<P> Once bacterial plaque has infiltrated the pocket, the transformation from biofilm into calculus continues . This results in an ulceration in the lining of the tissue, which begins to break down the attachment of the gum to the tooth . Gingival attachment begins to loosen further as the bacterial plaque continues to invade the space created by the swelling it causes . This plaque eventually transforms into calculus, and the process continues, resulting in deposits under the gum, and an increase in pocket depth . As the depth of the vertical space between the tooth and the gum reaches 5mm, a change occurs . The bacterial morphology, or make up, of the biofilm changes from the gram positive aerobic bacteria found in biofilm located supragingivally, or above the gumline . Replacing these gram positive bacteria of the general oral flora are obligate anaerobic gram negative bacteria . These bacteria are far more destructive in nature than their aerobic cousins . The cell walls of gram negative bacteria contain endotoxins, which allow these organisms to destroy gingival tissue and bone much more quickly . Periodontitis officially begins when these bacteria begin to act, resulting in bone loss . This bone loss marks the transition of gingivitis to true periodontal disease . In other words, the term periodontal disease may be synonymous with bone loss . </P> <P> The first evidence of periodontal disease damage becomes apparent in radiographs as the crestal bone of the jaw begins to become blunted, slanted, or scooped out in appearance . This destruction occurs as a result of the effect of bacterial endotoxins on bone tissue . Because the bone is alive, it contains cells in it that build bone, known as osteoblasts, and cells that break down bone, called osteoclasts . Usually these work at the same speed and keep each other in balance . In periodontitis, however, the chemical mediators, or by - products, of chronic inflammation stimulate the osteoclasts, causing them to work more rapidly than the cells that build bone . The net result is that bone is lost, and the loss of bone and attachment tissues is called periodontal disease . </P> <P> These processes will persist, causing greater damage, until the infectious bacterial agents (plaque) and local irritating factors (calculus) are removed . In order to effectively remove these at this stage in the disease process, brushing and flossing are no longer sufficient . This is due to several factors, the most important to note being the depth of the periodontal pocket . Brushing and flossing are effective only at removing the soft materia alba and biofilm in supragingival areas, and in pockets up to 3 mm deep . Even the best brushing and flossing is ineffective at cleaning pockets of greater depths, and are never effective in removing calculus . Therefore, in order to remove the causative factors that lead to periodontal disease, pocket depth scaling and root planing procedures are often recommended . </P> <P> Once the bacteria and calculus are removed from the periodontal pocket, the tissue can begin to heal . The inflammation dissipates as the infection declines, allowing the swelling to decrease which results in the gums once again forming an effective seal between the root of the tooth and the outside environment . However, the damage caused by periodontal disease never heals completely . Bone loss due to the disease process is irreversible . The gingival tissue of the gums also tends to suffer permanent effects once the disease reaches a certain point . Because gum tissue requires bone to support it, if bone loss has been extensive, a patient will have permanent recession of the gums, and therefore exposure of the roots of the teeth in involved areas . If the bone loss is extensive enough, the teeth may begin to become mobile, or loose, and without intervention to arrest the disease process, will be lost . </P>

Root planing is used in the treatment of pockets which are
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