Periodontal Disease is a bacterial infection which has targeted the periodontium as its primary focus. The Periodontium consists of the gums (gingiva), bone and ligaments that support the teeth and anchor them in the jaw. The bacteria which attack the Periodontium are part of the normal flora of bacteria which inhabit the oral cavity. When allowed to proliferate, they can become opportunistic and overwhelm the body’s natural immune response with the poisonous toxins these bacteria can produce. It is these same bacteria that form a whitish-yellow film called dental plaque on the teeth. If the plaque is not removed adequately by thorough brushing after meals, the plaque will solidify and form tenaciously sticky calculus (tartar), which only a dentist can thoroughly remove. If this process is not reversed, the supporting structures of the teeth, namely the gums, bone, and ligaments will start to be destroyed which will ultimately lead to tooth loss. Periodontal disease can occur at any age, but the incidence of this disease increases with age amongst the general population. Over half of all people over the age of 18 have some form of Periodontal Disease. After age 35, over 75% of all people are affected. There also seems to be a strong genetic factor associated with this disease process. If your parents lost teeth to Periodontitis, (or Pyorrhea as it was formerly called) it is likely you will be predisposed to the disease as well, and must take care to be vigilant to the early signs and symptoms of gum problems. Unfortunately, this disease is insidious in nature as it is usually asymptomatic and painless. Most patients do not know or even suspect that they have gum disease, and this is a major contributing factor to why most people to do not seek periodontal treatment. Although this disease is easily detected during regular dental examinations, many patients, even when advised that they have periodontal disease, will not follow through with treatment. This is mainly attributed to the fact that the progression of the disease is slow and painless. However, like most disease processes, early detection is critically important. Another fact worth noting here is that once jaw bone has been lost to periodontal disease, it is difficult to nearly impossible to regenerate bone. Although there are new bone grafting techniques and very “cutting edge” laser technologies that show promise for a medical breakthrough in this area, the best treatment available to date for Periodontal Disease is still Prevention. Via a regular routine of professional cleanings and check-ups coupled with a conscientiously applied regimen of excellent oral homecare consisting of brushing after meals, rinsing twice daily with a non-alcoholic chlorhexidine or fluoride based mouthwash, coupled with flossing at bedtime is still the best method to date of preventing Periodontal Gum Disease. Another advantage we might have over previous generations is that our dental awareness is much keener and we might truly come to realize the importance of strong teeth and bones.
Healthy Gums and Bone
During your hygiene recall exam and prophylaxis, the dentist or hygienist will use a small dental instrument to probe and measure the space between your teeth and gums. This area between the teeth and gums is called the sulcus, and the normal depth of a healthy sulcus or pocket is between 1 to 4 millimeters. These Periodontal pockets are considered to be healthy because they are self cleansing, namely that a toothbrush can reach down 1 - 4 mm between the tooth and gum to clean there. Typically no bleeding is associated with probing these pockets. Sulcular pockets greater than 4 millimeters are considered pathologic and are not able to be maintained and cleaned via regular toothbrushing or even flossing. Over time, the pocket depths will increase as they continue to harbor more food debris, dental plaque and calculus. These pockets will bleed quite easily upon probing. The dentist or hygienist will record a Periodontal Charting of all pocket depths, along with bleeding, inflammation, tooth mobility, gingival color, texture quality, and recession to make a diagnosis. X-Rays will be imperative in determining if there is underlying bone loss and to what extent bone damage has occurred as a result of the disease process. Once the diagnosis is made, the gum disease will be classified in accordance with the guidelines prepared by The American Dental Association and The American Academy of Periodontology.
There are four categories:
Type I Gingivitis: Inflammation of the gingiva characterized by gingival enlargement, bleeding on probing, gingival pocket formation, no bone loss.
Type II Early Periodontitis: Progression of Gingival inflammation into the crest of the alveolar bone with early bone loss, moderate pocket formation.
Type III Moderate Periodontitis: A more advanced state of the above condition with increased destruction; moderate to deep periodontal pockets; moderate to severe bone loss; tooth mobility.
