Ninety percent of all American adults suffer from some level of periodontal (gum) disease. This will include some level of inflammation, gum pocket formation, bone loss, pain, infection, loosening of teeth, and extractions.
Gum disease and bone loss occur from a variety of contributing factors, including poor oral hygiene, bacterial plaque, tartar formation, poor nutrition, alcohol, tobacco, poor circulation, the prevalence of pathogenic bacteria, a bad bite and ill-fitting restorations.
Proctor & Gamble provided a great service in the 1950’s by suggesting that patients have dental checkups every six months. For forty years, insurance companies have set their benefits for cleanings based upon this six-month period. This is not frequent enough for most patients with periodontal disease. Finally, some insurance companies are paying for dental cleanings every three or four months.
The overriding cause of periodontal disease is bacterial plaque. This plaque may be ever present because of poor oral hygiene, or it may be hiding in tartar (dental calculus) or under ill-fitting restorations, or in decayed areas. Byproducts of the plaque attack the connective tissue and underlying bone that hold your teeth in place. The dental hygienist’s and patient’s goal is to remove the pathogenic bacteria and prevent them from returning.
Your dentist or dental hygienist detects this disease by viewing dental x-rays, observing for bleeding gums, and by measuring the depths of the pocket spaces around your teeth. Ideal pocket depths are one to three millimeters. These can be kept clean with a toothbrush and dental floss and are easily maintained with regular cleanings. If you have pockets of four millimeters or greater, the hygienist requires more time to clean your tooth surfaces to create a healthy situation.
When your pocket measurements are taken, you will hear numbers called out, like “3,3,4–3,3,3–2,3,4–3…etc.”. If these were your pocket measurements, you should be pleased that they are not too bad and your periodontal disease is quite treatable. If the numbers are consistently “4’s” and “5’s” this is still not a desperate situation. The cause can be corrected, the pockets can be reduced and health can be re-established with a few extra visits to the hygienist. During these visits the hygienist will perform subgingival root planing. Many patients know this as deep scaling.
A more difficult situation would be to hear numbers like “3,2,3—3,3,3—6,3,3—3,6,3.” A group of three numbers refers to the pocket depths alongside one tooth. The two high numbers (6’s) among the good numbers indicate a problem that may require treatment by a specialist (a periodontist). In almost all situations like this there is a bite problem, a restoration that does not fit the tooth, or a crack that goes down the root of the tooth.
This last example may require a bite adjustment or replacement of an existing restoration. It may require antibiotic therapy by placing concentrated antibiotic paste inside the pocket. It may also require minor surgery to reduce the pocket depth. Patients treated properly at this point have an excellent chance of maintaining healthy gums in the future. The exception is when there is a crack down the root, in which case the tooth is usually destined for extraction.
Patients with many pockets over 4 millimeters and with some pockets of 7 millimeters or more have advanced periodontal disease. Subgingival root planing will still be necessary, but more aggressive treatment by the periodontist is called for. Fortunately, periodontists have many newer tools, including grafting techniques, that can still provide hope for patients with this disease.
How frequency of dental visits should be determined
The billions of damaging microbes that are in your mouth prior to dental hygiene visits are reduced to their weakest numbers immediately following your dental hygiene visits. At the conclusion of your hygiene visit, the hygienist may apply an anti-microbial treatment, usually chlorhexidine or Betadine, to further diminish the pathogenic bacteria in your mouth.
Dental studies show the above treatment regimen can provide effective reduction of the pathogenic bacteria for two to three months, perhaps longer if home care is outstanding. After this time, the germs return in sufficient numbers to again cause damage. Therefore, the goal of your periodontal therapy is to keep the bad guys from doing their job. It’s a war that must be fought every day.
Your dentist or hygienist will recommend a frequency of your return visits based upon what is necessary to minimize periodontal disease. In some patients, this means monthly care. Other patients can go a year between visits without ill effect.
Is your bone support your weakest link?
Our mouths are made up so that there is a weakest link. In the previous section we saw that grinding can wear down teeth. The weakest link was the teeth.
It is more common for the weakest link to be the supporting structure to the teeth…the bone and gums, collectively referred to by dentists as the periodontium. A fence post provides a suitable illustration of the breakdown process. Rocking the post from side to side loosens the earth around the post, creating a space around the portion of the post that is in the ground. The result is a loose post that eventually can be pulled out of the ground with your hands. We could imagine other causes of breakdown, such as rain, wind, and rodents that would cause a loss of soil around the post. Teeth and the periodontium behave in much the same way as this post.
The part of the post in the ground is analogous to the root of your tooth. The surrounding dirt is like the bone that holds your tooth in place. Sod over the soil would provide protection for the soil just like your gums protect the underlying bone.
In the article on tooth wear, we learned that it is possible to grind down teeth but have increased bone mass in response to the biting stresses. The teeth were the weakest link. Interestingly, most patients who exhibit worn down teeth have very strong bone and gums. It is as if their teeth were set in concrete. Extraction can be very difficult for these patients.
It is also possible to grind your teeth without appreciable tooth wear. This is exactly what happens if your weakest link is your periodontium. In its advanced stages this is a much more difficult and sadder disease than severe dental wear. Loss of bone from grinding occurs in an irregular pattern and is very difficult to stop unless recognized and treated aggressively early on.
A complete discussion of all the methods to prevent and treat periodontal disease is beyond the scope of this article. If you have periodontal disease, you will be introduced to many newer treatment regimens and some older ones that will help you achieve long-term dental health and a great smile in your golden years. Most dentists and dental hygienists will take the time to explain the progress of the disease in your mouth. Just ask!
PRO-TIP: Be proactive!
Ask what the numbers mean. Even ask to see the numbers. If you have isolated high numbers, be sure these areas are treated. If you have multiple 7’s, 8’s, 9’s or 10’s, you are likely to be losing some teeth. Be sure to ask what all your options are.
PRO-TIP: (if bacterial plaque is the main cause of your periodontal disease)
If you smoke, reduce, then quit smoking. Smoking and alcohol use are particularly lethal to gums and bones by reducing the circulation and encouraging the presence of pathogenic bacteria.
Use a mouth rinse that contains Chlorhexidine. Dentists commonly prescribe these mouth rinses for short term therapy. For longer term therapy, Listerine twice a day works quite well.
See your dentist and hygienist regularly. You may have intervals recommended of 2, 3 or 4 months. Bacteria do not wait six months to do their dirty deeds.
Ask for an anti-microbial rinse at the end of your deep cleanings. This will speed healing and encourage tissue shrinkage.
PRO-TIP: if You Have Severe Periodontal Disease
Make a decision to eliminate the pus under your gums. It will affect your overall health. This may mean some hard choices such as surgical pocket reduction, extractions, implants or bridgework in the location of misssing teeth, or even dentures.
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