Periodontitis

Periodontal disease is a progressive condition which begins with mild gum inflammation called gingivitis. It is the leading cause of tooth loss in adults living in the developed world, and should be taken very seriously. Periodontal disease (often called gum disease) is typically signified by red, swollen, painful, or bleeding gums, but in some cases has no noticeable symptoms.
Periodontal disease generally begins when the bacteria living in plaque cause an infection in the surrounding tissues of the teeth, causing them to become irritated and painful. Eventually, this infection will; cause the jawbone to recede and the tooth to become loose.
There are several reasons why periodontal treatment may be necessary:

• Moderate/advanced gum disease – This occurs when the gums are bleeding, swollen or red around most teeth and the jawbone has begun to recede.
• Localized gum recession – The infection which propagates moderate or advanced gum disease often begins in one area. Gum recession may also be caused due to over brushing with a hard bristle brush, or due to a tooth that is not positioned properly. Immediate treatment is required to prevent further spreading.
• Before crown lengthening – The periodontist may lengthen the crown of the tooth by removing surrounding soft tissue to provide more tooth exposure.
• Ridge augmentation – This procedure, often called “recontouring” may be required to correct an uneven gum line. Before embarking on treatment, a periodontist needs to treat any bacterial infections and periodontitis.

When left untreated, gingivitis (mild gum inflammation) can spread to below the gum line. When the gums become irritated by the toxins contained in plaque, a chronic inflammatory response causes the body to break down and destroy its own bone and soft tissue. There may be little or no symptoms as periodontal disease causes the teeth to separate from the infected gum tissue. Deepening pockets between the gums and teeth are generally indicative that soft tissue and bone is being destroyed by periodontal disease.
Here are some of the most common types of periodontal disease:

• Gingivitis and Mild Periodontitis – This is the mild inflammation of the gums which may or may not be signified by pain and bleeding. Education and advice will be provided on an effective cleaning regime thereafter.
• Moderate chronic periodontitis – When the pockets between the teeth and the soft tissues are measured to be between 4-6mm it is classified as moderate periodontitis (gum disease). Inflammation within supporting tissues cause deep pockets and gum recession. It may appear the teeth are lengthening, but in actuality, the gums (gingiva) are receding. This is the most common form of periodontal disease and is characterized by progressive loss of attachment, interspersed with periods of rapid progression.
• Advanced periodontitis – When the pockets between the teeth and the soft tissues in general exceed 6-7mm in depth, significant bone loss may have occurred; causing shifting or loss of teeth. Scaling and root planning will always be performed as the initial nonsurgical treatment. In addition to tose nonsurgical treatments, the periodontist may recommend surgical treatment to reduce pocket depth.
• Missing teeth – When teeth are missing as a result of bone loss, the periodontist can implant prosthetic teeth. These teeth are anchored to the jawbone and restore functionality to the mouth.
• Aggressive periodontitis – This form of gum disease occurs in an otherwise clinically healthy individual. It is characterized by rapid loss of gum attachment, chronic bone destruction and familial aggregation.
• Necrotizing periodontitis – This form of periodontal disease most often occurs in individuals suffering from systemic conditions such as HIV, immunosuppression and malnutrition. Necrosis (tissue death) occurs in the periodontal ligament, alveolar bone and gingival tissues.
• Periodontitis caused by systemic disease – This form of gum disease often begins at an early age. Medical condition such as respiratory disease, diabetes and heart disease are common cofactors.

It is extremely important to note that periodontal disease can progress without any signs or symptoms such as pain. This is why regular dental checkups are exceptionally important. Described below are some of the most common signs and symptoms of periodontitis.
If you have any of these signs or symptoms, the advice of a general dentist or periodontist should be sought as soon as possible:

• Unexplained bleeding while eating or brushing– Bleeding when brushing, flossing or eating food is one of the most common symptoms of a periodontal infection. The toxins in plaque cause a bacterial infection which makes the tissues prone to bleeding.
• Pain, redness or swelling – A periodontal infection may be present if the gums are swollen, red or painful for no apparent reason. It is essential to halt the progression of the infection before the gum tissue and jaw bone have been affected. It is also critical to treat the infection before it is carried into the bloodstream to other areas of the body.
• Longer-looking teeth – Periodontal disease can lead to gum recession. The toxins produced by bacteria can destroy the supporting tissue and bones, thus making the teeth look longer and the smile appear more “toothy.”
• Bad breath/halitosis – Although breath odor can originate from back of the tongue, the lungs and stomach, from the food we consume, or from tobacco use, bad breath may be caused by old food particles which sit between the teeth and underneath the gumline. The deeper gum pockets are able to house more debris and bacteria, causing a foul odor.
• Loose teeth/change in bite pattern – A sign of rapidly progressing periodontitis is the loosening or shifting of the teeth in the affected area. As the bone tissue gets destroyed, teeth that were once firmly attached to the jawbone become loose or may shift in position.
• Gum recession – Longer looking teeth can signal recession of the gums and bone loss due to periodontal disease. As this disease progresses and attacks the jawbone, (the anchor holding the teeth in place) the teeth may become loose or be lost alltogher.
• Pus – Pus oozing from between the teeth is a definitive sign that a periodontal infection is in progress. The pus is a result of the body trying to fight the bacterial infection.
• Gangrene in the tissues – Gangrene is hard to self diagnose but the general dentist and periodontist will check for its presence in the soft tissues, alveolar bone and periodontal ligament.
• Related health conditions – Heart disease, diabetes, osteopenia and osteoporosis are highly correlated with periodontitis and periodontal infections. The bacteria infection can spread through the blood stream and affect other parts of the body.

