Tobias K. Boehm (June 14, 2024)
A comeback of gum disease as seen on a representative part of a patient’s periodontal chart (Dr. Boehm, 2024)
Here is a problem that I saw at my work that likely happens all too common – gum disease that is coming back after treatment.
In this case, the comeback of gum disease was recognized at a patient’s dentist in a community clinic, and they sent the patient back to me for further treatment. When I saw this patient last at the end of surgical therapy, there were few signs of gum disease with low probing depth numbers (PD) and relatively few spots of gum bleeding (‘B’ in the row ‘Bleed/S’). While I will cover what these numbers mean in a different post, the important aspect of this case is that when this patient came back for further treatment, there were signs of gum disease everywhere. Probing depths were much increased (red numbers in ‘PD’) and bleeding from the gums seen virtually everywhere. In this case, the patient was bewildered why new treatment was needed even though she had cleanings done every 3 months.
This is not a case of an intractable gum disease that persists despite treatment (‘refractory periodontitis’) because treatment did control it at some point as shown above. This is also not a case of gum disease that keeps coming back because of some underlying medical condition or environmental factor that predisposes this individual to continuing gum disease.
How commonly gum disease recurs after a patient leaves a specialty practice is not well known as there is little research on this topic. It is known that continued supportive care in a private periodontal practice can result in very low tooth loss rates over time (0.07 teeth/patient/year) (1). Individuals who have no dental care or minimal dental care have much higher tooth loss rates (0.30 teeth/patient/year) (2), and individuals who receive dental care will likely fall within this wide range of tooth loss rates. If this is closer to expert-level care or no dental care likely depends on the skill and capabilities of the dental practice.
Why in this case the gum disease came back is simplest explained by that the level of care was just was not sufficient to keep the gum disease in check. The teeth were clean, but root surfaces felt grainy at the last exam suggesting root surface contamination. I checked with these individual common reasons that render preventive care ineffective. The timing was correct, as cleanings were done about every 3 months (3). The hygienist’s technique seemed appropriate as this individual reported that the hygienists used a variety of instruments to clean teeth. When I asked, this individual reported that the cleaning lasted 45 minutes. This is more than the 15-30 minutes that a practice consultant recommends for routine dental cleaning visits (4) and typical in general practice from my observations. Yet, it likely was still not enough time to thoroughly clean this individual’s root surfaces entirely as patients such as this individual typically need a longer, more detailed treatment visit that is called “periodontal maintenance” (3).
For typical gum disease, the reason supportive dental care works is that gum diseases are caused by growth of a variety of bacteria, viruses and other microorganisms on root surfaces that favor inflammation and destruction of gum tissue. It takes time for enough of these microorganisms to accumulate and become organized for this to happen, and regular thorough removal of these microorganisms prevents development of gum disease (5, 6).
Therefore, the typical treatment in this case and in most cases where gum disease came back after treatment is to revisit supportive care and checking to make sure it is effective. From a patient perspective, effective care should include at least the following:
- Effective oral hygiene: A dental professional should evaluate effectiveness of tooth brushing and suggest areas of improvement. Flossing may not be effective in individuals affected by severe gum disease (‘periodontitis’) that results in exposed concave root surfaces. Instead, oral hygiene aids such as interproximal brushes may need to be used, or additional devices such as end-tufted brushes or water flossers
- Effective tooth cleanings (‘periodontal maintenance’): numbing agents (‘local anesthetics’) may need to be used for areas with deeper pockets. Sufficient time needs to be allotted to the tooth cleaning, which may take 60-90 minutes of time spent cleaning. Typically, the cleaning requires a variety of instruments for different areas of the teeth. Most commonly, a machine-driven (‘ultrasonic’, sometimes called ‘Cavitron’ based on a common brand) approach using a single tip is not sufficient for this type of cleaning. Generally, the tooth cleaning should result in very clean feeling teeth with the initial scraping sounds during instrumentation diminishing towards the end of the cleaning. This is generally referred as ‘glassy’ or ‘silky’ root surfaces.
- Thorough examination of the gums and review of treatment options
From a patient perspective, there are several ways to avoid a comeback of gum disease after successful treatment:
- Follow oral hygiene recommendations and adhere to a daily routine
- Invest time and money in quality supportive care every 3 months by a trusted, competent dental provider
- If you have not had a physical exam by a medical professional since gum disease treatment, do get a check-up. Certain medical conditions such as Diabetes Mellitus can make gum disease worse, and increase the risk of new disease.
- If you use tobacco products, quit them. Tobacco use in general leads to worse gum disease and causes gum disease treatment more likely to fail.
- Strive for a healthy lifestyle with good nutrition, exercise and enough rest to support good overall health.
About the author:
Tobias K. Boehm, DDS, PhD, MBA, PC, DABP, DICOI, FGDIA is the founder of The Dental Institute, executive director at The Defeating Epilepsy Foundation and a professor at Western University of Health Sciences where he teaches and practices a periodontal specialist.
References
(1) Hasan F, Magan-Fernandez A, Akcalı A, Sun C, Donos N, Nibali L. Tooth loss during supportive periodontal care: A prospective study. J Clin Periodontol. 2024 May;51(5):583-595. doi: 10.1111/jcpe.13943. Epub 2024 Feb 26. PMID: 38409875. https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13943
(2) Al-Harthi S, Barbagallo G, Psaila A, d’Urso U, Nibali L. Tooth loss and radiographic bone loss in patients without regular supportive care: A retrospective study. J Periodontol. 2022 Mar;93(3):354-363. doi: 10.1002/JPER.21-0415. Epub 2021 Nov 1. PMID: 34564843. https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.21-0415
(3) American Academy of Periodontology (2003). Position Paper Periodontal Maintenance. Journal of Periodontology 74:1395-1401. https://aap.onlinelibrary.wiley.com/doi/pdf/10.1902/jop.2003.74.9.1395
(4) Seidel-Bittke, Debbie (n.d). Time Management for Dental Hygiene Appointment. https://dentalpracticesolutions.com/wp-content/uploads/2015/05/TIME-MANAGEMENT-FOR-Dental-Hygiene-Appt.pdf
(5) Feres M, Cortelli SC, Figueiredo LC, Haffajee AD, Socransky SS. Microbiological basis for periodontal therapy. J Appl Oral Sci. 2004 Dec;12(4):256-66. doi: 10.1590/s1678-77572004000400002. PMID: 20976394.https://www.scielo.br/j/jaos/a/fNJGs3Gr5mFn3QWW9PWQZtj/?lang=en
(6) Siddiqui R, Badran Z, Boghossian A, Alharbi AM, Alfahemi H, Khan NA. The increasing importance of the oral microbiome in periodontal health and disease. Future Sci OA. 2023 Jun 12;9(8):FSO856. doi: 10.2144/fsoa-2023-0062. PMID: 37621848; PMCID: PMC10445586. https://www.tandfonline.com/doi/full/10.2144/fsoa-2023-0062