What is Periodontal (Gum) Disease?

The term “periodontal” means “around the tooth” and refers to all the diseases of the periodontium.  This means that periodontal disease (also known as gum disease or periodontitis) is a pathological state that involves the gingiva (gum), the ligaments supporting the gingiva and the alveolar bone (jaw bone).  This inflammatory condition is an infection that gradually eats away at your alveolar bone and eventually causes tooth loss if you do not treat it as soon as possible.  We "get" periodontal disease from a combination of factors.  The plaque biofilm (living bacteria) needs to be present, along with this we can have older fillings or crowns that are not fitting properly, perhaps poor homecare combined with a family history of periodontal disease and individuals may have systemic disease such as diabetes, cardiovascular disease or arthritis.  All of these variables contribute to your susceptibility to create an environment in which the bacteria can grow quickly and depending upon your levels of stress and homecare commitment on a daily basis, the oral bacteria can irritate the gingiva, create toxins (poisons) and destroy the bone permanently.

What exactly is plaque?  Plaque--newly named plaque biofilm is a naturally occuring oral bacteria that everyone gets everyday; even if you do not eat.  It is a complex, tenaciously attached, beige-colored soft deposit composed of many different bacteria, saliva and food debris.  If the soft plaque biofilm is not removed thoroughly, it turns into a hard, mineralized substance known as calculus or tartar.  It can be formed on all tooth surfaces and dental prostheses (dentures, implants) and even orthodontic appliances.  The longer the calculus has been there the darker the color it is, turning from light beige to brown to black.

 Calculus is classified according to its location:  supragingival (above the gum) and subgingival (below or underneath the gum).  Supragingival calculus is usually light in color and chalky in consistency.  The mineral source is primarily the saliva and these deposits are prominent on the lower, front teeth by the tongue and on tooth surfaces near the upper back molars--where the salivary ducts help contribute to the formation of the calculus.  Subgingival calculus is usually darker in color and more dense.  This is by far the more destructive type of calculus and the bacteria that live within it can live without oxygen, be very aggressive, and can cause permanent bone loss.

When plaque and calculus are not removed completely and thoroughly, both from above the gumline and from below the gumline, then the plaque biofilm can begin to irritate and destroy the gingiva (gums), the ligaments supporting the tooth (periodontal ligaments), and the permanent jaw bone (alveolar bone).  Periodontal disease is a progressive disease that begins at its earliest stages beginning with inflammation and infection with the gum tissue itself before it starts to destroy the alveolar bone; this is called Gingivitis. 

 Inflammation and infection is the normal response of the living tissues to injury and irritations from the plaque biofilm.  The inflammation is the body's natural defense mechanism against the injury and in periodontal disease, the injury results primarily from the invasion of microorganisms and their microbial products into the gingival tissues.  Your body seeks to neutralize or destroy the plaque biofilm's toxins (poisons) as well as prepare the gingival tissues for repair and healing.  However, depending upon your immune system, your homecare, your overall systemic health and genetic predisposition to periodontal disease-- it is an ongoing battle of active infection and remission.  There is no "cure" for periodontal disease, there is only the treatment and maintenance during our hygiene visits along with your homecare and compliance in keeping your immune system at an optimal level that controls the disease process.

The more advanced state of gingivitis is Periodontitis or Periodontal Disease or Gum Disease.  This occurs when gingivitis is allowed to progress to the "deeper" areas of the dentition.  Periodontitis is a disease in which the gingiva as well as portions of the periodontal ligament, cementum (outer coating of the root of the tooth) and alveolar bone (jaw bone ) are affected by the inflammatory process--this is infection in your mouth.  Now that the infection has invaded the deeper supporting structures, the gingival sulcus (the natural space around the gum) loosens and creates a "Periodontal Pocket."  This pocket is now able to collect and trap even more plaque biofilm and food debris and destroy the periodontal ligament (the ligament holding the gum to the tooth) and has access to the alveolar bone (jaw bone) in which it begins to destroy the bone and gradually that is what loosens the teeth and tooth loss is inevitable.  We are here to detect any gingivitis/periodontal condition at the earliest stages and help you treat the disease and share with you what you can do to help prevent the disease from getting more advanced in your mouth and preventing any tooth loss.

