One of the mildest forms of gum disease is known as gingivitis. Gingivitis is more specifically inflammation of the gums without a loss of bone. Gingivitis is most commonly due to poor oral hygiene but the good news is that it is reversible!
Improving oral hygiene practices at home and coming in for regular hygiene appointments will tend to decrease the redness, swollen tissues, bleeding and tenderness.
Periodontal disease is a more advanced condition compared to gingivitis as there is now inflammation of the gums and loss of bone. Periodontal disease often arises due to untreated gingivitis.
Note: Many of us have experienced that mild poking sensation during a dental appointment where the hygienist is using a little ruler to measure ‘pocket depths’ and calls out several numbers. Well what your hygienist is doing is assessing for any areas of periodontal disease and bone loss.
There are many categories within periodontal disease that help isolate the source of the problem and identify the means of treatment because although poor oral hygiene is a major factor, it is not the only one.
We’ll cover a large amount of information in this article that can help prepare you for treatment, or prevent you from ever having to get it.
Gum disease can take many forms but is often recognized by most people as a red, puffy appearance, and a tender feeling. Other signs and symptoms may include: bad breath, mobile teeth, a receding gum line, or bleeding while brushing and flossing.
Categories of Periodontal Disease
A type of periodontal disease that may occur in an otherwise healthy individual with rapid onset. This type of periodontal disease was typically seen in younger individuals but may happen at any age. This specific form of the disease can have some genetic influence that may be difficult to control. The individual may or may not have red puffy gums like cases of gingivitis but they will have significant bone loss. Aggressive periodontal disease also tends to occur in specific areas rather then involving the whole mouth. If you happen to have aggressive periodontal disease, your dentist will be able to show you these localized sites of bone loss on an x-ray.
A type of periodontal disease that is usually more diffuse, involving more sites within the mouth and more common in adults. Inflammation of the gums and surrounding tissues is likely to occur, which can lead to bone loss and recession of the gum line. Unlike the aggressive form, chronic periodontitis tends to progress over a longer period of time without a genetic link. Instead, chronic periodontitis will be more commonly found in individuals with poor oral hygiene or smokers.
Necrotizing Ulcerative Gingivitis/Periodontitis
Necrotizing ulcerative gingivitis (NUG) refers to the gum tissue that has died, is grey in colour, and is sloughing off. Necrotizing ulcerative periodontitis (NUP) is when the gums, bone, and other surrounding tissues are dying, and being removed. NUP is a more advanced version of NUG, which is more commonly seen in patients that are immunocompromised such as those with HIV or immunosuppressed/malnourished individiuals living in third world countries.
Manifestation of a Systemic Disease
Periodontitis may arise in individuals with a current underlying systemic disease. These diseases typcially increase the level of inflammation in the body or alter the way an individual can respond to infection or heal. Some of these conditions include: cardiovascular disease, respiratory infection, diabetes, and rheumatoid arthritis.
Gum disease can be referred to as localized or generalized. Localized means that less than 30% of the possible areas show signs of the disease. Generalized refers to having more than 30% of the surfaces being involved. All of the above classifications of gum disease can be referred to as being localized or generalized depending on the degree of involvement.
Once the dentist or dental hygienist has identified the type and degree of involvement of gum disease, they will inform you of the recommended treatment. For those with periodontal disease, we say that patients are mild, moderate, or advanced cases, each requiring different levels of treatment.
Risk Factors of Periodontal Disease
Diabetics are extremely senstive to changes in blood sugar levels, have delayed healing capabilities, and are highly susceptible to periodontal disease. It is crucial that these patients come in for regular hygiene appointments and practice excellent oral hygiene at home. Your dentist and dental hygienist will likely ask for you HBA1C levels at your appointment because the level of control an individual has over their diabetes will have a significant influence over the treatment and expected success.
Periodontal disease is more common in older people but that is not to say it cannot happen in younger individuals also. The chronic form usually progresses gradually over time and is more common in adults where as the aggressive form typically occurs in younger individuals with a sudden onset.
It is not uncommon to see cancer and heart disease present among smokers but periodontal disease can be another commonly seen illness. Smoking causes inflammation of the tissues and also reduces the body’s ability to heal itself.
Some people are simply more susceptible to periodontal disease then others. If having a genetic predisposition is identified, early preventitve care will be essential as even aggressive home care may not be enough.
Conditions such as: cardiovasular disease, rheumatoid arthritis, and type II diabetes are some examples of conditions that exaggerate the body’s inflammatory response and as a result, cause localized destruction as seen in periodontal disease.
Fluctuations in hormone levels can cause adverse changes to an individual’s gums more so then bone. Pregnant mothers and teenagers going through puberty are often most susceptible to these kinds of changes. It is very important to practice good oral hygiene and have regular dental visits during these times as these individuals have exaggerated responses to small changes among bacteria within the mouth.
It is quite common to see some medications that give an individual dry mouth and increase their risk of getting tooth decay. There are many medications that may also increase a person’s risk of developing periodontal disease and may include: anti-depressants, anti-convulsants, heart medications, and oral contraceptives. It is important to disclose this information to your dentist so that they are aware of all possible risk factors and can communicate effectively with your physician or pharmacist if needed.
Proper nutrition is important for the health of tissues all over the body. Adequate vitamins and minerals are essential to the health and structure of many of these tissues. Nutrition is also important for the immune system so that it can fight off infection and prevent things like periodontal disease.
In today’s day and age, implants are becoming exceedingly popular when it comes to replacing missing teeth. Although implants are not a ‘natural’ tooth, the surrounding bone and tissues are still susceptible to gum disease. The same sort of inflammation that occurs in gum disease of natural teeth, can happen to an implant due to a build up of bacteria and your body’s response. There are two types of peri-implant disease and these are known as peri-implant mucositis and peri-implantitis. Peri-implant mucositis would refer to inflammation of the gums around an implant but there is still the expected level of bone around the impalnt. Peri-implantitis is the successor of peri-implant mucositis if not managed properly. In this case, bone loss does occur and can have a significant impact on the success of the implant. It is imperative that patients practice good oral hygiene at home especially when they do have an implant. Regular dental visists and professional cleanings from a dental hygienist to keep the areas around your implant and just below the surface clean, will reduce your chances of getting peri-implant disease.
In order to prevent gum disease, adequate oral hygiene from home is essential to removing the bacteria and plaque that ahdere to the teeth and cause inflammation in the surrounding gums and tissue. If this plaque is not removed and the inflammation persists, bone loss may become a result. Some of the things you can do from home are:
- Using an ELECTRIC toothbrush with soft bristles at least twice a day. Electric toothbrushes have been proven to remove more plaque and will reduce the chances of the gums receding due to over-scrubbing with a manual toothbrush
- Use FLUORIDATED toothpaste and mouth wash. The more exposure to topical fluoride the better. Not only does it have antimicrobial properties but it also help remineralize the teeth and protect against future tooth decay.
- FLOSSING at least once a day. It is very common to see tooth decay occurring in between the teeth where the toothbrush is not effective. Flossing alone does not necessarily reduce levels of decay and gum disease but flossing with a good technique can. The proper technique is to fit the floss between the teeth, hug one of the teeth by creating a ‘C’ shape around it, and flossing in an up and down manner. You would then do the same thing to the neighbouring tooth before pulling the floss out between the teeth.
- A HEALTHY DIET is important for the health of mouth as well as the whole body. Diets that are sufficient in all the major food groups will help ensure tissue health. It is also encouraged to reduce sugary or sticky-retentive snacks in order to reduce plaque build up and ultimately tooth decay or gum disease.
- SMOKING CESSATION is very important especially for those with periodontal disease as smoking will rapidly enhance the progression of the disease. For those without periodontal disease, smoking can signigicantly increase the risks of getting periodontal disease as well as certain oral cancers. Alcohol consumption should only be done with moderation for similar reasons.
Even though some people have excellent home care, it is still important to see the dentist and dental hygienist on a regular basis to cleanse the areas that are difficult to reach. Some people may be more susceptible to developing gum disease then others such as: smokers, genetic predispostion, diabetics, individuals taking certain medications, and older individuals. It is very important to follow the exam and hygiene frequency that is prescribed by your dentist and dental hygienist. Some hygiene appointments are recommended every 6 months and some every 3 months depending on your unique needs. It is not to say your exam and hygiene intervals will not change in the future but are the ones recommended for you at your particular stage in maintaining oral health.
When we diagnose a partient as having periodontal disease (the loss of tissue and bone), we classify them as being a mild, moderate or advanced case based on the level of bone loss that has already occurred. The dentist or dental hygienist will inform you of your recommended periodontal therapy treatment depending on your specific case. Mild, moderate, or advanced cases will be prescribed a certain number of hours to come back for deep cleaning appointments. What we are prescribing as your treatment is solely science based on the need to remove and cleanse the bacteria from the pockets, stop the body’s inflammatory response, and stimulate healing, which may involve even some bone regeneration!
Mild Periodontitis (Level I) – About 10% of bone has been lost. Some bone loss has occurred and periodontal therapy treatment is encouraged to stop the disease process from causing more damage and loss of support.
Two 1 hour appointments, or one 2 hour appointment will be recommended.
Moderate Periodontitis (Level II) – About 33% of bone has been lost. A significant amount of bone loss has occurred and the teeth have started to lose their support. Periodontal therapy treatment would be encouraged to stop the disease process and maintain as much remaining bone as possible.
Four 1 hour appointments, or two 2 hour appointments will be recommended.
