Gum Disease

Gum disease can be plaque and bacteria related or it may be non-bacteria related.

A – Bacteria-related gum disease:

In this category, plaque bacteria are the main cause of gum disease:

Gingivitis

Is when bacteria dominate the gum tissue around your teeth and as a result the gum becomes inflamed, this is called gingivitis. This inflammation is a natural defence mechanism from your body. It should be considered a signal that your body is giving, alerting you that you are under attack from bacteria.

How do I know if I have gingivitis?

There are signs and symptoms that you should watch for when suspecting gingivitis. One or a combination of one of these signs and symptoms may indicate gingivitis:

Bleeding gums when brushing: It is usually difficult to understand where exactly the bleeding is coming from.
Bleeding gums when using dental floss: Assuming you do floss correctly (not rubbing the floss between teeth), if you see bleeding from your gums while flossing, gingivitis is the most likely reason.
Bleeding while using interdental brushes/toothpicks: When the gum is inflamed, cleaning between teeth with interdental brushes may cause bleeding if you have gingivitis.
Bad breath
Red and puffy gums (usually a purple/red band may show at the gum line around teeth

While bacteria remain the cause of gingivitis, there are circumstances that can present with gingivitis:

Puberty
Menstrual cycle
Pregnancy
Medications (some medications)
Diabetes
Leukemia
Malnutrition and vitamin deficiencies

Gingivitis is generally reversible by appropriate treatment. However, if not managed properly, it can lead to a more serious condition called ‘Periodontitis’.

Periodontitis

When gingivitis progresses and is not treated, the bacterial invasion leads to deeper inflammation in the gum. This leads to the supporting bone of the tooth getting affected. When this bacterial invasion dominates, the consequence is resorption and recession of the bone around the tooth.

Depending on the location and extent of the bacteria present deep at the gum line, the whole circumference of the bone may be affected or it can be localised to a smaller region around the tooth. As the bone is recedes down, the gum around the tooth follows that path.

The gum that is well attached to the root surface and lying over the bone, becomes detached from the tooth in the deep areas, this is when a periodontal pocket is formed. That is loose gum around the root of the tooth.

When the bone resorption (bone loss) around the tooth/root reaches a threshold, the tooth can gradually become mobile. The final consequence of periodontitis is severe bone loss and eventual loss of teeth.

Unfortunately, the disease process is usually painless. Therefore, periodontitis remains relatively silent for quite a long time until it may be too late.

The general signs and symptoms of periodontitis are the same as gingivitis. In addition there may be some other additional signs and symptoms that could be good indicators for periodontitis, these include:

Feeling weakness with one or a few teeth in the mouth
Constant and frequent food impaction between teeth
Mobility of teeth (not readily felt usually)
Hypersensitivity with cold and hot stimuli
Migration of teeth
Tenderness on teeth under pressure while chewing or biting
Receding gums

What factors make me susceptible to Periodontitis?

From literature now we know that there are certain factors that may make some people more susceptible to periodontitis, these include but are not limited to:

Genetics / Family history of gum disease:
If you have parents who lost their teeth at a young age, that may be an indication for genetic susceptibility
Smoking (current or history of smoking):
Current and ex-smokers harbour bacteria in their mouth more specific towards gum disease. The changes occur over time and even after you quit smoking it tends to keep that effect for a very long time. Also, current smokers tend to have a compromised immunity against periodontal pathogens. Hence, the initiation and progression of periodontitis occurs in an easier way compared to never-smokers.
Diabetes:
There is good evidence in literature supporting a poorer immunity response from bacterial attack in diabetics. This is particularly more pronounced in uncontrolled diabetes. Even short periods of glucose fluctuation may have an impact on progression of gum disease.
Stress:
is one of the factors affecting immune response. Individuals may harbour periodontal pathogens and chronic stress may lead to compromised subclinical poor immune responses against bacteria, leading to the initiation and progression of gum disease.
Plaque bacteria/poor oral hygiene:
The ultimate cause of periodontitis is bacteria. Even in the absence of any other risk factors, chronic poor oral hygiene can lead to the development of periodontitis.
Vitamin D level:
There is substantial evidence that show low levels of Vitamin D, can be a contributing factor to the progression of periodontitis. Vitamin D has a strong role in immune response and its deficiency can compromise ones defence against bacteria.
Irregular attendance to dentist/hygienist:
While good personal oral hygiene can eliminate most of the plaque bacteria from the surface of teeth, there is always a thin plaque bacteria accumulation around the gum line. These are the areas that are difficult to clean by individuals. Therefore, professional scaling and cleaning of teeth is required on a regular basis. Ideally, and for those with no history of periodontal disease the interval should best be 6 monthly. This interval is usually shorter when active periodontal disease is present and also after treatment in susceptible individuals.
Poor dental state or poor restoration/denture state:
For example, the presence of multiple cavities on teeth can be a constant bacteria trap. This leads to bacteria growing constantly without being disturbed. Similarly, if dental fillings or a denture is made in a way that appropriate brushing is not possible, those sites will be at high risk of developing gum disease.

