Overview: Periodontitis is a bacterial infection of the tooth surface, below the gum line, that can cause destruction of the bone and ligament that holds the teeth in, resulting in the high risk for losing the affected teeth over time. This infection is usually painless and without symptoms, so the patient does not know they have periodontitis until it is too late. Teeth with end-stage severe periodontitis, that may be loose or sore, cannot usually be saved. In addition, periodontal disease is associated with an increased risk for heart disease, stroke and cancer. Diagnosed early enough in the disease process by your dentist or hygienist, periodontitis is treatable, but the disease can only be controlled with treatment, not cured, and your diligence at daily oral hygiene with meticulous brushing and flossing, as well as appointing for all recommended cleanings, is critical in preventing periodontitis recurrence. Smoking cessation, cessation of alcohol consumption, and control of diabetes is usually pivotal in obtaining successful treatment in affected patients.

Normal Anatomy: The teeth are anchored in bone, and attached to the bone by the periodontal ligament. A thin layer of gum tissue covers the bone. The gum forms a cuff around the tooth with a small crevice between the gum and tooth that in health is very shallow: only 1 to 3 millimeters deep. This is important because this shallow, healthy crevice is cleanable by you with careful brushing and flossing every day. It is also cleanable with professional teeth cleanings by a dentist or hygienist. If the crevice is deeper than 3 millimeters, as it can become in periodontitis, then the ability for both you and the dentist/hygienist to clean it is greatly reduced.

Plaque Bacteria and Gingivitis: There are billions of bacteria floating around inside of our mouths. These bacteria settle on the tooth surface above the gum line and grow into a sticky, tenacious, organized colony that only takes about 24 hours to form. This bacteria on the tooth surface is called plaque. It is comprised of organized colonies of bacteria embedded in a gelatinous matrix that the bacteria secrete to protect themselves, and protect them it does! It is important to remember that plaque is bacteria, not food. This plaque growth and accumulation happens constantly and cannot be effectively removed with rinsing or mouthwashes. You need to remove this plaque at least once every 24 hours, preferably every 12 hours, with careful and thorough brushing and flossing. The problem is that we are not born with the knowledge of how to brush and floss, therefore we often 'miss' areas during our daily brushing and flossing, leaving the bacteria in place near the gum line. After about two weeks of accumulation, the gum near the plaque starts to become inflamed. We often see this in children and teenagers. This stage of the infection is called gingivitis. It is a painless redness/swelling of the gums that the patient is usually unaware of. Some bleeding during brushing/flossing is possible but does not always occur.

Oral Hygiene: The Gold Standard for removing the daily accumulation of plaque (bacteria) is mechanical plaque removal with brush and floss. The interdental Proxabrush is very effective as well if it fits between the teeth. Over-The-Counter rinses, mouthwashes, picks, herbs, rubber stimulators and essential oils have minimal to no additional benefit as they do not remove nor kill the bacteria. We often hear patients say I feel less plaque or I get so much food out from in between my teeth. Food does not cause periodontal disease and we cannot feel when the plaque is removed. In addition, the bacteria feed on dissolved nutrients in our mouths, not pieces of food. The plaque is very sticky, like dried egg on a counter top, therefore only the mechanical action of daily brush and floss can remove a significant amount of these bacteria. Antibiotics alone dont kill them because they are stuck to the tooth, not inside the body where taking a pill would have an affect. In addition, antibiotics and other chemicals cannot penetrate the gelatinous matrix that the bacteria secrete for protection, although antibiotics can act as an effective adjunct to mechanical debridement if prescribed during periodontal treatment. Some toothbrushes work better at removing plaque. The Oral B is the brush that we recommend. Other powered rotary brushes work almost as well in our opinion. We do not recommend the Phillips Sonicare or any of the other sonic brushes as we have only seen minimal benefit in patients with periodontitis that use these devices. We do not recommend using a Waterpik since the clinical research shows it to be ineffective at reducing gum inflammation, despite all the food that the Waterpik removes. Without effective daily mechanical plaque removal by you, you will be at high risk for reinfection even after successful periodontal treatment. Reinfection will usually require retreatment and may result in loss of the affected teeth.

