What is a biomarker? How does this relate to cardiovascular or periodontal diseases?

A biomarker is anything that can be used as an indicator of a particular disease state, but it is typically a protein which can be measured in the blood and may reflect the severity of a disease.  The two biomarkers connected to both cardiovascular diseases and periodontal disease, are C-reactive protein (CRP) and PLAC2.

C-reactive protein was discovered almost a century ago, it is a biomarker for a protein produced by the liver in response to inflammation and infection.  Recent research suggests that patients with elevated basal levels of CRP are at increased risk of hypertension, diabetes, and cardiovascular disease.  Coronary artery disease can result from white blood cells responding to chronic inflammation in the heart arteries.  A level above 2.4 has been associated with double the risk of coronary event compared to levels below 1.   Periodontal disease was found to be a cause for elevated CRP levels some years ago.  Since periodontal infection involves a chronic bacterial infection, leading to bacterial bi-products entering the blood stream and triggering CRP to elevate.  ”Periodontal disease needs to be considered as a major contributor to increased levels of CRP by the medical community,” said Dr. Steven Offenbacher, member of the American Academy of Periodontology.  

Read more here  http://www.perio.org/consumer/happy-heart.htm

However, CRP levels in this instance should be used only as one indicator for further exploration.  If this test is normal, it can actually be a false positive for chonic infection and inflammation.  Often, we have actually tested and treated patients with advanced periodontal disease who have no elevation of CRP whatsoever, so this test alone is not an accurate assessment for a physician or cardiologist to use for thorough diagnosis of a chronic disease state.  On the other hand, we have also treated patients with elevated CRP who experience a reduction of CRP levels after our treatment.   CRP, or hs-CRP (high sensitivity CRP), can be requested during a routine blood draw with any physician or lab.  A patients overall health and more comprehensive labs should also be taken into consideration. While CRP is a “marker”, it is not a “player”, as we will see with the biomarker PLAC2.

PLAC2 is also a measure of a protein level in the blood.  This test was approved by the FDA in 2003.  PLAC2 is an enzyme which co-traffics with LDL (low density lipoproteins – bad cholesterol), then oxidizes in the arteries, leading to white blood cells coming to the area – foam cells are then formed, which leads to increased cytokines, MMP’s (inflammation)…this leads to a weakened fibrous cap (which covers the plaque build up in the arteries)…if this fibrous cap ruptures, as PLAC2 seems to promote, the person ends up with a thrombus (blood clot)…leading to heart attack or stroke. 

The only known cause of elevated PLAC2 at this time is periodontal disease.  PLAC2 is a major “player” in deadly coronary heart disease.   Anyone, especially anyone with hyperlipidemia (high cholesterol) and periodontal disease, should seriously consider having this biomarker checked.  If traditional approach periodontal treatment is not reducing this biomarker we highly recommend more definitive periodontal treatment to eliminate chronic infection and inflammation.  

To learn more about the PLAC2 test click here http://www.ocaheart.com/patient_services/patient_education/testsandprocedures/PLAC.asp

Vitamin D deficiency is a common problem world wide and is gaining much attention with researchers.  Vitamin D deficiency may be a major risk factor for many chronic diseases, such as:  periodontal disease, bone loss in the jaw and tooth loss, many types of cancer, numerous cardiovascular diseases, several auto-immune conditions, metabolic syndrome (weight gain and high BMI, prediabetes and type II diabetes, hypertension, low HDL cholesterol and high LDL cholesterol levels, high triglycerides), low mineral bone density (osteopenia), and osteoporosis.

What is significant about this is that periodontal disease in and of itself has been associated with many of the chronic diseases mentioned above.    We encourage anyone with any degree of periodontal disease to have the necessary blood tests performed to determine vitamin D levels.

Published papers and more information about vitamin D deficiency:

J Tenn Dent Assoc. 2011 Spring;91(2):30-3; quiz 34-5.
Vitamin D and its impact on oral health–an update.

The young female patient below came to PerioPeak with advanced stage periodontal disease, with generalized 5-13mm pockets.  This patient was very interested in a non invasive approach to treating her periodontal disease.  She had undergone traditional root planing (deep cleanings) with no results and still continued to have deep periodontal pockets with chronic infection and continued periodontal break down. 

She opted for Regenerative Periodontal Endoscopy, RPE over periodontal surgery and extractions of her teeth.

See her before and after photos

             Before RPE – 10mm pocket                                            10 months after RPE – 2mm

                Before RPE – 11mm pocket                                 10 months after RPE – 1mm

            Before RPE - 13mm pocket                                           10 months after RPE – 2mm

Before RPE 7-8mm  with bleeding                                      After RPE 2mm – health restored

    Before RPE  – 8mm pocket                                             After RPE 3mm – health restored

    Before RPE – 8mm pocket                                 10 months after RPE – 3mm health restored

Before RPE   9-10mm pockets                                      After RPE – 2mm tight healthy gums

Before RPE 8-9mm pockets                                                     After RPE 2-3mm

Before RPE – 7mm furcation                                      After RPE – 2mm – health restored

Before 7mm                                                               After – 3mm

View the before and after x-rays and more information about this case here.

View more cases here - Real people, real results.

Watch an actual RPE procedure on our You Tube Video

While traditional periodontal surgery (osseous or flap gum surgery) is still “standard of care” for the treatment of deep gum pockets, the literature simply does not support it.  Why is it still standard of care?  Great question.  These methods have been ”steeped in tradition, unhampered by progress” - for many decades. We encourage all periodontal sufferers to carefully review the research before undergoing any type of periodontal surgery. What will the results consistently demonstrate?  How will the gums and the teeth look after surgery?  Will there be long term sensitivity?  Will the results be long term? It is our stance that ”informed consent” about the results of traditional periodontal surgery be brought to the forefront of public understanding.  We strongly encourage anyone facing periodontal surgery to review surgical case results, as well as the published research.  Knowledge is empowering. 

 Clin Periodontol. 1987 Sep ;14 (8):445-52 3308969

4 Modalities Of Periodontal Treatment Compared Over 5 Years.
S P Ramfjord , R G Caffesse , E C Morrison , R W Hill , G J Kerry , E A Appleberry , R R Nissle , D L Stults
The purpose of the present study was to assess in a clinical trial over 5 years the results following 4 different modalities of periodontal therapy (pocket elimination or reduction surgery, modified Widman flap surgery, subgingival curettage, and scaling and root planing). 90 patients were treated. The treatment methods were applied on a random basis to each of the 4 quadrants of the dentition. The patients were given professional tooth cleaning and oral hygiene instructions every 3 months. Pocket depth and attachment levels were scored once a year. 72 patients completed the 5 years of observation. Both patient means for pocket depth and attachment level as well as % distribution of sites with loss of attachment greater than or equal to 2 mm and greater than or equal to 3 mm were compared. For 1-3 mm probing depth, scaling and root planing, as well as subgingival curettage led to significantly less attachment loss than pocket elimination and modified Widman flap surgery.

 For 4-6 mm pockets, scaling and root planing and curettage had better attachment results than pocket elimination surgery. For the 7-12 mm pockets, there was no statistically significant difference among the results following the various procedures. 

Dr. Caffesse emphasized, and was quite surprised, that his group had shown that there is no benefit to resective pocket reduction whatsoever.

Actual AFTER photo of osseous periodontal surgery

The study below actually demonstrates that patients are far worse off  AFTER periodontal surgery:

J. Clin. Perio. Volume 4 Issue 4 Page 240-249, December 1977

Periodontal Surgery In Plaque-Infected Dentitions
A clinical trial was performed to study the result of periodontal treatment following different modes of periodontal surgery in patients not recalled for maintenance care. The material consisted of 25 patients distributed into 5 groups. Following an initial examination, all patients underwent presurgical treatment including case presentation and instruction in oral hygiene measures. This instruction was given once. The various patient groups were then subjected to one of the following surgical procedures: 1) the apically repositioned flap operation including elimination of bony defects 2) the apically repositioned flap operation including curettage of bony defects but without removal of bone 3) the “Widman flap” technique including elimination of bony defects 4) the “Widman flap” technique including curettage of bony defects but without removal of bone 5) gingivectomy including curettage of bony defects but without removal of bone. Six, 12 and 24 months after completion of the treatment, the patients were recalled for assessment of their oral hygiene standard and periodontal conditions.

The results showed that case presentation and oral hygiene instruction given once, only temporarily improved the patient’s oral hygiene habits. Renewed accumulation of plaque in the operated areas resulted in recurrence of periodontal disease including a significant further loss of attachment. All five different techniques for surgical pocket elimination were equally ineffective in preventing recurrence of destructive periodontitis.

