In health, the gum and bone tissues that surround teeth are attached to the root surface by connective tissue fibers called the gingivo-dental fibers. This functional unit, called theperiodontium, is comprised of four types of tissue:
- cementum, which exists on the tooth root surface
- alveolar bone, which surrounds and supports the teeth in the jaw
- gingiva, or gum tissue, which is comprised of epithelium and a lamina propria of connective tissue
- periodontal ligament fibers, which run from the alveolar bone and insert into the cementum
In addition to the periodontal fibers that attach the tooth to the surrounding bone, there are also two types of connection between the tooth and the surrounding gum tissue. There is the more apical gingival fiber attachment and the more coronal junctional epithelium attachment. Together, these two are referred to as the gingival attachment apparatus and, in health, they keep the gingival tissue snug around the necks of the teeth.
In gingivitis, an inflammatory process in the gum tissue may cause a transient loss of this gingival attachment apparatus that is completely reversible if the inflammatory process is reversed. Gingivitis is therefor termed non-destructive periodontal disease because it does not entail loss of periodontal ligament fibers or alveolar bone. Once the inflammatory process initiates loss of periodontal fibers and/or bone, the gingivitis is deemed to have progressed to periodontitis.
Gingivitis – Classification and external resources
Severe gingivitis before (top) and after (bottom) a thorough mechanical debridement of the teeth and adjacent gum tissues. (N.B. The apparent change in tooth color is due entirely to metamerism; its effect on the color of the gums must therefor be taken into consideration.)
Gingivitis (“inflammation of the gum tissue”) is a term used to describe non-destructive periodontal disease.The most common form of gingivitis is in response to bacterial biofilms (also called plaque) adherent to tooth surfaces, termed plaque-induced gingivitis, and is the most common form of periodontal disease. In the absence of treatment, gingivitis may progress to periodontitis, which is a destructive form of periodontal disease.
While in some sites or individuals, gingivitis never progresses to periodontitis, data indicates that gingivitis always precedes periodontitis.
Signs and symptoms
The symptoms of gingivitis are somewhat non-specific and manifest in the gum tissue as the classic signs of inflammation:
Additionally, the stippling that normally exists on the gum tissue of some individuals will often disappear and the gums may appear shiny when the gum tissue becomes swollen and stretched over the inflamed underlying connective tissue. The accumulation may also emit an unpleasant odor.
When the gingiva are swollen, the epithelial lining of the gingival crevice becomes ulcerated and the gums will bleed more easily with even gentle brushing, and especially when flossing.
Gingivitis can be prevented through regular oral hygiene that includes daily brushing and flossing. Mouthwash or Hydrogen Peroxide can be helpful, usually using peroxide or saline solutions (water and salt), alcohol or chlorhexidine. Rigorous plaque control programs along with periodontal scaling and curettage also have proved to be helpful.
Periodontitis is a set of inflammatory diseases affecting the periodontium — that is, the tissues that surround and support the teeth. Periodontitis involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent loss of teeth. Periodontitis is caused by microorganisms that adhere to and grow on the tooth’s surfaces, along with an overly aggressive immune response against these microorganisms. A diagnosis of periodontitis is established by inspecting the soft gum tissues around the teeth with a probe (i.e. a clinical exam) and by evaluating the patient’s x-ray films (i.e a radiographic exam), to determine the amount of bone loss around the teeth. Specialists in the treatment of periodontitis are periodontists; their field is known as “periodontology” or “periodontics”.
The word “periodontitis” comes from peri (“around”), odont (“tooth”) and -itis (“inflammation”)
Periodontal disease – Classification and external resources
This radiograph shows significant bone loss between the two roots of a tooth. The spongy bone has receded due to infection under tooth, reducing the bony support for the tooth.
Moreover, terminology expressing both the extent and severity of periodontal diseases are appended to the terms above to denote the specific diagnosis of a particular patient or group of patients.
If up to 30% of sites in the mouth are affected, the manifestation is classification aslocalized; for more than 30%, the term generalized is used.
Signs and symptoms
Patients should realize that the gingival inflammation and bone destruction are largely painless. Hence, people may wrongly assume that painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient.
The primary etiology (cause) of gingivitis is poor oral hygiene which leads to the accumulation of a mycotic and bacterial matrix at the gum line, called dental plaque. Other contributors are poor nutrition and underlying medical issues such as diabetes. New finger nick tests have been approved by the Food and Drug Administration in the US, and are being used in dental offices to identify and screen patients for possible contributory causes of gum disease such as diabetes.
In some people, gingivitis progresses to periodontitis – with the destruction of the gingival fibers, the gum tissues separate from the tooth and deepened sulcus, called a periodontal pocket. Subgingival microorganism (those that exist under the gum line) colonize the periodontal pockets and cause further inflammation in the gum tissues and progressive bone loss. Examples of secondary etiology are those things that, by definition, cause microbic plaque accumulation, such as restoration overhangs and root proximity.
The excess restorative material that exceeds the natural contours of restored teeth, such as these, are termed “overhangs”, and serve to trap microbic plaque, potentially leading to localized periodontitis.
