Periodontal Disease

Definition

Periodontal diseases are a group of diseases that affect the tissues that support and anchor the teeth. Left untreated, periodontal disease results in the destruction of the gums, alveolar bone (the part of the jaws where the teeth arise), and the outer layer of the tooth root.

Description

Periodontal disease is usually seen as a chronic inflammatory disease. An acute infection of the periodontal tissue may occur, but is not usually reported to the dentist. The tissues that are involved in periodontal diseases are the gums, which include the gingiva, periodontal ligament, cementum, and alveolar bone. The gingiva is a pink-colored mucus membrane that covers parts of the teeth and the alveolar bone. The periodontal ligament is the main part of the gums. The cementum is a calcified structure that covers the lower parts of the teeth. The alveolar bone is a set of ridges from the jaw bones (maxillary and mandible) in which the teeth are embedded. The main area involved in periodontal disease is the gingival sulcus, a pocket between the teeth and the gums. Several distinct forms of periodontal disease are known. These are gingivitis, acute necrotizing ulcerative gingivitis, adult periodontitis, and localized juvenile periodontitis. Although periodontal disease is thought to be widespread, serious cases of periodontitis are not common. Gingivitis is also one of the early signs of leukemia in some children.

Gingivitis is an inflammation of the outermost soft tissue of the gums. The gingivae become red and inflamed, loose their normal shape, and bleed easily. Gingivitis may remain a chronic disease for years without affecting other periodontal tissues. Chronic gingivitis may lead to a deepening of the gingival sulcus. Acute necrotizing ulcerative gingivitis is mainly seen in young adults. This form of gingivitis is characterized by painful,

bleeding gums, and death (necrosis) and erosion of gingival tissue between the teeth. It is thought that stress, malnutrition, fatigue, and poor oral hygiene are among the causes for acute necrotizing ulcerative gingivitis.

Adult periodontitis is the most serious form of the periodontal diseases. It involves the gingiva, periodontal ligament, and alveolar bone. A deep periodontal pocket forms between the teeth, the cementum, and the gums. Plaque, calculus, and debris from food and other sources collect in the pocket. Without treatment, the periodontal ligament can be destroyed and resorption of the alveolar bone occurs. This allows the teeth to move more freely and eventually results in the loss of teeth. Most cases of adult periodontitis are chronic, but some cases occur in episodes or periods of tissue destruction.

Localized juvenile periodontitis is a less common form of periodontal disease and is seen mainly in young people. Primarily, localized juvenile periodontitis affects the molars and incisors. Among the distinctions that separate this form of periodontitis are the low incidence of bacteria in the periodontal pocket, minimal plaque formation, and mild inflammation.

Herpes infection of the gums and other parts of the mouth is called herpetic gingivostomatitis and is frequently grouped with periodontal diseases. The infected areas of the gums turn red in color and have whitish herpetic lesions. There are two principal differences between this form of periodontal diseases and most other forms. Herpetic gingivostomatitis is caused by a virus, Herpes simplex, not by bacteria, and the viral infection tends to heal by itself in approximately two weeks. Also, herpetic gingivostomatitis is infectious to other people who come in contact with the herpes lesions or saliva that contains virus from the lesion.

Pericoronitis is a condition found in children who are in the process of producing molar teeth. The disease is seen more frequently in the lower molar teeth. As the molar emerges, a flap of gum still covers the tooth. The flap of gum traps bacteria and food, leading to a mild irritation. If the upper molar fully emerges before the lower one, it may bite down on the flap during chewing. This can increase the irritation of the flap and lead to an infection. In bad cases, the infection can spread to the neck and cheeks.

Desquamative gingivitis occurs mainly in post-menopausal women. The cause of the disease is not understood. The outer layers of the gums slough off, leaving raw tissue and exposed nerves.

