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Family Health Magazine - DENTAL HEALTH

Periodontal Disease
Beat the silent tooth killer

Yes! It is possible to retain your teeth for the rest of your life. Beat the silent tooth killer periodontal disease and you have it made.

  • Up to 75 per cent of adults over age 30 have gum disease, the leading cause of tooth loss.
  • A 'pink' toothbrush can be a warning of damage caused by bleeding from the tissues.
  • Plaque or bacteria are the primary causes of periodontal diseases.
  • Complete care once daily will keep those bad bugs in check.

Periodontal disease is, in fact, a group of diseases. These diseases begin quietly, attacking the gums, bones and ligaments that anchor the teeth to the bone. Another name often used to describe the condition is gum disease. Up to 75 per cent of adults over age 30 suffer from gum disease - the leading cause of tooth loss.

The supporting structures of a tooth

Nature has designed a wonderful supporting system for the tooth (1A). The tooth is suspended in the jaw bone (1B) by a very thin, fine but strong system of ligaments (1C). Gingival (gum) tissue covers the bone (1D).

Around the neck of the tooth, the gum dips down to form a 2 to 3 mm deep crevice or sullus that surrounds the tooth. At the base of the sullus, in a healthy mouth, the gums form a tight cuff and seal - a fantastic barrier to the mouth bacteria and irritants.

Types of periodontal disease

When the surface of the gum tissue becomes inflamed and diseased, the condition is known as gingivitis. If allowed to continue, the surface gum inflammation can move into the deeper supporting structures of the bone and ligament and is known as periodontitis. Depending how severe the disease is, it is classified as mild, moderate or advanced. The most serious form of the disease tends to be slow, progressive and chronic. If not treated, it will lead to complete destruction of the supporting tissues, abscesses, and finally loss of the tooth.

Periodontitus can affect children but is rare. It is known as prepubertal periodontitus. A form of the disease affecting teenagers is known as juvenile periodontitus and can affect a few or many teeth. A rather aggressive form of periodontal disease known as rapidly progressive periodontitus has been described. This usually affects young adults aged 20 to 30 and will result in early tooth loss if untreated.

Signs of periodontal disease

The signs of periodontal diseases are subtle. A 'pink'” toothbrush can be a warning of damage caused by bleeding from the tissues. Persistent bad breath and taste are other warning signs. The gums may appear to be red, swollen and feel tender. The roots of the teeth may become visible. The teeth can loosen and separate, resulting in a bite change. Also, a change in the fit of a partial denture may be noticed. Pain and abscesses tend to occur in the final stages of the disease, usually when it is too late to save the tooth.

If you have any of these problems, ask your dentist to do a complete gum check-up. You can consult with a periodontist (gum specialist) for an evaluation without a referral.

Cause of periodontal disease

Periodontal disease is caused by certain types of bacteria (germs) that normally grow in the mouth. These bacteria organize to form colonies called plaque that collect at the tooth gum margins as an invisible, sticky film. With poor care of the teeth, the bacteria will grow and penetrate the tooth gum margins. Finally they spread into the underlying bone.

At the same time, the film of bacteria will harden to form calcium deposits called calculus on the teeth. Calculus attaches tightly to the tooth surfaces above and below the gum margins. These deposits, once formed cannot be brushed away. It takes a professional such as a dentist or hygienist, to remove the local irritants that have accumulated.

The bacteria continue to thrive on the rough surfaces of the calculus. If they establish themselves below the gum surfaces they produce toxins that damage the gum and bone tissue. With time the crevices around the teeth deepen as the bone underneath recedes to form a diseased space called a periodontal pocket (Fig. 2).

As the disease progresses the pockets get deeper until the root end is reached. The surface gum tissue may still look normal since the disease has progressed far below the surface (Fig. 3).

At this stage, the bacteria may begin to grow more rapidly to form a gum boil or abscess causing the tooth to become loose and tender. There might still be hope for the involved tooth if the abscess and inflammation can be controlled. If discomfort or pain persists, the only option is to remove the tooth.

Periodontal disease does not affect all the teeth at the same time nor to the same degree. Generally the back teeth have more severe breakdown than those in front. The difficulty in plaque removal and complicated root shapes account for this difference.

Factors contributing to periodontal disease

Plaque or bacteria are the primary causes of periodontal diseases. However, some factors can affect the progression of the disease.

