Periodontal Specialists – Dr. Herbert Veisman
GUM DISEASE AND MEN
Prostate-specific antigen (PSA) is an enzyme created in the prostate that is normally secreted in very small amounts. However, when the prostate becomes inflamed, infected, or affected by cancer, PSA levels rise. Research has shown that men with indicators of periodontal disease such as red, swollen or tender gums as well as prostatitis (inflammation of the prostate) have higher levels of PSA than men with only one of the conditions. This means that prostate health may be associated with periodontal health, and vice versa.
Research indicates that periodontal disease and cardiovascular disease are associated; having periodontal disease may actually increase your risk of cardiovascular disease. Both diseases are chronic inflammatory conditions, and researchers believe that inflammation is the connection between gum disease and heart disease. Since men are already more likely to develop heart disease than women, maintaining periodontal health is another way to reduce this risk.
Men with periodontal disease, especially those younger than 30 or older than 70, are at increased risk of developing impotence, according to research. Researchers believe that inflammation may be the link between the two conditions; prolonged chronic inflammation (the same type of inflammation that is associated with periodontal disease) can damage blood vessels leading to impotence.
Research has found that men with a history of gum disease are 14 percent more likely to develop cancer than men with healthy gums. Specifically, men with periodontal disease may be 49 percent more likely than women to develop kidney cancer, 54 percent more likely to develop pancreatic cancer, and 30 percent more likely to develop blood cancers.
GUM DISEASE AND WOMEN
A woman’s periodontal health may be impacted by a variety of factors.
During puberty, an increased level of sex hormones, such as progesterone and possibly estrogen, causes increased blood circulation to the gums. This may cause an increase in the gum’s sensitivity and lead to a greater reaction to any irritation, including food particles and plaque. During this time, the gums may become swollen, turn red and feel tender.
Occasionally, some women experience menstruation gingivitis. Women with this condition may experience bleeding gums, bright red and swollen gums and sores on the inside of the cheek. Menstruation gingivitis typically occurs right before a woman’s period and clears up once her period has started.
Some studies have suggested the possibility of an additional risk factor – periodontal disease. Pregnant women who have periodontal disease may be more likely to have a baby that is born too early and too small. However, more research is needed to confirm how periodontal disease may affect pregnancy outcomes.
All infections are cause for concern among pregnant women because they pose a risk to the health of the baby. The Academy recommends that women considering pregnancy have a periodontal evaluation.
MENOPAUSE AND POST-MENOPAUSE
Women who are menopausal or post-menopausal may experience changes in their mouths. They may notice discomfort in the mouth, including dry mouth, pain and burning sensations in the gum tissue and altered taste, especially salty, peppery or sour.
In addition, menopausal gingivostomatitis affects a small percentage of women. Gums that look dry or shiny, bleed easily and range from abnormally pale to deep red mark this condition. Most women find that estrogen supplements help to relieve these symptoms.
GUM DISEASE AND OTHER SYSTEMIC DISEASES
Researchers have suggested that a link between osteoporosis and bone loss in the jaw. Studies suggest that osteoporosis may lead to tooth loss because the density of the bone that supports the teeth may be decreased, which means the teeth no longer have a solid foundation.
Research has found that bacteria that grow in the oral cavity can be aspirated into the lungs to cause respiratory diseases such as pneumonia, especially in people with periodontal disease.
Researchers found that men with gum disease were 49% more likely to develop kidney cancer, 54% more likely to develop pancreatic cancer, and 30% morelikely to develop blood cancers.
GUM DISEASE AND HEART DISEASE
Several studies have shown that periodontal disease is associated with heart disease. While a cause-and-effect relationship has not yet been proven, research has indicated that periodontal disease increases the risk of heart disease.
Scientists believe that inflammation caused by periodontal disease may be responsible for the association.
Periodontal disease can also exacerbate existing heart conditions. Patients at risk for infective endocarditis may require antibiotics prior to dental procedures. Your periodontist and cardiologist will be able to determine if your heart condition requires use of antibiotics prior to dental procedures.
Additional studies have pointed to a relationship between periodontal disease and stroke. In one study that looked at the causal relationship of oral infection as a risk factor for stroke, people diagnosed with acute cerebrovascular ischemia were found more likely to have an oral infection when compared to those in the control group.
