There are two main forms of gum disease – gingivitis (inflammation of the gum) – this results in red looking, inflamed gums which may be swollen and bleed on brushing, and periodontitis, which involves bone loss around the teeth. Either may sometimes cause an unpleasant or metallic taste in the mouth.
Gingivitis is totally reversible, but bone loss due to periodontitis is unfortunately irreversible. Patients with periodontitis, may get the same symptoms as gingivitis, ie bleeding gums, but also, there may be halitosis (bad breath) and in the later stages of disease, mobility of the teeth, drainage of pus, spaces opening up between the teeth, occasionally pain, and ultimately tooth loss. In adults it is said that more teeth are lost through gum disease than through decay.
All gum disease is caused by plaque which is a sticky creamy coloured mass of bacteria and sugars coating the surface of the teeth. These bacteria produce toxins which along with the body’s immune response, are responsible for the damage. Without plaque, there can be no disease. As the disease progresses, and bone is lost, the sulcus around the tooth deepens and gum “pockets” develop which the toothbrush cannot easily get into. The bacteria are then able to colonize these spaces and allow the disease to progress unhindered. However, some individuals are far more susceptible to gum disease than others, be it due to the effects of smoking, some health conditions eg diabetes, immune disorders, or their genetic build up. While we can’t alter our genetics, stable control of diabetes and cessation of smoking are important aspects to try to address.
Gum disease is common but not normal. Most patients are not aware that their problem exists until they see a dentist, unless the gums are bleeding. Gum disease very rarely hurts until very advanced stages. Often patients think that if the gums bleed, they must be brushing them too hard. In reality, healthy gums very rarely bleed, so bleeding is almost always a sign of disease; a sign that more thorough brushing is required. In smokers with gum disease, often there is no bleeding due to the changes in the vasculature caused by the nicotine.
As previously mentioned, left untreated, gum disease can cause progressive loss of bone around the teeth (a bit like digging away the foundations around your house) with resulting mobility, gum abscesses with drainage of pus, and eventually tooth loss. Is this inevitable? No, not in this day and age.
Gingivitis can be completely reversed with improved oral hygiene. Depending on the areas involved, this may involve more thorough/effective use of the toothbrush and/or interdental cleaning aids such as TePe /Curaprox brushes and floss/tape. We are often asked about the use of gadgets like the WaterPik or AirFloss; while these are partially effective at plaque removal and may be of benefit in an individual not particularly susceptible to disease, we do not consider them effective enough to remove plaque from patients who are prone to periodontal bone loss and need a more thorough routine.
Mouthwashes have a limited use in controlling gum disease, and are certainly no substitute for effective manual cleaning. The most effective mouthwashes on the market are those containing Chlorhexidine (eg Corsodyl). However, Chlorhexidine used regularly generally causes staining of the teeth, so should only be used when specifically advised. Curasept mouthwash which also contains Chlorhexidine contains an ingredient which claims to prevent the staining. Of the other mouthwashes on the market, the Listerine family (eg Listerine Advanced Defence Gum Treatment) are probably the most effective of those that can be used regularly.
Assessment and Treatment of periodontal disease
Whilst periodontal bone loss cannot be reversed by an improvement in cleaning, it can be stopped in its tracks by a combination of professional treatment and a thorough home plaque removal regime. The sooner it is addressed, the easier it is to treat. Like many things in life, prevention is better than cure. Your dentist carries out a Basic Periodontal Examination (BPE) to assess the gum health at every examination and depending on the scores that are found, may arrange to carry out a six point pocket chart, which is akin to a “full structural survey” of the gums and bone support, to determine the extent of the disease.
Treatment of gum disease is very much a team effort, involving the dentist, patient, hygienist and possibly, if things are advanced or do not settle, a gum specialist (Periodontist) or a dentist with a special interest in gum treatment. From the patient’s perspective, control of gum disease involves almost a lifestyle change as there needs to be a firm commitment to ongoing care, both at home and at the Practice. Gum disease is unfortunately one of those conditions which is never totally cured but merely kept under control, through the care that is given both at home and in the surgery. Any amount of professional treatment will fail if the home care is not to the standard that is necessary. Regular ongoing care is essential; lapses in attendance from that which is recommended can prove very damaging.
We are lucky to have Dr Ennata (Enia) Adeleye working with us, who has a Masters degree (MSc) in Periodontics (gum disease), and whose practice is limited to treatment of gum disease. Since Enia joined us, she has produced some remarkable results, to help patients keep their teeth. Enia sees patients on referral both from dentists at the practice and from the surrounding area. Where possible Enia takes a thorough, non surgical approach, combined with intensive oral hygiene instruction; though for specific non responsive area, surgery may occasionally be indicated.
Plaque, calculus, and its removal
If plaque is left around the teeth for more than about 48 hours (that’s 4 lots of toothbrushing) the calcium salts in the saliva will cause it to harden forming calculus (tartar). This tartar has a rough surface so more plaque builds up and the situation perpetuates. Plaque and tartar can be present both above and below the gums but all plaque initially starts to form above the gum in accessible positions and only migrates below the gum if it is not initially removed.
Professional treatment revolves around removing the plaque and tartar from the tooth surfaces with the use of “ultrasonic scalers” or hand instruments. Local anaesthetic can be used to help treat particularly sensitive areas.
Our dentists and hygienists are also able to use the excellent Air N’Go air polishing system for thorough plaque and stain removal both above and below the gums.
This conservative approach will be successful in the majority of cases but in advanced or resistant cases, occasionally surgery to allow visualization of the roots and/or reposition the gum can be necessary.
There is now even some evidence linking gum disease to a variety of health issues including heart problems in later life, so treating your gums could possibly save more than just your teeth.
We are so often told “but I brush my teeth twice a day”. Unfortunately for some people there is a difference between brushing and actual cleaning. No one is pretending that tooth cleaning is easy. If you wash your hands and see that dirt remains under your nails, you’d probably have a further thorough attempt to remove it. However, the cream coloured plaque is not always easy to see, and the crevices around the teeth are more complex than our finger nails…but we all assume that we have got rid of it all every time. Sometimes we have patients who tell us they floss the front teeth but not the back teeth as they are harder to get to. Unfortunately gum disease overall is more prevalent around the back teeth because of their more complex anatomy and the fact that they are not generally cleaned as well. Gum disease varies from person to person and can affect just localized teeth at the front or back, or indeed, all teeth.
We have information sheets available on gum disease, toothbrushing, and interdental cleaning which are available at the Practice. Good toothbrushing technique is explained on our Cleaning page.
It is worthwhile noting that if a tooth is lost because of gum disease and a replacement tooth is requested then the options need careful consideration. Because bone is lost as part of the disease process, there is often not enough bone present to be able to place an implant without more complex procedures being undertaken. Implants themselves are also susceptible to gum disease and bone loss is often more aggressive than around teeth. Bridgework can be considered if the planned supporting teeth are not themselves too compromised. Dentures if poorly designed inevitably attract the build up of plaque around the teeth which can worsen the situation, for this reason chrome framework dentures are considered healthier than all plastic dentures. Often, if the tooth that has been lost is not aesthetically or functionally essential, it may be healthier to accept the space.