If your hands bled when you washed them, you would be concerned. Yet, many people think it’s normal if their gums bleed when they brush or floss. In a 1999 study, researchers at the U.S. National Institutes of Health (NIH) found that half of Americans over 30 had bleeding gums.

Swollen and bleeding gums are early signs that your gums are infected with bacteria. If nothing is done, the infection can spread and destroy the structures that support your teeth in your jawbone. Eventually, your teeth can become so loose that they have to be extracted.

“Perio” means around, and “dontal” refers to teeth. Periodontal diseases are infections of the structures around the teeth, which include the gums, periodontal ligament and alveolar bone. In the earliest stage of periodontal disease — gingivitis — the infection affects the gums. In more severe forms of the disease, all of the tissues are involved.

For many years scientists have been trying to figure out what causes periodontal disease. It is now well accepted that various types of bacteria in dental plaque are the major villains. Researchers also are learning more about how an infection in your gums can affect your overall health.

In recent years, gum disease has been linked to a number of other health problems. This is a new and exciting area of research, but it remains controversial. Studies have produced varying answers about the extent of the connection between gum disease and other medical problems, and more research is needed.

Researchers are studying possible connections between gum disease and:

• Atherosclerosis and heart disease — Gum disease may increase the risk of clogged arteries and heart disease, although the extent of this connection is unclear. Gum disease also is believed to worsen existing heart disease.
• Stroke — Gum disease may increase the risk of the type of stroke that is caused by blocked arteries.
• Diabetes — People with diabetes and periodontal disease may be more likely to have trouble controlling their blood sugar than diabetics with healthy gums.
• Respiratory disease— Gum disease may cause lung infections and worsen existing lung conditions when bacteria from the mouth reach the lungs.

What Causes Periodontal Disease?

Periodontal disease is caused by bacteria in dental plaque, the sticky substance that forms on your teeth a couple of hours after you have brushed. Interestingly, it is your body’s response to the bacterial infection that causes most of the problems. In an effort to eliminate the bacteria, the cells of your immune system release substances that cause inflammation and destruction of the gums, periodontal ligament or alveolar bone. This leads to swollen, bleeding gums, signs of gingivitis (the earliest stage of periodontal disease), and loosening of the teeth, a sign of severe periodontitis (the advanced stage of disease).

Practicing good oral hygiene and visiting your dentist regularly (about once every six months, or more often if you have gum disease) can prevent periodontal disease. Daily brushing and flossing, when done correctly, help remove most of the plaque from your teeth. Professional cleanings by your dentist or dental hygienist will keep plaque under control in places that are harder for a toothbrush or floss to reach.

If oral hygiene slips or dental visits become irregular, plaque builds up on the teeth and eventually spreads below the gum line. There, the bacteria are protected because your toothbrush can’t reach them. Good flossing may help dislodge the plaque; but if it is not removed, the bacteria will continue to multiply, causing a more serious infection. The buildup of plaque below the gumline leads to inflammation of the gums. As the gum tissues become more swollen, they detach from the tooth forming a space, or “pocket,” between the tooth and gums. In a snowball effect, the pockets encourage further plaque accumulation since it becomes more difficult to remove plaque. If left untreated, the inflammatory response to the plaque bacteria may spread to the periodontal ligament and alveolar bone, causing these structures to be destroyed.

Another problem is that if plaque is allowed to build up on teeth, over time it becomes calcified, or hardened, and turns into calculus (commonly called tartar). Since calculus is rougher than tooth enamel or cementum (a layer that covers the tooth root), even more plaque attaches to it, continuing this downward spiral. Using a tartar-control toothpaste may help slow accumulation of calculus around your teeth, but it can’t affect the tartar that has already formed below the gum line.

Risks and Prevention

Although bacterial plaque buildup is the main cause of periodontal disease, several other factors, including other diseases, medications and oral habits, also can contribute. These are factors that can increase your risk of gum disease or make it worse once the infection has set in.

