Periodontitis, a prevalent oral health issue affecting millions worldwide, is a severe form of gum disease, often referred to as a periodontal disease. Periodontitis is characterized by inflammation and infection of the gums and surrounding tissues. In the United States, 47.2% of adults, 30 years and older and 70.1% of adults, over the age of 65, have some form of the disease (1).

What is Periodontitis?

Periodontitis refers to the inflammatory state of the gingival tissues (gums) and the bone surrounding the teeth. It results from infections and inflammation causing damage to the gums and the surrounding bone. In its early stage, called gingivitis, symptoms include swollen, red gums that may bleed. In its advanced form, known as periodontitis, gums recede, bone loss occurs, and teeth may become loose or fall out. This condition primarily affects adults and is a significant threat to dental health (2).

Types of Periodontitis

Periodontitis is categorized by stages and grades. Staging classifies the severity and extent of the patient’s disease. The stages are based on the amount of destroyed/damaged tissue and take into consideration risk factors that can contribute to long–term case management. Stages are divided into four levels, with stage IV being the worst.

Grading works to assess the progression of periodontal disease, responsiveness to therapy, and the impact on systemic health.

Each case of periodontal disease is given a stage and a grade at the time of diagnosis (3).

Stages

Stages are then further determined by severity, complexity and extent, and distribution. The extent of the periodontal disease is added to the stage as a descriptor which includes localized (<30% of the teeth are involved), generalized (>30% of the teeth are involved), or molar/incisor only pattern.

Stage I

Clinical attachment loss of 1 – 2mm
Radiograph (xray) bone loss localized to the coronal third (<15% of lost bone)
No tooth loss (due to periodontal disease)
Max probing depth ≤ 4mm with mostly horizontal bone loss
Extent description

Stage II

Clinical attachment loss of 3- 4mm
Radiograph (xray) bone loss localized to the coronal third (15 – 33% of lost bone)
No tooth loss (due to periodontal disease)
Max probing depth ≤ 5mm with mostly horizontal bone loss
Extent description

Stage III

Clinical attachment loss of ≥5mm
Radiograph (xray) bone loss extends to the middle third of the root and beyond
≤4 teeth lost (due to periodontal disease)
Max probing depth ≤6 mm with horizontal bone loss, vertical bone loss of ≥3mm, furcation involvement (class II or III), and moderate ridge defects
Extent description

Stage IV

Clinical attachment loss of ≥5mm
Radiograph (xray) bone loss extending to the middle third of the root and beyond
≤5 teeth lost (due to periodontal disease)
Max probing depth ≤6 mm with horizontal bone loss, vertical bone loss of ≥3mm, furcation involvement (class II or III), severe ridge defects, masticatory dysfunction, secondary occlusal trauma (mobility of >2mm), bite collapse, bite drift, bite flaring, and. <20 teeth remaining
Extent description

Grading

Grading is assumed initially at a grade B, specific evidence needs to be provided to move a grade to A or C.

Grade A: Slow rate

No radiographic bone loss or clinical attachment loss over 5 years
% bone loss/age <0.25
Heavy biofilm deposits with low levels of destruction
Normoglycemic/no diagnosis of diabetes

Grade B: Moderate rate

Radiographic bone loss or clinical attachment loss < 2mm over 5 years
% bone loss/age 0.25 – 1.0
Destruction commensurate with biofilm deposit
< 10 cigarettes/day
HbA1C <7% in patients with diabetes

Grade C: Rapid rate

Radiographic bone loss or clinical attachment loss ≥ 2mm over 5 years
% bone loss/age ≥1.0
Destruction exceeds expectations with the given biofilm deposit
≥10 cigarettes/day
HbA1C ≥7% in patients with diabetes

Symptoms

Periodontitis may not show symptoms until it progresses. There are however some symptoms that can be noted (4).

Red and bleeding gums
Sensitive teeth
Receding gums
Soreness, and bad breath
Gaps may form between teeth and gums, known as gum pockets
Teeth may shift, become loose, or cause discomfort while chewing (5).

Causes

Periodontitis is primarily caused by plaque (6), which is composed of bacteria, and additional factors that can increase susceptibility to gum disease. The causes include:

Plaque Formation: Bacteria in plaque forms a thin film that coats the teeth. These bacteria feed on sugars and release waste products that inflame and swell the gums (7).
Smoking: Smoking can weaken the immune system and increase the risk of gum disease (8).
Diabetes: Uncontrolled diabetes can exacerbate gum inflammation and compromise the body’s ability to fight infection (9).
Hormonal Changes: Hormonal fluctuations during pregnancy can affect gum health and increase the risk of gingivitis and periodontitis in susceptible individuals (10).
Medications: Certain medications may cause gum enlargement, hindering proper cleaning and elevating the risk of gum disease (11).

