Periodontal Disease

What is Periodontal Disease?

Periodontal means "around the tooth." Periodontal disease, or "gum disease," refers to infection of the gums and bone "around the tooth." Periodontal disease progresses as the sulcus (pocket or space) between the tooth and gums gets filled with "bad" bacteria, plaque, and tartar, causing irritation and inflammation to the gingiva (gums). When these irritants remain in the pocket space, they can cause destructive damage to the teeth, gums, and eventually the bone that supports the teeth. This process is the leading cause of tooth loss in adults.

It is extremely important to note that gum disease often does not hurt. Some signs/symptoms of periodontal disease include:

  • Bleeding when brushing/flossing/eating: Toxins in plaque cause tissues that are prone to bleeding.
  • Inflamed, red, or painful gums: This is a sign of infection. It is essential to halt the disease here before it destroys the bone supporting teeth OR is carried into the bloodstream to affect other organs of the body.
  • Bad breath (halitosis) / bad taste in mouth: The deeper gum pockets are able to house more debris and bacteria, causing a foul odor/taste. Breath odor can also result from: the back of the tongue, the lungs and stomach, food we consume, tobacco use.
  • Receding gums: Bacterial toxins destroy the gums and bones that once covered the tooth roots. Teeth appear longer and the smile appears more "toothy."
  • Loose teeth / change in bite pattern: As the bone tissues get destroyed, teeth that were once firmly attached to the jawbone become loose or may shift in position. This can also cause pain with biting/chewing.
  • Pus: Pus between the teeth is a definitive sign of infection. Pus is a result of the body trying to fight the bacterial infection.
The Stages of Periodontal Disease
  1. Gingivitis: This is the first stage of periodontal disease, marked by inflamed, bleeding gums. This is caused by plaque and its associated toxins. There is no measurable bone loss.
  2. Periodontitis: Plaque hardens into calculus (tartar). As calculus and plaque build, the associated inflammation creates deeper pockets between the gums and teeth. These pockets are filled with bacteria. The gums are very irritated, inflamed, and bleed easily. Most crucial, slight to moderate bone loss results.
  3. Advanced Periodontitis: The gums, bone, and periodontal ligament supporting the teeth continue to be destroyed. Unless treated, the affected tooth will become loose and may be lost. Generalized moderate to severe bone loss results.

Periodontal treatment methods depend upon the type and severity of your disease. Your dentist and dental hygienist will evaluate for periodontal disease and recommend appropriate treatment.

How Can It Help?

There are 2 basic categories of periodontal treatments: active treatment and maintenance.

Active Treatment

Patients in active treatment demonstrate active periodontal disease. Active treatment can be divided into non-surgical and surgical treatment:

Non-Surgical Treatment

  • Scaling and root planing: This is also called a "deep cleaning." The area(s) requiring deep cleaning are numbed and plaque, tartar, and toxins are removed from above and below the glum line (scaling) while rough spots of root surfaces are made smooth (planing). This is usually performed 1-2 quadrants of the mouth per appointment. This procedure helps gum tissue heal and pockets to shrink. Medications like antibiotic mouth rinses and topically administered antibiotics may be used. Your dentist or dental hygienist may also recommend oral probiotic therapy.

Surgical Treatment

  • Pocket reduction surgery: This requires a surgical approach to remove plaque, tartar and bacteria from the subgingival root surfaces. This can also involve removal of excess tissue/pocket depth and recontour of bone loss areas to facilitate at-home hygiene. Often this procedure is performed by a periodontist. This can be approached via flap surgery (gums are surgically reflected away from the teeth) or via laser approaches (commonly LANAP). This procedure can also be applied to peri-implantitis (infection of bone/gums around a dental implant).
  • Tissue Grafting: When bone and gum tissues are destroyed, we can regrow these tissues via "grafting." This process can also be applied to affected implants (peri-implantitis).
  • Dental Implants: When teeth have been lost due to periodontal disease, the esthetics and functionality of your mouth can be restored via dental implants. Note that dental implants should only be placed in a healthy, disease-free oral environment, thus periodontal disease should be controlled prior to consideration.
Maintenance

It only takes 24 hours for plaque that is not removed from your teeth to turn into calculus (tartar). Good home hygiene helps control tartar, but those hard to reach areas will always need professional treatment.

