Periodontitis is often known as 'Gum Disease' and is a very common condition in which the gums and deeper periodontal structures become inflamed. This inflammation of the gums, which usually takes the form of redness, swelling and a tendency to bleed during tooth brushing, is the body’s response to certain bacteria that have been allowed to accumulate on the teeth. Although part of the body’s defence system, this inflammatory response can eventually cause serious damage. If left unchecked, the inflammation can spread down below the gums and along the roots of the teeth, causing destruction of the periodontal ligament and the supporting bone. This ultimately leads to the loosening and potential loss of the teeth.
What is periodontitis?
Periodontitis is inflammation of the gums and supporting structures of the teeth. It is one of the most common human diseases.
Periodontitis is caused by certain bacteria (known as periodontal bacteria) and by the local inflammation triggered by those bacteria. Although these periodontal bacteria are naturally present in the mouth, they are only harmful when the conditions are right for them to increase dramatically in numbers. This happens when a layer of bacteria and food debris, known as plaque, builds up and is left undisturbed on the teeth, commonly in hard-to-reach areas such as between the teeth.
The more dangerous bacteria are able to thrive and multiply, producing some harmful by-products which stimulate the body’s defensive inflammatory response in the gums. As the disease progresses, chronic inflammation causes the bone of the jaw to be destroyed and the teeth to be lost. In many people, this is a gradual process that takes place over many years and, if detected and treated, can be halted. However, some young adults have a very active form of the disease which causes early loosening and loss of the teeth.
How can I recognise periodontitis?
Periodontitis always begins with inflammation of the gums, known as gingivitis. This is not always easy to recognize but one of the first signs that you may become aware of is bleeding from the gums when you brush your teeth. The gums may look red and swollen and you might notice a discoloured layer of bacterial plaque on the teeth.
Left untreated, gingivitis may progress to periodontitis, often without any obvious signs to alert you. However, some changes that you might experience over time include: increased bleeding from the gums, which may be provoked by brushing or eating, or even be spontaneous; bad breath; changes in the positioning of the teeth in the jaws; lengthening of the teeth (gum recession); and possibly pain. Bleeding from the gums may be less noticeable in smokers, because of the effect of nicotine on blood vessels, and so the disease process may be masked.
It often happens that the presence of periodontitis is not recognized by an individual until they are 40 or 50 years of age, by which time a great deal of damage may have occurred. However, a dentist is able to detect signs of the disease at a much earlier stage during a routine examination and can monitor your periodontal status using a special assessment known as the Periodontal Screening Index.
What are the causes of periodontitis?
A healthy mouth is colonized by more than 700 different species of bacteria, most of which are completely harmless and live in harmony with their host. However, when tooth cleaning is not thorough enough, the bacterial deposits build up next to the gums, forming a plaque, and the conditions become suitable for more dangerous bacteria to flourish. The natural defences of the body are also compromised.
In all cases, periodontitis is caused by the build-up of bacteria in the form of dental plaque.
If the soft bacterial plaque is not removed by brushing, minerals are deposited within it over time and it becomes a hard deposit on the tooth called tartar. The presence of tartar encourages the growth of the bacterial plaque towards the tooth roots. As the inflammation progresses deeper, the attachment of the gum to the root is disrupted and a gap or periodontal pocket is formed between them. This pocket is an ideal place for harmful bacteria to colonize and in which to multiply, therefore driving the disease process forward. In their new habitat, the bacteria release toxins as products of their metabolism, which further trigger the body’s defence mechanisms.
The severity and speed of progression of periodontitis depends upon the balance of a number of factors: the number and type of bacteria present, how strong the individual’s defence mechanisms are, and the presence or absence of certain risk factors. For example, the more aggressive the bacteria and the weaker the immune response of the patient, the more active will be the disease. Added to that, some risk factors, such as smoking or diabetes, can further weaken the body’s defences and speed up the disease process. In the same way, certain drugs, such as antihypertensive or vasodilating agents and immunotherapy, affect the inflammatory response to plaque and make patients more susceptible to gingivitis. However, it is important to recognize that, without the accumulation of bacterial plaque, periodontitis will not occur.
What can I do to prevent periodontal disease?
Periodontal inflammation is not inevitable. The development of gingivitis and periodontitis can be prevented by adopting thorough oral hygiene habits, alongside regular professional examinations and support.
The basic elements of a good oral hygiene regime are:
- Cleaning the chewing surfaces and sides of the teeth twice daily, with a toothbrush (of an appropriate size and in good condition) and toothpaste.
- Cleaning the spaces between the teeth where the toothbrush bristles cannot reach, using either dental floss or an interdental brush, depending on the size of the space. This should be done once daily.
Dental floss should be used where the teeth are close together, with little or no space between them, while interdental brushes are suitable for larger gaps. Special care should be taken to clean thoroughly around crooked or crowded teeth, or around fillings, crowns and dentures, as plaque accumulates readily in these places and access might be limited.
Antibacterial mouthwashes are a useful supplement to brushing, as they inhibit bacterial growth and dampen inflammatory changes. They should be used after tooth brushing.
If, as a result of an inadequate cleaning technique, plaque deposits are left on the teeth, these will become mineralised and turn into hard, fixed deposits (calculus, commonly known as tartar) that cannot be removed with a toothbrush. Your dentist or periodontist will identify these tartar deposits during your regular dental inspection and remove them as part of a professional clean. After the deposits are removed, the teeth are polished with special pastes and cups to create a smooth surface that is less likely to accumulate plaque.
What are the consequences of periodontal disease?
Periodontitis is the leading cause of tooth loss.
If the progress of periodontal inflammation is not halted, the supporting structures of the teeth, including the surrounding bone, are destroyed. The teeth eventually loosen and are lost, or require extraction. Other problems patients may experience include painful abscesses, drifting of the teeth which may interfere with eating, and unsightly lengthening of the teeth with exposure of the roots, as a result of gum recession.
It is now understood that untreated periodontal disease can have effects on general health; for example, it poses an increased risk for complications during pregnancy (pre-eclampsia, premature birth and low birth weight) and also an increased risk for heart disease and diabetes.
What are the risk factors for periodontitis?
There are a number of factors that increase your chance of developing periodontitis and make it more likely to progress. Well-known risk factors include stress, some systemic diseases such as diabetes, and – most importantly - smoking.
Smoking and periodontitis
- Smokers are significantly more likely to develop periodontitis than non-smokers.
- Periodontal treatments (such as gum/ bone grafts and implants) are less successful in smokers than non-smokers due to poorer healing.
- Periodontitis progresses much faster, with more rapid tooth loss, in smokers.
- Of cases of periodontitis which does not respond to treatment, about 90% are in smokers.
How is periodontitis treated?
With careful assessment and treatment, it is usually possible to completely halt the progress of periodontitis. The key to success is to eliminate the bacterial plaque which is triggering the disease process and to establish excellent oral hygiene practices.
- Oral hygiene instruction and advice
The aim of the oral hygiene phase of treatment is to reduce the number of bacteria in the mouth and therefore reduce the level of inflammation. Your dental practitioner will first explain the causes of your periodontitis and explain exactly how to keep your teeth and gums clean. You will be given individual advice on how to use the various cleaning aids most effectively; for example, the most appropriate tooth brushing technique and the correct use of dental floss and interdental brushes.
- Professional cleaning
All soft deposits will be removed from accessible areas of the teeth and the teeth polished and treated with fluoride. Depending on the improvement seen in plaque control and gum health, further instruction and cleaning may be carried out in subsequent visits. The next step would be for your practitioner to remove all bacterial deposits and tartar from the root surfaces and gingival pockets.
- Antibiotic therapy
In some cases, with or without microbiological evaluation, antibiotics are prescribed to deal with active or persistent gum infections, which have not responded to oral hygiene measures.
After several weeks, your dentist or periodontist will make a full assessment of your gums to check the progress of your treatment. A special instrument called a periodontal probe is used to record the depth of any periodontal pockets and check for bleeding from the gums. If periodontal pockets are still present, further treatment options may be suggested, including surgical corrective therapy.
- Corrective (surgical) treatment
Sometimes, a surgical procedure is carried out to clean away plaque bacteria and deposits that are under the gum within periodontal pockets and on the root surfaces at the furcations (where the roots diverge). These areas are inaccessible to brushes and floss and inflammation will persist in these sites as long as bacteria are allowed to colonize them. Under local anaesthesia, the gum is lifted away and the root surfaces are cleaned under direct vision to ensure that all bacteria are removed. Sometimes, it is possible to treat bone loss at the same time using a special regenerative treatment. At the end of the procedure, the gums are sutured back into place around the teeth.
- Aftercare – supportive periodontal therapy
The long-term success of periodontal treatment depends both on your own efforts with oral hygiene and those of the practice team who provide your regular care and ongoing assessment. After the first phase of treatment has been completed, your dentist will need to review the condition of your gums at regular intervals to check that the inflammation has been halted. The frequency of your follow-up appointments will depend on the severity of disease and your individual risk of disease progression. Usually, follow-up visits are scheduled for every three to six months.
Regular follow-up appointments are vitally important to ensure that the disease process does not recur, causing further destruction of the gums and supporting bone. If there are signs of continuing disease, your dentist will be able to identify new or recurring sites of inflammation and treat them at an early stage. You will also be given advice on how to modify your oral hygiene practices to tackle the inflammation.
Successful periodontal treatment requires your full co-operation in regard to daily oral hygiene practices and attendance at regular follow-up appointments.