Most people do not know they have gum disease, until their dentist brings it to their attention. One of the reasons it comes as a surprise is that gum disease is a silent disease, with few obvious symptoms in its early stages.
One of the first warning signs is when the rim of the gum next to your teeth becomes red and swollen, and bleeds easily when touched. Most often, there is no discomfort at this stage, yet the disease has gained a foothold and is now known as “gingivitis.”
Gingivitis is reversible with improved oral home care and a professional cleaning. However, if left untreated, the danger exists that it will progress into an irreversible gum disease that damages the gums and bone surrounding the teeth.
Gum disease is a more advanced disease than gingivitis. Gum disease destroys jawbone and tissues supporting the teeth. Yet still, an individual may be unaware of the problem existing in their mouth. The signs are subtle at first, and often only dentist can detect it.
We are trained to look for:
Pockets occur when the collar of gum becomes infected, and separates from the tooth creating a space. This space is a “pocket.” A pocket is not necessarily formed when food gets stuck between teeth.
In spite of its common occurrence, gums are notsupposed to bleed any more than fingers, ears, or noses do on their own. If any of those starts bleeding, everyone knows to stop the bleeding, and look into it if it recurs. However, when gums continue to bleed, many simply ignore it,as if it were “normal”. Bleeding gums are not normal. When gums bleed, at the very least, a minor, reversible problem exists. Sometimes the bleeding is a sign that there are deeper problems, and without some kind of treatment, pockets and bone loss will continue to occur.
3. Bone loss
Dental x-rays, taken at regular intervals, chronicle the bone levels surrounding the teeth. Subtle changes in the bone levels are definite markers that periodontal breakdown is occurring.
If ignored, bone loss will progress and compromise teeth. Fact: 70% of all teeth removed from adults are due to bone loss from gum disease…not decay.
4. Loose Teeth
Something is wrong if your teeth are loose. Investigate the cause and seek treatment
Spaces are forming between front teeth: In general, teeth do not shift their position, though crowding of the lower (mandibular) front incisors does occur as we age. However, when spaces appear between some of the upper (maxillary) front teeth, it is time to figure out why. The most common reason for front teeth to flare out is advanced bone loss and lack of tooth support due to progressive gum disease.
Bad breath may be a sign that significant periodontal problems exist in someone’s mouth. Once the periodontal problems are under control, bad breath often goes away.
Occasionally, the first time a person knows they have a gum problem is when they get a periodontal abscess. An abscess occurs when bacteria are trapped in a gum pocket. They have no way of escaping and the pocket expands, forming an abscess. If treated in time, little damage occurs to the surrounding bone and tooth. Not treating an abscess in time, can lead to rapid and severe bone loss. When this happens, you require additional periodontal treatment.
It is important to note you may have gum disease and not experience any of these symptoms. Gum disease is silent and chronic, rarely giving an advanced warning that tissue destruction is taking place. That is why it is important to have regular dental checkups.
Gum disease is usually a slow, painless, progressive disease. Most adults with gum disease are unaware they have it. If diagnosed and treated early, however, the teeth can be saved.
During an examination, we inspects the color and firmness of the gums. We test teeth for looseness. The bite is checked. At some point, we may insert a small measuring instrument (actually it is a millimeter ruler) between the tooth and gum to measure the depth of the pockets. If the depths are greater than the norm of 1-3 millimeters, more deliberate therapy is required.
This “periodontal” examination is essential at frequent intervals for all adults, especially when there is a history of periodontitis in the immediate family (like a parent needing dentures by age forty) and/or if they smoke.
X-ray photos should be taken at appropriate times to evaluate changes in the bone supporting the teeth. X-ray photos also reveal dental decay and can be useful in detecting a variety of abnormalities.
Once a diagnosis has been made and a treatment plan formulated between the patient, their dentist, and the periodontist, the actual periodontal treatment is often performed in two phases, although a 3rd phase (surgery) is sometimes required.
Phase 1 – initial preparation & scaling
The first phase is the initial preparation. All patients need to complete this initial phase. This is when the patient learns which tools to use, and how to properly brush their teeth and clean in between their teeth.
In addition, during these visits, we perform multiple scaling (cleanings) of the teeth, attempting to remove all the plaque and tartar (calculus) stuck to the teeth. Often, changes can be seen right away. Bleeding reduces and the pockets get smaller.
Phase 2 – re-evaluation & possible further scaling
The second phase of periodontal treatment consists of re-evaluating the pocket depths and seeing if gums still bleed after the initial scaling. The more the patient exercises effective oral hygiene techniques, the more they can improve their condition.
There are times when additional scaling help attain the goal of smaller pockets. However, if the pockets are still too deep at the time of re-evaluation, patients need more treatment before returning to periodontal health.
Phase 3 – gum surgery
Surgery is indicated when non-surgical methods are not enough to stop the disease process. Periodontal surgery helps save teeth. When the pockets are so deep that scalings will not effectively clean them out, the dentist or periodontist gently separates and peels back the gums from the underlying structures.
Tartar and plaque can then be scraped off the roots,However, periodontal surgery accomplishes more than just scraping off tartar and plaque.
We know that bacteria impart chemicals, called endotoxins, onto the root surface. These endotoxins must be removed if gums are to reattach to the roots, in the quest of making pockets smaller. Without removing the endotoxins, periodontal treatment is hampered.
One way to remove endotoxin is to leech it out of the roots with mild acids…citric acid and tetracycline being two that are often used. Surgical access is essential to accomplish this. The other way to get the endotoxins off the roots is to scrape them off with careful scaling. Both are effective techniques performed during periodontal surgery.
Surgical treatment results in cleaner roots, shallower pockets, and healthier gums. The patient, can effectively maintain their periodontal health in this new and improved environment.
Guided tissue regeneration (GTR) involves the use of a biocompatible membrane material, often in combination with a bone graft, which promotes the growth of lost tissue and bone around your tooth. Not every case is suitable for grafting.
Contact us today to request additional information or to make an appointment with our gum treatment specialist (periodontist).
If you are not happy with your smile, there are cosmetic and dental procedures available that can help you achieve the look and smile you want. These procedures generally take the form of cosmetic gum surgery.
The following are the three most common gum related problems we are asked to treat:
A “GUMMY” SMILE
Do you feel that your teeth are too short and your smile is too “gummy”? They may actually be the proper length, but they are covered with too much gum tissue.
To correct this, our periodontist performs crown lengthening. During this procedure, excess gum and bone tissue is reshaped to expose more of the natural tooth. This can be done to one tooth, to even your gum line, or to several teeth to expose a natural, broad smile.
UNEVEN GUM LINE DUE TO RECEDING GUMS
Exposed tooth roots are the result of gum recession.
Perhaps you wish to enhance your smile by covering one or more of these roots that make your teeth appear too long. Or, maybe you are not bothered by the appearance of these areas, but you cringe because the exposed roots are sensitive to hot or cold foods and drinks.
Soft tissue grafts can be used to cover roots or develop gum tissue, which is absent due to excessive gingival recession.
During this procedure, your periodontist takes gum from your palate or another donor source to cover the exposed root. This can be done for one tooth or several teeth to even your gum line and reduce sensitivity.
LOST OR “COLLAPSED” GUMS DUE TO MISSING TEETH
Sometimes when you lose one or more teeth, you can get an indentation in your gums and jawbone where the tooth used to be. This happens because the jawbone recedes when it is no longer holding a tooth in place.
Not only is this indentation unnatural looking, it also causes the replacement tooth to look too long compared to the adjacent teeth.
Fortunately, your periodontist can fill in this “defect” with a procedure called ridge augmentation, recapturing the natural contour of your gums and jaw. A new tooth can then be created that is natural looking, easy to clean and beautiful.
What causes gum disease (periodontitis)?
The main cause of periodontitis is plaque that constantly forms and accumulates in our mouth. Plaque is an often-colourless mass of bacteria that sticks to teeth, crowns and bridges, and other tissues in the mouth. Plaque irritates the gums, i.e. causes an infection.
If not removed daily, plaque becomes the hard material known as tartar or calculus. Brushing and flossing alone cannot remove calculus. A hygienist, dentist or periodontist must remove it manually to stop it becoming worse.
With time, plaque and its by-products destroy the tissues that attach the gums to the teeth. The gums “pull away” from the teeth and pockets begin to form between the teeth and gums.
Plaque and calculus continues to fill these pockets. Unfortunately for us, the mouth is a perfect incubator. It is warm, dark, and moist, with tons of “food” for the bacteria to metabolize. The net result is that the bacterial plaque thrives, matures and eventually destroys the jawbone supporting the teeth.
Bacteria in plaque initiate the early changes to the gums. As the plaque matures on the teeth, the disease becomes more established to the point where it becomes irreversible.