• Genetics — Researchers believe up to 30% of the population may have a genetic susceptibility to periodontal disease. Having a genetic susceptibility, however, doesn’t mean gum disease is inevitable. Even people who are highly prone to periodontal disease because of their genetic make-up can prevent or control the disease with good oral care.
• Smoking and tobacco use — Smoking increases the risk of periodontal disease and the longer, and more one smokes, the higher the risk. If periodontal disease is present, smoking makes it more severe. Smoking is the main cause of periodontal disease that is resistant to treatment. Smokers tend to collect more tartar on their teeth, develop deeper periodontal pockets once they have gum disease and are likely to lose more bone as the disease progresses. Unlike many other factors that affect the health of your gums, you have control over this one. Quitting smoking can play a major role in bringing periodontal disease under control.
• Misaligned or crowded teeth, braces or bridgework — Anything that makes it more difficult to brush or floss your teeth is likely to enhance plaque and tartar formation above and below the gum line, which increases your chance of developing gum disease. Dentists and periodontists can show you the best ways to clean your teeth, especially in hard-to-clean circumstances. For example, there are special tools and ways of threading floss to clean around bridgework or slide under braces. And if overcrowded or crooked teeth are a problem, your dentist might recommend orthodontics to straighten out your smile and give you a better chance of preventing disease.
• Grinding, gritting or clenching of teeth — These habits won’t cause periodontal disease, but they can lead to more severe disease if inflammation is already present. The excessive force exerted on the teeth by these habits appears to speed up the breakdown of the periodontal ligament and bone. In many cases, patients can learn to stop this habit simply by recognizing when it is happening and then relaxing. If these efforts don’t work, your dentist or periodontist can create a custom guard appliance (sometimes called an occlusal guard, night guard, mouth guard or bite guard) that helps reduce the pressure of clenching or grinding on the teeth.
• Stress — Stress can worsen periodontal disease and make it harder to treat. Stress weakens your body’s immune system, which makes it harder for your body to fight off infection, including periodontal disease.
• Fluctuating hormones — Whenever hormones fluctuate in the body, changes can occur in the mouth. Puberty and pregnancy can temporarily increase the risk and severity of gum disease, as can menopause.
• Medications — Several types of medications can cause dry mouth, or xerostomia, including antidepressants, diuretics and high blood-pressure medications. Without the protection of adequate amounts of saliva, plaque is more likely to form. Other medications may cause the gums to enlarge, which in turn makes them more likely to trap plaque. These medications include phenytoin (Dilantin and other brand names), used to control seizures; cyclosporine (Neoral, Sandimmune), used to suppress the immune system; and nifedipine (Adalat, Cardizem and others) and other calcium channel blockers, used to treat angina or heart arrhythmias.
• Diseases — Although the exact mechanisms aren’t totally understood, certain diseases increase susceptibility to periodontal diseases. For example, people with diabetes are more likely to get periodontitis, than people without diabetes and it’s likely to be more severe. Other diseases, such as leukemia, inflammatory bowel disease and HIV infection, also can increase the risk. Having one of these diseases will make control of periodontal disease more difficult, but a good periodontist or dentist who is aware of the additional risks and difficulties should be able to offer the kind of guidance needed to maintain your periodontal health.
• Poor nutrition — Nutrition is important for overall good health, including a working immune system and healthy gums and mouth.

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Here’s how to give your kids an early ‘ and tear-free ‘ start to good oral health

Tip 1: Start super-soon

The Canadian Dental Association recommends that babies see a dentist within six months of cutting their first tooth or by one year of age, whichever comes first. “A lot of parents are surprised by that,” says Dr. Diederik Millenaar, a pediatric dentist in Vancouver. “But the baby teeth are going to last, in some cases, up to 12 or 13 years, so we need to establish good oral habits.”

An early visit gives the dentist an opportunity to teach parents how to brush properly and plan tooth-friendly meals and snacks. And it’s a chance to spot – and fix – any trouble that’s brewing. In fact, the earlier children start seeing a dentist, the more likely they are to avoid dental problems.

Tip 2: Examine your infant at home

Your kid will be more comfortable having her teeth checked in a dentist’s office if she’s already experienced it at home. Take time to peer into her mouth regularly. That can be hard to do with an infant, but try using the knee-to-knee technique: Sit facing another adult with your knees touching and lay your baby in the other adult’s lap to have a good look. At this age, even if she has no teeth, you should be wiping her gums gently with a clean wet washcloth after meals. You can also stimulate her mouth with a small, soft brush. All of this manhandling will prepare her for the professionals.

Tip 3: Let your kid tag along with you…maybe

Bringing your baby to your own dental appointments may be a good idea, because it can get him familiar with the setting and staff. But first, consider this: Is your child going to share your dentist, or will he see a pediatric dentist who specializes in treating pint-sized patients? Is your dentist’s office kid-friendly enough to make him comfortable? Are you overly anxious when you have a dental appointment? If you are, it’s best not to subject your sweetie to your own angst.

Tip 4: Prep at home for the visit

Before your child’s first dentist appointment, give her an idea what to expect by talking about it in words that she understands – and that won’t terrify her. Telling her the dentist will “count” or “look at” her teeth is sure to go over better than hinting she has a mouthful of decay to be drilled out. Avoid adding “and it’s not going to hurt,” says Dr. Millenaar. “Pediatric dentists don’t like those statements because it proposes the possibility of something in the office hurting, and that only contributes to anxiety.” Play “dentist” with a compliant stuffed animal or doll, and read positive-sounding picture books about dental appointments.

Tip 5: Time it properly

Be sure to schedule all dentist appointments for times when your child will be comfortable, rested and in a good mood. “Children have patterns of good and cranky behaviour at different times of the day,” says Dr. Millenaar. “You don’t want to bring them when they’re hungry or tired.” For obvious reasons, avoid giving your kid caffeine or sugar before the visit. And if you can, arrive early. “It allows children to play with toys in the waiting room and get used to the whole environment.”

Tip 6: Keep it positive

You don’t have to be over-the-top gushy, but do keep an upbeat attitude when you’re talking about the dentist, and on the day of the visit. Treat the appointment as something simple, routine and positive. “If you do that, your child is going to have a much, much better attitude towards the dentist and the whole dental experience,” says Dr. Millenaar. It may help to bring along a comfort item for your child, like a blankie or a favourite teddy.

Tip 7: Know when to quit

Despite your best efforts, it’s natural for your one-year-old to get anxious or upset when he’s in the hot seat. In most cases, it’s likely to pass. But if he just won’t stop screaming, don’t force the issue. It’s better for everyone if you try again another time.

What if you want your child to see a dentist but financial constraints are holding you back? Some regions of Canada have help available. In Manitoba, dentists offer a free first appointment for children under three. Ontario’s Peel Region offers no-cost dental screening to kids who qualify. Check with your provincial dental association to find out what programs might be available in your area.

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You’re no longer limited to visiting a dentist’s office the next time you need your teeth checked and a good cleaning. In fact, you can have it done in the comfort of your own home.

Registered dental hygienists in most provinces — excluding P.E.I., N.W.T. and the Yukon — are now authorized by provincial governments to assess a patient’s teeth and provide dental hygiene care without the presence of a dentist.

“The bottom line is that dental hygienists are recognized as primary health-care providers, and they can have their own, independent practice settings,” says Arlynn Brodie, president of the Canadian Dental Hygienists Association and a dental hygienist since 1988. “They can also offer mobile services to remote, rural populations, group homes, seniors and others who are housebound.”

It hasn’t always been this way. Just five years ago, if you lived in Ontario and wanted your teeth cleaned by a dental hygienist, you would first have to be examined by a dentist who would then give the “order” to the hygienist to initiate cleaning.

Historically, dentistry in Canada has been comprised of mostly male dentists overseeing an all-female staff of hygienists, who often doubled as “office girls.” Although the number of women becoming dentists has increased over the years, 97 per cent of dental hygienists are female.

In 2007, Ontario amended the Dental Hygiene Act to remove the ties between hygienists and dentists. There are now about 400 independent dental hygienists across Canada.

One of the main benefits for patients is the cost. Although the province sets fee guidelines, it’s up to each dental hygienist to decide how much to charge. In Ontario, for example, fees charged by independent hygienists are about 30-per-cent lower than those charged by dentists’ offices for the same service.

In addition to cleaning teeth, hygienists can give fluoride treatments, administer local anesthetic for dental hygiene or treatment, apply pit and fissure sealants to the top surfaces of teeth, and do scaling and root-planing.

Want to find a registered dental hygienist? Check the database on the College of Dental Hygienists website.

Timeline on the changing role of dental hygienists

1947: Ontario became the first province to legally recognize dental hygiene as a profession.

1951: The University of Toronto began offering a two-year diploma program in dental hygiene. The first class consisted of six students.

1963: The Canadian Dental Hygienists Association was formed by a few U of T alumni who felt it was time to have their own national voice.

1993: Ontario became the first province to recognize dental hygiene as a self-regulated profession.

2007: Ontario amended the Dental Hygiene Act to permit registered hygienists to clean a patient’s teeth without the presence of a dentist.

Source: The Canadian Dental Hygienists Association

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