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==Management== [[File:Generalized perio -touched up.jpg|thumb|right|This section from a panoramic [[radiograph|X-ray film]] depicts the teeth of the lower left quadrant, exhibiting generalized severe bone loss of 30β80%. The ''red line'' depicts the existing bone level, whereas the ''yellow line'' depicts where the gingiva was located originally (1β2 mm above the bone), prior to the person developing periodontal disease. The ''pink arrow'', on the right, points to a [[Furcation defect|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 No. 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 [[Commonly used terms of relationship and comparison in dentistry|interproximal]] bone, and because of their location in the mouth, where plaque and calculus accumulation is greatest because of the pooling of [[saliva]],{{Citation needed|date=December 2011}} mandibular anteriors are affected 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 [[toothbrush|brushing]] with daily [[flossing]]. Also, the use of an [[interdental brush]] is helpful if space between the teeth allows. For smaller spaces, products such as narrow picks with soft rubber bristles provide excellent manual cleaning. Persons with dexterity problems, such as with [[arthritis]], may find oral hygiene to be difficult and may require more frequent professional care and/or the use of a powered toothbrush. Persons with periodontitis must realize 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 microbial plaque and calculus is necessary to establish periodontal health. The first step in the treatment of periodontitis involves nonsurgical cleaning below the gum line with a procedure called "root surface instrumentation" or "RSI", this causes a mechanical disturbance to the bacterial biofilm below the gumline.<ref name=Preshaw04/> This procedure involves the 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 RSI, it may also be necessary to adjust the occlusion (bite) to prevent excessive force on teeth that have 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. It is important to note that RSI is different to [[scaling and root planing]]: RSI only removes the [[Calculus (dental)|calculus]], while scaling and root planing removes the calculus as well as underlying softened [[dentin]]e, which leaves behind a smooth and glassy surface, which is not a requisite for periodontal healing. Therefore, RSI is now advocated over root planing.<ref name=Preshaw04/> ===Reevaluation=== Nonsurgical [[scaling and root planing]] are usually successful if the periodontal pockets are shallower than {{convert|4|β|5|mm|abbr=on}}.<ref>{{cite journal | vauthors = Stambaugh RV, Dragoo M, Smith DM, Carasali L | title = The limits of subgingival scaling | journal = The International Journal of Periodontics & Restorative Dentistry | volume = 1 | issue = 5 | pages = 30β41 | year = 1981 | pmid = 7047434 }}</ref><ref>{{cite journal | vauthors = Waerhaug J | title = Healing of the dento-epithelial junction following subgingival plaque control. I. As observed in human biopsy material | journal = Journal of Periodontology | volume = 49 | issue = 1 | pages = 1β8 | date = January 1978 | pmid = 340634 | doi = 10.1902/jop.1978.49.1.1 }}</ref><ref>{{cite journal | vauthors = Waerhaug J | title = Healing of the dento-epithelial junction following subgingival plaque control. II: As observed on extracted teeth | journal = Journal of Periodontology | volume = 49 | issue = 3 | pages = 119β34 | date = March 1978 | pmid = 288899 | doi = 10.1902/jop.1978.49.3.119 }}</ref> The dentist or hygienist must perform a re-evaluation four to six weeks after the initial scaling and root planing, to determine if the person's oral hygiene has improved and inflammation has regressed. Probing should be avoided then, and an analysis by gingival index should determine the presence or absence of inflammation. The monthly reevaluation of periodontal therapy should involve periodontal charting as a better indication of the success of treatment, and to see if other courses of treatment can be identified. Pocket depths of greater than {{convert|5|β|6|mm|abbr=on}} which remain after initial therapy, with bleeding upon probing, indicate continued active disease and will very likely lead to further bone loss over time. This is especially true in [[molar (tooth)|molar]] tooth sites where [[Furcation defect|furcations]] (areas between the roots) have been exposed. ===Surgery=== If nonsurgical therapy is found to have been unsuccessful in managing signs of disease activity, periodontal surgery may be needed to stop progressive bone loss and regenerate lost bone where possible. Many surgical approaches are used in the treatment of advanced periodontitis, including open flap debridement and osseous surgery, as well as guided tissue regeneration and bone grafting. The goal of periodontal surgery is access for definitive calculus removal and surgical management of bony irregularities which have resulted from the disease process to reduce pockets as much as possible. Long-term studies have shown, in moderate to advanced periodontitis, surgically treated cases often have less further breakdown over time and, when coupled with a regular post-treatment maintenance regimen, are successful in nearly halting tooth loss in nearly 85% of diagnosed people.