Gum Disease

Gum Disease

What Comes between
You and Your Teeth

To lose a lover or even a husband or two during the course of one's life can be vexing," the sagacious Madame Armfeldt observes in A Little Night Music. "But to lose one's teeth is a catastrophe."

It's true. Unlike men, teeth are virtually impossible to replace. With teeth, nothing fits or works as well as the original article.

The secret to keeping your teeth is caring for your gums. The proof? Well, gum disease is the leading cause of tooth loss in people over 35. Since it usually arrives without warning, you've got to be on guard against it.

"It's a very subtle disease," says Susan Karabin, D.D.S., assistant clinical professor of periodontics at Columbia University in New York City. "There's not much pain, so patients are often unaware. The only signs are a little bleeding or sensitivity when they brush their teeth, and patients tend to ignore that."

The Part Hormones Play

About 70 percent of women 35 and older have some degree of gum disease, estimates Marjorie Jeffcoat, D.M.D., chairman of the Department of Periodontics at the School of Dentistry at the University of Alabama in Birmingham.

Gum disease doesn't seem to be any more common in women than in men. But women do tend to get worse cases during menstruation, pregnancy and possibly menopause, Dr. Jeffcoat says. At those times hormonal changes make gums more sensitive to bacteria.

Researchers have known for years that bacterial infections cause gum disease. But they're still not sure why gum disease first makes an appearance once you've reached your midthirties. Some speculate that its arrival follows years of damage to the gums.

Even the most committed brushers and flossers can get a mild form of gum disease called gingivitis. With gingivitis, your gums may bleed a bit when you brush, but that's all the warning you'll get. If you don't take care of it--by brushing and flossing daily and seeing your dentist for professional cleanings at least once every six months--gingivitis can open the door to periodontitis. A particularly nasty form of gum disease, periodontitis can quietly destroy the tissues that hold your teeth in place.

Who Gets It?

Research suggests that some people inherit a predisposition to gum disease. In one study, scientists at the Medical College of Virginia in Richmond compared the mouths of nearly 5,000 sets of identical and fraternal twins and concluded that genes "make an important contribution to periodontal disease." The researchers found that identical twins, who have identical genes, were twice as likely to have nearly identical levels of gum disease as fraternal twins, who have different genes.

Medications for epilepsy, depression, heart disease and allergies can also make you more vulnerable to gum disease. So can Type I, or insulin-dependent, diabetes and immune system disorders like AIDS, which weaken your ability to fight invading bacteria.

While some prescriptions hurt, others may help. Estrogen replacement therapy (ERT) seems to offset some symptoms of gum disease in postmenopausal women. Dental researchers at the State University of New York at Buffalo found that postmenopausal women who were getting ERT had about 20 percent less gum bleeding than those who weren't on the therapy.

The most important elements of any prevention plan, though, are brushing, flossing and regular visits to the dentist. Nearly 95 percent of cases of gum disease can be controlled or prevented, says Dr. Karabin.

The Problem with Plaque

The idea of brushing and flossing is to get rid of plaque. That's the film of bacteria, food particles and mucus that collects between your teeth and under your gumline. If you don't brush and floss it away, plaque hardens to form calculus, or tartar, which then has to be scraped away by your dentist or dental hygienist. You can't get rid of tartar yourself.

Plaque and tartar aren't simply an aesthetic liability. Even if your immune system is in top form, some of the bacteria they harbor produce toxins that irritate and damage your gums. Your immune cells can fight the bacteria, but with limited success. While battling the bugs, some of the cells inadvertently damage your gums as well, and they become swollen and tender. That's gingivitis.

During menstruation and pregnancy, the problem gets worse because progesterone and estrogen levels fluctuate, prompting immune cells in your gums to launch a more aggressive attack. This leaves your gums even more swollen, Dr. Jeffcoat explains. You end up with a very bad case of gingivitis.

If you have gingivitis but don't realize there's a problem, or you ignore it, there's a possibility your inflamed gums can start to pull away from your teeth. Gaps, or pockets, form between the tooth and gum. This is periodontitis. Unchecked, bacteria-laden plaque move into the pockets, infect and damage more gum, then do a job on the connective tissue anchoring your teeth to your jawbone--and ultimately the bone itself. Your teeth get loose and fall out.

