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Periodontitis

Periodontitis is a medical term that refers to the inflammation of the periodontium (tissues surrounding the tooth). It affects the tissues that support the teeth and include both the gums and nearby ligaments. Also, it can also affect the alveolar bone which supports the base or root of the teeth. The disease progresses with the passing of time, deteriorating these important structures. Therefore, the teeth lose grip and can move easily, they can even end up falling. This is the most common cause of tooth loss in adolescents and adults.

“Periodontitis is prevalent in adults but may also occur in children and adolescents; the amount of tissue destruction is generally commensurate with dental plaque levels, host defenses and related risk factors. A key feature of both chronic and aggressive periodontitis is site specificity: the characteristic periodontal pockets and the accompanying attachment loss and bone loss do not occur uniformly throughout the dentition. Consequently, the definition of a case of periodontitis heavily depends on which specific thresholds for both disease extent (the number of affected teeth) and disease severity (the magnitude of pocket depth, clinical attachment loss and alveolar bone loss at the affected teeth) are used. Because no sets of thresholds have been consistently used in epidemiological studies, estimates of the prevalence of periodontitis across populations vary substantially.”1

Generalized severe chronic periodontitis
Fig. 1. Generalized severe chronic periodontitis. Reprinted from “Prevention and Treatment of Periodontal Diseases in Primary Care” Dental Clinical Guidance (2014). http://www.sdcep.org.uk/wp-content/uploads/2015/01/SDCEP+Periodontal+Disease+Full+Guidance.pdf

The most frequent signals that characterize this alteration are the following

  • Halitosis (bad breath). “The most common spaces where halitosis originates are bacterial niches, such as the posterior tongue dorsum, periodontal tissue sites (including the gingival sulcus, pathological pockets and interdental spaces), defective dental restorations, deep carious lesions and poorly maintained dentures. Other pathological conditions from oral sources that can influence or provoke bad breath include xerostomia, dental abscesses, candidiasis, oral tumors, necrotizing periodontal diseases and pericoronitis. Oral malodor is primarily caused by the microbial degradation of both sulfur-containing and nonsulfurcontaining amino acids derived from proteins in exfoliated human epithelial cells and white blood cell debris, or present in plaque, saliva, blood and tongue coatings. The most active bacteria in this process are Porphyromonas gingivalis, Treponema denticola and Tannerella forsythia, anaerobic gram-negative bacteria that also have been associated with periodontal disease.”2
  • Changes in the color of the gums, where they will show a bright red or slightly purple color. The patient may also suffer sensitivity and pain in the area that gets worse with progression.
  • Frequent bleeding and inflammation of the gums (gingivitis). Hemorrhage may occur during brushing or spontaneously. “Gingival bleeding is perhaps the most common manifestation of the inflammatory process that presents daily at the dental clinic. Chronic marginal gingivitis accounts for most of this and is usually managed with simple periodontal therapy followed by oral hygiene instructions. Significant gingival bleeding that is of sudden onset and difficult to control, warrants further investigation.”3
  • Gingival recoil, which describes damaged and retracted gums, causing the teeth to appear more elongated than normal.
  • Loose teeth

 

What follows are the most frequent triggers of this disease

Gingivitis

It’s an abnormal inflammation of the gums. If left untreated it can aggravate into periodontitis. It usually develops from the accumulation of plaque and tartar at the base of teeth. Finally, microbes accumulate and begin to produce toxins that can cause irreparable damage. “Occurs mainly due to plaque accumulation and factors responsible for plaque formation and propagation are poor dental and oral hygiene. It is early and reversible disease. In this disease gum become red, swollen and bleed easily while provocation like touching, brushing or sometimes even spontaneous dental/gum bleeding happens. Gingivitis is a mild form of gum disease which can be reversible by daily brushing, flossing and regular cleaning by dentist, this procedure is called scaling along with proper medication. In gingivitis there is no tissue or bone loss. So it is essential to treat gingivitis as early as possible so that we can prevent the Periodontitis (advanced gum disease).”4

Surgical exposure of bone loss
Fig. 2. Surgical exposure of bone loss (arrow) resulting from periodontitis adjacent to a maxillary anterior tooth. Reprinted from “Periodontal diseases.” The lancet, 366(9499), 1809-1820. By Pihlstrom, B. L., Michalowicz, B. S., & Johnson, N. W. (2005).

