Monday, June 17, 2013

Gum disease. Understanding, Treatment and Prevention for Life

Gum disease. Understanding, Treatment and Prevention for Life

Dr Seow Onn Choong

Recently in a Ministry of Health survey highlighted that 85 % of Singapore’s population has some form of gum disease. Gum disease is the greatest cause of tooth loss in advance nations. The result of this survey is definitely not flattering. Throughout the years we have trained so many dentists. All our children are taken care by the school dental services from primary level until they reach university. Adults can attend polyclinics and the many private dental clinics in and around the neighbourhood. So other than for those who really cannot afford dental care there should be no reason for the poor showing?

In this article I would like to share with you my own experience on how I treat my patients.

 Gum disease is a multi factorial disease. Some of us are blessed with the right genes and thus seemed to have saliva that can keep the problem at bay. The majority are not so lucky and need to work hard at it. Furthermore they also need to find a dentist who not only can manage the problem but also teach them how to prevent it from progressing. If you can experience what my patient goes through, it would definitely help you to retain all your teeth for life. This article would be of interest not only to layman but also to all dentists. No doubt there will be sceptics among readers especially among other dentists; it has worked well for me and my patients.

What is gum disease?
Periodontal (gum) disease is an infection of the tissues surrounding and supporting the teeth. It is a major cause of tooth loss in adults. It can be categorise broadly into 2 stages:
1) Gingivitis: This the early stage of periodontal (gum) disease. The gums can become red, swollen and bleed easily. At this stage, the disease is still reversible and can usually be eliminated by daily brushing and flossing
2) Periodontitis: This is the more advanced stages of periodontal (gum) disease. The gums and bone that support the teeth can become seriously damaged. The teeth can become loose, fall out or have to be removed by a dentist.
Causes of gum disease
Periodontal (gum) disease is caused by plaque, a sticky film of bacteria that constantly forms on the teeth.  The idea behind its treatment is so simple, if one can remove this film of bacteria then gum disease will disappear. As usual it is easier said than done. We are all told to brush our teeth twice a day with all sorts of toothpaste available. We are also bombarded by adverts that mouthwashes can effectively remove all 99% of the bacteria. With all these plethora of anti plague materials at our disposal, there is definitely no need to see a dentist as gingivitis would be easily manage and not progress to the dreaded periodontitis.
Now why is it with such a simple solution yet many people suffers from it to the extent of losing their teeth?.
The problem lies in patients and dentists mindset. Let me elaborate.
To make it easier for the layman to grasp the concept of dental disease, think of it as the rusting of objects made of iron. Things made of iron being such a hard metal can be destroyed but rust. If you look at cavities, bacteria digest sugars to form acids which in turn breakdown your hard tooth structure. Your teeth are so hard that you can even crush bones and chew your food like a crusher yet it is amazing that bacteria can use such a route to soften and destroy your teeth. Once the bacteria reach the nerves in the pulp, it causes inflammation and the resultant toothache. Well if you cannot take the pain then the tooth must be extracted.
In gum disease a different set of bacteria is involved. The method this group of bacteria uses to cause you to
lose your teeth is even more amazing. It is like the bone and gums rusting away.  So simple that it makes it difficult for most people to understand. It results in why most people still lose their teeth to gum disease.

Lady complains she has a loose tooth

Using a mirror one can see the tooth has
grown longger

No choice but the tooth has to be removed
You can see the barnacle like
tartar covering the root

Mode of Action by the gum disease causing bacteria.
The gums are like your skin that protects the bone which in turn holds up your teeth. The teeth is not directly fused to the bone but held in its bone socket by a mesh of ligaments. These ligaments provide a suspension so that shocks involved in the chewing process are dampened and does not result in your teeth cracking. The ligaments are stuck to the root of the tooth through a cement-like layer known as cementum. In a new tooth the cementum covers the root surface. Underneath this cementum is the dentine layer. The dentine is made up of tubules, each of it have a nerve inside. The inner end of this tubule is connected to the pulp which is made up of blood vessels and larger nerves. The gums are connected to the tooth by ligaments too but just to a small surface area of the root. A small gap exist between the junction where the enamel meets the dentine i.e the part of the tooth exposed to the mouth and that part that is buried in bone. This is known as the periodontal space. This is also the tooth’s Achilles’ heel.
Once again, just as in the process of formation of cavities, many types of bacteria are involved. One group of bacteria produce a sticky film to adhere to the surface of your teeth just like algae sticking to wet surfaces. Through this process they are able to colonise the periodontal space. At the same time they produce toxins which your body can detect. Your body’s immune system goes into action and rushes to the site.  As these antibodies travel only in the blood stream, they cannot cross into the surface of your teeth which is bathed in saliva. So it is a case of the bacteria is in your mouth but not in your body. As these antibodies are destroyer cells, their accumulation at the gums causes the gums to be inflamed and swollen. This is the reason for bleeding gums.

The worst is yet to come.
However this is not the end of the story. The destroyer cells also destroy the bone underneath. As the bone is destroyed, the ligaments are also destroyed. This enable the bacteria to migrate down the root to colonise the cementum layer which being a rough layer is ideal for the bacteria to colonise. At the same time a second and more deadly process occurs. The bacteria absorb calcium from your saliva to harden itself into what we call tartar. This is nature’s way for the bacteria to protect itself. Tartar formation is very similar to the formation of barnacles, the shell like objects we see forming on all rocks and even on bottom of ships. This gives you an idea of how tough it is to get rid of the hardened deposits on your teeth.
To make matters worse, the swollen gums now cover this tartar layer shielding the bacteria from your tooth brush. During tooth brushing, the swollen gums bleed easily, so much so most people dare not brush the gums at the gingival junction. This leads to a vicious cycle of more and more tartar build-up with more and more bone destruction. A pocket is now formed. The bacteria, now has a safe haven and launches a guerrilla war against its host.

This is the chronic phase of the disease. Bone is continually destroyed. Occasionally there will be swelling of the gums, with associated pain. However there may be very little bleeding as most of the external gums is like scar tissue. At this stage the symptoms are easily overlooked by the sufferer. The main complaints are bad breath and sensitive teeth. With the mass media touting the efficacy of mouthwashes and desensitising toothpastes, most patients reach for these remedies. They are ignorant of their deteriorating condition. This is also the stage that is extremely difficult to treat. I will explain this when I highlight the different type of instruments involved in treating gum disease.
Prevention of gum disease.
Prevention is obviously the best form of treatment. This must start at a very early age i.e as young as   the first teeth have erupted out. Proper cleaning of the teeth and forming a habit of it, ensures that the child grows up with a set of good dentition.

The proper toothbrush technique
Proper tooth brushing technique is very important. The best method is to follow the contours of the gums. As you can see your gums meet the teeth in a semi circular shape, thus the brushing must be in a circular manner. It should also be angled to the junction where the gums meet the teeth i.e at 45 degree to the teeth.
Many dentists advocate the up down method. When you analyse the anatomy of the gum teeth interphase, you can see this is a defective technique. The critical junction cannot be cleaned at all. This method of tooth brushing was advocated because dentists notice that the exposed roots of teeth get abraded with aging. They blamed it on the horizontal method of brushing of teeth. From my observation abrasion cavities are caused by acids eroding away the tooth.
Do soft bristles and hard bristles make any difference?
Obviously it does. Soft bristles are advocated by majority. Once again it is due to the misleading belief of hard brushing causing abrasion cavities. Most soft tooth brush does not have the firmness to remove plaque. Medium soft toothbrushes keep their shape and tension better. Thus they are more effective. Rubbing of the gums is important. The layer of cells forming the surface of the gums renew themselves on a daily basis, thus the toothbrush stimulation is actually good for them. More important as research have shown is the structure of the bristle’s tips. It is now known that the tips must be rounded and polished. This not only reduces bacterial hiding in the rough surfaces but also does not cause micro laceration of the gums.
Regular changing of toothbrushes is equally import as the shape and tension must be intact.
Are mouthwashes really necessary?
Personally I am not an advocate of mouthwashes. There is a place for it especially when the gingivitis is serious and lots of bleeding occurs during tooth brushing. In this situation mouthwashes help speed up recovery. Once you have achieved proper brushing and flossing habits, there is no need to use mouthwashes. In fact chlorhexidine based mouthwashes can badly stain your teeth.
Flossing is more important than brushing.
Most of my patients remember me as the dentist that taught them how to floss properly. I can tell you if you do not floss your teeth, you will surely have gum disease.
The floss can clean not only in between your teeth but also right down underneath the gums. These are places where your toothbrush cannot reach. Worst of all mouthwashes too are not able to penetrate these areas as they are supposed to do.
People do not floss because they are usually not told the advantage. Just like any technique there is a learning curve. Once you have mastered it will not only help you prevent gum disease but also cavities.
What type of floss should I use?
There are many types of floss on the market with the most popular being the waxed floss. The wax is supposed to make it easy for you to slip part the tight contact areas. However till today I still cannot understand how the wax surface is suppose to rub away the algae like plaque.
The best type of floss is that with a large cleaning surface area. Initially it was made fluffy but patients complained it gets stuck. I have discovered one that comes like normal floss but once you rub against your teeth it expands and becomes fluffy. In Singapore it is sold under the Guardian Pharmacy in house brand as a floss for sensitive teeth.
The Flossing technique.
After sliding in between the teeth one should wrap it round the tooth and drag it as if one is using a towel to rub your body. Next pull it to the opposing surface and do the same.
For those who have difficulty in using their fingers, a floss holder will be a definite help.
The best time to floss is just after you have brush your teeth with the toothpaste still on your teeth. The floss can then drag the toothpaste into the areas where your toothbrush cannot reach. Thus not only are use making use of the flouride in the toothpaste to prevent cavities, you are the cleanng agents to remove the plaque.

