When I examine patients and have to inform them that they have gum disease, they are usually surprised to learn that the condition is actually taking bone away from their jawbone. What makes the diagnosis even more unexpected is that the condition is often initially slow and painless. Unfortunately, gum disease can eventually cause pain, swelling and tooth loss. Gum disease begins when plaque is not effectively removed by brushing and flossing. 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. This is an overview of the chain-reaction that follows:

• 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. These pockets and the associated bone loss are very bad for the teeth, and if left untreated, can ultimately cause teeth to loosen or fall out.

Gum disease can be greatly reduced and possibly prevented, by brushing at least three times a day, for about three minutes each time, and flossing at least once a day. I recommend that most patients see their dentist at least twice a year, but those with gum disease should go up to four times annually. Smokers are encouraged to quit, because smoking can increase the susceptibility to and severity of gum disease.