If left undisturbed, microbic plaque calcifies to form calculus, which is commonly called tartar. Calculus above and below the gum line must be removed completely by the dental hygienist or dentist to treat gingivitis and periodontitis. Although the primary cause of both gingivitis and periodontitis is the microbic plaque that adheres to the tooth surface, there are many other modifying factors. A very strong risk factor is one’s genetic susceptibility. Several conditions and diseases, including Down syndrome, diabetes, and other diseases that affect one’s resistance to infection also increase susceptibility to periodontitis.
Another factor that makes periodontitis a difficult disease to study is that human host response can also affect the alveolar bone resorption. Host response to the bacterial-mycotic insult is mainly determined by genetics; however, immune development may play some role in susceptibility.
Typically dental hygienists (or dentists) use special instruments to clean (debride) teeth below the gumline and disrupt any plaque growing below the gumline. This is a standard treatment to prevent any further progress of established periodontitis. Studies show that after such a professional cleaning (periodontal debridement), microbic plaque tend to grow back to pre-cleaning levels after about 3–4 months. Hence, in theory, cleanings every 3–4 months might be expected to also prevent the initial onset of periodontitis. However, analysis of published research has reported little evidence either to support this or the intervals at which this should occur.Instead, it is advocated that the interval between dental check-ups should be determined specifically for each patient between every 3 to 24 months.
Nonetheless, the continued stabilization of a patient’s periodontal state depends largely, if not primarily, on the patient’s oral hygiene at home as well as on the go. Without daily oral hygiene, periodontal disease will not be overcome, especially if the patient has a history of extensive periodontal disease.
Periodontal disease and tooth loss are associated with an increased risk of cancer.
A contributing cause may be low selenium in the diet: “Results showed that selenium has the strongest association with gum disease, with low levels increasing the risk by 13 fold.”
This section from a panoramic X-ray film depicts the teeth of the lower left quadrant, exhibiting generalized severe bone loss of 30–80%. The red line depicts the existing bone level, whereas the yellow line depicts where the gingiva was originally (1–2 mm above the bone), prior to the patient developing periodontal disease. The pink arrow, on the right, points to a furcation involvement, or the loss of enough bone to reveal the location at which the individual roots of a molar begin to branch from the single root trunk; this is a sign of advanced periodontal disease. The blue arrow, in the middle, shows up to 80% bone loss on tooth #21, and clinically, this tooth exhibited gross mobility. Finally, the peach oval, to the left, highlights the aggressive nature with which periodontal disease generally affects mandibular incisors. Because their roots are generally situated very close to each other, with minimal interproximal bone, and because of their location in the mouth, where plaque and calculus accumulation is greatest because of the pooling of saliva, mandibular anteriors suffer excessively. The split in the red line depicts varying densities of bone that contribute to a vague region of definitive bone height.
The cornerstone of successful periodontal treatment starts with establishing excellent oral hygiene. This includes twice daily brushing with daily flossing. Also the use of an interdental brush (called a Proxi-brush) is helpful if space between the teeth allows. Persons with dexterity problems such as arthritis may find oral hygiene to be difficult and may require more frequent professional care and/or the use of a powered tooth brush. Persons with periodontitis must realize that it is a chronic inflammatory disease and a lifelong regimen of excellent hygiene and professional maintenance care with a dentist/hygienist or periodontist is required to maintain affected teeth.
Most alternative “at-home” gum disease treatments involve injecting anti-microbial solutions, such as hydrogen peroxide, into periodontal pockets via slender applicators or oral irrigators. This process disrupts anaerobic microorganism colonies and is effective at reducing infections and inflammation when used daily. A number of potions and elixirs that are functionally equivalent to hydrogen peroxide are commercially available but at substantially higher cost. However, such treatments do not address calculus formations, and so are short-lived, as anaerobic microorganism colonies quickly regenerate in and around calculus.
In a new field of study, calculus formations are addressed on a more fundamental level. At the heart of the formation of subgingival calculus, growing plaque formations starve out the lowest members of the community, which calcify into calcium phosphate salts of the same shape and size of the original, organic bacilli. Calcium phosphate salts (unlike calcium phosphate; the primary component in teeth) are ionic and adhere to tooth surfaces via electrostatic attraction. Smaller, free-floating calcium phosphate salt particles are equally attracted to the same areas, as are additional calcified microorganism, growing calculus formations as unorganized, yet strong, “brick and mortar” matrices. The microscopic voids in calculus formations house new anaerobic microorganism, as does the top “diseased layer”.
Because the root cause of subgingival calculus development is ionic attraction, it was hypothesized that the introduction of oppositely charged particles around the formations may chelate calcium phosphate salt components away from the matrix, thus reducing the size of subgingival calculus formations. To accomplish this, a sequestering agent solution comprised partly of sodium tripolyphosphate (STPP) and sodium fluoride (charge -1) was tested on a patient with burnished and new subgingival calculus at a depth of 6 mm. The patient delivered the solution using an oral irrigator, once a day, for 60 days. The results were the successful elimination of all calculus formations studied.[Unreliable medical source?] This test was conducted using a subgingival endoscopic camera (perioscope) by an independent periodontist.
The promise of this new, alternative treatment is to keep subgingival calculus at bay, in concert with traditional periodontal treatments. In this way, periodontitis may be controlled by the patient, and complete restoration of dental health can be a collaborative effort between the patient and the dental professional.
If a patient has 7 mm or deeper pockets around their teeth, then they would likely risk eventual tooth loss over the years. If this periodontal condition is not identified and the patient remains unaware of the progressive nature of the disease then, years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain.