What is periodontitis ? Periodontal disease, commonly called gum disease, is a chronic and progressive inflammatory condition affecting the tissues surrounding and supporting the teeth (gingiva, periodontal ligaments and alveolar jawbone).
In the early stage the oral pathology is called gingivitis, gums get swollen, redness appears and the soft tissue may easily bleed while brushing and flossing. The more advanced and severe form of periodontal disease is known as periodontitis.
In this advanced form, gums are not attached to the teeth surface as they used to be, deep periodontal pockets forms, alveolar bone starts to reabsorb and dental elements becomes loose and fall even if they are healthy .
Among periodontitis causes, poor oral hygiene is the most recurring. Bacteria contained in the dental plaque inflame the gingival tissue around the teeth. Periodontal disease appears with its early symptoms: swelling, gum bleeding, redness and sore.
Systemic conditions such as HIV/AIDS, diabetes, osteoporosis and obesity, may also be considerated periodontal disease causes.
Most common periodontitis risk factors include: smoking, genetic predisposition, vitamins deficiency, and certain medications.
As reported by The American Academy of Periodontology in this article 47.2% of American adults (more or less 64.7 million people), suffer because of mild, moderate or advanced periodontitis, the more advanced stage of periodontal disease that leads to teeth loss
In adults, 65 years old and older, things get even worse in fact the percentage dramatically increases reaching 70.1%.
Periodontitis diagnosis is made by a periodontist through a full periodontal examination. Visual inspection of gingival tells the clinician how healthy your gums are. X-rays exam allows the doctor to evaluate the bone absorption grade.
Last but not least periodontal probing and charting give the periodontist the exact gum pockets depths around a tooth. After all these diagnosis procedures the professional can easily evaluate the state of health of the teeth supporting structures (periodontium).
Periodontitis treatment requires a full periodontal examination first and the professional teeth cleaning by the dentist or dental hygienist . Scaling and root planing have the scope to remove infected tissue from the tooth surface and from gum pockets. In the most severe cases, in order to complete the periodontal therapy, antibiotics and oral surgery represent the last resort to get rid of periodontitis.
3 periodontal disease stages and pathology progression
As shown by the image above, healthy gums are light pink and perfectly attached to the tooth surface. The gingival sulcus depth (or gingival groove) is about 1 to 3 mm. there is no dental plaque and no calculus (tartar) around teeth or below the gum line. Gums doesn’t bleed and do not hurt.
Periodontal disease stage 1: mild periodontitis definition
At its early stage, parodontopathy is commonly known as gingivitis because the inflammation affects the gingival tissue only that becomes red. Gums start to pull away from the tooth leaving a more deep gingival sulcus (3 to 5 mm).
Gum pockets (the space between the tooth cementum and the gingiva) form and get deeper day by day if leaved untreated.
When you brush and floss your teeth you may also see a few drops of blood mixed with the toothpaste and the water.
Due to the dental plaque and tartar accumulation, moderate bad breath or halitosis appears.
In this first periodontitis stage, the infection do not affect the alveolar bone yet so teeth are still stable and can support the chew pressure. Mild periodontitis is a reversible pathology meaning that the dentist can easily heal your gums.
Mild periodontitis treatment involves professional teeth and gums cleaning by the dentist or the dental hygienist and an adequate daily oral care at home. Antiseptic mouthwashes such as oral rinses with chlorhexidine gluconate are effective to keep bacteria and periodontal inflammation under control.
Periodontal disease stage 2: moderate periodontitis definition
The second stage of the parodontopathy adds more severe periodontitis symptoms to those listed above. Periodontal pockets are more deep, 5 to 7 mm. Gum recession leaves the tooth root uncovered and teeth appear longer.
Periodontal Inflammation attacks the supporting bone and 30% to 50% of jawbone is lost (clinical attachment loss).
Because of the initial bone resorption, teeth start to become slightly loose. The bad breath increases and you will feel an unpleasant taste in your mouth.
