What Is Periodontal Disease?

If your hands bled when you washed them, you would be concerned. Yet, many people think its normal if their gums bleed when they brush or floss.

Swollen and bleeding gums are early signs that your gums are infected with bacteria. If nothing is done, the infection can spread and destroy the structures that support your teeth in your jawbone. Eventually, your teeth can become so loose that they have to be extracted.

"Perio" means around, and "dontal" refers to teeth. Periodontal diseases are infections of the structures around the teeth, which include the gums, periodontal ligament and alveolar bone. In the earliest stage of periodontal disease — gingivitis — the infection affects the gums. In more severe forms of the disease, all of the tissues are involved.

For many years scientists have been trying to figure out what causes periodontal disease. It is now well accepted that various types of bacteria in dental plaque are the major villains. Researchers also are learning more about how an infection in your gums can affect your overall health.

Researchers are studying possible connections between gum disease and:

  • Atherosclerosis and heart disease — Gum disease may increase the risk of clogged arteries and heart disease, although the extent of this connection is unclear. Gum disease also is believed to worsen existing heart disease.
  • Stroke — Gum disease may increase the risk of the type of stroke that is caused by blocked arteries.
  • Premature births — a woman who has gum diseases during pregnancy may be more likely to deliver her baby too early and the infant may be more likely to be of low birth weight. One study showed that up to 18% of premature, low-birth-weight babies might be linked to maternal gum disease.
  • Diabetes — People with diabetes and periodontal disease may be more likely to have trouble controlling their blood sugar than diabetics with healthy gums.
  • Respiratory disease  Gum disease may cause lung infections and worsen existing lung conditions when bacteria from the mouth reach the lungs.

What Causes Periodontal Disease?

Periodontal disease is caused by bacteria in dental plaque, the sticky substance that forms on your teeth a couple of hours after you have brushed. Interestingly, it is your body's response to the bacterial infection that causes most of the problems. In an effort to eliminate the bacteria, the cells of your immune system release substances that cause inflammation and destruction of the gums, periodontal ligament or alveolar bone. This leads to swollen, bleeding gums, signs of gingivitis (the earliest stage of periodontal disease), and loosening of the teeth, a sign of severe periodontitis (the advanced stage of disease).

Practicing good oral hygiene and visiting your dentist regularly (about once every six months, or more often if you have gum disease) can prevent periodontal disease. Daily brushing and flossing, when done correctly, help remove most of the plaque from your teeth. Professional cleanings by your dentist or dental hygienist will keep plaque under control in places that are harder for a toothbrush or floss to reach.

If oral hygiene slips or dental visits become irregular, plaque builds up on the teeth and eventually spreads below the gum line. There, the bacteria are protected because your toothbrush can't reach them. Good flossing may help dislodge the plaque; but if it is not removed, the bacteria will continue to multiply, causing a more serious infection. The buildup of plaque below the gum line leads to inflammation of the gums. As the gum tissues become more swollen, they detach from the tooth forming a space, or "pocket," between the tooth and gums. In a snowball effect, the pockets encourage further plaque accumulation since it becomes more difficult to remove plaque. If left untreated, the inflammatory response to the plaque bacteria may spread to the periodontal ligament and alveolar bone, causing these structures to be destroyed.

Another problem is that if plaque is allowed to build up on teeth, over time it becomes calcified, or hardened, and turns into calculus (commonly called tartar). Since calculus is rougher than tooth enamel or cementum (a layer that covers the tooth root), even more plaque attaches to it, continuing this downward spiral. Using tartar-control toothpaste may help slow accumulation of calculus around your teeth, but it can't affect the tartar that has already formed below the gum line.

Risks and Prevention
Although bacterial plaque buildup is the main cause of periodontal disease, several other factors, including other diseases, medications and oral habits, also can contribute. These are factors that can increase your risk of gum disease or make it worse once the infection has set in.

  • Genetics — Researchers believe up to 30% of the population may have a genetic susceptibility to periodontal disease. Having a genetic susceptibility, however, doesn't mean gum disease is inevitable. Even people who are highly prone to periodontal disease because of their genetic make-up can prevent or control the disease with good oral care.
  • Smoking and tobacco use  Smoking increases the risk of periodontal disease and the longer, and more one smoke, the higher the risk. If periodontal disease is present, smoking makes it more severe. Smoking is the main cause of periodontal disease that is resistant to treatment. Smokers tend to collect more tartar on their teeth, develop deeper periodontal pockets once they have gum disease and are likely to lose more bone as the disease progresses. Unlike many other factors that affect the health of your gums, you have control over this one. Quitting smoking can play a major role in bringing periodontal disease under control.
  • Misaligned or crowded teeth, braces or bridgework — anything that makes it more difficult to brush or floss your teeth is likely to enhance plaque and tartar formation above and below the gum line, which increases your chance of developing gum disease. Dentists and Periodontist can show you the best ways to clean your teeth, especially in hard-to-clean circumstances. For example, there are special tools and ways of threading floss to clean around bridgework or slide under braces. And if overcrowded or crooked teeth are a problem, your dentist might recommend orthodontics to straighten out your smile and give you a better chance of preventing disease.
  • Grinding, gritting or clenching of teeth — these habits won't cause periodontal disease, but they can lead to more severe disease if inflammation is already present. The excessive force exerted on the teeth by these habits appears to speed up the breakdown of the periodontal ligament and bone. In many cases, patients can learn to stop this habit simply by recognizing when it is happening and then relaxing. If these efforts don't work, your dentist or Periodontist can create a custom guard appliance (sometimes called an occlusal guard, night guard, mouth guard or bite guard) that helps reduce the pressure of clenching or grinding on the teeth.
  • Stress  Stress can worsen periodontal disease and make it harder to treat. Stress weakens your body's immune system, which makes it harder for your body to fight off infection, including periodontal disease.
  • Fluctuating hormones — whenever hormones fluctuate in the body, changes can occur in the mouth. Puberty and pregnancy can temporarily increase the risk and severity of gum disease, as can menopause.
  • Medications — several types of medications can cause dry mouth, or xerostomia, including antidepressants, diuretics and high blood-pressure medications. Without the protection of adequate amounts of saliva, plaque is more likely to form. Other medications may cause the gums to enlarge, which in turn makes them more likely to trap plaque. These medications include phenytoin (Dilantin and other brand names), used to control seizures; cyclosporine (Neoral, Sandimmune), used to suppress the immune system; and nifedipine (Adalat, Cardizem and others) and other calcium channel blockers, used to treat angina or heart arrhythmias.
  • Diseases — Although the exact mechanisms aren't totally understood, certain diseases increase susceptibility to periodontal diseases. For example, people with diabetes are more likely to get periodontitis, than people without diabetes and it's likely to be more severe. Other diseases, such as leukemia, inflammatory bowel disease and HIV infection, also can increase the risk. Having one of these diseases will make control of periodontal disease more difficult, but a good Periodontist or dentist who is aware of the additional risks and difficulties should be able to offer the kind of guidance needed to maintain your periodontal health.
  • Poor nutrition — Nutrition is important for overall good health, including a working immune system and healthy gums and mouth

The Sequence of Gum Disease

Healthy Gums

Healthy gums are pink and firm. They don't bleed when brushed or flossed. The space between the gums and the teeth, called the sulcus, is 1 to 3 millimeters deep. (One millimeter is about the same thickness as a dime.)

Periodontal disease, a chronic bacterial infection, can affect one or many of your teeth. The disease has four stages: gingivitis, early periodontitis, moderate periodontitis and advanced periodontitis. Approximately 50% of adults have gingivitis, 35% have early to moderate periodontitis and 7% to 15% have advanced periodontitis.