Once your periodontal treatment is completed, your dentist and dental hygienist will recommend regular maintenance cleanings usually 2-4 times per year. These appointments will include:

  • Professional cleaning: Remove difficult plaque/calculus above and below the gum line.
  • Periodontal exam: Carefully evaluate pocket depths
  • Diagnostic x-rays: Essential to determine tooth and root proportions and detect progression of bone loss. Also aids in detecting decay, tumors, cysts.
  • Examination of existing restorations & tooth decay: Check all tooth surfaces for decay and evaluate health of existing fillings, crowns, etc.
  • Oral cancer screening: Check the face, neck, lips, tongue, throat, cheek tissues, and gums for signs of oral cancer.
  • Teeth polishing: Remove stain and plaque that is not otherwise removed during tooth brushing and scaling.
  • Oral hygiene recommendations: Review and recommend home oral hygiene aids as needed (electric toothbrush, special interdental devices, fluorides, rinses, etc)

What to Expect

Periodontal disease is diagnosed by your dentist or dental hygienist during a periodontal exam. This type of exam should always be a part of your regular dental checkup.

During this visit, a periodontal probe (small measuring instrument) is gently used to measure the sulcus (pocket or space) between the tooth and the gums. The depth of a healthy sulcus measures 3mm or less and does not bleed. The periodontal probe measurements >3mm are indicators of periodontal disease. As disease progresses (and bone is lost), these periodontal pockets usually get deeper.

To diagnose your periodontal status, your dental team will use: pocket depths, amount of bleeding, inflammation, tooth mobility, bone loss as measured on dental X-rays.

Periodontal status categories
  1. Normal, healthy periodontium
    • Treatment: Your dentist and dental hygienist will typically recommend regular dental check-ups with periodic dental radiographs and a professional cleaning every 6 months to maintain a healthy periodontal status.
  2. Gingivitis: This is the first stage of periodontal disease, marked by inflamed, bleeding gums. This is caused by plaque and its associated toxins. There is no measurable bone loss.
    • Treatment: When disease is caught in the early stages of gingivitis, no permanent damage has been done. You may require a more intense gingival therapy/scaling. Then your dental team will typically recommend 2-3 regular cleanings per year. We will also review and instruct your home oral hygiene routine.
  3. Periodontitis: Plaque hardens into calculus (tartar). As calculus and plaque build, the associated inflammation creates deeper pockets between the gums and teeth. These pockets are filled with bacteria. The gums are very irritated, inflamed, and bleed easily. Most crucial, slight to moderate bone loss results.
    • Treatment: If the disease has progressed to periodontitis, we will often recommend a special periodontal cleaning called scaling and root planing (deep cleaning). If the pockets do not heal after scaling and root planing, further surgical treatment may be recommended, including pocket reduction surgery and tissue grafting. Our team may also recommend a Periodontist (specialist in gum/bone) to bolster your dental care team.
  4. Advanced Periodontitis: The gums, bone, and periodontal ligament supporting the teeth continue to be destroyed. Unless treated, the affected tooth will become loose and may be lost. Generalized moderate to severe bone loss results.
    • Treatment: Advanced periodontitis often requires more advanced treatment, including surgical therapy like pocket reduction surgery, grafting, or even removal/replacement of the affected teeth. Our team may also recommend a Periodontist (specialist in gum/bone) to bolster your dental care team.

Frequently Asked Questions

What are the symptoms of gingivitis?

Bleeding (with gentle brushing, flossing) or red/inflamed gums are often the first signs of gingivitis. Remember that gingivitis is reversible - meaning that we can treat this with professional cleanings and improved home hygiene regimen.

What is the best way to prevent gum disease?

Of course, you should visit our office regularly for checkups including a professional cleaning and a thorough exam. However, remember that oral health starts at home - most patients are usually in the office for cleanings 2-4 times per year, but every day is an opportunity to maintain your brush/floss/rinse home hygiene routine to avoid harmful plaque accumulation.

Are there risk factors for developing periodontal disease?

There are genetic and environmental factors involved in the onset of gum disease, and in many cases the risk of developing periodontitis can be significantly lowered by taking preventative measures.

Here are some of the most common causes of gum disease:

  • Poor dental hygiene: Preventing dental disease starts at home with good oral hygiene and a balanced diet. Prevention also includes regular dental visits which include exams, cleanings, and x-rays. A combination of excellent home care and professional dental care will ensure and preserve the natural dentition and supporting bony structures. When bacteria and calculus (tartar) are not removed, the gums and bone around the teeth become affected by bacteria toxins and can cause gingivitis or periodontitis, which can lead to tooth loss.
  • Tobacco use: Research has indicated that smoking and tobacco use is one of the most significant factors in the development and progression of gum disease. In addition to smokers experiencing a slower recovery and healing rate, smokers are far more likely to suffer from calculus (tartar) build up on teeth, deep pockets in the gingival tissue and significant bone loss.
  • Genetic predisposition: Despite practicing rigorous oral hygiene routines, as much as 30% of the population may have a strong genetic predisposition to gum disease.  These individuals are six times more likely to develop periodontal disease than individuals with no genetic predisposition. Genetic tests can be used to determine susceptibility and early intervention can be performed to keep the oral cavity healthy.
  • Pregnancy and menopause: During pregnancy, regular brushing and flossing is critical. Hormonal changes experienced by the body can cause the gum tissue to become more sensitive, rendering them more susceptible to gum disease.
  • Chronic stress and poor diet: Stress lowers the ability of the immune system to fight off disease, which means bacterial infections may possibly beat the body’s defense system. Poor diet or malnutrition can also lower the body’s ability to fight periodontal infections, as well as negatively affecting the health of the gums.
  • Diabetes and underlying medical issues: Many medical conditions can intensify or accelerate the onset and progression of gum disease including respiratory disease, heart disease, arthritis and osteoporosis. Diabetes hinders the body’s ability to utilize insulin which makes the bacterial infection in the gums more difficult to control and cure.
  • Grinding teeth / Malocclusion: The clenching or grinding of the teeth can significantly damage the supporting tissue surrounding the teeth. Grinding one’s teeth is usually associated with a “bad bite” or the misalignment of the teeth. When an individual is suffering from gum disease, the additional destruction of gingival tissue due to grinding can accelerate the progression of the disease.
  • Medication: Many drugs including oral contraceptive pills, heart medicines, anti-depressants and steroids affect the overall condition of teeth and gums; making them more susceptible to gum disease. Steroid use promotes gingival overgrowth, which makes swelling more commonplace and allows bacteria to colonize more readily in the gum tissue.
How does my periodontal health affect my overall health?

Research studies have shown that there is a strong association between periodontal disease and other chronic conditions such as diabetes, heart disease, pregnancy complications, and respiratory disease. Periodontal disease is characterized by chronic inflammation of the gum tissue, periodontal infection below the gum line and a presence of disease-causing bacteria in the oral region. Halting the progression of periodontal disease and maintaining excellent standards of oral hygiene will not only reduce the risk of gum disease and bone loss, but also reduce the chances of developing other serious illnesses.

Common cofactors associated with periodontal disease:

  • Diabetes: A research study has shown that individuals with pre-existing diabetic conditions are more likely to either have, or be more susceptible to periodontal disease. Periodontal disease can increase blood sugar levels which makes controlling the amount of glucose in the blood difficult. This factor alone can increase the risk of serious diabetic complications. Conversely, diabetes thickens blood vessels and therefore makes it harder for the mouth to rid itself of excess sugar. Excess sugar in the mouth creates a breeding ground for the types of oral bacteria that cause gum disease.
  • Heart Disease: There are several theories which explain the link between heart disease and periodontitis. One such theory is that the oral bacteria strains which exacerbate periodontal disease attach themselves to the coronary arteries when they enter the bloodstream. This in turn contributes to both blood clot formation and the narrowing of the coronary arteries, possibly leading to a heart attack. A second possibility is that the inflammation caused by periodontal disease causes a significant plaque build up. This can swell the arteries and worsen pre-existing heart conditions. An article published by the American Academy of Periodontology suggests that patients whose bodies react to periodontal bacteria have an increased risk of developing heart disease.
  • Pregnancy Complications: Women in general are at increased risk of developing periodontal disease because of hormone fluctuations that occur during puberty, pregnancy and menopause. Research suggests that pregnant women suffering from periodontal disease are more at risk of preeclampsia and delivering underweight, premature babies. Periodontitis increases levels of prostaglandin, which is one of the labor-inducing chemicals. Elevated levels prostaglandin may trigger premature labor, and increase the chances of delivering an underweight baby. Periodontal disease also elevates C-reactive proteins (which have previously been linked to heart disease). Heightened levels of these proteins can amplify the inflammatory response of the body and increase the chances of preeclampsia and low birth weight babies.
  • Respiratory Disease: Oral bacterium linked with gum disease has been shown to possibly cause or worsen conditions such as emphysema, pneumonia and Chronic Obstructive Pulmonary Disease (COPD).  Oral bacteria can be drawn into the lower respiratory tract during the course of normal inhalation and colonize; causing bacterial infections. Studies have shown that the repeated infections which characterize COPD may be linked with periodontitis. In addition to the bacterial risk, inflammation in gum tissue can lead to severe inflammation in the lining of the lungs, which aggravates pneumonia. Individuals who suffer from chronic or persistent respiratory issues generally have low immunity. This means that bacteria can readily colonize beneath the gum line unchallenged by body’s immune system.

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