About Periodontal Disease

What is periodontal disease?

Periodontal, as with most science-type words, is from the Latin “perio” (around) + “donta” (tooth). Periodontal diseases, or gum diseases, are some of the most common infections in the United States. Approximately 75% of American adults have some form of periodontal disease, although many people are not aware they have a disease. Most periodontal disease is painless until it reaches the advanced stages.

Periodontal diseases are bacterial gum infections that, when left untreated or uncontrolled, will lead to the destruction of the attachment that hold the teeth in and also the bone supporting the teeth. The bacteria collect in the sticky plaque (biofilm) that is constantly forming on your teeth. The sticky plaque will pick up minerals from your saliva and within two days, will begin to harden into a substance called calculus (tartar). The calculus cannot be removed by brushing or flossing. It has to be removed by a dental professional. If the calculus forms below the gum line, it makes it more difficult to remove the plaque and bacteria.

Bacterial colonies grow in the small spaces around the teeth between the teeth and gums.  There are always bacteria in your mouth, but periodontal disease is caused by the growth of a particular type. The bacteria gather in colonies in a specific order in the bottom of the gum pockets. If the bacteria continue to multiply undisturbed, the different species continue to multiply in the pocket. It is the body’s response to the toxins produced by the bacteria that causes more and more destruction and deeper pockets, allowing more bacteria. After being disturbed, it takes about 90 days for the bacteria to reach critical numbers again. This cycle is why it is recommended that, if you have periodontal disease, you visit your dental professional for care on a three-month schedule.

Some people never experience any outward signs of the disease. Others experience redness, swelling, bleeding gums, some pain and bad breath. Not all of the teeth in an individual’s mouth may be affected at the same time or to the same degree of severity.

Normal Mouth Conditions:

In a normal, healthy mouth, the gums are coral pink, fit tightly around the neck of the tooth like a turtleneck, and fill the spaces between the teeth.

The teeth are held firmly in place by a combination of supporting bone, ligaments and gum tissue. The bone follows the outline of the root of each tooth, and the gum follows the upper contour of the bone.

In a healthy mouth, there is a small space, averaging 3mm in depth, between the uppermost gum and the bone around the tooth.  This area is what the dental professional measures at your visits.

There is a small space between the bone and the tooth root that is filled with ligament fibers and various kinds of cells. The ligaments attach the bone to the tooth root and act to hold the tooth firmly in the bone. The ligament fibers also act as shock absorbers that help the tooth withstand the forces exerted during biting and chewing.

Stages of Periodontal Breakdown:

Gingivitissigns of gingivitis

The first stage is gingivitis, the mildest form of periodontal disease. It is caused by irritation to your gums as a reaction to the toxins produced by the bacteria in the plaque on your teeth. In gingivitis, the gums are red, slightly swollen and may bleed easily.

Generally, there is little or no pain at this stage. If the bacterial plaque is not removed by regular home care (brushing and flossing) and visits to your dentist, the irritation will worsen. In addition, the soft sticky bacterial plaque will start to harden and have a rough surface.

If the bacteria continue uncontrolled, or the colonies remain uninterrupted, the disease can progress. The gum tissue may become more swollen and a deeper red to blue. The gum tissue tends to bleed very easily.

Gingivitis is reversible with good home care and professional cleanings.

Periodontitishealthy vs periodontal disease

If the bacteria is not controlled or interrupted, the plaque and the calculus continue to build up, increasing the level of irritation. Periodontitis occurs when the bacterial infection spreads to the bone. As the bacteria spreads to the bone and supporting ligaments, destruction of the supporting structures begins. The pockets around the teeth begin to increase in depth.

As the disease progresses, the gum tissue may begin to shrink back from the teeth (recede), following the disappearing bone. The deepening pockets allow space for the bacteria to multiply. As the ligament fibers and bone tissue are destroyed, the tooth may become loose.

Normal, healthy pocket depth vs Moderate to severe periodontitis:

As the bacteria continue to multiply, deepening the destruction, more bone and supporting structures are lost. As different stages of periodontal diseasethe infection worsens, pus may fill the pocket.  There may be swelling around the root. You may start to experience hot and cold sensitivity. You may experience pain and bleeding when you brush or floss.

As the destruction of the supporting tissues continues, teeth may loosen and be lost or recommended for extraction to maintain the health of the remaining teeth. You may also notice that more space appears between your teeth – indicating that they are loose and moving. You may also notice that they no longer bite together as they once did.

What other factors may contribute to periodontal disease?

