Periodontal Disease (Gum Disease)

The word periodontal means “around the tooth”.  Periodontal disease attacks the gums and the bone that support the teeth.  Plaque is a sticky film of food debris, bacteria, and saliva.  If plaque is not removed, it turns into calculus (tartar).  When plaque and calculus are not removed, they begin to destroy the gums and bone.  Periodontal disease is characterized by red, swollen, and bleeding gums.

Four out of five people have periodontal disease and don’t know it!  Most people are not aware of it because the disease is usually painless in the early stages.

Not only is it the number one reason for tooth loss, research suggests that there may be a link between periodontal disease and other diseases such as, stroke, bacterial pneumonia, diabetes, cardiovascular disease, and increased risk during pregnancy.  Researchers are determining if inflammation and bacteria associated with periodontal disease affects these systemic diseases and conditions.  Smoking also increases the risk of periodontal disease.

Good oral hygiene, a balanced diet, and regular dental visits can help reduce your risk of developing periodontal disease.

Signs and symptoms of periodontal disease:

  • Bleeding gums – Gums should never bleed, even when you brush vigorously or use dental floss.
  • Loose teeth – Also caused by bone loss or weakened periodontal fibers (fibers that support the tooth to the bone).
  • New spacing between teeth – Caused by bone loss.
  • Persistent bad breath – Caused by bacteria in the mouth.
  • Pus around the teeth and gums – Sign that there is an infection present.
  • Receding gums – Loss of gum around a tooth.
  • Red and puffy gums – Gums should never be red or swollen.
  • Tenderness or Discomfort – Plaque, calculus, and bacteria irritate the gums and teeth.

What is Periodontal (Gum) Disease?

The term “periodontal”means “around the tooth.”

Periodontal disease (also known as periodontitis and gum disease) is a progressive disease which affects the supporting and surrounding tissue of the gums, and also the underlying jawbone. If left untreated, periodontal disease can result in loose, unstable teeth, and even tooth loss. Periodontal disease is in fact the leading cause of tooth loss in adults in the developed world and should not be taken lightly.

Periodontal disease begins when the toxins found in plaque start to attack the soft or gingival tissue surrounding the teeth. This bacterium embeds itself in the gum and rapidly breeds, causing a bacterial infection. As the infection progresses, it starts to burrow deeper into the tissue causing inflammation or irritation between the teeth and gums. The response of the body is to destroy the infected tissue, which is why the gums appear to recede. The resulting pockets between the teeth deepen and, if no treatment is sought, the tissue which makes up the jawbone also recedes causing unstable teeth and tooth loss.

Periodontal disease is most often preceded by gingivitis which is a bacterial infection of the gum tissue.  A bacterial infection affects the gums when the toxins contained in plaque begin to irritate and inflame the gum tissues.  Once this bacterial infection colonizes in the gum pockets between the teeth, it becomes much more difficult to remove and treat.  Periodontal disease is a progressive condition that eventually leads to the destruction of the connective tissue and jawbone.  If left untreated, it can lead to shifting teeth, loose teeth and eventually tooth loss.

Periodontal disease is the leading cause of tooth loss among adults in the developed world and should always be promptly treated.

When left untreated, gingivitis (mild gum inflammation) can spread to below the gum line.  When the gums become irritated by the toxins contained in plaque, a chronic inflammatory response causes the body to break down and destroy its own bone and soft tissue.  There may be little or no symptoms as periodontal disease causes the teeth to separate from the infected gum tissue.  Deepening pockets between the gums and teeth are generally indicative that soft tissue and bone is being destroyed by periodontal disease.

Here are some of the most common types of periodontal disease:

  • Chronic periodontitis – Inflammation within supporting tissues cause deep pockets and gum recession.  It may appear the teeth are lengthening, but in actuality, the gums (gingiva) are receding.  This is the most common form of periodontal disease and is characterized by progressive loss of attachment, interspersed with periods of rapid progression.
  • Aggressive periodontitis – This form of gum disease occurs in an otherwise clinically healthy individual.  It is characterized by rapid loss of gum attachment, chronic bone destruction and familial aggregation.
  • Necrotizing periodontitis – This form of periodontal disease most often occurs in individuals suffering from systemic conditions such as HIV, immunosuppression and malnutrition.  Necrosis (tissue death) occurs in the periodontal ligament, alveolar bone and gingival tissues.
  • Periodontitis caused by systemic disease – This form of gum disease often begins at an early age.  Medical condition such as respiratory disease, diabetes and heart disease are common cofactors.

Some of the treatments for Periodontal Disease

There are many surgical and nonsurgical treatments the periodontist may choose to perform, depending upon the exact condition of the teeth, gums and jawbone.  A complete periodontal exam of the mouth will be done before any treatment is performed or recommended.

Here are some of the more common treatments for periodontal disease:

  • Scaling and root planing – In order to preserve the health of the gum tissue, the bacteria and calculus (tartar) which initially caused the infection, must be removed.  The gum pockets will be cleaned and treated with antibiotics as necessary to help alleviate the infection.  A prescription mouthwash may be incorporated into daily cleaning routines.
  • Tissue regeneration – When the bone and gum tissues have been destroyed, regrowth can be actively encouraged using grafting procedures.  A membrane may be inserted into the affected areas to assist in the regeneration process.
  • Pocket elimination surgery – Pocket elimination surgery (also known as flap surgery) is a surgical treatment which can be performed to reduce the pocket size between the teeth and gums.  Surgery on the jawbone is another option which serves to eliminate indentations in the bone which foster the colonization of bacteria.
  • Dental implants – When teeth have been lost due to periodontal disease, the aesthetics and functionality of the mouth can be restored by implanting prosthetic teeth into the jawbone.  Tissue regeneration procedures may be required prior to the placement of a dental implant in order to strengthen the bone.

Ask your dentist if you have questions or concerns about periodontal disease, periodontal treatment, or dental implants.

Common Signs & Symptoms

It is extremely important to note that periodontal disease can progress without any signs or symptoms such as pain.  This is why regular dental checkups are exceptionally important. Described below are some of the most common signs and symptoms of periodontitis.

If you have any of these signs or symptoms, the advice of a general dentist or periodontist should be sought as soon as possible:

  • Unexplained bleeding – Bleeding when brushing, flossing or eating food is one of the most common symptoms of a periodontal infection.  The toxins in plaque cause a bacterial infection which makes the tissues prone to bleeding.
  • Pain, redness or swelling – A periodontal infection may be present if the gums are swollen, red or painful for no apparent reason.  It is essential to halt the progression of the infection before the gum tissue and jaw bone have been affected.  It is also critical to treat the infection before it is carried into the bloodstream to other areas of the body.
  • Longer-looking teeth – Periodontal disease can lead to gum recession.  The toxins produced by bacteria can destroy the supporting tissue and bones, thus making the teeth look longer and the smile appear more “toothy.”
  • Bad breath/halitosis – Although breath odor can originate from back of the tongue, the lungs and stomach, from the food we consume, or from tobacco use, bad breath may be caused by old food particles which sit between the teeth and underneath the gumline.  The deeper gum pockets are able to house more debris and bacteria, causing a foul odor.
  • Loose teeth/change in bite pattern – A sign of rapidly progressing periodontitis is the loosening or shifting of the teeth in the affected area.  As the bone tissue gets destroyed, teeth that were once firmly attached to the jawbone become loose or may shift in position.
  • Pus – Pus oozing from between the teeth is a definitive sign that a periodontal infection is in progress.  The pus is a result of the body trying to fight the bacterial infection.

Types of Periodontal Disease

There are many different varieties of periodontal disease, and many ways in which these variations manifest themselves. All require immediate treatment by a periodontist to halt the progression and save the gum tissue and bone. Here are some of the most common types of periodontal disease along with the treatments typically performed to correct them:

Gingivitis

Gingivitis is the mildest and most common form of periodontitis. It is caused by the toxins in plaque and leads to periodontal disease. People at increased risk of developing gingivitis include pregnant women, women taking birth control pills, people with uncontrolled diabetes, steroid users and people who control seizures and blood pressure using medication.

Treatment: Gingivitis is easily reversible using a solid combination of home care and professional cleaning. The dentist may perform root planing and deep scaling procedures to cleanse the pockets of debris. A combination of antibiotics and medicated mouthwashes may be used to kill any remaining bacteria and promote the good healing of the pockets.

Chronic Periodontal Disease

Chronic periodontal disease is the most common form of the disease, and occurs much more frequently in people over 45. Chronic periodontal disease is characterized by inflammation below the gum line and the progressive destruction of the gingival and bone tissue. It may appear that the teeth are gradually growing in length, but in actuality the gums are gradually recessing.

