Monthly Archives: September 2009

Alternative Periodontal Disease Treatment Options for Deep Gum Pockets

Alternative Gum Disease Treatment Options for Deep Gum Pockets

This post will define the available professional “alternative gum disease treatment options” for deep gum pockets.  

When traditional therapies such as root planing (deep cleaning) with antibiotics, or basic laser periodontal therapy are exhausted, the next indicated step for a more definitive treatment to stop infection in unresponsive deep pockets may be traditional periodontal surgery.  However, many individuals decide to seek alternatives to traditional periodontal surgery for the following reasons in our experience:  to avoid pain and long term tooth sensitivity, to prevent large gaps or black triangles between the teeth, to avoid recession of the gums following surgery, to avoid extractions of teeth deemed hopeless,  and to avoid the potentially huge costs associated with periodontal surgery and tooth replacement. 

The following periodontal treatment options are at this time considered to be alternatives to traditional periodontal surgery.

Regenerative Periodontal Endoscopy℠ – Non invasive procedure to promote closure of deep gum pockets and repair bony defects.

This non-invasive procedure employs the use of a periodontal endoscope.  RPE℠ differs from a standard perioscopy procedure in many ways.  The inclusion of enzyme inhibitors and regenerative proteins to promote reattachment of pockets and bone fill.  In addition, RPE℠ is performed with very precise and efficient tools (piezo diamond tips), which allows skilled clinicians to complete the procedure more efficiently while preventing root damage and tissue trauma from occurring.   An occlusal adjustment is often performed to aid in overall healing. Teeth deemed hopeless can be treated with RPE℠ as an alternative to extractions due to the non-invasive nature of the procedure.

before RPE℠ After RPE℠ JPeg

Before RPE℠  – deep gum pockets/bone loss           After RPE℠ – reattachment of gum pockets/bone fill

See case studies (actual patients of PerioPeak Innovations)

Perioscopy – visual removal of tartar in deep pockets only

This non-invasive procedure employs the use of a dental endoscope to “see” microscopically into deep periodontal pockets. This allows the clinician to better remove the tartar and plaque (biofilm) from the roots which have already been root planed blindly without success.   It is simply “visually enhanced root planing” (removing tartar from pockets).  Local anesthetic is used.   The tools used to actually remove the root deposits (tartar) vary widely from clinician to clinician, as well as the actual proficiency and skill.   Results and long term results will vary due to skill level, experience, and technique.  This procedure may include adjunctive therapies such as antibiotics, either placed beneath the gums or given systemically.  While there is some impressive published research to support perioscopy, it has still not been embraced by the main stream dental profession as a viable treatment option for periodontal disease.  In some offices perioscopy is only employed when all other methods have been exhausted rather than utilizing it as a first phase treatment approach. 

Explorer In Hand ScalerTipOnCalculus

Perioscope in hand (miniature fiber optic)   –   48X magnification on a 10,000 pixel color monitor allows for real time pinpoint tartar removal in deep gum pockets.

 

PerioProtect – a non-definitive approach for first phase treatment, but an impressive maintenance program if necessary.

PerioProtect is a relatively new treatment non-definitive option for patients with unresolved periodontal infections and periodontal pockets.  This professional treatment involves having a custom mouth tray fabricated by the dentist  for the patient to use at home.  These trays are then filled with antibiotics, or antimicrobials such as hydrogen peroxide (depending on the need), and are worn several times a day, up to several hours a day.  PerioProtect is  intended to be an adjunctive therapy with traditional root planing and periodontal maintenance cleanings.  No surgery is performed to correct pockets and no dental endoscope is employed to aid in the removal of tartarand biofilm from deep gum pockets, therefore periodontal infections and gum pockets may continue to be a chronic problem. PerioProtect trays are supposed to kill bacteria in deep pockets, but the depth that the medicament will reach remains questionable due to lack of research.  The company has gone to great lengths to market their product but to date have only demonstrated their medicament reaching one pocket of 6mm.  Tartar trapped under the gum in deep pockets is not removed by this product, therefore results may be temporary.