The dentist only can perform the treatment of moderate periodontitis. The clinician has to remove the necrotic tissue caused by the bacteria infection first. The inflamed area needs several appointments to get back to the normal condition as well as scrupulous daily oral hygiene at home.
Periodontal disease stage 3: advanced periodontitis definition
The third stage of periodontitis is the last one before the tooth loss, the most aggressive and the most difficult to treat.
Usually dentists say that this periodontal disease type is not-reversible meaning that it is possible to decrease the gingival inflammation but not to remove it completely.
Aggressive periodontitis symptoms include periodontal pockets deeper than 7 mm. The Infection reaches the tip of the tooth root (apex). Bad breath becomes chronic and the bone loss is around 50% (clinical attachment loss). At this point teeth do not have adequate bone support and are close to fall spontaneously.
Aggressive periodontitis treatment may require laser therapy in order to kill as many bacteria as possible. Gum surgery Is the last resort to try to recover or replace the infected tissue.
Early signs and periodontitis symptoms
In the early stages, periodontitis has very few symptoms that is why it is called “the silent disease”.
Since gingival pain is not the most common sign, inflammation may progress significantly before patients look for dentist help.
Early signs may include:
- Modest gum bleeding after brushing and / or flossing;
- Change in the gums color from pink to red (gingival redness) because of the periodontal inflammation;
- Slight gum swelling;
- Moderate halitosis (bed breath);
- Change in taste perception of foods.
Advanced periodontitis symptoms:
- Gum bleeding is more frequent and it happens even without a trigger cause (spontaneously);
- Important gum recession that leaves uncovered the cementum of the tooth, which is more sensitive to plaque accumulation and to the bacteria action. Because of the gum recession, teeth may appear longer than usual;
- Deep gum pockets between the teeth surface and gums;
- Persistent bad breath and metallic taste in the mouth;
- Loose teeth: this is the result of the progressive supporting bone destruction caused by the bacterial inflammation;
- vertical bone loss;
- bite change (the relationship between the upper and lower teeth when they come together closing the mouth or chewing food);
- partial of full dentures do not fit your gums perfectly as they used to do;
- swollen face;
- ear and neck pain;
- jaw pain;
- swollen neck lymph nodes.
The gum abscess is another common periodontal disease symptom. It happens because bacteria within gum pockets create pus while necrotising the surrounding tissue. As much the pus accumulates as bigger the abscess becomes and a boil may appear in your mouth. At some point, the abscess needs to decrease the pressure within the boil therefore it drains by itself discharging the serum directly in the oral cavity.
Periodontitis natural treatment and home remedies
Nutrition plays a fundamental role in keeping our whole organism in good condition and this also applies to the mouth. A balanced diet, rich in vitamins and minerals as well as low in sugar, helps to keep oral cavity and gums pathologies away.
Alongside conventional drugs therapy, there are effective natural remedies that can relieve the symptoms of periodontal disease and promote healing. Among them we can find:
Coenzyme Q10 for periodontal disease
From its discovery (1957) to date, researches and clinical studies have shown that Coenzyme Q10 plays a fundamental role in the treatment of diseases affecting human tissues such as gingivitis and parodontopathy.
Our liver is able to synthesize this coenzyme from substances such as lipids and proteins.
As we age, this ability decreases therefore it is important to take dietary supplements or choose food containing it. Red meat, fish, seasonal fruits (apples, strawberries and oranges) are all rich in Coenzyme Q10 (CoQ10).
The main coenzyme Q10 features are:
- It strengthens the immune system and makes it stronger in fighting periodontal infection;
- It is a powerful antioxidant effective against free radicals;
- Contributes to the periodontal tissue natural replacement.
Vitamin D and calcium to treat periodontitis
Calcium and Vitamin D (also called the Sunshine Vitamin) are essential for the maintenance of our bones, maxilla and mandible included. Stronger bones can better resist to periodontal infection that cause diseases affecting the gingival tissue. In case of Vitamin D deficiency there are special supplements sold at pharmacies or herbal shops.
