Diagnosis - Treatment - Maintenance
The word periodontal means “around the tooth”. Periodontal disease attacks the gums and the bone that support the teeth. Plaque is a sticky film of food debris, bacteria, and saliva. It is also called a "bio-film". If plaque is not removed, it turns into calculus (tartar). When plaque and calculus are not removed regularly, they become a constant reservoir of bacterial toxins. The gum is bombarded 24 hours a day with poisonous substances that it has to fight. Our immune system reacts by removing all tissue that has been affected by the toxins. In this way gums tissue, anchoring fibres and eventually bone is destroyed. In the mouth periodontal disease is characterized by red, swollen, and bleeding gums that eventually results in loose teeth.
Four out of five people have periodontal disease and don’t know it! Most people are not aware of it because the disease is usually painless in the early stages.
Not only is it the number one reason for tooth loss, research suggests that there may be a link between periodontal disease and other diseases such as, stroke, bacterial pneumonia, diabetes, cardiovascular disease, and increased risk during pregnancy.
Smoking also increases the risk of periodontal disease.
Good oral hygiene, a balanced diet, and regular professional cleanings can help reduce your risk of developing periodontal disease.
Signs and symptoms of periodontal disease:
- Bleeding gums – Healthy gums never bleed, even when you brush vigorously or use dental floss.
- Loose teeth – Teeth that become loose have lost their anchoring fibres. (fibers that are attached to the tooth and the bone).
- New spaces opening between teeth – Especially in the front.
- Persistent bad breath – Caused by bacteria in the mouth.
- Pus around the teeth and gums – Sign that there is an infection present.
- Receding gums – Loss of gum around a tooth.
- Red and puffy gums – Gums should never be red or swollen.
- Tenderness or Discomfort – Plaque, calculus, and bacteria irritate the gums and teeth.
Periodontal disease is diagnosed during a periodontal examination. This type of exam is always part of your regular dental check-up.
A periodontal probe (small dental instrument with a round tip and mm markings) is used to gently measure the pocket (sulcus) between the tooth and the gums. In a healthy situation the sulcus measures three millimeters or less and does not bleed after it has been tested. The periodontal probe helps indicate if pockets are deeper than three millimeters. As periodontal disease progresses, the pockets usually get deeper.
We will use pocket depths, amount of bleeding, tartar and inflammation, tooth mobility, etc., to make a diagnosis that will fall into a category below:
Gingivitis is the first stage of periodontal disease. It has just affected the edge of your gum. Plaque and its toxic by-products irritate the gums, making them tender, inflamed, and likely to bleed. Pockets are still 4mm or less and can be treated by regular professional cleanings.
Plaque hardens into calculus (tartar). This often happens on the root surface, underneath the gum lime. It therefore cannot be seen with the naked eye. Regular x-rays will clearly show calcium buildup under your gums.
As calculus and plaque continue to build up, the gums begin to recede from the teeth. Deeper pockets form between the gums and teeth and become filled with bacteria and pus. The gums become very irritated, inflamed, and bleed easily. Pockets may reach the critical level of 5mm at which patients cannot clean them with normal homecare techniques anymore. The disease is left uncontrolled. Slight to moderate bone loss may be present.
The teeth lose more support as the gums, bone, and periodontal ligament continue to be destroyed. Pocket are generally 5mm or more. Unless treated, the affected teeth will become very loose and will be lost. Generalized, moderate to severe bone loss may be present. Teeth that are loose in a mouth usually have deep pockets with severe bone loss. Saving teeth like this may not be possible.
Periodontal treatment methods depend upon the type and severity of the disease. We will evaluate the periodontal situation in a patients mouth and recommend the appropriate treatment.
If the disease is caught in the early stages of gingivitis, and very little damage has been done to the surrounding bone, one to two professional cleanings will be recommended. You will also be given instructions on improving your daily oral hygiene techniques in addition to having regular professional cleanings. Normally this will improve the situation and the disease will be controlled.