Understanding these causes is the first step towards preventing gum disease. A combination of good oral hygiene practices and regular dental check-ups can significantly reduce the risk of periodontitis.

Treatment

Periodontal treatment can range from nonsurgical and surgical therapies. The stage and grade of the peridontal disease, will determine an approriate treatment plan and options.

Non-Surgical Therapy: This involves professional cleaning techniques such as scaling and root planing (SRP). SRP focuses on removing plaque and tartar from the tooth surfaces and below the gumline. It helps to reduce inflammation and promotes healing of the gum tissues (12).

Antibiotic Therapy: Antibiotics, may be prescribed in conjunction with non-surgical therapy to target and eliminate bacteria associated with periodontal disease. This can help to further reduce inflammation and improve treatment outcomes (13).

Surgical Therapy: In cases where non-surgical methods are insufficient, surgical intervention may be necessary. Surgical procedures like flap surgery, gingivectomy, or guided tissue regeneration aim to access and remove deep-seated plaque and tartar, reduce pocket depths, and promote tissue regeneration (14).

Periodontal Maintenance: Following initial treatment, ongoing maintenance is crucial to prevent disease recurrence and maintain periodontal health. Regular professional cleanings and examinations help to monitor gum health, detect any signs of recurrence early, and prevent further progression of the disease (15, 16).

Adjunctive Therapies: Various adjunctive therapies may be employed to enhance treatment outcomes. These include photodynamic therapy, laser therapy, and host modulation therapy, which aim to target bacteria, reduce inflammation, and promote tissue healing (17)..

Patient Education and Oral Hygiene Instruction: Educating patients about the importance of good oral hygiene practices, such as proper brushing and flossing techniques, and the role of lifestyle factors like smoking cessation in maintaining periodontal health is essential for long-term success (18).

Overall, a comprehensive approach combining various treatment modalities tailored to the individual patient’s needs is necessary for effective management of periodontal diseases and preservation of oral health.

Risk Factors

As previously mentioned, there are risk factors that can increase a person’s disease state. There are two cateogories of risk factors, modifiable and non-modifiable.

Modifiable Risk Factors

Modifable risk factors are factors that can be changed and controlled to help ruduce the effects of periodontitis.

Poor Oral Hygiene: Inadequate oral hygiene practices, such as irregular brushing and flossing, contribute to the accumulation of plaque and tartar, leading to gingivitis and periodontitis (19).
Smoking and Tobacco Use: Smoking and tobacco use significantly increase the risk of developing periodontal diseases. These habits impair blood flow to the gums, weaken the immune system’s response to infection, and hinder healing processes (20).
Genetic Factors: Genetic predisposition plays a role in determining an individual’s susceptibility to periodontal diseases. Certain genetic variations may increase the likelihood of developing severe forms of periodontitis (21).
Systemic Diseases: Systemic conditions such as diabetes, cardiovascular diseases, and respiratory diseases are associated with an elevated risk of periodontal diseases. Poorly controlled diabetes, in particular, can exacerbate gum inflammation and compromise the body’s ability to fight infection (22).
Hormonal Changes: Hormonal fluctuations during puberty, pregnancy, and menopause can affect gum health and increase the risk of gingivitis and periodontitis in susceptible individuals (23).
Stress: Psychological stress may impact the body’s immune response and increase inflammation, potentially contributing to the development and progression of periodontal diseases (24).
Poor Nutrition: Inadequate nutrition, particularly deficiencies in essential vitamins and minerals like vitamin C and calcium, can weaken gum tissues and compromise oral health (25).
Medications: Certain medications, such as immunosuppressants, antiepileptic drugs, and some antihypertensive medications, may have side effects that affect gum health and increase the risk of periodontal diseases (26).
Age: Advanced age is associated with an increased prevalence of periodontal diseases. Age-related changes in gum tissues and cumulative effects of other risk factors contribute to this higher risk among older adults (27).

