Periodontitis (gum disease)

Do your gums start bleeding when you brush or eat? Have they started receeding? Then you, like around 80% of the British population, could be suffering from periodontitis — otherwise known as gum disease.

When plaque and bacteria attack the gums the affected area recedes and becomes inflamed. This can lead to tooth loss and damage to the heart, lungs and kidneys as inflammation spreads around the body through the blood.


More often than not those affected by this condition do not realise that something is wrong. This is because gingivitis (gingiva is the dental term for gum) is pain free. However, the consequences may be severe: receeding gums, bone loss or an increased risk of stroke or heart attack. Recent studies even suggest a connection between periodontitis and Alzheimer's disease.

We offer you an immediate diagnosis and careful, meticulous treatment. The initial step is to analyse and improve your oral hygiene. Professional dental cleaning removes the causes of the inflammation — tartar and bacteria — from all gum pockets. After four to six weeks we re-evaluate the situation and if neccessary retreat remaining gum pockets until they are all inflammation free.

We place great importance on long term care as part of this treatment. Our structured recall system is a key part of this, ensuring patients come in for regular check-ups and dental hygiene appointments. Below you can find information on the symptoms of periodontitis and the treatment procedure used at our dental clinic.


Why do I have gum disease and what can I do to prevent it?

In this video Dr Hansen from Munich explains how gum disease can develop and what can be done to stop it and prevent it in the future. 


Periodontitis is the inflammation of the gums and the surrounding tissue. Along with tooth decay it is the most widely spread dental condition. It attacks the tissue that holds the teeth in place (the periodontium) and because it is not accompanied by any pain it often goes unnoticed for a long time.

The risk of contracting periodontitis increases with age. If left untreated it can result in tooth loss. The mouth is home to more than 600 types of bacteria, most of which pose no threat to your oral health. They form what is termed a biofilm — meaning plaque — on the tooth surfaces, the edge of the gum and interdental spaces. If plaque is not thoroughly and regularly removed it hardens and forms dental calculus, otherwise known as tartar.

Inflammation in the gums is known as gingivitis. The main symptom of gingivitis and the first warning sign is bleeding gums. The area where the gums meet the tooth forms a natural barrier which can often prevent bacteria from getting deeper into the gums. If gingivitis is left untreated, however, this protective wall becomes penetrable, and the inflammation can spread along the tooth to the bone and the periodontal ligament.

What happens next is a staged destruction of the tooth-bearing periodontium. As the gums recede part of the periodontium is destroyed. Next, something called a gum pocket forms. From this moment on yet more bacteria can enter. The body's own increased immune defences cause further destruction of the periodontium as they fight the bacterial attack. The gums recede even further as does the jaw bone. The tooth becomes loose. In the worst case the tooth may be lost — even without ever having been affected by tooth decay.

Not everyone is equally at risk of periodontitis. The process and the severity of the condition are dependent on certain internal and external factors:

  1. It has been scientifically proven that disposition to periodontitis might be passed down from generation to generation.
  2. Insufficient oral hygiene is the main contributor to the formation of periodontitis, beginning when dental calculus and bacteria cause gingivitis.
  3. Nicotine consumption has an adverse effect on the immune system. This means that smokers are twice to seven times more likely to suffer from gingivitis. Moreover smokers often do not know that they have gingivitis because the first warning signal — bleeding gums — often does not occur in them. The likelihood of treatment success is limited if the patient keeps smoking. 
  4. Diabetes increases the risk of periodontitis. Badly adjusted blood sugar values immediately impact on the immune systems of the periodontium. This means that gum inflammation may occur more frequently, and may take longer to heal.
  5. Psychological stress and hormonal changes also impact on the immune system, making periodontitis more likely to occur, and enabling it to develop more quickly. During pregnancy there is also an increased risk of contracting periodontitis.
  6. Inherent or acquired weaknesses in the immune system, such as AIDS, are a contributing factor to patients developing periodontitis.
  7. Certain medication, such as that aimed at reducing a patient’s blood pressure or other drugs that may weaken the immune system, can cause the gums to swell. This may be a contributing factor in the development of periodontitis.