Traditional and Alternative Treatment Options to Reduce Deep Gum Pockets

Periodontal Disease Treatment Options for Treating Deep Gum Pockets

It is important to consider all options very carefully and to find what actually works well long term (results as demonstrated by real case studies and published research).  In addition, it is also important to consider how a particular treatment fits into overall goals, expected outcomes, lifestyle, convenience, comfort, and budget.    Knowledge is empowering, we encourage all periodontal sufferers researching periodontal treatment options to consider all this information carefully.

Regenerative Periodontal Endoscopy- RPE℠

This advanced endoscopic procedure eliminates cutting the gums open. Instead, reattachment of the pockets are promoted with microscopic removal of calculus and the addition of regenerative protiens and systemic enzyme inhibitors.  RPE℠ may eliminate the need for aggressive periodontal surgery and/or extractions, but we encourage all patients to consider close monitoring by a periodontist throughout their life if they have a history of chronic periodontal problems.  RPE℠ is completed in one appointment and local anesthetic is used for comfort.

Gum gaps are minimized, or not created, following RPE℠ as with traditional periodontal surgery.

Picture1

6 weeks following RPE℠ – a nice esthetic result, health restored.

contact us for more information about RPE℠

Root Planing (deep scaling):

Root planing is still the “standard of care’ for the initial phase in treating all stages of periodontal disease, yet it is a non definitive, blind treatment approach.  The literature does not support this traditional approach in the advanced stages of periodontal disease –  it is usually followed by periodontal surgery due to the visual and clinical limitations. Root planing, or deep cleaning, is generally performed with local anesthetic (Novocaine), and is usually completed by sections, or quadrants.  The clinician performing this treatment employs the use of either standard aggressive scaling tools (curettes), or an ultrasonic scaling device, or both.  The goal of this procedure is to remove as much tartar and plaque from the roots below the gum line as possible by tactile means (blindly).  The deeper the pockets, the more challenging.   Sometimes roots can be damaged by “over-planing”, or over-scaling.   In addition, many studies over decades show that gum pockets with a depth over 4mm may have up to 30-50% of the calculus (tartar) left behind following traditional root planing.

Picture2 5 Perioscopy after SRP

Before root planing (deep cleaning)             After root planing (up to 50% of tartar left on root)

Below is a list of adjunctive therapy options used with root planing in an attempt to obtain a better result:

1) Soft Tissue Lasers – many clinicians may employ the use one of two types of lasers to eliminate plaque bacteria in and around the roots while performing root planing.  The problem with this technique is that it is performed by feel (tactile means), therefore infectious tartar remains trapped in deep gum pockets.  Multiple treatments are usually recommended, adding to the overall cost and inconvenience.  In addition, the literature has demonstrated little to no benefit for this technique.  The cost vs. value may not be justified.

2) Local Delivery Antimicrobials – there is a variety of different adjunctive products called LDA’s (local delivery antimicrobials) which a clinician can employ in an attempt to enhance the result of root planing.  The idea is to root plane as well as possible (no objective end point), then place an LDA into the pocket.  The available LDA’s are Arestin, Atridox, Perio Chip, and Actisite.  The idea of all of these products is to kill bacteria in the deeper periodontal pockets.  However, the research on all of these adjunctive therapies remains unimpressive.  Results are typically temporary and cost vs. value may not be justified.

3)  Periowave – not yet available in the U.S. (still in the FDA approval stage), Periowave utilizes a non-thermal laser light combined with a photosensitizing solution designed to kill bacteria associated with gum disease when used adjunctively with root planing.  As with any of these adjunctive therapies, this technique is non-definitive and the literature is not impressive.  No endoscope is employed;  therefore tartar may remain in deep pockets.

Periodontal Surgery (Osseous, Flap, and Regenerative):

Following root planing, and the various adjunctive therapies listed above, periodontal surgery may be recommended in an attempt to eliminate periodontal pockets.   Periodontal surgery is performed in sections, or quadrants, under local anesthetic and often with the addition of oral sedation or nitrous oxide.  There are three types of periodontal surgery aimed at eliminating periodontal pockets and arresting periodontal disease.

Picture3 Picture4

pictures of periodontal surgeries described below – note the tartar on the roots following traditional root planing

Osseous periodontal surgery – gums are pealed back using a scalpel and other surgical instruments, tartar is then removed from the roots with an ultrasonic and a drill.  The bone around the teeth is then contoured with a drill as uneven bone is removed, hence the term osseous surgery.  The extra gum tissue is cut away (gums are removed as pockets are cut out).   This is also called “pocket reduction” surgery.  The gums are then sutured around the teeth in a lower position on the roots, creating recession and black triangles (gaps between the teeth).   This procedure is very aggressive, and while it works well to “eliminate periodontal pockets”, it leaves much to be desired in aesthetics, patient comfort, post operative root sensitivity, cost, inconvenience with multiple appointments, and long term results.  Research even demonstrates that in some cases patients will lose bone more rapidly following this surgery than if they had not had surgery.  Since large gaps called “black triangles” are often the result of this surgery, (as well as gum recession and long term root sensitivity), one should take caution if exploring this option.

IMG_4079

Above: Gaps, recession, and long tooth appearance as a result of osseous periodontal surgery.

Note: the same result can be seen with “pocket reduction surgery” or flap periodontal surgery.

Flap periodontal surgery – flap surgery follows root planing to allow for more complete removal of tartar from the roots, especially in deeper pockets and tricky root morphology (furcations).  This procedure is explicitly for the purpose of removing tartar left behind following traditional root planing and is not intended for recontouring the bone or promoting regeneration of any kind.  The gums may or may not be “cut away” before sutering, in an attempt to reduce periodontal pockets to a level which can more easily be maintained (cleansed) by the patient.  It is important to note that any type of gum surgery creates scar tissue, as well as recession of the gums.   The literature does not support this technique over traditional root planing for long term results and efficacy, and according to one study can actually make the condition worse, accelerating bone loss.  One should take caution if exploring this option for treatment of any of the anterior teeth (front teeth) due to the possible negative impact on appearance (aesthetics).

Minimally Invasive Regenerative Periodontal Surgery, or MIST:   by far the most impressive type of surgery for the treatment of periodontal disease.  This surgery is very similar to osseous surgery, with the added benefit of placing regenerative materials.  The regeneration material used varies based on the type of periodontal defects present, and the clinicians knowledge and experience using a particular regeneration material.  The main regeneration proteins used are Emdogain and Gem 21.  We highly recommend Dr. Tom Wilson or Dr. Steve Harrel in Dallas, Tx.

Diabetes and Periodontal Disease

How is diabetes, or prediabetes, related to periodontal (gum) diseases?

One of the main risk factors for the development of periodontal disease is diabetes.   We now know that individuals with type II diabetes are three times more likely to develop periodontal disease.   Conversely, results from the National Health and Nutrition Examination Survey (NHANES) and its follow-up studies suggest that non-diabetic adults with periodontal disease develop type 2 diabetes more often than those without periodontal disease.

In 2003 the American Diabetes Association stated that periodontal disease is often found in people with diabetes.  However, there are millions of individuals who are unaware that they may be “prediabetic” (they have elevated blood sugar levels), and that this may be a contributing factor in their periodontal disease.   While diabetes and pre-diabetes occur in people of all ages and races, some groups have a higher risk for developing the disease than others.   Diabetes is more common in African Americans, Latinos, Native Americans, and Asian Americans/Pacific Islanders, as well as the aged population.  This means they are also at increased risk for developing pre-diabetes.

What we now understand about diabetes and periodontal disease is that an elevation in inflammatory mediators in the gums is the cause for the close association between diabetes and increased incidence of periodontal diseases .  Bacteria thrive in the individual with elevated blood glucose, stimulating pro-inflammatory mediators, which leads to an overproduction of a bone destroying enzyme called collagenase.  It is well established that elevated levels of collagenase lead to the destruction of the periodontal ligament and bone supporting the teeth.

