Can Often Go Unnoticed - Until It's Too Late

While you may not think periodontal disease affects you, 75% of adults over 35 show signs and symptoms. In fact, periodontal disease is the leading cause of tooth loss in adults. Why? Because it occurs at an age when cavities are usually a thing of the past and the initial symptoms often go unnoticed. Recent studies have also shown a possible link between periodontal disease and heart disease. One theory in support of this is that the bacteria that cause periodontal disease enter the bloodstream and promote blood clots and narrowing of the arteries that cause heart attacks. It has also been shown that if a woman develops severe periodontal disease during pregnancy, she is more likely to give birth to a low birth weight infant. Research I snow linking periodontal disease to many other health problems, as well. The following questions and answers will inform you about this often unseen problem.

What is periodontal disease? What causes it?

Periodontal disease, or gum disease, is a bacterial infection of the gums, ligaments and bone that support the teeth and anchor them in the jaw. The bacteria, which act mainly on certain carbohydrates in our diets, are normal inhabitants of the mouth, living in a thin film called plaque. If his plaque is left undisturbed, it may eventually harden into tartar, a hard mineral shell. When plaque builds on the tartar surface, it irritates and erodes healthy gum tissue. This early stage of periodontal disease is called gingivitis. If left untreated, pockets begin to form between the teeth and gum tissues. When the supporting bone becomes badly eroded, tooth loss can result. This stage is called periodontitis.

What are the symptoms of periodontal disease?

Because gum disease is painless until the final states, it often goes unnoticed. However, there are many indications of potential periodontal disease. Here is what to watch for: · gums that bleed when you brush your teeth · red, swollen or tender gums · gums that have pulled away from your teeth · a metallic taste or persistent bad breath · pus or discharge between your teeth and gums · loose or separating teeth · a change in the way your teeth fit together when you bite · a change in the fit of partial dentures Contact your dentist if you notice any of these symptoms.

If I have no symptoms, how do I know if I have gum disease?

Periodontal disease can be easily detected by your general dentist or a periodontist (a specialist in periodontal diseases) during regular dental examinations. Therefore, regular checkups, ideally every six months for most people, are crucial in catching periodontal disease in its early reversible stages.

During your checkup, the colour and firmness of your gums will be evaluated. Your teeth will be tested for tightness, and they way they fit together when you bite. During your periodontal examination, a small measuring instrument is painlessly inserted between the tooth and gum to measure the depth of the pockets. X-rays may be taken to evaluate the bone supporting the teeth.

What other factors can contribute to gum disease?

Smoking is a major risk factor to your oral health. Not only do the chemicals in tobacco have a harmful effect on your oral tissues, but can deplete Vitamin C and other nutrients and reduce your resistance to periodontal disease. A poor diet is also a contributing factor, especially a diet high in sugars and other sticky or gummy carbohydrates and low in the minerals and vitamins needed for healthy gums, teeth and bones. Hormone changes during pregnancy increase the blood supply to certain tissues in the body including the gums. As a result, 30 to 60 per cent of pregnant women experience red, tender or bleeding gums, teeth and bones. Stress can also be a contributing factor because it diminishes your body's ability to fight infection. Diabetes, AIDS and other health conditions can lower resistance to gum disease.

How can I prevent periodontal disease?

Brush your teeth twice a day with a soft-bristled toothbrush. Hold the brush at a 45 degree angle to the gum line and gently clean where the gums meet your teeth. · Clean between your teeth at least once a day with dental floss (or other interdental cleaners , such as rubber tips and oral irrigators , as recommended by your dentist) to remove bacteria, plaque and food particles your tooth brush can't reach. · Eat a balanced diet, which includes a variety from each of the basic food groups, to maintain optimum oral health · visit your dentist regularly, ideally every six months, for a preventive checkup and professional cleaning which is essential in the prevention of gum disease and the maintenance of good oral health.

What can I do if I already have periodontal disease?

See your dentist. In the early stages of gum disease, treatment usually involves removing the plaque and calculus in the pockets around the tooth and smoothing the root surfaces. This is called scaling and root planing. In combination with proper daily home care, this is all that is usually required to stop the development of the disease. If you wait until the symptoms are more advanced, a referral to a periodontist may be necessary, and in some cases, surgical treatment. Don't wait until it hurts. Periodontal disease can be prevented with regular dental visits

Janet Travell, M.D. was the White House Physician under Presidents Kennedy and Johnson, who wrote the landmark textbook Myofascial Pain and Dysfunction. Dr. Travell estimated that 90% of pain was due to muscles. As dentists we all learned in dental school that if the bite is not balanced, pain and other symptoms can develop. Our jaw is supported by a sling of muscles that guide our teeth together in our habitual bite or Centric Occlusion (CO). Even when our jaw is ostensibly resting, our muscles position our jaw near our bite. If our bite is in harmony with our muscles, everything feels good. That is to say that as long as our muscles are at physiologic rest, neither foreshortened nor elongated, there will be no muscle pain. But if our muscles have to strain on a regular basis in the "rest" position or in CO, symptoms can develop in patients who do not accommodate well. These symptoms can take the form of headaches, facial pain, neck and shoulder pain, feelings of ear congestion, dizziness, and other symptoms not commonly considered "dental."

