What is Periodontitis?
You might be surprised to learn that about 700 different types of tiny organisms, mostly harmless, live in the human mouth. Sometimes, however, harmful bacteria can also be present, but they are usually in a much lower amount. One of the most common dental problems that these bacteria can cause is called periodontitis. This term comes from two words: “periodont-” which relates to the structures around the teeth, and “itis” meaning inflammation. So, periodontitis is an inflammation of the structures around the teeth.
This disease often begins in the gum tissue. If not treated, the inflammation can spread to deeper tissues, disrupting the balance of the bone that supports the teeth, and eventually leading to tooth loss. There are many things that can contribute to the development of periodontal disease – it’s not just down to one single cause.
The main cause of periodontitis is a layer of bacteria, called a biofilm, that grows on the surfaces of teeth. However, how quickly the disease progresses can be influenced by several factors. These can include things like the person’s genes, their overall health, their lifestyle (such as diet and smoking), and other local factors like plaque and tartar on the teeth. Even social determinants can have an impact.
It’s also worth noting that the harmful effects of these bacteria aren’t just limited to the teeth and gums. They can also have a negative impact on a person’s overall health. This is why it’s so important to maintain good oral hygiene and seek help if you suspect you have a dental problem.
What Causes Periodontitis?
Periodontal disease, often referred to as gum disease, is mainly caused by a mix of bacteria that live in your mouth. There are also other factors that can speed up the disease’s progression, such as areas on the teeth that can trap plaque or bacteria, hardened plaque known as tartar, dental fillings that extend beyond the tooth, specific features of your teeth like a short trunk, projections of tooth enamel near the root, and other factors like genetics, smoking, and stress.
A ground-breaking study in 1965, named ‘Experimental Gingivitis in Man’, confirmed that dental plaque – the sticky film of bacteria constantly forming on our teeth – plays a key role in the start of gum disease. In this study, researchers found that if you stop brushing and flossing, you can develop gum inflammation (gingivitis) within 7 to 21 days. The good news is that this can be reversed within a week or so of starting to clean your teeth properly again.
Further research in 1966 showed that there’s a change in the type of bacteria in your mouth as your gum health declines. Usually, your gums are associated with certain types of bacteria that are helpful (gram-positive bacteria), but as gum disease develops, there’s a shift towards harmful bacteria (gram-negative bacteria).
Risk Factors and Frequency for Periodontitis
Gingivitis doesn’t always turn into periodontitis, it relies on how the person’s body responds. When we talk about periodontitis, there are two main types: chronic and aggressive periodontitis. Chronic Periodontitis (CP) often comes with a lot of plaque and calculus on the teeth. On the other hand, Aggressive Periodontitis (AgP) often appears in families and results in a lot of damage to the gums with few local factors involved.
Aggressive Periodontitis itself is divided into two categories: Local Aggressive Periodontitis (LAP) and Generalized Aggressive Periodontitis (GAP). The number of people who get LAP varies depending on their race and where they live. For example, it is found in 2.6% of African Americans, 1 to 5% of Africans, 0.2% of Asians, 0.5 to 1% of North Americans, and 0.3 to 2% of South Americans. As a whole, GAP occurs in about 0.13% of people and LAP in less than 1%.
- Periodontitis is divided into two major types: Chronic and Aggressive.
- Chronic Periodontitis often involves a lot of plaque and calculus.
- Aggressive Periodontitis tends to appear in families and cause a significant amount of gum damage.
- Aggressive Periodontitis is further categorized into Local and Generalized types.
- The occurrence of Local Aggressive Periodontitis varies by race and location.
- The overall occurrence rate of Generalized Aggressive Periodontitis is about 0.13%.
Unfortunately, chronic periodontitis is more common in developing countries than in developed countries. According to a survey by The National Health and Nutrition Examination Survey III (NHANES III), half the adult population in the United States suffers from gingival and periodontal diseases.
Signs and Symptoms of Periodontitis
Periodontal disease, an inflammatory condition affecting the gums, has a history dating back to 4000 years ago. Its symptoms were noted by several ancient societies, with Hippocrates and Pierre Fauchard providing detailed descriptions. Fauchard also mentioned various treatment methods, such as teeth cleaning and usage of mouthwashes and toothpaste.
In adults, chronic periodontitis is more common, and it can develop in younger patients too. Traditionally, progression of the disease is slow and linked to certain bacteria. However, this condition is not linked to genetic factors or immune system disorders. Common signs of chronic periodontitis include gum inflammation and periodontal pockets ranging from 4 to 12 mm. Although patients may overlook loss of attachment and bleeding gums due to its painless nature, these are telling signs of the disease. The disease often remains unnoticed because it is typically symptom-free.
Aggressive periodontitis, on the other hand, has distinct features that make it easier to diagnose. This type of gum disease appears in adolescents who are otherwise healthy, and it leads to rapid loss of the bone surrounding teeth. It isn’t necessarily associated with the presence of local factors like dental plaque, which is unusual considering the amount of damage caused to periodontal tissue. Key signs of aggressive periodontitis include early age onset, significant bone loss in molars and incisors, family predisposition, and rapid disease progression. There are two subtypes: localized aggressive periodontitis (LAP) impacts only molars and incisors, while generalized aggressive periodontitis (GAP) impacts most of the permanent teeth.
Testing for Periodontitis
If you’re suffering from chronic periodontitis (long-term gum inflammation) or aggressive periodontitis (a rapid form of gum inflammation), your dentist will conduct both clinical and radiographic (x-ray) examinations. During the clinical exam, your dentist will assess local factors, check for oddities in teeth development that can lead to increased plaque buildup, and look for signs of bleeding upon probing, which indicates inflammation in the tissue surrounding your teeth.
Your dentist will also measure the depth of any pockets that may have formed in your gums, either manually or using specialized tools that can sense pressure. Other things your dentist will check for include furcation involvement (when gum disease has affected the base of your teeth), gum recession, and the state of your periodontal attachment level, which is the connective tissue that keeps your teeth anchored.
After the clinical examination, your dentist will estimate any bone loss around your teeth using different types of x-rays such as periapical radiographs, bitewing radiographs, or a panoramic radiograph.
If you have aggressive periodontitis, classic clinical characteristics, along with x-ray evaluations, will help diagnose your condition. An oral pantomograph, which is a panoramic x-ray of the mouth, might show mirror-like arch defects in the molar region.
Certain bacteria, including Aggregatibacter, Porphyromonas gingivalis, Tanerella forsythia, and Campylobacter rectus have been found to be linked to periodontitis in various studies relating to microbiology and disease patterns.
Treatment Options for Periodontitis
The main goal of gum disease treatment is to improve your gum health and protect the tissues that hold your teeth in place. It is important to reduce both those factors that can directly harm these tissues, such as certain bacteria, and those more general lifestyle factors, for example, smoking or chewing tobacco.
When you visit your dentist, they will examine your teeth and gums and take X-rays. They’ll make a detailed map of your mouth, noting any particular problem areas. They will use this information, along with specific measurements – known as periodontal indices – to determine the extent of your gum disease. The dentist will also advise you on lifestyle changes that might help improve your oral health – quitting smoking, for instance, and upgrading your tooth brushing and flossing routine.
After this careful assessment and guidance, the dentist will start you on non-surgical gum disease treatment. This might involve a thorough clean of your teeth and gums, including scraping away any hardened plaque, using certain mouthwashes or toothpastes, or applying medicine directly to any infection in your mouth. Sometimes, you’ll also be prescribed oral antibiotics to support the initial deep clean of your teeth and gums.
It is vital that the dentist checks the progress of non-surgical treatment because some problem areas may not respond well. For these resistant sites, surgical treatment might be necessary, followed by an ongoing programme of preventive dental care.
What else can Periodontitis be?
Periodontal disease is a dental condition that can show up in various forms. These can include a gum abscess, a periodontal abscess (infection around the tooth), acute necrotizing ulcerative gingivitis (a severe gum infection), or lesions that affect both the tooth and the surrounding gum tissues.
If the disease is localized, meaning it’s found in just one area, it’s important to figure out whether the disease started in the tooth pulp or in the gum.
In certain cases where periodontitis (gum infection) doesn’t respond to treatment, it is labeled as refractory periodontitis. This means the condition is stubborn or resistant to treatment.
What to expect with Periodontitis
The outlook for teeth affected by a serious gum disease called periodontitis can be influenced by several factors.
For instance, the position of the teeth in the mouth can affect the prognosis. The lower canine tooth (the pointed tooth near the front of the mouth, located in the lower jaw) is least at risk, while the upper second molar (the flat tooth farthest in the back of the mouth, located in the upper jaw) is at the highest risk.
Other factors that can lead to a poorer prognosis include deepened pockets in the gums around the tooth, loose teeth, loss of bone supporting the teeth, involvement of the furcation (the area where the roots of a tooth split), improperly positioned teeth, and a poor ratio of the crown (visible part of the tooth) to the root (part of the tooth under the gums).
The patient’s efforts in maintaining good oral hygiene and ceasing smoking can help to improve the prognosis. This can also help in reducing the mobility of the tooth, leading to an overall better outcome.
Ongoing bleeding from certain sites in the gum during the maintenance phase of oral hygiene can increase the risk of losing more of the gum tissue that attaches the teeth to the gums. This risk is three times higher compared to sites that do not bleed.
Possible Complications When Diagnosed with Periodontitis
Periodontal disease is described as a condition where the host’s immune system responds with inflammation. The inflammation typically affects an area of the periodontal tissue between 15 cm^2 to 72 cm^2. If periodontal disease is not treated, the inflammation not only destroys the tissue around the teeth but also significantly impacts the entire body. It leads to increased levels of C-reactive protein, a substance produced in the liver responding to inflammation. This increase can affect the cardiovascular system and lead to diseases like Type II diabetes and chronic obstructive pulmonary disease. It can also contribute to lower birth weights in newborn babies.
In simple terms, the impact of untreated periodontal disease includes:
- Damage to tissue around the teeth
- Cardiovascular problems
- Increase in Type II diabetes
- Development of chronic obstructive pulmonary disease
- Lower birth weights in newborns
Preventing Periodontitis
The most important step in turning gum disease around and getting back to good oral health is to effectively clean your teeth. This involves showing you good brushing techniques, like the Bass brushing technique, using models, your own mouth, and video examples. It’s also important to teach you how to correctly clean between your teeth. When patients stick with these dental care instructions, they help ensure successful treatment and ongoing gum health.
Giving up smoking greatly influences the control of gum disease. Repeatedly encouraging and reinforcing good oral hygiene practices, tailored to each patient’s needs, plays a key role in improving the outlook of gum disease.