Periodontal health in patients with or without dry mouth: A retrospective study

Periodontal health in patients with or without dry mouth: A retrospective study

 

As our first line of treatment, patients to our office with a diagnosis of periodontal disease undergo non-surgical scaling and root planing (SRP) by our team of periodontal hygienists.  Following this initial treatment, patients return for their regular and ongoing periodontal maintenance appointments.

We have long known that our saliva, specifically our salivary flow rate (how much saliva we are able to produce) has an essential role in oral health.  

Therefore, the goal of this study was to ask the question “Do patients with dry mouth maintain similar clinical outcomes as patients without dry mouth 1-5 years after their initial deep cleaning?”

What we found: Probing depth (mm), the main clinical indicator for periodontal health, was similar in patients with and without dry mouth 1-5 years after their initial treatment.  

This is great news for patients who suffer from a condition known clinically as xerostomia, or dry mouth.  As long as patients with xerostomia continue to attend their regular and ongoing maintenance appointments, they see no difference in their oral health status compared to those with a normal salivary flow rate.

Written by: Taylor Sparrow, Peter C. Fritz, Philip Sullivan, and Wendy E. Ward

Link between Periodontal Disease and Diabetes

Link between Periodontal Disease and Diabetes

The human body is a single unit composed of a seemingly infinite number of biological processes that are so intertwined that a problem in any one system can have a profound effect on multiple other areas of the body.

As the entry point to the body, the mouth is no exception.

The two-way relationship between periodontitis and diabetes is the strongest among all systemic diseases.  Diabetes has been shown to increase the prevalence, severity (Stage), and rate of progression (Grade) of periodontitis.  And, periodontitis has been shown to influence blood sugar control in diabetic patients.

This link between gum disease and diabetes is not direct, but instead diabetes affects the pathogenesis of periodontal disease by altering the immune response and inflammation, increasing the risk of infection via high blood sugar, and by causing oral microbiome changes.

In the other direction, periodontal disease increases insulin resistance through persistent and chronic systemic inflammation.

Several studies have investigated the effect of a deep periodontal cleaning on diabetes.  They found that with the elimination of the bacterial infection, patients saw improved insulin sensitivity, improved glycemic control, and reduced HbA1c levels by 0.48% for at least 3 months following treatment.

This drastic reduction in glycosylated hemoglobin (Hba1c), which is a chronic measure of blood glucose, is similar to if you had added a second drug to a person’s usual diabetes medication regiment.

The link between gum disease and diabetes is so strong, that it has been suggested that periodontal disease be listed among the “classic complications” of diabetes, alongside stroke, kidney failure, and retinopathy.

Although the link is strong, 33% of people living with diabetes are unaware that it can affect their gum health.

Periodontal disease is a chronic bacterial infection resulting in inflammation.  Periodontal disease causes an immune response throughout the entire body, affecting many of the body’s systems.

Periodontal disease severity has been linked to many auto-immune, genetic, and acquired immune disorders.  These include:

  • Type I Diabetes
  • Rheumatoid Arthritis
  • Lupus
  • Crohn’s and Ulcerative Colitis
  • Irritable Bowel Syndrome
  • HIV
  • Vitamin D deficiency
  • Down’s Syndrome
Periodontal Disease 101

Periodontal Disease 101

Periodontal disease, also known as gum disease, begins with chronic bacterial growth in the mouth.  If left untreated, periodontal disease can eventually lead to tooth loss.

What are the Symptoms of Periodontal Disease?

Initially, bacteria build a home in the spaces between the tooth and the gum, called the periodontal pocket.  In the early stages, called gingivitis, the gums can become inflamed, red, sore, and can easily bleed when brushing or flossing.  Some people may even have persistent bad breath or a bad taste in their mouth.  If left untreated, inflamed and enlarged gums can even cause your teeth to shift and move.

Often this pain, inflammation and bleeding makes people want to brush and floss even less – exacerbating the problem.

Although the gums are inflamed and irritated, the tooth is still firmly rooted in the jaw bone.  However, as the bacterial infection grows, the bone tissue begins to be eaten away, like steel turning to rust.  When this happens, the teeth that were once anchored in the bone become loose and will eventually fall out.

Gum disease is the leading cause of tooth loss in adults, but unlike in children the tooth fairy can’t help you.

To stop the progression of this disease, it is important to see your periodontist for an accurate diagnosis and personalized treatment plan, which usually includes an initial deep cleaning followed by proper at home care and regular supportive periodontal therapy visits with your dental hygienist.

What causes Periodontal Disease?

Poor plaque control is the primary cause of periodontal disease.  Therefore, the first line of defence in reducing gum disease is at home care.

Other factors can make a person more susceptible to gum disease.  These factors include:

  • Family history of periodontal disease
  • Diabetic control
  • Heart disease
  • Medications – some medications have an effect on our oral health as they can increase or decrease saliva flow, which acts as a natural rinse in the mouth
  • Smoking status
  • Regular dental hygiene visits

How do I treat Periodontal Disease?

The first line of defence in reducing gum disease is at home care which includes;

  • brushing with a power toothbrush for 2 minutes twice daily
  • regular use of string floss to clean between the teeth
  • regular use of interdental brushes to clean between the teeth

To stop the progression of the disease, it is important to see your periodontist for an accurate diagnosis and personalized treatment plan, which usually includes an initial deep cleaning followed by proper at home care and regular supportive periodontal therapy visits with your dental hygienist.

What is my periodontist measuring?

What is my periodontist measuring?

Your periodontist and hygienist collect several values that give a good indication of your periodontal health and wellness at every appointment. 

To collect these values, a periodontal probe is used.  A probe is a very thin, small ruler.  The probe is gently inserted in the small space that exists between your tooth and your gum.  Some of the values that we are able to collect from this measurement are described below:

a. Bleeding on Probing – What percentage of sites bleed after gentle probing?  Bleeding indicates inflammation of the gums due to a bacterial infection.

b. Probing Depth – How deep is the pocket between the tooth and gum?  A healthy periodontal pocket is between 3 and 4mm.  A periodontal pocket deeper than 5mm requires deep cleaning.

c. Gingival Thickness – How thick or thin is the gum tissue surrounding the tooth rooth?  Just like Goldilocks, your periodontist and hygienist are measuring that your gums are not to thick and not to thin, but juuuust right.

d. Mobility – How loose are teeth?  The periodontal ligament around each tooth allows for some movement and mobility (think of the need for a skyscraper to have some room for movement in the wind), but the tooth should be snug in the bone and soft tissue.

e. Furcation Involvement – Has bone resorbed away from the tooth so much that the probe can fit between the roots of the teeth?

f. Plaque Score – How much visible plaque is on the tooth surface?

Like a report card, your periodontist and hygienist review these values at every appointment and look for areas of improvement as well as areas that require some more attention and focus.

Classifications of Periodontal Disease

Classifications of Periodontal Disease

Everyone lives with a small amount of inflammation and bacteria in their mouths, but it is when this bacterial infection in the gums proceeds to chew away at the bone that supports the tooth that we are diagnosed with periodontal disease.  Periodontal disease often goes undetected by the patient because there is no pain associated with the disease.  That is until teeth become loose, gums become red and inflammed and they begin to bleed when they are flossed or brushed.

In 2017, more than 170 clinicians and researchers came together to redefine the way that we classify periodontal disease.  Now, using language similar to that used in oncology (i.e., Stage 1 through 4) we are able to communicate the severity and rate of disease progression to patients and other clinicians better than ever before.

Your periodontist is a specialist in the gums and bone that support the teeth.  They collect information such as the depth of the pockets around your teeth, the amount of bone that’s been lost around the teeth (as seen on an x-ray), and the amount of bleeding and inflammation, and other factors like diabetes and smoking status to give an accurate diagnosis.  The diagnosis is made up of two factors, stage and grade.

First, a patients stage of disease is like the GPS of a car.  Stage describes the severity and complexity of the disease.  How straight of a path are we on from health to severe disease.  Staging of periodontal disease can rank from Stage 1, incipient periodontitis through to Stage 4, advanced periodontitis with extensive tooth loss.

Secondly, a patients grade of disease is like the speedometer of a care.  Grade describes how quickly the disease is progressing.  How fast are we moving from health to disease.  Grading of periodontal disease can rank from Grade A, slow rate through to Grade B, rapid rate.

Both smoking and diabetes status are known factors that can influence our Grade, how fast we are progressing from health to disease.  Being a non-smoker and having normal, controlled blood glucose levels slows the rate of progression.  Smoking more than 10 cigarettes per day and/or having an HbA1c greater than 7% rapidly increase the rate of disease progression.

Your periodontal diagnosis and classification should be updated every 5 years with a full mouth series of x-rays conducted at your periodontal office or general dentist.

The best way to prevent and to treat periodontal disease is by regular visits to your dental office as well as putting a high priority on oral hygiene at home.

Base Camp 11 – Periodontal Linkages with Other Dental Specialities

Base Camp 11 – Periodontal Linkages with Other Dental Specialities

Presented by: Dr. Luisa Schuldt, D.D.S., M.Sc., F.R.D.C. (C)

Join us for lecture 11 of the 12 part lecture series exploring cutting edge updates in the world of periodontics.  In this lecture, we introduce Dr. Luisa Schuldt to the Perio in the Peninsula Study Club.  Dr. Schuldt recently joined our Periodontal Wellness & Implant Surgery team and brings with her a wealth of knowledge from her years of experience as a practicing dentist and periodontist.

Periodontology is not an isolated realm. It is part of a wider scope of care in which interaction between many providers may be required to provide optimal dental care. This team of providers, depending on a patient’s individual needs, may require interaction between general dentist, hygienist, laboratory technician, physician, and one or more dental specialists including periodontist, endodontist, orthodontist and prosthodontist. Armed with innovative digital technologies, team members can achieve improved communication and coordination. Learning the linkages between periodontology and other dental specialities will facilitate a better understanding of the opportunities dental care providers have to work together in order to help our patients achieve aesthetically and functionally satisfying long-term treatment outcomes.

LEARNING OBJECTIVES:

  • Review important role of each member of the dental team
  • Explore new dental technologies and how these can improve communication and treatment planning
  • Understand how dental specialists can work together creating improved clinical outcomes

Base Camp 11 – Periodontal Linkages with Other Dental Specialities

Base Camp 7 – Metrics for Success: The Re-Evaluation

Presented by: Dr. Peter C. Fritz, B.Sc., D.D.S., F.R.C.D.(C)., Ph.D. (Perio), M.B.A. & Dr. Amanda B. Longo, B.Sc., M.Sc., Ph.D.

Join us as we continue along the treatment journey of the case studies first introduced in Lecture 2 (diagnosis and treatment planning), revisited in Lecture 4 (non-surgical periodontal therapy) and finally re-evaluated in Lecture 7. Close the loop on these example cases as we define the essential metrics necessary to quantify the success of SRP.

Learn of non-dental related metrics for success including strategies to promote mindfulness , the psychological process of purposely bringing one’s attention to experiences occuring in the present moment without judgement. Make room in our minds for strategies to improve what we can control and to let go of all that we cannot.

 

LEARNING OBJECTIVES:

  • Evaluate the success of non-surgical therapy
  • Understand the metrics essential for the Dental Hygienist’s Dashboard
  • Review the follow-up after both positive and negative outcomes
  • Develop proven strategies in mindfulness and chasing excellence in all that is in our control, and learning to respond to those factors that are outside of our ultimate control

Base Camp 11 – Periodontal Linkages with Other Dental Specialities

Base Camp 4 – Non Surgical Periodontal Therapy

Presented by: Dr. Peter C. Fritz, B.Sc., D.D.S., F.R.C.D.(C)., Ph.D. (Perio), M.B.A., Dr. Amanda B. Longo, B.Sc., M.Sc., Ph.D., Donna Lavoie, RDH, Linda Dakin, RDH & Taylor Sparrow, RDH

Together, we will revisit the series of case studies introduced and diagnosed in Lecture 2. As an interactive group, we will discuss and determine the most efficient and effective non-surgical periodontal treatment plan for each of these cases.

As a dynamic team, Dr. Peter Fritz, Amanda Longo and master clinicians, Donna Lavoie and Linda Dakin will present results of a two-year long trial investigating the effects of ultrasonic scaling alone compared to ultrasonics with the use of hand instrumentation.