DIABETES AND PERIODONTAL DISEASE
Diabetic patients are more likely to develop periodontal disease, which in turn can increase blood sugar and diabetic complications.
People with diabetes are more likely to have periodontal disease than people without diabetes, probably because people with diabetes are more susceptible to contracting infections. In fact, periodontal disease is often considered a complication of diabetes. Those people who don’t have their diabetes under control are especially at risk.
Research has suggested that the relationship between diabetes and periodontal disease goes both ways – periodontal disease may make it more difficult for people who have diabetes to control their blood sugar.
Severe periodontal disease can increase blood sugar, contributing to increased periods of time when the body functions with a high blood sugar. This puts people with diabetes at increased risk for diabetic complications.
Gingivitis is an inflammation of the gingiva, or gums. It is characterized by tender, red, swollen gums that bleed easily and may cause bad breath (halitosis). Gingivitis can be treated by good dental hygiene, proper diet, and stopping smoking. Untreated gingivitis can lead to periodontitis.
Periodontitis occurs when the gum tissues separate from the tooth and sulcus, forming periodontal pockets. Periodontitis is characterized by:
Gum inflammation, with redness and bleeding
Deep pockets (greater than 3 mm in depth) that form between the gum and the tooth
Loose teeth, caused by loss of connective tissue structures and bone
There are different forms of periodontal disease. They include:
Chronic Periodontitis. Chronic periodontitis is the most common type of periodontitis. It can begin in adolescence but the disease usually does not become clinically significant until people reach their mid-30s.
Aggressive Periodontitis. Aggressive periodontitis is a subtype of chronic periodontitis that can occur as early as childhood. It can lead to severe bone loss by the time patients reach their early 20s.
Disease-Related Periodontitis. Periodontitis can also be associated with a number of systemic diseases, including type 1 diabetes, Down syndrome, AIDS, and several rare disorders of white blood cells.
Necrotizing Periodontal Disease. Necrotizing periodontal disease is an uncommon acute infection of the gum tissue. It is characterized by painful and bleeding gums, bad breath, and rapid onset of pain. If left untreated, necrotizing periodontal disease can spread throughout the facial areas (cheeks, jaw) and cause extensive damage. Necrotizing periodontal disease is usually associated with systemic health conditions such as AIDS or malnutrition.
Periodontal disease is caused by plaque, which is formed from harmful bacteria. The mouth is full of bacteria but they tend to be harmless varieties. Periodontal disease usually develops because of an increase in bacteria quantity in the oral cavity and a change in balance of bacterial types from harmless to disease-causing bacteria. These harmful bacteria increase in mass and thickness until they form a sticky film called plaque.
In healthy mouths, plaque actually provides some barrier against outside bacterial invasion. When it accumulates to excessive levels, however, bacterial plaque sticks to the surfaces of the teeth and adjacent gums and causes infection with subsequent swelling, redness, and warmth.
When plaque is allowed to remain in the periodontal area, it transforms into calculus (commonly known as tartar). This material has a rock-like consistency and grabs onto the tooth surface. Tartar is much more difficult to remove than plaque, which is a soft mass. Once tartar has formed, it must be professionally removed by a dental practitioner.
Most American adults have some form of gum disease but are unaware of it. The main risk factors for periodontal disease include:
- Smoking or tobacco use
- Female hormonal changes
- Illnesses such as diabetes or HIV/AIDS, and the medications used to treat some conditions
- Genetic factors
Periodontitis typically occurs as people get older and is most common after age 35.
Smoking. Smoking is the major preventable risk factor for periodontal disease. Smoking can cause bone loss and gum recession even in the absence of periodontal disease. The risk of periodontal disease increases with the number of cigarettes smoked per day. Smoking cigars and pipes carries the same risks as smoking cigarettes.
Substance Abuse. Long-term abuse of alcohol and certain types of illegal drugs (amphetamines) can damage gums and teeth.
Diet. A healthy diet, including eating fruits and vegetables rich in vitamin C, is important for good oral health. Malnutrition is a risk factor for periodontal disease.
Stress. Psychological stress can cause the body to release inflammatory hormones that may trigger or worsen periodontal disease.
Female hormones affect the gums, and women are particularly susceptible to periodontal problems. Hormone-influenced gingivitis appears in some adolescents, in some pregnant women, and is occasionally a side effect of birth control medication.