  • If you smoke or use tobacco products you are more likely get periodontal disease at an early age. Also, the disease may be more severe and healing after treatment may take longer. Tobacco appears to depress the local immune system in the gum tissues. Without this protection to fight infection, bacteria accumulate in the underlying tooth support structures. Also, if you smoke, you will grow more of the disease-causing bacteria than non-smokers.
  • Women, during puberty and pregnancy, may have gum problems due to hormone changes. An increase in the hormone progesterone will cause the gum tissues to overreact to very minor irritants. Periodontal disease that has been lying undetected can often surface at this time.
  • Stress can also depress the immune system and make it difficult to fight infectious diseases like periodontal disease.
  • Medications, such as oral contraceptives, antidepressants and certain heart medication can affect oral health. Always tell your dental care professional what medication you are taking and about any change in your health history.
  • Clenching or grinding the teeth in the presence of bacteria can speed up the rate of destruction of the supporting tooth bone. The excessive force appears to be a contributing factor but the exact mechanism is not clear.
  • Periodontal disease tends to be more severe in uncontrolled diabetes. Recent studies have shown that untreated periodontal disease may make it more difficult to control insulin needs of those with diabetes. A gum check-up might be called for if your diabetes is under poor control.
  • Poor nutrition may make it more difficult for the body to fight infection. A well-balanced diet will help maintain periodontal health.

Diagnosis of periodontal diseases

Periodontal disease is diagnosed by a dental professional after a full examination. Your visit usually begins with medical-dental questions where you are asked your chief complaint. You are also asked about medications you use and medical conditions that can affect the course of periodontal disease.

To determine the degree of disease involvement, a periodontal probe is gently teased into the spaces between the gum and tooth. The lines on the probe allow the dentist to gauge the depth of the spaces present. There are lines on the probe which when positioned with the outside gum margin (Fig. 4) allow for a measurement to be taken. Generally a range up to 3 mm is considered normal, based on six measurements taken around each tooth. Recession (root showing) and mobility of the teeth are recorded.

A full evaluation of the supporting structures of the teeth requires an x-ray examination. If you have all of your teeth, eighteen pictures are needed. The radiation to the head and neck is less than a half day out in the sunshine. The x-ray pictures will allow the dentist to evaluate root lengths of the individual teeth as well as existing bone levels. Abscesses, decay or underlying changes can be identified. An analysis of your bite is done as well since clenching and grinding habits of the teeth may contribute to the disease process.

Finally, based on the clinical and x-ray information, you will receive a comprehensive treatment plan. The goals of periodontal therapy are to:

  • establish health and comfort
  • improve function and aesthetics
  • maintain health.

Oral Hygiene

An important part of controlling periodontal disease is the daily cleaning of the tooth gum margins. Since periodontal disease is caused by bacteria that are found in the mouth, they must be stopped from forming the plaque that will damage the tooth supporting structures.

Brushing and flossing are the basic oral hygiene techniques recommended for plaque removal around the tooth. Other oral hygiene aids such as rubber tips, toothpicks and oral irrigators may be recommended to help fine tune the cleaning process.

Many of the powered toothbrushes available make brushing much more efficient than hand brushing. The powered brush would be a worthwhile purchase if you do not seem to have time to brush properly or if arthritis affects your hands.

Plaque will reform over 24 hours so it is important to try to keep a regular schedule. Complete care once daily will keep those bad bugs in check. Bedtime is usually best for your thorough home care session. Pick a time and place for tooth cleaning that works for you.

Your dental practitioner will help design and customize an effective daily cleaning program for you. Often plaque removal is best done out of the bathroom - for instance, while reading or watching television.

Non-Surgical Therapy - Scaling and Root Planing

As mentioned earlier, when bacteria are left to accumulate on the teeth, they form deposits called calculus. The calculus deposits unfortunately cannot be removed by brushing and flossing. Only a professional can gain access to remove all the deposits.

The professional cleaning that removes plaque, calculus, and bacterial endotoxins from the root surface is known as scaling and root planing. Removal of the calculus combined with proper oral hygiene will allow the gum tissue to form a tight seal at the neck of the tooth. The seal will prevent bacterial penetration into the pocket. With the professional cleanings, tissue health and color will dramatically improve. Gum sensitivity and bleeding will reduce as well.

Special hand instruments called scalers and curettes have been developed to remove the calculus in an effective and comfortable manner (Fig. 5). The fine curettes come in different sizes and shapes. The instruments are designed so they can be gently teased into the pockets in order to scrape off the very adherent calculus deposits.

If the teeth or gum tissues are sensitive, your dentist can numb the teeth and tissues with a local anesthetic (freezing) to assure your comfort. Scaling and root planing is a meticulous process and may take a number of appointments. A quality professional cleaning will be the first step necessary in establishing periodontal health.

