Periodontitis

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Periodontitis

Definition

Periodontitis is a form of periodontal disease resulting in inflammation within the supporting structures of the teeth, progressive attachment, and bone loss. If left untreated, periodontitis can lead to tooth loss.

Description

Periodontal diseases involve the gum, and include gingivitis and periodontitis. These are both serious infections that begin when bacteria in plaque (a sticky, colorless film that constantly forms on the teeth) cause inflammation of the gums. Undiagnosed or ignored gingivitis—in either case, untreated—can result in periodontitis. When this occurs, plaque may spread and invade below the gum line. When toxins made by the bacteria in the plaque irritate the gums, an inflammatory response is elicited. This response becomes chronic; the body turns on itself and the disease advances. Tissues and bones that support the teeth break down. Pockets, or spaces between the teeth and gums, form—the result of severe infection of the periodontal tissue and gums (the gingiva, periodontal ligament, cementum, and alveolar bone). With progression of periodontitis, the pockets deepen. Destruction of the gum tissue and bone worsens. Despite the frequent presentation of very mild symptoms, teeth that have become loose because of these changes may have to be removed.

Plaque and tartar (calculus) accumulate at the base of the teeth. Inflammation causes a pocket to develop between the gums and the teeth, which fills with plaque and tartar. Soft tissue swelling traps this plaque in the pocket, and the bacteria from the plaque begin to develop and grow. Continued inflammation and bacteria growth eventually causes destruction of the tissue surrounding the tooth. An abscess may also develop, which increases the rate of bone destruction. Several bacterial products that diffuse through tissue are thought to play a role in disease formation.

Bacterial endotoxin is a toxin produced by some bacteria that can kill cells. The amount of endotoxin present correlates with the severity of the periodontitis. Other bacterial products include proteolytic enzymes (molecules that digest protein found in cells), thereby causing cell destruction. The immune response has also been implicated in tissue destruction. As part of the normal immune response, WBCs enter regions of inflammation to destroy bacteria. In the process of destroying bacteria, periodontal tissue is also destroyed.

Onset of periodontitus at an early age and an infection characterized by necrosis of the gingival tissue, periodontal ligament, and alveolar bone, have most commonly been observed with individuals with medical conditions including Down syndrome, Crohn's disease, AIDS, and any disease that reduces the number of white blood cells (WBCs) in the body for extended periods of time. Reduction of the number of WBCs makes it difficult for the body to fight off infection.

Distinct types of periodontitis

Although there are many kinds of periodontitis, the following are the ones most often presented at the dentist's office:

Gingivitis. The mildest type of periodontal disease, gingivitis is the reason that gums redden, swell, and bleed easily. Reversible with professional management and good home care, gingivitis is usually relatively painless or pain free.
Aggressive periodontitis. This occurs in patients with relative good health, clinically. Aggressive periodontitis includes rapid ligament attachment loss and bone destruction.
Chronic periodontitis. Patients with inflammation within the supporting tissues of the teeth and progressive attachment of the ligament and bone structure, characterized by pocket formation and/or recession of the gum tissue, are known to have chronic periodontitis. Although it occurs most frequently in adults, it can affect anyone, of any age. This progressive periodontitis affects gums and bones slowly, but can has also been known to advance quickly.
Periodontitis as a manifestation of systemic disease. In this case, the onset is often at a young age. It is generally associated with one of several physiogenic diseases, such as diabetes.
Necrotizing periodontal disease. This type of periodontal disease is characterized by necrosis (cell death) of gingival tissues, periodontal ligament, and alveolar bone. People with systemic conditions usually present with these symptoms; they may be malnourished, immunosuppressed, or have the human immunodeficiency virus (HIV).

Causes and symptoms

The initial symptoms of periodontitis are bleeding, inflamed gums, and bad breath. Periodontitis follows cases of gingivitis, which may not be severe enough to cause a patient to seek dental help. Although the symptoms of periodontitis are also seen in other forms of periodontal diseases, the key characteristic in periodontitis is a large pocket that forms between the teeth and gums. Another characteristic of periodontitis is that pain usually does not develop until late in the disease, when a tooth loosens or an abscess forms.

