Gum Disease

Gum disease may refer to:

• Gingivitis
• Periodontitis

Gingivitis (inflammation of the gums) (gingiva) around the teeth is a general term for gingival diseases affecting the gums. As generally used, the term gingivitis refers to gingival inflammation induced by bacterial plaque adherent to tooth surfaces.

Causes

Gingivitis is usually caused by bacterial plaque that accumulates in the spaces between the gums and the teeth and in calculus (tartar) that forms on the teeth. These accumulations may be tiny, even microscopic, but the bacteria in them produce foreign chemicals and toxins that cause inflammation of the gums around the teeth. This inflammation can, over the years, cause deep pockets between the teeth and gums and loss of bone around teeth otherwise known as periodontitis.

People with a healthy periodontium (gums, bone and ligament) or people with gingivitis only require periodontal debridement every 3-4 months. However, many dental professionals only recommend periodontal debridement (cleanings) every 3-4 months, because this has been the standard advice for decades, and because the benefits of regular periodontal debridement (cleanings) are too subtle for many patients to notice without regular education from the dental hygienist or dentist. If the inflammation in the gums becomes especially well-developed, it can invade the gums and allow tiny amounts of bacteria and bacterial toxins to enter the bloodstream. The patient may not be able to notice this, but studies suggest this can result in a generalized increase in inflammation in the body cause possible long term heart problems. Periodontitis has also been linked to diabetes, arteriosclerosis, osteoporosis, pancreatic cancer and pre-term low birth weight babies.

When the teeth are not cleaned properly by regular brushing and flossing, bacterial plaque accumulates, and becomes mineralized by calcium and other minerals in the saliva transforming it into a hard material called calculus (tartar) which harbors bacteria and irritates the gingiva (gums). Also, as the bacterial plaque biofilm becomes thicker this creates an anoxygenic environment which allows more pathogenic bacteria to flourish and release toxins and cause gingival inflammation. Alternatively, excessive injury to the gums caused by very vigorous brushing may lead to recession, inflammation and infection. Pregnancy, uncontrolled diabetes mellitus and the onset of puberty increase the risk of gingivitis, due to hormonal changes that may increase the susceptibility of the gums or alter the composition of the dentogingival microflora. The risk of gingivitis is increased by misaligned teeth, the rough edges of fillings, and ill-fitting or unclean dentures, bridges, and crowns. This is due to their plaque retentive properties. The drug phenytoin, birth control pills, and ingestion of heavy metals such as lead and bismuth may also cause gingivitis.

The sudden onset of gingivitis in a normal, healthy person should be considered an alert to the possibility of an underlying viral aetiology, although most systemically healthy individuals have gingivitis in some area of their mouth, usually due to inadequate brushing and flossing.

Symptoms

The symptoms of gingivitis are as follows:

• Swollen gums
• Mouth sores
• Bright-red, or purple gums
• Shiny gums
• Gums that are painless, except when pressure is applied
• Gums that bleed easily, even with gentle brushing, and especially when flossing.
• Gums that itch with varying degrees of severity
• Receding gum line

Prevention

Gingivitis can be prevented through regular oral hygiene that includes daily brushing and flossing. Rigorous plaque control programmes along with periodontal scaling and curettage also have proved to be helpful.

Diagnosis

It is recommended that a dental hygienist or dentist be seen after the signs of gingivitis appear. A dental hygienist or dentist will check for the symptoms of gingivitis, and may also examine the amount of plaque in the oral cavity. A dental hygienist or dentist should also test for periodontitis using X-rays or gingival probing as well as other methods.

Treatment

A dentist or dental hygienist will perform a thorough cleaning of the teeth and gums; following this, persistent oral hygiene is necessary. The removal of plaque is usually not painful, and the inflammation of the gums should be gone between one and two weeks. A gargling of brine water also helps. Oral hygiene including proper brushing and flossing is required to prevent the recurrence of gingivitis. Anti-bacterial rinses or mouthwash, in particular chlorhexidine digluconate 0.2% solution, may reduce the swelling and local mouth gels which are usually antiseptic and anaesthetic can also help.

Complications:

• Recurrence of gingivitis
• Periodontitis
• Infection or abscess of the gingiva or the jaw bones
• Trench mouth (bacterial infection and ulceration of the gums)

Periodontitis

Periodontitis is the name of a collection of inflammatory diseases affecting the tissues that surround and support the teeth. Periodontitis involves progressive loss of the bone around teeth which may lead to loosening and eventual loss of teeth if untreated.
Periodontitis is caused by bacteria that adhere to and grow on tooth surfaces (microbial plaque or biofilms), particularly in areas under the gum line.
Dentists diagnose periodontitis by inspecting the tissues around the teeth with a probe and by radiographs to detect bone loss around the teeth. Although the different forms of periodontitis are bacterial diseases, a variety of factors affect the severity of the disease. Important "risk factors" include smoking, poorly controlled diabetes, and inherited (genetic) susceptibility.

