A Comprehensive Guide to Periodontal Disease
I am confident this is the most comprehensive guide you will find on the internet regarding periodontal disease.
In this guide, I will share with you my knowledge, life-changing stories, and experiences around periodontal disease and treatment.
My name is Dr. Rana Shahi, DDS, MS, MSD, and owner of LA Periodontics & Implant Specialists --- which is one of the leading periodontal centers in Los Angeles and Brentwood, California.
So if you're searching to learn as much as you can about periodontal disease, I hope that you will find value in this guide.
DR. RANA G. SHAHI, DDS, MS, MSD
Diplomate, American Board of Periodontology
Periodontal disease (also called gum disease) is an inflammatory condition of the gums that can develop that affects the teeth and the bone structures that support them. While gum disease is relatively common compared to many other mouth-related diseases, it is not well understood by most people outside of the dental profession.
The dangers of gum disease should be taken seriously. The advanced stage of the disease can result in tooth loss, bone loss and significantly greater risk of developing serious conditions like heart disease, diabetes, and bacterial pneumonia.
Fortunately, gum disease can be prevented with the right habits and treatment intervention by a dentist. The following guide will teach you what you need to understand about gum disease, including how to spot it, how to tell different gum diseases apart and how the disease can contribute to or amplify serious medical conditions.
Use the table of content below to navigate to the information that you need most, or start from the beginning to gain a comprehensive understanding of the disease.
What Is Periodontal Disease?
Periodontal disease is the number one cause of tooth loss and edentulism in adults worldwide. It is the second most common dental disease behind dental caries or tooth decay. More commonly known as “gum” disease, periodontal disease afflicts both adults and children regardless of age, ethnicity, or gender. In the United States, nearly half of all adults have some form of dental disorder. According to the Center for Disease Control and Prevention (CDC), this startling statistic rises to over 70 percent of all adults by ages 65 and older. Based on the statistics provided by the CDC and other health organizations, it would not be an overstatement to call periodontal disease a pandemic disease that affects our species as a whole. Yet despite its ubiquity, periodontal disease is also completely preventable in most cases.
Our mouths are filled with bacteria and other microbes that live off of the dead cells and foods scraps in our oral cavities. No matter how much you brush, floss, or rinse with antimicrobial mouthwash, microbes will remain in your mouth. They are a fact of life. In fact, the average human mouth is home to 200 to 300 unique bacterial species all vying for space. However, when bacteria, particularly so-called gram-positive bugs such as Streptococcus mutans, grow out of control periodontal diseases can arise.
4 Levels of Periodontal Health
There are four levels of periodontal health, depending on the state of periodontium (structurally and clinically sound or reduced) and the relative treatment outcomes
Pristine periodontal health, with a structurally sound and uninflamed periodontium
Well-maintained clinical periodontal health, with a structurally and clinically sound (intact) periodontium
Periodontal disease stability, with a reduced periodontium
Periodontal disease remission/control, with a reduced periodontium
How Does Periodontal Disease Arise?
The primary cause of periodontal disease is a lack of dental and oral hygiene. Regular brushing and flossing, as well as routine visits to a dental clinic, are critical to prevent periodontal disease. However, genetics, diet, and each’s unique oral microbiome also play essential roles.
Typically, periodontal disease first manifests itself through gingivitis. Gingivitis is essentially the earliest stage of periodontal disease and is expressed through irritation, redness, swelling, and inflammation of the gums. Healthy gums, in comparison, are a pale, coral pink color and fit snuggly against teeth. One common sign of gingivitis and the early stages of periodontal disease is sensitivity, pain, or bleeding while brushing and flossing. Damage from gingivitis can, with treatment, be reversed.
As gingivitis progresses or is left untreated and unaddressed, it can become periodontitis. Gingival fibers hold the gum tissues close to the teeth. However, as gingivitis progresses, these fibers are destroyed, and gum tissues separate from the teeth allowing periodontal pockets to form. These pockets become traps for food debris and microbes. Late stage periodontal disease is characterized by serious infections of the gums and damaged soft tissues and bone structures. Eventually, periodontitis may result in lesions, ulcers, necrotic pockets, tooth loss, and complete edentulism.
How Can I Prevent Periodontal Disease?
An overabundance of certain strains of destructive bacteria is the primary cause of both gingivitis and periodontitis. Therefore, the best way to prevent periodontal disease is to control bacterial populations in the mouth and especially below the gumline. This can be achieved through a number of simple ways.
First, brush thoroughly and brush twice a day. Physically removing both bacteria and the food debris that fuels them is the best way to prevent plaque and tartar buildup on or near the gums.