Non-modifiable Risk Factors

Non-modifiable risk factors cannot be changed. These include:

Genetics: While listed also as a modifiable factor due to its influence on susceptibility, the specific genetic makeup of an individual is non-modifiable. This includes inherited genetic traits that predispose someone to periodontitis.
Age: The risk of developing periodontal diseases increases with age, and this factor cannot be altered.
Gender: Studies have shown that men are more likely to suffer from periodontal diseases than women, which may be attributed to both biological and behavioral factors that are inherently non-modifiable (28).
Ethnicity: Certain ethnic groups are found to have a higher prevalence of periodontal disease due to a combination of genetic, socioeconomic, and health care access factors, which are largely non-modifiable (29).
Certain Systemic Diseases: Diseases such as diabetes and heart disease, which can be managed but not cured, play a significant role in the susceptibility to periodontal diseases. Their presence is considered a non-modifiable risk factor in the context of periodontal disease risk.

By recognizing and understanding both modifiable and non-modifiable risk factors, individuals and healthcare providers can better strategize prevention and treatment plans for periodontal diseases.

Diagnosis

Diagnosing peridontitis/periodontal disease should be done by a dental professional. The professional will utilize several methods of grading criteria to aid them in the proper diagnosis.

Clinical Examination: Diagnosis of periodontal diseases primarily relies on a comprehensive clinical examination. This includes assessing probing depths, clinical attachment levels, bleeding on probing, tooth mobility, and furcation involvement (30).

Radiographic Evaluation: Radiographs, such as intraoral periapical and bitewing radiographs, are essential for assessing bone levels and detecting bone loss associated with periodontal diseases. The severity of the disease depends on the amount of lost alveolar bone. Dental professionals can additionaly utilize radiographs over time to montior the rates of bone loss (31).

Assessment of Risk Factors: Evaluation of risk factors, including smoking, diabetes, genetic predisposition, and systemic conditions, is integral to the diagnostic process. Identifying and addressing these risk factors are crucial for effective management of periodontal disease (32).

Microbiological Testing: Some dental professionals may utilize microbiological analysis. Although this is not as commonly utilized, it can provide valuable information about the composition of the oral microbiota, allowing for the identification and quantification of specific bacterial species. This can aid in proper antibiotic prescribing (33).

Other Diagnostic Aids: Additional diagnostic aids, such as assessment of gingival inflammation using methods like gingival crevicular fluid analysis or gingival bleeding indices, may complement the clinical examination in certain cases (34).

Prevention

Preventing peridontitis can be achieved through some healthy lifestyle modifications. While some risk factors, as we previously noted, are not modifiable other risk factors can be mitigated. Modifying certain behaviors to minimize risk can help manage and prevent further progression of the disease.

Maintaining Good Oral Hygiene: Proper oral hygiene practices, including brushing teeth twice a day with fluoride toothpaste and flossing daily, are fundamental for preventing periodontal disease. These practices help remove plaque and bacteria from the teeth and gums.

Regular Dental Check-Ups: Routine dental examinations and professional cleanings are essential for early detection and treatment of periodontal disease. Regular visits to the dentist enable monitoring of gum health and identification of any signs of gingivitis or periodontitis (1).

Smoking Cessation: Smoking is a significant risk factor. Smoking impairs blood flow to the gums, weakens the immune system’s response to infection, and hinders healing processes.

Healthy Diet: A balanced diet rich in fruits, vegetables, whole grains, and lean proteins provides essential nutrients for gum health and overall oral health. Limiting sugary snacks and beverages helps prevent plaque buildup and reduces the risk of gum disease.

Limiting Alcohol Consumption: Excessive alcohol consumption is associated with an increased risk of periodontal disease (1). Limiting alcohol intake can contribute to better oral health outcomes.

Stress Management: Managing stress through relaxation techniques, exercise, and mindfulness practices may help reduce inflammation and improve overall gum health. Chronic stress has been linked to an increased risk of periodontal disease.

Regular Exercise: Regular physical activity is beneficial for overall health and may also have positive effects on gum health. Exercise can help improve circulation, reduce inflammation, and support the immune system, contributing to better oral health outcomes.

Education and Awareness: Increased awareness and education empowers individuals to take proactive steps to protect their oral health and prevent gum disease (1).

Conculsion

An understanding of periodontitis is essential for prevention and managment of the disease. Utilizing resources for prevention and treatment of the disease is the ideal approach for optimal oral health. Seeking professional help for diagnosis, treatment and prevention is the ideal solution if you are suffering from the effects of periodontitis.

Was this article helpful?