| * Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does not advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is very detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.
IS PERIODONTAL DISEASE?
In order to clarify
the various aspects and progression of the disease, an understanding
of the anatomy of the region is helpful:
The region of
the mouth that consists of the gum and supporting structures is
called the periodontium. It is made up of the following parts:
- Gum (
gingiva). When healthy, the gingiva is pale pink, firm,
and immobile, with a smooth or stippled texture. The gingival
tissue between abutting teeth is shaped like a pyramid ending
in a peak.
- The crevice
between the gum and tooth (the sulcus).
- Root surface
The crest of the supporting bone, which can be viewed on x-rays,
is normally two millimeters below the point where the crown
of the tooth meets the root (the cementoenamel junction).
refers to a group of problems that arise in the gum sulcus, the
crevice between the gum and the tooth. Even in healthy mouths, the
sulcus is teeming with bacteria, but they tend to be harmless varieties.
Periodontal disease develops usually because of two events in the
In general, the
process that causes disease is as follows:
- An increase
in bacteria quantity.
in the balance of bacterial types from harmless to disease-causing
bacteria. [See What Causes Periodontal Disease?]
are generally divided into two groups:
bacteria increase in mass and thickness until they form a film
known as plaque.
- In healthy
mouths, plaque itself actually provides some barrier against
outside bacterial invasion. When it accumulates to excessive
levels, however, plaque adheres to the surfaces of the teeth
and adjacent gingiva and causes cellular injury, with subsequent
swelling, redness, and heat.
- When plaque
is allowed to remain in the periodontal area, it transforms
into calculus (commonly known as tartar).
- This material
has a rock-like consistency and adheres tenaciously to the tooth
surface. The color and hardness vary depending on the age of
the material and extrinsic factors, such as tobacco use. It
is much more difficult to remove than plaque, which is a soft
produces injury and inflammation that eventually destroys the
support structures and bone and can lead to tooth loss.
which causes lesions (wounds) that affect the gums.
which damages the bone and connective tissue that supports the
an inflammation of the gingiva, or gums. Is nearly always chronic,
but an acute form infrequently occurs.
Chronic Gingivitis . Ordinary chronic gingivitis affects
over 90% of the population. It characterized by tender, red, swollen
gums that bleed easily and may be responsible for bad breath ( halitosis)
in some cases. Treatment is very effective if initiated early in
the course of gingivitis. Without good management, however, the
problem can progress.
is characterized by the following:
periodontitis, although it doesn't always lead to this more severe
condition. In fact, some experts believe it is an entirely different
disease. There are different categories of periodontal disease,
including the following:
- Gum inflammation,
with redness and bleeding.
- Deep pockets
(greater than 3 millimeters in depth) form between the gum and
teeth, caused by loss of connective tissue structures and bone.
Chronic Periodontitis. Chronic periodontitis (also referred
to as adult periodontitis) may begin in adolescence as a slowly
progressing disease that becomes clinically significant in the mid-30's
and continues throughout life. Some experts question whether it
is a chronic unrelenting condition and suggest instead that it waxes
and wanes depending on the response of the immune system in fighting
the bacteria causing this disease.
Aggressive Periodontitis. Aggressive periodontitis (also
referred to as early onset periodontitis) often occurs in young
people. It is subdivided according to whether it begins before or
after puberty. Immune deficiencies and a genetic link have been
shown to be possible factors for all types of aggressive periodontitis.
If the condition is localized and treated, the outlook is positive.
People with severe and widespread aggressive periodontitis are at
high risk for tooth loss. It is notable that according to a study
in 2001, impaired infection-fighting white blood cells, together
with bacterial presence, can lead to aggressive periodontitis.
Periodontitis. Periodontitis can also be associated with a
number of systemic diseases, including type I diabetes mellitus,
Down's syndrome, AIDS, and several rare disorders of white blood
periodontitis is a very rare condition that begins with the
eruption of primary teeth in the first year and causes severe
inflammation and bone and tooth loss.
periodontitis (formerly known as periodontosis) begins at puberty
and is defined by severe bone loss around the first molars and
incisors. It is more common in girls than in boys. The clinical
signs such as inflammation, bleeding, and heavy plaque accumulation
are not present in this relatively rare disease. The treatment
is the same as in chronic periodontitis.
progressive periodontitis occurs in the early 20's to middle
30's. Severe inflammation and rapid bone and connective tissue
loss occur, and tooth loss is possible within a year of onset.
Acute Necrotizing Periodontal Disease. Acute necrotizing
periodontal diseases is an acute infection in the gums. It is characterized
by the following:
diet, smoking, and viral infections are predisposing factors for
dead tissue (necrosis).
onset of pain.
- Bad odor.
- The gum
tissue between the teeth, normally cone-shaped, is blunted.
ARE THE SYMPTOMS OF PERIODONTAL DISEASE?
In general, symptoms
progress over time and include the following:
Pain is usually
not a symptom, which partly explains why the disease may become
advanced before treatment is sought and why some patients avoid
treatment even after periodontitis is diagnosed.
and Swollen Gums . Initially, the gums are red and swollen
as in gingivitis.
Bleeding. Bleeding of the gums, even during brushing, is
a sign of inflammation and the major marker of periodontal disease.
One exception is juvenile periodontitis, in which symptoms are
mild or even absent. It should be noted that the gums of smokers
with periodontal disease tend to bleed less than nonsmokers.
Breath. Debris and bacteria can cause a bad taste in the
mouth and persistent bad breath.
Recession and Loose Teeth. As the disease advances the gums
recede, and supporting structure of bone is lost. Teeth loosen,
sometimes causing a change in the way the upper and lower teeth
fit together when biting down or a change in the fit of partial
Deepening periodontal pockets between the gums and bone can
become blocked by tartar or food particles. The infection fighting
white blood cells become trapped and die. Pus forms and an abscess
develops. Abscesses can destroy both gum and tooth tissue, cause
nearby teeth to become loose and painful, and may cause fever
and swollen lymph nodes.
CAUSES PERIODONTAL DISEASE?
is marked by inflammatory injuries (called lesions) from calculus,
a hard substance that forms from plaque, which is essentially bacterial
In the healthy
mouth, more than 350 species of microorganisms have been found.
Periodontal infections are linked to fewer than 5% of these species.
Healthy and disease-causing bacteria can generally be grouped into
Among the bacteria
most implicated in periodontal disease and bone loss are the following:
- The harmless
or helpful bacteria are usually known as gram positive aerobic
- In periodontal
disease, the bacterial balance shifts over to gram negative
anaerobic bacteria . Inflammatory disease and injury cannot
develop without these bacteria.
are related to gingivitis, but not plaque development. They include
various streptococcal species.
(A.) actinomycetemcomitans and Porphyromonas (P.) gingivalis.
These two bacteria appear to be particularly likely to cause
aggressive periodontal disease. In one study, both P. gingivalis
and A. actinomycetemcomitans, along with multiple
deep pockets in the gum, were associated with resistance to
standard treatments for gum disease. In another study, P.
gingivalis doubled the risk for serious gum disease. Particularly
virulent strains of this bacteria may be responsible for periodontal
disease. A 2001 study suggests that the P. gingivalis
produces enzymes, such as one called arginine-specific cysteine
proteinase, which may be the specific destructive factors that
disrupt the immune system and lead to subsequent periodontal
connective tissue destruction.
