Periodontal disease

Highlights
Symptoms of Periodontal Disease
Symptoms of periodontal disease include red and swollen gums, persistent bad breath, and gum
recession and loose teeth. Smoking, certain types of illnesses (diabetes), older age, and other
factors increase the risk for periodontal disease. If you have periodontal disease, your dentist may
refer you to a periodontist, a dentist who specializes in treating this condition. If left untreated,
periodontal disease can lead to tooth loss.
Prevent Periodontal Disease: Practice Good Dental Hygiene
Consistent good dental hygiene can help prevent gingivitis and periodontitis. The American Dental
Association recommends that everyone:

Brush twice daily with a fluoride toothpaste (be sure to replace toothbrushes every 1 - 3
months).

Clean between the teeth with floss or an interdental cleaner.

Eat a well-balanced diet and limit between meal snacks.

Have regular visits with a dentist for teeth cleaning and oral examinations.
Treatment
Scaling and root planning is the first approach for treating periodontal disease. This procedure is a
deep cleaning to remove bacterial plaque and calculus (tartar). Scaling involves scraping tartar
from above and below the gum line. Root planning smoothes the root surfaces of the teeth. Your
dentist will reevaluate the success of this treatment in follow-up visits. If deep periodontal pockets
and infection remain, periodontal surgery may be recommended.
Periodontal Disease and Heart Disease
Periodontal disease and heart disease are both inflammatory conditions. There appears to be an
association between periodontal disease and heart disease, but it is not yet clear if having one
condition increases the risk of developing the other. In a consensus statement published in
the American Journal of Cardiology in 2009, periodontists and cardiologists recommended that:

Patients who have periodontal disease and at least one risk factor for heart disease should
have a medical evaluation for heart problems.

Patients who have heart disease should have regular exams to check for signs of
periodontal disease.
The U.S. Preventive Services Task Force does not currently consider periodontal disease an
established risk factor for heart disease.
Introduction
The word periodontal means around the tooth. Periodontal disease is a chronic inflammatory
disease of the gum and tissues that surround and support the teeth. If left untreated, periodontal
disease can lead to tooth loss.
The Periodontium?
The part of the mouth that consists of the gum and supporting structures is called the
periodontium. It is made up of the following parts:

Gum (gingiva). When healthy, the gingiva is pale pink, firm, and does not move. It has a
smooth or speckled texture. The gingival tissue between teeth is shaped like a wedge.
The space between the gum and tooth, called the sulcus. The sulcus is the main place
where periodontal problems begin.
Root surface of the teeth (the cementum)
Connective tissue
Alveolar bone. The alveolar bone contains the teeth sockets and supports the teeth.

The structure of the tooth includes dentin, pulp and other tissues, blood vessels, and nerves
imbedded in the bony jaw. Above the gum line, the tooth is protected by the hard enamel covering.
Periodontal Disease
Periodontal diseases are generally divided into two groups:

Gingivitis, which causes lesions (wounds) that affect the gums

Periodontitis, which damages the bone and connective tissue that support the teeth
Periodontal disease is caused by bacteria. Even in healthy mouths, the sulcus is teeming with
bacteria, but they tend to be harmless varieties. Periodontal disease usually develops because of
two events in the oral cavity: an increase in bacteria quantity and a change in balance of bacterial
types from harmless to disease-causing bacteria. These harmful bacteria increase in mass and
thickness until they form a sticky film called plaque.

Click the icon to see an image of plaque and damaged gum tissue.
In healthy mouths, plaque actually provides some barrier against outside bacterial invasion. When
it accumulates to excessive levels, however, bacterial plaque sticks to the surfaces of the teeth and
adjacent gums and causes infection, with subsequent swelling, redness, and warmth.
When plaque is allowed to remain in the periodontal area, it transforms into calculus(commonly
known as tartar). This material has a rock-like consistency and grabs onto the tooth surface. It is
much more difficult to remove than plaque, which is a soft mass.