What makes gum disease (periodontitis) worse?
A variety of factors can affect periodontitis. Other factors can modify how your gums react to plaque or calculus, thereby altering your body’s response to the disease and affecting your overall health.
The worst offender is smoking. Study after study shows that in the face of an established periodontal condition, smokers have worse gums. Not only do they have deeper pockets and more bone loss, but also they do not heal as well as non-smokers do.
Many diseases affect the gums. The most notable is diabetes. Diabetics need to take good care of their teeth and gums because they are prone to more infections and greater problems than non-diabetics. Other diseases that cause suppression of your immune system (i.e. leukemia, AIDS) may also affect the gums.
Though nearly ¾ of the world’s population has some form of periodontitis, a genetic predisposition is the single biggest determinant as to how serious each case gets. Some individuals are more prone to periodontitis than others. Some get a mild form, while others get a severe case.
Why? It is likely we inherit a genetic predisposition to periodontitis, and this influences how severely it will affect us.
Dentists have always known that stress affects the gums. As far back as World War I, the soldiers fighting in the trenches noted the influence of stress. Their gums became acutely infected to the point where the tips between the teeth, called papillae, eroded away, leaving disfiguring craters and loss of bone.
Teeth became loose, and in severe cases, needed removal. This so-called “trench mouth,” has the more formal name of “Acute Narcotizing Ulceration Gingivitis”. ANUG is also known as Vincent’s Disease, and is a stress-related disease.
To a lesser extent, what we eat affects the gums. Individuals who are overweight and those consuming high amounts of carbohydrates (especially in sweets, cakes and sugared drinks) adversely affect their teeth and gums. Constant sucking on cough drops and hard sweets help the bacteria metabolize more quickly, and in greater numbers. This causes a greater risk for dental decay and more inflamed gums.
Regarding vitamins, Vitamin C or calcium supplements do not affect periodontitis, and taking these supplements will have no effect on periodontitis.
Medications affect the gums. Drug groups that concern periodontists are the calcium channel-blockers (used to treat certain heart conditions), Beta-blockers (used to treat high blood pressure and other heart conditions) and anti-epileptic medications. Though these medicines do not affect every person in the same way, and in fact, do not affect all who take them, sometimes they cause the gums to swell.
These gum swellings occur between the teeth, and make brushing and flossing difficult. In some instances, people need surgery to manage the swollen gums. If you take drugs in these categories and are experiencing swollen and bleeding gums, you may want to seek professional help.
Be aware of another common side effect of many medications: dry mouth. When the salivary flow decreases, you need better oral hygiene since decay and inflammation may increase. If you sense your mouth is dry, clean your mouth frequently, and rinse often with water.
Hormones also modify periodontitis. Although women in general tend to take better care of their teeth than men do, their oral health is not that much better. Why? Because periodic fluctuations in hormone levels during the different stages of a woman’s life can affect many different areas of the body, including the gingivae (the gums).
Recent studies have shown that 23% of women aged 30 to 54 have periodontitis and 44% of women aged 55 to 90 that still have their teeth also have periodontitis.
Puberty in women is marked by an increase in the level of sex hormones (progesterone, estrogen), which increase the level of blood flow to the gums, making them more sensitive to irritants like plaque or tartar. The gums may turn tender, red, and swollen during this time but these changes are usually temporary and diminish as a young woman gets older.
Pregnancy may bring certain gingival and periodontal changes for the expectant mother. During the second or third month of pregnancy, women may experience what is termed pregnancy gingivitis; a condition characterized by tender, swollen, bleeding gums. This condition, once present, may increase in severity through the eighth month of pregnancy, then begin to resolve.
In some cases, gums already sensitive and swollen due to pregnancy gingivitis can react strongly to irritants and form large lumps, called pregnancy tumors. These tumors are NOT cancerous and are generally painless. If these benign growths get in the way of chewing, or become unsightly they may need removal.
When a woman gives birth, most problems reverse themselves, and leave no lasting marks. In some cases, however, pregnant women (suffering from periodontitis) may find their condition is actually worse post-par-tum. Teeth may feel loose or spaces may be present between teeth that were not there before pregnancy.
When these symptoms occur, professional help is required. Women who use oral contraceptives may experience similar symptoms as pregnant women in the form of red, swollen, bleeding gums.
Women taking oral contraceptives should be aware that medications sometimes used to treat periodontitis (i.e. antibiotics) could decrease the efficacy of their contraceptive medication. Be sure to ask your dentist, periodontist, or pharmacist before taking any prescribed medication while on oral contraceptive therapy.
To a lesser extent, some women notice that their gums get puffy and bleed with the slightest touch right before their menstrual cycle begins. These symptoms disappear a few days after menses has started. Women on hormone replacement therapy can also observe subtle changes in their gums.
Oral changes in menopausal or post-menopausal women may include dry mouth, pain and burning sensations in the gums, cheeks or tongue, or altered taste. In addition, conditions where the gums peel off and leave a raw bleeding surface (termed desquamative gingivitis) are more prevalent in menopausal or post-menopausal women.
Who treats gum disease (periodontitis)?
Once we discover that you have periodontitis, we will initiate a program to return your gums to good health.
In advanced cases of periodontitis, improved oral home care and thorough dental cleanings are not enough. More has to be done to the pockets and bone.
We prefer to recommend dental specialists to treat advanced periodontal cases. That is where periodontists enter the picture.
Most people do not know what periodontitis is or even that the specialty of Periodontics exists. In a sentence, periodontists are charged with saving teeth. That is their mission and goal for all patients. They utilize many types and techniques of treatment to achieve this goal.
When teeth cannot be saved and need to be removed, they are often replaced with dental implants. These dental implants are as strong (actually they’re stronger) than natural teeth, and allow the patient to keep an intact set of teeth (dentition) without the need for removable bridges or dentures.
Is there a link between gum disease (periodontitis) and other illnesses?
Until recently, periodontitis was considered a localized problem with little or no effect on our overall health and well-being. Continuing research, however, has shown that periodontitis may have powerful and multiple influences on the onset and severity of many systemic conditions and diseases.
Periodontitis is a serious infection caused by plaque bacteria. Although much of the bacteria are confined to the pockets around the teeth, the micro-organisms that make up the plaque can invade the gum tissue and enter the bloodstream, circulating throughout the body.
Once inside, the bacteria are able to secrete destructive chemicals and virulence factors. These factors activate the body’s immune system to respond much in the same way as the body responds to infected cuts or illnesses like pneumonia – with inflammation, pain, and destruction of the tissues.
The presence of long-standing periodontitis can place you at an increased risk for cardiovascular disease, as well as premature, low birth weight babies. In addition, periodontitis is a serious threat to patients already affected by diabetes, respiratory diseases, and stroke.
Women, in particular, have special health needs during certain periods of their lives. These come during periods of maturity and change in their bodies: puberty, menstruation, pregnancy and menopause. What is not so widely known is that women’s oral health needs can also change during these times.
Bacterial infection has long been recognized as a risk factor for cardiovascular disease, including heart disease and stroke.
More and more research is finding that the presence of periodontitis, a chronic bacterial infection, can place a person at increased risk for heart disease, and increase the likelihood of a fatal heart attack by nearly two times (Beck et al, Journal of Periodontology, 1996).
This connection has recently been featured in prominent news outlets like TIME Magazine (Health. July 19, 1999: Vol. 154, No. 3), USA Today (News. Tuesday, February 17, 1998), and Men’s Health/ABC News (Monday, December 20,1999).
How does this happen? First, periodontitis increases the incidence of bacteraemia (bacteria in the blood), which allows more bacteria to enter the bloodstream and accumulate along blood vessels and heart tissues. In fact, bacteria commonly associated with periodontitis have been cultured from plaques taken from heart attack victims (Zambon et al, Journal of Dental Research, 1997).
Certain oral bacteria are also able to bind to platelets when introduced into the bloodstream, which can increase the formation of clots and growths on arteries and heart tissues (Herzburg et al, Journal of Period ontology, 1996).
The most recent significant research centers on systemic increases in inflammation and a very important marker for inflammation, C-reactive protein. Periodontitis increases the levels of C-reactive protein in the blood 4 times and a recent study in the New England Journal of Medicine found that C-reactive protein is the single most significant marker for heart disease – even more than cholesterol levels.
Research is ongoing to shed more light on these mechanisms. The bottom line is that approximately 50% of the deaths in the United States are attributable to the complications of cardiovascular disease.
Treating your periodontitis not only saves your teeth, it also can reduce long-term risk for heart disease and ensure your good health.
Diabetes affects millions of people, and of these, perhaps only one-half are diagnosed. It is obvious that diabetes is a serious health problem.
