Board Certified Periodontist

73 – Two Ways to Heal Periodontal Disease

Hi there. You are listening to the Perio Patient Podcast, a podcast for my patients and anyone else who cares to listen. Dr. Ben Young here, and I am a periodontist in private practice in the beautiful city of San Antonio, Texas.  

The title of this podcast is: Two Ways to Heal Periodontal Disease 

I hope the title caught your attention because that’s its purpose. The problem with titles, as you certainly know, is that they obviously cannot explain everything someone means to talk about within the space of a title. So, there is a possibility for misunderstanding. On the other hand, as I tried other titles, I found that the words I was selecting were very complicated. Let me give you an example of what you might have seen: How is this for a title? The Difference Between Repair and Regeneration.  

We will be talking about these concepts, but most people would have to really stretch their brains if this was the title to figure out before listening to me what they mean.  

You might come up with something and you might not, but it can be annoying – that’s at least how I feel when I encounter a title to something that I don’t understand AND, this is very important, I’m not sure I really care about. I completely understand that I am not necessarily competing with other topics around the same subject. I am competing with the other possibly more interesting things you could be doing with your time right now. So I will certainly try to keep this as interesting as I possibly can.  

The title: Two ways to heal periodontal disease — I hope, at least motivates you to listen, especially if you have or have had gum problems and are now investing in more time and money than you might have in the past, to not get it again or control it as best you can.  

It’s at least one good reason why people, especially patients, listen to any of my podcasts – they are to help keep their minds in the game a little because it is so easy for all of us to become absorbed in the daily urgent items on all of our to do lists. The things that seem to scream the loudest for our immediate attention.  

My podcast is to at least keep a little pilot-light on in the back of your mind that your health is important too. That it’s important, not only for those you care about, but for yourself, that you take care of yourself. It isn’t a selfish act. I’ve talked about that concept a time or two before. 

Little things, like teeth, because they are connected to the rest of you, can, when they have problems, affect your overall quality of life. This is why prevention is so important, and more importantly – is possible. “Bad teeth and gums” are certainly a problem but they don’t need to be accepted as just the way life is. You have to resist anything in your mind that seems to want you to cave into living in an unhealthy way. Can these things be solved overnight? Usually not, but it is the path you and I need to be on, to continually be wanting to improve – and listening for encouragement wherever we can find it.  

So now, the two ways to heal periodontal disease are by repair or regeneration.  

I know it sounds complicated, but remember how I started my talk about periodontal disease entitled “A Tooth Has Four Parts.” Do you recall why I gave it this title? It was to help anyone – any of my students and anyone on my team to be able explain to patients clearly and accurately what they need to know about periodontal disease. The title would tell them where to start.  

A tooth has four parts. Which means that it isn’t that complicated – it doesn’t have millions of parts, it can be explained. And in fact, if I can explain to you the four parts of a tooth, I can take it to the next level and explain to you the two ways we are trying to heal and correct or recover from periodontal tissue destruction.  

So, the four parts of a tooth are enamel, dentin, the pulp chamber or canal with the fourth one being the one no one outside of dentistry or the anatomic sciences or my particular patients know anything about. You should, unless this is your first visit to my podcast, understand that cementum is the microscopic layer that surrounds the root. If you want to review all this, go to my website: 

Under the microscope cementum looks a lot like bone – so it isn’t dentin, it comes from a different cell line embryonically.  

I was with a number of new dental students the other evening at a Christian Medical and Dental Associations local bible study and I asked them what lectures they had attended that day. They have at this point only been in school about one week.  

Guess what they were studying? Embryology – more specifically, the embryology of all the structures of the head and neck – and even more specifically – all the parts of the tooth as well as the surrounding structures.  

