May-June 2002 Volume 36 Number 3
by Carol Lewis
More than 75 percent of Americans over 35 have some form of gum disease. In its earliest stage, your gums might swell and bleed easily. At its worst, you might lose your teeth. The bottom line? If you want to keep your teeth, you must take care of your gums.
The mouth is a busy place, with millions of bacteria constantly on the move. While some bacteria are harmless, others can attack the teeth and gums. Harmful bacteria are contained in a colorless sticky film called plaque, the cause of gum disease. If not removed, plaque builds up on the teeth and ultimately irritates the gums and causes bleeding. Left unchecked, bone and connective tissue are destroyed, and teeth often become loose and may have to be removed.
A recent poll of 1,000 people over 35 done by Harris Interactive Inc. found that 60 percent of adults surveyed knew little, if anything, about gum disease, the symptoms, available treatments, and — most importantly — the consequences. And 39 percent do not visit a dentist regularly. Yet, gum disease is the leading cause of adult tooth loss. Moreover, a Surgeon General's report issued in May 2000 labeled Americans' bad oral health a "silent epidemic" and called for a national effort to improve oral health among all Americans.
The good news is that in most people gum disease is preventable. Attention to everyday oral hygiene (brushing and flossing), coupled with professional cleanings twice a year, could be all that's needed to prevent gum disease — and actually reverse the early stage — and help you keep your teeth for a lifetime.
In addition, several products have been approved by the Food and Drug Administration specifically to diagnose and treat gum disease, and even regenerate lost bone. These products may help improve the effectiveness of the professional care you receive. (See "FDA-Approved Products for Gum Disease".)
What is Gum Disease?
In the broadest sense, the term gum disease — or periodontal disease — describes bacterial growth and production of factors that gradually destroy the tissue surrounding and supporting the teeth. "Periodontal" means "around the tooth."
Gum disease begins with plaque, which is always forming on your teeth, without you even knowing it. When it accumulates to excessive levels, it can harden into a substance called tartar (calculus) in as little as 24 hours. Tartar is so tightly bound to teeth that it can be removed only during a professional cleaning.
Gingivitis and periodontitis are the two main stages of gum disease. Each stage is characterized by what a dentist sees and feels in your mouth, and by what's happening under your gumline. Although gingivitis usually precedes periodontitis, it's important to know that not all gingivitis progresses to periodontitis.
In the early stage of gingivitis, the gums can become red and swollen and bleed easily, often during toothbrushing. Bleeding, although not always a symptom of gingivitis, is a signal that your mouth is unhealthy and needs attention. The gums may be irritated, but the teeth are still firmly planted in their sockets. No bone or other tissue damage has occurred at this stage. Although dental disease in America remains a serious public health concern, recent developments indicate that the situation is far from hopeless.
Frederick N. Hyman, D.D.S., a dental officer in the FDA's dermatologic and dental drug products division, says that because people seem to be paying more attention to oral hygiene as part of personal grooming, the payoff is "a decline in gingivitis over recent years." Hyman adds that "gingivitis can be reversed in nearly all cases when proper plaque control is practiced," consisting, in part, of daily brushing and flossing.
When gingivitis is left untreated, it can advance to periodontitis. At this point, the inner layer of the gum and bone pull away from the teeth (recede) and form pockets. These small spaces between teeth and gums may collect debris and can become infected. The body's immune system fights the bacteria as the plaque spreads and grows below the gumline. Bacterial toxins and the body's enzymes fighting the infection actually start to break down the bone and connective tissue that hold teeth in place. As the disease progresses, the pockets deepen and more gum tissue and bone are destroyed.
At this point, because there is no longer an anchor for the teeth, they become progressively looser, and the ultimate outcome is tooth loss.
Signs and Symptoms
Periodontal disease may progress painlessly, producing few obvious signs, even in the late stages of the disease. Then one day, on a visit to your dentist, you might be told that you have chronic gum disease and that you may be at increased risk of losing your teeth.
