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