Those pearly whites you flash when you smile may seem firmly anchored in your mouth, but that’s not necessarily so. All it takes is a case of gum disease to slowly weaken and loosen your teeth and other supporting structures. A 2012 study by the US Centers for Disease Control and Prevention (CDC) published in the Journal of Dental Research showed that of the nearly 3,800 adults ages 30 and older whose data were evaluated, almost half had gum disease. In those over 65 years old, the incidence skyrocketed to more than 70%.
The CDC findings come as no surprise to Rebecca Schaffer, DDS, owner and primary dentist at Sundance Dental Care in Phoenix, Arizona. “Gum disease is a huge problem,” she says. Lack of dental insurance and fear of the dentist prevent many people from getting regular dental checkups. “But the mouth is very much a part of the body,” she says. “You can’t be healthy without a healthy mouth.”
Brushing your teeth after breakfast and at bedtime aren’t enough to keep gum disease at bay. There may be a few new steps you need to add to keep your teeth and gums healthy. And that advice goes for people with bleeding disorders, too. (See “Home Sweet Dental Home,” http://www.hemaware.org/story/home-sweet-dental-home.)
Gum disease and bacteria
The finger of blame for gum disease points at one primary perpetrator: bacteria. When you consume starchy or sugary foods or beverages, from candy and soda to potato chips and bread, bacteria in your mouth feed on the sugar in the carbohydrates. They produce plaque, a sticky film that coats teeth. If you don’t brush your teeth, the plaque absorbs calcium and phosphorus from your saliva. Soon a cementlike substance called tartar, or calculus, hardens under the gum line. Tartar makes plaque tough to remove.
At first, there may be no pain as your gums, or gingiva, become red, swollen and bleed readily—all signs of gingivitis. But left untreated, gingivitis can lead to periodontitis, literally inflammation of the area surrounding the teeth, including the gums, supporting tissue and bone.
The bacteria in your mouth produce endotoxins that irritate the gums, stimulating chronic inflammation around the base of teeth. Soon the gums pull away from the teeth, forming pockets where more plaque and tartar accumulate. Deep infection in these pockets can destroy tissues, such as ligaments and tendons. It can also cause painful tooth abscesses and infection of the jaw bone. “This process of chronic infection and inflammation destroys the tissues that are meant to hold our teeth in place,” Schaffer says. It’s slow and often painless. “You don’t feel anything until the end, until it’s too late.”
Signs and symptoms
Symptoms of gum disease include red, swollen, tender gums and bleeding while eating food, brushing or flossing your teeth. Other signs are receding gums and chronic bad breath. A change in your bite or in the fit of partial dentures, and loose teeth also signal advancing gum disease.
Who’s at risk?
The CDC study found that men were more likely to experience gum disease than women. Mexican Americans had the highest rate of any ethnic group—66.7%. Smokers and families living below the federal poverty level were also at increased risk.
Women are prone to gum disease, too, according to the American Academy of Periodontology (AAP). Gum disease is more likely during life stages associated with fluctuating hormone levels, such as puberty, pregnancy and menopause.
Other factors that can make you susceptible to gum disease include genetics, diabetes, dry mouth, HIV and rheumatoid arthritis. Drugs that reduce the flow of saliva and others, such as heart medications, oral contraceptives and steroids, can promote gum disease.
Gum disease may not sound serious, but if untreated, it can be. The endotoxin-producing bacteria from your mouth can enter your bloodstream through your gums, where they can lodge in your lungs or heart. In arteries, the bacteria can trigger inflammation that narrows the blood vessel walls, which can lead to heart attacks. “Studies have shown an association between periodontal disease and heart disease, rheumatoid arthritis and pregnancy outcomes,” Schaffer says. “Chronic inflammation affects the entire body.”
The AAP says that men with gum disease are 49% more likely to develop kidney cancer, 54% more likely to develop pancreatic cancer and 30% more likely to develop blood cancers.