Bacteria can enter the blood stream through inflamed gum tissue, being transported to other parts of the body with potentially serious effects on systemic health.

Diabetes

If your glucose values are badly adjusted, this may be a contributing factor in developing periodontitis. This also works the other around: periodontitis makes it harder to adjust your blood sugar levels. This is because the effectiveness of the insulin used in diabetes treatment is weakened due to gingivitis.

Strokes and heart attacks

Periodontitis patients have an increased risk of strokes and heart attacks. Moreover bacteria absorbed into the bloodstream through infected gum tissue can be a contributing factor to infections in the heart, artificial heart valves, and hip and knee joints.

Pregnancy

Pregnant women tend to be more susceptible to gingivitis and periodontal inflammation. A severe form of periodontitis can increase the risk of complications and low birth weight.

Periodontitis may go unnoticed because it is painless in its early stages, but there are warning signs:

  • Bleeding gums (when brushing or eating)
  • Swollen and red gums
  • Retreating gums
  • Sensitive tooth necks
  • Lasting bad breath and / or a continuously bad taste in your mouth
  • Pus exiting the gingival pockets
  • Loosening teeth

If you notice one or more of these warning signs see a dentist immediately. Only a Specialist periodontist can tell you whether you have periodontitis.

First of all we evaluate the level of severity of your condition. We take a large-scale x-ray (OPG) to better see the formation of your jaw bone. We also measure the depth of gum pockets. The level of bleeding and loosening of the teeth are assessed. If your periodontitis is severe or aggressive in nature we may prescribe antibiotics. For this purpose we will do a bacteria test, with results evaluated at our laboratory. This allows us to determine which type of antibiotics would be best in your case.

The treatment requires the dental surfaces to be free from plaque and the patient must have good oral hygiene. Only then can the treatment be successful in the long term. This is why, prior to commencing treatment, one or two appointments with our dental hygienist may be necessary. Our professional dental cleaning is the perfect preparation for this treatment, and by analysing your teeth we can determine how you can best care for them at home.

This is when periodontitis treatment can commence. We start by cleaning the pockets using hand tools. This is done under local anaesthesic. This treatment tends to be ultrasound aided, allowing us to smoothen the root surfaces to make it more difficult for bacteria to deposit in those areas.

Following treatment it takes two to three days for the gums to recover. During this period the inflammatory swelling will go down, meaning that your gums will again be tightly and strongly aligned with the necks of your teeth. However, this also means that your gums will shrink ever so slightly.

During the first few weeks after treatment the necks of your tooth may be sensitive. We will check the result over the course of the next few weeks. In most cases gingivitis is reduced following this initial treatment. Should treatment not be successful or the pockets be particularly deep, surgery may be required.

During follow-up treatment we will clean the root surfaces of your teeth by opening your gums. Cleaning will be done using hand tools and ultrasound again, also under local anaesthesic. This allows us to reach deep-rooted deposits.

Periodontitis usually leads to gum recession and in severe cases it damages the root and the tooth compartment in the jaw (known as the alveolar bone). In addition, the collagen fiber in the tissue which connects the root with the bone is damaged. All this can lead to tooth loss. Thanks to Guided Tissue Regeneration (GTR) and surgical gum correction, we can still save the teeth of our patients in these cases.

GTR refers to a procedure that restores the periodontium, the tissues that surround and support the teeth which may degenerate due to severe and aggressive periodontitis. GTR is necessary when the different types of tissue that make up the periodontium do not all recover at the same speed. The gums are effective at closing wounds, which means they tend to grow much faster than the root element, the collagen fibre bundles or the alveolar bone. However, it is these latter elements that ensure your teeth are securely kept in place. GTR helps by stimulating regeneration in these tissues, keeping the gums from spreading in an unbalanced way.