<ref>{{cite journal | vauthors = Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK | title = Long-term evaluation of periodontal therapy: II. Incidence of sites breaking down | journal = Journal of Periodontology | volume = 67 | issue = 2 | pages = 103β8 | date = February 1996 | pmid = 8667129 | doi = 10.1902/jop.1996.67.2.103 }}</ref><ref>{{cite journal | vauthors = Hirschfeld L, Wasserman B | title = A long-term survey of tooth loss in 600 treated periodontal patients | journal = Journal of Periodontology | volume = 49 | issue = 5 | pages = 225β37 | date = May 1978 | pmid = 277674 | doi = 10.1902/jop.1978.49.5.225 }}</ref> ===Local drug delivery=== Local drug deliveries in periodontology has gained acceptance and popularity compared to systemic drugs due to decreased risk in development of resistant flora and other side effects.<ref>{{cite journal | vauthors = Kalsi R, Vandana KL, Prakash S | title = Effect of local drug delivery in chronic periodontitis patients: A meta-analysis | journal = Journal of Indian Society of Periodontology | volume = 15 | issue = 4 | pages = 304β9 | date = October 2011 | pmid = 22368351 | pmc = 3283924 | doi = 10.4103/0972-124X.92559 | doi-access = free }}</ref> A meta analysis of local tetracycline found improvement.<ref name="pmid29238136">{{cite journal | vauthors = Nadig PS, Shah MA | title = Tetracycline as local drug delivery in treatment of chronic periodontitis: A systematic review and meta-analysis | journal = Journal of Indian Society of Periodontology | volume = 20 | issue = 6 | pages = 576β583 | year = 2016 | pmid = 29238136 | pmc = 5713079 | doi = 10.4103/jisp.jisp_97_17 | doi-access = free }}</ref> Local application of [[statin]] may be useful.<ref>{{cite journal | vauthors = Bertl K, Parllaku A, Pandis N, Buhlin K, Klinge B, Stavropoulos A | title = The effect of local and systemic statin use as an adjunct to non-surgical and surgical periodontal therapy-A systematic review and meta-analysis | journal = Journal of Dentistry | volume = 67 | pages = 18β28 | date = December 2017 | pmid = 28855141 | doi = 10.1016/j.jdent.2017.08.011 | hdl = 2043/23307 | url = http://urn.kb.se/resolve?urn=urn:nbn:se:mau:diva-16218 | hdl-access = free }}</ref> ===Systemic drug delivery=== Systemic drug delivery in conjunction with non-surgical therapy may be used as a means to reduce the percentage of the bacterial plaque load in the mouth. Many different antibiotics and also combinations of them have been tested; however, there is yet very low-certainty evidence of any significant difference in the short and long term compared to non-surgical therapy alone. It may be beneficial to limit the use of systemic drugs, since bacteria can develop antimicrobial resistance and some specific antibiotics might induce temporary mild adverse effects, such as nausea, diarrhoea and gastrointestinal disturbances.<ref name=Khattri20>{{cite journal | vauthors = Khattri S, Kumbargere Nagraj S, Arora A, Eachempati P, Kusum CK, Bhat KG, Johnson TM, Lodi G | title = Adjunctive systemic antimicrobials for the non-surgical treatment of periodontitis. | journal = Cochrane Database of Systematic Reviews | issue = 11 | pages = 1465β1858 | year = 2020 | volume = 2020 | id = CD012568 | doi = 10.1002/14651858.CD012568.pub2| pmid = 33197289 | pmc = 9166531 | s2cid = 226990528 }}</ref> === Adjunctive systemic antimicrobial treatment === There is currently low-quality evidence suggesting if adjunctive systemic antimicrobials are beneficial for the non-surgical treatment of periodontitis.<ref name=Khattri20/> It is not sure whether some antibiotics are better than others when used alongside scaling and root planing). ===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 three months to prevent repopulation of periodontitis-causing microorganisms, and to closely monitor affected teeth so early treatment can be rendered if the disease recurs. Usually, periodontal disease exists due to poor plaque control resulting from inappropriate brushing. Therefore, if the brushing techniques are not modified, a periodontal recurrence is probable. === Other === Most alternative "at-home" gum disease treatments involve injecting antimicrobial solutions, such as [[hydrogen peroxide]], into periodontal pockets via slender applicators or oral irrigators. This process disrupts anaerobic micro-organism colonies and is effective at reducing infections and inflammation when used daily. A number of other products, functionally equivalent to hydrogen peroxide, are commercially available, but at substantially higher cost. However, such treatments do not address calculus formations, and so are short-lived, as anaerobic microbial colonies quickly regenerate in and around calculus. [[Doxycycline]] may be given [[Adjuvant therapy|alongside the primary therapy]] of scaling (see [[#Initial therapy|Β§ initial therapy]]).<ref name="caton2011">{{cite journal | vauthors = Caton J, Ryan ME | title = Clinical studies on the management of periodontal diseases utilizing subantimicrobial dose doxycycline (SDD) | journal = Pharmacological Research | volume = 63 | issue = 2 | pages = 114β20 | date = February 2011 | pmid = 21182947 | doi = 10.1016/j.phrs.2010.12.003 }}</ref> Doxycycline has been shown to improve indicators of disease progression (namely probing depth and attachment level).<ref name="caton2011" /> Its mechanism of action involves inhibition of matrix metalloproteinases (such as collagenase), which degrade the teeth's supporting tissues ([[periodontium]]) under inflammatory conditions.<ref name="caton2011" /> To avoid killing beneficial [[Oral microbiology|oral microbes]], only small doses of doxycycline (20 mg) are used.<ref name="caton2011" /> [[Phage therapy]] may be a new therapeutic alternative.<ref>{{cite journal |vauthors=Steier L, de Oliveira SD, de Figueiredo JA |title=Bacteriophages in Dentistry-State of the Art and Perspectives |journal=Dent J |volume=7 |issue=1 |pages=6 |date=January 2019 |pmid=30634460 |pmc=6473837 |doi=10.3390/dj7010006 |doi-access=free}}</ref>
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