Brushing Up on Gum Disease : Part 2

by Food and Drug Administration (FDA)

(Page 2 of 3)

What triggers a destructive "burst" inside a periodontal pocket (or, for that matter, the transition from gingivitis to periodontitis) is unknown. But, as described by these British researchers, such events are most likely the result of unfavorable fluctuations in the balance between the type, quantity and location of bacteria in a person's mouth, the ability to resist bacterial infection, and the unique characteristics of an individual's inflammatory response.

Good News-Bad News

All this has something of a good news-bad news flavor to it. The good news is that most of us have less to fear than we may have been led to believe. Periodontal disease is often described as almost universal — a disease that can or will affect almost everyone and that can have "devastating" results. But most such statements are based on studies that are not only old (dating from the 1950s and early '60s) but that also combine gingivitis and periodontitis under the single heading "periodontal disease." More recent studies suggest that only about 10 percent of adults have periodontitis severe enough to possibly cause tooth loss. The percentage is lower in younger people and higher in older people. Even among these people, says epidemiologist Burt, it is unusual to have more than a few affected teeth. In one 1985 study of nearly 55,000 Italians, among those who had what are considered deep periodontal pockets the average number of affected teeth was fewer than one.

The "bad" news generated by all this new research into the causes and natural history of the periodontal diseases (as gingivitis and periodontitis are now referred to collectively) is that while most of us may be at lower risk than previously thought, it is still impossible to say who is at high or low risk individually. It can't be predicted who with gingivitis will develop periodontitis or who with shallow periodontal pockets will go on to develop deep pockets and possibly lose teeth.

Researchers are, however, working rapidly on methods to make such predictions. These techniques will involve tests of immune function and the types of bacteria in a person's mouth. Once available, they are expected to dramatically change current approaches to the treatment of periodontitis.

Today, periodontitis is treated either by surgically eliminating periodontal pockets or by cleaning affected tooth roots in a process known as scaling and planing. The current trend is towards the latter, and the ability to predict who is susceptible to worsening disease could accelerate the move in this direction. By one estimate, such predictions could make 90 percent of "pocket elimination" surgeries unnecessary.

Fighting Plaque

As yet, however, dentists can't make such predictions. And because both gingivitis and periodontitis are caused by the buildup of plaque, one dental maxim is as true now as ever: If you want to keep your teeth you have to keep them clean.

Only a dentist can diagnose and treat periodontitis. And only a dentist can remove the subgingival plaque responsible for periodontitis and its worsening. Nonetheless, according to Sebastian Ciancio, D.D.S., professor and chairman of the Department of Periodontology at the School of Dental Medicine, State University of New York at Buffalo, controlling the buildup of plaque above the gum line helps control both the quantity and harmful nature of plaque below the gum line. He says an ideal plaque control program involves periodic professional examinations and cleanings — "so you can start out with a clean mouth" — coupled with good cleaning at home.

The most effective method of plaque control at home is brushing and flossing. According to dental experts, most people don't brush their teeth properly and frequently miss some areas of their mouths, so it is a good idea to get instructions in effective brushing from a dentist or dental hygienist. One way to help determine how well you are brushing is through the use of disclosing agents (available over-the-counter), which make plaque easier to see.

As for toothbrush selection, studies show that soft bristles are better than hard at removing plaque. Toothbrushes are also less effective when splayed or matted and for this reason should be replaced at the first signs of wear. These considerations aside, virtually any toothbrush can be effective if properly used and a choice can usually be made based on personal preference or a dentist's advice.

There is a large and growing selection of dental flosses on the market today. According to the August 1989 Consumer Reports, which evaluated "anti-plaque" products, waxed and unwaxed floss are equally effective. Flosses do vary in strength and resistance to shredding, but as long as it doesn't break, the kind of floss you choose is less important than how well you use it — and whether you use it at all. Surveys show that fewer than 20 percent of Americans floss their teeth daily.

Though flossing is the only effective way to clean between the teeth, toothpastes can help in the removal of plaque from more accessible tooth surfaces. This is not because they have special "anti-plaque" ingredients, but because they contain abrasives and detergents that aid in the mechanical removal of plaque that occurs during toothbrushing. This is the source of the "anti-plaque" statements made on some toothpaste labels.

Several toothpastes are also now being marketed for preventing the buildup of "tartar." Tartar, which is plaque that has calcified and hardened on the teeth, was once thought to contribute to or even cause periodontal disease by physically irritating the periodontal tissues. It is now considered far less important, however, and, according to the January 1988 Journal of the American Dental Association, tartar control toothpastes have a "cosmetic benefit" only. They have no effect on gingivitis or periodontitis.

Theoretically, a toothbrush, floss, and toothpaste are all you need to control supragingival plaque. Yet estimates are that only 30 percent of the U.S. population clean their teeth adequately using these mechanical means alone. For this reason, dental researchers have been searching recently for additional ways to help people control plaque. In particular, this search has focused on mouthwashes.

There have been differences of opinion over the anti-plaque claims made for various mouthwashes (see "Anti-Plaque Mouthwashes" on page xx). But regardless of how effective a mouthwash might be, Ciancio points out that not everyone needs such products. "People who don't have periodontal problems don't need an anti-plaque mouthwash," he says. "If you are having problems — for instance, gums that bleed when you brush — see your dentist. If an anti-plaque mouthwash is recommended, what I advise is using the product for three to six weeks to see what a clean mouth feels like. Then stop and see if you can maintain that feeling with mechanical means alone. If not, resume the mouthwash for another few weeks, then try again to maintain a clean mouth mechanically."

This kind of conscientious effort at good plaque control holds great promise. When combined with researchers' rapidly growing knowledge about the causes of periodontal disease and how it can best be treated, the future offers a realistic prospect, says NIDR's director Loe, that "no one need ever lose a tooth to periodontal disease."

About the Author

www.fda.gov
FDA is A United States government body that oversees medical devices, including contact lenses, intraocular lenses, excimer lasers and eyedrops. In the US, these products must be approved by the FDA before they can be marketed.