Periodontitis:

Periodontitis :

 refers to a number of inflammatory diseases affecting the periodontium , that is, the tissues that surround and support the teeth. Periodontitis involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent loss of teeth. Periodontitis is caused by microorganism that adhere to and grow on the tooth's surfaces, along with an overly aggressive immune response against these microorganism. A diagnosis of periodontitis is established by inspecting the soft gum tissues around the teeth with a probe and radiographs by visual analysis, to determine the amount of bone loss around the teeth. Specialists in the treatment of periodontitis are periodontists; their field is known as "periodontology" and "periodontics".


Chronic Periodontitis, the most common form of the disease, progresses relatively slowly and typically becomes clinically evident in adulthood. Aggressive Periodontitis is a rarer form, but as its name implies, progresses more rapidly and becomes clinically evident in adolescence. Although the different forms of periodontitis are all caused by microorganism and mycotic infections, a variety of factors affect the severity of the disease. Important "risk factors" include smoking, poorly-controlled diabetes, and inherited (genetic) susceptibility.


A- Signs and symptoms


In the early stages, periodontitis has very few symptoms and in many individuals the disease has progressed significantly before they seek treatment. Symptoms may include the following:


 - Redness or bleeding of gums while brushing teeth, using dental floss or biting into hard food (e.g. apples) (though this may occur even in gingivitis, where there is no attachment loss)


- Gum swelling that recurs


- Halitosis, or bad breath, and a persistent metallic taste in the mouth


- Gingival recession, resulting in apparent lengthening of teeth. (This may also be caused by heavy handed brushing or with a stiff tooth brush.)


- Deep pockets between the teeth and the gums (pockets are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as collagenases)


- Loose teeth, in the later stages (though this may occur for other reasons as well)


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 insignificant, although this may be a symptom of progressing periodontitis in that patient.




B-  Cause :
Periodontitis is an inflammation of the periodontium—the tissues that support the teeth. The periodontium consists of four tissues:
I - the gingiva, or gum tissue;


II- the cementum, or outer layer of the roots of teeth;


III- the alveolar bone, or the bony sockets into which the teeth are anchored;


IV- the periodontal ligaments (PDLs), which are the connective tissue fibers that run between the cementum and the alveolar bone.




This X-ray film displays two lone-standing mandibular teeth, the lower left first premolar and canine, exhibiting severe bone loss of 30-50%. Widening of the PDL surrounding the premolar is due to secondary occlusal trauma.The primary etiology, or cause, of gingivitis is poor oral hygiene which leads to the accumulation of a mycotic , and bacterial matrix at the gum line, called dental plaque. Other contributors are poor nutrition and underlying medical issues such as diabetes. New FDA-approved finger nick tests are being used in dental offices to identify and screen patients for possible contributory causes of gum disease such as diabetes. In some people, gingivitis progresses to periodontitis - with the destruction of the gingival fibers, the gum tissues separate from the tooth and deepened sulcus, called a periodontal pocket. Subgingival microorganism (those that exist under the gum line) colonize the periodontal pockets and cause further inflammation in the gum tissues and progressive bone loss. Examples of secondary etiology would be those things that, by definition, cause microbic plaque accumulation, such as restoration overhangs and root proximity.




The excess restorative material that exceeds the natural contours of restored teeth, such as these, are termed "overhangs", and serve to trap microbic plaque, potentially leading to localized periodontitis.If left undisturbed, microbic plaque calcifies to form calculus, which is commonly called tartar. Calculus above and below the gum line must be removed completely by the dental hygienist or dentist to treat gingivitis and periodontitis. Although the primary cause of both gingivitis and periodontitis is the microbic plaque that adheres to the tooth surface, there are many other modifying factors. A very strong risk factor is one's genetic susceptibility. Several conditions and diseases, including Down syndrome, diabetes, and other diseases that affect one's resistance to infection also increase susceptibility to periodontitis.




Another factor that makes periodontitis a difficult disease to study is that human host response can also affect the alveolar bone resorption. Host response to the bacterial-mycotic insult is mainly determined by genetics; however, immune development may play some role in susceptibility.






C-  Prevention :


Daily oral hygiene measures to prevent periodontal disease include:




Brushing properly on a regular basis (at least twice daily), with the patient attempting to direct the toothbrush bristles underneath the gum-line, to help disrupt the bacterial-mycotic growth and formation of subgingival plaque.