If the disease has progressed to early periodontitis where some bone has been lost, special periodontal cleanings called scaling and root planning (deep cleaning) will be recommended. It is usually done in one half of the mouth at a time. To do this effectively without causing discomfort to the patient we normally anesthetize either the top or bottom jaw while it is cleaned. In this procedure, tartar, plaque, and toxins are removed from above and below the gum line (scaling) and rough spots on root surfaces are made smooth (planning). This removes the poisonous surface on the root and allows the gum to heal.
If the pockets do not heal after scaling and root planning, periodontal surgery may be needed to reduce pocket depths, thereby making it easier for the patient to clean.
Periodontal surgery is usually is done in two sessions. One for the top and one for the bottom. The area concerned is anaesthetized and the gum is carefully lifted away from the root surface. All infected tissues are removed and roots and bone cleaned meticulously under direct vision. When everything is clean and smooth, the roots are treated with special antibiotic solutions to improve healing and prevent new bacterial growth. In the end the gum is placed back and sutured into place. Sutures stay for about 7 - 10 days after which they can be removed.
After surgery patients experience very little discomfort. Teeth may be sensitive to hot or cold for a while but this usually subsides as the roots adapt to the new situation.
Results after surgery are usually excellent. The gum may shrink a bit and teeth may look longer. On the other hand pockets will be reduced to a level where maintenance is possible and the disease can be controlled.
We normally do these procedures in our practice but may also recommend that you see a Periodontist (specialist for gums and supporting bone).
Special antibiotics, medicated tooth paste, antibacterial mouth rinses, and a special brushing technique may be prescribed to help control infection during healing.
Once your periodontal treatment has been completed, we will recommend that you have regular maintenance cleanings (periodontal cleanings), usually 3 times a year.
The reason for this is that bacteria start to grow again within hours of any cleaning procedure. After 30 hours, cariogenic (bacteria that cause decay) bacteria become a problem. To prevent decay therefore, we need to clean properly once in 24 hours.
Underneath the gum it is a different situation. Here the anaerobic bacteria (living without oxygen) that cause periodontal disease cannot "stick" to the root surface. They need others to be there first. Therefore it takes 4 months until anaerobic bacteria can colonize the pocket.
If a pocket is cleaned with ultrasonic scalers every 4 months, gum disease causing bacteria cannot re-establish themselves and disease can be controlled.
At these cleaning appointments, the pocket depths will be carefully checked to ensure that they are healthy. Plaque and calculus that is difficult for you to remove on a daily basis will be removed from above and below the gum line.
In addition to your periodontal cleaning and evaluation, your appointment will usually include:
- Examination of diagnostic x-rays (radiographs): Essential for detection of decay, tumors, cysts, and bone loss.X-rays also help determine tooth and root positions.
- Examination of existing restorations: Check current fillings, crowns, etc.
- Examination of tooth decay: Check all tooth surfaces for decay.
- Oral cancer screening: Check the face, neck, lips, tongue, throat, cheek tissues, and gums for any signs of oral cancer.
- Oral hygiene recommendations: Review and recommend oral hygiene aids as needed. (Electric toothbrushes, special periodontal brushes, fluorides, rinses, etc.)
- Teeth polishing: Remove stain and plaque that is not otherwise removed during tooth brushing and scaling.
The main challenge in treating periodontal disease revolves around our human nature. The following issues will influence the outcome of any treatment and need to be addressed in order to obtain the desired results.
Accepting a diagnosis
Periodontal disease is usually without pain. Patients are not aware that something is going wrong and may wait until major damage has been done to their gums and bone. The first step to controlling periodontal disease is to accept that something needs to be done.
When a diagnosis is made and treatments recommended, many patients feel reluctant to follow through. The procedures may be uncomfortable, teeth may look longer and gums may shrink as they heal. All this prevents people taking the plunge. Accepting treatment will set you on the path to conquering the disease.
Committing to regular maintenance
Without regular maintenance periodontal treatments are a waste of time and money. Whatever caused the initial problem is likely to re-occur and patients and clinicians usually become frustrated.
Ultimately periodontal problems can be addressed by having them diagnosed, accepting a treatment and committing to a regular maintenance program. Once these steps are in place, chances are good that the disease can be controlled and teeth will be maintained.