(B.) forsythus is also strongly linked to periodontal
bacteria associated with periodontal disease are T. denticola,
T. sokranskii and P. intermedia . These bacter, together
with P. gingivalis , are frequently are present at the
same sites, and are associated with deep periodontal pockets.
Autoimmune and Inflammatory Response
suggests that periodontal disease may be an autoimmune disorder
, in which immune factors in the body attack the person's own
cells and tissue--in this case, those in the gum. It appears to
work as follows:
that this inflammatory response may have damaging effects not only
in the gums but also in organs throughout the body, include the
heart. [See How Serious is Periodontal Disease?]
- The bacteria
that form plaque and tartar release toxins that stimulate the
immune system to over produce powerful infection-fighting factors
cytokines are important for healing. In excess, however, they
can cause inflammation and severe damage.
of particular importance in periodontal disease are known as
tumor necrosis factor-alpha (TNF-alpha) and interleukin interleukin-1beta
and interleukin 4 (IL-1 and IL4), which are very active in the
- In excess,
these cytokines overproduce an enzyme called collagenase, which
breaks down proteins, including the connective tissue that holds
teeth in place.
(herpes simplex and varicella-zoster virus, the cause of chicken
pox and shingles) are known causes of gingivitis. A 2000 study found
that other herpes viruses (cytomegalovirus and Epstein-Barr) may
play a role in the onset or progression of some types of periodontal
disease, including aggressive and severe chronic periodontal disease.
All herpes viruses go through an active phase followed by a latent
phase and possibly reactivation.
Some experts hypothesize that these viruses may cause periodontal
disease in different ways, including release of tissue-destructive
cytokines, overgrowth of periodontal bacteria, suppressing immune
factors, and initiation of other disease processes that lead to
GETS PERIODONTAL DISEASE?
conditions cause gum inflammation and ulcers, not all people develop
periodontal disease. Certain factors put individuals at higher risk
Lack of Oral
Hygiene. Lack of oral hygiene encourages bacterial build-up
and plaque formation.
Sugar and Acid. The bacteria that cause periodontal disease
thrive in acidic environments. Therefore, eating sugars and other
foods that increase the acidity in the mouth increase bacterial
Poorly Contoured Restorations. Poorly contoured restorations
(fillings or crowns) that provide traps for debris and plaque can
also contribute to its formation.
Anatomical tooth abnormalities. Abnormal tooth structure
can increase the risk.
Adolescents. Gingivitis, in varying degrees, is nearly a universal
finding in children and adolescents. In rare genetic cases, children
and adolescents are subject to destructive forms of the disease.
Researchers have also observed some of the organisms seen in periodontal
disease in young children without signs of gum problems. Healthy
children, however, do not, generally harbor two primary periodontal
bacteria, P. gingivalis and T. denticola .
The disease is also uncommon in teenagers. According to one survey,
only 1% of 14 to 17 year olds have any sign of actual periodontal
Adults. One survey reported that 3.6% of adults between the
ages 18 and 34 had periodontal disease. A 2000 New Zealand study,
however, reported that one in seven 26 year olds (about 14%) had
signs of well-established periodontal disease. (It should be noted
that populations may differ in their risk.) As people age, the risk
for peridontal disease increases. Over half of American adults have
gingivitis surrounding three to four teeth and 30% have significant
periodontal disease surrounding an average of three to four teeth.
In a study of people over 70 years old, 86% had at least moderate
periodontitis and over a quarter of them have lost their teeth.
of periodontal office visits are made by women, even though women
tend to take better care of their teeth then men do. Female hormones
affect the gums, and women are particularly susceptible to periodontal
Before Menstruation. Gingivitis may flare up in some women
a few days before they menstruate when progesterone levels are high.
Progesterone dilates blood vessels causing inflammation, and blocks
the repair of collagen, the structural protein that supports the
Pregnancy. Hormone-influenced gingivitis appears in some
adolescents, in some pregnant women, and is occasionally a side
effect of birth control medication. During pregnancy gum inflammation
typically develops around the second month and reaches a peak in
the eighth month. It usually resolves after delivery. (It should
be noted that existing periodontal disease in pregnant women may
actually have some harmful effects.) [ See Pregnancy under
How Serious is Periodontal Disease?]
Oral Contraceptives. One study reported that taking oral
contraceptives containing the synthetic progesterone desogestrel
(but not dienogest, another common progesterone) increased the risk
for periodontal disease.
Menopause. During menopause, some women may develop a rare
condition called menopausal gingivostomatitis, in which the gums
are dry, shiny, and bleed easily. At that time, women may experience
abnormal tastes and sensations (eg, salty, spicy, acidic, burning)
in the mouth. Osteoporosis is related to estrogen loss after menopause
and is also associated with bone loss. [ See Osteoporosis
often occurs in members of the same family. Genetics, intimacy,
hygiene, or a mixture of factors may be responsible. Studies have
found that children of parents with periodontitis were 12 times
more likely to have the bacteria thought to be responsible for causing
plaque and, eventually, periodontal disease.
Genetic Factors. According to a 2000 study, not environment
or poor hygiene, but genetic factors may play the critical role
in half the cases of periodontal disease. Up to 30% of the population
may have some genetic susceptibility to periodontal disease. For
example, some people with severe periodontal disease have genetic
factors that affect an immune factor known as interleukin-1 (IL-1),
a cytokine involved in the inflammatory response. Such individuals
are up to 20 times more likely to develop advanced periodontitis
than those without such genes. Early onset and rapidly progressive
periodontal disease also have strong genetic components.
Intimacy. Intimate partners and spouses of people with periodontal
disease may also be at risk. Researchers have found that the bacteria
P gingivalis may be contagious after exposure to an infected
person over a long period of time. There is no risk from short exposure,
such as after a fast kiss or when sharing an eating utensil.
Smoking is the
single major preventable risk factor for peridontal disease, and
can cause bone loss and gum recession even in the absence of periodontal
disease. A number of studies indicate that smoking and nicotine
increase inflammation by reducing oxygen in gum tissue and triggering
an over-production of immune factors called cytokines (specifically
ones called interleukins), which in excess are harmful to cells
Furthermore, when nicotine combines with oral bacteria, such as
P. gingivalis , the effect produces even greater levels
of cytokines and eventually leads to periodontal connective tissue
breakdown. Studies suggest that smokers are 11 times more likely
than nonsmokers to harbor the bacteria that cause periodontal disease
and four times more likely to have advanced periodontal disease.
