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Autoklav   illustration by Nobel Biocare  
Dental microscope Implants

A dental implant is an artificial tooth root replacement and is used in prosthetic dentistry to support restorations that resemble a tooth or group of teeth.
There are several types of dental implants. The major classifications are divided into osseointegrated implant and the fibrointegrated implant.
Earlier implants, such as the subperiosteal implant and the blade implant were usually fibrointegrated.
The most widely accepted and successful implant today is the osseointegrated implant, based on the discovery by Swedish Professor Per-Ingvar Brånemark that titanium can be successfully fused into bone when osteoblasts grow on and into the rough surface of the implanted titanium .
This forms a structural and functional connection between the living bone and the implant.
A variation on the implant procedure is the implant-supported bridge, or implant-supported denture.

Anesthetic methods
Laughing gas
General anesthetic

Composition of Implants
A typical implant consists of a titanium screw (resembling a tooth root) with a roughened or smooth surface. The very first implants were made out of commercially pure titanium, however since it was discovered that the Titanium 6AL-4V (signifying the Titanium alloy containing 6% Aluminium and 4% Vanadium alloy) offered the same osseointegration level as commercially pure titanium, more and more implants were made out of it. Ti-6Al-4V alloy offers better tensile strength and fracture resistance. Today most implants are made out of the Ti-6Al-4V alloy and treated either by plasma spraying, etching or sandblasting to increase the surface area and the integration potential of the implant.


Implant surgery may be performed as an outpatient under general anesthesia or under local anesthesia by trained and certified clinicians including general dentists, oral surgeons, prosthodontists, and periodontists.
An increasing number of cosmetic dentists are also placing implants in relatively simple cases.
In the UK the General Dental Council has published strict guidelines on the training required for a dentist to be able to place dental implants in general dental practice.
The degree to which both graduate and post-graduate dentists' receive training in the surgical placement of implants varies from country to country but it seems clear that lack of formal training will lead to higher complication rates.




Surgical planning
Prior to commencement of surgery, careful and detailed planning is required to indentify vital structures such as the inferior alveolar nerve or the sinus and to properly orientate the implants for the most predictable outcome.
Two dimensional radiographs, such as orthopantomographs or periapicals are taken prior to the surgery.
In some instances, a CT scan will be also be obtained and specialized 3D CAD/CAM computer programs used to plan case.

Whether CT-guided or manual, a 'stent' may sometimes be required to facilitate the placement of implants. A surgical stent is an acrylic wafer that fits over either the teeth, the bone surface or the mucosa (when all the teeth are missing) with pre-drilled holes to show the position and angle of the implants to be placed.
The surgical stent may be produced using stereolithographic technology following computerized planning of a case from the CT scan.

toppen Basic

Basic procedure
In its most basic form the placement of an osseointegrated implant requires a preparation into the bone using either hand osteotomes or precision drills with highly regulated speed to prevent burning or pressure necrosis of the bone.
After a variable amount of time to allow the bone to grow onto the surface of the implant (osseointegration a tooth or teeth can be placed on the implant. The amount of time required to place an implant will vary depending on the experience of the practitioner and difficulty of the individual situation, but the procedure typically takes 10 to 30 minutes per implant.


Detail procedure
At edentulous (without teeth) jaw sites, a pilot hole is bored into the recipient bone, taking care to avoid the vital structures (in particular the inferior alveolar nerve or IAN and the mental foramen within the mandible).
Drilling into jawbone usually occurs in several separate steps. The pilot hole is expanded by using progressively wider drills (typically between three and seven successive drilling steps, depending on implant width and length).
Care is taken not to damage the osteoblast or bone cells by overheating. A cooling saline spray keeps the temperature of the bone to below 47 degrees Celsius (approximately 117 degrees Fahrenheit).
The implant screw can be self-tapping, and is screwed into place at a precise torque so as not to overload the surrounding bone (overloaded bone can die, a condition called osteonecrosis, which may lead to failure of the implant to fully integrate or bond with the jawbone).
Typically in most implant systems, the osteotomy or drilled hole is about 1mm deeper than the implant being placed, due to the shape of the drill tip. Surgeons must take the added length into consideration when drilling in the vicinity of vital structures.

toppen Surgical

Surgical incisions
Traditionally, an incision is made over the crest of the site where the implant is to be placed. This is referred to as a 'flap'. Some systems allow for 'flapless' surgery where a piece of mucosa is punched-out from over the implant site.
Proponents of 'flapless' surgery believe that it decreases recovery time while its detractors believe it increases complication rates because the edge of bone cannot be visualized. Because of these visualization problems flapless surgery is often carried out using a surgical guide constructed following computerized 3D planning of a pre-operative CT scan.


Healing time
The amount of time required for an implant to become osseointegrated is a hotly debated topic.
Consequently the amount of time that practitioners allow the implant to heal before placing a restoration on it varies widely. In general, practitioners allow 2–6 months for healing but preliminary studies show that early loading of implant may not increase early or long term complications.


1-stage, 2-stage surgery
When an implant is placed either a healing abutment, which comes through the mucosa is placed or a 'cover screw' which is flush with the surface of the dental implant is placed. When a cover screw is placed the mucosa covers the implant while it integrates then a second surgery is completed to place the healing abutment.

2-Stage surgery is sometime chosen when a concurrent bone graft is placed or surgery on the mucosa may be required for esthetic reasons. Some implants are one piece so that no healing abutment is required.

In straight forward cases patients can be implanted and restored in a single surgery, in a procedure labeled "Immediate Loading". In such cases a provisional prosthetic tooth or crown is shaped to avoid the force of the bite transferring to the implant while it integrates with the bone


Surgical timing
There are different approaches to place dental implants after tooth extraction. The approaches are:
1. Immediate post-extraction implant placement.
2. Delayed immediate post-extraction implant placement (2 weeks to 3 months after extraction).
3. Late implantation (3 months after tooth extraction).

According to the timing of loading of dental implants, the procedure of loading could be classified into:
1. Immediate loading procedure.
2. Early loading (1 week to 12 weeks).
3. Staged loading (3–6 months).
4. Late loading (more than 6 months).


Immediate placement
An increasingly common strategy to preserve bone and reduce treatment times includes the placement of a dental implant into a recent extraction site.
In addition, immediate loading is becoming more common as success rates for this procedure are now acceptable.
This can cut months off the treatment time and in some cases a prosthetic tooth can be attached to the implants at the same time as the surgery to place the dental implants.

Most data suggests that when placed into single rooted tooth sites with healthy bone and mucosa around them, the success rates are comparable to that of delayed procedures with no additional complications.


Use of CT scanning
When computed tomography, also called cone beam computed tomography or
CBCT (3D X-ray imaging) is used preoperatively to accurately pinpoint vital structures, the zone of safety may be reduced to 1 mm through the use of computer-aided design and production of a surgical drilling and angulation guide.





sinus lift

Complementary procedures
Sinus lifting is a common surgical intervention. A dentist or specialist with proper training such as a periodontist, prosthodontist, or oral surgeon thickens the inadequate part of atrophic maxilla towards the sinus with the help of bone transplantation or bone expletive substance.
This results in more volume for a better quality bone site for the implantation.
Prudent clinicians who wish to avoid placement of implants into the sinus cavity pre-plan sinus lift surgery using the precision diagnostic guidance afforded by a 3D CBCT X-ray, as in the case of posterior mandibular implants discussed earlier.

Bone grafting will be necessary in cases where there is a lack of adequate maxillary or mandibular bone in terms of front to back (lip to tongue) depth or thickness; top to bottom height; and left to right width.
Sufficient bone is needed in three dimensions to securely integrate with the root-like implant. Improved bone height—which is very difficult to achieve—is particularly important to assure ample anchorage of the implant's root-like shape because it has to support the mechanical stress of chewing, just like a natural tooth.
If an implant is too shallow, chewing may cause a dangerous jawbone crack or full fracture.

Typically, implantologists try to place implants at least as deeply into bone as the crown or tooth will be above the bone.
This is called a 1:1 crown to root ratio. This ratio establishes the target for bone grafting in most cases. If 1:1 or better cannot be achieved, the patient is usually advised that only a short implant can be placed and to not expect a long period of usability.

A wide range of grafting materials and substances may be used during the process of bone grafting / bone replacement.
They include the patient's own bone (autograft), which may be harvested from the hip (iliac crest) or from spare jawbone; processed bone from cadavers (allograft); bovine bone or coral (xenograft); or artificially produced bonelike substances (calcium sulfate with names like Regeneform; and hydroxyapatite or HA, which is the primary form of calcium found in bone).
The HA is effective as a substrate for osteoblasts to grow on. Some implants are coated with HA for this reason, although the bone forming properties of many of these substances is a hotly debated topic in bone research groups.
Alternatively the bone intended to support the implant can be split and widened with the implant placed between the two havles like a sandwich.
This is referred to as a 'ridge split' procedure..

Bone graft surgery has its own standard of care. In a typical procedure, the clinician creates a large flap of the gingiva or gum to fully expose the jawbone at the graft site, performs one or several types of block and onlay grafts in and on existing bone, then installs a membrane designed to repel unwanted infection-causing microbiota found in the oral cavity.
Then the gingiva is carefully sutured over the site. Together with a course of internal antibiotics and external antibiotic mouth rinses, the graft site is allowed to heal (several months).

The clinician typically takes a new panoramic x-ray to confirm graft success in width and height, and assumes that positive signs in these two dimensions safely predicts success in the third dimension, depth. Where more precision is needed, usually when mandibular implants are being planned, a 3D or cone beam X-ray may be called for at this point to enable accurate measurement of bone and location of nerves and vital structures for proper treatment planning. The same X-ray data set can be employed for the preparation of computer-designed placement guides.

Correctly performed, a bone graft produces live vascular bone which is very much like natural jawbone and is therefore suitable as a foundation for implants.




For dental implant procedure to work, there must be enough bone in the jaw, and the bone has to be strong enough to hold and support the implant. If there is not enough bone, more may need to be added with a bone graft procedure discussed earlier. Sometimes, this procedure is called bone augmentation. In addition, natural teeth and supporting tissues near where the implant will be placed must be in good health.

In all cases, what must be addressed is the functional aspect of the final implant restoration, the final occlusion. How much force per area is being placed on the bone implant interface? Implant loads from chewing and parafunction can exceed the physio biomechanic tolerance of the implant bone interface and/or the titanium material itself, causing failure. This can be failure of the implant itself (fracture) or bone loss, a "melting" or resorption of the surrounding bone.

The dentist must first determine what type of prosthesis will be fabricated. Only then can the specific implant requirements including number, length, diameter, and thread pattern be determined. In other words, the case must be reverse engineered by the restoring dentist prior to the surgery. If bone volume or density is inadequate, a bone graft procedure must be considered first. The restoring dentist may consult with the periodontist, endodontist, oral surgeon, or another trained general dentist to co-treat the patient. Usually, physical models or impressions of the patient's jawbones and teeth are made by the restorative dentist at the implant surgeons request, and are used as physical aids to treatment planning. If not supplied, the implant surgeon makes his own or relies upon advanced computer-assisted tomography or a cone beam CT scan to achieve the proper treatment plan.

Computer simulation software based on CT scan data allows virtual implant surgical placement based on a barium impregnated prototype of the final prosthesis. This predicts vital anatomy, bone quality, implant characteristics, the need for bone grafting, and maximizing the implant bone surface area for the treatment case creating a high level of predictability. Computer CAD/CAM milled or stereo lithography based drill guides can be developed for the implant surgeon to facilitate proper implant placement based on the final prosthesis occlusion and aesthetics.

Treatment planning software can also be used to demonstrate "try-ins" to the patient on a computer screen. When options have been fully discussed between patient and surgeon, the same software can be used to produce precision drill guides. A popular software package called Simplant (simulated implant) uses the digital data from a patient's CBCT to build a treatment plan, then produces a data set which is sent to a lab for production of a precision in-mouth drilling guide.




Failure of a dental implant is often related to failure to osseointegrate correctly. A dental implant is considered to be a failure if it is lost, mobile or shows peri-implant (after implant) bone loss of greater than 1.0 mm in the first year and greater than 0.2mm a year after.

Dental implants are not susceptible to dental caries but they can develop a periodontal condition called peri-implantitis. The cause may be infection that was introduced during surgery; or failure by the patient to follow correct oral hygiene routines. In either case, inflammation in the bone surrounding the implant causes bone loss (recession) which ultimately may lead to failure, often evidenced by the ability to "spin" an implant.

Peri-implantitis is often dealt with pre-emptively by clinicians who prescribe a course of antibiotics in the days prior to surgery; and post-surgically with another course of antibiotics and special oral rinses. Since peri-implantitis is generally easy to see on standard panoramic and periapical X-rays, prudent clinicians who suspect the problem will take an X-ray soon after surgery, and again at staged intervals post-operatively.

