Dentists and hygienists evaluate patients for the presence of gum infections by using a periodontal probe. The probe is a calibrated instrument that measures the space between the gum and tooth. In healthy patients, there is little or no space between the gum and tooth, typically less than 3mm (millimeters). If there is any bleeding, it is an indication of infection. If the space between the gum and tooth, called a periodontal pocket, increases beyond about 4mm, that is an indication of a periodontal infection. Pockets can be anywhere from 3 to 15 millimeters and larger. Typically, the deeper the pocket, the more severe the periodontal disease.
The mildest form of periodontal disease is called gingivitis. Gingivitis is characterized by red, puffy gums that bleed easily, particularly during hard tooth brushing or flossing, but with little or no discomfort. Some people with gingivitis will notice a bad taste in the mouth and bad breath. Typically, patients with gingivitis will not have pockets greater than 5mm. The primary cause of gingivitis is dental plaque — which is a sticky, colorless film containing bacteria, salivary proteins and food debris.
If discovered early, gingivitis is easily treated and reversed. A thorough cleaning by a dentist or hygienist combined with good oral home care (regular brushing and flossing) will usually eliminate the problem in about two weeks. Patients that have been treated for gingivitis typically should see a dentist or hygienist for professional tooth cleaning about three to four times per year to prevent reoccurrence of the problems. However, if left untreated, gingivitis can, in some patients, progress to a much more serious form periodontitis.
The transition from gingivitis to periodontitis typically begins when plaque is left undisturbed long enough to harden and calcify into calculus, or as it is sometimes called, tartar. Calculus commonly forms and can be seen behind the lower front teeth and on the upper molars on the cheek side. However, it can and does form anywhere in the mouth. Calculus is very hard and requires professional cleaning to remove. Think of calculus like barnacles on the teeth that tend to attract and promote bacteria that is harmful to the gums and underlying bone. Often, the calculus is invisible to the patient because it is attached to the tooth roots below the gum.
The bone loss process associated with periodontitis is surprisingly painless. The first signs of periodontitis are similar to those of gingivitis: bleeding, swollen gums, pus formation, bad taste, and bad breath. When the disease has gone untreated for a while, and there is sufficient bone loss, the patient may sometimes notice that his or her teeth are loose and spaces have begun to form between the teeth. Sometimes patients begin to clench or grind their teeth. The additional force of clenching can further aggravate periodontal disease, stimulate more bone loss, and result in more rapid deterioration.
The rate of bone loss can vary from rapid loss over months to slow progression over years. The amount and degree of bone loss depends on a variety of factors such as the patient’s resistance to infection, genetics, cigarette smoking, specific types of bacteria, oral home care, and intervention by a dental professional.
Treatment for periodontitis is matched to the severity of the disease. With more established periodontal infections, the calculus forms beneath the gumline requiring the patient’s teeth and gums to be anesthetized with a local anesthetic in order to remove it. This procedure is called scaling and root planing.
All of the periodontal procedures mentioned above are considered nonsurgical treatments. It should be understood that to stop periodontal disease, it is essential to remove the calculus from the teeth. This cannot be done with drugs, baking soda, toothpaste, or nutritional supplements. Currently, the only method proven to rejuvenate diseased, infected root surfaces involves calculus removal with specialized instruments. When a patient has very deep pockets (beyond 5 millimeters), nonsurgical root planing cannot reach the accumulated calculus. In these cases, other procedures, often including minor gum surgery, are required.
To allow for complete removal of calculus in deep pockets, the patient’s gums and teeth are anesthetized. The gums are elevated so the periodontist can see and treat the entire root surface and surrounding areas. Sometimes, the underlying bone is reshaped and smoothed to allow the gum to heal and reattach properly to the tooth without forming new pockets. In some circumstances, the lost bone can be regenerated to strengthen the support for the teeth. This is an exciting and rapidly improving possibility in our field, particularly with the activity in the biotechnology industry. After final healing, the treated areas can be more easily cleaned by the patient and hygienist to prevent future bone loss.
In the United States, periodontal disease is extremely common in adults. However, it is very treatable in all stages. Just like most diseases, early detection and appropriate treatment can prevent periodontal disease and the resulting bone loss. So see your dentist regularly, practice good oral hygiene at home, and you can look forward to healthy teeth and an attractive smile that will last a lifetime.