Flossing daily and using interdental brushes (if there is a sufficiently large space between teeth), as well as cleaning behind the last tooth, the third molar, in each quarter.


Using an antiseptic mouthwash. Chlorhexidine gluconate based mouthwash in combination with careful oral hygiene may cure gingivitis, although they cannot reverse any attachment loss due to periodontitis.


Using a 'soft' tooth brush to prevent damage to tooth enamel and sensitive gums.


Using periodontal trays to maintain dentist-prescribed medications at the source of the disease. The use of trays allows the medication to stay in place long enough to penetrate the biofilms where the microorganism are found.


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 attachment around teeth, identify any early signs of periodontitis, and monitor response to treatment.


Typically dental hygienists (or dentists) use special instruments to clean (debride) 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 (periodontal debridement), microbic 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 as well as on the go. Without daily oral hygiene, periodontal disease will not be overcome, especially if the patient has a history of extensive periodontal disease.


Periodontal disease and tooth loss are associated with an increased risk of cancer .

 A contributing cause may be low selenium in the diet: "Results showed that selenium has the strongest association with gum disease, with low levels increasing the risk by 13 fold."


D-  Management :


This section from a panoramic X-ray film depicts the teeth of the lower left quadrant, exhibiting generalized severe bone loss of 30-80%. The red line depicts the existing bone level, whereas the yellow line depicts where the gingiva was originally (1-2 mm above the bone), prior to the patient developing periodontal disease. The pink arrow, on the right, points to a furcation involvement, or the loss of enough bone to reveal the location at which the individual roots of a molar begin to branch from the single root trunk; this is a sign of advanced periodontal disease. The blue arrow, in the middle, shows up to 80% bone loss on tooth #21, and clinically, this tooth exhibited gross mobility. Finally, the peach oval, to the left, highlights the aggressive nature with which periodontal disease generally affects mandibular incisors. Because their roots are generally situated very close to each other, with minimal interproximal bone, and because of their location in the mouth, where plaque and calculus accumulation is greatest because of the pooling of saliva, mandibular anteriors suffer excessively. The split in the red line depicts varying densities of bone that contribute to a vague region of definitive bone height.The cornerstone of successful periodontal treatment starts with establishing excellent oral hygiene. This includes twice daily brushing with daily flossing. Also the use of an interdental brush (called a Proxi-brush) is helpful if space between the teeth allows. Persons with dexterity problems such as arthritis may find oral hygiene to be difficult and may require more frequent professional care and/or the use of a powered tooth brush. Persons with periodontitis must realize that it is a chronic inflammatory disease and a lifelong regimen of excellent hygiene and professional maintenance care with a dentist/hygienist or periodontist is required to maintain affected teeth.


E-  Initial therapy :


Removal of microbic plaque and calculus is necessary to establish periodontal health. The first step in the treatment of periodontitis involves non-surgical cleaning below the gumline with a procedure called scaling and debridement. In the past, Root Planing was used (removal of cemental layer as well as calculus). This procedure involves use of specialized curettes to mechanically remove plaque and calculus from below the gumline, and may require multiple visits and local anesthesia to adequately complete. In addition to initial scaling and root planing, it may also be necessary to adjust the occlusion (bite) to prevent excessive force on teeth with reduced bone support. Also it may be necessary to complete any other dental needs such as replacement of rough, plaque retentive restorations, closure of open contacts between teeth, and any other requirements diagnosed at the initial evaluation.


F-Reevaluation :


Multiple clinical studies have shown that non-surgical scaling and root planing is usually successful in periodontal pocket depths no greater than 4-5mm (See articles by Stambaugh RV, Int J Periodontics Rest Dent, 1981 or Waerhaug J, J Periodontol, 1978). It is necessary for the dentist or hygienist to perform a reevaluation 4–6 weeks after the initial scaling and root planing, to determine if the treatment was successful in reducing pocket depths and eliminating inflammation. It has been found that pocket depths which remain after initial therapy of greater than 5-6mm with bleeding upon probing are indicative of continued active disease and will very likely show further bone loss over time. This is especially true in molar tooth sites where furcations (areas between the roots) have been exposed.


