Periodontal Disease

The word periodontal means "around the tooth". Periodontal disease attacks the gums and the bone that support the teeth. Plaque is a sticky film of food debris, bacteria, and saliva. If plaque is not removed, it turns into calculus (tartar). When plaque and calculus are not removed, they begin to destroy the gums and bone. Periodontal disease is usually characterized by red, swollen, and bleeding gums.

Four out of five people have periodontal disease and don’t know it! Most people are not aware of it because the disease is usually painless in the early stages.

Not only is it the number one reason for tooth loss, research suggests that there may be a link between periodontal disease and other diseases such as, stroke, bacterial pneumonia, diabetes, cardiovascular disease, and increased risk during pregnancy. Smoking also increases the risk of periodontal disease.

Good oral hygiene, a balanced diet, and regular dental visits can help reduce your risk of developing periodontal disease.

Signs and symptoms of periodontal disease

Common Signs & Symptoms

It is extremely important to note that periodontal disease can progress without any signs or symptoms such as pain. This is why regular dental checkups and X-rays are exceptionally important. Described below are some of the most common signs and symptoms of periodontitis.

If you have any of these signs or symptoms, the advice of a general dentist or periodontist should be sought as soon as possible:

  • Unexplained bleeding — Bleeding when brushing, flossing, sleeping or eating food is one of the most common symptoms of a periodontal infection. The toxins in plaque cause a bacterial infection which makes the tissues prone to bleeding.
  • Pain, redness or swelling — A periodontal infection may be present if the gums are swollen, red or painful for no apparent reason. It is essential to halt the progression of the infection before the gum tissue and jaw bone have been affected. It is also critical to treat the infection before it is carried into the bloodstream to other areas of the body.
  • Longer-looking teeth — Periodontal disease can lead to gum recession. The toxins produced by bacteria can destroy the supporting tissue and bones, thus making the teeth look longer and the smile appear more "toothy."
  • Bad breath/halitosis — Although breath odor can originate from back of the tongue, the lungs and stomach, from the food we consume, or from tobacco use, bad breath may be caused by old food particles from blood and bacteria, which sit between the teeth and underneath the gumline. The deeper gum pockets are able to house more debris and bacteria, causing a foul odor.
  • Loose teeth/change in bite pattern — A sign of rapidly progressing periodontitis is the loosening or shifting of the teeth in the affected area. As the bone tissue gets destroyed, teeth that were once firmly attached to the jawbone become loose or may shift in position.
  • Pus — Pus oozing from between the teeth is a definitive sign that a periodontal infection is in progress. The pus is a result of the body trying to fight the bacterial infection.

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Causes of Periodontal Disease

Periodontal disease, which is also known as gum disease or periodontitis, is a chronic disease. If left untreated, periodontal disease may result in tooth loss. Periodontal disease begins with the presence of bacteria in the gingival tissues which surround the teeth. A group of bacteria is called plaque. The toxins excreted by the bacteria cause inflammation and irritation of the gingival tissues, resulting in a bacterial infection.

The bacterial infection is initiated when bacteria colonize in the gingival tissue. Pockets begin to form between the teeth and the gums from the inflammation of the gums. Inflammation of the gums is called gingivitis. If treated promptly by a dental hygienist, the effects of gingivitis are completely reversible. If the inflammation progress goes untreated, the underlying bone surrounding the tooth is destroyed. Bone loss around the tooth is called periodontal disease. Lack of bone support may lead to lose teeth and potential tooth loss. The bacteria from this infection may enter the bloodstream through the gums and travel throughout the body.

Common Risk Factors of Periodontal Disease

There are genetic and environmental factors involved in the onset of periodontal disease. In most cases, the risk of developing periodontitis can be significantly lowered by taking preventative measures.

Here are some of the most common risk factors of periodontal disease:

  • Poor oral hygiene - Preventing dental disease starts at home with good oral hygiene and a balanced diet. Prevention also includes regular dental visits which include exams, cleanings, and x-rays. A combination of excellent home care and professional dental care will help preserve the natural teeth and their supporting structures. When bacteria and calculus (tartar) are not removed, the gums and bone around the teeth are exposed to bacterial toxins. These toxins initiate gingivitis, which may progress to periodontal disease. Tooth loss is a characteristic of advanced periodontal disease.
  • Tobacco use — Research has indicated that smoking and spit tobacco are one of the leading risk factors in the development and progression of periodontal disease. Smoking inhibits the immune system’s ability to fight bacterial infection. Smokers are more prone to calculus (tartar) build up on the teeth, deep pockets in the gingival tissue, and bone loss. Additionally, smoking constricts the blood vessels and causes a decrease in blood flow through the gums. This leads to the development of additional gum problems leading to periodontitis.
Genetic predisposition — Despite practicing rigorous oral hygiene routines, as much as 30% of the population may have a strong genetic predisposition to gum disease.
  • Pregnancy and menopause — During pregnancy, regular brushing and flossing is critical. Hormonal changes experienced by the body can cause the gum tissue to become more sensitive, rendering them more susceptible to gum disease.
  • Chronic stress and poor diet — Stress lowers the ability of the immune system to fight off disease, which means bacterial infections may possibly beat the body’s defense system. Poor diet or malnutrition can also lower the body’s ability to fight periodontal infections, as well as negatively affecting the health of the gums.
  • Diabetes and underlying medical issues — Many medical conditions can intensify or accelerate the onset and progression of gum disease including respiratory disease, heart disease, arthritis and osteoporosis. Diabetes hinders the body’s ability to utilize insulin which makes the bacterial infection in the gums more difficult to control and cure.
  • Grinding teeth — The clenching or grinding of the teeth can significantly damage the supporting tissue surrounding the teeth. Grinding one’s teeth is usually associated with a "bad bite" or the misalignment of the teeth(Malocclusion). When an individual is suffering from gum disease, the additional destruction of gingival tissue due to grinding can accelerate the progression of the disease.
  • Medication — Many drugs including oral contraceptive pills, heart medicines, anti-depressants and steroids affect the overall condition of teeth and gums; making them more susceptible to gum disease. Steroid use promotes gingival overgrowth, which makes swelling more commonplace and allows bacteria to colonize more readily in the gum tissue.

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Types of Periodontal Disease

There are many different varieties of periodontal disease, and many ways in which these variations manifest themselves. All require immediate treatment by a periodontist to halt the progression and save the gum tissue and bone. Here are some of the most common types of periodontal disease along with the treatments typically performed to correct them:

Gingivitis

Gingivitis is the mildest and most common form of periodontitis. It is caused by the toxins in plaque and leads to periodontal disease. People at increased risk of developing gingivitis include pregnant women, women taking birth control pills, people with uncontrolled diabetes, steroid users and people who control seizures and blood pressure using medication.

Treatment: Gingivitis is easily reversible using a solid combination of home care and professional cleaning. The dentist may perform root planing and deep scaling procedures to cleanse the pockets of debris. A combination of antibiotics and medicated mouthwashes may be used to kill any remaining bacteria and promote the good healing of the pockets.

Chronic Periodontal Disease

Chronic periodontal disease is the most common form of the disease, and occurs much more frequently in people over 45. Chronic periodontal disease is characterized by inflammation below the gum line and the progressive destruction of the gingival and bone tissue. It may appear that the teeth are gradually growing in length, but in actuality the gums are gradually recessing.

Treatment: Unfortunately unlike gingivitis, chronic periodontal disease cannot be completely cured because the supportive tissue cannot be rebuilt. However, the dentist can halt the progression of the disease using scaling and root planing procedures in combination with antimicrobial treatments. If necessary, the periodontist can perform surgical treatments such as pocket reduction surgery and also tissue grafts to strengthen the bone and improve the aesthetic appearance of the oral cavity.

Aggressive Periodontal Disease

Aggressive periodontal disease is characterized by the rapid loss of gum attachment, the rapid loss of bone tissue and familial aggregation. The disease itself is essentially the same as chronic periodontitis but the progression is much faster. Smokers and those with a family history of this disease are at an increased risk of developing aggressive periodontitis.

Treatment: The treatments for aggressive periodontal disease are the same as those for chronic periodontal disease, but aggressive periodontal disease sufferers are far more likely to require a surgical intervention. This form of the disease is harder to halt and treat, but the dentist will perform scaling, root planing, antimicrobial, and in some cases laser procedures in an attempt to save valuable tissue and bone.

Periodontal Disease Relating to Systemic Conditions

Periodontal disease can be a symptom of a disease or condition affecting the rest of the body. Depending on the underlying condition, the disease can behave like aggressive periodontal disease, working quickly to destroy tissue. Heart disease, diabetes and respiratory disease are the most common cofactors, though there are many others. Even in cases where little plaque coats the teeth, many medical conditions intensify and accelerate the progression of periodontal disease.

Treatment: Initially, the medical condition which caused the onset of periodontal disease must be controlled. The dentist will halt the progression of the disease using the same treatments used for controlling aggressive and chronic periodontal disease.