Several risk factors play a role in the development of periodontal disease. The most important are age and oral hygiene. The number and type of bacteria present on the gingival tissues also play a role in the development of periodontitis. The presence of certain species of bacteria in large enough numbers in the gingival pocket and related areas correlates with the development of this disease.

There are a number of other factors that can affect gum health. These include smoking and using tobacco, genetics, pregnancy, puberty, stress, medications, clenching or grinding one's teeth, diabetes, poor nutrition, and other systemic diseases. For example, poor nutrition can contribute to compromising the body's immune system. This will make it more difficult for it to fight infection. There are also some drugs—such as a few heart medicines, antidepressants, and oral contraceptives—that can affect one's health. Smoking can cause bone loss and gum recession; they are much more likely than nonsmokers to have calculus form on their teeth, even when no periodontal disease is indicated. Smoking exacerbates inflammation by an overactive response of the immune system. It contributes to the early onset of periodontal disease. Serious diseases, such as heart disease, respiratory disease, or diabetes, may put one at higher risk for the development of infection of the gums. Individuals with diabetes may have more difficulty controlling infections.

Contrary to general opinion, age may not be a risk factor in the development of periodontal disease. There are risk factors that may make older people more prone to health problems, such as decreased immune status, taking medications, diminished saliva flow, depression, and general poor health. However, aging, in and of itself, does not constitute a serious risk factor for periodontal disease.

Symptoms of periodontitis are:

gum tissue that is red, swollen, or tender
gum tissue that bleeds easily; for example, during brushing or flossing
gums that seem to have pulled away from the teeth
a bad taste in the mouth; persistent bad breath due to the collection of debris and bacteria in the mouth
pus between the gums and teeth
loose or separating teeth
changes in the way the teeth meet when the mouth closes

Early signs of periodontitis may be mistaken for gingivitis, but warning signs should be heeded and professional dental care attention should be sought promptly.

Diagnosis

Diagnosis is made by clinical and radiologic evaluation of infected gums and bones. A medical history will be taken by the health care provider to assess the patient's overall systemic health. The patient may have a condition that is contributing to the presenting infection. A general dentist is usually the first person to diagnose and characterize the various stages of periodontitis.

Diagnosis of periodontitis includes measuring the size of the pockets formed between the gums and teeth. Normal gingival pockets are shallow. If periodontal disease is severe, bone loss will be detected in x-ray images of the teeth. If too much bone is lost, the teeth become loose and can change position. This will also be seen in x-ray images.

Treatment

The goal of treating periodontitis is to reduce inflammation and rid the mouth of the causes of the disease. Treatment requires professional dental care, commonly accomplished in the dental office by a registered dental hygienist (RDH). The pockets around the teeth must be cleaned, and all tartar and plaque removed. In periodontitis, tartar and plaque can extend far down the tooth root. Normal dental hygiene—brushing and flossing—cannot reach deep enough to be effective in treating periodontitis. In cases where pockets are very deep (more than 0.25 in, or 0.6 cm), surgery is required to clean the pocket. Over-the-counter (OTC) pain medications can be useful if the treatment is uncomfortable. These include Tylenol (acetaminophen), Advil (ibuprofen), and Motrin (ibuprofen).

A periodontist performs surgery in a dental office as an out patient procedure. Sections of gum that are not likely to reattach to the teeth may be removed to promote healing by healthy sections of gum. Abscesses are treated with a combination of antibiotics and surgery. The antibiotics may be delivered directly to the infected gum and bone tissues to ensure that high concentrations of the antibiotic reach the infected area such as Periostat. Abscess infections, especially of bone, are difficult to treat and require long-term antibiotic treatments to prevent a recurrence of infection, such as augmentin or tetracycline.

Periodontal case types
Source: American Academy of Periodontology, 1991.
Case Type 1—gingival disease	Inflammation of the gingiva characterized by changes in color, gingival form, position, surface appearance, and presence of bleeding and/or exudate.
Case Type II—early or slight periodontitis	Progression of the gingival inflammation into the deeper periodontal structures and alveolar bone crest, with slight bone loss. There is usually a slight loss of connective tissue attachment and alveolar bone.
Case Type III—moderate periodontitis	A more advanced stage of the preceding condition, with increased destruction of the periodontal structures and noticeable loss of bone support, possibly accompanied by an increase in tooth mobility. There may be furcation involvement in multirooted teeth.
Case Type IV—advanced periodontitis	Further progression of periodontitis with major loss of alveolar bone support usually accompanied by increased tooth mobility. Furcation involvement in multirooted teeth is likely.
Case Type V—refractory progressive periodontitis	Includes patients with multiple disease sites that continue to demonstrate attachment loss after appropriate therapy. These sites presumably continue to be infected by periodontal pathogens no matter how thorough or frequent the treatment provided. Also includes patients with recurrent disease at single or multiple sites.

Prognosis

Periodontitis can be treated. Prognosis will be good if bone loss has not been too extreme. Removal of the plaque and tartar may be uncomfortable, but any discomfort will subside as the healing process begins. Bleeding and tenderness of the gum tissue will diminish within one or two weeks after treatment. The gums usually heal and resume their normal shape and function. After successful treatment for periodontitis, pathologic pockets are less deep, and reattachment of the ligament will have occurred in most areas.

Health care team roles

A general dentist is commonly the first person seen in the dental field by a patient presenting periodontitis. The dentist evaluates the case and may recommend that the patient see a periodontist for further treatment. The periodontist will then re-evaluate the case and refer for deep pocket scaling and cleanings by the RDH or suggest surgery. The registered dental assistant (RDA) may assist the general dentist or periodontist in treatment and aiding in patient education. All staff members are part of the team effort to treat a patient with periodontitis. Patient care and understanding will aid in the reduction of this disease and the reduction of the time spent in the office. Patient education is vital in this treatment.

Prevention

Periodontitis can be prevented with good oral hygiene, including thorough toothbrushing and flossing. Regular professional dental cleanings and dental check ups are the best measures of prevention. Daily use of a toothbrush and flossing is sufficient to prevent most cases of periodontitis. Tartar control toothpastes help prevent tartar formation, but do not remove tartar once it has formed. Patient education is also important in teaching what environmental products aid in the development of periodontitis and what to avoid.

KEY TERMS

Alveolar bone— A set of ridges from the jawbones.

Inflammation— A painful redness and swelling of an area of tissue in response to infection or injury.

Periodontist— A dentist who specializes in treating the gum tissue and bones of the mouth.

Systemic— Not just one area, but the whole system, as in a whole body infection.

Resources

PERIODICALS

American Academy of Periodontology. "Cigar And Pipe Smoking Are As Dangerous as Cigarettes to Periodontal Health." Journal of Periodontology (January 5, 2001).

Armitage, Gary C. "Development of a Classification System for Periodontal Diseases and Conditions." Annals of Periodontology (December 1999).

Mullally, Brian H., Blanaid Breen, and Gerard J. Linden. "Smoking and Patterns of Bone Loss in Early-onset Periodontitis." Journal of Periodontology (April 1999).

ORGANIZATIONS

Adam.com Health and Medical Association Online. Atlanta Corporate Office 1600 River Edge Parkway, Suite 800 Atlanta, Georgia 30328 (770) 980-0888. 〈http://www.adam.com/home.htm〉.

American Academy of Periodontology, 4157 Mountain Road, PBN 249 Pasadena, MD 21122. (410) 437-3749. 〈http://www.perio.org〉.

American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. (312) 440-2500. 〈http://www.ada.org〉.