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The problems, from the swollen, tender gums
of gingivitis to the increasing destruction of soft
tissue and ultimately bone in periodontitis,
"happen so gradually that people thought that
was the way it was supposed to be," Ms.
Newcombe adds. Studies have found that about
half of older adults have some degree of gingivitis;
up to 20 per cent of the entire population have
some degree of periodontal disease.
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But dentists say it need not be for the vast
majority of people, including most elderly, if
they put consistent effort into oral hygiene.
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Daily brushing and flossing routinely break
down the natural and continuous build-up of
bacteria in the mouth, the waste products of
which form a substance called Plaque As plaque
accumulates around the teeth, gum tissue responds with
an inflammation reaction called gingivitis.
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"You get shiny gums that look like bruise fruit, "
observes Ginny Cathcart, co-ordinator of the
dental-hygiene program at Vancouver Community College.
"You touch them and you'll get pink blood on the toothbrush."
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This plaque-associated gingivitis is the most
common form of the condition, although there
are other categories, including gingivitis brought
on by pregnancy (steroid hormone influenced gingivitis)
HIV-associated gingivitis and gingival enlargement prompted by
certain medications.
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"Not everybody that gets gingivitis will eventually get
periodontal disease," says Ms. Cathcart, "but everybody that has periodontitis
had gingivitis to start with. It's important to treat gingivitis."
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Ms. Cathcart says a high-fibre diet will stimulate the gums and
vitamin C will aid good blood flow. But prevention and treatment of gingivitis
should centre on bathroom ablutions and periodic professional care. Brushing
should be done with a softbristled brush, gently but persistently penetrating
along the gumline and do it for several minutes rather than 30 seconds.
Electric toothbrushes, once a laughable piece of '1960's kitsch, are now much
refined and are sometimes recommended by dentists for their ability to follow
the contours of the gums.
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Flossing, a routine followed daily by as few as 15 per cent of
adults, penetrateg the tighter crevices between teeth that the brush can't reach,
disrupting bacteria colonies where it passes. And on a visit to the dentist's
office, manual scaling and planing with sharp instruments removes the plaque
which has hardened into tartar, also known as calculus.
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With brushing and flossing, "it's the thoroughness of the job
rather than how you do it," James Brookfield, a past president of the
Canadian Dental Association whose practice is in Kirkland Lake, Ont.
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Daily rinsing with an antiseptic mouthwash is also a useful
part of the regimen, adds Dr. Brookfield, an adviser to the Listerine Oral
Health Information Bureau in Toronto. (Prescription mouthwashes are sometimes
advised by dentists for gingivitis.)
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Periodontitis, often the result of gingivitis that has gotten
out of control, occurs when the gum tissue adhering to the tooth starts to
degenerate and reveals what is called attachment loss.
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WHAT CAUSES BAD BREATH?
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Bad breath or halitosis has a range of causes extending from
renal failure to sinus infections and blocked salivary glands. One of the
potentially useful things about halitosis, in fact, is that it can signal a
condition that requires treatment, including gingivitis, periodontitis and
other dental problems such as untreated cavities and abscess.
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"There are 360 [types of] bacteria that populate the oral cavity,"
explains Ginny Cathcart, co-ordinator of the dental hygiene program at Vancouver
Community College. "In an unhealthy situation, there are 10-to-20 types that take
hold."
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Halitosis-generating bacteria in the teeth are the kind that can
flourish with very little oxygen, breeding unrestrictedly in dark, inaccessible
crevices. Brushing, flossing, rinsing with antiseptic mouthwash and periodic
dental appointments will all discourage these promiscuous opportunists.
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- Salem Alaton
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"The tooth is sitting with the gum around it like a turtleneck
sweater," explains Dr. Brookfield. "If you can insert a probe into there about
two to three millimetres it may be all right, but if you can go in five or six
millimetres, then it goes too far."
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When the destruction of periodontitis extends from the soft tissue
of the gums to the bone of the jaw, the teeth themselves are in danger of
being lost.
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There may be a degree of genetic suscetibility to periodontitis,
and conditions like diabetes and various immune disorders can significantly
exacerbate the tendency. Smoking, as usual, heads the list of avoidable risks.
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"Tar and nicotine are very destructive to oral tissue," says
Ms. Newcombe. "People who are smokers really are heading down a path of
periodontal disease almost inevitably."
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Treatment for periodontal disease starts with scaling and root
planing, traditionally with the dentist getting inside the gumline at the
tooth wall with a metal instrument (curette) and scraping away the calculus.
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Today, "we rely more on ultrasonic instrumentation for this,
which allows you to remove the tartar or calculus much more effectively,"
comments Howard Tenenbaum, head of periodontics at the University of Toronto
faculty of dentistry. He likens this hard tartar to a coral reef.
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If problems persist, deeper scaling and planning is attempted.
A majority of patients respond well to these initial procedures. Beyond this,
antibiotics can come into play, testing having been done during the scaling to
identify the specific bacteria that are dominant in the disease.
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A new generation of antibiotics can be applied topically,
inserted into specific places in the gums where attachment loss is creating
an urgent problem.
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"Periodontitis is a chronic disease and it can recur," notes
Dr. Tenenbaum, who is also director of periodontics at Mount Sinai Hospital in
Toronto. "That's where topical antibiotics can be useful, when people have
two or three spots that are acting up."
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When the disease is too advanced however, with pockets of loose gum tissue so deep that other
methods cannot help, periodontal surgery "is still one of the mainstays of
treatment," Dr. Tenenbaum says.
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The standard gingivectomy to remove degenerated gum tissue has
evolved now to include procedures that make a flap of the gum, allowing
greater access to the tooth's roots for further cleaning and with healing
and cosmetic advantages.
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Like the gingivitis that precedes it, periodontitis comes in
various forms, including rare juvenile and prepubertal types that afflict
youngsters. Commonplace adult periodontitis is a potential issue for people
from their twenties on, but the upside is that risks needn't escalate sharply
with advancing years. The principle reason the elderly are more prone to gum
disease, as periodontal experts such as U of T's Dr. Richard Ellen have argued,
is that their capacity to maintain oral hygiene diminishes.
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About 85 per cent of patients being treated for periodontal
disease have the problem halted, Dr. Tenenbaum says. For those with refractive
or treatment- resistant disease, "now we're on the cusp of developing
regenerative treatments, which is very exciting," he remarks.
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While bone grafts have to date been only moderately successful,
a process called 11 guided tissue regeneration" using a synthetic membrane
has potential, as do the use of new biological materials such as bone and
enamel proteins.
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A Severe/Refractory Periodontal Disease and Investigative
Unit at U of T is also exploring such questions as genetic susceptiblity and
the potential benefits of anti-inflammatory agents and osteoporosis drugs
for treating gum disease.
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For the vast majority of Canadians, however, warding off
periodontitis comes down to what they do to prevent or treat those swollen
gums which Dr. Tenenbaum calls "the battlefield between the microbes and
the body."
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