Dr. Bennett Jacoby: About Periodontal Disease
Overview: Periodontitis is a bacterial infection of the tooth surface, below the gum line, that can cause destruction of the bone and ligament that holds the teeth in, resulting in the high risk for losing the affected teeth over time. This infection is usually painless and without symptoms, so the patient does not know they have periodontitis until it is too late. Teeth with end-stage severe periodontitis, that may be loose or sore, cannot usually be saved. In addition, periodontal disease is associated with an increased risk for heart disease, stroke and cancer. Diagnosed early enough in the disease process by your dentist or hygienist, periodontitis is treatable, but the disease can only be controlled with treatment, not cured, and your diligence at daily oral hygiene with meticulous brushing and flossing, as well as appointing for all recommended cleanings, is critical in preventing periodontitis recurrence.Smoking cessation and control of diabetes is usually pivotal in obtaining successful treatment in affected patients.
Health and Normal Dental Anatomy
(Healthy gum and bone is on the left side of this drawing)
Normal Anatomy: The teeth are anchored in bone, and attached to the bone by the periodontal ligament. A thin layer of gum tissue covers the bone. The gum forms a cuff around the tooth with a small crevice between the gum and tooth that in health is very shallow: only 1 to 3 millimeters deep. This is important because this shallow, healthy crevice is cleanable by you with careful brushing and flossing every day. It is also cleanable with professional teeth cleanings by a dentist or hygienist. If the crevice is deeper than 3 millimeters, as it can become in periodontitis, then the ability for both you and the dentist/hygienist to clean it is greatly reduced.
Plaque Bacteria and Gingivitis: There are billions of bacteria floating around inside of our mouths. These bacteria settle on the tooth surface above the gum line and grow into a sticky, tenacious, organized colony that only takes about 24 hours to form. This bacteria on the tooth surface is called “plaque.” It is comprised of organized colonies of bacteria embedded in a gelatinous matrix that the bacteria secrete to protect them, and protect them it does! It is important to remember that plaque, is bacteria, not food. This plaque accumulation happens constantly and cannot be effectively removed with rinsing or mouthwashes.You need to remove this plaque at least every 24 hours, preferably every 12 hours, with careful and thorough brushing and flossing. The problem is that we are not born with the knowledge of how to brush and floss, therefore we often "miss" areas during our daily brushing and flossing, leaving the bacteria in place near the gum line. After about two weeks of accumulation, the gum near the plaque starts to become inflamed. We often see this in children and teenagers. This stage of the infection is called “gingivitis”. It is a painless redness/swelling of the gums that the patient is usually unaware of. Some bleeding during brushing/flossing is possible but does not always occur.
Oral Hygiene: The “Gold Standard” for removing the daily accumulation of plaque (bacteria) is “mechanical” plaque removal with brush and floss. The interdental Proxabrush is very effective as well if it fits between the teeth. Over-The-Counter rinses, mouthwashes, toothpicks, herbs, rubber stimulators and essential oils have minimal to no additional benefit as they do not remove nor kill the bacteria. We often hear patients say “but it feels like it's working” or “but I get so much food out from in between my teeth”. Food does not cause periodontal disease and we cannot “feel” when the plaque is removed. In addition, the bacteria feed on dissolved nutrients in our mouths, not pieces of food. The plaque is very sticky, like dried egg on a counter top, therefore only the mechanical action of daily brush and floss can remove a significant amount of these bacteria. Antibiotics alone don’t kill them because they are stuck to the tooth, not inside the body where taking a pill would have any affect. In addition, antibiotics and other chemicals cannot penetrate the gelatinous matrix that the bacteria secrete for protection, although antibiotics can be partially effective if prescribed during periodontal treatment. Some toothbrushes work better at removing plaque. The Oral B is the brush that we recommend. Other powered rotary brushes work almost as well in our opinion. We do not recommend the Phillips Sonicare or any of the other “sonic” brushes as we have only seen minimal benefit in patients with periodontitis that use these devices.In some cases the Waterpik can be of slight additional benefit, provided that the patient does not “take away” time with their brush and floss to use the Waterpik. Without effective daily mechanical plaque removal by you, you will be at high risk for reinfection even after successful periodontal treatment. Reinfection will usually require retreatment and may result in loss of the affected teeth.
Periodontitis Progression and Tooth Loss: If areas of gingivitis are left untreated and uncleaned (by not brushing/flossing these hidden areas every day), this inflamed gum environment supports the growth of different bacteria that grow below the gum line.These new bacteria and their toxins begin to destroy the bone and ligament that retain the teeth.These bacteria and their toxins also trick our body’s immune system to destroy bone and ligament as well.This bone/ligament destruction occurs slowly and painlessly over the years, speeding up and slowing down, at an average rate of about 1 millimeter per year. It is important to remember that this bone loss is cumulative over time and rarely, if ever, reforms nor heals. If we don’t stop this bone loss before about ½ the bone height is destroyed, then the tooth is at high risk for loss because there is simply not enough bone to hold the tooth in while bearing the loads of chewing.It can take 10 to 20 years of slow, painless, bone destruction to cause tooth loss, and this usually occurs on several or many teeth, not just one. By the time you feel pain and swelling, it is often too late to save the affected tooth. There are certain circumstances in which a localized area can flare up quickly (hours/days) destroying a significant amount of bone in a very short time ("acute periodontal abscess). This is often associated with pain and swelling, and can even be life threatening if left untreated.
Periodontitis and Deep Pockets
(Periodontitis is shown on the right side of this drawing)
Deep Pockets:As the bone and ligament are destroyed, the gum height is usually not affected much, so you typically won’t see or feel any changes in your mouth. A significant problem is that while the gum may stay intact, there is no attachment to the tooth surface, thus a very deep and uncleanable “periodontal pocket” is formed. The very destructive bacteria live in this crevice and become mineralized into very hard and firmly attached “calculus” or “tartar” that as rough, irritating, full of bacterial toxins and covered in live bacteria.Brush, floss and rinses do not penetrate the deepest recesses of these pockets, nor remove the calculus; therefore, the bacteria and their toxins continue to accumulate and cause disease.
Treatment – Scaling and Root Planing (“SRP”):SRP may be recommended by your dentist or hygienist to treat some or all of the infected teeth. This may be a preparatory treatment for periodontal surgery or it may be the final treatment if Dr. Jacoby believes that no surgery will be needed to control your disease. This is dependent on how advanced the state of your disease is. SRP consists of numbing the affected area (local anesthetic injection) and then inserting specialized cleaning instruments below the gum line to scrape the bacteria, tartar/calculus and toxins off of the root surfaces. It is much more than a typical cleaning and focuses on areas below the gumline. Advanced clinical research in Periodontics have shown that well performed SRP is often very effective at controlling periodontal infection in pockets 4-5 millimeters deep, but the effectiveness of SRP is not nearly as effective when the pockets become deeper than 5 millimeters. This is because the dentist/hygienist cannot visualize the deep root surfaces to verify whether they have been completely cleaned. Still, even with partial cleaning, a benefit is usually seen with decreased inflammation and decreased rates of bone loss.Other research has shown that even deep periodontal pocket infection (> 5 mm) can be controlled with SRP alone. The drawback is that SRP is often required on a very frequent basis (as often as every three months.) This can be a very large financial burden , as SRP has a significant cost, and is usually only covered once every 2 years by insurance.
Periodontal (Osseous) Surgery
(During and after treatment)
Treatment – Periodontal/Osseous Surgery: For new or retreated patients, Dr. Jacoby usually recommends a complete periodontal exam about 8 weeks after SRP. At this visit, all probing depths are measured again, as in the first visit, along with bleeding points, pus and other criteria that assist in determining of there is inflammation present. If deep pockets with inflammation remain after SRP, this indicates that there are areas that are at high risk for having ongoing bone loss that could lead to eventual tooth loss. Deep pockets alone are not an indication of disease.The signs and symptoms of inflammation (bleeding, puss, redness, etc.) are an indication of the risk of ongoing infection. One of the primary treatment options in this case is periodontal surgery (also known as osseous surgery). This procedure involves Dr. Jacoby numbing the affected teeth with local anesthetic, and surgically opening up the gum tissue to expose the infected root surfaces (see diagram below.) The root surfaces are then meticulously cleaned. The bone and gum tissue are then recontoured such that the gum/tooth crevice is much more shallow. The tissue is then sutured in place with dissolvable suture. A packing material is sometimes put in place to assist in positioning the gum tissue.This type of surgery allows visual access to very deep infected pockets so that the debris can be removed and the disease arrested. After surgery, it is typical for patients to have significant pain, so narcotic pain medication is usually prescribed. Upon healing, it is common to have spaces in between the teeth that can catch food. You will need to keep these and all other areas free of feed and plaque accumulation. Root sensitivity to cold often occurs following surgery, which usually resolves in time, but not always.
Follow-up After Surgery: Excellent daily home plaque removal by you, and following the maintenance cleaning schedule recommended by Dr. Jacoby, are necessary to control plaque growth and prevent disease reoccurrence, as patients that don’t have adequate plaque control are at high risk for reinfection and subsequent tooth loss.With poor daily plaque control, the patient could even be worse off than if they had no surgery at all, as surgery in the presence of plaque, and the absence of maintenance, has been shown to actually increase the rate of bone loss as compared to no treatment. You can see that removing the bacteria at home on a daily basis is critical!
Extraction: While extracting the affected teeth is not the first choice in treatment, it is the only known cure for periodontal disease (all the other treatments control the disease; they don’t cure it.) Without a tooth, there can be no periodontal infection
Alternatives: Often times, the long and drawn-out process of scaling, root planing and surgery can be consolidated into one simple procedure using the Perioscope to see the bacterial deposits and the Nd:YAG laser to disinfect the pockets and stimulate regeneration of lost tissue. The vast majority of patients that have this procedure performed say that they have such minimal discomfort and heal so quickly that they don't need any pain medication at all!
1)Q: I used to see a little blood when I brushed or flossed and sometimes smelled something strange in my mouth, but that is gone now, and I don’t feel or see any problems, so maybe the disease went away on its own? ---A: Periodontal disease is usually “silent” (like high blood pressure or diabetes) and can only be diagnosed by a dentist. In other words it can be very advanced but patients are usually unaware of the active infection. Most patients feel fine even with advanced infection.
2)Q: I’ve cut back my smoking a lot. Are just a few cigarettes per day ok? ---A: Tobacco/marijuana use increases the risk for tooth loss even if treatment is attempted. Obviously less is better, but quitting is best.
3)Q: Isn’t there some rinse or antibiotic that I can take to cure this disease? ---A: Unfortunately no. These bacteria live between the gum and tooth which is not actually within the body, so any pill or rinse you take will not deliver the medication to the bacteria in a high enough concentration to kill them all. In addition, the bacteria exist in a sticky film that protects them from antibiotics and the immune system. Antibiotics also have no affect on the toxins that the bacteria create. That said, controlled clinical research has shown that a specific prescription rinse and certain potent antibiotics increase the effectiveness of periodontal treatment, therefore Dr. Jacoby often prescribes them as part of the overall treatment plan.
4)Q: I’ve always brushed my teeth every day, so why do I have periodontitis? ---A: Because you did not remove all the bacteria from all areas of your teeth frequently enough. We are not born with the knowledge to brush our teeth, and the bacteria are sticky and difficult to remove. It is very common for patients to think they are cleaning their teeth well, when in fact massive amounts of bacteria are left untouched on the tooth surfaces in hidden areas.
5)Q: I don’t know anyone else with this disease; why me? ---A: While periodontitis may have no symptoms, it affects up to 90% of the human population and is one of the most common chronic diseases known.
6)Q: Does taking calcium help? A: In most cases no. Calcium may be of benefit to patients with osteoporosis or “thinning of the bones”, but this does not usually come into play in patients with periodontitis.
7)Q: How does pregnancy affect this disease? A: During pregnancy, increased levels of the hormone progesterone occur. This has been shown to increase the level of existing inflammation. In other words, it can make the inflammation more pronounced, but it doesn’t cause the inflammation.
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