This is the typical picture of tartar
Most people think this is normal
Redness in gums and tartar seen

After cleaning
Can see how the original teeth
looks like all cleaned

The dentist’s role in the management of gum disease.   
Picking the right dentist to help you prevent and manage gum disease is a bit tricky.
Why do I say so? Just like the advent of hand phones and internet, the idea of treating gum disease is a very new science. In fact when I was a dental student in the late 70’s periodontics (the science of treating gum disease) was still in its infancy. Most dentists have their ideas fixed during student days and find it very difficult to change their mindset. As dental students we are only allowed to scrape the teeth with hand scalers as we were told then ultrasonics in a student’s hands will damage the surface of the teeth. Since then many studies have should ultrasonic scalers are very effective but I still see many visiting lecturers telling us that hand scaling is the gold standard. Because of that old idea some dental students still takes more than an hour to clean their patient’s teeth.
Who cleans your teeth?
Most Singaporeans are surprised that recently there is a new group of people who are not dentists and they are allowed to clean your teeth. In many countries it is the norm. They are known by various names such as hygienist, oral health therapist or other titles.
Well this group of people were trained to clean your teeth as the dental profession found that cleaning your teeth was a very time consuming exercise and it does not bring in much money. Dentists rather do the more sophisticated work such as surgeries, root canal treatment, crowns and bridges which are more expensive work. However the acceptance of such staff is still an issue.
Such auxillary staff are actually very useful in the dental clinic. They can spend more time to clean your teeth thoroughly and also teach you the proper techniques in maintaining good oral hygiene.
The dentist as the person that cleans your teeth.  
Some dentists don’t look forward to cleaning your teeth as it does not pay. Those who are willing to clean your teeth must charge a reasonable sum for their work. Well as the majority of the people in Singapore does not see the need to see a dentist, asking them to pay what they feel is a lot of money to clean their teeth seems blasphemous. Most people I talk to tells me they brush their teeth twice thus there should be no reason to see a dentist’ Furthermore, mouthwashes can kill all the bacteria as touted in the advertisements. This challenge from the patients usually discourages most young dentists. After all what you pay is what you get.  To make things worse, the technique of using a lot of hand scaling turns most patients away as it is not very pleasant. As we all know the university course is too cram with information but does not allow dental students sufficient time to learn the proper techniques. They would have to enter the school of hard knocks. If they are lucky they would get a good mentor who will show them the right path.
The anatomical reason for pain during scaling and why it puts people off from getting their teeth cleaned.
Pain is the biggest fear factor preventing people from seeking dental treatment. Scaling and polishing as it is known can be a very bad experience to most people. Let me try to explain the anatomical basis for you and your dentist to understand.
The tooth is made up basically 2 parts the part above the gums known as the crown and the part below known as the root. The crown is made up of enamel, a glass like layer that is no sensation. This layer is very tough so that you can chew your food. Once formed, they cannot replace themselves and will slowly wear down.
Underneath the enamel is a dentine layer which continues downward to make up the roots. Dentine is tubular in nature and is connected to the pulp. The pulp is the hollow part of the inside of the tooth that is filled with blood vessels and nerves. Each dentine tubule has nerve tissue inside.
 If you ask your dentist what is the function of dentine, most will tell you it is an early warning system in nature that tells you that there is a cavity or problem with your tooth. Early warning for what I may ask. Dentistry is only about 100 years old. So if you had tooth sensitivity before the advent of dentistry it was of no good.
Actually the function of dentine is to act like a trampoline to support the enamel. It acts as a dampener to prevent the masticatory forces in cracking the glass like enamel. As it is connected to the pulp, it is a live layer capable of repairing itself to a certain extent. It also connects to the ligaments to be connected to the bone.
Ironically, this is also the surface of the tooth that the tartar clings on to tightly and resist dislodgement even by the dentist. Microscopically it looks like a stack of pipes, creating the perfect surface for bacteria to cling onto. Well to make matters worse the nerve connections respond with pain when any dentists touch it when they try to clean the tartar. So how can we clean the teeth without any pain?.
The right instruments are very important.
This issue of instruments as a problem did not really occur to me until i came back from Brunei. Well that was really many years into professional service. I had diligently cleansed my patients’ teeth. Most of them do very well but quite a significant number of them either did not improve or got worse. Since I had time on hand I decided to attend a course in advanced periodontics so that i can improve my management of gum problems. The course was not as enlightening as I had hoped. There seems to be nothing new. Fortunately as part of the program I can bring one of my patients to work along one of the professor. So I was at the university clinic with my patient who i had problem solving his gum problem. We went through the whole routine. At the end of it I notice there was a new piece of scaling tip lying on the table top. My professor friend told me that this was a piece of new equipment given to her for testing. She found the new instrument too thin and potentially fragile. Also it lacked power. I asked her to give it to me.
Back in my clinic, I wasted no time in testing this new instrument. To my surprise i could detect pieces of tartar coming out of the gums as this new slim instrument could reach places where previously I thought I have touched. It was a real eye opener. Yes it was more silent and it seems to lack power. I tested it further on extracted teeth and I was amazed that it was shattering the tartar much better than the old scaling tip.
I did my research and found out the real reason.
Traditionally the ultrasonic tips were made hardy by making them thick so that they do not break easily. Being thick they cannot get in between the gums and your teeth. With changes in metal technology the manufactures were able to make hardy scaling tips but much thinner in size. Also they are able to withstand higher frequencies of vibration. With the increase in vibration speed the tips now move within smaller amplitudes to do their work. As you can see the scaling tips function like jack hammers which you see in the construction industry when they want to break up concrete. In dentistry we have this miniature jack hammer to break up your calcified tartar. When dentists have been used to larger amplitudes (larger shaking movements) obviously this new tip feels underpowered. Little do they know it is much more efficient than the older model. The added bonus is they are even less noisy now.
One more advantage of these fine tips is the cooling system. The scaling tips are moved by magnetic waves. A lot of heat is created. In the original models water is sprayed on the tips. This was not very efficient and the heat can cause a lot of discomfort. The new tips have their water coolant coming from within the metal. As the opening of this water flow is at the middle of the tip, the water is brought into the gum pocket. Studies have shown that this water is excited by the ultrasonic vibration creating many air bubbles that they not only help dislodge bacteria in the pockets, they also deactivate the bacteria. This is known as microstreaming.
So you can now understand if your dentist is not using such fine tips they will not be able to completely clean your teeth and your gum problem cannot be treated.
Salt blasting.
Next comes the part that is really not understood by the majority of dentists. This is the polishing part. Dentists always use the term scaling and polishing. So there are 2 parts to the visit. After you removed the tartar you must polish away the algae like plaque layer and any stains on your teeth. The majority of dentists use a rubber cup and polishing paste. For severe stains dentists make resort to pumice which is a very fine type of sand. As we can see the rubber cup cannot reach many places especially the gaps between your teeth.
For those of you who need to clean algae and stains from your home, you will know better than to use a high pressure jet to do the job. There is such an instrument in dentistry. It is call a prophy jet. This jet blast a specially produce salt (it is a special version of baking soda) at the surface of your teeth. It also sprays water onto the teeth at the same time so that the salt is immediately dissolved and you do not feel it accumulating in your mouth. Salt is a very mild abrasive and thus do not scratch your tooth surface but is extremely effective in blasting away the plaque.
