Those Pesky Perio Problems

Barbara Tritz
· May 13, 2019 ·

15 minutes

Recently, on Facebook, a hygienist posted a question to the group: “What mouthrinse should I have my patient use to help with a bleeding gum, moderate tartar build up and a bad breath problem?” Ah, were it that easy; a simple mouth rinse switch could wash all those problems down the drain. Rather than try to answer that question in one of those little bubbles on Facebook, I decided to give her and you, my wonderful readers, an answer here. Pesky perio problems are everywhere. Too bad mouthwash won’t fix the problem.

Perio Problems

Periodontal disease, or as you may know it, gingivitis, is a symptom of a much bigger problem. Bleeding gums signal a systemic issue. Something is wrong not only in the mouth, but also the body. It’s just showing up first in the mouth. Simply changing mouthwash won’t make much difference. Let’s get to the root (sorry about the pun) of the matter.

First, Some Oral Health History

Prehistoric man did not brush or floss, yet did not have oral issues. He did not even have a name for it, because it did not exist in his world. Plaque, that soft stuff that accumulates on our teeth, is full of bacteria. Prehistoric man had plaque, yet little to no dental disease. What changed for modern man? Our diet changed, big time. We went from hunter/gatherer to farmer about 12,000 years ago. This shifted the bacteria in our mouths and gut. It became less diversified. The carbohydrates we started eating, and then in recent times the addition of refined sugar and processed foods, has really shifted our bacteria, our “microbiome” to an entirely new and, unfortunately, pathogenic level. Now, with the addition of more acidic foods and drinks, along with antimicrobials, antibiotics, disinfectants, smoking, and heavy metals, our microbiome, a finely tuned microbial ecosystem, is often no longer in balance.

Truth is, we need our little bacterial buddies to stay healthy. Wiping them out with antibacterial rinses and antibiotics is not the best way to maintain health in either the mouth or body. Bad bacteria do live alongside our good bacteria, just in smaller numbers, and stay that way as long as things stay “in balance”. We call this the threshold level. Our clinical goal should be to establish a healthy bacterial microbiome community, not wipe them all out. We NEED that bacteria biodiversity.

Beating Bleeding Gums

Oral health and wellness starts by looking at all three issues: oral hygiene, gut dysbiosis (diet), and host genetic response. We can’t cure the one without addressing the other two.

Oral Hygiene Primer

Oral hygiene- ah, if only, if only there were the perfect mouth rinse, toothbrush, and toothpaste that really cured or prevented gum disease. There really is not, despite all the claims. Each brush, paste, and rinse has properties that address various problems or issues such as sensitive teeth, reduce plaque build up, whiten teeth, “cure” bad breath, and remineralize teeth. It just depends what you want your products to do. Mostly, I think people pick toothpastes that taste good. Nothing wrong with that (as long as it’s not too abrasive), especially if it helps you brush longer.

For me, at home, the first goal is get all the plaque off every 12 to 24 hours, and not spend 20 minutes in the bathroom doing this. I want to be efficient and effective. The best way to see how good of a job you do is to use disclosing tablets and see what plaque is left on the teeth, gums, tongue, and tissues. Then go back and improve your technique. My mantra to my patients: brush your gums, gently.

Use that toothbrush, investigate floss or other ways to clean in-between teeth and under the gumline. Clean your tongue with a tongue scraper, twice daily. Your throat and tonsils need attention too. That’s where I’d recommend gargling with baking soda water. More on that in a moment.

Is there a magic mouth rinse? Ideally, yes! Your very own healthy, flowing saliva! It contains all the micronutrients your mouth needs to feed your healthy microbiome. Unfortunately, salivary flow is reduced by smoking (tobacco, e-cigs, or cannabis -hello Washington State, it’s really not healthy), medications, systemic illnesses, and mouth breathing. Over 800 medications have reduced saliva flow as a side effect. As I have written in Elixir Fixer for Your Dry Mouth, you won’t notice dry mouth symptoms until it’s flow is 60% reduced. Then, it’s a crisis! Get that saliva flowing for a healthy microbiome. AND! by the way, close your mouth, breathe through your nose. (To check if you are mouth breathing, place a business card between your lips and see how long you can hold it there. When ya drop the card, you’re mouth breathing.)

