Periodontitis, also known as gum disease and pyorrhea, is a set of inflammatory diseases affecting the tissues surrounding the teeth. Periodontitis involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent loss of teeth. Periodontitis is caused by microorganisms that adhere to and grow on the tooth's surfaces, along with an over-aggressive immune response against these microorganisms. A diagnosis of periodontitis is established by inspecting the soft gum tissues around the teeth with a probe (i.e., a clinical examination) and by evaluating the patient's X-ray films (i.e., a radiographic examination), to determine the amount of bone loss around the teeth. Specialists in the treatment of periodontitis are periodontists; their field is known as "periodontology" or "periodontics".
ClassificationThe 1999 classification system for periodontal diseases and conditions listed seven major categories of periodontal diseases, of which 2–6 are termed destructive periodontal disease, because the damage is essentially irreversible. The seven categories are as follows:
- Chronic periodontitis
- Aggressive periodontitis
- Periodontitis as a manifestation of systemic disease
- Necrotizing ulcerative gingivitis/periodontitis
- Abscesses of the periodontium
- Combined periodontic-endodontic lesions
ExtentThe "extent" of disease refers to the proportion of the dentition affected by the disease in terms of percentage of sites. Sites are defined as the positions at which probing measurements are taken around each tooth and, generally, six probing sites around each tooth are recorded, as follows:
SeverityThe "severity" of disease refers to the amount of periodontal ligament fibers that have been lost, termed "clinical attachment loss". According to the American Academy of Periodontology, the classification of severity is as follows:
- Mild: of attachment loss
- Moderate: of attachment loss
- Severe: ≥ of attachment loss
Signs and symptomsIn the early stages, periodontitis has very few symptoms, and in many individuals the disease has progressed significantly before they seek treatment. Symptoms may include:
- Redness or bleeding of gums while brushing teeth, using dental floss or biting into hard food (e.g., apples) (though this may occur even in gingivitis, where there is no attachment loss)
- Gum swelling that recurs
- Spitting out blood after brushing teeth
- Halitosis, or bad breath, and a persistent metallic taste in the mouth
- Gingival recession, resulting in apparent lengthening of teeth. (This may also be caused by heavy-handed brushing or with a stiff toothbrush.)
- Deep pockets between the teeth and the gums ( pockets are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as collagenases)
- Loose teeth, in the later stages (though this may occur for other reasons, as well)
Associated conditionsPeriodontitis has been linked to increased inflammation in the body, such as indicated by raised levels of C-reactive protein and interleukin-6. It is linked through this to increased risk of stroke, myocardial infarction, and atherosclerosis. It also linked in those over 60 years of age to impairments in delayed memory and calculation abilities. Individuals with impaired fasting glucose and diabetes mellitus have higher degrees of periodontal inflammation, and often have difficulties with balancing their blood glucose level owing to the constant systemic inflammatory state, caused by the periodontal inflammation. Although no causal association was proven, a recent study showed correlation between chronic periodontitis and erectile dysfunction.
CausesPeriodontitis is an inflammation of the periodontium, i.e., the tissues that support the teeth. The periodontium consists of four tissues:
- gingiva, or gum tissue,
- cementum, or outer layer of the roots of teeth,
- alveolar bone, or the bony sockets into which the teeth are anchored, and
- periodontal ligaments (PDLs), which are the connective tissue fibers that run between the cementum and the alveolar bone.
MechanismAs dental plaque or biofilm accumulates on the teeth near and below the gums, there is a shift in the composition of the biofilm from essentially streptococcus to an actinomyces dominant plaque. Motile bacteria is also seen more frequently.Listgarten MA, Hellden L. "Relative distribution of bacteria at clinically healthy and periodontally diseased sites in human" J Clin Periodontol 1978; 5:115–32.> As this happens, inflammation sets in the gingiva. Initially, this takes the form of gingivitis, which represents inflammation confined to the soft tissues above the bone level. Inflammation in the gingiva can remain at the gingivitis level for a long period and will not progress to periodontitis, unless in the presence of local conditions or generalized host susceptibility.Offenbacher, S. (1996). "Periodontal diseases: pathogenesis". Ann. Periodontol. 1, 821–78. When this shift occurs, the immune system's response to plaque accumulation shifts from a predominantly neutrophilic mediated response to lymphocytic and plasma cell-mediated response.Page R, Schroeder HE. "Pathogenesis of inflammatory periodontal disease. A summary of current work" Lab Invest 1976; 33:235–49.> Clinically, the gingiva presents swelling, redness and a tendency to bleed. This modifies the environment, leading to changes in the composition of the biofilm itself. As this happens, a predominantly gram-negative environment is established, with periodontal pathogens emerging. These include A. actinomycetemcomitans, the red complex bacteria (P. gingivalis, T. forsythia, T. denticola) and to a lesser extent the orange complex bacteria (F. nucleatum, P. micros, P. intermedia, P. nigrecens, E. nodatum and S. constellates).Socransky SS, Haffajee AD, Cugini MA, Smith C, Kent RL Jr. "Microbial complexes in subgingival plaque" J Clin Periodontol 1998; 25:134–44. Strongest bacterial association to chronic periodontitis is with P. gingivalis. Numerous virulence factors have been identified for this pathogen. This allows P. gingivalis to elude defense mechanism and perpetuate inflammation inside the periodontium. Prolonged inflammation in the periodontium leads to an apical shift in the attachment of the gingiva to the tooth with deepening pockets and bone loss around the teeth. Untreated periodontitis progresses unevenly over time but results in loss of function, tissue destruction, and tooth loss.
PreventionDaily oral hygiene measures to prevent periodontal disease include:
- Brushing properly on a regular basis (at least twice daily), with the patient attempting to direct the toothbrush bristles underneath the gumline, helps disrupt the bacterial-mycotic growth and formation of subgingival plaque.
- Flossing daily and using interdental brushes (if the space between teeth is large enough), as well as cleaning behind the last tooth, the third molar, in each quarter
- Using an antiseptic mouthwash: Chlorhexidine gluconate-based mouthwash in combination with careful oral hygiene may cure gingivitis, although they cannot reverse any attachment loss due to periodontitis.
- Using periodontal trays to maintain dentist-prescribed medications at the source of the disease: The use of trays allows the medication to stay in place long enough to penetrate the biofilms where the microorganism are found.
- Regular dental check-ups and professional teeth cleaning as required: Dental check-ups serve to monitor the person's oral hygiene methods and levels of attachment around teeth, identify any early signs of periodontitis, and monitor response to treatment.
- Microscopic evaluation of biofilm may serve as a guide to regaining commensal health flora.Bonner M. To Kiss or Not to Kiss. A cure for gum disease. Amyris Editions, 2013 EAN : 978-28755-2016-6
Managementdepicts the teeth of the lower left quadrant, exhibiting generalized severe bone loss of 30–80%. The red line depicts the existing bone level, whereas the yellow line depicts where the gingiva was located originally (1–2 mm above the bone), prior to the patient developing periodontal disease. The pink arrow, on the right, points to a furcation involvement, or the loss of enough bone to reveal the location at which the individual roots of a molar begin to branch from the single root trunk; this is a sign of advanced periodontal disease. The blue arrow, in the middle, shows up to 80% bone loss on tooth #21, and clinically, this tooth exhibited gross mobility. Finally, the peach oval, to the left, highlights the aggressive nature with which periodontal disease generally affects mandibular incisors. Because their roots are generally situated very close to each other, with minimal interproximal bone, and because of their location in the mouth, where plaque and calculus accumulation is greatest because of the pooling of saliva, mandibular anteriors suffer excessively. The split in the red line depicts varying densities of bone that contribute to a vague region of definitive bone height.]] The cornerstone of successful periodontal treatment starts with establishing excellent oral hygiene. This includes twice-daily brushing with daily flossing. Also, the use of an interdental brush is helpful if space between the teeth allows. For smaller spaces, products such as narrow picks with soft rubber bristles provide excellent manual cleaning. Persons with dexterity problems, such as arthritis, may find oral hygiene to be difficult and may require more frequent professional care and/or the use of a powered toothbrush. Persons with periodontitis must realize it is a chronic inflammatory disease and a lifelong regimen of excellent hygiene and professional maintenance care with a dentist/hygienist or periodontist is required to maintain affected teeth.
Initial therapyRemoval of microbial plaque and calculus is necessary to establish periodontal health. The first step in the treatment of periodontitis involves nonsurgical cleaning below the gumline with a procedure called scaling and root planing. This procedure involves the use of specialized curettes to mechanically remove plaque and calculus from below the gumline, and may require multiple visits and local anesthesia to adequately complete. In addition to initial scaling and root planing, it may also be necessary to adjust the occlusion (bite) to prevent excessive force on teeth that have reduced bone support. Also, it may be necessary to complete any other dental needs, such as replacement of rough, plaque-retentive restorations, closure of open contacts between teeth, and any other requirements diagnosed at the initial evaluation.
ReevaluationMultiple clinical studies have shown nonsurgical scaling and root planing are usually successful if the periodontal pockets are shallower than . The dentist or hygienist must perform a re-evaluation four to six weeks after the initial scaling and root planing, to determine if the patient's oral hygiene has improved and inflammation has regressed. Probing should be avoided then, and an analysis by gingival index should determine the presence or absence of inflammation. The monthly reevaluation of periodontal therapy should involve periodontal charting as a better indication of the success of treatment, and to see if other courses of treatment can be identified. Pocket depths of greater than which remain after initial therapy, with bleeding upon probing, indicate continued active disease and will very likely lead to further bone loss over time. This is especially true in molar tooth sites where furcations (areas between the roots) have been exposed.
SurgeryIf nonsurgical therapy is found to have been unsuccessful in managing signs of disease activity, periodontal surgery may be needed to stop progressive bone loss and regenerate lost bone where possible. Many surgical approaches are used in the treatment of advanced periodontitis, including open flap debridement and osseous surgery, as well as guided tissue regeneration and bone grafting. The goal of periodontal surgery is access for definitive calculus removal and surgical management of bony irregularities which have resulted from the disease process to reduce pockets as much as possible. Long-term studies have shown, in moderate to advanced periodontitis, surgically treated cases often have less further breakdown over time and, when coupled with a regular post-treatment maintenance regimen, are successful in nearly halting tooth loss in nearly 85% of patients.
MaintenanceOnce successful periodontal treatment has been completed, with or without surgery, an ongoing regimen of "periodontal maintenance" is required. This involves regular checkups and detailed cleanings every three months to prevent repopulation of periodontitis-causing microorganisms, and to closely monitor affected teeth so early treatment can be rendered if the disease recurs. Usually, periodontal disease exists due to poor plaque control, therefore if the brushing techniques are not modified, a periodontal recurrence is probable.
Alternative treatmentsPeriodontitis has an inescapable relationship with subgingival calculus (tartar). The first step in any procedure is to eliminate calculus under the gum line, as it houses destructive anaerobic microorganisms that consume bone, gum and cementum (connective tissue) for food. Most alternative "at-home" gum disease treatments involve injecting antimicrobial solutions, such as hydrogen peroxide, into periodontal pockets via slender applicators or oral irrigators. This process disrupts anaerobic micro-organism colonies and is effective at reducing infections and inflammation when used daily. A number of other products, functionally equivalent to hydrogen peroxide, are commercially available, but at substantially higher cost. However, such treatments do not address calculus formations, and so are short-lived, as anaerobic microbial colonies quickly regenerate in and around calculus. Doxycycline may be given alongside the primary therapy of scaling (see § initial therapy). Doxycycline has been shown to improve indicators of disease progression (namely probing depth and attachment level). Its mechanism of action involves inhibition of matrix metalloproteinases (such as collagenase), which degrade the teeth's supporting tissues ( periodontium) under inflammatory conditions. To avoid killing beneficial oral microbes, only small doses of doxycycline (20 mg) are used. Local deliveries of antibacterial agents into periodontal pockets have been extensively studied since 1979.This mode of drug delivery avoids most of the problems associated with systemic therapy, limiting the drug to its target site, and hence achieving a much higher concentration. Local drug delivery agents in treatment of periodontitis has gained acceptance and popularity compared to systemic drugs due to decreased risk in development of resistant flora, opportunist infection, and side effects. Tetracycline as local drug delivery agent is effective, user-friendly, and cost-effective and can be more widely used in nonsurgical periodontal therapy.
PrognosisDentists and dental hygienists measure periodontal disease using a device called a periodontal probe. This thin "measuring stick" is gently placed into the space between the gums and the teeth, and slipped below the gumline. If the probe can slip more than below the gumline, the patient is said to have a gingival pocket if no migration of the epithelial attachment has occurred or a periodontal pocket if apical migration has occurred. This is somewhat of a misnomer, as any depth is, in essence, a pocket, which in turn is defined by its depth, i.e., a 2-mm pocket or a 6-mm pocket. However, pockets are generally accepted as self-cleansable (at home, by the patient, with a toothbrush) if they are 3 mm or less in depth. This is important because if a pocket is deeper than 3 mm around the tooth, at-home care will not be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach in depth, the hand instruments and cavitrons used by the dental professionals may not reach deeply enough into the pocket to clean out the microbial plaque that causes gingival inflammation. In such a situation, the bone or the gums around that tooth should be surgically altered or it will always have inflammation which will likely result in more bone loss around that tooth. An additional way to stop the inflammation would be for the patient to receive subgingival antibiotics (such as minocycline) or undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so they become 3 mm or less in depth and can once again be properly cleaned by the patient at home with his or her toothbrush. If patients have 7-mm or deeper pockets around their teeth, then they would likely risk eventual tooth loss over the years. If this periodontal condition is not identified and the patients remain unaware of the progressive nature of the disease, then years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain. According to the Sri Lankan tea laborer study, in the absence of any oral hygiene activity, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment (>2 mm/year). About 80% will suffer from moderate loss (1–2 mm/year) and the remaining 10% will not suffer any loss. --> -->
Epidemiologyfor periodontal disease per 100,000 inhabitants in 2004.
- Canadian Academy of Periodontology — What is periodontitis?
- Periodontal disease in dogs and cats — Blue Cross Animal Hospital's write up on periodontal disease.