptoms of injury in the periodontal ligament are commonly:

1. Pain or discomfort around one or more teeth on percussion, function,and/or parafunction. Pain is one of the four cardinal signs of inflammation (dolor/pain, calor/heat, rubor/redness, and tumor/swelling). Pain then is a sign of inflammation in the periodontal ligament.

2. Tooth mobility as determined with bidigital manipulation of teeth using the handles of 2 hand instruments. One handle is placed on the buccal surface and the other is placed on the lingual surface of clinical crowns. Tooth mobility is defined as visibly perceptible movement of a tooth away from its normal position when a light force is applied.

Tooth mobility may be physiologic (ie, horizontal movement limited to the width of the periodontal ligament), or pathologic (ie, horizontal and/or vertical movement beyond the expected boundaries of the periodontal ligament). Mobility occurs when fibers of the periodontal ligament are injured or destroyed by inflammation resulting from excessive forces acting on teeth. It will also occur when the adaptive capacity of the periodontium has been altered by marginal inflammation or systemic disease. Mobility is commonly observed when a tooth has reduced periodontal attachment.

The Miller classification scheme for tooth mobility in occlusal trauma  is as follows:

- Grade (degree) I. The slightest distinguishable movement in a horizontal direction. Tooth mobility is classified as physiologic mobility.

- Grade (degree) II. Movement in a horizontal direction of a tooth within 1 mm of its normal position.

- Grade (degree) Ill. Movement of a tooth in a horizontal direction greater than 1 mm from its normal position. Grade Ill mobility also includes teeth that are depressible and/or can be rotated in their periodontal support.

3. Fremitus as determined by palpable or visible movement of teeth under vertical (axial) or horizontal (nonaxial) occlusal forces. Fremitus is detected using fingertips placed on the crowns of teeth while the patient occludes. Fremitus is functional mobility.

4. Pathologic migration of teeth. Pathologic migration of teeth usually occurs when teeth have lost their normal periodontal support due to periodontitis and subsequently migrate from their normal position in the dentition in response to occlusal and nonocclusal forces.

5. Tooth loss

6. Posterior bite collapse. Posterior bite collapse is the product of tooth loss and pathologic migration.

7. Widened periodontal ligament spaces around affected teeth in radiographs. Widened periodontal ligament (POL) spaces usually indicate that an adaptive response has occurred either to excessive force on a normal periodontium or to normal or excessive forces on a reduced periodontium. Widened PDL spaces together with an intact laminadura suggest that repair occurred following injury.

What Is the Basis for Force Control and Occlusal Therapy in Occlusal trauma?

The essence of occlusal therapy is to treat the lesion of trauma from occlusal trauma and to create an environment that will allow the injured attachment apparatus to repair itself within the limits imposed by the adaptive capacity of the host. It is not a form of therapy for periodontitis. There is some evidence to suggest that periodontitis patients who receive periodontal inflammatory disease control therapy along with ocdusal adjustment will display minor (<1 mm) gains in attachment compared to those who did not receive occlusal adjustment.

Repair to the attachment apparatus will depend directly upon the effectiveness of force control and indirectly upon the effectiveness of improvements in the adaptive capacity before force control (ie, control of marginal inflammation and control of diabetes mellitus).

What Are the Components of a Force Control Treatment Plan for a Periodontal Patient? What Determines Which Component Is Appropriate in a Given Case? How Are the Components Sequenced?

A typical force control treatment plan for a patient with the diagnosis of generalized moderate chronic periodontitis with occlusal traumatism would be:

Re-evaluation of inflammatory disease control in occlusal trauma . After a minimum of 4-6 weeks (the time for repair of the dentogingival junction), the patient is re-examined and the results of that examination are compared with those recorded at the initial examination. This is a critical stage in treatment as decisions about the working diagnosis and continuing active therapy are made depending upon the answers to the following questions:

1. Are there any persistent signs and symptoms of gingival inflammation or debris present?

2. If so, is there anything short of periodontal surgery that can be done to improve the conditions?

3. Is there any residual tooth mobility/fremitus?

If the answer to the first and second question is no and the answer to the third question is yes, the patients working diagnosis of generalized moderate ohronio periodontitis with occlusal trauma is supported, and treatment should proceed to the occlusal therapy phase.

If, however, the answer to the first and seoond question is yes, then considerations for improving the patients oral hygiene, refining scaling and root planing, instituting antimicrobial therapy, additional Correction of plaque retentive factors, and discussions concerning progress made in smoking cessation might be appropriate.

Assuming that the answers to the first and second questions are no and the answer to the third question is yes, the next step in treatment is to determine what is responsible for the mobility and fremitus.

• Assessment of parafunctional occlusal habits of compulsion in occlusal trauma .

Check this video on Occlusal Trauma and its effect on teeth!!

Calculus removal. Both hand- and power-driven instruments have limited utility in calculus removal from periodontal pockets. As a guideline, calculus removal becomes progressively more inefficient in sites with probing depths greater than 3 mm, and the limit of any effective instrumentation occurs in probing depths over 6 mm. These reports support the notion that closed (nonsurgical) access for scaling and root planing in pockets less than 3 mm may be as effective as open (surgical) access. When probing depths are greater than 6 mm, residual calculus is inevitable. These sites will require surgical access for effective root debridement.

The limitations in achieving the goals and objectives of  root planing may be a function of either:

• Probing depth at the time of instrumentation

• The method of access to root surfaces (eg, surgical versus nonsurgical)

• Root grooves and concavities

Furcation involvements

• Technical ability of the operator

Root planing

Root planing will reduce the biomass of pathogenic bacteria and calculus in periodontal pockets. The reduction in bacterial load will allow improved periodontal health in most cases of chronic periodontitis. Mild cases of periodontitis may not require additional surgical therapy. In more advanced cases, repeat sessions of scaling and root planing are not indicated, as they probably will not improve soft tissue health beyond that achieved by one or two sessions of therapy. Still, where surgery is indicated, presurgical scaling and root planing will improve tissue health and enhance surgical outcomes.

Removal of disease affected cementum. The cementum of the coronal third of the root ranges from 10-150 tm. It is thinnest nearest the cementoenamel junction and becomes progressively thicker toward the root apex. Because it is thin and is readily accessible to instrumentation, all cervical cementum is usually removed in 1-4 strokes of a curette. In advanced cases of periodontitis that involve the thicker cementum at the mid-root, and where clinical access may be reduced by deeper pocket depths or root anatomy, the removal of cementum is predictably less complete. Other factors that affect the amount of tooth structure removed during scaling and root planing are the forces applied at the working end of the instrument and the number of strokes with an instrument against a given root surface. Ultrasonic instruments remove less tooth structure than do hand curettes.

Both hand curettes and power-driven instruments used for root planing  remove affected cementum containing endotoxin. Curettes are more effective than ultrasonic instruments in removing endotoxin from root surfaces, and under ideal conditions, hand curettes are capable of rendering root surfaces previously in contact with diseased periodontal tissues totally free of endotoxin.

Decreased probing depths and gains in periodontal attachment. As a general rule, subgingival scaling and root planing with hand- and/or power-driven instruments will yield decreases in probing depths and, in most cases, gain in periodontal attachment. Deeper periodontitis sites are more likely to gain attachment than shallow sites, and there does not seem to be a limit to pocket depth where these effects will not be observed to one degree or another. These changes usually occur within the first month following treatment and can be maintained with good oral hygiene and monthly supragingival cleanings for up to three months.

What Is Meant by Critical Probing Depth?

The downside of  root planing is the observation that a loss of clinical attachment will invariably occur when shallow pockets are mechanically instrumented. Concepts of critical probing depths have emerged as decision-making guidelines for nonsurgical and surgical periodontal therapy. Scaling and root planing initial probing depths 2.9 mm will result in a net loss of periodontal attachment while performing the same procedures on pockets >2.9 mm will result in a net gain in periodontal attachment. Similarly, the critical probing depth for surgical treatment is 4.2 mm.

Judicious instrumentation to control inadvertent tissue injury is appropriate in shallow periodontal pockets during root planing . Since the injury produced by instrumentation is a painful blunt tearing of the tissues of the dentogingival junction, the use of local anesthesia for patient comfort should be avoided to minimize unwanted soft-tissue injury. Local anesthesia should be reserved for periodontitis cases where deep pockets (>6 mm) are the rule and where instrument efficiency and effectiveness is limited.

Reduce the load of pathogenic bacteria. Visual clinical measures of supragingival plaque accumulation on teeth are usually affected most by supragingival instrumentation and oral hygiene practices by the patient. Subgingival instrumentation is not a requirement for changes in visual measures. Subgingival scaling and root planing are effective in reducing the number of bacterial morphotypes associated with inflammatory disease (motile rods and spirochetes) as seen in dark- field or phase contrast microscopy. Hand, sonic, and ultrasonic instrumentation appear to be equally effective in producing these changes and in creating an environment where morphotypes associated with periodontal health (nonmotile cocci and rods) will predominate. However, these changes are not permanent, and the proportions of pocket bacterial rnorphotypes will return baseline levels in 2-3 months. Frequent professionally performed supragingival debridements will have little effect on this trend. It is clear that aibgingival instrumentation is a critical guideline in achieving the clinical goals and objectives of  root planing.

The requirement for the elimination of periodontal pathogens does not appear to be absolute as clinical improvements in plaque levels, inflammation, probing depths, and attachment levels may be achieved with scaling and root planing when pathogens are reduced, but not necessarily eradicated. The observations that the goals and objectives of scaling and root planing can be achieved by only reducing the numbers of periodontal pathogens supports the notion that a critical mass of pathogenic bacteria are required before the host becomes susceptible to periodontal diseases.

Control gingival inflammation. Scaling and root planing will predictably reduce gingival inflammation. As it has been with other clinical measures of successful scaling and root planing, the instrumentation must be subgingival to achieve this outcome. Hand, sonic, and ultrasonic instruments appear to be equally effective in reducing gingival inflammation

What Is Soft Tissue Management (STM)?

In its broadest sense, STM refers to local mechanical and chemotherapeutic approaches to improving and controlling periodontal health. As such, oral hygiene instructions, the use of antimicrobial agents as mouthrinses or crevicular irrigants, subgingival scaling and root planing with hand- and power- driven instruments, correcting unserviceable dental restorations, and supragingival coronal polishing are important elements of STM. STM bears striking resemblance to the typical initial therapy periodontal treatment plans that have been used successfully for inflammatory periodontal disease control and that are included in the Parameters of Care. STM should be limited to the management of gingivitis and slight periodontitis with <2 mm of clinical attachment loss where bacterial deposits on teeth are usually accessible and can be removed efficiently and effectively.

 Root concavities, root grooves, furcation invasions, and other anatomical factors that could affect the completeness of debridement are usually not an issue in these cases. Moderate periodontitis (3 or 4 mm of clinical attachment loss) and severe periodontitis ( 5 mm clinical attachment loss) cases should be considered for referral to a periodontist where issues of force control, surgical access, pocket elimination, regeneration of lost attachment, and gingival augmentation can be addressed by clinicians trained and experienced in the management of advanced periodontitis.

Chairside diagnostic instruments that measure volatile sulfur compounds, periodontal pocket temperatures, and the motility of pocket bacteria have been used in patient education STM. These methods are not described in the Glossary of Periodontal Terms nor are they included in the Parameters of Care.

Scaling and root planing are fundamental procedures in nonsurgical periodontal therapy. The target of scaling and root planing is the removal of subgingival bacteria and the removal of affected cementum. The effectiveness of scaling and root planing is limited by root anatomy, pocket depths, the skill and experience of the provider, and the overall systemic health of the patient. The outcomes of scaling and root planing include lowered plaque scores, reduced gingival bleeding scores, gain in periodontal attachment, gingival recession, and reductions in probing depths. Instrumentation of root surfaces must be subgingival in order to achieve these results.

