What is periodontitis and gingivitis?
Gum disease is a very common condition where the gums become sore, swollen and infected. Gum disease is generally classified in two ways;
GINGIVITIS - Means inflammation of the gums. It is the early warning stage of gum disease. It causes your gums to become swollen, red and painful and you will notice they can bleed easily. At this stage the gingivitis is reversible if you see your hygienist. At this appointment the hygienist will thoroughly clean away the hard and soft plaque deposits from your teeth and help you establish a good cleaning regime at home.
PERIODONTITIS – Means inflammation of the periodontium, which are the structures that support your teeth. This is when gum disease becomes more advanced. You will experience all of the above symptoms of gingivitis but the infection becomes more established and affects the jaw bone. Over time if left untreated you may notice your teeth become loose and move. In some cases it may lead to the tooth or teeth being lost. Bad breath (halitosis) can also occur at this stage. Periodontitis is a non reversible disease as the supporting bone that hold your teeth in place is lost. Working together with your dentist and hygienist can help to achieve stability of the disease with the hope that it gets no worse.
So what do periodontitis and gingivitis actually mean? Anything with 'itis' on the end means ‘inflammation of', so a good example would be tonsillitis meaning inflammation of the tonsils.
A fact that is worth noting is that gum disease accounts for 30-35% of teeth needing extractions!
There are two main types of periodontitis: the first 'chronic periodontitis' is far more common and it classically springs to mind when someone mentions gum disease. Chronic is a term that basically means long term. If a disease is chronic, it suggests that the body's natural defences are somewhat in balance with the bacteria (an analogy would be a tug of war scenario) and whilst it may progress, it will do so at a slow rate.
There are a small number of acute (short lasting) conditions which occur when the balance is tipped in favour of the bacteria or when some more aggressive bacteria join the fight and overwhelm the natural defenses resulting in a gum infection. These gum infections, which are comparatively rare, include 'Periodontal Abscess', 'Acute Necrotising Ulcerative Gingivitis' and 'Acute Herpetic Gingivostomatitis'.
The other main type is aggressive periodontitis; it is a particularly nasty form of the disease which causes a much more rapid breakdown. Fortunately only a very small percentage of all people with periodontitis suffer from this.
There have been a number of studies in recent times suggesting a link between gum disease and heart disease. Exactly how the two are linked has not yet been established, but many dentists are convinced that there is a link. Both diseases are inflammatory and have a number of mutual risk factors.
Factors that have been shown to increase the risk of getting both heart disease and gum disease (separately) include smoking, diabetes and age (getting older). We are not yet able to say that gum disease 'causes' heart disease or vice versa but if you have chronic heart problems, you are 50% more likely to suffer periodontitis and if you have periodontitis, you are 50% more likely to suffer some heart trouble.
Inflammation is a major risk for heart disease and the concern is that periodontal disease may increase inflammation throughout the body.
Research is ongoing in this area, but it is safe to say that as cardio-vascular (heart) disease is the leading killer of men and women in the Western World so we feel it is not worth taking any risks with your health. This is why we promote plaque removal and prevention so strongly. Visit www.efp.org/efp-manifesto for further information
Although treatment cannot regenerate bone already lost, it is aimed at preventing further deterioration and will help to halt the loosening or loss of the teeth.
Treatment should be seen as the start of a life long maintenance programme to which the patient has to be totally committed. Regular, professional deep cleaning of your teeth carried out by the hygienist will help to promote a healthy environment in the mouth.
Home care is vitally important to help to keep gum disease at bay, this means keeping our mouths impeccably clean. Ideally we are trying to help all our patients have less than 10% plaque in their
mouths. Great oral hygiene really is the key to delaying the progress of the disease, as without it,
no matter what the dentist or hygienist does, a losing battle will be being fought. Stopping smoking also improves the outcome of treatment as smokers are known to be at a higher risk of developing periodontitis.
Those areas which we are unable to keep clean with a toothbrush, floss and inter-proximal brushes such as deep periodontal pockets, require a specialist's touch.
Initially the hygienist will want to remove the hard and soft plaque deposits from the teeth, to allow a more accurate assessment of the teeth and gums. We carry out an in-depth charting of the teeth (full pocket chart) to allow us to measure the bone loss. We then have a base line reading which we can refer to later on during and after your treatment. We tend to take these detailed charts every few years to monitor the gum and bone health.
The “full pocket chart” will let the hygienist map out the areas where periodontitis requires further treatment and identify in the future any areas that are deteriorating. In areas of pocketing the hygienist is likely to need to perform some sub gingival debridement (deeper cleaning under the gums). This is likely to require some areas of the mouth to be numbed with local anaesthetic for your comfort. Two appointments are usually required to avoid making the whole mouth numb all at once. The appointments are arranged close together, this is known as ‘disinfecting’ and has been shown to have a more favourable outcome.
The ultrasonic scaler is the instrument most widely used to clean the teeth at hygiene appointments. The tip vibrates forwards and backwards at high speeds to help break up both hard and soft plaque deposits. It uses water to cool the tip and flush out all the debris from around your gum margin. This is the first step of the treatment. Suction is used and regular breaks are given to ensure patient comfort.
When it comes to cleaning under the gums, we have special tips that we can attach to the ultrasonic scaler to allow us to get further down into the pockets to clean the root surfaces of your teeth. This is known as root surface debridement. We will also use a specially designed set of hand instruments that thoroughly clean the root surface. These are made at different angles to allow the different areas of the various teeth to be cleaned.
Treatment of your mouth becomes more difficult when you have pockets that extend over 6mm. Complex root shapes that are exposed, especially in between the roots of molar (back) teeth, limited mouth opening and teeth out of normal position can also provide problems. This is why treatment with a specialist periodontist may be recommended.
A periodontist is a dentist who specialises in periodontal disease. Sometimes it is necessary to refer more complex cases of gum disease to a periodontist to achieve the best possible outcome for the patient.
It may however, be necessary to consider surgical treatment if:
- Pockets are over 6mm and not healing after initial treatment
- The furcation of molar roots exposed (area where the roots divide off under the tooth)
- There is excess gum that requires removal
- Help is required to reconstruct/regenerate problem gum areas
- In most cases, it is always best to proceed with the simpler non-surgical approach to begin with if pockets are under 6mm. Usually this type of treatment with appropriate home care by THE PATIENT is sufficient to reduce the pocketing to normal levels.
Surgery can be used for some cosmetic reasons:
- To increase the height of teeth to allow them to be restored more effectively
- To improve the aesthetic appearance
There is no point undertaking this type of treatment unless there is a full commitment from the patient to maintain the learnt oral hygiene routines at home. As mentioned previously, smoking has a very significant negative impact on gum health, as well as overall health.
At every dental hygiene appointment the hygienist will carry out an assessment of your gum health. This will either be in the form of a BPE (a basic periodontal examination) or an in depth charting known as a FPC (full pocket chart). This more detailed charting allows us to measure your gum and bone health around each and every tooth at 6 sites.
A blunt probe is used to gently probe the gum area. This is walked around the sulcus of the tooth, at this time the hygienist is able to monitor any areas that have any soft or hard plaque or bleeding. Also the pocket depths are measured and recorded. This is so we can identify any worsening of periodontal condition early on, as once the bone is lost it cannot grow back.
The way in which we assess the gum health using the BPE assessment is demonstrated in the diagrams below, highlighting the numbers we call out during your appointment.