Periodontology, or also known as periodontics, is a branch of dentistry that deals with the prevention, diagnosis, and treatment of diseases that affects the gums and other supporting structures of the teeth. This specialty also deals with the treatment of dental implants and performing cosmetic periodontal procedures. These supporting structures are called periodontium (from the Greek word peri “around” and odous “teeth”), which includes the alveolar bone (part of the jaw bone that supports the teeth), cementum (tissue that connects the teeth and gums), gingiva (gums), and the periodontal ligament (supports the cementum). The specialist in this field of dentistry is known as a periodontist or periodontal specialist. These specialists are often called the “plastic surgeons of dentistry” because they can use a wide range of techniques in order to remodel soft tissue or even reshape the structure of the jaw bone.
Educational Requirements
Bachelor’s Degree
A bachelor degree is the first step into becoming a periodontist. Just like all dentists or medical professionals, an aspiring periodontist must complete a four-year (in general) pre-medical bachelor’s degree program. This period is when the strong foundation in science, instrumentation, laboratory work, and the basic understanding of the major concepts in medicine is laid. This period also provides opportunity for the student to develop the discipline and passion that they would need in order to further develop their education and career. Although there is no specific degree program required for aspiring periodontists, it is advised that the selected program chosen should at least be able to cover courses on theoretical and practical science pre-requisites that will be used to pass the Dentistry Admissions Test (DAT) and be admitted into an accredited medical school. Some dental schools require specific undergraduate courses as a pre-requisite for their program, therefore it is the student’s responsibility to ensure that all these required courses are part of his/her undergraduate coursework.
In the United States, the U.S. Secretary of Education is required to oversee accreditation and publish a list of accredited colleges and university. It is the aspiring periodontist’s responsibility to make certain that their chosen college or university for their pre-medical degree is accredited by the Department of Education and acceptable to any medical school or to the specific medical school of their choice. Aside from the accreditation, it is also necessary for the student to maintain a Grade Point Average (GPA) that is higher than the minimum requirement of their target school. In general, aspiring medical students should at least obtain a 3.0 cumulative GPA and a 3.0 or higher for all science and laboratory work. Some exclusive medical schools require a higher cumulative GPA than others so it is necessary for the aspiring medical school student to check the requirements of the school that they are planning to apply to and plan accordingly.
Maintaining a good working relationship with teachers, mentors, and course mates can also help in developing the skills needed for medical school. These people can also help in making educational decisions and serve asreferences for the required letter of recommendation. They can provide their objective remarks on the student’s ability, work ethic, potential, and overall professionalism. It is also highly recommended for the student to gain leadership experience and be exposed to the field of medicine and patient care. These experiences can be acquired through clubs and volunteer work in community health centers, medical missions, public and private hospitals, and feeding programs. In some states, a medical school adviser is available for consultations and further guidance. These advisers can provide brochures and information about the medical programs and the schools that offer it. Their advice will allow the students to plan their course of action and prepare for the financial and academic requirements of the program.
Dental Admissions Test (DAT)
The Dental Admissions Test or DAT is a test that is usually taken during the junior or the senior year of the undergraduate degree. This test usually differs from one country to another. It is used to evaluate the student's knowledge and understanding on the fundamental concepts and theories of the applicable sciences that will be needed for medical school and professional practice. It also assesses the student's problem solving and critical thinking skills. Different schools have different DAT score cutoff so it is necessary for the student to be aware of it. In some countries, DAT scores are acceptable up to three years, allowing students to take additional classes and gain more training and experience between graduating from their bachelor's degree and starting medical school. The DAT result of the student will be included to their other application requirements and will be submitted to the school or schools that they are applying to.
Dental School
After graduating from their bachelor's degree and passing the DAT, students can apply or seek acceptance into their preferred medical school. Respected medical schools are very competitive in nature. A strong academic standing with a high GPA (especially in applicable sciences) will increase the student’s chance of getting into a respectable dental school. Paired with good letters of recommendations, a high DAT score to prove their knowledge in scientific theories and principles can go a long way in ensuring a slot. In some cases, the school only accepts a certain range of DAT score that is why it is necessary for the student to familiarize with the requirements of the school they are applying to.
Dental school usually takes place over a four year period. The first two years are dedicated in doing in-class coursework to further expand their knowledge in anatomy, biology, chemistry, pathology, physiology, and other necessary sciences that will strengthen their foundation as a dental practitioner. Usually, this period is completed after taking an exam in order to gauge the student’s readiness to proceed to the next stage of their dental school program.
