Frequently Asked Questions – Periodontology

Gingivitis is a disease of the gums that makes gum bleed, red and sometimes very sensitive. The bone is not affected in cases of gingivitis.

This is a question that only your periodontist can answer with certainty. What everybody should know though, is that gum bleeding is pathologic and not a normal situation and when it happens you should see a periodontist or at least a general dentist.

In some other cases you might see receeding gums, bad breathing, tooth mobility or you might even notice that your teeth moved. In all these cases you need a periodontal consult.

People may have periodontitis and not know it nor feel it One reason for that is that usually the first symptom of periodontitis is gum bleeding during toothbrushing which many people think as normal. If you think that your gums do not bleed and still your dentist feels that you have periodontitis, it is possible that you would expect to see tones of blood to come out of your gums while you brush. Whereas what you should expect to see it is usually only some drops of blood on teeth after brushing. And that is still pathologic.

Moreover if you are a smoker the symptom of gum bleeding further reduces because smoking causes vasoconstriction.

The periodontist is a specialized dentist dedicated to the diagnosis, treatment and prevention of periodontal diseases. In order to obtain the degree of specialization and be qualified as a periodontist he/she must study for an additional three years after completing his studies in general dentistry.

The main cause of periodontitis is bacterial plaque: a sticky film that constantly builds on your teeth, as well as your body’s response to that film. The bacterial plaque forms in all people , but it does not cause periodontitis in everybody.

Whether you will have periodontitis has to do also with daily home oral care (including proper brushing and flossing), number of visits to the dentist for professional cleaning, smoking, gene predisposition as well as certain diseases like diabetes.

Periodontitis is not a contagious disease. So you should not be afraid that you may transmit it to your family. But periodontitis is a disease that has gene predisposition. In other words it is hereditable.

Smoking causes periodontitis and that is a fact. Another fact is that non-smokers have better results after periodontal treatment than smokers. This does not mean that smokers will not benefit from the treatment of periodontitis. If you are a smoker you should know that you carry an extra risk factor for periodontitis, while if you choose to quit, you automatically benefit from the periodontal treatment the same way as if you never smoked. And that stands even for those that heavily smoked for years. But, the destruction on the bone and the supporting tissues of teeth that has happened over the years does not change.

You should know that your teeth may be succeptible to periodontal disease and not succeptible to tooth decay (caries). So probably when your dentist told you that you have good teeth, ment that your dentition is not succeptible to caries. In other words it is possible that people with periodontitis do not have problems with tooth decay and vice versa.

The answer is yes, periodontitis can be treated. But there is a misunderstanding: Some people expect that after the periodontal treatment , they will not have to deal ever again with their gums. They assume that since periodontitis is a microbial infection, it will be treated the same way as a flu or an intestinal disease caused by microbes.

Unfortunately, this is not the case. This is because periodontitis is not only caused by germs but is also related to the host (ie the person suffering from it) and his immune response to the microbial infection. In addition, there are other etiological or predisposing factors such as smoking, genetic predisposition, oral hygiene and even some diseases such as diabetes mellitus which can complicate the clinical image of the patient.

So after the fulfilment of the periodontal therapy, you have to clearly understand that you must follow a strict maintenance schedule. That means that you should visit your periodontist regularly for professional cleaning and localized scaling and root planing at intervals that the periodontist will advise you to.

The periodontal treatment can vary depending on how far the disease has progressed. So after the initial periodontal examination, your periodontist will work with you to determine the best treatment option to bring back the periodontal health in your mouth.

In most cases the periodontal treatment starts with proper oral hygiene instructions and a special “cleaning” of the roots that is called scaling and root planing. In some cases there might be need for a surgical approach in certain areas of the mouth.

After the fulfilment of the periodontal therapy and in order to maintain the periodontal health that has been achieved, the periodontist will regularly re-evaluate your gums. At these re-evaluation visits your mouth will be examined for signs of new disease and the new calculus and plaque that have built up will be removed.

