What is periodontal disease?

Periodontal disease (gum disease) is one of the top global oral health concerns as stated by WHO. Around 80–90% of the adult population has some form of gum disease, of which 50% has the advanced form, known as periodontitis.

Periodontal disease is a bacterial infection involving inflammation of the tissues that surround and support the teeth. It is caused by bacteria in dental plaque, which is a soft, sticky film that is formed on the tooth surface. Dental plaque can be removed by tooth brushing.

With time, plaque may harden into calculus (tartar). Calculus is rough, causing more plaque to attach to it. If it is not removed, the bacteria can cause inflammation around the gum. This is the initial form of gum disease, known as gingivitis. Gingivitis is reversible with good and effective plaque control.

Gingivitis, if not treated, leads to further progression whereby the by-products of the bacteria (endotoxins) cause further destruction to the supporting structure of the tooth. This results in bone loss and pocket formation (periodontitis).

Timely detection and treatment of the disease can help to arrest destruction and restore gum health. Periodontitis will eventually lead to tooth mobility and loss if left untreated.

What are the signs of periodontal disease?

Healthy gingiva:
Pink, evenly scalloped, firm
Does not bleed on brushing

Gingivitis:
Gum that bleeds easily on brushing
Red and swollen gums
May otherwise be painless and look normal

Periodontitis:
Red and swollen gums, may be accompanied by pain
Shaky teeth, shifting of teeth
Receding gums, longer-looking teeth
Abscess (gum boil) or pus
Bad breath

Initial progression of periodontal disease may not have obvious signs and symptoms. Procrastination in addressing the initial tell-tale signs, or postponing dental visits, may lead to adverse and irreversible loss of the supporting tooth structure. The key is regular dental visits to your dentist for early detection.

Is periodontal disease related to my systemic health?

There is increasing evidence suggesting the association of periodontal disease with cardiovascular disease. Periodontal bacteria can have a direct effect by entering the bloodstream or indirectly cause an increase in the inflammatory burden of the body system. These may aggravate cardiovascular events.

Other factors that have established causative effect on periodontitis are diabetes and smoking.

Diabetes:
Diabetics have 2 to 3 times greater risk of developing periodontal disease
Severe periodontitis in patients with diabetes may lead to higher blood sugar levels and poorer glycaemic control
Diabetics with severe periodontitis are also at higher risk of complications such as heart attack, stroke, and eye and kidney damage
Severe periodontitis increases risk of developing pregnancy (gestational) diabetes
Treatment of periodontal disease can help to improve glycaemic control. Improving gum health can help to control diabetes and lower your risk of complications

Smoking:
Severity of periodontal disease increases with the extent and number of years of smoking
Smokers have poorer response to periodontal treatment
Chances for recurrence of periodontal disease after treatment is higher in smokers; therefore, regular long-term periodontal maintenance is important in achieving a stable outcome

Other systemic conditions that may have an influence on periodontal disease:

What are the available treatments for periodontal disease?

Non-surgical treatment:

Scaling and Root Planing refers to the cleaning of teeth and root surfaces. While scaling takes care of the superficial deposits, root planing gets to the root of the problem well below the gums.

In carrying out root planing, the Periodontist (gum specialist) uses special instruments that are designed to reach the bottom of your gums to remove hidden deposits, with the objective of reducing toxins on the root surface to a level compatible with health. The procedure is often done with local anaesthesia.

Surgical treatment:

There are various surgical procedures. Your periodontist may advise and indicate surgery depending on your disease presentation.

Open Flap Debridement:
To gain access to sites which are inaccessible via non-surgical cleaning. It may be due to deep pockets beyond the reach of instruments, or fissures and concavities on the root surfaces. This procedure involves the reflection of the gums for direct access and instrumentation of the root surface. Long-term objective is to create shallow pockets which facilitate plaque removal and infection control.

Regenerative Procedures:
To reduce pocket depth and to re-establish periodontal health through reconstruction of tooth-supporting tissue. This procedure is selectively carried out in sites whereby the tooth-supporting bone loss is angular, allowing graft materials to be contained.

Root separation and resection:
The indication for this procedure is a multi-rooted tooth with infection that is confined to a single root. Remaining root/roots will need to have a good level of healthy supporting structure. The infected root is surgically removed, leaving the other root/roots behind. Prior to the surgery, the tooth will require root canal treatment to prevent infection of the root canal system.

Soft-tissue re-contouring:
This procedure is targeted at sites with uneven gum margin, commonly due to drug-induced gingiva overgrowth. It may also be needed in sites with gingiva recession as a result of detrimental oral hygiene habits such as excessive tooth brushing and flossing. The uneven gum margins are evened out either through resection or soft tissue grafting.

What can I expect from periodontal treatment?

A. Non-surgical treatment

The initial treatment, which may consist of a few visits, will be to remove the tartar around your teeth by scaling and polishing. In this treatment, an ultrasonic instrument is held against the tooth to dislodge the deposits. The duration of treatment depends on the extent and tenacity of the deposits on your teeth. It can be long and uncomfortable if you have not had scaling for some time. This treatment is often accompanied by bleeding, which in fact is a sign of gum disease.

You may experience increased tooth sensitivity for a period of time, as the root of the tooth will become more exposed to the oral environment. Instrumentation carried out during gum treatment invariably causes the infected parts of the gums to be abraded and can leave your gums sore for a few days after treatment.

B. Surgical treatment

Surgery may be indicated if signs of inflammation persist after non-surgical treatment. Prior to commencing this stage, meticulous daily upkeep of your oral hygiene should be in place to ensure optimal surgical outcome. All periodontal surgeries are carried out under local anaesthesia, where the teeth involved and the surrounding tissues will be anaesthetised and you remain fully conscious.

Ultrasonic instruments will be used to remove residual debris on the exposed root surfaces. Uneven supporting bone may be levelled or the defects grafted, depending on assessment by your periodontist during surgery. Stitches of the surgical site will be done, and periodontal dressing may be placed to stabilise and protect the wound.

A review is scheduled usually a week later to remove this dressing and the stitches. Maintaining good daily oral hygiene is important during this healing period. Smoking should be avoided, as it has been shown to impair periodontal healing.

C. Maintenance

Your daily routine of tooth brushing and flossing is the key to having healthy gums. Your periodontist/dentist will go through with you the techniques of getting this done correctly if you have not been doing so.

As the onset or continued development of gum disease is often insidious and silent, you are encouraged to visit your periodontist/dentist regularly.