Risk of failure is increased in smokers. For this reason implants are frequently placed only after a patient has stopped smoking as the treatment is very expensive. More rarely, an implant may fail because of poor positioning at the time of surgery, or may be overloaded initially causing failure to integrate. If smoking and positioning problems exist prior to implant surgery, clinicians often advise patients that a bridge or partial denture rather than an implant may be a better solution.

Failure may also occur independently of the causes outlined above. Implants like any other object suffers from wear and tear. If the implants in question are replacing commonly used teeth, then these may suffer from wear and tear and after years may crack and break up. This is a very rare occurrence, however possible. The only way to 'avoid' or prolong this from happening is to visit your dentist frequently.


There are no absolute contraindications to implant dentistry, however there are some systemic, behavioral and anatomic considerations that should be considered.

Particularly for mandibular (lower jaw) implants, especially in the vicinity of the mental foramen (MF), there must be sufficient alveolar bone above the mandibular canal also called the inferior alveolar canal or IAC (which acts as the conduit for the neurovascular bundle carrying the inferior alveolar nerve or IAN).

Failure to precisely locate the IAN and MF invites surgical insult by the drills and the implant itself. Such insult may cause irreparable damage to the nerve, often felt as a paresthesia (numbness) or dysesthesia (painful numbness) of the gum, lip and chin. This condition may persist for life and may be accompanied by unconscious drooling.

Lack of sufficient alveolar bone is another contraindication to the procedure. Typically, a preoperative in-office panoramic X-ray is taken to establish (with allowances for image distortion, a known problem with panoramic X-rays) in two dimensions (height and width) the amount of available bone. A bone graft or augmentation procedure may be performed and allowed to heal several months before implantation surgery. A new panoramic X-ray will help determine if the graft was successful.

This is an important step inasmuch as improved bone height is much more difficult to achieve than more increased bone depth. For mandibular grafts, helical cone beam computed tomography (CBCT) enables measurement of bone height (top to bottom), width (left and right) and depth (front to back) to an accuracy of 0.1mm or better. The precision of cone beam has stimulated a new industry that produces computer-designed surgical guides based on the cone beam X-ray's digital data. These surgery aids are employed by implantologists to precisely locate and drill into the mandible and maxilla, and to avoid vital structures.

Uncontrolled type II diabetes is a significant relative contraindication as healing following any type of surgical procedure is delayed due to poor peripheral blood circulation. Anatomic considerations include the volume and height of bone available. Often an ancillary procedure known as a block graft or sinus augmentation are needed to provide enough bone for successful implant placement.

There is new information about intravenous and oral bisphosphonates (taken for certain forms of breast cancer and osteoporosis, respectively) which may put patients at a higher risk of developing a delayed healing syndrome called osteonecrosis. Implants are contraindicated for some patients who take intravenous bisphosphonates.

The many millions of patients who take an oral bisphosphonate (such as Actonel, Fosamax and Boniva) may be advised to stop the administration prior to implant surgery, then resume several months later. But this protocol may not be necessary. As of January, 2008, an oral bisphosphonate study reported in the February 2008 Journal of Oral and Maxillofacial Surgery, reviewing 115 cases that included 468 implants, concluded "There is no evidence of bisphosphonate-associated osteonecrosis of the jaw in any of the patients evaluated in the clinic and those contacted by phone or e-mail reported no symptoms." (JOMS, Volume 66, Issue 2, Ppgs 223-230).

The American Dental Association had addressed bisphosphonates in an article entitled "Bisphosphonate medications and your oral health," (JADA, Vol. 137, page 1048, July 2006.) In an Overview, the ADA stated "The risk of developing BON [bisphosphonate-associated osteonecrosis of the jaw] in patients on oral bisphosphonate therapy appears to be very low...". The ADA Council on Scientific Affairs also employed a panel of experts who issued recommendations [for clinicians] for treatment of patients on oral bisphosphonates, published in June, 2006. The overview may be read online at but it has now been superseded by a huge study—encompassing over 700,000 cases—entitled "Bisphosphonate Use and the Risk of Adverse Jaw Outcomes." Like the 2008 JOMS study, the ADA study exonerates oral bisphosphonates as a contraindication to dental implants. (JADA, January 2008, 139:23-30).

Bruxism (tooth clenching or grinding) is another contraindication. The forces generated during bruxism are particularly detrimental to implants while bone is healing; micromovements in the implant positioning are associated with increased rates of implant failure. Bruxism continues to pose a threat to implants throughout the life of the recipient. Natural teeth contain a periodontal ligament allowing each tooth to move and absorb shock in response to vertical and horizontal forces. Once replaced by dental implants, this ligament is lost and teeth are immovably anchored directly into the jaw bone. This problem can be minimized by wearing a custom made mouthguard (such an NTI appliance) at night.

Postoperatively, after implants have been placed, there are physical contraindications that prompt rapid action by the implantology team. Excessive or severe pain lasting more than three days is a warning sign, as is excessive bleeding. Constant numbness of the gingiva (gum), lip and chin—usually noticed after surgical anesthesia wears off—is another warning sign. In the latter case, which may be accompanied by severe constant pain, the standard of care calls for diagnosis to determine if the surgical procedure insulted the IAN. A 3D cone beam X-ray provides the necessary data, but even before this step a prudent implantologist may back out or completely remove an implant in an effort to restore nerve function because delay is usually ineffective. Depending upon the evidence visible with a 3D X-ray, patients may be referred to a specialist in nerve repair. In all cases, speed in diagnosis and treatment are necessary.

    see the original article with all citations and references here:  
  Bone loss

Bone loss is the end result of tooth loss unless the tooth root
is replaced by a dental implant.

    Preserve bone with dental implants - the tooth replacement as close to natural teeth as possible.  
missing tooth
    Anterior teeth in place

Missing tooth root leads
to bone loss

Bone melts away where
tooth is missing, leaving a visible defect


bone loss : all teeth in place  
    Posterior teeth in place Bone begins to deterioate where posterior teeth are missing Bone loss over time can be significant  
    Teeth in place in lower jaw

complete tooth loss causes
the jaw to shrink

Significant bone deterioration leads to facial structure collapse  
    illustrations and text by Nobel Biocare  
     For "bone loss" caused by a periodontal desease refer to the periodontitis section here :  
toppen Periodontitis

see the original article with all citations and references here:


Information in Norwegian :


Periodontitis (peri = around, odont = tooth, -itis = inflammation) refers to a number of inflammatory diseases affecting the periodontium — that is, the tissues that surround and support the teeth. Periodontitis involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent loss of teeth. Periodontitis is caused by bacteria that adhere to and grow on the tooth's surfaces, along with an overly aggressive immune response against these bacteria. A diagnosis of periodontitis is established by inspecting the soft gum tissues around the teeth with a probe and radiographs by visual analysis, to determine the amount of bone loss around the teeth. Specialists in the treatment of periodontitis are periodontists; their field is known as "periodontology" and "periodontics".

Chronic Periodontitis, the most common form of the disease, progresses relatively slowly and typically becomes clinically evident in adulthood. Aggressive Periodontitis is a rarer form, but as its name implies, progresses more rapidly and becomes clinically evident in adolescence. Although the different forms of periodontitis are all caused by bacterial infections, a variety of factors affect the severity of the disease. Important "risk factors" include smoking, poorly-controlled diabetes, and inherited (genetic) susceptibility.


Periodontitis is very common, and is widely regarded as the second most common disease worldwide, after dental decay, and in the United States has a prevalence of 30-50% of the population, but only about 10% have severe forms.

Studies found an association between ethnic origin and periodontal diseases. In the USA, African-Americans have a higher prevalence of periodontal disease compared with Latin individuals as well as non-Hispanic people of European descent. In Israeli population, individuals of Yemenite, North-African, Asian, or Mediterranean origin have higher prevalence of periodontal disease than individuals from European descent. This could be attributed to genetic predisposition as well as social-cultural-behavioral differences (eg., smoking, oral hygiene, access to dental treatment) between populations.


Periodontitis is an inflammation of the periodontium—the tissues that support the teeth. The periodontium consists of four tissues: the gingiva, or gum tissue; the cementum, or outer layer of the roots of teeth; the alveolar bone, or the bony sockets into which the teeth are anchored; the periodontal ligaments (PDLs), which are the connective tissue fibers that run between the cementum and the alveolar bone. This X-ray film displays two lone-standing mandibular teeth, the lower left first premolar and canine, exhibiting severe bone loss of 30-50%. Widening of the PDL surrounding the premolar is due to secondary occlusal trauma.

