DENTAL BONE LOSS

 


DENTAL BONE LOSS :

Loss of bone supporting the teeth is the main result of periodontal disease, which is also called gum disease.

Periodontal means around the tooth, and periodontal disease is a gum infection that affects the tissues and bone that support the teeth.

There is a pocket around the teeth which when healthy is usually less than 3mm deep. When not properly cleaned, the harmful bacteria in the pockets multiply and cause the tissues to get inflamed and damaged, which causes the dental bone loss. As the pockets get deeper, it gets more difficult to clean, which makes the disease progress; the end result of which is tooth loss.

BUT IT’S REVERSIBLE, RIGHT?

NO. It is irreversible, but it is arrestable. Meaning, the bone will never grow back, but you can prevent further loss. This is done by having deep cleanings (called scaling and root planing) at regular intervals. The interval varies on a case by case basis, but is usually every 3-6 months.


SIGNS OF GUM DISEASE/DENTAL BONE LOSS:

If you have any of the signs below, you may have gum disease and need to get it checked out by your dentist.

  • Gums that bleed easily
  • Red, swollen, or tender gums
  • Gums that have pulled away from your teeth
  • Persistent bad breath, halitosis
  • Pus between the teeth and gums
  • Loose or separating teeth
  • A change in the way your teeth come together when you bite
  • A change in the fit of partial dentures

Many people think “if it don’t hurt, don’t fix it”. This is not one of those cases. If periodontal disease progresses, you will continue to lose bone around your teeth and they will eventually fall out.

Below are some photos which illustrate the process.


HOW IT IS MEASURED:

With a PERIODONTAL PROBE. That is the instrument that is used to measure the gum pockets that surround your teeth. Often times when you have a dental exam, you will hear your dentist calling out numbers like 3, 4, 4, etc. In general, 3 or below is good, 4 is marginal, and anything higher than a 4 is not good. If you start hearing numbers in the 7+ range, you have significant dental bone loss and are at a veryhigh risk for losing your teeth. The higher the number, the more advanced the peridontal disease and dental bone loss.

Most patients are probed at intial visits once all permanent teeth have erupted, and at least once a year after that, depending on their particular condition.



WHAT MAKES DENTAL BONE LOSS WORSE?

SMOKING:

Along with all the other problems it causes, it definitely will make your periodontal disease progress 2.5-6 times faster. Periodontal treatments are also much less successful in patients who smoke, which basically means that smoking will make you lose your teeth. The nicotine in cigarettes is a vasoconstrictor, which decrease blood flow to the gums, which decreases oxygen, nutrients, and white blood cells- which fight off infections; all of which helps promote gum disease and loss of bone.

ELECTRONIC CIGARETTES:

These are increasing in popularity and many people have asked if they, like normal cigarettes, are a risk factor in increased periodontal disease. Electronic cigarettes have nicotine, so their effect on the gums is similar to regular cigarettes. So while they may help be more socially acceptable, they are still very harmful to your gums.

SMOKELESS TOBACCO:

This can affect the gums and teeth in the area that it’s placed, but does not have the same generalized effect that smoking has. On the other hand, many people place it in different areas, so it can affect all teeth.

Also, both smoking and use of smokeless tobacco increase the risk for oral cancer.

SYSTEMIC DISEASES:

HIV infections, AIDS, blood cell disorders, or other systemic diseases can decrease the body's resistance to infections which make the gum disease more severe.

UNCONTROLLED DIABETES:

Diabetes and periodontal disease have been linked, and if one is uncontrolled, it can affect the other. Uncontrolled dental bone loss will make your diabetes more difficult to control and vice versa. So get them BOTH under control, and they very well may help each other!

CARDIOVASCULAR DISEASE:

Like diabetes above, periodontal disease has been linked to cardiovascular disease and as above, getting your dental bone loss under control can help your cardiovascular health as well.

POOR ORAL HYGIENE:

If you are unable to remove the plaque and tarter around your teeth which host the bugs/bacteria, they will continue to multiply, the gum disease will progress, and you will continue to lose bone supporting your teeth.

OSTEOPOROSIS:

This may contribute to periodontal disease, but its effect may also be linked to quality of home care. In other words, with good home care, it may have less of an effect than if home care is poor.

MEDICATIONS:

DILANTIN, CALCIUM CHANNEL BLOCKERS, and CYCLOSPORIN may promote GINGIVAL OVERGROWTH. When this happens, often times the gums need to be SURGICALLY cut back.

Some medications can also reduce salivary flow leading to dry mouth, which irritates tissues and leaves your teeth and gums more prone to decay and gum disesase.

ILL FITTING DENTAL WORK:

Bridges, partials, fillings, crowns, or other dental work that are not properly in place can hold plaque in places that are difficult or impossible to clean, which will promote periodontal disease.

PUBERTY, PREGNANCY, ORAL CONTRACEPTIVES:

These can change hormone levels in the body which can cause the gum tissues to become more sensitive to toxins and can increase the growth of some strains of bacteria.

