Bone Loss and Periodontal Disease: Root Cause, Prevention, & Clinical Indicators of Successful Treatment
By Sarah Balaster, DMD
In our minds, bone loss is synonymous with periodontal disease. It has been drilled into us through multiple-choice exams in dental or dental hygiene school, repeated at conferences, reinforced through continuing education, and discussed in nearly every forum on periodontal disease.
Bone loss—specifically radiographic bone loss—has become so closely linked with periodontal disease that the 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 bone loss distinguishes gingivitis from periodontitis.
Gingivitis is the mildest form of gum disease, presenting clinically as bleeding, swelling, and redness. Landmark studies show that gingivitis is reversible with plaque control, good home care, and improved hygiene. However, once the line is crossed into periodontal disease and bone loss is detectable, professional intervention is required.
This raises several key questions:
- What is the root cause of bone loss associated with periodontitis?
- What steps can clinicians take to prevent it?
- How can we intervene once it is present?
- And how do we set patients up for long-term success?
Bone Loss and Inflammation
From a high level, periodontal disease is the result of chronic inflammation gone unchecked. Its clinical presentation and symptoms are caused by the host response to an unresolved insult.
Inflammation itself is not inherently harmful—it is the body’s internal guidance system, alerting us that something is wrong. Acute inflammation is a protective process: for example, a swollen or tender foot signals the need for rest so the injury can heal. Acute inflammation is healthy and resolvable.
Chronic inflammation, however, occurs when the body fails to eliminate the insult. Over time, the host begins to harm itself, perpetuating a destructive cycle. In periodontal disease, the offending factor is pathogenic bacterial biofilm—either on its own or tightly bound within calculus.
Pathogenesis of Periodontal Bone Loss
In chronic periodontal lesions, we see:
- Breakdown of the periodontal ligament
- Edema and ulcerations in the pocket epithelium
- Apical migration of pathogenic bacteria
On a cellular level, neutrophils and macrophages flood the site as the host response continues against the chronic bacterial insult. Biochemically, pro-inflammatory cytokines such as IL-1 and TNF-alpha increase, along with proteinases like MMPs (matrix metalloproteinases). MMPs degrade collagen in bone.
The process also stimulates osteoclast activity (bone resorption) and suppresses osteoblast activity (bone formation), further accelerating alveolar bone destruction.
Understanding these mechanisms is essential—but we must not lose sight of the initial driver: the pathogenic biofilm.
Clinical Intervention
The first step in professional intervention is to remove the insult that the body cannot eliminate on its own. While removal can prevent progression, often residual damage remains and must be addressed. Simply eliminating the causative factor does not always set patients up for long-term success.
As clinicians, we must:
- Restore an oral environment less susceptible to recurrent disease
- Address local contributing factors (overhanging margins, tooth position, anatomical variations)
- Consider systemic factors such as smoking and diabetes, which strongly influence disease progression
Comprehensive Examination and Treatment Options
A thorough exam should include:
- Radiographs
- Periodontal charting
- Intraoral examination
- Complete medical and dental history
From this data, establishing the stage and grade of periodontal disease will guide treatment.
Milder cases may be treated with:
- Scaling and root planing (SRP)
- SRP plus local or systemic antibiotics
- SRP with adjunctive use of lasers for bacterial reduction
More advanced cases may require:
- Osseous surgery
- Guided bone and tissue regeneration
- Tooth extraction and replacement
Notably, Laser Assisted New Attachment Procedure (LANAP) offers a less invasive option for severe disease. LANAP is the only FDA-cleared laser-assisted periodontal therapy capable of true regeneration—new cementum, periodontal ligament, and alveolar bone.
Follow-Up and Long-Term Success
Regardless of treatment, follow-up is essential. Post-treatment evaluations should include the same comprehensive data collection as the initial exam, ensuring that outcomes are assessed and adjusted as needed.
Long-term success also depends on:
- Establishing a structured periodontal maintenance program
- Partnering with patients on plaque control and home care
- Ongoing motivation and education
- Collaboration with physicians in cases where systemic health plays a role
- Correction of local factors that compromise oral hygiene
Conclusion
The relationship between bone loss and periodontal disease is deeply intertwined, with bone loss serving as a hallmark of disease progression.
By understanding the root causes—biofilm, inflammation, and host response—while addressing both local and systemic risk factors, clinicians can intervene effectively. Through comprehensive care, proper maintenance, and patient partnership, we can optimize treatment outcomes and support long-term oral health.
