What is Periodontal Disease?
Periodontal diseases are conditions that affect the supportive structures around the tooth, which are the gum tissue, the alveolar bone (the part of the jaw bone that houses the teeth), the cementum (the covering of the root of the tooth), and the periodontal ligament (the tissue that holds the tooth in place).
Gingivitis, the mildest form of periodontal disease, is quite common and may affect up to 90% of people. It is an inflammation of the gums due to bacteria and debris build-up along the gum line and the tooth, creating what’s known as dental plaque. The good news is, gingivitis can be reversed with improved oral hygiene. Periodontitis, on the other hand, is a more advanced and chronic inflammatory disease that’s irreversible. Here, bacteria penetrate deeper into the tissues and surrounding structures that support the tooth. The body tries to defend against these bacteria, but in doing so, it also ends up damaging the tooth-supporting structures, leading to loss of gum and bone attachment, which can result in tooth loss.
In 2017, the American Academy of Periodontology and the European Federation of Periodontology came up with a new classification for periodontal and peri-implant diseases. Under this, periodontitis can be categorized into three types:
1. Necrotizing periodontal diseases
2. Periodontitis
3. Periodontitis as a manifestation of systemic diseases
Necrotizing periodontal disease is a severe, rapidly progressing form of gum disease often found in patients with a weakened immune system, such as those with HIV. This type of periodontal disease results in gum tissue death between the teeth, bleeding, and associated pain.
What Causes Periodontal Disease?
Periodontal diseases, which affect the gums, can be caused by a variety of factors. These can include things unique to the patient, such as risk factors and improper cleaning of the mouth and teeth.
Risk factors can be sorted into two types: modifiable and non-modifiable. Modifiable factors are those you can change, like smoking, not cleaning your teeth well enough, having diabetes, or being pregnant. On the other hand, non-modifiable factors are those you can’t change, like your age and your genetics, including certain genetic diseases.
Not cleaning your teeth properly can have a big impact on the start and development of gum diseases. If you don’t clean your teeth the right way, harmful bacteria and plaque can build up on your teeth, which causes gingivitis (gum inflammation) and can even lead to periodontitis (serious gum infection). Studies have shown that more plaque on your teeth leads to more serious and common gum diseases.
When you don’t clean your teeth well enough, certain harmful bacteria that cause gum diseases can get into deeper parts of your gums. Once there, they can worsen the disease. The main types of bacteria found in periodontitis include Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia. If these bacteria can get deep into your gums, they can cause inflammation by setting off the release of inflammatory chemicals from your body.
Smoking is the most important modifiable risk factor of gum diseases. It can increase your chance of getting gum diseases by 5 to 20 times. Furthermore, smoking is linked with greater loss of bone and tissue around your teeth, deeper pockets around your teeth linked with the disease, and tooth loss, as compared to non-smokers. Also, smoking can make treatments for gum diseases less effective.
Diabetes also greatly contributes to gum diseases. Diabetes is linked with certain harmful processes that increase damage to your gums, like slowed healing of wounds. In patients with diabetes, severe gum disease is linked with a higher risk of death compared to patients with no or mild disease.
Pregnancy is linked with changes in hormone levels, which have been shown to encourage inflammation that is linked with gingivitis and periodontitis. Although it’s not completely understood, pregnancy hormones have been linked with increased levels of Porphyromonas gingivalis, a major bacteria involved in gum disease. Both low and high levels of estrogen have been shown to contribute to gingivitis.
Age is a non-modifiable risk factor of gum diseases. Older people have been shown to have a stronger inflammatory response to plaque on their teeth, with more inflammatory cells involved. This increased inflammation puts older people at higher risk of their gums being damaged. Furthermore, because age is linked with a loss of coordination, older people may not be able to clean their teeth as well. This can result in more plaque, which increases the risk of gum diseases. In addition, studies have shown more loss of the attachment of the gums in people aged 60 to 90 compared to those under 50.
Lastly, several genetic diseases have been shown to cause gum diseases. These diseases include Down syndrome, Ehlers-Danlos syndrome (types IV and VIII), and Crohn’s disease.
Risk Factors and Frequency for Periodontal Disease
Periodontal diseases, or gum diseases, are the most common oral diseases seen globally, affecting almost 90% of the population worldwide. In the United States, about half of adults currently have some form of gingivitis, a mild form of gum disease, and up to 80% have experienced some form of periodontal disease in their lifetime. Certain groups are more likely to develop gum diseases.