So, you can understand what to look for in unhealthy gingiva.  Let's review what healthy gingiva (gums) look and feel like.  The color of your healthy gingiva is light, coral pink.  In people of darker skin color, there is a natural melanin pigmentation so the deeper your skin color, the darker tone to your gum tissue.  This is normal and your dental hygienist can show you what to look for so you can detect any signs of disease early.  The texture to healthy gum tissue is called "stippling."  It is very much like the dimpled texture of an orange peel; this is a very good sign of health.  The contour of the gum tissue--how it fills in and around the tooth--should completely fill the spaces around the tooth--this is the body's natural defense to keep food debris and bacteria out from between the teeth and gumline.  The consistency and size of the gingiva should be firm and flat-looking.  Healthy gum tissue does NOT bleed (there are some hormonal exceptions for women).  Healthy gums feels good, no discomfort, no pain even when flossing or brushing.  Healthy gingiva never has exudate (pus) around them even during any flossing or brushing.  On our dental x-ray images, we can show you healthy bone levels too--healthy mouths should have no bone loss!

One of the best tests to diagnose, identify, and judge how involved your gingivitis/periodontal condition is, is by taking some accurate periodontal measurements around the gumline with a periodontal probe.  This special, painless measuring device allows Dr. Ford and your dental hygienist to take several readings around the circumference of the tooth and it gives us a numerical reading of how deep the periodontal pocket or space is below the gumline.  We know from recent research that you can floss, brush and use oral hygiene aids and you can reach approximately 3mm below the gumline.  Therefore, up to 3mm with no bleeding is considered healthy.    A measurement of 4mm is considered gingivitis and measurements 5mm or greater are considered periodontal disease because we know when the bacteria moves deeper than 5mm it begins to infect and destroy the alveolar bone.  This is the defining difference of gingivitis and periodontitis.

Four out of five people have periodontal disease and don't know it!  Most people are not aware of it because the disease is usually painless at the beginning stages and even at the moderate stages.  Only when the disease is at the more advanced stages-- almost at the irreversible stage--are there stronger signs of discomfort, odor, and tooth movement.  Not only is periodontal disease the number one reason for tooth loss, research suggests that there may be a link between periodontal disease and other diseases such as heart attacks, stroke, bacterial pneumonia, diabetes, cardiovascular disease, and increased risk of harm to the baby during pregnancy. 

Researchers are still trying to determine if inflammation and bacteria associated with periodontal disease is affecting these systemic diseases and conditions or if the systemic conditions are causing periodontal disease.  Tobacco use is a prime example of a habit that strongly increases the risk of periodontal disease and oral cancer.  Therefore, good oral hygiene, a balanced diet, and regular dental visits can help reduce your risk of developing periodontal disease. 

For additional information, please see The American Dental Association website:  ada.org

Types of Periodontal Disease

When left untreated, gingivitis (early stage of gum disease) can spread to below or underneath  the gum line.  When the gums become irritated by the toxins contained in plaque, a chronic inflammatory response causes the body to break down and destroy its own bone and soft tissue; this is an infection.  There may be little or no symptoms as periodontal disease causes the teeth to separate from the infected gum tissue.  Deepening pockets between the gums and teeth are generally indicative that soft tissue and bone is being destroyed by periodontal disease.

Here are some of the most common types of periodontal disease:

• Chronic Periodontitis – Inflammation within supporting tissues cause deep pockets and gum recession.  It may appear the teeth are lengthening, but in actuality, the gums (gingiva) are receding.  This is the most common form of periodontal disease and is characterized by progressive loss of attachment, interspersed with periods of rapid progression.
• Chronic Gingivitis - Generalized gum inflammation with the gums bleeding easily, however the plaque biofilm has not reached deep enough under the gum tissue to cause permanent bone loss.  Very common in teenagers/young adults who have not been consistent with their homecare, but have a great immune system.  Some times hormonal conditions such as pregnancy, menopause or menstral cycles can contribute to this type of gingivits.
• Acute Nectrotizing Ulcerative Gingivitis (ANUG/NUG) - a very painful, usually acute condition in which the gums are very swollen, painful to touch, red and shiny.  Often times found in young adults with alot of stress, poor hygiene and poor nutrition, example college students.
• Mouth-Breathing Gingivitis - a very specific type of inflammation around the front gums usually more pronounced on the upper--very red, shiny gums that bleed easily.  Often time caused by allergies, stuffy noses from colds, habitual breathing through the mouth or nighttime breathing through the mouth--we can treat that fairly easily, ask Dr. Ford.
• Allergic Gingivitis - involved an abnormal response of the tissues to specific agents.  Allergic reactions caused by sensitivity to certain foods or drugs -- sometimes from certain mouthwashes, toothpastes, or flavoring in many products--leaves the tissues sore, red and sometimes with ulcerations.
• Aggressive Periodontitis – This form of gum disease occurs in an otherwise clinically healthy individual.  It is characterized by rapid loss of gum attachment, chronic bone destruction and familial aggregation.  Associated many times with systemic conditions such as Diabetes, Arthritis and AutoImmune Diseases.
• Necrotizing Periodontitis – This form of periodontal disease most often occurs in individuals suffering from systemic conditions such as HIV, immunosuppression and malnutrition.  Necrosis (tissue death) occurs in the periodontal ligament, alveolar bone and gingival tissues. Many times a specialist, such as a Periodontist treats these individuals with surgery to remove the infected tissue.
• Refractory Periodontitis - These individuals usually have very little plaque or calculus, but have very deep pockets (6mm and much greater) around certain teeth--that's why it's SO important for Dr. Ford and your dental hygienist to use the periodontal probe.  It's the pocketing that is the true diagnosis for this type of periodontal disease.

Treatment for Periodontal Disease

There are many nonsurgical treatments Dr. Ford and his dental hygienists may choose to perform, depending upon the exact condition of the teeth, gums and jawbone.  A complete periodontal exam of the mouth will be done before any treatment is performed or recommended.

Here are some of the more common treatments for periodontal disease:

• Scaling, Root Planing and Gingival Currettage – In order to preserve the health of the gum tissue, the bacteria and calculus (tartar) which initially caused the infection, must be removed with special hygiene instruments when you are numb.  The gingival pockets need instrumentation to remove the infected tissue and sometimes powdered antibiotics are necessary to help treat the infection and accelerate the healing.  A prescription mouthwash may be incorporated into daily cleaning routines to boost your own sytemic healing process.  (Please see the "Treatment" section of Dr. Ford's website for further details).
• Tissue Regeneration – When the bone and gum tissues have been destroyed, regrowth can be actively encouraged using grafting procedures.  A membrane may be inserted into the affected areas to assist in the regeneration process. Or a grafting procedure may be done using your own tissue or synthetic tissue to cover the recession and create a healthy, thick band of attachment to discourage further recession.  This is a surgical procedure that we will discuss in detail with you in person.
• Pocket Elimination Surgery – Pocket elimination surgery (also known as flap surgery) is a surgical treatment which can be performed to reduce the pocket size between the teeth and gums.  This is only necessary when the pocket depths are SO deep that even the special scalers the dental hygiene use are unable to reach the calculus under the gums.  Surgery on the jawbone is another option which serves to eliminate indentations in the bone which foster the colonization of bacteria.  We will arrange a consultation with our incredible Periodontist (Gum Specialist) if this surgical procedure is necessary for you.  Dr. Ford will always try a non-surgical procedure first to treat your periodontal condition-- and then only if necessary will consider surgical options for you.
• Dental Implants – When teeth have been lost due to periodontal disease, the aesthetics and functionality of the mouth can be restored by implanting prosthetic teeth and roots.  Tissue regeneration and bone grafting procedures may be required prior to the placement of a dental implant in order to strengthen the bone.  Dr. Ford will take the time and discuss all the details about your specific conditions and he will specialize any treatment necessary to restore your smile.

Please ask Dr. Ford and your dental hygienist if you have questions or concerns about periodontal disease, periodontal treatment, or dental implants.