 

Following local anaesthesia the gums are opened up — only a small cut is needed to reveal the surface of the root. We begin by removing plaque and dental calculus, and should craters have formed in the jaw bone they are filled with bone substitute. 

The area is then covered with a membrane, creating a barrier between the gums and the dental root as well as the bone tissue. The cavity created allows the collagen tissue fibres and the bone tissue to regenerate freely. The membrane does not need to be removed because it is absorbable, and the last step is to stitch the area up.

Periodontitis often results in retreating gums, leaving the necks of teeth exposed. These tend to be extremely sensitive to cold, heat, sweetness and sourness. In addition there is usually an aesthetic issue, especially with the visible front teeth which can seem unusually long. A lot of patients then tend to avoid an open and unrestrained smile. 

Plastic-aesthetic gum correction can help by regenerating the lost gum area. In this micro-surgical procedure tissue from your palate is transplanted onto the exposed tooth necks, or alternatively existing gum material may be loosened and stretched until the areas exposed have been covered.

Following an in-depth conversation discussing your options we will decide together which method may be best suited to you.

We will, of course, discuss the costs of your treatment in detail prior to your treatment.

 

Periodontitis is a chronic disease, which means aftercare is critical to keep it from returning. 

This consists of the following three aspects:

  • excellent oral hygiene at home
  • having your teeth cleaned professionally two to four times a year
  • having regular check-ups

This will guarantee long lasting effects from treatment, but without careful aftercare there is a high risk of periodontitis returning.



Severe periodontitis: how Guided Tissue Regeneration (GTR) works

Around 16 million Brits have periodontitis, many without knowing it. In about 12 per cent of people a severe form of gum disease is present. Thankfully the condition is treatable and GTR can help to regain some of the lost tissue.

Recognising and treating severe periodontal disease

Many patients overlook unremarkable symptoms such as bleeding gums, redness of the gums or bad breath. They become aware of their periodontal disease only at an advanced stage, when the gums receed, the cervical part of the teeth hurt or the teeth wobble. An early diagnosis is important as it improves the chances of treatment success significantly.

While the cleaning of the periodontal pockets in the early stages is usually sufficient, severe periodontitis can require a surgical intervention and the administration of antibiotics. If needed, GTR, which is sometimes used in combination with the administration of growth agents or bone replacement materials, can be used to regain some of lost tissue and bring the gums back to a position where they have formerly been.

Restoration of the periodontium

The periodontium consists of different types of tissue, which behave differently in cases of severe periodontitis. The gums, for example, grow very fast to close the wounds, while the root cementum, the collagen fiber bundles and the alveolar bone take more time to heal. Guided Tissue Regeneration ensures that these structures can recover faster, and thus it also re-establishes a firm hold of the teeth in the bone. As bone health influences gum health it additionally stops the recession of the gums. The basic requirements for this procedure to succeed are optimal oral hygiene and regular visits to the dental hygienist.

How does it work?
Under local anesthesia, the root surface is surgically exposed and thoroughly cleaned. After that, the bone defects are filled with artificial bone and a barrier between the gums and the root surface is created using a special membrane. This creates a pocket that the periodontium can use for regeneration. Since we use a resorbable membrane its removal with a second surgery is not necessary. Special gels applied to the root surface can also stimulate tissue regeneration. When we operate in the aesthetical region a gum transplant (connective tissue graft) may also be used to improve and re-establish the gum anatomy.

Success, risks and costs

GTR is not a major surgery, but it has to be performed thoroughly and precisly. It should therefore be entrusted to an experienced periodontist or dental surgeon. The risk of complications such as infection or an opening of the gums above the membrane is low. The success rates of the GTR are high (above 90%), and if the defect is deep and narrow rather than flat and wide the membrane remains covered by the gums and infection is unlikely.

