Tooth loss, more reasons to take care of your gums

By PROF DR DASAN SWAMINATHAN

Red, puffy and bleeding gums is a common complaint from patients visiting the dentist. Gums should never bleed even when you brush or use dental floss. If your gums bleed even sometimes, something is wrong. Gums should never be red or swollen.

World Health Organization sources have indicated that a significant proportion of adult populations suffer from some form of periodontal disease, or more commonly known as “gum disease”, and it has even overtaken dental caries as the main cause of tooth loss.

More than 60% of adults in Malaysia tend to suffer from some form of periodontal disease. It is also the main cause of tooth loss amongst our adult population. Oral health professionals in Malaysia are now spending more time treating this disease than before.

The modern era is characterised by longevity and better health, but unfortunately, many adults continue to suffer from periodontal disease, leading to early loss of teeth, and jeopardizing quality of life.

Every day, a sticky, almost invisible film forms on tooth surfaces, which is derived from salivary glycoproteins. If not removed by proper oral hygiene, it matures into what is called plaque, (also called plaque biofilm or oral biofilm), and this biofilm is the primary aetiology of periodontal disease.

If you do not remove this plaque biofilm, it will be contaminated by bacteria, which are found in abundance in the oral cavity. It is said that there are more than 650 species of bacteria present in our mouths, and some of these bacteria can lead to periodontal disease if it multiplies outside the normal range.

Plaque biofilm can be seen particularly at the gingival margins. The bacteria within the plaque biofilm produces toxins that make the gums red, swollen and bleed easily.

This inflammation is the start of periodontal disease.

The toxins produced by the bacterial plaque biofilm not only cause inflammation of the gingival tissue, but also cause destruction of the alveolar bone, which holds the root of our teeth.

When sufficient bone has been lost, the tooth loosens. Finally, when deprived of most of the periodontal ligament and supporting bone, the tooth becomes so loose that it either falls off or has be extracted.

Our immune system, which has a role in targeting the bacteria within the plaque biofilm, can also contribute to the destruction of the tooth-supporting tissue, which will eventually lead to tooth loss.

There are several local and systemic contributing factors that can lead to the initiation and progression of the disease.

Symptoms of gum disease are bleeding gums, migration of teeth, receding gums, mouth malodour (halitosis), taste disturbances and tooth loss as the disease progresses.

Signs of gum disease include inflamed gingiva (gums) and the space between the neck of the tooth and soft tissue known as sulcus becoming deeper, resulting in a term called periodontal pocketing (which harbours multiple anaerobic bacteria causing the destruction of the supporting structures).

There will be radiographic changes indicating the destruction of alveolar bone.

Periodontal disease in the early stages, only involving the supra gingival area, is called chronic gingivitis, and when it proceeds to the roots of teeth via periodontal pocketing, and affects the supporting structures of teeth like the periodontal ligament and alveolar bone, it is called chronic periodontitis.

Gingivitis is reversible if early treatment is sought, but periodontitis is irreversible, and treatment only prevents more damage.

It is unfortunate that what is lost due to the disease (especially bone) is hard to gain back, even with sophisticated dental treatments.

No early signs

In its early stages, periodontal disease is almost painless, and this will prevent many individuals from seeking dental help and intervention.

You may not notice the gradual onset of puffiness of your gingiva or pay attention to occasional bleeding when brushing.

Four out of five teenagers and adults have some form of periodontal disease, and most do not even know it.

That is why people lose more teeth from periodontal disease than from all other reasons combined.

But the good news is that most periodontal disease can be prevented, or treated in its early stages.

Most people have varying resistance to the disease at different times in their lives. For example, a person’s immune system may be normal for years, and then when immunity diminishes, it can cause the “resting” periodontal disease to flare up.

No one knows why our resistance to the disease varies.

Periodontal disease can have an active phase where the disease progresses rapidly, and a “quiet phase” where the disease practically “hibernates” for a certain period of time.

Some experts feel that the immune system of the host plays a major role in these cyclic changes in the progression of the disease.

Periodontal disease and

systemic disorders

Ongoing research and scientific papers over the last decade have linked periodontal disease to systemic conditions like diabetes mellitus, atherosclerosis, cardiovascular diseases, strokes, osteoarthritis, respiratory tract and lung infections, obesity and renal disorders.

These conditions are considered as systemic host-mediating factors that can contribute to the progression of periodontal disease.

Research has now shown that diabetics are more susceptible to gum disease, and gum disease in turn has been implicated in poor glycaemic control in these individuals.

Even some cancers are linked to periodontal disease, and recently, Alzheimer’s disease has also been mentioned.

The exact mechanism whereby this association occurs is still being debated, but it has been suggested that the by-products of periodontal pathogens and the host immune response to this bacterial infection may play a contributory role.

Research and clinical trials conducted at Universiti Malaya’s Faculty of Dentistry on the association of periodontal disease and systemic conditions like diabetes and obesity have shown that there is a link. More research is being carried out to determine this link.

Findings from such research will make the prevention and management of periodontal disease even more important for our patients.

Management of periodontal disease

Periodontal disease is very unpredictable. We think that the disease is caused by a group of bacteria present in our mouth and not by any one particular microorganism.

Thus, it is difficult to develop a vaccine for the disease as several species of microorganisms may be involved in the initiation and progression of the disease.

The main clinical periodontal parameters that dentists assess are the plaque and bleeding scores, and periodontal pocket depths, before we can embark on any non-surgical or surgical interventions.

This will give us information on the stage of disease progression. Radiographic evaluation of the hard structures can also be done to evaluate, among other findings, the alveolar bone levels.

The management of periodontal disease will consist of removing the bacterial plaque biofilm from the mouth, along with any deposits in the supra-gingival and sub-gingival parts of the teeth, and making the roots of the teeth as clean as possible by a procedure known as scaling and root planning/debridement.

Scaling and root planning/debridement aims to reduce the bacterial load in the mouth by removing deposits that are contaminated by bacteria.

Local contributing factors like overhanging restorations, ill-fitting prosthesis, carious lesions and malocclusion can act as traps for bacterial plaque biofilm and have to be addressed.

The bacterial plaque biofilm can become calcified (if not removed regularly) into hardened calculus (tartar). Calculus can also harbour plaque biofim due to its rough surface, and its removal has to be done professionally because of its tenacity.

The systemic host-mediating factors may require referral to our medical colleagues, if the patient is not under medical care.

To maintain this lowered level of bacterial load, it is imperative that patients practise proper oral hygiene. Oral hygiene education has now become an important and integral aspect of periodontal therapy, and should be reinforced at every visit and review.

Mouth rinses like chlorhexidine, which have antibacterial effects, can be used as an adjunct to mechanical oral hygiene methods like tooth brushing and flossing.

These mouth rinses are especially useful in individuals with poor manual dexterity, such as patients who have had a stroke.

It is also useful in patients who have undergone periodontal and maxillofacial surgery to look after their oral hygiene during the post-surgical phase.

I would advocate antimicrobial mouth rinses for any individual who has issues maintaining their mechanical plaque control.

The prevention of periodontal disease is literally in our hands, and together with oral health professionals, we can try and identify the disease early and prevent it from causing damage to tooth-supporting tissue, thus, preventing tooth loss and improving our quality of life.

We should make regular visits to the dentist and we should treat oral health as an important aspect of our lives. (The Star/ANN)

Prof Dr Dasan Swaminathan is a specialist periodontist. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice.