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Periodontitis is a non-curable inflammatory disease that causes irreversible destruction to supporting structures around teeth in the oral cavity. Early detection and treatment are critical to preventing tooth loss and to provide optimal outcomes of improved oral and systemic health.
The cause of periodontitis is different for everyone; however, there are certain peramaters that must be met before the disease process begins.
For periodontal disease to begin, it requires a dysbiotic microbiota (imbalanced bacterial load) and a susceptible host.
When pathogenic bacteria reaches a certain quantity, the host's body begins a system-wide inflammatory response to fight off the bacterial infection. A prolonged inflammatory response to bacterial pathogens that aren't removed in a timely manner causes irreversible damage to supporting tooth structures and perpetuates further dysbiosis and disease.
Common causes for increased risk of periodontal disease
Poor oral hygiene habits
Lack of preventative dental care
Crowded, misaligned teeth
Compromised immune system from chronic illness, especially those that are inflammatory-based
Examples: cardiovascular disease, autoimmune diseases, IBS, etc.
Diabetes
Negative stress
Poor mental health status
Tobacco use, including vaping
Excessive alcohol consumption
Genetics & epigenetics
Medications
Xerostomia (dry mouth)
Poor nutrition
Pregnancy
Age
Dysfunctional breathing habits
Examples: mouth breathing, snoring, sleep apnea
Clenching and grinding
Tooth decay
Faulty restorations
Generally speaking, periodontal disease is a painless process.
However, there are signs and symptoms that may occur as a warning of potential oral infection [2].
Reddish or purplish gum tissue
Bleeding, swollen gum tissue
Bad breath (halitosis)
A change in the way teeth fit together
Gum tissue recession
Loose teeth
Pain when chewing
Generalized or localized gum tissue soreness
Pus (infection) around the gum line
Unpleasant taste
“Black triangles” between teeth
When it comes to periodontal disease, the best
treatment is prevention.
Maintaining routine preventative dental visits is one of the best ways to avoid oral inflammatory diseases such as gingivitis or more advanced periodontitis.
With more individualized treatment protocols emerging in dentistry, it's becoming standard of care for dental healthcare providers to recommend cleanings every 3-4 months instead of every 6 months. This recommendation should be based on clinical presentations and whole-health assessments performed at each visit and focus on each patient's specific disease status and treatment needs; not all patients require additional visits.
The best way for patients to understand their oral health status, risk factors, and ideal treatment options is to ask questions.
Open communication between providers and patients is a requirement for individualized care.
If a patient doesn't understand why they need additional appointments or what the therapy goals are, they are less likely to maintain long-term compliance, and their oral and systemic health will suffer.
Topics that should be discussed during assessment
In-depth health history review
Review of any changes to medications
Numerous medications create side effects in the oral cavity
Assess for systemic inflammatory diseases, which increase the risk of oral inflammation and thus periodontal disease
Examples: diabetes, cardiovascular disease, autoimmune disease, cancer, etc.
History of surgery or upcoming surgical procedures, including medical and dental surgeries
Active periodontal disease increases the risk of delayed healing and adverse outcomes of surgical procedures
Nutritional counseling aimed at lowering inflammatory diets
A referral to a nutritionist may (and should) be given for more comprehensive care if an inflammatory diet is common for patients
Tobacco cessation counseling, if needed
Use of tobacco products, including vaping, increases the risk of periodontal disease significantly, decreases response to therapy provided, and delays healing
Stress management & mental health
Chronic negative stress is known to increase inflammation in the body
Poor mental health often lowers an individual's ability to maintain optimal diet and oral health practices
Exercise routines
Exercise is known to reduce systemic inflammation, improve stress management, and aid in mental health challenges
The clinical assessment used to diagnose
periodontal disease is multifactorial.
The use of a periodontal probe measures the depth at which bacteria is able to enter under the tissues surrounding teeth.
Probing depths in healthy patients are 2-3mm with limited (<10%) bleeding
Probing depths seen with gingivitis are 4mm with generalized (>30%) moderate to severe bleeding
Probing depths seen with periodontitis are 5mm+ with localized or generalized bleeding
Probing depths 6-7mm+ often require treatment by a periodontist, a dentist with advanced training in treating more involved cases of periodontal disease
[3]
There are four main factors of health versus disease assessed when completing a comprehensive periodontal chart
Probing depth: the distance (in millimeters) from the top of the gum tissue measuring down to where the tissue attaches to the tooth or surrounding bone
Gingival recession / gingival margin: the distance (in millimeters) from the top of the gum tissue to the start of the enamel at the cementoenamel junction (CEJ)
Tooth mobility: the level (class 1-4) of mobility each tooth presents with
Furcation involvement: the distance (in millimeters, measured as class 1-3) for how far between two roots of a single tooth (usually a molar) a dental probe can reach
The greater the number for all four areas assessed, the worse long-term prognosis a tooth has.
Dental radiographs are required to assess the status of bone levels between and around teeth. The trained eye of a dental healthcare professional will be able to show patients areas on their radiographs where bone changes have occurred.
[1]
The more bone loss visualized on a radiograph, the worse long-term prognosis a tooth has.
Once all medical/systemic and clinical parameters are assessed, a trained dental healthcare professional should discuss each patient's risk factors, level of disease, and treatment options available. Keeping a patient actively involved in their oral health (and thus systemic health) status is essential for long-term commitment to improving habits and routines for optimal outcomes.
Once diagnosed, treatment of oral disease in a timely manner is essential for optimal outcomes and overall health.
To make informed decisions, patients must understand treatment options available to them, including how each procedure is performed, its benefits, and any potential adverse outcomes.
Treatment options:
Non-surgical periodontal therapy (NSPT) [2]
Scaling and root planing (i.e. deep cleaning)
Removal of plaque, biofilm, and calculus above and below the gum line to lower microbial counts and promote a healthier oral environment for healing
The goal is the reduction or elimination of bleeding and a decrease in the periodontal probing depths to facilitate easier oral health maintenance by patients with their homecare
Surgical periodontal therapy (SPT) [2]
Pocket reduction surgery (i.e. osseous surgery)
A periodontist (i.e. gum specialist) performs scaling and root planing that includes temporarily lifting of the gum tissue to directly visualize areas of harbored bacteria, allowing for thorough cleaning deeper under the gum tissue that traditional NSPT cannot adequately reach
LANAP (laser-assisted new attachment procedure)
Use of a specialized laser to remove infected gum tissue around teeth without requiring lifting of the gum tissue or sutures
The laser targets only diseased tissue while also promoting healing
Tissue (gum) grafting
Placement of a tissue graft over areas of significant recession associated with more advanced forms of periodontal disease
The goal is to reduce the amount of recession and thicken the tissue around the teeth, which can help lower sensitivity
Bone grafting
Bone graft material, or ‘scaffolding’, is placed at sites where the bone has been lost due to periodontal disease
The goal is for the body to regenerate its own bone in the area over time
Treatment adjuncts to SPT [2]
Guided tissue regeneration (GTR)
Used in combination with bone grafting to allow more bone regrowth instead of soft tissue regrowth in areas grafted
Platelet-rich plasma (PRP) or fibrin (PRF)
Uses a patient’s own blood sample to acquire plasma or fibrin, which is placed at a site treated with bone grafting or GTR
This can shorten recovery time, reduce post-surgical pain, and boost healing
The most common adverse outcomes of both NSPT and SPT [2]
Increased recession with possible increased tooth sensitivity
Increased tooth mobility
Inadequate response
Tooth loss is possible even with treatment
Insufficient maintenance
Periodontal disease has stages of being active and inactive
Without proper long-term maintenance, relapse can occur with further destruction of the supporting tooth structures
Delayed healing
Highly based on systemic health factors such as diabetes or cardiovascular disease
Impacted by tobacco use, including vaping
Treatment of periodontitis, either NSPT OR SPT, does not guarantee no tooth loss will happen. Progression of periodontal disease is still possible after treatment!
Periodontal disease is known to be episodic in nature, meaning it has times of being stabilized and well-controlled and times when active infection and destruction reoccur. Keeping up with routine dental visits to maintain a healthy oral status and monitor for recurrence is essential for the long-term success of any gingival or periodontal therapy received.
However, it's important to understand that some patients have more virulent bacterial pathogens present and/or a lower systemic immune response for healing. Because of this, receiving periodontal therapy does not guarantee there will be no further progression of the disease, including tooth loss. This is why early, individualized care is essential for the best long-term outcomes.
Check back soon to read part two of this series on periodontal disease where we will take a deeper dive into the specific pathogens associated with this chronic disease & their impact on all systems of the body.
Talk soon,
Liz Laney, BSDH, RDH
Oral-Systemic RDH & Educator
Have questions about periodontal disease or want to know more?
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Sources
Hong KA. Dental questions: Why are X-rays so useful? Thousand Oaks Family Dentistry. March 24, 2018. https://www.thousandoaksfamilydentistry.com/blog/dental-questions-why-are-x-rays-so-useful.
Periodontal Disease (Gum Disease). Cleveland Clinic. April 10, 2023. https://my.clevelandclinic.org/health/diseases/21482-gum-periodontal-disease. z
Periodontal Examination. Perio-tools.com. https://www.perio-tools.com/periodontal-examination/.
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