The primary etiology, or cause, of gingivitis is poor oral hygiene which leads to the accumulation of a bacterial matrix at the gum line, called dental plaque. Other contributors are poor nutrition and underlying medical issues such as diabetes. New FDA-approved finger nick tests are being used in dental offices to identify and screen patients for possible contributory causes of gum disease such as diabetes. In some people, gingivitis progresses to periodontitis - with the destruction of the gingival fibers, the gum tissues separate from the tooth and deepened sulcus, called a periodontal pocket. Subgingival bacteria (those that exist under the gum line) colonize the periodontal pockets and cause further inflammation in the gum tissues and progressive bone loss. Examples of secondary etiology would be those things that, by definition, cause plaque accumulation, such as restoration overhangs and root proximity. The excess restorative material that exceeds the natural contours of restored teeth, such as these, are termed "overhangs", and serve to trap plaque, potentially leading to localized periodontitis.

If left undisturbed, bacterial plaque calcifies to form calculus, which is commonly called tartar. Calculus above and below the gum line must be removed completely by the dental hygienist or dentist to treat gingivitis and periodontitis. Although the primary cause of both gingivitis and periodontitis is the bacterial plaque that adheres to the tooth surface, there are many other modifying factors. A very strong risk factor is one's genetic susceptibility. Several conditions and diseases, including Down syndrome, diabetes, and other diseases that affect one's resistance to infection also increase susceptibility to periodontitis.

Another factor that makes periodontitis a difficult disease to study is that human host response can also affect the alveolar bone resorption. Host response to the bacterial insult is mainly determined by genetics; however, immune development may play some role in susceptibility.


Signs and symptoms
In the early stages, Periodontitis has very few symptoms and in many individuals the disease has progressed significantly before they seek treatment. Symptoms may include the following: Redness or bleeding of gums while brushing teeth, using dental floss or biting into hard food (e.g. apples) (though this may occur even in gingivitis, where there is no attachment loss) Gum swelling that recurs Halitosis, or bad breath, and a persistent metallic taste in the mouth Gingival recession, resulting in apparent lengthening of teeth. (This may also be caused by heavy handed brushing or with a stiff tooth brush.) Deep pockets between the teeth and the gums (pockets are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as collagenases) Loose teeth, in the later stages (though this may occur for other reasons as well)

Patients should realize that the gingival inflammation and bone destruction are largely painless. Hence, people may wrongly assume that painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient.


Daily oral hygiene measures to prevent periodontal disease include: Brushing properly on a regular basis (at least twice daily), with the patient attempting to direct the toothbrush bristles underneath the gum-line, so as to help disrupt the bacterial growth and formation of subgingival plaque. Flossing daily and using interdental brushes (if there is a sufficiently large space between teeth), as well as cleaning behind the last tooth in each quarter. Using an antiseptic mouthwash. Chlorhexidine gluconate based mouthwash in combination with careful oral hygiene may cure gingivitis, although they cannot reverse any attachment loss due to periodontitis. Always use a 'soft' tooth brush to prevent causing damage to your tooth enamel and sensitive gums. Using periodontal trays to maintain dentist-prescribed medications at the source of the disease. The use of trays allows the medication to stay in place long enough to penetrate the biofilms where the bacteria are found. Regular dental check-ups and professional teeth cleaning as required. Dental check-ups serve to monitor the person's oral hygiene methods and levels of attachment around teeth, identify any early signs of periodontitis, and monitor response to treatment.

Typically dental hygienists (or dentists) use special instruments to clean (debride) teeth below the gumline and disrupt any plaque growing below the gumline. This is a standard treatment to prevent any further progress of established periodontitis. Studies show that after such a professional cleaning (periodontal debridement), bacteria and plaque tend to grow back to pre-cleaning levels after about 3–4 months. Hence, in theory, cleanings every 3–4 months might be expected to also prevent the initial onset of periodontitis. However, analysis of published research has reported little evidence either to support this or the intervals at which this should occur.[2] Instead it is advocated that the interval between dental check-ups should be determined specifically for each patient between every 3 to 24 months.

