What Is Gum Disease (Periodontitis)?

Periodontitis means "inflammation around the tooth" - it is a serious gum infection that damages the soft tissue and bone that supports the tooth. All periodontal diseases, including periodontitis, are infections which affect the periodontium. The periodontium are the tissues around a tooth, tissues that support the tooth. With periodontitis, the alveolar bone around the teeth is slowly and progressively lost. Microorganisms, such as bacteria, stick to the surface of the tooth and multiply - an overactive immune system reacts with inflammation.

Untreated periodontitis will eventually result in tooth loss, and may increase the risk of stroke, heart attack and other health problems. Bacterial plaque, a sticky, colorless membrane that develops over the surface of teeth, is the most common cause of periodontal disease.

In dentistry, periodontics deals with the prevention, diagnosis and treatment of diseases involving the gums and structures which support teeth. There are eight dental specialties, of which periodontics is one. If you want dental implants, you see a periodontist.

In most cases, periodontitis is preventable. It is usually caused by poor dental hygiene.

Periodontitis is:

1. Inflammation of the periodontium.

2. A chronic inflammatory disease of the periodontium occurring in response to bacterial plaque on the adjacent teeth; characterized by gingivitis, destruction of the alveolar bone and periodontal ligament, apical migration of the epithelial attachment resulting in the formation of periodontal pockets, and ultimately loosening and exfoliation of the teeth.

What is the difference between periodontitis and gingivitis?

Gingivitis occurs before periodontitis. Gingivitis usually refers to gum inflammation while periodontitis refers to gum disease and the destruction of tissue and/or bone. Initially, with gingivitis, bacteria plaque accumulates on the surface of the tooth, causing the gums to go red and inflamed; teeth may bleed when brushing them. Even though the gums are irritated and bothersome, the teeth are not loose. There is no irreversible damage to bone or surrounding tissue.

Untreated gingivitis can progress to periodontitis. With periodontitis, the gum and bone pulls away from the teeth, forming large pockets. Debris collects in the spaces between the gums and teeth, and infect the area. The patient's immune system attacks bacteria as the plaque spreads below the gum line. Bone and connective tissue that hold the tooth start to break down - this is caused by toxins produced by the bacteria. Teeth become loose and can fall out.

Put simply, Periodontitis involves irreversible changes to the supporting structures of the teeth, while gingivitis does not.

What are the signs and symptoms of periodontitis

A symptom is something we feel and describe to the doctor, while a sign is something others, including the doctor can see. For example, pain is a symptom while redness or inflammation is a sign.

Periodontitis signs and symptoms can include:

• Inflamed (swollen) gums, gum swelling recurs
• Gums are bright red, sometimes purple
• Gums hurt when touched
• Gums recede, making teeth look longer
• Extra spaces appear between the teeth
• Pus may appear between the teeth and gums
• Bleeding when brushing teeth
• Bleeding when flossing
• Metallic taste in the mouth
• Halitosis (bad breath)
• Loose teeth
• The patient's "bite" feels different because the teeth do not fit the same

What are the causes of periodontitis?

• Dental plaque forms on teeth - this is a pale-yellow biofilm that develops naturally on teeth. If is formed by bacteria that try to attach themselves to the tooth's smooth surface.
• Brushing teeth gets rid of plaque, but it soon builds up; within a day or so.
• If it is not removed, within two or three days it hardens into tartar. Tartar is much harder to remove than plaque. Another name for tartar is calculus. Getting rid of tartar requires a professional - you cannot do it yourself.
• Plaque can gradually and progressively damage teeth and surrounding tissue. At first, the patient may develop gingivitis - inflammation of the gum around the base of the teeth.
• Persistent gingivitis can result in pockets developing between the teeth and gums. These pockets fill up with bacteria.
• Bacterial toxins and our immune system's response to infection start destroying the bone and connective tissue that hold teeth in place. Eventually the teeth start becoming loose, and can even fall out.

What are the risk factors for periodontitis?

A risk factor is something that increases the risk of developing a condition or disease. For example, obesity is a risk factor for diabetes type 2 - this means that obese people have a higher chance of developing diabetes. The following risk factors are linked to a higher risk of periodontitis:

• Smoking - regular smokers are much more likely to develop gum problems. Smoking also undermines the efficacy of treatments.
• Hormonal changes in females - puberty, pregnancy, and the menopause are moments in life when a female's hormones undergo changes. Such changes raise the risk of developing gum diseases.
• Diabetes - patients who live with diabetes have a much higher incidence of gum disease than other individuals of the same age
• AIDS - people with AIDS have more gum diseases
• Cancer - cancer, and some cancer treatments can make gum diseases more of a problem
• Some drugs - some medications that reduce saliva are linked to gum disease risk.
• Genetics - some people are more genetically susceptible to gum diseases

Diagnosing periodontitis

A qualified dentist should find it fairly straightforward to diagnose periodontitis. The dentist will ask the patient questions regarding symptoms and carry out an examination of his/her mouth.

The dentist will examine the patient's mouth using a periodontal probe - a thin, silver stick-like object with a bend at one end. The probe is inserted next to the tooth, under the gum line. If the tooth is healthy, the probe should not slide far below the gum line. In cases of periodontitis, the probe will reach deeper under the gum line.


Two types of periodontal probes. 1. Michigan O Probe (left). 2. Naber's Probe (right)

The dentist may order an X-ray to see what condition the jaw bone and teeth are in.

What are the treatment options for periodontitis?

The main aim of the periodontist, dentist or dental hygienist, when treating periodontitis, is to clean out bacteria from the pockets around the teeth and prevent further destruction of bone and tissue.

For best treatment results, the patient must maintain good oral hygiene and care. This involves brushing teeth at least twice a day and flossing once per day. If there is enough space between the teeth, an interdental brush (Proxi-brush) is recommended. Soft-picks can be used when the space between the teeth is smaller. Patients with arthritis, and others with dexterity problems may find that using an electric toothbrush is better for a thorough clean.

It is important that the patient understands that periodontitis is a chronic (long-term) inflammatory disease - this means oral hygiene must be maintained for life. This will also involve regular visits to a dentist or dental hygienist.

Initial treatment

It is important to remove plaque and calculus (tartar) to restore periodontal health.

The healthcare professional will use clean (non-surgically) below the gumline. This procedure is called scaling and debridement. Sometimes an ultrasonic device may be used. In the past Root Planing was used (the cemental layer was removed, as well as calculus).

Medications

• Prescription antimicrobial mouthrinse - for example chlorhexidine. It controls bacteria when treating gum disease, as well as after surgery. Patients use it like they would a regular mouthwash.
• Antiseptic "chip" - this is a small piece of gelatin which is filled with chlorhexidine. It controls bacteria and reduces periodontal pocket size. This medication is placed in the pockets after root planing. The medication is slowly resealed over time.
• Antibiotic powder/gel (ARESTIN^®) - a gel that contains minocycline hydrochloride, an antibiotic. This medication controls bacteria and shrinks periodontal pockets. It is placed in the pockets after scaling and root planing. It is a slow-release medication.
• Antibiotic microspheres - miniscule particles containing minocycline, an antibiotic. Also used to control bacteria and reduce periodontal pocket size. They are placed into pockets after scaling and root planing. A slow-release medication.
• Enzyme suppressant - keeps destructive enzymes in check with a low-dose of doxycycline. Some enzymes can break down gum tissue, this medication holds back the body's enzyme response. Taken orally as a pill, and is used with scaling and root planing.
• Oral antibiotics - either in capsule or tablet form and are taken orally. They are used short-term for the treatment of acute or locally persistent periodontal infection.

Advanced periodontitis

If good oral hygiene and non-surgical treatments are not enough, the following surgical interventions may be required:

• Flap surgery - the healthcare professional performs flap surgery to remove calculus in deep pockets, or to reduce the pocket so that keeping it clean is easier. The gums are lifted back and the tarter is removed. The gums are then sutured back into place so they fit closely to the tooth. After surgery, the gums will heal and high tightly around the tooth. In some cases the teeth may eventually seem longer than they used to.
• Bone and tissue grafts - this procedure helps regenerate bone or gum tissue that has been destroyed. With bone grafting, new natural or synthetic bone is placed where bone was lost, promoting bone growth.
  
  In a procedure called guided tissue regeneration, a small piece of mesh-like material is inseted between the gum tissue and bone. This stops the gum from growing into bone space, giving the bone and connective tissue a chance to regrow.
  
  The dentist may also use special proteins (growth factors) that help the body regrow bone naturally.
  
  The dental professional may suggest a soft tissue graft - tissue taken from another part of the mouth, or synthetic material is used to cover exposed tooth roots.

Experts say it is not possible to predict how successful these procedures are - each case is different. Treatment results also depend on how advanced the disease is, how well the patient adheres to a good oral hygiene program, as well as other factors, such as smoking status.

What are the complications of periodontitis?

The most common complication from periodontitis is the loss of teeth. However, patients with periodontitis are also at a higher risk of having respiratory problems, stroke, coronary artery disease, and low birth weight babies.

Pregnant women with bacterial infections that cause moderate-to-severe periodontal disease have a higher risk of having a premature baby.

Periodontitis can make it harder for patients with diabetes to control blood sugar.

Prevention

The best way to prevent periodontitis is to follow a program of good oral hygiene, one that you begin early and practice consistently throughout life. That means brushing your teeth at least twice daily — in the morning and before going to bed — and flossing at least once a day. Better yet, brush after every meal or snack or as your dentist recommends. A complete cleaning with a toothbrush and floss should take three to five minutes. Flossing before you brush allows you to clean away the loosened food particles and bacteria.

Also, see your dentist or dental hygienist regularly for cleanings, usually every six to 12 months. If you have risk factors that increase your chance of developing periodontitis, you may need professional tooth cleaning more often.

References:
Sources: National Health Service (NHS), UK. National Institutes of Health (NIH), USA. University of Maryland Medical Center. Medical News Today archives.

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