Periodontal Disease

Glossary

Gingiva (gums, not gooms) is the pink tissue covering the bone of your jaw and attached to the teeth. It is keratinized like the palms of your hands and the soles of your feet. Gingiva, when intact, protects the underlying structures from the bacteria found in your mouth.

Sulcus is the cuff of gum tissue surrounding your tooth. Think of it as like a turtleneck sweater. In a normal, healthy mouth the sulcus is 3 mm or less in depth and does not bleed when probed.

Epithelial attachment is at the bottom of the sulcus where the gingival attaches to the tooth. In periodontal disease (periodontitis), the EA moves lower down the tooth, forming a periodontal pocket. Periodontal probing measures the depth of the pocket and serves as a determinant of the severity of the periodontal disease.

Plaque is a sticky, gelatinous material composed of food debris and bacteria. It is formed by the bacteria soon after eating carbohydrates, especially sugar. When plaque mineralizes, it forms calculus (tartar). Plaque can be removed by the patient; calculus must be removed by the dentist or hygienist. The bacteria in plaque produce endotoxins (poisons) that cause the lining of the sulcus to ulcerate and bleed.

Types of Periodontal Disease

Gingivitis is an inflammation of the gum tissue caused by plaque. This inflammation is characterized by redness, swelling, and susceptibility to bleeding. The bleeding is because the gingival sulcus has become ulcerated by the presence of bacterial toxins. This ulceration heals quickly when the plaque is removed (about 3-4 days). Calculus will also cause gingivitis because it, too, is full of bacteria producing toxins. Gingivitis may be exaggerated by the hormones of pregnancy and puberty.

Periodontitis is an infection of the periodontium -the complex of structures including the gingiva, epithelial attachment, cemental root surface, periodontal ligament, and bone. This deep seated disease process will cause a great deal of inflammation, infection, and destruction of bone. Eventually the teeth are no longer supported with sufficient bone, become loose, and are lost.

Progression of the Disease

If a patient does not remove plaque on a daily basis, the presence of bacteria in the plaque will cause gingivitis. Gingivitis, in itself, is not a very pathologic process but is an indicator that the patient may be at risk for periodontitis.

With continued and constant inflammation and plaque, the underlying structures will become affected/infected. The epithelial attachment will migrate down the root surface of the tooth. Once the EA has moved, the sulcus becomes deeper and is now called a periodontal pocket. This pocket may eventually become deeper than the patient can clean with a brush and floss. This means that bacteria in the pocket are never removed and are able to infect the bone and cause bone loss.

Bone loss may occur slowly or quickly, depending on the severity of the infecting bacteria and the patient's own body defenses. Bone seldom is destroyed in a regular pattern, so bone loss will accentuate the progression of periodontitis and make it worse.

Left unattended and untreated, this process of inflammation, infection, and destruction will lead to deeper periodontal pockets, more bone loss, and eventual tooth loss. Periodontal disease is an infection involving over a square foot of surface area of oral tissue surface. It affects your entire body, especially your cardiac health. There is a link between periodontal disease and cardiac disease. The bacteria involved in periodontal disease seem to be the same bacteria that inhabit the plaques found in a diseased heart. A healthy mouth equals a healthy heart and a healthy body.

Treatment of Periodontal Disease

For gingivitis, only thorough plaque removal is needed. If calculus is present, it should be professionally removed to decrease the amount of bacteria around the tooth. The ulceration and resultant bleeding will decrease within four days.

For early periodontitis, plaque control and a professional cleaning are initial requirements. If the periodontal pocketing can be reduced to a healthy, normal, non-bleeding sulcus, only maintenance will be required.

If more destruction has occurred, there is root surface exposed within the pocket that is teeming with bacteria. Scaling and root planning (SRP) will be the first treatment. SRP means all plaque and tartar are removed from the tooth and the root surface. Then the root surface is meticulously smoothed (planed) to help prevent return of the plaque/tartar/bacteria. SRP is usually done with anesthesia (root surfaces are touchy) and takes a great deal of time to do adequately. It is a non-surgical procedure. After SRP, healing and resolution take place. This may be the only treatment necessary if a normal, healthy sulcus can be re-established and maintained by the patient.

For moderate to severe periodontal disease or for localized areas not responding to SRP, surgery is indicated. Periodontal surgery may involve repositioning the sulcus, bone recontouring, or bone grafting. Often, parts of the patient's mouth may require all of these techniques or only one. The goal of periodontal surgery is to restore a normal architecture to the periodontium so that a normal, healthy sulcus returns and can be maintained by the patient. Periodontal surgery is usually performed by a periodontist, a specialist in the treatment of the periodontium.

Maintenance

Once health has been returned, it must be maintained. Regular home oral hygiene procedures (brushing and flossing) must be consistently followed or the periodontal disease will return. Regular professional care must be maintained, also. More than twice a year checkups will be required. Alternate visits of periodontist/general dentist are very common.

Avoidance of Periodontal Disease

Prevention is always easier than treatment. Regular, consistent home care with proper brushing and flossing is needed. Regular, consistent professional visits are needed to both treat and educate patients in the care of teeth and gingiva.