Periodontitis
129139
226083923
2008-07-16T19:26:54Z
Showerbreeze
7486590
/* Treatment of established disease */
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{{Infobox_Disease |
Name = Periodontal disease |
Image = Paro1.JPG |
Caption = 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. |
DiseasesDB = 29362 |
ICD10 = {{ICD10|K|05|4|k|00}} |
ICD9 = <!--{{ICD9|xxx}}--> |
ICDO = |
OMIM = |
MedlinePlus = 001059 |
eMedicineSubj = |
eMedicineTopic = |
MeshID = |
}}
'''Periodontitis''' (''peri'' = around, ''odont'' = tooth, -''itis'' = inflammation) refers to a number of inflammatory [[disease]]s affecting the tissues that surround and support the [[teeth]]. Periodontitis involves progressive loss of the alveolar bone around the teeth and may eventually lead to the loosening and subsequent [[tooth loss|loss of teeth]] if left untreated. Periodontitis is caused by a convergence of [[bacteria]] that adhere to and grow on the tooth's surfaces, along with an overly aggressive immune system response against these bacteria. Periodontitis is very common and in the USA has a prevalence of 30-50% of the population, but only about 10% have severe forms. A diagnosis of periodontitis is established by inspecting the soft gum tissues around the teeth with a probe and [[radiograph]]s by visual analysis to determine the amount of bone loss around the teeth. Specialists in the treatment of periodontal diseases are known as [[periodontist]]s and in the USA [[periodontics]] is an [[American Dental Association]]-recognized specialty.
Although the different forms of periodontitis are all caused by bacterial infections, a variety of factors affect the severity of the disease. Important "risk factors" include smoking, poorly controlled [[diabetes]], and inherited (genetic) susceptibility.
== Etiology ==
Periodontitis is an inflammation of the [[periodontium]] - the tissues that support the teeth in the mouth. The periodontium consists of four tissues:
* the [[gingiva]], or gum tissue
* the [[cementum]], or outer layer of the roots of teeth
* the [[dental alveolus|alveolar bone]], or the bony sockets into which the teeth are anchored
* the [[periodontal ligament]]s (PDLs), which are the [[connective tissue]] fibers that run between the cementum and the alveolar bone.
[[Image:Periodontalboneloss.JPG|275px|thumb|right|This [[radiograph|X-ray film]] displays two lone-standing [[mandible|mandibular]] teeth, #21 and #22, or the lower left first premolar and canine, exhibiting severe bone loss of 30-50%. Widening of the [[periodontal ligament|PDL]] surrounding the [[premolar]] is due to [[occlusal trauma|secondary occlusal trauma]].]]
If left untreated, periodontitis causes progressive, irreversible bone loss around teeth, looseness of the teeth and eventual [[tooth loss]]. Periodontitis is a very common disease affecting approximately 50% of U.S. adults over the age of 30 years. Periodontitis is thought to occur in people who have preexisting [[gingivitis]] - an inflammation that is limited to the soft tissues surrounding the tooth and does not yet affect the alveolar bone.
The primary [[etiology]], or cause, of gingivitis is the accumulation of a bacterial matrix at the gum line, called [[dental plaque]]. 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 bacteria (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 would be those things that, by definition, cause plaque accumulation, such as restoration overhangs and root proximity.
[[Image:Overhangs.jpg|275px|thumb|left|The excess restorative material that exceeds the natural contours of restored teeth, such as these, are termed "overhangs", and serve to trap plaque, potentially leading to localized periodontitis.]]
If left undisturbed, bacterial plaque calcifies to form [[dental calculus|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 bacterial 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 insult is mainly determined by genetics, however immune development may play some role in susceptibility.
==Signs and symptoms==
Symptoms may include the following:
*occasional redness or bleeding of gums while brushing [[teeth]], using dental floss or biting into hard food (e.g. apples) (though this may occur even in gingivitis, where there is no attachment loss)
*occasional gum swellings that recurs
*[[halitosis]], or bad breath, and a persistent metallic taste in the mouth
*gingival recession, resulting in apparent lengthening of teeth. (This may also be caused by heavy handed brushing or with a stiff tooth brush.)
*deep pockets between the teeth and the gums ([[gingival and periodontal pockets|pockets]] are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as ''[[collagenases]]'')
*loose teeth, in the later stages (though this may occur for other [[occlusal trauma|reasons]] as well)
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.
==Prevention==
Daily [[oral hygiene]] measures to prevent periodontal disease include:
*[[toothbrush|brushing]] properly on a regular basis (at least twice daily), with the patient attempting to direct the toothbrush bristles underneath the gum-line, so as to help disrupt the bacterial growth and formation of subgingival plaque.
*[[flossing]] daily and using interdental brushes (if there is a sufficiently large space between teeth), as well as cleaning behind the last tooth in each quarter.
*using an antiseptic [[mouthwash]]. [[Chlorhexidine gluconate]] based mouthwash or [[hydrogen peroxide#Therapeutic use|hydrogen peroxide]] in combination with careful oral hygiene may cure gingivitis, although they cannot reverse any attachment loss due to periodontitis. (Alcohol based mouthwashes may aggravate the condition).
*regular dental check-ups and professional teeth cleaning as required. Dental check-ups serve to monitor the person's oral hygiene methods and levels of attachment around teeth, identify any early signs of periodontitis, and monitor response to treatment.
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), bacteria and 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.<!--
--><ref name="Cochrane2005recall">{{cite journal | author=Beirne P, Forgie A, Clarkson J, Worthington HV | title=Recall intervals for oral health in primary care patients | journal=Cochrane Database for Systematic Reviews | year=2005 | pages=CD004346 | volume= | issue=2 | issn= 1469-493X | pmid = 15846709 | doi=10.1002/14651858.CD004346.pub2}}</ref>
Instead it is advocated that the interval between dental check-ups should be determined specifically for each patient between every 3 to 24 months.<!--
--><ref name="NHS-NICE">{{cite web | author=National Institute for Health and Clinical Excellence | authorlink=National Institute for Health and Clinical Excellence| title=NICE guidance issued on frequency of dental check-ups | date=27 Oct, 2004 | url=http://www.library.nhs.uk/oralhealth/viewResource.aspx?resID=64336 | publisher=National Library for Health (UK) | accessdate=2006-05-07}}</ref><!--
--><ref name="BBCnews2004">{{cite news |author= BBC News |url=http://newswww.bbc.net.uk/1/low/health/3950587.stm
|title=Call for tailored dental checks - Routine six-monthly dental check-ups should become a thing of the past, new guidance recommends |date=Wednesday, 27 October, 2004 |accessdate=2006-05-07}}</ref>
Nonetheless, the continued stabilization of a patient's periodontal state depends largely, if not primarily, on the patient's [[oral hygiene]] at home if not on the go too. Without daily [[oral hygiene]], periodontal disease will not be overcome, especially if the patient has a history of extensive periodontal disease.
*
o Oral irrigation**
Managing gum disease is all about daily plaque control - essentially sound oral hygiene. That means, in most cases, stopping the plaque in your mouth is really in your own hands. Brush every day. Floss every day. Period. Your dentist or oral hygienist may recommend fluoride toothpaste or tartar reduction rinses. Colgate Total is approved by the FDA for helping to prevent advanced gum disease by reducing plaque and tartar. Biotene enables saliva production which is our bodies way to wash away bacteria.
Dental professionals recommend oral irrigation as a great way to really clean teeth and gums. Oral irrigators get what tooth brushes and floss can't reach, - 3-4 mm under the gum line - so plaque and tartar and the resulting advanced gum disease don't come back.
Oral irrigators flood the mouth with a jet of water under pressure to flush offending food particles and bacteria from the mouth and from under the gum line where the infection is. It is just like a wound on your arm - you must keep it clean for it to heal. And there are studies that even advanced gum disease responds well to oral irrigators. Do not use any mouthwash that has alcohol as an ingredient. The alcohol kills the good bacteria as well as the bad. www.oralbreeze.com
== Treatment of established disease ==
[[Image:Generalized perio -touched up.jpg|450px|thumb|right|This section from a panoramic [[radiograph|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 bone was originally, 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 [[Commonly used terms of relationship and comparison in dentistry|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 [[toothbrush|brushing]] with daily [[flossing]], [[mouthwash]] use. 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. 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 or [[periodontist]] is required to maintain affected teeth.