In one study over 40% of smokers lost their teeth by the end of
The risk of periodontal disease increases with the number of cigarettes
smoked per day. Smoking cigars and pipes carries the same risks
as smoking cigarettes. Exposure to second-hand smoke is also associated
with a 50% to 60% increased risk for developing periodontal disease,
according to a 2001 study. Fortunately, when smokers quit, their
periodontal health gradually recovers to a state comparable to that
Associated with Periodontal Disease
Much evidence exists on the link between diabetes type 1 and
2 and periodontal disease. People with these diseases have 15 times
the risk of the nondiabetic population. Diabetes causes abnormalities
in blood vessels and high levels of specific inflammatory chemicals,
such as interleukins, that significantly increase the chances of
periodontal disease. High levels of triglycerides (which are common
in type 2 diabetes) appear to impair periodontal health. A high
blood sugar level, which is the hallmark of diabetes, has even been
associated with severe periodontal disease in people without
diabetes, according to a 2000 study. Obesity, which is common in
type 2 diabetes, may also predispose a person to gum disease. Studies
in 1999 and 2000 suggest controlling both type 1 and 2 diabetes
may also help reduce periodontal problems.
Osteoporosis. Osteoporosis (loss of bone density) has been
associated with periodontal disease in postmenopausal women. There
is some evidence that some treatments for osteoporosis, such as
bisphosphonates, may reduce bone loss, including the bony structures
that support the teeth.
Herpes-Related Gingivitis. Herpes virus is a common cause
of gingivitis in children and has become increasingly common in
adults. It typically starts out with a purplish color and "boggy"
sensation in the gums (especially inside). Multiple blisters may
form across the mucus membranes in the mouth and gums, followed
by ulcers. They usually resolve in seven to 14 days.
HIV-Associated Gingivitis. HIV-associated gingivitis has
been reported in 15% to 50% of patients with AIDS. HIV positive
individuals harbor larger numbers of periodontal bacteria (candida
albicans, P. gingivalis, black-pigmented anaerobic rods, and A.
actinomycetemcomitans) than people without HIV. Severe pain is characteristic,
along with odor, spontaneous bleeding, ulcers, and swollen, bright
red gums. The inflammation never recedes, but halitosis and acute
episodes can be managed by conventional cleaning treatments. Its
severest form, known as necrotizing stomatitis, can be diagnostic
for AIDS; in addition to bleeding, the gums in the front of the
mouth are a yellowish-gray color, and bone thrusts out.
Other Diseases. Autoimmune conditions (eg, Crohn's disease,
rheumatoid arthritis, lupus erythematosus, CREST syndrome) have
been associated with a higher incidence of periodontal disease.
Other diseases associated with periodontitis include leukemia and
other cancers, tuberculosis, syphilis, Wegener's granulomatosis,
amyloidosis, and many genetic disorders.
Vitamin C Deficiencies
Vitamin C helps the body repair and maintain connective tissue,
and its antioxidant effects are important in the presence of tissue-destroying
oxidants in periodontal disease. A large 2000 study found that people
who consumed less than the recommended daily allowance of vitamin
C, 60 mg (about one orange), were one and a half times more likely
to develop severe gingivitis than those who consumed more than 180
mg of vitamin C per day. (It should be noted that smoking also depletes
vitamin C supplies.)
Socioeconomic, and Geographic Factors
is most likely to affect the poor. Children and the elderly suffer
the worst oral care, and ethnic minorities follow. A 2002 study
reported that the amount of oral bacteria was greater in people
who visited their dentist least and when educational levels were
low. Ethnicity played no role. It is distressing enough that 44
million Americans lack medical insurance, but almost two and a half
times that number (108 million Americans) lack dental insurance.
In one survey in five states (Arizona, California, Hawaii, Oregon,
and Wisconsin), the rate of total tooth loss was less than 20%,
while in three states (Kentucky, Louisiana, and West Virginia) it
was greater than 40%.
can be a side effect of nearly twenty different drugs, most commonly
phenytoin (Dilantin), cyclosporine (Sandimmune), and a short-acting
form of the calcium channel blocker nifedipine (Procardia).
Other Causes of Gum Inflammation
A number of other conditions can also cause gum inflammation, and
some have been associated with periodontal disease. They include
stress. A review of studies in 2000 that investigated the association
between psychological stress and periodontal disease confirmed
the impact of stress on the immune system. Thus, stress can
probably influence chronic inflammatory diseases, like periodontitis.
Psychological stress should therefore be assessed before and
during treatment. As of yet, however, there is no definite proof
of that stress leads to periodontal disease.
sores (aphthous ulcers).
in psychologically disturbed patients.
gingival fibromatosis. A rare genetic disease associated with
both gum overgrowth and hairiness. It is often associated with
gingivitis and periodontal disease.
gingivitis. With this condition the outer layer of the gum tissue
desquamates (peels away), exposing an acutely red surface. It
usually occurs as a result of an allergic reaction or of skin
diseases such as lichen planus, benign mucous membrane pemphigoid,
bullous pemphigoid, and pemphigus vulgaris (although one study
also suggested that bacteria may play role in this gum disease
as it does in more common forms). This condition generally resolves
when the allergic reaction or skin disease is treated and clears
up. It is fairly common in middle-aged women.
SERIOUS IS PERIODONTAL DISEASE?
outcome of uncontrolled periodontal disease is tooth loss. As the
destructive factors cause the breakdown of bone and connective tissue,
there remains no anchor for the teeth.
A much less severe
but nevertheless distressing problem caused by periodontal disease
is bad breath, although coatings on the tongue may contribute more
to bad breath than even periodontal disease.
Disease and Stroke
have reported a one and a half- to four-fold increased risk for
heart disease in people with periodontal disease. (The four-fold
risk was in men with extensive gum disease, bleeding from every
tooth.) In one study, 85% of heart attack patients had periodontal
disease compared to 29% of people with no heart problems. Periodontal
disease has also been associated with stroke. In addition, high
cholesterol blood levels have been associated with both chronic
periodontal disease and coronary artery disease.
Recent evidence is pointing to the inflammatory response as the
common element. This is an over-reaction of the immune system that
causes injury to tissues in the body. A common link between patients
with both heart conditions and periodontal disease may be elevated
levels of C-reactive protein (CRP), a marker for the inflammatory
response. Some experts believe, then, that immune factors causing
this response are released into the blood stream during periodontal
disease and cause injury in the arteries supplying blood to the
heart. Other evidence suggests that the bacteria itself, particularly
P. gingivalis, may play a direct role in arterial injury.
Treating and eliminating periodontitis does not appear to have any
effect on preventing heart disease, however. Some experts believe
that there is no actual causal relationship, but that common factors
induce inflammation and damage resulting in diseases in the blood
vessels and in the gums. Studies in 2000 and 2001 suggest that the
only significant association between periodontal disease and heart
disease is a socioeconomic one. In the 2000 study, for example,
patients who had both conditions were more likely to be poor, African
American, older, and overweight. They were also more likely to have
other risk factors for heart disease, including smoking and diabetes.
