The name "periodontitis" means "means inflammation around the tooth." Microorganisms, such as bacteria, stick to the surface of the tooth and in the pockets surrounding the tooth, and they multiply. As the immune system reacts and toxins are released, inflammation occurs.
Bacterial plaque, a sticky, colorless membrane that develops over the surface of teeth, is the most common cause of periodontal disease. If plaque it not removed, it can harden to form tartar, or calculus.
Most cases of periodontitis are preventable through good dental hygiene.
- Periodontitis, or gum disease, affects the area around the tooth, including the bone and the gum.
- It happens when bacteria and plaque build up around the tooth, and the immune system launches a reaction.
- Good oral hygiene is part of both treatment and prevention, but sometimes surgery is necessary too.
- Smoking increases the risk of gum disease and of treatment not working.
- There appears to be a link between gum disease and conditions elsewhere in the body, such as heart disease.
The main aim of treatment is to clean out bacteria from the pockets around the teeth and prevent further destruction of bone and tissue.
Good oral hygiene
Regular brushing with a soft brush and fluoride toothpaste can help prevent gum disease.
Good oral hygiene should be followed daily, even if the teeth and gums are healthy, to prevent infection.
Proper dental care involves brushing teeth at least twice a day and flossing once a day. If there is enough space between the teeth, an interdental brush is recommended.
Soft-picks can be used when the space between the teeth is smaller. Patients with arthritis and others with dexterity problems may find that using an electric toothbrush is better for a thorough cleaning.
Periodontitis is a chronic, or long-term, inflammatory disease. If good oral hygiene is not maintained, it will recur.
Scaling and cleaning
It is important to remove plaque and calculus to restore periodontal health.
A healthcare professional will carry out scaling and debridement to clean below the gumline. This may be done using hand tools or an ultrasonic device that breaks up the plaque and calculus. Root planing is done to smoothe rough areas on the roots of the teeth. Bacteria can lodge within the rough patches, increasing the risk of gum disease.
Depending on how much plaque and calculus there is, this may take one or two visits.
Cleaning is normally recommended twice a year, and possibly more often, depending on how much plaque accumulates.
A number of medicated mouthwashes and other treatments are available.
Prescription antimicrobial mouth rinse, such as chlorhexidine: This is used to control bacteria when treating gum disease and after surgery. Patients use it as they would a regular mouthwash.
Antiseptic chip: This is a small piece of gelatin that is filled with chlorhexidine. It controls bacteria and reduces periodontal pocket size. It is placed in the pockets after root planing. The medication is slowly resealed over time.
Antibiotic gel: This gel contains doxycycline, an antibiotic. It helps control bacteria and shrink periodontal pockets. It is placed in the pockets after scaling and root planing. It is a slow-release medication.
Antibiotic microspheres: Very small particles containing minocycline, an antibiotic, are placed into pockets after scaling and root planing. This slow-release medication is also used to control bacteria and reduce periodontal pocket size.
Enzyme suppressant: This keeps destructive enzymes in check with a low-dose of doxycycline. Some enzymes can break down gum tissue, but this medication can delay the body's enzyme response. It is taken orally, as a pill, and it is used with scaling and root planing.
Oral antibiotics: Available in capsule or tablet form, these are taken orally. They are used short-term for the treatment of acute or locally persistent periodontal infection.
If good oral hygiene and non-surgical treatments are not effective, surgical intervention may be needed.
Flap surgery: The healthcare professional performs flap surgery to remove calculus in deep pockets, or to reduce the pocket so that keeping it clean is easier. The gums are lifted back, and the tarter is removed. The gums are then sutured back into place, so they fit closely to the tooth. After surgery, the gums will heal and fit tightly around the tooth. In some cases, the teeth may appear longer than before.
Bone and tissue grafts: This procedure helps regenerate bone or gum tissue that has been destroyed. New natural or synthetic bone is placed where the bone was lost, promoting bone growth.
Guided tissue regeneration (GTR) is a surgical procedure that uses barrier membranes to direct growth of new bone and gum tissue at sites where one or both of these are lacking. It aim to regenerate tissue and repair defects that have resulted from periodontitis.
In this procedure, a small piece of mesh-like material is inserted between the gum tissue and bone. This stops the gum from growing into bone space, giving the bone and connective tissue a chance to regrow. The dentist may also use special proteins, or growth factors, that help the body regrow bone naturally.
The dental professional may suggest a soft tissue graft. This involves taking tissue from another part of the mouth, or using synthetic material to cover exposed tooth roots.
Success depends on how advanced the disease is, how well the patient adheres to a good oral hygiene program, and other factors, such as smoking status.