Gingivitis
Gingivitis is an inflammation of the gingiva, or gums. It is characterized by tender, red, swollen
gums that bleed easily and may be responsible for bad breath (halitosis) in some cases. Gingivitis
can be treated by good dental hygiene, proper diet, and stopping smoking. Untreated gingivitis can
lead to periodontitis.
Periodontitis
Periodontitis occurs when the gum tissues separate from the tooth and sulcus, forming periodontal
pockets. Periodontitis is characterized by:

Gum inflammation, with redness and bleeding

Deep pockets (greater than 3 mm in depth) that form between the gum and the tooth
Loose teeth, caused by loss of connective tissue structures and bone
There are different forms of periodontal disease. They include:
Chronic Periodontitis. Chronic periodontitis is the most common type of periodontitis. It can begin
in adolescence but the disease usually does not become clinically significant until people reach
their mid-30s.
Aggressive Periodontitis. Aggressive periodontitis is a subtype of chronic periodontitis that can
occur as early as childhood. It can lead to severe bone loss by the time patients reach their early
20s.
Disease-Related Periodontitis. Periodontitis can also be associated with a number of systemic
diseases, including type 1 diabetes, Down syndrome, AIDS, and several rare disorders of white
blood cells.
Necrotizing Periodontal Disease. Necrotizing periodontal disease is an acute infection of the gum
tissue. It is characterized by painful and bleeding gums, bad breath, and rapid onset of pain. If left
untreated, necrotizing periodontal disease can spread throughout the facial areas (cheeks, jaw)
and cause extensive damage. Necrotizing periodontal disease is usually associated with systemic
health conditions such as HIV or malnutrition.
Risk Factors
More than 75% of American adults have some form of gum disease but most are unaware of it. Risk
factors for periodontal disease include:
Oral Health
Oral Hygiene. Lack of oral hygiene, such as not brushing or flossing regularly, encourages bacterial
buildup and plaque formation.
Sugar and Acid. The bacteria that cause periodontal disease thrive in acidic environments. Eating
sugars and other foods that increase the acidity in the mouth increase bacterial counts.
Poorly Contoured Restorations. Poorly contoured restorations (fillings or crowns) that provide traps
for debris and plaque can also contribute to periodontitis.
Anatomical Tooth Abnormalities. Abnormal tooth structure can increase the risk of periodontal
disease.

Wisdom Teeth. Wisdom teeth, also called third molars, can be a major breeding ground for the
bacteria that cause periodontal disease. In fact, for patients in their 20s, periodontal disease is
most likely to occur around the wisdom teeth. Periodontitis can occur in wisdom teeth that have
broken through the gum as well as teeth that are impacted (buried). Adolescents and young adults
with wisdom teeth should have a dentist check for signs of periodontal disease.
Age
While gingivitis is nearly universal among children and adolescents, periodontitis typically occurs
as people get older and is most common after age 35.
Female Hormones
Female hormones affect the gums, and women are particularly susceptible to periodontal
problems. Hormone-influenced gingivitis appears in some adolescents, in some pregnant women,
and is occasionally a side effect of birth control medication.
Menstruation. Gingivitis may flare up in some women a few days before they menstruate, when
progesterone levels are high. Gum inflammation may also occur during ovulation. Progesterone
dilates blood vessels causing inflammation, and blocks the repair of collagen, the structural protein
that supports the gums.
Pregnancy. Hormonal changes during pregnancy can aggravate existing gingivitis, which typically
worsens around the second month and reaches a peak in the eighth month. Pregnancy does not
cause gum disease, and simple preventive oral hygiene can help maintain healthy gums. Any
pregnancy-related gingivitis usually resolves within a few months of delivery. Because periodontal
disease can increase the risk for low-weight infants and cause other complications, it is important
for pregnant women to see a dentist.
Menopause. Estrogen deficiency after menopause reduces bone mineral density, which can lead to
bone loss. Bone loss is associated with both periodontal disease and osteoporosis (loss of bone
density).
Family Factors
Family History. Periodontal disease often occurs in members of the same family. Genetic factors
may play a role.
Intimacy. The bacteria that causes periodontal disease may be able to passed to others through
saliva.
Lifestyle Factors
Smoking. Smoking is the single major preventable risk factor for periodontal disease. Smoking can
cause bone loss and gum recession even in the absence of periodontal disease. The risk of
periodontal disease increases with the number of cigarettes smoked per day. Smoking cigars and
pipes carries the same risks as smoking cigarettes.
Substance Abuse. Long-term abuse of alcohol and certain types of illegal drugs (amphetamines)
can damage gums and teeth.
Diet. A healthy diet, including eating fruits and vegetables rich in vitamin C, is important for good
oral health. Malnutrition is a risk factor for periodontal disease.
Stress. Psychological stress can cause the body to release inflammatory hormones, which may
trigger or worse periodontal disease.
Medical Conditions Associated with Periodontal Disease

