Periodontal disease

Inflammations of the gum

Causes, treatment, technique, tips and complications

What is a periodontal disease?


This means a disease of the tooth supporting tissue. The tooth supporting tissue includes the gum, the jaw and the grains connecting the tooth with the jaw. It´s a popular saying periodontal disease. This disease often is underestimated, although more teeth fall victim to it than to the caries!

Do not wonder if you can´t find the expression “periodontal disease” in a dental practice, because the dentists only use this expression for bone dissolving without any inflammation. Dentists take the expressions gingivitis (that means only an inflammation of the gum) and periodontitis  (inflammation of the gum with bone dissolving).

Which attributes does the periodontitis have?

Bleeding of the gum is an important indication of an inflammation. Sometimes one only recognizes it while brushing one´s teeth searchingly. (cave: bleedings of the gum appear very late with smokers!)

Retrogression of the gum: the teeth seem to become longer. Sometimes they even start hiking,e.g. the upper teeth in the front. The fissure between the middle teeth becomes bigger and bigger then.

Suspicious is also a dark-red discolouration of the gum (normally it is light-pink)and longer lasting bad breath (which also can have other causes) in advanced cases can even foetid whitely yellow secretion between the teeth appear, if you squeeze the gum and sometimes there is even a swelling. If the teeth become loose (then the destruction of the teeth supporting tissue has progressed): if you don´t treat this disease when the first warning signals appear, the gum unsolders from the tooth. A gingival pocket is formed and at the bottom of it the jaw around the tooth is dissolved more and more until the tooth becomes loose. A loosened tooth is already an indication for a far advanced disease.














   

      


















How does it come to a periodontitis?

Pathogens (bacteria) invade in the space between tooth and gum. If the bacteria find enough alimentary bases in terms of plaque, they augment very fast and lead to an inflammable reaction with dissolving of the surrounding tissue. First of all, only the gum above the bone is affected. Then the inflammation spreads out more and more and the bone around the tooth with the fine trains, carrying the tooth, is dissolved slowly but steady. Difficult while combating these bacteria is the fact, that it mostly not involves a certain phylum, but a mixing culture. By the way, the germs arrive at the mouth of the patient already in the babyhood. Therefore, one advises a couple, who wants to have children, to rehabilitate their teeth in time. At the beginning, the presence of the bacteria doesn´t lead yet to a periodontitis. But if there are other factors like plaque (vide below: pandering factors), then it comes to a fatal dissolving reaction of the tooth supporting tissue.

Which factors influence the periodontitis?

O the biggest risk factor is smoking, especially heavy smoking (about 15 cigarettes a day). Furthermore problematical with smokers is, that an inflammation of the gum often goes ahead a long time without the characteristical bleeding, and therefore the patient often recognizes it very late. If a smoker becomes a non-smoker, he suffers from more and more gum-bleeding at the beginning, even if the condition of the gum improves.

O unfavourable brushing techniques or insufficient oral hygiene lead to debris of soft and hard coverings on the teeth. In this plaque, there are a lot of bacteria (pathogens). Thereby an inflammation is caused, dissolving the tooth supporting tissue.

O even a wrong debit of the teeth can support this disease.

O beside it, there are still some other general diseases (like diabetes), which have a negative influence on the defence struggle of the body against the bacteria of the gum.

O finally, there are heritable factors. Twin research showed, that even identical twins in totally different environs and life situations present resemblances with the state of the gum. In the meantime, one found places in the genotype (DNA), which produce so-

called “Interleukine” (proteins that control the cells of defence). If one of these genes has changed, the patients suffer from a 17-times higher risk to get a periodontitis.

O recently, immuno-deficiencies incurred more and more in the visual focus of the scientific research. I don´t mean AIDS or another heavy immuno-deficiency, but the individual differences in the defence mechanism of the patient compared to the bacteria.

O in the last time one discussed more and more often about the stress factor. This is in accordance with my own experience, that especially in or after phases of stress appear more often gum-bleedings.


I brush my teeth constantly. Why do I suffer from more problems with the gum than others, who care less for their teeth?

Brushing one´s teeth is only one factor among others. Indeed there are men, who hate brushing teeth but who have a totally healthy gum. I like comparing it with smoking. There are smokers, who are still healthy at the age of 90 years, and others don´t feel this way, because of the second-hand smoking.