Smoking

This habit damages the tissues that form the oral cavity, increasing the risk of developing certain diseases. “Smokers are much more likely than non-smokers to develop periodontitis. Moreover, oral smokeless tobacco can lead to gingivitis, loss of tooth support, and precancerous gingival leucoplakia at the site of quid placement. The risk of periodontal disease in longterm smokers is equal to that of lung cancer, and smoking has a strong negative effect in response to periodontal treatment and other oral surgical interventions. In the USA, about half the risk of periodontitis can be attributable to smoking. By contrast with tobacco use, a small but significant association exists between alcohol consumption and loss of periodontal support.”5

“All forms of tobacco (cigarettes, cigars, pipes, bidis, snuff, snus, and chewing tobacco) are associated with a variety of oral diseases and disorders. The most serious oral consequence of tobacco use is an increased risk for cancer of the oral cavity. Tobacco use is also a primary etiologic factor for periodontal disease (including increased pocket depth, poor prognosis of therapy, failure of dental implants and tooth mobility), poor wound healing following oral surgery and gingival recession. Cosmetic concerns include halitosis, staining of teeth and restorations, a reduced taste sensation, tooth abrasion and gingival pigmentation. Tobacco use also has a significant impact on the overall health of the nation’s population. Dentists have the opportunity to play a role in promoting healthy lifestyles by incorporating tobacco cessation programs into their practices.”6

Hormonal alterations

The gums become more sensitive and susceptible to future dental pathologies.

Diabetes

Periodontitis can appear as a precocious symptom of this disease. “High glucose concentration leads to the formation of advanced glycation end – products (AGEs), which play a key role in the periodontium. They cause changes and reduced collagen synthesis, apoptosis of periodontal fibroblasts and osteoblasts, conditions leading to reduced bone reconstruction and osteopenia. They also interact with endothelial cells by increasing oxidative stress in mucosal tissues of diabetic patients. Also, AGEs increase the concentration of interleukin and tumor necrosis factor (TNF-α), which contributes to the deterioration of PD. Finally, advanced glycation end – products affect neutrophil polymorphonuclear leukocytes (PMN), contributing to decreased chemotaxis, adhesion and phagocytic ability of the latter.”7

Certain pathologies

For example, AIDS and various types and subtypes of cancer can present this alteration throughout its evolution. “Chronic gingivitis and periodontitis are the most common forms of gingival and periodontal disease in HIV-infected individuals. The relationship between periodontal health and the prevalence and severity of chronic gingivitis and periodontitis among immunosuppressed HIV infected individuals remains controversial. Some authors have demonstrated no significant difference in gingival and periodontal status among the HIV seropositive, those with AIDS, and the general population. Many studies have been conducted in order to detect the frequency of HIV-associated periodontal disease and its prevalence varies from 0 to 47%. Studies have associated a severe attachment loss or increased periodontal attachment loss in individuals with more advanced stages of AIDS. However, an association between periodontal disease and immune status in the HIV-infected individual is not yet clear”8

Certain medications

Some drugs cause a reduction in the amount of saliva produced by the oral mucosa. Saliva contains certain substances that protect our tissues from microbes. Less saliva means less defensive resources for our oral health. “The role of saliva in the neutralization of acids produced within the dental plaque and its involvement in the remineralization of demineralized enamel areas is well-documented. The results of six controlled clinical caries studies have indicated that chewing sugar-free gum after meals results in a significant reduction in the formation of dental caries. This effect also is caused by increased salivary flow attributed to the chewing process rather than to the sorbitol in these chewing gums.”9

Genetic factor

If there is a relative in your family who has suffered from this problem, you are then more likely to develop the condition.

Your dentist or specialist can carry out a series of examinations or medical tests to identify the origin of the alterations. The most common are a physical exam, allowing the dental expert to appreciate the level of abnormal recoil of the gums. Also, he/she can evaluate the accumulation of dental plaque or tartar on the roots. The other test is X-rays to obtain an image of the affected area where the reduction of the support of the teeth (or its absence) is appreciated.

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).”10

“The primary goal of periodontal therapy is to preserve the natural dentition by achieving and maintaining a healthy functional periodontium. It consists of patient motivation and oral hygiene instructions as well as mechanical removal of supra and subgingival plaque and calculus deposits, correction of plaque-retentive factors (eg. overhangs) and risk factor modification (eg. smoking cessation). Many terms have been used to describe this process such as nonsurgical periodontal therapy, initial periodontal therapy, hygiene phase therapy, mechanic therapy and cause-related periodontal therapy. Many adjunctive treatment modalities have been clinically used and investigated for their efficacy.”11

