Periodontal disease

An in-depth report on the causes, diagnosis, treatment, and prevention of periodontal disease.

Highlights

Symptoms of periodontal disease include red and swollen gums, gums that bleed while brushing, persistent bad breath, receding gums, and loose teeth. Smoking, certain illnesses (such as diabetes), older age, stress, and other factors increase the risk for periodontal disease.

If you have periodontal disease, your dentist may refer you to a periodontist, a dentist who specializes in treating this condition. Without proper treatment, periodontal disease can lead to tooth loss.

Consistent good dental hygiene can help prevent gingivitis and periodontitis. The American Dental Association recommends that everyone:

• Brush twice daily with a fluoride toothpaste (be sure to replace toothbrushes every 1 to 3 months).
• Clean between the teeth with floss or an interdental cleaner.
• Eat a well-balanced diet and limit snacking between meals.
• Have regular visits with a dentist for teeth cleaning and oral examinations.
• If you smoke, you should quit. Smoking is a major risk factor for gum disease.

Scaling and root planing is the first approach for treating periodontal disease. This procedure is a deep cleaning to remove bacterial plaque and calculus (tartar). Scaling involves scraping tartar from above and below the gum line. Root planing will smooth the root surfaces of the teeth. Your dentist will reevaluate the success of this treatment in follow-up visits. If deep periodontal pockets and infection remain, periodontal surgery may be recommended.

Periodontal disease and heart disease share certain common risk factors, such as smoking and diabetes. Untreated or inadequately controlled moderate-to-severe periodontal disease may increase the risk for heart disease. However, according to the American Heart Association:

• There is no definitive proof that gum disease causes heart disease and stroke.
• There is no definitive proof that treating gum disease can help prevent heart disease and stroke.
• More evidence is needed to establish a cause-and-effect relationship between these conditions.

In general, periodontists and cardiologists recommend that:

• People who have periodontal disease and at least one risk factor for heart disease should have a medical evaluation for heart problems.
• People who have heart disease should have regular exams to check for signs of periodontal disease.

Introduction

Periodontal disease is disease of both gums and bone. The word "periodontal" means "around the tooth." Periodontal disease is a chronic inflammatory disease of the gum and tissues that surround and support the teeth. If left untreated, periodontal disease will lead to bone loss, which can lead to tooth loss.

The Periodontium

The periodontium is the part of the mouth that consists of the gum and supporting structures. It is made up of the following parts:

• Gingiva (gum). When healthy, the gingiva is pale pink, firm, and does not move. It has a smooth or speckled texture. The gingival tissue between teeth is shaped like a wedge.
• Sulcus (pocket). The sulcus is the space between the gum and tooth. It is the main place where periodontal problems begin.
• Cementum (Root surface of the teeth)
• Connective tissue
• Alveolar bone. The alveolar bone contains the teeth sockets and supports the teeth.

The structure of the tooth includes outer layers made of enamel and cementum. The inner layers include dentin, pulp and other tissues, blood vessels, and nerves. The cementum covers the root and is embedded in the bony jaw. Above the gum line, the tooth is protected by the hard enamel shell.

Periodontal Disease

Periodontal diseases are generally divided into two groups:

• Gingivitis , which causes inflammatory lesions that affect the gums, is a milder form of gum disease.
• Periodontitis , which involves damage to the bone and connective tissue that support the teeth, is a more serious form of gum disease.

Gingivitis

Gingivitis is an inflammation of the gingiva, or gums. It is characterized by tender, red, swollen gums that bleed easily and may cause bad breath (halitosis). Gingivitis can be treated by good dental hygiene, proper diet, and stopping smoking. Untreated gingivitis can lead to periodontitis.

Periodontitis

Periodontitis occurs when the gum tissues separate from the tooth and sulcus, forming periodontal pockets. Periodontitis is characterized by:

• Gum inflammation, with redness, puffiness, and bleeding
• Deep pockets (greater than 4 mm in depth) that form between the gum and the tooth
• Loose teeth

There are different forms of periodontal disease. The most common include:

Causes

Risk Factors

Most adults have some form of gum disease but are unaware of it. The main risk factors for periodontal disease include:

• Smoking or tobacco use
• Age
• Female hormonal changes
• Stress
• Medications
• Chronic health conditions
• Genetic factors

Age

Periodontitis typically occurs as people get older and is most common after age 35.

Lifestyle Factors

Female Hormones

Female hormones affect the gums, and women are particularly susceptible to periodontal problems.

Genetic Factors

Periodontal disease often occurs in members of the same family. Genetic factors play a role in making some people more susceptible to periodontal disease. This is most true with aggressive periodontitis. If one child is found to have periodontal disease, all siblings should be checked for the disease.

Medical Conditions Associated with Periodontal Disease

If you take a bisphosphonate drug such as alendronate (Fosamax, generic) discuss with your dentist any potential risks from dental procedures (such as extractions and implants) that involve the jawbone.

Oral bisphosphonates, which are used to treat osteoporosis, have in rare cases caused osteonecrosis (bone destruction) of the jaw. (Intravenous bisphosphonates, which are used in cancer treatment, are more likely to cause osteonecrosis.) Your dentist or oral surgeon may need to take special precautions when performing dental surgery. In any case, be sure to inform your dentist of all medications you take.

Oral Health Risk Factors

Complications

Effect on Heart Disease

Researchers are studying the association between periodontal disease and heart disease. These two conditions share common risk factors (such as smoking and diabetes). However, some studies suggest that the link between periodontal disease and heart disease involves more than shared risk factors. An inflammatory response, which occurs in both periodontal disease and heart disease, may be the common element.

According to the American Heart Association, there is currently not enough evidence to prove that periodontal disease increases the risk for heart disease or stroke, or that treating gum disease can help prevent these cardiac conditions. The U.S. Preventive Services Task Force does not recommend including periodontal disease among the factors used for estimating a healthy person's risk of developing heart disease.

Cardiologists and periodontists currently encourage each other to monitor both conditions in their patients. Periodontists recommend that people who have periodontal disease and at least one risk factor for heart disease have an annual medical exam to check their heart health. Cardiologists suggest that people with atherosclerosis and heart disease have regular periodontal exams.

Effect on Diabetes

Diabetes is not only a risk factor for periodontal disease. Periodontal disease itself can worsen diabetes, both type 1 and type 2, and make it more difficult to control blood sugar.

Effect on Respiratory Disease

Bacteria that reproduce in the mouth can also be carried into the airways in the throat and lungs, increasing the risks for respiratory diseases such as pneumonia. These bacteria can also worsen chronic lung conditions such as emphysema.

Effect on Pregnancy

Bacterial infections that cause moderate-to-severe periodontal disease in pregnant women may increase the risk for premature delivery and low birth weight infants. The bacteria from gum disease and tooth decay may trigger the same factors in the immune system that cause premature dilation and contractions.

Women should have a periodontal examination before becoming pregnant or as soon as possible thereafter. Because women with diabetes are at higher risk for periodontal disease, it is especially important that they see a dentist early in pregnancy. Doctors are still not sure if treating periodontal disease can improve birth outcomes. In any case, periodontal treatment is safe for pregnant women.

Symptoms

Symptoms or periodontal disease typically progress over time and include:

• Red and Swollen Gums are one of the first signs of periodontal disease.
• Gum Bleeding: Bleeding of the gums, even during brushing, is a sign of inflammation and the major marker of periodontal disease.
• Bad Breath: Debris and bacteria can cause a bad taste in the mouth and persistent bad breath.
• Gum Recession and Loose Teeth: As the disease advances, the gums recede, and the supporting structure of bone is lost. Teeth loosen, sometimes causing a change in the way the upper and lower teeth fit together when biting down or how partial dentures fit.

Abnormally bulging, protruding, or swollen gums are a possible sign of disease.

• Abscesses: Deepening periodontal pockets between the gums and bone can become blocked by tartar or food particles. Infection-fighting white blood cells become trapped and die; pus forms, and an abscess develops. Abscesses can destroy both gum and tooth tissue, cause nearby teeth to become loose and painful, and may cause fever and swollen lymph nodes.

Pain is usually not a symptom, which partly explains why the disease may become advanced before treatment is sought and why some people avoid treatment even after periodontitis is diagnosed.

Diagnosis

The dental practitioner typically performs a number of procedures during a routine dental exam to check for periodontal disease. If periodontal disease is suspected, your dentist may refer you to see a periodontist. A periodontist is a dentist who specializes in the diagnosis and treatment of periodontal disease.

Medical History

The dentist will first take a medical history to reveal any past or present periodontal problems, and any medications or underlying diseases that might be contributing to the problem. The dentist will also ask questions about your daily oral hygiene regimen (brushing, flossing).