For many years it has been known that patients with diabetes are more likely to have periodontitis than people without diabetes. In fact, periodontitis has been recognized as another complication of diabetes (Loë, Diabetes Care, 1993).
However, recent studies have found the opposite is also true: the presence of periodontitis can make it more difficult to control blood sugar levels in diabetics. Treatment of periodontitis has been shown to result in significantly reduced blood sugar levels (Grossi et al, Journal of Periodontology, 1996, 1997). Research is ongoing to confirm how this occurs.
What has been confirmed is that the presence of periodontitis causes the diabetic patient to have elevated blood glucose levels for extended periods of time. This puts diabetic patients at increased risk of other systemic complications such as kidney disease, heart disease, blindness, nerve disorders and impaired wound healing.
Pre-term Low Birth Weight Babies
Smoking, drug abuse, alcoholism, and hypertension are all confirmed risk factors that contribute to pre-term, low birth weight babies.
Recent scientific data shows that a new risk factor, periodontitis, can increase the risk of premature, low birth weight infants by SEVEN times – a risk greater than that posed by tobacco or alcohol (Offenbacher et al, Journal of Periodontology, 1996).
Follow-up studies at multiple Centres have reached similar conclusions (Jeffcoat et al, Journal of the American Dental Association, 2001). In fact, a recent study found that treatment of gum disease in pregnant women decreased the chances of a pre-term, low birth weight infant by FIVE times (Lopez et al, Journal of Periodontology, 2002).
The facts are indeed alarming: pre-term low birth weight babies (weight < 2500 grams at birth) are 40 times more likely to die, and are at increased risk for congenital deformities.
More research is necessary to define the underlying mechanisms by which periodontal infections can affect the unborn child. However, one thing is clear: if you are thinking about becoming pregnant or are at risk for periodontitis, the American Academy of Periodontology recommends that a periodontal examination be included as part of your prenatal care.
Our immune system is a powerful, indispensable tool necessary to fight off infection. For a long time, scientists have known that smoking, the aging process, and other health problems that suppress or hinder the immune system place patients at risk for respiratory diseases like bronchitis, pneumonia, emphysema, and chronic obstructive pulmonary disease (COPD).
Recent studies point to periodontitis as a potential risk factor for the development of these respiratory diseases.
It is important to note that this area of research is ongoing but several facts have been established. The same bacteria that are associated with periodontitis can also cause pulmonary disease (Lorenz and Weiss, Western Journal of Medicine, 1994; Benkalaramain et al, Chest, 1994).
Therefore, it is possible that diseased gums act as a reservoir for potentially infectious respiratory bacteria (Dahlen and Wickstrom, Oral Microbiology and Immunology, 1995). In fact, a recently completed 25-year study found that patients with bone loss caused by periodontitis places patients at a significantly increased risk of COPD (Hayes et al, Annals of Periodontology 1998).
What is the big deal if I lose a tooth?
Besides helping us look good, teeth are important for a host of other reasons.
For one, strong firm teeth enable us to chew our food more comfortably. Properly masticated food makes for better digestion.
Everyone likes a healthy, bright smile. First impressions count. Besides making you look and feel good, teeth help us to speak clearly. People, who have had the misfortune of losing all their teeth and wearing dentures, can have difficulty speaking. They also cannot eat all the things they want, are often self-conscious about their “choppers,” complain that they cannot taste their food as well as they used to, and may even have trouble breathing when they sleep.
Those are enough reasons to keep our teeth, and the best way to start is with good oral hygiene.
Is maintenance required after periodontal treatment?
Yes, in most cases. As mentioned earlier, periodontitis is a chronic condition that is not cured but can be stabilized and maintained. Periodontists have a great track record when it comes to getting periodontal conditions under control. Once the initial treatment has been completed, maintenance care is essential for future good oral health.
Periodontitis often follows certain patterns. Pockets and bone loss usually begin in the maxillary (upper) molars, followed by the mandibular (lower) molars. In time, it will involve other teeth, as well.
Once formed, periodontal pockets do not get worse on a daily basis. Rather, pockets can remain stagnant for long periods of time, only to have short bursts of problems when they worsen, only to become stabilized again. We call this periodontal breakdown “episodic.”
Along the way, abscesses can occur, and pockets and bone loss can progress to the point that teeth need to be removed. Treatment retards and, in many instances, can even stop this progressive gum/bone deterioration.