Parodontology

Gingivitis

Diseased gums are easy to spot—they're red, they're inflamed. If yours are red around the area where your tooth meets the gum—if that area is sensitive to the touch, or if it bleeds when you brush or floss — you've most likely got some amount of gingivitis.

Here's how it happens: Bleeding, sensitive gums are usually signs that plaque is hiding somewhere in the area, probably within the gum's pockets, that deepened furrow between the neck of the tooth and the gum. A pocket is a sulcus that's become too deep, and the deeper the space, the more difficult it is for both you and even your dental expert to reach. So, since cleaning it is impossible, plaque can pile up with no disturbances from a toothbrush, floss or any at-home tool. After a while, the plaque hardens, and it must be removed.

This plaque is a different kind of plaque from the one that de-mineralizes a tooth. This plaque is formed from anaerobic bacteria. When these bacteria accumulate around the gum area on the root surface, the gum becomes inflamed, sort of like a splinter that's lodged itself under skin. This is another example of an inflammatory response. And this is a crucial time. If you don't take care of this inflammation, you'll soon find yourself crossing over from gingivitis to the much darker world of periodontal disease and bone loss.

Periodontal Disease

While gum disease is very visible, periodontal disease is not. It’s elusive because it is usually painless at the beginning, but can worsen and become quite serious without you even realizing it. Like gum inflammation, bone destruction can be intercepted by your dentist during your regular hygiene visits. If the disease hasn’t reached severe levels, a treatment called Phase One, can be effective in stopping bone destruction.

Phase One

Phase One involves a lot of scraping, digging and smoothing of the diseased root surface. Called scaling and root planing, it's a non-surgical treatment that involves removing the offending substance above and below the gum.

Scaling removes the deposits of tartar above and below the gum. A scaler looks like a pen with a curved end, making it easier for the hygienist to get into the hard-to-reach spots, such as the pockets. Scaling also removes any diseased bacteria (called bacterial endotoxins) that may have gotten under the gum and stuck to the root surfaces. After scaling, most dootors go over the area again with an ultrasonic vibrating tool, which acts like a mini sand blaster that literally blasts the more accessible hardened deposits off the teeth.

Root planing goes after the bacterial endotoxins under the gum and removes any diseased cementum (that cell layer covering the outside of the root that keeps the tooth attached) that might be there as well. Root planing smoothes the area the same way a carpenter buffs away roughness in a piece of wood.

If the gum tissue is also inflamed, the hygienist or dentist will do something called curettage. Curettage removes the inner lining of the inflamed tissue, which then allows the new tissue to heal against the newly cleaned, “buffed” root surface.

Once cleaned out, the gum tissue should shrink and tighten around the newly cleaned root surface, eliminating much of the pocket. Once the tissue is healed, the pocket then has to be monitored to see if phase one was successful.

Before we sends you home to care for your tender healing gums, we may also insert a chemotherapeutic agent into the area, either in a chip that she'll stick under your gum flap or a gel, which she'll insert with a syringe. They usually contain an antibiotic, such as doxycycline or minocycline, which kills any remaining bacteria, speeds healing time and helps the pocket shrink faster. They're time-released and continue to work for about ten days. Many doctors also like to give patients an anti-bacterial rinse, called Hexoral (lab name: chlorhexidine gluconate). It stains teeth, so you need to over compensate with an at-home stain removing, whitening product during the entire time that you use it.

Phase Two: Perio-Flap Surgery

If the scaling and root planing and curettage aren't enough, the pockets have to then be surgically removed. Flap surgery removes the excess soft tissue and shapes the underlying bone so that the pocket will heal back to a less deep, healthy sulcus. Afterwards, the gums get sutured back into place, so the tissue fits tightly around the tooth again.

Flap surgery allows the docotors to visualize the bone, so he can then either take away bone to remove the defect (which is the pocket) or graft new bone into the defect— in effect, adding to it. It all depends on the anatomy of the particular defect.

before

after

Bone and Tissue Grafting

Like skin grafting, bone and tissue grafting encourages regrowth. The technique is called tissue regeneration, it involves a small piece of meshed fabric that gets placed between the bone and gum tissue. Tissue regeneration also helps prevent the gum tissue from growing into the area where the bone should be growing, so both can grow back in peace.

