The word “periodontal” means “around the tooth,” and refers to the supporting structures of alveolar bone, connective tissues, and gums which keep the teeth in the jaw. Periodontal disease is the number one cause of tooth loss, exceeding even tooth decay, but it is often ignored, perhaps because there is very little pain, particularly in earlier stages of the disease.
Most often, periodontal disease originates in poor oral hygiene. When we eat foods, especially starches or sugars, bacteria in the mouth multiply and settle on the teeth in a soft biofilm known as plaque. If this plaque is not removed from the teeth by brushing or flossing, it hardens to form tartar, often at the gum line, between the enamel of the tooth and the root. This tartar fosters the buildup of further bacteria-laden plaque layers. While most mouth bacteria are harmless, bacteria from bacterial groups which thrive without oxygen can be damaging to the gums. The presence of such bacteria and their wastes promotes inflammation at the gum line and degeneration in gum tissue. Gums, which appear as pink and stippled in texture when healthy, take on a shiny, reddened appearance and appear puffy or swollen. They may bleed when the teeth are brushed or even during eating. Sometimes the teeth become more sensitive to cold or sweet. There may be an odour to the breath. These are warning signs that it is time to treat the disease.
At this early stage, periodontal disease is known as gingivitis. Although gingivitis almost always precedes the development of more serious periodontal disease, gingivitis can be reversed when treated successfully. For most patients, gingivitis is very responsive to good tooth cleaning habits at home. Teeth should be brushed ideally at least twice a day with a soft brush, and flossed at least once. Toothpastes or mouthwashes containing anti-tartar buildup agents can be used and the tongue brushed as well. Tartar buildup which has already occurred should be removed by a dentist or dental hygienist, and regular cleanings at the dentist every four to six months are essential.
However, some patients have already developed or go on to develop the more serious periodontal disease known as periodontitis. In periodontitis, damaged gums begin to recede from the teeth below the gum line. Deep pockets form at the sulcus or groove between teeth and gum line, and these become filled with bacteria and plaque. More tissues become involved, and the body mounts a full-scale immune response. In the process, connective and underlying bone tissues are destroyed, largely by cells from the body’s own immune system. Because brushing and flossing alone cannot clean out the deepened sulcus, it becomes necessary to restore the attachment of the gum. A dentist or dental hygienist can often accomplish this by a more extensive tooth cleaning known as scaling and root planing.
In scaling and root planing, tartar and plaque are cleaned out above and below the gum line, and the roots of the tooth are cleaned off, smoothed, and exposed to air. The cleaning is usually performed over a period of several appointments. The area can also be treated with antibiotics or antimicrobial washes, or by laser to further destroy harmful bacteria. In the following weeks, the gums reattach to the cleaned and smoothed roots. Sometimes this is all that is needed to clean out infected pockets and restore normal depth to the sulcus between tooth and gum. After that, it is up to the patient, again, to maintain his or her periodontal health through proper brushing and flossing at home and routine follow-up cleanings at the dentist.
In more serious cases, where more of the root is involved with tartar buildup, gum surgery is performed. A “flap” of gum tissue is actually taken away from the root while the root is cleaned. If the root exhibits indentation after cleaning, sometimes stimulants are painted on the root to achieve some level of bone regeneration. The gum is then sutured back into place. Additional surgical intervention might include bone grafting to the alveolar bone around the tooth if there has been sufficient bone destruction. There might also be guided gum or bone regeneration at the root-gum interface. Additionally, gum grafts might be made to cover sensitive gum line areas or improve appearance.
Again, these interventions are often successful, and, with good oral home care, periodontal health can be maintained.
If intervention is not made, however, and the disease is allowed to advance, the results will be tooth movement, tooth pain, and, eventually, tooth loss. The patient will be left with little choice other than dental implants, perhaps accompanied by further bone graft. Failure to proceed with treatment is not a good option even at this point as both inflammation and further alveolar or jawbone loss often continue after teeth are gone.
Reasons for the advance of chronic periodontal disease are varied. About 30% of patients have a genetic tendency towards periodontal disease. These patients may display a six-fold increase in more serious periodontal disease and must monitor their periodontal health more carefully than others. Another factor which favours the development of chronic periodontitis is age. Cumulative periodontal destruction affects the majority of people. 86% of people over seventy display at least moderate periodontitis and a quarter of these have already lost their teeth. Many people are affected by more rapid periodontal degeneration after the age of thirty, and, though the development of periodontal disease may proceed unevenly, it is generally true that all patients must be progressively more vigilant with their periodontal health as they age. Hormonal fluctuations can also play a role in the development of inflammation in the mouth with women in menses, pregnancy, and menopause, and women should be more alert to changes in the mouth at these times. For some patients, the habit of bruxism (tooth grinding) can worsen periodontal disease already in progress because the habit causes added stress to the tooth support structures. This is just one more reason why a mouth guard should be worn at night by patients subject to night time bruxism. An even more serious risk factor for periodontal disease is the habit of smoking. Smoking promotes inflammation, inhibits healing, and disguises the bleeding which so often alerts patients to the presence of the disease. Other serious risk factors are the myriad drugs which either suppress immune function or inhibit saliva production, both serious risk factors for periodontal disease. These would include drugs used to treat cancer or AIDS, but also seemingly harmless and commonly used drugs such as calcium channel blockers used to treat high blood pressure, anti-depressants and anti-seizure drugs, and even contraceptives. Stress and poor diet can also be separate factors for immune suppression and, therefore, periodontal disease.
Most patients are concerned with treating periodontal diseases because of their oral health. However, there is mounting evidence that periodontal disease may have some causative role in other adverse medical events. There are convincing studies linking low birth weights and premature births with the existence of periodontal disease in pregnant women. There is also evidence linking heart disease, stroke, lung disease, and diabetes with periodontal disease. Such relationships may be due to the inflammatory nature of periodontal disease and the tendency for bacterial spread from the mouth to other parts of the body, whether through the blood or air passages. For many reasons, then, it becomes important to recognize and treat periodontal disease.
For many patients, both gingivitis and periodontitis are identified at the dentist’s office. In this regard, dental cleanings and the observations they permit have become indispensable doorways to advice about and treatment of periodontal disease. In routine cleanings and examinations, the dentist or hygienist may notice swelling, redness, or bleeding around the teeth. He or she can instruct or remind patients about the good tooth and gum cleaning practices which will check gum and bone deterioration. At teeth cleaning appointments, also, the dentist or hygienist measures the depth of the sulcus to see if dental pockets exceed an accepted three millimetres. He or she may also notice that the teeth have become loose, have moved, or are changed in the orientation of the bite. Problems with previous dental work or with wisdom teeth may be noted. In dental x-rays, bone loss may be evident. In all these cases, further dental intervention may be discussed. These routine visits are essential, then, not only for cosmetic reasons and examination for tooth decay or mouth cancer, they are also important for recognition and treatment of ongoing periodontal disease and to remind patients, young and old, of their particular responsibilities in maintaining their own periodontal health.