Now I know, this sounds like diving into the deep end of the pool of information about dentistry – which is what they are having to do – but there is a shallow end – the side of the pool I’m inviting you to wade into just a little with me – and to appreciate that all the parts of your body grew from certain cell lines that can be traced back all the way to the egg and the sperm of your parents. From there, going forward in time, they begin to divide and differentiate – meaning take on the unique characteristics of where they will operate within your body. How do they do this? Every cell as it is created through this division process, receives a copy of DNA that will reside within its nucleous. The DNA contains the master plan of your entire body – everything required for you to grow and survive. The differentiation of cells occurs, because there are interactions within the cell as well as between the cells that turn on and off particular parts of the DNA that will be activated. In other words, embryonic cells have the potential of becoming dentin or heart muscle, but as they divide and differentiate certain biochemical events occur that cause the cells in the heart to do what they are supposed to do and the cells in and around teeth to do what they are supposed to do. I look at it this way. What is happening is not that complicated, because it can be observed – now that we have methods of viewing things the naked eye is incapable of seeing – even though it is extremely complicated in understanding how this takes place and what all the influences are to bring this about.  

So let’s talk a moment about the differentiation of parts of the tooth. 

The cells that form the dentin, which is more mineral or hard substance than it is cells, is laid down by cells that grow inward ending up within the pulp. The purpose of this pulp chamber at least in part is to nourish these particular cells which are given the name: “Odontoblasts.” Because of these cells dentin can continue to grow throughout life – not that it necessarily does, but we do see that pulp chambers and canals can become smaller as people age, sometimes disappearing entirely. Usually, those teeth that have had a lot of injury have more dentin growing within the tooth because it is a way the body works to protect you against injury. 

How about enamel? The cells that formed the enamel are called “Ameloblasts” and grew toward the outside of the tooth as they laid down the hardest substance in your body made primarily of calcium and phosphate ions organized within a crystal structure called “hydroxyappetite.” We talk about this more in the podcasts having to do with fluoride. And so, again back now to the time of your development in utero, infancy and childhood, as each tooth erupted into your mouth, the cells that made the enamel were shed away – which means you and I cannot grow the enamel back. Maybe someday, but not right now. And because we cannot regenerate (there’s that word, regeneration), we have to repair it (that other word, repair). So repairing damaged teeth becomes the subject of the types and characteristics of restorative materials – which you can ask your comprehensive dentist or one of those dental students, if you happen to know any of them, all about.  

What about cementum? Now we are going to the heart of my particular specialty, periodontics.  

Unlike dentin, it was formed by cells on the outside similar to enamel, but unlike enamel, cementum has a much smaller thickness. Also, cementum, like bone, and unlike enamel and dentin, contain active cells living within it.  What I think is its most important feature, because this goes to its purpose or function, is that it holds one end of little fibers that span a space between the tooth and the bone and gums surrounding it. These fibers are also called ligaments and because they surround the tooth they are described with the term peri – which is found in Latin coming from Greek to mean “around.” Odont is the route word for “tooth.” Perio-odont – around the tooth. Periodontal disease or diseases are those maladies that destroy the function of this attachment. But with this destruction, soft tissue is also changed, and bone shrinks away, and then, eventually, if unstopped, the tooth falls out.  

The process of this destruction begins in the gums and is caused by certain bacteria living in the mouth that have in common the ability to stick to a hard surface and thicken to the point of causing, in periodontal diseases disease pathway, an inflammatory response. Essentially a war is started and the innocent civilians in the area – the body’s cells and structures created by these cells are killed off or damaged.  

With all of this preparatory information we can now talk about healing after periodontal disease destruction. Step one, stop the war. Remove the enemy combatants – the bacterial colonies we call plaque or biofilm, that have established themselves where the patient can no longer reach them, and then keep them away as long as possible by the patient stepping in and performing daily, very gentle, plaque control measures to continue to disrupt the colonies so it slows them down as long as possible.  

So now imagine that this attachment apparatus that includes the cementum on the tooth side holding fibers or ligaments that bridge a small space and attach on the other side to bone and soft tissues has now been damaged. It was damaged by the bacterial colonies in and around where the tooth and gums come together. The fibers are destroyed being lost first near where the enamel of the crown meets the root structure made of dentin with this microscopic layer of cementum and as this destruction continues the pockets grow deeper. Within the pockets now is exposed cementum that becomes contaminated by the toxins within the bacteria. These toxins can inhibit new cells to grow back over this area of the cementum. Also, remember that the cementum as well as the fibers were formed as part of embryologic development. This manner of re-formation is no longer available to us in the same way it once was.  

