Periodontal  Updates

The following articles are some that caught my eye and were important enough I thought to pass on. There is a quick summary on each one then the full article is included below. Periodontal disease is becoming more and more recognized as a major health risk beyond the thought of loosing ones teeth...

Floss or Die ! You should read this entire article. The evidence is mounting quickly that heart disease and periodontal disease go hand-in-hand. The studies are impressive and some span 30+ years.
Are spouses at risk of being infected with perio disease? It seems obvious after reading this that periodontal disease is contagious.
Gum Disease-Heart Disease Link Link to article written by the American Academy of Periodontology
VERY INTERESTING and factual.

Floss or Die !!

Sounds like something from a standup comic routine doesn't it ?

This article comes as no surprise to me or to most others within the dental profession. For many years, it has been recommended by the American Heart Association to administer to someone with a heart condition (especially heart murmurs) antibiotics before having their teeth cleaned.

WHY ?
It is a known that the bacteria in and around the gums will invade the bloodstream during a cleaning appointment and there is a chance that a rapid bacterial infection will occur within a damaged heart from these same bacteria. The more irritation from gum disease, the more bacteria in the bloodstream. In a healthy mouth, the gums will not bleed during home care nor at the hygiene appointment.

It is in this light that the following article is VERY interesting in regards to everyone's general health.

From the Associated Press

Anybody who has been to a dentist has heard it: Flossing and brushing keep the gums healthy so your teeth don't fall out. But the hygienist probably didn't mention your heart. Scientists are investigating the idea that bad gums create mischief in places far from the mouth. They say the bacteria that live around the teeth, or perhaps the body's reaction to them, may even contribute to disease that eventually could do you in. At a recent conference on the subject at the University of North Carolina, Dr. Raul Garcia playfully flashed a slide that warned: "Floss or die."

Garcia a dentist at the Department of Veterans Affairs Outpatient Clinic in Boston, admits there is no proof that bad gums do anything worse than ruin your teeth. But a strong circumstantial case is emerging. "It's not an unreasonable hypothesis, although on the surface it appears to be a leap of faith," said Dr. Steven Offenbacher, a dental researcher at the University of North Carolina.

Offenbacher is studying the possibility that gum disease is a major trigger of premature births. Others are examining theories that it helps clog the arteries and cause heart attacks or that it contributes to diabetes.

About three-quarters of adults older the 35 have some degree of periodontal disease, a condition that often gives off few warnings except, perhaps, red gums and bleeding when brushing. Under the gum surface, however, are billions of bacteria. In theory, they create a smoldering, low-grade infection that inflicts its damage slowly over time.

The main evidence so far comes from studies that follow large numbers of people to see if those who have bad gums fare differently from those who don't . The studies strongly hint that people with periodontal disease have a higher than usual risk of heart attacks.

Among the most impressive is the VA's Informative Aging Study in Boston, which has followed 1,231 men who were outwardly healthy when they were given thorough dental exams in the 1960s. The men who started out with bad gums have had about twice the death rate as others, especially from heart disease.

Another study, conducted over six years on 44,119 male health professionals at the Harvard School of Public Health, found that those with 10 or fewer teeth had about a two-thirds higher risk of heart disease than men with nearly all their teeth.

Yet another study from the Marshfield Medical Research Foundation in Wisconsin checked on the health of 9,760 Americans surveyed in the early 1970s. By 1987, heart disease was 25 percent more common in those who had gum disease at the outset. Men younger than 50 at the start of the study had about a 75 percent greater risk of heart trouble.

These studies suggest bad gums could be as strong a risk factor for heart attacks as smoking

The statistical link with premature births is less convincing.

Doctors have long noticed that women with bad teeth seem more likely to give birth prematurely. Offenbacher studied 124 women and found those with gum disease were about eight times more likely than usual to deliver dangerously small premature babies.

There are three main theories about a possible connection between gum disease and trouble elsewhere in the body:
  • Gum bacteria escape from the mouth, perhaps when people brush, then travel through the bloodstream and release dangerous toxins. A chief suspect, the dental bug Porphyromonas gingivalis, can make blood clot and may help clog heart arteries. Gum germs have been found inside artery-plugging plaque.
  • Bacteria-fighting blood cells give off proteins that could have unintended harmful effects thought out the body. Among these are such potent chemicals as tumor-necrosis factor and prostaglandin's. Some of these may trigger too-early labor by making the uterus contract.
  • Gum disease itself is not the trouble. Instead, a tendency to have gum disease, heart attacks and premature labor all result form the same underlying deficiency.

"Like everything else, it's probably a combination of these, said Dr. Robert Genco, a dental researcher at the State University of New York at Buffalo

So, the bottom line is there is a MUCH better reason to perform good hygiene at home and have regular hygiene appointments. We'll do our job to inform you of the periodontal condition present and now we might say a relationship to your heart health.

Are Spouses at Risk of Being Infected with Periodontal Disease ?

by Trisha E. O'Hehir, RDH

Research is providing information about the specific bacteria associated with destructive periodontal disease. Porphyrmonas gingivalis is one species specifically associated with severe periodontal infection. When measuring bacteria within infected pockets, this particular bacteria often comprises a large proportion of the microbial flora. In healthy sites, a small proportion of the bacteria are P. gingivalis.
What researchers don't know is whether this bacteria in undetectable numbers is part of the normal oral flora and simply increases during disease or if it is only found in disease. If this bacteria only appears during periodontal infection, the question must be asked as to the source of these bacteria. If the bacteria must come from a source outside the individual, is it possible that bacteria can be transmitted between spouses?

Husbands, wives participate in study
Researchers in the Netherlands attempted to answer this question by analyzing bacteria between husbands and wives. They evaluated a small group of eight married couples. All 16 patients had severe periodontal disease as measured by pocket depth greater than or equal to 5 millimeters. None of the study participants underwent periodontal therapy. In addition, non of them had taken antibiotics during the past six months. After a clinical examination, bacterial samples were taken from several of the periodontal pockets. Samples were also taken from the dorsom of the tongue, buccal mucosa and the tonsilar area.
Several laboratory tests were done to cultivate bacterial growth. After identifying the P. gingivalis bacteria, a highly sensitive chromosomal DNA fingerprinting analysis was carried out. This recently developed test is capable of determining distinct DNA patterns. The identification of distinct patterns of bacterial strains can be useful in obtaining evidence of bacterial transmission.
All of the individuals tested were found to have P. gingivalis. Six of the eight couples studied showed identical DNA patterns. The patterns between couples were distinct and identical. It was clear that the husband and wife of each of these couples had the same bacteria.
In the other two couples, each person demonstrated a clearly distinct enzyme pattern for P. gingivalis. One possible explanation for the difference could be that at one time they had identical bacteria which then formed mutation strains of P. gingivalis. They may have been identical at one time, but are now distinctly different. It must also be considered the bacterial variations measured were due to breakdown during testing. The testing process itself may be responsible for the differences.
Although these findings strongly suggest that bacteria were transmitted between husband and wife, the direct effects are still unknown. Since both spouses in the couples had signs of periodontal disease, there are two possible explanations.
First, it can be concluded that one spouse had the infection, and it was transmitted to the other resulting in periodontal breakdown. The transmission would therefore be from an infected partner to a healthy partner.
The second explanation identifies one spouse with periodontal disease and the other with a susceptibility to the colonization of these bacteria. Transmission in this case would be from an infected spouse to a susceptible spouse.

Children not susceptible
When comparing the transmission of periodontal bacteria to the transmission of bacteria causing caries (decay), we know that Streptococcus mutans are transmitted from mother to infant at a relatively early age. P. gingivalis is not measured in children, except occasionally in cases of juvenile periodontitis. Transmission is only between adults and not from parents to children.
Researchers have been able to implant P. gingivalis into periodontal pockets of monkeys with gingivitis. This action resulted in progression of the disease to periodontitis. A pilot study involving two adult volunteers also demonstrated the possibility of implanting P. gingivalis in already inflamed pockets. Colonization of the bacteria was measured by the researchers.
Further research is needed in this areas to determine if the spouses of periodontal patients are at risk for developing destructive periodontal disease because of the transmission of P. gingivalis.

 

*******************************************************************
Trisha E. O'Hehir, RDH, BS. lives in Flagstaff, Arizona. She is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics.

Periodontal (Gum) Disease

FAQ's
Defining Terms
Stages of Periodontal Disease
X-Rays in Periodontal Diagnosis
Periodontal Therapy 

First a few frank comments about periodontal disease...

HOME CARE, HOME CARE, HOME CARE

One of the biggest misconceptions concerning periodontal disease is that the dentist / hygienist will control the disease. The responsibility of controlling the disease process rests completely with the PATIENT ! This is not to say that professional care (i.e. diagnosis, education, therapy) is not necessary - it 's just that MANY people that have had the best of care, do not perform the diligent home care regimen they should. Once a person has been diagnosed, they forever have periodontal disease. There is NO cure - it can only be maintained, and should be reevaluated at regular intervals so as not progress to the point of tooth loss.

Bacteria is the MAIN culprit. Bacteria exists in everyone's mouth. Some strains of bacteria are much more aggressive than others.

FAQs
What is the cause of most tooth loss in adults?
Periodontal disease - NOT decay

Can I inherit this problem?
Yes, you can. You may inherit the problem of unusually heavy plaque and tartar buildup, or even problems with your immune system which leave you much more susceptible.

Can I tell that I'm having this problem myself?
Not in the earliest stages, it takes a dentist or hygienist using a special instrument to determine early onset.

If my gums bleed when I brush, am I in desperate trouble?
Not necessarily, but the earlier the treatment, the more likely long-term success.

Does everyone diagnosed require surgery?
Not at all. In fact conservative therapy has proven to be successful in the majority of cases diagnosed early.

Is bad breath a sign of periodontal problems?
Possibly, because the very same bacteria can cause both problems.

How long does it take for plaque to reform after a professional cleaning?
1 day

Are there are factors besides bacteria?
Yes, stress, poor nutrition, a poor bite and especially smoking.

Do you know what the difference is between the terms periodontal disease, gum disease and pyorrhea? There is no difference, they are synonymous terms. Periodontal disease is the most common disease in the world, it is estimated that over 70% of the adult population in this country have some periodontal problems..

Periodontal disease is a chronic infection that slowly attacks and destroys the gums and bone that support the teeth. The fact that it is a chronic disease means that a person can not be "cured", rather they must work at controlling the factors which will bring on the full disease process. Other examples of chronic disease are heart disease and diabetes - they can be managed, but NOT cured.

Let's begin by defining terms.

  • “PERIO” means around and “DONTAL” means tooth. By saying “around”, this means that periodontal disease has to do with the gum tissues and bone that support the teeth
  • PLAQUE is a bacteria that is collecting onto teeth and gums. In small numbers, there is no problem, but when it collects in large numbers it causes damage to the teeth (decay) and supporting tissues (period ontal disease)
  • CALCULUS is a hard buildup that occurs around the teeth. This must be removed with a professional cleaning. The combination of calculus and plaque is the primary cause of periodontal disease.
  • TARTAR is the same as calculus.
  • PERIODONTAL POCKETS are areas where the jawbone has been eroded away by the disease process.
  • PERIODONTAL PROBE is a dental instrument used to detect and measure the depth of pockets.
  • GINGIVA is another word for your gums.
  • GINGIVITIS is used to describe the first stage of periodontal disease. The gums are puffy and bleed.

 

When a screening is performed (and it should be performed at each hygiene appointment), a periodontal probe is used. This probe is a depth measurement device - the measurements are taken in millimeters (mm). With very little pressure the probe is slipped down next to the root of the tooth until there is resistance. The mark which is then at the gum line demonstrates the depth of the gum pocket. Healthy gums do have pockets but they don't bleed and are no deeper than 3mm.

THE PRIMARY STAGES OF PERIODONTAL DISEASE


Healthy Tissues
  • No bleeding or puffy gums, pockets all measure to a normal 3mm or less.

Periodontitis I (Gingivitis)
  • Bleeding gums when measured, puffy in appearance and pockets no greater than 3mm. No damage to the supporting bone in this stage.

Periodontitis II
  • Bleeding and puffy gums that measure slightly more than normal at up to 5mm.

Periodontitis III
  • Bleeding and swollen gums with pockets that will measure up to 6mm and more. Recession beginning to appear.


X-Rays in Periodontal Diagnosis

X-rays play a vital part in the overall diagnosis of periodontal disease. They compliment the periodontal pocket charting.
NORMAL X-RAY

In this first film, the bone and supporting tissues are normal. Your gums don't show up on x-rays but the bone does. The red line is drawn across the top of the bone seen on the film.



PERIODONTAL X-RAY

In this film, the PERIO BONE LEVEL refers to the level of bone left supporting the teeth after the destructive process has occurred. HEALTHY BONE LEVEL demonstrates the ideal (See the NORMAL X-RAY above). The BONE LOSS BETWEEN MOLAR ROOTS demonstrates an area where the bone has dropped down below where the roots of the molar divide.



PERIODONTAL THERAPY

Through stages I, II, and III it is usually a more conservative nonsurgical approach that is taken. The usual treatment sequence after proper diagnosis and documentation is performed is -

SCALING and ROOT PLANING

SCALING consists of removing the hard calculus and plaque around the collar of the tooth as well as below the gumline. ROOT PLANING removes the calculus and plaque off the root surface well below the gumline (into the pocket). Depending on the case, these procedures may or may not require numbing. Hand instruments called scalers as well as high-frequency polishers will be used to accomplish a complete and thorough job.

SURGICAL TREATMENT

When the pockets are very deep, procedures must be performed so that all infection, plaque and calculus may be removed. Sometimes the bone around is no longer smooth and it must be corrected. There are times that bone may be actually added to areas where it has eroded away.

Incorrect Splint Fabrication

Example of incorrect splint fabrication and resulting problems:

This page comes from the frustration of seeing repeatedly the mistakes made by what I must assume are good dentists that have the best of intentions when it comes to trying make splints/nightguards for patients they see. Some I know are simply misguided; a sad but true fact.

This is just such an example: A person has a splint/nightguard made and they do not do well with their TMD problems primarily because the splint(s) are made incorrectly and do not provide a correct position for the jaw socket to remain in.

In this particular case Cathy came to my office with two previously made splints/nightguards. She was to wear one during the day and one at night. The problem is not that she was made two different splints (one upper / one lower), the biggest problem is that neither one of them is made for a physiologically correct joint position. In other words, when she closes into touch the surface of the splint it is natural to seek a contact with the splint that has the most number of teeth touching as possible. Why? Because this is what feels most natural to the person wearing the splint. So in this case shown below, yes Cathy can touch much more solid than the photos reveal, but she must come very far out of a correct jaw joint position to do so. There is the problem. Since she had problems with her TMJ's before wearing the splint and now the splints are not made correctly, she really stands no chance of improving.

It is very easy to demonstrate with Cathy (because of her young age and the ease of seating her joints to correct position via a light touch to the tip of the chin) that the joints are not in a correct socket position when she closes into maximum contact on the splint/nightguard.