Diabetes is not
only a risk factor for periodontal disease, but periodontal disease
may exacerbate or even cause diabetes. Some evidence has suggested
that the bacteria causing periodontal disease may enter the blood
stream and activate cytokines, the damaging factors in the immune
system, which then may even destroy cells in the pancreas, where
insulin is produced. One study found that treating periodontal disease
reduced the need for insulin in some people with diabetes.
on Respiratory Disease
reproduce in the mouth can also be carried into the airways of throat
and lungs, increasing the risks for respiratory diseases and worsening
chronic lung conditions, such as emphysema.
infections that cause moderate to severe periodontal disease in
pregnant women may also increase the risk of premature delivery
and low birth weight infants. Research indicates that the bacteria
from periodontal disease may trigger the same factors in the immune
system as genital and urinary tract infections do. These biologic
substances called prostaglandins and tumor necrosis factor produce
inflammation in the cervix and uterus that can cause premature dilation
and contractions. Some experts recommend that women have a periodontal
examination before becoming pregnant or as soon as possible thereafter.
Because women with diabetes are at higher risk for periodontal disease,
it is particularly important for diabetics to see a dentist early
CAN PERIODONTAL DISEASE BE PREVENTED?
and good oral hygiene are critical in preventing gum disease. Regular
and effective tooth brushing and mouth washing, however, are effective
only above and slightly below the gum line. Once periodontal disease
develops more intensive treatments are needed.
It is important
to reduce both the quantity, and in particular the frequency,
of sugar intake. Snacks and drinks should be free of sugars (other
than natural sugars found in fruits and vegetables); sugar-containing
foods should be consumed with meals and ideally followed by brushing.
Since fruit juices can also cause tooth erosion in children, milk
and water use should be emphasized.
Smoking may play
a significant role in over half the cases of chronic periodontal
disease, according to research published in 2000. For smokers, quitting
is one of the most important steps toward regaining periodontal
in children has helped to account for the decline in periodontal
disease in adults. Because fluoride prevents decay, back molars,
which keep the teeth in place, are spared, and are thus less vulnerable
to bacteria. Even before teeth first erupt, babies' gums should
be wiped clean with a bit of gauze bearing a dab of fluoride toothpaste.
Supplementation with fluoride tablets or drops may be recommended
for children 6 months or older who drink unfluoridated water or
who are at risk for dental problems. A prescription from the child's
pediatrician or dentist is required.
Some dentists recommend a fluoride gel for adult patients who are
still at risk for tooth decay or sensitivity, but extra fluoride
is generally not necessary for adults who use fluoride toothpaste.
is a silent disease; individuals rarely experience pain and may
not be aware of the problem. A periodontal examination by a general
dentist once or twice a year should reveal any incipient or progressive
problems. A full mouth series of x-rays is advised every two to
three years. This will alert the dentist to early bone loss and
other disorders of the oral cavity.
Dentists now often perform Periodontal Screening and Recording (PSR)
using a probe to measure gum pockets. This procedure used to be
performed only by periodontists but is now encouraged as part of
a regular dental examination. The dentist will identify any areas
where deep pocketing has occurred, where the health of the gingiva
appears compromised, and where there is undue mobility of teeth.
It is the general dentist's responsibility to identify periodontal
disease and inform the patient. If the condition is severe, the
dentist may want to refer the patient to a periodontist. [ See
What Will Confirm a Diagnosis of Periodontal Disease?, in
this report. ]
brushing, mouth cleansing, and flossing should be everyone's defense
against periodontal disease.
Brushing Guidelines. The following are some recommendations
If brushing after
each meal is not possible, rinsing the mouth with water after eating
can reduce bacteria by 30%.
use a dry brush. One study reported that when people brushed
their teeth without toothpaste first, using a soft dry brush,
their plaque deposits were reduced by 67% and gum bleeding dropped
- No brush
of any size, shape, or gimmick is effective if it is incorrectly
positioned in the mouth. Place the brush where the gum meets
the tooth, with bristles resting along each tooth at a 45-degree
by dry brushing the inside the bottom row of teeth, then the
inner top teeth, and last the outer surfaces.
the brush back and forth so the bristles extend under the gum
the broad, biting surfaces of the back teeth.
- Dry brushing
should take about a minute and a half.
- A paste
is then applied and the teeth should be rebrushed in the same
- The tongue
should be scrubbed for a total of about 30 seconds. A tongue
scraper used with an anti-bacterial mouthwash (such as Listerine)
is more effective than a toothbrush in removing bacteria.
- One should
rinse the toothbrush thoroughly and then tap it on the edge
of the sink at least five times to get rid of debris. (It should
be noted that detergents in toothpaste that remain on the brush
may help prevent bacterial contamination of the brush.)
should finish the process. A mouthwash may also be used. [For
these processes, see below.]
Toothbrushes. A vast assortment of brushes of varying sizes
and shapes are available, and each manufacturer makes its claim
for the benefits of a particular brush. Toothbrushes should be replaced
every month. Not only do they become breeding grounds for bacteria,
but the worn bristles are less effective at removing plaque.
People should look for the American Dental Association (ADA) seal
on both electric and regular brushes.
For individuals with average dexterity, a four- or five-rowed, soft,
nylon-bristled toothbrush is sufficient.
Electric toothbrushes, particularly those with a stationary grip
and revolving tufts of bristles, can be advantageous for some people
with physical disabilities. They include the following:
however, that if a regular toothbrush works, then it isn't necessary
to buy an expensive electric one.
toothbrushes with heads that move back and forth up to 4,200
times a minute remove significantly more plaque than ordinary
brushes. Brands are Bausch & Lomb's Interplak, Braun's Oral-B
Plaque Remover, and Water Pik's Plaque Control.
- Even more
high-tech brushes are now available that use sound waves to
remove plaque. Brands include Sonicare, SenSonic, Soniplak,
and UltraSonex. One study showed considerable improvement in
groups using sonic toothbrushes, particularly in those with
moderate periodontal disease.
The most important factor in buying any toothbrush, electric or
manual, is to choose one with a soft head. Soft bristles get into
crevices easier and do not irritate the gums. One study found that
those who used a soft toothbrush had 4.7% of exposed tooth below
the gum line compared to 9.4% with hard brush users. A useful toothbrush
called Alert has been developed that flashes a red light when too
much pressure is being placed on the gums.
Toothpaste. The object of a good toothpaste is to reduce
the development of plaque and eliminate periodontal causing microorganisms
without destroying the organisms that are important for a healthy
mouth. All brands should show ADA approval. Even a good toothpaste,
however, cannot be delivered past 3 millimeters below the gum line,
where periodontitis develops.
Toothpastes are a combination of abrasives, binders, colors, detergents,
flavors, fluoride, humectants, preservatives, and artificial sweeteners.
Highly abrasive toothpastes should not be used, especially by individuals
whose gums have receded.
Active agents contained in toothpastes may include the following:
The value of many mouthwashes is highly controversial. Many have
only temporary antibacterial value. Some can even harm the mucus
membrane and they can be dangerous to children who drink them. Those
that are considered plaque fighters are chlorhexidine and Listerine,
which is available over the counter.
Most commercial toothpastes contain fluoride, which both strengthens
tooth enamel against decay and enhances remineralization of
the enamel. Fluoride also inhibits acid-loving bacteria, especially
after eating, when the mouth is more acidic. Some argue that
this antibacterial activity may help control plaque.
