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Geoffrey R. Bauman, DMD, MS | What is Gum Disease? in Newark

Geoffrey R. Bauman, DMD, MS / Board Certified,  American Board of Periodontology
Fellow, Midwest Implant Institute



What is Gum Disease?


What is gum disease and what is the goal of treatment?   Gum Disease, or Periodontitis by its professional name, is a disease that progressively destroys the bone around the teeth such that the teeth are eventually lost if left untreated.  The disease results when the resistance of an individual starts declining (usually around the age of the forties to early fifties) and the bacterial film on the teeth  (not food...food can cause cavities, but has little to do with gum disease), which the body could effectively defend against before, begins to attack the gum and bone attachment, breaking them down.  Prior to this "susceptible" age, the immune system was able to heal the gums and bone when broken down. However, once the body's immune system starts to decline and we become susceptible, we are no longer "maintenance free".

Periodontitis prevention and treatment is "all about the film" on the teeth.   The film that can be felt on the teeth when waking in the morning is a bacterial film.  And this film is the disease once you reach the susceptible age for Periodontiitis.   Each time you remove it thoughly you will have cured yourself for the next 14-24 hours.  Since this film grows back about every 14-24 hours, it is important to be sure to remove it twice per day.  If it accumulates much longer than that, it will begin to become more poisonous for the gums and bone.  And as it dies, the dead bacteria within the film become calculus-  the hard, porous, mineralized substance which, in turn, holds even more bacteria within it.  Once the calculus forms it will need to be removed by that dental hygienist at the next dental cleaning.  If it accumulates too heavily, then root planing/deep cleaning may be required,  a more extensive and detailed procedure.  

The bacterial film (known as dental plaque) grows on the teeth whether we eat or not.  In fact, the act of chewing detergent foods tends to wipe the film off on the tops and sides of the teeth.  The action of the detergent food as well as the movement of tongue, cheeks and lips all help to clean the film off...except in between the teeth where nothing naturally cleanses and next to the gum line where the tooth surface tends slope inwardly and shelter the bacterial film against these natural cleansing mechanisms.   


Essentially, the only way bacteria can get under the gums to attack the bone is by sticking to the teeth as a bacterial film.  This is because the gums produce a fluid in the little ditch around the tooth which flushes everything loose out.  So if bacteria want to get to your bone, they can't just "swim" into the ditch.  They would be washed out.  The bacteria must stick to your tooth and "grow" their way under the gum by extension to get to your bone.  Herein lies the method to beat the diesase.  If the patient can just remove the film from the tooth surface (particularly between the teeth since that's where most of it forms), it will take about 14 hours for the bacteria to re-stick and grow their way back under the gums.  Therefore, if the bacterial film is thoroughly removed morning and evening, it never accumulates enough to break the bone down.


Periodontitis is fully preventable by thorough removal of the bacteria film twice per day by the patient and regular cleanings to clean up areas of tartar formed where the patient misses with daily bacterial film removal (see below).  Although brushing is still important, the disease primarily attacks between the teeth, so one can brush better and more frequently and still not be able to control the disease.  The disease attacks primarily between the teeth because that is where most of the bacteria accumulates.  When two film-covered tooth surfaces are backed up to one another, as between the teeth, the entire space fills with bacteria.  The tongue can't feel its presence so most patients aren't motivated to clean between the teeth.  However, cleaning between the teeth is the key to prevention as well as the cure.

Periodontitis is usually fully curable...if the patient doesn't wait until the disease is too far along.   The actual cure is, as described under "Prevention" above, performed by the patient by thorough removal of the bacterial film, especially by flossing.  However, once damage has occurred, professional treatment may be required to repair the damage.  The disease, like heart disease, is a "silent killer" of the gums and bone.  Once the the patient actuallly senses pain or the teeth become very loose, it is often too late.  Therefore, many patients don't accept periodontitis treatment because it "doesn't bother me" yet.   So don't wait until it hurts...although occasionally there are some later such cases that can be successfully treated.  It is just much more difficult and much more expensive for the more advanced situations. 

How is periodontitis controlled?  If the patient will not commit to removing the bacteria film twice per day, it is difficult to stop the disease entirely.  Through treatment and more frequent periodontal cleanings (periodontal recall) the disease can be slowed fairly well...but we will not fully stop it until the patient commits to doing the home care (particularly flossing).  The disease is a result of the patient's lowered resistance against the bacterial film as well as a failure to heal when the bacteria break the gums and bone down.  If the patient religously removes the bacterial film from the teeth in the morning and evening every day, then the gums and bone won't break down.  So the patient won't have to worry about the fact that their gums and bone don't heal like they use to if they don't break down in the first place.  There are studies that show once per day flossing works, but I've found a much better result with patients who floss twice per day.     If a patient will commit to keeping the bacteria off the teeth twice per day, then we can usually be successful at treating the disease. 

What is the professional's role in controlling the disease?  The dentist's/hygienist's role is to remove any obstacles to the patients ability to access and remove the bacterial film.   There are two main obstacles to the patient being able to access the bacteria film and thus to keep himself/herself "cured":   1)  Calculus (tartar is another name for calculus)  and 2) periodontal pockets (deep ditch between the gums and tooth that forms as the bone is lost and in which the bacteria can hide from the patient's brush and floss).   

Calculus is the hard, porous, mineralized deposit that forms on the tooth/root which the hygienist removes at dental cleanings.  It is actually nothing more than dead bacterial film which didn't get removed by brushing/flossing while it was soft, and  which then mineralizes from minerals in your saliva as the bacteria die.  The mineralized dead bacteria (calculus) then become a porous home for more bacteria to hide from flossing and brushing.  Therefore, unless the calculus is removed, the patient can't thoroughly remove the bacteria when brushing and flossing.  And once gum disease has begun, and the patient has lost bone, the roots become accessible to the bacteria.  Roots have pores in them into which the tartar can form.  That is why the initial step in the treatment of periodontitis is usually "root planing" (deep cleaning) to get the calculus planed "out" of the roots.  Root planing is much more involved than simply "clicking" the tartar off of enamel as in a dental cleaning.  

The second major obstacle to thoough removal of the film by the patient is periodontal pockets.  Pockets occur when the little "ditch" between the tooth and the gum becomes much deeper.  As the bacterial film breaks down the attachment of the gums and bone to the tooth ditch between the gums and tooth increases in depth.  Once this ditch becomes deeper than 4 mm,  the patient can no longer access the film with flossing and brushing.   So the bacteria effectively "hide" in the pocket and continue destroying bone. 

Fortunately after root planing,  pockets will sometimes reduce to 4 mm or less.  The reduction if inlammation allows for shrinkage of the gums which, in turn, reduces the pocket depth.  So in such a case, the calculus as well as the pockets are resolved with just root planing alone and not rquire surgery.   In this case, if the patient will continue twice-daily home care (especially flossing) and seeing the hygienist regularly (the preponderance of studies over the past 30 years have shown that periodontal patients need cleanings every 3 months) the patient will likely remain "cured".

What if the root planing doesn't resolve my pockets?  If the pockets are not resolved by the root planing and the patient is actually doing the home care then the dentist/periodontist must eliminate the pockets (through gum surgery).  Otherwise the disease will continue where the patient can't get to the bacteria film in the pockets and those teeth will  continue to lose bone and eventually likely be lost.   Sometimes patient just don't want to do surgery.  And if the home care is not good, I tend not to recommend it because the lack of adequate home care is what caused the disease in the first place.  However, when a patient is committed to keeping the teeth clean, then we must do the surgery or the patient just won't be able to keep the pockets clean....and the disease will continue at those teeth until lost.