Oral Examination

• The dentist uses a mirror and a periodontal probe, a thin instrument calibrated in millimeters (mm), which is used to measure pocket depth.
• The probe is held along the length of the tooth with the tip placed into the pocket. The tip of the probe will then touch the bottom of the pocket.
• The dentist will "walk" the probe to 6 specified points on each tooth, 3 on the buccal (cheek), and 3 on the lingual (tongue) sides. The dentist measures the depth of the probe at each point.
• Pocket depths greater than 4 mm indicate disease.

These measurements help determine the condition of the connective tissue and amount of gingival overgrowth or recession.

Treatment

According to the American Academy of Periodontology, treatment for periodontal disease should focus on achieving oral health in the least invasive and most cost-effective manner. Your dentist or periodontist will usually begin with a non-surgical approach (scaling and root planing), then reevaluate your condition in follow-up visits. If infection or deep periodontal pockets remain, surgical treatment may be recommended.

Periodontal treatment approaches can basically be categorized as:

• Nonsurgical Approaches . Scaling and root planing (deep cleaning of tartar and bacteria from gum line and tooth root surfaces), which may include the use of topical or systemic antibiotics.
• Surgical Approaches . Periodontal surgical techniques include flap surgery (periodontal pocket reduction), gum grafts, bone grafts, and guided tissue regeneration.
• Restorative Procedures . Crown lengthening is an example of a restorative procedure that may be performed for cosmetic reasons or to improve function. For people who have already lost teeth to advanced periodontitis, dental implants are another option.

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.

Non-Surgical Treatment

The dentist may apply a topical anesthetic to numb the area before beginning the procedure. 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. Finally, the dentist will polish the tooth using abrasive paste applied to a vibrating instrument with a rubber cap. Polishing produces a smooth surface, making it temporarily harder for plaque to adhere.

Antibiotics for periodontal disease come in various forms. They may be taken as a prescription mouthwash rinse, or placed topically as dissolving gels, threads, or microchips into the periodontal pockets. In some cases, the dentist may prescribe a short course of systemic antibiotics with low-dose doxycycline pills, or amoxicillin with metronidazole.

Surgical Treatment

• The periodontist makes an incision and folds back the gum surface away from the tooth and surrounding bone.
• The diseased root surfaces are cleaned and curetted (scraped) to remove deposits.
• Gum tissue is sewn back into a position to minimize pocket depth.
• The periodontist may also contour the remaining bone or attempt to regenerate lost bone and gingival attachment through bone grafts or guided tissue regeneration.

For several days following surgery, you should rinse your mouth with warm salt water to help reduce swelling. Post-surgical discomfort is usually treated with over-the-counter medications such as ibuprofen or the application of ice packs.

• Free gingival graft removes a thin layer of tissue from the palate of the mouth and sutures onto the exposed root surface. However, many people find the healing of the donor site on the roof of the mouth to be more painful than the actual surgical procedure.
• Subepithelial connective tissue graft removes tissue from inside the palate (as opposed to the outside, as with the free gingival graft). Recovery is less painful with this method.
• Alloderm Regenerative Tissue Matrix uses specially processed tissue derived from donated cadavers. No tissue is taken from the patient.

A synthetic graft has also been developed, but it is not yet clear if results are as successful as with the other graft methods.

• The surgeon places bone graft material into the defective area.
• The material may come from the patient (autogenous), from a cadaver (allograft), or from an animal such as a cow (xenograft). An autogenous graft is considered the best approach.
• The gum is then sewn back into place.
• During the next 6 to 9 months, the bone regrows in the jaw area helping to reattach the teeth to the jaw.

Guided tissue regeneration is a more advanced technique that may be used along with bone grafting:

• A specialized piece of fabric called a barrier membrane is placed between the gum and the existing bone defect.
• The gum is then sewn over the fabric. The fabric prevents the gum tissue from growing down into the bone defect and allows the bone and the attachment to the root to regenerate.

Restorative and Cosmetic Treatments

Prevention

In addition to regular visits to a dentist, the best prevention for periodontal disease takes place at home. Healthy habits and good oral hygiene, including daily brushing and flossing, are critical in preventing gum disease and maintaining good oral health after periodontal treatment.

Tooth Brushing

Correct tooth brushing is the first defense against periodontal disease. Here are some tips for brushing correctly:

• Use a soft-bristled brush that fits the size and shape of your mouth.
• Place the brush where the gum meets the tooth, with bristles resting along each tooth at a 45-degree angle.
• Move the brush back and forth gently. Use short vertical or circular strokes. Do not brush horizontally along the tooth.
• Begin by brushing the outer tooth surfaces, followed by the inner tooth surfaces, and then the chewing surfaces of the teeth.
• Brush your tongue to help remove additional bacteria.
• Flossing should finish the process. A mouthwash may also be used.

