Periodontal Disease

Understanding the risks of periodontal disease can motivate patients to adhere to a good oral homecare routine.

Periodontal disease begins with gingivitis – a mild form that causes the gums to become red, swollen and prone to bleeding. The good news is that, with professional treatment and good oral homecare, the disease is reversible.

Left untreated, however, gingivitis can advance to periodontitis. Plaque can spread and grow below the gum line over time, and toxins produced by the bacteria in plaque irritate the gums. The toxins stimulate a chronic inflammatory response, causing the tissues and bone that support the teeth to break down. In turn, the gums separate from the teeth, forming pockets, which can become infected. As the disease progresses, the pockets deepen and more gum tissue and bone are destroyed. Eventually, teeth can become loose and may need to be removed.

The most common forms of periodontitis include:

• Aggressive periodontitis.Aggressive periodontitis occurs in patients who are otherwise clinically healthy. Common features include rapid attachment loss and bone destruction, and familial aggregation.
• Chronic periodontitis. Chronic periodontitis results in inflammation within the supporting tissues of the teeth, progressive attachment and bone loss. This is the most frequently occurring form of periodontitis and is characterized by pocket formation and/or recession of the gingiva. It is prevalent in adults, but can occur at any age. Progression of attachment loss usually occurs slowly, but periods of rapid progression can occur.
• Periodontitis as a manifestation of systemic diseases. This often begins at a young age. Systemic conditions, such as heart disease, respiratory disease and diabetes, are associated with this form of periodontitis.
• Necrotizing periodontal disease. Necrotizing periodontal disease is an infection characterized by necrosis of gingival tissues, periodontal ligament and alveolar bone. These lesions are most commonly observed in individuals with systemic conditions such, as HIV infection, malnutrition and immunosuppression.

Dental professionals should remind their patients that while brushing, flossing and using mouthwash can help prevent periodontal disease, a number of factors in addition to plaque can affect their gums:

• Studies indicate that older people have the highest rates of periodontal disease. Data from the Centers for Disease Control and Prevention indicates that over 70 percent of Americans 65 and older have periodontitis.
• Smoking and/or tobacco use. In addition to being at risk of illnesses such as cancer, lung disease and heart disease, tobacco users also are at increased risk for periodontal disease. Studies have shown that tobacco use may be one of the most significant risk factors in the development and progression of periodontal disease.
• Research has indicated that some people may be genetically susceptible to gum disease. Despite aggressive oral care habits, these people may be more likely to develop periodontal disease. Identifying these people with a genetic test before they even show signs of the disease and getting them into early intervention treatment may help them keep their teeth for a lifetime.
• Stress is linked to many serious conditions, including hypertension and cancer. It’s also a risk factor for periodontal disease. Research demonstrates that stress can make it more difficult for the body to fight off infection, including periodontal diseases.
• Some drugs, such as oral contraceptives, anti-depressants and certain heart medicines, can affect oral health. Dental professionals should ask their patients what medications they take and inquire about any changes in their overall health.
• Clenching or grinding teeth. Clenching or grinding teeth can put excess force on the supporting tissues of the teeth, speeding up the rate at which these periodontal tissues are destroyed.
• Other systemic diseases. Other systemic diseases that interfere with the body’s inflammatory system may worsen the condition of the gums. These include cardiovascular disease, diabetes, and rheumatoid arthritis.
• Poor nutrition and/or obesity. 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 the gums. In addition, research has shown that obesity may increase the risk of periodontal disease.

Although symptoms of periodontal disease often don’t appear until an advanced stage of the disease, dental professionals can educate their patients to recognize warning signs, including:

• Red, swollen or tender gums or other pain in the mouth.
• Bleeding while brushing, flossing, or eating hard food.
• Gums that are receding or pulling away from the teeth.
• Loose or separating teeth.
• Pus between the gums and teeth.
• Sores in the mouth.
• Persistent bad breath.
• A change in the way the patient’s teeth fit together when he/she bites.
• A change in the fit of partial dentures.