Menstruation. Gingivitis may flare up in some women a few days before they menstruate, when progesterone levels are high. Gum inflammation may also occur during ovulation. Progesterone dilates blood vessels causing inflammation, and blocks the repair of collagen, the structural protein that supports the gums.
Pregnancy. Hormonal changes during pregnancy can aggravate existing gingivitis, which typically worsens around the second month and reaches a peak in the eighth month. Any pregnancy-related gingivitis usually resolves within a few months of delivery. Because periodontal disease may increase the risk for low-weight infants and cause other complications, it is important for pregnant women to see a dentist.
Menopause.Estrogen deficiency after menopause reduces bone mineral density, which can lead to bone loss. Bone loss is associated with both periodontal disease and osteoporosis (loss of bone density). The hormonal changes associated with menopause can cause dry mouth, which can lead to tooth and gum problems.
Periodontal disease often occurs in members of the same family. Genetic factors play a role in making some people more susceptible to periodontal disease.
Medical Conditions Associated with Periodontal Disease
Diabetes. There is a strong association between diabetes (both type 1 and 2) and periodontal disease. Diabetes causes changes in blood vessels, and high levels of specific inflammatory chemicals such as interleukins, that significantly increase the chances of developing periodontal disease.
Heart Disease. Periodontal disease and heart disease share common risk factors (smoking, older age, diabetes) but it is not yet clear if having one condition increases the risk for developing the other (see Complications section of this report).
Other Medical Conditions. A number of medical conditions can increase the risk of developing gingivitis and periodontal disease. They include conditions that affect the immune system such as HIV/AIDS, leukemia, and possibly autoimmune disorders (Crohn’s disease, multiple sclerosis, rheumatoid arthritis, lupus erythematosus).
Prescription Medications. Gingival overgrowth can be a side effect of many drugs including certain types of oral contraceptives, antidepressants, and heart medications. Any drug that has a side effect of dry mouth can increase the risk for gum disease.
If you take a bisphosphonate drug such as alendronate (Fosamax, generic) discuss with your dentist any potential risks from dental procedures (such as extractions and implants) that involve the jawbone. Oral bisphosphanates, which are used to treat osteoporosis, have in rare cases caused osteonecrosis (bone destruction) of the jaw. (Intravenous bisphosphantes, which are used in cancer treatment, are more likely to cause osteonecrosis.) Your dentist or oral surgeon may need to take special precautions when performing dental surgery. In any case, be sure to inform your dentist of all medications you are taking.
Oral Health Risk Factors
Oral Hygiene. Lack of oral hygiene, such as not brushing or flossing regularly, encourages bacterial buildup and plaque formation.
Poorly Contoured Restorations. Poorly contoured restorations (fillings or crowns) that provide traps for debris and plaque can also contribute to periodontitis.
Tooth Structure . Abnormal tooth structure can increase the risk of periodontal disease.
Wisdom Teeth. Wisdom teeth, also called third molars, can be a major breeding ground for the bacteria that cause periodontal disease. Periodontitis can occur in wisdom teeth that have broken through the gum as well as teeth that are impacted (buried). Adolescents and young adults with wisdom teeth should have a dentist check for signs of periodontal disease.
Effect on Heart Disease
Cardiologists and periodontists currently encourage each other to monitor both conditions in their patients. Periodontists recommend that patients who have periodontal disease and at least one risk factor for heart disease have an annual medical exam to check their heart health. Cardiologists suggest that patients with atherosclerosis and heart disease have regular periodontal exams.
Effect on Diabetes
Diabetes is not only a risk factor for periodontal disease. Periodontal disease itself can worsen diabetes and make it more difficult to control blood sugar.
Effect on Respiratory Disease
Bacteria that reproduce in the mouth can also be carried into the airways in the throat and lungs, increasing the risks for respiratory diseases such as pneumonia and worsening chronic lung conditions, such as emphysema.
NON-SURGICAL PERIODONTAL TREATMENT
Non-surgical periodontal treatment does have its limitations. When it does not achieve periodontal health, surgery may be indicated to restore periodontal health.
SCALING AND ROOT PLANING
Scaling and root planing is a careful cleaning of the root surfaces to remove plaque and calculus [tartar] from deep periodontal pockets and to smooth the tooth root to remove bacterial toxins. Scaling and root planing is often followed by adjunctive therapy such as local delivery antimicrobials and host modulation, as needed on a case-by-case basis.
