Periodontal ("Gum") Disease

What exactly is it ?????

Periodontal or - Gum - Disease is many things....First, you should know that it's VERY popular!!! It's been estimated that  80% or more of us have it to some degree !  Also, there are different forms of it that  are treated in different ways depending on how   advanced  it has gotten and how much damage has been done from it,    and also just where  it is... that is, is it on the front of the tooth , or on the tongue side?  or is it in the in-between space between  two teeth ?  These factors  become very important  when it comes to designing  appropriate treatment....

But for now let's concentrate on   developing a  simple model of what it most often is  and why it is so important  to diagnose and treat it in the earliest stages possible.

I made the  following drawings  to illustrate the basic stages in the progression of periodontal   disease.  It shows "Healthy" or "normal" on the left.   As we  go  to the right we pass through the  center drawing showing the beginning changes which are reversible and  then   progressing  to the right, the damages caused by advanced disease  so that permanent changes have taken place.

I will explain  each in more detail and try  to  help you understand why understanding the changes  is so important.

perio drawings in 72 dpi.jpg (39897 bytes)


******Please do not skip reading "Healthy"... read this first so you will understand  how the disease changes things....

Healthy - In the healthy state, the tooth is surrounded by and held tightly by  the bone of the jaw.  The  tooth is embedded  deeply into this bone so it has  lots of support.  Between the bone and the tooth is  a very narrow fibrous ligament (periodontal ligament) that  attaches the tooth to the bone.  It also acts as a   kind of shock absorber to allow shocks and pressures  against the tooth to permit the tooth to have a little "give".... to allow it to  move slightly and spring back into  position without  causing the bone  or the tooth to   crack.  It's a good thing and your friend!

The gum covers the bone ( you wouldn't want your bones to show ) comes up  slightly above the  bone and   surrounds  the tooth with a  "cuff" , much like the cuff on a shirt sleeve or pants.  This cuff is formed by the  final delicate edge of the gum which fills the  space  between the teeth  and makes a  smooth flowing shape from the tooth  to the  rest of the  gum tissue.   Because of this shape the  teeth can stay pretty clean without much work on your part and the spaces between the teeth are closed to  food and junk  can't easily get stuck there and get yucky....

This is important.... under that  little final edge of the gum that forms a cuff, inside that cuff, there is a   little space between the tooth and  that edge of gum tissue that is normally   no  deeper than  1/8".   That important  space is called the "Sulcus" (gingival sulcus).

The skin on the  outside of the edge of the gum  is normal  gum skin.... and  it just flips over and   forms the lining of the  sulcus... just normal gum skin.

That normal  gum skin lining the  sulcus does not bleed easily ... no more than the  rest of the  gum skin outside the sulcus.  If you  scrape or cut it, of course it will bleed, but normal stimulation doesn't bother it.... it's healthy and normal.


Gingivitis - The center drawing shows what happens if that little edge of gum tissue around the tooth gets inflamed.  Most often it  gets inflamed  because  too many bacteria  have been  accumulating  in the sulcus between the gum and the tooth surface.  It may be because you have not been brushing well enough, or because it's  in a place between the teeth where the  brush can't get to well enough and you have not been using  floss to  keep it clean.

For some people lots of bacteria can collect and it's not a problem - the gum stays ok.  For others with a  lower immune system response, even a small amount of bacteria creates a problem.  It's just like  when two people go out in  wet, cold nasty weather - dressed equally - and one  comes down with a case of pneumonia and the other doesn't.  We differ in how well we fight off infections.  For some of us gum infection is a never-ending   problem while for others  it never seems to need any  thought or effort.   Some of us can  brush  quickly and absent-mindedly and  never floss ...and  the gums  still stay  great!  Others  can do it all - and   well - and still have a battle keeping  healthy. It's just not fair, right?

Anyway, notice what happened in the  center drawing.  The  top edge of the  gum  swelled up and got  bigger.  Also, the  inner lining of the  sulcus got  very red and  inflamed.  The effect of the  swelling is that the sulcus   gets DEEPER.  Now if the   original problem  was that too many bacteria  were collecting  in the shallow sulcus and it was  difficult to keep clean..... look at it now! It's even deeper and so  much more bacteria can collect and it's even harder to get it clean !!!  You can see now that as the gum swells, the problem causing the  swelling  gets worse, causing even more swelling.... this is a  "snowballing" cycle that  just gets worse and worse and harder and harder to get under control.

Additionally, just to make things worse, the inflamed  gum skin lining  inside the  sulcus  is getting   more and more inflamed and RAW.   It  gets to the  point of being so inflamed that any stimulation - even just  normal eating - will cause it to BLEED.  At this point  we no longer call it a  sulcus( the term for a HEALTHY gum crevice) .... it is now  called a "POCKET" , a term reserved for  a pathologic situation... a DISEASED sulcus.  Why is this important?

Well aside from the idea that it's a little  yucky to have your gums bleed,  and the fact that it  makes your mouth taste and  possibly even smell bad .... it's also invites deeper INFECTION.   If blood can  easily come OUT, then bacteria  can just as easily go IN.   When bacteria  go in to the  gum tissue, there are two major considerations.  One is the local effect  the infection can  have on the   gum, bone and tooth  right there.  The other has to do with  what happens  when these bacteria spread  through your body and end up in your heart, lungs, brain, kidneys, etc. ( See Gum Disease & Heart Disease on this site).  In this article I will stick with the LOCAL effects.