Diabetes. There is an association between diabetes (both type 1 and 2) and periodontal disease.
Diabetes causes changes in blood vessels, and high levels of specific inflammatory chemicals such
as interleukins, that significantly increase the chances of developing periodontal disease.
Heart Disease. There appears to be an association between periodontal disease and heart disease,
but it is not yet clear if having one condition increases the risk for developing the other
(see Complications section of this report).
Other Medical Conditions. A number of medical conditions can increase the risk of developing
ginigivitis and periodontal disease. They include conditions that affect the immune system such as
HIV/AIDS, leukemia, and possibly autoimmune disorders (Crohn's disease, multiple sclerosis,
rheumatoid arthritis, lupus erythematosus).
Prescription Medications. Gingival overgrowth can be a side effect of many different drugs, most
commonly phenytoin (Dilantin), cyclosporine (Sandimmune), and a short-acting form of the calcium
channel blocker nifedipine (Procardia).
There have been a few reports of osteonecrosis (bone decay) of the jaw in patients who take oral
bisphosphonate drugs such as alendronate (Fosamax). These drugs are used to treat and prevent
osteoporosis. However, almost all cases of osteonecrosis of the jaw associated with
bisphosphonate drugs have occurred during or after the use of intravenous bisphosphonates, which
are usually given to treat bone cancer or other cancers that have spread to the bone. Symptoms of
osteonecrosis of the jaw include loose teeth, exposed jawbone, pain or swelling in the jaw, gum
infections, and poor healing of the gums.
As a precaution, the American Dental Association (ADA) recommends that patients who are
prescribed or are to receive bisphosphonate drugs get a thorough dental exam before beginning
drug therapy, or as soon as possible after beginning therapy. The ADA also recommends that
patients who take oral (pill form) bisphosphonate drugs should discuss with their dentists any
potential risks from dental procedures (such as extractions and implants) that involve the jawbone.
In any case, be sure to inform your dentist if you are taking any type of bisphosphonate drug. Your
dentist or oral surgeon may need to take special precautions when performing dental surgery.
Complications
DAVID ELTZ -- COMPLICATIONS GOES AFTER RISK FACTORS / BEFORE SYMPTOMS
Effect on Heart Disease
The association between periodontal disease and heart disease is being investigated. An
inflammatory response, which occurs in both periodontal disease and heart disease, may be the
common element. Some studies have reported that people who have severe periodontal disease
have an increased risk for heart disease and stroke.
However, is still not clear if periodontal disease actually causes heart disease. Periodontal disease
may be a marker of risk for heart conditions rather than a direct risk factor. The U.S. Preventive
Services Task Force does not currently recommend using periodontal disease as a way to
determine a healthy persons risk of developing heart disease.
It is also not clear if treating gum disease can reduce the risks of heart disease and improve health
outcomes for patients with periodontal disease and vascular heart problems. Studies have been
mixed, but research is ongoing.
Cardiologists and periodontists currently encourage each other to monitor both conditions in their
patients. Periodontists recommend that patients who have periodontal disease and at least one risk
factor for heart disease have an annual medical exam to check their heart health. Cardiologists
suggest that patients with atherosclerosis and heart disease have regular periodontal exams.

