Periodontal Disease

Periodontal (gum) disease is a bacterial infection of the gum tissue in the mouth. It is a gradual, often painless process that leads to the destruction of the supporting structures of the teeth and supporting bone in the jaw. It is one of the most common diseases known to humans, effecting most people at some point in their lifetime. Many people who have it don’t even realize it. It can begin in early childhood and can even be inherited. It is a disease that is not completely curable and will progress and get worse if not treated. However, the progression of it can be controlled with proper treatment and improved oral hygiene habits. Advanced stages can require extensive treatment that can be very expensive. If left untreated, the loss of bone and teeth are likely.

Symptoms of Periodontal Disease

1. Gums bleed when brushing and/or flossing.
2. Gums that are unusually red or purple in color.
3. Gums that are swollen and/or tender.
4. Gums that pull/move away, exposing more of the tooth or root (recession) which makes the teeth look longer.
5. Reoccurring bad breath and/or bad taste in the mouth.
6. Changes in the way the teeth fit together (bite).
7. Permanent teeth that feel loose or move slightly.
8. Permanent teeth that have developed spaces between the teeth.

Experiencing one or more of these symptoms, could be an indication of mild to moderate periodontal disease. Experiencing multiple symptoms could be an indication of moderate to severe periodontal disease.

Diagnosis of Periodontal Disease

The following criteria are used in assessing the degree of periodontal disease:

1. Patient’s History – dental history, medical problems, dietary and oral hygiene habits and other symptoms.

2. Visual Examination – thorough inspection of teeth for plaque and calculus buildup, mobility of teeth, bleeding, recession and the way the patient’s bite comes together.

3. X-ray Exam – thorough evaluation of the supporting bone.

4. Periodontal Pocket Measurements – A special instrument is used to measure the depth of the spaces (pockets) between the gums and teeth. Measurements are usually in millimeter increments. Measurements of 1-3 mm are generally considered healthy, 4 mm is a measurement indicating concern, and measurements of 5 mm or greater, particularly when there is bleeding or bone loss usually indicate periodontal disease is present. Areas of the mouth that have measurements of 4-7 mm or less, can usually be treated non-surgically with a procedure known as scaling and root planing.

Pocket depths, bleeding gums, bone loss, inflammation, recession of the soft tissue, mobility of the teeth, calculus build-up, and other clinical criteria are all considerations when determining the level of periodontal disease and which type of treatment is best for the patient.

How Periodontal Disease Progresses

The main cause of periodontal disease is poor oral hygiene. Poor brushing and flossing habits allow plaque (a sticky, colorless film of bacteria) to build up on the teeth and harden. This common early form of periodontal disease, known as gingivitis, usually has mild, ongoing inflammation of the gums and little to no pain. As the hardened buildup (calculus) accumulates, the continued inflammation and irritation to the gums causes the gums to separate from the teeth, forming pockets. These pockets collect bacteria, food particles, etc., gradually causing them to become deeper. Bleeding and sore gums are common with advanced buildup and pocket depths.

As the level of the disease worsens the gums begin to recede (pull/move away from the affected teeth, exposing more and more of the teeth and roots. Root sensitivity is common with recession. Root exposure can also lead to tooth decay. Eventually the tissue and bone holding the affected tooth/teeth in place are destroyed and the tooth/teeth become loose and may fall out.

Smoking, diseases (such as diabetes), harmful habits (such as grinding and clenching), stress, lack of rest, poor diet, growth and developmental processes (such as crowding of the teeth and poor bite) contribute to the progression of periodontal disease.

Treatment

The most basic preventive measure against periodontal disease is proper brushing, flossing, and routine professional dental cleanings to remove the excess bacterial plaque and build up that naturally occurs. Mild to moderate periodontal disease can often be treated non-surgically coupled with more frequent professional dental cleanings and improved home care. Advanced levels of the disease may require surgical treatment. As the level of periodontal disease progresses, the irreversible effects of advanced stages often lead to treatment options that are much costlier. However, through early education, recognition, and treatment, periodontal disease can be prevented, controlled, and unnecessary treatment and extensive cost avoided.

Non-Surgical Treatment

When periodontal disease is caught in time (when pocket depths are within 4-6 mm) there is a conservative, nonsurgical treatment which can be performed. Scaling and root planning is also known as conventional periodontal therapy, or deep cleaning. This is the process of removing the toxins, plaque and calculus from the teeth and roots, above and particularly below the gum line. In some cases, antibiotic medications are used in combination with this treatment.