Necrotizing Periodontal Disease

This form of the disease rapidly worsens and is more prevalent among people who suffer from HIV, immunosuppression, malnutrition, chronic stress or choose to smoke. Tissue death (necrosis) frequently affects the periodontal ligament, gingival tissues and alveolar bone.

Treatment: Necrotizing periodontal disease is extremely rare. Because it may be associated with HIV or another serious medical condition, it is likely the dentist will consult with a physician before commencing treatment. Scaling, root planing, antibiotic pills, medicated mouth wash and fungicidal medicines are generally used to treat this form of the disease.

If you have any question or concerns about the different types of periodontal disease and treatments, please ask your dentist.

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Mouth - Body Connection

Research studies have shown that there is a strong association between periodontal disease and other chronic conditions such as diabetes, heart disease, pregnancy complications and respiratory disease.

Periodontal disease is characterized by chronic inflammation of the gum tissue, periodontal infection below the gum line and a presence of disease-causing bacteria in the oral region. Halting the progression of periodontal disease and maintaining excellent standards of oral hygiene will not only reduce the risk of gum disease and bone loss, but also reduce the chances of developing other serious illnesses.

Common cofactors associated with periodontal disease:

Diabetes

A research study has shown that individuals with pre-existing diabetic conditions are more likely to either have, or be more susceptible to periodontal disease. Periodontal disease can increase blood sugar levels which makes controlling the amount of glucose in the blood difficult. Conversely, diabetes thickens blood vessels and therefore makes it harder for the mouth to rid itself of excess sugar. Excess sugar in the mouth creates a breeding ground for the types of oral bacteria that cause gum disease.

Heart Disease

There are several theories which explain the link between heart disease and periodontitis. One such theory is that the oral bacteria strains which exacerbate periodontal disease attach themselves to the coronary arteries when they enter the bloodstream. This in turn contributes to both blood clot formation and the narrowing of the coronary arteries, possibly leading to a heart attack.

A second possibility is that the inflammation caused by periodontal disease causes a significant plaque build up. This can swell the arteries and worsen pre-existing heart conditions. An article published by the American Academy of Periodontology suggests that patients whose bodies react to periodontal bacteria have an increased risk of developing heart disease.

Pregnancy Complications

Women in general are at increased risk of developing periodontal disease because of hormone fluctuations that occur during puberty, pregnancy and menopause. Research suggests that pregnant women suffering from periodontal disease have a greater risk of preeclampsia.

Respiratory Disease

Oral bacterium linked with gum disease has been shown to possibly cause or worsen conditions such as emphysema, pneumonia and Chronic Obstructive Pulmonary Disease (COPD). Oral bacteria can be drawn into the lower respiratory tract during the course of normal inhalation and colonize; causing bacterial infections. Studies have shown that the repeated infections which characterize COPD may be linked with periodontitis.

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Periodontal Disease and Diabetes

It is well documented that people who suffer from diabetes are more susceptible to developing infections than non-diabetes sufferers. It is not widely known that t periodontal disease is often considered the sixth complication of diabetes; particularly when the diabetes is not under proper control.

Reasons for the Connection

Experts suggest the relationship between diabetes and periodontal disease can worsen both conditions if either condition is not properly controlled.

Here are ways in which diabetes and periodontal disease are linked:

  • Increased blood sugar — Moderate and severe periodontal disease elevates sugar levels in the body, increasing the amount of time the body has to function with high blood sugar. This is why diabetics with periodontitis have difficulty keeping control of their blood sugar.
  • Blood vessel thickening — The thickening of the blood vessels is one of the other major concerns for diabetes sufferers. The blood vessels normally serve a vital function for tissues by delivering nutrients and removing waste products. With diabetes, the blood vessels become too thick for these exchanges to occur. This means that harmful waste is left in the mouth and can weaken the resistance of gum tissue, which can lead to infection and gum disease.
  • Smoking — Tobacco use does a great deal of damage in the oral region. Not only does tobacco use slow the healing process, it also vastly increases the chances of an individual developing periodontal disease. For diabetics who smoke, the risk is exponentially greater. In fact, diabetic smokers aged 45 and over are twenty times more likely to develop periodontal disease.
  • Poor oral hygiene — It is essential for diabetics to maintain excellent levels of oral health. When daily brushing and flossing does not occur, the harmful oral bacteria can ingest the excess sugar between the teeth and colonize more freely below the gum line. This exacerbates the metabolic problems that diabetes sufferers experience.

