Diagnoses

Periodontitis

About this diagnosis

Alternate terms: Gum disease; Periodontal disease; Pyorrhea.

Untreated gingivitis can progress to the point where the gingival attachment fibers to tooth and bone are lost; and beyond that to the point where bone destruction results (Figure 1). This bacterial illness is called periodontal disease, and is the number one cause of tooth loss in adults. It is also referred to as "gum disease" and by the antiquated term, "pyorrhea."
Learn more: Diagnoses › Gingivitis

Periodontal disease is not curable. However, it can be controlled indefinitely through treatment by a dental professional, excellent home care, and regular follow-up. Evidence from both the medical and dental professional literature supports the conclusion that treating periodontal disease in the dentist's chair before it progresses may prevent expensive medical treatment and life-threatening illness.

Periodontal disease negatively affects your general health

Untreated chronic periodontal disease has been shown to contribute to poor systemic health. It seems intuitive that poor oral health and poor general health might be related. In fact, strong evidence continues to mount supporting this conclusion. If the proverbial lecture from dentists and hygienists to brush and floss seems blase, consider these facts. Periodontal disease has been linked to:

• Cardiovascular disease (blood vessels of the heart)
• Peripheral vascular disease (blood vessels of the body)
• Strokes
• Poor control of blood sugar among diabetics
• Pre-term labor, intra-uterine growth restriction (IUGR), and low birth-weight babies

What do all of these have in common? They are each related to our circulatory system (blood vessels), and substances that move through our bodies in our circulatory systems. If you have been diagnosed with periodontal disease, you should make a priority of having it treated, and actively managing it to prevent its progression.

Heart Disease

Several theories exist to explain the link between periodontal disease and heart disease. One theory is that oral bacteria can affect the heart when they enter the blood stream, attaching to fatty plaques in the coronary arteries (heart blood vessels) and contributing to clot formation. Coronary artery disease is characterized by a thickening of the walls of the coronary arteries due to the buildup of fatty proteins. Blood clots can obstruct normal blood flow, restricting the amount of nutrients and oxygen required for the heart to function properly. This may lead to heart attacks.

Another possibility is that the inflammation caused by periodontal disease increases plaque build up, which may contribute to swelling of the arteries. One way to measure your risk for this type of inflammation is through a simple blood test for the level of "C-reactive Protein (CRP)," a liver enzyme that is elevated in persons with chronic inflammation. CRP has been shown to be at least as important as cholesterol as a predictor of whether a person will suffer a heart attack.

Researchers have found that people with periodontal disease are almost twice as likely to suffer from coronary artery disease as those without periodontal disease.

Periodontal disease can also exacerbate existing heart conditions. Patients at risk for infective endocarditis may require antibiotics prior to dental procedures. Your general dentist, periodontist and cardiologist will be able to determine if your heart condition requires use of antibiotics prior to dental procedures.

Stroke

Studies have pointed to a relationship between periodontal disease and stroke. In one study that looked at the causal relationship of oral infection as a risk factor for stroke, people diagnosed with acute cerebrovascular ischemia were found more likely to have an oral infection when compared to those in the control group.

Onset and Progression of the Disease

A periodontal probe inserted between the tooth and gingiva where the tooth emerges into the mouth should measure 0 to 3mm of when the gums are healthy. The gums should not bleed when flossed or probed, and probing or flossing should not be painful. The collagen and elastin attachment fibers that hold the gums to the teeth and underlying bone are intact.

In gingivitis, there is no loss of, or irreversible damage to the attachment fibers between the teeth and gums, but if the condition is ignored, the attachment fibers will be severed. The pocket that develops around the teeth will retain food debris, and the normal aerobic (oxygen-breathing) bacteria of the mouth will diminish in number in favor of the types that cause periodontal disease. Bacteria that accumulate in gum pockets contribute immediately to bad taste and bad breath (halitosis).