Although bacterial plaque is the primary cause of periodontal disease, other factors may affect the health of your gums.

  • Smoking/tobacco use: Smokers and tobacco users are statistically more likely to get periodontal disease, and to get the more severe forms. Healing following treatment is generally slower.
  • Pregnancy and puberty: Hormonal changes can cause the gums to become red and tender and to bleed more easily. In some people, the hormonal levels may cause the  gum tissue to overgrow or enlarge.
  • Stress: Stress may interfere with the body’s ability to fight infections, including periodontal disease.
  • Medications: Certain medications may affect the oral health as a side effect. It is always important that you inform your dental care professional of any medications you may be taking, including over the counter medications and any herbal preparations.
  • Clenching or grinding your teeth: Clenching or grinding your teeth may put the teeth under stress that they were never meant to endure. These unusual forces may increase the speed at which the supporting tissues are destroyed.
  • Diabetes: Diabetics may be more prone to developing periodontal disease.  Periodontal disease can be more severe in uncontrolled diabetes. Untreated or uncontrolled periodontal disease may also make it more difficult to control diabetes.
  • Poor nutrition: A diet that is lacking in certain vitamins and minerals make it more difficult for the body’s immune system to function properly and fight off infections.
  • Systemic diseases: Some diseases that affect the immune system may worsen the conditions in the mouth.

Is periodontal disease contagious?

There are some theories that because periodontal disease is bacterial in origin, the bacteria can be transmitted to other people. Thus, in theory, making the disease contagious. However, the presence of the bacteria alone does not always result in periodontal disease. There are other factors, called pre-disposing genetic factors, which may also be necessary in determining who does or does not develop periodontal disease if the bacteria are present. There are tests available, although not through our office, that some believe can tell you whether or not you have the genetic predisposing marker.

Treatment options

Once your periodontist has examined you and determined that periodontal disease is present, what are the treatment options?

  • Home care improvements
  • Scaling and root planing
  • Overall cleanings every three months
  • Osseous surgery
  • Occlusal adjustments

Other treatments you may have in our periodontal office:

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Periodontal Disease and Women

As most people know, a woman’s body is ruled by ever changing hormones. The hormones are particularly prominent at specific times: puberty, menstruation, pregnancy and menopause. These hormonal changes, in addition to other body changes, affect the reaction of gum tissues to local irritants such as the bacterial plaque.

Puberty: During puberty, the body experiences an increase in the level of the sex hormones progesterone and estrogen. For females, this increase in progesterone and estrogen causes an increase in blood flow and circulation in the gum tissue. Increase in the blood supply may increase the reaction of the gums to local irritants such as food particles, bacterial plaque and/or calculus. The gums may swell and may become tender. Removal of the local irritant either by good home care (brushing and flossing, etc.) or by your dental professional will return the gums to normal. However, the tenderness and swelling will return if the teeth and gums are not maintained. If not treated or kept under control, the gum and supporting bone may be damaged. The over-reaction to small local stimuli will abate as the young woman ages.

Menstruation: The onset of menstruation is another milestone in the young women’s development. Again because of the change in the levels of progesterone being released before a woman’s period starts, the gums increase the reaction to irritants. This may increase the incidence of bleeding gums for some. The tenderness and bleeding generally begins three to four days prior to the onset of the menstrual cycle. The young woman may notice that her gums are bright red and swollen between the teeth. This is often referred to as menstruation gingivitis. Small sores may also appear on the tongue and on the inside of the cheeks. Good home care with brushing and flossing are very important for good oral health. The hormonally caused gingivitis generally begins to subside once the menstrual period begins.

Pregnancy: During pregnancy, hormones can fluctuate more than at any other time. Gingivitis often appears in the second or third month of pregnancy as your gums react to localized irritants. Approximately 60-75% of pregnant women will experience gingivitis.

If your gums are healthy prior to becoming pregnant, and you maintain good oral care, you are less likely to experience problems later in your pregnancy. If the gingivitis is left untreated, it can develop into the more serious periodontal disease, resulting in bone destruction and tooth loss.

The levels of progesterone and estrogen will continue to increase throughout your pregnancy. It is important that you not only maintain good home care, but you should also see your dentist. Most doctors recommend that you have elective treatments only during your second trimester or early third trimester.

Occasionally, the gum tissue continues to over react and grows into a “lump” called a pregnancy tumor. The pregnancy tumor is non-cancerous, and generally not painful. It may become painful if the tumor begins to interfere with biting or chewing or if food or plaque collect underneath it. It generally appears during the third month, but can occur at any time during the pregnancy.