Diagnosis and Treatment

It is of paramount importance for people suffering from any type of diabetes to see the dentist at least twice yearly for checkups and professional cleanings. Studies have shown that simple non-surgical periodontal treatments can lower the HbA1c (hemoglobin molecule blood test) count by as much as 20% in a six month period.

The dentist will use medical history, family history and dental X-rays to assess the risk factors for periodontal disease and determine the exact condition of the gums, teeth and underlying jawbone. If necessary the dentist will work in conjunction with other doctors to ensure that both the diabetes and the gum disease are being managed and controlled as effectively as possible.

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Periodontal Disease and Pregnancy

Researchers have shown that periodontal disease in expectant mothers actually exposes their unborn child to many different risks; particularly if they also happen to be diabetes sufferers.

Pregnancy causes many hormonal changes which increase the risk of the expectant mother to develop gingivitis (inflammation of the gum tissue) and periodontal disease. These oral problems have been linked in many research studies to preeclampsia, low birth weight of the baby and premature birth. Expectant women should seek immediate treatment for periodontal disease in order to reduce the risk of pre-natal and post-natal complications.

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Periodontal Disease and Osteoporosis

Osteoporosis is a common metabolic bone disease which frequently occurs in postmenopausal women, and occurs less frequently in men. Osteoporosis is characterized by bone fragility, low bone mass and a decrease in bone mineral density. Many studies have explored and identified a connection between periodontal disease and osteoporosis.

A study conducted at the University of New York at Buffalo in 1995 concluded that post-menopausal women who suffered from osteoporosis were 86% more likely to also develop periodontal disease.

Reasons for the Connection

Though studies are still being conducted in order to further assess the extent of the relationship between osteoporosis and periodontal disease, the researchers have thus far made the following connections:

  • Estrogen deficiency — Estrogen deficiency accompanies menopause and also speeds up the progression of oral bone loss. The lack of estrogen accelerates the rate of attachment loss (fibers and tissues which keep the teeth stable are destroyed).
  • Low mineral bone density — This is thought to be one of several causes of osteoporosis, and the inflammation from periodontal disease makes weakened bones more prone to break down. This is why periodontitis can be more progressive in patients with osteoporosis.

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Periodontal Disease and Respiratory Disease

Periodontal disease (also called periodontitis and gum disease) has been linked to respiratory disease through recent research studies. Researchers have concluded that periodontal disease can worsen conditions such as chronic obstructive pulmonary disease (COPD) and may actually play a causal role in the contraction of pneumonia, bronchitis and emphysema.

There are a number of different respiratory diseases linked to periodontal disease. Pneumonia, COPD, and bronchitis are among the most common. Generally, bacterial respiratory infections occur due to the inhalation of fine droplets from the mouth into the lungs. COPD is a leading cause of death and should be taken very seriously.

Reasons for the Connection

The fact that respiratory disease and periodontal disease are linked may seem far-fetched, but there is plenty of evidence to support it.

Here are some of the reasons for the link between periodontal disease and respiratory disease:

  • Bacterial spread — The specific type of oral bacterium that causes periodontal disease can easily be drawn into the lower respiratory tract. Once the bacteria colonize in the lungs, it can cause pneumonia and exacerbate serious conditions such as COPD.
  • Low immunity — It has been well-documented that most people who experience chronic or persistent respiratory problems suffer from low immunity. This low immunity allows oral bacteria to embed itself above and below the gum line without being challenged by the body’s immune system. Not only does this accelerate the progression of periodontal disease, it also puts the sufferer at increased risk of developing emphysema, pneumonia and COPD.
  • Modifiable factors — Smoking is thought to be the leading cause of COPD and other chronic respiratory conditions. Tobacco use also damages the gingiva and compromises the good health of the oral cavity in its entirety. Tobacco use slows the healing process, causes gum pockets to grow deeper and also accelerates attachment loss. Smoking is not the sole cause of periodontal disease, but it is certainly a cofactor to avoid.
  • Inflammation — Periodontal disease causes the inflammation and irritation of oral tissue. It is possible that the oral bacteria causing the irritation could contribute to inflammation of the lung lining, thus limiting the amount of air that can freely pass to and from the lungs.

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Diagnosis

Periodontal disease is diagnosed by your dentist or dental hygienist during a periodontal examination. This type of exam should always be part of your regular dental check-up.