Most periodontists would agree that after scaling and root planing, many patients do not require any further active treatment. However, the majority of patients will require ongoing maintenance therapy to sustain health.
TRAY DELIVERY SYSTEMS
A tray delivery system consists of a custom-fit tray made from impressions of the patient’s mouth. Patients use the tray at home to deliver medications that have been prescribed by their dentist. Tray delivery systems were cleared by the Food and Drug Administration (FDA) since they are similar to fluoride trays traditionally used to prevent tooth decay. However, the FDA clearance process did not determine that any specific medication delivered via tray delivery systems has been proven to be a safe or effective way to treat gum disease. Additionally, numerous clinical studies have suggested that topically applied medicines do not reach the source of periodontal infections. When determining the best course of treatment for your specific case, be sure to discuss the pros and cons of all available treatment options with your dental professional.
PERIODONTAL POCKET REDUCTION PROCEDURES
Over time, these pockets become deeper, providing a larger space for bacteria to live. As bacteria develop around the teeth, they can accumulate and advance under the gum tissue. These deep pockets collect even more bacteria, resulting in further bone and tissue loss. Eventually, if too much bone is lost, the teeth will need to be extracted.
Your periodontist has measured the depth of your pocket(s). A periodontal pocket reduction procedure has been recommended because you have pockets that are too deep to clean with daily at-home oral hygiene and a professional care routine.
During this procedure, your periodontist folds back the gum tissue and removes the disease-causing bacteria before securing the tissue into place. In some cases, irregular surfaces of the damaged bone are smoothed to limit areas where disease-causing bacteria can hide. This allows the gum tissue to better reattach to healthy bone.
Reducing pocket depth and eliminating existing bacteria are important to prevent damage caused by the progression of periodontal disease and to help you maintain a healthy smile. Eliminating bacteria alone may not be sufficient to prevent disease recurrence. Deeper pockets are more difficult for you and your dental care professional to clean, so it’s important for you to reduce them. Reduced pockets and a combination of daily oral hygiene and professional maintenance care increase your chances of keeping your natural teeth – and decrease the chance of serious health problems associated with periodontal disease.
ARE YOU A CANDIDATE FOR DENTAL IMPLANTS?
The ideal candidate for a dental implant is in good general and oral health. Adequate bone in your jaw is needed to support the implant, and the best candidates have healthy gum tissues that are free of periodontal disease.
Dental implants are intimately connected with the gum tissues and underlying bone in the mouth. Since periodontists are the dental experts who specialize in precisely these areas, they are ideal members of your dental implant team. Not only do periodontists have experience working with other dental professionals, they also have the special knowledge, training and facilities that you need to have teeth that look and feel just like your own. The dentist and periodontist will work together to make your dreams come true.
WHAT IS A DENTAL IMPLANT PROCEDURE LIKE?
This procedure is a team effort between you, your dentist and the periodontist. The periodontist and dentist will consult with you to determine where and how your implant should be placed. Depending on your specific condition and the type of implant chosen, your periodontist will create a treatment plan tailored to meet your needs.
- Replacing a Single Tooth If you are missing a single tooth, one implant and a crown can replace it.
- Replacing Several Teeth If you are missing several teeth, implant-supported bridges can replace them.
- Replacing All of Your Teeth If you are missing all of your teeth, an implant-supported full bridge or full denture can replace them.
- Sinus Augmentation A key to implant success is the quantity and quality of the bone where the implant is to be placed. The upper back jaw has traditionally been one of the most difficult areas to successfully place dental implants due to insufficient bone quantity and quality and the close proximity to the sinus. Sinus augmentation can help correct this problem by raising the sinus floor and developing bone for the placement of dental implants.
- Ridge Modification Deformities in the upper or lower jaw can leave you with inadequate bone in which to place dental implants. To correct the problem, the gum is lifted away from the ridge to expose the bony defect. The defect is then filled with bone or bone substitute to build up the ridge. Ridge modification has been shown to greatly improve appearance and increase your chances for successful implants that can last for years to come.
WHAT CAN I EXPECT AFTER RECEIVING A DENTAL IMPLANT?
