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Periodontology
10/9/17
By: Callan Meskimen
Periodontal disease is a very common disease but more often than not is
hygienists it’s our job to educate our patients on the importance of good oral
surrounding the tooth structures such as the periodontal ligament, alveolar bone
structure, cementum and gingival tissue. There are many different risk factors to
periodontal disease. Some of the most common factors are: the person’s life style,
contracting infections.
The main cause of periodontal disease is the bacteria formed in the dental
plaque. There are approximately 400 species of bacteria present in the oral cavity
and with insufficient removal the bacteria will start to accumulate. Immediately
after one brushes plaque starts to form called pellicle. Pellicle is the beginning stage
of biofilm and is composed of saliva and glycoproteins. Pellicle helps the bacteria
adhere to the supragingivial tooth structure and starts to layer and colonize. The
bacterium also mixes with the minerals in our mouth, our saliva, exudate and
consist of gram-positive cocci and rods. Overtime the biofilm increases in mass and
produce glucan that helps more bacteria stick to the colony and provides the colony
Actinomyces, will start to increase in numbers and cover the cocci. In over a week
spirochetes and vibrios are now starting to develop along the gingival margin,
becoming anaerobic. As the supragingival plaque matures and grows the gingiva
starts to become inflamed and allows the plaque to move apically beneath the gum
lines. This allows for more anaerobic gram- negative bacteria to form, such as
which is inflammation of the gums, is seen. Gingivitis is reversible with good oral
hygiene, but if the bacterium is left untouched has the potential to lead to
pocket and extends down into the structures around the tooth such as the
periodontal ligament, alveolar bone and cementum resulting in the loss of the bone
and gingiva. The start of periodontal disease is bleeding upon probing and deeper
probing depths of 4mm and up. Bacterium such as P. gingivalis is very prominent in
body’s immune system works to remove the infection, but the bacterium has many
self-defense mechanisms to prevent the body from eliminating them. In the end the
body is unable to prevent the destruction of the bacterium and if left untreated may
can be either localized and or generalized throughout the mouth. Different areas of
the mouth can be at different stages of periodontal disease at the same time and
other areas of the mouth may be relatively healthy. As stated earlier the start to
inflammation, redness of tissue, and no clinical attachment loss. Gingivitis may also
have bleeding upon probing, exudate and probing depths of 4mm or less. The next
of 1-2mm, radiographic loss of the alveolar crest and probing depths of less than or
related to clinical attachment loss of 3-4mm, furcations, bleeding upon probing and
pocket depths of less than or equal to 6mm. Patients may have either vertical or
horizontal bone loss and tooth mobility may be seen at this stage. The next stage is
of less than or equal to 5mm, suppuration, class 2 and 3 furcation and pocket depths
greater than or equal to 7mm. Patients may have suppuration and major horizontal
and or vertical bone loss and mobility. Lastly is refractory periodontal disease.
and continues to show attachment loss despite attempts to slow the progression.
the removal of biofilm, scaling and root planning and antimicrobial therapy
(local/systemic). Treatment such as removing biofilm will help reduce the amount
of plaque build up in the mouth and will prevent the supragingival gram-positive
bacteria from moving into the periodontal pockets and becoming gram-negative. A
different treatments of biofilm removal. They collected the microbe samples and
their plaque score. After the third treatment the results showed the mean of the
plaque score decreased from 72% to 0%, the mean of gingival index decreased from
.82 to .77 and the total number of bacteria reduced one-third of the original number.
Scaling and root planning includes removal of both subgingival and supragingivial
plaque and calculus as well as smoothing the root surface to prevent biofilm buildup
MEDLINE-Pub med database comparing scaling and root planning alone and scaling
and root planning with antibiotics. They measured clinical attachment level,
bleeding on probing and probing depths. All of the patients were classified as
metronidazole for 3,6,9 and 12 months. The research showed that combination of
SRP and antibiotics amoxicillin and metronidazole achieved the best outcome for
treatment.
Localized antibiotic therapy includes a dental professional applying a
minocycline. The local antibiotic when used in combination with scaling and root
planning helps to decrease the amount of bacteria left after SRP by either killing the
bacteria and or inhibiting the growth of the bacteria. The localized antibiotic
Dentistry, “From the present study, it can be concluded that both the drugs were
equally effective in reducing the plaque scores as well as gingival scores. It was
further observed that Arestin resulted in better results at 6 weeks while Periochip
gingivoplasty, periodontal flap surgery and soft tissue grafts. Whichever treatment
the clinician and the patient agree on the treatment wont work or be beneficial if the
patient isn’t having good homecare. We must teach the patient that the only way
they are going to maintain their periodontal status is to have excellent oral hygiene.
By us removing the biofilm and scaling and root planning we are allowing their body
to heal, but if they aren’t doing their part and keeping the bacteria out of the
periodontal pockets the bacteria will accumulate and their periodontal condition
will only continue to get worse. The same thing goes systemic and local antibiotic
therapy. If they aren’t working to keep their mouths free of plaque the antibiotics
wont be able to keep up with the biofilm. Any type of treatment weather its
nonsurgical or surgical cannot and will not work unless the patient is willing to
change their lifestyle and habits. We must stress how crucial it is for them brush at
least twice a day, floss daily and follow our home care instructions.