YOU MAY CLICK ON THE IMAGES BELOW TO ENLARGE THEM (Use the back button on your browser to return)



This is the lower splint. The thumb on the chin is to verify and hold a correct jaw joint position. The first contact on the splint is in the far rear molar area. If I remove my thumb from her chin and tell her to close.....she will make better contact on the splint (therefore not so open in the front). BUT, when she closes to this better tooth contact, the jaw joints have to come far out of socket to achieve this. The patient said that she had difficulty in finding a comfortable place to rest in this splint.



Pictured here is the upper splint. This attempt at a correct position is a much better try than the lower splint but none the less, it is still not made correctly. The last image of the model simply shows the splint placed onto Cathy's models (which are correctly related on an articulator) - the "offness" is still the same as in the mouth.
NOTE - This photo is taken when there is a first contact on the splint. She is NOT holding open.



This is a physiologically CORRECT splint / nightguard (call it what you wish). The joints are in socket and all the teeth strike the surface of the splint in this exact position.

NOTE - This is actually the splint pictured above (upper) that has been added to and adjusted to the correct position.

Splint (and nightguard) Fabrication

I often get questions about how to recognize whether a splint is made correctly. There is not a standard for splint fabrication just as there is no standard for TMJ therapy. Why do I and other practitioners like myself believe that the method described below is the most correct? Because the method follows VERY sound physiological/orthopedic principles...such as your jaw joint wants to be in socket (like every other joint in your body).

THE IMAGES BELOW MAY BE ENLARGED BY CLICKING ON THEM (Use the back button on your browser to return).

INITIAL RECORDS

Before a splint can be made, correct records must be obtained.

A record of how the upper jaw relates to the jaw joint (TMJ) is taken. This is called a facebow transfer. The reason for placing the facebow into the ears is because the ear opening are just 1/4 inch behind the joint - therefore a great reference point.
NOTE - Soft wax on the facebow adapts to the upper teeth.
splint1 small The facebow is now adjusted to place and ready to remove.

Wax bites - special wax softened in warm water. The manipulation of the lower jaw is the MOST important technique for proper records. The instructions are to relax the jaw as completely as possible and the doctor then guides the jaw into its most correct position - at that point the teeth are pressed into the wax. The patient does NOT squeeze into the wax.

On the left - wax tabs before taking records.
On the right - wax bite records.

An articulator is an instrument that duplicates jaw joints. Here the facebow (with ear extensions removed) is attached to the articulator. The upper model is placed onto the wax of the facebow. Stone is mixed to attach the upper model.
Stone sets hard, the articulator is turned upside down and the wax bites are used to relate the upper model to the lower. Stone is mixed to attach the lower model.

The models are related NOT to where all the teeth touch, but rather to where they first contact when the jaw joint (TMJ) is in its most correct position.

The models are ready for a splint to be made. A splint is rock hard and most often made of heat/pressure cured clear acrylics.

SPLINT DELIVERY

When the splint returns from the laboratory it is imperative that adjustments be made to "fine tune" the splint to the correct position for the jaw joint.


Make sure the splint fits onto the upper teeth with ABSOLUTELY no movement or rocking.

The lower jaw is manipulated (just as when taking the wax bites) to a correct jaw joint position. Using red bite paper the lower teeth are tapped against the hard splint surface. This will mark the first point of contact.

The arrow here points to the first point of contact.
NOTE - the biting side of the splint is absolutely smooth.

The splint is taken to the mouth numerous times and marked with bite paper. The splint surface is adjusted with burs until there are even marks for all lower teeth striking against the acrylic.

When the splint is in place and the jaw is moved left, right or forward the front six teeth should cause separation of all back teeth off of the surface of the splint. This is accomplished by means of a ramp built into the front part of the splint. With bite paper placed, the lower jaw is moved left, right and forward - this leaves marks represented by lines rather than dots.

A correctly adjusted splint that shows proper guidance by the front 6 teeth.
NOTE - A lower splint can be successfully designed and delivered.

 

NOTE - There are variations from the delivery method outlined above that can be used to deliver a splint.
They ALL should finish with the marks shown above.

 

All these steps are important to a correctly constructed splint/nightguard.

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