The last two years of the dentistry program involves actual treatment of patient under the direct supervision of a dental faculty. This part of the program is usually referred to as Rotations. This period is where the students learn patient care and necessary techniques for diagnosis and treatment. During this period, the concepts and skills that the students have learned during their previous education experience will be used and tested.
The students will also have the chance to experience and explore a wide variety of dental specialties and work environments that could help them identify their interests and further hone their skills. Once the required training is completed and a dental degree is attained, the student must pass the National Board Exam. Passing the NBE will allow the aspiring periodontist to enlist in a graduate program for periodontics.
Residency
After obtaining their dental license, the aspiring periodontist must enter a residency program. This program is usually two and a half to three years long and provides a more hands-on experience in patient care and extensive laboratory work under the supervision of an experienced doctor and professor. Diagnostic methods and dental techniques are also studied extensively and the dentists participate in clinical trials of new therapies while also learning intricate aspects of dental implants and other surgical techniques.
Dental schools generally require the exam scores from the National Board Examination, a dental degree, transcript of records, portfolio, and letters of recommendation. According to the American Academy of Periodontology, it is recommended for the schools to accept students with a class standing in the upper 50 percent and a National Board Examination score of 80 percentile. There are very few medical schools that offer a periodontology program, which is why the applicants are expected to be ready for a tight competition. Being able to submit a portfolio containing previous and applicable work, advanced studies, and volunteer experience will increase the chance in being accepted to a dental school.
Board Certification and Licensing
Licensing is required after the completion of the educational requirements. In the United States, all the dental professionals are required to pass written and practical examinations before establishing their practice. Majority of the states have a specific licensing requirements and it is advisable for every dentist to be knowledgeable of these requirements along with the submission deadlines, timelines, and disciplinary action associated with their license.
The board certification on the other hand is usually accomplished after obtaining a dental license. There are two general requirements set by the American Board of Periodontology. These are:
Passing oral and written exams on all phases of periodontal diseases and its treatment, including dental implants.
Presentation of detailed reports on a board range of actual treatment.
Roles and Responsibilities
Unlike most dentists that may refer more acute cases to their respective specialists, periodontists are known to treat a wide range of severe cases. They are further involved in the development and implementation of treatment plans which may involve examinations, implants, and surgeries. Generally, a dentist refers a patient to a periodontist if there is evidence of a developing gum disease. The most common reasons for periodontal treatments are:
Moderate or advanced gum disease: Occurs when gums are swollen and bleeding around most teeth. This might also cause the jaw bone to recede.
Gingivitis: Swelling of gums and other tissues. This is usually caused by dental plaque and it is also known as the early stages of gum disease.
Crown lengthening: Removing the soft tissue surrounding the tooth in order to provide more tooth exposure, followed by lengthening the crown of the tooth.
Localized gum recession: Localized infection that may also be triggered by over brushing with a hard bristle brush or due to a tooth that is not positioned properly. Immediate treatment is necessary in order to prevent the spread of the infection.
Ridge augmentation: Also known as “recontouring”, this procedure is required to correct an uneven gum line. Treatment of any underlying infections and periodontitis is required before doing this procedure.
The treatment of periodontal diseases requires years of specialized training in both non-surgical treatments and periodontal plastic surgery procedures. Knowledge in using diagnostic tools and skills that involves thorough investigation is also necessary to identify the cause of the disease and determine the best approach to treatment. After determining what the problem is and its underlying cause, the periodontist may be called to perform any of the following treatments:
Specialty X-rays and evaluations (i.e. cephalogram and 3-D cone beam scan).
Dental implants: Installing dental implants is an option to replace missing teeth and provide a permanent solution to removable dentures. The replacement tooth is made of titanium and is placed into the jawbone to support tooth replacement structures such as crowns, bridges, and dentures.
Scaling and root planning: the careful cleaning of the root surfaces to remove the plaque and tartar (calculus) from deep periodontal pockets. It also smoothens the tooth root and allows the bacterial toxins to be easily removed.
Tray delivery systems: This system consists of a custom-fit tray made from impressions of the patient’s mouth. This tray can be used at home to deliver medications that have been prescribed their dentists.
Osseous surgery: Also known as pocket depth reduction. This procedure involves folding the gum back away from the tooth in order for the periodontist to observe the tooth root surfaces. This way, the bacterial deposits crusted to the tooth can be removed and the gum can reattach to a degree.