What should be considered after the procedure?

Most importantly, do not smoke. Smoking reduces the size of the blood supplying vessels and thus less oxygen reaches the wound. Additionally, for the first two weeks after the procedure, patients should not brush their teeth at the treated site and should use mouthwashes (Corsodyl 0.2%) instead. The success of the treatment is checked after six months. The long term success of the treatment depends significantly on the compliance and oral hygiene of the patient. Read our recommendations for after surgery here.

Periodontitis is associated with lifelong aftercare, because the inflammation can flare up even after a successfull therapy. Therefore you should have thorough oral hygiene with an electric toothbrush, use fluoride toothpaste and interdental brushes, have check-ups with a dentist regularly, and have professional teeth cleaning done to clean hard to reach areas.

The preservation of your teeth will pay off, because you can avoid the need for complex procedures like dental implants. Keeping your own teeth is always preferable.

 


A special form of periodontitis — peri-implantitis

No pain, but dental implant loss: recognise peri-implantitis in good time and prevent it.

In the UK, around 30,000 implants are placed each year. Most heal successfully (98 per cent initially), but some are lost within a few years because of peri-implantitis. This is inflammation of the gums and the bone surrounding the implant, which is often painless and undetected. Read below how to recognise the inflammation and prevent it at an early stage.

Frequency of peri-implantitis
The success rates of dental implants and their respective restorations are very good: after ten years, on average 90 to 95 per cent are still intact. When implants are lost, they are often overloaded, with poor bone quality, lack of follow-up care, and bad oral hygiene.

If the patient does not attend regular check-ups, unnoticed inflammation around the implant can occur. In fact, 10 to 16 per cent of patients have peri-implantitis. If left untreated, sooner or later this will lead to implant loss.

If the gums are inflamed without affecting the bone, there is a so-called mucositis. Although it is harmless, as it does not endanger the implant, it is present in 40 to 48 per cent of implant patients.

How peri-implantitis develops
With peri-implantitis, not only is the tissue inflamed, but the bone recedes, which in turn endangers the stability of the implant. The cause of inflammation is bacteria that attach themselves to the implant surface and trigger an immune reaction in the body.

Recognise symptoms early
The symptoms of peri-implantitis are not always easy to interpret. Like periodontitis, it causes little discomfort: pain is rare, but can occasionally occur when the affected gums on the implant edge are touched. However, pain directly after implant surgery often has other causes.

In the advanced stage, bleeding may occur during tooth brushing. The gums turn dark red, and swelling and pus can form under the gums. Some patients also complain of bone pain or receding gums.

What treatment options are there?
Depending on the immune system of the patient, the disease tends to progress rapidly. The sooner peri-implantitis is diagnosed, the better the chances of survival of the implant.

First, the dentist determines the so-called probing depth and checks how deep the periodontal pockets are. The deeper the pocket, the greater the inflammation. Depending on the findings, it is usually sufficient to remove plaque, administer antiseptics and motivate the patient to improve their oral hygiene. Plaque can be removed with hand instruments or with powder blasters (eg airflow) that are more efficient and comfortable for the patient.

In the absence of therapeutic success or greater severity of the disease surgery may be necessary. Which form of therapy is most effective, however, is currently difficult to say because there is a lack of meaningful studies.

How to prevent peri-implantitis
Your dentist will ask you to come to check-ups on a regular basis. This helps to uncover plaque formations or the early stages of peri-implantitis in good time. Especially if periodontitis has been diagnosed before implantation, follow-up care is important as the risk of peri-implantitis is comparatively higher. You can also have a professional implant cleaning performed after the routine check to remove more bacteria.

When cleaning your teeth, think about the problematic interdental spaces and the edge of the gum, where bacteria like to settle. Biofilm also adheres very well to the rough implant surface.

In addition, implant users are advised to quit smoking. Tobacco use increases the risk of implant loss even with thorough oral hygiene.


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