A periodontist is a dental specialist who treats diseases and other problems of the periodontium (gums and bone supporting and surrounding the teeth). Periodontists often see people who suffer from periodontal disease, which is an infection-based inflammation of these gum or bony tissues. Treatment could range for something as simple as gum recession around a single tooth to the complex placement of dental implants to provide anchorage for a new set of teeth.
Usually, your general dentist or dental hygienist will refer you do a periodontist for examination and treatment. A periodontist has 2-3 years of additional training in dental diagnosis and treatment, and will confer with your general dentist regarding your treatment. Together, they will offer a strategy that will attempt to help you maintain your cosmetic and chewing function.
Periodontal diseases are infections or diseases that lies outside the tooth. This involves the structures that support our teeth, and are primarily the connective fibers, gum tissues and jaw bones. Periodontal diseases are some of the oldest and most prevalent diseases today, and studies have shown that a majority of adults have at least one area in their mouths that can be classified as having periodontal disease. While an older name for periodontal disease is pyorrhea, or bleeding gums, it is important to remember that the gums are but one part of our periodontium. Periodontal disease is today a major cause for tooth loss in adults.
Periodontal diseases are not diseases in the sense that we are normally accustomed to. Periodontal diseases progress as an unchecked invasion of bacteria, which appear to us as plaque (the soft, filmy, white material coating our teeth). There are few signs or symptoms of periodontal disease, and usually no pain or discomfort. Many people only notice bleeding or puffy gums. If untreated, periodontal diseases can progress until the tooth becomes visibly loose, or until pus oozes from the spaces between the tooth and gum. Often by this time it is too late to save the tooth, and it must be extracted. Some people have in the past lost all their teeth, and never had more discomfort than a mild headache.
So what makes for periodontal disease? This is, in fact, a complicated disease which is different for each person, but there are some generalizations. A useful way to look at periodontal disease is via the three B's: Bugs, Biology and Behavior. Simply put, there is an interaction between our genetic inheritance (our biology) and the nature of bacteria inhabiting our mouths (the bugs), and our personal ability to remove the bacteria as they attempt to colonize and infect our mouths (our behavior). Let's look at these components one at a time:
Research has shown us that there is a complex interplay between the various bacterial species that contribute to periodontal disease. Not all bacteria are bad, some in fact are important to us and are required for digestion, etc. Of the more than 300 bacteria found in our mouths, only a handful are known to be pathogenic ("pathogenic" means disease-causing). These have special characteristics, but most share one common characteristic: they colonize fairly slowly, usually requiring other bacteria to colonize our teeth and gums first. Periodontists sometimes take specific bacteria samples (plaque) if we suspect that the bacteria involved are virulent, or that the person is not recovering adequately from periodontal treatment.
Our biological inheritance is mostly beyond our control, but is still important that we make some attempt to understand how our biology either predisposes us to periodontal disease or helps us to combat it. In particular, when we speak of our biological inheritance, we are concerned mostly with the function of our immune system. Most of us, even those with moderate to severe periodontal disease, may have fully functioning immune systems. There are many systemic ("systemic" means throughout the body) diseases that can affect our immune system, for example diabetes, and viral infections. Additionally, we could also have a special sensitivity to certain bacteria that could lead to periodontal diseases, while our overall immune system is healthy. Additionally, our immune system may be too energetic in removing bacteria, and can in the process actually dissolve the structures that support our teeth, or may cause us to be overly sensitive to these bacteria, in which case it is not the bacteria but our own body that causes the loss of the tissues and bone surrounding out teeth. Lastly, age does play an important role in this process, and can slow down both the response of our immune systems and the healing capacities of our body.
This is the third ingredient that makes up periodontal disease, and that which we have the most control over. This is seen as our ability to exercise adequate plaque control. The most reliable way to practice plaque control is through "mechanical" means. This means, simply by mechanically touching the plaque on our teeth with a device to remove it. To remove the bacteria, you have to touch them, with the bristles of a tooth brush, a toothpick, floss, or some other device. The key to success is to access the crown and root surfaces of the tooth where bacteria colonize. There are many surfaces and contours to teeth; if there any spaces between teeth and under the gum line which you cannot get to clean, the bacteria will be able to infect these areas freely and cause future problems. Effective plaque control is a never ending process, for as long as we have teeth, we must dedicate time daily to remove the bacteria as they colonize.