In mild and some moderate chronic periodontitis cases, the clinical outcomes of scaling and root planing may preclude the need for periodontal surgery.

Check the video below on Root Planing:

Oral hygiene and local antimicrobial procedures, the removal of iatrogenic factors, occlusal therapy, and systemic antibiotic procedures are not invasive and, therefore, conform to nonsurgical concepts.

The term surgical treatment is reserved for those periodontal procedures that are performed in a deliberately open environment where incisions are made, periodontal soft tissue is elevated to expose tooth roots and alveolar bone, and the soft tissue is either replaced or repositioned over the roots and bone. During surgical access, resective or regenerative procedures may be performed on the bony defects produced by periodontitis.

SCALING AND ROOT PLANING

Scaling and root planing are the cornerstones of almost all initial therapy treatment plans for periodontitis and may be the only mechanical therapy required for the management of mild (1-2 mm clinical attachment loss) chronic periodontits. While scaling and root planing procedures are utilized routinely, they remain among the most technically demanding procedures performed in periodontics. When performed with optimal access and skill, scaling and root planing will produce a decrease in gingival inflammation, a reduction in periodontal probing depths, and a gain in periodontal attachment. With less than optimal access and skill, the out comes from scaling and root planing will, by extension, be less than optimal.

What Is Scaling and Root Planing? What Are the Goals and Objectives of Scaling and Root Planing?

Scaling and root planing are two technically similar periodontal procedures. Both involve the mechanical application of hand- and/or power-driven instruments to tooth surfaces to remove plaque, stain, and calculus. Clinically, it is frequently difficult to separate one from the other. Scaling may be performed on either coronal or radicular surfaces in periodontitle cases, but in gingivitis cases, scaling should be limited to coronal surfaces. Root planing is only performed on root surfaces that have been denuded of periodontal attachments . In addition to the removal of plaque, stain, and calculus, it also includes the removal of diseased cementum containing imbedded calculus, and toxic bacterial debris such as endotoxin.

The goals and objectives of scaling and root planing are both technical and biologic. The technical goals and objectives of scaling and root planing (the mindset of the clinician at the time), are to produce hard, smooth tooth surfaces free of calculus and cementum affected with endotoxin and/or other bacterial contaminants. In the process, the bacterial load adjacent to periodontal tissues is reduced.

The biologic goals and objectives of scaling and root planing are to produce a tooth surface and sulcular ecosystem that is biocompatible with periodontal epithelial cell and connective tissue adhesion. Decreases in gingival inflammation, reductions in periodontal probing depths, the presence of Gram- positive beneficial bacterial species, and gains in periodontal attachment are the outcomes by which effective scaling and root planing are measured.

What Is Disease-Affected Cementum? What Is Endotoxin and Where Does it Come From?

Disease-affected cementum is cementum that has been stripped of periodontal attachment by periodontitis and has been exposed to the septic contents of the periodontal pocket. It contains remnants of embedded calculus, whole bacteria, and the products of microbial life. The most studied of these is bacterial endotoxin. Endotoxin and whole bacteria may be found as deep as 12 microns beneath the cemental surface.

Endotoxin is the lipopolysaccharide component of the outer membrane of Gram-negative cell walls. It is exported as membrane vesicles during the lifespan of most Gram-negative bacteria. The biologic activity of endotoxin includes attraction of inflammatory cells, activation of the complement system, stimulation of bone resorption, fibroblast cytotoxicity, pyrogenicity, and mitogenic activity with B-lymphocytes. Endotoxin will produce a severe local inflammatory reaction when injected experimentally in tissue.

What Are the Instruments Used in Scaling and Root Planing? What Techniques Are Employed?

Calculus detection and removal are learned skills that gradually improve with experience. Exquisite tactile sensitivity, mediated by hand, sonic, and ultrasonic instruments is essential. Correct instrumentation is then an essential prerequisite to detection and removal. There are many different instruments specifically designed for scaling and root planing, and there are probably as many personal preferences for instruments as there are instruments. The following is a guide to the four general categories of instruments used in scaling and root planing.

Periodontal probes and explorers are used to detect calculus deposits. Probes will also confirm that deposits have been removed and that the roots have been planed to hard and smooth surfaces. The ultralight Motfitt-Maryland periodontal probe with Williams markings is an excellent choice for subgingival calculus detection. The 3A curved explorer or the Nabers furcation probe may also be used for calculus detection and are particularly helpful in root concavities or furcation invasions.

Scalers are the instruments of choice for Scaling and root planing. Scalers have a bulky working end and a rigid shank. Both tend to limit their tactile sensitivity. In cross section, the most popular scalers (sickle scalers) have a triangle shaped blade with 2 opposed cutting edges. Scalers should not be used in deep (>4 mm) pockets so as to minimize injury to gingival tissues.

Hoes and files belong with scalers as instruments whose cutting edges are designed to function at right angles to the tooth surface and they should be used almost exclusively for heavy supragingival deposit removal. Frequently, calculus removal with scalers, hoes, and files will be incomplete, and more delicate instruments with greater tactile sensitivity and access capability will be required to remove residual deposits and smooth cementum or dentin. Scalers, hoes, and files are used with a vertical pull-type stroke.

Curettes are the instruments of choice for scaling and root planing. They are generally smaller than scalers and are designed to permit a traumatic entry to the subgingival space. The tactile sensitivity of most curettes is greater than scalers and, as such, curettes are well suited for subgingival calculus detection, calculus removal, and root planing. Area specific curettes (Gracey and Goldman-Fox) have a single cutting edge at 60° to the root surface and are designed to instrument specific tooth surfaces in specific regions of the mouth. For example, the Gracey 13/14 is designed to instrument the distal surfaces of molar and premolar teeth, while the Gracey 9/10 is designed to instrument the buccal or lingual surfaces of the same posterior teeth. Gracey curettes have been modified for improved access and reduced tissue injury. Universal curettes (Crane- Kaplan 6, McCalls 17s/1 8s, Columbia 4R/4L) have 2 culling edges at 90° to the root surface and may be used in any region of the mouth. Curettes may be used with vertical, oblique, horizontal, or circumferential pull-type strokes.

What Are Power-Driven Scalers? How Are They Used for Scaling and root planing ?

Power-driven scalers are usually used to provide a rapid calculus and stain removal with a minimum of discomfort to the patient or trauma to hard or soft tissues. Power-driven scalers use either ultrasonic or sonic energy for debridement.

Ultrasonic instruments use either magnetostrictive or piezoelectric technology to convert electrical energy to physical energy at the instrument tip for scaling and root planing . Instrument tips vibrate from 25,000-40,000 cycles per second at an amplitude between 10-30 pm. The heat generated by magnetostrictive instruments requires copious amounts of water for cooling. In the cooling process, water cavitation (similar to the effect produced by a propeller in water) occurs which releases dissolved gases. The resulting spray, along with the water itself facilitates the removal of dislodged debris. Recent advances in ultrasonic instrument design, such as thinner ultrasonic tips, have improved access in deep pockets and provide subgingival delivery of antimicrobial agents.

Sonic instruments are classified as air-turbine instruments. They use the air pressure from high-speed handpiece lines to produce tip vibrations from 2,000-6,000 cycles per second.

Power-driven instruments may be used  for scaling and root planing in both supragingival arid sutigingival areas. It is recommended that the instrument be kept adequately cooled, that the instruments be kept in constant motion, and that the side (not the tip) of the instrument be used against tooth structure at all times. Many ultrasonic units may be used with a variety of irrigants such as chlorhexidine or povidone-iodine.

Are There Any Medical Risks to the Patient and or the Provider When Power-Driven Instruments Are Used to Scaling and root planing?

Magnetostrictive ultrasonic instruments may de-program some cardiac pacemakers. As it is not in the province of dental health professionals to decide whether or not a patient with a cardiac pacemaker may be at such a risk, it is recommended that a medical consultation be obtained before magnetostrictive ultrasonic instrumentation is performed.

Cultivable oral bacteria are present in aerosols created by sonic and ultrasonic instruments, and there seems to be no difference in the number of colony-forming units produced from aerosols generated by magnetostrictive, piezoelectric, or turbine driven instruments. Antimicrobial mouthrinses before power-driven instrumentation will reduce the number of cultivable bacteria in aerosols.

It is beyond the intended scope of this manual to describe the technical aspects of scaling and root planing. It is recommended that the reader consult one of the textbooks devoted to the subject listed in the Selected Readings section.

How Do Power-Driven Instruments Perform When Compared to Conventional Hand Instruments for Scaling and root planing ?

Comparison studies of the performance of power-driven instruments with hand instruments on extracted teeth have produced equivocal data. Both are partially effective in removing calculus and cementum while scaling and root planing . Tests on extracted teeth suggest that both methods are equally effective in removing debris from teeth, but that hand instruments alone, or following power-driven instrumentation, produced the smoothest tooth surface. Other reports have presented contrasting data indicating the superiority of power-driven instruments in producing smooth tooth surfaces while scaling and root planing.

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Maintenance of Periodontal health

What Are the Components of the Periodontal Health Visit?

The basic periodontal health maintenance appointment should have the following components:

• Update and review the medical history – This aspect is particularly important related to the onset of Type 2 diabetes mellitus in adult patients, and changes in patient medications, both prescribed and self-administered. Queries to the patient must take more than one form, for simply asking the question; Has anything related to your health changed since your last visit with us? this may not garner the necessary information. Asking patients to list their current medications, whether or not they are continuing to take previously reported medications, and inquiring about recent visits to the physician may all elicit more meaningful answers.
• Update the dental history – This review may seem unnecessary for the patient being treated solely in one office. Unfortunately, for whatever reason, some recommended treatment may not have been completed and a periodic review of patient treatment will uncover any incomplete treatment needs. The patient who sees both a generalist and a specialist or specialists must update his/her dental history to acknowledge the following, or decide not to follow treatment recommendations for good periodontal health.
• Extraoral and intraoral hard and soft tissue examinations – This step will uncover any clinically evident hard and soft tissue lesions that may require some follow-up attention.
• Dental examination – This step will reveal clinically evident decay and/or restorations that have outlived their usefulness.
• Periodontal evaluation – This step includes review of oral hygiene effectiveness (best accomplished before plaque and calculus is removed), marginal inflammatory control as demonstrated by bleeding on gentle skimming, and reduction or maintenance of probe depths. Use of the Periodontal Screening and Recording (PSR) system may simplify documentation of this review.
• Radiographic review – Review of existing radiographs can corroborate clinical findings and the decision for new radiographs may be made. Vertical bitewing films should be exposed for patients with posterior interproximal bone loss.
• Removal of supra- and subgingival plaque
• Scaling and root planning where indicated
• Polishing the teeth – Selective polishing, using a rubber cup and abrasive prophylaxis paste only where plaque and stain are evident, has been advocated to maintain tooth structure, particularly the fluoride-rich layer of enamel on the surface of the crown. An air abrasive type of polishing unit may be used as long as the abrasive stream is not directed onto root surfaces or composite resin restorations.
• Topical fluoride application – This step helps to restore the fluoride-rich surface that may have been removed during the polishing step.
• Final oral hygiene instructions and the dispensing of appropriate personal hygiene implements

How Is the Patient’s Periodontal Health Maintenance Interval Determined?

The Periodontal Health maintenance interval should be determined on an individual basis. Among the factors to be considered are the initial level of disease, the aggressiveness of the attachment loss, the patient is response to therapy, the patient is ability to perform effective plaque control, and the post-treatment stability of gingival inflammation and attachment levels. Maintenance intervals may be as short as 1-2 months, up to about 6 months between appointments. Patients who have already demonstrated a susceptibility for attachment loss should be seen no less often than every 4 months.

How Compliant Is the Average Periodontal Patient?

