What is periodontitis?

There are several factors that increase your chance of developing periodontitis and make the disease more likely to progress. Among the common risk factors are:

Smoking

• Smokers are much more likely to develop periodontitis than non-smokers.
• Periodontitis progresses much more quickly – and with more rapid loss of teeth – in smokers than in non-smokers.
• Even with good oral hygiene at home, smokers experience greater bone loss and are more likely to develop gum pockets that house a greater number of harmful bacteria.
• Periodontal treatments (e.g. implants and gum or bone grafts) are less successful in smokers than non-smokers because healing is generally poorer. 
• About 90% of cases where periodontitis does not respond to treatment involve smokers.
• In ex-smokers, the condition of the gums can improve within a few years and with good professional care. Just one year after quitting, former smokers respond better to treatment than patients who still smoke.
• Quitting smoking is strongly advised.

Genetics

• Some people may have more of a genetic predisposition to suffering gum disease than others.
• The way the immune system reacts to harmful bacteria can differ from person to person because of genetic differences. As a result, people do not all develop the same symptoms of periodontitis.

Age

• Periodontitis can start at the age of 18 in rare cases, and in very rare cases even in adolescence. 
• But most cases develop after the age of 35. 
• Because the disease usually progresses slowly, those affected do not detect the first problems until much later – sometimes when it is already too late.
• In old age, the consequences of periodontitis can be more serious, in terms of greater bone loss and more tooth loss.

Type-2 diabetes

• Diabetics whose blood sugar is not managed have a higher risk of developing periodontitis.
• Periodontitis and diabetes have a two-way effect on each other. Diabetics whose blood sugar is not managed have a higher risk of developing periodontitis. And patients with periodontitis have a higher risk of suffering diabetes. 
• Diabetics with well-managed blood-sugar levels do not have a higher risk for periodontitis. 
• The treatment of one disease has a positive effect on the treatment of the other. 
• It is important that people with diabetes are examined by a dentist to see if they have periodontitis and patients with periodontitis should be tested for diabetes by their doctor.

Poor diet

• An unhealthy diet – one high in processed foods and refined carbohydrates – increases the tendency for gums to become inflamed. 
• In both gingivitis and periodontitis, this can lead to more swelling at the gum line and increased damage to the tooth-supporting structures.
• An unhealthy diet also increases the risk of diabetes, which can further exacerbate periodontitis.

Stress

• Mental and emotional stress can weaken the immune system and lower the resistance of the gums to harmful bacteria.
• People with a weakened immune system may be more susceptible to gum disease.
• The resulting greater bacterial load adds to the unfavorable effect on an already compromised immune system.
• Individuals suffering from stress or depression may spend less time on their daily oral hygiene at home.

Inflammation of the gums is neither normal nor inevitable. Gum diseases –gingivitis and periodontitis – can be prevented by looking after your teeth and gums. This means adopting good habits in oral hygiene and getting regular professional check-ups (at least once a year).

The basic elements of good oral hygiene are:

• Brush your teeth at least twice a day, for at least two minutes, using a manual or an electric toothbrush.
• Clean between teeth at least once a day using interdental brushes (also known as interproximal brushes) and dental floss if the gaps are too small for brushes. You may need to use differently sized brushes for differently sized gaps. This interdental cleaning should be done before brushing your teeth.
• After brushing your teeth, antiseptic mouthwashes may be used as they can prevent plaque accumulation for up to 12 hours. Chlorhexidine mouthwashes are the most efficient, but have some side effects such as tooth staining, black tongue, change in taste, and sometimes erosion of the mouth’s soft tissues. Chlorhexidine mouthwashes are recommended to be used for a maximum of two weeks. Ask your dentist whether you should use a mouthwash, and which one would be appropriate to your situation.

Special care should be taken to clean thoroughly around crooked or crowded teeth, and around fillings, crowns, and dentures because plaque builds up easily in these places which might be hard to access.

Optimal oral hygiene can therefore vary widely from person to person. It is important to consult your dentist or dental hygienist about which are the best techniques in your case and to ask them for instructions.

There are two main tooth-brushing techniques. The Bass tooth-brushing technique is the most commonly recommended technique both for people with healthy gums and with periodontitis. The Stillman technique is often recommended for patients with gingival recessions.

Watch these videos on how to perform tooth cleaning at home:

1. The Stillman brushing technique

2. The Bass brushing technique

3. Interdental brushing

If your cleaning technique is poor, deposits of plaque remain on the teeth and will become “mineralised”, turning into hard deposits known as calculus or tartar, which cannot be removed by a toothbrush. But your dentist or periodontist (a dentist who specialises in periodontal health) can identify these deposits during a regular check-up and remove them as part of professional cleaning. Once the tartar is removed, the teeth are polished (using special cups and pastes) to create a smooth surface that is less likely to accumulate plaque.

Ask your dentist for a basic periodontal examination as part of your regular dental check-up.