Other Causes of Gum Conditions

Pregnancy:

A challenged immune system:

Your gums might bleed more when your immune system is burdened, such as when you have a cold. That's because the mouth picks up viruses more easily when the immune system is down, causing gums to be more swollen and sensitive.

Stress:

While our bodies are used to the usual expected levels of stress, excessive amounts of it can be too much, and the body’s stress can overload the mouth. Finding alternative ways to alleviate stress should return the gums to normal.

Heredity:

Researchers discovered that changes in a gene for the enzyme cathepsin-C are responsible for a condition known as Papillon-Lefevre syndrome. Along with scaly and warty skin thickening and an erosion of the soft tissues that line the mouth and connecting gums, another symptom is inflamed gums.

Juvenile Periodontosis:

As its name suggests, juvenile periodontosis affects young people, specifically those who have a virulent type of bacteria that's hard to stop and treat successfully. In many cases, these patients can lose their first molars and front teeth if aggressive periodontal therapy isn't performed. Fortunately, there are microbiological techniques that can isolate the bacteria to make this disease easier for periodontists to diagnose and treat. Treatment involves a microbiological and surgical approach, which along with meticulous home care, often cures this condition.

NOTE:

Occasional bleeding is common in gums, especially if you're just starting out on a disciplined flossing regime. But the bleeding should dissipate within a week. If it doesn't, and you've already had any plaque properly removed by your dental hygienist, it is urgent that you see a dentist. Sometimes bleeding gums are signals of something much more serious, such as a blood disorder or even leukemia. When the puffiness isn't related to a plaque issue, a blood test should be done to determine whether there is another health issue.

DOs and DONTs for Healthy Gums

• Do brush and floss teeth at least twice a day. Carry a hygienically protected toothbrush (in a toothbrush case) and floss with you.
• Don't go overboard with sugared and fatty foods.
• Do take calcium and vitamin C—both promote healthy gums. There are new supplements that are being introduced to the market that will help soft tissue healing and improved health.
• Don't stress out. Your gums are just one in a long list of parts of your body that suffer from too much stress.
• Do get your teeth professionally cleaned at least twice a year— more if your gums look inflamed or if you've had significant dentistry in the past. (Restorative dentistry is especially prone to breaking down because the artificial surface is like a magnet to plaque, much more so than a natural surface.)
• Do eat foods high in fiber, such as fruits and vegetables, which fortify both the hard and soft tissues of the mouth.

Brushing and Flossing

BRUSHING & FLOSSING: Sure, you brush your teeth twice a day. You may even brush for the required two minutes. But has anyone ever taught you exactly how to brush?

IT'S ALL IN THE WRIST: To begin, hold the toothbrush at a 45- degree angle to the tooth, so that the bristles gently move between the spaces and between the gum and the tooth in a gentle sideways motion. Next, sweep the brush up, then down. This movement will move the bacteria away from the critical area around the gum.

COVER ALL BASES: It's imperative that you work on all surfaces, including the cheek surface by the upper teeth, the inner surface on the upper teeth and the same for the bottom ones.

CHILL OUT: Don't take your frustrations out on your teeth. If you find your gums reddening after you brush, you're brushing too hard.

TIME FACTOR: Brushing should take at least two minutes--that's critical to keep everything in there healthy and plaque-free. Count it out or set a timer—just don't stop before the two-minute mark.

THREE TIMES A BRUSHER: Ideally, you should brush your teeth when you wake up, at bedtime and after every meal. But, three times is a pretty good average to keep.

A LITTLE GOES A LONG WAY: Although toothpaste commercials show actors squirting huge swirls of toothpaste onto their toothbrushes, you really don't need more than a pea-sized amount to do the job. More than that, and you're just wasting it. Kids need even less-about the size of the tip of a match, in fact.

