Gum Disease: Introduction
Gum disease is primarily an infection. It is caused by bacteria which can infect the tissues around the teeth.
These bacteria can cause the gums to swell and bleed.T hey can also cause the loss of the bone that support the teeth. When this happens, teeth can get loose and may develop acute infections called abscesses which can be very painful.
Bacteria also trigger an immune or inflammatory response by the body. Although it is important to fight off any infection, our bodies reaction to these bacteria contributes to the loss of bone. Eventually teeth can be lost due to periodontal disease. Newer studies have shown that the bacteria can also spread from the mouth, through the blood stream, throughout the body. This may have implications on cardiovascular disease, diabetes and pregnancy.
As periodontal disease progresses the types of bacteria change. Initially, the bacteria are not very harmful but as disease advances the bacteria become more and more destructive.
Plaque & Tartar
Bacteria are found in plaque and tartar.
Plaque is what remains on our teeth after we eat. If plaque is allowed to stay on the teeth without being brushed away – it turns into tartar.
Tartar is a mineralized substance which cannot be brushed away by the patient; it must be removed with dental instruments by a hygienist, dentist or Periodontist.
Some people develop tartar more quickly than others. Tartar also houses and protects bacteria from our body’s natural defences (the immune system). Many people ask why antibiotics cannot be used routinely for gum disease. The reason is that antibiotics (like immune cells) will not be able to penetrate the tartar where the bacteria sit. For this reason much of gum treatment is directed towards removing the plaque and tartar.
Progression of Gum Disease
Plaque and tartar can be seen on the surfaces of teeth when we look in the mouth.
However they can also be found below the gumline in pockets.
A pocket is a small space between the gum and tooth. Pockets are present in healthy gums- even those without gum disease. When plaque, tartar and bacteria get below the gum line in pockets, they become harder to clean out.
Healthy Gums
In health, pockets tend to be between 0-3 mm deep. Pockets between 0-3 mm can be cleaned out easily at home with a toothbrush, dental floss and by dental cleanings. When pockets are between 0-3 mm, the bacteria in them are exposed to a lot of oxygen and are not very destructive.
Early Gum Disease and Gingivitis
When plaque, tartar and bacteria collect in a pocket and are there for too long, or when our ability to fight the infection is decreased, gum disease can start. There is a change in the types of bacteria that infect the pocket and inflammation starts. When the gums get inflamed, they will start to swell, turn red and bleed when brushed or flossed. This is gingivitis. During gingivitis, or early periodontitis, the pockets tend to get a little deeper due to the swollen tissues. Bacteria, plaque and tartar collect where they cannot be accessed to clean them out. Pockets tend to be between 3-5 mm
Moderate to Advanced Periodontitis
When the bacteria are left undisturbed in the pocket for longer periods of time, or when our body’s resistance is lowered, the bacterial colonies change even more and the bacteria become more destructive. As well, our body responds to this and sends more blood cells to fight the infection. The combination of the bacterial infection and our immune response results in a loss of the bone supporting the tooth and a deepening of the pocket. This makes it impossible to clean down the root of the tooth even with dental instruments.
Dentists and hygienists can clean the upper surface of the root – but not deeper down where the bone loss is occurring. As the condition progresses the pockets get deeper (over 5 mm) and more bone loss occurs. Over time bone is worn away, the pockets can get deeper, the teeth get loose and abscesses can start to develop.
Signs & symptoms
Often gum disease, like many other serious conditions has no signs or symptoms until it is advanced and often the patient does not know they have a problem.
Over time, however, certain signs and symptoms may be noticed by either the person with gum disease or those around them. These possible warning signs include:
Red swollen gums
Bleeding when flossing or brushing (may not happen in smokers)
Bad breath or taste in the mouth
Receding gums
Loose teeth
Change in tooth position or an increase in the spaces between teeth
Causes: Overview
There are many factors which may cause gum disease or make it worse. Each person has specific issues that will impact upon their gum health. Basically, gum disease starts because there is either too much bacteria or there is something that makes the person susceptible to infection. The following are some of the factors that contribute to the development of gum disease.
There are many factors which may cause gum disease or make it worse. Each person has specific issues that will impact upon their gum health. Basically, gum disease starts because there is either too much bacteria or there is something that makes the person susceptible to infection. The following are some of the factors that contribute to the development of gum disease.
Oral Hygiene
Cleaning ones teeth and gums well are the best manner of protection against gum disease. Most forms of gum disease are thought to be caused by the bacteria that are in plaque and tartar. If plaque is cleaned off before it turns into tartar, the risk of damage is greatly reduced. There are many ways of keeping teeth and gums clean. The first line of defence involves brushing twice a day and flossing once a day. Just using a toothbrush and floss are not enough and it is important that they be used properly. Beyond these aids, mouthrinses and other cleaning tools might be of help.