Which brings us to the first manner of healing we have available and this is repair. Repair is simply getting all the tissues healthy where they are and not doing anything to grow them back to where they were before the disease event occurred.  

When the attack is minor, there isn’t much lost and so repair is the reasonable option.  

From a probing standpoint, initial probes in a diseased area actually sink into the damaged tissues – that’s a good reason why it often hurts to have the probing examination at first during the active disease phase. Later, after the area heals, the same probing pressure will not be uncomfortable comparatively speaking.  

The scaling away of the tartar or calculus – which is the mineralized structure of the bacterial colonies – removes the major irritant of the disease holding much of the toxins from the dead bacteria and also colonies of bacteria that are hiding out withing the tartar or calculus.  

Simple scaling and root planing – a procedure only to be performed once a diagnosis of periodontal disease has been made, can predictably improve probing depths by two millimeters. This all is repair, not regeneration. We know this by studying the histology of treated areas and seeing that we do not return to the periodontal ligament in cementum look where disease was once present. Instead we see a different kind of attachment as a result of a certain skin cell line sticking to the surface of the dentin (remember much of the cementum has been removed with the scaling and root planing process, thus removing some of the toxins in this area). Is it all removed? No. Is all of the calculus removed after scaling and root planing? Microscopically, no. But what should have happened is that the body is able to recover and that skin cell line is then able to stick to the root closing off the pocket.  

Of course when the pocket began as 4 mm, scaling and root planing can change it to 2 mm. When the pocket is 7 mm, it can change to 5 mm – which is still a problem. Also, keep in mind, I said the improvement is on the average 2 mm, but this does not mean that for a particular area this is what will happen. This is why we have to remeasure sites later and why this becomes part of the routine for the management of periodontal disease longterm.  

So let’s talk about Regeneration.  

Regeneration is when a diseased site, after treatment, shows that cementum has returned to covering the dentin surface and that fibers are projecting from the cementum and attaching once again on the other side with bone and gum tissues.  

To prove regeneration requires studies where we can look at block sections of teeth along with bone and soft tissues and show that an area had been contaminated and then, following a particular treatment, the area has new cementum and fibers. The point here is that we cannot know clinically on patients whether or not healing has occurred by regeneration or repair. We can surmise, however, that if pockets have changed dramatically, that it is very possible that at the base of the deepest pockets, some regeneration may have occurred.  

So let me conclude with this. 

We have a number of techniques today that enhance the potential of regeneration. The first is the LANAP procedure which has the idea of regeneration within the label. Laser assisted new attachment procedure is talking about new attachment, which is another way of saying regeneration. There is another new term that is being used more today that speaks to the same result and this is LAR or laser assisted regeneration.  

How does it work? With the first laser pass, the bacteria causing the disease in the deepest depths of the pocket as well as the surrounding tissues is killed off. Then the root surface is instrumented removing the calculus and smoothing the root (this is scaling and root planing), then the resulting bleeding within the pocket is warmed by a second laser pass at a different setting. This seals the pocket which buys time for the body’s cells to begin to repair and in some cases regenerate new cementum and fibers.  

The last technology that enhances the possibility of regeneration are membranes that exclude the skin cells from growing rapidly down the root surface. Placing a membrane of a certain biologically acceptable material between bone and soft tissue during a surgical flap procedure gives the body’s bone cells time to replicate and fill in defects. It may also enhance the possibility of regenerating cementum.  

Finally, we now have the ability to draw a person’s blood, spin it down and make membranes than not only exclude the skin cells or epithelium from migrating into a defect, but also contain the individual’s white blood cells along with other growth factors that can stimulate cells to differentiate into bone, fibers and cementum.  

Well, that’s it for today. Go rest your brain.  

This has been The Perio Patient Podcast and I am still Dr. Ben Young. Thanks for listening. Bye for now.