B – Non-bacteria related gum disease:

In this category, bacteria have no role in occurrence of the gum disease. The presentation of gum disease may be different than gingivitis. The causes include:

Viral infections
Allergic reactions
Autoimmune disease with oral disease presentations
Fungal infections
Traumatic lesions (chemical, mechanical, thermal)
Foreign body reaction
Malignancies (cancer)

If you have any questions, or concerns
regarding gum disease

FAQs

What causes gingivitis and periodontitis?

It is essentially the bacteria causing gingivitis and periodontitis. However, the individual`s susceptibility is an important factor to determine whether someone would develop periodontal disease or not. In the past, only a few bacteria were known to be responsible for gum disease. There is over 700 bacteria identified in the oral cavity. The majority of these bacteria are health-related. Advent of modern microbiological techniques has revealed that it is the dysbiosis that occurs in periodontally susceptible individuals. That is, the proportion of health-related bacteria and disease related bacteria changes.

What is the right treatment for periodontitis?

The ultimate goal in the treatment of periodontitis is to have healthy, functional and aesthetic teeth.

During your consult appointment a comprehensive clinical examination is carried out. All baseline periodontal pockets are measured and recorded on file. Dental X-rays are generally needed to know the status of bone around each tooth.

Blood test may be requested as well. It is generally useful to bring your most recent full blood test to your periodontist. If your blood test result is more than 1 year old, a new full blood test would be requested through your General Medical practitioner. Also, you would need to provide your periodontist with your medical GP or Specialist contacts.

Once all the clinical and radiographic data are collected, a provisional treatment plan can be established. Also an initial evaluation of prognosis for each tooth is determined. However, this part and the treatment plan will be reviewed later after the non-surgical phase of therapy.

The right approach in treatment includes 3 phases:

1. Elimination/modification of risk factors:

Although genetic susceptibility cannot necessarily be modified or changed, all other above-mentioned risk factors can be modified and controlled. This makes the first step in the treatment of periodontal disease and becomes part of the discussion with your periodontist at an early stage of treatment.

2. Mechanical debridement:

a) Non-surgical treatment

This phase involved mechanical removal of plaque bacteria. The role of periodontist/hygienist is to access the depth of periodontal pockets, where bacteria are growing in, and remove them. The treatment includes using ultrasonic and hand scalers. Since deep periodontal pockets in are being accessed during the treatment, this procedure is always done under local anaesthesia so that you feel no pain. However, you will still hear the scratching noises during deep scaling.

Depending on the number of teeth affected, the procedure is carried in between 2-4 appointments.

b) Review:

About 2 months after the completion of debridement phase, the periodontal examination is repeated. All the periodontal pockets are re-measured. The prognosis of each tooth is re-evaluated. In some cases, especially when advanced periodontitis is to be treated, a mini-review appointment is scheduled before the final re-measurements to assess the overall healing, oral hygiene. Also a general whole mouth polishing of teeth is carried out in this appointment.

Roughly 2 months after completion of non-surgical therapy and following comprehensive review of the periodontal state of all teeth a decision is made to whether surgical treatment would be required to eradicate the disease.

c) Surgical treatment:

As a general rule surgical therapy is not always indicated for periodontitis. However, very deep periodontal pockets would require open access in order to completely clean the root surfaces off plaque bacteria. While non-surgical treatment could be considered “blind debridement” most individuals respond well to this treatment. However, if recurrent infection (deep pocket) is present despite a good oral hygiene, after non-surgical therapy, surgical treatment would provide direct access to the infected sites.

Hence, the decision to do surgical therapy is usually left until individual’s response to non-surgical therapy is evaluated. The advantage of this approach is fewer sites would require surgery when an appropriate non-surgical treatment is carried out first and any tentative surgical treatment would be confined to a small region where recurrent or non-responsive sites are identified.

3. Maintenance treatment:

This should be considered the most important phase of periodontal treatment. Since most individuals with periodontitis bear some genetic susceptibility, without a regular supportive therapy, periodontitis would tend to recur over time. This involves seeing your periodontist and hygienist besides your general dentist at regular intervals. At each visit, your general medical state and risk factors are reviewed, the general and specific state of your gums will be assessed, your oral hygiene is tested and a professional scaling will be carried out.

The frequency of these maintenance appointments can vary between 2 to 6 appointments per year for each individual, depending on their medical and periodontal risk factors. For a patient with good oral hygiene, usually these appointments should become less frequent after the first year. Ultimately, the goal would be to have only 2 appointments per year for supportive periodontal therapy after the first year.

In the long run, only a well planned, customised and regularly scheduled supportive periodontal therapy can guarantee a stable treatment outcome.