Scaling and root planing of the entire mouth usually takes multiple appointments of approximately one to two hours. Anesthesia is commonly used for comfort and the treatment is divided into portions of the mouth, either one quadrant per appointment or half of the mouth per appointment. These appointments are generally scheduled one to two weeks apart. By making the root smooth again, the gum inflammation begins to subside and reattach to the tooth. If the pockets are kept clean of plaque on a daily basis, the gum tissue will return to health.

Some patients may experience mild discomfort for up to two weeks. Medication is rarely prescribed for pain. After allowing three to four weeks for the gums to heal, a reevaluation appointment is scheduled so the dentist and/or hygienist can check on the healing of the gums, status of the pocket depths compared to the original pocket depths, perform a thorough fine scaling and polishing, and review of continued care.

Surgical Treatment

When periodontal disease progresses past the moderate stage, surgery is usually necessary to prevent any further loss of soft tissue, bone or teeth. There are a variety of surgical solutions. Your dentist and/or periodontist will determine exactly what type of procedure is appropriate given the specific conditions. Some common types of periodontal surgery are:

Gingival Flap Surgery – If pockets are greater than 5 millimeters in depth, the periodontist would conduct this procedure to reduce the periodontal pockets. Most patients who have been diagnosed with moderate to severe periodontitis would go through this procedure. The periodontist would cut the gum tissue to separate the gum tissue from the teeth, conduct a thorough deep cleaning with an ultrasonic scaling device as well as hand instruments to remove plaque, biofilm and buildup below the pockets.

Gingivectomy – This procedure is conducted to remove excess gum tissue that may be overgrown on the teeth to provide a better area to clean the teeth. The periodontist would numb the gum tissue and cut and eliminate the extra gum tissue in the mouth.

Gingivoplasty – This type of gum surgery is used to reshape healthy gum tissue around the teeth to make them look better. If a person has tooth recession where the gum is pushed away from the tooth, a gingivoplasty can be done. A gum graft can be done where the tissue is taken from the roof of the mouth (this is called a graft) and then stitched into place on either side of the tooth that is recessed.

After gum surgery, your dentist/periodontist or hygienist will inform you about post-operative care and how to care for your gum tissue and teeth thereafter. Special tooth brushes, antimicrobial fluoride toothpastes, floss and antibacterial mouth rinses may be recommended.

Continued Aftercare

Conventional periodontal therapy (scaling and root planing) and/or surgical procedures are only the first part of treatment for periodontal disease. Increased home care (as directed by your dentist or hygienist) combined with more frequent periodontal maintenance therapy appointments are essential.

Periodontal maintenance therapy appointment should be scheduled every 3-4 months (as recommended by your dentist or hygienist) to control your periodontal disease and to keep it from getting worse. Periodontal disease can only be controlled, not cured. Periodontal maintenance therapy appointments allow for a more thorough cleaning to clean the deeper pockets associated with moderate to severe periodontal disease. In addition, more frequent examinations of the gum tissue and measurements of the pocket depths are important.

Without a strong commitment to increased home care and regular periodontal maintenance therapy appointments, there is a high chance that the periodontal condition will rapidly worsen and the progression of the disease will continue.

Consequences of Neglecting Periodontal Disease Treatment

When gum disease isn’t treated at the early stages (gingivitis), it can progress into more serious gum disease (moderate to severe periodontal disease). When diagnosed and treated quickly, sometimes it can be halted all together. However, if the level of disease is not dealt with until a later stage, it can result in the need for life-long treatments, and on a more regular basis than your normal cleanings. This can be much costlier as well.

When left untreated, advanced/severe periodontal disease breaks down the bone that surrounds teeth, and eventually can cause tooth loss in addition to severe decay. Surgical solutions are often necessary and the possibility of irreparable damage to bone and lost teeth is high. The cost of periodontal and reconstructive bone surgery can be quite expensive.

Gum disease has also been shown to create a greater risk for other serious health conditions. This includes heart disease, stroke, premature births, diabetes, and respiratory disease.

Financial Responsibility

Unfortunately, dental benefits and/or dental insurance usually only cover basic preventive care. Typically, two cleanings per year and small portions of additional types of needed periodontal treatment are covered. This leaves most of the financial responsibility on the patient.

The best way to avoid additional or expensive costs for treatment is to treat periodontal disease when it is first diagnosed and strictly follow the recommendations of your dentist/hygienist for oral hygiene regimen and frequency of professional cleanings/periodontal maintenance therapy appointments. Although periodontal disease cannot be cured, the good news is that it can be controlled and the progression of disease and costs can be prevented.