Early (Mild) Periodontitis

Initially, this may go unnoticed by most people. The symptoms of gingivitis typically worsen. The gums may be slightly more tender and can have a greater tendency to bleed. Periodontal pockets will measure in the range of 3 to 5 millimeters. (One millimeter is about the same thickness as a dime.)

What can be done: Once periodontitis has set in, good oral hygiene should remain top priority, but specific periodontal treatments will be needed. For mild periodontitis, a conservative, non surgical approach can still be used to get the disease under control.

The first step is scaling and root planing, a deep cleaning technique. Scaling and root planing remove plaque and calculus (tartar) from under the gum line and smooth any bumps or rough areas on the tooth roots, where plaque tends to accumulate.

In some cases, antibiotics are used in combination with scaling and root planing. Antibiotics to treat periodontal disease can be swallowed as a pill or applied in gel, powder or chip form and placed directly into the affected area of the mouth.

When scaling and root planing and/or antibiotic treatment are not successful, periodontal surgery may be needed.

Important: Unlike in gingivitis, the effects of periodontitis are not always reversible. Even if the disease is brought under control, it is a chronic condition that can always resurface if oral hygiene becomes lax. It's important that people diagnosed with Periodontist diligently follow up on their Periodontist' recommendations.

Moderate Periodontitis

Although periodontitis usually progresses slowly, it can worsen in bursts. Therefore, if mild periodontitis goes untreated, more bone and connecting fibers can be destroyed. In addition, it is important to note that recent studies suggest a link between periodontal health and overall health.

What happens: The inflammatory response to the bacteria in your plaque continues to wreak havoc on the connective tissue and bone around the teeth. The pockets around teeth deepen as more tissue is destroyed.

Symptoms: Gums may become even more red and puffy and bleed easily. Because there is a greater amount of tissue destruction, teeth may begin to loosen. Teeth may start to hurt when you chew or become more sensitive to hot or cold. Pockets measure 5 to 7 millimeters. (One millimeter is about the same thickness as a dime.)

What can be done: Mild to moderate periodontitis typically responds to scaling and root planing and the use of antibiotics. In some cases, more extensive treatment may be needed, including a different antibiotic or several courses of antibiotics. If antibiotic treatment fails, the next step is usually periodontal surgery to reshape the gums or encourage new growth of the bone that has been lost because of periodontal disease.

If periodontal disease has destroyed the fibers and bone that support the teeth in the jaw, the teeth may become loose. If this happens, the loose teeth may have to be splinted to other teeth to stabilize them.

 

Advanced Periodontitis

What happens: Bone and connective tissues continue to be destroyed.

Symptoms: The symptoms are similar to those of moderate periodontitis, but worse. Teeth can become very loose and it may hurt to bite or chew. Because the teeth are so loosely connected to the underlying bone, they may reposition themselves in the mouth. Pressing on the gums may produce pus, a sure sign of a severe infection. Pockets measure more than 7 millimeters. (One millimeter is about the same thickness as a dime.)

 

What can be done: This stage of the disease will require surgical treatment, such as periodontal pocket reduction surgery or bone regeneration. During periodontal pocket reduction surgery, the gum tissue is folded back, the disease-causing bacteria are removed, the tooth roots are smoothed, and the gums are secured back in place. This helps the gum tissue to reattach to healthy bone. A bone regenerative procedure also involves folding back the gum tissue. Then, bone grafts or tissue-stimulating proteins are placed where the bone has been destroyed. This helps to encourage the body's natural ability to regrow the lost bone and tissue.

Loose teeth may be splinted to stabilize them. Extremely loose and/or painful teeth may need to be extracted.

Your First Visit to a Periodontist

If you are referred to a Periodontist, your first visit will be for an evaluation. This typically involves a review of your dental, medical and social histories. If you have any medical problems, it is crucial that you describe them to the Periodontist because so many systemic diseases can affect your mouth and the health of your gums. He or she also will want to know about any medications you are taking, since these also can affect your gums.

If you smoke, your Periodontist will ask you to make an earnest effort to quit whatever the condition of your gums. This is especially important before a surgical procedure.Smoking increases the risk of periodontal disease, makes the disease worse once you have it, and decreases the effectiveness of periodontal treatment by affecting your body's ability to heal properly.

The first visit always includes an examination of your head, neck and jaw joints (temporomandibular joints, or TMJs); a general oral examination of all of the structures in your mouth and throat (tongue, tonsils, cheeks, etc.); evaluation of your teeth; and a full examination of the health of your gums, called a periodontal examination.

In addition to the examination, your Periodontist also will need X-rays of your teeth. A type of X-ray called a periapical X-ray helps the dentist or Periodontist determine the extent and pattern of bone loss around each tooth. These X-rays show the entire tooth from the crown (top) to the end of the root, which anchors the tooth in your jaw. You also may need an X-ray of your entire mouth, known as a panoramic radiograph (OPG). This type of picture provides information about other important structures in your skull, such as the maxillary sinuses and jaw joints.

Once the examination is done, your Periodontist will develop a plan to treat your periodontal problems. Since people have different wants and needs, there is no single treatment that is best.

In addition, you may find that Periodontist differ in their treatment philosophies. Some Periodontist believe in attacking the disease aggressively with surgical treatment, while others believe in more conservative, nonsurgical approaches. It's important that you understand why your Periodontist is recommending a particular form of therapy and that you feel comfortable with the proposed treatment plan.

Regardless of the specific type of treatment, all patients will be placed in a maintenance program in which they will be asked to come in for regular follow-up examinations and cleanings. These cleanings and checkups are critical to maintain the health of your mouth and gums, and to help to prevent the disease from worsening again in the future. For someone who has gingivitis and no other problems, most Periodontist will recommend twice-yearly visits. For people with more significant periodontal problems, the schedule might be once every three months.

Types of periodontal disease

Periodontal disease can refer to any condition that affects the structures supporting your teeth. However, the most common forms of periodontal disease are caused by bacterial infections of the gums, connective tissue or bone around the teeth. Therefore, the term periodontal disease generally refers to diseases associated with dental plaque, which contains bacteria. These can range from mild gingivitis, in which only the gums are affected, to severe disease that causes loss of the supporting structures of the tooth, and results in tooth loss.

There are several types of periodontal disease.

Gingivitis
Gingivitis is the mildest form of periodontal disease and involves the gums. It's caused by bacteria in plaque, which produce substances that can harm the gums.

Gingivitis is quite common. Almost 75% of adults over age 35 have some evidence of this condition. Certain groups of people are at increased risk:

  • People with poorly controlled diabetes
  • Pregnant women
  • Women taking oral contraceptives
  • People taking steroids
  • People taking certain drugs, such as cyclosporine (Neoral, Sandimmune, SangCya), antiseizure medications and calcium channel blockers

If you have gingivitis, your gums will be red and swollen, and bleed easily. There is usually little or no discomfort, but gingivitis can progress to a more serious form of periodontal disease, called periodontitis. Gingivitis can be reversed with professional treatment (a thorough cleaning, including removal of plaque below the gum line) and good oral care at home.

Chronic Periodontitis
Periodontitis is a more advanced form of periodontal disease than gingivitis. Periodontitis involves all of the supporting tissues of the teeth: the gums, connective tissue and bone.

Chronic periodontitis is the most common form of periodontitis. Between 10% and 15% of the population has some degree of periodontitis. The older you are, the more likely you are to get the disease.

If you have periodontitis, your gums become detached from your teeth, causing spaces to form between the teeth and gums. These spaces are called periodontal pockets. The dental plaque that accumulates in these pockets eventually causes the destruction of bone that supports the teeth. In the more severe stages of periodontitis, teeth can become loose and may even fall out.

Periodontitis usually is not painful. Some people notice that their gums are bleeding and receding, and that they have bad breath or a bad taste in their mouth. However, periodontitis sometimes does not cause any symptoms that you would notice, although your dentist can diagnose it during an examination. The condition usually worsens quite slowly, over several years.