BABY BRUSHING: Healthy first teeth also contribute to proper alignment of the jawbones and eventual bite. As soon as that first baby tooth appears, a child's teeth (or tooth) must be brushed twice a day. In the beginning, you can wrap a piece of gauze around your finger and rub it across the teeth; no toothpaste is necessary until around the time of a child's third birthday. Before using a toothpaste that contains fluoride, check with your dentist. If your child is already getting fluoride supplements or drinks a lot of fluoridated water, don't use fluoridated toothpaste. If your dentist recommends fluoride toothpaste, only use a match-tip sized dab. Kids like to swallow toothpaste.

FLOSSING PROMOTES TOOTH LONGEVITY: What your brushing can't reach, flossing can. It removes food particles and plaque that elude your toothbrush since the little stuff often hides behind and between the teeth. In fact, dentists consider it even more crucial in the prevention of tooth decay and periodontal disease than brushing. But just like brushing incorrectly, flossing incorrectly can do more harm than good. Make sure you're doing it right.

FLOSSING CORRECTLY:

• Rip off about 18 inches of the floss and wrap it around your pointer or middle finger. Wind the remaining floss around the same finger of the opposite hand, so you've got about seven inches between each hand.
• Pick a spot to start and make that your designated starting place, so you'll get into the routine of it. Most people pick the space between their two centrals or the molar farthest in the back.
• Direct the floss up between the teeth, and once it's in place, hold it taut. Use a sawing motion as you glide it between the teeth.
• Next, you need to get the floss under the soft tissue, so move it under there in a C-shaped fashion, gliding it back and forth. This will remove the plaque from those critical spaces between your teeth without doing any damage to that sometimes-sensitive soft tissue. If you hold it instead in a vertical “U” position and pull it up into the soft tissue you can actually do damage.
• Should your floss get stuck, don't tug on it to get it out. Just slide it out toward you from between the teeth, then reposition it and try again. Repeat the same process with each of your teeth.

NO EXCUSES:

If the idea of flossing just bores you and you'd rather skip it, I bet we can change your attitude.
Run the floss through a few nooks between your teeth.
Now smell it.
Nice, huh?

FLOSS FOR YOUR LIFE:

There is a direct link between flossing and the prevention of heart disease. Countless studies have proven that poor dental cleaning and a lack of flossing can lead to heart disease. Researchers recently found that diseased gums released higher levels of bacterial pro-inflammatory components into the bloodstream. These components can find their way to other organs, including the heart, and increase their risk of failure. There is clear evidence that periodontal disease is implicated in promoting the formation of lesions in blood vessel walls. This translates into an increased risk for major cardiovascular and cerebrovascular (stroke) events.

Cleanings

Any problems your smile has, or any nascent difficulties, will be caught early by your hygienist. Get a professional cleaning from your hygienist two to three times a year, more often if you've had a sizeable amount of dental work done. She'll find the plaque that you've missed, she'll scrape off the tartar that your brush and floss can't, and in doing this she'll help keep cavities and other complications away. Professional cleanings are like insurance for your smile. The investment can save you thousands of dollars in the long run, as smaller problems diagnosed along the way can prevent much bigger problems from occurring later on.

The purpose of a professional cleaning is not only to remove the tartar above the gum and bacteria-induced deposits below the gum as well as to polish off extrinsic stains from teeth, but to also get a comprehensive lesson in oral care. As she goes through each step of the cleaning process, your hygienist should explain what she's doing, why she's doing it and why your teeth may be sensitive or may start bleeding. An adjustable mirror or an intra-oral camera (a more high-tech version of the mirror) is attached to the examining light, which allows you to watch your hygienist at work and understand what she's talking about. It's one thing to hear your hygienist say, “You really need to pay more attention to your back molars,” but it's quite another thing to actually see her working on those back molars and fully comprehend what that work involves so you can replicate it at home. Finally, based on the condition she finds your mouth in, she should give you an updated primer on the certain oral care techniques you need to incorporate into your home care routine.