Do your gums bleed when you brush your teeth?  Do you have bad breath? Do your teeth have a noticeable beige yellow colour? Do your teeth wobble easily when you push on them with your finger? If you say ‘yes’ to any of these questions, you may have periodontal (gum) disease! Please continue reading for important information on periodontal disease.

What causes periodontal disease (gum disease)?

Even healthy looking gums can harbour the microorganisms that fall into the category of bacteria. Insufficient cleaning and tooth care can cause build-up of these microorganisms, resulting in gum inflammation and infection and leading to the formation of tartar. Meanwhile, a proliferation of microorganisms leads to an increase in the sulphuric acid gases released by bacteria into the mouth – causing bad breath. Increased levels of bacteria cause the formation of a film plaque on the surface of the teeth. If this layer, called bacterial plaque, is not brushed off, it becomes ‘tartar’; as a result of the mineral settlement in saliva. Tartar is noticeable: the teeth will appear to be stained, and their colour will change. If tartar is not removed by a professional cleaning procedure, gum diseases that start with inflammation of the gum tissue (gingivitis) can develop into periodontitis. Redness, bleeding, swelling of the gums, plaque, gum recession and increased tooth mobility are the symptoms of periodontitis. Apart from poor oral hygiene, periodontitis can be caused by disorders of the immune system. For example, individuals with low levels of immunoglobulins in the blood are more prone to periodontal diseases. As well, the curvature of the tooth row, which can create difficulties with brushing the teeth, can also provide a basis for the development of these diseases. Since these features are associated with heredity, we can say that getting periodontal diseases, to some extent, depends on genetic predisposition.


The mouth, oesophagus, stomach and intestines form the digestive system; all interrelated levels of which are inhabited by bacteria. As the digestive system is integrated, a failure to undergo regular medical check-ups and maintain proper dental care at home after periodontal procedures allows opportunistic pathogens to re-colonize the oral cavity and continue to cause damage. Thus, it is necessary to get regular gum treatment. All humans have in their mouth varying levels of bacteria, bacterial plaque and tartar, which do reappear some time after cleaning: as such, the fight against the diseases caused by periodontal bacteria is lifelong. Periodontitis can be treated, and normal conditions within the mouth can be restored, but disease-inducing microorganisms do not give up, and the disease returns when oral hygiene is neglected. Due to the reappear nature, fighting against periodontal disease is ineffectual and if the treatment is not applied, tooth loss is the inevitable outcome. Only by consistent fight and care can this disease be kept in check for many years.


Establishing a habit of brushing the teeth tops the list of measures required to protect gum health. Ideally, teeth are brushed with fluoride-rich toothpaste an hour after a meal. Acids produced during meals cause partial demineralization, i.e. the loss of minerals from the enamel layer, and soften the tooth’s structure. Therefore, rather than brushing your teeth immediately after eating, wait until the minerals present in the oral environment have settled onto demineralized teeth. Brushing immediately after meals can lead to the erosion of tooth enamel. In brushing after every meal, fluoride-rich toothpaste should be applied to a dry brush: do not dampen the toothbrush with water. For two minutes, clean the line between the teeth and gums, moving the toothbrush in small oval and circular motions. Then, perform sweeping motions from the gums to the teeth (from red to white) and, at the end, brush the tooth surface in circular motions. These brushing procedures should be performed for the upper and lower jaws, front, side and back teeth for the same length of time.


Even with regular and thorough brushing, plaque will appear in every mouth over time, and can develop into tartar, which tightly adheres to the enamel and root surfaces. Tartar has a very rough surface, one to which bacteria can easily attach and this, in turn, causes bacteria to multiply. Over time, the consistent build-up of new bacteria also escalates plaque development and the affected areas expand. Bacteria attached to the plaque release toxins into the oral environment and cause the destruction of collagen; the acid secreted by bacteria (exotoxin) into the oral environment leads to the dissolution of collagen fibres that are major integral components of the gums and bone tissues. Our body initiates the inflammation process – a defensive reaction – as a protection from the negative effects of these bacteria; the inflammation process refers to the movement of our protective white blood cells, or leukocytes, and various enzymes through the blood into the area affected by the bacteria. To accelerate this movement, the body dramatically increases the number of capillary vessels functioning in the area and leaves their ends open, allowing leukocytes to exit and attack bacteria. Depending on the number of inflamed capillaries, the affected area may swell, take on a dark red colour, develop oedema (watery fluid build-up) and bleed.