Gingivectomy/gingivoplasty: This procedure is performed to treat severe cases of gum disease that do not respond to antibiotics and root planning. For this surgery, a local anesthetic is applied to the gums and a laser (or scalpel) is used to remove loose or diseased gum tissue. After the removal of the tissue, a protective dressing is placed over the gum in order to protect them as they heal.
Crown lengthening: Also known as crown exposure, is a procedure performed under local anesthesia. This procedure removes gum tissue and/or bone to expose more of the tooth, allowing a crown or filling to be put in place. This procedure is often performed when the tooth breaks off at the gum or a crown or filling is removed and the tooth underneath is significantly decayed.
Gum Grafting: Also known as soft tissue augmentation is a procedure performed to repair the defect and prevent additional recession and bone loss caused by gum recession. During the procedure, gum tissue is taken from the palate and other donor source and applied on top of the exposed root to protect the root and reduce tooth sensitivity.
Dental Bone Grafts: The process of placing bone grafts involves separating the gums from the teeth to access the tooth root and underlying bone then the roots will be thoroughly cleaned and any holes or damaged bone area will be filled with graft material. Placing dental bone grafts is a regenerative treatment for patients who have lost quality and quantity of supporting bone tissue as a result of a periodontal disease. This procedure is often performed before placing the dental implants on the patient.
Guided Bone and Tissue Regeneration: This is a relatively new process of eliminating pockets in the gum to combat periodontal diseases. The gum pockets are thoroughly cleaned and a membrane (usually bioabsorbable) is inserted between the soft tissue and the pocket in the bone. These membrane covers the gum pockets in order to prevent the rapid growth of soft tissue and allow slower growing bone tissue to regenerate.
Dental Fillings: This restorative treatment is used to improve the appearance and functionality of teeth affected by damage or decay. This is usually done by a general dentist but there are times that patients may require additional support from periodontists after or during the filling procedure, such as placement of a crown, implant, or bridge.
Dental Bridges: Natural looking tooth replacements that help maintain facial structure, reduce stress on the jaw, and fill in the gaps caused by missing teeth.
Educate patients on the most appropriate home cleaning method, correct brushing and flossing techniques, importance of regular maintenance of oral health, and proper medication to aid with the treatment.
In some cases, treatment plans may require sophisticated technology for treatment and involve a variety of procedures. Some periodontal procedures are done for cosmetic reasons, therefore the role of a periodontist is not only for treating diseases but also for aesthetic purposes. While most dentists and medical professionals work in their own private practices, periodontists often work in a group practice, hospital, clinic, or dental school. A periodontist’s team is usually comprised of a dentist and a dental hygienist.
Salary
According the United States Bureau of Labor Statistics, the field of dentistry expects an 18 percent growth of practitioners in their field. The average annual salary range for periodontists in the United States is between $102,533 and $294,822 with a national average annual salary of $185,000 and a median salary of $178,044. The range and median salary varies depending on geographical location, type of employment, and years of job experience.
PayScale.com reports that an entry level periodontist with less than five years of experience can expect to receive an average total compensation of $147,000. This compensation includes tips, bonuses, and overtime pay. A periodontists with five years to ten years of experience can expect to receive an average compensation of $154,000 while a periodontist with 10 to 20 years of experience are expected to earn an average total compensation of $215,000. A periodontist with a career experience of 20 years and above can expect to earn an average total compensation of $203,000. The reports based on the answers of periodontists to PayScale’s salary questionnaire also states that periodontists generally report a high level of job satisfaction and most of them medically insured.
Another important factor in determining the average income of a periodontist is their type of practice. According to SalarySumo.com, periodontists in private practice on their own can make up to $306,000 per year while those who are practicing their profession in the field of academics and research have the annual salary ranging from $100,000 to $190,000. Periodontists in the field of dental prosthetics earns an annual salary within the range of $111,000 to $212,000. Periodontists who are in public practice (i.e. Hospitals and public clinics) have the annual salary in between $102,000 and $197,000 while those in the private practice (i.e. Private hospitals and private clinics) receive salaries between $105,000 and $215,000 annually.
