Periodontal Disease (Gum Disease)

Periodontal disease, also called gum disease, is a group of inflammatory conditions that damage the gums and the bone that supports the tooth.  There are various types of periodontal diseases.  Gingivitis and chronic periodontitis are by far the most common types of gum disease.

GINGIVITIS

Gingivitis is the early/milder form of gum disease.  This condition is characterized by inflamed gums due to the presence of undisturbed bacterial plaque around teeth.  At this point the inflammation is limited to the gums and the damage is generally fully reversible through excellent oral hygiene and regular dental cleanings.  Thoroughly brushing your teeth twice a day and flossing daily removes plaque and prevents gingivitis.

“Gingivitis, if untreated, can progress into periodontitis with associated bone loss”

CHRONIC PERIODONTITIS

Periodontitis is a more serious condition where the inflammation extends to the bone leading to bone loss around the teeth.  This bone destruction can cause teeth to loosen and may lead to tooth loss.  Periodontitis is the leading cause of tooth loss in adults over the age of 50 in the United States.

How periodontitis develops

Periodontitis is primarily caused by the interaction between bacteria and our immune system.  Plaque is a sticky film of bacteria that forms around the teeth and migrates into a small space between the gum and the tooth.  If undisturbed, the colonies of bacteria in plaque will multiply and mature.  As the plaque matures the conditions become favorable for the growth of harmful bacteria (i.e., periodontal pathogens).  The periodontal pathogens grow in the space that naturally exists between the gum and the tooth, and some of them can invade the tissues.  These microorganisms trigger an inflammatory response that extends to the bone and elicits the action of bone-chewing cells called osteoclasts.  As the gums become inflamed and the bone is destroyed, the space between the gum and the tooth becomes deeper and periodontal pockets develop.  As these pockets become deeper, tooth brushing and flossing become less and less effective at eliminating the bacterial plaque between the gum and the tooth.  Undisturbed bacterial plaque can become calcified leading to the formation of calculus (also referred to as tartar).  The porous and irregular surfaces of calculus are a perfect place for bacteria to grow.  As pockets get deeper and calculus develop on the root surfaces of the teeth, periodontal disease and bone loss become progressively worse and the treatment becomes more complex.  For this reason early diagnosis and treatment is important.

 The bone destruction associated with periodontitis is rarely accompanied by pain.  Periodontitis generally progresses slowly over time, but sometimes a “burst” in disease progression can occur.  The disease can affect all the teeth in the mouth or may only involve one or a few teeth.

Since undisturbed bacterial plaque is the primary cause of periodontal disease, excellent plaque control is also vital for the successful treatment of periodontitis.  However, once periodontitis is established good plaque control and conventional cleanings alone are not sufficient to prevent further disease progression and bone loss.  Depending on the severity of the disease, distribution in the mouth, and multiple patient-specific factors, the treatment of periodontitis may include:

• Non-Surgical Periodontal Treatments
• Bone Grafting and Regenerative Procedures
• Pocket Reduction Procedures
• Gum Grafting
• Dental Implants

Symptoms of Periodontitis

Healthy gums are firm, pale-pink, and fit snugly around teeth.  Periodontal disease generally doesn’t hurt.  Signs and symptoms of periodontitis can include:

• Swollen or puffy gums
• Red or purplish gums
• Gums that feel tender
• Gums that bleed easily
• Spitting out blood after brushing or flossing
• Bad breath
• Pus between your teeth and the gums
• Loose teeth
• Painful chewing
• Spaces gradually developing between your teeth
• Gums pulling away from your teeth (gum recession)

“Periodontal disease is usually painless and can go undetected until it is too late”

“The signs of periodontitis are often less distinct in patients who smoke. However, the disease generally progresses faster among smokers.”

When to Seek Treatment?

It is important that you follow your dentist’s recommended schedule for checkups and cleanings.  If you notice signs or symptoms of periodontitis, make an appointment with your dentist.  Your general or family dentist, will refer you to a periodontist if he/she feels that your condition and treatment-needs are beyond the scope of general practice and may require advanced care.  If you are still concerned, you may see a periodontist.  A referral is generally not required to see a periodontist for an opinion.  The sooner you seek care, the better your chances of reversing damage from periodontitis.

