Periodontitis, also known as gum disease and pyorrhea
is a set of inflammatory diseases affecting the tissues surrounding 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 microorganisms that adhere to and grow on the tooth’s surfaces, along with an over-aggressive immune response against these microorganisms. A diagnosis of periodontitis is established by inspecting the soft gum tissues around the teeth with a probe (i.e., a clinical examination) and by evaluating the patient’s X-ray films (i.e., a radiographic examination), to determine the amount of bone loss around the teeth. Specialists in the treatment of periodontitis are periodontists; their field is known as “periodontology” or “periodontics”.
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:
- 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
- Spitting out blood after brushing teeth
- 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 toothbrush.)
- 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 gingival inflammation and bone destruction are largely painless. Hence, people may wrongly assume painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient.
Associated conditions
Periodontitis has been linked to increased inflammation in the body, such as indicated by raised levels of C-reactive protein and interleukin-6. It is linked through this to increased risk of stroke, myocardial infarction, and atherosclerosis. It also linked in those over 60 years of age to impairments in delayed memory and calculation abilities. Individuals with impaired fasting glucose and diabetes mellitus have higher degrees of periodontal inflammation, and often have difficulties with balancing their blood glucose level owing to the constant systemic inflammatory state, caused by the periodontal inflammation. Although no causal association was proven, a recent study showed correlation between chronic periodontitis and erectile dysfunction.
Causes
Periodontitis is an inflammation of the periodontium, i.e., the tissues that support the teeth. The periodontium consists of four tissues:
- gingiva, or gum tissue,
- cementum, or outer layer of the roots of teeth,
- alveolar bone, or the bony sockets into which the teeth are anchored, and
- periodontal ligaments (PDLs), which are the connective tissue fibers that run between the cementum and the alveolar bone.
The primary cause of gingivitis is poor or ineffective 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. Diabetics must be meticulous with their homecare to control periodontal disease. New finger prick tests have been approved by the Food and Drug Administration in the US, and 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 microorganisms (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 causes are 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.
Smoking is another factor that increases the occurrence of periodontitis, directly or indirectly, and may interfere with or adversely affect its treatment.
Ehlers–Danlos syndrome is a periodontitis risk factor and so is the Papillon–Lefèvre syndrome also known as palmoplantar keratoderma.
If left undisturbed, microbial 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 microbial plaque that adheres to the tooth surfaces, 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-mycoticinsult is mainly determined by genetics; however, immune development may play some role in susceptibility.
According to some researchers periodontitis may be associated with higher stress. Periodontitis occurs more often in people from the lower end of the socioeconomic scale than people from the upper end of the socioeconomic scale.