Simple prevention: brushing and flossing
If gingivitis is caught before it progresses, it is often reversible. That is, if you seek professional help early enough and maintain a consistent oral care regimen. That means using your toothbrush at least twice a day and maneuvering the dental floss around your teeth daily. Think of the bedtime regimen as safeguarding your mouth overnight. It takes 24 hours for the bacteria to reproduce and colonize, says Schaffer. “You don’t want to leave sugar and debris on your teeth while you’re sleeping,” she adds.
People with bleeding disorders do not get a pass on these dental hygiene habits. “Brushing and flossing have been shown in study after study in people with hemophilia, von Willebrand disease (VWD) and other bleeding disorders to make the gums stronger,” Schaffer says. Tougher gums bleed less or not at all, she says.
Your gum health should be logged onto a chart at least once a year. Using a probe, the dentist or hygienist checks the depth of your gums, noting any bleeding, recessions or presence of pockets. The probe measures how deep the pockets are in millimeters (mm). Healthy pockets are 1–3 mm. Those 4–6 mm indicate early to moderate gum disease. Any pocket deeper than 6 mm shows advanced gum disease, with possible bone loss.
This so-called “periodontal exam” may require a bleeding prevention plan, depending on your disorder and severity. “If somebody has severe hemophilia, even if he’s on prophylaxis, the dentist and hematologist need to discuss this together, especially if there’s a lot of inflammation,” Schaffer cautions. Swishing and/or rinsing with Amicar® (aminocaproic acid), an oral clotting agent, may be all that’s needed for some patients, she says. For patients with VWD, just a sniff of Stimate® (desmopressin acetate) nasal spray may suffice. “The treatment has to be individualized,” stresses Schaffer.
If you have gum disease, your dentist may refer you to a periodontist, a dentist with additional training in periodontics. A periodontist will perform a comprehensive exam to evaluate your teeth and bite, level of plaque buildup, health of your gums and underlying bone structure via X rays.
Nonsurgical treatment for gum disease involves scaling and planing. Scaling removes tartar and bacteria from your teeth and underneath your gums. Planing smooths root surfaces, preventing tartar buildup. Both can be done with lasers, ultrasonic tools or hand instruments. Surgical solutions may involve tissue and/or bone grafts, or dental implants. Because those entail cutting and suturing, people with bleeding disorders would need a plan in place to prevent bleeding.
In contrast, laser therapy employs a pulsed light beam that breaks up the infected tissue in the pockets around the gums and kills the disease-causing bacteria. The benefits of laser therapy are: it’s less invasive, there’s little to no bleeding, and there’s minimal pain and swelling. Further, often only a light anesthetic is needed. Patients are relieved to discover that post-operative pain and sensitivity are virtually nil, and healing begins right away. Many return to work the next day.
“Depending on the extent of the gum disease and the bleeding disorder, laser therapy is a great option when done properly,” Schaffer says. When the laser is aimed at the bottom of the pockets, it stimulates soft tissue, and the tooth’s root and bone to regenerate and attach. It also causes blood to coagulate, causing a healthy clot to form and promoting faster healing.
Schaffer has performed laser therapy on patients with bleeding disorders. “The outcome has been really good,” she says. But first, do your homework. “It has to be done with the right laser by someone who has had good training,” she says. Further, the periodontist or dentist should consult your hematologist before the procedure is done, she adds. And, as with all medical procedures, call your insurance company to find out about your coverage.
Take advantage of the resources at your HTC. “A lot of HTCs have dentists who are qualified,” Schaffer says. “Many are underutilized.” So ask a member of your HTC team for a referral. “Find a dentist who welcomes and is willing to treat someone with a bleeding disorder,” says Schaffer. She works with the Arizona Hemophilia Foundation, a chapter of the National Hemophilia Foundation.
So don’t delay, make your dental appointment today. Your teeth and gums are depending on you.