Treatment: Unfortunately unlike gingivitis, chronic periodontal disease cannot be completely cured because the supportive tissue cannot be rebuilt. However, the dentist can halt the progression of the disease using scaling and root planing procedures in combination with antimicrobial treatments. If necessary, the periodontist can perform surgical treatments such as pocket reduction surgery and also tissue grafts to strengthen the bone and improve the aesthetic appearance of the oral cavity.

Aggressive Periodontal Disease

Aggressive periodontal disease is characterized by the rapid loss of gum attachment, the rapid loss of bone tissue and familial aggregation. The disease itself is essentially the same as chronic periodontitis but the progression is much faster. Smokers and those with a family history of this disease are at an increased risk of developing aggressive periodontitis.

Treatment: The treatments for aggressive periodontal disease are the same as those for chronic periodontal disease, but aggressive periodontal disease sufferers are far more likely to require a surgical intervention. This form of the disease is harder to halt and treat, but the dentist will perform scaling, root planing, antimicrobial, and in some cases laser procedures in an attempt to save valuable tissue and bone.

Periodontal Disease Relating to Systemic Conditions

Periodontal disease can be a symptom of a disease or condition affecting the rest of the body. Depending on the underlying condition, the disease can behave like aggressive periodontal disease, working quickly to destroy tissue. Heart disease, diabetes and respiratory disease are the most common cofactors, though there are many others. Even in cases where little plaque coats the teeth, many medical conditions intensify and accelerate the progression of periodontal disease.

Treatment: Initially, the medical condition which caused the onset of periodontal disease must be controlled. The dentist will halt the progression of the disease using the same treatments used for controlling aggressive and chronic periodontal disease.

Necrotizing Periodontal Disease

This form of the disease rapidly worsens and is more prevalent among people who suffer from HIV, immunosuppression, malnutrition, chronic stress or choose to smoke. Tissue death (necrosis) frequently affects the periodontal ligament, gingival tissues and alveolar bone.

Treatment: Necrotizing periodontal disease is extremely rare. Because it may be associated with HIV or another serious medical condition, it is likely the dentist will consult with a physician before commencing treatment. Scaling, root planing, antibiotic pills, medicated mouth wash and fungicidal medicines are generally used to treat this form of the disease.

If you have any question or concerns about the different types of periodontal disease and treatments, please ask your dentist.

Diagnosis

Periodontal disease is diagnosed by your dentist or dental hygienist during a periodontal examination.  This type of exam should always be part of your regular dental check-up.

A periodontal probe (small dental instrument) is gently used to measure the sulcus (pocket or space) between the tooth and the gums.  The depth of a healthy sulcus measures three millimeters or less and does not bleed.  The periodontal probe helps indicate if pockets are deeper than three millimeters.  As periodontal disease progresses, the pockets usually get deeper.

Your dentist or hygienist will use pocket depths, amount of bleeding, inflammation, tooth mobility, etc., to make a diagnosis that will fall into a category below:

Gingivitis

Gingivitis is the first stage of periodontal disease.  Plaque and its toxin by-products irritate the gums, making them tender, inflamed, and likely to bleed.

Periodontitis

Plaque hardens into calculus (tartar).  As calculus and plaque continue to build up, the gums begin to recede from the teeth.  Deeper pockets form between the gums and teeth and become filled with bacteria and pus.  The gums become very irritated, inflamed, and bleed easily.  Slight to moderate bone loss may be present.

Advanced Periodontitis

The teeth lose more support as the gums, bone, and periodontal ligament continue to be destroyed.  Unless treated, the affected teeth will become very loose and may be lost.  Generalized moderate to severe bone loss may be present.

Causes of Periodontal Disease

There are genetic and environmental factors involved in the onset of gum disease, and in many cases the risk of developing periodontitis can be significantly lowered by taking preventative measures.

Here are some of the most common causes of gum disease:

  • Poor dental hygiene – Preventing dental disease starts at home with good oral hygiene and a balanced diet.  Prevention also includes regular dental visits which include exams, cleanings, and x-rays.  A combination of excellent home care and professional dental care will ensure and preserve the natural dentition and supporting bony structures.  When bacteria and calculus (tartar) are not removed, the gums and bone around the teeth become affected by bacteria toxins and can cause gingivitis or periodontitis, which can lead to tooth loss.
  • Tobacco use – Research has indicated that smoking and tobacco use is one of the most significant factors in the development and progression of gum disease.  In addition to smokers experiencing a slower recovery and healing rate, smokers are far more likely to suffer from calculus (tartar) build up on teeth, deep pockets in the gingival tissue and significant bone loss.
  • Genetic predisposition – Despite practicing rigorous oral hygiene routines, as much as 30% of the population may have a strong genetic predisposition to gum disease.  These individuals are six times more likely to develop periodontal disease than individuals with no genetic predisposition.  Genetic tests can be used to determine susceptibility and early intervention can be performed to keep the oral cavity healthy.
  • Pregnancy and menopause – During pregnancy, regular brushing and flossing is critical. Hormonal changes experienced by the body can cause the gum tissue to become more sensitive, rendering them more susceptible to gum disease.
  • Chronic stress and poor diet – Stress lowers the ability of the immune system to fight off disease, which means bacterial infections may possibly beat the body’s defense system.  Poor diet or malnutrition can also lower the body’s ability to fight periodontal infections, as well as negatively affecting the health of the gums.
  • Diabetes and underlying medical issues – Many medical conditions can intensify or accelerate the onset and progression of gum disease including respiratory disease, heart disease, arthritis and osteoporosis.  Diabetes hinders the body’s ability to utilize insulin which makes the bacterial infection in the gums more difficult to control and cure.
  • Grinding teeth – The clenching or grinding of the teeth can significantly damage the supporting tissue surrounding the teeth.  Grinding one’s teeth is usually associated with a “bad bite” or the misalignment of the teeth.  When an individual is suffering from gum disease, the additional destruction of gingival tissue due to grinding can accelerate the progression of the disease.
  • Medication – Many drugs including oral contraceptive pills, heart medicines, anti-depressants and steroids affect the overall condition of teeth and gums; making them more susceptible to gum disease.  Steroid use promotes gingival overgrowth, which makes swelling more commonplace and allows bacteria to colonize more readily in the gum tissue.

Treatment of Gum Disease

Periodontists specialize in the treatment of gum disease and the placement of dental implants.  A periodontist can perform effective cleaning procedures in deep pockets such as scaling and root planing, and also prescribe antibiotic and antifungal medications to treat infection and halt the progression of the disease.

In the case of tooth loss, the periodontist is able to perform tissue grafts to promote natural tissue regeneration, and insert dental implants if a tooth or several teeth are missing.  Where gum recession causes a “toothy” looking smile, the periodontist can recontour the gingival tissue to create an even and aesthetically pleasing appearance.

Preventing periodontal disease is critical in preserving the natural dentition.  Addressing the causes of gum disease and discussing them with your dentist will help prevent the onset, progression, and recurrence of periodontal disease.

If you have any questions or concerns about the causes or treatments pertaining to gum disease, please ask your dentist.

Periodontal Disease, Heart Disease and Stroke

Periodontal disease, heart disease and stroke may seem to be unlikely bedfellows, but researchers have found that gum disease sufferers are nearly twice as likely to also suffer from coronary heart disease.  In addition, research studies have discovered that oral infection is indeed a risk factor for stroke.  People diagnosed with acute cerebrovascular ischemia were more likely to also be experiencing some degree of periodontal disease.

Periodontal disease is a progressive condition in which the gingival tissue surrounding the teeth is infected by the colonization of bacteria.  Bacteria found in plaque colonize first above, then below the g gumline causing the tissue to pull away from the teeth.  If periodontal disease is left untreated, deep pockets form between the gums and the teeth and the tissue of the underlying jawbone is also destroyed.  The destruction of bone tissue causes the teeth to shift, wobble or completely detach from the bone.

Coronary heart disease occurs when the walls of the coronary arteries become progressively thicker due to the buildup of fatty proteins.  The heart then suffers from a lack of oxygen and must labor significantly harder to pump blood to the rest of the body.  Coronary heart disease sufferers sometimes experience blood clots which obstruct normal blood flow and reduce the amount of vital nutrients and oxygen the heart needs to function properly.  This phenomenon often leads to heart attacks.

Reasons for the Connection

There is little doubt that the presence of periodontal disease can exacerbate existing heart conditions.  The periodontist and cardiologist generally work as a team in order to treat individuals experiencing both conditions.

There are several theories which may explain the link between heart disease, stroke and periodontal disease, which include the following:

  • Oral bacteria affect the heart – There are many different strains of periodontal bacteria.  Researchers assert that some of these strains of bacteria enter the bloodstream and attach to the fatty plaques in the heart blood vessels (coronary arteries).  This attachment then contributes to clot formation causing grave danger to the individual.
  • Inflammation – Periodontal disease causes severe inflammation in the gum tissue which elevates the white blood cell count and also the high sensitivity C-reactive protein levels.  Research studies have shown that elevated levels of C-reactive proteins have been linked to heart disease.
  • Infectious susceptibility – Individuals who experience particularly high levels of oral bacteria may have weaker immune systems and an inadequate host inflammatory response.  These factors may induce specific vascular effects which have previously been shown to contribute in the onset of certain forms of heart disease.

Diagnosis and Treatment

Since periodontal disease appears to be a risk factor for both heart attack and stroke, it is extremely important to seek immediate treatment.  Initially, the periodontist will conduct thorough examinations to assess the exact condition of the teeth, gums and jawbone.  X-rays can be helpful in determining whether bone loss is prevalent in the upper and lower jaw.

The dentist is able to conduct deep cleaning treatments such as scaling and root planing to remove hardened calculus (tartar) deposits from the gum pockets.  An antibiotic may be prescribed to ensure that the bacterium is completely destroyed and the periodontal infection does not spread.  In most cases, periodontal disease can be prevented with regular cleanings and proper home care.

If you have questions or concerns about periodontal disease and its relation to heart disease and stroke, please ask your dentist.

Periodontal Disease and Pregnancy

Researchers have shown that periodontal disease in expectant mothers actually exposes their unborn child to many different risks; particularly if they also happen to be diabetes sufferers.

Periodontal disease generally begins with a bacterial infection in the gum (gingival) tissue, which progressively destroys the tissue and the underlying bone.  If left untreated, the bacterial infection causes an inflammatory reaction in the body, which can significantly deepen the gum pockets (space between the teeth and gums) and forces the gum and jawbone to recede.  Eventually, the progressive nature of periodontal disease causes the teeth to become loose and unstable, and eventually fall out.

Pregnancy causes many hormonal changes which increase the risk of the expectant mother to develop gingivitis (inflammation of the gum tissue) and periodontal disease.  These oral problems have been linked in many research studies to preeclampsia, low birth weight of the baby and premature birth.  Expectant women should seek immediate treatment for periodontal disease in order to reduce the risk of pre-natal and post-natal complications.

Reasons for the Connection

There are many different reasons why periodontal disease may affect the health of the mother and her unborn child:

  • Prostaglandin – Periodontal disease appears to elevate levels of prostaglandin in mothers who are suffering from the more advanced forms of the condition.  Prostaglandin is a labor-inducing compound found in one of the oral bacteria strains associated with periodontitis.  Elevated levels of prostaglandin can cause the mother to give birth prematurely and deliver a baby with a low birth weight.
  • C – reactive protein (CRP) – This protein, which has been previously linked to heart disease, has now been associated with adverse pregnancy outcomes including preeclampsia and premature birth.  Periodontal infections elevate C-reactive protein levels and amplify the body’s natural inflammatory response.  Periodontal bacteria may enter the bloodstream causing the liver to produce CRP which leads to inflamed arteries as well as possible blood clots.  These inflammatory effects can then lead to blocked arteries causing strokes or heart attacks.
  • Bacteria spread – The bacteria which colonize in the gum pockets can readily travel through the bloodstream and affect other parts of the body.  In pregnant women, research has found that oral bacteria and associated pathogens have colonized in the internal mammary glands and coronary arteries.

Diagnosis and Treatment

There are many safe, non surgical treatment options available for pregnant women.  It is of paramount importance to halt the progress of periodontal disease in order to increase the chances of a safe and healthy delivery.

Initially, the dentist will assess the exact condition of the gums and jawbone in order to make a precise diagnosis.  Scaling and root planing are two common non-surgical procedures used to rid the tooth-root surfaces of calculus (tartar) and remove the bacterial toxins from the gum pockets.

