Periodontal Disease

Periodontal disease overview:

“Perio” means around, and “dontal” refers to teeth. Periodontal diseases are infections of the structures around the teeth. This includes the gums, periodontal ligament and alveolar bone.

Gingivitis  In the earliest stage of periodontal disease — gingivitis — the infection affects the gums. In more severe forms of the disease, all of the tissues are involved.

Periodontitis:
Un-treated,  gingivitis can advance to “periodontitis”.   In periodontitis, gums pull away from the teeth and form “pockets” that are infected. The body’s immune system fights the bacteria as the plaque spreads and grows below the gum line. Bacterial toxins and the body’s enzymes fighting the infection actually start to break down the bone and connective tissue that hold teeth in place. If not treated, the bones, gums, and connective tissue that support the teeth are destroyed. The teeth may eventually become loose and have to be removed.

An estimated 80 % of American adults suffer from Periodontal (or gum) disease to varying degrees.

Periodontal disease usually begins to develop during the 30s or 40s, and is the leading cause of tooth loss in adults.

Periodontal disease is typically not painful until it gets to the advanced stages, so it often goes untreated and is allowed free reign to do damage.

Common Symptoms:

  • Swollen gums that are shiny, bright red, or purple-red in appearance
  • Bleeding gums during brushing
  • Persistent bad breath (halitosis)
  • Bad taste in the mouth
  • Gum recession – appearance of lengthened teeth
  • Formation of deep pockets between teeth and gums
  • Pus between the teeth and gums
  • Loose or shifting teeth
  • Abscesses
  • Loss of bone and tissue that hold teeth in place
  • Gums that are tender when touched but are typically painless otherwise, unless a tooth abscess is also present

Diagnosis:

Inspection of the Gum Area.

The dentist inspects the color and shape of gingival tissue on the cheek (buccal) side and the tongue (lingual) side of every tooth. Redness, puffiness, and bleeding upon probing indicate inflammation and possible periodontal disease.

Periodontal Screening and Recording is a painless procedure used to measure and determine the severity of periodontal disease:

Probing – Periodontal probing determines how severe your disease is. A probe is like a tiny ruler that is gently inserted into pockets around teeth. The deeper the pocket, the more severe the disease.

The dentist will “walk” the probe to six specified points on each tooth, three on the cheek and three on the tongue sides. The dentist measures the depth of the probe at each point.   Pocket depths greater than 3 mm indicate disease.

Testing Tooth Movement. Tooth mobility is determined by pushing each tooth between two instrument handles and observing any movement. Mobility is a strong indicator of bone support loss.

X-rays can help detect breakdown of bone surrounding your teeth.

Common Causes of Periodontal Disease:

Periodontal disease is caused by bacteria in dental plaque, the sticky substance that forms on your teeth soon after you have brushed. In an effort to get rid of the bacteria, the cells of your immune system release substances that inflame and damage the gums, periodontal ligament or alveolar bone. This leads to swollen, bleeding gums, a sign of gingivitis (the earliest stage of periodontal disease).

Inflammation causes a pocket to develop between the gums and the teeth, which then fills with the plaque, tartar, and microorganisms. This causes the soft tissue to swell and traps the plaque in the pocket.5,7,8 Research shows that the toxins produced by these “bad bugs” stimulate the immune system to over-produce powerful infection-fighting agents called cytokines, which in excess can attack a person’s own tissues and cells, leading to increased inflammation and damage.4

Other factors which can cause periodontal disease include:

  • Smoking/Smokeless Tobacco Use – Recent studies show that this may be one of the most significant risk factors in the development and progression of gum disease.
  • Genetics – Research shows that up to 30% of the population may be genetically susceptible to gum disease despite aggressive oral health care habits.
  • Female hormones – Hormones released before menstruation, during pregnancy, with the use of oral contraceptives, and during and after menopause affect the gums and can cause symptoms of gum disease.
  • Stress – Research demonstrates that the immune system has a much more difficult time fighting off infection in the presence of stress. This means that the mild form of gum disease—gingivitis—is much more likely to advance to periodontitis when stress is part of the equation.
  • Medications – Nearly 20 drugs have been shown to cause gingival overgrowth. Most commonly these are phenytoin (Dilantin®), cyclosporine (Sandimmune®), and a short-acting form of the calcium channel blocker nifedipine (Procardia®).
  • Diabetes – Those with diabetes are at higher risk for developing and having more severe infections and incidence of periodontal disease.
  • Poor Nutrition – Not only has research linked deficiencies of vitamin C, folic acid, coenzyme Q10 (CoQ10), and calcium to gum disease, but a diet low in nutrients can impair the body’s immune system, making it much more difficult to fight infections.5,9 Additionally, the bacteria that cause periodontal disease thrive in acidic environments. Thus, eating sugars and foods that raise the acidity in the mouth also increases bacterial counts.
  • Toxic metals used in dentistry
  •  Misaligned or crowded teeth, braces or bridgework — Anything that makes it more difficult to brush or floss your teeth is likely to enhance plaque and tartar formation.   You can use special tools and ways of threading floss to clean around bridgework or slide under braces.
  • Grinding, gritting or clenching of teeth — These habits, which exert excess force on the teeth can lead to more severe disease if your gums are already inflamed.    This pressure appears to speed up the breakdown of the periodontal ligament and bone.   A bite guard or night guard may be indicated.
  • Stress — Stress can make periodontal disease worse and harder to treat. Stress weakens your body’s immune system making it harder for your body to fight off infection.
  • Fluctuating hormones — Whenever hormone levels go up and down in the body, changes can occur in the mouth. Puberty and pregnancy can temporarily increase the risk and severity of gum disease as can menopause.
  • Medications — Several types of medicines can cause dry mouth, or xerostomia. Examples include certain drugs for depression and high blood pressure. Without the protection of adequate amounts of saliva, plaque is more likely to form. Other medicines may cause the gums to enlarge, which makes them more likely to trap plaque. These medicines include:
    • Phenytoin (Dilantin and other brand names), used to control seizures
    • Cyclosporine (Neoral, Sandimmune), used to suppress the immune system
    • Nifedipine (Adalat, Cardizem and others) and other calcium channel blockers, used to treat chest pain or heart arrhythmias.

