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What is a periodontist?

A periodontist is a specialist dentist who has additional training and qualifications needed to diagnose and treat gum problems. In the UK the specialist training pathway in Periodontics involves 2 to 3 years of general professional postgraduate training followed by a four-year specialist course which consists both of formal teaching and hands-on training. The bulk of the work of a periodontist is the management of gum disease but may also include periodontal plastic surgery (surgery to change the appearance of the gums) and the surgical placement of dental implants. Increasingly, periodontists are now being called upon to manage gum problems around implants.

What is periodontal (gum) disease?

Gum disease is caused by plaque, which is the film of bacteria (germs) which builds up naturally on the teeth. The average mouth may have 200-300 different sorts of bacteria living together – the mix contains harmless or protective bacteria and harmful ones too. If the film of plaque is allowed to build up over some days, it becomes quite organised and the more harmful sorts of bacteria start to predominate. As a reaction to this, the body builds up defences in the gums and the gums become inflamed. The part of the gum just close to the plaque changes from a pink to a red colour and may swell a little. There may be some bleeding of the gums after brushing teeth or eating hard food. This stage of the disease is called gingivitis and if the plaque is removed over a period of time, the reaction settles down and everything returns to normal.

In some people, if the plaque is allowed to stay, this can lead to further problems. Any plaque which is left on the tooth surface for some days may pick up minerals from the saliva and become hard and scaly – what is commonly known as calculus (tartar). This acts as a fantastic porous structure in which the bacteria can live! In some individuals, this may progress to the gum disease called periodontitis. The gums are usually (but not always) red, inflamed and can bleed, but in addition there is breakage of the attachment between the gums and the teeth, producing a defect called a periodontal pocket. A vicious circle is established because the plaque bacteria can grow down into the gap that has appeared between the gum and the tooth, in a place where it is harder to remove them. Periodontitis can progress down the full length of the roots of the teeth causing them to first become loose and then fall out. The bone supporting the teeth dissolves and is lost in parallel with the loss of attachment. Other signs of disease may include receding gums, making the teeth look longer.

There are several factors which have an influence on the disease process. First and foremost is the effect of smoking. It is well known that smoking, in any amount, will aggravate the disease process so smokers will experience disease which is significantly worse than if they were not a smoker. Severe gum disease at an early age tends to run in families and we therefore understand that there is a certain degree of influence of the genetics of the individual which has a role. The medical condition of the individual, especially if they have poorly controlled diabetes, or if they are on certain medications, is also a factor which can worsen their gum disease.

Can you fix the problem?

By and large it is not generally possible to replace the missing gum attachment and bone which was lost through the process of gum disease. Instead, the goal of treatment is to establish the right conditions so that the remaining bone and attachment is preserved. Teeth with a reduced but healthy attachment may continue to function for several years. Having periodontitis is similar to having diabetes or other chronic medical condition, in that the problem is never fully fixed but is instead managed to reduce its effects on the patient.

How do you treat periodontitis?

The treatment of gum disease consists of

1. A detailed examination of the gums during which the periodontist can assess the extent and severity of the disease and recommend a specific treatment plan.

2. Advice and support for the patient to learn how to perform detailed daily tooth cleaning aimed at efficient and complete removal of the plaque from all accessible surfaces of the teeth. Treatment will only work well if you clean your teeth as we ask you to. Generally this will involve a combination of a manual or electric toothbrush and either floss or interdental brushes to clean in between the teeth.

3. Advice and support for the patient to give up smoking, if this is applicable.

4. Removal of any teeth which are beyond treatment.

5. Complete and thorough professional removal of the bacterial plaque and calculus deposits from the teeth, both above and below the gum line. To accomplish this painlessly it is usually necessary for the teeth and gums to be anaesthetised by means of injections, and the treatment may need 2-6 sessions to complete. The procedure may be called root planing or root surface debridement or deep scaling. Removal of the plaque and calculus is usually performed with ultrasonic powered instruments and manual instruments. Occasionally it may also be necessary to smooth down any rough edges on restorations such as fillings or crowns, or the periodontist may recommend their replacement. After the procedure, the gums may feel a bit sore for 1 or 2 days.

6. A healing period of 6-12 weeks. During this time, the typical response is for the general level of inflammation of the gums to reduce. As this happens, the gums will appear to shrink and the teeth will look a little longer. The exposed root surfaces may be initially quite sensitive to cold. To reduce this sensitivity, you may wish to apply fluoride toothpaste to the teeth and reduce the intake of acidic food/drink. There are other treatments we can suggest if the sensitivity is not getting better. The benefits of the initial treatment may also include fresher breath and sometimes teeth that were feeling loose may feel somewhat firmer. The improvement will depend on how good you are at cleaning your teeth and how severe the disease was to start with.

7. After the six to twelve week healing period, a second examination needs to be performed. The condition of the gums is assessed again and is compared to the initial examination. In this way it is possible to evaluate the response to the initial treatment and make further plans.

8. If with the treatment so far, all the periodontal pockets around the teeth have reduced to a level which we consider possible for you and the professional team to keep healthy, then a programme of supportive periodontal therapy otherwise known as periodontal maintenance is started. Typically this involves three-monthly visits for detailed cleaning and an annual or bi-annual visit to the periodontist for examination to ensure that there is no further deterioration. Depending on the individual circumstances, the periodontal maintenance treatment may be done by a hygienist, the general dentist or the periodontist.

9. If there are still some deep pockets after initial treatment, there are various ways in which they can be managed. We may recommend pocket reduction surgery to surgically reduce the pocket depths or may suggest re-cleaning the pockets from time to time. Some defects allow us the exciting opportunity to attempt periodontal regeneration where we try to regenerate the missing bone and gum attachment. After periodontal surgery to treat pockets or regenerate tissue, you will start a programme of maintenance as described already.

10. In the long term, it is not unusual for patients with periodontitis to need re-treatment or to eventually lose some of the teeth which had initially severe disease. The important thing to remember is that without treatment, the lifespan of the teeth would be greatly reduced and treatment is nearly always successful in prolonging the life of teeth affected by periodontitis.

Is this treatment expensive?

We charge from £130 for intial consultation including intra-oral (small) x-rays if required, as well as a written report to your dentist. All treatment costs depend on the complexity of the work and we inform all patients of fees applicable to them before we start treatment. When compared to replacement of teeth with dental implants, we believe periodontal treatment offers excellent value for money.