Risk Factors for Periodontitis

The main modifiable cause of periodontal (gum) disease is dental plaque, but other factors can affect the health of your gums.  Factors that can increase your risk of having periodontitis and bone loss around your teeth include:

• PLAQUE CONTROL: Bacterial plaque is the primary cause of gum disease.  Plaque that is not removed will mature leading to the proliferation of harmful bacteria, inflammation and gum disease.  This plaque can harden over time leading to the formation of calculus (i.e., “tartar”) that cannot be cleaned by brushing or flossing.  The presence of calculus further increases the risk for periodontitis.  Only professional cleanings by a dentist or dental hygienist can remove calculus.
• SMOKING/TOBACCO USE: Along with bacterial plaque, smoking/tobacco use, is the most important modifiable risk factor for the development and progression of periodontitis and bone loss around teeth.  Tobacco is also linked with many serious illnesses including oral and throat cancer, other cancers, lung disease and heart disease, as well as numerous other health problems.
  
• GENETICS: Despite good oral care habits, some people develop severe periodontal disease.  In the meantime others with not such good habits may develop little or no disease.  Research indicates that our genetic differences account for up to 50% of the differences – in terms of periodontal disease – between different people of the same age in the population (i.e., 50% of the population variance is accounted by genetics).  At the present time, the profession is only beginning to understand the role of specific genes in the pathogenesis of periodontal diseases.  In the future, genetic testing may prove useful for identifying people at increased risk for periodontitis, and for predicting treatment outcomes.
• DIABETES – OTHER MEDICAL CONDITIONS: People with diabetes, especially those with poorly controlled sugar levels, are highly susceptible to periodontal disease.  Other conditions that cause decreased immunity including leukemia, HIV/AIDS, and certain cancer treatment may also affect the gums.
• AGE: Severe periodontal disease is more common in older people.  Data from the Centers for Disease Control and Prevention indicates that over 70% of Americans 65 and older have periodontitis.  However, aging per se is not likely to increase the rate of progression of susceptibility to the disease.  Most studies indicate that young and older adults lose bone around their teeth at similar rates.  However, since the loss of gum and bone around teeth is often not fully reversible with treatment, older individuals are obviously more likely to present severe tissue destruction.  It is important to note that aging does not appear to have a huge effect on the outcome of periodontal therapy.  However, age is an important factor to be considered when assessing patient susceptibility to periodontal tissue destruction.
• CLENCHING OR GRINDING YOUR TEETH: Clenching or grinding your teeth can put excess force on the supporting tissues of the teeth.  In patients with ongoing periodontitis, clenching and grinding can speed up the rate at which the bone and periodontal tissues are destroyed.
• STRESS: There is an increasing body of evidence regarding the possible effect of stress on the immune system.  Stress has also been associated with bruxism (i.e., grinding your teeth).  Some evidence suggests that psychological stress, depression, and personal coping mechanisms may be risk factors for periodontal disease.  Psychological stress may make it more difficult for the body to fight off infection, including periodontal diseases.
• MEDICATIONS: Many medications that can reduce the flow of saliva, which has a protective effect on the mouth.  Without sufficient saliva, the gums and teeth are more vulnerable to infections including gum disease.  Some medicines can cause abnormal overgrowth of the gum tissue which can make plaque removal more difficult.  Some medications to manage high blood pressure, immune suppressants, medications for osteoporosis, anti-rejection medications, and others can affect your oral health.  It is important that you inform your dental care provider about the medications you are currently taking.
• POOR NUTRITION: 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.  In addition, research has shown that obesity and metabolic changes associated with it may increase the risk of periodontal disease.

OTHER TYPES OF PERIODONTITIS

Chronic periodontitis is the most common type of periodontitis.  Other less common types include the following:

• Aggressive periodontitis generally occurs in otherwise healthy young individuals.  This type of periodontitis generally starts during the teenage years and tends to progress more rapidly than chronic periodontitis.  There are two basic types of aggressive periodontitis: Localized Aggressive Periodontitis (which only affects a few teeth in the mouth) and Generalized Aggressive Periodontitis.  Aggressive periodontitis appears to have a strong genetic component.  The disease aggregates in families; siblings of affected patients are approximately twenty times more likely to have the condition than the general population and some studies suggest a clear pattern of inheritance.  Localized Aggressive Periodontitis affects 1%, and Generalized Aggressive Periodontitis affects 0.1% of the US population under age 35.
• Periodontitis as a manifestation of systemic diseases often begins at a young age and is secondary to medical conditions and syndromes that affect immune function, inflammatory response, and tissue organization.  Conditions that can lead to periodontitis at an early age include hematological disorders, genetic disorders, and others.
• Necrotizing periodontal disease is an infection characterized by necrosis (tissue dying) of parts of the gums and sometimes the bone around the teeth.  The occurrence of these lesions has been reducing, and are now relatively rare.  These lesions are most commonly observed in individuals with severe stress, malnutrition, AIDS, and immunosuppression.