Summary:

The rate of destruction for “no surgical intervention” vs “perio surgery”: Nyman & Linde & Rosling of Switzerland, in Journal of Clin Perio, 4:240,1977.

The rate of bone destruction was .1-.3 mm/yr. with no periodontal surgery performed vs. 1-2mm/yr. rate of bone destruction after periodontal surgery. 

Informed consent is an important issue when discussing all the options for periodontal treatment.  We encourage all periodontal sufferers to thoroughly educate themselves about expected clinical outcomes of all available periodontal surgery treatment options. 

In many cases surgical intervention and extractions of teeth should be a last resort.  It is our assertion that definitive non surgical attempts should be considered as a first phase treatment approach to reduce the need for surgical intervention and tooth extractions.   Learn more

1) Periodontal Abscess picture and x-ray

The above picture clearly shows a “pimple” on the gum.  Upon probing (measuring the depth of the infection) we find a 10mm pocket.  The x-ray clearly demonstrates the bone loss associated with a periodontal abscess.  This tooth was very loose upon examination, with severe inflammation and heavy bleeding noted.  Symptoms included tender and painful gums, odor, pus coming out from all areas around the tooth, and shifting or extruding of the tooth. 

This patient was advised to have this front tooth extracted by her dentist and periodontist, and it was recommended to have an implant placed.  A very expensive option. She decided to research less invasive alternatives and found the PerioPeak Innovations clinic, and RPE – Regenerative Periodontal Endoscopy.  She was treated in 2004 and remains stable.  See her results below:

 4 weeks  after RPE - no abscess, health restored.        The  x-ray reveals bone fill after 6 months

gum abscess – swollen, red, loose tooth – 7mm        2 weeks after RPE – 1mm health restored

Traditional Treatment for a Periodontal Abscess is often extraction of the tooth, root canal therapy, or periodontal surgery, depending on the severity of the infection and bone loss.  Sometimes a traditional deep cleaning is combined with antibiotics to try to stop the infection.  This treatment approach is typically non effective.

We offer an advanced solution for abscessed teeth, which is outlined throughout this web site.  Abscessed teeth are non invasively treated in our clinic with an innovative endoscopic technique called RPE – Regenerative Periodontal Endoscopy.  This treatment is unique to PerioPeak Innovations – we utilize regenerative proteins, periodontal endoscopy, and enzyme inhibitors to achieve remarkable and affordable clinical results.

2)  Periodontal/Endodontic Abscess Picture and X-ray

Before RPE – loose, abscessed tooth          After RPE – health restored

This Endodontic/periodontal abscesss was considered hopeless with traditional methods and philosophy.  With RPE a root canal therapy is completed first to eliminate the infection in the nerve.

Before RPE – deep periodontal pockets observed around entire tooth, measuring 10mm -  RPE was completed the same day as root canal procedure, optimizing both therapies and creating a rapid healing response, preventing the need for extraction.

RESULTS: 6 months after RPE and root canal therapy- nice bone fill and very tight, healthy gum tissue.  This patient was able to avoid extraction of this tooth and an implant - a very expensive treatment option requiring multiple appointments.  RPE is one simple appointment – with no down time and no pain following treatment.

Home Remedies and associated serious health risks:  we do not condone the use of home remedies of any kind for any type of periodontal or endodontic abscess.   The virulent, pathogenic bacteria involved in periodontal (gum) abscesses can enter the blood stream and lungs, promoting infection and inflammation throughout the body.  Periodontal disease has been linked to stroke, heart attack, diabetes complications, and lung infections.  Recent research also reveals a connection between periodontal disease, cancer, alzheimer’s, and rheumatoid arthritis.

For this reason we recommend that tooth and gum abscesses be treated as a serious medical condition requiring immediate professional attention. 

See more pictures of abscessed teeth treated successfully with RPE.

This post will define the available professional “alternative gum disease treatment options” for deep gum pockets.  

When traditional therapies such as root planing (deep cleaning) with antibiotics, or basic laser periodontal therapy are exhausted, the next indicated step for a more definitive treatment to stop infection in unresponsive deep pockets may be traditional periodontal surgery.  However, many individuals decide to seek alternatives to traditional periodontal surgery for the following reasons in our experience:  to avoid pain and long term tooth sensitivity, to prevent the creation of gaps or black triangles between the teeth, to avoid recession of the gums following surgery, to avoid extractions of teeth deemed hopeless,  and to avoid the potentially huge costs associated with periodontal surgery and tooth replacement. 

The following periodontal treatment options are at this time considered to be alternatives to traditional periodontal surgery.

Regenerative Periodontal Endoscopy – Non invasive procedure to promote closure of deep gum pockets and repair bony defects.

This non-invasive procedure employs the use of a periodontal endoscope.  RPE differs from a standard perioscopy procedure in many ways.  The inclusion of enzyme inhibitors, a soft tissue laser, and regenerative proteins may promote reattachment of pockets and promote bone fill.  In addition, RPE is performed with very precise and efficient tools (piezo titanium and diamond tips), which allows skilled clinicians to complete the procedure more efficiently and also prevents root damage and tissue trauma from occurring.   An occlusal adjustment is often performed to aid in overall healing. Teeth deemed hopeless can be treated with RPE as an alternative to extractions due to the non-invasive nature of the procedure.

Before RPE  - deep gum pockets                                                      After RPE

See real case studies (actual patients of PerioPeak Innovations)

Perioscopy – visual removal of tartar in deep pockets only

This non-invasive procedure employs the use of a dental endoscope to “see” microscopically (up to 48X) into deep periodontal pockets. This allows the clinician to better remove the tartar and plaque from the roots which have already been root planed blindly without success.   It is simply “visually enhanced root planing” (removing tartar from pockets).  Local anesthetic is used.   The tools used to actually remove the root deposits (tartar) vary widely from clinician to clinician, as well as the actual proficiency and skill.   Results and long term results will vary due to skill level, experience, and method.  This procedure may include adjunctive therapies such as antibiotics, either placed beneath the gums or given systemically.  While there is some impressive published research to support perioscopy, it has still not been embraced by the main stream dental profession as a viable treatment option for periodontal disease.  In some offices perioscopy is only employed when all other methods have been exhausted, rather than utilizing it as a first phase of treatment. 

Perioscope in hand (miniature fiber optic)   -   48X magnification on a 10,000 pixel color monitor allows for real time pinpoint tartar removal in deep gum pockets.

PerioProtect – a non-definitive approach

PerioProtect is a relatively new treatment non-definitive option for patients with unresolved periodontal infections and periodontal pockets.  This professional treatment involves having a custom mouth tray fabricated by the dentist  for the patient to use at home.  These trays are then filled with antibiotics, or antimicrobials such as hydrogen peroxide (depending on the need), and are worn several times a day, up to several hours a day.  PerioProtect is  intended to be an adjunctive therapy with traditional root planing and periodontal maintenance cleanings.  No surgery is performed to correct pockets and no dental endoscope is employed to aid in the removal of tartar from deep gum pockets, therefore periodontal infections and gum pockets may continue to be a chronic problem. PerioProtect trays are supposed to kill bacteria in deep pockets, but the depth that the medicament will reach remains questionable.  The company has gone to great lengths to market their product but to date have only demonstrated their medicament reaching one pocket of 6mm.  Tartar trapped under the gum in deep pockets is not removed by this product, therefore results may be temporary.   The research is unremarkable at this time.

It is important to consider all options very carefully and to find what actually works well long term (results as demonstrated by real case studies and published research).  In addition, it is also important to consider how a particular treatment fits into overall goals, expected outcomes, lifestyle, convenience, comfort, and budget.    Knowledge is empowering, we encourage all periodontal sufferers researching periodontal treatment options to consider all this information carefully.

Regenerative Periodontal Endoscopy- RPE

This advanced endoscopic procedure eliminates cutting the gums open. Instead, reattachment of the pockets are promoted with microscopic removal of calculus and the addition of regenerative protiens and systemic enzyme inhibitors.  RPE may eliminate the need for aggressive periodontal surgery and/or extractions, but we encourage all patients to consider close monitoring by a periodontist throughout their life if they have a history of chronic periodontal problems.  RPE is completed in one appointment and local anesthetic is used for comfort. 

Gum gaps are minimized, or not created, following RPE as with traditional periodontal surgery. 

6 weeks following RPE – a nice esthetic result, health restored.

contact us for more information about RPE

Root Planing (deep scaling):

Root planing is still the “standard of care’ for the initial phase in treating all stages of periodontal disease, yet it is a non definitive, blind treatment approach.  The literature does not support this traditional approach in the advanced stages of periodontal disease –  it is usually followed by periodontal surgery due to the visual and clinical limitations. Root planing, or deep cleaning, is generally performed with local anesthetic (Novocaine), and is usually completed by sections, or quadrants.  The clinician performing this treatment employs the use of either standard aggressive scaling tools (curettes), or an ultrasonic scaling device, or both.  The goal of this procedure is to remove as much tartar and plaque from the roots below the gum line as possible by tactile means (blindly).  The deeper the pockets, the more challenging.   Sometimes roots can be damaged by “over-planing”, or over-scaling.   In addition, many studies over decades show that gum pockets with a depth over 4mm may have up to 30-50% of the calculus (tartar) left behind following traditional root planing.  

