I’m going to call you “Dr. Goldenfingers”. You have such a light touch.
Barbara C., Boynton Beach, FL
What is Periodontal Disease?
The word, “periodontal”, means “around the tooth”. The anatomic structures that surround and support the tooth are: the gum tissue (gingiva), the bone, and the periodontal ligament. A tooth does not attach directly to the bone. A normal periodontal attachment consists of connective tissue fibers of the periodontal ligament, which attach to the root of the tooth on one end, and into the bone on the other. These fibers also extend into the gingiva (gum) where the tooth emerges into the mouth. The gingiva then rises beyond the periodontal attachment, forming a cuff, or collar around the neck of the tooth.
Bacterial plaque, which is present in all mouths, accumulates within the collar that the gum forms around the tooth. If the bacteria is not removed daily with effective brushing, flossing, or other appropriate techniques, the gums become inflamed. This condition is known as gingivitis, and it is characterized by sore, puffy gums which bleed easily. Bad breath also results.
Even if you are brushing and flossing regularly, after a few months, some of the plaque will calcify around the teeth. This calcified plaque is known as tartar, or calculus, which can only be removed by a dentist or dental hygienist. The calculus has a rough, chalky surface, which harbors more bacterial plaque. When diagnosed at this early stage, the only treatment required is thorough professional scaling and polishing (prophylaxis), and development of effective home care practices by the patient.
If undetected or untreated, inflammation in the gums (gingivitis) begins to extend deeper into the periodontal attachment. This inflammation causes detachment of the periodontal ligament from the tooth, and loss (resorption) of the supporting bone, resulting in periodontal pocket formation. Bacteria is then able to advance into the pocket, where it can no longer be removed by patient home care. Isolated from the oral environment, more aggressive bacteria begin to multiply, leading to infection and pus. Left untreated, pockets deepen, resulting in progressive bone loss and gum recession. Over time, teeth begin to loosen and shift, and are eventually lost. Periodontitis is the major cause of adult tooth loss.
In a periodontal examination, we want to assess how much damage has occurred, identify where ongoing disease continues, and develop a treatment plan to stop progressive periodontal attachment loss and restore a healthy dentition. We check for mobile (loose) teeth, and measure the amount of gum recession. We evaluate the degree of inflammation by checking for puffiness and bleeding, as well as the presence of pus.
The most important part of a periodontal exam is the detection and measurement of periodontal pockets. This is done with a periodontal probe. The tip of the probe is gently placed between the gum and the tooth to measure the depth of the collar of gum tissue. Generally, probing depths of 0 – 3 millimeters are consistent with health because they are cleansable by routine patient home care. Probing depths of 4 millimeters and deeper are noted as periodontal pockets, which are not cleansable by the patient, and are therefore likely to deepen over time, if untreated.
Pockets are measured and recorded on a periodontal chart. At our office, we use computerized periodontal charting. This gives us clear, legible records for better communication with referring doctors and insurance providers. Computerized periodontal charting also facilitates long term tracking of a patient's periodontal health.
Computerized periodontal charting
A complete periodontal examination includes a full mouth series of intraoral radiographs (x-rays), to check bone levels and tooth root anatomies. If not available from your general dentist, computerized digital radiographs can be taken at our office. Digital radiographs provide instant results, with greater diagnostic detail than older film-based radiographs, while reducing x-ray exposure by over 50%.. They can be transmitted electronically to your general dentist or insurance provider. Because they do not use chemical processing with special disposal requirements, digital radiographs are also more environmentally friendly than film-based systems.
Digital Intraoral Radiographs viewed on computer screen
Digital Panoramic Radiograph viewed on computer screen
“Occlusion” refers to the bite relationships of your teeth when they come together. In a healthy mouth, all teeth come together evenly, and the jaws meet at a central position where teeth interlock comfortably. If one or more teeth contact before the others, or if contacts occur at an angle that pushes a tooth, this is known as an occlusal prematurity. Occlusal prematurities result in occlusal trauma to a tooth. Occlusal trauma by itself can cause an uncomfortable bite, bone loss around a dental implant, or loosening of teeth. When superimposed on a tooth with periodontitis, occlusal trauma can increase bone loss around that tooth.
