Periodontal or gum disease is a pathological inflammatory condition of the gum and bone support (periodontal tissues) surrounding the teeth. It occurs in both chronic and acute forms. Acute periodontal disease is usually associated with specific infections, micro-organisms, or trauma. The chronic inflammation of the soft gum tissue surrounding the teeth is associated with the bacterial plaque which covers the teeth and gums. A very high proportion of all people living in Europe including Ireland have some inflammation of the gingival tissue at the necks of the teeth. This condition is termed gingivitis, which is characterised by redness of the gum margins, swelling and bleeding on brushing.
The 2 most common periodontal diseases are
• Gingivitis: inflammation of the gum at the necks of the teeth
• Periodontitis: Inflammation affecting the bone and tissues of the teeth.
Gingivitis was once seen as the first stage in a chronic degenerative process which resulted in the loss of both gums and bone tissue surrounding the teeth. However, this is no longer the case, as this condition can be reversed by effective oral hygiene practices on the part of the individual. No specific public health measure has been developed to prevent gingivitis other than the instruction of groups and individuals on how to remove the bacterial plaque from around the teeth and gums with a toothbrush and floss.
The net effect of the instructional programme given by health professionals and through commercial advertising and a general increase in the standard of living seems to have resulted in mouths being generally cleaner and showing less signs of inflammation.
When periodontal disease reaches the bone and supporting tissue it is termed periodontitis and is characterised by the formation of pockets or spaces between the tooth and gums. This may progress and cause chronic periodontal destruction leading to loosening or loss of teeth. The dynamic of the diseaseis such that the individual can experience episodes of rapid periodontal disease activity in a relatively short period of time followed by periods of remission.
The rate of progression of this disease process in an individual is dependent on:
(1) The virulence of the plaque and
(2) The efficiency of the local and systemic responses in the person (host).
Current research suggests that the host responses are influenced by specific environmental and genetic factors which can determine the susceptibility of the host generally to periodontal disease or the susceptibility of a particular site (tooth) within the mouth. In this regard, it is common for more severe forms of periodontal disease to present in individuals with compromised immune systems, e.g. in Diabetes, HIV infection, Leukaemia and Down’s Syndrome. There is increasing evidence that smoking and stress cause an accelerati on of the disease process and a particular virulent type of periodontal disease. Acute Necrotizing Ulcerative Gingivitis (Vincents infection) occurs almost exclusively in smokers.
As already stated, the vast majority of gum disease can be easily prevented by thorough plaque removal once a day. However, irregularities around the teeth will encourage the accumulation of plaque making tooth cleaning difficult. Such factors include overhanging edges on fillings and poorly contoured fillings and also some types of partial denture designs. Calculus (tartar) is plaque which has calcified and hardened and may cause plaque to accumulate more readily. For the majority of the population, however, periodontal disease can be effectively treated and maintained by professional care and proper oral hygiene practices on the part of the individual.
The most important method of limiting periodontal disease is by plaque control directed to maintaining gingival health. This must be considered at two levels – what people can do for themselves by way of plaque control on a daily basis, and what dentists and hygienists can do to eliminate plaque retention factors and to advise the individual on the most appropriate home care.
The most important plaque control method is tooth brushing and it should be established as a daily routine from early childhood. Tooth brushing skills should be taught to people of all ages. The precise technique is less important than the result, which is that plaque is removed effectively and daily without causing damage to the teeth or gums.
Recommended Toothbrushing Technique
A gentle scrub technique is effective for most people and is easy to teach and readily accepted. Careful use of this method with a recommended type of brush should be encouraged, as it will provide effective plaque removal. Most authorities recommend a brush with a small head bearing densely packed soft to medium synthetic filaments. Daily effective toothbrushing may be associated with some gingival recession. However, slight recession is preferable to the diseases caused by plaque. Faulty toothbrushing techniques involving excessive pressure may considerably increase recession and loss of tooth substance by mechanical abrasion and must therefore be corrected.
Plaque disclosing agents which colour plaque to make it easily visible can be a useful aid to improving plaque control. They will not in themselves remove plaque, but will show areas where plaque remains after brushing. Dental floss and other interdental cleaning aids are of value if used correctly and they will usually require professional advice and instruction. An adjunctive method of plaque control is the use of antiseptics, of which chlorhexidine is the most effective. Although this antiseptic is on general sale in Ireland in mouthrinse and gel forms, its tendency to stain teeth and impair taste makes it generally unacceptable for long-term use. Toothpastes and mouthrinses containing other chemical agents, while less effective than chlorhexidine, do not have these side effects and are of some value to gingival health.
It is the responsibility of the dental clinician to ensure that any treatment provided minimizes plaque retention; this is a part of treatment planning. Clear advice must be given on the need to clean bridges, dentures and orthodontic appliances (braces) effectively and regularly. Calculus can form on teeth both above gum level and within periodontal pockets and it will need careful scaling for its removal. The need for this should be made clear to the public. While appropriate professional treatment is important, the highest priority should be given to effective daily oral hygiene by the individual.