Circuit 1, station 8

Periodontal Disease
Periodontal diseases are a group of diseases affecting the supportive structures surrounding the teeth, including the gingiva, alveolar bone, cementum, and periodontal ligament. The disease can be reversed and tooth loss is typically prevented if detected and treated in the early stages. Maintaining good oral hygiene and visiting your dentist twice a year for cleanings and exams will help you avoid periodontal disease.
Types of Periodontal Disease
1. Gingivitis: The first stage of periodontal disease
The most common form of periodontal disease is gingivitis, which is an inflammation of the gingiva due to the buildup of bacteria and debris between the gum line and tooth. Gingivitis is limited to the gingiva and does not extend to the periodontal attachment (periodontal ligament, cementum, and alveolar bone).
If left untreated, gingivitis can progress to a more severe form of the disease called periodontitis.
1. Periodontitis: The advanced stage of periodontal disease
Periodontitis is a chronic, destructive, and irreversible inflammatory disease that leads to the loss of attachment of the periodontium and alveolar bone loss. In 2017, the American Academy of Periodontology introduced a new classification of periodontal and peri-implant diseases, which includes three categories of periodontitis: necrotising periodontal diseases, periodontitis, and periodontitis as a manifestation of systemic diseases.
• Necrotising periodontal diseases: A necrotising periodontal disease is a bacterial infection that causes necrosis of the gums, jawbone, and periodontal ligament. This is the most severe form and is frequently encountered in people with systemic issues such as malnutrition, drug addiction, immunosuppression, and HIV.
• Periodontitis: There are different types of periodontitis, including chronic and aggressive periodontitis. Chronic periodontitis is the most common type and involves a slow and progressive loss of gum tissue attachment to the teeth, which can lead to bone loss. Aggressive periodontitis, on the other hand, develops rapidly and can cause severe bone and tooth loss in a short amount of time.
• Periodontitis as a manifestation of systemic diseases: Periodontitis is a common manifestation of two general categories of systemic diseases: Certain hematologic disorders (e.g. acquired neutropenia, leukaemia) and some genetic diseases (e.g. Down syndrome, familial/cyclic neutropenia, leukocyte adhesion deficiency syndromes) are examples of these diseases. Periodontitis has been also linked to several systemic conditions, including diabetes, heart, and kidney disease, Alzheimer’s, asthma, osteoporosis, and cancer.
Aetiology of Periodontal Disease
Periodontal diseases arise from several factors, including patient-specific risk factors and inadequate oral hygiene practices. Modifiable risk factors include smoking tobacco, poor oral hygiene, diabetes mellitus, and pregnancy, while non-modifiable risk factors include age and heredity. Inadequate oral hygiene practices can lead to the buildup of bacteria and plaque on the teeth, which initiates gingivitis and potentially progresses to periodontitis.
Tobacco smoking is the most significant modifiable risk factor of periodontal diseases and can increase the risk by 5-20 fold. Diabetes mellitus is also a major contributor to periodontal diseases, as it is associated with certain pathologic processes that enhance periodontal breakdown. Pregnancy is linked to gingivitis and periodontitis due to hormonal changes that promote an inflammatory response. Age is a non-modifiable risk factor for periodontal diseases, with older individuals having a more severe inflammatory response to plaque deposition.
Lastly, several genetically linked systemic disorders have been shown to manifest as periodontal diseases. It is essential to maintain proper oral hygiene practices and address risk factors promptly to prevent the development of periodontal diseases.
Symptoms of Periodontal Disease
Periodontal diseases can manifest in several ways, with early stages often going unnoticed due to their asymptomatic nature. However, as the disease advances, it can cause various symptoms such as:
• Bleeding during brushing or flossing
• Halitosis (bad breath)
• Pain and tenderness while chewing
• Sensitive teeth
• Receding gums
• Discoloring plaque
• Tooth mobility
• Loss of teeth
Chronic periodontitis is a common type of periodontal disease that can affect anyone, but it’s more prevalent in middle-aged to older adults. The severity of this disease is classified based on the amount of clinical attachment loss (CAL). The classification is as follows:
• Mild: CAL of 1 to 2 mm
• Moderate: CAL of 3 to 4 mm
• Severe: CAL of more than 5 mm
In contrast, aggressive periodontitis is a rapidly progressing form of disease that tends to affect younger patients. This condition presents with similar symptoms to chronic periodontitis, but it tends to target specific teeth, particularly first molars, and incisors. It often occurs in the absence of significant plaque accumulation.
