How is gum disease (periodontitis) treated?

Periodontitis is a disease in which the tissues attaching the tooth to the jawbone are destroyed by long-standing inflammation. The gum comes away from the root, the space between them (the pocket) deepens and the bone is lost. MSD Manuals writes that this process usually develops from untreated gingivitis, that there is often no pain, and that as it progresses the teeth can become loose and be lost.

The aim of treatment is to stop the inflammation and bring the pockets down to a depth the patient can keep clean at home. The EFP guideline ties this to a measurable target: if the pocket depth is 4 millimetres or less and there is no bleeding when measured with a probe, the pocket is considered 'closed'. This is a criterion that ties whether treatment has worked not to debate but to measurement.

Under the 2017 classification, periodontitis is divided into stages (I to IV) and into grades (A, B, C) by how fast it progresses. The stage shows how much supporting tissue has been lost and how complex treatment will be. In stage IV, the consequences of tooth loss come into the picture too: teeth fanning out, shifting position, the bite collapsing. The EFP's separate guideline states that at this stage further treatments are needed after gum treatment.

Treatment in the guideline has four steps. The first step is for everyone: improving care at home, cleaning plaque and tartar above the gum, and controlling risk factors. The second step is cleaning the root surface below the gum. The third step is surgery for areas that do not respond to the second step. The fourth step is regular maintenance to protect the result. After each step, measurements are taken again, and the next step follows if needed.

The effect of root surface cleaning has been measured. In the studies the guideline is based on, after 6 to 8 months pocket depth decreased by 1.7 millimetres on average, on average 74 per cent of pockets closed, and bleeding on probing fell by 63 per cent. In pockets deeper than 6 millimetres, the reduction averaged 2.6 millimetres. These results were mostly obtained in selected patients in good general health, in a research setting; they may differ in everyday practice.

Periodontitis is not a disease that ends, but one that is kept under control. It has been shown that patients who do not come regularly to maintenance appointments have more tooth loss and more disease progression. That is why the EFP counts maintenance as a separate step of treatment and recommends that sticking to maintenance be strongly supported.

Bone that has been lost usually does not come back. In some particular bone defects (in the guideline, intrabony defects 3 millimetres deep or more), a partial gain is possible with regenerative surgery; but this does not apply to every area. The realistic aim of treatment is to protect the remaining support.

Pocket measurements and X-rays decide at which step to stop. The list below gives a rough direction; the definite decision is made at the examination.

The sequence below is based on the EFP guideline for stages I to III. If your dentist's plan follows this sequence, you are on the right track; if a step is being skipped, ask why.

1. 1

   A full pocket chart and X-rays

   Pocket depth and bleeding are recorded at several points around each tooth, and the bone level is seen on X-rays. This first chart is the only basis for measuring success later. Ask for a copy.

2. 2

   Care at home and cleaning above the gum

   Brushing and cleaning between the teeth are shown to you, tartar above the gum is removed, and filling edges that hold plaque are corrected. If you smoke, support to stop, and if you have diabetes, blood sugar control, are part of this step.

3. 3

   Root surface cleaning below the gum

   With the area numbed, tartar and plaque inside the pocket are cleaned off with hand or ultrasonic instruments. According to the guideline, there is no difference in results between doing it quarter of the mouth by quarter over several sessions and completing the whole mouth within 24 hours. Because a temporary inflammatory response in the body has been reported with methods where the whole mouth is done in a short time, your general health is taken into account.

4. 4

   Reassessment

   Once the tissue has healed, the same chart is drawn up again. Pockets that have closed are moved into the maintenance programme. For pockets that stay at 4 to 5 millimetres, the cleaning is repeated; for those that stay at 6 millimetres or more, surgery is discussed.

5. 5

   Surgery (if needed)

   The gum is lifted back so the root surface can be seen directly and cleaned; the pocket is reduced or, in suitable bone defects, regenerative methods are used. The EFP recommends that advanced surgery be done by dentists with additional training or by specialists.

6. 6

   Supportive maintenance

   At the maintenance appointment, the pockets are measured, plaque and tartar are cleaned off and, if needed, areas where the disease has come back are treated again. The interval is set for each person at between 3 and 12 months.

None of the following replaces root surface cleaning; some are considered in addition to it, and some come into it when teeth are lost.

In periodontitis treatment, side effects are usually mild and temporary. The real risk comes from the wrong expectations and from treatment left half done.

The sequence below is a general framework for root surface cleaning and what follows. Timings vary from person to person and with the stage of the disease.

1. The first few days after cleaning

   There may be tenderness in the gums, sensitivity to cold and slight bleeding. Giving up brushing during this period is the most common mistake; keep going with a soft brush.

2. The first weeks

   The swelling goes down, the bleeding decreases and the gums firm up. The teeth may look longer; this is part of healing.

3. Reassessment

   Once the tissue has healed, the pocket chart is drawn up again. Ask how many pockets have closed and which have stayed deep; the decision on surgery is made with this measurement.

4. After surgery (if done)

   If stitches were placed, they are removed at the check-up your dentist sets; once the area has healed, the pockets are measured again.

5. The maintenance period

   A check-up and clean every 3 to 12 months. Your care at home and your risk factors determine this interval.

The scope of periodontitis treatment varies greatly from person to person. The main factors that determine it:

Stage and spread

Disease limited to a few teeth and stage III or IV disease covering the whole mouth do not call for the same treatment.

Whether surgery is needed

Pockets that close with root cleaning do not need surgery; in areas that stay deep and have bone defects, regenerative surgery needs additional materials and time.

Risk factors

Smoking and uncontrolled diabetes affect both the result and the number of sessions needed.

Maintenance interval

How often the lifelong maintenance takes place determines the long-term scope.

Teeth lost or to be extracted

If extraction and tooth replacement are needed, the plan goes beyond gum treatment.