AGE:

The older you are, the more likely you are to exhibit some level of periodontal disease, however, there are elderly patients who do not.

GENETICS:

If your parents have a history of dental bone loss or tooth loss, you may be more susceptible to it as well. It also may be more aggressive, so you need to be more aware of any warning signs.

There is also research that has shown that the bacteria that causes periodontal disease can be transferred via saliva from parent to children.


TYPES OF PERIODONTAL DISEASE:

GINGIVITIS:

Gingivitis, which is inflammation of the gums, is the precursor to periodontal disease. This is when the gums are red, swollen, and bleed easily. This stages is reversible with professional treatment and improved home care.

CHRONIC PERIODONTITIS:

When left untreated, peridontal disease becomes a chronic issue and causes the loss of tissue attachment and the loss of bone supporting the teeth. Periodontal pockets form and increase, which makes it more difficult to clean and snowballs the problem.

At this stage the disease is irreversible, but treatment can prevent further damage. Chronic periodontitis is often generalized to the entire mouth.

AGGRESSIVE PERIODONTITIS:

This is a highly destructive form of periodontal disease and needs to be treated as soon as possible. It often occurs in isolated areas so early detection can be missed if not examined properly.

JUVENILLE PERIODONTITIS:

Periodontal disease is not exclusively in elderly individuals. It is not common, but does occur even in teenagers, and when it does, it is often very aggressive and must be addressed as soon as identified.

ACUTE NECROTIZING ULCERATIVE PERIODONTITIS:

ANUG, or NUG, is an infection which causes necrosis (death) of the gingival tissues, associated periodontal structures, and surrounding bone. This condition is usually extremely painful, bleeding, and foul smelling. Contributing factors include stress, tobacco use, and HIV infection.




HOW CAN I PREVENT DENTAL BONE LOSS FROM GETTING WORSE??

The two biggest factors are:

  1. HOME CARE, and
  2. RECEIVING COMPETENT TREATMENT, including SCALING AND ROOT PLANING

HOME CARE:

You need to be METICULOUS with brushing and flossing. You need to brush at least TWICE/day, and floss at least ONCE/day. Plaque takes about 24 hours to form on teeth surfaces, which is where the recommendations stem from.

It is recommended to brush and floss before going to bed because while you sleep, your saliva flow decreases, and saliva does help to decrease bacterial activity on the teeth and gums.

TREATMENT:

Once you start getting gum disease, it may not be possible for a toothbrush to completely clean all the gum pockets. This is why scaling and root planing by your hygienist may be recommended.

Scaling and root planing is cleaning the root surfaces of the teeth, which get exposed when a patient has lost bone supporting the teeth. The irregular root surfaces gather bacteria much more readily than the smooth surfaced enamel (outer layer), therefore often times the cleanings will take longer, and need to be done more frequently. While many people having cleanings every 6 months, those with periodontal disease may need to be cleaned every 3-4 months.

This type of cleaning is typically done by quadrants, so multiple visits may be needed in order to complete treatment. It also often requires anesthesia, since it can be a bit uncomfortable.

There is a product called Oraqix, which is a local anesthetic that is administered without a needle and is applied only in the areas that need to be anesthetized, is quick acting and not too long lasting (~30 min), so ask your hygienist if this is something that can be used.

PERIODONTAL MAINTENANCE THERAPY:

After the scaling and root planing is completed, you will likely need regular periodontal maintenance therapy in order to keep your periodontal disease under control. This is a type of cleaning that is a bit more involved than a standard cleaning/prophy and like the scaling and root planing, requires the dental hygienist to clean under the gums.

OTHER DENTAL BONE LOSS TREATMENT AIDS:

There are other aids available to help control dental bone loss/periodontal disease as well.



CHLORHEXIDINE GLUCONATE, ARESTIN, AND OTHER ANTIBIOTICS:

CHLOHEXIDINE GLUCONATE (PERIDEX) mouthwash is sometimes recommended. The main drawback to this is that it tends to STAIN teeth when used frequently.

PERIOSTAT, doxycycline, is an oral antibiotic that is normally taken as 20mg doses twice per day for up to 9 months. This is prescribed by your dentist in some cases of periodontal disease.

Your dentist also may elect to place ANTIBIOTICS in your gum pockets, in order to try and firm up the gums. They are placed after the cleaning is done, and are biodegradable so they do not normally need to be removed. After placement, your dentist will likely advise you not to brush or floss BELOW THE GUM for 10-14 days. (After 14 days, the products lose their effectiveness).

There are 3 products currently available.

ATRIDOX: This is a DOXYCYCLINE product.
PERIO CHIP: This is a CHLORHEXIDINE product.
ARESTIN: This is a MINOCYCLINE product.

These antibiotics are placed underneath your gums in the areas of dental bone loss, normally at the same appointment when your deep cleaning is done. They have been shown to be more effective in decreasing the gum disease when done in conjunction with the deep cleaning, than the deep cleaning alone.

It does not hurt when it is placed, and can be placed in multiple areas at the same appointment. The antibiotics remain in the areas of dental bone loss for about 14 days, helps to eliminate any infection that was missed, and helps keep the pockets disinfected for up to 4 weeks to allow for improved wound healing.

After Arestin or other antibiotics are placed under the gum, you should avoid brushing the area for about 12 hours and not floss for about 48 hours (or as your dentist directs).

There normally is an additional cost for this treatment, but if it can help to avoid periodontal surgery, it would be well worth it.




PERIODONTAL SURGERY:

Surgery can be very beneficial, but unfortunately tends to be fairly painful post operatively. In general, it is not the first course of treatment of dental bone loss, but may be needed if other treatments do not produce satisfactory improvements.

Most periodontal patients should have scaling and root planing first, and the dental bone loss should be re-evaluated prior to surgery being indicated.

BONE GRAFTS AND RIDGE AUGMENTATION:

Periodontists often will do bone grafting procedures in order to help rebuild bone in certain areas, or along with implants being placed. If you have advanced periodontal disease, bone grafting can't be done to replace all of your bone, but it is more done in isolated areas.

OSSEOUS SURGERY:

This is done when patients have severe dental bone loss, and is done to decrease the pockets around the teeth. This allows patients to clean more effectively around the gums. On the flip side, often times more tooth will be exposed, so your teeth may look longer and you may get some root sensitivity.

GINGIVAL GRAFTS:

When you have gum recession or thin tissue, sometimes it is necessary to graft tissue over the particular area to support the teeth and prevent further dental bone loss or tooth loss. Often times the tissue is taken from the roof of your mouth, and grafted to the particular area it is needed, often the lower anterior region.

IMPLANTS (also done by ORAL SURGEONS ):

Think of drilling a screw into BONE! Then attaching a TOOTH to that screw. Simple. Excellent, excellent, excellent; but NOT ALL patients are good candidates!! Unfortunately…

Implants are only as strong as the neighboring teeth. For example, if you have severe periodontal disease, implants may not be your best option. Also, you do need a sufficient amount of bone to support the implant. Sometimes additional surgeries need to be done prior to the implant being placed.

CROWN LENGTHENING:

Surgery done to expose more tooth. Say your tooth BREAKS OFF at the GUMLINE...

HOW IS YOUR DENTIST SUPPOSED TO FIX THAT?

Think of buying an ice cream cone at your favorite ice cream parlor. They hand you the cone wrapped in paper, right? After you eat the ice cream down to the cone, you have to UNWRAP the paper to eat more cone, right? CROWN LENTHENING surgery is like unwrapping the paper (gums) from the ICE CREAM CONE (tooth), to EXPOSE more TOOTH. After more tooth is exposed, THAT can be RESTORED.

DON’T LIKE THAT GUMMY SMILE?

Periodontal surgery can be done to fix that. The gums can be lifted to expose more teeth, and show less gums.

GINGIVECTOMIES:

Unlike most periodontal surgery which includes the removal or recontouring of bone, a gingivectomy is when only the gum tissue is removed or recontoured. This can be done with a conventional blade, or using some type of electrosurgery type tool, which removes tissue as well as cauterizes it to help control bleeding.

CROWN EXPOSURE FOR ORTHODONTIC AIDED ERUPTION:

When teeth, often times the canines, are impacted, sometimes a periodontist will need to do surgery in order to expose the tooth so the orthodontist can utilize a chain and help the tooth erupt into proper position.

Periodontists also sometimes do minor surgical procedures such as fiberotomies, corticotomies, or gingivectomies in conjunction with orthodontic treatment.

TUNNELING:

This is done when a molar has significant bone loss, and the furcation (where the roots split) is exposed. Sometimes the bone is removed between the roots in order to make cleaning easier. Yes, this is making the periodontal disease worse, but if it can be maintained better it may be better in the long term. This is not done often.

REMOVAL OF EXOSTOSES:

Sometimes bony growths, such as tori or other benign bony over growths need to be removed prior to placement of dentures or other prosthetics.

BIOPSIES:

Periodontists also often do biopsies to remove lesions or abnormal tissue growths. These will almost always be sent to a lab in order to definitively diagnose what they are.


FRENECTOMIES:

The lingual frenum is that flap of tissue that attaches underneath your tongue to the floor of your mouth. Sometimes it is attached closer to the tip of the tongue, or even up on the gums behind the lower front teeth. Depending on where it is, it can severely limit the action of the tongue, and may need to be cut surgically. This is called a lingual frenectomy. It is a relatively minor procedure, but will allow the tongue much greater movement to aid in speaking, eating, and other activities.

Sometimes a frenectomy is needed at the midline of the upper or lower lips as well, called a labial frenectomy. On the upper lip, sometimes it cause a gap (diastema) between the two front teeth. It can also cause dentures to dislodge, so it can improve their fit.


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