[For more information, see In-Depth Report #03: Coronary artery disease.]
Effect on Diabetes
Diabetes is not only a risk factor for periodontal disease. Periodontal disease itself can worsen
diabetes and make it more difficult to control blood sugar.
Effect on Respiratory Disease
Bacteria that reproduce in the mouth can also be carried into the airways in the throat and lungs,
increasing the risks for respiratory diseases and worsening chronic lung conditions, such as
emphysema.

Click the icon to see an image of emphysema.

Effect on Pregnancy
Bacterial infections that cause moderate-to-severe periodontal disease in pregnant women can
increase the risk for premature delivery and low birth weight infants. The more severe the
infection, the greater the risk to the baby. Research indicates that bacteria from gum disease and
tooth decay may trigger the same factors in the immune system that cause premature dilation and
contractions.
Women should have a periodontal examination before becoming pregnant or as soon as possible
thereafter. Because women with diabetes are at higher risk for periodontal disease, it is especially
important that they see a dentist early in pregnancy. Doctors are still not sure if treating
periodontal disease can improve birth outcomes. In any case, periodontal treatment is safe for
pregnant women.
Symptoms
Symptoms or periodontal disease typically progress over time and include:

Red and Swollen Gums

Gum Bleeding. Bleeding of the gums, even during brushing, is a sign of inflammation and
the major marker of periodontal disease.
Bad Breath. Debris and bacteria can cause a bad taste in the mouth and persistent bad
breath.
Gum Recession and Loose Teeth. As the disease advances, the gums recede, and the
supporting structure of bone is lost. Teeth loosen, sometimes causing a change in the way the
upper and lower teeth fit together when biting down or how partial dentures fit.

Abnormally bulging, protruding, or swollen gums are a possible sign of disease.

Click the icon to see an image of recessed gums.

Abscesses. Deepening periodontal pockets between the gums and bone can become
blocked by tartar or food particles. Infection-fighting white blood cells become trapped and die.
Pus forms, and an abscess develops. Abscesses can destroy both gum and tooth tissue, cause
nearby teeth to become loose and painful, and may cause fever and swollen lymph nodes.

Click the icon to see an image of a tooth abscess.

Pain is usually not a symptom, which partly explains why the disease may become advanced
before treatment is sought and why some patients avoid treatment even after periodontitis is
diagnosed.
Diagnosis
The dental practitioner typically performs a number of procedures during a routine dental examine
to check for periodontal disease. If periodontal disease is suspected, your dentist may refer you to
see a periodontist. A periodontist is a dentist who specializes in the diagnosis and treatment of
periodontal disease.
Medical History
The dentist will first take a medical history to reveal any past or present periodontal problems, any
underlying diseases that might be contributing to the problem, and any medications the patient is
taking. The dentist will also ask questions about the patients daily oral hygiene regimen (brushing,
flossing).
Oral Examination

Inspection of the Gum Area. The dentist inspects the color and shape of gingival tissue on the
cheek (buccal) side and the tongue (lingual) side of every tooth. Redness, puffiness, and bleeding
upon probing indicate inflammation and possible periodontal disease.
Periodontal Screening and Recording (PSR). PSR is a painless procedure used to measure and
determine the severity of periodontal disease:

The dentist uses a mirror and a periodontal probe, a fine instrument calibrated in
millimeters (mm), which is used to measure pocket depth.
The probe is held along the length of the tooth with the tip placed in the pocket. The tip of
the probe will then touch the point where the connective tissue attaches to the tooth.
The dentist will "walk" the probe to six specified points on each tooth, three on the buccal
(cheek) and three on the lingual (tongue) sides. The dentist measures the depth of the probe at
each point.
Pocket depths greater than 3 mm indicate disease.
These measurements help determine the condition of the connective tissue and amount of gingival
overgrowth or recession.
Testing Tooth Movement. Tooth mobility is determined by pushing each tooth between two
instrument handles and observing any movement. Mobility is a strong indicator of bone support
loss.
X-rays. X-rays are taken to show any loss of bone structure supporting the teeth.
Treatment
According to the American Academy of Periodontology, treatment for periodontal disease should
focus on achieving oral health in the least invasive and most cost-effective manner. Your dentist or
periodontist will usually begin with a non-surgical approach (scaling and root planning) and then
reevaluate your condition in follow-up visits. If infection or deep periodontal pockets remain,
surgical treatment may be recommended.
Periodontal treatment approaches can basically be categorized as:

Nonsurgical Approaches. Scaling and root planning (deep cleaning of tartar and bacteria
from gum line and tooth root surfaces), which may include the use of topical or systemic
antibiotics.

Surgical Approaches. Periodontal surgical techniques include flap surgery (periodontal

pocket reduction), bone grafts, and guided tissue regeneration.

Restorative Procedures. Crown lengthening is an example of a restorative procedure that

may be performed for cosmetic reasons or to improve function. For patients who have already
lost teeth to advanced periodontitis, dental implants are another option.
In addition to treatment in a dentist office, regular dental visits and cleanings (usually every 3
months) are important for maintenance as is practicing good oral hygiene at home
(see Prevention section of this report).
Non-Surgical Treatment
Scaling and Root Planing. Scaling and root planning is a deep cleaning to remove bacterial plaque
and calculus (tartar). It is the cornerstone of periodontal disease treatment and the first procedure
a dentist will use. Scaling involves scraping tartar from above and below the gum line. Root
planning smoothes the root surfaces of the teeth.
The dentist may apply a topical anesthetic to numb the area before beginning the procedure. Both
ultrasonic and manual instruments are used to remove calculus. The ultrasonic device vibrates at a
high frequency and helps loosen and remove tartar. A high-pressure water spray is then used to

flush out the debris. The dentist will use manual instruments called scrapers and curettes to scrape
away any remaining plaque or calculus and smooth and clean the tooth crown and root surfaces.
Finally, the dentist will polish the tooth using abrasive paste applied to a vibrating instrument with
a rubber cap. Polishing produces a smooth surface, making it temporarily harder for plaque to
adhere.
Antibiotics. At the time of scaling and root planning, your dentist may recommend the use of
antibiotic medications. Because of the risk of developing antibiotic-resistant infections, antibiotics
are recommended only when necessary (for example, in cases of severe active infection).
Antibiotics for periodontal disease come in various forms. They may be taken as a prescription
mouthwash rinse, or placed topically as dissolving gels, threads, or microchips into the periodontal
pockets. In some cases, the dentist may prescribe a short course of systemic antibiotics in a lowdose of doxycyline taken in pill form.
Surgical Treatment
Flap Surgery (Periodontal Pocket Reduction). Surgery allows access for deep cleaning of the root
surface, removal of diseased tissue, and repositioning and shaping of the bones, gum, and tissues
supporting the teeth. The basic procedure is known as flap surgery: It is performed under local
anesthesia and involves:

The periodontist makes an incision and folds back the gum surface away from the tooth
and surrounding bone.

The diseased root surfaces are cleaned and curetted (scraped) to remove deposits.

Gum tissue is sewn back into a position to minimize pocket depth. The gum is covered with
gauze to soak up any blood.

The periodontist may also contour the remaining bone or attempt to regenerate lost bone
and gingival attachment through bone grafts or guided tissue regeneration.
For several days following surgery, patients should rinse their mouths with warm salt water to help
reduce swelling. Gauze pads should be changed. Post-surgical discomfort is usually treated with
over-the-counter medications such as ibuprofen or the application of ice packs.
Bone Grafting. In some cases of severe bone loss, the surgeon may attempt to encourage regrowth
and restoration of bone tissue that has been lost through the disease process. This involves bone
grafting:

The surgeon places bone graft material into the defect.

The material may come from the patient (autogenous), from a cadaver (allograft), or from
an animal such as a cow (xenograft). An autogenous graft is considered the best approach.

The gum is then sewn back into place.