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.
The signs and symptoms of periodontitis include:
As the gums recede, the teeth look longer. Gaps can also appear between the teeth.
- inflamed or swollen gums and recurrent swelling in the gums
- bright red, sometimes purple gums
- pain when the gums are touched
- receding gums, which make the teeth look longer
- extra spaces appearing between the teeth
- pus between the teeth and gums
- bleeding when brushing teeth or flossing
- a metallic taste in the mouth
- halitosis, or bad breath
- loose teeth
The person may say their "bite" feels different because the teeth do not fit as they did before.
Periodontitis vs gingivitis
Gingivitis occurs before periodontitis. It usually refers to gum inflammation, while periodontitis refers to gum disease and the destruction of tissue, bone, or both.
Gingivitis: Bacterial plaque accumulates on the surface of the tooth, causing the gums to become red and inflamed. The teeth may bleed during brushing. The gums are irritated and bothersome, but the teeth are not loose. There is no irreversible damage to bone or surrounding tissue.
Untreated gingivitis can progress to periodontitis.
Periodontitis: The gum and bone pull away from the teeth, forming large pockets. Debris collects in the spaces between the gums and teeth and infects the area.
The immune system attacks bacteria as the plaque spreads below the gum line into the pockets. Bone and connective tissue that hold the tooth start to break down, because of toxins produced by the bacteria. Teeth become loose and can fall out. The changes may be irreversible.
Dental plaque is a pale yellow bioform that collects on teeth as part of a natural process. It is formed by bacteria that try to attach themselves to the tooth's smooth surface. Brushing teeth gets rid of plaque, but after a day or so, it will build up again.
If it is not removed, it hardens into tartar, also known as calculus. Tartar is harder to remove than plaque, and it cannot be done at home. It requires professional treatment.
Plaque can gradually and progressively damage teeth and surrounding tissue. At first, gingivitis may develop. This is an inflammation of the gum around the base of the teeth.
If gingivitis persists, pockets can develop between the teeth and gums. These pockets fill up with bacteria.
Together with the immune system's response to infection, bacterial toxins start destroying the bone and connective tissue that hold teeth in place. Eventually, the teeth start becoming loose, and they may fall out.
Gum disease is more likely to become severe if there are high levels of aggressive bacteria, and if the person's immune system is weakened.
The following risk factors are linked to a higher risk of periodontitis:
Smoking: Regular smokers are more likely to develop gum problems. Smoking also undermines the efficacy of treatment. Ninety percent of cases that do not respond to treatment are in smokers.
Diabetes: Those living with diabetes have a higher incidence of gum disease than other individuals of the same age.
AIDS: Gum disease is more common in people with AIDS.
Cancer: Cancer and some cancer treatments can increase the chance of gum disease.
Drugs: Medications such as antihypertensive drugs or vasodilating agents—which relax and dilate the blood vessels—immunotherapy drugs, and medications that reduce saliva can all increase the chance of gum disease.
Genetic factors: Some people are more susceptible to gum disease due to genetic factors.
A dentist can normally diagnose periodontitis by looking at the signs and symptoms and carrying out a physical examination.
The dentist will probably insert a periodontal probe next to the tooth, under the gum line. If the tooth is healthy, the probe should not slide far below the gum line. In cases of periodontitis, the probe will reach deeper under the gum line. The dentist will measure how far it reaches.
An X-ray may help assess the condition of the jaw bone and teeth.
The most common complication is the loss of teeth, but periodontitis may impact a person's overall health in other ways.
It has been linked to a higher risk of a range of other diseases, including respiratory problems, stroke, and coronary artery disease, although how they are linked remains unclear.
One study of people with chronic coronary artery disease, lasting 3.7 years, found that for every five teeth lost, there was a 17-percent higher risk of cardiovascular death, a 16-percent higher risk of all-cause death, and a 14-percent higher risk of stroke.
Scientists are not yet certain why this happens. It may be that bacteria from periodontitis infects the coronary arteries, that the periodontal bacteria trigger an overall immune response that affects the cardiovascular system, or there may be another link.
It remains unclear whether gum disease leads to heart disease or the other way round. There is no evidence as yet that better oral care will lead to better cardiovascular health.
During pregnancy, if a bacterial infection causes moderate-to-severe periodontal disease, there is a higher risk of preterm birth. Periodontitis has also been linked to low birth weight and pre-eclampsia.
Postmenopausal women with periodontal disease are more likely to develop breast cancer, according to research published in Cancer Epidemiology, Biomarkers Prevention. Those with a history of smoking are particularly affected.
Periodontitis can also make it harder for patients with diabetes to control blood sugar.