As you know, your own teeth require conscientious at-home oral care and regular dental visits. Dental implants are like your own teeth and will require the same care. In order to keep your implant clean and plaque-free, brushing and flossing still apply!
After treatment, your periodontist will work closely with you and your dentist to develop the best care plan for you. Periodic follow-up visits will be scheduled to monitor your implant, teeth and gums to make sure they are healthy.
One out of every two American adults aged 30 and over has periodontal disease, according to recent findings from the Centers for Disease Control and Prevention (CDC). A study titledPrevalence of Periodontitis in Adults in the United States: 2009 and 2010estimates that 47.2 percent, or 64.7 million American adults, have mild, moderate or severe periodontitis, the more advanced form of periodontal disease. In adults 65 and older, prevalence rates increase to 70.1 percent. This study is published in the Journal of Dental Research, the official publication of the International and American Associations for Dental Research.
Periodontal disease is a chronic inflammatory disease that affects the gum tissue and bone supporting the teeth, according to theAmerican Academy of Periodontology (AAP). If left untreated, periodontal disease can lead to tooth loss. Research has also shown that periodontal disease is associated with other chronic inflammatory diseases, such as diabetes and cardiovascular disease. The AAP has worked closely with CDC since 2003 on periodontal disease surveillance.
The findings are based on data collected as part of CDC’s 2009-2010 National Health and Nutrition Examination Survey (NHANES), designed to assess the health and nutritional status of adults and children in the United States. The 2009-2010 NHANES included for the first time a full-mouth periodontal examination to assess for mild, moderate, or severe periodontitis, making it the most comprehensive survey of periodontal health ever conducted in the U.S. Researchers measured periodontitis because it is the most destructive form of periodontal disease. Gingivitis, the earliest stage of periodontal disease, was not assessed.
Previous NHANES relied on partial mouth periodontal examinations and may have missed disease in teeth that were not examined. Since periodontal disease is not evenly distributed in the mouth, estimates based on partial mouth examinations may have underestimated actual prevalence rates in the U.S. population by as much as 50 percent.
“This is the most accurate picture of periodontal disease in the U.S. adult population we have ever had,” said Pamela McClain, DDS, President of the American Academy of Periodontology and a practicing periodontist in Aurora, Colorado. “For the first time, we now have a precise measure of the prevalence of periodontal disease, and can better understand the true severity and extent of periodontal disease in our country. The AAP values its collaboration with CDC to better understand the burden of periodontal disease in Americans.”
The findings also indicate disparities among certain segments of the U.S. population. Periodontal disease is higher in men than women (56.4 percent vs. 38.4 percent) and is highest in Mexican-Americans (66.7 percent) compared to other races. Other segments with high prevalence rates include current smokers (64.2 percent); those living below the federal poverty level (65.4 percent); and those with less than a high school education (66.9 percent).
According to Paul Eke, MPH, PhD, lead author and CDC epidemiologist, the findings may drive public health policy. “We have demonstrated a high burden of periodontal disease in the adult U.S. population, especially among adults 65 and older. Periodontal disease is associated with age, and as Americans live longer and retain more of their natural teeth, periodontal disease may take on more prominence in the oral health of the U.S adult population. Maintaining good periodontal health is important to the overall health and well-being of our aging population. Our findings support a need for public health programs to improve the oral health of adults.”
Co-author Robert Genco, DDS, PhD, Distinguished Professor at The State University of New York at Buffalo and Past President of the American Association for Dental Research (AADR) and the International Association for Dental Research (IADR), believes these findings elevate periodontal disease as a public health concern. “We now know that periodontal disease is one of the most prevalent non-communicable chronic diseases in our population, similar to cardiovascular disease and diabetes.”
Dr. McClain noted that these findings support the need for comprehensive periodontal evaluations annually. “To really know if you have periodontal disease, a dental professional must examine each tooth above and below the gum line. A visual examination alone, even by the most qualified dentist, is not enough. These findings suggest that many more people have periodontal disease than previously thought, so it is more important than ever to receive a comprehensive periodontal evaluation from your dental professional every year.”
Surveillance of periodontal disease in U.S. adults will continue through the 2014 NHANES to include more racial and ethnic segments of the population. Both CDC and AAP support additional efforts to continue to understand periodontal disease prevalence trends. This data will guide public health policy decisions including appropriate prevention and treatment recommendations.