During the next 6 9 months, the bone regrows in the jaw area helping to reattach the teeth
to the jaw.
Guided Tissue Regeneration. Guided tissue regeneration is a more advanced technique that may
be used along with bone grafting:

A specialized piece of fabric called a barrier membrane is is placed between the gum and
the existing bone.
The gum is then sewn over the fabric. The fabric prevents the gum tissue from growing
down into the bone and allows the bone and the attachment to the root to regenerate.
Restorative and Cosmetic Treatments
Crown Lengthening. Crown lengthening is a surgical procedure performed to expose more of the
tooth. It involves readjusting the gum and bone levels by removing small sections of bone and
resewing the gums into a new position to allow more tooth exposure.
Dental Implants. For patients who have lost teeth to periodontal disease, dental implants are an
option, although an expensive one. Dental implants are an artificial type of tooth root used to

create permanent prosthetic teeth. Implants are screws placed into the jawbone. Prosthetic teeth
are attached to the implant.
Prevention
In addition to regular visits to a dentist, the best prevention for periodontal disease takes place at
home. Healthy habits and good oral hygiene, including daily brushing and flossing, are critical in
preventing gum disease and maintaining good oral health after periodontal treatment.
Tooth Brushing
Correct tooth brushing is the first defense against periodontal disease. Here are some tips for
making sure you brush correctly:

Use a soft-bristled brush that fits the size and shape of your mouth. Place the brush where
the gum meets the tooth, with bristles resting along each tooth at a 45-degree angle.
Place the brush where the gum meets the tooth, with bristles resting along each tooth at a
45-degree angle.
Move the brush back and forth gently. Use short (tooth-wide) strokes.
Begin by brushing the outer tooth surfaces, followed by the inner tooth surfaces, and then
the chewing surfaces of the teeth.
For the inside surfaces of the front teeth, gently use the tip of the brush in an up-and-down
stroke.
Brush your tongue to help remove additional bacteria.
Flossing should finish the process. A mouthwash may also be used.
If brushing after each meal is not possible, rinsing the mouth with water after eating can reduce
bacteria by 30%.
Toothbrushes. A vast assortment of brushes of varying sizes and shapes are available, and each
manufacturer makes its claim for the benefits of a particular brush. Look for the American Dental
Association (ADA) seal on both electric and regular brushes.
Electric toothbrushes, particularly those with a stationary grip and revolving tufts of bristles, can be
helpful, especially for people with physical disabilities. However, in general, studies have reported
no major differences between electric and manual toothbrushes in their ability to remove plaque. If
a regular toothbrush works, it isn't necessary to buy an expensive electric one.
The most important factor in buying any toothbrush, electric or manual, is to choose one with a
soft head. Soft bristles get into crevices easier and do not irritate the gums, thereby reducing the
risk of exposing teeth below the gum line compared to hard brushes.
Be sure to rinse your toothbrush with water after each use. Toothbrushes should be replaced every
1 - 3 months. Not only do they become breeding grounds for bacteria, but the worn bristles are less
effective at removing plaque. To prevent the spread of infection, never share toothbrushes.
Flossing
The use of dental floss, either waxed or unwaxed, is critical in cleaning between the teeth where
the toothbrush bristles cannot reach. To floss correctly:

Break off about 18 inches of floss and wind most of it around the middle finger of one hand
and the rest around the other middle finger.
Hold the floss between the thumbs and forefingers and gently guide and rub it back and
forth between the teeth.

When it reaches the gum line, the floss should be curved around each tooth and slid gently
back and forth against the gum.
Finally, rub gently up and down against the tooth. Repeat with each tooth, including the
outside of the back teeth.
Here are some tips in choosing the right floss or flossing device:

Use a floss that does not shred or break.