Periodontitis - As the infection takes hold in the fleshy part of the  gum next to the   sulcus, now turned into a  POCKET, the  chemistry in that  gum tissue  is altered.  Bone is a living tissue which is constantly being built up and  torn down, much like how your skin is constantly  renewed.

The changed chemistry  from the infection in the gum tissue  all around the fragile top thin edge of the bone causes the  bone to RECEDE, that is, the  tearing down starts to happen   faster than the rebuilding of the bone, so the bone begins to  "shrink away".  Meanwhile the  gum begins to  split away from where it was attached to the root of the  tooth so that  where it  IS attached   tends to follow the  bone.  As the  bone recedes down the root, so does the  part of the gum that  attaches to the tooth.

You can now easily see that   the  gum "pocket" is now  getting even deeper than it was   during the Gingivitis stage , which means that the difficulty  of keeping it clean has become even harder than it was in the  Gingivitis stage.

More important is the fact that now tissues  are not just irritated and inflamed - as in gingivitis - now they have actually been destroyed, lost.  The changes seen in Gingivitis  were   essentially REVERSIBLE... and fairly easily so.  The changes seen in Periodontitis are mainly no longer reversible.  The treatment is totally different and more involved.  Fortunately  there have  been some wonderful new treatment procedures that can  often repair and GET BACK the lost  gum and bone, but   it is not easy and not 100% predictable. 



Implications - If you get nothing else out of this discussion, please  get this...  The earlier the  gum problem is discovered and treated, the better the outcome, and the easier the treatment , which usually means   less discomfort and expense and less time involved in treatment.  Also,   the less likely  that there will be  any systemic infection problems   in other parts of your body from bacteria  which got into your body   through your  gums. 


I hope this brief discussion has been helpful and informative.  Good luck!



March 2013 Update

For several years there have been studies and reports linking  gum disease to many medical problems as being  a partly causative factor. Insurance companies very recently began to look at that possible  connection.  Of course they are looking at ways to keep you healthier so that they don't have to pay out as much in medical benefits.  Here's a press release from CIGNA Insurance Company, one of the big ones!

Cigna Study Supports Association between Treated Periodontal Disease and Reduced Hospital Admissions and ER Visits, and Lower Medical Costs

·         Three-year Cigna study finds potential benefits from treating periodontal disease

·         Periodontal disease and tooth decay are the two biggest threats to dental health

BLOOMFIELD, Conn.--(BUSINESS WIRE)--Regular visits to the dentist may do more than just brighten your smile, they may also lead to fewer hospital visits and trips to the emergency room, as well as lower your medical costs. These are the conclusions from a three-year Cigna dental study that looked at the potential benefits of treated periodontal (gum) disease. The findings were recently presented at the International Association for Dental Research (IADR) conference in Seattle. IADR is a non-profit organization dedicated to advancing research and increasing knowledge to improve oral health worldwide.

“We are pleased to be part of the dental community’s ongoing research into the links between good oral health and good overall health.”

“Advancing our understanding of how treatment for gum disease can affect overall health may help lead to the creation of evidence-based treatment standards that could benefit millions of people and simultaneously help reduce medical costs,” said Dr. Robert Genco, a member of Cigna's Dental Clinical Advisory Panel.

According to the Centers for Disease Control and Prevention (CDC), periodontal disease and tooth decay are the two biggest threats to dental health and are mostly seen in adults. Periodontal diseases are infections of the gums and bone that surround and support the teeth. Half of Americans aged 30 or older – 64.7 million people – have periodontitis, the more advanced form of periodontal disease.

Cigna’s study looked at periodontal patients from 2009 through 2011. On average, patients who received gum disease treatment had better outcomes than patients without treatment. Hospital admission rates were 149 per thousand (67%) lower, emergency room visits were 100 per thousand (54%) lower, and medical costs were $1,020 per year (28%) lower.

“These results suggest that treating gum disease has benefits beyond better oral health and may also help to control medical costs for some patients,” said Clay Hedlund D.D.S., Cigna's dental director. “We are pleased to be part of the dental community’s ongoing research into the links between good oral health and good overall health.”

In addition to Dr. Hedlund, Dr. Robert Genco, a distinguished professor at the SUNY University at Buffalo Schools of Dental Medicine and Medicine & Biomedical Sciences and member of the Cigna Dental Clinical Advisory Panel, and Alex Marano, a Cigna informatics senior specialist, presented the findings at the IADR Conference.



Michael C. Goldman, DDS

General and Cosmetic Dentistry
3815 East-West Highway
Chevy Chase, Maryland 20815
Phone (301) 656-6171

See other topics including "Gum Disease vs. Gum Health" listed  in Topics below.



Holism in dentistry is an approach to dental treatment, primarily  caring for  patients' health and safety from both a conventional as well as  "alternative healthcare" point of view.   It is sometimes called "biological" dentistry or "biocompatible" dentistry.  In it's fullest sense, I believe it   acknowledges and deals with  the mind, body and spirit of the patient, not just his or her "teeth".  See Topics / Info.....

Cosmetic dentistry is about doing   quality , esthetic dentistry in a way that looks natural to begin with, and furthermore,   can even  improve  one's  attractiveness through techniques such as bonding, bleaching, veneers, caps, implants and more.  It can   be like "instant orthodontics" in correcting  crooked, twisted or misplaced teeth in many instances.  Dark or misshapen teeth can be restored.   Smiles that lack youthful vigor or beauty can be revitalized! See Topics / Info..

Bleaching, veneers, bonding, caps, bridges, and implants  are cosmetic dentistry treatments that are also  discussed in  Cosmetic Dentistry, and more...