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Periodontitis

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Ismail Munir

Overview

Periodontitis is essentially the chronic inflammation of the periodontium that includes four constituents: cementum, periodontal ligament (PDL), alveolar bone, and gingival tissue. If it progresses, the disease can lead to the loss of PDL and breakdown of the alveolar bone which in turn causes tooth destruction. There are over 800 species of bacteria that can invade your oral hygiene and reside on the formed plaque. Most common disease-causing organisms include anaerobes such as Treponema denticola and Porphyromonas gingivalis. Moreover, the interaction of the bacterial exposure with your immune response to it, is what ultimately leads to periodontitis<a href="#accordion">[1][2]</a>.

&nbsp;

Periodontitis is a subtype of periodontal disease which is divided into two types, namely:

&nbsp;

<ol>
	<li>&nbsp;Gingivitis: A nondestructive and reversible gingival inflammation which can be influenced by any nonspecific bacteria.</li>
	<li>&nbsp;Periodontitis: It refers to the irreversible destructive inflammation of teeth due to the breakdown of their supporting tissues. This takes place because of exposure to some periodontal pathogens.</li>
</ol>

&nbsp;

What happens in periodontitis is that your gum and bone are retracted from your teeth, creating pockets at the structural base of your tooth and causing it to become extremely exposed. After which, foreign bodies collect in the gap between the gums and teeth and ultimately, lead to an infection. Your immune system is then compelled to attack the bacterial invasion as the plaque makes its way down the gum line and into these newly formed pockets. The result of this process is an immune reaction, which leads to the release of toxins and inflammation causing the bone and the connective tissues to disintegrate slowly<a href="#accordion">[6]</a>.&nbsp;

According to multiple surveys, periodontal diseases were regarded as one of the most common inflammatory diseases found in adults. In 2010, 3.9 billion people around the globe were seen to have periodontal disease. The prevalence rate of mild periodontitis was reported to be 35% and moderate to severe periodontitis to be 11%. In fact, it is becoming such a concern that the US Centers for Disease Control and Prevention labeled periodontal disease as a global pandemic responsible for disability, speech impairment, low self-esteem, and reduced quality of life<a href="#accordion">[3]</a>.&nbsp;&nbsp;

Studies carried out by the National Oral Health Surveys focused on periodontal health in the United States of America and found that 82% of adolescents had gingivitis. Furthermore, a study done in the United Kingdom revealed that residents of the country get exposed to moderately severe diseases with the most common risk factors being the buildup of plaque and calculus<a href="#accordion">[4]</a>. On that note, it is worth mentioning another study was carried out which proved that the ratio of adolescents who have calculus was somewhere around 35% to 70% in developing countries, whereas in developed countries, it was seen to be 4% to 34%<a href="#accordion">[5]</a>. Even in Pakistan, studies by the National Oral Health Survey along with a few others concluded that the prevalence of periodontitis was up to 98%, whereas advanced periodontitis had a prevalence of 31%<a href="#accordion">[4]</a>.&nbsp;

<div>&nbsp;</div>

Signs And Symptoms

Physiologically, your gums should be firm in consistency and the colour must be pale pink. However, if you have periodontitis, the scenario can change as the disease causes<a href="#accordion">[8]</a>:

&nbsp;

<ul>
	<li>Swollen gums</li>
	<li>Purple or red gums</li>
	<li>Bad breath, also known as halitosis</li>
	<li>Pus settled between your gums and teeth</li>
	<li>Pain while you chew</li>
	<li>Receding gums (gums that pull away)</li>
	<li>Loosened teeth in the socket&nbsp;</li>
</ul>

<div>&nbsp;</div>

Based on pathophysiology, periodontitis can be grouped into three different forms, namely:

&nbsp;

<ol>
	<li>Periodontitis</li>
	<li>Necrotising Periodontitis: In this exclusive variant, the patient will present with a history of pain, and the periodontist will be able to appreciate ulceration of the gingival margin, and/or deposits of fibrin at sites where gingival papillae have been decapitated. The disease may also include exposure to the marginal alveolar bone.</li>
	<li>Periodontitis As A&nbsp;Direct Manifestation Of&nbsp;Systemic Diseases: In periodontitis as a direct manifestation of systemic disease, a primary systemic disease co-exists with periodontitis and the management plan should be initiated according to the recommendations laid down by the International Statistical Classification of Diseases and Related Health Problems (ICD) codes<a href="#accordion">[11]</a>.&nbsp;</li>
</ol>

