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Article: How Gum Disease Works DR. JERRY GORDON
Gum disease is caused by plaque, a bacterial film that continuously forms around the teeth. Plaque is responsible for sore, puffy and bleeding gums, bad breath, loose teeth, and tooth loss.

Gum disease is caused by plaque, a bacterial film that continuously forms around the teeth. Plaque is responsible for sore, puffy and bleeding gums, bad breath, loose teeth, and tooth loss.

Periodontal or gum disease is a bacterial infection affecting an estimated 56 million Americans, and is about as widespread as the common cold!

How do the gums become infected?

Gum disease is caused by plaque, a bacterial film that continuously forms around the teeth. Plaque is responsible for sore, puffy and bleeding gums, bad breath, loose teeth, and tooth loss. It is the main reason that people lose their teeth. Until recently, the prospect of losing one's teeth was the main thing a person suffering from gum disease had to worry about. Now, a building body of research has discovered possible links between gum disease and heart disease, heart attack, stroke, respiratory problems, and low birth-weight babies.

Bacterial plaque infects the gums (gingival tissues) when our brushing and flossing does not remove it. Plaque is composed of bacteria that can cause destruction to the gum, connective tissue, and bone that joins our teeth to the jaw. In the healthy mouth, there are hundreds of types of bacteria that naturally live there. Like most bacteria, they have names that defy pronunciation. Most of the inhabitants of our mouth are harmless members of the Streptococcus and Actinomyces species, and are largely gram-positive bacteria. In a patient with gum disease, we see increasing numbers of bacteria, including spirochetes, Bacteroides gingivalis and intermedius, Fusobacterium nucleatum, Eikenella corrodens, Wolinella recta, and others. These bacteria are mainly gram-negative and anaerobic. What this means is that many of the bacteria associated with gum disease can survive without oxygen, which makes sense because they are wreaking havoc with our jawbone deep under the gum-line.

Gum disease causes bone loss because these harmful bacteria in our mouths force our bodies to defend against them.

The chain reaction that follows goes something like this:

  • The bacteria produce toxins and enzymes under the gum-line, causing a chronic infection.
  • This infection causes the immune system to kick in. The body releases chemical substances called cytokines.
  • The cytokines in turn cause a cascade of reactions within the gum and surrounding tissue.
  • One of the substances released is a family of enzymes known as matrix metalloproteinases (MMPs).
  • One of the MMPs is collagenase, an enzyme that breaks down gum and bone.
  • The loss of gum and bone causes the formation of a periodontal pocket. The dentist can measure these pockets with a small probe to determine the extent of the disease.

The cause and effect of gum disease

These pockets are very bad for your teeth, and if left untreated they eventually cause your affected teeth to fall out.

How Does a Dentist Diagnose Gum Disease?

Gum disease is diagnosed by both clinical (hands-on) and radiographic (x-ray) examinations. During a clinical exam, the dentist uses an instrument called a probe to measure the gums. A probe is like a small metal ruler using millimeter increments. The dentist probes the gum around the tooth and takes a series of measurements (usually six). If the gum bleeds when the dentist gently probes it, this often indicates the presence of gum disease.

The probe

Visual examination of a person with gum disease may reveal red, puffy, swollen or receding gums. Large deposits of plaque and calculus (tartar) are often visible in people with gum disease, especially those who have not seen a dentist in years. The teeth may be mobile, that is, the dentist is able to move the tooth a millimeter or two within the socket. A healthy tooth will not budge! The dentist may detect pus when putting gentle pressure on a puffy area of the gums. Foul mouth odor (bad breath) is also commonly associated gum disease.

Red and puffy gums typical of gum disease

X-rays are also helpful in the diagnosis of gum disease. The dentist will usually require a full mouth series of x-rays (18 films) to document the approximate level of the bone around the teeth. (Dentists often take a full mouth series of x-rays even if the patient does not have gum disease to serve as a baseline for future use.) Bone loss appearing on the x-ray can be uniform (horizontal bone loss), uneven (vertical bone loss), or a combination of both.

X-ray of the normal bone level

X-ray of the bone loss caused by gum disease

There are several stages of gum disease. In most cases, gum disease begins as gingivitis, an inflammation of the gums. People with gingivitis have red, puffy gums that often bleed after brushing their teeth. They may wake up and have blood on their pillow in the morning. Ironically, some people whose gums bleed after brushing decide to brush less or avoid brushing out of fear- this avoidance of brushing often leads to more advanced gum disease.

