What is periodontitis?
Periodontitis is inflammation of the gums and supporting structures of the teeth. It is one of the most common human diseases. It is caused by certain bacteria (known as periodontal bacteria) and by the local inflammation triggered by those bacteria. Although these periodontal bacteria are naturally present in the mouth, they are only harmful when the conditions are right for them to increase dramatically in numbers. This happens when a layer of bacteria and food debris, known as plaque, builds up and is left undisturbed on the teeth, commonly in hard-to-reach areas such as between the teeth.
The more dangerous bacteria can thrive and multiply, producing some harmful by-products which stimulate the body’s defensive inflammatory response in the gums. As the disease progresses, chronic inflammation causes the bone of the jaw to be destroyed and the teeth to be lost. In many people, this is a gradual process that takes place over many years and, if detected and treated, can be halted. However, some young adults have a very active form of the disease which causes early loosening and loss of the teeth.
What are the stages of periodontitis?
Periodontitis starts as inflammation and gets worse over time.
Periodontitis begins with inflammation in the gums known as gingivitis. One of the first signs of gingivitis is that your gums will bleed when you brush or floss your teeth.
You might also notice some discoloration on your teeth. This is called plaque. Plaque is a buildup of bacteria and food debris on your teeth. Although bacteria are always present in your mouth, they only become harmful when conditions allow them to increase dramatically. This might happen if you don’t brush or floss, or get dental cleanings regularly.
Early periodontal disease
In the early stages of periodontitis, your gums recede, or pull away, from your teeth and small pockets form between gums and teeth. The pockets harbor harmful bacteria. Your immune system tries to fight the infection, and your gum tissue starts to recede. You’ll likely experience bleeding during brushing and flossing as well, and possibly some bone loss.
Moderate periodontal disease
If left to progress to moderate periodontal disease, you might experience bleeding and pain around the teeth and gum recession. Your teeth will begin to lose bone support and become loose. The infection can also lead to an inflammatory response throughout your body.
Advanced periodontal disease
In advanced disease, the connective tissue that holds your teeth in place begins to deteriorate. The gums, bones, and other tissue that support your teeth are destroyed. If you have advanced periodontitis, you might experience severe pain while chewing, severe bad breath, and a foul taste in your mouth. You’ll likely lose your teeth.
Pathophysiology of periodontitis disease
Periodontitis usually develops when gingivitis, usually with abundant plaque and calculus (a concretion of bacteria, food residue, saliva, and mucus with calcium and phosphate salts) beneath the gingival margin, has not been adequately treated. In periodontitis, deep pockets form in the periodontal tissue and can harbor anaerobic organisms that do more damage than those usually present in simple gingivitis. Colonizing organisms include Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Eikenella corrodens, and many gram-negative bacilli.
The organisms trigger chronic release of inflammatory mediators, including cytokines, prostaglandins, and enzymes from neutrophils and monocytes. The resulting inflammation affects the periodontal ligament, gingiva, cementum, and alveolar bone. The gingiva progressively loses its attachment to the teeth, bone loss begins, and periodontal pockets deepen. With progressive bone loss, teeth may loosen, and gingiva recedes. Tooth migration is common in later stages, and tooth loss can occur.
What causes gum disease?
Improper oral hygiene that allows bacteria in plaque and calculus to remain on the teeth and infect the gums is the primary cause of gum disease. But there are other factors that increase the risk of developing gingivitis. Here are some of the most common risk factors:
- Smoking or chewing tobacco prevents gum tissue from being able to heal.
- Crooked, rotated, or overlapping teeth create more areas for plaque and calculus to accumulate and are harder to keep clean.
- Hormonal changes in puberty, pregnancy, and menopause typically correlate with a rise in gingivitis. The increase in hormones causes the blood vessels in the gums to be more susceptible to bacterial and chemical attack. At puberty, the prevalence of gingivitis ranges between 70%-90%.
- Cancer and cancer treatment can make a person more susceptible to infection and increase the risk of gum disease.
- Alcohol negatively affects oral defense mechanisms.
