Periodontal disease: treatment

and Martina Feichter, medical editor and biologist

Florian Tiefenböck studied human medicine at the LMU Munich. In March 2014, he joined as a student and has supported the editorial team with medical articles ever since. After receiving his medical license and practical work in internal medicine at the University Hospital Augsburg, he has been a permanent member of the team since December 2019 and, among other things, ensures the medical quality of the tools.

Periodontal treatment in stages

Periodontitis treatment aims to free the tooth holding apparatus from the inflammation and to prevent (further) degradation. If periodontitis is discovered early, a basic treatment for the inflammation is often sufficient. However, if this does not work or the periodontitis has progressed further, additional surgical interventions are necessary. In both cases, periodontitis patients need permanent follow-up care by the dentist.

Controlling risk factors, including smoking and diabetes, is important for successful periodontal treatment. Periodontitis patients should refrain from smoking and have existing diabetes under control with medical help.

Phase 1: basic treatment

Good oral hygiene is a prerequisite for the success of periodontal disease treatment. In comprehensive advice and instructions, the dentist (or a specially trained specialist) explains to the patient how to use the (electric) toothbrush, dental floss and interdental brushes correctly. As a demonstration, plaque is often made visible with tooth coloring tablets before the dentist removes them.

The "subgingival instrumentation" is also very important, i.e. the removal of bacterial plaque and tartar below the gumline, on the tooth necks and exposed tooth roots. One speaks here of "closed" periodontal treatment because the gums are not cut open. The dentist cleans the gingival pockets under local anesthesia, usually with thin instruments (curettes or scalers), an ultrasound device or rotating instruments. Alternatively, subgingival instrumentation with an Erbium-YAG laser can be considered.

The dentist also smooths accessible surfaces of the tooth roots to prevent bacteria from attaching again. The edges of any protruding crowns and fillings are also smoothed.

As part of the basic periodontal treatment, the patient can also opt for professional tooth cleaning (PZR): In short, the teeth are cleaned, polished and (mostly) fluoridated. Patients usually have to pay for a PZR out of their own pocket.

Possibly antibiotics

Basic treatment is often enough to stop the inflammation underlying periodontal disease. In severe cases, however, additional antibiotic therapy may be necessary. Patients are usually prescribed antibiotic tablets for this. Sometimes antibiotics are also applied locally by applying them directly into a gingival pocket as a gel or ointment. In order to select a suitable antibiotic, it can be useful to first determine which bacteria are in the patient's gum pockets using laboratory tests.

Phase 2: Surgical Interventions

Surgical periodontal treatment (previously open periodontal treatment) includes cleaning deep gum pockets, regeneration of the periodontal structures and plastic surgery to restore the gums, as required.

Cleaning of deep gum pockets

To do this, the dentist opens the pockets with a small incision under local anesthesia. This makes the areas infected with bacteria easier to access. Now the dentist cleans the exposed root areas and removes diseased tissue. Finally, he sutures the cut so that the gums are tight against the tooth again. Through this procedure the gums should adhere better and the pockets are eliminated (gingival pocket elimination).

Regeneration of the tooth support system

It becomes necessary when a long-lasting or aggressive periodontitis has already destroyed so much connective tissue and bone that the teeth lose their hold. The following methods are available, which can be used individually or in combination:

Guided tissue regeneration (GTR)

This periodontal treatment aims to stimulate new formation (regeneration) of connective tissue fibers and jawbones and thus to promote the healing process of the damaged tooth support system. To do this, the dentist places a special membrane (a kind of thin film made of material that can be broken down by the body) between the gums and bones. Its purpose is to prevent the faster growing gums from growing uncontrollably into the depths, so that the other, slower growing parts of the tooth support system (such as bones, root cement) have time and space to regenerate.

Introduction of growth agents

With this method of surgical periodontal treatment, active ingredients are applied to the cleaned root surface, which enable the formation of new bone and the regression of gingival pockets - so-called enamel matrix proteins ("growth proteins").

Insertion of bones or bone substitute materials

Bone tissue degraded by periodontitis can be at least partially rebuilt with a bone graft. The body's own bone tissue is usually used as the transplant (autologous bone transplant). The dentist takes it from the patient's back of the jaw in a small operation and transplantes it to the defective area (bone pocket).

Alternatively, demineralized, freeze-dried bone tissue from another person can be transplanted: the dentist obtains such allogeneic bone grafts from tissue banks. After all organic components have been removed, bone tissue from other species (e.g. cattle, pigs or corals) can also be transplanted (xenogeneic bone grafts). In addition, calcium phosphate and glass ceramics can serve as artificial bone substitute material.

The transplants can only improve the existing bone structure - complete regeneration has not yet been possible with them.

Regeneration of the gums

Under certain circumstances, so much gums have been destroyed as a result of periodontitis that tooth necks or tooth root sections are exposed. This has two disadvantages: On the one hand, the exposed areas on the tooth are often difficult to clean, which makes them prone to renewed inflammation and tooth decay (root caries). On the other hand, visible tooth necks and roots are an aesthetic problem for many sufferers. The gums can then be rebuilt in plastic surgery. There are two ways to do this:

free mucosal graft
Sliding flap

With a free mucosal graft, the patient's hard palate serves as donor tissue: the dentist cuts a piece of mucous membrane of the required size from the palate, then places it on the exposed tooth areas and sutures it. The wounds in the donor area usually heal well after several weeks. The graft itself heals in about four months.

For a so-called sliding flap, the dentist makes an incision in the healthy gums near the exposed tooth. He pushes the tissue flap obtained in this way onto the exposed tooth root and sews it in place. A distinction is made between lateral (laterally displaced) and coronal displacement flaps. With coronal flaps, the gums are incised below the diseased area and pulled upwards (in the lower jaw) or downwards (in the upper jaw) to the exposed teeth.

Sometimes free mucosal grafts and displacement flaps are combined to achieve more cosmetically beautiful results.

Phase 3: Aftercare

Since periodontitis is a chronic disease, good follow-up care must be required on a long-term basis - especially if the gums are already receding. Because then the tooth necks and roots are exposed and are therefore significantly more prone to caries, as they are not protected by an enamel layer - like the teeth. The aftercare consists of:

consistent oral hygiene
regular check-ups at the dentist
regular professional teeth cleaning (possibly several times a year)

Dentists often recommend their periodontal disease patients to have structured follow-up care - called "supportive periodontal therapy" (UPT). It includes check-ups at the dentist every three to a maximum of 12 months (depending on the degree of periodontitis). At these appointments, the dentist checks the success of the periodontal treatment so far, checks the oral hygiene and cleans the teeth. The elements of this structured aftercare are not paid for by the health insurance companies.

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