LEARNING OBJECTIVES:

  • Review contemporary versus traditional instrumentation
  • Discover the armamentarium required to deliver non-surgical periodontal care
  • Unveil the results of a long anticipated methods development study involving the use of ultrasonics instrumentation alone versus ultrasonics plus hand instrumentation
  • Revisit five case studies of gingivitis and various stages and grades of periodontal disease

Base Camp 11 – Periodontal Linkages with Other Dental Specialities

Base Camp 1 – Introduction & Review of Periodontal Disease Classification

Presented by: Dr. Peter C. Fritz, B.Sc., D.D.S., F.R.C.D.(C)., Ph.D. (Perio), M.B.A.

A new global classification system for periodontal health, diseases and conditions, as well as peri-implant diseases and conditions, was revealed at the EuroPerio9 congress, the world’s leading congress in periodontology and implant dentistry in June 2018. The comprehensive classification is based upon the most contemporary evidence and includes a staging and grading system for periodontitis, indicating severity and extent of disease, accounting for lifetime disease experience and taking into account the patient’s overall health status. The complete review and consensus reports is the outcome of a joint workshop held by the European Federation of Periodontology and the American Academy of Periodontology in 2017.

This huge undertaking was one of vital importance, ensuring that an international language for clinical care, research and education is established, and updating the 1999 classification system to account for rapid advances in scientific knowledge over the last 20 years.

In the new classification, clinical health is defined for the first time and periodontitis is described in four stages, ranging from Stage 1 (least severe) to Stage 4 (most severe). The risk and rate of disease progression has been categorized into three grades from lowest risk of progression (Grade A) to the highest (Grade C). The grading considers risk factors such as smoking and the presence of concomitant diseases, such as diabetes.

The new classification provides a globally consistent approach to diagnosis and management and ultimately improves outcomes for our patients. It reflects what has been expertly reviewed today about the disease and attempts to:

  • Improve clinicians’ level of comprehension and appreciation of disease progression.
  • Clarify gingival health and mucogingival conditions and address peri-implant diseases for the first time.
  • Eliminate overlap of former disease categories and achieve more diagnostic precision.

 

LEARNING OBJECTIVES:

  • Learn how the worldwide consensus was reached and how the new classification differs from the original 1999 version.
  • Familiarize yourself with an innovative model for identifying and diagnosing periodontal disease that introduces a multi-dimensional staging and grading system, similar to the method used in oncology.
  • Gain an appreciation for the complex nature of each patient and his/her individual response to treatment.  Use this pragmatic and user-friendly system to focus the complex clinical situation.
  • Describe what new dental students will be taught about identifying and classifying periodontitis in their patients.
  • Gain a comprehensive understanding of the link between periodontal disease and other systemic chronic health conditions most commonly affecting Canadians.
  • Gain an appreciation for the importance of prevention of periodontal disease for the management of overall health.
  • Learn to correctly identify and classify periodontal disease progression using International nomenclature according to the most recent Practical Classification System for Periodontal Diseases, 2018.
  • Understand the non-surgical and surgical treatment options used for managing periodontal and peri-implant diseases
  • Investigate current and emerging areas of periodontal research.

Intra/Extra-oral Examination

Intra/Extra-oral Examination

The intra-oral and extra-oral soft tissue examination is an essential part of all dental exams.  This examination is performed in a thorough and systematic nature to ensure that no parts of the head and neck region are missed or overlooked.

This examination can be broken down into sequential steps to review all tissues and to determine if they are within normal limits (WNL) or if there is an abnormality noted.

If an abnormality is noted in an intra/extra-oral examination, further detailed notes about the abnormality such as size, colour, location, surface texture, and consistency are made.  Information about the onset, location, duration, characteristics, aggravating and alleviating factors, related symptoms, and treatment are all considered by your dental hygienist and periodontist.

As part of a full intra/extra-oral examination for abnormalities in our oral pathology, a detailed medical history, family history, drug/medication history, and social history are taken.

As a patient, we can prepare for our intra/extra-oral examination by being aware of any abnormal colouration, bumps, textures, or sensations in our head and neck region. 

A full video of what to expect during a full intra/extra-oral examination by your dental hygienist or periodontist can be viewed below.