Smoking
Whether you smoke, dip or chew tobacco you are more likely to have periodontal disease and to have it more severely than those who do not use any form of tobacco. It also depresses your immune system making you more susceptible to viruses and bacterial infections. In recent years, tobacco use has been shown to be one of the most significant risk factors for developing gum disease.
Research has shown that smokers have more tartar, deeper pockets, and more tooth loss due to gum disease than non-smokers. Furthermore, smokers do not respond as well to treatment of gum disease as non-smokers. There are also certain forms of treatment of gum disease such as bone grafting to replace lost bone or implants to replace lost teeth that are significantly less successful in a smoker. In some cases, smokers may not be candidates for certain treatments.
Genetics / Family History
In certain cases, there might be a family history of gum disease. A genetic marker that does correlate with gum disease has been identified. The exact link with gum disease, however, has not been determined yet. In general, there tends to be a stronger genetic component when gum disease starts earlier (under 35 years old) or when it progresses rapidly. If a genetic link is suspected, it is important to have children screened for gum disease from an early age.
Large Fillings / Crowns (Gaps) / Bridges
When teeth are badly broken down they must be restored with fillings, crowns or bridges. Although necessary to remove infection and keep teeth intact, large fillings and crowns (especially if they are below the gum line) make it harder to keep teeth and gums clean.
Pregnancy
During pregnancy there is an increase in certain hormones as well as other changes to various tissues such as blood vessels. These changes can make women more susceptible to gum disease as well as certain other mouth conditions. This can be particularly worrisome because there are newer findings suggesting that when pregnant women have gum disease there is an increased chance of having a premature delivery and a lower birth-weight baby.
Medical Conditions / Medications
Certain medical conditions can make you more susceptible to gum disease. The most obvious are those that can affect the immune system and the most common is diabetes.
Diabetes
Diabetes is a disease that causes altered levels of sugar in the blood. While some diabetics control their disease with insulin, most control it through diet and exercise. If you have diabetes, you know that you have to work closely with your physician to monitor the status of your diabetes and to keep it under control. In addition, you should work closely with your dentist or periodontist to keep your mouth and gums free from infection (Gum disease is an infection) as this may have a significant impact on the control of your diabetes.
Diabetic patients are at a higher risk for developing all types of infections including periodontal disease, which can impair your ability to process and utilize insulin. This may cause the diabetes to be more difficult to control and the infection to be more severe than in a non diabetic patient.
For many years we have known that people with diabetes are more likely to have periodontal disease than people without diabetes.
Other problems that may occur in diabetics are :
1. Delayed wound healing
2. Reduction of saliva may lead to an increase of plaque and calculus accumulation which may lead to more advanced periodontal disease. As well, a reduction in saliva flow can also lead to an increase in cavity formation.
3. Burning mouth sensation
4. If your diabetes is not well controlled then your dentist or periodontist may have to work closely with your physician to keep your diabetes under control. Uncontrolled diabetes makes your treatment of periodontal disease less predictable and it may take longer to heal.
Recently, research has shown us that the relationship goes both ways. Untreated periodontal disease may make it more difficult for diabetics to control their blood sugar. In other words controlling periodontal disease may help you to control your blood sugar.
Treatment: Overview
Like many other conditions, the best type of treatment is prevention. It is important to brush and floss regularly. Brushing should be done twice a day using proper technique. Flossing should be performed once a day and again, it is important that the technique be proper. Electric toothbrushes may be of use in some situations, but care must be taken not to brush too hard with one and to select one that has been proven to be effective.
There are other items that might be helpful depending on a person’s particular condition. These include: Proxabrushes, Rubber tip stimulators which can be used when there are large spaces between the teeth, Sulca brush and End tufted brush.
Scaling & Root Planing
Scaling and root planing refers to a cleaning of the root surface by a hygienist, dentist or periodontist. Scaling refers to cleaning off larger pieces of tartar (which hold the bacteria and their toxins); root planing involves smoothing out the root surface so it is harder for tartar to attach to it. In addition, root planing allows us to remove diseased and infected parts of the root surface. When the tartar and bacteria are removed, there may be a reduction in the amount of gum inflammation. In these instances there may be some recession of gums and there can be an increase in the spacing between teeth. Teeth may be a bit more sensitive to hot, cold or sweets.
Sometimes it is suggested to have sessions of scaling and root planning more frequently than the average 6-9 month interval. This may be suggested to maintain gum health after treatment, or instead of surgical treatment if there is a lot of inflammation and not much bone loss.
Open Flap Curettage
Studies have shown that when the pockets are too deep (over 5 mm) scaling and root planning offers limited benefits. This is because the instruments cannot adequately reach down deep enough to get access to the tartar. Additionally, when the pockets are deep, the person doing the scaling and root planning cannot see where they are cleaning. An example is trying to clean your elbows with long sleeves. Unless the sleeves are rolled up it is very hard to get access to clean. In these situations, it is preferable to gently detach the gums slightly from the teeth. This allows the operator to gain access and vision to all areas of the tooth surface so that they can be well cleaned. It also allows some of the infected gum tissue to be easily removed. The gums are then sutured back against the teeth.