For gingivitis to occur there must be sufficient number of bacteria to cause damage. This is known as the “Critical Mass”. The jet spray is so efficient that after you have sprayed your teeth there is very few bacterial cells left on the teeth surfaces. We know this will grow again but it would take a much longer time to reach critical mass than less efficient rubber cup polishing. Even in patients prone to periodontitis, regular cleaning i.e about once every 3 months will prevent not only the critical mass factor but also prevent any mass of bacteria from maturing sufficiently to cause gum disease.
When I bought my first prophyjet, the aim was to remove stains especially tobacco stains. When it comes to stain removal no other equipment can do it as well as the prophyjet. That was more than 28 years ago. Those days I could not understand the idea of plaque being like an algae layer and this salt blaster was so effective in removing it. If you ask any dentist who does not use this jet they will tell you that their lecturers had quoted studies of the past to say these machines would scratch the surfaces of the teeth. I hope they can see my patients teeth to see if they have worn out.
Treatment of advanced periodontitis.
Most people are shocked when they find there is either a swollen gum and at the same time they feel the  tooth can move. This is the stage of advanced periodontitis.
Sadly majority of dentists cannot put themselves in the same shoe as their patient. At this stage a lot of root surface is exposed. As I have mentioned earlier, the root surfaces are very sensitive during scaling. The majority of the dentists are very aggressive when they see this stage of affairs. They want to help you to save your teeth and thus try to cleanse of the tartar. Worse of all they try to dig into the gum pockets even though they cannot see inside. In fact some dentists will inject local anaesthetic prevent pain. Most dentist call this method Deep Cleansing. All these can really put the patient off. However all is not loss.
The art of peeling onions.
Well what has onions to do with gum disease. Just as in peeling onions you remove one layer after another layer. This the art of cleaning the tartar by layers. Gum disease  usuallytake many years to form. It is not an acute condition that will kill you, so there is no need to cure it overnight. When the patient first comes in, the most important issue is they must understand their problem and know the methods to stop the disease. The first phase is only to clean only tartar that is seen or easily accessible. The dentist can apply densitising tooth paste to the roots to reduce sensitivity during scaling. The new generation of toothpaste use for sensitive teeth are very effective. They should also encourage the patient to use it at home.  For some patients who are very fearful I usually apply local anaesthetic cream on the gums. This can calm them down and they do not anticipate pain when the scaling tip touches their gums. The patient is recalled in 2 weeks. You will be amaze in the improvement to the situation. From then the dentist can repeat the scaling. Seems like peeling onions isn’t it? This method is very acceptable to most people and the results are amazing.
Only a few will need further treatment, namely surgical removal of the pockets and the need of bone grafting.  
I have been using the combined jet and the slim tip since 1997. The majority of my patients who come regularly for their S&P have done very well in maintaining their teeth. This is especially true for the patient I brought along to the professor’s clinic. He is more than 74 years old now and his shaky teeth has all stabilise without any loss.
Tooth loss due to cavities and or gum disease should have disappeared.
 I graduated in 1978. That makes it 35 years ago. I still see one of my patients who have been seeing me for 36 years and she has not lost a tooth since. How is that so?
Well she was my patient in my final year of dental school. Some dentist had pull out one of front tooth and she wanted a fixed replacement i.e a bridge. Porcelain fused to metal crowns and bridges were relatively new technology then and thus it was expensive. As a  dental student case she need only pay for the lab charges.
She comes for her 6 monthly checkups and cleaning without fail.
I hope this article will help all the people all over the world to learn how to take care of their teeth and keep it for life. Many dentists may disagree with my method but then my success is that the majority of my patients don’t allow me to retire.


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  3. wihh nice info
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    Obat tradisional periodontitis

  4. Well thanks for the all the detailed information about the gum disease, i know the best dental clinic that will definitely help people.

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  6. This comment has been removed by the author.

  7. Hai friend am a regular reader of your your blogs. Your last post is help my friend for taking dental treatment without fear thanks for sharing this article and keep going.

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