Pregnancy gingivitis and pregnancy tumors most often subside after delivery but may not go away completely. You should consult your dentist for further treatment.

There is current research that is pointing to another problem of periodontal disease affecting pregnant women. Although not conclusive, research is demonstrating a link between periodontal disease and low birth weight and premature birth.

Research indicates that the infections of the bacterial toxins of periodontal disease initiate an immune system response. One of the responses of the immune system is that the body releases prostaglandins. Prostaglandins are fatty acids that are involved in inflammation control and smooth muscle contractions. Normally, during pregnancy, prostaglandin levels gradually increase peaking during delivery. In theory, the extra prostaglandin produced as a reaction to the bacterial infection of periodontal disease, or any infection may act as a signal to start labor. This may result in the baby being born too early and/or too small.

A study completed in February of 2006 suggests that a connection also exists between the bacteria of periodontal disease and incidence of preclampsia. This condition appears in late second trimester or early third trimester.

Another pregnancy related occurrence that will affect your teeth and gums is morning sickness. Frequent morning sickness could result in more tooth decay because of the frequent exposure of the teeth to stomach acids. Make sure to brush and rinse with water after vomiting. Just the act of brushing will sometimes cause vomiting. If that is the case, rinse with water, brush without toothpaste and use a fluoridated mouthwash. Morning sickness may cause loss of appetite and poor nutrition.

Oral contraceptives: If you take any kind of birth control pills, you may be subject to the same gingival conditions as someone who is pregnant. The oral contraceptives also increase the levels of progesterone and estrogen similar to pregnancy. It is the levels of the hormones, which cause the body to over-react to the local irritants in gum tissues. It is important to inform your doctor or dentist that you are taking oral contraceptives. There are antibiotics that may be prescribed to treat the periodontal infection that interfere with the effectiveness of the birth control.

Menopause: In general, most women do not have oral problems associated with menopause. Taking estrogen supplements does not cause gum problems. Taking progesterone supplements may increase the gum’s response to the local irritants, similar to other hormone driven gingivitis/periodontitis.

On rare occasions, a woman may experience menopausal gingivostomatitis. Symptoms may include gums that are dry, bleed easily and may range in color from pale to deep red.  They may also experience dry, burning sensations in the mouth, abnormal taste sensations especially to salt, peppery or sour, and extreme sensitivity to hot or cold foods or drinks. Dry mouth symptoms may increase decay rates and make dentures or partial dentures difficult to remove. Your doctor can recommend medications that may ease the symptoms.

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Periodontal Disease and Diabetes

Recently, there has been a lot of attention given to the relationship between periodontal disease and other systemic diseases. Diabetes is one of the systemic diseases, which seem to have a strong connection with periodontal disease.

Diabetes is a disease in which the body is exposed to high levels of sugars, primarily glucose, in the blood system and throughout the body, including saliva. This may be caused by the lack of a hormone (insulin) responsible for the body’s ability to utilize sugar, or the body’s inability to correctly use the insulin. The American Diabetes Association estimates that 12-14 million Americans have some form of diabetes. Many are not even aware that they have the disease.

Periodontal disease is an infection caused by particular bacteria found in the mouth. The bacteria thrive in environment rich in sugars and carbohydrates. In most people, the body’s immune system helps keep the bacterial levels under control.

In someone who has a history of uncontrolled or poorly controlled diabetes, the effects of high blood sugar cause the walls of the blood vessels to thicken, making them less elastic.  The loss of elasticity in the blood vessels  results in a reduction in blood flow, which results in less available oxygen and nutrients, and also limits access to the body’s immune system defenses. All of this adds up to the fact that a diabetic, and particularly an uncontrolled diabetic, is more prone to infection and less able to fight one.

Another oral problem that often results from diabetes is dry mouth caused by a lack of saliva production. Saliva is very important to the health of oral structures. The function of saliva is to moisten food, provide some anti-bacterial protection and to act as a self-cleansing mechanism. Without the presence of saliva, the bacterial plaque will not be washed away and will not only build up more quickly but will also be more “sticky”.

Over a period of time, the plaque will absorb minerals and become hard “tartar”. The presence of plaque and tartar cause the gums to become irritated and inflamed. If the effects of diabetes hamper the body’s infection fighting system, the infection continues to worsen, leading to more severe periodontal disease and possible tooth loss.

The relationship goes both ways. Periodontal disease is an infection. An infection of any kind makes it more difficult for a diabetic to control blood sugar levels. This causes an increase in time when the body has to function with the destructive consequences of higher blood glucose levels. Approximately 1/3 of the population with Type II diabetes, also have severe periodontal disease.

