Periodontal ("Gum") Disease
What exactly is it ?????
Periodontal or - Gum - Disease is many things....First, you should know that it's VERY popular!!! It's been estimated that 80% or more of us have it to some degree ! Also, there are different forms of it that are treated in different ways depending on how advanced it has gotten and how much damage has been done from it, and also just where it is... that is, is it on the front of the tooth , or on the tongue side? or is it in the in-between space between two teeth ? These factors become very important when it comes to designing appropriate treatment....
But for now let's concentrate on developing a simple model of what it most often is and why it is so important to diagnose and treat it in the earliest stages possible.
I made the following drawings to illustrate the basic stages in the progression of periodontal disease. It shows "Healthy" or "normal" on the left. As we go to the right we pass through the center drawing showing the beginning changes which are reversible and then progressing to the right, the damages caused by advanced disease so that permanent changes have taken place.
I will explain each in more detail and try to help you understand why understanding the changes is so important.
******Please do not skip reading "Healthy"... read this first so you will understand how the disease changes things....
Healthy - In the healthy state, the tooth is surrounded by and held tightly by the bone of the jaw. The tooth is embedded deeply into this bone so it has lots of support. Between the bone and the tooth is a very narrow fibrous ligament (periodontal ligament) that attaches the tooth to the bone. It also acts as a kind of shock absorber to allow shocks and pressures against the tooth to permit the tooth to have a little "give".... to allow it to move slightly and spring back into position without causing the bone or the tooth to crack. It's a good thing and your friend!
The gum covers the bone ( you wouldn't want your bones to show ) comes up slightly above the bone and surrounds the tooth with a "cuff" , much like the cuff on a shirt sleeve or pants. This cuff is formed by the final delicate edge of the gum which fills the space between the teeth and makes a smooth flowing shape from the tooth to the rest of the gum tissue. Because of this shape the teeth can stay pretty clean without much work on your part and the spaces between the teeth are closed to food and junk can't easily get stuck there and getty yucky....
This is important.... under that little final edge of the gum that forms a cuff, inside that cuff, there is a little space between the tooth and that edge of gum tissue that is normally no deeper than 1/8". That important space is called the "Sulcus" (gingival sulcus).
The skin on the outside of the edge of the gum is normal gum skin.... and it just flips over and forms the lining of the sulcus... just normal gum skin.
That normal gum skin lining the sulcus does not bleed easily ... no more than the rest of the gum skin outside the sulcus. If you scrape or cut it, of course it will bleed, but normal stimulation doesn't bother it.... it's healthy and normal.
Gingivitis - The center drawing shows what happens if that little edge of gum tissue around the tooth gets inflamed. Most often it gets inflamed because too many bacteria have been accumulating in the sulcus between the gum and the tooth surface. It may be because you have not been brushing well enough, or because it's in a place between the teeth where the brush can't get to well enough and you have not been using floss to keep it clean.
For some people lots of bacteria can collect and it's not a problem - the gum stays ok. For others with a lower immune system response, even a small amount of bacteria creates a problem. It's just like when two people go out in wet, cold nasty weather - dressed equally - and one comes down with a case of pneumonia and the other doesn't. We differ in how well we fight off infections. For some of us gum infection is a never-ending problem while for others it never seems to need any thought or effort. Some of us can brush quickly and absent-mindedly and never floss ...and the gums still stay great! Others can do it all - and well - and still have a battle keeping healthy. It's just not fair, right?
Anyway, notice what happened in the center drawing. The top edge of the gum swelled up and got bigger. Also, the inner lining of the sulcus got very red and inflamed. The effect of the swelling is that the sulcus gets DEEPER. Now if the original problem was that too many bacteria were collecting in the shallow sulcus and it was difficult to keep clean..... look at it now! It's even deeper and so much more bacteria can collect and it's even harder to get it clean !!! You can see now that as the gum swells, the problem causing the swelling gets worse, causing even more swelling.... this is a "snowballing" cycle that just gets worse and worse and harder and harder to get under control.