Second, floss every day. Correctly flossing helps to remove plaque and debris from in between teeth as well below the gum line. Flossing is especially important because it is a useful way to reach the nooks and crannies, cracks and crevices that can’t be easily reached with a toothbrush. This is where many, however, make mistakes. Not only do many people choose not to floss regularly, but some also do not floss with the proper technique.
Third, visit a dental clinic for professional cleaning. Professional dental cleanings, typically performed by a dental hygienist and included in many dental examinations, utilizes treatment tools and techniques that aren’t easily available to most.
As a result, a thorough professional cleaning can help reset your mouth. Hardened calculus and other difficult to remove bacterial growths can be quickly taken care of with an ultrasonic scaler and other clinical equipment. Most importantly, visiting a dental clinic for a cleaning allows a professional to examine, identify, and diagnose any potential dental concerns.
Finally, there are a variety of other active ways to help manage your oral microbiome to ensure that destructive bacteria remain under control. One critical factor is diet. What you eat and what you put your teeth and gums in contact with every meal matters quite a bit. Diets that promote general health, such as balanced eating routines that include plenty of vegetables and avoid simple carbohydrates and refined sugars, will also be useful for your teeth and gums. A healthy, strong body promotes healthy, firm gums. On a microbial level, limiting bacteria-fuelling sugars will also reduce the likelihood of periodontal disease arising. Other healthy life choices include avoiding or abstaining from alcohol and tobacco, which are known to be extremely damaging.
Forms of Periodontitis
Necortizing Periodontal Diseases
- Necrotizing Gingivitis
- Necrotizing Periodontitis
- Necrotizing Stomatitis
Periodontitis as Manifestation of Systemic Diseases
The classification of these conditions should be based on the primary systemic disease according to the International Statistical Classification of Diseases and Related Health Problems (ICD) codes.
- Stages: Based on Severity and Complexity of Management
Refer to Chapter 2 in this guide for further descriptions of the following four stages.
- Stage 1: Initial Periodontitis
- Stage 2: Moderate Periodontitis
- Stage 3: Severe Periodontitis with potential for additional tooth loss
- Stage 4: Severe Periodontitis with potential for loss of the dentition
- Extent and distribution: localized; generalized; molar-incisor distribution
- Grades: Evidence or risk of rapid progression, anticipated treatment response.
- Grade A: Slow rate of progression
- Grade B: Moderate rate of progression
- Grade C: Rapid rate of progression
- Stages: Based on Severity and Complexity of Management
How Can I Treat Periodontal Disease?
Periodontal disease needs to be treated quickly and aggressively to minimize damage to the gums and gingival recession. Early-stage gum disease, known as gingivitis, can be easily treated and damage reversed with daily brushing, flossing, and visits to a dental clinic for professional cleanings. Late stage gum disease, or periodontitis disease, is more difficult to rectify. By this point, toxic byproducts of plaque and bacteria have already wreaked havoc on not only gum tissues but also the bone and ligaments that anchor the teeth in place.
Periodontists rely on a number of procedures to treat periodontitis. Depending on the severity, scope, and progression of the disease, procedures can be either nonsurgical or surgical in nature. Nonsurgical treatment of periodontitis is known as scaling and root planing (SRP). Sometimes referred to as “deep cleaning” by some dental clinics, scaling and root planing involves scaling, or scraping, off bacteria and planing, or smoothing, the surfaces of the roots in order to prevent bacteria from adhering. Scaling and root planing can be slightly uncomfortable and some patients may require or request local anesthetics.
Tray delivery systems for treating periodontal disease are also available. However, tray-based treatments have not yet been shown to be effective.
Surgical procedures for advanced periodontitis include pocket reduction, gum grafting, and bone grafting. Pocket reduction, also known as flap surgery, gingivectomy, or osseous surgery, is a procedure designed to access the roots of teeth in order to remove deep pockets of bacteria. This is often done after a scaling and root planing procedure and may require tiny sutures that remain in place for a week to 10 days. Once destructive bacteria has been removed, a gum graft or bone graft may be required to fully repair the damage.
Good Oral Hygiene
Good oral hygiene has always been considered a mainstay of periodontal health. It is usually achieved by a combination of good personal oral hygiene and regular professional care. It must be remembered that plaque accounts for only 20 percent of the direct risk of developing periodontitis, thus it must not be forgotten that the remaining 80 percent of the direct and indirect risk and modifying factors may be responsible for the development of periodontal diseases. While oral hygiene remains the most important factor in obtaining and maintaining periodontal health, it should not be the sole focus of attention.