Occlusal prematurities are treated with occlusal (bite) adjustment. This is performed during the initial phase of periodontal therapy, either by Dr. Pechter, or your general dentist. Usually, you will be asked to bite on a ribbon placed between your upper and lower teeth, which marks the high spots. These can then be evened out with careful selective grinding by the dentist. In more severe cases, crowns or splinting of teeth may be required, and for major malocclusions, orthodontic therapy may be recommended.
Another source of occlusal trauma is clenching or grinding of your teeth. This subconscious habit is known as bruxism. Bruxing is stress – related, and usually occurs when sleeping. It does not happen every night, or all night, and it can not be consciously controlled by the patient. Most patients are unaware of their bruxing, so it is usually diagnosed by tell-tale findings on the teeth. Bruxing causes occlusal trauma to all of the teeth, and often leads to excessive wear, flattening, and shortening of the teeth. In addition to increased bone loss and mobility, gum recession results due to clefts which form in the roots just beneath the tooth enamel. Bruxism can also cause headaches, jaw, and jaw joint pain (temporo-mandibular joint or TMJ).
Bruxism is managed by fabricating a custom fitted bite guard. This is a clear plastic or acrylic appliance, similar to an orthodontic retainer, that fits over the biting surfaces of either the upper or lower teeth. There are also bite guards that fit over only the front teeth. The style of bite guard chosen is based upon the strength and distribution of teeth to be protected, the presence of TMJ involvement, and patient preference. Bite guards sold over the counter in pharmacies are not appropriate, and may cause additional damage because the bite is not customized to meet the specific needs of the patient.
Several medical conditions are closely associated with periodontal disease. The most thoroughly researched of these is diabetes. It has been well established that diabetics have lowered resistance to bacterial infections in general, and to periodontits in particular. Patients with either type I or type II diabetes will often display more severe inflammation of the gums and more rapid periodontal bone loss, which is often difficult to control. Newer research, however, indicates that the reverse is also true; the presence of periodontitis will worsen the severity of diabetes in these patients. It is especially important for patients with diabetes to be seeing a periodontist regularly. Not only are they at a higher risk for periodontal disease, but controlling their periodontal disease will improve control of their diabetes.
Periodontal disease has also been associated with other health issues, including heart disease and stroke. Researchers have found that people with periodontal disease are almost twice as likely to suffer from heart disease and have nearly twice the risk of a heart attack as those without periodontal disease. Current scientific findings have pointed to chronic inflammation around the teeth as the link between periodontal disease and other systemic inflammatory disorders, including cardiovascular disease, diabetes, rheumatoid arthritis, kidney disease, and even certain cancers. Although periodontitis may contribute to these medical conditions, this should not be interpreted to mean that periodontal disease has a causative role. More research is needed to pinpoint the precise biological mechanisms involved. However, since existing data has shown that patients with periodontal disease are at higher risk for these other medical conditions, it is important to consider periodontal health in any effort to achieve overall health. In the words of former Surgeon General C. Everett Koop, “A person is not healthy without good oral health.”
A higher incidence of gum inflammation and periodontal involvement has long been observed in pregnant women. This condition has even been given the name of “pregnancy gingivitis”. It is thought to be related to hormonal changes which occur during pregnancy, that can lead to an exaggerated inflammatory response to oral bacteria. Since birth control pills work by mimicking the hormonal changes of pregnancy, women using oral contraceptives also show an increased incidence of periodontal involvement.
Recent research suggests that pregnant women with periodontal disease may be up to seven times more likely to have premature, underweight babies. The likely cause of this periodontitis – pregnancy problem is a labor-inducing chemical found in oral bacteria called prostaglandin. High levels of prostaglandin are found in women with severe periodontal disease. Other research has identified periodontal bacteria in the amniotic fluid of some pregnant women. Any disturbance to the amniotic fluid that surrounds the unborn baby, could be dangerous to both the mother and child.
If you are pregnant, or thinking of becoming pregnant, it is recommended that you have your teeth and gums checked for any signs of periodontal involvement as early as possible. If diagnosed, a non surgical procedure known as scaling and root planing, may be recommended to remove bacteria and calculus (tartar) from the root surfaces of the teeth. If you are already pregnant, treatment would usually be performed during the second trimester of the pregnancy. Studies have shown that scaling and root planing may reduce the risk of preterm, low birth weight babies for pregnant women with periodontal disease by up to 84%.
For more information about the relationship of dental health to medical health, there are several articles which can be accessed from the Patient Information section of our website.
All photographs shown are actual cases treated by Dr. Pechter.