Objectives of Periodontal Treatment;

While periodontal diseases are characterized as local infections, the treatment is based on the principle of mechanical removal of bacterial products from the environment. In other words, periodontal treatment is an antimicrobial therapy, which aims to reduce the level of bacteria to a normal range and to eliminate the bacteria that have penetrated the tissue. It envisages the measurement of the depth of the periodontal pocket, along with evaluation of clinical data such as the amount of bleeding, tooth mobility (shaking) and x-rays, followed by planning the treatment. Laser treatments are supportive elements of the main pattern of treatment, though their functionality is still controversial.


Scaling is performed with hand-held instruments (dental scalers, curettes) and/or sonic-ultrasonic cleaning devices. Usually, three sessions take place, with an interval of three to four days between each one. This procedure is called the “initial periodontal treatment”. Generalized gingivitis: An inflammatory disease that develops due to untreated gum inflammation. It is characterized by periodontal pockets throughout the oral cavity and deeper than 2 mm in some places. Root planning is conducted in addition to a gingivitis treatment program. Mouthwashes are also used to support the treatment.


Necrotizing ulcerative periodontitis diseases: This group of diseases consists of necrotizing ulcerative gingivitis (NUG) and necrotizing ulcerative periodontitis (NUP). NUG and NUP are the diseases associated with immunodeficiency and/or poor oral hygiene and are mainly caused by anaerobic pathogens. They are characterized by ulcers on the gums, formation of a greyish film (pseudo membrane) on the edges of free gums, and noticeably bad breath. The initial treatment is carried out to ensure proper oral hygiene; antibiotics with ornidazole and metronidazole derivatives, which are effective against anaerobes, are used.


Chronic periodontitis: A disease in which gum inflammation spreads to deeper tissues and the depth of periodontal pockets exceeds 2-3 mm due to reabsorption of the supporting bone. Within three weeks following the initial periodontal treatment, follow-up is conducted on the depth of periodontal pockets and the level of attachment. The decision on whether to conduct subgingival curettage or flap surgery is taken depending on the healing rate and the depth of periodontal pockets. Some schools recommend that in any case subgingival curettage should first be applied and flap surgery performed after a few weeks. Subgingival curettage is performed under general anaesthesia and the process consists of removing granulation tissue from deeper tissues using hook-shaped instruments called dental scalers, and root planning. Flap surgery involves surgical removal of the affected tissue, reduction of the depth of periodontal pockets and root planning. Lately, the treatment’s level of success has increased due to the use of laser applications for surface detoxification.


Aggressive periodontitis: Less common than adult periodontitis, aggressive periodontitis is characterized by destruction of the tissue due to short attacks by periodontal pathogens associated with immunodeficiency. The treatment is similar to that of adult periodontitis. Routine monitoring is required after the diagnosis is established.


Localized aggressive periodontitis (LAgP): Most prevalent in young people, LAGP is characterized by the development of infrabony pockets in the mesial and incisal of six-year teeth. Treatment is similar to that of chronic periodontitis, but with application of flap surgery in the areas of formation of infrabony pockets.


Generalized aggressive periodontitis (GAgP): This disease is characterized by rapidly progressive destruction of the periodontal tissue of all teeth except for the central incisors and first molars. Applied treatment is similar to the treatment of chronic periodontitis.


Periodontitis as a manifestation of systemic diseases: Periodontal complications that arise in connection with a variety of systemic diseases such as neutropenia, Down syndrome, Papillon–Lefèvre syndrome and histiocytosis, and manifestations that resemble chronic periodontitis, are grouped under this category.


Periodontal abscess: This refers to lesions in the form of purulence of the periodontal ligament inside the gum tissue. This category is subdivided into gingival abscesses, periodontal abscesses and pericoronal abscesses.


Periodontitis associated with endodontic lesions: Periodontal lesions caused by endodontic lesions are evaluated under this group.


Developmental or acquired deformities and conditions: Periodontal lesions caused by mucogingival deformities with various aetiologies, and appropriate treatment solutions are reviewed under this title.


Refractory gingivitis and periodontitis: In cases of periodontal diseases in which the clinical picture is characterized by the persistent destructive effects of pathogens even after application of treatment, “refractory” is used to emphasize that these diseases are resistant to cure. When reviewing diseases of this kind, immune system disorders should be considered.


Antibiotics, non-steroidal anti-inflammatory drugs (nsaids) and antiseptic mouthwashes are prescribed as a supporting therapy for all types of periodontitis. Patients suffering from various forms of periodontitis must be very patient and closely cooperate with their dentists to achieve good results. In addition, patients with periodontal diseases must continue the treatment, as the factors contributing to the development of these complications can reappear at any moment of their lives. They must realize that the struggle against bacteria is lifelong.


Please consult your dentist for detailed information.