Gum disease (Gingivitis and Periodontitis)
 
Gum disease is caused by bacteria that live naturally in your mouth and collect on the teeth in a highly organised biofilm which we know as plaque.

These bacteria, their toxins and your immune system’s response to them result in inflammation of the gums around your teeth (known as gingivitis).

This inflammation damages the gum tissue which then separates from the tooth surface to form a pocket under the visible gum line (known as periodontitis).

Exposure of the root surface following this gum separation then allows the bacteria to migrate deeper under the gum. The bacteria secrete chemicals that are toxic to your tissues and produce unpleasant-smelling compounds (known as VSC’s or volatile sulphur compounds). The toxic chemicals are absorbed into the root surfaces, thereby contaminating them.

The normal depth of a gum crevice around a tooth is 0-3mm. Pockets of 4mm and above are regarded as being impossible to keep clean by normal home-care. It is within these deeper pockets that bacteria then proliferate as plaque. The destructive process continues in bursts of activity, gradually making the pockets deeper, which in turn fill with an ever-greater volume of plaque bacteria.

The disease causes gradual loss of bone from around the teeth through this infection. If unchecked, the teeth may start to become loose or to gradually drift from their positions under the influence of chewing forces. The bone loss that is seen is not a result of bone infection, but is a slow motion attempt by the bone to run away from the inflammation site.

One cannot get rid of the bacteria in one’s mouth completely, since on the whole their function is protective, like skin or gut bacteria. But, for a variety of reasons, some people are susceptible to gum damage by these bacteria. The reasons are partly due to bacteria types, partly due to your immune and genetic makeup and partly due to local factors such as cleaning ability, tooth and gum anatomy and the presence dental work that may be difficult to clean.

Deeper pockets allow an environment to develop that favours growth of more damaging types of bacteria. The more pocket volume you have the greater the bulk and the virulence of the types of bacteria and the greater the damage that is done.

(A patient with 28 teeth and an average of 6 mm pocket depth in each site has a surface area of gum inside the pockets that is inflamed and covered in bacteria equivalent roughly to the size of one's palm. Imagine a sore this size on your skin which is covered in bacteria).

There is also now good evidence, especially in males, that bacteria from these pockets circulate around the body and cause damage to the lining of blood vessels. This in turn may predispose to earlier coronary artery disease. In women, periodontal disease is linked to lower birth weight babies.

Bacterial plaque is the cause of both gingivitis and periodontitis. However, the body’s response to the volume of plaque is a critical factor in whether the disease advances. Some people barely ever brush their teeth yet disease does not advance even after many years of neglect. Others may have immaculate oral hygiene and are meticulous with their cleaning, yet disease still seems to advance. Most of the population sit somewhere in between where a reduction in plaque volume and improvement in cleaning will lead to a marked improvement in gum health and breath odour.

Objectives of treatment

The overall plan for treatment in most patients has the following objectives:

  1. To eliminate as much of the pocketing as possible. This is carried out by physically cleaning all exposed root surfaces under the gumline under local anaesthetic for your comfort. I would advise doing this in one day to reduce the risk of re-contamination of cleaned sites. This will remove most of the toxins and allow a degree of healing. Occasionally some teeth may be beyond reasonable hope and I will advise that these are removed early to prevent more bone damage.
I will sometimes give you two antibiotics to take on the day of treatment and for 7-14 days afterwards. These will help to keep bacterial numbers at bay during the healing phase and will also be in your system during deep cleaning when bacterial numbers in the bloodstream increase. I normally recommend Amoxicillin 500mg (or Clindamycin 150mg if you are allergic) and Metronidazole 400mg 8 hourly, starting on the morning of your visit.
This regimen will have certain side effects. Primarily, it may give you a tummy upset due to disrupting gut bacteria. I would recommend taking “friendly bacteria” supplements containing Lactobacillus and Acidophilus bacteria (available in most bio-yoghurts) to help avoid this. Please do not drink alcohol during your course of antibiotics, since there is a specific reaction of Metronidazole with alcohol that may make you feel ill.
  1. To keep and restore as much of the bone lost as possible. Removing bacterial plaque load from the tooth and root surfaces will help to keep bone from being lost further. In some areas, there may even be some bone regeneration as a direct result of the body's own healing process. However, in areas where there has been extensive bone loss, regeneration will be limited. There are also methods for building up new bone for improving the support condition of the affected teeth. I will go over these with you in more detail as required following this initial cleaning phase.
  1. To commence and continue a regular maintenance programme. This is as important as the initial treatment itself. Your susceptibility to gum disease is unlikely to change, so your cleaning needs to be of a very high standard to enable control of the disease in the future. I cannot stress too strongly the importance of very regular (ideally 6-8 weekly) maintenance visits with the hygienist or with myself once the initial cleaning has been completed. Multiple well-controlled studies have confirmed that the long-term success of periodontal treatment is related directly to the frequency of maintenance visits. Not having hygiene visits after extensive treatment simply leads to relapse after a few months. The response of the tissues and the individual teeth will allow us then to make better-informed decisions regarding long-term care and maintenance.