Help with Healing

Sometimes you need something else to kickstart the healing process. I look towards baking soda water (one cup warm water to one teaspoon baking soda) to raise the pH and kick out the acid loving pathogens (figuratively speaking). Wet baking soda is wonderful. It’s gentle, contrary to popular misconceptions. I also love Dentalcidin with Biocidin. It’s a bio botanical and works well to reduce the bad bacteria. My third favorite antibacterial agent is ozone oil. I must admit it does not taste great but oh my, it works so well to speed healing. Ozone is just super oxygen, and it oxygenates the tissues and plaque. Since these are anaerobic pathogens, it works fast to change that bad bacterial plaque to allow the good guys to move in. (FYI – ozone also works really well at reversing tooth decay.) I also use tools like piksters, softpiks, and extra compact toothbrushes to work these agents in-between the teeth and under the gumline to help reduce the bacteria and fungus that causes infection under the gumline. Oral probiotics (see below) add more good bacteria to help heal bleeding gums and stop the harmful effects of bad bacteria. Magic bullets? No, but all helpful tools to achieving that healthy mouth. Nutrition is also vital. Vitamins like Zinc, Vitamin C, Magnesium, Vitamin D3, Vitamin K2 and Vitamin A are all an important part of improving your immune system and healing gums. Fat soluble vitamins need healthy fat to make’m work.

What about the good bacteria? Yes, lets repopulate them! My favorite probiotics include Probiora, ProbioMax and everything that Dr. Steven Lin recommends. He’s an incredible source of information.

Ever heard of prebiotics? Prevention is always the best – and one of my favorite toothpastes called Revitin is a unique product that is gentle, natural, and contains prebiotics that feed the good bacteria. This revolutionary toothpaste contains vitamins, enzymes and minerals. It does not wipe out all the bacteria, just the bad ones.

What about all those over the counter rinses? I don’t often recommend mouthwash. Many of them are too acidic.
Why does this matter? When the pH of the mouth drops below 5.5 the minerals flow out of the teeth. If you have a favorite mouthrinse, call the company and ask them what the pH of their product is!

(A short science information break here: pH is the symbol for hydrogen ion concentration expressed in numbers. It corresponds to the acidity or alkalinity of an aqueous solution. It ranges from 0 to 14, with 7 being neutral. The pH of the mouth likes to be near 7.0.)

When the bacteria from periodontal disease (or tooth decay) are present, they create an acidic environment and basically poop acid in the mouth. This acid environment then takes minerals out of teeth. We call this demineralization. This is when teeth start to dissolve. That’s not good.

Acidic foods, drinks, (Gasp) mouthwash can also be acidic. A few years ago I contacted companies and got the pH of their products. As a refresher; when the pH of the mouth drops below 5.5, minerals flow out of the teeth.

Here’s my partial list (there are so many more rinses):

  • Scope Mouthwash 5.5
  • Smart Mouth Mouthrinse 4.4
  • Breath RX Mouthrinse 4.6
  • Peroxyl Antiseptic Mouthrinse 3.9
  • The Natural Dentist Anti-gingivitis Rinse 3.3
  • The Natural Dentist 3.7
  • Tom’s of Maine Wicked Fresh Mouthrinse 3.1
  • Smile Guard Orthodontic Brace Relief Rinse 6.1
  • Listerine Total Care Anticavity Mouthrinse 3.5
  • Listerine Zero 4.3
  • Listerine Whitening Vibrant White Pre-Brush Rinse 5.8
  • Listerine Antiseptic Mouthrinse 4.2
  • Act Mouth Rinse 6.0 – 7.6
  • Act Restoring Mouthrinse 6.6
  • Crest Pro Health Toothpaste 5.6
  • Crest Pro Health Mouth Rinse 3.8 to 4.8
  • Crest 3-D White Multi Care Whitening Rinse 5.4
  • Therabreath Oral Rinse 9.9
  • Carifree Treatment Rinse 11

After a swig of one of these products, it takes the mouth between 30 to 60 minutes to return to a neutral pH of 7.0. This is called the Stephan Curve. (Soda pop, diet soda, coffee, tea, and many foods have the same effect.) Here’s something to consider – many people swish just before bed. Due to their low salivary flow and mouth breathing, their mouths remain acidic ALL NIGHT LONG! It’s then no surprise when tooth decay becomes an issue, especially along the gumline.