Unlike gingivitis, periodontitis cannot be completely reversed because the lost supporting tissues usually are impossible to rebuild. However, treatment and good oral hygiene can improve your oral health, stop the progression of periodontitis, and prevent tooth loss and other serious consequences.

Treatment for periodontitis typically includes a thorough cleaning called scaling and root planing. In certain situations, treatment of periodontitis may require additional steps, such asantibiotic therapy and/or periodontal surgery.

Aggressive Periodontitis
Aggressive periodontitis progresses faster than chronic periodontitis. Aggressive periodontitis tends to run in families, and is more common in smokers.

Aggressive periodontitis used to be considered a "young person's disease," but it is no longer classified this way. However, it is more common in younger people than chronic periodontitis. Like chronic periodontitis, aggressive periodontitis is caused by the bacteria found in dental plaque. Recent research has suggested that susceptibility to this form of periodontitis is an inherited trait.

The treatment for this disease generally is the same as treatment for chronic periodontitis. However, aggressive periodontitis can be more difficult to treat than the chronic form of the disease, and some people do not respond to treatment.

Periodontitis as a Symptom of Systemic Diseases
Periodontitis can be a symptom of one of several systemic diseases including certain types of leukemia’s, neutropenias and genetic disorders. The characteristics of this type of periodontitis usually depend on the underlying medical condition, although the disease can look and act like aggressive periodontitis. These gum conditions are most common in younger patients who do not have large accumulations of dental plaque.

The treatment for this type of periodontitis involves controlling the underlying medical problem first, followed by treatment similar to that for chronic or aggressive periodontitis.

Other medical conditions, such as diabetes and HIV infection, can intensify all forms of periodontitis. People with these diseases are more prone to developing severe periodontitis. However, unlike people who have periodontitis as a manifestation of systemic disease, these individuals usually have a fair amount of dental plaque and/or calculus (tartar) on their teeth.

Necrotizing Periodontal Diseases
Necrotizing periodontal diseases are rapidly progressing forms of disease that are characterized by loss of the little triangles of tissue between the teeth, bleeding gums and significant pain. Other symptoms include bad breath and a whitish film on the surface of the gums. Patients with these forms of periodontal disease also may develop a fever and swollen glands.

The American Academy of Periodontology recognizes two forms of necrotizing periodontal diseases: ulcerative gingivitis (NUG) (link) and necrotizing ulcerative periodontitis (NUP). As the names imply, NUG results in destruction of gum tissue while NUP affects the gums, connective tissue and alveolar bone.

These conditions most commonly are observed in people whose immune systems have been suppressed. Risk factors include smoking, poor nutrition, psychological stress, and HIV infection.

The treatment for NUG typically involves oral hygiene instruction, scaling and root planing, systemic antibiotics, and the use of a mouth rinse containing chlorhexidrine. Because NUP, a relatively rare form of periodontal disease, may be associated with underlying medical conditions such as HIV infection, your dentist will consult with your physician. The treatment is very similar to that for NUG, and may include use of antifungal medications.

Periodontal Examination and Probing

A periodontal examination and probing is one way your general dentist or dental specialist can evaluate the health of your gums and teeth. They help your dentist diagnose the gum diseases gingivitis and periodontitis and also check for receding gums, exposed roots, tooth grinding (bruxism), and other problems.

Periodontal measurements can be taken by any dentist or dental specialist, as well as by dental hygienists. If you are referred to a Periodontist (gum-disease specialist) for evaluation, these measurements will be taken during your first visit.

Here's what your dentist will evaluate during a periodontal examination and what to expect:

  • Any lumps or lesions in the mouth or changes in color of the gums, inner cheeks or tongue — Changes such as these can indicate oral cancer or a precancerous condition. Some infections also cause these changes. Your dentist may be able to diagnose your condition in the office, or you may be referred to a specialist.
  • Whether any of your teeth are missing or loose, and how loose they are — Loose teeth can indicate periodontal disease. Loose teeth also can be the result of a problem with your bite (the way your teeth come together) or tooth grinding (bruxism).
  • The color, texture, size and shape of your gums — Healthy gums are firm and pink. Reddish or bluish-red gums or puffy or spongy gums can indicate disease. Enlarged or swollen gums and gums that are shaped differently than normal also can indicate problems.
  • Whether you have any restorations, such as fillings, crowns, bridges, dentures or implants
  • How much plaque is on your teeth — Plaque is the coating that forms on your teeth and contains large numbers of bacteria that can cause decay and/or periodontal disease. The amount of plaque gives your dentist an idea of your oral hygiene habits. You may be missing certain areas of your mouth when you brush and floss.
  • The depth of the space between your tooth and gum (called the sulcus) — Spaces, or pockets, that are deeper than normal indicate gum disease: either gingivitis (the early stage) or periodontitis (more advanced disease). To measure these spaces, the dentist uses a periodontal probe, which is nothing more than a tiny millimeter ruler with a blunt tip. Your dentist slides the probe between the tooth and gums at various places around each tooth to measure the depth of the spot where the gum attaches to the tooth. Healthy gums adhere tightly to the tooth so that the probe penetrates only 1 to 3 millimeters. Diseased gums tend to swell and detach from the tooth, forming what are known as pockets. In advanced forms of periodontitis, the pocket can be more than 10 millimeters deep, so the probe reaches all the way to the tip of the root of the tooth. This means that much of the soft tissue and bone anchoring the tooth in place has been lost.
  • Whether your gums bleed during probing — after your dentist has measured the depths of the gum tissue around your teeth, he or she will look to see whether the probing caused bleeding. Bleeding after probing is an indicator of gum disease.
  • Gum recession — normally, the roots of your teeth are covered by gum tissue. Numerous factors, however, may cause the gums to recede. These include inflammation, teeth that are badly positioned, and overly aggressive tooth brushing. Once the roots of the teeth have been exposed, the teeth may become sensitive to changes in temperature, are more susceptible to decay, and may not appear cosmetically pleasing. Dentists use periodontal probes to measure the extent of gum recession by measuring the distance between the crown of the teeth and the gum margin.
  • How your teeth come together when you bite (also called occlusion or bite) — too much tooth-on-tooth force can affect your teeth and gums. This can result from the way your teeth come together when you bite down, or from habits such as grinding and clenching your teeth. Your dentist will be able to identify some problems simply by looking at your teeth because excessive force can cause tooth wear. He or she may use special wax or a special blue paper to evaluate your bite. The wax or paper is placed on the biting surface of your teeth and you tap your teeth together or grind them slightly. The wax shows an imprint of your teeth, and the paper leaves marks on your teeth that help your dentist see where your teeth may be meeting with too much force.

In addition to the periodontal examination, you also may need X-rays of your teeth. A type of X-ray called a periapical X-ray helps the dentist or Periodontist determine the extent and pattern of bone loss around each tooth. These X-rays show the entire tooth from the crown (top) to the end of the root, which anchors the tooth in your jaw. You also may need an X-ray of your entire head, known as a panoramic radiograph. This type of picture provides information about other important structures in your skull, such as the maxillary sinuses and jaw joints (temporomandibular joints or TMJs).

Many dentists check all of these factors at every dental visit, but don't write down the results unless something has changed from the previous visit. Repeating these measurements helps your dentist track the progress of treatment. For example, if you need scaling and root planing, your dentist will chart these measurements before the treatment and again several weeks or months later to see if the treatment was effective.

Each dentist has his or her own method for keeping track of periodontal measurements, although most charting methods probably look similar. Many offices today use computers to keep track of the measurements.