Colgate's Total toothpastes contain both fluoride and triclosan.
Total is the first FDA approved toothpaste for the prevention
of tooth decay, gingivitis, and plaque. Triclosan remains in
the mouth after use and is an extremely potent anti-bacterial
agent. Of some concern, however, are studies reporting development
of bacteria resistant to triclosan. More studies are needed.
salts. Metal salts, such as stannous and zinc, serve mostly
as anti-bacterial agents in toothpastes. Stannous fluoride gel
toothpastes do not reduce plaque, however, even though they
have some effect against the bacteria that cause it, but slightly
reduce gingivitis. Such toothpastes can cause staining that
requires professional cleaning. Crest Plus Gum Care contains
a stabilized form of stannous fluoride. Studies conducted by
the manufacturer suggest that is has antibacterial activity
and that it might be more effective than Colgate's Total in
reducing gingivitis and bleeding.
extracts (such as sanguinarine). Viadent toothpaste and mouthwash
contain an anti-bacterial herbal extract called sanguinarine.
The two products provide minimal results when used individually,
but if the mouthwash and toothpaste are used together they have
produced plaque reductions of 17% to 42% and reductions of gingivitis
of 18% to 57% during a six-month period. It should be noted
that some questions have been raised about the safety of prolonged
use of sanguinarine.
and baking soda. Toothpastes with these ingredients (Mentadent)
appear to offer no benefits against gum disease. In fact, tooth
whiteners are usually made with carbamide peroxide, which breaks
down into hydrogen peroxide, and brushing with hydrogen peroxide
is not recommended. Studies have indicated that overuse of this
solution may actually damage cells and soften tooth surfaces.
Of concern was a recent animal study suggesting a link between
hydrogen peroxide and precancerous cell changes in the mouth.
Researchers retracted the findings because of these implications
and pointed out that no cancer lesions have developed in any
animals since the study began. People who smoke or drink alcohol,
however, might avoid products with hydrogen peroxide in them.
sugar substitutes (eg, xylitol), and detergents (delmopinal).
are being investigated for their use in mouthwashes. For example,
one mouthwash (HistaWash) is produced from histatins, peptides found
in saliva. Studies are reporting that it protect against gum disease
and prevents other infections in the mouth as well.
(Peridex or PerioGard) is available by prescription only. It
reduces plaque by 55% and gingivitis by 30% to 45%. Patients
should rinse for one minute twice daily. They should wait at
least 30 minutes between brushing and rinsing since chlorhexidine
can be inactivated by certain compounds in toothpastes. It has
a bitter taste. It also binds to tannins, which are in tea,
coffee, and red wine, so it has tendency to stain teeth in people
who drink these beverages.
is composed of essential oils and is available over the counter.
It reduces plaque and gingivitis, when used for 30 seconds twice
a day. It leaves a burning sensation in the mouth that most
people better tolerate after a few days of use. Some people
might object to or have concerns about the high alcohol content
in the standard version. Other forms of Listerine that have
a different taste and lower alcohol content retain the same
active ingredients and appear to be as effective. The usual
regimen is to rinse twice a day. Generic equivalents are available.
containing cetylpyridinium (Scope, Cepacol) and stannous fluoride
and amine fluoride (Meridol) have some effect on plaque. None
are as effective as Listerine or chlorhexidine, but they may
still have some value for people who cannot tolerate the other
- In spite
of claims for Plax, some studies report that Plax offers no
better protection against plaque or periodontal disease than
does rinsing with water. Even Advanced Formula Plax, which may
show a minor reduction in plaque levels, does not seem to provide
any protection against periodontal disease.
Flossing. In spite of the importance of flossing, only 2%
to 10% of the population perform this technique regularly.
The use of dental floss, either waxed or unwaxed, is critical in
cleaning between the teeth where the toothbrush bristles cannot
reach. In spite of this, nearly two-thirds of people do not floss.
To floss correctly, the following steps may be helpful:
Here are some
tips in choosing the right floss or flossing device:
off about 18 inches of floss and wind most of it around the
middle finger of one hand and the rest around the other middle
- Hold the
floss between the thumbs and forefingers and gently guide and
rub it back and forth between the teeth.
- When it
reaches the gum line, the floss should be curved around each
tooth and slid gently back and forth against the gum.
rub gently up and down against the tooth. Repeat with each tooth,
including the outside of the back teeth.
- If, on
repeated flossing attempts, the floss becomes shredded or cannot
be removed easily from between the teeth, a rough crown or overhanging
filling may be the cause. In such cases, the restoration should
be redone. Such areas create spaces for the collection of food
debris, plaque, and calculus.
Saliva and Drinking Water. Saliva is important for diluting
the toxins created by plaque. Of particular interest is a 2000 study
on nitrite, a substance in saliva whose concentration increased
after eating foods containing nitrates. Nitrite converts to the
gas nitric oxide (NO), which, under acidic conditions, may prevent
the growth and survival of bacteria involved in periodontal disease.
- Use a
floss that does not shred or break.
a very thin floss, which can cut the gum if brought down with
too much force or not guided along the side of the tooth.
who have very tight spaces between their teeth should consider
flosses that are made of Gore-Tex. This floss slips easily between
tight teeth and will not tear on sharp edges. It does cost slightly
- A floss
threader is an invaluable aid for the person who has bridgework.
Made of plastic, it looks like a needle with a huge eye, or
loop. A piece of floss is threaded into the loop, which can
then be inserted between the bridge and the gum. The floss that
is carried through with it can then be used to clean underneath
the false tooth or teeth and along the sides of the abutting
handy device for cleaning under bridges is a Proxabrush. This
is a tiny narrow brush that can be worked in between the natural
teeth and around the attached false tooth or teeth.
- The Floss
Plus easy flosser device is also effective and may make it easier
for some people to floss.
toothpicks, such as Stim-U-Dent, may be effective for wide spaces
between teeth but should never replace flossing. Standard toothpicks
should never be used for regular hygiene.
products, such as Oral B Innerclean and the Water Pik Flosser
are as effective as manual flossing. These devices are expensive
but may improve compliance.
Drinking at least seven glasses of water a day helps reduce inflammation
in the mouth by producing more saliva. Increasing water intake is
particularly important as one ages, when less saliva is produced.
Chemicals and Supplements
and A. One study showed that women with diabetes who took vitamins
E and A during pregnancy had reduced incidence of periodontal inflammation.
Vitamins are not recommended for prevention of periodontal disease,
however. Vitamin A is toxic in high doses, and this study was too
narrow to extrapolate for the general population. It is an interesting
finding, however, because of its potential for more research in
Coenzyme Q-10. Coenzyme Q-10 (CoQ10), also called ubiquinone
is a vitamin-like antioxidant compound that occurs naturally in
the body and plays a role in energy production. Research shows that
the gums of people with periodontal disease are often significantly
deficient in CoQ10, and some evidence suggests that topical or oral
CoQ10 may be effective in slowing the disease process. There is
no strong proof, however, and more research is needed.
