Directly or indirectly, gum disease has been the number one cause of tooth loss in adults since ancient times. The bacterial plaque we hear about, destroys the tissues supporting the teeth and exposes the roots to decay. It appears that the more scientists are able to describe the specifics of this disease process, the more choices we have to treat it. How are dentists supposed to determine the best course of treatment for each case, especially with all the new products flooding the marketplace? And should patients always go along with their dentists’ recommendations?

Acute abscesses always require immediate attention. Once emergencies are addressed, how important is it to care for periodontal problems if nothing hurts? The answer is emphatic: treatment matters…the sooner the better. Unlike most medical problems that are hidden deep inside our bodies, dentists are able to render complete exams that are not invasive. They can scan dental x-rays for bone loss, probe the gums for areas that bleed, and measure the depths of pockets next to the roots. Once it is determined that a periodontal condition exists, treatment should ensue in a stepwise fashion.

First and foremost, periodontitis (gum disease) responds well to aggressive cleaning techniques known as root planing and scaling. Instruments are used to remove the plaque and tartar at and below the gum line. Along with improved oral hygiene measures, most pockets shrink to a satisfactory, maintainable level. During this initial treatment phase, dentists may suggest a host of adjunctive agents to help attain better results. These products include anti-microbial mouthrinses (Peridex), hollow fibers filled with tetracycline (Actisite), a doxycycline-impregnated gel (Atridox), an absorbable wafer containing chlorhexidine (Periochip), and a new pill (Periostat) that contains too little doxycycline to be an antibiotic but has enough punch to slow-down the body’s production of an enzyme - collagenase - that destroys the gum tissues. Each of these adjuncts comes with a price tag that may or may not warrant its use. While they all offer some degree of benefit, none replace scaling and root planing.

When should adjunctive therapies be used? It is reasonable to employ additional treatments when the pockets do not respond to the conventional root planing and scaling. However, if an improvement has occurred but it’s not enough, there’s no reason why more scaling can’t be tried. Any of the above products can be used for stubborn, resistant problem spots, but none are meant to treat abscesses or serve as substitute for periodontal surgery. In the face of persistent pockets and widespread bone loss, surgery should be performed to help reduce the pocket depths and, in many cases, help regenerate lost bone. At the expense of putting a label to this approach, surgery can be viewed as "conservative" when appropriately used.

So why the Egyptians? Thousands of years ago, they knew to scrape the hard accretions (tartar) off the teeth. It worked then and it still works today.

Is Fluoride a worry?

Worry if the water you’re drinking doesn’t contain enough decay-preventing fluoride. About 62 percent of Americans using public water supply systems receive fluoridated water, according to a study conducted in 1992 by the Centers for Disease Control and Prevention. It costs about 50 cents/year/person to add this fluoride. Numerous studies have concluded that adding a proper level of fluoride to water is a safe and cost-effective way of stopping tooth decay, but not everyone agrees.

Critics say that fluoride does more harm than good. They claim that fluoridation is the root of Alzheimer’s Disease, cancer, and osteoporosis. Yet there are no studies to support such claims. In fact, two major studies conducted by the Centers for Disease Control and Prevention state that "water fluoridation is safe and effective at the levels recommended by the Public Health Service and that there was no evidence of harmful health effects."

Fluoride can be found naturally in most water. Like most other compounds, too much fluoride can be harmful. Furthermore, it can be argued that fluoride is often found in soda and beer when they are manufactured in areas with fluoridated water. And it’s in many toothpastes. The fact is, however, that it is the most cost-effective way to prevent tooth decay and disadvantaged children may not have ready access to fluoride supplements or good oral hygiene habits, so fluoridating the water is the best way for them to get this needed compound.

When is fluoride most effective? When the baby teeth and adult teeth are still in the jaw bones...before they erupt into the mouth. Why? Because the fluoride forms a chemical bond with the enamel, making it stronger and more resistant to dental decay. Afterwards, once the teeth have erupted, the fluoride is less effective.