If brushing after each meal is not possible, rinsing the mouth with water after eating can help reduce bacteria.

Electric toothbrushes, particularly those with a stationary grip and revolving tufts of bristles, can be helpful, especially for people with physical disabilities. However, in general, studies have reported no major differences between electric and manual toothbrushes in their ability to remove plaque. If a regular toothbrush works, it isn't absolutely necessary to buy an electric one.

The major benefit of electric tooth brushes is that you do not have to be a good brusher to remove the plaque. The other benefit is that most electric brushes have a built in timer, which identifies when the recommended time to brush your teeth (2 minutes) is up. Most people with manual tooth brushes do not brush their teeth long enough.

The most important factor in buying any toothbrush, whether electric or manual, is to choose one with a soft head. Soft bristles get into crevices easier and do not irritate the gums, thereby reducing the risk of exposing teeth below the gum line compared to hard brushes.

Be sure to rinse your toothbrush with water after each use. Toothbrushes should be replaced every 1 to 3 months. Worn bristles are less effective at removing plaque, and old toothbrushes may become breeding grounds for bacteria. To prevent the spread of infection, never share toothbrushes.

Flossing

The use of dental floss, either waxed or unwaxed, is critical in cleaning between the teeth where the toothbrush bristles cannot reach. You can floss before or after brushing; what is important is to floss daily. To floss correctly:

• Break off about 18 inches of floss and wind most of it around the middle finger of one hand and the rest around the other middle finger.
• Hold the floss between the thumbs and forefingers and gently guide and rub it back and forth between the teeth.
• When it reaches the gum line, the floss should be curved around each tooth and slid gently up and down against the tooth.

If you have trouble flossing, some devices may help:

• A floss threader may be helpful for people who have bridgework. Made of plastic, it looks like a needle with a huge eye, or loop. A piece of floss is threaded into the loop, which can then be inserted between the bridge and the gum. The floss that is carried through with it can then be used to clean underneath the false tooth or teeth and along the sides of the abutting teeth.
• An interdental cleaner (Proxabrush) is a tiny narrow brush that can be worked in between the natural teeth or around an attached false tooth.
• Special toothpicks such as Stim-U-Dent may be used for wide spaces between teeth but should never replace flossing. Standard toothpicks should never be used for regular hygiene.
• An electric water pik delivers a steady jet of water and can help remove plaque build-up between teeth.

Toothpastes and Mouthwashes

Ingredients contained in toothpastes may include:

• Fluoride. Most commercial toothpastes contain fluoride, which both strengthens tooth enamel against decay and enhances remineralization of the enamel. Fluoride also inhibits acid-loving bacteria, especially after eating, when the mouth is more acidic. This antibacterial activity may help control plaque.
• Triclosan. Triclosan is an anti-bacterial substance that may help reduce mild gingivitis.
• Metal salts. Metal salts, such as stannous and zinc, serve as anti-bacterial substances in toothpastes. Stannous fluoride gel toothpastes do not reduce plaque, even though they have some effect against the bacteria that cause it, but slightly reduce gingivitis.
• Peroxide and baking soda. Toothpastes with these ingredients claim to have a whitening action, but while they may help remove stains there is little evidence they whiten the actual color of the teeth. In addition, these substances ;do not appear to offer much protection against gum disease.
• Antibacterial sugar substitutes (xylitol), and detergents (delmopinol)

• Antimicrobial mouthwashes, such as Listerine, reduce plaque and gingivitis. Chlorhexidine (Peridex or PerioGard) is an antimicrobial mouthwash available only by prescription to specifically target gingivitis-causing bacteria. It is often prescribed before or following periodontal surgery. Chlorhexidine can temporarily stain teeth.
• Fluoride mouthwashes (Act, generics) are helpful in preventing cavities.
• Breath-freshening mouthwashes containing cetylpyridinium (Scope, Cepacol, generics) have limited effects on plaque.
• Mouthwashes that contain alcohol (such as certain Listerine products) are dangerous for children under age 12. Fluoride mouthwashes should not be used by children younger than age 6.

Lifestyle Changes

Resources

• www.nidcr.nih.gov -- National Institute of Dental and Craniofacial Research
• www.perio.org -- American Academy of Periodontology
• www.ada.org -- American Dental Association
• www.aaoms.org -- American Association of Oral and Maxillofacial Surgeons