&nbsp;

Furthermore, periodontitis can be staged and graded based on its severity &amp; complexity and the disease progression risk respectively. The severity in the staging is scrutinized based on the Clinical Attachment Loss (CAL) which is calculated by a circumferential assessment of the erupted dentition whereas the complexity is based upon the extensiveness of the management plan needed and the prognosis of the disease. On this basis, the following stages are deduced:

&nbsp;

<ul>
	<li>Stage I: Initial Periodontitis</li>
	<li>Stage II: Moderate Periodontitis</li>
	<li>Stage III: Severe periodontitis with potential for additional tooth loss</li>
	<li>Stage IV: Advanced periodontitis with extensive tooth loss and potential for loss of dentition</li>
</ul>

&nbsp;

As mentioned earlier, grading involves the future risk approximation and also the response of the disease to the management plan. Hence, three grades are defined on this basis:

&nbsp;

<ul>
	<li>&nbsp;Grade A: Slow rate of progression</li>
	<li>&nbsp;Grade B: Moderate rate of progression</li>
	<li>&nbsp;Grade C: Rapid rate of progression</li>
</ul>

<div>&nbsp;</div>

Causes

The development of periodontitis is initiated by plaque formation which is a sticky layer in the oral cavity with bacteria as its major constituent. If plaque is not resolved in time, it can cause periodontitis. It can exist in various sites by the following mechanisms<a href="#accordion">[7]</a>:

&nbsp;

<ul>
	<li>Plaque Formation On The Teeth: If you are habitual in consuming starch and sugars in great quantity, it increases the chances of the residing bacteria coming in contact with it. Brushing your teeth twice a day and flossing once a day is an efficient way to fight against plaque formed on the teeth. However, it should be kept in mind that plaque recurs sooner rather than later. Hence, an efficient oral hygiene routine is necessary.</li>
</ul>

&nbsp;

<ul>
	<li>Plaque Formation Under The Gum Line: If plaque is allowed to stay on your teeth, it can transform into a calculus called tartar. Tartar is even harder to get rid of and is loaded with bacteria. Tartar cannot be removed at home and a professional dental cleaning is needed to get rid of it.</li>
</ul>

&nbsp;

<ul>
	<li>Plaque Which Leads To Gingivitis:&nbsp; Although it is the mildest form of gum disease, gingivitis can also be caused by plaque because of the irritation and inflammation of the gum tissue around the base of your teeth. However, gingivitis can be treated with efficient dental treatment and satisfactory oral care.</li>
</ul>

&nbsp;

<ul>
	<li>Pre-Existing Inflammation Of The Gums:&nbsp; If a pre-existing inflammation of the gums exists, it can create pockets between your gums and teeth and in turn fill them with plaque, tartar, and bacteria. With passing time, these newly formed pockets become deeper, increasing the severity of the disease. If left untreated, these deeply seeping infections can cause tissue loss and bone disintegration.</li>
</ul>

<div>&nbsp;</div>

The best screening test for periodontitis or any other dental disease is pretty simple: regular dental checkups. Two visits per year are usually advised, i.e. one every six months. The checkup should be scheduled despite any problems since the entire purpose of these checkups is to prevent any issues from developing.

A relatively new screening method has also been introduced which involves checking the salivary levels of haemoglobin and lactate dehydrogenase. Studies show that it yields accurate results while being less invasive and uncomfortable. Higher Haemoglobin levels in the saliva and have been linked with gingival inflammation. Whereas, lactate dehydrogenase is a specific indicator of oral mucosal lesions with tissue breakdown. However, more studies are needed prior to the mainstream use of salivary biomarkers

Another way to screen for periodontitis is The Community Periodontal Index (CPI). It was originally made by the World Health Organization (WHO) to measure community oral health. However, the issue with CPI is that it requires probing, which ultimately puts any patient with preexisting periodontitis at risk of bacteremia (bacteria in the bloodstream)<a href="#accordion">[9]</a>.&nbsp;

<div>&nbsp;</div>

Diagnosis

Because of the immense pain and the risk of complications that follow the onset of periodontitis, it becomes crucial to diagnose the infection as soon as possible. Everything starts with reaching out to your dentist and scheduling an appointment. After which your periodontist may<a href="#accordion">[7]</a>:&nbsp;

&nbsp;

<ul>
	<li>Measure the depth of the pocket of the groove that lies between your gums and teeth by placing a dental probe at the side of your tooth below your gum line. This can be placed at multiple sites in your mouth. In a healthy mouth, the pocket depth is somewhere around 1 to 3 mm. However, pockets that are deeper than 4 mm can signify periodontitis.</li>
	<li>Consider taking dental X-rays to ensure there is any bone loss in the areas which may have come across deeper pocket depths.</li>
</ul>

<div>&nbsp;</div>

Treatment

Treatment of periodontitis is crucial as the infection can seep into your systemic circulation and cause diseases like respiratory infections and even coronary artery disease. The healthcare practitioners that can treat periodontitis include periodontists, dentists or dental hygienists. The treatment goal is to extensively remove the disease-causing particles from the pockets and to prevent any further damage that the surrounding bone may endure. The treatment can be divided into nonsurgical and surgical types, and the procedures included in them are as follows<a href="#accordion">[7]</a>:

&nbsp;

<h5>Nonsurgical Options</h5>

Nonsurgical procedures are used for non-advanced periodontitis. The procedures are less invasive and may include:

&nbsp;

<ul>
	<li>Scaling: Scaling has the ability to remove the tartar and bacteria from the surface of your tooth and below the gums. Instruments used in this procedure can include a laser or an ultrasonic device.</li>
</ul>

&nbsp;

<ul>
	<li>Root Planning: Root planning includes smoothening the surfaces of the root, which prevents further accumulation of tartar and bacteria. Furthermore, it also eliminates any bacterial byproducts that might aid in inflammation and prolong the healing process.</li>
</ul>

&nbsp;

<ul>
	<li>Using Antibiotics: Antibiotics can be delivered via topical or oral preparations that fight the bacteria involved. Topical antibiotics include mouthwashes or gels containing antibiotics which are placed in the space between your teeth and gums or in the pockets after thorough cleaning.&nbsp;</li>
</ul>

&nbsp;

<h5>Surgical Options</h5>

Surgical options are the management of choice for advanced periodontitis. Treatment requires dental surgery, and the following are the procedures that can be performed:

&nbsp;

<ul>
	<li>Flap Surgery (Pocket Reduction Surgery): In this procedure, your periodontist will make small multiple incisions in your gum to lift back a portion of the gum. This exposes the roots and enables the periodontist to effectively do scaling and root planning. As the infection can cause bone loss, it may need recontouring (reshaping). However, after the procedure and the healing process, you will need to keep the area clean and maintain good oral hygiene.</li>
</ul>

&nbsp;

<ul>
	<li>Soft Tissue Grafts: In the advanced variant of the disease, your gum line repositions itself. Hence, some degree of stabilization is needed. This is where the soft tissue graft comes in handy and the idea behind it is to remove a small amount of tissue from the roof of your mouth, also called the palate. Also, donor tissue&nbsp; can be used to attach the extracted tissue onto the affected site. The procedure helps to reduce further gum recession and even helps to cover the exposed roots.</li>
</ul>

&nbsp;

<ul>
	<li>Bone Grafting: Bone grafting refers to a procedure that is performed when there is a loss of bone which surrounds the root of the tooth. The graft can be made up of small fragments of your bone or even synthetically made bone can be used as well. The idea behind is to prevent tooth loss by providing enough strength to hold your tooth in its place. The graft also serves as a base for the regrowth of the natural bone.</li>
</ul>

&nbsp;

<ul>
	<li>Guided Tissue Regeneration: This exclusive procedure is helpful because it allows the regrowth of bone that has been destroyed by bacteria during the disease progression. Your dentist will place a special piece of biocompatible fabric between the pre-existing bone and your tooth. The material aims to prevent diseased unwanted tissue from entering the regenerating area, hence allowing for optimized healing.</li>
</ul>

&nbsp;

<ul>
	<li>Tissue Stimulating Proteins: This involves a technique in which a specialized gel is applied to a diseased root. The gel is packed with the same proteins which are found in the enamel when it is developing. Hence, stimulating the growth of a healthy bone.</li>
</ul>

<div>&nbsp;</div>

Periodontitis cannot be allowed to progress because of its potential to cause systemic diseases including coronary artery disease. Hence, efficient intervention is of utmost importance. However, if for some reason it does progress, the following complications can become evident<a href="#accordion">[6]</a>:&nbsp;

&nbsp;

<ul>
	<li>Bad breath, also known as halitosis</li>
	<li>Loss of teeth</li>
	<li>Difficulty sleeping</li>
	<li>Periodontitis, especially during pregnancy, can increase the risk of preterm birth, low birth weight, and preeclampsia</li>
	<li>Difficulty in eating</li>
	<li>Medical conditions such as respiratory infections and <a href="https://www.merisehat.pk/disease/coronary-artery-disease" target="_blank">coronary artery disease</a></li>
</ul>

<div>&nbsp;</div>

Like in any disease, some factors can significantly increase your risk of periodontitis. Following are the risk factors that you need to bear in mind<a href="#accordion">[5][7][9]</a>:

&nbsp;

<ul>
	<li>Poor Oral Hygiene: This can lead to plaque deposition, and set a base for the inflammation to occur.</li>
</ul>

&nbsp;

<ul>
	<li>Smoking: It is one of the most important risk factors for periodontitis that need to be addressed. Studies show that a reduction in periodontal disease prevalence is directly proportional to decreased smoking rates. Other researches also prove that smokers are at thrice the risk to develop severe periodontal disease as compared to non-smokers.</li>
</ul>

&nbsp;

<ul>
	<li>Hormonal Changes: Research proves that hormonal changes in women raise the risk of them getting periodontal disease. This happens exclusively before menstruation and during ovulation due to a progesterone surge. This, in turn, blocks the repair of collagen fibers that can cause blood vessel dilatation.</li>
</ul>

&nbsp;

<ul>
	<li>Genetics: Some people are more susceptible to developing periodontitis due to their genetic predisposition.</li>
</ul>

&nbsp;

<ul>
	<li>Certain Medications: Some drugs such as phenytoin, cyclosporine, and nifedipine can induce abnormal growth of gingival tissues that can occasionally complicate the removal process of dental plaque. This has proved to aggravate the pre-existing disease.</li>
</ul>

&nbsp;

<ul>
	<li>Diabetes:&nbsp;Studies show that gingival crevicular fluids and saliva have higher concentrations of inflammatory mediators (which include various types of cytokines) in diabetic patients diagnosed with periodontitis in comparison to non-diabetic people with periodontal disease.</li>
</ul>

&nbsp;

<ul>
	<li>Vitamin C And D Deficiency: Both of these vitamins are vital to ensure good gum health and bone strength.&nbsp;&nbsp;</li>
</ul>

<div>&nbsp;</div>

To prevent the disease from happening, the most efficient way is to take care of your oral hygiene which is possible to do at home. According to the American Dental Association (ADA), the following guidelines have been advised<a href="#accordion">[6]</a>:&nbsp;

&nbsp;

<ul>
	<li>Brushing your teeth for 2 minutes twice a day. Using a soft bristle is advised, regardless if it&rsquo;s a manual or an electric device.</li>
	<li>Using fluoride toothpaste as it helps rebuild the weakened tooth enamel.</li>
	<li>Be vigilant that you are brushing all surfaces.</li>
	<li>Replace your toothbrush after every 3 to 4 months.</li>
</ul>

<div>&nbsp;</div>

Gut microbiota is the bacteria that live in your gut with a balance of good and bad so that it can have an overall better impact. However, the latest studies prove that there is an association between periodontitis and disturbed gut microbiota. We drink almost 1-1.5 liters of saliva a day, but the difference in patients with periodontitis is that their saliva is loaded with infection-causing bacteria. It was also revealed that the salivary microbiota can live in the intestine for up to 24 hours weakening the intestinal immune response. The study has opened new avenues for scientists to develop even better intervention techniques as the pathogenesis has become clearer because of this newly found association<a href="#accordion">[10]</a>.&nbsp; &nbsp;

&nbsp;

Key Points

<ul>
	<li>Periodontitis is essentially the chronic inflammation of the periodontium that includes four constituents namely cementum, periodontal ligament (PDL), alveolar bone and gingival tissue.</li>
	<li>The interaction of the bacterial exposure with your immune system&rsquo;s response is what ultimately leads to periodontitis.</li>
	<li>In periodontitis your gum and bone are retracted from your teeth, creating pockets at the structural base of your tooth causing it to become extremely exposed.</li>
	<li>Your immune system is then compelled to attack the bacterial invasion as the plaque makes its way down the gum line and into these newly formed pockets.</li>
	<li>Release of toxins and inflammation causes the bone and the connective tissues to disintegrate slowly.</li>
	<li>In 2010, 3.9 billion people around the globe were seen to have periodontal disease.</li>
	<li>The prevalence rate of mild periodontitis was reported to be 35% and moderate to severe periodontitis to be 11%.</li>
	<li>US Centers for Disease Control and Prevention labelled periodontal disease as a global pandemic responsible for disability, speech impairment, low self-esteem, and reduced quality of life.</li>
	<li>A study done in the United Kingdom revealed that residents of the country get exposed to the moderately severe disease with the most common risk factors being the buildup of plaque and calculus.</li>
	<li>In Pakistan, studies by the National Oral Health Survey along with a few others, concluded that the prevalence of periodontitis was up to 98%, whereas advanced periodontitis had a prevalence of 31%.</li>
	<li>Periodontitis can be grouped into three different forms namely Periodontitis, Necrotising periodontitis and Periodontitis as a Direct Manifestation of Systemic Diseases.</li>
	<li>Furthermore, periodontitis can be staged and graded based on its severity, complexity, and disease progression risk respectively</li>
	<li>There are stages 1 through 4 which are based on severity, and grades A through C are based on how responsive the disease is to the provided treatment.</li>
	<li>The major cause of periodontitis is the buildup of plaque at various sites such as teeth and gums. Another cause is pre-existing gingival inflammation. Symptoms of periodontitis include halitosis, receding gums, swollen pink gums and painful chewing.</li>
	<li>The best screening test for periodontitis or any other dental disease is pretty simple: regular dental checkups.</li>
	<li>Two visits per year are usually advised, i.e.&nbsp;one being every six months.</li>
	<li>A relatively new screening method has also been introduced which is to check the salivary levels of hemoglobin&nbsp;and lactate dehydrogenase.</li>
	<li>Another way to screen for periodontitis is the Community Periodontal Index (CPI). However, the disadvantage of CPI is that it requires probing, which ultimately puts any patient with preexisting periodontitis at risk of bacteremia (bacteria in the bloodstream).</li>
	<li>To diagnose periodontitis, your dentist might order dental x-rays. Or measure the depth of the pocket of the groove that lies between your gums and teeth by placing a dental probe at the side of your tooth below your gum line.</li>
	<li>The non-surgical treatment options include scaling, root planning and using antibiotics.</li>
	<li>The surgical treatment includes flap surgery (pocket reduction surgery), soft tissue grafts, bone grafting, guided tissue regeneration, and tissue-stimulating proteins.</li>
	<li>Periodontitis cannot be allowed to progress because of its potential to cause systemic diseases including coronary artery disease. However, if it does, it can cause complications like halitosis, difficulty in eating and even respiratory infections.</li>
	<li>Risk factors include smoking, hormonal changes in women, medications like nifedipine, and specific vitamin deficiencies.</li>
	<li>Prevention can be done by brushing your teeth twice a day, along with efficient flossing and mouthwash.</li>
	<li>Latest studies prove that there is an association between periodontitis and disturbed gut microbiota. Salivary microbiota can live in the intestine for up to 24 hours weakening the intestinal immune response.</li>
</ul>

[1] Torabi S, Soni A. Histology, Periodontium. [Updated 2022 Mar 26]. In: StatPearls. Treasure Island (FL): StatPearls Publishing.

[2] Saini R, Marawar PP, Shete S, Saini S. Periodontitis, a true infection. J Glob Infect Dis. 2009;1(2):149-150.

[3] Bui FQ, Almeida-da-Silva CL, Huynh B, et al. Association between periodontal pathogens and systemic disease. Biomedical Journal. 2019;42(1):27-35.

[4] Bokhari SA, Suhail AM, Malik AR, Imran MF. Periodontal disease status and associated risk factors in patients attending a Dental Teaching Hospital in Rawalpindi, Pakistan. J Indian Soc Periodontol. 2015;19(6):678-682.

[5] Nazir MA. Prevalence of periodontal disease, its association with systemic diseases and prevention. Int J Health Sci (Qassim). 2017;11(2):72-80.

[6] Periodontitis: Treatment, home remedies, and symptoms. Medical News Today.

[7] Periodontitis. Mayo Clinic

[8] Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontol 2000. 2013;62(1):59-94.

[9] Nomura, Yoshiaki et al. “A new screening method for periodontitis: an alternative to the community periodontal index.” BMC oral health vol. 16,1 64. 2 Jun. 2016

[10] Bao J, Li L, Zhang Y, et al. Periodontitis may induce gut microbiota dysbiosis via salivary microbiota. International Journal of Oral Science. 2022;14(1).