For my cavity-prone patients, I recommend they test their pH first thing in the morning, and then periodically throughout the day to get a sense of how acidic their mouth remains. Get pH paper that can be used on saliva.

Another point: Swishing really doesn’t go where the plaque biofilm is most destructive. It can’t reach underneath the gumline where the biofilm is hanging out, under crevices/fillings/crown margins or in-between teeth (despite what the commercials would have you believe). All these out-of -reach spots allow the bacteria and other pathogens to live, grow, thrive and repopulate. Swishing just can’t get there from here, so to speak.

Really Addressing the Infection

Use a phase Contrast microscope,
Seeing is Believing

As many of you know, I use a chairside phase contrast microscope to monitor the bacterial microbiome in my patients’ mouths. If there are lots of the bad guys on that microscope monitor, I want to change things, and fast. I start with the baking soda water I mentioned above, but if that’s not cutting it, I move up the ladder, so to speak. I do happen to like “bleach water,” one part bleach to 25 parts water (more is not necessarily better) and, I admit, it is an acquired taste. However, I do not recommend using it for long, perhaps a month. Again, I don’t want to kill all the bacteria and pathogens, just get things back to homeostasis. In addition to upping their homecare routine and products, the patient also must have the tartar and plaque removed professionally. More on that in a moment. Bottom line: Test, treat, and retest, repeat, until things are healthy. (And do that testing with a dental team that will help you! Don’t go it alone!)

Other Things to Consider when Treating Gum Disease

In addition to tartar and plaque biofilm removal, we need to look beyond the teeth to the airway, and how the patient breathes. Mouth breathing can be responsible for much of our periodontal issues. Dry mouth, fragile tissues, thick gooey plaque, underdeveloped facial growth causing crowding, and sleep disordered breathing all play a big role in teeth and gum problems. This leads to impaired mouth syndrome and putting out fires at every appointment.
It’s time to stop playing dental “whack-a-hole.” Get thyself to an Orofacial Myofunctional Therapist and get an assessment!

Dental Infection Wound Management

Here’s the best way to use the above solutions: I recommend my patients place either the baking soda water or the bleach water in their water irrigators (such as a Waterpik or Hydroflosser).

Here’s the rub: by placing anything but water in the irrigator, you void the warranty. My goal is to treat the infection under your gums like a wound. Cleanse, flush, and medicate. Treat the infection under the gumline like a wound, because it is! Can you do that with only water? No. Just like a cut on your leg, it needs more than plain water to medicate it. The bad guys are taking over and need a boot out. Use your irrigator pointing the tip under the gumline and around crown margins – gently. (When done, flush the tank with clean water after EVERY use so the baking soda or bleach water solutions don’t ruin the tubing.) Getting a new unit is way cheaper than the cost of gum disease. Remember, gum disease is an infection under the gumline. If your gums are inflamed, your arteries are ALSO inflamed!! Gum infection does not stay in your gums, it invades your entire body. Treat it as you would any wound. Flush, medicate and cleanse.

Professional Care

Love looking at bugs!

Recently, I took plaque samples from both the tongue and then a tonsil stone (Those white things that accumulate in the tonsil crevices. They have the texture of cottage cheese and are verrry smelly.) and put these samples on a microscope slide. Hope my attached video makes it you! OH BOY were they also full of pathogens! Bottom line, you have to also scrape your tongue to reduce the bacteria that lives at the base of your tongue follicles. Brushing your tongue is NOT sufficient to get what lives there out. You have to squeeze the plaque bacteria out from these follicles. Daily. Your breath will smell better for it.

How do we clean out tonsil stones? Depends. An ear, nose and throat doc is probably the best person to help you clean out those tonsil stones, also called tonsilloliths. Best I can suggest for home treatment is gargling with baking soda water. Gargling is also a very good myofunctional exercise, by the way… For ease of use I like Alka-Whites. These are flavored, pre-measured baking soda tablets that dissolve in warm water and dispense from a small container. No fuss, no muss, and NO mess. Getting rid of the tonsil stones is not only more healthy, but also improves bad breath!

Premeasured Baking soda with Turmeric. Dissolve completely in HOT water, add to your irrigator, add more warm water and then flush tank after use.

What is Tartar?

Plaque is that soft stuff that makes you feel like you’re wearing teeth mittens. You can brush, scrape, pick, polish and generally remove this at home. When plaque is left on your teeth, it starts to harden and petrify. That’s what’s called tartar, or in the dental jargon, calculus. And, yes, we have all heard the jokes about “it’s as hard as the math calculus.” Calculus is similar to a coral reef for the bacterial pathogens, and is a nice comfy home for them. It’s at this point that you probably need professional help getting it off. I term this “gum health therapy” or perio therapy. The idea is to get in there and remove all the tartar.

Tartar

You need to have all the tartar removed, period. If not, the infection remains. It’s like a sliver under your skin. it irritates and infects tissues. Bacteria lives within the tartar and keeps things infected. How do we know we removed ALL the tartar? Unless we can see it, we don’t. Hygienists do their best. We have many classes and much practice on “feeling” the teeth to be sure we did a good job. In order to get a hygiene license we are tested on our ability to remove it “all.” Sad truth is, much tartar is left behind. Relying on blind scaling and hope is not a good treatment plan.

Seeing is Believing

Hard to see but at the 6:00 position is a chunk of tartar

What’s a person to do? First, a story: About 18 years ago, I got a brochure in the mail that rocked my world. It was an advertisement for a product called a perioscopy unit. It was a microscopic camera that would project on a video monitor. It could go under the gumline and see tartar, cracks in teeth, decay, and whatever else was there. Revolutionary! I knew that product was a big game changer. Unfortunately, it was $20,000 and I was a very part-time hygienist, as I had little children at home. My goal was to learn and use one, someday.

Seeing tartar makes it easy to remove it gently

Fast forward 18 years, “someday” has arrived! I can finally report I now use a perioscopy unit and LOVE it! There is definitely a learning curve, so I’m somewhere along that curve and am very enthusiastic about it. It truly is the perfect and really, only way to do gum therapy. There is so much junk under the gumline and unless you can see it, you either leave tartar and biofilm, or over scale and damage tooth root structure. Why this has not become the standard of care is a good question. Maybe, if patients start demanding better non surgical gum therapy, this would finally, 20 years after its first debut, catch on!! It’s all within dental hygiene’s legal practice act and way better than surgery. Gum surgery should be a last resort, and even better, extinct.

Additional Periodontal Disease Treatment

In addition to removing the tartar and biofilm, I also use ozone gas to disinfect under the gumline. There are lots of bad pathogens within the gum tissues, and even into the tooth tubules. Gas can go where water or oil cannot. To complete the healing process, I then place an enamel matrix protein to help healing and reattachment. We reevaluate the tissues within two weeks. My microscope is the perfect crystal ball to see who and what is living beyond the gumline. Test, treat and retest. Seeing is truly believing.

Part Two- The Unhappy Gut

When I was in school, and throughout all my years as a clinical hygienist, no one ever talked about digestion and what’s called “gut dysbiosis”. Was that ever a profound revelation for me! I had many patients who did exactly what I recommended, yet still had bleeding, perio problems, bone loss, and many bad pathogens on the microscope. Truth was, I was as discouraged as my patients, and felt like a bit of a fraud. What was I doing wrong? Why were my wonderful words of oral wisdom failing my patients?

Little did I realize until recently, gum disease and periodontal problems start with what we put into our guts. Our digestive system is the true crux of our oral and systemic health. The health of the gut as well as the nutrition of the food matters as much if not more than our oral hygiene. All new information to me! I have written three blog posts on the gut, and nutrition for a healthy mouth. I won’t rewrite that all here. Just doing a short review. If you have gum disease, you won’t heal until you address any nutritional deficiencies, micronutrient problems or absorption issues. Remember, it’s not all about the plaque, the gut is the second leg of this stool.

What is gut dysbiosis? Malabsorption, maldigestion, small bowel overgrowth of bacteria, inappropriate bacteria in the gut, leaky gut and bacterial or yeast undergrowth or overgrowth. The stomach lining is only one cell thick and can have problems digesting our foods. They call this leaky gut. Bacteria, undigested food particles, and endotoxin from pathogens, and dead bacteria flood your immune system. The stomach loses its ability to be an effective barrier. Leaky gut has been linked to IBS, Autoimmunity, Type 2 Diabetes, and even Alzheimer’s disease. The gut dysbiosis sends inflammatory signals all over your body! More research is needed, but bleeding gums and periodontal problems could be one of the first signs of gut dysbiosis.