We will never be able to completely remove all bacteria, but we only need to remove enough so that our immune system can "take care" of the rest. This is especially true under the tissue surfaces, especially under the gums and around areas where the roots divide or have openings.
The majority of dental problems that we are faced with are completely avoidable. The sad fact remains, however, that even though periodontal disease is at least 90% preventable, otherwise healthy people still get it, and the resulting tooth loss is still commonplace. Crucial to the maintenance of one's teeth is effective plaque control and timely appointments at the dental office. This varies for each person, but appointment recalls of anything from 3-4 months is normal. With the idea in mind that our primary goal is to prevent disease from occurring, the recall appointments are called prophylactic appointments, or "prophies." The "prophy" is solely a preventative measure, and during this kind of "cleaning," attention is directed at the crown of the tooth, and to those spaces just under the gum line. For the healthy individual, this can be done in 30-60 minutes.
Depending on the number of spaces deeper than 4 mm, and the degree of inflammation, among other things, once the diagnosis of periodontal disease has been established it too late to use a preventative procedure. One must then abandon the prophy, and perform active treatment.
There are three basic phases of active treatment:
Root Planing is the removal of deposits from the root surface, as well as the smoothing of these surfaces. Curettage, if performed, usually starts off with root planing, but additionally requires the gently scraping of some gingival tissue to remove inflamed tissue, and tissue that may contain bacteria. Both treatments are usually performed with local anesthetic. These treatments are done on a quarter of the mouth (or quadrant) at a time, although a given dentist or hygienist can group these procedures together. There is a 4-6 week period to follow, and then the patient is re-evaluated to gauge tissue response and ability to practice effective plaque control. It is important to try to schedule these appointments together as tightly as possible.
Generally, one hopes to see an overall reduction in inflammation with less deep spaces, although may be spaces still be deeper than 4 mm. If a space is 4-5 mm but the individual can remove the bacteria successfully, this can be maintained as such, usually with a tight recall interval, say of 3-4 months. Keep in mind that the ultimate goal of maintaining dental health is the prevention of bacteria from re-colonizing the teeth and tissues. It is possible to stay healthy, even if there has been substantial loss of the bone around teeth, as long as this loss of bone does not progress further. One of the most reliable forms of feedback that both the dentist and the patient can use is the presence and severity of bleeding from the tissues. Additionally, there are other indicators of tissue health: consistency and coloration of the tissue being the foremost.
The initial root planing and curettage appointments are effective in removing bacteria in shallow to moderately deep spaces. In areas deeper than 4 mm, the bacterial invasion may be unchecked by root planing, hence we opt for this second phase, one geared toward the elimination of these spaces, and the eradication of all bacteria and deposits in and around the root surfaces. This may include removal of unhealthy tissue and bone ( called an "osseous" procedure) and the restoration of a healthier contour to the teeth and periodontal tissues. For many individuals this results in a closer adaptation of the gum tissues to the teeth and underlying bone, and can only be achieved by receeding the gums. This is usually not a problem for back teeth, but is done minimally for front teeth, often resulting in a compromise solution.
People who have demonstrated periodontal problems in the past need to see the periodontist, general dentist, or dental hygienist more often than other individuals. Recall appointments of 2 - 4 months are customary if you wish to maintain your dental health.
Ideally there has not been a significant amount of bone destruction around the teeth, and the gum (gingival) tissues covering the bone and the necks of the teeth (roots) are firm and strongly attached to the tooth and the bone. Periodontists often perform a grafting procedure to cover the roots of teeth that are unhealthy or have receeded. We select a donor site, usually the roof of the mouth, and move tissue here to the chosen site. We also graft bone as well, if we see an area of bone loss that is amenable to a fill with bone from a remote site.
Between the efforts of the periodontal therapists (especially the hygienist) and your own oral hygiene, we can prevent tooth loss. This has been a long-winded explanation of a process that we still don't have enough information about, but I hope that it gives you a deeper understanding of your periodontal and dental health.
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