A periodontal probe (small dental instrument) is gently used to measure the sulcus (pocket or space) between the tooth and the gums. The depth of a healthy sulcus measures three millimeters or less and does not bleed. The periodontal probe helps indicate if pockets are deeper than three millimeters. As periodontal disease progresses, the pockets usually get deeper.

Your dentist or hygienist will use pocket depths, amount of bleeding, inflammation, tooth mobility, etc., to determine the treatment.

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Periodontal Treatment

Periodontal treatment methods depend upon the type and severity of the disease. Your dentist and dental hygienist will evaluate for periodontal disease and recommend the appropriate treatment.

Periodontal disease progresses as the sulcus (pocket or space) between the tooth and gums gets filled with bacteria, plaque, and tartar, causing irritation to the surrounding tissues. When these irritants remain in the pocket space, they can cause damage to the gums and eventually, the bone that supports the teeth!

If the disease is caught in the early stages of gingivitis, and no damage has been done, one to two regular cleanings will be recommended. You will also be given instructions on improving your daily oral hygiene habits and having regular dental cleanings.

  • Scaling and root Planing - If the disease has progressed to more advanced stages, a special periodontal cleaning called scaling and root planing (deep cleaning) will be recommended. It is usually done one side of the mouth at a time while the area is numb. In this procedure, tartar, plaque, and toxins are removed from above and below the gum line (scaling) and rough spots on root surfaces are made smooth (planing). This procedure helps gum tissue to heal and pockets to shrink. Medications, special medicated mouth rinses, and an electric tooth brush may be recommended to help control infection and healing.

If the pockets do not heal after scaling and root planing, periodontal surgery may be needed to reduce pocket depths, making teeth easier to clean. Your dentist may also recommend that you see a Periodontist (specialist of the gums and supporting bone).

  • Tissue regeneration — When the bone and gum tissues have been destroyed, regrowth can be actively encouraged using grafting procedures. A membrane may be inserted into the affected areas to assist in the regeneration process.
  • Pocket elimination surgery — Pocket elimination surgery (also known as flap surgery) is a surgical treatment which can be performed to reduce the pocket size between the teeth and gums. Surgery on the jawbone is another option which serves to eliminate indentations in the bone which foster the colonization of bacteria.
  • Dental implants — When teeth have been lost due to periodontal disease, the aesthetics and functionality of the mouth can be restored by implanting prosthetic teeth into the jawbone. Tissue regeneration procedures may be required prior to the placement of a dental implant in order to strengthen the bone.

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Maintenance

It only takes twenty four hours for plaque that is not removed from your teeth to turn into calculus (tartar)! Daily home cleaning helps control plaque and tartar formation, but those hard to reach areas will always need special attention.

Once your periodontal treatment has been completed, your dentist and dental hygienist will recommend that you have regular maintenance cleanings (periodontal cleanings), usually four times a year. At these cleaning appointments, the pocket depths will be carefully checked to ensure that they are healthy. Plaque and calculus that is difficult for you to remove on a daily basis will be removed from above and below the gum line.

In addition to your periodontal cleaning and evaluation, your appointment will usually include:

  • Examination of diagnostic x-rays (radiographs): Essential for detection of decay, tumors, cysts, and bone loss. X-rays also help determine tooth and root positions.
  • Examination of existing restorations: Check current fillings, crowns, etc.
  • Examination of tooth decay: Check all tooth surfaces for decay.
  • Oral cancer screening: Check the face, neck, lips, tongue, throat, cheek tissues, and gums for any signs of oral cancer.
  • Oral hygiene recommendations: Review and recommend oral hygiene aids as needed. (Electric toothbrushes, special periodontal brushes, fluorides, rinses, etc.)
  • Teeth polishing: Remove stain and plaque that is not otherwise removed during tooth brushing and scaling.

Good oral hygiene practices and periodontal cleanings are essential in maintaining dental health and keeping periodontal disease under control!

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Periodontist

Periodontists specialize in the treatment of gum disease and the placement of dental implants. A periodontist can perform effective cleaning procedures in deep pockets such as scaling and root planing, and also prescribe antibiotic and antifungal medications to treat infection and halt the progression of the disease.

In the case of tooth loss, the periodontist is able to perform tissue grafts to promote natural tissue regeneration, and insert dental implants if a tooth or several teeth are missing. Where gum recession causes a "toothy" looking smile, the periodontist can recontour the gingival tissue to create an even and aesthetically pleasing appearance.

Preventing periodontal disease is critical in preserving the natural dentition. Addressing the causes of gum disease and discussing them with your dentist will help prevent the onset, progression, and recurrence of periodontal disease.

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