Periodontal disease

Periodontitis, or Pyorrhea, is a disease involving inflammation of the gums (gingiva), often persisting unnoticed for years or decades in a patient, that results in loss of bone around teeth. This differs from gingivitis, where there is inflammation of the gingiva but without bone loss; it is the loss of bone around the teeth that differentiates between these two oral inflammatory diseases.

Aetiology

Plaque bacteria and bacterial toxins that accumulate below the gum-line may cause inflammation of the gums, termed gingivitis. If the gum inflammation persists for enough years it may cause loss of bone around teeth. The loss of the surrounding bone (that holds the teeth in the jaws) may, over time, result in loss of the teeth. Periodontitis is the second most important cause of edentulism (toothlessness), after tooth decay.

In most cases this disease is linked to poor oral hygiene. In particular, patients must regularly clean underneath their gumline in order to help disrupt the build-up of plaque and inflammation-generating toxins below the gumline. Some people, however, can have a genetic pre-disposition to the disease. Once initiated, the disease can progress more rapidly in people who have diabetes, especially if the diabetes is poorly controlled. Smoking is a strong risk factor for periodontal disease as it contains chemicals that can exacerbate existing inflammation, enhance bacterial growth, and prevent the synthesis of collagen, an important factor in healing damaged gingival tissue.

Symptoms

Symptoms may include the following:

occasional redness or bleeding of gums while brushing teeth, using dental floss or biting into hard food (e.g. apples)
occasional gum swellings that recur
halitosis or bad breath
persistent bad taste in the mouth
recession of gums resulting in apparent lengthening of teeth. This may also be caused by heavy handed brushing using a hard tooth brush.
pockets between the teeth and the gums (Pockets are sites where the jaw bone has been destroyed gradually or by repeated swellings).
loose shaky teeth in later stages

Patients should realize that the gingival inflammation and bone destruction are largely painless. Hence people may wrongly assume that painless bleeding after teeth cleaning is unimportant, although this may be a symptom of periodontitis progressing in that patient.

Prevention

Daily oral hygiene measures to prevent periodontal disease include:

brushing properly on a regular basis (2 times a day), with the patient attempting to direct the toothbrush bristles underneath the gum-line, so as to help disrupt the bacterial and plaque growth that may occur there.
flossing daily and using interdental brushes if there is sufficient space between teeth and behind the last tooth in each quarter.
using an antiseptic mouthwash. Chlorhexidine gluconate based mouthwash or Hydrogen Peroxide in combination with careful oral hygeine may cure gingivitis, although they cannot reverse any bone loss due to periodontitis. (Alcohol based mouthwashes may aggravate the condition).
regular dental check-ups and professional teeth cleaning as required. Dental check-ups serve to monitor the person's oral hygiene methods and levels of bone around teeth, identify any early signs of periodontitis, and monitor if it has responded to treatment.

Typically dental hygienists (or dentists) use special instruments to clean teeth below the gumline and disrupt any plaque growing below the gumline. This is a standard treatment to prevent any further progress of established periodontitis. Studies show that after such a professional cleaning, bacteria and plaque tend to grow back to pre-cleaning levels after about 3-4 months. Hence, in theory, cleanings every 3-4 months might be expected to also prevent the initial onset of periodontitis. However analysis of published research has reported little evidence either to support this or the intervals at which this should occur. Instead it is advocated that the interval between dental check-ups should be determined specifically for each patient between every 3 to 24 months.

Nonetheless, the continued stabilization of a patient's periodontal state depends largely, if not primarily, on the patient's oral hygiene at home if not on the go too. Without daily oral hygiene, periodontal disease will not be overcome, especially if the patient has a history of extensive periodontal disease.

Treatment of established disease

If good oral hygiene is not yet already undertaken daily by the patient, then twice daily brushing with daily flossing, mouthwashing and use of an interdental brush needs to be started.

A dental hygienist or a Periodontist can use professional scraping instruments, such as scalers and currettes to remove bacterial plaque and calculus (formerly referred to as tarter) around teeth and below the gum-line. There are devices that use a powerful ultra-sonic vibration and irrigation system to break up the bacterial plaque and calculus.

It is difficult to induce the body to repair bone that has been destroyed due to periodontitis. Much depends on exactly how much bone was lost and the architectural configuration of the remaining bone. Vertical defects are those instances of bone loss where the height of the bone remains somewhat constant except in the localized area where there is a steep, almost vertical drop. Horizontal defects are those instances of more generalized bone loss, resulting in anywhere from mild to severe loss of initial bone height. Sometimes bone grafting surgery may be tried, but this has mixed success. Bone grafts are more reliable in instances of vertical defects, where there might be a sufficient "hole" within which to place the added bone. Horizontal defects are rarely if ever able to be grafted properly, as there is nowhere to secure the bone.

Dentists sometimes attempt to treat patients with periodontitis by placing tiny wafers dispensing antibiotics underneath the gumline in affected areas. However, the general scientific consensus is that antibiotic treatment is of minimal value in treating bone loss due to periodontitis. It may help to recover about one millimeter of bone, but it is questionable if this is of significant therepeutic value.

Assessment and prognosis

Dentists or dental hygienists "measure" periodontal disease using a device called a periodontal probe. This is a thin "measuring stick" that is gently placed into the space between the gums and the teeth, and slipped below the gum-line. If the probe can slip more than 3 millimetres length below the gum-line, the patient is said to have a "gingival pocket" around that tooth. This is somewhat of a misnomer, as any depth is in essence a pocket, which in turn is defined by its depth, i.e., a 2 mm pocket or a 6 mm pocket. However, it is generally accepted that pockets are self-cleansable (at home, by the patient, with a toothbrush) if they are 3 mm of less in depth. This is important because if there is a pocket which is deeper than 3 mm around the tooth, at-home care will not be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach 5, 6 and 7 mm in depth, even the hand instruments and cavitrons used by the dental professionals cannot reach deeply enough into the pocket to clean out the bacterial plaque that cause gingival inflammation. In such a situation the pocket or the gums around that tooth will always have inflammation which will likely result in bone loss around that tooth. The only way to stop the inflammation would for the patient to undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so that they become 3 or less mm in depth and can once again be properly cleaned by the patient at home with his or her toothbrush.

If a patient has 5 mm or deeper pockets around most of their teeth, then they would then risk loss of all of their teeth over the years. If this not identified and the patient remains unaware of the progressive periodontal disease then, years later, they may be surprised that most of the teeth have suddenly seemed to become loose and that most or all of them may need to be extracted.

According to the Sri Lankan Tea Labourer study, in the absence of any oral hygiene activity, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment (>2 mm/year). 80% will suffer from moderate loss (1-2 mm/year) and the remaining 10% will not suffer any loss.

Footnotes

External links

http://www.nlm.nih.gov/medlineplus/ency/article/001059.htm (Medical Encyclopedia, NIH)
http://www.mayoclinic.com/invoke.cfm?id=DS00369 (Mayo Clinic)
http://www.collagenex.com/core_periodontal.asp

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