'''Initial Therapy:''' Removal of bacterial plaque and calculus is necessary to establish periodontal health. The first step in the treatment of periodontitis involves non-surgical cleaning below the gumline with a procedure called Scaling and Root planing. This procedure involves use of specialized curettes to mechanically remove plaque and calculus from below the gumline, and may require multiple visits and local anesthesia to adequately complete. In addition to initial scaling and root planing, it may also be necessary to adjust the occlusion (bite) to prevent excessive force on teeth with reduced bone support. Also it may be necessary to complete any other dental needs such as replacement of rough, plaque retentive restorations, closure of open contacts between teeth, and any other requirements diagnosed at the initial evaluation.
'''Reevaluation:''' Multiple clinical studies have shown that non-surgical scaling and root planing is rarely successful in periodontal pocket depths greater than 4-5mm ''(See articles by Stambaugh RV, Int J Periodontics Rest Dent, 1981 or Waerhaug J, J Periodontol, 1978)''. Therefore it is necessary for the dentist or periodontist to perform a reevaluation 4-6 weeks after the initial scaling and root planing, to determine if the treatment was successful in reducing pocket depths and eliminating inflammation. It has been found that pocket depths which remain after initial therapy of greater than 5-6mm with bleeding upon probing are indicative of continued active disease and will very likely show further bone loss over time. This is especially true in molar tooth sites where furcations (areas between the roots) have been exposed.
'''Surgery:''' If the initial non-surgical treatment was not successful in controlling periodontitis, or if anatomical bony defects persist, periodontal surgery may be necessary to control periodontal disease. There are a myriad of procedures which may be applied, depending on each tooth's site-specific disease pattern. These procedures are usually performed by a [[periodontist]].
These procedures include (but are not limited to):
* Open flap [[debridement]]
* Modified Widman flap surgery
* Apically positioned flaps with or without osseous resection
* Guided tissue regeneration with or without bone grafting
'''Maintenance:''' Once successful periodontal treatment has been completed, with or without surgery, a lifelong regimen of "periodontal maintenance" is required. This involves regular checkups and cleanings of every 3-4 months to prevent repopulation of periodontitis-causing bacteria, and to closely monitor affected teeth so that early treatment can be rendered if disease recurs.
***Brush, Irrigate and Rinse (In that order)
*Brush your teeth at least twice a day, once in the morning and just before going to bed. Use a soft bristle. An electric toothbrush cleans much more effectively than a non powered one.
*Irrigate your teeth and under the gum line where brushing and flossing can't reach. That is where the bacteria are colonizing and creating the inflammation. Irrigate with a steady stream of water using an electric counter top tank irrigator or one that hooks to your shower or sink faucet. The easier it is to use, the more often you will use it. You are irrigating to remove the loosely attached bacteria before it becomes plaque.
*Rinse
• Make a rinse with one ounce of hydrogen peroxide and one ounce of warm water. Swish the liquid around in your mouth for 15 to 20 seconds and then spit it out. The mixture will penetrate deep into infected areas destroying many germs and bringing much needed oxygen to the damaged cells.
• After the initial rinse, wait five minutes and then repeat the process with a solution of one-half teaspoon of salt and one-half glass of warm water. The salt not only kills germs, it also shrinks swollen gums.
• Use both rinses four times a day for three days (if the disease is mild) or for five days (if it is advanced). After that period, your gums should be improved enough to allow you to eliminate the peroxide rinse and use only the salt solution ... once every other day for a few more weeks.
• Alternate with a good anti-bactericidal mouthwash (e.g., Biotene or Crest Pro-Health) that does not stain teeth or contain alcohol. Biotene helps your body produce saliva which is nature's way to wash out bacteria.
• Within 30 days, your dental health should be significantly improved.