The different possible factors make the question after the guilt of the origin of the inflammation of the gum senseless. The rebuke of a doctor “ You haven´t brushed enough, you have to blame for this on your own” is as dangerous as if the patient doesn´t take the blame.

Other factors are the evils of early days. At this age one underestimates the importance of oral hygiene – and then the basis of a periodontitis is established, which one can hardly fight against later.

Another factor is, that the patient can´t remove the debris, that is already under the gum. This has to be done by the dentist.

How often does a periodontitis appear?




Only 20 % of the adult germans have a totally healthy gum situation. Lots of germans have a soft form of a gum inflammation. About every 10 th person suffers from an especially heavy form of periodontitis. Often the teeth are concerned in different heavy ways.

At which time the periodontitis is treated?

Pre-treatment:

Before starting the treatment, all of the debris, calculus and protruding old fillings and crowns with protruding brinks have to be removed. Even inflammations in the inside of a tooth may lead to inflammations of the gum and also have to be treated. Wrong debits

of the teeth are corrected by changing the occlusal surfaces of the teeth or by giving the patient a so-called “Knirscherschiene” (grinding splint). The patient is shown brushing his teeth optimal, that means he gets a special instruction for tooth brushing.

Main-treatment:

The main-treatment directs to removing the plaque and the calculus above and under the gum. Therefore the surface of the root is cleaned, planed and polished. In advanced cases, the gum and the root of the tooth has to be treated surgically, that means under vision.

After-treatment:

A continuous after-treatment with removing of the eventually new uprisen debris is absolutely necessary for a successful gum treatment. Therefore, one recommend re-calls every 3 or 6 months. The time between these re-calls depends on the form of

periodontitis and on the attendant disease. At the re-calls the uprisen debris and plaque is removed like it is described above.

Furthermore, the gum is controlled on it´s physical condition and the patient is shown a better oral hygiene at places, that are hardly reachable, if this is necessary.

A conscientious and successful treatment of a periodontitis requires a lifelong care for the patient”!

It´s important, that a patient contacts his dentist immediately in the acute stage and doesn´t wait until the next re-call. The warning signals of an acute shear is bleeding, but less pain.

If the cause of gum inflammations are bacteria, why doesn´t one give an antibiotic like with other diseases, too?

A periodontitis means a destruction of the tooth supporting tissue through bacteria and the inflammable defence of the body against these pathogens. Though, different germs are involved. Other pathogens arrive, too, but they do less harm and even take away the alimentary base from the pushy bacteria. There´s no antibiotic, that defeats well all pushy bacteria and impedes a new nidation. Giving antibiotics only brings temporary success. But important for a successful periodontitis treatment is a stable result!

Furthermore, bacteria can hide from the antibiotic in the gum like under a pituitary coat.

In the meantime, there are successful test specifications, therewith you can prove the existence of especially pushy bacteria. This is useful with dangerous forms of the periodontitis like the form that´s often seen with adolescents, pushy forms with adults and those forms, that are able to resist any treatment. As soon as you get the result of the test specification, one is able to set in an aimed antibiotic.


Why is an operative intervention necessary? The last time my dentist only “scratched”.

After the first treatments one analyses how deep the gingival pockets are. It´s difficult, to clean a deep pocket without having any vision. But if the gum is opened, the surface of the tooth root can be seen and cleaned much more better.

The decision, if an operation is necessary, depends on how deep the gingival pockets are: 5,5 mm are seen as a criterion. But you can´t esteem this as absolute value. Teeth with only one root, like we have them in the front, don´t have to be treated with an operative intervention, even if the gingival pockets are deeper than 5 mm, because one can clean these teeth even without any vision. The teeth much more behind have more than one root and there an operative cleaning under vision has been always useful. Especially the inflammations between the roots of the bigger teeth, the molars (they have two or three roots per tooth), and v-shaped osseous defects are better treated under vision.


When is the right time to treat inflammations of the gum?

Often we see inflammations of the gum only in such a late stage, that the prospects of success aren´t optimal any more (“ 5 minutes to twelve”).Article 20  out of the guideline of the Association of Statutory Health Insurance Physicians tells: “ The prognosis of the periodontitis depends on the moment of treatment. It´s only advantageous, if the treatment starts early.” Cleaning the teeth and removing the debris (even under the gum) is useful with every form of gum inflammations. If the gingival pockets aren´t that deep, one won´t immediately put through an operative intervention.


What´s reachable with such a treatment of the gum?

One can stop an advancing of the inflammation. But tooth supporting tissue and bone, that´s lost once, is only reconstructable with special methods.

Aim of the gum treatment is reaching a tooth supporting tissue without inflammations and impeding the nidation of destructive bacteria. But one can´t see this as a healing up, like we know it from other diseases. The loosened teeth may become a little bit more stable. But they won´t reach such a stable stage, they had before the periodontitis.


If I won´t get a treatment of my periodontitis, what could happen then (out of loosing my teeth earlier)?

Patients with a periodontitis suffer from apoplexies three times more often and getting a heart attack is about 80 %. The risk of a premature birth is higher even six times with pregnant women.

One assumes, that the bacteria in the gum reach into the blood circulation with their metabolism products or their antigens, produced naturally in the body. There the bacteria have an influence on the diseases described above. Furthermore, the digestive tract doesn´t start only in the stomach, but also in the mouth yet. And food, reduced to small pieces, with roughages is important for the organism.

With loosened teeth one can hardly chew food with roughages adequate and therefore one relinquishes.

Another result of periodontitis is bad breath, but that´s out of the medical view not very important: it just makes you “lonely”.


How long will my teeth stay?

This is a frequently asked and justifiable question, that can´t be answered. There´s no measurement telling you something about the prognosis of a tooth.

The periodontitis and therewith the destruction of the tooth supporting tissue goes on in shears. Between these shears, there are often less destructive intervals over some years. Mostly the patient doesn´t recognize such a shear, because it´s seldom connected with feeling pain and bleeding is the only sign, that a patient can perceive (unfortunately faithless with smokers).

The experience shows, that a periodontitis is especially aggressive, if there are bleedings at more than two teeth in the half of one jaw.

As soon as there are less bleedings, the destruction of the bone goes on slowly. Unfortunately, it´s not possible to guarantee the patient not to worry about a further advance of the disease, if there´s no bleeding.

Often the patients think, that the movement of a tooth is also a measurement for how long the tooth stays in the mouth. This assumption is delusory: molars seem to be stable because of their roots (2 or 3), although they are only still less in the bone. On the other hand, teeth in the front, which have become loosened are able to rest in the mouth for a longer time. Important is the age of the patients. A loosened tooth with a 25-years-old patient has a much worse chance than a tooth showing the same movement with a 60- years-old patient.

Another point is the form of the periodontitis. There´s the aggressive form, that is much more dangerous than the periodontitis form often seen with adults showing a slow progress.


I already had such a gum treatment. Why did this inflammation rise up again?


Even a gum treatment, that has been done optimal, only can reduce the number of bacteria with taking away the alimentary base and making it more difficult to start a nidation. But having a gum without pathogens is definitely not possible!

The bacteria will always try to settle down in this area. If you don´t try to work against this development through regular after-

treatments and a good oral hygiene, then the bacteria can settle down again and the gum becomes inflamed.


What can I do on my own?


First of all, you have to practise a good tooth brushing technique. This is grindingly for many. Especially using the dental floss takes a lot of patience. But above all, the space between the teeth is deciding in combating the periodontitis. For an effective oral hygiene some sessions with an individual advice are necessary. Then the technique for brushing teeth is shown and verified. But nowadays of course not schoolmasterly, it´s more like “help for self-help”.


My experiences show a common problem: brushing teeth isn´t practised if there is pain and bleeding, because the patients think, that the inflammation becomes even worse with the alluringness of a tooth brush or with using dental floss.

After the main-treatment regular check-ups after 3-6 months are useful therewith the inflammation doesn´t rise up again. 

Of course other causes, that endanger the tooth supporting tissue, should be fighted against, too (especially smoking).


Which tooth brush is the best one?


Tooth brushes should have rounded bristles, made synthetically. Bacteria can rest a long time on natural bristles. The head of the tooth brush shouldn´t be that big, therewith all areas in the mouth are reachable.


Are the electrical tooth brushes still worse than the manual tooth brushes?


Recently one can negate this question, applied on the new types with rotating bristles. I don´t want to give recommendations for special trade names on the internet. But I can suggest not only to pay attention on the cost price, but also on the prices for the replacement bristles.



Which tooth paste is the best one?


The tooth paste should contain fluorides and less bleaching contents, because these may change the natural surface of the teeth. I buy low-priced tooth pastes from discounters, because the pros and cons of the different contents have been the subject of great controversy among scientists.


Which dental floss should I use?


At the university we still learned, that waxed dental floss should be refused. This is no longer current. With choosing a dental floss, the most important is to be able cleaning one´s teeth simply and effectively. It´s less important, what different studies tell us about the pros. The use of dental flosses out of teflon is simplier. The conventional dental flosses consist out of twisted nylon single grains, which solve easier. But be careful: solving or tearing of the dental floss can also be the result of a rough edge at the tooth. Therefore, I recommend contacting your dentist. He or she may tell you, if the cause is the tooth or your technique while using the dental floss.

There are also special types with the conventional nylon dental flosses, like the superfloss: it improves with it´s different surfaces the cleaning effect. This is very useful under bridges.

But every beginning is hard. Not for nothing, only 2-3 % of the germans use dental floss. This is sad, because dental flosses clean the spaces between the teeth much more better than a tooth brush ever could. Especially in the area between the teeth often arises an inflammation.


I would like brushing my teeth better. But all the time I´m trying it intensively, it starts bleeding or it even hurts!


It´s true, that bleeding is a warning signal. But mostly the irritation with the tooth brush or with the dental floss is not the basic evil, but an advanced inflammation of the gum. In these cases I recommend a check-up at your dentist and a professional cleaning of your teeth by the dentist respectively by his team. As soon as the dangerous inflammation is fighted against, the problems while brushing become better. But there are also cases, where an unfavourable brushing technique intensifies the bleedings. In this case you should also contact your dentist.


It´s always dangerous to throttle brushing teeth because of bleedings and to wait until the problems become better on their own!!!


You can have a look on the internet pages from the association of dentists in Nordrhein, concerning the protection of oneself from tooth diseases:


Prophylaxis is important ”


Which pain should I better be prepared for while being treated?


The operative intervention is put through in local anaesthesia and it is not aching. The pain of the wound is different after the local anaesthesia has stopped taking effect. It depends on the operative complexity. But normally the pain can be suppressed very well with the today´s analgesics.


Which side effects could appear?


After a surgical cleaning of your teeth, they seem to have become a little bit longer. This is related to the inflammation of the gum before the treatment, when the gum had swollen. After the operation, the gum reclines on the taken down bone. This effect may even lead to changes in your pronounciation, because air may come through between the teeth while formatting sounds/while speaking. Furthermore, it may lead to hypersensitive teeth.


In my opinion these possible side-effects should be accepted to save one´s own teeth as long as possible.


Above all I´m interested in the retrogession of the gum and the ugly extension of the teeth. First of all, this should be treated.


Nowadays there are a lot of operation techniques, you can count on with a predictable success. Especially with the operation microscope the success of some techniques have improved.


Although one shouldn´t forget, that this plastic surgery only can be successful, if the new created skin/gum above the tooth is enough bone supported and every namable inflammation reaction has been eliminated before.


Do the teeth become more stable again after the gum treatment?

Often the patient doesn´t recognize a more stable situation after having had a standard therapy, even if special dental equipments (like the so-called Periotest) can verify this. The standard-treatment doesn´t regenerate the lost tissue, it only combats the inflammation.

Reconstruction of bone: vide below



How many sessions will be necessary?


The number of necessary sessions varies very much.

The pre-treatment needs often 3-5 sessions, the surgical intervention 2-4 sessions, the after-treatment further 2-4 sessions and then follow check-ups after 3-6 months. A faithful and successful treatment of periodontitis requires a lifelong care for the patient.




Is it possible to build up gum again, that has been lost, to cover visible parts of the teeth?

Recently there are a lot of proved plastic surgeries, one often utilises while building up gum. Supposition is always a previous successful treatment of the inflammation (vide above). Furthermore, often a new building up of the lost bone is recommended, because a single building up of the gum without building up any bone allows uprising of deep gingival pockets, which are very unfavourable for cleaning……



How can one build up again lost bone?

The dental technique always goes on further. Some years ago, the treatment of the gum was merely a measure to prevent further destruction, but nowadays one knows much more.


By means of building up new bone, one is able to get back some mm´s of the lost bone if the gingival pockets are very steep.


After having removed the inflammation, there are different techniques to build up again the lost bone.


In my opinion, the gold standard is building up new bone with bone of the patient himself from other areas of the jaw, where it isn´t absolutely necessary, e.g. from the area where the wisdom teeth are/were – especially from the upper jaw. But even tooth spaces are qualified to take bone from. Gold standard doesn´t mean, that other methods are worse. In science it means, that other new developed methods have to measure up to the conventional techniques before one asserts to have contrived something new. Furthermore, there´s the possibility to substitute lost bone by replacement material. This serves as place marker for the ingrowing bone and some compounds are said to support the bone building.

Furthermore, one is able to superimpose special films/membranes over those bone funnels.

While the wound healing, the fast proliferating cells of the soft tissue can´t penetrate into the bone cavity and both, the relatively idle bone and the cells that build the tooth supporting tissue, have enough time to spread themselves “without ruffle” in the cavity. The dentist uses for this technique often the abbreviation “GTR”=Guided tissue regeneration. One is able to treat lost bone between the roots of teeth, that have some roots (molars), very well, if the defect of bone doesn´t go on until the other side. Often this method yields a reconstruction of new bone of about 2 mm in a bone funnel, respectively if the funnel is 4 mm or even deeper. More bone reconstruction is rather seldom. You can have a closer look at a detailed explanation concerning this membrane technique under http://www.ukrv.de/ch/paro/spallek/gtrtech.html .

Every new method is verified constantly and scientifically. The DGZMK (Deutsche Gesellschaft für Zahn-Mund- und Kieferheilkunde) always makes official statements on the actual methods.

Less promising is reconstruction bone, that has been lost equably (horizontal lost bone).

The treatment becomes more difficult, if the bone is lost between the roots of the large molars. If the bone loosing isn´t too deep, one can support the reconstruction of the tooth supporting tissue with a membrane.


Recently, one supports the bone healing with special enzymes. Although there are no firmed long-term results for these methods yet, one must have a close look on the development, because interesting and sparing techniques for the patient could be framed. In the meantime, the treatment with special proteins (Emdogain R ) is scientifically respected.

Altogether, the possibilities of gum treatment have enriched obviously in the last years, not only by new techniques but also by view magnifying (e.g. operation microscope), fine instruments and suture materials.



I´ve heard about special liquids, therewith one is able to build up again lost bone without an operation. What do you think about it?


(vide comment about implants)

These substances are like proteins, that support the bone reconstruction. We call them BMP: Bone morphogenetic protein. They exist since about 10 years.

In the meantime, such substances are constituted successfully in the orthopedics. One has to wait when they can be utilised in dentistry.

It´s advisable to have a close look on the development in research here, because there are already good results in studies with animals. The problems are multifaceted. Admittedly in the meantime, one could produce pure human BMP (vide above), but one still has to find a suitable vehicle, which keeps this substance densely at the still healthy bone cells. The vehicle has furthermore to prevent, that BMP arrives at the bloodstream. In the bloodstream BMP is degraded immediately. But as soon as the BMP is used up, the bone regenerating stops instantly.



Does my health insurance fund pay for the treatment?


Perhaps the statutory health insurance pays for the standard treatment like regular pre- and after-treatments and even for the surgical cleaning. Therefore exist undisputed guidelines for dentists and health insurances, which are telling, that the health insurances shouldn´t be encumbered with charges, as soon as saving a tooth or teeth isn´t useful any more because of bad prospects of success.


It´s the case e.g., if the teeth are already movable with the pressure of the tongue or the lips, or if the inflammation has already spread between the roots. But mangling compliance of the patient is an exclusion criterion.

Another supposition for the allowance of a systematical gum treatment through the statutory health insurance is a pre-treatment. This includes the removing of plaque over the gum. This form of pre-treatment has been criticised by the academics more and more in the last time, because the dangerous plaque isn´t located over but under the gum. The private health insurances don´t require this form of pre-treatment.

Special techniques like bone reconstruction with membranes have to be paid privately sometimes. Please inquire after this at your dentist.


Further good pages concerning inflammations of the gum

http://www.zahngesundheit.de/zahn.htm



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