The treatment method of choice for periodontal disease is scaling and root
planning. Over 90% of patient’s main treatment is scaling and root planning while
Hygiene,” thorough scaling and root planing (SRP) is still considered the gold
periodontal disease. They have an additional three years of schooling after dental
school and provide nonsurgical and surgical treatments. Dental hygienists are
such as scaling and root planing. The professional preforming the treatment will
have a treatment plan that is specific to the patient and their needs. Treatment is
determined by the overall health status of the patient and the severity of their
disease. SRP is done with a periodontal pocket depth greater than 3mm and
candidates are patients that have bleeding upon probing, clinical attachment loss,
furcactions, pocket depths of 4mm and above, inflammation of the gums and are
treatment if scaling and root planning is not helping maintain the patient.
The process of scaling and root planning is first determining the diagnosis of
the patient and planning the treatment plan. Patients diagnosed with slight
periodontal case type may not need anesthesia and may only take one appointment
to finish the treatment. They also may not need to be on a three-month recall and
only visit the dentist twice a year if their periodontal diagnosis is maintained.
Patients with moderate and advanced diagnosis may need anesthesia and several
appointments either one quad per visit or one side per visit. These patients may also
patient comfort and complete biofilm and deposit removal. Then the dental
professional will use an ultrasonic to remove biofilm and flush out the periodontal
thick calculus sub and supragingivally. The dental professional then will use hand
instruments to scale the rest of the deposits of calculus on the teeth and the
dentin containing calculus and bacteria and creating a smooth hard surface free of
Hygienist, “root planing involves a specific effort to instrument every portion of the
root surfaces, not simply identifiable calculus deposits”. The main goal of SRP is to
quadrant depending on the patients’ needs and treatment plan. Many factors come
into play with the pricing of SRP such as the patient’s insurance, if the treatment is
methods are required. Patients with a more advanced or aggressive diagnosis may
need more SRP treatments and maintenance appointments resulting in higher costs
There are many benefits to SRP such as removing harmful plaque and
bacteria from the periodontal pockets and gums to allow for proper healing and
decreased probing depths. This procedure helps the patient maintain their
well as prevention in gum disease SRP also aids in preventing bad breath and dental
decay by the removal of bacteria and tarter removal. SRP is the treatment of choice
by many because the patient only benefits from the removal of bacteria. By
smoothing the surfaces of the roots bacteria is less likely to attach and grow and
disrupting the bacteria gives the body a break from constantly fighting off the
babies and heart disease. A study was conducted in 2013 on the effects of SRP and
reducing preterm birth. Results found a significant reduction in preterm birth rate
in patients whom were considered high risk. But, for the other women not
considered high risk SRP failed at producing enough evidence to aiding in reducing
preterm birth. Another study that was conducted in 2016 on the comparison of SRP
Along with benefits of scaling and root planing drawbacks are often
accompanied with the treatment. One draw back of thorough SRP is the necessity of
several appointments. For the dental professional to perform effective SRP they may
need several appointments to focus on each and every tooth surface. Maintenance
therapy also will need to be conducted resulting in the patient needing to have a
three month recall. Another drawback on SRP is the necessity for local anesthesia.
Some patients dislike the numbing feeling, the injection all-together and the risk of
patients may have discomfort from the removal of the biofilm and calculus deposits
causing the tooth to be more vulnerable for time being. Lastly, scaling and root
planing may not be enough to treat the patient and they may possibly need
The failure rate for SRP is quite low, but with comparison of SRP alone and
SRP with other adjunctive treatment results have shown more progress with
adjunctive therapy. A study was done in 2016 by, The Journal of Evidence Based
Dental Practice, comparing SRP alone and SRP with adjunctive therapies. Results
concluded that with doxycycline there was a clinical attachment gain of .35mm and
chlorhexidine chips added .40mm clinical attachment gain. The conclusion of the
need to work together and communicate about what is expected. Both have their
own set of responsibilities and guidelines they need to follow. Success will only be
possible if both participants hold up their end. The patient’s responsibilities are
flossing daily or using floss aids, irrigating chemotherapeutics (if Dr. permitted), and
regularly visiting the dentist to monitor their progress. The patient may also need
to change their life style such as adjusting their diet to less cariogenic foods, and
cessation of smoking. The clinician is expected to adjust the treatment plan to the
patients needs. They need to know when scaling and root planning isn’t enough and
adjust the treatment plan accordingly whether it’s applying localized antibiotic
patients on what the best oral hygiene regime is for their patients and show them
the correct way to brush and floss. It is also important for the clinician to fully
educate their patient on their disease and the importance of compliance and the
altered to the patients needs. Scaling and root planning is a multiple appointment
process and includes anesthetizing the patient for comfort and complete removal of
biofilm and calculus. The patient will also need to be brought back in for
maintenance. Home care alterations that patients need to incorporate are brushing
their teeth for at least two minutes twice a day and follow the dental hygiene
instructions their clinical gave them. If a local antibiotic was administered the
patient may also need to avoid brushing and flossing in areas where the antibiotic
was placed. If the patient is prescribed with a systemic antibiotic they will need to
remember to take it for the allotted amount of time. To help reduce the bacterial
uptake the hygienist may have also included in the home care regiment of a
the patient. They may not show up for their three-month appointments, they may
continue to have bad oral hygiene, forget to take the antibiotics, ignore the advice of
good nutrition and continue with bad habits such as smoking and drinking.
and surrounding tooth structures. With treatment such as scaling and root planing
the clinician and the patient to work together to prevent the disease from
progressing. Patient home care is one of the most important factors for scaling and
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