Periodontal Examination and Probing

A periodontal examination and probing is one way your general dentist or dental specialist can evaluate the health of your gums and teeth. They help your dentist diagnose the gum diseases gingivitis and periodontitis and also check for receding gums, exposed roots, tooth grinding (bruxism), and other problems.

Periodontal measurements can be taken by any dentist or dental specialist, as well as by dental hygienists. If you are referred to a Periodontist (gum-disease specialist) for evaluation, these measurements will be taken during your first visit.

Here's what your dentist will evaluate during a periodontal examination and what to expect:

  • Any lumps or lesions in the mouth or changes in color of the gums, inner cheeks or tongue — Changes such as these can indicate oral cancer or a precancerous condition. Some infections also cause these changes. Your dentist may be able to diagnose your condition in the office, or you may be referred to a specialist.
  • Whether any of your teeth are missing or loose, and how loose they are — Loose teeth can indicate periodontal disease. Loose teeth also can be the result of a problem with your bite (the way your teeth come together) or tooth grinding (bruxism).
  • The color, texture, size and shape of your gums — Healthy gums are firm and pink. Reddish or bluish-red gums or puffy or spongy gums can indicate disease. Enlarged or swollen gums and gums that are shaped differently than normal also can indicate problems.
  • Whether you have any restorations, such as fillings, crowns, bridges, dentures or implants
  • How much plaque is on your teeth — Plaque is the coating that forms on your teeth and contains large numbers of bacteria that can cause decay and/or periodontal disease. The amount of plaque gives your dentist an idea of your oral hygiene habits. You may be missing certain areas of your mouth when you brush and floss.
  • The depth of the space between your tooth and gum (called the sulcus) — Spaces, or pockets, that are deeper than normal indicate gum disease: either gingivitis (the early stage) or periodontitis (more advanced disease). To measure these spaces, the dentist uses a periodontal probe, which is nothing more than a tiny millimeter ruler with a blunt tip. Your dentist slides the probe between the tooth and gums at various places around each tooth to measure the depth of the spot where the gum attaches to the tooth. Healthy gums adhere tightly to the tooth so that the probe penetrates only 1 to 3 millimeters. Diseased gums tend to swell and detach from the tooth, forming what are known as pockets. In advanced forms of periodontitis, the pocket can be more than 10 millimeters deep, so the probe reaches all the way to the tip of the root of the tooth. This means that much of the soft tissue and bone anchoring the tooth in place has been lost.
  • Whether your gums bleed during probing — after your dentist has measured the depths of the gum tissue around your teeth, he or she will look to see whether the probing caused bleeding. Bleeding after probing is an indicator of gum disease.
  • Gum recession — normally, the roots of your teeth are covered by gum tissue. Numerous factors, however, may cause the gums to recede. These include inflammation, teeth that are badly positioned, and overly aggressive tooth brushing. Once the roots of the teeth have been exposed, the teeth may become sensitive to changes in temperature, are more susceptible to decay, and may not appear cosmetically pleasing. Dentists use periodontal probes to measure the extent of gum recession by measuring the distance between the crown of the teeth and the gum margin.
  • How your teeth come together when you bite (also called occlusion or bite) — too much tooth-on-tooth force can affect your teeth and gums. This can result from the way your teeth come together when you bite down, or from habits such as grinding and clenching your teeth. Your dentist will be able to identify some problems simply by looking at your teeth because excessive force can cause tooth wear. He or she may use special wax or a special blue paper to evaluate your bite. The wax or paper is placed on the biting surface of your teeth and you tap your teeth together or grind them slightly. The wax shows an imprint of your teeth, and the paper leaves marks on your teeth that help your dentist see where your teeth may be meeting with too much force.

In addition to the periodontal examination, you also may need X-rays of your teeth. A type of X-ray called a periapical X-ray helps the dentist or Periodontist determine the extent and pattern of bone loss around each tooth. These X-rays show the entire tooth from the crown (top) to the end of the root, which anchors the tooth in your jaw. You also may need an X-ray of your entire head, known as a panoramic radiograph. This type of picture provides information about other important structures in your skull, such as the maxillary sinuses and jaw joints (temporomandibular joints or TMJs).

Many dentists check all of these factors at every dental visit, but don't write down the results unless something has changed from the previous visit. Repeating these measurements helps your dentist track the progress of treatment. For example, if you need scaling and root planing, your dentist will chart these measurements before the treatment and again several weeks or months later to see if the treatment was effective.

Each dentist has his or her own method for keeping track of periodontal measurements, although most charting methods probably look similar. Many offices today use computers to keep track of the measurements.

Gum disease is the main reason people need periodontal treatment, but other gum conditions require treatment, too. Here is an overview of treatment for various conditions.

Goals of periodontal treatment

 Treatment of Gum Disease

Gum (or periodontal) disease includes a number of conditions caused by bacterial infections of the soft tissue and bone that supports the teeth within the jawbones. The disease can cause tissue and bone to be destroyed, and can lead to tooth loss.

A combination of professional treatment and your efforts can stop the progression of gum disease and prevent further tissue destruction. Depending on the stage of gum disease, treatment ranges from a thorough cleaning to sophisticated types of periodontal surgery.

Treatment at any stage of periodontal disease can make your gums healthier. Some people assume that losing teeth is a natural part of aging, but if you work with your dental professional to keep your gums healthy, you should be able to keep your teeth for a lifetime.

The main goals of periodontal treatment are to:

  • Eliminate the bacterial infections that cause gum disease
  • Control the inflammatory process that is responsible for destruction of the tissues anchoring the teeth to the jawbones
  • Create a healthy periodontal environment that is easy for you and your dental professional to maintain

The earliest stage of gum disease, gingivitis, usually can be stopped before it causes significant destruction of soft tissue or bone. Your general dentist or dental hygienist can treat most cases of gingivitis with a combination of in-office cleanings and instruction in good oral hygiene.

In some people, gingivitis will progress to the more advanced stages of gum disease that involve loss of the structures that anchor the teeth to the jawbones. These more advanced stages are known as periodontitis and usually require more aggressive forms of treatment than gingivitis. In this case, it is likely that your dentist will refer you to a Periodontist (a gum specialist) for treatment.

Treatment of Gum Recession
Gums can recede, or shrink, even if there's no bacterial infection. One of the main causes of gum recession is improper brushing. Using a hard- or medium-bristled toothbrush can cause gums to wear away. Using too much force can also cause gums to recede over time. As the gums recede, the roots of the teeth are exposed. This may cause the teeth to become sensitive to hot and cold temperatures. In addition, teeth with significant amounts of gum recession are more prone to developing root cavities. Periodontist can treat recession by taking gum tissue from one part of your mouth and moving it to the area where the gums have receded. This is known as a soft tissue graft.

Treatment of Gum Overgrowth
For some people, the problem isn't too little gum tissue, but too much. Some people have what is known as a "gummy smile," in which the teeth look very small and the gums seem very large. Also, some medications, such as phenytoin (Dilantin and other brand names), cyclosporine (Neoral, Sandimmune) and nifedipine (Adalat, Cardizem), can cause an overgrowth of gum tissue. Periodontists can remove excess gum tissue through a procedure known as Gingivectomy.

Scaling and root planing

What Is It?
Scaling and root planing is the most common and conservative form of treatment for periodontal (gum) disease. Scaling is the removal of calculus (commonly called tartar) and plaque that attach to the tooth surfaces, especially below the gum line along the root surface. Because plaque is more likely to stick to rough surfaces, the root surface is smoothed down in a process called root planing. Root planing removes any remaining calculus and smoothes root-surface irregularities.

Plaque is a sticky substance, full of bacteria, that usually forms on your teeth. When plaque hardens over time, it is called calculus.

What It's Used For
Scaling and root planing are done to remove the irritants (plaque and calculus) that can cause periodontal disease. For early stages of the disease, especially gingivitis, this treatment may be all that is needed to get the condition under control. With more advanced gum disease, this may be the first step before moving on to surgical treatment.