What you can do:

1) Get Tested

We highly recommend an HbA1c blood test for an accurate assessment of average glucose levels over time.  In our experience the simple fasting glucose test is not a good indicator of borderline or current diabetes.

Go to www.diabetes.org for more information

2) Learn More

A great comprehensive paper by water pik on diabetes

The two way connection

“Research has emerged that suggests that the relationship between periodontal disease and diabetes goes both ways – periodontal disease may make it more difficult for people who have diabetes to control their blood sugar.  Severe periodontal disease can increase blood sugar, contributing to increased periods of time when the body functions with a high blood sugar. This puts diabetics at increased risk for diabetic complications. Thus, diabetics who have periodontal disease should be treated to eliminate the periodontal infection.”  (American Academy of Periodontology)

Go to www.perio.org for more information abou the “mouth-body” connection, there are numerous articles on this topic.

3) Get definitive periodontal treatment

4)  Look into adjunctive medication which can help. How to help control chronic inflammation and destructive levels of collagenase enzymes created by elevated glucose levels and lack of good glycemic control.

Also Important to consider:

Prevention and proactive treatment of periodontal disease is fundamentally important in patients with diabetes because of the potential negative impact of untreated periodontitis on glycemic control and diabetic complications.  But as we have observed, one disease ‘feeds’ the other.  Addressing this two way connection is crucial to achieving periodontal health.  Host factors contributing to both periodontal disease and glycemic control must be defintively addressed if we are to expect success and remission of both diseases.

At PerioPeak Innovations we pinpoint and address all risk factors which may be contributing to your periodontal disease.  We pride ourselves in finding the cause – rather than just treating the effect.  Our mission is to provide comprehensive periodontal care,  empowering all of our clients for long term periodontal and overall health.

Find out how our advanced non-surgical approach for chronic periodontal disease can help to maintain optimal health.

Further important considerations with diabetes, periodontal disease, and cardiovascular disease:

Below is an exerpt from J. Periodontal 7/09 – The American Journal of Cardiology and Journal of Periodontology Editor’s Concensus:  Periodontitis and Artherosclerotic Cardiovascular Disease.

Metabolic Syndrome

Metabolic syndrome is diagnosed when 3 of the following features are present: (1) increased waist circumference(men ‡40 in [‡102 cm], women ‡35 in [‡88 cm]), (2) increased serum triglyceride level (150 mg/dl [1.7 mmol/L]) and/or drug treatment for elevated triglycerides (most commonly fibrates and nicotinic acid), (3) decreased serum HDL cholesterol level (men <40 mg/dl [1.03mmol/L], women <50 mg/dl [1.3 mmol/L]) and/or drug treatment for decreased serum HDL cholesterol, (4) elevated blood pressure (‡130mmHg systolic and/or ‡85mmHg diastolic) or antihypertensive drug treatment of patients with histories of hypertension, and (5) elevated fasting glucose (blood glucose ‡100 mg/dl) and/or drug treatment for hyperglycemia.

Recommendation:

Patients with periodontitis meeting criteria for metabolic syndrome should be identified, and all risk factors for atherosclerotic CVD should be treated, beginning with lifestyle changes aimed at weight reduction. Metabolic syndrome is closely linked to insulin resistance and is a secondary target of lipid therapy because the risk factors for metabolic syndromeare highly concordant and, in aggregate, enhance the risk for atherosclerotic CVD at any serum level of LDL cholesterol.

Many patients with periodontitis meet criteria for the metabolic syndrome.  Because measures of systemic inflammation are a common feature of periodontitis and metabolic syndrome, it may be particularly important to identify patients who meet these criteria for CVD prevention strategies.  We highly recommend The Bale Doneen approach to early diagnosis, intervention, and prevention.

Find a provider near you www.baledoneenmethod.com