Although the symptoms of periodontal disease often are subtle, the condition is not entirely without warning signs. Certain symptoms may point to some form of the disease. They include:
- Gums that bleed during and after toothbrushing
- Red, swollen or tender gums
- Persistent bad breath or bad taste in the mouth
- Receding gums
- Formation of deep pockets between teeth and gums
- Loose or shifting teeth
- Changes in the way teeth fit together on biting, or in the fit of partial dentures
|Dentists (D.D.S. or D.M.D.)||Overall managers of dental health. Dentists can treat periodontal disease as part of the overall dental care they provide to their patients.|
|Periodontists (D.D.S. or D.M.D.)||Dentists who have completed additional training that allows them to specialize in diagnosing, treating and preventing gum disease. Some are skilled at replacing missing teeth with dental implants.|
|There is no difference between the degrees D.D.S. (doctor of dental surgery) and D.M.D. (doctor of dental medicine). Some dental schools award one, and some award the other.|
Even if you don't notice any symptoms, you may still have some degree of gum disease. Some people have gum disease only around certain teeth, such as those in the back of the mouth, which they cannot see. Only a dentist or a periodontist — a dentist who specializes in gum disease — can recognize and determine the progression of gum disease.
The American Academy of Periodontology (AAP) says that up to 30 percent of the U.S. population may be genetically susceptible to gum disease. And, despite aggressive oral care habits, people who are genetically predisposed may be up to six times more likely to develop some form of gum disease. Genetic testing to identify these people can help by encouraging early treatment that may help them keep their teeth for a lifetime.
During a periodontal exam, your gums are checked for bleeding, swelling and firmness. The teeth are checked for movement and sensitivity. Your bite is assessed. Full-mouth X-rays can help detect breakdown of bone surrounding your teeth.
Periodontal probing determines how severe your disease is. A probe is like a tiny ruler that is gently inserted into pockets around teeth. The deeper the pocket, the more severe the disease.
In healthy gums, the pockets measure less than 3 millimeters — about one-eighth of an inch — and no bone loss appears on X-rays. Gums are tight against the teeth and have pink tips. Pockets that measure 3 millimeters to 5 millimeters indicate signs of disease. Tartar may be progressing below the gumline and some bone loss could be evident. Pockets that are 5 millimeters or deeper indicate a serious condition that usually includes receding gums and a greater degree of bone loss.
Following the evaluation, your dentist or periodontist will recommend treatment options. Methods used to treat gum disease vary and are based on the stage of the disease.
The goal of periodontal treatment is to control any infection that exists and to halt progression of the disease. Treatment options involve home care that includes healthy eating and proper brushing and flossing, non-surgical therapy that controls the growth of harmful bacteria and, in more advanced cases of disease, surgery to restore supportive tissues.
Although brushing and flossing are equally important, brushing eliminates only the plaque from the surfaces of the teeth that the brush can reach. Flossing, on the other hand, removes plaque from in between the teeth and under the gumline. Both should be used as part of a regular at-home, self-care treatment plan. Some dentists also recommend specialized toothbrushes, such as those that are motorized and have smaller heads, which may be a more effective method of removing plaque than a standard toothbrush.
John J. Golski, D.D.S., a Frederick, Md., periodontist, says that the rationale behind flossing is not "just to get the food out." From the periodontal standpoint, Golski says, "You're flossing to remove plaque — the real culprit behind gum disease," adding that proper brushing and flossing techniques are critical.
During a typical checkup your dentist or dental hygienist will remove the plaque and tartar from above and below the gumline of all your teeth. If you have some signs of gingivitis, your dentist may recommend that you return for future cleanings more often than twice a year. Your dentist may also recommend that you use a toothpaste or mouth rinse that is FDA-approved for fighting gingivitis.
In addition to containing fluoride to fight cavities, Colgate Total — the only toothpaste approved by the FDA for helping to prevent gingivitis — also contains triclosan, a mild antimicrobial that has been clinically proven to reduce plaque and gingivitis if used regularly. A chlorhexidine-containing rinse, also approved to fight plaque and gingivitis, is available only with a prescription.
If your dentist determines that you have some bone loss or that the gums have receded from the teeth, the standard treatment is an intensive deep-cleaning, non-surgical method called scaling and root planing (SRP). Scaling scrapes the plaque and tartar from above and below the gumline. Root planing smoothes rough spots on the tooth root where germs collect and helps remove bacteria that can contribute to the disease. This smooth, clean surface helps allow the gums to reattach to the teeth.
A relatively new drug in the arsenal against serious gum disease called Periostat (doxycycline hyclate) was approved by the FDA in 1998 to be used in combination with SRP. While SRP primarily eliminates bacteria, Periostat, which is taken orally, suppresses the action of collagenase, an enzyme that causes destruction of the teeth and gums.
Periodontal procedures such as SRP, and even surgery, are most often done in the office. The time spent, the degree of discomfort, and healing times vary. All depend on the type and extent of the procedure and the person's overall health. Local anesthesia to numb the treatment area usually is given before some treatments. If necessary, medication is given to help you relax. Incisions may be closed with stitches designed to dissolve and may be covered with a protective dressing.