Aloe Vera: natural periodontal disease treatment
Aloe Vera is a topical periodontitis natural remedy. Composed of many substances including cinnamic acid, Aloe Vera is well known for its anti-inflammatory, soothing and healing action. Patients can use Aloe Vera gel directly on the inflamed gums to get immediate relief.
Propolis: periodontitis home remedy
Natural remedy with antibacterial and anti-inflammatory properties.
Tea Tree essential oil
Tea tree oil (essential oil) is the best natural remedy in case of periodontitis. A few drops of tea tree essential oil are enough to calm down the inflamed tissues around the teeth
Periodontitis causes and risk factors
Periodontitis is the inflammation of the periodontal structures that keep each tooth in place. The medical term is periodontium that is made by:
- Gingival tissue, also called gum tissue;
- Cementum: the external surface of the teeth roots,
- Alveolar bone: the sockets where, in normal condition, dental elements are kept into
- Periodontal ligaments (PDLs), are fibers made of connective tissue that physically connect the tooth root to the alveolar bone.
Now that we know which anatomic structures are involved in maintaining teeth in their position, it is more easy to understand how periodontitis leads to bone loss and teeth to fall.
The primary cause of periodontitis is the bacterial plaque. Plaque is an invisible and sticky biofilm that adheres to the gums and teeth. The plaque bacteria produce toxins that inflame gums and erode teeth enamel.
If not removed, the plaque hardens (especially below the gum line) and becomes tartar (calculus) which cannot be removed just by using the toothbrush. The tartar feeds the periodontal inflammation that slips into the gingival pockets to get to the bone. When gingivitis progresses to periodontitis, the infection causes the bone to reabsorb, teeth remain without the necessary bony support and fall.
Among periodontitis causes, microbial plaque accumulation it the primary but not the only one cause. In fact, there are several additional periodontal disease causes that may include systemic conditions and bad behaviors as described below.
Genetic susceptibility and hereditary factors
Different studies reveal that 30% of the world population inherit the genetic susceptibility to develop periodontal disease. The hereditary factors explains the reason why even people who practice good oral hygiene suffer because of gingivitis that progress to periodontitis.
Inadequate dental restorations, braces and partial dentures
Orthodontic braces increase the risk of gingivitis and chronic periodontitis because metal or plastic brackets, metal bands and arch wire offer to the plaque many hiding places. Brushing and flossing while wearing orthodontic braces is a pain.
Brackets make difficult to completely remove food debris from your teeth. The plaque left between brackets can trigger the infection that causes periodontal inflammation, bleeding and swelling. Adults and children with orthodontic braces should pay more attention to their dental hygiene.
Partial dentures, dental bridge and defective prosthetic restoration (dental crown, tooth filling) may also cause the microbial plaque retention. In case this happens, it is highly recommended to ask your dentist to fix the problem.
Bad habits: smoke and alcohol abuse
Smoking is one of the main periodontitis risk factors. In fact researches reveal that chances of developing periodontitis are much more high in smokers than in non-smokers.
Nicotine contained in the cigarettes is a vasoconstrictor, meaning that it causes the blood vessels to shrink. The main consequence of tighter blood vessels is that gingival tissue get much less oxygen and white blood cells. Now it is easy to guess the reason why inflammation can progress more easily: simply because bacteria find less opponents.
In addition, periodontitis treatment is less effective in smokers than in people who never smoked cigarettes in their life due to the poorer healing.
Malnutrition and Vitamins deficiency
Among the causes of periodontitis we should also include malnutrition that is the consequence of non-optimal living conditions, as in some less developed countries.
Vitamins deficiency happens when the diet is poor in minerals and vitamins that are necessary for our body.
