Periodontal Diseases

Periodontology is a branch of dentistry that includes gum diseases and their treatment. The word periodontal means the periphery of the tooth. Gingiva means gingiva. The terms used for gingivitis are “gingivitis” and “periodontitis”.

1. What is Gingivitis?

Gingivitis is the early stage of gum disease. The gingiva becomes red, swollen, edematous, and bleeding. There is no destruction in the alveolar bone that supports the tooth yet. Gingivitis often occurs due to improper oral care. With good oral care and treatment, the gums return to their former form.

The most important symptom is bleeding that occurs spontaneously or as a result of a stimulus (tooth brushing, biting, etc.). Since smoking disrupts the vascular structure in the mouth, it can prevent bleeding and cause the most important symptom to be hidden, and thus, gingivitis in a patient who is not under regular control can reach further dimensions. Factors that increase the disease include diabetes, tobacco use, genetic factors, systemic diseases, stress, improper diet, hormonal changes, pregnancy, HIV infections, and the use of certain drugs.

2. What is Periodontitis?

Untreated gingivitis can progress to periodontitis. Over time, the toxins of the bacteria in the plaque accumulated on the teeth irritate the gingiva and these toxins initiate the chronic inflammatory response. The supporting bones and tissues around the tooth begin to break down. The gingiva separates from the tooth, a pocket is formed. As the disease progresses, the pocket deepens, and gingival and bone destruction increase. If this process is not treated, bone destruction in the teeth will increase and the tooth will need to be extracted.

There are many forms of periodontitis; The most common ones are:

1. a) Aggressive Periodontitis: Rapid bone loss is the most common feature and is associated with hereditary (genetic) factors.
2. b) Chronic Periodontitis: As mentioned above, inflammation in the tissues supporting the teeth causes bone destruction and gingival recession by progressing. Clinically, this is in the form of pocket formation or gingival recession. Although it is common in adults, it can occur at any age.

Although bone loss is usually slow in patients with chronic periodontitis, there may be periods of rapid destruction.

1. c) Periodontitis as a symptom of systemic disease: It usually starts at a young age. Certain heart diseases, lung diseases, and diseases such as diabetes are associated with this type of periodontitis.
2. d) Necrotic Periodontal Disease: It is an infectious disease characterized by necrosis of the gingiva and surrounding tissues. These lesions are most commonly observed in HIV-positive, malnourished, and immunocompromised patients.
3. What are the Risk Factors for Gum Diseases?

Although plaque is the main cause of periodontal diseases, the other factors mentioned below also affect gingival health.

1. Age: As a result of studies, it has been determined that the rate of periodontal disease is higher in elderly people.
2. Use of cigarettes/tobacco products: Smoking is associated with many diseases such as lung diseases such as cancer and heart diseases. Smoking increases the risk of periodontal disease. As a result of the studies, it has been determined that smoking is the most important risk factor for the onset and progression of periodontal diseases.
3. Genetics: As a result of research, it has been shown that some people are more genetically predisposed to gum disease. Detection of this predisposition is possible with genetic tests. Patients in this group are helped to preserve their teeth for life with preventive treatments.
4. Stress: Stress is linked to many serious problems such as cancer, high blood pressure, and other health problems. It is also a risk factor for periodontal diseases. Studies have shown that stress negatively affects the body’s defense mechanism in its fight against infection and triggers the periodontal disease.
5. Medications: Birth control pills, anti-depressants, and some heart disease medications can also affect oral health.
6. Clenching and grinding of teeth: Since these habits cause excessive force to the teeth, they can lead to the destruction of periodontal tissues and the rapid progression of the existing disease.
7. Other systemic diseases: Diseases that inhibit the body’s immune system also negatively affect gingival health. These diseases include cardiovascular diseases, diabetes, and rheumatoid arthritis.
8. Malnutrition and obesity: Malnutrition is an important factor that negatively affects the body’s immune system. Since periodontal diseases start as an infection, a weak immune system and bad eating habits adversely affect gingival health. In recent studies, it has been determined that obesity also increases the risk of periodontal disease.
9. Symptoms of Gum Diseases

Gum diseases often progress without symptoms and symptoms do not appear until the advanced stage of the disease. However, warning signs of gum disease include:

• Redness, swelling, tenderness, and pain in the gums
• Bleeding gums when brushing, flossing, and eating something hard
• Gingival recession, teeth appearing longer than they are
• Tooth loss or gaping in teeth
• Pus from the gums
• Formation of sores in the mouth
• Persistent bad breath
• Mismatch with existing partial dentures

5. Prevention of gingival diseases

Periodontal diseases, also known as gingival diseases, are diseases caused by the accumulation of bacterial plaque in the tooth and between the gingiva.

When the gingival disease is not treated, inflammation disrupts the structure of the gingiva and bone; causing gingival recession and tooth loss. It also causes tooth loss, as research has shown. In addition, studies have shown that gum disease is associated with many diseases such as diabetes and heart disease. The fact that gum disease is a preventable and treatable disease is a point where patients are lucky.

The preventive habits mentioned below should be practiced daily and regularly.

1. a) Toothbrushing: Brushing teeth ensures the elimination of food attachments and plaque between the teeth and gums after meals. Brushing the tongue should also not be forgotten.
2. b) Floss use: Daily flossing ensures the removal of food residues and plaque between the teeth. Since the toothbrush cannot enter between the teeth and the gum line, dental floss should be used to clean these areas.
3. c) Use of mouthwash: Mechanical cleaning, ie toothbrush, and dental floss are essential in oral care. Mouthwash helps reduce plaque.
4. d) Knowing the risk factors: Smoking, diabetes, and genetic factors increase the risk of periodontal disease. Considering these factors, the frequency of going to the dentist is adjusted.
5. e) Going to the dentist: Regular dental check-up every 6 months is necessary for the continuity of oral health.
6. Gum Diseases and Systemic Diseases

As a result of research, it has been shown that periodontal diseases are associated with many other diseases. Inflammation caused by periodontal disease increases the occurrence of other diseases in the body. Treating inflammation helps treat periodontal disease and helps treat other chronic inflammatory conditions.

1. a) Diabetes and Gum Diseases: Periodontal disease is likely to develop in diabetic patients, and periodontal disease in diabetics is followed by an increase in blood sugar and diabetic complications in these patients. The relationship between diabetes and periodontal diseases is bidirectional: severe periodontal disease increases blood sugar; therefore, there is an increase in diabetic complications related to it. Diabetics are more likely to develop periodontal disease than non-diabetics.
2. b) Heart Diseases and Gum Diseases: The relationship between periodontal disease and heart disease has been shown in many studies. Although the cause-effect relationship has not been fully proven, it has been determined that the inflammation caused by periodontal disease increases the risk of heart disease. Periodontal disease can increase existing heart disease. Studies have shown that patients with Acute Cerebrovascular Ischemia have oral infections and there is a relationship between periodontal disease and stroke. However, additional studies are needed.
3. c) Osteoporosis: Many scientific studies have shown that there is a relationship between osteoporosis and osteoporosis in the jawbone. Osteoporosis can cause tooth loss by causing a decrease in the density of the jawbone.
4. d) Respiratory tract diseases: It has been determined that bacteria in the mouth settle in the lungs with the breath taken and cause respiratory diseases such as pneumonia.
5. e) Cancer: There is a 49% or more risk of kidney cancer in men with gum disease; Scientific studies have shown that the risk of developing pancreatic cancer is 54%, and the risk of blood cancer is 30%.
6. Treatment Methods of Gum Diseases

The first step of the treatment of gingivitis or periodontitis is calculus cleaning and oral hygiene. Providing oral hygiene, correct tooth brushing technique, and timing; is the use of dental floss or interface brushes for interface cleaning.

Depending on the severity of the disease and many other factors, there are surgical and non-surgical periodontal treatment methods. TPeriodontal treatment aims to provide pocket elimination and establish gingival health.

* Non-Surgical Periodontal Treatment (Subgingival Curettage)

In this treatment method, plaque and tartar on the root surface and in the pocket are cleaned, bacterial toxins are removed and the root surface is smoothed. This procedure is done with local anesthesia. Sometimes local antibiotics, systemic antibiotics, host modulators, and dental laser can be used to assist this process.

* Surgical Periodontal Treatments

In periodontal pocket elimination, the gingiva is surgically removed, all inflammatory tissues are cleaned, bacterial residues in the pocket on the root surface, dental calculus are cleaned, if necessary, the irregular and damaged bone surface is corrected, and regenerative procedures can be performed depending on the condition of bone destruction.

* Regenerative methods, are surgical periodontal treatment methods. The gingiva is lifted, the root surface and surrounding inflammatory tissues are cleaned, and membrane, bone grafts, or tissue-stimulating proteins are used.

Surgical and non-surgical treatment methods are very important in reducing the pocket depth and eliminating existing bacteria and stopping the progression of periodontal disease. Elimination of the pocket alone is not enough to ensure gingival health. To prevent the disease from recurring, it is imperative to provide daily correct oral hygiene and to continue the periodontal control appointments determined by the physician for life.

8. Gingival Recessions and Treatment Methods

Gingival recession due to periodontal diseases is caused by loss of attachment and bone destruction in the gingiva due to existing inflammation. It is the most common cause of gingival recessions.

Sometimes the gingiva is healthy, but the gingival recession is observed. This situation is mostly caused by habits such as wrong tooth brushing, tooth grinding, faulty prosthesis or filling-induced occlusal nails or edge incompatibility, crowding or incorrect positioning of the teeth, smoking, and an increase in age.

In addition to the causes of gingival recession, whether the gingiva is thin or thick is a factor that determines the severity of the recession.

Since the treatment methods of periodontal diseases are explained under a separate title, the treatment methods for a gingival recession will be mentioned in this section. The first step in the treatment of gingival recessions is to identify the cause. According to the degree of recession, preventive methods, elimination of the cause, and surgical treatment of the open root surface are performed. These mucogingival surgical methods are either shifting the gingiva from the adjacent area, taking grafts from the patient’s hard tissue, or using artificial grafts and similar materials, depending on the indication.

9. Gingival Growths

Gingival enlargements can develop due to inflammation caused by bacteria, hormonal reasons (such as pregnancy and puberty), medication (nifedipine, cyclosporine A, and phenytoin group drugs), or tumoral causes (benign or malignant), and some systemic disorders. Treatment of gingival enlargements includes removing the growing tissues and restoring the gingiva to its former healthy borders, as well as eliminating the factors.

10. Periodontal Plastic Surgery

Periodontal plastic surgery is a procedure performed in smile design or other prosthetic restoration treatments. Correction of the gingiva that is excessively visible when smiling, correction of the reverse smile line, treatment of gingival recessions, crown lengthening operations, removal of long muscle attachments, reconstruction of the triangular gingiva between the teeth and raising the edentulous area are the treatments methods in this group.

Correction of the gingival smile (gummy smile) and crown elevation, which is one of the periodontal plastic surgery methods, can be performed not only by leveling the gingiva but also with bone surgery together with the gingiva.

11. Peri-implant Diseases

Peri-implant diseases are inflammatory conditions affecting the hard and soft tissues around the implant. As with natural teeth, bacteria settle on the implant under the gum; over time, it irritates the gingival tissue and causes inflammation; damaging the tissue. If not detected early, bone destruction will occur and the implant may be damaged or even lost.