History
Periodontal and gingival diseases have plagued early humans and evidences of its existence has been well established through the recovery and study of the remains of the skeletal remains of Homo sapiens and their relatives. Due to its significance, the study of dental tissues of prehistoric humans and its diseases has developed into a specific discipline called “Paleopathology” or “Paleostomatology”. Evidence of chronic periodontal diseases as well as developmental malformations have been found in the oldest Paleolithic remains and through pictorial representation, researchers have also begun to obtain evidence of possible medical practice in Paleolithic humans.
Early Civilization
One of the oldest civilization that is known to work with developing glazes to be used on pottery and tiles is the Sumerian civilization. The skeletal remain of the people in this civilization have disclosed the presence of periodontal infections, osteoarthritis, fractures, and possible jaw tumors and cysts. The Babylonians also recorded significant accounts on dentistry and the existence of periodontal diseases. In the clay tablets of the Great Library of Ashurbanipal, Assyrian practices in medicine as well incantations and ingredients for relief of disease were recorded among other things. The library includes a number of periodontal disease remedies, such as the application of a mixture of pine turpentine, myrrh, asafetida, and opopanax on a man’s teeth in order to strengthen it and stop the itching or pain in the gums.
Most of the early civilizations viewed diseases as caused by demonic possessions and bad wind. Even though the perception of the disease is influenced by religious beliefs, some remedies are actually rational. An example of this is the early Egyptians’ use of astringent mouth rinses for gingival diseases.
The Chinese and the Indian early civilizations are one of the most notable in terms of their instrumentation and technique. They are also similar in terms of the importance that they give in testing and observing medical protocols. As early as 1500-800 B.C., Indians have recorded the use of herbal remedies and artificial eyes and teeth. Though medicine in this period was mainly "supernatural" and the treatments relied heavily on prayers and incantations, their travelling physicians were equipped with medicinal remedies and surgical instruments.
Two major books with detailed accounts on diseases and treatments survived, they are the Susruta samhita and the Charaka samhita. Susruta is known to be a surgeon and he has performed numerous dissections of human cadavers. His detailed account of his surgeries includes the instruments he used as well as the actual technical procedures. Susuruta also offers an accurate description of periodontitis, taking note on tooth mobility and suppuration from gingiva. He is also known for his descriptive instructions on proper tooth brushing and use of mouthwashes to clean the tongue. Charaka’s medicine on the other hand is often a mixture of magic and religion. Most of his treatments revolves on the use of incantations and charms but he also advocate tooth brush and mouthwashes to clean the teeth and tongue. He devoted several sections of his book to the oral hygiene and management of oral disease.
Early Chinese medicine emphasized direct and careful observation of patients. Their knowledge in medicine gradually became more sophisticated largely because of the importance that they give on recording procedures and notes. During 3000 B.C. - 960 A.D. surgery was practiced and tooth extraction was often advised for tooth ache especially if the gums are swollen and the tooth was already loose. Notes of several respected surgeons during that time has accurately described symptoms of periodontal diseases and was able to differentiate one disease from another.
Late Middle Eastern and Mediterranean Civilizations
The knowledge of the medicinal and dental practices of the Hebrews are from the Old Testament and the Talmud. Various commentators of the Talmud mentioned the teeth and the digestion processes of the human body. The writings in the Talmud was revealed to be traditional and mentions of using pepper, salt, ginger, and cannel to calm dental pain were recorded.
Artifacts from the remains of the early Phoenicians revealed their mastery in working with gold, and loose teeth were presumably supported by wires this material. On the other hand, the Etruscans used gold frames (compared to the gold wire binding by the Phoenicians) to support loose teeth and stabilize the surrounding ones. Dental instruments were also found in the tombs of both the Phoenicians and the Etruscans.
Pre-Columbian America
Both the Mayan and the Incan medicine may have been advance for their time but it is also closely allied to religion. Diseases during both of their times were still considered to be a form of punishment from their deities. Careful drillings of the cavity to permit the insertion of gold or jade fillings but absence of caries in the anterior teeth suggested that the procedure is for cosmetic purposes rather than therapeutic purpose for these inlays.