There are genetic and environmental factors involved in the onset of gum disease, and in many cases the risk of developing periodontitis can be significantly lowered by taking preventative measures.
Here are some of the most common causes of gum disease:

• Poor dental hygiene – Preventing dental disease starts at home with good oral hygiene and a balanced diet. Prevention also includes regular dental visits which include exams, cleanings, and x-rays. A combination of excellent home care and professional dental care will ensure and preserve the natural dentition and supporting bony structures. When bacteria and calculus (tartar) are not removed, the gums and bone around the teeth become affected by bacteria toxins and can cause gingivitis or periodontitis, which can lead to tooth loss.
• Tobacco use – Research has indicated that smoking and tobacco use is one of the most significant factors in the development and progression of gum disease. In addition to smokers experiencing a slower recovery and healing rate, smokers are far more likely to suffer from calculus (tartar) build up on teeth, deep pockets in the gingival tissue and significant bone loss.
• Genetic predisposition – Despite practicing rigorous oral hygiene routines, as much as 30% of the population may have a strong genetic predisposition to gum disease. These individuals are six times more likely to develop periodontal disease than individuals with no genetic predisposition. Genetic tests can be used to determine susceptibility and early intervention can be performed to keep the oral cavity healthy.
• Pregnancy and menopause – During pregnancy, regular brushing and flossing is critical. Hormonal changes experienced by the body can cause the gum tissue to become more sensitive, rendering them more susceptible to gum disease.
• Chronic stress and poor diet – Stress lowers the ability of the immune system to fight off disease, which means bacterial infections may possibly beat the body’s defense system. Poor diet or malnutrition can also lower the body’s ability to fight periodontal infections, as well as negatively affecting the health of the gums.
• Diabetes and underlying medical issues – Many medical conditions can intensify or accelerate the onset and progression of gum disease including respiratory disease, heart disease, arthritis and osteoporosis. Diabetes hinders the body’s ability to utilize insulin which makes the bacterial infection in the gums more difficult to control and cure.
• Grinding teeth – The clenching or grinding of the teeth can significantly damage the supporting tissue surrounding the teeth. Grinding one’s teeth is usually associated with a “bad bite” or the misalignment of the teeth. When an individual is suffering from gum disease, the additional destruction of gingival tissue due to grinding can accelerate the progression of the disease.
• Medication – Many drugs including oral contraceptive pills, heart medicines, anti-depressants and steroids affect the overall condition of teeth and gums; making them more susceptible to gum disease. Steroid use promotes gingival overgrowth, which makes swelling more commonplace and allows bacteria to colonize more readily in the gum tissue.

The periodontist will initially assess the whole mouth in order to ascertain the progress of the disease. After diagnosing the periodontist may treat the bacterial infection with antibiotics in conjunction with nonsurgical or surgical treatment or both.
The choice of procedure depends upon the exact condition of the teeth, gums and jawbone.
Here are some of the more common treatments for periodontal disease:

• Scaling and root planing – In order to preserve the health of the gum tissue, the bacteria and calculus (tartar) which initially caused the infection, must be removed. The gum pockets will be cleaned and treated with antibiotics as necessary to help alleviate the infection. A prescription mouthwash may be incorporated into daily cleaning routines.
• Deep pocket cleanings – As gingivitis and periodontitis progress, it becomes more difficult to cleanse the pockets between the soft tissues and the teeth. The periodontist can scale and root plane the teeth (sometimes under local anesthetic) to remove debris and infection-causing bacteria.
• Pocket elimination surgery – Pocket elimination surgery (also known as flap surgery) is a surgical treatment which can be performed to reduce the pocket size between the teeth and gums. Surgery on the jawbone is another option which serves to eliminate indentations in the bone which foster the colonization of bacteria.
• Laser treatment – This can be used to reduce the size of the pockets between the teeth and the gums.
• Tissue & Bone regeneration – When the bone and gum tissues have been destroyed, regrowth can be actively encouraged using grafting procedures. A membrane may be inserted into the affected areas to assist in the regeneration process.
• Bone grafting for implants – Dental implants can only be positioned if there is sufficient bone to attach the prosthetic tooth to. If bone loss has occurred, bone grafting is an excellent way to add or “grow” bone so that an implant may be properly secured.
• Dental implants – When teeth have been lost due to periodontal disease, the aesthetics and functionality of the mouth can be restored by implanting prosthetic teeth into the jawbone. Tissue regeneration procedures may be required prior to the placement of a dental implant in order to strengthen the bone.
• Osteoplasty (hard tissue recontouring) – Once periodontitis has been treated, the periodontist can recontour the hard tissue to make the smile both natural-looking and aesthetically pleasing.
• Crown lengthening – In order to expose more of the natural tooth, the periodontist can remove some of the surrounding gingival tissue.
• Gingivoplasty (soft tissue recontouring) – As gums recede due to periodontitis, the teeth may appear longer; causing a “toothy” smile. The periodontist can remove tissues or straighten the gum line to make the teeth look more even.