When the fibrous attachment between the tooth and gums is destroyed by bacteria (and by the patient's immune response to them, which is also destructive to tissue), the base of the gum pockets collapse, exposing the underlying bone to the bacteria. Early periodontitis (Figure 4) is sometimes evident on X-ray images by development of pitting in the bone next to the teeth, and periodontal pockets that measure 4 to 6mm in depth. This is significant because a patient can no longer get toothbrush bristles or floss into the deepest part of the pockets for removal of the plaque inside of them.
Learn more: Glossary › Plaque

The plaque begins to harden and mineralize, and becomes rigidly fused to the tooth. Mineralized plaque is known as "calculus" or "tartar", and creates a physical barrier to access by the patient. Underneath the calculus deposits, the bacteria and the patient's immune system continue to destroy periodontal tissues. Without treatment, the process continues until so much bone is destroyed the teeth become mobile and are lost. Depending on how aggressive the disease is, it may take several years for periodontitis to run its course, and with treatment, progression can be halted indefinitely.

Periodontal disease is graded according to how extensive the damage to the periodontal tissues is when diagnosed, and how many teeth are affected. Generalized periodontal disease is diagnosed when all or the majority of the teeth are affected. Localized periodontal disease is diagnosed when one to a few teeth are involved. Incipient (early) periodontal disease is diagnosed when less than 20% of the supporting bone around a tooth (or teeth) has been affected. Moderate periodontal disease is diagnosed when 20% to 40% of the tooth-supporting bone has been affected. Severe periodontal disease is diagnosed when more than 40% of the tooth-supporting bone has been affected.

Periodontal disease is also classified by treatment status. After the bacteria and its supportive niche (e.g. calculus, gum pockets) have been eliminated through dental treatment, and the patient's oral hygiene efforts have been improved, a re-evaluation of the condition is conducted. If inflammation is eliminated, probing measurements are stable, and X-ray images show evidence of improved hard-tissue health, the patient is said to be periodontally stable. Stable periods in which the disease is in remission may last for years. If all efforts to control the disease have produced no improvement, the disease is said to be refractory.

The age of the patient, and rate of progression of periodontal disease are also used to classify the illness. For example, localized juvenile periodontitis generally affects the first permanent molars and incisor teeth of adolescent children. Aggressive periodontitis (also called "early onset periodontitis") occurs in young people, and is further classified according to whether it strikes before or after onset of puberty. Periodontal disease is said to be rapidly progressive if the disease process produces significant measurable destruction on short (two to four month) recall intervals. Tooth loss is possible within a year of diagnosing rapidly progressive periodontitis.

Periodontal disease is epidemic, with some 75% of adults suffering from it to one degree or another. There are several dozen different species of bacteria known or believed to contribute to periodontal disease (Figure 6). In those patients with the disease, there seems to be a shift in the balance of oral microbes from "gram positive aerobes" to "gram negative anaerobes".

The "gram" positive or negative designation of a species of bacteria refers to whether or not that particular species picks up a laboratory stain called "gram stain". Many of the most destructive bacteria to periodontal support structures are gram negative, meaning that they do not pick up gram stain.

Aerobic bacteria require oxygen to thrive. Anaerobic bacteria do not. In the depths of a periodontal pocket, the amount of oxygen available for cell respiration is low, which is probably why the anaerobic bacteria tend to flourish there. Most of the bacteria that destroy periodontal structures are anaerobic. "Facultative" aerobes can use oxygen, but do not require it.

Regardless of the bacteria that are present, however, another requirement for development of the disease seems to be a susceptible host (i.e. not only are the bacteria present, but they actually cause disease in the patient because the patient is susceptible). Susceptibility to periodontal disease may be influenced in part by such factors as hormonal fluctuations, stress, smoking and genetic predisposition. The incidence of periodontal disease is higher in patients with systemic illnesses and conditions such as diabetes, Down's syndrome, Crohn's disease, leukemia and other blood disorders and AIDS.