What You Can Do

Up to the very end, you may not suspect anything's amiss. You can't see the bacteria attacking your gums, of course, and you can't see the periodontal pockets that are forming. They're too small. That's why you have to visit the dentist regularly for checkups. Between visits, here's what you should do to hold on to your teeth.

Brush, brush, brush. Do it at least twice a day with a soft toothbrush and a fluoride toothpaste. A hard brush can irritate your gums, so you don't want that, says Joan Otomo-Corgel, D.D.S., adjunct assistant professor at the School of Dentistry at the University of California at Los Angeles. The fluoride is for cavity protection. Researchers aren't sure whether fluoride fights the bacteria that hurt your gums, says Dennis Mangan, Ph.D., director of the Periodontal Diseases Program at the National Institute of Dental Research in Bethesda, Maryland. But they know it strengthens the teeth, making it harder for acids produced by bacteria to erode the tooth enamel.

To get the most out of brushing, follow this advice from the American Dental Association (ADA): Hold your toothbrush beside your teeth horizontally, with the bristles at a 45-degree angle to your gumline. Move the brush back and forth in short strokes several times before starting on a new section. Brush both the outer and inner surfaces of every tooth. To clean the inside of your front teeth, hold the brush vertically and make several gentle up-and-down strokes with the front bristles. Move on to the chewing surfaces, brushing them with back-and-forth strokes. Finish by brushing your tongue.

And brush again. Make it three times a day if you've got braces, crowded teeth, a bridge or a family history of gum disease; if you take medications that aggravate gum problems; or if you're menstruating, pregnant or going through menopause, says Dr. Otomo-Corgel.

Floss daily. A toothbrush can't clean between your teeth and under your gumline. That's where floss fits in: It can slip through every crevice. To use it like a pro, the ADA suggests this approach: Take an 18-inch piece of floss and wrap it around both index fingers. Guiding the floss with your thumbs, slide it between your teeth. Curve the floss into a C-shape against one tooth and gently slide it into the space between the gum and the tooth until you feel resistance. Hold the floss against the tooth and gently scrape the side, moving the floss away from the gum. Move on to the next tooth, and don't forget to floss the back side of your last molar.

Pick at it. If you can't floss, clean your teeth with a toothpick. Gently run one around the neck of each tooth. Don't stab! "A toothpick won't do as good a job as floss, but it'll help," Dr. Jeffcoat says.

Try a rinse. "In my opinion, Listerine, which has the American Dental Association's seal of approval, is the only over-the-counter rinse that's proven its mettle against plaque," says Dr. Karabin. Try it. Or ask your dentist about rinses containing chlorhexidine, such as Peridex. These also have the ADA's approval but are available only by prescription. The jury is still out on other over-the-counter "anti-plaque" rinses like Plax. So far, there's no scientific evidence that they work.

Build your bones. Finnish researchers studied 227 postmenopausal women and concluded that those with strong bones were more likely to keep their teeth than those who'd lost bone density to osteoporosis. To protect your bones and teeth, eat calcium-rich foods like low-fat yogurt, skim milk, low-fat cheese, sardines and canned salmon (with the bones), says Kendra Kaye, M.D., clinical assistant professor of medicine at the University of Pennsylvania School of Medicine and attending physician at Graduate Hospital, both in Philadelphia. Shoot for at least 1,000 milligrams of calcium daily. Make it 1,200 milligrams if you're pregnant and 1,500 milligrams daily if you're past menopause and not on ERT. Take a calcium supplement if you don't get enough from the foods you eat.

And remember to exercise, Dr. Kaye says: It helps keep bones strong. You don't have to join a gym. You can walk the dog, ride your bike around the neighborhood, jump rope in the backyard--whatever it takes to get at least 30 minutes of exercise at least three times a week.

Hit a high C. Vitamin C helps keep your gums healthy, says JoAnne Allen, D.D.S., a dentist in Albuquerque. So make sure you have a least five servings of C-rich foods--like citrus fruits, tomatoes, strawberries, green and red peppers and broccoli--daily.

