Periodontics

PERIODONTIC SPECIALISTS

A periodontist is a dentist who specialises in the prevention, diagnosis, and treatment of periodontal disease and in the placement of dental implants. Periodontists are also experts in the treatment of oral inflammatory diseases. Periodontists receive extensive training in these areas including three additional years of education beyond dental school. They are familiar with the latest techniques for diagnosing and treating periodontal disease and are also trained in performing cosmetic periodontal procedures.

Periodontists often treat more problematic periodontal cases, such as those with severe gum disease or a complex medical history. Periodontists offer a wide range of treatments, such as scaling and root planing (in which the infected surface of the root is cleaned) or root surface debridement (in which damaged tissue is removed). They can also treat patients with severe gum problems using a range of surgical procedures. In addition, periodontists are specially trained in the placement and repair of dental implants.

THE INITIAL CONSULTATION

During the first visit, the periodontist reviews the patient’s complete medical and dental histories. It is extremely important for the periodontist to know if any medications, such as anticoagulant medication, are being taken or if the patient is being treated for any conditions that can affect periodontal care, such as heart disease, diabetes, or pregnancy.

The periodontist examines the gums, checks to see if there is any gum line recession, assesses how the teeth fit together when biting and checks the teeth to see if any are loose. The periodontist will also take a small measuring instrument called a probe and place it between the teeth and gums to determine the depth of those spaces, known as periodontal pockets. This helps the periodontist assess the health of the gums. X-rays may also be taken to observe the health of the bone below the gum line.

WHO SHOULD SEE A PERIODONTIST?

Some patients’ periodontal needs can be managed by the general dentist. However, as more and more patients are exhibiting signs of periodontal disease, coupled with research that suggests a relationship between periodontal disease and other chronic diseases of aging, periodontal treatment may necessitate a greater understanding and increased level of expertise by a trained specialist. Patients who present with moderate or severe levels of periodontal disease or patients with more complex cases will be best managed by a partnership between the dentist and periodontist.

GUM DISEASE SYMPTOMS

Gum disease is often silent, meaning symptoms may not appear until an advanced stage of the disease.

Warning signs of gum disease include the following:

• Red, swollen or tender gums or other pain in your mouth

• Bleeding while brushing, flossing, or eating hard food

• Gums that are receding or pulling away from the teeth, causing the teeth to look longer than before

• Loose or separating teeth

• Pus between your gums and teeth

• Sores in your mouth

• Persistent bad breath

• A change in the way your teeth fit together when you bite

• A change in the fit of partial dentures

 

PREVENTING PERIODONTAL DISEASE

Periodontal disease, also known as gum disease, is caused when bacteria builds up between the gums and teeth. When the bacteria begin to grow they form a protective film or gel called plaque. This plaque helps to create a more ideal environment for the bacteria; protects the bacteria from your bodies’ defences and also protects them from antibiotics.   Once the bacteria/plaque colonize the teeth and root surfaces the gums surrounding the tooth can become inflamed.

If left untreated, this inflammation can cause the gums and supporting bone structure to deteriorate. This can lead to gum recession and tooth loss. In addition, research has shown that gum disease may be associated with other diseases, such as diabetes and heart disease.

Luckily, periodontal disease can be preventable. Adding these habits to your daily routine can help.

Brush your teeth. Brushing after meals helps remove food debris and plaque trapped between your teeth and gums. Don’t forget to include your tongue, bacteria love to hide there.

Floss. Flossing at least once a day helps remove food particles and plaque between teeth and along the gum line that your toothbrush can’t quite reach.

Rinse with mouthwash. Using a mouthwash can help reduce plaque and can remove remaining food particles that brushing and flossing missed.

 

Know your risk. Age, smoking, diet and genetics can all increase your risk for periodontal disease. If you are at increased risk, be sure to talk with your dental professional. 

 

RISK FACTORS THAT MAY AFFECT GUM DISEASE

What causes periodontal (gum) disease is plaque, if there is no plaque there is no periodontal disease; however, other factors may affect the rate of progression of the disease. It is likely also that the presence of multiple risk factors combines to lower the threshold for the initiation of disease.

SMOKING/TOBACCO USE

Studies have shown that tobacco use may be one, or the most significant risk factor in the progression of periodontal disease.  Smoking affects many different aspects of the body’s immune system and healing. The risk of destruction from smoking has an odds ratio of 2.5-6.8 which basically means that if you smoke the rate of destruction from periodontal disease may be anything up to nearly 7x greater than for a non-smoker. This for most people is dose dependent so the more you smoke the more severe the rate of destruction, however, for a few people it makes no difference and you could smoke 2 cigarettes per day and have the same effect as smoking 20 or 30.  Smoking not only affects how fast the destruction occurs, it also affects how quickly your tissues heal; for surgical procedures for instance the success rates are less in smokers versus non-smokers.

GENETICS

Studies have shown that 40-80% of people with periodontal disease have a genetic change or polymorphism  is linked to increased susceptiblity to gum disease.  Even with intensive home and professional oral care, these people may not only be more likely to develop periodontal disease but also require more intensive maintenance regime’s.

STRESS

Stress is a risk factor in many systemic ailments such as hypertension, cancer, and numerous other health problems. Stress is a risk factor for periodontal disease. Stress down regulates the immune system and healing.  Negative life events such as unemployment, quality of marriage and life events such as the death of a loved one may cause a burst of activity in periodontal disease and a sudden deterioration in periodontal health.  Stress combined with poor oral hygiene and smoking are a known risk factor complex for necrotizing ulcerative gingivitis that we see occasionally and was highly prevalent in military recruits during the 1^st World War.

MEDICATIONS

Some drugs, such as steroids, anti-depressants, and some heart medicines may affect your oral health.  It is important to notify your dental provider of any changes in your general health or changes to medications you are taking.   

CLENCHING OR GRINDING YOUR TEETH

Arguments have been made that bruxing (grinding) or jaw clenching may adversely load the supporting periodontal tissues and this could increase the rate of periodontal tissues destruction.

OTHER SYSTEMIC DISEASES

Other systemic diseases that interfere with the body's inflammatory system may worsen the condition of the gums. These include cardiovascular disease, diabetes, and rheumatoid arthritis.

Diabetic and cardiovascular risk in patients diagnosed with periodontitis

Authors: Zhang DH et al.

Summary: Patients with periodontitis at an Australian dental hospital underwent casual blood glucose level, total cholesterol level, HbA1c level, BP, bodyweight and height measurements to assess their diabetes mellitus and CV disease risks in this pilot study; 42 of the 159 individuals approached to participate were enrolled. Undiagnosed prediabetes (HbA1c level ≥5.7%) was identified in 24 participants (57.1%) and undiagnosed diabetes (HbA1c level ≥6.5%) in three participants (7.15%).

There were also 14 participants (33.3%) with hypertension (BP ≥140/90mm Hg), 17 (40.5%) with hypercholesterolaemia, 12 (28.6%) who were smokers and 24 (57.1%) with a BMI >25 kg/m2. GP referrals were made for 24 participants (57.1%) due to elevated disease markers.

Comment (JL): Periodontitis has been strongly linked with both diabetes and CV disease. It has been estimated that, in Australia, up to half of type 2 diabetes cases remaining undiagnosed. A two-way relationship exists between periodontitis and diabetes, with the prevalence, severity and extent of periodontitis positively correlated with control of diabetes and vice versa. The inflammatory nature of periodontitis plays a deleterious role in damaging the circulatory system by impairing blood vessel endothelium function, promoting atheroma formation and increasing the risk of thrombotic and embolic events. Forty-two participants with moderate-to-severe periodontitis, and an average age of 51.3 years, were included in this study. It was found that 24 were prediabetic, three were diabetic, 14 were hypertensive, 17 had hypercholesterolaemia and 24 had a BMI score that categorised them as overweight or obese.

Reference: Aust Dent J. 2015;60(4):455-62

POOR NUTRITION AND OBESITY

A diet low in important nutrients can compromise the body's immune system and make it harder for the body to fight off infection. Because periodontal disease begins as an infection, poor nutrition can worsen the condition of your gums. This may be more prevalent in people with unusual eating habits.  In addition, research has shown that metabolic syndrome may increase the risk of periodontal disease.

AGE

While studies indicate that older people have the highest rates of periodontal disease; for instance the Centre’s for Disease Control and Prevention noted that greater than 70% of Americans above the age of 64 have periodontitis, age per se is not a risk factor for periodontal disease.

 

GUM DISEASE AND WOMEN

A woman's periodontal health may be impacted by a variety of factors.

PUBERTY

During puberty, an increased level of sex hormones, such as progesterone and possibly estrogen, causes increased blood circulation to the gums. This may cause an increase in the gum's sensitivity and lead to a greater reaction to any irritation, including food particles and plaque. During this time, the gums may become swollen, turn red and feel tender.

MENSTRUATION

Occasionally, some women experience menstruation gingivitis. Women with this condition may experience bleeding gums, bright red and swollen gums and sores on the inside of the cheek. Menstruation gingivitis typically occurs right before a woman's period and clears up once her period has started.

PREGNANCY

Some studies have suggested the possibility of an additional risk factor – periodontal disease. Pregnant women who have periodontal disease may be more likely to have a baby that is born too early and too small. However, more research is needed to confirm how periodontal disease may affect pregnancy outcomes.

All infections are cause for concern among pregnant women because they pose a risk to the health of the baby. The Academy recommends that women considering pregnancy have a periodontal evaluation.

MENOPAUSE AND POST-MENOPAUSE

Women who are menopausal or post-menopausal may experience changes in their mouths. They may notice discomfort in the mouth, including dry mouth, pain and burning sensations in the gum tissue and altered taste, especially salty, peppery or sour.

In addition, menopausal gingivostomatitis affects a small percentage of women. Gums that look dry or shiny, bleed easily and range from abnormally pale to deep red mark this condition. Most women find that estrogen supplements help to relieve these symptoms.

 

GUM DISEASE AND MEN

Periodontal health for men is extremely important as it may impact a variety of other health factors.

Research has found that periodontal disease is higher in men (56.4 percent) than in women (38.4 percent). This may be because men are less likely to go to the dentist or because men have worse indicators of periodontal health than women, including higher incidence of dental plaque, tartar, and bleeding on probing. However, periodontal health for men is extremely important as it may impact a variety of other health factors.

PROSTATE HEALTH

Prostate-specific antigen (PSA) is an enzyme created in the prostate that is normally secreted in very small amounts. However, when the prostate becomes inflamed, infected, or affected by cancer, PSA levels rise. Research has shown that men with indicators of periodontal disease such as red, swollen or tender gums  as well as prostatitis (inflammation of the prostate) have higher levels of PSA than men with only one of the conditions. This means that prostate health may be associated with periodontal health, and vice versa.

HEART DISEASE

Research indicates that periodontal disease and cardiovascular disease are associated; having periodontal disease may actually increase your risk of cardiovascular disease. Both diseases are chronic inflammatory conditions, and researchers believe that inflammation is the connection between gum disease and heart disease. Since men are already more likely to develop heart disease than women, maintaining periodontal health is another way to reduce this risk.

IMPOTENCE

Men with periodontal disease, especially those younger than 30 or older than 70, are at increased risk of developing impotence, according to research. Researchers believe that inflammation may be the link between the two conditions; prolonged chronic inflammation (the same type of inflammation that is associated with periodontal disease) can damage blood vessels leading to impotence.

CANCER

Research has found that men with a history of gum disease are 14 percent more likely to develop cancer than men with healthy gums. Specifically, men with periodontal disease may be 49 percent more likely than women to develop kidney cancer, 54 percent more likely to develop pancreatic cancer, and 30 percent more likely to develop blood cancers.

GUM DISEASE IN CHILDREN

Chronic gingivitis. aggressive periodontitis and generalized aggressive periodontitis are types of gum disease in children.

 

TYPES OF PERIODONTAL DISEASES IN CHILDREN

Chronic gingivitis is common in children. It usually causes gum tissue to swell, turn red and bleed easily. Gingivitis is both preventable and treatable with a regular routine of brushing, flossing and professional dental care. However, left untreated, it can, eventually, advance to more serious forms of periodontal disease.

Aggressive periodontitis can affect young people who are otherwise healthy. Localized aggressive periodontitis is found in teenagers and young adults and mainly affects the first molars and incisors. It is characterized by the severe loss of alveolar bone, and ironically, patients generally form very little dental plaque or calculus.

Generalized aggressive periodontitis may begin around puberty and involve the entire mouth. It is marked by inflammation of the gums and heavy accumulations of plaque and calculus. Eventually it can cause the teeth to become loose.

SIGNS OF PERIODONTAL DISEASE IN CHILDREN

Four basic signs will alert you to periodontal disease in your child:

Bleeding
Bleeding gums during tooth brushing, flossing or any other time

Puffiness
Swollen and bright red gums

Recession
Gums that have receded away from the teeth, sometimes exposing the roots

Bad breath
Constant bad breath that does not clear up with brushing and flossing

IMPORTANCE OF GOOD DENTAL HYGIENE IN ADOLESCENCE

Hormonal changes related to puberty can put teens at greater risk for getting periodontal disease. During puberty, an increased level of hormones, such as progesterone and possibly estrogen, cause increased blood circulation to the gums. This may cause an increase in the gum's sensitivity and lead to a greater reaction to any irritation, including food particles and plaque. During this time, the gums may become swollen, turn red and feel tender.

As a teen progresses through puberty, the tendency for the gums to swell in response to irritants will lessen. However, during puberty, it is very important to follow a good at-home dental hygiene regimen, including regular brushing and flossing, and regular dental care. In some cases, a dental professional may recommend periodontal therapy to help prevent damage to the tissues and bone surrounding the teeth.

ADVICE FOR PARENTS

Early diagnosis is important for successful treatment of periodontal diseases. Therefore, it is important that children receive a comprehensive periodontal examination as part of their routine dental visits. Be aware that if your child has an advanced form of periodontal disease, this may be an early sign of systemic disease. A general medical evaluation should be considered for children who exhibit severe periodontitis, especially if it appears resistant to therapy.

The most important preventive step against periodontal disease is to establish good oral health habits with your child. There are basic preventive steps to help your child maintain good oral health:

• Establish good dental hygiene habits early. When your child is 12 months old, you can begin using toothpaste when brushing his or her teeth.   When the gaps between your child's teeth close, it's important to start flossing.

• Serve as a good role model by practicing good dental hygiene habits yourself.

• Schedule regular dental visits for family checkups, periodontal evaluations and cleanings.

• Check your child's mouth for the signs of periodontal disease, including bleeding gums, swollen and bright red gums, gums that are receding away from the teeth and bad breath.

NON-SURGICAL PERIODONTAL TREATMENT

Almost all periodontal therapy can be accomplished with non-surgical periodontal therapy (scaling and root planing).  This is the least invasive and most cost-effective periodontal treatment.

Scaling and root planing involves the careful removal of bacterial plaque and calculus or tartar from the root surface as well as bacterial toxins that may be absorbed onto the root surface.

Pockets that are not responding to therapy after being treated 2 or 3 times may be scheduled for surgical treatment where the gum is lifted back from the tooth so that the root of the tooth can be visualised and access to the root surface improved.