- Stress impairs the body’s immune response to bacterial invasion.
- Mouth breathing can be harsh on the gums when they aren’t protected by the lips, causing chronic irritation and inflammation.
- Poor nutrition, such as a diet high in sugar and carbohydrates and low in water intake, will increase the formation of plaque. Also, a deficiency of important nutrients such as vitamin C will impair healing.
- Diabetes mellitus impairs circulation and the gums ability to heal.
- Medications such as antiseizure medications increase the risk for gum disease.
- Infrequent or no dental care
- Poor saliva production
Risk factors of periodontitis
Studies indicate that older people have the highest rates of periodontal disease. Data from the Centers for Disease Control and Prevention indicates that over 70% of Americans 65 and older have periodontitis.
Tobacco use is linked with many serious illnesses such as cancer, lung disease and heart disease, as well as numerous other health problems. Tobacco users also are at increased risk for periodontal disease. Studies have shown that tobacco use may be one of the most significant risk factors in the development and progression of periodontal disease.
Research has indicated that some people may be genetically susceptible to gum disease. Despite aggressive oral care habits, these people may be more likely to develop periodontal disease. Identifying these people with a genetic test before they even show signs of the disease and getting them into early intervention treatment may help them keep their teeth for a lifetime.
Stress also is a risk factor for periodontal disease. Research demonstrates that stress can make it more difficult for the body to fight off infection, including periodontal diseases.
Some drugs, such as oral contraceptives, anti-depressants, and certain heart medicines, can affect your oral health.
Clenching or Grinding Your Teeth
Clenching or grinding your teeth can put excess force on the supporting tissues of the teeth and could speed up the rate at which these periodontal tissues are destroyed.
Other Systemic Diseases
Other systemic diseases that interfere with the body’s inflammatory system may worsen the condition of the gums. These include cardiovascular disease, diabetes, and rheumatoid arthritis.
Poor Nutrition and Obesity
A diet low in important nutrients can compromise the body’s immune system and make it harder for the body to fight off infection. Because periodontal disease begins as an infection, poor nutrition can worsen the condition of your gums.
Symptoms of periodontitis
Healthy gums are firm and pale pink and fit snugly around teeth. Signs and symptoms of periodontitis can include:
- Swollen or puffy gums
- Bright red, dusky red or purplish gums
- Gums that feel tender when touched
- Gums that bleed easily
- Pink-tinged toothbrush after brushing
- Spitting out blood when brushing or flossing your teeth
- Bad breath
- Pus between your teeth and gums
- Loose teeth or loss of teeth
- Painful chewing
- New spaces developing between your teeth
- Gums that pull away from your teeth (recede), making your teeth look longer than normal
- A change in the way your teeth fit together when you bite
Periodontitis – Possible Complications
These complications can occur:
- Infection or abscess of the soft tissue
- Infection of the jaw bones
- Return of periodontitis
- Tooth abscess
- Tooth loss
- Tooth flaring (sticking out) or shifting
- Trench mouth
At a dental visit, a dentist or dental hygienist will:
- Examine your gums and note any signs of inflammation.
- Use a tiny ruler called a “probe” to check for and measure any pockets around the teeth. In a healthy mouth, the depth of these pockets is usually between 1 and 3 millimeters. This test for pocket depth is usually painless.
- Ask about your medical history to identify conditions or risk factors (such as smoking or diabetes) that may contribute to gum disease.
The dental professional may also:
- Take an x-ray to see whether there is any bone loss.
- Refer you to a periodontist. Periodontists are experts in the diagnosis and treatment of gum disease and may provide you with treatment options that are not offered by your dentist.
When gingivitis progresses to periodontitis, treatment becomes much more complicated. Only your dentist and hygienist can perform periodontal treatment, which involves special dental procedures, and can require oral surgery. If your dentist determines that you have periodontitis, the treatment will depend on the severity of the infection. Some options include:
Tooth Scaling and Root Planing: During this two-step procedure to treat periodontitis, your dental professional will scrape off the tartar that has built up on teeth both above and below the gum line (tooth scaling). Next, your dental professional will smooth rough spots on the tooth roots, making it more difficult for bacteria to collect and cause more plaque and tartar buildup.
Flap Surgery: If the gum inflammation and pockets next to the teeth persist after a deep tooth-cleaning procedure, your dentist may recommend flap surgery. Flap surgery is a common dental procedure to treat periodontitis that is performed by a specialist called a periodontist. During flap surgery, the tartar is removed from the pockets that have formed alongside the teeth. The pockets are then closed with stitches, so the gum tissue once again hugs the teeth. Reducing the pockets makes it easier and more comfortable to brush and floss your teeth.
Grafts: In severe cases of periodontitis in which bone and tissue have been destroyed, you may need bone or tissue grafts to replace the infected tissue. Your graft may involve a technique called guided tissue regeneration, in which a small piece of mesh is placed between the jaw bone and gums to allow both bone and tissue to re-grow. Guided tissue regeneration helps keep the gum tissue from expanding into the area where the bone should be, so both bone and tissue grafts have room to grow.
Doxycycline Gel: Gel that contains doxycycline (an antibiotic) provides periodontal disease treatment by killing bacteria and shrinking the pockets that periodontal disease can cause along the gum line. Your periodontist applies the gel to the pockets after a tooth scaling/root planing procedure, and the antibiotic is released gradually over a period of about a week.
Chlorhexidine Chip: Another periodontal disease treatment involves placing a small, antimicrobial gelatin chip in a tissue pocket along the gum line after tooth scaling/root planing, and the antimicrobial is released gradually over time.
Minocycline Microspheres: For this type of periodontal disease treatment, the periodontist places tiny particles containing minocycline as an antibiotic in the tissue pockets after a tooth scaling/root planing procedure.
Doxycycline Pill: Your periodontist may prescribe an antibiotic pill for periodontal disease treatment in addition to tooth scaling and root planing. A low-dose doxycycline pill can help prevent overactive enzymes from breaking down gum tissue after periodontal disease treatment.
The effects of periodontitis can be stopped through regular checkups and treatment and continued good oral hygiene. This is also a part of treatment once an infection occurs.
It is important to:
- Brush the teeth with a suitable toothbrush and toothpaste at least twice a day, carefully cleaning the chewing surfaces and the sides of the teeth.
- Use floss or an interdental brush every day to clean between the teeth, in the spaces that the brush cannot reach. Dental floss can clean small gaps, but a dental brush is useful for a larger space.
- Take extra care when cleaning around uneven surfaces, for example, closely-packed teeth, crooked teeth, crowns, dentures, fillings, and so on.
- After brushing, use an antibacterial mouthwash to help prevent bacteria from growing and to reduce any inflammatory reaction in the mouth.
According to the American Dental Association (ADA), it is best to:
- Brush the teeth for 2 minutes, twice a day with either a manual or electric toothbrush that has soft bristles
- Use a fluoride toothpaste
- Rinse the brush well after use and store upright
- Replace the toothbrush every 3 to 4 months, more if the bristles are matted or frayed
- Choose a brush with the ADA seal of acceptance
Brushes should not be shared, as bacteria can pass from person to person in this way.
How to prevent Periodontitis?
Luckily, periodontal disease can be preventable. Adding these habits to your daily routine can help.
Brush your teeth. Brushing after meals helps remove food debris and plaque trapped between your teeth and gums. Don’t forget to include your tongue, bacteria loves to hide there.
Floss. Flossing at least once a day helps remove food particles and plaque between teeth and along the gum line that your toothbrush can’t quite reach.
Swish with mouthwash. Using a mouthwash can help reduce plaque and can remove remaining food particles that brushing and flossing missed.
Know your risk. Age, smoking, diet and genetics can all increase your risk for periodontal disease. If you are at increased risk, be sure to talk with your dental professional.
See a periodontist. Get an annual comprehensive periodontal evaluation (CPE) from a dental professional. A CPE looks at your teeth, plaque level, gums, bite, bone structure and other risk factors for periodontal disease. Identifying symptoms of gum disease early is key to protecting your teeth and gums.