 

Systemic and other factors

Occasionally, systemic conditions may be contributing to the problem by damping down your natural immune response to your bacteria. The most common by far is diabetes, which can run in families. I normally advise patients presenting with advanced disease to arrange an up-to-date diabetes test with your GP as soon as practicable. Diabetes and periodontal disease are intricately linked, with one affecting the severity of the other, so if you do have a tendency, it is best to discover it or rule it out at an early stage.

What to expect after treatment

Following cleaning, the gums will be somewhat sore for a day or two. The level of discomfort is usually not so great as to stop you from going on about your daily business.

There will be some gum recession over the next few weeks as your inflamed tissues heal. The gums shrink back slightly from their current positions. This is not further loss of gum but merely shrinkage of inflamed tissues to healthy levels.

Unfortunately, the exposure of the root and the recession of the gum is an unavoidable consequence of periodontal disease and its treatment and is alluded to in a famous statement that patients with periodontal disease have the choice of “longer teeth or teeth no longer”.

The sensitivity of the teeth to temperature will also temporarily increase in most cases, though this is transient and will resolve of its own accord over a few days or weeks.

It may be difficult for you to clean properly for a few days if the gums are sore, but you will be provided with a chlorhexidine gluconate mouthwash (Corsodyl) which is a very effective substance at preventing new bacterial growth (however, it will not remove established plaque adherent to the teeth). Corsodyl is used commonly as a “chemical toothbrush” to control plaque levels during healing. It can be used for long periods but has the tendency to stain teeth so most patients only use it for a week or two till they are able to thoroughly clean their teeth normally.

Long term outlook

Whilst much of gum disease can be successfully treated and controlled with the above procedures, usually further intervention is required in areas that prove resistant to the initial treatment. This may involve simply repeating the deep cleaning procedure in selected sites.

Alternatively, surgical procedures to regenerate bone and gum can be used that will be targeted at specific sites and these will be discussed with you when your initial response to the above therapy is assessed a few months after treatment.

There is no doubt that patients susceptible to gum disease require lifelong hygiene maintenance to ensure disease remains controlled and visits every 6-12 weeks are routine. This is a small investment to keep teeth and bone that would otherwise be lost.

Teeth lost through gum disease are very challenging to replace due to the concurrent loss of bone. Dental implant treatment in such patients is compromised by sparse availability of bone which may need to be augmented with separate procedures. Once carried out, implants and any augmented bone may also be susceptible to the equivalent of gum disease around implants.

Early inflammation is referred to as peri-implant mucositis (the equivalent of gingivitis) and can be reversed by improving oral hygiene and removing any adherent biofilm on the implant prosthesis.

Unchecked, this can advance to peri-implantitis (the equivalent of periodontitis) and can normally only be treated only with a surgical approach. The implant may be lost if this disease is allowed to progress.
Regular hygiene maintenance and immaculate levels of oral hygiene must be maintained for long term stability of results.



(This information sheet contains general information and must be read in conjunction with your personalised treatment plan, which gives specific advice)
. LCIAD Ltd 2011

 

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