Addressing risk factors can also help prevent the onset of periodontitis. So, giving up smoking, avoiding or reducing stress, eating a healthy diet, and exercising can all play a role in supporting good oral hygiene in preventing periodontitis

There are several stages involved in diagnosing periodontitis.

1. Clinical examination

A clinical examination in the dental practice is the only way to properly assess the condition of the gums and the tooth-supporting structures. 

In an initial check-up, the dentist or hygienist will perform a basic periodontal examination that takes only a few minutes. This examination quickly determines if gingivitis or periodontitis is present.

The dentist or dental hygienist will use a special probe (called a periodontal probe) and the depth of penetration at the gum line is measured gently and precisely at various sites in the mouth. The probe measures the distance between the gum line and the bottom of the “pocket”. At healthy sites, the probing depth is 3mm or less, but where periodontitis is present, the depth is 4mm or more.

After this short examination, further tests are carried out only if there is evidence of periodontitis – i.e. damage to the tooth-supporting structures.

In addition, in what is termed a periodontal chart, the height of the jawbone (attachment level) is recorded precisely. A periodontal chart is indispensable for the correct diagnosis of periodontitis and for planning subsequent treatment.

2. X-rays

The diagnosis of periodontitis can be confirmed only by carrying out X-rays. The selection of the X-rays needed to diagnose periodontitis is made after the clinical examination. 

In the simplest cases, only two images (so-called “bite-wing” images) are needed, but more extensive cases may require up to 14 additional X-rays and/or a panoramic X-ray of the whole mouth. These X-ray images show the jawbone surrounding the tooth and make it possible to estimate the severity of bone loss.

In each X-ray made at the dental practice, teeth must be checked for caries as well as for periodontitis.

3. Microbiological tests

Microbiological tests examine the composition of the dental plaque for specific harmful bacteria:

• Prevotella intermedia
• Porphyromonas gingivalis
• Agregatibacter actinomycetemcomitans
• Treponema denticola

The results of these tests can provide information that will enable the dentist or periodontist to provide the appropriate care and avoid unnecessary treatment.

4. Classifying the disease

There is an internationally recognised system for classifying cases of gingivitis and periodontitis.

Cases of periodontitis are classified according to four stages and three grades. The stages describe the severity and extent of the disease, while the grades describe the likely rate of progression.

By classifying cases of periodontitis in this way, dentists and periodontists can provide the appropriate form of treatment for each individual patient.

With careful professional assessment and treatment, it is usually possible to completely halt the progress of periodontitis. The key to success is eliminating the bacterial plaque that triggers the disease process and establishing excellent oral-hygiene practices. There are six stages in the successful treatment of periodontitis:

1. 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 thereby reduce the level of inflammation. Your dentist will first explain the causes of your periodontitis and give you clear instructions on how to keep your teeth and gums clean. You will be given advice on how to use different tools and techniques: for example, the most appropriate tooth-brushing technique and the correct use of interdental brushes, dental floss, and antiseptic mouthwashes.
2. Professional cleaning 
   All bacterial deposits (plaque and tartar) are removed from accessible areas of the teeth, and the teeth are then polished and treated with fluoride. If necessary, the dentist will also remove all bacterial deposits and tartar from the root surfaces and gum pockets. 
3. Antibiotic therapy
   In some cases, antibiotics are prescribed to deal with active or persistent gum infections that have not responded to oral-hygiene measures.
4. Reassessment
   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 greater than 3mm are still present, further treatment options may be suggested, including corrective surgical therapy.
5. Corrective surgical therapy
   Sometimes, a surgical procedure is carried out to remove plaque bacteria and deposits within periodontal pockets and on the root surfaces at the furcations (where the roots diverge). These areas are inaccessible to brushes and floss, so inflammation will stay there as long as bacteria are allowed to colonise them. Under local anaesthesia, the gum is raised and the root surfaces are cleaned to ensure that all bacteria are removed. It is sometimes possible to treat bone loss at the same time using a special regenerative treatment. At the end of the procedure, the gums are stitched back into place around the teeth. Stitches are usually removed between one and two weeks after surgery. It has also been shown that regenerative periodontal surgery – which aims to reconstruct lost bone around the teeth – improves the prognosis of the teeth, prolonging their longevity and making them maintainable 
6. Aftercare – supportive periodontal therapy
   The long-term success of periodontal treatment depends on two factors: the patient’s own oral hygiene and regular care from their dentist or periodontist. 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 and has not returned. 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 periodontitis does not return and cause further destruction of the gums and the bone and ligament that support the teeth. If there are signs of continuing disease, your dentist will be able to treat it at an early stage. You will also be given advice on how to change your oral-hygiene practices to tackle the inflammation.

Successful periodontal treatment requires your full co-operation in daily oral-hygiene practices and attendance at regular follow-up appointments.

Periodontology is the study of the specialised system of hard and soft tissues that support your teeth and keep them in their place in the jaw. This apparatus, known as the periodontium, has some very important functions: 

• It securely attaches the teeth to the jaws.
• It acts as a shock absorber during biting and chewing, and so helps to prevent damage to the teeth. 
• It maintains the teeth in a stable position within the jaws so that that they work together efficiently and comfortably during chewing.

The periodontium is made up of several individual structures that work together:

• The tooth socket: the bony pouch in the jawbone in which the tooth is positioned. 
• The cementum: a layer that covers the roots of the teeth.
• The periodontal ligament: a complex arrangement of tiny fibres, between the root cementum and the tooth socket, which holds the tooth in place almost like a sling.

Because the different parts of the periodontium are made from living tissues, they can adapt to changes in our mouths over time, making the tiny changes in shape and thickness that keep the position of the teeth stable.

In many ways, the mouth acts as a mirror of the general condition of our bodies. Our periodontal status can often tell us more than simply what is happening locally in our gums. Although periodontitis is always triggered by the accumulation of plaque on the teeth, diseases affecting the rest of the body – known as systemic diseases – can weaken the supporting structures of the teeth.

Also, some serious disorders are known to show themselves in the mouth before they are evident in any other part of the body. Sometimes a trained periodontist is the first person to detect the signs of a general disease, such as diabetes or blood disorders, when examining a patient’s mouth. 

Periodontists are dental practitioners who specialise in the prevention and treatment of diseases of the tooth-supporting tissues – the periodontium. Although all dentists receive training in the diagnosis and treatment of mild to moderate periodontal disease, severe or complex cases are usually referred to a periodontist, who will have undertaken additional training and acquired special expertise in the area.

Within the field of periodontology, there is also a range of different specialist procedures that focus on specific types of treatment. The treatments a periodontist provides include: non-surgical periodontal therapy, regenerative periodontal therapy, soft-tissue grafting and recession coverage, pre-prosthetic surgery, and bone reconstruction with implant placement or therapy.

Click here for more information on training to be a periodontist.

There are well-established links between periodontitis and several other diseases that can have serious consequences for general health.

Diabetes

There is a two-way relationship between periodontitis and type-2 diabetes: people with periodontitis have a higher risk of diabetes and patients with diabetes are three times more likely to develop periodontal disease.

There are higher levels of insulin resistance in people with periodontitis and controlling diabetes is more complicated when a patient also has periodontitis.

People who have both diabetes and periodontitis are at greater risk of suffering some severe medical complications – including cardiovascular disease, chronic kidney disease, and retinopathy – than people who have diabetes alone.

The treatment of one disease has been shown to have a positive effect on the treatment of the other. For instance, periodontal treatment in people with diabetes results in a significant reduction in blood-sugar – glycated haemoglobin (HbA1c) – levels.

It is important that people with diabetes are examined by a dentist to see if they have periodontitis and patients with periodontitis should be tested for diabetes by their doctor. 

For more information: EFP Perio & Diabetes campaign:

• Recommendations for patients and the public
• What you should know, what you should do
• Perio and Diabetes: FAQs
• Infographic: People with periodontitis are likely to develop diabetes mellitus – and vice versa LINK
• Infographic: Periodontal treatment for people with diabetes
• Video: Perio and Diabetes

Cardiovascular disease

Periodontitis is associated with several forms of cardiovascular diseases (CVD) and may be a preventable risk factor for suffering these diseases.

Gum disease is a chronic condition that may make it harder to prevent CVD and it may even aggravate CVD in patients who already have the disease.

There is evidence that periodontal treatment and correct oral hygiene helps in the prevention of CVD. For instance, patients who brush their teeth twice a day and have a good oral-health routine may have less risk of acute CVD events.

Periodontal treatment in CVD patients is safe, although in some cases – where patients receive anti-coagulant or anti-platelet therapy – safe haemostatic measures need to be taken.

Problems in pregnancy

During pregnancy, increased hormonal levels can affect the way that the body reacts to dental plaque and this can lead to swollen and bleeding gums (gingivitis) and to the more serious form of gum disease known as periodontitis.

Associations between gum disease and adverse pregnancy outcomes have been demonstrated: a pregnant woman with poor gum health runs a greater risk of suffering from pre-eclampsia, of giving birth prematurely, and of giving birth to an underweight child.

Maintaining oral health and gum health during pregnancy is crucial both for pregnant women themselves and for their unborn children.

For more information: EFP Oral Health & Pregnancy campaign

• Guidelines for women on oral health and pregnancy
• Key messages for women on oral health and pregnancy
• Oral health and pregnancy: FAQs
• Infographics on oral health and pregnancy:
  • Women’s oral health during pregnancy
  • Treating periodontal disease during pregnancy
  • Gum disease: what it is, how it evolves
• Videos on oral health and pregnancy

Other diseases

Periodontitis has been linked with more than fifty diseases and conditions, including chronic kidney disease, Alzheimer’s Disease, rheumatoid arthritis, and certain types of cancer.

For more information: EFP Manifesto: Perio & General Health