Additionally, just to make things worse, the inflamed gum skin lining inside the sulcus is getting more and more inflamed and RAW. It gets to the point of being so inflamed that any stimulation - even just normal eating - will cause it to BLEED. At this point we no longer call it a sulcus( the term for a HEALTHY gum crevice) .... it is now called a "POCKET" , a term reserved for a pathologic situation... a DISEASED sulcus. Why is this important?
Well aside from the idea that it's a little yucky to have your gums bleed, and the fact that it makes your mouth taste and possibly even smell bad .... it's also invites deeper INFECTION. If blood can easily come OUT, then bacteria can just as easily go IN. When bacteria go in to the gum tissue, there are two major considerations. One is the local effect the infection can have on the gum, bone and tooth right there. The other has to do with what happens when these bacteria spread through your body and end up in your heart, lungs, brain, kidneys, etc. ( See Gum Disease & Heart Disease on this site). In this article I will stick with the LOCAL effects.
Periodontitis - As the infection takes hold in the fleshy part of the gum next to the sulcus, now turned into a POCKET, the chemistry in that gum tissue is altered. Bone is a living tissue which is constantly being built up and torn down, much like how your skin is constantly renewed.
The changed chemistry from the infection in the gum tissue all around the fragile top thin edge of the bone causes the bone to RECEDE, that is, the tearing down starts to happen faster than the rebuilding of the bone, so the bone begins to "shrink away". Meanwhile the gum begins to split away from where it was attached to the root of the tooth so that where it IS attached tends to follow the bone. As the bone recedes down the root, so does the part of the gum that attaches to the tooth.
You can now easily see that the gum "pocket" is now getting even deeper than it was during the Gingivitis stage , which means that the difficulty of keeping it clean has become even harder than it was in the Gingivitis stage.
More important is the fact that now tissues are not just irritated and inflamed - as in gingivitis - now they have actually been destroyed, lost. The changes seen in Gingivitis were essentially REVERSIBLE... and fairly easily so. The changes seen in Periodontitis are mainly no longer reversible. The treatment is totally different and more involved. Fortunately there have been some wonderful new treatment procedures that can often repair and GET BACK the lost gum and bone, but it is not easy and not 100% predictable.
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Implications - If you get nothing else out of this discussion, please get this... The earlier the gum problem is discovered and treated, the better the outcome, and the easier the treatment , which usually means less discomfort and expense and less time involved in treatment. Also, the less likely that there will be any systemic infection problems in other parts of your body from bacteria which got into your body through your gums.
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I hope this brief discussion has been helpful and informative. Good luck!
Michael C. Goldman, DDS
General and Cosmetic Dentistry
3815 East-West Highway
Chevy Chase, Maryland 20815
Phone (301) 656-6171See other topics including "Gum Disease vs. Gum Health" listed in Topics below.
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Holistic dentistry is an approach to dental treatment, primarily caring for patients' health and safety from both a conventional as well as "alternative healthcare" point of view. It is sometimes called "biological" dentistry or "biocompatible" dentistry. In it's fullest sense, I believe it acknowledges and deals with the mind, body and spirit of the patient, not just his or her "teeth". See Topics / Info.....
Cosmetic dentistry is about doing quality , esthetic dentistry in a way that looks natural to begin with, and furthermore, can even improve one's attractiveness through techniques such as bonding, bleaching, veneers, caps, implants and more. It can be like "instant orthodontics" in correcting crooked, twisted or misplaced teeth in many instances. Dark or mis-shapen teeth can be restored. Smiles that lack youthful vigor or beauty can be revitalized! See Topics / Info..
In holistic dentistry there is an effort to find biocompatible materials to use to reduce toxicity for everyone, especially the chemically sensitive. Amalgam use is avoided in holistic dentistry (" amalgam free" or "mercury free") due to concern about possible toxicity problems. Amalgam removal and replacement with natural-looking bonded materials is a common holistic dentistry treatment as well as a common cosmetic dentistry treatment. Detoxification, especially of residual mercury deposits in body tissues from amalgams is often done. Root canals are controversial in holistic dentsitry and are discussed under topics. And much more....
Bleaching, veneers, bonding, caps, bridges, and implants are cosmetic dentistry treatments that are also discussed in Cosmetic Dentistry, and more...
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