Preparation
For some patients, scaling and root planing can cause discomfort. A local anesthetic may be used to numb the portion of your mouth that is being worked on.

How It's Done
Scaling and root planing are done with a combination of ultrasonic scalers and hand instruments. Ultrasonic instruments are electric or air-powered devices that have two components: 1) a relatively dull metal tip that vibrates at a very high frequency and "knocks" plaque and calculus off the tooth, and 2) a water irrigation system that cools the tip and helps to flush out debris from around the teeth. Hand instruments are not powered. They have cutting edges and are pressed against your teeth by your dentist or hygienist. These instruments come in various shapes and sizes. Different instruments are used for different teeth, and even for different surfaces of the same tooth.

Typically, ultrasonic instruments are used first to remove large deposits of plaque and calculus from the crowns and roots of the teeth. Hand instruments called scalers and curettes then are used to remove any remaining material and make sure that the tooth surface is clean and smooth. When working under the gum line, your dentist or hygienist cannot see the plaque or calculus, so he or she will rely on the sense of touch to feel for roughness on the root surface.

If you have gingivitis (the earliest stage of gum disease) or localized periodontitis (more advanced gum disease located in only one part of your mouth), scaling and root planing usually can be completed in one visit. However, if you have periodontitis throughout your mouth, your Periodontist typically will do a quarter of your mouth (a quadrant) at a time. This means that four visits will be necessary to complete the scaling and root planing.

Follow-Up
For two to three days after the treatment, you may have some soreness and sensitivity to hot and cold temperatures. Over-the-counter pain relievers can relieve this discomfort.

You may be asked to use an antiseptic mouth rinse after scaling and root planing, especially when soreness of the gums prevents effective oral hygiene measures. However, brushing and flossing should be continued as usual. Some minor bleeding can be expected the first days after scaling and root planing, but this usually stops within a week.

Risks
treating periodontitis decreases gum inflammation and also eliminates periodontal pockets, which can trap plaque. Therefore, if treatment is successful, your gums will shrink or recede. The extent of shrinkage depends on the initial depth of the pocket and the severity of periodontitis. The more severe the disease, the larger the recession of the gums after successful therapy. As a result, some part of the root is exposed, making the tooth look longer and making it more sensitive to hot and cold temperatures. To prevent root cavities, your dentist may prescribe a fluoride-containing gel, and will emphasize the importance of good plaque control.

If your medical doctor has told you that you need to take antibiotics before certain dental procedures, you should inform your dentist or hygienist about this before you undergo scaling and root planing.

Soft-tissue grafts

What It Involves
there are three different types of soft-tissue grafts: free gingival grafts, connective-tissue grafts and pedicle grafts.

In a free gingival graft, a small strip of flesh is removed from the roof of the mouth. The tissue, called the "graft," is then stitched to the existing gum tissue in the area being treated. This is often used for people who naturally have minimal amounts of gum tissue around their teeth and need to have them enlarged.

In a connective-tissue graft, a flap is cut in the roof of the mouth, forming a "trap door." The tissue under the flap is removed. The flap is then stitched over the area. The tissue that was removed, known as sub epithelial connective tissue, is then slipped under the gum tissue surrounding an exposed root surface and anchored in place with sutures. This is the most commonly used procedure for treating root exposure.

In a pedicle graft, a flap of tissue from around an adjacent tooth is partially cut away with one edge still attached. The flap, also called a pedicle, is then slid sideways to cover the exposed root, and is stitched in place. A pedicle graft can be more successful than a free gingival graft because at least some of the blood vessels that feed the grafted section remain in place. However, a pedicle graft can be done only if an adjacent tooth has enough gum tissue to "share" with the tooth being treated.

With all of these procedures, many Periodontist will use periodontal packing to cover and protect the grafted tissue for the first week or two of healing.

Discomfort Factor
with free grafts and connective-tissue grafts, you will have two wounds, near the tooth and on the roof of your mouth, where the graft tissue was removed. The wound on the palate is often described as feeling like a significant pizza burn. Prescription pain medication can help control discomfort after surgery.

Aftercare
Keeping the mouth clean is important, so unaffected teeth will have to be brushed and flossed as usual. Mouth rinses that contain chlorhexidine usually are prescribed to assist in plaque control during the healing period. Antibiotics may be prescribed, but usually are not.

Side Effects of Treatment
Typically, there are no long-term side effects after soft-tissue grafting. In some cases, the new gum tissue may need some reshaping using a procedure called gingivoplasty to make the gum look as natural as possible.

Crown lengthening

What Is It?
This common procedure involves the removal of gum tissue, bone or both to expose more of a tooth's structure.

What It's Used For
Crown lengthening is done when a tooth needs to be restored, but there is not enough tooth structure above the gum line to support a filling or a crown.

This can happen when a tooth breaks off at the gum line, or a crown or filling falls out of a tooth that has extensive decay underneath. If your dentist wants to repair the tooth using a crown or a large filling, he or she may need to expose more of the tooth by removing some soft tissue or bone.

In rare cases, a condition called gummy smile — when an unusually large amount of gum tissue shows around the upper teeth — can be treated using crown lengthening.

Preparation
you will visit a Periodontist for a consultation before the procedure. During the consultation, the specialist will review your medical history and your X-rays, and set a date for the surgery.

Your Periodontist will instruct you on how to keep the area clean after the surgery. You may receive a tooth cleaning before the procedure.

If the tooth needs a crown, your Periodontist may have a temporary crown put on the tooth to protect it. This also makes the crown-lengthening procedure easier because the tooth is already prepared for the crown, and the Periodontist can see precisely how much soft tissue or bone will need to be removed.

Once the area has healed completely — in about three months — your dentist will prepare the tooth again, and make a new temporary crown before making the final crown.

How It's Done
This procedure is done under local anesthesia. The amount of time it takes varies depending on the number of teeth that requires treatment. Although your problem may involve only one tooth, crown-lengthening surgery typically includes neighboring teeth so that the tissues can be reshaped gradually. If only soft tissue is removed, the procedure probably will take less time than if both soft tissue and bone are removed.

The Periodontist will make incisions to "flap" the gums away from the teeth. This provides access to the roots of the teeth and the surrounding bone. In some cases, by simply removing a little gum tissue when the incisions are made, enough tooth structure will be exposed for your dentist to place a crown of filling. However, in most situations it will also be necessary for the Periodontist to remove some bone from around the roots of the teeth. The bone is removed using a combination of hand instruments (resembling chisels) and rotary instruments (similar to the drill and burs used to treat cavities).

Once the Periodontist is satisfied that enough tooth structure is exposed, the surgical area will be washed with sterile salt water and the flaps will be stitched together. At this point, your teeth will look longer because the gums are now sitting at a lower level then before the surgery. Some dentists use a periodontal dressing — called an intraoral bandage — to cover the surgical site.

Any temporary crowns will be removed before the procedure begins and replaced afterward.

The Periodontist will make incisions to remove the soft tissue and to provide access to the tooth roots and the underlying bone. Bone removal allows more of the tooth structure to be exposed. If this is necessary, the bone is removed using a combination of hand instruments (like small chisels) and rotary instruments (similar to the drill used to treat cavities).

After the soft tissue and bone have been removed, the incisions are sutured. This will cause more of the tooth or teeth to be exposed. Some dentists use a periodontal dressing to cover the incisions.

You will be given prescriptions for pain medication and a chlorhexidine mouth rinse. Your dentist will review oral-hygiene instructions, and ask you to follow a somewhat soft diet. You can brush the teeth in the area that was worked on, but you should avoid the gums. You can remove food particles around the affected teeth with a toothpick or a water irrigator.

Follow-Up
For the first day, use ice on your face to keep swelling down.

After the procedure, you will return to the Periodontist in 7 to 10 days to have the sutures removed, and then return again 4 to 6 weeks later for a follow-up visit.

Your gums should heal for at least three months before the tooth is prepared for the final crown. If you don't wait this long, the gums may shrink as they heal and the margins of the crown could show, or other problems could develop. You will visit your regular dentist to have the crown or filling placed, and then again for a follow-up visit.

Risks
as with all surgical procedures, there is a risk of prolonged bleeding during crown lengthening, as well as a risk of developing an infection after the procedure. Additionally, many patients will experience sensitivity to hot and cold because the roots of the teeth are now exposed. This will go away when the roots are covered with new temporary crowns.

Because of the tissue and bone removal, the affected tooth may look longer than adjacent teeth. However, this is only a cosmetic consideration.

  • Removing bone from around a tooth can loosen it. In addition, if the tooth is ever lost, the removal of bone could reduce the chances of successfully placing a dental implant in that area. Your Periodontist will consider these details during your consultation.

Maintenance Therapy

Periodontal disease is a chronic (long-lasting) problem and can return without regular dental care and careful attention to oral hygiene at home. Therefore, one of the keys to successful nonsurgical or surgical treatment for periodontal disease is regular follow-up care.

Maintenance therapy appointments are usually one-visit sessions with your dentist or periodontist or their hygienists. These visits can be scheduled between two and four times a year depending on the severity of your periodontal condition, whether you have a history of recurrent periodontal disease, and whether you demonstrate an increased susceptibility to the disease. You also may need more frequent visits if you smoke or have another disease that increases your risk of periodontal disease.

A typical maintenance visit will include:

  • A periodontal examination
  • An evaluation of the amount of plaque on your teeth and your oral hygiene; a review of the proper techniques for brushing, flossing or other cleaning techniques, when needed
  • Cleaning and polishing of your teeth, including the removal of plaque, calculus (tartar) and stains
  • X-rays, if needed
  • Treatment to manage tooth sensitivity, if needed

If you have teeth that are very sensitive, your dental professional may need to apply a dental anesthetic in order to clean them. Either a topical or an injectable anesthetic can be used.

If your dentist or Periodontist determines during your maintenance appointment that your periodontal disease continues to return, he or she will discuss appropriate treatment with you. Proper follow-up care should minimize the likelihood of the disease returning. Also, if your disease does return, it tends to be rather localized and more easily treated than in people who forgo maintenance care for long periods of time.

Antimicrobial therapy

What Is It?
Antimicrobial therapy refers to the use of chemical agents that either kill or inhibit the growth of bacteria that cause periodontal (gum) disease. The two most common forms of antimicrobial therapy are antiseptics and antibiotics. Products containing antiseptics are usually used to help prevent periodontal disease, while antibiotics are used to treat periodontal disease. Antiseptics are found in oral rinses. This article presents information on antibiotics that are placed under the gums or given as pills, typically in conjunction with a procedure called scaling and root planing.

What It's Used For
Because periodontal diseases are caused by bacteria, dentists and Periodontist (who specialize in treating gum disease) may use antibiotics to help treat them. In dentistry, antibiotics are commonly prescribed for the treatment of an acute (sudden and short-term) infection in the gums called an abscess. Antibiotics are also used to treat other conditions, including:

  • Necrotizing ulcerative gingivitis (NUG), a rare, aggressive form of periodontal disease
  • Rapidly progressive, aggressive forms of periodontitis (advanced gum disease)
  • Periodontal disease that has not responded to other types of treatment
  • Periodontal disease in people who have weakened immune systems or other serious medical conditions

Antibiotics usually are given to supplement the beneficial effects of scaling and root planing, a common treatment for periodontal disease. Although many forms of periodontal disease are successfully treated using this combined approach, other situations may require additional treatment, including periodontal surgery.

Because periodontal diseases are caused by bacteria, you may be wondering why antibiotics aren't considered a routine part of periodontal therapy. In today's world, health professionals are extremely concerned about bacteria becoming resistant to the effects of antibiotics. This can happen when antibiotics are overused or when prescriptions are not taken exactly as instructed by your dentist or physician. Therefore, because most forms of gingivitis and periodontitis can be successfully treated without antibiotics, these drugs are avoided unless absolutely necessary.

Preparation
Once your dentist has decided on an antibiotic, you will have scaling and root planing. This procedure removes plaque and calculus (tartar) from under your gum line and smoothes any bumps or irregular areas on your tooth roots, where plaque can accumulate easily.

Because scaling and root planing, as well as local delivery of antibiotics, can be somewhat uncomfortable, these procedures usually are done under local anesthesia. You will be given an injection to numb the area.

How It's Done
Antimicrobial therapy for periodontal disease can be given in pill form or applied directly. If you are given antibiotics in pill form, you will take them for 7 to 10 days.

Local therapy is given in the dentist's chair and involves placing the antibiotic directly into the affected parts of your mouth. There are several types of local therapy, including:

  • Gel — Your dentist injects a gel containing doxycycline under your gums. The area is sealed and covered with a special bandage called a periodontal pack. After 7 to 10 days, your dentist removes the bandage and any remaining gel.
  • Chip — Your dentist places a chip containing chlorhexidine under your gums. The chip dissolves over 7 to 10 days.
  • Powder — Your dentist squirts a powder containing minocycline under your gums. The powder dissolves over three weeks.

Follow-up
Oral therapy 
It is extremely important that you practice ideal oral hygiene. Brush at least twice a day for at least two minutes per session, and floss at least once a day.

Take your medication exactly as directed for the full amount of time prescribed. This reduces the risk that surviving bacteria will become resistant to the medication, and helps to make sure that the medication works as intended.

Local antibiotic therapy 
After the placement of local antibiotics, you may feel something under your gums, but it shouldn't be uncomfortable. Avoid flossing the treated teeth so you do not dislodge the medication. Sometimes the dentist will place a covering called a periodontal pack around the gums. If you receive a periodontal pack, do not disturb it. Your Periodontist will want to examine you again in 7 to 10 days to remove the periodontal pack and/or the remnants of the antibiotic. After this, you can resume your standard brushing and flossing routine.

Both types of antimicrobial therapy 
Your dentist will check you again after two or three months to see if the therapy is helping. If your disease does not respond to antibiotics, the next step will depend on several factors, including the severity of your disease. Your dentist can prescribe a different antibiotic or schedule periodontal surgery. Some people may receive several rounds of antibiotics before their disease responds.

Once you have had successful treatment for periodontal disease, it's important to help keep the disease under control. Maintenance therapy involves regular visits to your dentist or Periodontist, which can include:

  • Evaluation of your oral hygiene and review of the proper techniques for brushing and flossing
  • A periodontal examination
  • Cleaning and polishing of your teeth
  • X-rays every few years

Risks
The major risk of antibiotic therapy is an allergic reaction to the medication. If you know you are allergic to certain antibiotics, it is important that you tell your dentist. If you are not aware of an allergy and experience any adverse reaction (such as rash, hives or stomach upset) after you have taken an antibiotic, stop taking the drug and contact your dentist. You may need to switch to another antibiotic.

Inappropriate use of antibiotics can lead to the bacteria becoming resistant to the antibiotics' effects. Therefore, it is up to your dental professional to use antibiotics appropriately. It also is important for you to follow instructions for taking the medication and take all of the medication prescribed.

Gingivectomy

What Is It?
Gingivectomy refers to the surgical removal of gum tissue (gingiva). Gingivoplasty is the surgical reshaping of gum tissue around teeth with healthy gums. Both procedures typically are performed by Periodontist, dentists who specialize in treating gums and the other supporting structures of your teeth.

What It's Used For
Gingivectomy originally was developed to treat periodontal disease. Today, Gingivectomy is more commonly used as a cosmetic technique. Gum tissue may need to be removed for two reasons:

  • Gaps (pockets) have formed between the teeth and gums, trapping food particles, harboring colonies of bacteria, and making it difficult to keep the area clean. If the pockets involve only soft tissue, they can be removed by performing a Gingivectomy (trimming the gums).
  • There is too much gum tissue around your teeth. In addition to being a cosmetic concern, this can make it difficult to keep your teeth and gums clean. In severe situations, this condition can interfere with chewing and speech. An overgrowth of gum tissue can be caused by certain drugs, such as anti-seizure medications, or there may be no apparent cause.

Reshaping the gums through gingivoplasty can help gums look more natural. This procedure can be used to correct malformed or asymmetrical gums caused by genetics, disease or trauma, and might be done solely for cosmetic purposes. Gingivoplasty often is done alone, but can be done during or after a Gingivectomy or a gum graft (which adds tissue to the gum line).

Preparation
Before either procedure, your Periodontist will talk to you about oral hygiene after the procedure and any other instructions you will need to follow. Before a Gingivectomy or gingivoplasty, you should receive a thorough cleaning and, possibly, root planing, to remove tartar (calculus) from existing pockets.

How It's Done
Gingivectomy and gingivoplasty usually are done with scalpels, but also are done with electro surgery units, lasers and/or diamond dental burs. Your Periodontist also might use specialized instruments that were designed for Gingivectomy, with angled blades to help them get around teeth.

Before either procedure, you will receive a local anesthetic by injection to numb your gums. A Gingivectomy can take from a few minutes to more than an hour, depending on how much tissue is being removed. Gingivoplasty typically are done in a couple of minutes.

Follow-Up
After a Gingivectomy or gingivoplasty, a type of bandage called a periodontal dressing will be placed on your gums. This usually is left in place for a week to 10 days, during which you will need to follow a somewhat soft diet and avoid spicy and crunchy foods. Your dentist might give you prescriptions for pain medication and a chlorhexidine mouthwash.

It is very important to keep your mouth clean during the healing period. You will be advised not to brush your teeth in the surgical area while the pack is in place. You will be able to brush and floss the rest of your mouth normally. When the pack comes off, you can brush and floss your teeth normally, but gently. It is not uncommon for the healing tissues to bleed when you floss or brush immediately after the dressing is removed.

After 7 to 10 days, you will return to your Periodontist to have the pack removed. Your gums will begin to look normal in three to four weeks, but it can take two to three months for the tissue to heal completely.

Risks
There are no major risks to either procedure. Infection is very rare. Bleeding is a possibility, but also is rare. The affected area might ooze blood for the first 24 to 48 hours, but after that, it should not bleed much, if at all.

The effects of smoking on oral health

When you see the warning on cigarette packages — "Quitting smoking now greatly reduces serious risks to your health." — What smoking-related diseases come to mind? Lung cancer, probably. Emphysema, maybe. But, did you know that half of periodontal (gum) disease in smokers is caused by smoking? Chronic (long-term) gum disease can lead to the loss of your teeth.

"Studies conducted to examine the effects of smoking on oral health have found that tobacco use may be one of the biggest risk factors in the development of periodontal disease,"

Not only does smoking increase the chance that you will develop gum disease, it makes treatment much more difficult and less likely to be successful. Smoking also lessens your mouth's ability to heal, so much so that many of the treatments you may want and need will not work well if you continue to smoke.

For example, crowns and bridges in a person who has gum disease will not look very good because the gum disease will cause bone loss and receding gums around the crown edges. Implants are much more likely to fail in people who smoke. Popular cosmetic procedures, such as porcelain laminates, also will not be successful in a person who smokes.

Periodontal (gum) disease is a bacterial infection that destroys soft tissue and bone that anchors your teeth to your jawbones. The bacteria found in dental plaque that forms in the pockets around your teeth and your body's reaction to the plaque contribute to the breakdown of soft tissue and bone.

Smoking tobacco products can make gum disease get worse more quickly. In early stages of the disease, you may notice that your gums bleed when you brush or floss. As the infection worsens, your gums begin to break down and pull away from your teeth, forming pockets. Later, the pockets between your teeth and gums deepen as more of the supporting structures are destroyed. Ultimately, your teeth may become loose and painful and may even fall out.

Studies have shown that smokers have more calculus (tartar) than nonsmokers. This may be the result of a decreased flow of saliva. Smokers have more severe bone loss and more deep pockets between their teeth and gums than nonsmokers. Among specific findings, smokers were 2.6 to 6 times more likely to have gum destruction than nonsmokers, and severe bone loss was 4.7 times greater among current or former heavy smokers compared with people who never smoked.

"Smokers have less gum bleeding and redness, which can lead to the false impression that the gums are healthy. It is therefore very important that tobacco smokers have regular dental exams to evaluate their oral and gingival health," Dr. Albert says.

Researchers still are studying just what smoke does to oral tissue, but it appears to interfere with basic functions that fight disease and promote healing. Researchers have found that smoking affects the way gum tissue responds to all types of treatment.

"It is believed that the chemicals contained in tobacco interfere with the flow of blood to the gums, leading to a slow down in the healing process and making the treatment results less predictable and often unfavorable," Dr. Albert says.

One reason smokers are more likely than nonsmokers to lose their teeth if they get gum disease is that smoking can slow the healing process after periodontal treatment or any kind of oral surgery. One study found that smokers were twice as likely as nonsmokers to lose teeth in the five years after completing periodontal therapy. Additionally, theAmerican Academy of Periodontology reports that in most studies of nonsurgical periodontal treatment, smokers showed less improvement than nonsmokers. Smokers also responded less favorably than nonsmokers to surgical treatment.

"It is not just cigarette smoke that contributes to periodontal disease," Dr. Albert says. All tobacco products, including pipe tobacco, smokeless tobacco and cigars, can affect the health of your gums.

In a study conducted at Temple University and published in the Journal of Periodontology in 2000, researchers reported that 17.6% of former cigar or pipe smokers had moderate to severe gum disease.

In addition, experts say pipe smokers experience similar rates of tooth loss as cigarette smokers, and smokeless tobacco can cause the gums to recede, increasing the chance of losing the bone and fibers that hold teeth in place.

The only good news about smoking and the health of your teeth and gums is that the Surgeon General's warning holds true — quitting now does greatly reduce serious risks to your health. A recent study reported that the likelihood of having periodontal disease was not significantly different among former smokers who had quit 11 years before and people who never smoked.

Even reducing the amount you smoke seems to help. One study found that people who smoked more than a pack and a half per day were six times more likely to have periodontal disease than nonsmokers, whereas those who smoked less than a half pack per day had only three times the risk.

"The dental office is a good place to visit for help with quitting. Your dentist can show you the effect of smoking on your mouth and teeth. She or he can help you set a quit date and provide you with advice on which medications can help you quit, such as nicotine patches or gum," 

Oral Cancer
Tobacco use may pose the greatest threat to your health as a risk factor for oral cancer. The American Cancer Society reports that:

  • About 90% of people with mouth cancer and some types of throat cancer have used tobacco. The risk of developing these cancers increases with how much is smoked or chewed and the length of the habit.
  • Smokers are six times more likely than nonsmokers to develop these cancers.
  • About 37% of patients who continue to smoke after cancer treatment will develop second cancers of the mouth, throat or larynx, compared with only 6% of those who stop smoking.
  • Tobacco smoke from cigarettes, cigars or pipes can cause cancers anywhere in the mouth or the part of the throat just behind the mouth, as well as cancers of the larynx, lungs, esophagus, kidneys, bladder and several other organs. Pipe smoking also can cause cancer in the area of the lips that contacts the pipestem.
  • Smokeless tobacco is associated with cancers of the cheek, gums and inner surface of the lips. Smokeless tobacco increases the risk of these cancers by nearly 50 times.

Implant Failure
Implants can be used to replace lost teeth in people who smoke, but smokers should know they are at increased risk for the procedure to fail.

"Studies that have examined dental implants in smokers and nonsmokers have consistently found that patients who smoke have more implant failures,"  "As a result, it is important that patients who smoke and who are considering having a dental implant placed be made aware of the fact that their tobacco use increases the chance that the implant will fail.

"They should be encouraged to quit smoking before undergoing the procedure and should be provided with tobacco-cessation counseling and support," he says.

Osseous surgery

What Is It?
Osseous surgery is a procedure that reshapes the bone that holds a tooth or teeth in place.

What It's Used For
Osseous surgery is a treatment for the gum disease called periodontitis. People with periodontitis develop holes called defects in the bone surrounding their teeth. Osseous surgery reshapes the bone to get rid of the defects. This procedure is often used to treat bone loss around multiple teeth.

Preparation
You need to undergo initial periodontal therapy (scaling and root planing) before your surgical appointment. You also must have a good level of oral hygiene. A local anesthetic is used to numb the area for surgery.

How its Done
The Periodontist will separate the gums from your teeth to gain access to the roots and surrounding bone. After the roots have been thoroughly cleaned, a drill (similar to the one used to treat dental decay) and sharp hand instruments are used to reshape the bone around the teeth. Bone is removed in certain areas to restore the normal rise and fall of the bony cup, but at a lower level. Imagine that you have a scarf that has frayed along one edge and you decide to trim off the frayed part. The damage is gone, but the scarf is shorter. The gums are then placed back over the remaining bone and stitched in place.

Follow-Up
Pain medications may be prescribed to ease discomfort after surgery.

It is very important for you to keep your mouth as clean as possible while the surgical site is healing. This means you should brush and floss the rest of your mouth normally. If the surgical site is not covered by a periodontal pack, you can use a toothbrush to gently remove plaque from the teeth. Antimicrobial mouth rinses containing chlorhexidine are commonly prescribed after periodontal surgery. Although these rinses do not remove plaque from the teeth, they kill bacteria and help your mouth heal.

You may also have some swelling after surgery. This can be minimized by applying an ice pack to the outside of your face in the treated area. In some situations, antibiotics may be prescribed to prevent an infection and these should be taken as instructed. Your Periodontist will want to reexamine the area in 7 to 10 days.

Risks
After the surgery, you may have some bleeding and swelling. There is a risk that you could develop an infection.

Your gums in the area that was treated are more likely to recede over time. The teeth that were treated may become more sensitive to hot and cold and may develop cavities in the roots.

Gingival flap surgery

What Is It?
Gingival flap surgery is a procedure in which the gums are separated from the teeth and folded back temporarily to allow a dentist to reach the root of the tooth and the bone.

What It's Used For
Gingival flap surgery is used to treat gum disease (periodontitis). It may be recommended for people with moderate or advanced periodontitis, especially if the initial, non-surgical treatment (scaling and root planing) has not eliminated the gum infection. It may also be done in conjunction with another procedure known as osseous (bone) surgery.

Preparation
Your periodontist or your dental hygienist will first remove all plaque and tartar (calculus) from around your teeth and make sure that your oral hygiene is good. Before flap surgery, your periodontist will determine whether your general health or your current medications allow for a surgical procedure to be carried out.

How It's Done
After numbing the area with a local anesthetic, the Periodontist will use a scalpel to separate the gums from the teeth and then lift or fold them back in the form of a flap. This gives the Periodontist direct access to the roots and bone supporting the teeth. Inflamed tissue is removed from between the teeth and from any holes (defects) in the bone. The Periodontist will then do a procedure called scaling and root planing to clean plaque and tartar. If you have bone defects, your Periodontist may eliminate them with a procedure called osseous recontouring, which smoothes the edges of the bone using files or rotating burs.

After these procedures are completed, the gums will be placed back against the teeth and anchored in place using stitches. Some Periodontist use stitches that dissolve on their own, while others use stitches that have to be removed a week to 10 days after the surgery. Your Periodontist may also cover the surgical site with an intraoral bandage known as a periodontal pack or dressing.

Follow-Up
you will have mild to moderate discomfort after the procedure, but the Periodontist can prescribe pain medication to control it. Many people are comfortable with just an over-the-counter pain reliever.

It is very important for you to keep your mouth as clean as possible while the surgical site is healing. This means you should brush and floss the rest of your mouth normally. If the surgical site is not covered by a periodontal pack, you can use a toothbrush to gently remove plaque from the teeth. Antimicrobial mouth rinses containing chlorhexidine are commonly prescribed following periodontal surgery. Although these rinses do not remove plaque from the teeth, they kill bacteria and help your mouth to heal.

You may have some swelling, and this can be minimized by applying an ice pack to the outside of your face in the treated area. In some situations, antibiotics may be prescribed to prevent an infection, and these should be taken as instructed. Your Periodontist will want to reexamine the area in 7 to 10 days.

Risks
After the surgery, you may have some bleeding and swelling. There is a risk that you could develop an infection.

Your gums in the area that was treated are more likely to recede over time. The teeth that were treated may become more sensitive to hot and cold. The teeth also are more likely to develop cavities in the roots.

Bone graft (regenerative surgery)

What Is It?
A bone graft (regenerative surgery) is a procedure that is used to recreate hard and soft supporting tissues lost due to gum disease.

What It's Used For
Regenerative surgery is a treatment for the gum disease called periodontitis. People with periodontitis lose gum coverage and bone support around their teeth. Regenerative surgery regrows these lost tissues.

Preparation
You need to undergo initial periodontal therapy (scaling and root planing) before your surgical appointment. You also must have a good level of oral hygiene. A local anesthetic is used to numb the area for surgery.

How It's Done
The goal of regenerative surgery is to coax the body into rebuilding the structures that attach a tooth to the jaw, including bone. The Periodontist will separate the gums from your teeth to gain access to the roots and surrounding bone. The roots will be thoroughly cleaned. The holes (defects) in the bone are filled in with a graft material and covered with a physical barrier.

Bone grafting materials commonly used include bits of a patient's own bone, cadaver bone, cow bone and synthetic glasses. The patient's own bone is preferable. The barriers, used to prevent soft tissue from growing into the bony defect, are made from human skin, cow skin or synthetic materials.

The gums are then repositioned over the treated site and secured in place with stitches. During the next six to nine months, your body fills in the periodontal defect with new hard and soft tissue, effectively reattaching the tooth to your jaw.

Follow-Up
Pain medications may be prescribed to ease discomfort after surgery.

It is very important for you to keep your mouth as clean as possible while the surgical site is healing. This means you should brush and floss the rest of your mouth normally. If the surgical site is not covered by a periodontal pack, you can use a toothbrush to gently remove plaque from the teeth. Antimicrobial mouth rinses containing chlorhexidine are commonly prescribed after periodontal surgery. Although these rinses do not remove plaque from the teeth, they kill bacteria and help your mouth heal.

You may also have some swelling after surgery. This can be minimized by applying an ice pack to the outside of your face in the treated area. Antibiotics usually are prescribed to prevent an infection and these should be taken as instructed. Your Periodontist will want to reexamine the area in 7 to 10 days.

Risks
After the surgery, you may have some bleeding and swelling. There is a risk that you could develop an infection.

Your gums in the area that was treated are more likely to recede over time. The teeth that were treated may become more sensitive to hot and cold and may develop cavities in the roots

DID YOU KNOW?

Most people loose their teeth through Gum disease. To help to prevent the loss of your teeth, we follow the latest technique /methods modern Periodontics......ReadMore