Stop smoking. Tobacco delivers a triple whammy to your teeth and gums. "Smoking removes calcium from the bone and suppresses the immune system," Dr. Allen says. "It also decreases blood supply to the mouth, so if there's anything that needs healing, there's less blood to do it." If you chew tobacco, quit that, too.

Relax. Stress can take a toll on your immune system, which needs its strength to fend off bacterial invaders, Dr. Jeffcoat says. To beat stress, soak in a warm tub, go for a walk, listen to soothing music or just breathe deeply.

See the dentist. Go at least once every six months. "Even the best tooth cleaners, after three to four months, get to the point where they can't keep things clean anymore," says Douglas Hall, D.D.S., a periodontist in Edmond, Oklahoma.

If your gums look inflamed or bleed when you brush, head for the dentist even if it's been less than six months since your last visit.

And go every three months if you're pregnant or have other risk factors for gum disease. During pregnancy, make sure you schedule a visit before your third trimester, Dr. Otomo-Corgel says. In the last trimester, you shouldn't lie flat on your back as you would for a dental cleaning. In that position, the baby will put too much pressure on the major veins in your midsection, which could restrict blood flow and make you pass out, she explains. If you must see a dentist during the last trimester, ask the dentist or hygienist to let you sit in a semi-reclining position.

Get cleaned. In the office, your dentist or hygienist should scrape away the hardened tartar between your teeth and under your gumline, Dr. Otomo-Corgel says. When you get home, you should redouble efforts to brush and floss plaque away before it hardens to form more tartar.

Say "Periodontal exam, please." Make sure you get a periodontal exam with every checkup. Your dentist or hygienist should look for and measure pockets using a periodontal probe, which looks like a tiny ruler. She should also take periodic x-rays to determine whether you're losing bone, Dr. Otomo-Corgel says. A full-mouth x-ray every two to three years is sufficient if you've had little trouble with cavities or gum disease in the past, Dr. Jeffcoat says. If you have chronic trouble, once a year may be best for you.

What to Do When You've Got It

A diagnosis of gum disease isn't the prelude to an elegy to your lost tooth. Periodontists (gum specialists) have the know-how to save even loose teeth these days. Here's a rundown of your options.

Get to the root of the problem. If you've got periodontal pockets between the tooth and gum, you probably need more than just the regular cleaning at your dentist's. A scaling and root planing may be in order, says Dr. Otomo-Corgel. This is a more intense version of the cleaning you usually get. After scraping away the tartar above and just below the gumline, your dentist reaches farther down below the gumline with her instruments and scrapes clean the roots of each tooth.

Ask about antibiotics. If scraping and planing still don't close the pockets, you may have some particularly truculent bacteria in your mouth. Antibiotics may fix that, says Sebastian Ciancio, D.D.S., professor and chairman of the Department of Periodontology at the State University of New York at Buffalo. Your dentist or periodontist can prescribe oral antibiotics. Or she can slide antibiotic-saturated fibers into the pockets, wait ten days, and then remove them after the antibiotics have had a chance to rout the bacteria, Dr. Jeffcoat says.

Rebuild tooth and gum. Your mouth isn't a lost cause even if gum disease has progressed to the point where you've lost bone and gum tissue. It's possible to stimulate regrowth of both bone and gum. Your periodontist first cleans away all tartar, then inserts small meshlike pieces of fabric in each pocket between the tooth and gum. These fabric barriers create space into which bone can grow. Since gum regrows faster than bone, you need the barrier to reserve some growing room for the bone. After several weeks, the periodontist removes the fabric barriers. "Some dentists will place a bone graft under the material to stimulate regeneration of lost bone," says Dr. Jeffcoat.

Some periodontists prefer to use newer dissolving barriers, which don't have to be removed because your body absorbs them after a few weeks.

Reclaim a lost tooth. If you lose a tooth, you still have options. Your dentist can replace the tooth with a fixed bridge--a false tooth attached to wires that loop around the remaining teeth on each side. Or she can put in a removable bridge, a less expensive alternative to a fixed one.

For something closer to the original article, she can give you a dental implant. To do this, she implants a titanium screw in your jawbone. After the bone grows into the implant, which can take eight weeks to six months, she can top the screw with a crown.