Periodontitis (Gum Disease)

How is Gum Disease Assessed?

Your dentist now needs to gain a much clearer picture of disease; how severe it is, which teeth are affected and what factors are contributing to the disease in your mouth. Your treatment can then be planned appropriately.

A full periodontal chart will be taken, where the dentist will walk a probe around each of your teeth and record the measurements at 6 points.

This can be a bit uncomfortable if your gums are unhealthy, but the amount of pressure used with the round-ended probe is minimal. I describe it as 'feeling a bit pokey'. This will clearly identify areas that need further treatment and provide a basis on which the progress of your disease can be assessed and treatment monitored. Whilst doing this they will often record which sites have plaque and which sites bleed- two important factors to know about.

If your gums are very swollen this may result in what we call 'false pocketing', where it looks as though you have pockets of attachment loss, but this is just the perception caused by swelling of the gums.

In this case, it is important that we first reduce this gum inflammation to clearly identify if there has been any true loss of the bony support for your tooth.

During this detailed assessment, the dentist may note some other important points relevant to the disease:
  • Furcation involvement
If the disease has progressed quite far in your back (molar) teeth, it may expose the area in-between the roots, we call this the 'furcation'. It is important because it not only indicates the disease is slightly more severe but can pose quite a cleaning challenge.

This is the amount of root you have exposed. It needs to be added to the probing depth in order to provide a clearer picture of the true amount of attachment loss you have experienced. Note that not all recession is associated with gum disease, it maybe due to brushing too hard with your toothbrush.
  • Mobility
The more a tooth moves, the more severe the gum disease and the amount of attachment loss. To test this, the dentist will gently move your teeth from side to side and judge how much movement the tooth has. We grade mobility I, II or III. I means the tooth moves a little more than normal, II,a couple of millimetres each way and III anything beyond this up to the point where you feel like you could almost pull it out with your just your fingers.

It is worth remembering that ligaments hold your teeth; if they are perfectly healthy, they can normally be moved just a fraction. As children’s baby teeth have their roots resorbed by the adult teeth coming through underneath, they will become looser and will eventually simply fall out.

The developing adult teeth interestingly, also move for a while when they first come through, as the roots are still forming underneath the gum. So don't wiggle them as they are coming through the gum.
  • Plaque retentive factors
This refers to anything that makes plaque (bacteria) collect more quickly and creates difficulty cleaning the area. These factors need to be addressed as they can result in the gum disease progressing more quickly than it would have otherwise.

Here are some examples:

(i) Tooth position
If you have teeth that are nicely straight and in- line, it is generally easier to clean around and between them, compared with teeth that are crooked or out of position. Having braces, whilst being a plaque retentive factor itself, can help sort this out.

Imagine you are trying to vacuum a room (your mouth) and all the chairs (teeth) are nicely spaced and in-line with each other- you will certainly be quicker and more effective than if the chairs were all randomly spaced and all contacting each other at different points. The vacuum may not pass through properly and it may be difficult to do a good job without moving the chairs.

(ii) Existing fillings
Fillings with margins that do not follow the shape of the tooth (often referred to as 'overhangs' and most commonly seen with amalgam) will trap extra plaque and can lead to localized areas of bone loss. The more these extend under the gum, the more potential trouble they cause, because cleaning is made that bit more difficult. It is important that these areas are identified and corrected by your dentist.

(iii) Caries (or as it is more commonly known- decay or a cavity) makes keeping the tooth clean trickier. If decay occurs just on the surfaces of exposed roots, it is known as 'root caries'. This is more common in older people because they have more recession and is a particular problem due to the proximity to the gum.

(iv) Calculus or tartar attracts more plaque than a clean tooth surface and once built up, it cannot be removed with normal brushing. We can get what we call supra (above) gingival (gum) calculus meaning calculus that builds up above the gum line or sub (under) gingival (gum) calculus which is a much more significant problem when it builds up below the gum. The latter requires some loss of attachment to have already occurred. This is what dentists are trying to remove when they do deep gum cleaning.

(v) Poor crown and bridge margins
If you have any crown or bridgework that extends too far under the gum or is the wrong shape, it can affect the attachment of the gum and the ability to keep the tooth clean. It could result in a chronic gingivitis that may eventually progress to bone loss in some cases (but not all).

(vi) Braces and partial dentures
These deserve a mention as they make cleaning more tricky and extra care has to be taken to ensure good plaque removal, or the effect on teeth and gums can be pretty bad.

How Severe is my Gum Disease?

We say you have ‘mild’ gum disease, if up to 1/3 bone loss has happened and we call it ‘moderate’ if up to 1/2 the bone support for your tooth has been lost.

Severe or advanced bone loss is the term we use, if over 50% of bone around the root has gone and if you have exposed the furcations of any molar teeth, (the areas in between the roots of back teeth with multiple roots).

If we look at your disease in terms of probing depths: Normal would be 1-3mm; moderate probing depths would show 4-6mm pockets and anything over 7mm we would call a ‘deep’ pocket.

The dentist will also classify your disease into ‘localized’, meaning it only affects a couple of areas or teeth in your mouth compared to ‘generalized’, where most are affected. Therefore, advanced generalized periodontitis would mean most areas in the mouth show a loss of over 6mm. Moderate localized periodontitis on the other hand would likely mean a single tooth or couple of teeth still had over half the amount of normal bone support but less than 1/3.

What Affects my Prognosis?

The prognosis of your gum disease and indeed individual teeth is affected by a number of things:
  • How far the disease has already progressed in your mouth
  • How well you look after your teeth at home
  • The skill/ experience of the dentist in treating your condition
  • The presence of risk factors, such as age, smoking, diabetes, genetic susceptibility and plaque retentive factors.
By maintaining a good level of oral hygiene and thus oral health, you will increase the likelihood of a good response to treatment and the prognosis long term will be better than those who always have large amounts of plaque and calculus in their mouths.

A dentist will often assign a diagnosis to particular teeth to help them plan appropriate treatment. If a prognosis is good/ favourable- it is thought the tooth will be kept for life, given that appropriate treatment and maintenance (ongoing care) is provided and effective oral home care is carried out.

Those with a ‘questionable’ prognosis have exactly that- we are unsure exactly how they will respond to treatment and disease may or may not progress to more significant levels.

Hopeless teeth are unlikely to respond to a period of treatment – if these teeth are not painful they may be kept in the mouth- most would be quite mobile and often uncomfortable and therefore may be best extracted.

Certain tooth factors such as the position of the tooth in the smile and whether it helps to retain a denture or a bridge may also affect the decision whether or not to extract the tooth. Bear in mind that teeth suffering from moderate to severe periodontal disease are in most cases not suitable for involving in complex treatment plans. If a more definite solution is sought, then the tooth should generally be removed.