So You Need Periodontal Treatment

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This handout consists of two parts - Dental and Nutrition Medicine. It provides you with information that will help you to understand periodontal disease it's treatment and also nutritional aspects that can assist in dealing with periodontal treatment. Periodontal disease is usually a slow disease and most people are not aware that they have it. The most obvious signs of periodontal disease are red, swollen, receding or bleeding gums, bad breath, or a bad taste, within the mouth.

PART 1- DENTAL

GINGIVITIS

Gingivitis is inflammation of the gums that occurs when the bacterial plaque that forms on your teeth is not removed by correct tooth brushing. Gingivitis results in red, swollen, tender gums, which bleed easily when, brushed. Not flossing also contributes to developing gingivitis. In this case, the gums may look red and swollen, but generally only bleed when cleaned with dental floss. Gingivitis is caused by the accumulation of "Plaque" on the tooth and gum surfaces. Plaque is a colorless, sticky film containing millions of bacteria and their by-products, which constantly grow on the teeth. It is these by-products from the bacteria that cause the inflammation. If gingivitis is not treated, it may lead to the more serious disorder, referred to as Periodontitis.

PERIODONTITIS

Periodontitis is the destructive inflammation of the gums in which the bone and supporting tissues of the teeth are lost. If the tissue destruction proceeds unchecked, then the teeth will become loose and eventually be lost. Within the infected crevice around the tooth the bacteria become calcified, to form a material called "Calculus". The treatment of periodontitis is to remove the disease causing bacteria and their by-products. Consequently, it is important that this calculus is removed from the teeth to eliminate the infection.

Moderate Periodontitis - pocket depths less than 5-6 mm
Severe Periodontitis - pocket depths greater than 6mm

SUSCEPTIBILITY TO PERIODONTAL DISEASE

Periodontal disease is one of the most common diseases in the world. One's susceptibility is primarily determined by what level of resistance you inherit from your parents. Hence periodontal disease often runs in families. In general, other factors that are associated with Periodontal Disease can be divided into two categories.

Extrinsic (local) factors:

1. Bacterial- Plaque, calcium, enzymes etc
2. Mechanical- Calculus, food impaction, poor restoration and malocclusion.
3. Para function- Bruxism, clenching

Intrinsic (systemic) factors:

1. Endocrine dysfunction's- Puberty, pregnancy, post menopausal
2. Metabolic- Diabetes, leukemia
3. Psychosomatic or emotional disorders- eg stress
4. Drugs, smoking and metallic poison A smoker's resistance to periodontal disease is greatly reduced. Smokers have far more periodontal destruction as smoking depresses the immune system, which protects against progressive periodontitis.
5. Nutritional deficiency- Protein absorption/ synthesis problems, vitamin and mineral deficiency states, inadequate dietary intake of protein, fibre, essential fatty acids or a high intake of carbohydrates, sugars.
6. Medications- Birth control pills, Cyclosporine and some blood pressure medications such as Nifedipine.

HEALTH AFFECTS OF PERIODONTAL DISEASE

Studies have shown that numerous diseases are linked to oral infections including:

• Cardiovascular disease-stroke, heart attack, high blood pressure, atherosclerosis (See also Part 2)
• Brain abscesses
• Arthritis
• Implant infection
• Hematological infection
• Low birth weight, pre-term infants
• Diabetes

TREATMENT

Severe cases are best treated by a specialist- consultations can be arranged at Brunswick Holistic Dental Centre to see Adrian Hoffman. Moderate cases can be treated by your dentist or hygenist.
       
INITIAL TREATMENT

1. Dental - The treatment of periodontitis is to scale the roots of the teeth to remove the plaque and calculus from below the gum line. This removes the cause of the periodontal infection resulting in the healing of the inflammation. Scaling, cleaning and root planning are the methods most commonly used to clean the teeth and are preformed by using a combination of an ultrasonic scaler and hand scalers. Local anaesthetic is generally used during these procedures to help eliminate discomfort. Total healing of the periodontal tissues takes at least 8 weeks. Occasionally (less than 10% of the time) the areas of infection do not respond to the scaling and root planning. In these circumstances, referral to a periodontist to retreat the area is generally recommended or gum surgery may be required.

Note - Following successful periodontal treatment, the gum will often shrink back as the swelling resolves. In some instances noticeable spaces may appear between teeth, this can concern some patients.

1. Consultation with our nutritional medicine consultant via phone conference to relieve and remove intrinsic (systemic) factors.

MAINTENANCE TREATMENT

The long term success of periodontal therapy is dependant on the patient carrying out good plaque control and attending the periodontist for regular professional cleaning and reassessment. This is referred to as a maintenance visit. This is because the bacteria that cause the periodontal disease normally grow in the mouth, and if allowed to regrow, then the disease will reoccur. Consequently, to prevent the recurrence of periodontal disease, the following are essential: good oral hygiene, regular reassessment visits, maintaining a good strong immune system, regular health check ups and lifestyle counseling.

ORAL HYGINE

The thorough removal of plaque accumulation around the teeth is very important. If good oral hygiene is not instituted then gingivitis will recur where plaque is left. In susceptible patients with severe disease, this occurs in approximately three months and in patients that are more resistant, it can take up to 1 year. As nobody is perfect at cleaning their teeth, regular periodontal maintenance visits are very important.

REGULAR REASSESSMENT VISITS

Regular reassessment visits are essential for people with periodontal disease, as this allows the opportunity to check for areas where plaque is inadvertently left on the teeth. If these areas are professionally cleaned at this visit, then redevelopment of the disease will be prevented at these sites. Consequently, recurrence of periodontal disease can be prevented.

KEYS TO SUCCESS

Must reduce sugar consumption, including honey and other natural sugar.
Excellent plaque control. i.e. brushing and flossing techniques and mouthwashes.
Thorough mechanical cleaning by a dentist or specialist
Good health and mental attitude perhaps looking at overall health.
Visits to the nutritional medicine consultant.
Supplements to aid healing e.g. aloe vera juice and co enzyme Q10, Vitamin C, Folic Acid, Vitamin E, Zinc.

MOUTHWASH

Savacol mouthwash and throat rinse is a broad spectrum antiseptic with prolonged action. It will help with gum disease and sensitivity after the teeth have been cleaned.

Half strength twice a day for 2 weeks before treatment and half strength twice a day for 2 weeks after treatment. Use these instructions unless advised differently by your dentist. Prolonged use may cause harmless but unsightly brown staining on the teeth, which can be removed by your dentist or hygienist.

CONCLUSION

In almost all instances, if the patient is well motivated to carry out proper oral hygiene and presents for regular reassessment appointments, their dentition and periodontal tissues can quite readily be maintained for life.

Every patient is an individual; thus, a personalised description and explanation of your periodontal treatment requirements will be discussed with you. We would like to inform you of your treatment requirements, the time involved, your maintenance program and the costs involved.

At all times our concern is to ensure that any discomfort is minimised, and staff at Brunswick Holistic Dental Centre are well trained on how to care for you as a person, not just your periodontal problems.

PART 2- Nutrition Medicine

WHY IS IT IMPORTANT TO HAVE A NUTRITIONAL PROGRAM AS WELL AS DENTAL TREATMENT?

Your nutritional status is a determinant of your health status and will affect how well your immune system reacts to any breach of it's defense mechanisms.  Periodontal disease is often the outward manifestation of a systemic health issue, and can be the first indication that your body is not functioning optimally.

The gingival sulcus that surrounds each tooth is ideal for the growth of bacteria as it is resistant to the cleansing action of saliva and the gingival fluid provides a rich nutrient source for microorganisms. As a result, the bacterial overgrowth secrete detrimental compounds such as:

• Endotoxins and exotoxins
• Free radical and collagen destroying enzymes
• Leukotoxins
• Bacterial antigens, waste products and toxin compounds

These compounds affect the defense mechanisms, resulting in inflammation, bone destruction, increased gingival permeability and increased penetration of bacteria and bacteria byproducts in a feedback cycle. This feedback cycle is perhaps the most problematic when left untreated.

The destruction of the collagen matrix has a direct impact on the amount of bone destruction and the rate of inflammation in the mouth. The amount of free radical damage, mechanical trauma and tissue destruction is also affected. Smoking has particular implications in periodontal and cardiovascular disease due to the free radical damage and the reduction in ascorbic acid levels, potentiating its damaging effects.

What is involved?

An appropriate supplement regime and eating plan can:

• Decrease wound healing time
• Improve membrane and collagen integrity
• Decrease inflammation and free radical damage
• Enhance your immune status

To maintain the integrity of collagen matrix it is necessary to determine if the cofactors for collagen synthesis are present in sufficient quantities. These factors are:

• Protein
• Vitamin C
• Vitamin B6
• Vitamin A
• Zinc
• Copper

Other nutrients required for optimal cell function include:

• CoQ10
• Vitamin E and Selenium
• Calcium
• Folic acid

Protein intake must be adequate to ensure maintenance of the collagen matrix. Periodontal collagen has a high rate of protein turnover and the integrity of the collagen matrix in this area is extremely vulnerable. The protein must be of high quality, i.e. a complete protein, in an easily assimilated form.

Vitamin C plays a major role in maintaining the membrane and collagen integrity as well as immuneocompetence. Decreased levels are associated with increased permeability of the mucosa to endotoxins. It is also required for it's antioxidant and anti-inflammatory properties and it's ability to decrease wound-healing time.