Avoid a very thin floss, which can cut the gum if brought down with too much force or not
guided along the side of the tooth.
A floss threader may be helpful for people who have bridgework. Made of plastic, it looks
like a needle with a huge eye, or loop. A piece of floss is threaded into the loop, which can then
be inserted between the bridge and the gum. The floss that is carried through with it can then
be used to clean underneath the false tooth or teeth and along the sides of the abutting teeth.
Another handy device for cleaning under bridges is a Proxabrush, which is an interdental
cleaner. This is a tiny narrow brush that can be worked in between the natural teeth and around
the attached false tooth or teeth.
Special toothpicks such as Stim-U-Dent may be used for wide spaces between teeth but
should never replace flossing. Standard toothpicks should never be used for regular hygiene.
Electric water piks may also be helpful.
Toothpastes and Mouthwashes
Toothpaste. Toothpastes are a combination of abrasives, binders, colors, detergents, flavors,
fluoride, humectants, preservatives, and artificial sweeteners. Avoid highly abrasive toothpastes,
especially if your gums have receded. The objective of a good toothpaste is to reduce the
development of plaque and eliminate periodontal-causing bacteria without destroying the
organisms that are important for a healthy mouth.
Ingredients contained in toothpastes may include:

Fluoride. Most commercial toothpastes contain fluoride, which both strengthens tooth
enamel against decay and enhances remineralization of the enamel. Fluoride also inhibits acidloving bacteria, especially after eating, when the mouth is more acidic. This antibacterial activity
may help control plaque.

Triclosan. Triclosan is an anti-bacterial substance that may help reduce mild gingivitis.

Metal salts. Metal salts, such as stannous and zinc, serve as anti-bacterial substances in
toothpastes. Stannous fluoride gel toothpastes do not reduce plaque, even though they have
some effect against the bacteria that cause it, but slightly reduce gingivitis.

Peroxide and baking soda. Toothpastes with these ingredients claim to have a whitening
action, but while they may help remove stains there is little evidence they whiten the actual
color of the teeth. In addition, these substances appear to offer no benefits against gum
disease.

Antibacterial sugar substitutes (xylitol), and detergents (delmopinol)

Mouthwash. The American Dental Association recommends (in addition to daily brushing and
flossing) antimicrobial mouthwash to help prevent and reduce plaque and gingivitis,
andfluoride mouthwashes to help provide additional protection against tooth decay.

Chlorhexidine (Peridex or PerioGard) is an antimicrobial mouthwash available by

prescription to help reduce plaque and prevent gingivitis. Patients should rinse for 1 minute
twice daily. They should wait at least 30 minutes (and preferably 2 hours) between brushing and
rinsing since chlorhexidine can be inactivated by certain compounds in toothpastes. It has a
bitter taste. It also binds to tannins, which are in tea, coffee, and red wine, so it has tendency to
stain teeth in people who drink these beverages. Studies are mixed as to its effectiveness for
preventing or reducing periodontal disease.

Listerine is another antimicrobial mouthwash. Generic equivalents are available. It is

composed of essential oils and is available over the counter. It reduces plaque and gingivitis,
when used for 30 seconds twice a day. It leaves a burning sensation in the mouth that most
people better tolerate after a few days of use. The usual regimen is to rinse twice a day.
(Listerine PocketPaks, which are strips that dissolve on the tongue, have no proven effects on
plaque and gingivitis.)

Mouthwashes containing cetylpyridinium (Scope, Cepacol, generics) have moderate

antimicrobial effect on plaque, but only if they are used an hour after brushing. None are as
effective as Listerine or chlorhexidine, but they may still have some value for people who cannot
tolerate the other mouthwashes.
Mouthwashes containing stannous fluoride and amine fluoride (Meridol) are moderately
effective, but are also not as effective as effective as Listerine or chlorhexidine.
Fluoride mouthwashes (Act and generics) are helpful in preventing cavities.
Mouthwashes that contain alcohol are dangerous for children and should be kept away
from them.
Lifestyle Changes
Diet. A well-balanced and nutritious diet is important for good oral health. Limit between-meal
snacks and be sure to brush and floss after every meal. It is also important to drink lots of water to
help increase saliva and flush away plaque.
Quitting Smoking. Smoking is a main risk factor for periodontal disease. For smokers, quitting is
one of the most important steps toward regaining periodontal health

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