In the last decade periodontists have begun to understand that periodontal disease is a results of bacteria interacting with the patient's defense systems. How the patient's body responds to the bacterial (plaque) assault depends on the "host" resistance. Some people are fortunate, and have minor periodontal disease even with poor dental care. Other patients may get advanced periodontal disease and bone loss with the same amount of bacteria. In other words, some patients are much more susceptible to periodontal disease, and these patients must be particularly diligent with their oral hygiene and maintenance to reduce the bacteria challenge. The following are factors that can have a significant impact on periodontal health.
Smokers have a 7 times greater chance of losing their teeth than non-smokers. A patient who smokes and who is also genetically susceptible (See Genetics) has a 20-fold increased chance of losing his/her teeth. This is one of the few host factors that can be altered, and every effort should be made to stop smoking completely, for periodontal and general health reasons. The photograph says it all.
Diabetics are at increased risk for periodontal breakdown. People with type II diabetes are 3 times as likely to develop periodontal disease as nondiabetics. Not only are diabetics more susceptible, the disease can also alter the pocket environment, contributing to bacterial overgrowth. Smokers with diabetes increase their risk of tooth loss by 20 fold. Fortunately, periodontal treatment is generally successful with the controlled diabetic. Increased diligence with plaque control and periodontal maintenance is key.
When under stress, our bodies produce hormones, like adrenaline and cortisone, which can worsen periodontal disease. An obvious example is "trench mouth", so named because of the severe outbreak experienced by troops in trenches in World War One. This stressful environment often resulted in acutely infected and bleeding gums that were very painful. We now know that under this high stress the normal mouth bacteria composition changed, resulting in an overgrowth of spirochetes that produced the disease. Acute necrotizing ulcerative gingivitis (ANUG), as it is called today, is sometimes seen in students during finals, or in other high stress situations. These acute conditions are generally easy to treat, but the long-term stress under which many of us live may make us more susceptible to chronic periodontal breakdown.
Women are at higher risk for gum inflammation during puberty, menstruation, and the second and third trimester of pregnancy, when there are increased levels of estrogen and other sex hormones. Some women notice their gums bleed easily, and are red and puffy. Normally these symptoms disappear when the levels of circulating hormones decrease, and with good plaque control, no permanent damage occurs. Women taking oral contraceptives may also experience these changes in their gums.
A number of medications effect the gums. The classic example is Dilantin, which produces a severe overgrowth of gum tissue in some patients. This makes cleaning the teeth difficult, if not impossible, resulting in periodontal breakdown. Surgically trimming the gum back to the normal shape is often the only solution, but unless the medication can be changed, re-growth almost always occurs. While few patients are on Dilantin, similar gum overgrowth is seen in some patients taking calcium channel blockers, drugs commonly used for heart conditions. These medications-which include Cardizem, Procardia, Verapimil, and several others-can result in overgrown gums, which adversely affect periodontal health and must be closely monitored.
Reduction in bone mass has been associated with gum disease and related tooth loss, particularly in postmenopausal women. However, clinically we have found that with treatment and follow-up periodontal disease can be successfully treated.
It has been found that about one person in four carries a genotype that makes them more susceptible to periodontal disease. Because a periodontist sees advanced cases, he may be reasonably certain that a patient is susceptible and treat accordingly. Being susceptible does not mean teeth will be lost, but rather that plaque control must be ideal, and that pockets must be eradicated as completely as possible so daily oral hygiene will access all areas.
If a case is not severe, genetic testing is now available and may be useful to evaluate the patient's resistance. If he or she is not susceptible, less surgery may be needed, with minor pockets being treated with scaling and root planing and maintained with regular cleanings. If the test is positive, more aggressive treatment and pocket elimination is needed.
Genetic testing is done by taking a sample of saliva, which is then submitted for analysis. It is a one-time expense, and in certain cases can help formulate the best treatment plan.