Susan Runner, D.D.S., chief of the Dental Devices Branch in the FDA's Center for Devices and Radiological Health, says that devices have been approved both for diagnosing gum diseases and promoting regeneration of periodontal tissue.
"Periodontal membranes, along with bone-filling material, are used in treatment of the condition to help repair damage resulting from periodontal disease," Runner says. "Tissue engineering devices mimic the biological characteristics of the wound-healing process, and may help stimulate bone cells to grow."
Opinions about which treatment methods to use vary in the periodontal field. For some people, certain procedures may be safer, more effective, and more comfortable than others may be. Which treatment your dentist or periodontist chooses will most likely depend on how far your disease has progressed, how you may have responded to earlier treatments, or your overall health.
"Generally, we all have the same goals, but the methods for getting to them may be different," says Golski. "One size doesn't fit all." Professional treatment can promote reattachment of healthy gums to teeth, reduce swelling, the depth of pockets, and the risk of infection, and stop further damage.
"But in the end," Golski says, "nothing will work without a compliant patient."
Antibiotic treatments can be used either in combination with surgery and other therapies, or alone, to reduce or temporarily eliminate the bacteria associated with periodontal disease.
However, doctors, dentists and public health officials are becoming more concerned that overuse of these antibiotics can increase the risk of bacterial resistance to these drugs. When germs become resistant to antibiotics, the drugs lose the ability to fight infection.
"The resistance we're worried about," explains Robert Genco, D.D.S., Ph.D., chairman of the oral biology department at The State University of New York at Buffalo, "is in association with antibiotics in the traditional use; those at higher levels in the blood that kill bacteria."
Jerry Gordon, D.M.D., of Bensalem, Pa., shares Genco's concerns. "There is a role for antibiotics in periodontal disease," Gordon says, "but you have to be very selective in your use."
Each time a person takes penicillin or another antibiotic for a bacterial infection, the drug may kill most of the bacteria. But a few germs may survive by mutating or acquiring resistance genes from other bacteria. These surviving genes can multiply quickly, creating drug-resistant strains. The presence of these strains may mean that the person's next infection will not respond to another dose of the same antibiotic. And this overuse would be detrimental to people if they develop a life-threatening illness for which antibiotics would no longer be helpful.
John V. Kelsey, D.D.S., dental team leader in the FDA's dermatologic and dental drug products division, says, "The widespread use of systemic antibiotics is generating resistant organisms, and that's a problem." And that fact, he says, "has prompted the industry to develop new strategies that would reduce the risk of resistance developing."
For example, three relatively new drugs — Atridox (doxycycline hyclate), PerioChip (chlorhexidine gluconate), and Arestin (minocycline) — are antibiotics that were approved in sustained-release doses to be applied into the periodontal pocket. Local application of antibiotics to the gum surface may not affect the entire body, as do oral antibiotics.
Oral Health and Overall Health
According to the Centers for Disease Control and Prevention (CDC), researchers have uncovered potential links between periodontal disease and other serious health conditions. In people with healthy immune systems, the influx of oral bacteria into the bloodstream is usually harmless. But under certain circumstances, the CDC says, the microorganisms that live in the human mouth can cause problems elsewhere in the body "if normal protective barriers in the mouth are breached."
If you have diabetes, for example, you are at higher risk of developing infections such as periodontal disease. These infections can impair the body's ability to process or use insulin, which may cause your diabetes to be more difficult to manage. Diabetes is not only a risk factor for periodontal disease, but periodontal disease may make diabetes worse.
However, the CDC cautions that there is not enough evidence to conclude that oral infections actually cause or contribute to cardiovascular disease, diabetes and other serious health problems. More research is underway to determine whether the associations are causal or coincidental.
Other Common Measures for Treating Gum Disease
- Curettage — a scraping away of the diseased gum tissue in the infected pocket, which permits the infected area to heal.
- Flap surgery — involves lifting back the gums and removing the tartar. The gums are then sewn back in place so that the tissue fits snugly around the tooth. This method also reduces the pocket and areas where bacteria grow.
- Bone grafts — used to replace bone destroyed by periodontitis. Tiny fragments of your own bone, synthetic bone, or donated bone are placed where bone was lost. These grafts serve as a platform for the regrowth of bone, which restores stability to teeth.
- Soft tissue grafts — reinforce thin gums or fill in places where gums have receded. Grafted tissue, most often taken from the roof of the mouth, is stitched in place over the affected area.
- Guided tissue regeneration — stimulates bone and gum tissue growth. Done in combination with flap surgery, a small piece of mesh-like fabric is inserted between the bone and gum tissue. This keeps the gum tissue from growing into the area where the bone should be, allowing the bone and connective tissue to regrow to better support the teeth.
- Bone (osseous) surgery — smoothes shallow craters in the bone due to moderate and advanced bone loss. Following flap surgery, the bone around the tooth is reshaped to decrease the craters. This makes it harder for bacteria to collect and grow.
- Medications — in pill form are used to help kill the germs that cause periodontitis or suppress the destruction of the tooth's attachment to the bone. There are also antibiotic gels, fibers or chips applied directly to the infected pocket. In some cases, a dentist will prescribe a special anti-germ mouth rinse containing a chemical called chlorhexidine to help control plaque and gingivitis. These are the only mouth rinses approved for treating periodontal disease.
FDA-Approved Products for Gum Disease
A number of products are available to control infection and reduce inflammation.
|What it Is||Why it's Used||How it's Used|
|Colgate Total - triclosan and fluoride toothpaste|
|Over-the-counter toothpaste containing the antibacterial triclosan||The antibacterial ingredient reduces plaque and resulting gingivitis. The fluoride protects against cavities.||Used like a regular toothpaste.|
|Peridex or generic - chlorhexidine mouth rinse|
|Prescription mouth rinse containing an anti-microbial called chlorhexidine||To control bacteria, resulting in less plaque and gingivitis.||Used like a regular mouthwash.|
|A tiny piece of gelatin filled with chlorhexidine||To control bacteria and reduce the size of periodontal pockets.||Chip is placed in the pockets after root planing, where the medicine is slowly released over time.|
|A gel that contains the antibiotic doxycycline||To control bacteria and reduce the size of periodontal pockets.||Placed in pockets after scaling and root planing. Antibiotic is released slowly over a period of about seven days.|
|Thread-like fiber that contains the antibiotic tetracycline||To control bacteria and reduce the size of periodontal pockets.||These fibers are placed in the pockets. The medicine is released slowly over 10 days. The fibers are then removed.|
|Tiny round particles that contain the antibiotic minocycline||To control bacteria and reduce the size of periodontal pockets.||Microspheres placed into pockets after scaling and root planing. Particles release minocycline slowly over time.|
|A low dose of the medication doxycycline that keeps destructive enzymes in check||To hold back the body's enzyme response. If not controlled, certain enzymes can break down bone and connective tissue.||This medication is in pill form. It is used in combination with scaling and root planing.|
For More Information on Periodontal Diseases
National Institutes of Health
National Institute of Dental and Craniofacial Research (NIDCR)
Public Information and Liaison Branch
45 Center Drive MSC 6400
Bethesda, MD 20892
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Division of Oral Health, MS F-10
4770 Buford Highway, NE
Atlanta, GA 30341
American Academy of Periodontology
737 N. Michigan Ave.
Chicago, IL 60611
1-800-356-7736 (to find a periodontist in a particular region)
Other Potential Factors That Contribute to Gum Disease
While plaque is the primary cause of periodontal disease, the American Academy of Periodontology (AAP) says that other factors are thought to increase the risk, severity and speed of gum disease development. These can include:
- Tobacco use — one of the most significant risk factors associated with the development of periodontitis. People who smoke are seven times more likely to get periodontitis than nonsmokers, and smoking can lower the chances of success of some treatments.
- Hormonal changes — may make gums more sensitive and make it easier for gingivitis to develop.
- Stress — may make it difficult for the body's immune system to fight off infection.
- Medications — can affect oral health because they lessen the flow of saliva, which has a protective effect on teeth and gums. Some drugs, such as the anticonvulsant medication diphenylhydantoin and the anti-angina drug nifedipine, can cause abnormal growth of gum tissue.
- Poor nutrition — may make it difficult for the immune system to fight off infection, especially if the diet is low in important nutrients. Additionally, the bacteria that cause periodontal disease thrive in acidic environments. Eating sugars and other foods that increase the acidity in the mouth increases bacterial counts.
- Illnesses — may affect the condition of your gums. This includes diseases such as cancer or AIDS that interfere with the immune system.
- Clenching and grinding teeth — may put excess force on the supporting tissues of the teeth and could speed up the rate at which these tissues are destroyed.