Systemic Effects of Periodontal Disease:

  • Atherosclerosis and heart disease
  • Stroke
  • Premature births
  • Diagetes
  • Respiratory disease
  • Chronic kidney disease and complications of dialysis
  •  Obesity
  • Osteoporosis
  •  Rheumatoid arthritis

The causes of systemic effects are all metastatic in nature, and include the following:

• Spread of gram negative bacteria to the whole  body as a result of ulceration of the epithelial lining of periodontal pockets;

• Inflammation caused by the immunologic response to the pathogens and their toxins spreading to the rest of the body (1).

Infection within the periodontal tissues may be the source of dissemination of virulent pathogenic bacteria to distant sites throughout the body. This increases the burden of systemic inflammation implicated in a number of chronic disease states.(2)

In a landmark paper published in 2002, Beck and Offenbacher(3) eloquently described the threat that periodontal disease may pose to overall health, by coining the term ‘systemic periodontitis.’
References
1. Li X, Kolltveit KM, Tronstad L, et al. Systemic diseases caused by oral infection. Clin Microbiol Rev, Oct. 2000, 547-558.
2. Iacopino AM. Periodontitis and diabetes interrelationships: role of inflammation. Ann Periodontol 2001; 6:125-137.
3. Beck JD, Offenbacher S. Relationships among clinical measures of periodontal disease and their associations with systemic markers. Ann Periodontol 2002;7:79-89.

What can I do to Prevent Gum Disease?

  • Brush your teeth twice a day
  • Floss every day
  • For those who can’t or don’t floss an oral irrigator is extremely effective
  • Visit the dentist routinely for a check-up and professional cleaning
  • Eat a well balanced diet

How is Periodontal Disease Treated?

The main goal of treatment is to control the infection. The number and types of treatment will vary, depending on the extent of the gum disease. Any type of treatment requires that the patient keep up good daily care at home. Additionally, modifying certain habits, such as nutrition may be critical.

Deep Cleaning (Scaling and Root Planing)

Scaling and root planning is a deep cleaning to remove bacterial plaque and calculus (tartar). It is the cornerstone of periodontal disease treatment and, following home care assessment,  the first procedure a dentist will use. Scaling involves scraping tartar from above and below the gum line. Root planning smoothes the root surfaces of the teeth. These procedures may need to be performed with anesthetic.

Both ultrasonic and manual instruments are used to remove calculus. The ultrasonic device vibrates at a high frequency and helps loosen and remove tartar. A high-pressure water spray is then used to flush out the debris. The dentist will use manual instruments called scrapers and curettes to scrape away any remaining plaque or calculus and smooth and clean the tooth crown and root surfaces.

Medications
Medications may be used with treatment that includes scaling and root planning.

Surgical Treatments
Flap Surgery — occasionally, surgery might be necessary if inflammation and deep pockets remain following treatment with deep cleaning and medications.

In addition to treatment in a dentist office, regular dental visits and cleanings (usually every 3 months) are important for maintenance as is practicing good oral hygiene at home.

Related Links:

American Dental Association  on Periodontal / Gum  Disease:  http://www.ada.org/3063.aspx

The Natural Recovery Plan – What causes gum disease?:  http://www.thenaturalrecoveryplan.com/articles/What-Causes-Gum-Disease.html

Some positive nutritional influences on periodontal disease:

American Dental Hygienists Association – Nutrition and Periodontal Disease:  http://www.adha.org/CE_courses/course7/periodontal_disease.htm

Study of CoQ10-enzymes in gingiva from patients with periodontal disease and evidence for a deficiency of coenzyme Q10:   http://www.ncbi.nlm.nih.gov/pubmed/4151519ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed

Effect of topical application of Coenzyme Q10 on adult periodontitis:  http://www.sciencedirect.com/science/article/pii/0098299794900345

 

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