== Assessment and prognosis ==
Dentists and dental hygienists "measure" periodontal disease using a device called a [[periodontal probe]]. This is a thin "measuring stick" that is gently placed into the space between the gums and the teeth, and slipped below the gum-line. If the probe can slip more than 3 millimetres length below the gum-line, the patient is said to have a "gingival pocket" around that tooth. This is somewhat of a misnomer, as any depth is in essence a pocket, which in turn is defined by its depth, i.e., a 2 mm pocket or a 6 mm pocket. However, it is generally accepted that pockets are self-cleansable (at home, by the patient, with a toothbrush) if they are 3 mm or less in depth. This is important because if there is a pocket which is deeper than 3 mm around the tooth, at-home care will not be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach 5, 6 and 7 mm in depth, even the hand instruments and cavitrons used by the dental professionals cannot reach deeply enough into the pocket to clean out the bacterial plaque that cause gingival inflammation. In such a situation the pocket or the gums around that tooth will always have inflammation which will likely result in bone loss around that tooth. The only way to stop the inflammation would be for the patient to undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so that they become 3 or less mm in depth and can once again be properly cleaned by the patient at home with his or her toothbrush.
If a patient has 5 mm or deeper pockets around their teeth, then they would 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.
According to the [[Sri Lankan Tea Labourer]] study, in the absence of any oral hygiene activity, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment (>2 mm/year). 80% will suffer from moderate loss (1-2 mm/year) and the remaining 10% will not suffer any loss.<!--
--><ref name="JclinPeriodontol1995-Preus">{{cite journal | author=Preus HR, Anerud A, Boysen H, Dunford RG, Zambon JJ, Loe H | title=The natural history of periodontal disease. The correlation of selected microbiological parameters with disease severity in Sri Lankan tea workers | journal=J Clin Periodontol | year=1995 | pages=674–8 | volume=22 | issue=9 | pmid=7593696 | doi=10.1111/j.1600-051X.1995.tb00825.x}}</ref><!--
--><ref name="ComDentOralEpidemiol1984-Ekanayaka">{{cite journal | author=Ekanayaka A | title=Tooth mortality in plantation workers and residents in Sri Lanka | journal=Community Dent Oral Epidemiol | year=1984 | pages=128–35 | volume=12 | issue=2 | pmid=6584263 | doi=10.1111/j.1600-0528.1984.tb01425.x}}</ref>
== See also ==
* [[Periodontist]]
* ''[[Actinomyces naeslundii]]'' - a kind of bacterium
* [[Calculus (dental)]] - tartar
* [[Campylobacter]] - a kind of bacterium
* [[Dental plaque]] - bacterial biofilm that clings to teeth
* [[Halitosis]] - bad breath due to oral bacteria
* [[Oral hygiene]] - how to promote good health of the mouth
* [[Edentulism]] - condition of one or more missing teeth
* [[Gingivitis]] - inflammation of the gums
* [[Gum graft]] - a type of gum surgery, to replace lost gum tissue
* [[Head and neck anatomy]] - biological composition above the shoulders
* [[Osteoimmunology]] - studies the immune system with respect to bones
* [[Oral microbiology]] - study of the microorganisms of the oral cavity
* [[LANAP]]- Laser Assisted New Attachement Procedure
== Further reading ==
* {{cite journal|last=Pihlstrom|first= BL|coauthors=Michalowicz BS, Johnson NW|year=2005|title=Periodontal diseases|url=|journal=Lancet|issn=0140-6736|volume=366|issue=9499|pages=1809–20|pmid=16298220|doi=10.1016/S0140-6736(05)67728-8}}
== Footnotes ==
<references/>
== External links ==
* [http://periodoncia2.blogspot.com/2007/05/clases-de-periodoncia-2.html PERIOBLOG: Clases y artículos de Periodoncia - Cátedra de Periodoncia II de la Facultad de Odontología de la UNMSM, Decana de América a cargo del Dr. Sixto Grados Pomarino]
* [http://www.mayoclinic.com/invoke.cfm?id=DS00369 Mayo Clinic]
* [http://www.cap-acp.ca/en/public/periodontal_disease.htm Canadian Academy of Periodontology - What is periodontitis? ]
*[http://www.colgate.com/app/Colgate/US/OC/Information/ADA/Article_2005_08_ADAHealthyBehaviorsGums.cvsp Healthy behaviors equal healthy gums] - An article from ADA (American Dental Association)
{http://www.mcvitamins.com/periodontal.htm]Bleeding gums and loose teeth what can be done
{{Periodontology}}
{{Oral pathology}}
[[Category:Oral pathology]]
[[Category:Infectious diseases]]
[[Category:Periodontology]]
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