Does My Patient Have TMD?

Malocclusion causes TMD. While nutrition and stress may be contributing factors, malocclusion is the overriding etiologic factor. How do we know if our patient's symptoms are occlusally related? First of all, it is always a good idea to check with the physician to make sure that the symptoms are not medical in origin. Next, take a proper history. Find out if the patient grinds his or her teeth, has TMJ crepitus, headaches, facial pain, dizziness or any of the other common symptoms of TMD. In your clinical exam, look for overbites, overjets, abfractions, tori, scalloped tongue, mouth breathing, anterior open bite, cross bite, wear facets, attrition, crowding, balancing interferences, incline interferences, missing teeth, and otherwise unexplainable perio problems. Continue your exam by palpating the muscles of mastication and facial expression, particularly the masseter, temporalis, lateral pterygoid, medial pterygoid, and digastrics. When a number of these signs and symptoms emerge in your examination, you may be looking at a TMD patient.

What Can Be Done?

Find the ideal occlusion. There are two major components of proper occlusion, and it is important to establish both of them ideally to relieve TMD. What can be done in everyday practice to properly diagnose and treat these legitimately suffering patients? The first component is an ideal cranio-mandibular position, where the muscles can truly relax in physiologic rest. Ultra low frequency TENS (transcutaneous electroneural stimulation) enables the properly trained clinician to find the ideal cranio-mandibular position, where tonus alone holds the jaw in rest position. Further enhancement of the correct position can be determined with electromyography, sonography, and kinesiography Then, ideal cusp-fossa relationships must be established, being careful to avoid balancing interferences and incline interferences in CO and in function.

What Are Some Practical Treatments?

Once the bite is recorded, there are a number of modalities to treat the TMD patient. If the ideal occlusion is very close to the existing CO, coronoplasty (selective grinding) can be used, guided by TENS. If the bite is significantly over closed, retruded, tilted, skewed, or otherwise tweaked, a fixed or removable orthotic (splint) can be fabricated, based upon the bite registration recorded at the ideal cranio-mandibular position. Orthotics, built as a facsimile of the ideal opposing dentition, often provide significant relief to the TMD patient. In many cases, long-term orthotic therapy is the treatment of choice. When restorations are required to provide a long-term solution, it is important to ensure that symptoms have resolved and that the bite has stabilized over time in the orthotic. Using the adjusted orthotic as a bite record for mounting casts in the laboratory, the case can then be designed using a wax up for the treatment of choice-- from a single onlay to a full mouth reconstruction, depending on the demands of the case. Orthodontics can also be used to move the teeth into the ideal craniomandibular position as established in the orthotic phase. However, it is critical to perform selective grinding after orthodontics to avoid pathologic interferences in CO and in function.

Know When to Treat and When to Refer

TMD patients can be perplexing. Oftentimes, TMD patients have complex restorative problems, upper airway obstruction, limited windows of comfort, and other complications. Until you become experienced in treating difficult cases, know when to treat and when to refer. To help you decide if a case is beyond your ability, look carefully at your diagnostic results. Is the patient a mouth breather? If so, an ENT may need to determine if the cause is enlarged tonsils and adenoids, allergies, or a deviated septum. These issues need to be resolved. Does the patient normally require multiple bite adjustments after even the smallest filling? Does the beautiful new crown never feel quite right? If so, you may be dealing with a patient who has a limited zone of comfort. Does the patient have a complex bite such as a class 3, edge to edge, or open bite in the anterior or posterior? Does the patient have complicated dentistry that is beyond your level if you need to replace it? If so, you may be over your head. In many cases such as overbite, attrition, retruded mandible, and easyto- please patients, treatment can be less complex. TMD can often be treated by placing the patient in an ideal cranio mandibular position found with the assistance of TENS. In the more complex situations mentioned above, consider a referral to a more experienced clinician.

Dr. Bernstein is a Clinical Instructor at the Las Vegas
Institute for Advanced Dental Studies. He maintains a
private practice in Piedmont, California emphasizing
complex cosmetic cases, TMD, and sedation, in an environment of outstanding personal service.

Article provided by LVI Visions: www.lvivisions.com