Food Extracts. A 2001 study found that avocado and certain
soy extracts prevented the damaging effects of interleukins, immune
factors responsible for inflammation and injury during periodontal
Hormone Replacement Therapy
Research suggests that postmenopausal women who take hormone replacement
therapy (HRT) experience fewer periodontal problems. Studies indicate
that estrogen reduces gum bleeding and bone loss. (HRT is very effective
in preventing osteoporosis, a condition in which bone loss occurs
and which is strongly linked with peridontal disease.) HRT has some
risks, as well, and women should discuss this treatment thoroughly
with their physician.) [For more information
40 Menopause, Estrogen Loss and Their Treatments.]
WILL CONFIRM THE DIAGNOSIS OF PERIODONTAL DISEASE?
The dental practitioner
typically performs a number of procedures to determine a diagnosis
of periodontal disease.
will first take a medical history to reveal any past or present
periodontal problems, any underlying diseases that might be contributing
to the problem, and any medications the patient is taking. After
noting the general state of oral hygiene, the practitioner may ask
about the quality of home dental care.
of the Gum Area. The practitioner inspects the color and shape
of gingival tissue on the cheek (buccal) side and the tongue (lingual)
side of every tooth and compares these qualities to the healthy
ideal. Redness, puffiness, and bleeding upon probing indicate inflammation.
If the gum formation between teeth is blunt and not pointed, acute
necrotizing periodontal disease may be indicated.
Periodontal Screening and Recording (PSR). PSR is a painless
procedure used to measure and determine the severity of peridontal
enable the practitioner to determine the condition of the connective
tissue and amount of gingival overgrowth or recession. PSR appears
to be even more reliable than x-rays in diagnosing gum disease.
- The practitioner
uses a mirror and a periodontal probe, a fine instrument calibrated
in millimeters, which is used to measure pocket depth. (A new
automatic probing device may prove to be even more sensitive
and accurate than the standard manual probe that most dentists
- The probe
is held along the length of the tooth with the tip placed in
the pocket. The tip of the probe will then touch the point where
the connective tissue attaches to the tooth.
- The dentist
will "walk" the probe to six specified points on each tooth,
three on the buccal (cheek) and three on the lingual (tongue)
sides. The dentist measures the depth of the probe at each point.
depths greater than 3 millimeters indicate disease.
Testing Tooth Movement. Tooth mobility is determined by pushing
each tooth between two instrument handles and observing any movement.
Mobility is a strong indicator of bone support loss.
X-rays. X-rays are taken to show any loss of bone structure
supporting the teeth. Eighteen x-rays make up the full mouth series
necessary for diagnosis.
ARE THE PROCEDURES FOR TREATMENT OF PERIODONTAL DISEASE?
Goals. Once periodontal disease has been identified, the goals
of treatment are the following:
Phases. To achieve these goals, there are three phases of professional
- To arrest
and control the progress of the disease.
- To leave
the periodontal tissues in an easily maintainable state.
- If possible,
to restore the supporting structures, which include bone, gum
tissue, and ligaments.
before Treatment. In cases where the individual has a mitral
valve prolapse or history of rheumatic heart disease, pretreatment
with an appropriate antibiotic is required before any dental work,
including cleaning. This is necessary to prevent the possibility
of bacterial endocarditis, which can be life threatening.
Cleaning, Scaling, and Curettage.
(if needed). Surgery is indicated when deep pockets remain underneath
the gum after extensive cleaning sessions. The depth of these
pockets must be reduced.
After the active treatment is completed and the mouth is in
a relative state of health, the patient should have regular
cleanings lasting 45 minutes to an hour, approximately every
three months. These may be done by the dental hygienist, the
periodontist, or the general dentist. They patient may alternate
between them. Home care, of course, must be continued. [ See
How Is Periodontal Disease Prevented, above.]
Benefits of Treatment. Studies vary over the effectiveness
of active treatments and maintenance programs. While a study of
elderly Chinese adults found no difference in tooth loss between
those who had access to health care compared to those who didn't,
another study reported that those who had active maintenance were
much less likely to lose their teeth than those who did not. Some
dentists have reported a success rate of 85% when professional treatment
and good home maintenance are combined.
Treatment helps nonsmokers more than smokers, particularly when
pockets are deep and persistent. One study found that periodontal
treatment in people with diabetes type II actually helped improve
blood sugar levels. Whether treatment will help reduce other health
risks, including heart attack and stroke, is unknown.
Scaling, and Curettage
and sometimes curettage are used to manage periodontal disease.
They are usually accomplished in a series of three to four visits
spaced about a week apart.
Cleaning and Scaling. The dental hygienist or practitioner
generally uses both ultrasonic and manual instruments to remove
Curettage removes the diseased soft tissue lining the periodontal
pockets. It is a manual procedure and permits a deeper and more
complete cleaning than ultrasound. It does not add any significant
benefits for shallow pockets. Local anesthesia is often used. Fine
scaling instruments, called curettes, serve two functions:
above the gum is easily seen. The dental professional usually
detects calculus below the gum by careful probing with a dental
- The hygienist
or dentist may use an ultrasonic instrument for removal of the
more accessible calculus. This probelike device vibrates at
a frequency range higher than is audible to the human ear. Some
people with low tolerance for the ultrasonic probe may wish
to request nitrous oxide.
- A spray
of water is used with ultrasound to prevent overheating and
to flush out the debris that is dislodged.
- When the
probe contacts the rock-like calculus, deposits fracture off
the tooth fairly efficiently.
(PVP-I), a potent antiseptic, can reduce the level of gingivitis
and may be more beneficial than water as the irrigant used during
ultrasonic treatment. Further studies are needed.
and root planing with steel instruments may cause loss of the tooth
surface and increased sensitivity of the teeth over time. Newer
plastic instruments may be just as effective without damaging the
hard structure of the tooth.
- They scrape
and clean the root surfaces.
- They also
plane the surfaces in an attempt to smooth and remove the outer
layer of diseased material.
Polishing. Polishing is the finishing procedure. It employs
a rubber cup with an abrasive paste to remove plaque and stains
on the crown portion of the tooth. It produces a smooth surface,
making it harder for plaque to adhere. Its benefits are short lived,
Instructions for Home Care. Finally, the dental hygienist
or practitioner should offer thorough instructions on home care
to insure the removal of bacteria on a daily basis. This includes
proper use of the toothbrush, paste, mouth rinses, floss, floss
threaders, and proxabrushes. Home care can effectively eliminate
the plaque above the gums and down to 2 mm below the gums.
Follow-Up. The dentist will check the pocket depths around
the teeth after the cleaning and curettage process has been completed.
Further treatment needs are determined by the results of these initial
- If the
cleaning processes have reduced inflammation, observation only
- If an
abscess is present, surgery is often warranted. (One case study
suggested that simply draining an abscess caused by deep pockets
and allowing the periodontal pockets to improve and the gum
tissue to return to health may avoid the need for surgery. If,
in such cases, tissue health has not been achieved, and if the
pocket depth is greater than 4 mm, surgery may be necessary.)
access for deep cleaning of the root surface, removal of diseased
tissue, and repositioning and shaping of the bones, gum, and tissues
supporting the teeth. (Some studies have reported that although
surgical treatment reduced pocket depth more than non-surgical therapies
for at least one year after the procedure, benefits from surgery
do not persist beyond five years, except in very deep pockets.)