“Aggressive periodontitis are rare pathologies, mainly found in patients of African ethnicity or African descent. Early onset, family aggregation and rapid progression are usually their main characteristics. Consensus have been established on the forms of the disease: localized and generalized. Immunological, genetic and microbiological factors are strongly associated, and seem to determine the two presentation forms. The concept of exclusivity of the periodontal pathogen Aggregatibacter actinomycetemcomitans in aggressive periodontitis has been partially depreciated. Controversies have also arisen about the classification of aggressive periodontitis as a clinical entity independent from chronic periodontitis, because they share a common genetic basis, which would explain the phenotypic expression of the same disease. The diagnostic and therapeutic protocol does not differ much from that of other periodontal diseases; however special attention should be paid to family history, systemic condition, early diagnosis, specialized management by a periodontist, plaque control and frequent monitoring of periodontal pockets.”12

To effectively eliminate periodontitis, different recommendations are carried out. First, all tartar or dental plaque need to be removed from the surface of the teeth. This is done through a brief scraping. Second, good dental hygiene is imperative. This can be achieved through frequent brushing, flossing, the use of mouthwash and dental checkups every 6 months. Thirdly, avoid smoking and alcohol consumption, along with a healthy lifestyle that includes proper diet and moderate physical exercise. If you suspect periodontitis, check immediately with your dentist or specialist to avoid major complications that the disease brings. Prevention is key.

 

References:

(1) Kinane, D. F., Stathopoulou, P. G., & Papapanou, P. N. (2017). Periodontal diseases. Nature Reviews Disease Primers, 3, 17038. Available online at https://www.researchgate.net/publication/318158042_Periodontal_diseases

(2) De Geest, S., Laleman, I., Teughels, W., Dekeyser, C., & Quirynen, M. (2016). Periodontal diseases as a source of halitosis: a review of the evidence and treatment approaches for dentists and dental hygienists. Periodontology 2000, 71(1), 213-227. Available online at http://www.unitau.br/files/arquivos/category_1/Artigo_1_1487774735.pdf

(3) Gleeson, P. (2002). Spontaneous gingival haemorrhage: Case report. Australian dental journal, 47(2), 174-175. Available online at https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1834-7819.2002.tb00324.x

(4) Singh, B., & Singh, R. Gingivitis–A silent disease. Available online at https://www.researchgate.net/publication/288115367_Gingivitis_-_A_silent_Disease

(5) Pihlstrom, B. L., Michalowicz, B. S., & Johnson, N. W. (2005). Periodontal diseases. The lancet, 366(9499), 1809-1820. Available online at https://www.pharmaden.net/wp-content/uploads/2013/11/30.pdf

(6) Rankin, K. V., Jones, D. L., & Crews, K. M. (2010). Tobacco cessation education for dentists: An evaluation of the lecture format. Journal of Cancer Education, 25(3), 282-284. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2923230/

(7) Maragkos, P., Kaima, A., & Ioannis Kyriazis, M. D. (2017). The Interaction between Diabetes and Periodontal Disease. International Journal of Caring Sciences, 10(2), 1104. Available online at http://www.internationaljournalofcaringsciences.org/docs/52_kyriazis_special_10_2.pdf

(8) Lemos, S. S., Oliveira, F. A. D., & Vêncio, E. F. (2010). Periodontal disease and oral hygiene benefits in HIV seropositive and AIDS patients. Available online at https://pdfs.semanticscholar.org/70ed/4f776eefd722e17f1a061af70fd0b650d83b.pdf

(9) Stookey, G. K. (2008). The effect of saliva on dental caries. The Journal of the American Dental Association, 139, 11S-17S. Available online at https://jada.ada.org/article/S0002-8177(14)63877-0/pdf

(10) Kasper, K. Treatment for Periodontal Disease. Available online at http://www.kathleenkasperdds.com/Periodontal.pdf

(11) Plessas, A. (2014). Nonsurgical periodontal treatment: review of the evidence. Oral Health Dent Manag, 13(1), 71-80. Available online at http://www.oralhealth.ro/volumes/2014/volume-1/Paper546.pdf

(12) Benza-Bedoya, R., & Pareja-Vásquez, M. (2017). Diagnóstico y tratamiento de la periodontitis agresiva. Odontoestomatología, 19(30), 29-39. Available online at http://www.scielo.edu.uy/pdf/ode/v19n30/en_1688-9339-ode-19-30-00029.pdf

 

Robert Velasquez
13 October, 2018

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Hello everyone, my name is Robert Velazquez. I am a content marketer currently focused on the medical supply industry. I studied Medicine for 5 years. I have interacted with many patients and learned a lot...read more:

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