Advanced Periodontitis (Level III) – More than 33% of bone has been lost. A large amount of bone has been removed due to the inflammation and body’s immune response. It is not uncommon to see mobile or shifting teeth when patient’s have lost so much support. Periodontal therapy treatment is highly recommended to patients in order to retain most of their natural teeth.
Four 1.5 hour appointments, or two 3 hour appointments will be recommended.
At our office, we are understanding when it comes to patients being faced with large treatment plans and bills, and know that it can seem daunting or frustrating especially when the problems lie below the surface of the gums, unable to be seen. Sometimes you may not have even felt any discomfort prior to us addressing our concerns at your regular hygiene appointment. We do however feel it is our duty to address these issues when found and provide you with all the knowledge you need to make an informed decision for yourself on whether or not you would like to proceed with the recommended treatment.
Periodontal treatment deals with the tissue and bone surrounding the teeth. Periodontal surgery consists of many different procedures that the dentist or periodontist may employ to optimize the health and structure of the patient’s bone and gums. We offer several periodontal surgery procedures in our office tailored to your unique needs, which include:
If your tooth lets say was fractured at the gum line, decay extended below the gums, or you just have what’s called a ‘gummy smile,’ you may be in need of crown lengthening. During this procedure, the dentist may remove a bit of gum tissue, bone, or both. The purpose of the procedure is to expose more of the tooth surface so that it can be properly restored with a crown. Without crown lengthening, a tooth cannot be restored properly and has a much greater chance of failure. The procedure involves the dentist making sure you are completely frozen before creating a small incision in the gums so that they are able to tease back a flap and have direct access to the tooth and bone below the gum surface. The dentist will then remove a small amount of bone around the tooth just enough to expose the tooth the right amount above the gum or bone height. Once the dentist is happy with the length, they will tease the gums back into place and suture the incision back together. After a healing time of about 3 months, the tissues will have settled and the tooth will have just the right amount of exposure out of the gums. The dentist will now prepare the tooth for a final crown.
Open Flap Debridement (OFD)
If a patient has advanced or aggressive periodontitis espeically in a localized area, we may recommend an open flap debridement (OFD) procedure. When bone has receded extensively, our instruments are no longer able to navigate between the gums and the tooth effectively to remove all the plaque. During an OFD, the dentist will have you completely frozen before creating a small incision in the gums so that they are able to tease back a flap and have direct access to the tooth and bone below the gum surface. Once cleaned, the dentist will tease the gums back into place and suture the incision back together. This type of procedure may be highly effective when dealing with advanced or aggressive periodontitis and may just help retain those teeth!
Connective Tissue Graft (CTG)
In our mouth we have actually two types of gums. One type is the tough, keratinized gums that attach to the bone and what we generally consider our gums surrounding our teeth. The other type is the soft, non-keratinized gums that have no attachment to the bone or teeth. These two types of gum tissue tend to blend together at a line away from the teeth. If the blended line approaches or contacts the teeth due to loss of the keratinized gums, that means there is now no gum tissue directly attached to the bone and the bone is free to recede. A connective tissue graft is recommended for patients when they have very little or no remaining attached or keratinized gums. A CTG will help prevent bone loss by surgically placing a piece of self or synthetic tissue in the area of interest.
If you have lost considerable bone and if the particular bony defect has enough remaining ‘walls’ remaining to support new bone, you may be a candidate for bone grafting. During a bone grafting procedure, the dentist will have you completely frozen before creating a small incision in the gums so that they are able to tease back a flap and have direct access to the tooth and bone below the gum surface. Bone grafting involves adding a synthetic bone matrix to the bony defect and placing a mesh-like barrier over the site and bone grafting material. The dentist will then tease the gums back into place and suture the incision back together. Typical scenarios that may warrant the use of bone grafting may be: trying to regenerate bone around teeth with advanced perio, or before implant placement to ensure there is enough bone and increase the likelihood of treatment success.
A freunum is a fold of tissue that prevents other organs or tissues from moving too far from one another. For example, that tie below your tongue that keeps it anchored to the floor of your mouth, that is a frenum. Frenectomies are usually recommended when the frenums are doing more harm then good. If a frenum for example, is pulling on the gums everytime you engage your facial muscles and causing them to recede, a frenectomy would be ordered to relieve this pressure on the gums and will help prevent gum recession and bone loss. If this frenum pull were to continue, it is likely the patient would need a connective tissue graft in the future. A frenectomy is a fairly straightforward procedure in which, the dentist will ensure you are completely frozen before making a small incision in the frenum to relieve the pressure.
Commonly seen in people who have had their wisdom teeth extracted, the gum tissue at the very back of the mouth begins to grow to the height or slightly above the molar teeth. This tissue can serve as a trap for food, plaque and bacteria because it is so hard to clean. It is recommended to have this tissue removed in order to prevent inflammation of the surrounding gums or tooth decay. The procedure involves the dentist ensuring you are completely frozen before removing a small wedge of tissue (similar to cutting a piece of pie), and then suturing the two ends together.