One study suggests that only about 16% of patients receiving periodontal therapy comply with recommended periodontal health maintenance intervals. Other studies have demonstrated a similar lack of compliance. Behavior modification is difficult even when the patient is faced with a life-threatening disease. There are many factors contributing to a lack of compliance including:

• Denial and negligent attitude towards own health

• Acknowledging the problem means the patient must participate in his own care

• Many patients want the dental profession to take responsibility for and fix their problems

• Compliance decreases as treatment time or the complexity of the required behavioral change increases

Several steps to improve patient compliance have been proposed:

• Simplify behavioral change

• Accommodate the patient

• Remind patients of appointments

• Keep compliance records

• Inform the patient about the necessity for and consistency of keeping maintenance appointments

• Provide positive reinforcement

• Ensure the dentists involvement

What Type of Biological Modulation May Be Used to Control Recurrent Periodontal Disease in the periodontal health Maintenance Patient?

Maintaining stable post-treatment attachment levels may be difficult. There are several approaches to treating new areas of attachment loss or to prevent new attachment loss. In situations where the attachment loss is localized, local delivery of antibiotics or antimicrobial agents such as doxycyline, minocycline, or chlorhexidine is possible. For situations where new attachment loss may be more widespread, the use of systemic antibiotic therapy may be warranted.

Systemic administration of a subantimicrobial dose of doxycycline (SDD) has been advocated to help prevent attachment loss. SDD has been shown to stabilize the activity of collagenase and other matrix metalloproteinases and therefore slow down the destructive inflammatory process. Initial clinical studies to receive U.S. Food and Drug Administration approval were of 9 months duration. There is minimal evidence of the effect of SDD over longer time periods, It has been suggested that SDD thay be effective in controlling other collagenase-based inflammatory disorders.

When Should a Patient Be Comprehensively Retreated for Recurring Periodontal Disease?

There are no clear-cut guidelines as to when a patient should re-enter comprehensive periodontal treatment. Fortunately, in most cases, only localized sites remain a problem. One rule of thumb would be that if the patients recurrent problems cannot be addressed in 2-3 appointments, consideration should be given toward a new round of comprehensive therapy. In addition, a patient who has recently completed surgical therapy but continues to have difficulty should be treated with alternative therapies, such as antibiotics, and further control of risk factors, with additional surgical therapy held in abeyance.

When Should a Patient Be Referred for Specialty periodontal health Care?

The decision on when to refer a patient for specialty care must be made between the general practitioner and patient, with the periodontist available to provide the necessary treatment. In general, most periodontists prefer to treat the patient from the beginning of initial therapy through advanced therapy. In certain situations, particularly when the general practitioners office can provide high quality initial therapy or when there is a questionable need for referral, the patient may be referred for specialty care after the results of initial therapy have been evaluated.

This arrangement should be worked out in advance as it is uncomfortable for both the patient and periodontist if additional initial therapy is recommended by the specialist. In most cases, third party carriers will not provide benefits for this additional treatment. This situation also begs the question in the patients mind as to the quality of the care received in the generalists office. Effective communication between the general dentist and periodontist is paramount to a clear understanding of the overall course of the patients treatment.

Check this video to know about periodontal health!!

A patient must be able to control the etiologic agents of both caries and periodontal disease on a daily basis for therapy to be successful so as to have Prevention of Periodontal Disease. As plaque can reorganize on the teeth and subgingivally within 24 hours, daily plaque removal is essential.

prevention of periodontal disease

What Are the Components of Personal Plaque Control in Prevention of Periodontal Disease?

Personal plaque control consists predominantly of the mechanical disruption of plaque on the facial, lingual, and interproximal surfaces of the teeth. This disruption may be achieved using a manual toothbrush, powered toothbrush, floss, interdental brush, specialized brushes, and other instruments. Antimicrobial agents such as chlorhexidine or the essential oils may be used as adjuncts to mechanical plaque removal.

What Methods of Tooth brushing May Be Recommended to a Patient?

The toothbrush can remove plaque on accessible surfaces to have Prevention of Periodontal Disease. No matter what tooth brushing method is chosen, the manual toothbrush should have soft nylon bristles and a small head, either a child’s size brush or a size 20 or the equivalent. A smaller brush head allows the brush to be properly adapted to the irregularities of tooth anatomy and arrangement. A smaller head also lessens the potential for activating the gag reflex and may reach posterior surfaces more comfortably and effectively than a larger headed brush. For use in delicate areas, the bristles may be softened by running the brush head under hot water before use.

There are many toothbrush designs available today. Each brush manufacturer presents claims why that particular brush is superior to others. In reality, brushes of many different designs will effectively remove plaque when used properly and thus Prevention of Periodontal Disease from occuring.

Bass Method for Prevention of Periodontal Disease

The bristles of the toothbrush are placed at a 45 angle to the tooth surface at the gingival margin, trying to get the bristles into the gingival sulcus. The brush is then moved in short back-and-forth motions for about 20 strokes. The brush head is then moved around the arch, both on the facial and lingual surfaces. The occlusal surfaces are cleaned by manipulating the bristle ends into the pits and fissures of the tooth crown. This is the currently preferred method of manual brushing.

Other Methods:

Modified Stiliman Method for Prevention of Periodontal Disease

The brush bristles are resting partially on the cervical area of the teeth and partially on the gingiva pointing toward the gingival margin. Pressure is applied to the brush to cause the gingiva to blanch. The brush head is then moved in short back-and-forth strokes with the brush moving coronally at the same time. The sides of the bristles, instead of the bristle tips, are used to disrupt the plaque. This method is classified as a roll technique.

Charters’ Method for Prevention of Periodontal Disease

The brush is placed against the surface of the teeth with the bristles pointing away from the gingival margin. The back-and-forth motion is a massaging stroke for the gingiva. This method may be used for gentle plaque removal.

What Methods of Inter-proximal Cleaning May Be Recommended to a Patient?