Type IV Advanced Periodontitis: Further progression of disease with severe destruction of the periodontal structures; increased mobility
Contributing Factors and Warning Signs
The affects of dental plaque and tartar buildup on the gums and underlying bone can be compounded by any of the following factors:
Periodontal Disease, although often painless, is a progressive disease and will continue unabated until either teeth are lost or human intervention via dental treatment is rendered. However, there are early warning signs that the patient should take note of and seek dental attention immediately:
A) Bleeding Gums
Periodontal treatment depends upon the type and severity of the disease, with the main goal being the eradication of the disease process from the gums, bone and ligaments that surround the teeth. If the disease is caught in the early stages of Gingivitis, and no damage has been done to the underlying periodontium, one or two regular cleanings at an accelerated interval of every 3 months might be recommended. You will also be given instructions on improving your daily homecare, namely to brush after every meal, to rinse once in the morning and once at bedtime with a non-alcohol based chlorhexidine or fluoridated mouthwash, and to floss once daily, preferably before bedtime. The order of these acts before bedtime should be: brush, floss, then rinse. If the disease has progressed to a more advanced stage, a more robust treatment will be required. Treatment of more advanced gum disease is generally divided into two phases.
If the disease has progressed beyond simple gingival inflammation (Gingivitis), a special periodontal cleaning called “Deep Scaling and Root Planing” will be recommended. This procedure is often times performed with topical or local anesthesia to remove the bacterial plaque and calculus deposits that have formed below the gum line. Typically, this procedure is performed one quadrant at a time, and as there are four quadrants in the mouth (Upper right, Lower right, Upper left, Lower left) the dentist will generally opt to treat the two right quadrants at one visit, and two left quadrants at a second visit one week later. This allows the patient to be comfortable and eat on the non-treated side while the treated side heals. This treatment, along with improved conscientious homecare helps the gum tissue to heal, pockets to shrink, and may be the only treatment necessary in mild cases of Early Periodontitis. This patient will also be placed on a shortened 3 month recall interval for professional prophylaxis to ensure the disease has been arrested and clinical health maintained. As an adjunct to this procedure, utilizing a relatively new technique, we are now able to deliver local therapeutic agents such as Minocycline directly to the site of periodontal pocketing and minor abscess inflammation. This technique is not only proving to be very effective, it enables specific affected areas to heal much more quickly than ever before while sparing patients from having to take systemic antibiotics from which resistance can develop. Another over the counter device is also helpful in fighting gum disease, namely the electric toothbrush. If the periodontal patient does not already have one, one will be recommended.
If pocket reduction is not adequate enough after “Deep Scaling and Root Planing”, or in cases which demonstrate deeper pockets and underlying bone loss, Phase II therapy will be required. Phase II therapy usually includes Periodontal surgery and osseous recontouring. In simplest terms, the gum (gingiva) is reflected back away from the teeth and bone (this is called a “flap”) to expose the underlying roots and bone deformities. The bone is contoured to emulate a more natural physiologic profile, and the root surfaces are smoothed of any rough spots or calculus, with the gingiva currettaged and sutured back to place. When the gum heals, healthy pocket depths of 1-4 millimeters will be re-established, with the pockets once again self cleansing and without bleeding upon probing. In some cases that are extensive with dramatic bone loss, we may also recommend that the patient be referred to a Periodontist, who is a specialist at gum disease and Periodontal Surgery.
Additional Treatment Modalities
Sometimes, Periodontal Phase I and Phase II therapy is not sufficient to totally treat and complete a case. Additional treatment may be required to give the patient every chance to achieve clinical health that they themselves can maintain between recall visits. These additional modalities include:
A) Occlusal adjustment to eliminate trauma from biting on specific teeth
It takes less than an hour for plaque to form on your teeth, and it can take less than 24 hours for that same plaque to turn in to tartar (calculus). The patient must remain aware that homecare is really bacteria population control, and when bacteria are allowed to proliferate, that is when the damage occurs to your teeth, gums and bone. Conscientious daily homecare helps control plaque and tartar formation and also keeps the amount of oral bacteria below a detrimental level.
Also, once the active phase of treatment has been completed and clinical health has been restored, it is extremely important that patients be seen by our hygienist for routine dental and periodontal cleaning on a regular basis, preferably 4 times a year. This regimen, along with the diligent homecare previously described, (brushing after every meal, non-alcohol based chlorhexidine or fluoride mouthwash, and daily flossing preferably just before bedtime) will give the patient the best chance for preventing recurrence of the disease and maintaining long term periodontal health.