By James T. Ubertalli, DMD, Private Practice, Hingham, MA
(See also Introduction to Periodontal Diseases.)
Periodontitis is a severe form of gingivitis in which the inflammation of the gums extends to the supporting structures of the tooth.
- Plaque and tartar build up between the teeth and gums and then spread to the bone under the teeth.
- The gums swell and bleed, the breath smells bad, and teeth become loose.
- Doctors take x-rays and measure the depth of pockets in the gums to determine how severe periodontitis is.
- Repeated professional cleanings and sometimes dental surgery and antibiotics are needed.
Periodontitis occurs in people who are susceptible to a more serious infection of periodontal tissue (tissue surrounding the teeth) than occurs in simple gingivitis. Many diseases and disorders, including diabetes(especially type 1), Down syndrome, Crohn disease, leukopenia, and AIDS, can predispose a person to periodontitis. In people with AIDS, periodontitis progresses quickly. Smoking, vitamin C deficiency (scurvy), and emotional distress also are risk factors for periodontitis.
Periodontitis can affect people of any age, including young children. Some people have severe gingivitis for many years without developing periodontitis. Others may develop periodontitis, especially at early ages (20 to 30 years old), without first having significant gingivitis.
Periodontitis is one of the main causes of tooth loss in adults and is the main cause of tooth loss in older people. Infection destroys the bone that holds the teeth in place. The erosion weakens the attachments and loosens the teeth. An affected tooth may eventually fall out or need to be pulled (extracted).
Most periodontitis is the result of inflammation of the gums (gingivitis) and a long-term accumulation of plaque (a filmlike substance made up primarily of bacteria) and tartar (hardened plaque) on the teeth and the gums. Pockets form between the teeth and gums and extend downward between the root of the tooth and the underlying bone. These pockets collect plaque in an oxygen-poor environment, which promotes, in people with certain immune system susceptibilities, the growth of aggressive forms of bacteria. The plaque and bacteria cause chronic inflammation that damages the tissue and bone that hold teeth in place. If the disease continues, eventually so much bone is lost that the tooth may become painfully loose and the gums recede. Tooth loss typically starts in a person’s 40s.
The rate at which periodontitis develops differs considerably, even among people with similar amounts of tartar. Such differences occur because each person’s plaque contains different types and numbers of bacteria and because periodontitis results from the person’s unique immune system response to bacteria in the plaque. Periodontitis may cause bursts of destructive activity that lasts for months followed by periods when the disease apparently causes no further damage.
The early symptoms of periodontitis are tender, swollen, bleeding, and red gums and bad breath (halitosis). As more and more bone is lost, the teeth loosen and shift position, and chewing becomes painful. Frequently, the front teeth tilt outward. Periodontitis usually does not cause pain unless an infection, such as a collection of pus (abscess) forms in a pocket, the teeth loosen enough to move while chewing, or the person has periodontitis caused by HIV.
- A dentist’s evaluation
- Sometimes x-rays
To diagnose periodontitis, dentists inspect the teeth and measure the depth of the pockets in the gums with a thin probe. X-rays are taken to see how much bone has been lost.
- Treatment of risk factors
- Professional cleanings
- Sometimes surgery and tooth removal
- Sometimes antibiotics
People who have risk factors, such as poor oral hygiene, diabetes, and smoking, should receive treatment for these risk factors. Treatment of risk factors increases the success of the dentist’s treatments of periodontitis.
Unlike gingivitis, which usually disappears with good oral hygiene (daily brushing and flossing), periodontitis requires repeat professional care. People who have good oral hygiene can clean only 2 to 3 millimeters (1/12 inch) below the gum line. However, dentists can clean pockets up to 6 to 7 millimeters (¼ inch) deep using scaling and root planing techniques, which thoroughly remove plaque and tartar and the diseased root surface.
For pockets 5 millimeters (1/5 inch) deep or more, surgery is often required. Dentists or periodontists may access the tooth below the gumline by surgically opening a flap of gum tissue (periodontal flap surgery). They thoroughly clean the teeth and correct bone defects (sometimes by bone grafting) under the flap and then sew the flap back in place. Dentists or periodontists may also remove part of the infected and separated gum (a gingivectomy) so that the rest of the gum can reattach tightly to the teeth and people can then remove the plaque at home. Sometimes teeth are removed (extracted). If the mouth is sore after surgery, a chlorhexidine mouth rinse used for 1 minute twice a day may be temporarily substituted for brushing and flossing.
Dentists may prescribe antibiotics (such as amoxicillin or metronidazole), especially if a collection of pus (abscess) has developed. Dentists may also insert materials (filaments or gels) that contain antibiotics into deep gum pockets, so that high concentrations of the drug can reach the diseased area. Periodontal abscesses cause a burst of bone destruction, but immediate treatment with surgery and antibiotics may allow much of the damaged bone to quickly grow back.