- Older people
- Males
- African-Americans
- People with lower income and education levels
This indicates that these groups may have a higher risk of severe periodontal disease.
Signs and Symptoms of Periodontal Disease
Periodontal diseases are conditions that affect your gums. Many times, these conditions show no signs in their early stages as they begin with inflammation without causing pain or discomfort. Common signs of gum diseases usually include bleeding gums when you brush or floss your teeth, bad breath, pain or sensitivity while eating certain foods, loose teeth, and changes to the gums such as receding gums or discoloration. In severe cases, periodontal diseases may result in tooth loss.
Chronic periodontitis, a common type of gum disease, can affect people of any age but is most commonly seen in middle-aged and older adults. The seriousness of this disease is determined by a measure called clinical attachment loss (CAL), which refers to the extent of damage around a tooth. If the tooth has lost 1 to 2mm of gum support, the disease is mild. If it lost 3 to 4mm, it’s considered a moderate condition. But if the tooth has lost 5mm or more of gum support, the condition is severe.
Another form of gum disease progresses rapidly and is more common in young people. This version of the disease affects specific teeth, especially the first molars and incisors, and can occur without significant plaque buildup, which is commonly seen in chronic periodontitis.
Regular dental check-ups play a crucial role in early detection and treatment of these conditions. During these visits, your dentists will review your medical history, examine your teeth and gums for signs of disease like inflammation or receding gums, and use dental probes and x-rays to measure the depth of dental pockets and check for bone loss. A probing depth greater than 3mm may indicate gum disease, and depths greater than 6mm often require more aggressive treatment due to the difficulty in cleaning these deep pockets.
Testing for Periodontal Disease
To diagnose gum diseases (known as periodontal diseases), doctors compare the current state of your gums to what they should normally look like. This process involves looking at your teeth and gums, physically examining your gums with a special tool, and taking x-rays to evaluate the health of your underlying bone.
When your gums are healthy, they have a dimpled, pale pink appearance and fit snugly around the bone underneath. There’s also a tiny gap (about 1 to 3 millimeters wide) between the bottom edge of the gum and the tooth where it’s perfectly normal for there to be no bleeding.
On the other hand, symptoms of periodontal disease include gums that bleed easily, even when you’re not brushing or flossing too hard. Other signs include pain, bad taste in the mouth, bad breath, deeper gaps between the gums and teeth (known as periodontal pocketing), visible bone loss on x-rays, loosening of the teeth, and eventual tooth loss. The x-rays of a patient with gum disease will show a loss in the bone that holds the tooth in place, usually near a deep periodontal pocket where harmful bacteria could be causing the disease.
If gum disease is not treated, the bone loss could continue to the point where the tooth no longer has enough support. This could make the tooth loose and eventually fall out.
Treatment Options for Periodontal Disease
The treatment of gum disease, or periodontitis, usually starts with the simplest methods. First, your dentist will perform a professional teeth cleaning. This includes a process called scaling, which is scraping off the tartar from your teeth, and root planning, cleaning out the pockets in your gums to remove harmful bacteria. Your dentist will also guide you on how to properly clean your teeth at home to improve your oral health. After the cleaning, you should come back to the dentist to see if your gums have improved.
Maintaining your oral hygiene will greatly help in managing gum disease. Poor oral health is a major cause of periodontitis, so it’s essential to brush, floss, and rinse your mouth every day. Regular check-ups with your dentist are also necessary to track the progress of your condition.
One of other causes of gum disease is tobacco smoking. Not only does it increase the risk of developing gum disease, but it can also make the condition worse and lower the success rate of any treatments. However, if you quit smoking, you can lower the risk of severe gum disease.
Another condition that can worsen gum disease is diabetes. Uncontrolled blood sugar levels may lead to a more severe gum condition, and at the same time, having severe gum disease can be deadly for those with uncontrollable blood sugar. This means that managing your blood sugar can also improve your gum condition.
If gum disease continues to progress despite these efforts, antibiotics can be used. One commonly used product is chlorhexidine gluconate, an antimicrobial compound usually used as a mouth rinse. It can also come in the form of a gel, varnish, or chip. Regular toothbrushing combined with chlorhexidine can significantly reduce plaque build-up, which is the main culprit behind gum disease.
