Gum diseases are among the most frequent pathologies in humans, the most common being gingivitis and periodontitis.
Gingivitis has a high prevalence, affecting more than 80% of patients. While advanced periodontitis, which is the most serious, occupies the sixth position in the ranking of the most prevalent diseases in the world and affects approximately 10% of the world’s population. If we take into account not only advanced periodontitis, but periodontitis as a whole, it would affect almost 40-50% of the population.
Both pathologies are defined as inflammatory diseases associated with bacterial biofilm (also called bacterial plaque). In the case of gingivitis the inflammatory process only affects the gingiva, while in periodontitis there is a progressive destruction of the rest of the periodontal tissues that support the teeth (the alveolar bone, the periodontal ligament and the root cementum). In periodontitis the process is chronic and multifactorial, i.e. it is associated, in addition to a dysbiotic biofilm, to a multitude of risk factors that participate in the onset, progression and severity of the disease. Some of the risk factors with more scientific evidence are tobacco consumption or having prediabetes or diabetes.
The importance of these pathologies lies not only in their frequency or in the impact they have at the oral level, of which we are more aware, but also in the significant impact they have on the quality of life of patients and on their systemic health. Patients with periodontitis are more at risk of having masticatory dysfunction that directly affects their nutrition, in addition to the aesthetic alterations it causes. But not only that, it can also cause difficulties in speaking, the quality of life indicators associated with oral health are lower, patients feel vulnerable, suffer more anxiety, etc…
What are the warning signs?
Bleeding is the first sign that should alert us that the gum is diseased, it serves to diagnose whether we have gingivitis or periodontitis. It is not normal, as many people believe, that the gums have to bleed when brushing our teeth or eating. They should not bleed and if they do it is because they are inflamed, indicating that there is a problem in them. There is only one exception: in patients who smoke, even if the gums are swollen there may be no bleeding. This is due to the direct action of tobacco that causes vasoconstriction of the capillaries that prevents bleeding and, therefore, masks the disease. So in smokers it is common to realize that there is a problem in the gums when it is too late and other signs appear later.
In addition, there are other symptoms to detect that we have periodontitis, but they are late. That is to say, normally for us to be able to detect the disease it has had to advance causing a lot of destruction of the supporting tissues of the teeth. Some of them are gum recession (the gum margin changes its position leaving the roots of the teeth that should have been covered by it uncovered) and tooth mobility (the patient notices that the teeth are looser). As a consequence of this progressive destruction of the supporting tissues of the teeth, spaces appear between the teeth that were previously covered or it causes the displacement of the teeth changing their position and/or favors the appearance of dentin hypersensitivity. It also causes halitosis, bad taste in the mouth and may cause pain, although it is not very frequent.
How is it diagnosed?
In order to make an early diagnosis of periodontal pathologies, it is important to perform periodic check-ups. With a clinical examination by a dental specialist, the disease can be diagnosed in its early stages. Periodontal probing is a simple examination to determine if there has been destruction of the tissues that support the teeth. To do this we use the periodontal probe, which is a millimetered instrument with which the position of the supporting tissues of the teeth is assessed tooth by tooth and it is determined if there has been any type of loss (clinically it is called “determining the insertion loss”). In addition, it helps us to identify the presence of periodontal pockets around the teeth, locations that occur as the disease progresses and where it is easier for a dysbiotic biofilm to develop and the disease to become chronic.
What is the difference between gingivitis and periodontitis?
Although both pathologies are inflammatory diseases, gingivitis is the inflammation that only affects the gum, the most superficial part of the periodontal tissues, not affecting the rest of the tissues. In addition, after the appropriate treatment to remove bacterial plaque and an improvement in oral hygiene techniques, the gums can be restored to a healthy state without any subsequent sequelae.
On the other hand, the consequences of periodontitis are more serious. In periodontitis, the rest of the tissues that support the teeth are affected, i.e. the cementum, bone and periodontal ligament. In periodontitis, the tissues that have been lost cannot recover and the teeth lose their support. In fact, if left to evolve freely, it can lead to tooth loss.
Periodontitis is a complex disease to manage because it is multifactorial. There are many risk factors, such as smoking or diabetes, that are involved in the onset, development and severity of the disease, which must be taken into account and incorporated into the treatment. Traditionally it has been considered that periodontitis only occurs in people who do not brush their teeth or who have very poor hygiene, but this is not always the case due to the participation of other risk factors. It is clear that bacteria are involved in the development of the disease, but not only bacteria, we must take into account the other risk factors involved.
What treatments are carried out?
The treatment is somewhat different if we are dealing with a patient with gingivitis or periodontitis, being the treatment of periodontitis longer and more complex.
In the case of a patient with gingivitis, the first thing to determine is the cause of the gum inflammation. It is usually due to an increase in biofilm caused by poor oral hygiene. We would begin by determining what factors have caused this increase in bacterial plaque, for example, if brushing is being done correctly. Although it is also necessary to determine other possible factors that could be favoring the development of the disease such as taking certain medications or hormonal changes.
Once the cause has been established and the appropriate recommendations have been given so that it does not happen again, the treatment is usually the removal of the biofilm by mechanical mechanisms. It has several names depending on each professional, such as cleaning, prophylaxis, tartrectomy, etc. Regardless of the name, in all of them it is necessary to eliminate the excess biofilm that is causing the inflammation of the gum. In this sense, there are different ways to do it, from the latest technology with aeropulpers to the traditional ultrasonic devices or to do it manually with curettes.
Periodontal treatment is usually much more complex and is carried out in different stages or steps:
- After the diagnostic phase, the first stage is to determine the risk factors that may be participating in the onset and progression of the disease, both the patient and the professional must be aware of them and try to avoid them. In addition, the promotion of healthy habits that will help us better control the disease should be recommended. It is very important that patients stop smoking, exercise regularly, avoid a sedentary lifestyle and eat a healthy diet.
- Next, we would start with the basic therapy of scaling and root planing (although it is not well used, it is also commonly called curettage), which consists of deconstructing the calculus (known as tartar) that is usually found under the gum, in the periodontal pockets. It can be destructured both with ultrasonic and manual instruments, as well as performed with different protocols, from all in the same session, in two consecutive days, or each quadrant once a week to complete the four. Normally, depending on the preferences of the professional and the patient’s situation, one or the other way of performing it is chosen. The objective is that once the calculus is eliminated, the periodontal pockets are reduced in size.
- Between four and six weeks after this first phase, the reevaluation is performed. At this appointment, the clinical condition of the gums, especially the existence of periodontal pockets, is measured again with our periodontal probe. In patients with periodontal pockets between 4-6 mm only with the basic therapy of scaling and root planing is usually enough to control them, but if they are larger than 6 mm it is usually not enough and then it would be necessary to go to the next phase.
- In those cases of more severe periodontitis it may be necessary to move to the surgical phase and have to perform periodontal surgeries. The purpose of these surgeries would be to surgically reduce the size of the periodontal pockets. Their purpose is to avoid the existence of these spaces between the gum and the tooth around the teeth, since they are favorable locations where a pathogenic biofilm can develop again, favoring the development of the pathology.
- However, the most important part of any periodontal treatment is what is called periodontal maintenance. They are visits with a periodic frequency that can vary from four to two times a year depending on the characteristics of the disease in each patient. In these visits the periodontal situation of the patient will be controlled, the presence of risk factors will be checked and the elimination of the biofilm that may have formed during that time will be carried out. As the disease is chronic, its treatment should also be chronic.