New Oral – Gut Research

Here’s more food for thought! A healthy mouth microbiome seeds the gut with good bacteria. SO vital. But, recent research also points out that periodontal disease bacteria can also translocate to the gut, contributing to gut dysregulation. I wonder which came first – periodontal disease bacteria or gut dysbiosis? Or does one seed the other and it progresses aggressively?

Bad Breath

Bad breath – so many causes. It can be the result of acid reflux, mouth breathing, post nasal drip, liver disease, diabetes, asthma, bowel obstruction and of course perio disease problems or tooth decay. Tongue cleaning twice daily certainly reduces odor. Find the root cause and treat accordingly. Salivary diagnostics are a great place to start. The test looks at the bacteria and can point to oral causes or systemic causes. Test! Why, oh why is the dental profession so reluctant to prescribe testing to get to the root of the matter. Medicine does it all the time. It’s about time we do as well.

Establishing the Microbiome – More Questions than Answers

Babies born vaginally acquire a healthy microbiome from their mother. C-section babies don’t get the same support, so what can we do to help them out? Did the rise of C-sections in the US have anything do with the rise in periodontal disease (50% of the population in the USA have some level of gum disease) and IBS sufferers? Things to think about and read further research.

Gene Play

The third leg of this gum disease therapy is your genetic makeup. Your genes however, are not your destiny. They can be altered. Genetic testing can and should be done as part of a periodontal gum therapy program. It’s better to be prepared with information so you can fight this battle with every resource within your power.

I personally think everyone should have a risk profile done as a young person so that the proper preventive strategies can be implemented early. Recently, I have, unfortunately, seen two young ladies in their early to mid 30’s with severe aggressive gum disease. It’s rare. There’s no way of distinguishing its onset from the early stages of gingivitis when they were much younger. Then, like a runaway train, it takes off, leaving bone loss destruction in its wake. Because gum disease is not painful, people don’t know they have it. Thus, the reason I use my microscope on every single patient, no matter the age and every single hygiene appointment. Ideally, we should also be doing salivary diagnostics as well. Cost is a factor, but really it shouldn’t be. It’s money (and teeth) saved in the long run! Salivary diagnostics can tell us a lot about the person’s risk level and bacterial/fungal /viral profiles. Sorta like a crystal ball to the heart of the matter! Armed with all this information, we can then take much more preventive action BEFORE bone loss occurs. There are medications and protocols I would use if I saw you were at risk genetically for bone loss. Going up the proverbial totem pole of procedures and prevention.

Again, your genes are not your destiny. Be armed with knowledge!

To Review!

To swish or not to swish, that was the question.

If you want minty breath, go ahead. Just be sure it’s not too acidic. Don’t rely on it to fix any gum infection or the bad breath. Find the real cause(s) and treat that. It’s unfortunately not a simple fix, and one that takes more than a quick trip to the hygienist every six months. Put on your dental super sleuth detective hat and find the real issues. Addressing the infection means looking beyond the teeth/gums to the gut, nutrition, genes, breathing, airway, sleep apnea, facial development, immune system, and muscles. It may mean more frequent recare to change that microbiome and raise the pH. It means test, treat, and retest as you figure out where the real problem lies. It may mean sending the patient to a functional medicine doctor to look beyond the teeth. Remove ALL the tartar and plaque. Perioscopy is so cool and so important. Learn it.

Patients, you are a big part of the solution, but just know your dental insurance will probably not cover this kind of complete, comprehensive care. They don’t care if your gums are infected. They cover two “cleanings” a year and that’s about all. Instead, work with your incredible, wonderful and caring dental superhero and get well! No more Perio problems for you!

My goal for each and every patient is to help them be their healthiest, best, self. Be the healer and be healed!

Happy Mother’s Day.

Sincerely,

Barbara

~Barbara

Your Dental Hygiene Super Sleuthing, Super Hero

Hello, I'm Barbara Tritz

Unveiling the Stories Behind Dental Hygiene

Loving science, especially biology, from an early age, Barbara is a registered dental hygienist, certified biological hygienist, and orofacial myofunctional therapist. In 2019, she received the Hu-Friedy/ADHA Master Clinician Award from the American Dental Hygienist Association.

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