Before root planing (deep cleaning)             After root planing (up to 50% of tartar left on root)

Below is a list of adjunctive therapy options used with root planing in an attempt to obtain a better result:

1) Soft Tissue Lasers – many clinicians may employ the use one of two types of lasers to eliminate plaque bacteria in and around the roots while performing root planing.  The problem with this technique is that it is performed by feel (tactile means), therefore infectious tartar remains trapped in deep gum pockets.  Multiple treatments are usually recommended, adding to the overall cost and inconvenience.  In addition, the literature has demonstrated little to no benefit for this technique.  The cost vs. value may not be justified.

2) Local Delivery Antimicrobials – there is a variety of different adjunctive products called LDA’s (local delivery antimicrobials) which a clinician can employ in an attempt to enhance the result of root planing.  The idea is to root plane as well as possible (no objective end point), then place an LDA into the pocket.  The available LDA’s are Arestin, Atridox, Perio Chip, and Actisite.  The idea of all of these products is to kill bacteria in the deeper periodontal pockets.  However, the research on all of these adjunctive therapies remains unimpressive.  Results are typically temporary and cost vs. value may not be justified.

3)  Periowave - not yet available in the U.S. (still in the FDA approval stage), Periowave utilizes a non-thermal laser light combined with a photosensitizing solution designed to kill bacteria associated with gum disease when used adjunctively with root planing.  As with any of these adjunctive therapies, this technique is non-definitive and the literature is not impressive.  No endoscope is employed;  therefore tartar may remain in deep pockets.

Periodontal Surgery (Osseous, Flap, and Regenerative):

Following root planing, and the various adjunctive therapies listed above, periodontal surgery may be recommended in an attempt to eliminate periodontal pockets.   Periodontal surgery is performed in sections, or quadrants, under local anesthetic and often with the addition of oral sedation or nitrous oxide.  There are three types of periodontal surgery aimed at eliminating periodontal pockets and arresting periodontal disease.

pictures of periodontal surgeries described below – note the tartar on the roots following traditional root planing

Osseous periodontal surgery – gums are pealed back using a scalpel and other surgical instruments, tartar is then removed from the roots with an ultrasonic and a drill.  The bone around the teeth is then contoured with a drill as uneven bone is removed, hence the term osseous surgery.  The extra gum tissue is cut away (gums are removed as pockets are cut out).   This is also called “pocket reduction” surgery.  The gums are then sutured around the teeth in a lower position on the roots, creating recession and black triangles (gaps between the teeth).   This procedure is very aggressive, and while it works well to “eliminate periodontal pockets”, it leaves much to be desired in aesthetics, patient comfort, post operative root sensitivity, cost, inconvenience with multiple appointments, and long term results.  Research even demonstrates that in some cases patients will lose bone more rapidly following this surgery than if they had not had surgery.  Since large gaps called “black triangles” are often the result of this surgery, (as well as gum recession and long term root sensitivity), one should take caution if exploring this option.

Above: Gaps, recession, and long tooth appearance as a result of osseous periodontal surgery.

Note: the same result can be seen with “pocket reduction surgery” or flap periodontal surgery.

Flap periodontal surgery - flap surgery follows root planing to allow for more complete removal of tartar from the roots, especially in deeper pockets and tricky root morphology (furcations).  This procedure is explicitly for the purpose of removing tartar left behind following traditional root planing and is not intended for recontouring the bone or promoting regeneration of any kind.  The gums may or may not be “cut away” before sutering, in an attempt to reduce periodontal pockets to a level which can more easily be maintained (cleansed) by the patient.  It is important to note that any type of gum surgery creates scar tissue, as well as recession of the gums.   The literature does not support this technique over traditional root planing for long term results and efficacy, and according to one study can actually make the condition worse, accelerating bone loss.  One should take caution if exploring this option for treatment of any of the anterior teeth (front teeth) due to the possible negative impact on appearance (aesthetics).

Minimally Invasive Regenerative Periodontal Surgery: by far the most impressive type of surgery for the treatment of periodontal disease.  This surgery is very similar to osseous surgery, with the added benefit of placing regenerative materials.  The regeneration material used varies based on the type of periodontal defects present, and the clinicians knowledge and experience using a particular regeneration material.  The main regeneration proteins used are Emdogain and Gem 21.  We highly recommend Dr. Tom Wilson in Dallas, Tx for this procedure if non surgical methods have already been exhausted.

One of the main risk factors for the development of periodontal disease is diabetes.   We now know that individuals with type II diabetes are three times more likely to develop periodontal disease.   Conversely, results from the National Health and Nutrition Examination Survey (NHANES) and its follow-up studies suggest that non-diabetic adults with periodontal disease develop type 2 diabetes more often than those without periodontal disease.

In 2003 the American Diabetes Association stated that periodontal disease is often found in people with diabetes.  However, there are millions of individuals who are unaware that they may be “prediabetic” (they have elevated blood sugar levels), and that this may be a contributing factor in their periodontal disease.   While diabetes and pre-diabetes occur in people of all ages and races, some groups have a higher risk for developing the disease than others.   Diabetes is more common in African Americans, Latinos, Native Americans, and Asian Americans/Pacific Islanders, as well as the aged population.  This means they are also at increased risk for developing pre-diabetes.

What we now understand about diabetes and periodontal disease, is that an elevation in inflammatory mediators in the gums is the cause for the close association between diabetes and increased incidence of periodontal diseases .  Bacteria thrive in the individual with elevated blood glucose, stimulating proinflammatory mediators, which leads to an overproduction of a destructive enzyme called collagenase.  It is well established that elevated levels of collagenase lead to the destruction of the periodontal ligament and bone supporting the teeth.

What you can do:

1) Get Tested

“There are two different tests your doctor can use to determine whether you have pre-diabetes:  the fasting plasma glucose test (FPG) or the oral glucose tolerance test (OGTT).  The blood glucose levels measured after these tests determine whether you have a normal metabolism, or whether you have pre-diabetes or diabetes.  If your blood glucose level is abnormal following the FPG, you have impaired fasting glucose (IFG); if your blood glucose level is abnormal following the OGTT, you have impaired glucose tolerance (IGT).”

Go to www.diabetes.org for more information

2) Learn More

A great comprehensive paper by water pik on diabetes

The two way connection

“Research has emerged that suggests that the relationship between periodontal disease and diabetes goes both ways – periodontal disease may make it more difficult for people who have diabetes to control their blood sugar.  Severe periodontal disease can increase blood sugar, contributing to increased periods of time when the body functions with a high blood sugar. This puts diabetics at increased risk for diabetic complications. Thus, diabetics who have periodontal disease should be treated to eliminate the periodontal infection.”  (American Academy of Periodontology)

Go to www.perio.org for more information abou the “mouth-body” connection, there are numerous articles on this topic.

3) Get definitive periodontal treatment

4)  Look into adjunctive medication which can help. How to help control chronic inflammation and destructive levels of collagenase enzymes created by elevated glucose levels and lack of good glycemic control.

Also Important to consider:

Prevention and proactive treatment of periodontal disease is fundamentally important in patients with diabetes because of the potential negative impact of untreated periodontitis on glycemic control and diabetic complications.  But as we have observed, one disease ‘feeds’ the other.  Addressing this two way connection is crucial to achieving periodontal health.  Host factors contributing to both periodontal disease and glycemic control must be defintively addressed if we are to expect success and remission of both diseases.

At PerioPeak Innovations we pinpoint and address all risk factors which may be contributing to your periodontal disease.  We pride ourselves in finding the cause - rather than just treating the effect.  Our mission is to provide comprehensive periodontal care,  empowering all of our clients for long term periodontal and overall health.

Find out how our advanced non-surgical approach for chronic periodontal disease can help to maintain optimal health.

Further important considerations with diabetes, periodontal disease, and cardiovascular disease:

Below is an exerpt from J. Periodontal 7/09 – The American Journal of Cardiology and Journal of Periodontology Editor’s Concensus:  Periodontitis and Artherosclerotic Cardiovascular Disease.

