How is periodontitis treated?

In Germany, statutory health insurance will cover the costs involved in the systematic treatment of periodontitis if it is medically necessary. Certain other conditions must be met too. For instance

• Keeping up with proper oral hygiene
• Quitting smoking
• Getting good treatment for diabetes

Before starting systematic periodontitis treatment, the dentist files a request for the statutory health insurance to cover the costs, and the health insurer makes a decision. People who need nursing care or are disabled don't need to submit a separate application.

Dentists often offer other treatments too, but you usually have to pay for them yourself. For example, they often recommend having professional teeth-cleaning before starting the actual periodontitis treatment. They also offer some treatments that aim to rebuild the tissues and bone that support the teeth (the periodontium), as well as laser treatment and photodynamic therapy.

In order for periodontitis treatment to be able to work, good oral hygiene is essential. This means thoroughly and regularly cleaning your teeth and the gaps between them, as well as taking good care of your gums. Even if the periodontitis has already led to bone loss or tooth loss, regular good oral hygiene can help to keep the rest of the teeth. This is also important if you need dentures, so they can be fixed to teeth with the healthiest possible supportive tissue.

In order to improve your oral hygiene, at the start of the treatment you will be shown how to properly use a toothbrush (electric or normal), interdental brushes and dental floss. To do so, your dentist or a specially trained dental hygienist will dye the plaque on your teeth so that you can see it and learn how to clean your teeth thoroughly. This training in oral hygiene also includes practical exercises. In Germany, the costs of this training are covered by statutory health insurers if it is part of treatment for periodontitis.

Tartar (calculus) is removed too. Known as scaling, this is done with the help of special hand-held instruments (called scalers or curettes), ultrasound devices or rotating instruments. In Germany, statutory health insurers cover the costs of tartar removal once a year. Protruding edges of fillings and crowns are smoothed down too, if necessary.

The dental practice may also offer professional teeth-cleaning, which you have to pay for yourself. This involves removing hard and soft deposits (tartar and plaque). The cleaned teeth are usually also treated with a fluoride gel or varnish.

Deep cleaning involves removing bacterial plaque and hardened deposits (tartar or calculus) that have formed below the gum line, on the surfaces of the neck of the teeth, and on the exposed roots of the teeth. A local anesthetic is typically used to numb the area beforehand. This is also known as root planing. It is done using special instruments or an ultrasound device, for instance.

Research suggests that this treatment reduces gum bleeding and can help prevent tooth loss.

Removing bacterial plaque and hard tartar with a laser, or combining conventional deep cleaning with laser therapy, might have advantages. Initial research also suggests that certain photodynamic techniques could have advantages. In photodynamic therapy, a light-sensitive dye is applied to the affected areas and then exposed to a laser beam. This causes a reaction that produces aggressive oxygen, which is meant to kill the bacteria. But it's not yet possible to draw any reliable conclusions about how effective these approaches are.

Sometimes dentists offer the following treatments too, although it's not clear whether they can help to treat periodontitis:

• Using a gel containing enamel matrix proteins. These are special proteins that are thought to help regenerate (build up) the bone that supports the teeth if periodontitis has led to bone loss.
• Using antiseptic substances (usually chlorhexidine) to stop bacteria from growing back.
• Hyperbaric oxygen therapy. This involves sitting in a pressure chamber and breathing in pure oxygen. Having more oxygen in your blood and body tissues is meant to support the healing process.

If the periodontitis is very severe, additional treatment with antibiotics (e.g. tablets) might be considered. But antibiotics won't be effective enough on their own.

Periodontitis is only treated with antibiotics if there are good reasons for doing so. Research has not yet clearly shown whether antibiotics are effective or who they can help. Some studies suggest that the antibiotic tablets reduce inflammation in the gums in people with severe periodontitis if they are used together with deep cleaning. That could help to prevent tooth loss over the long term. It is not clear whether locally applied antibiotics help.

In open surgery, the dentist makes small cuts in the gums where they are inflamed so that they can be pulled away from the teeth (flap surgery). This makes it easier for him or her to get to the root of the tooth and clean it thoroughly. Then the gums are sewn together so that they are once again snug against the teeth. A local anesthetic is needed for this procedure.

It usually takes about a week for the wound to heal. The stitches can then be removed. Sometimes the gums permanently recede somewhat after the operation, making the teeth look a bit “longer.” Part of the reason why this happens is because the inflammation and the swelling of the gums goes down.

Research hasn't shown that open surgical procedures are any more effective than "closed" deep cleaning. But more research is needed to be able to draw any reliable conclusions about the pros and cons of open surgery.

In Germany, statutory health insurances pay for an open surgical procedure to treat severe periodontitis with deep gum pockets if deep cleaning and improved oral hygiene hasn't helped enough.

The procedure can be combined with treatments that you have to pay for yourself. For instance, it's possible to combine open surgery with one of the three treatments mentioned below. But there's either a lack of good studies on the effectiveness of these combinations, or the currently available research has found that they don't have any advantages compared to deep cleaning.

• Osteoplasty: When periodontitis causes bone damage, the bones sometimes have an uneven surface with crater-like pits on them. Osteoplasty is surgery to smooth this uneven surface.
• Barrier membrane: During open surgery, the dentist can also place a special biodegradable membrane between the gums and the tooth. This is done to help bone tissue grow back. The membrane is also meant to prevent the gum tissue from attaching to the root of the tooth before the periodontium has recovered. This procedure is called guided tissue regeneration (GTR).
• Enamel matrix proteins: These growth proteins are applied to the damaged bone with the aim of encouraging the bone tissue to grow again.

In order for periodontitis treatment to be able to work, good oral hygiene afterwards is essential. It can help to prevent the disease from coming back too. You can only stop periodontitis from returning if you also take good care of your teeth and gums at home. This means brushing your teeth at least twice a day and cleaning the gaps between them with an interdental brush or dental floss.

Three to six months after having deep cleaning treatment, the dentist takes another close look at the teeth, gums and bone again to check whether the treatment has been successful. If the depth of the gum pockets hasn’t improved enough, the dentist will clean the part of the teeth under the gum line again. In other words, the "closed" deep cleaning is repeated on the affected teeth. Open surgery is typically recommended if the gum pockets are very deep.

The follow-up treatment of periodontitis is known as “supportive periodontal therapy.” It is done to check how successful the treatment has been and to help stop things from getting worse. It starts after three to six months and lasts two years. In Germany, the costs are covered by statutory health insurers. It is possible to apply for an extension – usually of up to six months. The frequency of appointments for supportive periodontal therapy will depend on how severe the periodontitis is.

These appointments involve checking how good your oral hygiene is and whether your gums bleed easily. If needed, you will be shown how to maintain and improve good oral hygiene. The supportive periodontal therapy includes professional teeth-cleaning too. Here the dentist removes plaque and tartar that have re-formed above and below the gum line. He or she also checks whether you have deep gum pockets or any loose teeth. X-rays are taken to see whether there is any bone loss.

Some people who have problems with their gums feel guilty about not doing enough for their oral hygiene or because they continue to smoke even though they know that it's bad for their teeth. They may be worried about losing teeth too.

An understanding dentist can help you and encourage you to stick to your goal of improving your oral hygiene. It is also helpful to stay well-informed and regularly talk with your dentist about how the treatment is going. That includes discussing what is working well and how you might be able to improve your oral hygiene.

Having to brush your teeth regularly, using the right technique, and remembering to use interdental brushes and dental floss can be bothersome and sometimes hard to stick to. Introducing daily dental care routines can help you keep it up. Many people say that they find it easier to maintain good oral hygiene when they see how it improves the health of their teeth and gums.