Trench mouth is an acute, necrotizing (causing tissue death), ulcerating (causing open sores) form of gingivitis. It causes pain in the affected gums. Fever and fatigue are usually present also. Trench mouth, also known as Vincent's disease, is a complication of mild cases of gingivitis. Frequently, poor oral hygiene is the main cause. Stress, an unbalanced diet, or lack of sleep are frequent cofactors in the development of trench mouth. This form of periodontal disease is more common in people who smoke. The term "trench mouth" was created in World War I, when the disease was common in soldiers who lived in the trenches. Symptoms of trench mouth appear suddenly. The initial symptoms include painful gums and foul breath. Gum tissue between teeth becomes infected and dies, and starts to disappear. Often, what appears to be remaining gum is dead tissue. Usually, the gums bleed easily, especially when chewing. The pain can increase to the point where eating and swallowing become difficult. Inflammation or infection from trench mouth can spread to nearby tissues of the face and neck.

Periodontitis is a condition in which gingivitis has extended down around the tooth and into the supporting bone structure. Periodontitis is also called pyorrhea. Plaque and tarter buildup sometimes lead to the formation of large pockets between the gums and teeth. When this happens, anaerobic bacteria grow in the pockets. The pockets eventually extend down around the roots of the teeth where the bacteria cause damage to the bone structure supporting the teeth. The teeth become loose and tooth loss can result. Some medical conditions are associated with an increased likelihood of developing periodontitis. These diseases include diabetes, Down syndrome, Cohn's disease, AIDS, and any disease that reduces the number of white blood cells in the body for extended periods of time.

— John T. Lohr, PhD

An inflammatory lesion caused by bacteria affecting the tissues housing the roots of the teeth. The disease, sometimes called pyorrhea, increases in prevalence and severity with increasing age, and it is the principal cause of tooth loss in adult humans throughout the world. When only the gum tissue or gingiva is affected, the disease is called gingivitis, but when the process extends into the deeper structures it is known as periodontitis. The diseased tissues appear abnormally red and slightly swollen, and they tend to bleed, sometimes profusely, when the teeth are brushed. In some cases the gums may become thickened and scarred, and they may recede, exposing the root surface. As the disease advances, the attachment of the gum to the tooth is lost, creating a periodontal pocket, a large portion of the gum is destroyed, and the bone surrounding the roots is resorbed. The teeth become loose, abscesses form, and extraction is required.

Both gingivitis and periodontitis are caused by bacteria that form plaques on the surfaces of the teeth at the gingival sulcus or pocket. These plaques may contain 250 or more separate microbial species. Plaques of any microbial composition can cause gingivitis, but specific bacteria appear to be necessary for induction of periodontitis. Among the bacteria involved in periodontitis are various species of Porphyromonas, Bacteroides, Actinobacillus, Eikenella, Fusobacterium, Wolinella, and other less well-characterized species. Spirochetes are present in active lesions, but their role remains unclear. The bacteria extend apically along the interface between the tooth root and the gingival tissue and causes periodontal pockets to form.

The principal features of the pathogenesis of periodontitis have been described. The lesions begin as an acute inflammatory response followed by a dense accumulation of lymphoid cells. There is a net loss of collagen in the area nearest the junctional epithelium and periodontal pocket, with scarring and fibrosis of the connective tissues at more distant sites. The junctional epithelium is converted into an ulcerated pocket epithelium, the alveolar bone housing the tooth roots is resorbed, and the periodontal ligament is destroyed. Products released by infiltrating leukocytes, including prostaglandins, interleukins and collagenase, and other hydrolytic enzymes, are involved in tissue destruction.

Bacterial colonization and extension activate several host defense mechanisms. The most effective of these is the accumulation of functional neutrophilic granulocytes between the surface of the plaque and the gingival tissue. These cells tend to counter and limit microbial extension. The bacteria appear to invade the periodontal connective tissues, where they induce immunopathologic and other destructive inflammatory reactions in the host, and these lead, in major part, to the observed tissue destruction. Periodontal destruction is episodic, with periods of exacerbation characterized by highly acute inflammation, followed by periods of quiescence.

Although bacteria are essential for induction of the disease, predisposing factors are also important, though their elucidation is not complete. Individuals who manifest functionally abnormal neutrophilic granulocytes or monocytes are unusually susceptible to the severe early onset forms of periodontitis. The leukocyte abnormality appears to be genetically transmitted. The early-onset forms have been designated as prepubertal, juvenile, and rapidly progressive periodontitis; adult periodontitis has a later onset and does not seem to be related to leukocyte abnormalities. Some persons with acquired immune deficiency syndrome (AIDS) manifest a highly destructive, unique form of periodontitis. Other predisposing conditions include unusually stressful situations and periods of hormone imbalance occurring at puberty, during pregnancy, and in some women taking birth control drugs.

Good daily oral hygiene practices, including vigorous brushing of the exposed surfaces of the teeth and use of dental floss, interproximal brushes, and other devices to clean between the teeth, constitute the most effective measures to prevent periodontal disease. Basic ingredients of treatment of existing disease include bringing the infection under control and establishing conditions which preclude reinfection. All of the microbial deposits must be removed from the crown and root surfaces. In individuals with severe forms of periodontitis, these procedures may be supplemented by use of antibiotics either systematically or directly into the pocket. These procedures usually lead to reduction of the inflammation and to some shrinkage in the gums, but the periodontal pockets remain. Based on the traditional view that treated pockets may become reinfected and the disease may continue to spread, surgical treatment may be performed with the aim of reducing pocket depth and restoring normal tissue contours. Alternatively, regenerative procedures use various grafting materials, including freeze-dried decalcified bone or bone substitutes and guided tissue regeneration. To perform guided tissue regeneration, flaps are opened in the gingival tissue and the root surfaces are thoroughly cleaned; a porous membrane is placed around the tooth, covering the bone defect with or without placing grafts, and flaps covering the membranes are sutured into place. The membrane permits the wound site to become populated with cells having the capacity to generate new bone, cementum, and periodontal attachment. See also Tooth disorders.

Any disturbance of the periodontium or supporting structures of the teeth. Diseases affecting the periodontium include periodontitis, periodontosis, gingivitis, gingival enlargement, atrophy, and traumatism and may be loosely divided into two types: inflammatory and dystrophic. Etiologic factors may be local or systemic or may involve an interplay between the two.

Definition

Periodontal diseases are a group of diseases that affect the tissues that support and anchor the teeth. Left untreated, periodontal disease results in the destruction of the gums, alveolar bone (the part of the jaws where the teeth arise), and the outer layer of the tooth root.

Description

Periodontal (meaning "around the tooth") disease is usually seen as a chronic (long-term) inflammatory disease. An acute (sudden) infection of the tissue surrounding the teeth (periodontal tissue) may occur, but acute inflammation usually resolves on its own and is not treated by a dentist.

Periodontal diseases affect the gums, which consist of the gingiva, periodontal ligament, cementum, and alveolar bone. The gingiva is a pink-colored mucous membrane that covers part of the teeth and the alveolar bone. The periodontal ligament, also called the periodontal membrane, is the tough, fibrous tissue that holds the teeth in the gums. The cementum is a bony layer that covers the lower parts of the teeth. The alveolar bone is a set of ridges along the jaw bones (maxillary and mandible) from which the teeth arise.

Periodontal disease most often develops when a pocket or space is formed between the teeth and the gums. This pocket is called the gingival sulcus. A number of distinct forms of periodontal disease are known, including gingivitis, acute necrotizing ulcerative gingivitis, adult periodontitis, and localized juvenile periodontitis. Although many people have some form of periodontal disease, serious cases are not common.

Gingivitis is an inflammation of the outermost soft tissue of the gums. The gums become red and inflamed, lose their normal shape, and bleed easily. Gingivitis may remain a chronic disease for years without affecting other periodontal tissues. Chronic gingivitis may lead to a deepening of the pockets between the gum and tooth. In some children, gingivitis and bleeding gums are among the early signs of leukemia.

Acute necrotizing ulcerative gingivitis is seen mainly in young adults. This form of gingivitis is characterized by painful, bleeding gums, and death (necrosis) and erosion of gums between the teeth.

Localized juvenile periodontitis is a less common form of periodontal disease and is seen mainly in young people. Localized juvenile periodontitis usually affects the molars (back grinding teeth) and incisors. Among the distinctions that separate this form of periodontitis are the low incidence of bacteria in the periodontal pocket, minimal plaque formation, and mild inflammation.

Pericoronitis is a condition found in children whose molars are in the process of erupting through the gum. The disease is seen more frequently in the lower molar teeth. As the molar emerges, a flap of gum still covers the tooth. The flap of gum traps bacteria and food, leading to mild irritation. If the upper molar fully emerges before the lower one, it may bite down on the flap during chewing and increase the irritation of the flap, leading to infection. In severe cases, the infection can spread to the neck and cheeks.

Periodontitis, also called pyorrhea, is a condition in which gingivitis has extended down around the tooth and into the supporting bone structure. Plaque and tarter build-up lead to the formation of large pockets between the gums and teeth. When this happens, anaerobic bacteria (bacteria that do not need oxygen) grow in the pockets. The pockets eventually extend down around the roots of the teeth where the bacteria cause damage to the bone structure supporting the teeth.

Herpetic gingivostomatitis, which is relatively common in children, is an inflammation of the gums and mouth caused by the herpes simplex virus. This disease is contagious, but tends to heal without medical intervention in about two weeks.

Desquamative gingivitis occurs mainly in postmenopausal women and is not well understood.

Trench mouth, also called Vincent's disease, is a suddenly developing (acute) complication of gingivitis. It causes tissue death and open sores on the gums and is often accompanied by fever, fatigue, and painful bleeding gums. Trench mouth usually develops because of poor oral hygiene, stress, fatigue, and smoking. It requires immediate treatment by a dentist, since pain can increase to the point where eating and swallowing become difficult, and the inflammation can spread to nearby tissues of the face and neck.

Demographics

Periodontal disease is common. It is estimated that 9–17 percent of children between the ages of three and 11 years have gingivitis. The number increases sharply at puberty, with 70–90 percent of teens developing the disease. More boys than girls have gingivitis, probably because girls have better oral hygiene habits than boys, rather than because of any physiological differences.

Some medical conditions are associated with an increased likelihood of developing periodontitis. These diseases include diabetes, Down syndrome, AIDS, and any disease or condition that compromises the immune system and reduces the number of white blood cells in the body for extended periods.

Causes and Symptoms

Bacteria present on the gingival tissues cause periodontal diseases. The mechanisms by which bacteria in the periodontal pocket cause tissue destruction in the surrounding region are not fully understood. However, removal of bacteria through good oral hygiene practices and regular dental care helps reduce or eliminate these diseases. There are indications that a tendency toward developing periodontal disease is genetic, with up to 30 percent of the population being highly susceptible despite aggressive oral hygiene habits.

Other factors that put individuals at higher risk for developing periodontal diseases include smoking, stress, poor diet, and taking certain medications such as antidepressants, some heart medicines, and oral contraceptives. Gingivitis can be aggravated by hormones and may temporarily worsen during puberty and pregnancy. Individuals with diabetes and diseases that depress the immune system are more likely to develop periodontal disease.

The main symptoms of periodontal disease include:

• bleeding gums
• red, sore, or swollen gums
• gums that have receded from the base of the teeth
• chronic bad breath
• loose permanent teeth
• open sores on the gums

When to Call the Dentist

Beginning as toddlers, all children need regular checks-up by a dentist. Children who have chronically bleeding gums, open sores on the gums, or who complain of gum or tooth pain, should see a dentist promptly. Those with bleeding gums should see their pediatrician urgently, as this is also a symptom of leukemia in some children.

Diagnosis

Diagnosis of periodontal disease is made by observation of infected gums. Usually a dentist diagnoses and characterizes the various types of periodontal disease. Many periodontal diseases are distinguished based on the severity of the infection and the number and type of tissues involved.

Diagnosis of periodontitis includes measuring the size of the pockets formed between the gums and teeth. Normal gingival pockets are shallow. If periodontal disease is severe, jawbone loss will be detected in x rays of the teeth. If too much bone is lost, the teeth become loose and can change position. This will also be seen in x-ray images.

Treatment

Tartar can be removed only by professional dental treatment. Following treatment, periodontal tissues usually heal quickly. Administering the needed vitamins and improving diet treats gingivitis caused by poor nutrition or vitamin deficiencies. Removing debris under the flap of gum covering the molar treats pericoronitis.

Treatment of periodontitis requires professional dental care. The pockets around the teeth are cleaned, and all tartar and plaque removed. In periodontitis, tartar and plaque can extend far down the tooth root. Normal dental hygiene, brushing and flossing, cannot reach deep enough to effectively treat periodontitis. In cases where pockets are very deep (more than 0.25 in, or 0.64 cm, deep), surgery is required to clean the pocket. This is performed in a dental office. Sections of gum that are not likely to reattach to the teeth may be removed to promote healing by healthy sections of gum. Abscesses are treated with a combination of antibiotics and surgery. If antibiotics are needed for gum disease, they are usually given orally. The antibiotics may be delivered directly to the infected gum and bone tissues to ensure that high concentrations reach the infected area. Abscess infections, especially of bone, are difficult to treat and require long term antibiotic therapy to prevent a reoccurrence of infection.

There are no useful drugs to treat herpetic gingivostomatitis, but acyclovir is used in high-risk patients or those with a compromised immune system. Herpes lesions heal by themselves without treatment. After the herpetic lesions have disappeared, the gums usually return to normal if good oral hygiene is resumed.

Prognosis

Most cases of periodontal disease are mild and can be cleared up with improved oral hygiene, as well as tooth and gum cleaning by a trained professional. Serious cases of periodontal disease may be persistent, but they can usually be controlled. Untreated periodontal disease may cause teeth to loosen and fall out, and infection may spread to surrounding tissues.

Prevention

Good oral hygiene, a well-balanced nutritious diet, and regular dental visits for tooth cleaning all help prevent periodontal disease. Prompt attention to gingivitis can prevent it from progressing to more serious periodontal diseases.

Parental Concerns

Sometimes parents are less concerned about their child's first (baby) teeth than their permanent teeth. However, poor oral hygiene and lack of care of the first set of teeth are apt to be reflected in problems with the gums and the permanent teeth.

Resources

Books

Berkow, Robert, ed. Merck Manual of Medical Information. Whitehouse Station, NJ: Merck Research Laboratories, 2003.

Gorbach, S. L., et al. Infectious Diseases. 2nd ed. Philadelphia: W. B. Saunders Co., 1998.

Periodicals

Academy of Periodontology. "Position Paper: Guidelines for Periodontal Therapy." Journal of Periodontology 72 (2001): 1624–28.

American Dental Association. "Preventing Periodontal Disease." Journal of the American Dental Association 132 (Sept. 2001): 1339.

American Dental Association. "Treating Periodontal Disease." Journal of the American Dental Association 134 (Feb. 2003): 259.

Web Sites

"Periodontal (Gun) Diseases." American Academy of Periodontology. [cited June 11, 2004]. www.perio.org

Stephen, James. "Gingivitis." eMedicine.com [cited August 11, 2004]. www.emedicine.com/emerg/topic217.htm.

[Article by: Tish Davidson, A.M. John T. Lohr, Ph.D.]

The noun has one meaning:

Meaning #1: a disease that attacks the gum and bone and around the teeth
  Synonym: periodontitis