Nonetheless, the continued stabilization of a patient's periodontal state depends largely, if not primarily, on the patient's oral hygiene at home if not on the go too. Without daily oral hygiene, periodontal disease will not be overcome, especially if the patient has a history of extensive periodontal disease.

A contributing cause may be low [selenium] in the diet: "Results showed that selenium has the strongest association with gum disease, with low levels increasing the risk by 13 fold."

for bone loss
bone loss  
    This section from a panoramic X-ray film depicts the teeth of the lower left quadrant, exhibiting generalized severe bone loss of 30-80%. The red line depicts the existing bone level, whereas the yellow line depicts where the bone was originally, prior to the patient developing periodontal disease. The pink arrow, on the right, points to a furcation involvement, or the loss of enough bone to reveal the location at which the individual roots of a molar begin to branch from the single root trunk; this is a sign of advanced periodontal disease. The blue arrow, in the middle, shows up to 80% bone loss on tooth #21, and clinically, this tooth exhibited gross mobility. Finally, the peach oval, to the left, highlights the aggressive nature with which periodontal disease generally affects mandibular incisors. Because their roots are generally situated very close to each other, with minimal interproximal bone, and because of their location in the mouth, where plaque and calculus accumulation is greatest because of the pooling of saliva, mandibular anteriors suffer excessively. The split in the red line depicts varying densities of bone that contribute to a vague region of definitive bone height.  

Treatment of established disease
This section from a panoramic X-ray film depicts the teeth of the lower left quadrant, exhibiting generalized severe bone loss of 30-80%. The red line depicts the existing bone level, whereas the yellow line depicts where the bone was originally, prior to the patient developing periodontal disease. The pink arrow, on the right, points to a furcation involvement, or the loss of enough bone to reveal the location at which the individual roots of a molar begin to branch from the single root trunk; this is a sign of advanced periodontal disease. The blue arrow, in the middle, shows up to 80% bone loss on tooth #21, and clinically, this tooth exhibited gross mobility. Finally, the peach oval, to the left, highlights the aggressive nature with which periodontal disease generally affects mandibular incisors. Because their roots are generally situated very close to each other, with minimal interproximal bone, and because of their location in the mouth, where plaque and calculus accumulation is greatest because of the pooling of saliva, mandibular anteriors suffer excessively. The split in the red line depicts varying densities of bone that contribute to a vague region of definitive bone height.

The cornerstone of successful periodontal treatment starts with establishing excellent oral hygiene. This includes twice daily brushing with daily flossing. Also the use of an interdental brush (called a Proxi-brush) is helpful if space between the teeth allows. Persons with dexterity problems such as arthritis may find oral hygiene to be difficult and may require more frequent professional care and/or the use of a powered tooth brush. Persons with periodontitis must realize that it is a chronic inflammatory disease and a lifelong regimen of excellent hygiene and professional maintenance care with a Dentist/Hygienist or Periodontist is required to maintain affected teeth.

Initial therapy: Removal of bacterial plaque and calculus is necessary to establish periodontal health. The first step in the treatment of periodontitis involves non-surgical cleaning below the gumline with a procedure called Scaling and Debridement. In the past, Root Planing was used (removal of cemental layer as well as calculus). This procedure involves use of specialized curettes to mechanically remove plaque and calculus from below the gumline, and may require multiple visits and local anesthesia to adequately complete. In addition to initial scaling and root planing, it may also be necessary to adjust the occlusion (bite) to prevent excessive force on teeth with reduced bone support. Also it may be necessary to complete any other dental needs such as replacement of rough, plaque retentive restorations, closure of open contacts between teeth, and any other requirements diagnosed at the initial evaluation.

Reevaluation: Multiple clinical studies have shown that non-surgical scaling and root planing is usually successful in periodontal pocket depths no greater than 4-7mm (See articles by Stambaugh RV, Int J Periodontics Rest Dent, 1981 or Waerhaug J, J Periodontol, 1978). It is necessary for the dentist or hygienist to perform a reevaluation 4–6 weeks after the initial scaling and root planing, to determine if the treatment was successful in reducing pocket depths and eliminating inflammation. It has been found that pocket depths which remain after initial therapy of greater than 5-6mm with bleeding upon probing are indicative of continued active disease and will very likely show further bone loss over time. This is especially true in molar tooth sites where furcations (areas between the roots) have been exposed.