Surgical procedures vary depending on the individual diagnosis and
needs of the patient.
Open Flap Curettage . The basic procedure is known as open
flap curettage. It involves the following:
Regeneration. A more advanced technique is called guided tissue
regeneration, which is being used to stimulate bone and gum tissue
- The periodontal
surgeon lifts, or flaps, the gums away from the tooth and surrounding
- The diseased
root surfaces are cleaned and curetted (scraped) to remove deposits.
- Gum tissue
is replaced into positions to minimize pocket depth.
- The periodontist
may also contour the remaining bone and attempt to regenerate
lost bone and gingival attachment through bone grafts and guided
tissue regeneration [ see below ].
One 1999 study
found that guided tissue regeneration techniques surpassed open
flap curettage alone in improving pocket depth and attachment gain.
In one study of patients who were followed for four to seven years
after guided tissue regeneration, the general failure rate was 41%.
In smokers, however, the failure rate was 80%.
the root surfaces and diseased bone are meticulously cleaned
out. Preventing bacterial contamination is very important; the
more residual bacteria, the greater the chance that the treatment
- A specialized
piece of fabric is sewn around the tooth to cover the crater
in the bone left after the cleaning. It is either absorbable
or nonabsorbable. (Studies are reporting highly beneficial results
with new absorbable materials, including one that is coated
with the antibiotic doxycycline.)
- The gum
is then sewn over the fabric. The fabric prevents the gum tissue
from growing down into the bone defect and allows the bone and
the attachment to the root to regenerate.
four to six weeks the nonabsorbable fabric must be removed using
a minor surgical procedure. The absorbable membrane may be left
in. In general, there is little difference in outcome between
absorbable and nonabsorbable procedures. The absorbable fabric
may not be as effective as standard grafts if gum tissue is
thin, although newer materials may prove to produce better results.
Bone Grafting. In some cases of severe bone loss, the surgeon
may attempt to encourage regrowth and restoration of bone tissue
that has been lost through the disease process. This involves bone
Pain and Discomfort. Post-surgery discomfort is usually managed
easily with over-the-counter medications, such as ibuprofen. If
discomfort is severe, stronger analgesics may be prescribed. Some
patients experience sensitivity to hot or cold temperatures from
exposed roots; these problems can be managed with topical fluoride
treatments or, in severe cases, with dental restoration.
- The surgeon
places bone graft material into the defect.
- The material
may be either bone from the same patient or a substance called
decalcified freeze-dried bone allografts (DFDBA) which is obtained
from a donor. In one study, bone gain from freeze-dried bone
was still maintained after three years, although another study
indicated that commercial batches of DFDBA varied in their ability
to induce new bone growth. Bone from older donors appears to
be less effective for restoring new bone.
- This material
then stimulates new bone growth in the area.
and Gum Grafting Treatments
techniques can also be very useful for improving the looks of the
gum as well as adding support to the teeth. During this procedure,
the periodontist takes gum tissue from the palate or another donor
source to cover the exposed root in order to even the gum line and
reduce sensitivity. Other procedures are available to improve the
look of the gums and teeth. The gum line can be sculpted to improve
uneven or excess gums and to cover exposed roots as gums recede.
report that they are achieving greater success with tooth implants
in patients who have lost teeth due to periodontal disease. The
average cost for a single implant is high, however, $1,000 to $2,000,
and one implant requires five to seven months for completion.
Note on Laser Surgery
Academy of Periodontology is concerned with misleading claims
about the use of lasers. To date, research has not shown the
laser to be of great value in the removal of calculus below
the gum line or on root surfaces. One small study in 1999
found laser therapy to be less effective than traditional
scaling and root planing, and it may, in fact, damage the
root surface. Nor has it been approved for use on any hard
tissue, bone, or teeth. Laser surgery has been approved for
soft tissue surgery, for example in gingivectomies (the surgical
removal of gum tissue to reduce pocket depth) and frenectomies
(the surgical removal of connective tissue and muscular bands
of tissue usually located between the upper central incisors).
Since these operations are easily performed with the traditional
use of a scalpel, however, it is questionable whether the
benefits of laser surgery outweigh its high cost.
ARE ANTIBIOTICS BEING USED FOR LONG-TERM PREVENTION OF PERIODONTAL
being investigated in combination with surgery, curettage, or alone
to eliminate or prevent disease-causing bacteria after periodontal
procedures. A number of antibiotic treatments are being used to
help this problem. They are available in oral from or used in devices
that are applied locally, directly to the gum. In a 2001 English
study, dentists only infrequently used antibiotics, particularly
oral forms. Nevertheless, a substantial minority of them believed
that local application of antibiotics is more effective than periodontal
Some experts are concerned that long-term use of antibiotics increases
the risk of bacterial resistance to these drugs, which is a growing
health problem in general. Of some encouragement was a 2000 review
of four studies, which indicated that low dose antibiotics do not
increase the risk of bacterial resistance. However, long-term studies
are still needed
antibiotics, which include tetracycline hydrochloride, doxycycline,
and minocycline, are the primary agents used. They not only
have anti-bacterial actions, but also, they reduce inflammation
and help block collagenase, the protein that destroys connective
tissue and bone, even in low doses. In fact, it is these two
actions, rather than their antibacterial properties, which seem
to contribute most to periodontal protection.
- The antibiotic
roxithromycin belongs to the family known as macrolides. It
has actions against inflammation and growth involved in periodontal
Delivery of Antibiotics to the Gums
of antibiotics to the gum surface does not affect the entire body
like oral antibiotics do, and they are preferred whenever possible.
One study published in 2000 found that local application of doxycycline
alone was as effective as scaling and root planing in treating periodontal
infections. A number of treatments are available.
Actisite. Actisite is a thin strip similar to dental floss,
which is treated with tetracycline hydrochloride.
have shown reduced pocket depth and less bleeding of the gums, which
is superior to root planing alone. These benefits seem to last for
six months after the thread is removed. One study showed that scaling
and root planing plus short-term antibiotic-thread therapy reduced
the need for gum surgery and tooth extractions by 88%. After five
years, however, there appears to be no difference in periodontal
health between the antibiotic group and those who had scaling and
root planing alone. While it cannot replace curettage, Actisite
provides additional therapy in the treatment of localized periodontal
- The treated
thread is temporarily inserted between the tooth and gum. (Using
multiple strips may be more beneficial than using a single strip.)
is usually inserted without an anesthetic. Most patients do
not experience pain. (In one study, 10% felt discomfort during
insertion and 11% reported temporary redness of the area after
- The treated
thread releases a steady concentration of tetracycline to the
diseased gum tissue. Only a very small amount of the drug is
released into the bloodstream, so there are rarely any side
10 days the thread is removed.