The first non-reversible stage of the disease is early periodontal disease. Early periodontal disease is confirmed when the dentist can probe a periodontal pocket depth of four or five millimeters (healthy gums measure one to three millimeters). Moderate periodontal disease has five to seven millimeter probe readings, and advanced periodontal disease is generally any probe reading greater than seven millimeters. As the disease progresses from early to advanced, the gums will often become more swollen and inflamed, the teeth may become loose, and people who wear partial dentures may notice a change in how they fit. The dentist will often be able to probe between the tooth roots (furcation) in people with moderate or advanced periodontal disease. All three stages of periodontal disease commonly affect adults.

One rare form of gum disease affects children, at or slightly before adolescence. It is called Juvenile Periodontitis, and is characterized by bone loss around the child's front teeth (central incisors) and first molars.

How Will I Know If I Have Gum Disease?

In the vast majority of cases, periodontal disease is completely painless. Except for occasional bleeding when tooth brushing, and puffy gums (weren't they always that way?), most people have no idea that they have gum disease. Gum disease only becomes painful when the teeth become loose and it hurts when biting hard foods, or the gum becomes swollen with a periodontal abscess. By this time, the bone loss around the teeth is often so severe that little can be done, and the tooth may have to be pulled.

You may remember the story of the frog being placed in a kettle of boiling water. If the frog is thrown in when the water is boiling, he will jump right out. However, if the frog is placed in the water at room temperature, and the heat is slowly raised, he will become cooked without knowing it or protecting himself. Gum disease is very much the same; you could be on your way to losing your teeth and wearing dentures without even knowing it!

How Will I Know If I am at Risk?

There are several factors that increase the risk and severity of gum disease. Some research has pointed to a genetic link in gum disease. If your parents, brothers or sisters, have gum disease, you may be more likely to have it as well. You may not know if people in your family have or had gum disease, but if they have worn dentures for most of their lives, their tooth loss may have been caused by gum disease.

People who have medical problems that affect the immune system are more at risk for developing gum disease. Diseases such as AIDS, leukemia, and diabetes are a few that fall into that category.

Medical conditions or treatments that reduce salivary flow can make a person more susceptible to gum disease. Diseases such a Sjogren Syndrome, dysfunction or removal of the salivary glands, those who have undergone cancer chemotherapy or radiation, or who take any of the hundreds of prescription drugs that can cause dry mouth may be more likely to develop gum disease. Saliva is important in protecting us from gum disease because it lubricates the mouth as a self-cleansing mechanism, and it contains other substances that protect the gums from disease.

Teeth that are crooked or misshaped can contribute to gum disease. Likewise, poor dental treatment, such as fillings that don't fill in the gaps between the teeth completely, or crowns (caps) that are too big, bulky, or whose edge (margin) digs too far under the gum-line can also irritate the gums, making them more susceptible to gum disease.

Habits such as smoking, poor oral hygiene (sometimes due to a lack of manual dexterity), emotional stress, and poor nutrition can also significantly contribute to the severity of gum disease. In the past, and today in many developing countries, poor nutrition can also significantly contribute to the severity of gum disease. For example, a lack of vitamin C causes the disease called scurvy, and one of the first signs of scurvy is gum disease.

Besides Losing My Teeth, What Other Health Problems are Associated With Gum Disease?

Over the last few years, a number of studies have shown a high correlation between gum disease and heart disease, heart attack, stroke, respiratory problems, and low birth-weight babies. Consider the following study: Dr. Walter Loesche, a professor of dentistry from the University of Michigan, and his colleagues, studied a sample of 400 men at the Ann Arbor VA hospital in Michigan to determine if a relationship exists between gum disease and heart disease. Analysis of the plaque in men with gum disease found higher levels of gram-negative anaerobic bacteria in patients with heart disease than in patients without heart disease. This type of bacteria contains lipopolysaccharides (a fat and carbohydrate compound) that may be released into the bloodstream and cause obstructive clots in our arteries. A clogged coronary artery supplying the heart can cause a fatal heart attack. Dr. Loesche has established that men over 60 years of age whose gums bleed around almost every tooth (a main symptom of gum disease) were four and a half times more likely to have coronary heart disease.

Dr. Loesche has also established a link between more advanced gum disease and cerebral vascular accident or stroke. People who had lost more than six millimeters of bone around the tooth roots and had gum disease involving many teeth (15 to 28) were highly associated with stroke risk. People, who had had regular dental examinations, at least once a year, were four times less likely to have a history of stroke.

This study deserves serious attention, especially due to the prevalence of both periodontal and heart disease in this country.

How is Gum Disease Treated, and Does it Hurt?

Gum disease is treated a number of different ways, depending on how advanced it is. The main ways to treat gum disease is with deep cleaning under the gums, gum surgery, bone grafts, and antibiotics. Oral hygiene technique and instruction also plays a critical role in the treatment of gum disease.

Gingivitis, the earliest stage of gum disease, is the only one that can be cured. Gingivitis can be cured with improved oral hygiene, which includes brushing properly at least three times a day, for about three minutes each time, and flossing at least once a day. Antiseptic mouth rinses such as those containing Chlorhexidine Gluconate (Peridex) or those containing thymol such as Listerine can also help eliminate gingivitis.

Early periodontal disease is treated with a procedure known as scaling and root planning. The dentist or dental hygienist uses thin curettes and gently removes the plaque and tartar under the gum-line. The tooth roots are also smoothed, to make it more difficult for plaque to adhere to them in the future. This procedure is rarely painful, but some patients may prefer local anesthesia to numb the area prior to treatment. The gums will heal in a few weeks, and the previously red, puffy gums will usually appear healthy; tighter and more stippled, like the surface of an orange.

Moderate and advanced periodontal disease is usually first treated with scaling and root planning as mentioned above. After the gums heal, the surgical procedure is scheduled, partly because the dentist cannot effectively remove plaque that is more than five millimeters under the gum-line. Treatment usually involves a quarter of the mouth at a time (from the last molar in the mouth, to the front [central incisor] tooth on the same side). The dentist numbs the mouth in the area that requires treatment. The gum is then gently separated from the bone, and the remaining plaque and tartar are removed, along with areas of diseased gum. In many cases, gum disease leaves the bone choppy and irregular, which requires it to be smoothed and shaped. If there are vertical areas of bone loss, the dentist may consider a bone graft. The material used for the graft may be either artificial, synthetic, or from other sources. The grafting material is placed into the area of bone loss, and a membrane, often Gortex, is used to cover the graft. The gum is then stitched up, and bubble gum like packing is placed over the area.

Gum surgery is usually not painful. Believe it or not, I have had patients actually sleep through the procedure. There will be varying degrees of discomfort, however, after the anesthesia wears off. The dentist will usually prescribe narcotic pain medication as well as an antibiotic in some cases. Discomfort will generally persist for a few days. The patient returns in about one week to have the packing and stitches removed. If a graft was used, the patient may have to wait six weeks for removal of the graft membrane and specialized stitches.

After the packing and stitches have been taken out, the antiseptic mouth rinse Peridex is often prescribed for several weeks after surgery to promote healing. The teeth in the area that have been treated may be sensitive to cold for weeks or months after treatment. This is because the tooth roots are now exposed to the rest of the mouth. The dentist can use in office desensitizers, prescribe high concentration fluoride gels, and recommend desensitizing toothpastes such as Sensodyne or Crest for Sensitive teeth to combat the sensitivity to cold.

Antibiotics are sometimes used in conjunction with surgical treatment of the gums. The most common antibiotics used are tetracycline, amoxicillin, and metronidazole. These drugs are used to kill some of the bacteria associated with gum disease.

The goal of surgical gum treatment is to bring the gums to a level where the patients can effectively remove most of the plaque by themselves when brushing and flossing. When a patient has four millimeter or greater periodontal pockets, they cannot remove most of the plaque. After any gum treatment, the patient should come to the dentist every three months for maintenance. The dentist can then remove any plaque or tartar missed by the patient.

There are several products on the dental market that are placed around the gums and provide a controlled release of antibiotics. One product that I use is a minocycline powder called Arestin (www.arestin.com). The ease of use and effectiveness make it a very useful adjunct in the treatment of periodontal disease.

Even though there is no cure for gum disease, appropriate gum treatment by your dentist can greatly reduce the likelihood of losing your teeth at an early age. How much time can gum treatment buy? That is hard to say exactly because there are so many factors that influence the outcome. One common estimate is that gum treatments can double the life expectancy of a tooth. In other words, if a tooth was going to last 15 years without treatment, gum therapy can stretch it out to 30 years.

Can Any Dentist Treat Gum Disease?

Most general dentists treat early gum disease. Moderate and Advanced gum disease requiring surgery is usually treated by a dental specialist called a periodontist. Some general dentists who have had addition training are comfortable treating most if not all aspects of their patient's gum disease.

How Can I Prevent Gum Disease?

Gum disease can be greatly reduced by effective brushing at least three times a day, for about three minutes each time, and flossing at least once a day. Regardless of what you see on TV, no toothpastes or mouthwash can help cure any form of gum disease except gingivitis. See your dentist at least twice a year, more if you are diagnosed with gum disease. Follow through with all of your dentist's recommendations. If you smoke or use smokeless tobacco, quit, and eat a well balanced diet consisting of fruits and vegetables. By doing these simple things, you will greatly increase your chances of having teeth that last a lifetime!

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Dr. Gordon is the dental columnist for the Bucks County Courier Times. He has published more than 300 articles since 1998. Dr. Gordon was recently asked to provide commentary about mid-level providers for the influential dental journal Dental Abstracts.

Dr. Gordon responds to an article in Dental Abstracts challenging his views.

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