Periodontitis Progression and Tooth Loss: If areas of gingivitis are left untreated and uncleaned (by not brushing/flossing these hidden areas every day), this inflamed gum environment supports the growth of different bacteria that grow below the gum line. These new bacteria and their toxins begin to destroy the bone and ligament that retain the teeth. These bacteria and their toxins also trick our bodys immune system to destroy bone and ligament as well. This bone/ligament destruction occurs slowly and painlessly over the years, speeding up and slowing down, at an average rate of about 1 millimeter per year. It is important to remember that this bone loss is cumulative over time and rarely, if ever, regrows nor heals. If we dont stop this bone loss before about the bone height is destroyed, then the tooth is at high risk for loss because there is simply not enough bone to hold the tooth in while bearing the loads of chewing. It can take 10 to 20 years of slow, painless, bone destruction to cause tooth loss, and this usually occurs on several or many teeth, not just one. By the time you feel pain and swelling, it is often too late to save the affected tooth. There are certain circumstances in which a localized area can flare up quickly (hours/days) destroying a significant amount of bone in a very short time ('acute periodontal abscess). This is often associated with pain and swelling, and can even be life threatening if left untreated.

Deep Pockets: As the bone and ligament are destroyed, the gum height is usually not affected much, so you typically wont see or feel any changes in your mouth. A significant problem is that while the gum may stay intact, there is no attachment to the tooth surface, thus a very deep and uncleanable periodontal pocket is formed. The very destructive bacteria live in this crevice and become mineralized into very hard and firmly attached calculus or tartar that as rough, irritating, full of bacterial toxins and covered in live bacteria. Brush, floss and rinses do not penetrate the deepest recesses of these pockets, nor do they remove the calculus; therefore, the bacteria and their toxins continue to accumulate and cause bone and ligament destruction.

Treatment Scaling and Root Planing (SRP): SRP may be recommended by your dentist or hygienist to treat some or all of the infected teeth. This may be a preparatory treatment for periodontal surgery or it may be the final treatment if Dr. Jacoby believes that no surgery will be needed to control your disease. This is dependent on how advanced the state of your disease is. SRP consists of numbing the affected area (local anesthetic injection) and then inserting specialized cleaning instruments below the gum line to scrape the bacteria, tartar/calculus and toxins off of the root surfaces. It is much more than a typical cleaning and focuses on areas below the gumline. Advanced clinical research in Periodontics have shown that well performed SRP is often very effective at controlling periodontal infection in pockets 4-5 millimeters deep, but the effectiveness of SRP is not nearly as effective when the pockets become deeper than 5 millimeters. This is because the dentist/hygienist cannot visualize the deep root surfaces to verify whether they have been completely cleaned. Still, even with partial cleaning, a benefit is usually seen with decreased inflammation and decreased rates of bone loss. Other research has shown that even deep periodontal pocket infection (> 5 mm) can be controlled with SRP alone. The drawback is that SRP is often required on a very frequent basis (as often as every three months.) This can be a very large financial burden, as SRP has a significant cost, and is usually only covered once every 2 years by insurance.