G- Surgery :


If non-surgical therapy is found to have been unsuccessful in managing signs of disease activity, periodontal surgery may be needed to stop progressive bone loss and regenerate lost bone where possible. There are many surgical approaches used in treatment of advanced periodontitis, including open flap debridement, osseous surgery, as well as guided tissue regeneration and bone grafting. The goal of periodontal surgery is access for definitive calculus removal and surgical management of bony irregularities which have resulted from the disease process to reduce pockets as much as possible. Long-term studies have shown that in moderate to advanced periodontitis surgically treated cases often have less further breakdown over time and when coupled with a regular post-treatment maintenance regimen are successful in nearly halting tooth loss in nearly 85% of patients (Kaldahl WB, Long-term evaluation of periodontal therapy: II. Incidence of sites breaking down. J Periodontol. 1996 Feb;67(2):103-8. and Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol. 1978 May;49(5):225-37.


H- Maintenance :


Once successful periodontal treatment has been completed, with or without surgery, an ongoing regimen of "periodontal maintenance" is required. This involves regular checkups and detailed cleanings every 3 months to prevent repopulation of periodontitis-causing microorganism, and to closely monitor affected teeth so that early treatment can be rendered if disease recurs. Usually periodontal disease exist due to poor plaque control, therefore if the brushing techniques are not modified, a periodontal recurrence is probable


I- Alternative treatments :


Periodontitis has an inescapable relationship with subgingival calculus (tartar). The first step in any procedure is to eliminate calculus under the gum line, as it houses destructive anaerobic microorganisms that consume bone, gum and cementum (connective tissue) for food.


Most alternative “at-home” gum disease treatments involve injecting anti-microbial solutions, such as hydrogen peroxide, into periodontal pockets via slender applicators or oral irrigators. This process disrupts anaerobic microorganism colonies and is effective at reducing infections and inflammation when used daily. There are any number of potions and elixirs that are commercially available which are functionally equivalent to hydrogen peroxide; only at substantially higher cost. These treatments, however, do not address calculus formations, and are therefore short-lived, as anaerobic microorganism colonies quickly regenerate in and around calculus.


In a new field of study, calculus formations are addressed on a more fundamental level. At the heart of the formation of subgingival calculus, growing plaque formations starve out the lowest members of the community, which calcify into calcium phosphate salts of the same shape and size of the original, organic bacilli. Calcium phosphate salts (unlike calcium phosphate; the primary component in teeth) are ionic and adhere to tooth surfaces via electrostatic attraction. Smaller, free floating calcium phosphate salt particles are equally attracted to the same areas, as are additional calcified microorganism, growing calculus formations as unorganized, yet strong, “brick and mortar” matrices. The microscopic voids in calculus formations house new anaerobic microorganism, as does the top “diseased layer”.


Because the root cause of subgingival calculus development is ionic attraction, it was hypothesized that the introduction of oppositely charged particles around the formations may chelate calcium phosphate salt components away from the matrix, thus actually reducing the size of subgingival calculus formations.


To accomplish this, a sequestering agent solution comprised partly of Sodium Tripolyphosphate (STPP) and Sodium Fluoride (charge -1) was tested on a patient with burnished and new subgingival calculus at a depth of 6mm. The patient delivered the solution using an oral irrigator, once a day, for sixty days. The results of this test were the successful elimination of all calculus formations studied.[13][Unreliable medical source?] This test was conducted using a subgingival endoscopic camera (Perioscope) by an independent periodontist.


The promise of this new, alternative treatment is to keep subgingival calculus at bay, in concert with traditional periodontal treatments. In this way, periodontitis may be controlled by the patient, with complete restoration of dental health being a collaborative effort between the patient and the dental professional.


J- Prognosis :


Dentists and 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 or 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 6 and 7 mm in depth, the hand instruments and cavitrons used by the dental professionals may not reach deeply enough into the pocket to clean out the microbic plaque that cause gingival inflammation. In such a situation the bone or the gums around that tooth should be surgically altered or it will always have inflammation which will likely result in more bone loss around that tooth. An additional way to stop the inflammation would be for the patient to receive subgingival antibiotics (such as minocycline) or 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 7 mm or deeper pockets around their teeth, then they would likely risk eventual tooth loss over the years. If this periodontal condition is not identified and the patient remains unaware of the progressive nature of the disease then, years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain.


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.

 K- Epidemiology :

Periodontitis is very common, and is widely regarded as the second most common disease worldwide, after dental decay, and in the United States has a prevalence of 30-50% of the population, but only about 10% have severe forms.



In Israeli population, individuals of Yemenite, North-African, Asian, or Mediterranean origin have higher prevalence of periodontal disease than individuals from European descent. This could be attributed to genetic predisposition as well as social-cultural-behavioral differences (eg., smoking, oral hygiene, access to dental treatment) between populations.