Additional factors must be addressed in the quest for attaining or maintaining periodontal health.
Source: Journal of Periodontology, Lang and Bartold, page 812
How Can I Cosmetically Repair & Renew Damaged Gums and Teeth?
While gums cannot grow back naturally once destroyed by periodontal disease, there are cosmetic procedures available to restore and repair them. Soft tissue graft surgery, or a gum graft, can replace areas of missing or irreparably damaged gums with new tissue. Grafted tissue not only covers exposed roots and prevents reinfection but also repairs and restores the patient’s smile.
Sometimes the destruction from periodontal disease even affects the bones. When bone loss occurs as a result of periodontitis, a bone graft procedure may be recommended. The patient’s own natural bone taken from another location on the body or, donor processed, or synthetic bone materials can be embedded in areas of limited bone depth in order to provide a strong and sturdy foundation for the gums. Bone grafts are also important for the restoration of a patient’s jawline and natural smile.
What Do Healthy Gums Look Like?
The gums can react quickly and noticeably to the presence of periodontal disease, especially where the gum line meets the teeth. However, gums can develop problems for other reasons as well, such as direct trauma. Before you learn the specific warning signs and symptoms that point to gum disease in Chapter 5, you should understand how gums appear in their healthiest state.
The Appearance of Healthy Gums
While unhealthy gums can exhibit a range of different problems, healthy gums appear largely the same across all ages and groups. Healthy gums will exhibit all of the following features.
A light pink color
Healthy gums are a uniform light pink, usually a shade close to coral pink. The pink color should extend from the bottom where the gums meet the lips to the top where they close around the neck of the teeth.
By contrast, unhealthy gums are marked by a range of different colors. They may be marked by redness, especially blotchy red and purple spots below or above the teeth. Periodontitis specifically can be marked by bright red borders where the gums meet the teeth. White spots on the gums can also point to health problems that should be evaluated by a dentist.
A firm connection to the teeth
Healthy gums should feel firm to the touch and be firmly connected to the teeth. If the area around the teeth is rubbed, the gums should not show movement, or pull away from where they connect to the teeth.
Unhealthy gums may feel soft and swollen rather than firm. They may shift in position around the gum line when pressure is applied. This is usually accompanied by pain, sensitivity and the presence of red coloration.
A stippled texture
Healthy gums have a consistent texture to the touch that is sometimes described as “stippling”. This texture is marked by a series of tiny pits and often compared to the texture of the outside of an orange peel. This should be a tight texture that does not shift as fingers or probes are moved across the gums.
On unhealthy gums, swelling results in a much smoother texture that can also be painful to the touch.
The absence of blood when brushing or probing
Healthy gums can safely handle the sensations of brushing, flossing or probing without bleeding. While some gums are sensitive and can require an adjustment period when flossing is first introduced, even sensitive gums will eventually adjust to the pressure of flossing and not bleed.
If bleeding appears even after light probing, or if the gums appear unable to develop callouses in response to regular flossing, it may be a sign of periodontal disease.
The absence of periodontal pockets
Healthy gums will have no periodontal pockets around the teeth. Periodontal pockets are gaps between the teeth and the gums at the gumline. When these pockets are present, the gum can be slightly lifted to expose the teeth underneath.
The presence of these pockets means that bacteria can now reach a part of the tooth that should be protected from any exposure.
How To Keep Your Gums Healthy
Keeping gums healthy involves the prevention of bacterial growth. The environment inside the mouth is a healthy one for certain harmful kinds of bacteria. However, common hygiene practices are usually enough to keep these populations low. The following habits can keep your mouth sanitized and resistant to bacteria.
Habits That Keep Gums Healthy
Brushing and flossing daily, up to 3 times per day after meals
Using electric toothbrush with soft bristles (is ideal)
Using fluoride toothpaste with a range of 1000-1500ppm flouride that features the American Dental Association (ADA) seal
Having annual professional cleanings performed by a dental professional
One major benefit of practicing these habits is that they empower your immune system overall. Poor gum health is a risk factor for heart disease and may worsen the condition. More information about gum health and heart disease will be covered in Chapters 8 and 9.
When To See A Periodontist
Though gum disease may retreat in response to better hygiene in the earliest stages of the disease, at some point intervention by a periodontist is necessary. You should see a periodontist if bleeding becomes frequent, if the pain becomes acute or if there is any evidence that the gums may be receding.
If these signs are ignored, advanced stages of Periodontitis will occur that may involve tooth loss and the loss of dentition. Refer to Chapter 2 regarding Forms of Periodontitis.