Part of my new patient experience for a newcomer to my practice is to ask some basic questions about what they know and don’t know about their oral health. One of my questions to any new patients is, “What’s your understanding of your current gum health?” Most patients reply, “I’m not sure” but may remember something about “bleeding gums” or “numbers” that the hygienist recorded in their chart. Some are well-educated on their oral health, but most require a more in-depth conversation. It’s clear to me that dentists, in general, haven’t done a good job educating our patients about how we measure and monitor gum disease and give patients a basic understanding of what gum disease is. Here’s a brief explanation:
In essence, gum disease, (also referred to clinically as “periodontal disease”), is an inflammatory condition in the gum tissue that causes the gum tissue and the underlying bone to become infected, and ultimately causes the bone to be destroyed around the tooth roots. The beginning stage of gum disease—which only affects the gum tissue itself—is called “gingivitis.” Gingivitis means swelling or inflammation of the gums. The telltale symptoms of gingivitis are tender, red, swollen gum tissue that bleeds easily upon brushing or flossing of teeth. If your gums bleed, you have gingivitis.
Most of the population has experienced gingivitis at some time or another. Gingivitis is exacerbated by bacterial “plaque” accumulation at or underneath the gum tissue. If you’ve skipped brushing or flossing for a day or two, you’ve probably experienced gingivitis. By the way, plaque is a natural film of both dead and live bacteria that continuously accumulate on the teeth. Research has found that what was thought to be a simple film of bacteria is actually a complex ecosystem of bacteria called “biofilm.” (Click here for more information on biofilm). The longer you go without cleaning your teeth, the thicker this plaque layer/biofilm becomes, and the worse the gingivitis gets. Fortunately, gingivitis is completely reversible with a few days of improved oral hygiene. You’ll know when your gums are starting to heal because your gums will get sore and the teeth will hurt to bite on. This is a common reason for people to abandon their hygiene efforts because they assume they must be doing damage to their gums, when in fact the discomfort is a sign that the gums have started the healing process. This is much like exercising for the first time after a long period with no exercise; muscles become sore when they begin the process of repairing and getting stronger. In a similar fashion, the collar of the gum tissue surrounding the teeth becomes tender during the healing process for two or three days. After the healing process is complete, the discomfort quickly dissipates and the bleeding during brushing and flossing disappears.
This first stage of gums disease, called gingivitis, is a reversible process and can be eliminated with good oral hygiene; brushing two times per day and using floss, toothpicks, or some other means of cleaning between the teeth at least once per day. However, if gingivitis is left untreated it can lead to permanent damage to the bone that holds the tooth roots securely in the jawbone. This happens when the body’s immune system can’t effectively fight the bacteria causing gingivitis. It’s a complex chemical process that takes place but we can simplify the process by saying that the bacteria produce chemical compounds that weaken the stretchy resilient fibers in the gums called “collagen fibers.” These resilient fibers within the gum tissue normally help form a barrier between the oral environment and the bone surrounding the roots. Essentially, the gums form a tight seal around the roots of the teeth when the gums are healthy, but when the gums are inflamed, bacteria form damaging chemical compounds that destroy the collagen fibers in this gum tissue. It’s like having the rubber seal break on a food-canning jar; once the seal is broken, bacteria can enter the jar and spoil the food. Like the gum tissue, the bone also contains collagen; therefore the same damaging chemical compounds also begin causing the destruction of the bone. This bone destruction can sometimes be repaired with very specialized gum surgery but is generally not a reversible process. Another very important point is that the whole process of periodontal bone destruction is completely painless; we typically don’t know it’s happening unless it is diagnosed in a dental office.
The evidence of this bone destruction can be easily detected by looking at dental X-rays or by measuring the distance between the edge of the gum collar around the tooth to where the gums attach to the root surface. This distance is referred to as the “sulcus depth,” and in healthy gum tissue should measure between 1 and 4mm deep. These measurements are the numbers most people remember the dentist or hygienist recording during an examination or cleaning appointment. The severity of the gum disease (bone destruction) is graded from mild to advanced based on the sulcus depths, much like cancer is graded from stage one to stage four. Sulci that measure five or more millimeters are called “pockets.” The location of and the depth of the sulci give the hygienist a virtual topographic map of the bone levels called a “periodontal chart” and allow the hygienist to clean and monitor these areas of the mouth affected by gum disease.
These diseased sites in the mouth require cleaning beneath the gums, (within the pocket), as opposed to the hygienist cleaning or polishing the enamel at and above the gum line. This type of cleaning is referred to as “periodontal therapy” and requires different instruments used in a more intricate way than for someone with healthy gums or gingivitis only. Thus, cleanings for people with gum disease take longer and generally cost more money than cleanings for people with healthy gums. The frequency of the cleanings is the other primary difference between cleanings for people with periodontal disease and those with healthy gums. Typically, people with healthy gums receive cleanings every six months, whereas those with periodontal disease receive periodontal therapy on a three to four-month period for their entire life. If periodontal disease were curable, this wouldn’t be necessary. However, due to the complex biologic etiology of the disease, consistent and frequent therapy along with diligent home care are the only defenses we currently have.
To understand this treatment protocol in terms of an analogy in the natural world, think of the bacteria that cause periodontal disease like an ant colony. If you’ve ever kicked an ant hill in the woods, you’ve probably observed the colony of ants feverishly rebuilding their home after it’s been knocked down to ground level. The ants want to rebuild their home as quickly as possible and this process would become increasingly more difficult to do if the person were to kick the anthill over and over again. Obviously, the more frequently the anthill is kicked, the more difficult it is for the ants to rebuild their colony. Think of the bacteria living beneath your gum line as an ant colony. The more frequently that colony is disturbed by the hygienist cleaning, the harder it is for the bacteria to replicate, thus reducing their damaging effect on the gums and the surrounding bone.
In summary, gum disease is a progressive disease, starting with gingivitis and progressing into periodontal bone loss. Gingivitis is the first stage of gum disease, and is reversible, while the more advanced stages of gum disease affect both the gum and the underlying bone. The bone loss that occurs due to more advanced stages of gum disease are sometimes repairable with surgical procedures but generally speaking is non-reversible.