Peri-implant diseases are classified into 2 categories:

1. a) Peri-implant Mucositis: The disease is limited to the soft tissue around the implant. There is no destruction in the bone yet. Usually, peri-implant mucositis is the precursor to peri-implantitis. This early stage, if successfully treated, will return and healthy tissue around the implant will regenerate.
2. b) Peri-implantitis: This picture occurs because inflammation around the soft tissue damages the bone supporting the implant. Peri-implantitis usually requires surgical treatment.

The symptoms of peri-implant diseases are similar to those of gum disease. These:

• Redness of the gums.
• There are symptoms such as brushing bleeding.

As with natural teeth, the use of brushing floss, and regular dental check-ups are essential for implants.

In addition to inflammation, other risk factors for the development of peri-implant diseases; the presence of periodontal disease in the past; poor oral care, smoking, and uncontrolled diabetes.

12. Laser Applications in Dentistry

Laser technology, discovered by Theodore H. Maiman in the USA in 1960, took its name from the initials of the words “Light Amplification by Stimulated Emission of Radiation”, but entered Turkish as “laser”.

About 20 years after the discovery of the laser, it entered the medical world and later started to be used in dentistry. In dentistry, it first found application in treatment options involving soft tissues. Surgical procedures have been simplified with the use of laser in dentistry. Due to the low damage to the tissue, the use of lasers is becoming widespread in various stages of surgical procedures. The biggest advantage of soft tissue operations is that they are non-bleeding, a rapid recovery is observed, and sterilization is ensured by the effect of laser in the working area. Since it does not vibrate in hard tissue and anesthesia is not needed in small interventions, it has become an alternative for patients of all ages with a fear of the dentist.

With lasers on soft and hard tissue, processes are applied at different powers and different frequencies. Each operation has different operating conditions. The wavelength obtained after the procedure is performed is selected and affects only the tissue to be treated. Today, there are different types of lasers with different wavelengths such as Nd YAG laser, Diode laser, Erbium laser, CO2 laser, and KTP laser. The tissues that each laser can affect differ.

When using laser devices, protective measures must be taken. Especially during the application, the physician, assistant, and patient must wear protective glasses.

Use of Laser in Soft Tissue

Soft tissue lasers with special wavelengths are used in three basic areas such as biostimulation, regional infection control, and incision in soft tissues for the mouth. Laser is used to reducing the number of microorganisms that cause inflammation in the gums and discomfort in the gums after surgical procedures in the mouth. It is possible to perform gingivectomy, gingivoplasty, and frenectomy procedures with laser without bleeding, stitches, and with less anesthesia. Since there is no bleeding, it also provides the opportunity to continue other procedures without waiting. In cases where periodontal pockets are curetted, it is also possible to use the sterilization effect of the laser to change the microbial content of the periodontal pocket after curettage. The bloodless removal of tumoral formations in the mouth, the use of stitches, and faster healing can be achieved with the use of a laser. The application of laser in the early stages of aphthae occurring in the mouth eliminates the patient’s pain and prevents the opening of the wound. Thus, it has been reported that the patient’s nutritional and speech potential decreases. It has been reported that healing can be accelerated and controlled by stimulating the healing tissues (biostimulation) with very low doses of laser applications.

Use of Laser in Hard Tissue

The laser can be used in hard tissues, especially in cleaning superficial caries in teeth, without the need for anesthesia. In addition, it is possible to remove the bone with laser without vibration in surgeries involving the jawbones. Although it is successful in hard tissue applications, the disadvantage of the laser is that the operation takes a long time. It can also be used to sterilize root canals during root canal treatment. In the local treatment of inflammation around the implants placed in the jawbones, healing can be achieved with a laser without the need for antibiotics. As an alternative to toothpaste and clinical fluoride application used to relieve existing tooth sensitivity, it is possible to block the dentin canals and relieve the sensitivity with laser application.

Teeth Whitening and Laser

As an alternative to traditional bleaching techniques, bleaching can be achieved by activating the bleaching agents with a laser.