Comprehensive evaluation and treatment
In 2011, the American Academy of Periodontology published the Comprehensive Periodontal Therapy Statement, which recommends that all adults receive an annual comprehensive evaluation of their periodontal health. In its statement, the AAP noted that “as a result of advances in knowledge and therapy, the majority of patients can retain their dentition over their lifetime with proper treatment, reasonable plaque/biofilm control, and continuing care.”

A comprehensive assessment of a patient’s current health status, history of disease and risk characteristics should include the following:

• Extra- and intraoral examination to detect non-periodontal oral diseases or conditions.
• Examination of teeth and dental implants to evaluate the topography of the gingiva and related structures; to measure probing depths, the width of keratinized tissue, gingival recession, and attachment level; to evaluate the health of the subgingival area with measures such as bleeding on probing and suppuration; to assess clinical furcation status; and to detect endodontic-periodontal lesions.
• Assessment of the presence, degree and/or distribution of plaque/biofilm, calculus and gingival inflammation.
• Dental examination, including caries assessment, proximal contact relationships, the status of dental restorations and prosthetic appliances, and other tooth- or implant-related problems.
• An occlusal examination that includes determining the degree of mobility of teeth and dental implants, occlusal patterns and discrepancy, and determination of fremitus.
• Interpretation of current and comprehensive diagnostic-quality radiographs to visualize each tooth and/or implant in its entirety and assess the quality/quantity of bone and establish bone loss patterns.
• Evaluation of potential periodontal-systemic interrelationships.
• Assessment of the need for and suitability of dental implants.
• Determination and assessment of patient risk factors, such as age, diabetes, smoking, cardiovascular disease and other systemic conditions associated with development and/or progression of periodontal disease.

Clinical findings, together with a diagnosis and prognosis, should be used to develop a treatment plan, including non-surgical, surgical, regenerative and cosmetic periodontal therapy or dental implant placement, to arrest or deter further disease progression, according to the AAP. When indicated, the plan should include:

• Medical and dental consultation or referral for treatment, when appropriate.
• Surgical and non-surgical periodontal and implant procedures to be performed.
• Consideration of adjunctive restorative, prosthetic, orthodontic and/or endodontic consultation or treatment.
• Provision for ongoing re-evaluation during periodontal or dental implant therapy and throughout the maintenance phase of treatment.
• Consideration of diagnostic testing, which may include microbiologic, genetic or biochemical assessment or monitoring during the course of periodontal therapy.
• Consideration of risk factors, including, diabetes and smoking, which play a role in the development, progression and management of periodontal diseases.
• Periodontal maintenance program, including ongoing evaluation and reevaluation for treatment.

Source: The American Academy of Periodontology. For more information visit https://www.perio.org/consumer/types-gum-disease.html.

The oral-systemic health connection
Periodontal disease may begin in the mouth, but patients don’t always realize that its effect on their health can reach much further. Research has shown that periodontal disease is associated with several other diseases:

• People with diabetes are more susceptible to contracting infections, including periodontal disease. In fact, periodontal disease is often considered a complication of diabetes. Those who don’t have their diabetes under control are especially at risk. Furthermore, periodontal disease may make it more difficult for people who have diabetes to control their blood sugar. Severe periodontal disease can increase blood sugar, contributing to increased periods of time when the body functions with a high blood sugar and putting people with diabetes at increased risk for diabetic complications.
• Heart disease. While a cause-and-effect relationship has yet to be proven, several studies have shown that periodontal disease increases the risk of heart disease. Scientists believe that inflammation caused by periodontal disease may be responsible for the association. Periodontal disease can also exacerbate existing heart conditions.
• Studies have pointed to a relationship between periodontal disease and stroke.
• Researchers have suggested a link between osteoporosis and bone loss in the jaw, placing people at risk for tooth loss.
• Respiratory disease: Research has found that bacteria that grow in the oral cavity can be aspirated into the lungs, causing respiratory diseases such as pneumonia, especially in people with periodontal disease.
• Researchers found that men with gum disease were49 percent more likely to develop kidney cancer, 54 percent more likely to develop pancreatic cancer, and 30 percent more likely to develop blood cancers.

Source: The American Academy of Periodontology. For more information visit https://www.perio.org/consumer/types-gum-disease.html.