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In our minds, bone loss is synonymous with periodontal disease. It has been drilled into us via multiple choice exam after multiple choice exam in dental or dental hygiene school, it is repeated in conferences, continuing education, and almost every forum of discussion around periodontal disease. Bone loss, specifically radiographic bone loss, has become so indicative of periodontal disease percentage of radiographic bone loss was included as a diagnostic indicator in the 2017 World Workshop on the classification of periodontal disease. We know that it is bone loss that distinguishes gingivitis from periodontitis. Gingivitis is the mildest form of gum disease with clinical indicators such as bleeding, swelling, and redness. Our landmark studies demonstrate that gingivitis is reversible with plaque control, home care, and improved hygiene, but once the line is crossed to periodontal disease and bone loss is clinically detectable, professional intervention is necessary for resolution. What is the root cause of bone disease associated with periodontitis, what are steps that we can take as clinicians to prevent this, how can we intervene once it is present and what can we do to help set up successful patient outcomes?
From 10,000 feet periodontal disease is chronic inflammation gone unchecked, its clinical presentation and symptoms resulting from the host response to an unresolved insulting factor. Inflammation as a whole is not a bad thing, it is our body's internal guidance system alerting us when something is wrong. Inflammation is a process driven by our cells in response to signals from our body when there is a need to fend off a perceived injury, insult, or intrusion. The acute arm of inflammation lets us know when something is injured for example a cut foot may be tender or swollen signaling that it is best to not overuse that part of our body so it may heal. Acute inflammation is healthy, acute inflammation is resolvable, it is the other arm of inflammation, chronic inflammation, that is destructive. Chronic inflammation occurs when the body fails to remove the insulting factors and through all its attempts to do so the host begins to injure itself and the chronic inflammatory cycle begins. Chronic inflammation is at the heart of periodontal disease the insulting factor being bacteria biofilm either in itself or intimately ingrained in calculus.
In chronic periodontal lesions, we see a breakdown of the periodontal ligament, edema, ulcerations in the pocket epithelial lining, and apical migration of the pathogenic insulting bacteria. On a cellular level there is an increase in neutrophils and macrophages, our hosts’ response team to this unwavering chronic bacterial insult. On a biochemical level, there is an increase in pro-inflammatory cytokines (IL-1 and TNF-alpha being key players) and proteinases, of specific note MMPs (Matrix Metalloproteinases). MMPs are collagenases capable of degrading the collagen in bone. The mechanism of bone loss also includes the enhancement of osteoclast activity and weakening of osteoblast activity, both changes exacerbate the progressive destruction of the alveolar bone. Understanding the mechanism of action and cause of this destruction is important but we must not lose sight of what is responsible for the host response in the first place, the pathogenic biofilm.
The professional intervention that we provide as clinicians for our patients begins by removing the insult and injury that the body was not able to eliminate on its own. At its core removal of the insulting factor would prevent the progression of periodontal disease often this is easier said than done. Once we remove the insulting factor in many cases we are left with damage that needs to be repaired because mere elimination of the causative factor will not set our patients up for success. We must both treat them and leave them with an oral environment less susceptible to the recurrence of disease. As clinicians, we must also consider the impact of local factors (overhanging margins, tooth position, anatomical features) and systemic factors specifically smoking and diabetes on the disease progression.
When selecting a treatment intervention for periodontal disease it is best to begin with a comprehensive exam including radiographs, periodontal charting, intraoral exam, and a comprehensive medical and dental history. Once findings have been collected, the establishment of the stage and grade of periodontal disease will further guide treatment intervention selection. Milder forms of periodontal disease can be addressed with scaling and root planning, scaling and root planning in conjunction with local or systemic antibiotics and even scaling and root planning in conjunction with dental lasers used for bacterial reduction. As the disease becomes more severe our interventions become more aggressive and invasive.
Treatment options can include osseous surgery, guided bone and tissue regeneration, tooth extraction, and replacement. It is of note that there are treatment intervention options capable of treating more severe forms of periodontal disease with less invasive methodologies such as Laser Assisted New Attachment Procedure (LANAP). LANAP is the only laser-assisted periodontal mono-therapy protocol that is FDA-cleared for true regeneration, formation of new cementum, periodontal ligament, and alveolar bone. Once treatment intervention is completed regardless of the treatment executed it is imperative that we bring our patients back for follow-up and assessment of the effectiveness of the chosen course of treatment, course correcting if necessary. These follow-up exams should include the same data collection as our initial comprehensive evaluation. The establishment of periodontal maintenance programs to prevent the recurrence of the disease that include routine visits to a dental professional partnered with adequate home care and ongoing motivation and home care instruction are necessary for successful treatment outcomes. In cases where systemic impacts are partnering with the patient and their physician may also be necessary. Finally identifying any other local factors that are preventing adequate plaque control which may need correction and addressing them will further set up you and your patient for long-term success.
The relationship between bone loss and periodontal disease is deeply intertwined,
with bone loss serving as a hallmark indicator of disease progression. As clinicians, it is helpful to understand the root causes of periodontal disease, inflammation, and bone loss. By understanding the etiology of periodontal disease progression, addressing both local and systemic factors, ensuring thorough plaque control, and partnering with patients, and their physicians when necessary, we can optimize treatment outcomes and promote long-term oral health for our patients.
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