In a word, yes! Prognosis and success of periodontal treatment has always centered around the reduction of pocket depths and improved oral hygiene measures. Coupled with periodic gum treatments (cleanings) it has been reasonable to assume that most patients - and their teeth - would fare well. To a large extent, that’s true. But not everyone finds the ride a smooth one after finishing periodontal treatment.

In a fascinating study that analyzed "prognosis versus actual outcome," Michael McGuire and Martha Nunn utilized a genetic marker (IL-1 genotype) that identifies individuals at higher risk for developing severe periodontal disease to see if it would help improve the accuracy of prognoses and prediction of tooth loss. They studied 42 patients who had been in periodontal maintenance care for 14 years. Nine were smokers, and thirty had a history of smoking.

What they found gives pause for long-range dental treatment plans. When the patient proved positive for the IL-1 genotype marker, they had an increased risk of tooth loss by 2.7 times. If they were a heavy smoker, their risk was increased by 2.9 times. The combined effect of IL-1 genotype and heavy smoking increased the risk of tooth loss by 7.7 times. All other parameters used for evaluating periodontal success - tooth mobility, pocket depths, crown-to-root ratio, and percent bone loss - added to this model for tooth loss.

So what can we learn from this? Since periodontal diseases are multi-factorial, knowledge of the patient’s genotype is more important in predicting future risk than explaining past disease. Knowing the IL-1 genotype status would be important in developing a treatment plan and predicting tooth survival for a new patient who smokes and who presents with periodontal disease. Knowledge of a maintenance patient’s IL-1 status would help target therapy for non-responding areas, causing the dentist not to take a "wait-and see approach" but to become more aggressive as soon as a problem is identified. On the other end of it, creating a smoke-cessation program is vital for the long-range dental success for heavy smokers.

McGuire M.K. and Nunn, M.E.: Prognosis versus actual outcome. IV. The effectiveness of clinical parameters and IL-1 genotype in accurately predicting prognoses and tooth survival. J Perio 70:49-56, 1999.

Gums and systemic diseases

In Newsletter 1, we reported how untreated periodontal disease can lower birth weights of newborns. In Newsletter 3, we discussed how bacteria from the gums find their way into the circulatory system and can impact on coronary artery disease as well as cause infections in those diagnosed with mitral valve prolapse. We also discussed a link between periodontal disease and pre-existing diabetic conditions. Now we want to discuss how gum disease relates to chronic pulmonary disease and estrogen replacement therapy.

Many agents cause pneumonia, including bacteria, mycoplasma, fungi, parasites, and viruses. Any of these can infect the pulmonary tissues, precipitating a life-threatening pneumonia. In particular, bacterial pneumonia will become more prevalent as more bacteria become resistant to antibiotics. Individuals aspirate these bacteria into the lower respiratory tract. If the host defense system fails to eliminate them, pneumonia may result. Some of these potential pathogens - the bugs that cause disease - arise in the bacterial mix found in patients with periodontal disease. When it comes to "catching" pneumonia from your own mouth, medically healthy patients have little to worry about. However, a compromised patient faces greater risks of contracting pneumonia when their periodontal condition is left untreated. Patients with emphysema and chronic obstructive pulmonary disease may be at greater risk, too, with untreated periodontal problems. The answer seems clear: keep your mouth and gum tissues as healthy as possible.

A host of articles and studies support the prevalent notion that deficient estrogen levels are associated with decreases in bone density throughout the body, including the jaw bones. It is important to note that a decrease in bone density refers to the "quality" of the bone, not to its quantity. How does this translate to teeth and periodontal disease? As a person ages and demonstrates a hormonal link to systemic bone mass, the bone supporting the teeth becomes less dense, but the volume of bone around the tooth stays essentially the same.

Now reports are surfacing that indicate systemic bone loss can contribute to premature tooth loss in periodontal conditions. * The converse that post-menopausal hormone therapy has been associated with a lower risk for tooth loss, has always been found.** Evidence suggests that tooth loss may be an early sign of osteoporosis, giving the dentist a unique opportunity to refer patients for further diagnosis and treatment.

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