PART - I

		Introduction

Each tooth consists of two parts: the crown and the root(s).

Normally, only the crown is visible in the mouth. The roots anchor the tooth in the bone.

The gums are a specialized type of skin that surrounds the teeth and covers the bone holding the teeth.

Each front tooth has one root. Back teeth have one, two, or three roots.

		Normal Gums

This diagram shows the gums of a person who has a light complexion. People with dark skin normally have gums that are quite a bit darker.

		Infected Gums

Sometimes, gums that are infected look like this.
But many people who have gum infections, even in a advanced stages, may have gums that look essentially normal. That is why only a thorough examination by a dental professional can detect most gum problems.

		Stages of Periodontal Diseases

Periodontal diseases can be divided into two stages:

	Gingivitis
	Periodontitis

		Gingivitis

Gingivitis is a superficial infection that is limited to the gum tissue and does not yet affect the underlying bone. The gums may look normal, but may have some of the following signs:

	Redness and puffiness
	Bleeding when brushed
	Bad odor

		Periodontitis

When the infection spreads from the gum to the underlying bone, it is termed periodontitis ( once called pyorrhea). In this stage, bone that supports the teeth is lost. There are several types of periodontitis, some more aggressive than others. If periodontitis is untreated, tooth loss can occur.

In some cases the gums appear red and swollen, and other signs may warn you of trouble:

1.	Spaces begin to appear between the teeth. This can be a sign of an advanced problem.
2.	Loosening of one or more of the teeth. This is almost always a sign of severe bone loss.
3.	Receding gums. Periodontal diseases may cause gums to shrink away from the crown and expose some of the root. This makes the teeth look longer. Gum recession is not normal at any age.
4.	Vague aching, itching, or other discomfort of the gums.

Periodontal diseases are almost always painless, and only rarely do you notice changes, especially in the early stages. Therefore you probably will not notice gum puffiness or pay attention to occasional bleeding when you brush. Or you may think that the longer look of your teeth is normal for your age. But the fact is, four out of five teenagers and adults have a periodontal disease, and most don't know it. That is why people lose more teeth from periodontal diseases than from all other reasons combined.

But the good news is that most periodontal disease can be prevented or, if already started, can be treated. This is particularly true if action is taken in the early stages of disease.

		Plaque is the Primary Cause of Periodontal Infections

Every day a sticky, almost invisible film forms on the teeth. This film is plaque, a continually spreading mass of disease-causing bacteria and their waste products. Plaque grows on the teeth and down into the crevice between the gum and tooth. When the underlying bone is lost, this crevice deepens and is called a pocket.

In very large amounts, plaque can be seen or can be felt with the tongue as a fuzzy, unclean coating on the teeth.

The bacteria of plaque produce toxins (poisons) that damage the gums and underlying bone.

		Plaque Become Calculus

If you do not completely remove plaque every day by toothbrushing and flossing, it leads to the formation of calculus ("tartar"), a stony crust with a pitted, rough surface.

It takes only a little more than a day for any plaque left on your teeth to turn into calculus.

You can't remove calculus yourself. It clings to the teeth with such force that only a dentist or hygienist can remove it.

It is possible to see calculus that forms above the gums. It appears as a brownish or black deposit around the necks of the teeth. However, it is the hidden calculus under the gums that does the most harm.

Calculus greatly complicates the problem of preventing periodontal diseases. Each day's new plaque embeds itself in the rough surface of calculus in such a way that no toothbrush, or dental floss, or any other home dental device can ever remove it!

Thus, all calculus will always have plaque embedded on its surface. And all plaque is capable of starting or worsening periodontal diseases.

It is very important that you never let calculus get a start. Floss and brush away plaque every day. Never let plaque remain long enough to become calculus.

To sum up oral hygiene:
	You can remove sticky plaque from your teeth.
	You can't safely remove calculus or the plaque that forms on the surface of calculus, especially below the gums.

		Plaque Toxins Destroy Bone

The toxins produced by the bacteria in plaque not only infects the gums, but also destroy the underlying bone that supports the teeth.

As the gum infection continues, so does the bone destruction, usually without any symptoms, especially in the early stages of the disease.

ADVANCE PERIODONTAL DISEASE

Disease has caused severe recession of the gums and has destroyed half the bone holding these teeth. These teeth are loose.

When sufficient bone has been lost, the tooth loosens. When a tooth loosens, the destruction of bone around it may accelerate.

Finally, when deprived of most of the supporting bone, the tooth becomes so loose that it either falls out or must be removed.

		Natural Resistance or Susceptibility to Periodontal Diseases

Very few people are totally resistant to periodontal diseases. Most are quite susceptible.

However, most people have a varying resistance to these diseases at different times in their lives. For examples, a person's resistance may be normal for years. Then resistance temporarily diminishes and periodontal disease appears, or disease that was under control flares up.

While periodontal diseases cannot be cured, in most cases you and your dentist together can slow down or arrest the disease. For the majority of people, tooth loss can be prevented.

		The Periodontal Examination

You cannot accurately diagnose periodontal diseases yourself:

	They most often start between back teeth where you can't see them.
	They will almost always be painless.
	There is usually no "pink toothbrush" (bleeding) to warn you.

Therefore even if you never have cavities, and your mouth feels fine, go for regular dental checkups. Your dentist and hygienist can spot disease early, when it is the easiest- and least costly-to treat. This early detection is possible only with a measuring instrument called the periodontal probe. This device can find periodontal disease long before they show up on x-rays.

The dentist or dental hygienist will gently examine for hidden areas of disease (pockets).