Maintenance: Once successful periodontal treatment has been completed, with or without surgery, an ongoing regimen of "periodontal maintenance" is required. This involves regular checkups and detailed cleanings every 3 months to prevent repopulation of periodontitis-causing bacteria, and to closely monitor affected teeth so that early treatment can be rendered if disease recurs. Usually periodontal disease exist due to poor plaque control, therefore if the brushing techniques are not modified, a periodontal recurrence is probable


Assessment and prognosis
Dentists and dental hygienists "measure" periodontal disease using a device called a periodontal probe. This is a thin "measuring stick" that is gently placed into the space between the gums and the teeth, and slipped below the gum-line. If the probe can slip more than 3 millimetres length below the gum-line, the patient is said to have a "gingival pocket" around that tooth. This is somewhat of a misnomer, as any depth is in essence a pocket, which in turn is defined by its depth, i.e., a 2 mm pocket or a 6 mm pocket. However, it is generally accepted that pockets are self-cleansable (at home, by the patient, with a toothbrush) if they are 3 mm or less in depth. This is important because if there is a pocket which is deeper than 3 mm around the tooth, at-home care will not be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach 6 and 7 mm in depth, the hand instruments and cavitrons used by the dental professionals may not reach deeply enough into the pocket to clean out the bacterial plaque that cause gingival inflammation. In such a situation the bone or the gums around that tooth should be surgically altered or it will always have inflammation which will likely result in more bone loss around that tooth. An additional way to stop the inflammation would be for the patient to receive subgingival antibiotics (such as Arestin) or undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so that they become 3 or less mm in depth and can once again be properly cleaned by the patient at home with his or her toothbrush.

If a patient has 7 mm or deeper pockets around their teeth, then they would likely risk eventual tooth loss over the years. If this periodontal condition is not identified and the patient remains unaware of the progressive nature of the disease then, years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain.

According to the Sri Lankan Tea Labourer study, in the absence of any oral hygiene activity, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment (>2 mm/year). 80% will suffer from moderate loss (1-2 mm/year) and the remaining 10% will not suffer any loss.


Alternative Treatments
Periodontitis has an inescapable relationship with subgingival calculus (tartar). The first step in any procedure is to eliminate calculus under the gum line, as it houses destructive anaerobic bacteria that consume bone, gum and cementum (connective tissue) for food.

Most alternative “at-home” gum disease treatments involve injecting anti-microbial solutions, such as hydrogen peroxide, into periodontal pockets via slender applicators or oral irrigators. This process disrupts anaerobic bacteria colonies and is effective at reducing infections and inflammation when used daily. There are any number of potions and elixirs that are commercially available which are functionally equivalent to hydrogen peroxide; only at substantially higher cost. These treatments, however, do not address calculus formations, and are therefore short-lived, as anaerobic bacteria colonies quickly regenerate in and around calculus.

In a new field of study, calculus formations are addressed on a more fundamental level. At the heart of the formation of subgingival calculus, growing plaque formations starve out the lowest members of the community, which calcify into calcium phosphate salts of the same shape and size of the original, organic bacilli. Calcium phosphate salts (unlike calcium phosphate; the primary component in teeth) are ionic and adhere to tooth surfaces via electrostatic attraction. Smaller, free floating calcium phosphate salt particles are equally attracted to the same areas, as are additional calcified bacteria, growing calculus formations as unorganized, yet strong, “brick and mortar” matrices. The microscopic voids in calculus formations house new anaerobic bacteria, as does the top “diseased layer”.

Because the root cause of subgingival calculus development is ionic attraction, it was hypothesized that the introduction of oppositely charged particles around the formations may chelate calcium phosphate salt components away from the matrix, thus actually reducing the size of subgingival calculus formations.

To accomplish this, a sequestering agent solution comprised partly of Sodium Tripolyphosphate (STPP) and Sodium Fluoride (charge -1) was tested on a patient with burnished and new subgingival calculus at a depth of 6mm. The patient delivered the solution using an oral irrigator, once a day, for sixty days. The results of this test were the successful elimination of all calculus formations studied. This test was conducted using a subgingival endoscopic camera (Perioscope) by an independent periodontist.

The promise of this new, alternative treatment is to keep subgingival calculus at bay, in concert with traditional periodontal treatments. In this way, periodontitis may be controlled by the patient, with complete restoration of dental health being a collaborative effort between the patient and the dental professional.

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