Treatment Periodontal/Osseous Surgery: For new or retreated patients, Dr. Jacoby usually recommends a complete periodontal exam about 8 weeks after SRP. At this visit, all probing depths are measured again, as in the first visit, along with bleeding points, pus and other criteria that assist in determining of there is inflammation present. If deep pockets with inflammation remain after SRP, this indicates that there are areas that are at high risk for having ongoing bone loss that could lead to eventual tooth loss. Deep pockets alone are not an indication of disease. The signs and symptoms of inflammation (bleeding, puss, redness, etc.) are an indication of the risk of ongoing infection. One of the primary treatment options in this case is periodontal surgery (also known as osseous surgery). This procedure involves Dr. Jacoby numbing the affected teeth with local anesthetic, and surgically opening up the gum tissue to expose the infected root surfaces (see diagram below.) The root surfaces are then meticulously cleaned. The bone and gum tissue are then recontoured such that the gum/tooth crevice is much shallower. The tissue is then sutured in place with dissolvable suture. This type of surgery allows visual access to very deep infected pockets so that the debris can be removed and the disease arrested. After surgery, it is typical for patients to have significant pain, so narcotic pain medication is usually prescribed. Upon healing, it is common to have spaces in between the teeth that can catch food. You will need to keep these and all other areas free of feed and plaque accumulation. Root sensitivity to cold often occurs following surgery, which usually resolves in time, but not always.

Follow-up After Surgery: Excellent daily home plaque removal by you, and following the maintenance cleaning schedule recommended by Dr. Jacoby, are necessary to control plaque growth and prevent disease reoccurrence, as patients that dont have adequate plaque control are at high risk for reinfection and subsequent tooth loss. With poor daily plaque control, the patient could even be worse off than if they had no surgery at all, as surgery in the presence of plaque, and the absence of maintenance, has been shown to actually increase the rate of bone loss as compared to no treatment. You can see that removing the bacteria at home on a daily basis is critical!

Extraction: While extracting the affected teeth is not the first choice in treatment, it is the only known cure for periodontal disease (all the other treatments control the disease; they dont cure it.) Without a tooth, there can be no periodontal infection.

1)Q: I used to see a little blood when I brushed or flossed and sometimes smelled something strange in my mouth, but that is gone now, and I dont feel or see any problems, so maybe the disease went away on its own? ---A: Periodontal disease is usually silent (like high blood pressure or diabetes) and can only be diagnosed by a dentist. In other words it can be very advanced but patients are usually unaware of the active infection. Most patients feel fine even with advanced infection.

2)Q: Ive cut back my smoking a lot. Are just a few cigarettes per day ok? ---A: Tobacco/marijuana use increases the risk for tooth loss even if treatment is attempted. Obviously less is better, but quitting is best.

3)Q: Isnt there some rinse or antibiotic that I can take to cure this disease? ---A: Unfortunately no. These bacteria live between the gum and tooth which is not actually within the body, so any pill or rinse you take will not deliver the medication to the bacteria in a high enough concentration to kill them all. In addition, the bacteria exist in a sticky film that protects them from antibiotics and the immune system. Antibiotics also have no affect on the toxins that the bacteria create. That said, controlled clinical research has shown that a specific prescription rinse and certain potent antibiotics increase the effectiveness of periodontal treatment, therefore Dr. Jacoby often prescribes them as part of the overall treatment plan.

4)Q: Ive always brushed my teeth every day, so why do I have periodontitis? ---A: Because you did not remove all the bacteria from all areas of your teeth frequently enough. We are not born with the knowledge to brush our teeth, and the bacteria are sticky and difficult to remove. It is very common for patients to think they are cleaning their teeth well, when in fact massive amounts of bacteria are left untouched on the tooth surfaces in hidden areas.

5)Q: I dont know anyone else with this disease; why me? ---A: While periodontitis may have no symptoms, it affects up to 90% of the human population and is one of the most common chronic diseases known.

6)Q: Does taking calcium help? A: In most cases no. Calcium may be of benefit to patients with osteoporosis or thinning of the bones, but this does not usually come into play in patients with periodontitis.

7)Q: How does pregnancy affect this disease? A: During pregnancy, increased levels of the hormone progesterone occur. This has been shown to increase the level of existing inflammation. In other words, it can make the inflammation more pronounced, but it doesnt cause the inflammation.

Implant infection can occur soon after implant placement or many years later. Infection occurring soon after implant placement tends to progress more rapidly than infection that occurs after the bone has grown into the implant ('osseointegration'). Any type of implant infection needs treatment, but prevention is best.

