Periodontitis (peri = around, odont = tooth, -itis = inflammation) 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 a convergence of bacteria that adhere to and grow on the tooth's surfaces, along with an overly aggressive immune response against these bacteria. 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".
Although the different forms of periodontitis are all caused by bacterial infections, a variety of factors affect the severity of the disease. Important "risk factors" include smoking, poorly-controlled diabetes, and inherited (genetic) susceptibility. This genetic susceptibility to destructive periodontal disease can now be tested with the PST® test, however the efficacy of this test remains to be studied in a long-term peer-reviewed prospective trials.
If left untreated, periodontitis causes progressive, irreversible bone loss around teeth, looseness of the teeth and eventual tooth loss. Periodontitis is a very common disease affecting approximately 50% of U.S. adults over the age of 30 years. Periodontitis is thought to occur in people who have preexisting gingivitis — an inflammation that is limited to the soft tissues surrounding the tooth and does not yet affect the alveolar bone.
The primary etiology, or cause, of gingivitis is the accumulation of a bacterial matrix at the gum line, called dental plaque. Other contributors are poor nutrition and underlying medical issues such as diabetes. A double blind study showed a supplement that decreased pocket depth and bleeding. 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 bacteria (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 plaque accumulation, such as restoration overhangs and root proximity.
If left undisturbed, bacterial 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 bacterial 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 insult is mainly determined by genetics; however, immune development may play some role in susceptibility.
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.
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), 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.
The cornerstone of successful periodontal treatment starts with establishing excellent oral hygiene. This includes twice daily brushing with daily flossing, mouthwash use. 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. 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 or periodontist is required to maintain affected teeth.
Initial Therapy: Removal of bacterial 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 Root planing. 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.
Reevaluation: Multiple clinical studies have shown that non-surgical scaling and root planing is rarely successful in periodontal pocket depths greater than 4-5mm (See articles by Stambaugh RV, Int J Periodontics Rest Dent, 1981 or Waerhaug J, J Periodontol, 1978). Therefore it is necessary for the dentist or periodontist 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.
Surgery: If the initial non-surgical treatment was not successful in controlling periodontitis, or if anatomical bony defects persist, periodontal surgery may be necessary to control periodontal disease. There are a myriad of procedures which may be applied, depending on each tooth's site-specific disease pattern. These procedures are usually performed by a periodontist. These procedures include (but are not limited to):
"LANAP, or the Laser Assisted New Attachment Procedure:" Many patients consider traditional surgery an unacceptable idea due to traditional surgery's need to remove gum tissue with a scalpel, flapping back the gum tissue to gain access to the bone and roots, bone removal, and stitches. The attendant longer-appearing teeth due to post-surgical gum recession, root sensitivity, or perception of post-operative pain cause these patients to avoid receiving badly-needed periodontal care. LANAP is a procedure which involves an FDA-approved protocol by which a free-running Nd:YAG laser, the PerioLase MVP-7 by Millennium Dental Technologies, is employed to disinfect the periodontal pocket, remove the disease pocket's epithelial lining, and seal the pocket after calculus removal to encourage healing. Studies have shown this technique's superiority to scaling and root planing (Dr. Raymond Yukna, University of Colorado, International Journal of Periodontics and Restorative Dentistry, December 2007). Patients as well report an experience which is sparing of the gum tissue and the post-operative pain which is often associated with conventional surgical therapy.
Maintenance: Once successful periodontal treatment has been completed, with or without surgery, a lifelong regimen of "periodontal maintenance" is required. This involves regular checkups and cleanings of every 3-4 months to prevent repopulation of periodontitis-causing bacteria, and to closely monitor affected teeth so that early treatment can be rendered if disease recurs.
If a patient has 5 mm or deeper pockets around their teeth, then they would 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.
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