Periodontal Disease

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of periodontal disease

Alternative Names

Gingivitis

Prevention

Healthy habits and good oral hygiene are critical in preventing gum disease. Regular and effective tooth brushing and mouth washing, however, are effective only above and slightly below the gum line. Once periodontal disease develops more intensive treatments are needed.

Dietary Changes

It is important to reduce both the quantity, and in particular the frequency, of sugar intake. Snacks and drinks should be free of sugars (other than natural sugars found in fruits and vegetables); sugar-containing foods should be consumed with meals and ideally followed by brushing. Since fruit juices can also cause tooth erosion in children, milk and water use should be emphasized.

Quitting Smoking

Smoking may play a significant role in over half the cases of chronic periodontal disease, according to research published in 2000. For smokers, quitting is one of the most important steps toward regaining periodontal health.

Fluoride Treatments

Fluoride treatment in children has helped to account for the decline in periodontal disease in adults. Because fluoride prevents decay, back molars, which keep the teeth in place, are spared, and are thus less vulnerable to bacteria. Even before teeth first erupt, babies' gums should be wiped clean with a bit of gauze bearing a dab of fluoride toothpaste. Supplementation with fluoride tablets or drops may be recommended for children 6 months or older who drink unfluoridated water or who are at risk for dental problems. A prescription from the child's pediatrician or dentist is required.

Some dentists recommend a fluoride gel for adult patients who are still at risk for tooth decay or sensitivity, but extra fluoride is generally not necessary for adults who use fluoride toothpaste.

Dental Examinations

Periodontitis is a silent disease; individuals rarely experience pain and may not be aware of the problem. A periodontal examination by a general dentist once or twice a year should reveal any incipient or progressive problems. A full mouth series of X-rays is advised every two to three years. This will alert the dentist to early bone loss and other disorders of the oral cavity.

Dentists now often perform Periodontal Screening and Recording (PSR) using a probe to measure gum pockets. This procedure used to be performed only by periodontists but is now encouraged as part of a regular dental examination. The dentist will identify any areas where deep pocketing has occurred, where the health of the gingiva appears compromised, and where there is undue mobility of teeth. It is the general dentist's responsibility to identify periodontal disease and inform the patient. If the condition is severe, the dentist may want to refer the patient to a periodontist.

Daily Dental Care

Correct tooth brushing, mouth cleansing, and flossing should be everyone's defense against periodontal disease. (It should be noted that good hygiene is probably not sufficient to prevent periodontal disease in many people who are susceptible to this autoimmune condition. Regular visits to a dentist are extremely important in high-risk individuals.)

Brushing Guidelines. The following are some recommendations for brushing:

• First use a dry brush. One study reported that when people brushed their teeth without toothpaste first, using a soft dry brush, their plaque deposits were reduced by 67% and gum bleeding dropped by 50%.
• No brush of any size, shape, or gimmick is effective if it is incorrectly positioned in the mouth. Place the brush where the gum meets the tooth, with bristles resting along each tooth at a 45-degree angle.
• Begin by dry brushing the inside the bottom row of teeth, then the inner top teeth, and last the outer surfaces.
• Wiggle the brush back and forth so the bristles extend under the gum line.
• Scrub the broad, biting surfaces of the back teeth.
• Dry brushing should take about a minute and a half.
• A paste is then applied and the teeth should be rebrushed in the same way.
• The tongue should be scrubbed for a total of about 30 seconds. A tongue scraper used with an anti-bacterial mouthwash (such as Listerine) is more effective than a toothbrush in removing bacteria.
• One should rinse the toothbrush thoroughly and then tap it on the edge of the sink at least five times to get rid of debris. (It should be noted that detergents in toothpaste that remain on the brush may help prevent bacterial contamination of the brush.)
• Flossing should finish the process. A mouthwash may also be used.

If brushing after each meal is not possible, rinsing the mouth with water after eating can reduce bacteria by 30%.

Toothbrushes. A vast assortment of brushes of varying sizes and shapes are available, and each manufacturer makes its claim for the benefits of a particular brush. People should look for the American Dental Association (ADA) seal on both electric and regular brushes.

In spite of the wide variety of nonelectric toothbrushes, both in shape and bristle design, a study of eight brands found no significant differences in effectiveness among them.

Electric toothbrushes, particularly those with a stationary grip and revolving tufts of bristles, can be advantageous for some people with physical disabilities. They include the following:

• Electric toothbrushes with heads that move back and forth up to 4,200 times a minute remove significantly more plaque than ordinary brushes. Brands are Bausch & Lomb's Interplak, Braun's Oral-B Plaque Remover, and Water Pik's Plaque Control.
• Even more high-tech brushes are now available that use sound waves to remove plaque. Brands include Sonicare, SenSonic, Soniplak, and UltraSonex.

In general, studies have reported no differences between electric and manual toothbrushes in their ability to remove plaque. (One study showed considerable improvement in groups using sonic toothbrushes, particularly in those with moderate periodontal disease.) Experts recommend, however, that if a regular toothbrush works, then it isn't necessary to buy an expensive electric one.

For individuals with average dexterity, a four- or five-rowed, soft, nylon-bristled toothbrush is sufficient. The most important factor in buying any toothbrush, electric or manual, is to choose one with a soft head. Soft bristles get into crevices easier and do not irritate the gums. One study found that those who used a soft toothbrush had 4.7% of exposed tooth below the gum line compared to 9.4% with hard brush users. A useful toothbrush called Alert has been developed that flashes a red light when too much pressure is being placed on the gums.

Experts generally recommend replacing toothbrushes each month Not only do they become breeding grounds for bacteria, but the worn bristles are less effective at removing plaque. (One study reported that a three-month old toothbrush was as effective as a new one at removing plaque, although it's probably wise not to go longer than three months.)

Toothpaste. The object of a good toothpaste is to reduce the development of plaque and eliminate periodontal causing microorganisms without destroying the organisms that are important for a healthy mouth. All brands should show ADA approval. Even a good toothpaste, however, cannot be delivered past 3 mm below the gum line, where periodontitis develops.

Toothpastes are a combination of abrasives, binders, colors, detergents, flavors, fluoride, humectants, preservatives, and artificial sweeteners. Highly abrasive toothpastes should not be used, especially by individuals whose gums have receded.

Active agents contained in toothpastes may include the following:

• Fluoride. Most commercial toothpastes contain fluoride, which both strengthens tooth enamel against decay and enhances remineralization of the enamel. Fluoride also inhibits acid-loving bacteria, especially after eating, when the mouth is more acidic. Some argue that this antibacterial activity may help control plaque.
• Triclosan. Colgate's Total toothpastes contain a fluoride and triclosan, an extremely potent anti-bacterial agent. The toothpaste also contains an agent that keeps triclosan active in the mouth for 12 hours. Total is the first FDA approved toothpaste for the prevention of tooth decay, gingivitis, and plaque. Still the benefits of this toothpaste are limited and are most pronounced in people with severe gingivitis. Of some concern are studies reporting development of bacteria resistant to triclosan. More studies are needed. Anyone with periodontal disease should not rely on this product alone.
• Metal salts. Metal salts, such as stannous and zinc, serve mostly as anti-bacterial agents in toothpastes. Stannous fluoride gel toothpastes do not reduce plaque, however, even though they have some effect against the bacteria that cause it, but slightly reduce gingivitis. Such toothpastes can cause staining that requires professional cleaning. Crest Plus Gum Care contains a stabilized form of stannous fluoride. Studies conducted by the manufacturer suggest that is has antibacterial activity and that it might be more effective than Colgate's Total in reducing gingivitis and bleeding.
• Enzymes called glucanases.
• Plant extracts (such as sanguinarine). Viadent toothpaste and mouthwash contain an anti-bacterial herbal extract called sanguinarine. The two products provide minimal results when used individually, but if the mouthwash and toothpaste are used together they have produced plaque reductions of 17% to 42% and reductions of gingivitis of 18% to 57% during a six-month period. It should be noted that some questions have been raised about the safety of prolonged use of sanguinarine.
• Peroxide and baking soda. Toothpastes with these ingredients (Mentadent) appear to offer no benefits against gum disease. In fact, tooth whiteners are usually made with carbamide peroxide, which breaks down into hydrogen peroxide, and brushing with hydrogen peroxide is not recommended. Studies have indicated that overuse of this solution may actually damage cells and soften tooth surfaces. Of concern was a recent animal study suggesting a link between hydrogen peroxide and precancerous cell changes in the mouth. Researchers retracted the findings because of these implications and pointed out that no cancer lesions have developed in any animals since the study began. People who smoke or drink alcohol, however, might avoid products with hydrogen peroxide in them.
• Antibacterial sugar substitutes (e.g., xylitol), and detergents (delmopinal).

Mouthwashes. The value of many mouthwashes is highly controversial. Many have only temporary antibacterial value. Some can even harm the mucus membrane and they can be dangerous to children who drink them. Those that are considered plaque fighters are chlorhexidine and Listerine, which is available over the counter.

• Chlorhexidine (Peridex or PerioGard) is available by prescription only. It reduces plaque by 55% and gingivitis by 30% to 45%. Patients should rinse for one minute twice daily. They should wait at least 30 minutes between brushing and rinsing since chlorhexidine can be inactivated by certain compounds in toothpastes. It has a bitter taste. It also binds to tannins, which are in tea, coffee, and red wine, so it has tendency to stain teeth in people who drink these beverages.
• Listerine is composed of essential oils and is available over the counter. It reduces plaque and gingivitis, when used for 30 seconds twice a day. It leaves a burning sensation in the mouth that most people better tolerate after a few days of use. Some people might object to or have concerns about the high alcohol content in the standard version. Other forms of Listerine that have a different taste and lower alcohol content retain the same active ingredients and appear to be as effective. The usual regimen is to rinse twice a day. Generic equivalents are available. (Listerine PocketPaks, which are strips that dissolve on the tongue, have no proven effects on plague and gingivitis.)
• Mouthwashes containing cetylpyridinium (Scope, Cepacol) have moderate effect on plaque, but only if they are used an hour after brushing. None are as effective as Listerine or chlorhexidine, but they may still have some value for people who cannot tolerate the other mouthwashes.
• Mouthwashes containing stannous fluoride and amine fluoride (Meridol) is moderately effective, but also not as effective as effective as Listerine or chlorhexidine.
• Fluoride mouthwashes (Reach Act) are helpful in preventing cavities.
• Plax offers only modest protection against plaque and gingivitis. Even Advanced Formula Plax, which may show a minor reduction in plaque levels, does not seem to provide any protection against periodontal disease.
• Some chemicals are being investigated for their use in mouthwashes. For example, one mouthwash (HistaWash) is produced from histatins, peptides found in saliva. Studies are reporting that it protect against gum disease and prevents other infections in the mouth as well.