Vitamin B6 is required in many enzyme functions, particularly amino acid metabolism. It is also required for the synthesis of other nutrients. Insufficiency or deficiency can result in periodontal disease, fatigue and neurological problems as it alters calcium and magnesium metabolism.

Vitamin A deficiency predisposes you to developing periodontal disease, as it is also necessary for collagen synthesis and maintenance of epithelial and mucosal surface integrity.

Zinc functions synergistically with Vitamin A in many processes. The zinc to copper ratio is an indicator of the severity of periodontal disease. Adequate zinc levels reduce wound-healing times, stabilise membranes, have an antioxidant activity, and inhibit plaque growth.

CoQ10- Research (Nakamura et al. 1974; Hansen et al 1976) has shown that people with periodontal disease are also deficient in CoQ10 and the disease is halted by supplementation as part of a total program.

Vitamin E and Selenium work synergistically in antioxidant mechanisms are particularly important where there are silver amalgam fillings present in the mouth.

Calcium intake has also been found to impact (Nishida et al. 2000) on the development of periodontal disease. Those people with low calcium intakes were twice as likely to have periodontal disease.

Folic Acid is another vitamin which has been shown to bind plaque derived Endotoxins, enabling them to be removed. It appears that epithelial cells in the mouth may suffer an 'end organ' deficiency of folate. (These are available in the form of Deluxe Scavenger)

Other supplements shown to assist in treating periodontal disease are:

• Japanese green Tea extract have been shown to combat oral plaque and bacteria, it also inhibits collagenase, which becomes overactive in the presence of bacteria overgrowth destroying healthy collagen in the gums.
• Aloe Vera appears to increase collagen turnover and has anti-inflammatory activity.
• Tea Tree oil inhibits 14 of 15 oral types of bacteria.

Is Heart Disease Lurking Under Your Gums?

Good dental hygiene means much more than a winning smile and fresh breath. It could save your life.

Your mouth is a perfect breeding ground for bacteria. If left to fester, these bacteria can invade your gum tissue, make it into your bloodstream and cause inflammation of the arteries. Inflammation attracts white blood cells and platelets. They clump along the arterial wall, increasing the risk of blood clots, hemorrhage, stroke and heart disease.

The Tooth-Heart Connection

A major study by the US Department of Veterans Affairs found that men with severe periodontal bone loss had 150% greater risk of heart disease. The third National Health and nutrition Examination Survey, meanwhile, found that those with severe periodontal disease were nine times more likely to have a heart attack. An even larger study, the Arteriosclerosis Risk in Communities study, reports that patients with gum disease have a 1.5 fold increased rate of heart disease.

Despite this connection, conventional medicine has completely ignored oral health in their heart recommendations. Yet gum disease is completely preventable. We can show you an easy, inexpensive, safe and effective way to keep your mouth in good shape and reduce your risk of blood clots, heart disease and stroke.

Weapons of Heart Destruction in Your Mouth

Bacteria can enter your bloodstream through a cut, they can also enter trough diseased gums. These bacteria cause inflammation.

The Inflammation Association

Chronic infection activates your white blood cells. This can cause arterial lesions and encourages plaque to adhere to the walls of your arteries. This causes thickening of the wall of the artery, which is the same as a narrowing of the artery. The result is reduced blood flow to your heart and brain, increasing risk of heart attack and stroke. (A study by New York Presbyterian Hospital has confirmed this.)

I have mentioned before that elevated C-reactive protein levels indicate a high risk for heart disease. A groundbreaking study conducted in 1997 by the University of North Carolina at Chapel Hill, also linked high C-reactive protein inflammatory molecule levels (CRP) with patients who had gum disease.

A recent study at the University at Buffalo compared CRP levels in people with periodontal disease to 65 healthy patients. Normally 25% of the population exhibits elevated CRP. This percentage jumped to 38% for the group with periodontal disease. Further studies show that C-reactive protein levels drop when the gum disease is treated.

University of Michigan researchers have found periodontal bacteria in the fatty deposits found in the lining of the blood vessels of patients with periodontal as well as cardiovascular disease.

Another study conducted by the University at Buffalo reveals a further connection. People with diseased gums had significantly higher levels of bacterial inflammatory components in their bloodstream.

Another Side Effect of Heart Disease

Some pharmaceuticals increase your risk of gum disease. Diuretics reduce your production of saliva, which increase plaque build-up. Calcium channel blockers such as Procardia and Cardizem can enlarge your gums. This makes it more difficult for you to clean your teeth and gums effectively. Ironically, these are the very drugs that you may be taking to treat your heart disease!

The "statin" cholesterol drugs are the worst in this regard. They block the best treatment for gum disease; Coenzyme Q10. If you are taking one of these drugs, talk to your doctor about alternatives. You can find a discussion of some available alternatives in previous Health Confidential letters.