Some diabetics also complain of a burning sensation on the tongue or in the mouth in general.

In order for your dental professional to best treat your oral conditions, please make sure they are alerted that you have diabetes. To help keep periodontal disease under control in diabetics, it is important to have regular dental care. To help keep diabetes under control, it is important to control your periodontal disease. Diabetics may require more frequent visits to a dental professional, use of medicated mouth rinses or even oral antibiotics. A daily routine of brushing and flossing is important in controlling bacterial plaque. On a positive note, a controlled diabetic has no greater risk for periodontal disease than someone without diabetes. Controlled diabetics also tend to have a lower rate of tooth decay. This may be the result of a diet low in refined sugars and carbohydrates, two probable causes for the onset of decay.

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Heart and Periodontal Disease

Although not a scientific certainty, there have been studies that show a link between periodontal disease and heart disease. However, additional research is needed.  It has been suggested that some people with periodontal disease are more likely to have a heart attack than someone without periodontal disease. How the two are connected is still being studied, but there are some strong theories.

The bacteria present in the oral cavity can enter the blood stream and attach themselves to the fatty deposits (plaque) in the heart arteries. (This plaque is not to be confused with dental plaque). This contributes to the blockage of arteries, forming clots. These clots may act to block the flow of blood to the heart, or may break loose and travel the blood stream to the heart, brain or lungs. The clots can also cause an obstruction large enough to block blood flow, thus blocking oxygen, blood and nutrients to the heart, causing a heart attack, stroke or respiratory problems.

The bacterial attack of periodontal pathogens triggers the body’s disease fighting system, including inflammation. The inflammation causes the body to increase fatty plaque build-ups in the arteries. This reaction may contribute to the swelling in the heart arteries. As inflammation increases, the liver reacts to the chronic presence of bacterial toxins by increasing the production of a protein, C-reactive protein (CRP). The CRP has the affect of inflaming arteries and promoting clot formation, increasing the risk of heart attacks.

There is research that supports the theory that an elevated level of CRP is a more accurate indicator of heart problems than many tests currently being used. Dr. Gordon Douglass, President of the American Academy of Periodontists stated:

“This could help early diagnosis of potential heart disease sooner rather than later, as most people visit their dentist or periodontist at a minimum of twice a year.”

Check with your dental professional. The test is relatively new and may not be available at your dentist or periodontist.

Research continues into the connection between periodontal disease and several systemic diseases, including heart disease. Whatever the final outcome, it appears that good oral health has a stronger effect on the entire body than once thought.

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Respiratory Disease and Periodontal Disease

The connection between periodontal disease and respiratory problems is another area of systemic disease that is currently under study.

New research is beginning to point to a relationship between the bacteria of periodontal disease and respiratory problems. It is believed that the bacteria of periodontal disease break loose from the teeth or from the periodontal pockets into the saliva. From there, the bacteria are breathed into the upper respiratory tract. Once in the respiratory system, the bacteria travel to the lower respiratory organs, the lungs and bronchial tree, and set up an infection. The infection can contribute to breathing problems and possibly permanent damage.

At this stage, the research is not indicating that someone may develop lung problems from the periodontal bacteria alone. The bacterial presence may contribute to problems that already exist or increase the risk of a person contracting such respiratory problems as emphysema, COPD, bronchitis and pneumonia, even if it is just a genetic predisposition to respiratory problems.

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Smoking and Periodontal Disease

The relationship between smoking and periodontal health has been under study for decades. In 1996 the American Academy of Periodontology published a study that claimed a “causal relationship” between periodontal disease and smoking. The report stated that smoking was the primary environmental factor of periodontal disease.  Depending upon the extent of the habit, tobacco users can be up to five to 20 times more at risk for periodontal disease than non-smokers. A large national study indicated approximately 75% of periodontal disease could be attributed to smoking. Another recent study indicated that smokers with periodontal disease experience heart attacks at a rate that is twice that of non-smokers of the same age.

In the body, nicotine causes an enzyme to be produced that destroys collagen, a building block of tissues necessary for repair. Nicotine also causes reduction in the production of collagen. The destruction process happens at a faster pace than the building, thus preventing or slowing the availability of collagen for wound healing. Other reports show that a specific cellular protein that binds particular cells necessary for healing is also affected. This means that not only is the destruction of tissues accelerated, but also the production rate of elements needed for repair of damaged tissue is slowed.