Evaluation/Diagnosis of Periodontal Disease
The diagnosis of periodontal disease is critical to treating and managing the disease effectively. This requires a comparison of findings with the normal periodontium.
The normal periodontium is characterised by pale pink gingiva that is well adapted to the underlying bone. There is a 1 to 3 mm physiological sulcus between the gingiva and the tooth that usually doesn’t bleed. However, signs of periodontal disease include bleeding gums, pain, bad taste/odour, periodontal pocketing, radiographic bone loss, clinical attachment loss, and eventually tooth loss.
Treatment / Management of Periodontal Disease
The initial phase of periodontal disease treatment is a professional dental cleaning, which includes scaling and root planing to remove dental plaque and calculus both above and below the gum line. The patient must return for a re-evaluation to determine if the disease process was arrested, and oral hygiene instructions are given.
The most important aspect of managing a periodontal disease is addressing the risk factors that can contribute to the disease process. These risk factors include poor oral hygiene, smoking, and diabetes.
Antibiotics may be recommended in cases of periodontal disease that do not respond to non-pharmacological therapies. These antibiotics can be administered locally or systemically and may include medications such as chlorhexidine gluconate and minocycline hydrochloride microspheres. Although systemic antibiotics may be necessary, the most common antimicrobial agents prescribed include tetracyclines, penicillins, macrolides, quinolones, cephalosporins, and nitroimidazole compounds, depending on the susceptible microorganisms and antibacterial resistance.
Severe cases should be referred to a periodontist, who may use periodontal surgery to regain lost bone and attachment.
Differential Diagnosis
It is important to note that periodontal disease can mimic other conditions and vice versa. Some conditions that may mimic periodontal disease include:
• Periodontal abscesses
• Endodontic lesions
• Leukaemia
• Side effects of certain medications, including calcium channel blockers, immunosuppressants, and anticonvulsants
• Squamous cell carcinoma
Staging and Grading
The most recent staging guidelines for periodontitis were published in 2017 and divide the classification into staging and grading. The staging system assesses the severity and extent of management required and assigns a stage based on factors like clinical attachment loss, radiographic bone loss, and tooth loss. On the other hand, the grading system is a measure of the disease’s progression rate, with evidence for associated risk factors, such as smoking and diabetes mellitus, taken into consideration.
Complications
If left untreated, periodontal disease can lead to a range of complications. One of the most direct consequences is tooth loss, which occurs as the disease leads to increased destruction of the periodontium, including the periodontal ligament and alveolar bone that normally anchor the teeth.
Diabetic patients with severe periodontal disease are at 3.2 times greater mortality risk than people with diabetes without periodontal disease. Periodontal disease may also initiate insulin resistance as it is associated with hyperglycemia, impaired glucose tolerance, and poor glycemic control.
The inflammation biomarker, C-reactive protein (CRP), is elevated in patients with periodontal disease, which is also associated with cardiovascular disease and cardiovascular events. While a direct relationship between bacterial levels found in periodontal disease and atherosclerosis has not been established, the link between them is apparent.
Maternal periodontal disease is significantly associated with infant birth weight, and as periodontal disease increases from none to severe, infant birth weight tends to decrease.
Conclusion
Periodontal disease is a common and potentially serious condition that affects the oral health and overall well-being of millions of people worldwide. Proper diagnosis, staging, and grading of the disease are essential to providing appropriate treatment and management. Collaboration between healthcare professionals and patient education can help to reduce the risk of occurrence and manage the progression of the disease, ultimately improving the oral and overall health of patients.