Etiology

Periodontitis is an inflammation of the periodontium -the tissues that support the teeth in the mouth. The periodontium is comprised of:

• the gingiva, or gum tissue
• the cementum, or outer layer of the roots of teeth
• the alveolar bone, or the bony sockets into which the teeth are anchored
• the periodontal ligaments (PDLs), which are the connective tissue fibres that connect the cementum and the gingiva to the alveolar bone.

The primary etiology, or cause, of gingivitis is the accumulation of a bacterial matrix at the gum line, called dental plaque. In some people, gingivitis progresses to periodontitis - the gum tissues separate from the tooth and form a periodontal pocket. Subgingival bacteria (those that exist under the gum line) colonize the periodontal pockets and cause further inflammation in the gum tissues and progressive bone loss. Examples of secondary etiology would be those things that cause plaque accumulation, such as restoration overhangs and root proximity.

The excess restorative material that exceeds the natural contours of restored teeth, such as these, are termed overhangs, and serve to trap plaque, potentially leading to localized periodontitis. If left undisturbed, bacterial plaque calcifies to form calculus. Calculus above and below the gum line must be removed completely by the dental hygienist or dentist to treat gingivitis and periodontitis. Although the primary cause of both gingivitis and periodontitis is the bacterial plaque that adheres to the tooth surface, there are many other modifying factors. One of the most predominant risk factors of periodontal disease is tobacco use. Another very strong risk factor is one's genetic susceptibility. Several conditions and diseases, including Down syndrome, diabetes, and other diseases that affect one's resistance to infection also increase susceptibility to periodontitis.

Another factor that makes periodontitis a difficult disease to study is that human host response can also affect the alveolar bone resorption. Host response to the bacterial insult is mainly determined by genetics, however immune development may play some role in susceptibility.

Signs and symptoms

Symptoms may include the following:

• occasional redness or bleeding of gums while brushing teeth, using dental floss or biting into hard food (e.g. apples) (though this may occur even in gingivitis, where there is no attachment loss)
• occasional gum swellings that recurs
• halitosis, or bad breath, and a persistent metallic taste in the mouth
• gingival recession, resulting in apparent lengthening of teeth. (This may also be caused by heavy handed brushing or with a stiff tooth brush.)
• deep pockets between the teeth and the gums (pockets are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as collagenases)
• loose teeth, in the later stages (though this may occur for other reasons as well)

Patients should realize that the gingival inflammation and bone destruction are largely painless. Hence, people may wrongly assume that painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient.

Prevention

Daily oral hygiene measures to prevent periodontal disease include:

• brushing properly on a regular basis (at least twice daily), with the patient attempting to direct the toothbrush bristles underneath the gum-line, so as to help disrupt the bacterial growth and formation of subgingival plaque and calculus.
• flossing daily and using interdental brushes (if there is a sufficiently large space between teeth), as well as cleaning behind the last tooth in each quarter.
• using an antiseptic mouthwash. Chlorhexidine gluconate based mouthwash or hydrogen peroxide in combination with careful oral hygiene may cure gingivitis, although they cannot reverse any attachment loss due to periodontitis. (Alcohol based mouthwashes may aggravate the condition).
• regular dental check-ups and professional teeth cleaning as required. Dental check-ups serve to monitor the person's oral hygiene methods and levels of attachment around teeth, identify any early signs of periodontitis, and monitor response to treatment.
• Typically dental hygienists (or dentists) use special instruments to clean (debride) teeth below the gum line and disrupt any plaque growing below the gum line. This is a standard treatment to prevent any further progress of established periodontitis. Studies show that after such a professional cleaning (periodontal debridement), bacteria and plaque tend to grow back to pre-cleaning levels after about 3-4 months. Hence, in theory, cleanings every 3-4 months might be expected to also prevent the initial onset of periodontitis. The continued stabilization of a patient's periodontal state depends largely, if not primarily, on the patient's oral hygiene at home if not on the go too. Without daily oral hygiene, periodontal disease will not be overcome, especially if the patient has a history of extensive periodontal disease.