Other Topical Applications. Other treatments that employ
topical antibiotics are under investigation and include the following:
Long term results
are still unknown for any of these newer procedures.
is a gel or strip applied to the gum product. It is composed
of metronidazole. This agent is not always categorized as an
antibiotic, since it has unique actions that are effective against
parasites as well as bacteria. In one study comparing tetracycline
with metronidazole cellulose strips, tetracycline worked faster
but metronidazole achieved a greater bacterial reduction.
is a doxycycline gel that conforms to the gum surface and then
solidifies. Over the next few days, it releases the antibiotics.
- A new
product called PerioChip is a chip that is placed into the gum
pocket after scaling. Over time, it slowly releases chlorhexidine,
a powerful bacteria-killing antiseptic. Early studies are reporting
benefits in reducing pocket depths, but it is still not known
whether these improvements are sustained.
microspheres that involve loading the antibiotic into tiny capsules
and applying them to the gums are being invested. Studies are
now reporting that they are effective in reducing pocket depth
and bone loss when used in conjunction with scaling and root
planing. Patients obtain these benefits regardless of their
smoking status, age gender or extent of the periodontal disease.
of doxycycline (a ten-day treatment) is useful for eliminating acute
inflammation and infection. The use of oral antibiotics for long-term
use has been controversial, except in special circumstances.
Periostat. The first oral antibiotic specifically developed
for periodontal disease was low-dose doxycyline (Periostat). The
doses are too low to actually fight bacteria but they are sufficient
to block the actions of collagenase, the enzyme that destroys the
connective tissues holding the teeth. Some studies suggest is improves
tooth attachment by 50%. Taking a common nonsteroidal anti-inflammatory
drug, such as aspirin or ibuprofen (Advil), along with doxycycline
may enhance the effectiveness of this treatment. Periostat is taken
for a number of weeks, however, and some experts are concerned that
such long-term use may pose a risk for the development of antibiotic-resistant
bacteria or other, still unknown, adverse effects.
Metronidazole and Amoxicillin for Chronic Periodontal Disease.
One 2000 study reported that a combination of metronidazole
plus amoxicillin taken for one week a month for four months arrested
disease progression and improved existing levels of chronic periodontal
disease. Common side effects include allergic reactions, stomach
upset, yeast overgrowth, and sensitivity to sunlight (with tetracycline).
Long-Term Antibiotics for Severe Conditions. Long-term use
of antibiotics is advised for the control of juvenile periodontitis,
refractory periodontitis, rapidly progressing periodontitis, and
prepubertal periodontitis. The most widely used drugs are the tetracyclines
and metronidazole (Flagyl). Amoxicillin is also useful.
The Keyes technique
involves monitoring and controlling specific groups of bacteria
to facilitate treatment of periodontal disease. It consists of three
and root planing are known successful treatments against periodontal
disease, the benefits of other aspects of the Keyes technique are
questionable. Some researchers believe it is too difficult to distinguish
disease-producing bacteria from those normally found in the mouth
and that microscopic monitoring has been outmoded by new technological
advances. Another study reported that knowledge of the bacterial
species played no role in treatment outcome. The recommended home
care regimen involving hydrogen peroxide and baking soda has been
shown to have little or no effect, and may actually damage gum tissue.
monitoring of bacteria in plaque samples.
therapy, which includes scaling, root planing, and extensive
curettage along with detailed oral hygiene instructions.
oral antibiotic treatment if results from local therapy are
OTHER AGENTS ARE BEING TESTED FOR PERIODONTAL DISEASE?
Anti-inflammatory Drugs (NSAIDs)
NSAIDs are agents
that block factors that cause inflammation and pain. The most common
NSAIDs are the following:
oral hypoglycemics may need to adjust the dosage if they also need
to take NSAIDs because of possible harmful interactions between
NSAIDs include aspirin, ibuprofen (Motrin IB, Advil, Nuprin,
Rufen), naproxen (Aleve), ketoprofen (Actron, Orudis KT). One
study suggested that ibuprofen or naproxen is more effective
than aspirin or acetaminophen for acute tension-type headache.
NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox,
diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis,
Oruvail), indomethacin (Indocin).
- The agents
have been investigated not only for pain relief in periodontal
disease but in slowing the disease process.
use of even over-the-counter NSAIDs may be hazardous for anyone
and has been associated with the following side effects:
and gastrointestinal bleeding. This is the major danger with
long-term use of NSAIDs. [ See Box Ulcers and Gastrointestinal
blood pressure. This is a particular problem in those on medications
to reduce hypertension. Piroxicam (Feldene), naproxen (Aleve),
and indomethacin (Indocin) appear to pose the greatest risks
for high blood pressure. (Sulindac has the smallest effect.)
People with hypertension, severe vascular disease, kidney, or
liver problems, and those taking diuretics must be closely monitored
if they need to take NSAIDs.
- May delay
the emptying of the stomach, which could interfere with the
actions of other drugs. The elderly are at special risk.
ringing in the ear.
- Skin rash.
has also been noted.
or bizarre sensation (in some higher-potency NSAIDs, such as
may pose a higher risk for kidney injury, which would be of
concern in patients with kidney problems. Any sudden weight
gain or swelling should be reported to a physician.
Matrix Protein Derivative
The gel Emdogain
contains amelogenin and is a derivative of a major protein in the
structure (the matrix) of enamel that helps stimulate gum tissue
growth. It is applied during surgery and forms a coat over the roots
of the teeth. The gel itself dissolves after two days, leaving the
active substance behind. Studies are reporting that it is safe and
may significantly reduce the effects of periodontal disease. A 2001
study suggested that the benefits, as indicated by bone attachment,
can persist for at least four years. (Results were similar to guided
growth factors, included substances called recombinant human (rh)
platelet-derived growth factor-BB (PDGF-BB) and (rh) insulin-like
growth factor-I (IGF-I) are also showing promise for restoring bone.
Research is underway
to find a vaccine against periodontal disease. To date, animal studies
show promise, but an effective vaccine for people is years away.
ELSE CAN HELP BE OBTAINED FOR PERIODONTAL DISEASE?
of Dental and Craniofacial Research (NIDCR), National Institutes
of Health., MD 20892-2290. Call (301-496-4261) or (http://www.nidr.nih.gov/)
National Oral Health Information Clearinghouse, NOHIC Way, Bethesda,
MD 20892-3500 (part of NIDR). Call (301-402-7364) or (http://www.aerie.com/nohicweb/)
American Academy of Periodontology, 737 North Michigan Avenue, Suite
800, Chicago, Ill 606ll.
To find a periodontist in a particular region, call (800-FLOSS-EM)
or (312-573-3240) or (http://www.perio.org/).
For educational brochures covering the basics of periodontal disease
and surgical treatments, send a self-addressed, stamped envelope
and request pamphlets on gum disease.
American Dental Association, Department of Information and Education.
2ll East Chicago Avenue, Chicago, IL 606ll.. (http://www.ada.org/)
Academy of General Dentistry. Suite 1200, 211 E. Chicago Ave., Chicago,
IL 60611. Call (1-888-AGD-DENT) or (1-888-243-3368). (http://www.agd.org/)