Metabolic Syndrome -

Metabolic syndrome is diagnosed when 3 of the following features are present: (1) increased waist circumference(men ‡40 in [‡102 cm], women ‡35 in [‡88 cm]), (2) increased serum triglyceride level (150 mg/dl [1.7 mmol/L]) and/or drug treatment for elevated triglycerides (most commonly fibrates and nicotinic acid), (3) decreased serum HDL cholesterol level (men <40 mg/dl [1.03mmol/L], women <50 mg/dl [1.3 mmol/L]) and/or drug treatment for decreased serum HDL cholesterol, (4) elevated blood pressure (‡130mmHg systolic and/or ‡85mmHg diastolic) or antihypertensive drug treatment of patients with histories of hypertension, and (5) elevated fasting glucose (blood glucose ‡100 mg/dl) and/or drug treatment for hyperglycemia.

Recommendation:

Patients with periodontitis meeting criteria for metabolic syndrome should be identified, and all risk factors for atherosclerotic CVD should be treated, beginning with lifestyle changes aimed at weight reduction. Metabolic syndrome is closely linked to insulin resistance and is a secondary target of lipid therapy because the risk factors for metabolic syndromeare highly concordant and, in aggregate, enhance the risk for atherosclerotic CVD at any serum level of LDL cholesterol.

Many patients with periodontitis meet criteria for the metabolic syndrome.  Because measures of systemic inflammation are a common feature of periodontitis and metabolic syndrome, it may be particularly important to identify patients who meet these criteria for CVD prevention strategies.  We highly recommend The Bale Doneen approach to early diagnosis, intervention, and prevention. 

Find a provider near you www.baledoneenmethod.com

Gum disease, also known as periodontal disease, is a chronic inflammatory and infectious disease. Often there may not be signs or symptoms until the disease is well into the advanced stages unless you are routinely examined by a dentist.  Below is a list of all possible, more acute symptoms of moderate to advanced periodontal or gum disease.

1)  Halitosis (bad breath)

2)  Loose teeth, bite changes

3)  bleeding gums

4)  painful gums

5)  puffy, red gums

6)  pain when chewing

7)  pussy discharge from the gums

8)  gums pulling away from teeth (gum recession) and noticeably longer teeth.

9)  bad taste

10) noticeable gaps between teeth (“black triangle” appearance)

This picture is a good example of a patient in the advanced stages of periodontal disease.  Note the gum recession and “black triangles” between the teeth, as well as the puffy, bleeding gums. 

Find out how periodontal (gum) disease can be effectively treated with Regenerative Periodontal Endoscopy, or RPE.  

Some less obvious symptoms and signs of periodontal disease in the moderate to advanced stages may be chronic fatigue, swelling of the lymph nodes, or the inability to control blood sugar levels in individuals with diabetes.   Since periodontal disease is a chronic inflammatory disease, it takes a tremendous amount of energy for the body to “control it”.  The immune system is constantly being taxed in an effort to rid the body of infection.   The bacteria involved in periodontal diseases are pathogenic, meaning they are harmful to the body, causing infection.

While periodontal disease is characterized by a chronic infection leading to chronic inflammation in some, it is the actual inflammatory process (an upregulated or exaggerated inflammatory response) which leads to more advanced bone and tissue loss around the teeth.  The body is so efficient at ridding itself of this infection  -for survival purposes – that the infection/inflammation process will often continue if no professional treatment is pursued, until the affected tooth is extruded by the body (the tooth falls out).

New research is proving that the old model of “infection leading to chronic inflammation” may actually be the other way around in many individuals.  Chronic hyper-inflammatory response ( ”hyper-responder”) in many susceptible individuals may actually lead to a chronic infections.

These individuals are prone to inflammatory periodontal disease.  Traditional approaches will not generally stop the infection, especially long term.  Read more about genetic tendencies.

To determine if you have periodontal disease we highly recommend a professional examination, including full mouth x-rays and periodontal charting, by a gum specialist, or periodontist.  These professionals have many years of specialized training beyond dental school and are able to reach a more accurate diagnosis.   If you have been “maintaining” your chronic periodontal disease (infection) in a general dental practice with maintenance cleanings, and you have the moderate to advanced stages of gum disease, it is imperative to seek more specialized professional help.

Lack of proper diagnosis and definitive intervention of periodontal disease can lead to serious, even life threatening, and very expensive health problems as we now know.  But the millions of dollars spent “replacing teeth lost to periodontitis” is often overlooked.

Below is a picture of extractions from a single day in a periodontal specialty practice:

All of the individuals who lost these teeth had routine dental cleanings and maintenance in a general dental practice.  The cause of tooth loss is multi factorial, but nearly all of this is preventable with more advanced technology and intervention.

This blog is filled with detailed information as to what causes tooth loss and the limitations of main stream approaches to arresting or curing periodontal diseases.  We encourage you to explore all of this objective information.

See pictures and read about the limitations of traditional root planing

Read about genetics and periodontal disease

Regenerative Periodontal Endoscopy - RPE, helps to repair the periodontal foundation and sets the stage for improved periodontal health by eliminating microscopic calculus (tartar) and bacteria deep below the gumline, removing infected tissue, and stimulating attachment repair with natural proteins.  How to maintain this level of health long term is the subject of this post.  We strive to empower periodontal sufferers through education.  There are several aspects to be considered, including excellent home care, regular professional cleanings, addressing bite problems, smoking cessation, considering anti-inflammatory medications when necessary, having good blood sugar control (nutrition), reducing stress, and promoting overall general health and wellness.

Home Care:

Excellent self care (home care) is of course very important if optimal periodontal health is to be maintained.  It has been our experience that once the chronic inflammation and destruction are addressed with RPE, maintaining excellent periodontal health becomes much easier.   We highly recommend the water pik and an Oral-B sonic toothbrush for general self cleansing.  We have found this combination of home care tools to be most beneficial for daily removal of biofilm more effectively.

Recently, an innovative product which claims to dissolve calculus (tarter) below the gumline has captured our attention.   This product, called Periogen by Global Tonic, is an easy to use powder dissolved in water.  Periogen is used with a water pik and/or an irrigator for deeper pockets.  While this may be a tremendous breakthrough, these claims have not been substantiated yet with studies.  However, it has been our experience that regular use of this product ”seems to” change the nature of the calculus, making it easier to remove during maintenance cleanings.   Again, this has not been proven with research and is merely anecdotal information. While Periogen may have benefit in loosening or dissolving some calculus between cleanings it may also be helpful in keeping areas clean and healthy which may be more challanging for any type of periodontal treatment to help repair, ie, advanced furcations (advanced bone loss between roots), which may be considered to have a poor prognosis long term.

It is important to note that using any irrigation product, or home care aid, will not definitively address the very serious nature of the periodontal disease process alone.  Periodontal disease is a multifactoral medical condition and requires a very comprehensive, multifaceted, and definitive professional treatment approach. 

For more information for any of these products check out these links:

www.oralb.com

www.waterpik.com

www.periogen.com

www.globaltonic.com

Host response modulation: 

For many individuals good home care along will not be enough to maintain optimal periodontal health.   Genetic tendancies will often dictate the progression of periodontal disease.  We now know that 1/3 of the population have a genetic tendancy to develop advanced periodontal disease through no fault of their own.  This can be described as an allergy, or “hyper-inflammatory” response to plaque bacteria.  In the literature these individuals are referred to as “hyper-responders”, with an immune system that actually up-regulates itself even in the presence of very little plaque bacteria.  A lot of research is being conducted in this area of periodontal pathogenesis and how to address it.  Periodontal specialists are now discovering the need for more proactive and aggressive treatment of these individuals including the use of “host modulated therapy”.  The most successful form of host modulated therapy is the addition of a medication called PerioStat, also known as SDD (sub-antimicrobial dose doxycycline 20mg), for the purpose of addressing the hyper-inflammatory mechanisms internally.   Few individuals may not be able to tolerate this medication either due to allergy or side effects, this is rare.  Others may not be able to get the prescription necessary to obtain this effective medication.  Unfortunately, few dental professionals are educated in it’s therapeutic use.

Recently at PerioPeak, a natural approach fora type of host modulated therapy has been discovered.  We feel this is a very exciting breakthrough to help chronic and destructive gum inflammation.  To learn more about this natural alternative go to www.periogain.com

Learn more about genetic periodontal disease and host modulated therapy

Nutrition and Supplementation:

One important host factor for healthy gums, which can be controlled by the individual, is diet and nutrition.  We have uncovered numerous research papers supporting this statement.  A diet high in antioxidants and natural anti-inflammatories, and low in refined carbohydrates, is a good start. 

We also highly recommend supplementation with these key vitamins for improved periodontal and overall health:  Vitamins B12,C, D, E, Magnesium, Calcium, Co-enzyme Q10, and Omega three fatty acids.  We recommend a comprehensive physical examination once a year with a physician or naturopath to determine nutritional needs, and to identify any health concerns which could be contributing to periodontal disease.