Infection that occurs after osseointegration has been divided into two stages: the first stage is when bacteria have colonized the tooth or implant surfaces causing a reversible inflammation of the gums and connective tissue without any bone destruction. This is known as 'peri-implant mucositis' and is equivalent to gingivitis around natural teeth. The second stage represents the progression of peri-implant mucositis to the point that bone destruction has occurred. This is known as 'peri-implantitis' and is equivalent to periodontitis around natural teeth. Collectively, these two stages of the disease are known as peri-implant infection.

Peri-implant infection is common with peri-implant mucositis occuring in up to 64% of implants. This can, but does not always, lead to the bone destruction that defines peri-implantitis, which occurs in approximately 10-15% of implants. Peri-implantitis has been found to be clustered in approximately 20% of implant patients, with smoking and a history of periodontitis as major risk factors. Approximately 10% of all implants are lost over a 10 year period due to peri-implantitis.

The process begins when bacteria colonize the crown or implant surface within minutes of implant placement. If the right combination of virulent bacterial species is left to grow without adequate daily hygiene and periodic professional maintenance, then inflammation can occur after several weeks of bacterial accumulation, resulting in peri-implant mucositis. This inflammation, if left untreated, can lead to destruction of the bone seen in peri-implantitis. The implant can fail and be lost if enough bone is destroyed. Fortunately, the infection usually progresses very slowly and painlessly so that if an implant is lost, many years of use have been enjoyed by the patient. Unfortunately, the bacteria that cause this infection have been strongly associated with other systemic diseases such as heart disease, stroke, cancer, diabetes, etc. Important points to remember are: 1) peri-implant infection is usually painless so you will not know that it has occurred, and 2) while it can be treated and controlled, there is no cure, and it won't resolve on its own, therefore constant follow-up and maintenance is needed.

The only known means to diagnose peri-implant infection is periodontal probing by a dental professional. X-rays and a visual examination can add useful information, but the infection cannot be diagnosed without probing, as your dentist cannot see the inflammation below the gum line on an x-ray or with their eyes alone. If there is infection around an implant, then bleeding or pus will be seen on probing. Deep pockets do not necessarily indicate any bone loss, but does indicate inaccessible areas that are difficult or impossible for you to clean.

The bacteria constantly try to colonize all the surfaces in your mouth, especially your teeth, so they need to be removed with brush and floss on a daily basis. There are likely areas that are inaccessible for you to clean, so professional cleaning is required. The frequency of these cleanings is best determined by a dentist experienced in treating implant infection.

Oftentimes, even the dentist and hygienist cannot clean the implant crowns effectively while they are in place. For this reason, it is best if implant crowns are made with an access hole so that the dentist can periodically remove the retaining screw that holds the crown onto the implant. This does not remove the implant, but allows removal of the crown which is where the infection starts. With the crown off, it can be fully disinfected as often as needed and the implant itself can be accessed easily for cleaning and assessment, which is rarely possible with the crown in place. This process, known as 'implant maintenance' (CDT Code D6080) often needs to be performed every 3 months. The rationale behind this is that even if there is bone destroying inflammation at the crown/implant interface, the inflammation will not have the ability to destroy any implant supporting bone if the bacteria are being cleaned out every 3 months.

Its important to understand that the screw access hole in the crown can be made very small and plugged with tooth colored material, although some crowns, especially on your front teeth, often cannot be made with the screw access hole on the back side of the tooth. As its unacceptable to place the access hole on the front surface of a front tooth, these crowns are rarely made with a screw access hole. They can be cemented in with a special cement that allows removal of the crown to gain access to the retaining screw, but this has not been perfected.

Implant Direct branded implants are very amenable to crown removal as their retaining screws are inexpensive and are made of titanium which is very durable, therefore these screws can be loosened and retightened many times before replacement of the screw is required. 3i Implants use a special screw that costs considerably more than the Implant Direct screw, and 3i recommends replacement with a new screw after each removal.