Greece, Rome, and Byzantium
Greek medicine were sought to counter the nature of imbalance. The most notable figure in ancient Greek medicine was Hippocrates, he was revered as “The Father of Modern Medicine” because of his significant contributions in the field. He was known to pioneer the concept of disease prevention through proper nutrition and hygiene as well as letting nature help the healing process rather than instituting damaging procedures. In his accounts, he gave an importance in clinical observations and he also wrote numerous accounts on jaw dislocations and fractures as well as a wide range of systemic diseases. If Hippocrates was for Greece, Rome had Celsus. He was a physician who wrote a large work on medicine. He named it “Celsus De Re Medicina" and it contains numerous description of diseases and its course of treatment. It also offered treatment for a number of periodontal diseases. The Byzantium, on the other hand, had four major medical writers during their era. They are Oribasius, Aetios of Amida, Alexander of Tralles, and Paul of Aegina. The information collected from their accounts include treatment to tooth ache (Through myrrh mouthwash and tubes of cinquefoil) as well as information regarding the dentrifice.
Middle Ages
The fall of the Roman Empire caused science and medicine to develop slowly. This was accompanied by the rise of Islam and the golden age of the Arabic science and medicine. The Arabic practices derived their processes from the recorded accounts of the Greeks and refined it by adding more novel approaches particularly in the field of surgery. In the early middle ages, medicine were practiced by monks who are very knowledgeable in using herbs as treatment.
One of the most notable person during this time is Albucasis. He was born and lived in Moorish Spain and he wrote a 30-volume medical encyclopedia called al Tsarif. This book was translated into Latin during the twelfth century and was used as a reference in European universities in the seventeenth century. His contribution in the field of dentistry and periodontology was outstanding. He wrote a very comprehensive account on tooth extractions, described the techniques of scaling teeth using the instruments that he developed, used wire to splint loose teeth, filled occlusal abnormalities, used anesthetic drug for tooth ache, treated discolored teeth with abrasive pastes, and showed a clear understanding on the major etiologic role of calculus deposit. Possibly the greatest of the Arabic physicians was Avicenna. His comprehensive treatise on medicine entitled Canon was in continuous use for almost 600 years. He also used an extensive “material medica” for oral and periodontal diseases and rarely resorted to surgery. The first universities and medical schools were founded right before the end of the Middle Ages.
The Renaissance
With the rebirth of the classical scholarship, scientific thought and knowledge gave birth to advancements in the field of anatomy and surgery. During the fifteenth century, Serefeddin Sabuncuoglu from Turkey expanded Albucasis’ work. He included illustrations of the surgical removal of hypertrophic and swollen gingiva and lingual frenum. Another brilliant mind named Paracelsus developed an interesting theory of disease called “the doctrine of calculus”. He recognized the connection between the extensive formation of tartar on the teeth and toothache. He even stated that the pain from toothache is comparable to the pain produced by calculus in other organs, such as the kidneys.
Bartholomaeus Eustachius was another outstanding anatomist who wrote a book on dentistry. He named it “Libellus de dentibus” and it was composed of 30 chapters. This book was considered as the first book on teeth and it offers new descriptions and concepts based on research and clinical studies.
Dentistry and Periodontics in the 18th Century
In America, barbers and blacksmiths were considered as the first dentists.
1840 – The University of Baltimore opened and it was considered as the first dental school.
1859 – The American Dental School was founded and it was now the oldest and largest Dental Society in the world.
1890 – Dr. John Riggs describes periodontal disease and called it Riggs Disease or pyorrhea. He also marketed a 156 proof mouthwash called “The Anti-Riggs”.
1896 – Dr. G.V. Black describes cavity preparations. He will later be called as the father of modern dentistry.
1906 – Dr. C. Edmund Kells showed the first dental radiograph. He was also the first to use female dental assistants and surgical aspirators
1914 – Two physicians named Dr. Grace Rodgers Spalding and Dr. Gillette Hayden formed the American Academy of Oral Prophylaxis and Periodontology. It will later be reamed as the American Academy of Periodontology in 1919.
1929 – Orthodontics was recognized as the first dental specialty
1941 - Periodontics recognized as a dental specialty
1965- The classic study demonstrating the cause effect relationship of plaque and gingivitis was done by H. Loe
1982- Goodson, Haffajee, Socransky et al published several papers that described initiation and progression of periodontal disease as measured by attachment loss.
1985- Spindel et al published an article saying plaque really was not the cause of dental diseases.
1996- A study by Offenbacker et al related pre-term, low birth weight babies to periodontal disease.
In the late 90’s the evidence began to mount regarding the link between cardiovascular disease (CVD) and periodontal disease.
Periodontics and medicine in general is a constantly evolving field. The second half of the nineteenth century marked the development of major procedures and theories in medical science. This developments started an era that can be called as modern medicine. With technological improvements happening day by day, we are headed forward faster than before.
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