Note: This page is essential reading if you want to understand the causes of gum disease and the importance of daily oral hygiene.  For a full discussion of the treatment of periodontal disease click on the icon below:

Periodontal disease begins with poor oral hygiene, but it is easily prevented by brushing, and by cleaning between the teeth with floss or thin toothpicks.  It is, however, VERY difficult to stop once it starts. It is usually painless, and by the time the first acute abscess starts, some teeth may already be beyond saving. The first sign of periodontal disease is bleeding gums. The last sign of periodontal disease is no teeth. 

Good oral hygiene once a day will prevent, and even cure gum disease, but it MUST include cleaning between the teeth in some fashion.  Using dental floss to clean between the teeth is still the gold standard, however many people consider it a chore because it requires two hands, a learning curve, and a bit of a daily ritual.  For people who do not, or will not floss, the easiest way to clean between the teeth is with thin toothpicks called Stimudents or alternatively, Doctors Brush Picks (you can buy them in most drug stores). Stimudents or Brush Picks work very well and I find that people have no problems using them since they can be used with one hand (say, while driving or watching TV) and you don't have to be standing in front of a mirror to use them. First, if you are using wooden Stimudents, you wet one with saliva and  then insert it between the teeth so that it extends as far between the teeth as it will go, for most areas of the mouth, until you can feel the wood point with your tongue. When first used, inflammation of the gums causes the process to hurt a bit, but after a week, the bleeding stops, the space admits the toothpick more easily, and the pain is gone.  Actually, they are habit forming, and they feel good to use once the inflammation is under control.

What is Periodontal disease?

In order to understand gum disease, you must first understand the way the teeth and supporting structures are built. The part of the tooth you can see in your mouth is called the crown of the tooth. It is held in the mouth by the root which is embedded in your jaw bone.  It is attached to the bone by way of a thin "stocking" called the periodontal ligament. The bone is, of course covered by the gums which are called the gingiva. The gingiva attach to the teeth slightly below the highest level they reach on the tooth. 

The topmost part of the gingiva is called the gingival crest, and the inside of the little pocket between the gingival crest and the bottom of the pocket is called the gingival sulcus.  All the bony and soft tissue that supports the tooth is called the periodontium and when this organ becomes sick, we say the patient has Periodontal disease.

Plaque

Whenever you fail to brush your teeth, you notice a yellowish sticky paste that accumulates on them. That material is plaque. It is NOT just food debris. If you take a bit of it and look at it under a microscope you can see millions and millions of squirming worm like germs (see the picture on the right). When I was in the military, we used to have two headed microscopes that would allow two people to see what was on the slide at the same time. We would take a speck of plaque from between two of the patient's teeth and place it in a bit of water under a cover slip and watch them slithering around. It was very impressive, and it prompted a lot of people who never gave it much thought to brush their teeth.

Plaque is incredibly toxic.  The germs that naturally thrive in your mouth have evolved the ability to create a thick mucous-like film made out of polysaccharides (dextrans---which are chains of sugars linked together and colored pink in the graphic).     This film can anchor itself and anything embedded in it tenaciously to the surface of the teeth.  Within this microfilm, entire communities of microorganisms set up housekeeping. The electro-chemical properties of the microfilm cause it to attach solidly to the teeth while at the same time maintaining such a perfect environment for the germs that they multiply until bacteria account for nearly 100% of the mass of the plaque.  The two images below are electron micrographs of masses of mature dental plaque.  The close-up on the right shows a typical "corncob" aggregation composed of long, rod-like bacteria covered with masses of tiny round cocci which are, in fact, separate bacteria which live in a symbiotic (mutually beneficial) relationship with the rods.

The process of recession    

Dental professionals and students of dental technologies  who want a more detailed understanding of the anatomy of the teeth and their supporting structures may wish to proceed to the two pages I have written and illustrated especially for them.  These pages contain good illustrations and detailed text explaining the anatomy of the gingiva, periodontal ligament and bony structures supporting the teeth.  Click on the icon to the right.

There used to be a saying that when someone got old, they were becoming "long of tooth".   This phrase referred to the fact that as a person aged into senility, the gums that surrounded the teeth seemed to recede down the tooth exposing more and more of the roots.  Thus, the teeth looked longer than they did when that person was young.  This process is called recession, and it is really part of the process of periodontal disease.  Today, we know that the disease can be prevented by using good oral hygiene, however, the process of proper cleaning of the teeth did not become common until the late 19th century.  What follows is an explanation of why elderly persons become "long of tooth".

The bacteria in plaque carry on all their life functions in your mouth. They eat the same foods you do (especially sugar), and they metabolize it and produce waste products which they simply excrete into the microfilm that surrounds them. They turn the sulcus around each one of your teeth into a toilet. These waste products are called endotoxins and they cause the gingiva to get red and swollen. Your body creates lots of new little blood vessels in the area so that it can mount a defense against the onslaught of infection. These little blood vessels are in turn attacked by the bacteria and become very fragile and bleed easily. That accounts for the bleeding gums when you fail to clean your teeth daily

This first stage of periodontal disease is called gingivitis and is easily reversed by simply cleaning the teeth thoroughly once a day. Within two weeks of beginning daily cleaning (including between the teeth), all the bleeding stops and the gingiva become pink and healthy, provided you are able to clean to the bottom of the sulcus all around each tooth. Any place you leave plaque, the process continues in that area only.

But remember that the disease is painless, and most people learn to ignore the bleeding. This condition usually continues until early middle age by which time the teeth have entered into the second stage of periodontal disease; bone loss. The bone loss is an evolutionary adaptation to protect the body from outright infection of the bone (known as osteomyelitis). In the wild state, if bacteria actually entered the sterile spaces of the body as it would in the case of osteomyelitis, the individual would die. Nature "felt" it was better to lose the teeth as we grew older than to die at a young age from a common ongoing process. Note in the diagram at the left that the gingival crest has remained fairly high, but the sulcus has deepened into what is known technically as a periodontal pocket.

As the pocket deepens, it becomes harder and harder to clean to the bottom of the sulcus, and by this time, you probably are in need of the services of a dentist (or hygienist) to literally scrape the now hardened plaque (called calculus in the USA, or tarter in Britain) off the sides of the teeth.  In the picture at the top of this page, you can see some of this calculus on the exposed roots of the teeth. You may also note in the same picture that the teeth are in unusual positions. Due to the lack of bony support, the teeth begin to move in response to the pressures of chewing. This process is called pathologic migration. The process of pathologic migration does not take place until the third and final stage of periodontal disease. By the time the bone loss becomes so severe that there is not enough support to keep the teeth from moving, the patient is about ready for his (or her) denture (or dental implants if he can afford them).

The image on the left above is an x-ray taken in the year 2000 (Ignore the date.  The x-ray was taken in 2000, but photographed in 2004).  The arrow labeled "A" points to the cementoenamel junction which is a landmark that never changes on a tooth.  The arrow labeled "B" points to the crest of the bone that actually supports the tooth on one side of the tooth while the arrow labeled "C" points to the crest of the supporting bone on the other side of the tooth.  The image on the right above was taken approximately five years later in the winter of 2004.  Note that the tooth now seems to sit in a "cup" in the bone.  (This requires some imagination, since an x-ray is a two dimensional projection of a three dimensional object.  The "cup" represents an infrabony pocket.)  Note the large increase in the distance between the arrows.  Note also that only the tip of the root of the tooth now is supported by bone.  These are the effects of periodontal disease.  This patient had presented in my office because of pain and mobility in the tooth.  In her case, the disease process was caused by poor hygiene made worse by bruxing (grinding and clenching).  Compare these x-rays with the three diagrams above, and it is easy to see the similarities. 

The images above illustrate another real case that presented in my office.  The two central teeth had become mobile and painful and were removed for the comfort of the patient.  The images on the right show one of them after extraction.  It has been turned so that you are viewing the tooth from the right side (not front-on as you see them in the patient's mouth on the left).  The image on the far right has been colored to illustrate the anatomical structure of the tooth and its relationship to the bone and gums.  The crown of the tooth is colored green and is better defined by the black dotted line.  In health, this is the only part of the tooth above the attachment of the gums, and thus the only part that should be available to accumulate plaque and calculus.  The blackened area between the crown and the red gum attachment area is a part of the root that has been exposed to saliva and germs because of periodontal disease.  This area used to be covered by bone before the disease carried it off.  The black material is calculus and it is this material that is scraped off the tooth roots during the course of treatment for periodontal disease.  The red area is the position of the actual attachment of the gums to the tooth root.  In health, this area would not be as wide as it is in this situation.  Its increased width is a result of the inflammatory process mounted by the body in defense against the invasion of the plaque organisms that are constantly attacking it.  The blue area is that part of the root that remained immersed in bone.  One can see that there is a great deal more tooth above the bone line than below it, and this is the reason that the tooth became mobile and painful to touch.

 

The image on the right is an accurate model built to demonstrate the relationship of healthy teeth to the bone that supports them.  (Click on the image to go to the site where you can buy this sort of typodont.) Even the color of the teeth and bone are fairly accurate.  You can see where the enamel on the teeth stops and the roots begin.  Note that the bone is level across the entire row of teeth,  with between 2 to 3 millimeters of root exposed.  The exposed root actually serves the purpose of allowing the gums to attach to the teeth as well as to the bone underneath.

The other side of the same model is built to represent the way the bone and teeth look in a fairly advanced case of periodontal disease.  The yellow and black crust on these teeth is an accurate representation of "calculus" (hardened plaque) buildup.  (The material we in the US call "calculus" is called "tartar" by the British.)  Note not only the irregular shape of the bone, but also the fact that many of the roots of the teeth are sitting in "wells" in the bone (infrabony pockets) which further reduces the support that the bone can give the teeth.  In cases like these, the teeth are already somewhat mobile (loose).

These are the same teeth, but photographed from the inside.  This view allows you to see the bony pockets more clearly.  The disease starts at about the age of 25 and progresses painlessly until the level of the bone has been reduced enough to cause the teeth to become loose and sore.  During the entire time, the major symptom that the patient might notice is bleeding gums, especially when eating things like apples, or when brushing the teeth.

This view shows the front of the same dentaform.  The teeth on the left show the normal, healthy bony support that everyone is born with.  The teeth on the right show destruction of the bone due to periodontal disease.  Periodontal disease is caused by poor dental hygiene.  It can be arrested, but the bone can never be restored to its original level.  It is infinitely easier to prevent the disease by good brushing and flossing habits (Stimudents can be substituted for floss)  than it is to stop it once it starts!

One more thing needs to be mentioned.  Poor hygiene is always the primary cause of periodontal disease, however the bony destruction proceeds at a pace that depends on certain factors such as the current health of the patient, and also on the amount of pressure he places on his teeth due to grinding and clenching (referred to on this site as bruxing).  Most people grind and clench their teeth at one time or another, but some people carry this unconscious habit to extremes.  People who have poor hygiene have an accelerated bone loss due to the disease if they are chronic grinders and clenchers.  People who have these habits should be especially careful about brushing, and using floss or Stimudents to clean between the teeth daily.  We say that grinding and clenching habits, while not a primary cause of gum disease, are codestructive and cause a bad situation to progress at a faster rate. See my page on TMJ for more on these habits

Poor hygiene leading to periodontal disease is one of the three major factors that affect the health of the teeth.  For a good overview of how all three factors interrelate. click here for my article on Why some people have such nice teeth while others have nothing but trouble.

Is there a link between periodontal disease, coronary artery disease and stroke?

Scientific studies have shown that there is a link between the presence of severe periodontal disease and the presence of cardiovascular disease and cerebral vascular disease (stroke).  This association is especially apparent in the occurrence of stroke (cerebral vascular accident--CVA).  It does not appear, however, that there is a causal relationship between periodontal disease and Coronary Artery Disease/Cerebrovascular disease.  A correlation between two processes does not necessarily imply that one causes the other.  In this case, the correlation appears to be caused by overlying factors that influence both processes separately.  These factors appear to be environmental and genetic factors, as well as acquired risk factors such as smoking, mental anxiety, depression, obesity, diabetes mellitus and exposure to tobacco.

One study involving over 4,000 patients and 17 years of followup showed no evidence of a decreased risk of coronary heart disease or stroke if chronic periodontitis was eliminated.  (The study was from the July 2001 issue of The Journal of the American Dental Association.  The lead author was P.P. Hujoel, PhD, assoc. prof, school of dentistry, Univ. of Washington, Seattle.)  In other words, there is no evidence that either disease is involved in causing the other.  On the other hand, although past studies have not supported a causal relationship between periodontitis and cardio/cerebral artery disease, other studies have concluded that periodontal disease is a risk factor, or marker independent of traditional CAD risk factors, with relative risk estimates ranging from 1.24 to 1.35.  In other words, persons with severe periodontal disease are between 24% and 35% more likely also to have coronary artery disease. This means that the presence of severe periodontal bony destruction may serve as a marker for persons who are also more susceptible to vascular diseases.  This still does NOT infer that if you have periodontal disease, you also have coronary or cerebral artery disease.  It simply means that you MIGHT be more susceptible to CAD/CVA.

As of the spring of 2010, a causal relationship between periodontal disease and coronary artery disease still has not been found, although there does appear to be a link between endothelial function and active periodontal disease.  (Cardiovascular disease involves damage to the endothelium (lining) of the blood vessels through the buildup of redundant tissue called plaques.)  Treating periodontal disease does appear to improve endothelial function, however it is not yet clear if this has any affect on the outcome of the progression of cardiovascular disease.  (Higashi Y, Goto C, Hidaka T, Nakamura S, Fujii Y, et al.)

A blood test which measures the level of C-reactive protein (CRP) is a sensitive marker of inflammation.  CRP levels can help to identify those patients whose immune system responds most actively to stimuli. The amount of inflammation caused by an ischemic stroke is measurable by determination of CRP concentrations.  Furthermore, the level of CRP helps to predict outcome of CVA (i.e. how severe the cerebral damage will be).   Periodontal disease, cardio vascular disease and cerebral artery disease are all characterized by inflammation, and all are associated with high levels of CRP. 

For much more on the relationship of periodontal disease to systemic immune functions please see The American Journal of Cardiology and Journal of Periodontology Editors’ Consensus: Periodontitis and Atherosclerotic Cardiovascular Disease.

The linkage between periodontal disease and diabetes

Diabetes is a disease that interferes with the metabolism of glucose.  Glucose is the sugar that all other forms of sugar are converted to before entering the bloodstream.  The term "metabolism" involves the way that glucose is utilized in all the individual cells throughout the body.  Since glucose is the essential fuel that makes all other cellular functions possible.  Anything that interferes with its utilization can cause those cells to malfunction.  This includes all the cellular components that compose the periodontal tissues.

Persons with uncontrolled, or poorly controlled diabetes are much more prone to rapid bone loss resulting from periodontal disease.  On the other hand, the presence of periodontal disease depends strictly on the persistent presence of dental plaque on and around the teeth at the periodontal attachment.  In other words, good oral hygiene will always prevent the disease, regardless of the presence or absence of diabetes or other metabolic diseases.  Thus, diabetes does not CAUSE gum disease.  It can, however, accelerate the destruction of bone in the presence of poor oral hygiene.  Good oral hygiene (including good interproximal--between the teeth--hygiene) will prevent periodontal disease even in the presence of uncontrolled diabetes.  Poor oral hygiene, in the presence of uncontrolled diabetes is a prescription for the loss of a person's teeth.

Finally, there is no known linkage in the other direction.  The presence of periodontal disease does NOT necessarily infer that a patient also has diabetes.

How periodontal disease is treated

How to prevent periodontal disease

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