Gum disease - periodontitis
A big subject! Let's try condense it into understandable terminology.
Within 30 seconds of teeth being polished to a smooth surface, they accumulate debris from saliva. We call this the acquired pellicle. The acquired pellicle is the first stage of colonisation of the tooth surface by a whole ecosystem of bacteria. Onto the acquired pellicle, land the pathfinder species of bacteria that make the scaffolding for other bacteria to grow on and bit by bit the plaque matures until after about 24 hours it starts to look like a busy jungle teeming with different sorts of life.
It's a bit like the Marram Grass planted in sand dunes to help stabilise the surface so that other plants can settle around them and gradually other species of plants can grow in amongst them, bringing an ever more diverse ecosystem.
Here's are a couple of still photographs of dental plaque taken here at the practice using our dark ground microscope.
These stills don't really give idea of how vibrant plaque is. Plaque is like a jungle!
Plaque accumulates on all surfaces where it's not naturally worn away. So it collects most easily in nooks and crannies, such as between the teeth or the crevice where the gum joins the tooth. Given a couple of weeks undisturbed, this mat picks up calcium from saliva and turns hard into tartar (or as we call it, calculus, which is the Latin word for stone). As this mixture of bacteria and debris thrives it generates toxins as a by product - it's these toxins that do damage.
We have two basic types of bacteria involved -
Aerobes, that is those that live using air and anaerobes, that live without air. Simplistically, the aerobes are generally round or rod shaped
Anaerobes are spiral bacteria (spirochaetes).
For bacteria to live without air (like us) is quite difficult, so instead of a simple metabolism of glucose to water and carbon dioxide they use a more complex reaction. This generates nasty chemicals that we can smell - a sort of rotting flesh smell, or a metallic taste. Interestingly another type of spirochaete called Helicobacter Pylori causes stomach ulcers and the gas it generates can be found with a breath test.
So, toxins oozing from this film of bacteria make the gum inflamed. When just the edge of the gum is inflamed we call it gingivitis - gingiva means gum and itis means inflamed. When it progresses further and starts to destroy the bone that holds the teeth in, we call it periodontitis (peri means around, odont is tooth - so we have, inflammation around the tooth).
How do we know something is inflamed? Something that's inflamed will have blood pumped into the area to help the healing process.
- Restriction of movement
Obviously, gums don't move like a joint such as an ankle, so the bottom option doesn't apply. And they're too small to generate enough heat to notice. As for pain, we only see pain in gums when they're bad - really bad.
So that leaves us with redness and swelling. A good set of gums should be tightly attached to the underlying bone and so have a stippled effect where bundles of collagen bind it down. Where there isn't natural pigmentation of the gum the gum is reddened instead of pale pink. If the gum has brown pigmentation, this redness is harder to detect. But there's no pain. The first sign that something's amiss is usually bleeding from the gum edge when brushing or eating. Bleeding gums are not normal - get them looked at by a Professional!
How do dentists and hygienists measure how good or bad your gums are?
- At your check up, by gently feeling in the crevice at the edge of the gums using a probe with a ball on the end. This is described as a Basic Periodontal Examination (BPE). We record bleeding, tartar build up and how far into the gum the probe will go using something called CPITN developed by the World Health Organisation. If you are identified as being increased risk, we then do a map of the gum using a probe marked in millimetres and x-rays of the bone surrounding the teeth.
Here's an interesting one - if you open this link, it's a PDF of a real set of patient notes that are anonymised. Imagine you're looking at someone from the front. There's a line vertically down the middle that separates left from right, and a horizontal one that separates upper teeth from lower teeth. Starting at the midline, each "corner" has teeth numbered from 1 to 8. Each tooth is unique, so if teeth are missing, the other teeth keep their original numbers. The numbers drawn on the chart are millimetres that a probe can be slid up the crevice in the edge of the gum. The teeth have been measured at the four "corners". 3mm or less has not been charted. A circle indicates that pus is coming out of the gum on that day. The lines of recording nearest the middle horizontal line are oldest and get newer as the get further away.
Over a period of just over two years - with very thorough removal of plaque and calculus from the teeth and careful cooperation between hygienist and patient, this patient has all but eradicated the gum problems in the mouth. If we're honest - two years ago was make or break time. The gum has tightened round the teeth and pocketing has reduced dramatically.
This bleeding can be suppressed if you smoke. So your gums could be a disaster and you could be completely unaware. Give up smoking - you know it makes sense!
Even with technology as it stands, we don't really understand why some people progress from simple, reversible inflammation of the gum edge to irreversible loss of the bone that holds the teeth. It's a combination of things - poor cleaning technique, genetics, stress, smoking, diabetes and so on.
Let's face it, we can't change your genes. But, we can guess whether you're more genetically prone to bone loss than other people. And we can help you stop smoking. We'll also point you the right way if diabetes is suspected.
So what can we do to help you?
- We've known for a long time in dentistry that the most effective control of gum disease is simple - proper, regular scale and polishing to remove ALL the debris on the teeth and then getting your daily routine correct to stop it coming back. Even dental staff (including dental hygienists) need scale and polishing, so we all need directing as to which parts we're good at and which bits we miss.
I'm going to disappoint you now - I'm going to make no attempt to say what's the right and wrong technique here. Every mouth is different, so the technique starts with a standard method and is then tailored to each individual.Tailoring that technique is in our hygienists' hands.
Come and see us!
© Hesslewood Lodge Dental Practice, 26/05/2016