Nicotine utilizes oxygen in its action to increase the destruction of collagen. On a cellular level, oxygen needed for normal function is used by the nicotine and not available for the body’s use. Without necessary oxygen, the cells of the body cannot respond to inflammation caused by bacterial attack body-wide. The systems that respond to inflammation and tissue destruction are not able to do so and the infection and tissue destruction continues.

Another factor to consider in the relationship between smoking and periodontal disease is the type of bacteria present in the host. Periodontal pockets are deeper than normal pockets around the teeth. Because of the depth and difficulty in keeping the pockets clean, periodontal pockets allow more bacteria to live and multiply. In a recently published report, smokers had a higher level of bacterial activity at pocket depths of 4mm than did non-smokers with the same conditions. It also showed that the upper jaw was more affected than the lower jaw.

Bleeding gum tissue of adult smokers with chronic periodontitis seems less than expected in relation to the severity of the disease. The gum tissue exposed to the constant heat and chemical contact of the smoke appears thick, fiberous and overgrown. The surface may appear gray or whitish rather than the coral pink of healthy tissue. The nicotine causes the tissue to form a layer similar to a callous for protection, and the small blood vessels close or narrow. For a period of approximately 2-3 hours after one cigarette, a person experiences a 45% reduction in blood flow, which also decreases available oxygen needed to respond to infections. The narrowing of blood vessels and thicker oral tissues may explain why smokers with periodontal disease do not exhibit the bleeding gums that are a common sign of periodontal disease.

The heat and chemical exposure also affects the tissue on the roof of the mouth and tongue. The environment causes nicotine stomatitis, a blanching of the tissue around salivary glands with a red center indicating the salivary outlet.

The longer the oral tissues are exposed to the effects of the heat and chemicals, the denser and whiter the tissue becomes.

Young adult smokers are more likely to exhibit bleeding because the more extensive tissue changes have not yet occurred. The extent of bone loss in young smokers is far greater than those of young non-smokers.

A smoker’s sense of taste is often affected. Generally it involves salt or bitter tastes. It appears that tastes for sweet or sour are less affected. The loss of taste will become progressively worse with continued use of tobacco products. Research indicates that the use of smokeless tobacco does not affect taste.

If a person continues to smoke, it will be difficult to impossible to control the periodontal disease. A smoker does not respond to the initial treatment phase, scaling and root planning, as well as non-smokers. Their healing and recovery reactions to this non-surgical treatment are compromised by tobacco use. Because of this, it is recommended that smokers have frequent maintenance visits to compensate for the destruction that is smoking related and to slow further damage.

Tobacco users are more likely to experience tooth loss than non-smokers. Over forty-one percent of smokers over the age of 65 are toothless, compared to 20% of the non-smoking population.

Tobacco users should also have a good regular home care program. Daily brushing and flossing are imperative. In addition to the cellular level problems caused by tobacco use, a patient may experience bad breath and teeth stained a yellow to brown color due to the sticky tars in cigarette smoke.

The sticky coating is difficult to remove with homecare. It can even be difficult for your hygienist to remove.  Stain may be more of a problem for dentures. Because the material used is softer and more porous than your teeth, the stain becomes more deeply embedded in the acrylic material, making it more difficult or impossible to remove.

Bacteria are difficult to control in tobacco users and the person is less responsive to either surgical or non-surgical treatments. This affect on healing is body-wide, not just limited to the mouth. Treatments that include use of specific short-term systemic antibiotics and antibiotics delivered directly into the periodontal pocket are often indicated.

Bad breath, or halitosis, is a problem for smokers and users of smokeless tobacco. The halitosis is caused by a combination of plaque build-up, bacteria, and toxic elements from the tobacco. Bad breath is generally worse in a pipe smoker because of the amount of sulfur in pipe tobacco.

Sinus infections are common among tobacco users. It primarily affects the sinus on your face, under your eyes. Infections are primarily due to swelling of the sinus tissues caused by the toxic tobacco smoke, the heat from the smoke and damage to the small hair-like projections in the nasal passages that move and filter inhaled air.

Without stopping tobacco use, the tissue destruction will likely continue. If tobacco use is halted, the tissue health will begin to improve. Bleeding may increase due to the reduction in the fibrous nature of the gum tissue. It is a sign that the tissue is improving. Lost bone will not be replaced, but as the patient improves post-smoking, they will become a better candidate for periodontal surgery to aid in pocket reduction and possible bone repair. There has been some research that seems to indicate that the condition of a smoker in one year of having periodontal disease is equal to the condition of a non-smoker’s gum and underlying bone after having periodontal disease for 15 years.

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