Fine ultrasonic instruments have been developed to make calculus removal even more efficient and comfortable. The ultrasonic tips come in various shapes to help access the nooks and depressions on the root surfaces where the calculus deposits may be hiding. These high-tech instruments introduce a fine water or antiseptic solution to help flush out deposits and bacteria.

If the periodontal disease is advanced, an antibiotic may be prescribed along with the scaling and root planing. Irrigation of the infected pockets with an antibiotic or antiseptic solution can be help as well in chasing those 'bad bugs' away during the professional cleanings.

Non-surgical scaling and root planing procedures are a highly effective method controlling gum inflammation and eliminating periodontal disease. However, there are limits to the extent of healing possible through scaling and root planing procedures alone.

Surgical Therapy

To create optimal health, there is a critical level of calculus removal necessary from the root surfaces in order form a gum seal around the neck of the tooth. The deeper the pockets are, the more difficult it is to achieve this level. That is why early detection of the disease is so important. In the early phase of periodontal disease the pockets tends to be shallow making calculus removal so much easier.

If disease activity continues in spite of proper oral hygiene and careful scaling and root planing, surgical options may be considered. Surgery allows access to the deeper areas of the root surfaces for complete calculus removal. However, if a person is not practising optimum oral hygiene, surgical therapy is not a good idea since healing will be poor. The commitment to daily plaque removal must be very strong to assure optimum healing and post-surgical success.

The surgical treatment is considered a minor surgical procedure that can easily be done in the dental office with local anesthesia (freezing). Once the problem is identified, a small incision is made on the inside and outside tooth gum margins of the involved teeth (Fig. 6). The gum tissue is gently teased away from the necks of the teeth to give access to the underlying root surfaces (Fig. 7).

The root surfaces are inspected and all residual calculus is removed. The infected tissues located in the bony defects are removed as well. Where disease has eroded the bony surfaces, the bone may need to be smoothed. This will allow the gum tissues to snug up tightly around the necks of the teeth when stitched back into place (Fig. 8).

A small dressing (cast) is placed around the surgical site for comfort. The stitches and dressing are usually removed about a week later. We do not seem to slow patients down too much. Most are back to normal activities the next day. Healing progresses very rapidly in the mouth!

Surgical reconstructive techniques have also been developed to help restore the lost bone and gum tissues due to periodontal disease. Bone and gum grafts are available to be used in appropriate locations. Your periodontist can offer the best surgical options for your particular problem.

Supportive Periodontal Therapy - Monitoring and Cleaning

To prevent return of periodontal disease, regular visits to your dental professional are necessary. Reinforcement of oral hygiene, inspection of the supporting structures and professional cleanings all serve to maintain the existing bone levels.

Much research has been done to investigate the best recall interval for a professional cleaning. If you have had periodontal disease, it appears that intervals of three to four months between visits are successful in preventing recurrence of disease. Otherwise, a six month interval is likely adequate to maintain health.

Everyone is different and has unique requirements. Factors such as rate of calculus build-up, depth of periodontal pockets, oral hygiene and susceptibility to periodontal disease are all taken into account when establishing a personal recall interval. An ideal recall interval provides a quality professional cleaning at the time the bad bacteria are trying to re-establish themselves in the pockets.

Periodontal Disease and Other Health Issues

Recently a case control study of 124 pregnant or postpartum mothers showed that periodontal disease represents a clinically significant risk factor for pre-term low birth weight babies. If the mother had periodontal disease, there was a seven-fold chance of delivering a pre-term low birth weight baby. The low grade bacterial infection might affect the placenta. Further investigations are underway.

There may also be an increased risk of bacterial pneumonia for those with active periodontal disease and poor oral hygiene. The bacteria from the gums may travel to the lungs and cause serious infections. Patients in intensive care units and nursing home residents who are at greater risk for bacterial pneumonia may be infected by this process.

Periodontal disease may be a risk factor for heart disease and stroke. Increased bone loss in the mouth seems to be associated with heart and stroke problems. It is believed that periodontal bacteria infections can block the blood vessels and cause these serious health problems. New research, knowledge and diagnostic tests are helping to improve our already successful result.

By keeping your gum and teeth healthy, you can continue to enjoy the crunch of biting into an apple. If you have any concerns about your gum conditions, contact a periodontist for a gum check-up. Your teeth are worth it!

FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specified medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physician promptly. © Copyright 2019, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 0S1    [DH_FHb93]
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