Rationale of Periodontal Treatment

by Dr. Marcel Hallare

The effectiveness of periodontal therapy is made possible by the remarkable healing capacity of the periodontal tissue

Properly performed, periodontal treatment can be relied on to accomplish the following:

1. eliminate pain 2. eliminate gingival inflammation and gingival bleeding 3. reduce periodontal pockets and eliminate infection

4. stop pus formation 5. arrest the destruction of soft tissue and bone 6. reduce abnormal mobility 7. establish optimal occlusal function 8. restore tissue destroyed by disease in some instances

9. reestablish the physiologic gingival contour necessary for preservation of periodontal health 10. prevent the recurrence of disease 11. reduction of tooth loss

Local Therapy

The cause of periodontitis and gingivitis is bacterial plaque accumulation on the tooth surface in close proximity to gingival tissue

The accumulation of plaque can be favored by a variety of local factors:

1. calculus 2. overhanging margins of restorations 3. food impaction

The removal of plaque and all the factors that favor its accumulation is therefore the primary consideration in local therapy

Systemic Therapy

Systemic therapy may be employed as an adjunct to local measures and for specific purposes such as:
1. the control of systemic complications from acute infections 2. chemotherapy to prevent harmful effects of posttreatment bacteremia nutritional 3. supportive nutritional therapy 4. the control of systemic diseases that aggravate the patients periodontal condition

Systemic therapy for treatment of the periodontal condition and in conjunction with local therapy is indicated in localized and generalized aggressive periodontitis

In these diseases, systemic antibiotics are used to completely eliminate the bacteria that invade the gingival tissues and can repopulate the pocket after scaling and root planing

In studies, Nonsteroidal anti-inflammatory drugs such as flubiprofen and ibuprofen can slow down the development of experimental gingivitis, as well as the loss of alveolar bone in periodontitis These drugs are propionic acid derivatives and act by inhibiting the cyclooxygenase pathway of anachidonic acid metabolism, thereby reducing prostaglandin formation Administered orally or applied topically

Future treatment modalities may attempt not to control the bacterial cause of disease, but also suppress the self-destructive components of the host inflammatory response.

FACTORS THAT AFFECT HEALING

In the periodontium, as elsewhere in the body, healing is affected by local and systemic factors

Local Factors

Systemic conditions that impair healing may reduce the effectiveness of local periodontal treatment and should be corrected before, or along with, local procedures

Healing may be delayed by:

1. excessive tissue manipulation during treatment 2. trauma to the tissues 3. presence of foreign bodies 4. repetitive treatment procedures that disrupt the orderly cellular activity in the healing process

An adequate blood supply is needed for the increased cellular activity during healing

If this is impaired or insufficient, areas of necrosis will develop and delay the healing process

Healing is improved by debridement, immobilization of the healing area, and pressure on the wound

Systemic Factors

Healing capacity diminishes with age, probably due to atherosclerotic vascular changes, which is common in aging and result in reduction of blood circulation Healing is delayed in patients with generalized infections and in those with diabetes and other debilitating diseases

Healing is retarded by insufficient food intake; bodily conditions that interfere with the use of nutrients; and deficiencies in vitamin C, proteins, and other nutrients

Healing is also affected by hormones Systemically administered glucocorticoids such as cortisone hinder repair by depressing the inflammatory reaction or by inhibiting the growth of fibroblast, the production of collagen, and the formation of endothelial cells

Systemic stress, thyroidectomy, testosterone, adrenocorticotropic hormone, and large doses of estrogen suppress the formation of granulation tissue and retard healing Progesterone increases and accelerates the vascularization of immature granulation tissue and appears to increase the susceptibility of the gingiva to mechanical injury by causing dilation of the marginal vessels

HEALING AFTER PERIODONTAL THERAPY

The basic healing processes are the same following all forms of periodontal therapy They consist of the removal of degenerated tissue debris and the replacement of tissue destroyed by disease Regeneration, repair, and new attachment are aspects of periodontal healing

Regeneration

Regeneration is the growth and differentiation of new cells and intercellular substances to form new tissues or parts It takes place by growth from the same type of tissue that has been destroyed or from its precursor

In the periodontium, gingival epithelium is replaced by epithelium, and the underlying connective tissue and periodontal ligament are derived from connective tissue

Bone and cementum are not replaced by existing bone or cementum but by connective tissue, which is the precursor of both

Undifferentiated connective tissue cells develop into osteoblasts and cementoblasts, which form bone and cementum

Regeneration of the periodontium is a continuous physiologic process Under normal conditions new cells and tissues are constantly being formed to replace those that mature and die This is termed wear and tear repair

It is manifested by mitotic activity in the epithelium of the gingiva and the connective tissue of the periodontal ligament, by the formation of new bone, and by the continuous deposition of cementum

Regeneration is also going on during destructive periodontal disease Most gingival and periodontal diseases are chronic inflammatory processes and, as such, are healing lesions Regeneration is part of the healing

However, bacteria and bacterial products that perpetuate the disease process and the inflammatory exudate they elicit are injurious to the regenerating cells and tissues and prevent the healing from proceeding to completion

By removing bacterial plaque and creating the conditions to prevent its new formation, periodontal treatment removes the obstacles to regeneration and enables the patient to benefit from the inherent regenerative capacity of the tissue

Repair

Repair simply restores the continuity of the diseased marginal gingiva and reestablishes a normal gingival sulcus at the same level on the root as the base of the preexistent periodontal pocket This process, called healing by scar, arrests bone destruction without necessarily increasing bone height

Restoration of the destroyed periodontium involves mobilization of epithelial and connective tissue cells into the damaged area and increased local mitotic divisions to provide sufficient number of cells

New Attachment

It is the embedding of new periodontal ligament fibers into new cementum and the attachment of the gingival epithelium to a tooth surface previously denuded by disease Epithelial adaptation is the close apposition of the gingival epithelium to the tooth surface without complete obliteration of the pocket

The pocket space does not permit passage of the probe These deep sulci lined by long, thin epithelium may be as resistant to disease as true connective tissue attachment

The absence of bleeding or secretion on probing, the absence of clinically visible inflammation, and the absence of stainable plaque on the tooth surface when the pocket wall is deflected from the tooth may indicate that the deep sulcus persists in an inactive state, causing no further loss of attachment

Post-therapy depth of 4 or even 5mm may therefore be acceptable in these cases

New attachment and osseous regeneration have been a constant but elusive goal of periodontal therapy

Melcher pointed out that the regeneration of the periodontal ligament is the key to new attachment because it provides continuity between the alveolar bone and the cementum and also because it contains cells that can synthesize and remodel the three connective tissues of the alveolar part of the periodontium

During the healing stage of a periodontal pocket, the area is invaded by cells from four different sources: oral epithelium, gingival connective tissue, bone, and periodontal ligament The final outcome of periodontal pocket healing depends on the sequence of events during the healing stages

If the epithelium proliferates along the tooth surface before other tissues reach the area, the result will be a long junctional epithelium

If the cells from the gingival connective tissue are the first to populate the area, the result will be fibers parallel to the tooth surface are remodeling of the alveolar bone with no attachment to the cementum

If bone cells arrive first, root resorption and Ankylosis may occur

Only when cells from the periodontal ligament proliferate coronally is there new formation of cementum and periodontal ligament

The End