The advantages to the pregnant woman are plentiful.  The risks of pregnancy complications caused by periodontal disease are reduced by as much as 50%, and these treatments will alleviate many unpleasant and harmful effects associated with gingivitis and periodontal infection.

Dentists can provide dental education and recommendations to the pregnant women on effective home care which can reduce risks that may affect her and/or her child’s health.  Risks of periodontal disease can be vastly reduced by proper home care, smoking cessation, dietary changes and the ingestion of supplementary vitamins.

If you have any questions or concerns about periodontal disease and its affect on pregnancy, please ask your dentist.

Treatment

Periodontal treatment methods depend upon the type and severity of the disease.  Your dentist and dental hygienist will evaluate for periodontal disease and recommend the appropriate treatment.

Periodontal disease progresses as the sulcus (pocket or space) between the tooth and gums gets filled with bacteria, plaque, and tartar, causing irritation to the surrounding tissues.  When these irritants remain in the pocket space, they can cause damage to the gums and eventually, the bone that supports the teeth!

If the disease is caught in the early stages of gingivitis, and no damage has been done, one to two regular cleanings will be recommended.  You will also be given instructions on improving your daily oral hygiene habits and having regular dental cleanings.

If the disease has progressed to more advanced stages, a special periodontal cleaning called scaling and root planing (deep cleaning) will be recommended.  It is usually done one quadrant of the mouth at a time while the area is numb.  In this procedure, tartar, plaque, and toxins are removed from above and below the gum line (scaling) and rough spots on root surfaces are made smooth (planing).  This procedure helps gum tissue to heal and pockets to shrink.  Medications, special medicated mouth rinses, and an electric tooth brush may be recommended to help control infection and healing.

If the pockets do not heal after scaling and root planing, periodontal surgery may be needed to reduce pocket depths, making teeth easier to clean.  Your dentist may also recommend that you see a Periodontist (specialist of the gums and supporting bone).

It is of paramount importance to halt the progression of periodontal disease before it causes further damage to the gum tissues and jawbone.  The dentist will initially assess the whole mouth in order to ascertain the progress of the disease.  When a diagnosis has been made, the dentist may treat the bacterial infection with antibiotics in conjunction with nonsurgical or surgical treatment or both.

In the case of moderate periodontal disease, the pockets (under the gumline) of the teeth will be completely cleared of debris using a procedure called scaling and root planing.  The pockets may be filled with antibiotics to promote good healing and kill any bacteria that remain.

Severe periodontitis can be treated in several different ways, such as:

  • Laser treatment – This can be used to reduce the size of the pockets between the teeth and the gums.
  • Tissue & bone grafting – Where a considerable amount of bone or gum tissue has been destroyed, the dentist may elect to graft new tissue by inserting a membrane to stimulate tissue growth.
  • Pocket elimination surgery – The dentist may choose to perform “flap surgery” to directly reduce the size of the gum pockets.

If you have any further questions about the signs and symptoms of periodontal disease, please ask your dentist.

Maintenance

It only takes twenty four hours for plaque that is not removed from your teeth to turn into calculus (tartar)!  Daily home cleaning helps control plaque and tartar formation, but those hard to reach areas will always need special attention.

Once your periodontal treatment has been completed, your dentist and dental hygienist will recommend that you have regular maintenance cleanings (periodontal cleanings), usually four times a year.  At these cleaning appointments, the pocket depths will be carefully checked to ensure that they are healthy.  Plaque and calculus that is difficult for you to remove on a daily basis will be removed from above and below the gum line.

In addition to your periodontal cleaning and evaluation, your appointment will usually include:

  • Examination of diagnostic x-rays (radiographs): Essential for detection of decay, tumors, cysts, and bone loss.X-rays also help determine tooth and root positions.
  • Examination of existing restorations: Check current fillings, crowns, etc.
  • Examination of tooth decay: Check all tooth surfaces for decay.
  • Oral cancer screening: Check the face, neck, lips, tongue, throat, cheek tissues, and gums for any signs of oral cancer.
  • Oral hygiene recommendations: Review and recommend oral hygiene aids as needed. (Electric toothbrushes, special periodontal brushes, fluorides, rinses, etc.)
  • Teeth polishing: Remove stain and plaque that is not otherwise removed during tooth brushing and scaling.

Good oral hygiene practices and periodontal cleanings are essential in maintaining dental health and keeping periodontal disease under control!