For the patient with no or minimal attachment loss, flossing is the interproximal technique of choice. There is no clear-cut difference in effectiveness between waxed and unwaxed floss. It should be stressed to the patient that floss be used in an up-and-down motion, not in a shoeshine motion. Many patients will revert to improper technique even after proper instruction. Dental tape, basically a wider version of floss, may also be used for Prevention of Periodontal Disease.

Once attachment loss has occurred and root concavities are accessible, floss loses its effectiveness. Interproximal brushes, toothpicks, and rubber tips may be used in these circumstances. With moderate to severe attachment loss, a manual brush and an interproximal brush will outperform the manual brush and floss in plaque removal.

Interproximal brushes may be cylindrical or conical in shape. The advantage of an interproximal brush is that the bristles may be worked into root concavities and furcation areas exposed by attachment loss. The interdental brush should be used in both a back-and-forth and rotary motion to ensure maximum adaptability of the bristles. The brush should be used from both a facial and lingual or palatal approach to remove all plaque for Prevention of Periodontal Disease.

The end-tuft brush may be used on interproximal surfaces where there is no adjacent tooth and on the distal areas of the most posterior teeth. With a bend in the handle and tapered bristles, the end-tuft brush fits almost perfectly in the distal furcation of the most posterior maxillary molar.

What Role do Powered Toothbrushes Have on Personal Plaque Control?

It has been demonstrated that powered toothbrushes remove more plaque than manual toothbrushing alone for Prevention of Periodontal Disease, when both are used properly. There is no evidence to suggest that the use of a powered brush alone is as effective as appropriate manual brushing along with appropriate interproximal cleaning with floss or an interproximal brush.

Powered brushes may be useful as a motivational tool to assist patients in cleaning their teeth on a daily basis. These brushes may also assist patients with arthritis or other debilitating conditions that make holding or manipulating a manual brush difficult or impossible. While there are several distinctive designs of powered brushes, each design has its strong points and weaknesses, but all of these brushes perform at similar levels of effectiveness for Prevention of Periodontal Disease.

What Antimicrobial Agents Can Assist in Controlling Plaque and Gingival Inflammation?

When selecting a chemotherapeutic agent, it is important to distinguish between the ability to remove plaque and substantiated evidence of a therapeutic effect for Prevention of Periodontal Disease. Many mouth rinses can reduce the amount of plaque over rinsing with water, but without a positive therapeutic effect, the justification for recommending such an agent is minimal.

To date, two basic agents have been shown to have a significant therapeutic effect on gingivitis over a 6-month period. Chlorhexidine gluconate, 0.12%, in an alcohol-containing vehicle, now available in generic as well as brand name form, and phenolic compound/essential oil-based mouth rinses can be used to help control gingivitis. Chlorhexidine kills bacteria when used for 30 seconds twice daily. Side effects include increased calculus formation, staining of teeth and restorations, and altered taste. Caution should be taken when recommending a chlorhexidine rinse for a patient with composite resin restorations for Prevention of Periodontal Disease.

The essential oils, thymol, menthol, and eucalyptol, along with methyl salicylate for flavoring, constitute the active ingredients in most phenol-based mouth rinses. These rinses also contain between 20% to 27% alcohol in the vehicle. Discretion should be taken in recommending these rinses to recovering alcoholics.

There are other mouth rinses and mouthwashes that show a therapeutic effect for periods of time shorter than the 6 months stipulated by the U.S. Food and Drug Administration for approval as a therapeutic agent. Some agents have a detergent effect to remove plaque and contain glycerin or other compounds that leave teeth feeling smooth to the tongue. These agents have not been shown to have any significant therapeutic benefit to the patient.

What Are the Ingredients in a Dentifrice Is Periodontal Therapy Successful? (Toothpaste)

Toothpaste, in conjunction with tooth-brushing, serves to keep periodontal disease away :

• Minimize plaque buildup

• Provide an anti-caries effect

• Remove stain

• Freshen breath

The ingredients found in most toothpastes for Prevention of Periodontal Disease include:

• Polishing or abrasive agent. May be silica, calcium carbonate, alumina, or other mild abrasive. The polishing agent removes stain, stained pellicle, and plaque.

• Binder or thickener. May be the alginates or carboxymethylcellulose. These binders give the toothpaste its consistency and flowability when expressed from the tube.

• Surfactant. Detergent such as sodium lauryl sulfate that foams to aid in debris removal. Detergents may also have inherent antimicrobial properties that contribute to plaque control.

• Humectant. May be glycerin, sorbitol, or polyethylene glycol. Provides moisture to the paste and keeps it from drying out, even when left exposed for short periods of time.

• Flavoring. May be spearmint, wintergreen, or peppermint. Some patients may have allergic sensitivity reactions to certain flavoring agents, particularly those with a cinnamon base.

• Active (therapeutic) ingredient. May be fluoride for caries protection, triclosan as an antiplaque agent, pyrophosphate as an anticalculus agent, potassium nitrate as a desensitizing agent, or peroxide compounds as whitening agents.

What is the American Dental Association Seal of Acceptance?

The American Dental Association (ADA) Seal of Acceptance is earned by product manufacturers after submitting their products to rigorous testing under standards defined by the ADA. As this is a costly and lengthy process, manufacturers of consumer products more often seek approval than those of professional products. This Seal may be carried on product packaging.

THERAPEUTIC ENDPOINTS

How much treatment is enough for Prevention of Periodontal Disease? The answer to that question is found in an understanding of the endpoints of therapy. These endpoints must be practical and realistic for each individual patient. Once the goals of therapy have been achieved, frequent and regular re-evaluation and periodontal maintenance become integral parts of periodontal therapy. It has been well documented that patients retain more teeth for longer periods after therapy with appropriate maintenance  than without that care.

This question goes to the core of periodontics as a discipline in dentistry. There are many studies that have proven that periodontal therapy, when appropriately executed and with good patient compliance to oral hygiene regimens and scheduled maintenance visits, can reduce tooth loss due to periodontal disease by up to 70%. In one group of treated patients with periodontal disease followed an average of 22 years, overall tooth loss was 7.1%. Occasionally, teeth will be lost in even the most compliant patient. Those few patients (<10% of the total) that fall into the extreme downhill group, may continue to lose attachment and subsequently lose teeth in spite of all efforts.

What Are the Goals of Periodontal Therapy?

The primary goal of periodontal therapy is the maintenance of the natural dentition in health and Prevention of Periodontal Disease, comfortable function, with pleasing aesthetics and satisfaction for the life of the patient. This goal persists even in the face of the expanding use and success of endosteal implants. Improvements in implant therapy have given the practitioner new treatment planning and decision-making challenges regarding the retention or removal of natural teeth. In spite of these successes, the overarching goal must still be the Prevention of Periodontal Disease and maintenance of the natural dentition when practically possible.

What Teeth Can Be Expected to Have the Greatest Longevity and Which Teeth Are Lost Most Frequently Due to Periodontal Disease?

Excluding third molars, maxillary second molars are lost most often to periodontal disease. This would be expected both due to complex root anatomy and the difficulty in performing effective oral hygiene because of the tooth location. Mandibular canines and first premolars are the teeth most likely to be retained.

What Clinical Parameters May Be Used to Judge the Success of Periodontal Therapy?

There are several clinical and radiographic parameters that may be used to judge the success of periodontal therapy, including:

Reduction or absence of bleeding on probing

Bleeding on gentle probing (25 g of force) is still the best prognostic indicator of the potential for future attachment loss. Absence of bleeding on probing is a 98% negative predictor that the site will lose attachment in the future. Conversely, approximately 30% of sites that bleed at consecutive maintenance visits over one year are at risk for future attachment loss. Since it is impossible to predict exactly which site will lose attachment, the thrust of therapy is to control inflammation at all sites for Prevention of Periodontal Disease.

Reduction of probing depth and gains in periodontal attachment

Periodontal therapy is focused on the removal of etiologic agents and contributing factors and the subsequent maintenance of health. One way to improve this possibility for both the patient and practitioner is to reduce probing depths. Greater success is achieved in creating and maintaining a plaque-free environment with shallow pockets compared to pockets greater than 5 mm in depth. Persistence of periodontal pathogens and progressive loss of attachment is associated with deeper pockets. Pocket depth may be reduced by inflammatory control achieved with initial therapy, respective surgery (eg, gingivectomy, apically positioned flap with osseous surgery), or by repair or regeneration of lost periodontal attachment.

Positive radiographic changes

Positive radio-graphic changes related to the success of periodontal therapy include the reappearance of a crestal lamina dura at the interproximal osseous crests, evidence of bone fill in areas of regenerative therapy, narrowing of the periodontal ligament space in teeth subject to occlusal trauma, and the absence of calculus on coronal and root surfaces. While radio-graphs made in clinical practice are not standardized, valuable comparisons may still be made between pretreatment and post-treatment films.

Occlusal stability

Tooth mobility is caused by the presence of edema in the gingival and periodontal tissues, loss of attachment, and the effects of occlusal forces on the attachment apparatus. After inflammatory control is completed, teeth often exhibit decreased mobility. This is due to the elimination of edema and the reformation of the supragingival connective tissue fibers that contribute to tooth stability, particularly when there has been attachment loss. Judicious occlusal adjustment by selective grinding to relieve fremitus may also contribute to increased tooth stability. Mobile teeth may be successfully maintained in a state of health. Increasing mobility or hypermobility are indicators that an occlusion remains unstable even after therapeutic intervention. Targeted occlusal therapy for Prevention of Periodontal Disease, removable or fixed splints, may be indicated in this case.

What Are the Limitations of Periodontal Therapy?

There may be significant limitations to what periodontal therapy can accomplish. First and foremost, the patient must be dedicated to a daily ritual of personal plaque control. Without this, successful treatment becomes an uphill battle. There may be limitations due to the amount of attachment loss, root anatomy, uncorrectable local or systemic factors, uncontrollable occlusal forces, mobility, and last but not least, the diagnostic acumen and skill of the clinician.

What Can Be Done for the Patient Who Fails to Respond to Periodontal Therapy?

It is important to identify those factors that may contribute to a patients continued attachment loss. Failures in therapy may be related to either diagnostic or therapeutic shortcomings. Even with accurate diagnoses and flawless treatment, the occasional patient will continue to lose attachment.

Diagnostic deficiencies in Prevention of Periodontal Disease:

• Related to health history: Undetected diabetes, immune compromise, or other systemic disorder

• Improper use, or nonuse, of the periodontal and furcation probe

• Improper radiographic examination: Particularly the use of bitewing films of less than a diagnostic quality to detect interproximal bone loss; vertical bitewing films are recommended to adequately visualize posterior interproximal bone height

• Abnormal anatomy rendering complete root detoxification impossible

• Unidentified microbes not eradicated by conventional mechanical therapy

• Undetected traumatic occlusion

• Pulpal pathosis

Therapeutic deficiencies, failure to:

• Instruct the patient adequately in plaque control

• Formulate a comprehensive treatment plan

• Control the etiological agents

• Identify and correct local contributing factors

• Treatment failures related to diagnostic deficiencies

• Select proper of therapeutic modalities

• Execute proper initial therapy with adequate follow-up

• Provide adequate surgical techniques

• Utilize an effective maintenance program

How is Prognosis Determined?

Patients are extremely interested in whether or not the proposed treatment is going to be effective, It would be beneficial for clinicians to give their patients a reasonably accurate prediction of treatment success. Unfortunately, prognostic acumen is limited. Except for those teeth that originally have a good prognosis, projections were ineffective at projecting the fate of teeth, accuracy in predicting was in about the 40% range. Initial mobility, increasing mobility, and smoking were seen as factors negatively affecting prognosis.

Check out the video on Prevention of Periodontal Disease:

The gum infection symptoms are either clearly visible or sometimes they are hidden and do not appear unless the infection spreads and becomes severe. The gums tend to get infected due to poor oral hygiene or because of improper maintainence of the dental health.

gum infection symptoms

In this condition, the gums become red and swollen and they begin to recede from the teeth. The gum infection symptoms include formation of bacterial layer between the teeth which causes sores and ulcers of severe kind. There is pain associated with this which can increase with the increase in infection.

The pain varies from mild gentle one to a acute and severe one. The most common complaint of pain due to this infection is described as stabbing, sharp, shooting, burning sensation and tearing kind. But sometimes the pain may not be associate with the gum infection symptoms which can also cause one to ignore the condition.

Various kinds of other reasons can also hold good for infection in the gums like deficiency of vitamins, deficiency of Iron, and other disorders like improper immune system etc. All these kinds of conditions may result in gum infection symptoms that might be an alarm to go for a quick treatment.

These symptoms are sometimes easily visible while in some cases are very hard to figure out. Infection may go unnoticed if these symptoms don’t come in our view. Generally the most severe cases of gum infections have this reason behind it.

One may also find gum disorders when suffering from high fever for a long time. Generally this is prevalent in children who have fever continuously for many days. The gums in such cases tend to change color, start to recede and the teeth become loose. Small blisters may also form, thus indicating gum infection symptoms.

There might also be puffiness of the gums that may not have any of the above symptoms. But the moment you start chewing hard things, your gums bleed. Going for bleeding gums treatment is essential because the more you let it free, the more it spreads causing every part of gums to bleed.

Bleeding gums treatment

Essential when you go for bleeding gums treatment, it is more to do with cleaning of the bacteria that may be residing in and around your teeth. It is severe infection that tends to make the gums bleed. This can be cured by slowly and gradually cleaning of the entire mouth and making it free from bacteria. It also requires proper maintenance of hygiene later on as there are high chances that the bacteria might return back.

Bleeding gums treatment also includes the precaution to be taken after the cleaning process. Generally fruits with high acidic content in it tend to irritate the already sensitive gums and teeth. Very spicy and salty food can also aggravate the condition of the infection. One must avoid eating hard or sharp food types like chips etc to avoid any stabbing of food particles into the infected gums.

If the bleeding starts instantly, try to stop it by pressing a gauze pad soaked in ice cold water. This instantly stops the bleeding. After this ensure to eat slowly and gently and avoid using regular brush to clean your teeth. Do not rush in cleaning your teeth and instead be slow and gentle. Bleeding gums treatment works only when you take these precautions.

Before trying to go for bleeding gums treatment by yourself, try to consult your dentist at least over the phone. A professionally dental doctor would give you best advice that is best for your dental health. Sometimes the advice may cut short your treatment and instead you end up at his clinic. So its better to consult a doctor before taking any step.

Lastly, do not take the condition lightly as this bleeding may become severe causing other health issues. Right step at the right time shall ensure a safe and good bleeding gums treatment thus saving you from future pain and expenses.

This disease if not treated on time, can become severe enough to put you through dental surgery bringing you pain and extensive medical expenses. Gingivitis mouthwash helps in cleaning this bacterial infection and keeping it away. This can also be used to prevent the disease from occuring.

Gingivitis mouthwash

Although there are many who try to debate on the effectiveness of gingivitis mouthwash, yet more and more number of people are beginning to use it actively. Many have even begun replacing the regular habit of brushing teeth twice daily with it. It is well known that people love to avoid brushing and would go for any alternatives present for it.

Essentially, a good gingivitis mouthwash must necessarily be free of alcohol and should have natural ingredients. So when one chooses to buy it from the market, these things should be first checked. For proper periodontal health, accurate mouthwash should be used.

Many dentists are these days recommending the use of mouthwash, along with the regular brushing and flossing. One of the main reason is because of the laziness shown by people in brushing their teeth daily. Also, gingivitis mouthwash reaches in those places where brush does not reach, thus giving a complete hygiene to your teeth and gums.

One of the main reasons to choose an alcohol free mouthwash is that alcohol tends to create dry environment and this is the best kind of environment for the bacteria to thrive. Along with that, gingivitis mouthwash having alcohol can also irritate the infected gums thus making the condition worse. This precisely why an alcohol free one is better.

One may either go for those gingivitis mouthwash that are present in the market for sale or they might opt for the homemade herbal ones. The knowledge of benefits of herbal medicine is now wide spread and indisputable. The amazing fact is that many professional dentists are recommending people to opt for herbal medicines too along with the regular main stream medicines.

Although the commercial medicines are generally safe, however there are many medicines out there that may cause severe allergic reactions on usage. Therefore, if you plan to choose the right mouthwash for yourself, ensure to know its contents.

So along with your regular brushing and flossing, start using the gingivitis mouthwash for a healthy dental life.

Although, the first answer to the question Is gingivitis contagious is a simple and big NO. But sometimes it cannot be answered in one word and may require a lengthy explanation that may justify the spreading of this condition in some cases.

Is gingivitis contagious

People might have different kinds of gingivitis condition that may vary from severe to mild inflammations. The question Is gingivitis contagious arises mostly because people close to an infected person generally tend to suffer from this condition.

There are many reasons due to which a person may get this condition. Some drugs or medications tend to swell the gums around the teeth, leaving them susceptible for the bacteria to settle down. It has been often seen that those who use heavy medications tend to get bacteria infection in the mouth.

The Is gingivitis contagious is also asked by those who live around such patients. Mostly those who are with the patient all the time tend to get such doubts. Although one may not necessarily say that such patients can be source of this disease for others, yet one cannot completely rule it out.

The answer to the question Is gingivitis contagious can be Yes in cases where the infected person might come in contact with the other people physically. For example, through saliva that is while kissing or coughing etc. However, just because the bacteria gets passed off to another person does not mean he will get the disease because this again depends on individuals respective body immunity.

Canadian scientific studies have answered Is gingivitis contagious with a Yes, showing their statistics that 30% to 70% of people tend to get infected by the bacteria passed on from the infected person. The infection level however might vary depending on immune system, as mentioned above.