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February 5, 2009 – Vol. 3 • No. 6
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Avoiding gum disease’s slippery slope

Although tooth decay can occur at any age, adults have to be vigilant about another problem that starts in the 30’s — gum disease.

The mouth is teeming with bacteria — more than 400 different types— and gum disease is caused by 10 to 15 of them, according to Dr. Nadeem Karimbux, an assistant dean of dental education at Harvard School of Dental Medicine.

A bad taste in the mouth is usually the first sign of gum disease. Bad breath is another. But the most common red flag is bleeding when brushing the teeth or flossing.

“People often think they have brushed too hard, but most of the time, it is due to gum disease,” said Karimbux.

The problem is that many people say they think that bleeding is a normal part of brushing or flossing. It’s not.

The American Academy of Periodontology makes the point — if your hands bled each time you washed them, you would know something was wrong and do something about it. Some ignore the problem thinking that the infection is minor. Yet, according to the organization, the mass of tissue in your mouth is roughly equal to the mass of skin on your arm from the wrist to the elbow.

Inflammation can be mild, moderate or severe.

Gingivitis is a mild form of the disease and often goes undetected. It develops when plaque, a sticky film of bacteria, forms on the teeth after eating foods high in sugar and starch. Generally, good brushing removes plaque, but if allowed to remain on the teeth for a few days, it can harden into a substance called tartar, or calculus, which can inflame the gums. Tartar acts as a reservoir for bacteria and can be removed successfully only through professional deep cleaning.

The longer the plaque and tartar remain on the teeth, the more the gums become inflamed. Untreated gingivitis can progress to periodontitis, a more severe form of gum disease.

Periodontitis is the most common cause of tooth loss among adults. It can weaken the bone holding the teeth in place and cause the gums around the neck of the teeth to recede, thereby loosening the teeth.

To understand how periodontal disease impacts the gum and teeth, Karimbux draws a comparison. Look at how the skin on a finger meets the nail. If the skin begins to pull away from the nail, the nail will loosen. Likewise, as gum disease advances, the area around the tooth gets infected and begins to separate from the neck of the tooth. If the separation continues, a pocket develops allowing the bacteria to spread to the jawbone.

When severe, the bacteria can dissolve the bone of the jaw, which is visible on X-rays.

The problem is that there usually is no pain. Also, it takes years for this condition to progress. The disease can go into remission and resurface again depending on the strength of the immune system. Sometimes the body can fight it; other times not.

Gum disease starts around the age of 35 to 40.

“Generally, it is estimated that 85 to 90 percent of the adult population has some form of gum disease,” said Karimbux.

Some people are impacted more than others. Those who lack access to good oral care and those of lower socioeconomic levels tend to have a higher incidence.

Gum disease is no minor infection.

Periodontitis is not confined to the mouth — the inflammation can enter the bloodstream and wreak havoc on the cardiovascular system. Inflammation is linked to the formation of plaque in the arteries of the heart and brain that can result in a heart attack or a stroke.

Periodontitis is also linked to premature birth, low birth weight and respiratory conditions. Its impact on diabetes is well documented.

“It works both ways,” Karimbux said. “Uncontrolled periodontal state can affect diabetes. But deep cleaning of the teeth can improve a diabetic state. It’s a two-way street.”

Periodontitis is on the rise. The incidence is increasing largely because people are living longer and keeping their teeth longer. Other things happen with age — medications have an impact; the flow of saliva, which protects the mouth, decreases; and the immune system becomes diminished.

And that is why Elena Ramos has to be particularly vigilant.

For her part, Ramos walks the walk. She makes sure her children — Elizabeth, 4 and Dallas, 6 — get good dental care. Both participate in Smart Smiles at Orchard Gardens K-8 School and receive care from dental health professionals from Boston University Goldman School of Dental Medicine. Smart Smiles is a preventive dental program sponsored by the Massachusetts Coalition for Oral Health.

Ramos herself goes to her dentist regularly for check-ups and cleanings.

And for good reason. Ramos has another problem. About 12 years ago, she was diagnosed with lupus, an autoimmune disease common among women of color.

Lupus is an inflammatory disease that can impact a number of organs in the body, including the skin, joints, heart, lungs, blood, kidneys and brain.

People with lupus are also prone to sores and infections in their mouths. According to the Lupus Foundation of America, about 95 percent of lupus patients suffer from some type of oral health problem, and periodontitis is one of them.

It’s the inflammation that causes concern, especially as Ramos gets older.

Without proper management of cavities and gum disease, Ramos would increase her risk of inflammation and infection. While a strong immune system tries to fight bacteria, a compromised one — such as one impacted by lupus — is not so successful. In addition, steroids that are used to treat lupus reduce saliva’s ability to protect the mouth from bacteria.

People with lupus face an additional problem. While gum disease alone increases the possibility of cardiovascular disease, lupus can do the same.

Ramos is well aware of her risks. She admits that she has experienced swelling of the gums from time to time, and last year, she was diagnosed with high blood pressure. Fortunately, she has been able to keep her disease under control and she wants to keep it that way.

“I go every three or four months to be examined,” said Ramos.

Karimbux adds a note of caution. Periodontitis is not always preventable, but deep cleaning can slow it down.

“Progression can be slowed down with good oral hygiene and regular maintenance appointments with your periodontist (gum specialist),” said Karimbux.

Dental hygiene student Tomoko Kusunose examines Dallas Ramos, 6, while his sister Elizabeth, 4, looks on. Both participate in Smart Smiles.

Nadeem Karimbux, D.M.D., M.MSc
Assistant Dean
Office of Dental Education
Harvard School of Dental Medicine

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