Current Concepts in the Management of Periodontitis

Abstract

Periodontitis is a common disorder affecting >40% of adults in the United States. Globally, the severe form of the disease has a prevalence of 11%. In advanced cases, periodontitis leads to tooth loss and reduced quality of life. The aetiology of periodontitis is multifactorial. Subgingival dental biofilm elicits a host inflammatory and immune response, ultimately leading to irreversible destruction of the periodontium (i.e. alveolar bone and periodontal ligament) in a susceptible host. In order to successfully manage periodontitis, dental professionals must understand the pathogenesis, primary aetiology, risk factors, contributing factors and treatment protocols. Careful diagnosis, elimination of the causes and reduction of modifiable risk factors are paramount for successful prevention and treatment of periodontitis. Initial non-surgical periodontal therapy primarily consists of home care review and scaling and root planing. For residual sites with active periodontitis at periodontal re-evaluation, a contemporary regenerative or traditional resective surgical therapy can be utilised. Thereafter, periodontal maintenance therapy at a regular interval and long-term follow-ups are also crucial to the success of the treatment and long-term retention of teeth. The aim of this review is to provide current concepts of diagnosis, prevention and treatment of periodontitis. Both clinical and biological rationales will be discussed.

Keywords: Biofilm; dental plaque; non-surgical periodontal therapy; oral hygiene; periodontal disease.

Fig. 1

Periodontitis is multifactorial in nature and results from the presence of pathogenic bacteria, the host inflammatory and immune responses and other identified environmental and systemic risk factors.

Fig. 2

Global prevalence of severe periodontitis, , in comparison to diabetes, hypertension, depression and asthma.

Fig. 3

Management of a restoration with excessive contour. (a) Pre-operative radiograph; over-contoured restoration was present on the distal aspect of the mandibular right second molar, causing biofilm and food accumulation in the area. As a result, the distal aspect of the mandibular right second molar exhibited 6–7 mm probing depths. (b) Post-operative radiograph; the restoration was modified in order to improve the distal contour of the mandibular right second molar.

Fig. 4

A mandibular right central incisor with severe alveolar bone loss and secondary occlusal trauma. (a) Pre-operative radiograph; the mandibular right central incisor exhibited a severe vertical bone loss. Clinically, the tooth exhibited excessive mobility as a result of occlusal trauma. (b) One year post-operative radiograph; after initial periodontal therapy with occlusal adjustment and splinting, radiographic evidence of increased height of alveolar bone was noted for the mandibular incisors. No surgical treatment was performed.

Fig. 5

A mandibular right second molar with a distal cemental tear. Right mandibular second molar exhibited cemental tear on its distal surface. This was associated with an infrabony defect as well as a deep periodontal pocket (9 mm).

Fig. 6

Effect of home care on reducing periodontal inflammation. Improved home care/biofilm removal should be demonstrated prior to beginning active periodontal therapy. Patient presented with generalised gingival marginal erythema as well as oedema in the maxillary arch. Moderate deposits of dental biofilm were noted at the gingival margin. As a result of home care, after 9 weeks, significant resolution of gingival erythema and oedema were noted. Minimally visible dental biofilm was present, indicating effective home care. Scaling and root planing was then initiated, specifically aimed at the removal of supragingival and subgingival calculus. After completing initial cause-related therapy and achieving a stable periodontium, the maxillary left lateral incisor was extracted due to its linguoversion and endodontic pathology. (a) Initial. (b) After 9 weeks of home care. (c) Periodontal re-evaluation: 6 weeks after completing initial cause-related therapy (i.e. home care, scaling and root planing; no periodontal surgery was performed).

Fig. 7

Resective periodontal surgery in the area of a mandibular right first molar. (a) Mandibular right first molar with a persistent probing depth of 7 mm on mid-buccal aspect, with grade II furcation. An infrabony defect was associated with the presence of cervical enamel projection. (b) Advanced furcation involvement was confirmed. Osseous recontouring in combination with removal of the cervical enamel projection was planned. The buccal convexity of the roots was reduced in order to decrease the horizontal furcation depth. (c) Completion of recontouring prior to closure of the surgical wound. Resolution of infrabony defect, complete removal of cervical enamel projection and reduction in horizontal furcation depth were achieved.

Fig. 8

Regenerative periodontal therapy on a mandibular right second molar. (a) Pre-operative radiograph; the mandibular right second molar exhibited a vertical bone loss on its distal surface. (b) Post-operative radiograph; after 5 months of healing following laser-assisted periodontal regenerative therapy, an increase in the height of alveolar bone was noted on the distal surface of the mandibular right second molar. (c) Post-operative radiograph; after 10 months of healing following laser-assisted periodontal regenerative therapy. Further increase in the height of alveolar bone as well as an increase in alveolar bone density were noted on the distal surface of the mandibular right second molar.

Fig. 9

Different types of periodontal alveolar defects. (a) Two-walled alveolar defect (mesial and palatal walls). (b) Three-walled alveolar defect (distal, lingual and buccal walls; photograph courtesy of Dr Howard Yen, periodontist). (c) Combined alveolar defect (coronally 1-walled defect and apically 3-walled defect).

Fig. 10

A decision tree for treating a patient with periodontitis.