Why Do My Gums Always Bleed?
So many patients have said these words to me over the years that if I could get all of them to say it together simultaneously, I would have a chorus, also singing “they wouldn’t bleed if you didn’t poke them.” While bleeding gums are considered normal, since it’s so common for people to have gum disease, bleeding gums are also a sign of a potentially serious systemic disease. They are a clear indication that the barrier intended to keep microorganisms in the mouth and out of the circulatory system isn’t properly performing its important role. Gum disease is not a healthful condition. My patients, whom I love and respect, may not intend to encourage periodontal disease, but they are doing so.
My deep concern lies in the fact that people with gum disease are, in fact, potentially seriously ill and do not even realize they have a problem, or if they do, think it’s of no more consequence than a cold. The challenge for me is that this country is not up in arms over gum disease, because it is a disease so insidious, so painless, so seemingly benign—yet so dangerous—that it is allowed to affect perhaps 90 percent of the adult population, while we continue to pour oral health products containing antifreeze and alcohol on diseased gums. Heart disease alone kills the equivalent of six fully loaded 747 Jumbo Jets every day, about 2,190 Jumbos a year, with deaths approaching 800,000 people. I say we’ve got to do a lot better than we do at present to address this dismal situation. And we can. If gum disease was as painful as a continuous bee sting or a burn, perhaps the hundred million or so Americans who have moderate to advanced gum disease would be ringing their physicians’ and dentists’ phones off the hook This type of pain would serve to alert people to the fact that they did, in fact, have some sort of problem as well as motivate them to do something about it. Nothing of this sort will happen, of course, because gum disease is, as I said, usually painless, and bleeding gums aren’t given much thought.
Since you are reading this blog, I may be preaching to the converted, but we in the dental profession and the population we treat must take periodontal disease much more seriously. Not to do so bodes ill for making any progress in ameliorating the ravages of this ubiquitous, insidious disease.
How Do We Know If We’ve Got Gum Disease?
Periodontal disease literally means disease that is “located around a tooth” and is generally meant to refer either to infections around the teeth, such as gingivitis, an early stage of periodontal disease, or to more deep-seated infections around the teeth resulting in pockets and the loss of tooth-supporting bone, known variously as early, moderate, or advanced periodontitis. Exact gradations of the disease range from simple, easily cured conditions requiring little professional therapy to exceedingly complex ones requiring therapy from a periodontist (a gum specialist). End-stage periodontal disease results in extraction, the only therapy possible, and thus the loss of the tooth. While the traditional perspective is a tooth-by-tooth, oral-centric focus, my perspective is that we should be thinking about early, moderate, and advanced systemic disease that shows up first in the mouth.
There can be many causes of periodontal disease, and someone can have several factors working against them at any given time. One of the biggest factors in determining whether or not you have gum disease is how well you can control plaque by exercising whatever oral hygiene efforts you customarily perform.
Plaque, the sticky stuff that coats the teeth above and below the gums, is a major factor in the development and perpetuation of gum disease. Since up to 400 types of microorganisms are living, dying, rotting, stinking, and producing a whole host of destructive enzymes under the gums, and therefore next to the teeth, the plaque is very high on the list of periodontal disease causes. One gram of biofilm from any source, whether above or below the gum margins, or even from the top of the tongue, can contain as many as 100-200 trillion organisms (a heavy load for any mouth); therefore, safe, effective methods of controlling these organisms on a daily basis are critical to maintaining oral health.
Although poor oral hygiene and plaque control is frequently the primary cause of gum problems, there are also other factors that contribute to periodontal disease (even an immaculately clean mouth can be diseased). They include:
- Nutritional deficiencies (98 percent of the population fits into this category because, as a nation, we are overfed and undernourished);
- A diet high in sugar, white flour, and other refined carbohydrates (these foods depress the immune system);
- Diabetes (decreased resistance to infection, poor circulation);
- Alcohol (dehydration, poor diet, the topical effect of alcohol on gums, vitamin depletion);
- Stress (compromised immune system);
- Bruxism (grinding) and malocclusion (bad bite);
- Volatile sulfur compounds (derived from decomposing food debris—VSC breaks down protein, decomposing microorganisms, desquamated cellular debris under the gums);
- Smoking, chewing, dipping, or using tobacco in any form (tobacco has many ill effects on oral soft tissues, including oral cancer and periodontal disease);
- Drug reactions, especially to the birth control pill and steroids (mouth-drying effects, reduced immune-system competency);
- Hereditary factors (not commonly seen, but in some, its influence shows up early and can quickly result in major bone loss and loss of teeth);
- Poorly fitting dental appliances (too much stress on remaining teeth), bad margins, or over- or under-contoured restorations or crowns;
- Food impaction between teeth (causing bone loss, chronic inflammation, localized pressure);
- Habits, such as chronic nail biting, improper use of toothpicks, and overzealous brushing or flossing;
- Foreign-body reaction (bone loss can occur rapidly when foreign material is lodged under the gums—popcorn hulls, tomato seeds, or toothpick remnants can all cause mischief in just days or weeks);
- Chronic immune diseases or HIV/AIDS infection;
- Inflammation, the chief culprit in most periodontal disease-systemic disease connections.