Another product is a compound made up of tiny particles of minocycline hydrochloride that are placed in the pockets in your gums after cleaning. Similar to the chlorhexidine chip, it effectively reduces the build-up of dental plaque.
In rare cases, antibiotics taken internally might be needed for severe cases of gum disease. Medications could include tetracyclines, penicillins, macrolides, quinolones, cephalosporins, and nitroimidazole compounds. These can be prescribed individually or in combination depending on the type of bacteria present in your gums.
If gum disease is serious or not improving, your dentist might refer you to a gum specialist known as a periodontist. In some cases, surgery might be needed to thoroughly clean pockets in the gums or attempt to restore bone and tissue loss caused by the disease.
What else can Periodontal Disease be?
A few medical conditions might look like common dental diseases, such as gingivitis, but they’re not. Here are a few examples:
- Periodontal abscesses: These are pockets of infection that form in the gums around the teeth.
- Endodontic lesions: These are infections that start within the tooth and can eventually affect the gums, making it look like a gum disease.
- Leukemia: This type of cancer can sometimes cause gum swelling and bleeding, which might be mistaken for gingivitis.
Also, certain medicines like calcium channel blockers, immunosuppressants, and anticonvulsants can cause a condition called gingival hyperplasia. This condition, which causes gum swelling, can often be mistaken for gingivitis. Additionally, a type of skin cancer known as squamous cell carcinoma can sometimes lead to bone loss in the jaw, imitating stubborn periodontal disease resistant to standard treatments such as cleanings and medications .
What to expect with Periodontal Disease
The outlook for periodontal disease, also known as gum disease, depends on several things such as how advanced the disease is, how fast it’s progressing, and what additional factors might be making it worse. The more advanced and faster-moving the disease, the worse the outlook. Other things like smoking or uncontrolled diabetes can also impact the outlook.
To figure out the outlook for this disease, doctors often use the McGuire guide. This guide gives an individual tooth a score of good, fair, poor, questionable, or hopeless. How each tooth scores is based on things like the patient’s age, overall health, how well they take care of their teeth, their socioeconomic status, what type and how much bone loss there is, and the current condition of their gums.
This guide can be very useful for the initial evaluation of the disease, for follow-up evaluations after treatment of the gum disease, and for long-term monitoring. Make sure your dentist is using this guide in your gum disease treatment planning.
Possible Complications When Diagnosed with Periodontal Disease
Periodontal disease, commonly known as gum disease, can cause tooth loss due to the damage it does to the structures that hold the teeth in place. This includes the gum tissue and bone. But, it doesn’t just affect your mouth. Research has shown that it can be linked to other health conditions like diabetes, heart disease, and complications during pregnancy such as low weight in newborns.
People with diabetes are more likely to get gum disease. It’s thought that people with Type 2 diabetes and severe gum disease are three times more likely to die than people with diabetes alone. Diabetes can slow the healing process and increase the breakdown of structures in the mouth, and these effects can be worse if the diabetes is not well-controlled. Interestingly, gum disease can also make it harder for people with diabetes to maintain proper blood sugar levels. It’s also thought that high blood sugar may contribute to the growth of the bacteria that cause gum disease.
Gum disease is also linked with heart disease. People with gum disease often have higher levels of a chemical called C-reactive protein (CRP), which is a sign of inflammation in the body. Higher CRP levels can be a sign of heart disease, and are often associated with heart problems. Therefore, the bacteria present in gum disease could contribute to the development of atherosclerosis, or hardening of the arteries, although this relationship is still being investigated.
Finally, gum disease during pregnancy can have an effect on a newborn’s weight. Research has shown a connection between the presence of gum disease in the mother and low birth weight in the infant. The worse the mother’s gum disease, the lower the child’s birth weight tends to be.
Affected Health Areas:
- Tooth loss
- Type 2 diabetes
- Poor blood sugar control related to diabetes
- Heart disease
- Hardening of the arteries
- Complications during pregnancy
- Low birth weight infants
Preventing Periodontal Disease
It’s important for patients to be informed about how they can reduce health risk factors. This includes habits such as smoking and maintaining good oral hygiene. An integrated team of health professionals should work together to keep an eye on and manage any underlying health conditions like diabetes. Regular dental check-ups and practicing good oral hygiene at home should be strongly encouraged to everyone for maintaining good health.