Periodontitis linked to systemic conditions
Heart diseases and strokes
Periodontal inflammation and gum disease can increase the risk of heart disease and stroke. Studies and research have shown that bacteria responsible for periodontitis can enter the bloodstream and reach the heart. They trigger the inflammation and narrowing of the coronary arteries causing the heart disease.
The oral bacteria expose the patient to develop blood clots, increasing the probability of stroke.
Osteoporosis and tooth loss
The teeth loss in patients affected by osteoporosis and periodontitis is faster because osteoporosis decreases the jawbone density and parodontopathy destroys the bone itself. Teeth remain without the necessary support structure and fall.
Periodontal disease and diabetes
Periodontal infection makes more difficult to control blood sugar levels.
This happens because an infection in any part of the body increases the amount of sugar in the blood. So diabetics need a larger dose of insulin to counterbalance. Periodontal inflammation also makes blood glucose levels more difficult to control.
Stress and immunosuppressive conditions
Every day our immune defenses protect us from a wide variety of potentially dangerous bacteria.
The human body can fight dangerous bacteria and viruses thanks to the immune defenses developed during human evolution and adaptation to the environment.
However, when the body is under stress, our defenses are lowered, bacteria get the better and start their pathogenic action.
At the gums level, inflammation tends to increase due to stress, allowing bacteria to cause gingivitis that progress to periodontal disease.
Immunosuppressive conditions, e.g. HIV / AIDS and leukemia lower the immune system promoting the progression of gingival tissue inflammation to periodontitis.
Periodontitis during pregnancy
Statistical studies have confirmed that pregnant women with periodontal problems are much more likely to give birth to premature babies than women with healthy gums.
Beyond that, periodontitis during pregnancy seems to limit the growth fetal growth in the mother’s womb. The baby is more likely to be born underweight.
Periodontal disease diagnosis by the periodontist
The periodontal disease diagnosis is made by a dentist specialized in periodontics. The periodontal examination consists in two main parts: the first is the visual/mechanical assessment of the patient’s oral condition.
The clinician proceeds looking for gum pockets and, if any, it is necessary to measure their depth and record the position creating a chart. The periodontal charting is useful to check the gum disease progression or healing.
During the visual assessment, the periodontist will also look for loose or shifting teeth.
The second step of the periodontal examination is made by x-rays exam and genetic test.
X-rays exam reveals the quantity of bone loss due to the bacterial inflammation.
The periodontitis genetic test (PerioPredict® Genetic Risk Test rebranded ILUSTRA™ Inflammation Management Program) can predict periodontitis risk by evaluating the genetic susceptibility and hereditary factors.
Once the periodontist knows the whole situation of your oral health, then he or she can formulate the prognosis a proceed with the right periodontitis treatment.
How is periodontitis treatment ?
After the periodontal visit and taking x-rays, the periodontist proceeds with the first step of the parodontopathy therapy that involves the professional teeth cleaning by the dentist or dental hygienist.
Independently from periodontal disease stages, the first procedure to cure the parodontopathy requires the professional cleaning of each tooth surface (masticatory included). The clinician or the hygienist will use manual and/or ultrasonic tools to remove as much plaque as possible to decrease the infection source.
Scaling or curettage and root planning
When the dentist detects hardened plaque below the gumline, then a specific dental cleaning tools called curettes or scalers are required to remove tartar hard deposit from the tooth root.
The root planning it is the procedure that the periodontist uses to smooth the roots of the teeth and remove all the necrotic gingival tissues and the periodontal infection.
After plaque and tartar deposits removing, the dentist will use a special paste and gummy cups to polish your teeth roots and crowns. In fact a smooth surface can limit or delay the microbial biofilm where bacterial infection starts.
After cleaning the pockets, it is necessary to keep them clean and disinfected. For this purpose the dentist places very small gelatinous flaps containing an antibiotic called doxycycline which is released slowly.
In addition to local antibiotics, your periodontist may prescribe you a turn of systemic antibiotics e.g. Amoxicillin (oral tablet or capsule) to fight the chronic periodontitis which more difficult to cure due to the infection resistance.
In case non-surgical therapy does not allow to reach the expected healing result, periodontal surgery represents the last chance to stop the progression of the inflammation and the loss of the bone. In addition, the periodontal surgery main scope is to regenerate lost bone where possible.
There are different periodontal surgery procedures:
- Open flap debridement
- Gum Grafts
- Bone grafting
Periodontitis laser therapy
Periodontitis laser therapy is a complementary and relatively new dental procedure to cure periodontal disease without surgery. Laser can easily target the infected gingival tissue and burn it without causing any damage to the surrounding natural structures.
In addition, the laser can promote the tissue and bone regeneration as well as stop the gum bleeding almost immediately since the first treatment.
Periodontal disease laser therapy is less invasive than oral surgery and the recovery is faster.
Maintenance and regular follow-ups
Periodontal disease is a difficult pathology to eradicate therefore the best result coming with dentist treatments and the daily oral hygiene maintenance at home by the patient.
Regular follow-ups allow the doctor to keep under control the inflammation and evaluate the healing process. Regular follow-ups also allow your dentist to discover in advance new inflammation sites and treat them in their early stage.
Is periodontal disease contagious ?
The previous question as well as the following “Can periodontitis be passed on by kissing or sharing a toothbrush ?” are the more asked by patients.
You should re member that parodontopathy, independently by the stages, is a inflammatory response to bacteria living in the microbial plaque accumulated below the gumline. In other words, the inflammation is the sign our body is trying to fight the infection.
That being said, it is possible to spread bacteria causing the periodontitis infection through saliva.
In case of you know one or more your family members suffer because of parodontopathy, it is always recommended not to share eating tools such as fork or spoon. In order to avoid bacteria to spread through saliva, it is better not to share oral health equipment such as the toothbrush.
How can I prevent periodontitis ?
You can prevent periodontal inflammation and stop the progression of gingivitis to periodontitis by adopting adequate oral hygiene habits. The good oral care also requires visiting your dentist twice a year for professional teeth cleaning and full mouth examination.
As mentioned at the beginning of the article, bacteria are the main gingivitis cause especially when microbial plaque accumulates below the gumline. If not removed, dental plaque mineralize becoming hard calculus deposits (tartar).
There are a few simple but important rules to follow in order to prevent gingivitis to develop to periodontal disease; some of them are listed below:
Periodontal disease prevention therefore begins at home practicing the most accurate oral hygiene as possible.
Dentists always advice patients to brush at least two times after each meal (lunch and dinner). One minute per dental arch is enough. Remember not to use toothbrushes with hard bristles because you may accidentally damage your gums and make them to bleed.
Dental floss, interdental brushes and floss picks
Tiny spaces in between teeth are difficult to keep clean. Flossing with conventional dental string helps you to remove more plaque close to the papilla and under the gumline. If the gap between your teeth is large, interdental brushes are the right tools to complete the oral hygiene practice.
Floss picks are more easy to use for children and people with big fingers. Remember to pay more attention cleaning around rooked or crowded teeth, below dental bridges and the visible surface of partial impacted wisdom teeth.
Choose the appropriate mouthwash
The mouthwash is very important to fight bacteria in your mouth so periodontists advice their patients to use an antibacterial mouthwash with chlorhexidine gluconate (0.2% minimum).
Electric toothbrush and WaterPik
Several tests have demonstrated that using an electric toothbrush it is possible to easily remove more plaque than using a manual one. The reason is that the toothbrush head can move in different directions cleaning more deeply.
WaterPik has proved very useful and effective in removing food debris from between dental elements, braces and brackets.
Avoid sticky food and sugar drinks
Acidic or sticky food as well as sport sugar drinks create an acidic oral environment where bacteria can easily proliferate and grow in number. The result of the unbalanced ratio between all microorganisms that live in our mouth is gum inflammation.