Treatment of established disease

This section from a panoramic X-ray film depicts the teeth of the lower left quadrant, exhibiting generalized severe bone loss of 30-80%. The red line depicts the existing bone level, whereas the yellow line depicts where the bone was originally, prior to the patient developing periodontal disease. The pink arrow, on the right, points to a furcation involvement, or the loss of enough bone to reveal the location at which the individual roots of a molar begin to branch from the single root trunk; this is a sign of advanced periodontal disease. The blue arrow, in the middle, shows up to 80% bone loss on tooth #21, and clinically, this tooth exhibited gross mobility.

Periodontal disease generally affects mandibular incisors aggressively. Because their roots are generally situated very close to each other, with minimal interproximal bone, and because of their location in the mouth, where plaque and calculus accumulation is greatest because of the pooling of saliva, mandibular anteriors suffer excessively. The split in the red line depicts varying densities of bone that contribute to a vague region of definitive bone height. If good oral hygiene is not yet already undertaken daily by the patient, then twice daily brushing with daily flossing, mouth washing and use of an interdental brush needs to be started. Technique with these tools is very important. Aged persons may find that use of these interdental devices more necessary and easier, since the gaps between the teeth may become larger.

A dental hygienist or a periodontist can use professional scraping instruments, such as scalers and curettes to remove bacterial plaque and calculus (formerly referred to as tartar) around teeth and below the gum-line. There are devices that use a powerful ultra-sonic vibration and irrigation system to break up the bacterial plaque and calculus. Local anesthetic is commonly used to prevent discomfort in the patient during this process.

It is difficult to induce the body to repair bone that has been destroyed due to periodontitis. Much depends on exactly how much bone was lost and the architectural configuration of the remaining bone. Vertical defects are those instances of bone loss where the height of the bone remains somewhat constant except in the localized area where there is a steep, almost vertical drop. Horizontal defects are those instances of more generalized bone loss, resulting in anywhere from mild to severe loss of initial bone height. Sometimes bone grafting surgery may be tried, but this has mixed success. Bone grafts are more reliable in instances of vertical defects, where there might be a sufficient "hole" within which to place the added bone. Horizontal defects are rarely if ever able to be grafted properly, as there is nowhere to secure the bone.

Dentists sometimes attempt to treat patients with periodontitis by placing tiny wafers dispensing antibiotics underneath the gum line in affected areas. However, the general scientific consensus is that antibiotic treatment is of minimal value in treating bone loss due to periodontitis. It may help to recover about one millimeter of bone, but it is questionable if this is of significant therapeutic value.

Alternatively, regular subgingival flushing with an anti-calculus composition can dissolve subgingival calculus (tartar) thus facilitating natural healing without surgery. This process is widely used for supragingival tartar via tartar-control toothpastes. Subgingival application of an anti-calculus composition requires a subgingival syringe or an oral irrigator.

One such anti-calculus composition (Periogen) contains sodium tripolyphosphate, tetrapotassium pyrophosphate, sodium bicarbonate, citric acid and sodium fluoride.

In the composition, tetrapotassium pyrophosphate (TKPP) is a cleaning agent designed to clear away biofilms in order to facilitate chemical access to calculus. Sodium tripolyphosphate (STPP) acts as the anti-calculus agent, activated by sodium fluoride (.04%), providing a chelating action on the structure of the calculus.

Sodium bicarbonate and citric acid are product activators which assist in dissolving the composition in water for periodontal delivery via a subgingival syringe or oral irrigator with a periodontal tip.

Assessment and prognosis

Dentists or dental hygienists "measure" periodontal disease using a device called a periodontal probe. This is a thin "measuring stick" that is gently placed into the space between the gums and the teeth, and slipped below the gum-line. If the probe can slip more than 3 millimetres length below the gum-line, the patient is said to have a "gingival pocket" around that tooth. This is somewhat of a misnomer, as any depth is in essence a pocket, which in turn is defined by its depth, i.e., a 2 mm pocket or a 6 mm pocket. However, it is generally accepted that pockets are self-cleansable (at home, by the patient, with a toothbrush) if they are 3 mm or less in depth. This is important because if there is a pocket which is deeper than 3 mm around the tooth, at-home care will not be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach 5, 6 and 7 mm in depth, even the hand instruments and cavitrons used by the dental professionals cannot reach deeply enough into the pocket to clean out the bacterial plaque that cause gingival inflammation. In such a situation the pocket or the gums around that tooth will always have inflammation which will likely result in bone loss around that tooth. The only way to stop the inflammation would be for the patient to undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so that they become 3 or less mm in depth and can once again be properly cleaned by the patient at home with his or her toothbrush.

If a patient has 5 mm or deeper pockets around their teeth, then they would risk eventual tooth loss over the years. If this periodontal condition is not identified and the patient remains unaware of the progressive nature of the disease then, years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain.