Periodontal disease is usually due to chronic bacterial infections. While cavity is caused by bacteria’s products (the acidic substances they produce) that dissolve the strong tooth structure (demineralization), periodontal disease is caused by the interactions between the bacteria and the host (the person). Research has shown that the individual’s own immune system reaction in response to the presence of bacteria or to their products directly causes the destruction of the periodontal structure. Because periodontal diseases include a very wide range of disease presentation, I will restrict my discussion of periodontal disease to the most common type: adult periodontitis.
This disease affects about 25-30% of the population in general, and more prevalent in the Asian and the African populations than Caucasians, and more in the older generation with age over 40 than the younger generation. It can be generalized (affecting all the teeth in the mouth) or site-specific (only some teeth). The most typical presentation of this type of periodontal disease has some or all of the following characteristics:
- Pocket formation
- Bone loss
- Tooth mobility
The presence of these characteristics enables the dentist to make the diagnosis of the disease and evaluate how extensive the disease has progressed. Before I move on, let me explain what “pocket formation” means. When you look how a tooth is anchored to the alveolar bone in cross-section, you will see the bone surrounds the tooth root and the tooth crown is exposed to the oral cavity. The gum is covering the bone and surrounding the neck of the tooth as simplified in the following diagram:
If you look close to the picture, you will notice that there is a crevice between the gum and the tooth. Dentist can measure the depth of this crevice by using a dental probe. Normally, this crevice should not be deeper than 3mm or 0.3 cm. When it is deeper than 3mm, we call this crevice a pocket.
Periodontal disease causes the formation of these pockets around the tooth. The procedure of using a probe to measure the depth of the pocket is called probing. It can be quite sensitive to the patient when the dentist is carrying out this procedure, but it has a very high diagnostic value to detect periodontal disease. Pocket formation and bleeding on probing are two positive signs of active periodontal disease existing. How do pockets form? In brief, it is caused by the destruction of the alveolar bone. What destroys the bone? It is the growth of oral bacteria around the area that causes the bone destruction. Why bacteria grow around the area? Normally it is the lack of regular oral hygiene that gave the oral bacteria the opportunity to thrive. The more bone loss happens, the deeper the pocket is formed. What is bad about pocket formation? When we brush our teeth, the bristles of the brush can reach a shallow crevice, so that any food debris can be removed from accumulating in that space. When pockets form, it provides a space for the food debris to hide there because now the toothbrush cannot reach to the bottom of the pockets. This debris is very nutritious for your oral bacteria, so they thrive inside these pockets. This phenomenon then goes into a vicious cycle as more food debris (nutrients for the bacteria) is trapped in a pocket leads to the thrive of bacteria, which leads to more bone loss, which leads to the formation of deeper pockets, which traps more food debris to supply to the bacteria to thrive. Can you imagine the picture?
Taking dental x-ray is another important diagnostic means for detecting periodontal disease because x-ray shows the bone height around the teeth or how much bone has been lost. In the mouth with healthy teeth, we can see the outline of the alveolar bone on x-ray films with a regular scalloping pattern and has the height around the neck level of the teeth. In contrast, in the mouth with periodontal disease involved teeth, the bone level is usually much lower and it is quite uneven across the teeth.
As we mentioned earlier, the more the surrounding bone is lost, the less stable is the tooth. Hence, loose teeth or tooth mobility is another characteristic of periodontal disease. When the teeth become very mobile, they may become quite painful as abscess can form around deep pockets. Mobile tooth will eventually lead to tooth loss.
There are many factors that lead to periodontal disease; my list in the following are the common ones with the first one the commonest:
- Lack of oral hygiene or regular professional teeth cleaning
- Intrinsic host factor (some people are more susceptible than others, may be related to genetic makeup of an individual as people whose parents or siblings with a history of periodontal disease are much more susceptible than other people)
- Diabetic patients
- Bad restorations that prevent you to clean the area well. Examples of these are overhang restorations and crowns.
What are the treatment options for periodontal diseases?
The first line of treatment for periodontal disease is carried out by the patients themselves. Once you have periodontal disease, personal oral hygiene is more important than everything else. Thorough tooth brushing in the correct way practiced at least two times a day and flossing at least one time a day are the minimal requirement if you want to control periodontal disease. I cannot emphasize enough about flossing. I know many people do not floss because they think it is too time consuming, or they find the teeth bleed when they floss, or they are just lazy to do the work. Let me assure you this: once you try flossing everyday, gradually you will find it not much time consuming as you may think. I remember the first few times I tried flossing, it took me at least 10 minutes and I had to look at my mouth in a mirror in order to slide the floss between teeth. Now I can floss all the teeth in less than 3 minutes and I don’t even need to open my eyes to do it! The second thing I can assure you: in the first week of flossing, you may find that your gum bleed when you floss. However, if you keep on doing it everyday, you will start to notice minimal or no bleeding at all. Why? You have bleeding when you start to practice flossing because you have never flossed before or you have not flossed lately. As a result, your gum is in a chronic stage of inflammation and is very easy to bleed. If you keep flossing everyday, gradually you are changing the oral hygiene environment so that your gum now goes back to healthy and tough stage where there is no more inflammation. With healthy gum, flossing will not cause bleeding any more. You have to make this your personal experience so that you can see how much change flossing has brought to your gum! If you are not flossing just because you are lazy, then let me tell you how much your “laziness” can cost you! People with gum disease can spend thousands of dollars in order to control it or improve it. Flossing can help you prevent cavity as well. You can imagine how much money you can save from flossing when you think about how expensive dental treatments are!
The second line of treatment is by your dental professionals such as your dentist or the dental hygienist.
Research has shown that the direct cause of bone destruction and pocket formation is the dental plaque. Have you ever used a toothpick to scratch the surface of the teeth? You can try to do it now. What did you pick up from it? You may notice some white or yellowish sticky material comes off from the surface of your teeth. This substance is called the dental plaque, which is composed primarily of microorganisms, and mostly bacteria. Daily tooth brushing and flossing can efficiently remove the accumulation of this dental plaque. When this dental plaque is left on tooth surface for long enough, it will turn into calculus (more commonly known to the public as Tartar). The soft plaque is now hardened by precipitation of mineral salts found in the saliva. While plaque can be removed by personal oral hygiene measures such as flossing and brushing, calculus cannot. That is why you need to have regular professional cleaning in a dental office. Plaque can turn into calculus as soon as in 4 to 8 hours in some people while some people do not develop calculus easily. How do dental professionals remove calculus? The procedure of removing calculus is called scaling. It can be carried out with hand instruments or by ultrasonic scalers. When scaling is done inside a deep pocket, literally removing the calculus on the root of a tooth, this procedure will be called root planing. Because root planing procedure can be quite sensitive to the patient, local anesthetics (needle injection) is usually delivered for patient comfort.
The rationale of scaling and root planing is to remove plaque and calculus, the source of periodontal disease. Most of the time, root planing can reduce the depth of the pocket or completely eliminate it, as the gum will reattach to the tooth surface when the surface becomes clean again. This is very important if you still remember how pockets cause the progression of periodontal disease in a vicious cycle.
A life-long battle to control gum disease!
Sometimes scaling and root planing is not enough to control periodontal disease. When the dentist reevaluates the situation after scaling and root planing procedure, he/she may decide to go for more aggressive treatment option: periodontal surgery. In brief, the goals of periodontal surgery are to eliminate pockets and to regenerate bone, which has been lost. Unfortunately, it is very difficult to regenerate bone, once it was lost due to periodontal diseases. On the other hand, pockets reduced or eliminated by periodontal surgery (and root planing alike) will come back whenever the oral hygiene of the patient slackens. Therefore, we often say that periodontal disease can only be controlled but not treated and it is a life-long battle for the patients and their dental professionals.