After curettage, the pockets are shallower and so the patient has an easier time cleaning the root surface afterwards. The possible side effects are spaces between the teeth that may also be more sensitive to hot, cold or sweet.
Osseous Pocket Reduction Surgery
At times, the primary goal of the surgery is to reduce the pocket as well as clean the root surface. This is called pocket reduction surgery. Like curettage, the gums are detached from the teeth. During pocket reduction surgery, however, more of the bone around the teeth has to be reduced so that the gums will fit more intimately. This allows the root surfaces to be cleaned by the patient after the procedure. The side effects (spaces between teeth and sensitivity) are a little more pronounced after pocket reductions and sometimes bone must be removed from adjacent teeth that don’t have gum disease.
Regeneration
In certain situations, we can attempt to grow back bone that has been lost. This procedure is referred to as regeneration. Regeneration involves placing a material: either bone, an artificial substitute of bone or a protein into the area of bone loss (the bone defect). Regeneration cannot even be considered in many areas and even when it is attempted in ideal conditions, the results are not predictable. The most common technique used for regeneration now involves the placement of a protein into the bony defect. This protein is one that is around in humans as we develop in the uterus to form the tissues around the teeth. After it is placed, the gums around the teeth that have been regenerated cannot be cleaned for at least 6 months to a year and it may take at least that long for any evidence of bone growth to occur.
Extraction
Sometimes a tooth has experienced a lot of bone loss and there is a large infection around it. In these situations, we may have to consider removing a tooth or teeth. This is usually done when it is felt that keeping the tooth will cause problems to other teeth around it or to a patients health in general. Often times teeth are removed so that the patient can have dental implants.
Maintenance/ Cleaning appointments
None of the above treatments are cures. There is NO CURE for gum disease. The treatments above serve to clean the root surface and remove the infection. There is always bacteria in the mouth, however, and if we do not brush and clean properly the food we eat will also feed the bacteria and infections will start again.
The best way to maximize the benefits of treatment and prevent the disease from coming back is to:
1. Improve cleaning at home
2. Get a professional cleaning (hygienist, dentist or Periodontist) at the suggested frequency. Often, 3 months between cleanings is suggested because studies have shown that it takes about 3 months for the bacteria to turn into those that can destroy bone and the tissues supporting the teeth. If someone has remained stable over time while having their teeth cleaned every 3 months, then the interval between cleanings can be lengthened.
3. Try to reduce any destructive habits such as smoking.
Importance of Treatment: Overview
One of the primary reasons to treat gum disease is to preserve your teeth. Left untreated, gum disease results in the loss of the bone supporting the teeth and eventually the teeth will be lost. There are however other reasons for treating gum disease. Periodontal diseases are basically infections, and the bacteria from the periodontal pockets can spread through the bloodstream throughout the body. Newer evidence has shown that these bacteria can have effects on your general health.
Heart Disease and Periodontal Disease
We have known for a long time that bacteria may affect the heart. Now there is a growing body of evidence suggesting that people with periodontal disease, which is fundamentally a bacterial infection, may be at more risk for heart disease. They may also have nearly twice the risk of having a fatal heart attack than people without periodontal disease.
While more research is needed to confirm how periodontal disease may affect your heart, one possibility is that periodontal bacteria enter the blood through the inflamed gums and cause small blood clots that contribute to clogged arteries. Whether or not you have heart disease it would seem prudent to make sure your dentist has evaluated you for gum disease. Have gum disease treated as soon as possible, if not to save your teeth perhaps to save your heart!
Diabeties and Periodontal Disease
For many years we have known that diabetics are more likely to have periodontal disease than non-diabetics. Current research has shown that the relationship goes both ways. Untreated periodontal disease may make it more difficult for diabetics to control their blood sugar. In other words controlling periodontal disease may help you to control your blood sugar.
Pregnancy and Periodontal Disease
Many risk factors contribute to mothers having babies that are born prematurely at a low birthweight. It is common knowledge that smoking, alcohol use, drug use and infections contribute to this problem.
Now evidence is mounting to suggest a new risk factor , periodontal disease. Pregnant women who have periodontal disease may be 7 times more likely to have a baby that is born prematurely and with low birth weight. More research is needed but if you are planning to become pregnant be sure to include a periodontal evaluation as part of your pre-natal care. Healthy gums may lead to a healthier baby.
Respiratory and Periodontal Disease
It is possible that if you have periodontal disease you may be at an increased risk for respiratory diseases. What we know so far is that mouth infections like periodontal disease are associated with an increased risk for respiratory infections. More research is needed to understand this relationship but the association seems clear.