Robert Genco, D.D.S., Ph.D., editor-in-chief of the Journal of Periodontology, says, “It seems clear that gum disease, far from being just an oral health problem, actually represents a significant health risk to millions of people.” Dr. Genco further states, “Periodontal disease is characterized by inflammation and bacterial infection of the gums surrounding the teeth. The bacteria that are associated with periodontal disease can travel in the bloodstream to other parts of the body, and that puts health at risk.” Additionally, Dr. Genco says, “People think of gum disease in terms of their teeth, but they don’t think about the fact that gum disease is a serious infection that can release bacteria into the bloodstream. The end result could mean additional health risks for people whose health is already affected by other diseases—or lead to serious complications like heart disease.”
While the list of factors playing a role in periodontal disease is extensive, and despite the dire (and correct) warnings of Dr. Genco, the good news is that most of these factors (genetics excepted) are under our control. Even though we still have no say in picking our parents, all is not lost. There is a whole array of help available to alter the course of the disease, and it is possible to achieve levels of oral and systemic health that were, perhaps, inconceivable and unachievable just a few years ago. This information will be covered in Chapters 7 and 8, but below are some warning signs that might indicate the presence of gum disease.
Signs and Symptoms of Periodontal Disease
- Puffy, red, or swollen gums (swollen gums can be nearly purple, even bluish);
- Bleeding gums (healthy gums do not bleed);
- Loose teeth (bone loss and inflammation can loosen teeth);
- Shiny gums (normal gums aren’t shiny);
- Changes in the way dental appliances fit (something has moved, not usually the appliance);
- Mouth sores (they need to be checked because, just as a blister or sore isn’t normal on the arm, neither is it in the mouth);
- Bad breath (halitosis can be a prominent sign of gum disease);
- A high-sensitivity CRP test reading showing CRP to be elevated (such a reading is regarded as pathological).
CRP is a blood test that measures CRP in milligrams (mg) per liter (L), or CRP mg/L (CRP may be reported in different units by your lab). CRP levels of less than 1 mg/L represent a low risk for heart disease, and readings between 1-3 mg/L indicate an average risk for cardiovascular disease. CRP levels of 3 mg/L or higher put people in the high-risk group.
While any elevation of CRP can have serious health consequences, a recent dental study reports that CRP becomes a risk factor for cardiovascular disease, peripheral vascular disease, and stroke at levels of 1.34 mg/L and above.
Please note that although a high-sensitivity CRP test isn’t routinely ordered by dentists, either as a diagnostic tool or as a means of monitoring treatment, it should be, because it is a marker that can be tracked. Perhaps more dentists will request this blood test for their patients in the future, but for now, you can request it yourself. If your dentist isn’t willing to order this lab test for you, request it from your physician, and have it done annually, at least. It is a very important test, and you need to know your score. High CRP levels can correctly predict a future clotting event, sometimes as much as eight years in advance.
It is never a good idea to diagnose your own disease, but if you do have any of the above signs and symptoms, you should make an appointment with your dentist or periodontist to get a definitive diagnosis. When I suspect periodontal disease, one in-office test I perform is to take my finger and push the gum tissue right where the gum meets the tooth to see if any blood or pus appears. I often get quite a bit of both, along with their odors. While I’m not suggesting you diagnose yourself by pushing on your own gum margins, pus and blood expressed in this manner is a sure sign of a serious health problem for which prompt professional attention is advised.
Finally, and this is based on the current literature as well as my own observations over the last thirty years, the odds are nearly 95 percent that gum disease will show up if there is a careful, complete examination of the mouth and teeth. A competent, concerned dentist can diagnose this for you, so I encourage you to glean all you can from this blog, and find someone you trust to help minimize, or even eliminate, periodontal disease as a factor in your life. It’s a serious disease, and by applying the appropriate health-enhancing information in this blog, in combination with competent and timely periodontal therapy, you will have little reason to worry about gum disease as a continuing health risk in your life.