It should be made clear that no toothpaste and no mouthwash are able to treat or to prevent periodontitis. The periodontal treatment is specific and can only be given by specialists. Prevention of periodontitis can be achieved through a proper oral hygiene regimen: correct toothbrushing along with dental flossing or use of interdental brushes. Toothpaste and mouthwash can be used as an adjunctive for a good oral home care and they cannot in any case repalce toothbrushing or dental flossing.

That does not mean that you should not use toothpaste and mouthwash. In contrast, the use of toothpaste is necessary when you brush your teeth for many reasons. First of all because of the sense of freshness and cleanliness it leaves you after you finish brushing. Then because of the flouride almost every toothpaste has, teeth are protected from caries. As far as mouthwash is concerned, it must be noted again that its role is adjunctive. It cannot treat, nor prevent the periodontal disease but its use is very pleasant to patients leaving a fresh and clean breathing.

At this point it should be noted that certain mouthwash containing chlorhexidine should not be used on a regular basis. Usually the mouthwash containing chlorhexidine are prescribed by the periodontist during the conservative periodontal treatment or after some surgical perio treatments. In this case you should follow religiously the instructions given, since if these mouthwash are overused, they can be the cause of many problems such as teeth and tongue staining, more calculus build up, metalic taste and even tolerance of the microbes and incapability of chlorhexidine to act in the future.

You will not be in pain during the periodontal treatment. Your periodontist will make sure you are very well numbed (topically anesthetized) before the start of each procedure.

You should not expect any pain after the conservative treatment of periodontitis (scaling and root planing). In rare cases, some people have mentioned a mild pain in the scaled gums that passes very easily with a simple painkiller like acetaminophen. As far as food is concerned, there is no special restriction, but you should wait first till the anesthesia wears out, so as not to bite your lips and tongue by mistake. It is also advisable to avoid taking very crispy foods which could be crushed and the small fragments could then penetrate into the gums and cause in some rare cases injury or even inflammation. In some cases where air polishing has been used, you should avoid consuming certain foods and beverages that may cause pigmentation in teeth such as coffee, tea, cola, red fruits, red vegetables and red wine and definitely do not smoke for a period 1 to 2 hours after the dental appointment. What you should expect though after scaling and root planing is increased root sensitivity, specially when you eat or drink cold stuff. This root sensitivity is not permanent and will gradually disappear after maybe some weeks. Your periodontist might prescribe some gel treatment for your teeth after the night toothbrushing. These gels have fluoride in large percentage. Fluoride helps make the roots of teeth stronger against feelings of cold.

For the patients that have had surgical perio treatment, the expected intolerance is more. But the anti-inflammatory medication that the periodontist has prescribed are usually enough to deal with issues of pain. You should avoid eating anything for at least a couple of hours after surgery. The food should be soft and not warm, specially the first few days after the surgery. Specific instructions (most of the times in written) will be given to any individual that will have a surgical periodontal treatment.

The treatment of periodontitis may last several months. Basically the initial phase of periodontal therapy, meaning the conservative scaling and root planing usually lasts one and a half month. From that point and beyond, the periodontist will judge whether there is need for further surgical treatment. The time that the second phase will last is relative to the number of surgical procedures needed as well as how soon the patient wishes to have them done. A usual period between two surgical procedures is one to two months.

The final result of periodontal disease left untreated is teeth falling, because of loss of bone structure, which suppports them in the mouth. The loss of natural dentition has detrimental consequenses to a person’s quality of life. Without teeth you cannot enjoy food, you cannot speak properly, you cannot smile, you cannot socialize. You can argue that fact by saying that nobody is left without teeth nowdays. There are solutions for replacing the natural dentition with either a removable denture or dental implants. This is definetely true, but you should keep in mind that in case you lost your teeth due to periodontitis, there will be bone loss and that will create problems in the stability of the denture. In case you decide to go with implants, after loosing your teeth of periodontitis, you should know that there will probably be need for bone grafing which will raise the cost and the time of therapy as well as the patient’s discomfort. Then remember that if you lost teeth due to periodontitis, there is a possibility that your implants will be affected by the same disease (it is called periimplantitis). So not seeking for periodontal therapy, if needed makes no sense at all.

Besides the effects of periodontal disease in the mouth, there are also side effects in one’s general health. Periodontal disease has been associated with diabetes in a two way relationship: Diabetes can increase the chance of having periodontitis but also periodontal disease can make it more difficult to control blood sugar in diabetic patients. Also periodontitis has been associated with increased risk of heart disease and heart attack and increased risk of a preterm low birth weight baby in case of periodontitis during pregnancy. So it is true when the Ancient Greek used to say that the health starts from the mouth.

The treatment of periodontitis should definitely be completed before any new prosthodontic work (meaning a new crown or bridge). If the crown is placed first without treating the inflammation which is caused by periodontitis, the inflammation will then worsen. Another reason for the periodontal treatment to go first is that the gum line will probably be at a different level after the periodontal treatment. So if you had a new crown done and then you had done your periodontal treatment, it is very possible that the margin of the crown will show due to a change in the gum line.

If you need new fillings done, these should also be taken care of after the finish of periodontal treatment, unless a tooth is in pain. In this case there might be need for root canal treatment which will go first.

The etiology of periodontitis is multifactorial. One of the etiological factors is genetic predisposition. Due to this fact, it cannot be fully prevented. But since the other etiogical factors are environmental, it is possible to prevent it up to a point or at least delay its onset. One thing that can be definitely done is to preserve the teeth the longest possible even if there is periodontitis in the mouth (with the aid of proper prevention and care).

The first step to periodontitis prevention is good oral home care. That means proper toothbrushing together with the use of floss or interdental brushes in a daily basis. The second step to prevention is regular visits to the dentist (at least twice a year) for professional cleaning. The general dentist is usually the first to perceive the onset of periodontitis and refers to the periodontist. In case you have any doubt, you may ask for a periodontal consult yourself without the need of a referal. Finally, for those of you that smoke, in order to prevent periodontitis (and many other diseases), you should seriously consider quit smoking.

It is very important to realize that after the completion of the periodontal therapy, a strict maintenance protocol should be followed. This means that you should visit your periodontist at regular intervals for professional cleaning and localized scaling and root planing. The frequency of the visits will be tailored to the individual needs of each person by the periodontist. Many people think that once they have their periodontal treatment finished, they never have to deal with periodontitis again, which is something completely incorrect. Other people, when they are told that they need to see a periodontist pretty much lifetime for maintenance, they back out. Before you do that yourself, you should remember that everybody should visit their dentist twice a year for a professional cleaning. So having to visit your periodontist three or maybe four times a year for something that feels a lot like a cleaning (maintenance visit) it is not such a big deal.

Moreover to maintain the result of the periodontal treatment, it is essential to follow a proper oral hygiene regimen, to quit or at least reduce smoking and in case you are diagnosed with a disease such as diabetes (that is known to cause periodontitis), to keep this disease under control.

If you follow all of the above, it is very unlikely to have a disease exacerbation. But even if it happens, your periodontist will most possibly be able to solve the problem with minor intervention.

It must be made clear that if you have periodontitis, you need to have your teeth cleaned more often than if you didn’t have. Moreover in cases of periodontitis, a simple dental cleaning is not enough. During the maintenance periodontal visit your teeth will be professionally cleaned and will also be scaled and root planed in localized areas. The most suitable person to offer this treatment is a periodontist. In certain cases the periodontist may judge that the scaling and root planing can be done less frequently (for example one to two times a year instead of three to four times) and suggest regural cleanings in the mean time with the general dentist.