Your dentist will also need a complete set of x-rays to help in diagnosis and treatment planning.

		The Specialist

If you have a periodontal problem that does not respond to routine care, or if you have advanced disease, you may need to see a periodontist.

A periodontist is a specialist in the care of the gums and supporting bone. He has years of extra schooling and experience that permit him to use special techniques to treat more difficult or more advanced periodontal problems.

First let's look at some important relationship between the teeth, the gums, and the bone.

The teeth within the square opposite will appear in the diagrams that follow.

This drawing shows what is beneath the surface.

Many thousands of fibers, called periodontal fibers, go from their origins on the roots of the teeth into the gums or the surrounding bone.

Those fibers that enter the gums pull the gums into tight collar around the necks of the teeth.

The great mass of fibers that go from the roots into the bone attach the teeth to the bone.

Some people mistakenly believe that teeth are " in the gums." Not so. Teeth are in bone. The gums are a protective covering over this bone. In a healthy mouth, the gums hug the teeth like tight collars to prevent bacteria and food debris from invading the bone. Simply put, the gums protect the bone, and the bone holds the teeth.

This isolated tooth is enlarged nine times the normal size.

The fibers going from the root into the gum pull the gum tightly against the crown. There is a small crevice between the gum and tooth that you don't see when you look in your mouth. This area, where the gum lies against the crown, has been called the gum crevice (or sulcus).

The depth of this crevice is of major importance.

We have placed a periodontal probe gently to the bottom of the crevice to measure its depth. The attachment of the gum limits how far the instrument can go.

* The margin of the gum is its upper edge.

The markings on the periodontal probe are 1 mm apart. (An actual millimeter is the distance between these two lines .)

Normal crevices measures 1 to 3 mm deep. The crevice in this drawing is 2 mm deep.

The next few sections will help you to understand how periodontal diseases actually progress.

Keep in mind as you read that you and your dentist can prevent periodontal diseases. Even if disease has started, you and your dentist together can treat it. Most people do not have to lose their teeth.

		Normal and Healthy

Periodontal fibers hold the normal gum tightly against the tooth.

		Stage One of Disease: Gingivitis

Plaque has caused infection. The gum usually looks normal. Often, only your dentist can discover disease at this stage. Inflammation damages the periodontal fibers that hold the gum tightly against the tooth. This allows plaque to enter deeper into the gum crevice, Where it can do even more damage.

Professional treatment and good personal home care at this earliest stage can usually arrest the disease. The gums restore themselves to full health, with no permanent damage.

		Stage Two: Early Periodontist (Early Bone Loss)

Normal and Healthy

If plaque irritation persists, it causes the attachment of the gum to move down the root. This "creeping" of the gum attachment makes the crevice deeper.

A crevice more than 3 mm deep is considered a pocket. Pockets are very hard to keep clean. They are impossible to keep clean once calculus has formed within them. The toxins from the plaque in the pocket shown opposite have also destroyed some adjacent bone.

Professional treatment plus good home care can slow or stop the progress of disease at this stage.

Normal and Healthy

		Stage Three: Moderate Periodontitis (Moderate Bone Loss)

Continuing infection has caused the loss of up to one third of bone support, as the gum attachment has crept further down the root. Pockets depths usually range from 5 to 6 mm. Again, professional treatment plus good home care can stop the progress of disease at this stage.

		Stage Four: Severe Periodontitis (Advanced Bone Loss)

Half or more of the original bone holding the tooth has been lost and pockets usually are 7 mm or deeper. The margin of the gum may withdraw down the root. This recession of the gums exposes part of the root and makes the tooth look longer.

Even in this advanced stage of periodontal disease, professional treatment and proper home care usually help considerably. In some cases it is possible to replace lost bone by using advanced surgical techniques.

Adjacent diagram shows how much bone loss and gum recession have taken place at STAGE FOUR.

Most treatment involves:

		Personal Oral Hygiene

One of the most important things a dental professional will do is take the time to teach you proper flossing and brushing. Few people do it correctly without instruction. The cost of not learning to floss and brush the rightway could be the loss of your teeth.

It is important to floss every day.
Dental floss removes the plaque from between the teeth, where the toothbrush can't reach.
If you brush but don't floss, you are doing only half the job.

It is important to brush correctly every day.

Toothbrush bristles removes the plaque from exposed surface of the teeth. It is the tips of the bristles of a toothbrush that do the work. Therefore, when the bristles have bent over or curled from use, replace your brush.

Drugstores sell inexpensive disclosing tablets that contain a harmless vegetable dye. You should occasionally dissolve one in your mouth after flossing and brushing. It will temporarily stain any plaque you have missed, showing you areas where you must take a special effort to clean more thoroughly.

		Professional Removal Of Plaque And Calculus

Your dentist or dental hygienist will gently remove the calculus above and below the gum. In some cases of moderate and severe periodontitis, it may be necessary to lift the gum back to remove as much calculus as possible or to attempt to regrow lost bone.

Your dentist will check any restorations for correct shape and fit. Fillings and crowns that no longer fit will trap bacteria and food debris. This can cause severe periodontal problems. Have such fillings or crowns repaired or replaced.

		Professional Assessment of the "Bite"

A balanced bite (one where the teeth meet evenly during chewing) is important for many reason, but it can be crucial when periodontal inflammation is being treated. Too much force on a tooth with periodontal disease can cause bone loss to accelerate.

Your dentist may inspect the way your upper and lower teeth come together (the "bite") to see if the force of chewing are evenly distributed among all the teeth. If you are chewing on some teeth harder than on others, he may gently reshape the biting surface of these teeth until they meet evenly.