Periodontitis is a chronic multifactorial inflammatory disease initiated by bacterial microorganisms and characterised by a severe chronic inflammation that leads to progressive destruction of the tooth supporting apparatus, tooth loss and eventually to masticatory dysfunction.
• is common.
• reduces chewing function.
• impairs aesthetics.
• causes tooth loss.
• causes disability.
• leads to social inequality.
• reduces quality of life.
• has a significant impact upon escalating public health costs.
In addition, periodontitis is a chronic inflammatory disease with potentially negative consequences for general health. Cross-sectional and prospective epidemiological studies have shown that periodontitis increases the risk of poor glycemic control in patients with diabetes mellitus as well as diabetes complications and associated morbidity. Successful periodontal interventions also improve glycemic control in type 2 diabetes patients. Periodontitis is also independently associated with cardiovascular diseases and adverse pregnancy outcomes in some populations. Additional emerging evidence also appears to link periodontitis with nosocomial pulmonary infections, certain types of cancer and rheumatoid arthritis.
The evidence for an association between Diabetes and Periodontitis is as follows:
• Plausibility – Type-2 diabetes is preceded by systemic inflammation, leading to reduced pancreatic ß-cell function, apoptosis and insulin resistance. Increasing evidence supports elevated systemic inflammation (acute-phase and oxidative stress biomarkers), resulting from the entry of periodontal organisms and their virulence factors into the circulation, thus providing biologically plausible mechanisms underpinning the adverse impact of periodontitis upon diabetes and its complications.
• Epidemiological data. Consistent and robust evidence is available which demonstrates that severe periodontitis adversely affects glycemic control in diabetes and glycemia in non-diabetes patients. In addition, in patients with diabetes, there is a direct and dose-dependent relationship between periodontitis severity and diabetes complications. Emerging evidence indicates an increased risk for diabetes onset in patients with severe periodontitis.
• Intervention studies. Randomised clinical trials consistently demonstrate that mechanical periodontal therapy associates with approximately a 0.4% reduction in HbA1C at 3-months, a clinical impact equivalent to adding a second drug to a pharmacological regime for diabetes.
The evidence for an association between Cardiovascular diseases and Periodontitis is as follows:
– Periodontitis leads to entry of bacteria into the blood stream. The bacteria activate the host’s inflammatory-immune response by multiple mechanisms. Several animal models have demonstrated that the host’s inflammatory response favours atheroma formation, maturation and exacerbation.
• Epidemiological data.
There is consistent epidemiological evidence that periodontitis imparts increased risk for future cardiovascular disease, independently of other confounding factors.
• Intervention studies.
There is moderate evidence that periodontal treatment reduces systemic inflammation as evidenced by reductions in C-reactive protein (CRP) and oxidative stress, and leads to improvements of surrogate clinical and biochemical measures of vascular endothelial function.
The evidence for an association between adverse pregnancy outcomes and Periodontitis is as follows:
Current evidence supports the idea that oral microorganisms and their products enter the blood circulation and travel directly to the foetal environment where they cause inflammatory and immune responses affecting the fetoplacental unit. These bacteria in the circulation may also circulate to the liver, where inflammatory agents are produced, which in turn then circulate to the developing foetus.
In clinical studies, low birth weight, pre-term birth and pre-eclampsia have all been associated with the presence of periodontitis in the mother, when all other risk factors have been accounted for. However, the strength of the connection found between periodontitis and these pregnancy outcomes varies between studies, and some show no association. The heterogeneity of data is likely due to differences in the study designs, study populations and different methods used for assessing and classifying periodontal disease.
• Intervention Studies.
Results from clinical trials have shown that, in general, scaling and root planning carried out during the second trimester of pregnancy, with or without antibiotic therapy, does not significantly improve adverse pregnancy outcomes, such as preterm birth and low birth weight. However, some clinical trials did report a favourable effect overall and it is possible that certain populations of pregnant women may benefit from periodontal therapy, even though others will not. One reason for negative study results may be that the
interaction between periodontitis and pregnancy outcomes is more complex than our current understanding and the study results may have been affected by the type and timing of treatment employed and by the types of patients selected.
There is emerging evidence for associations between periodontal diseases and chronic obstructive airways disease, chronic kidney disease, rheumatoid arthritis, cognitive impairment, obesity, metabolic syndrome and some cancers. To date, the only evidence for causality is in relation to respiratory microorganisms that colonize the oral/periodontal biofilm and may subsequently cause a hospital-acquired pneumonia (nosocomial pneumonia) in ventilated patients.
Respiratory pathogens arising from oral/periodontal biofilm reservoirs may be aspirated in certain risk patients within hospital environments and result in a nosocomial pneumonia.
• Epidemiological data
Supports a role for the oral/periodontal biofilm acting as a reservoir for respiratory pathogens in patients with poor oral hygiene and periodontitis, which may cause nosocomial pneumonia.
• Intervention studies
Randomized controlled trials strongly support a role for improving oral hygiene in the prevention of nosocomial pneumonias in acute care hospital environments and nursing homes.
• Patients with diabetes who have extensive tooth loss should be encouraged to pursue dental rehabilitation to restore adequate mastication for proper nutrition. Oral health education should be provided to all patients with diabetes.
• For children and adolescents diagnosed with diabetes, annual oral screening is recommended from the age of 6–7 years by referral to a dental professional. Patients with diabetes should be advised that other oral conditions such as dry mouth and burning mouth may occur, and if so, they should seek advice from their dental practitioner. Also, patients with diabetes are at increased risk of oral fungal infections and experience poorer wound healing than those who do not have diabetes.
• Patients who present without a diabetes diagnosis, but with obvious risk factors for type 2 diabetes and signs of periodontitis should be informed about their risk for having diabetes, assessed using a chairside HbA1C test, and/or referred to a physician for appropriate laboratory-based diagnostic testing and follow-up care.
Given the current evidence, it is timely to provide the following guidelines for periodontal care
in diabetes patients for medical and dental professionals and recommendations for patients/the
• Patients with diabetes should be told that periodontal disease risk is increased by poorly controlled diabetes. They should also be advised that if they suffer from periodontal disease, their glycaemic control may be more difficult to manage, and they are at higher risk for diabetic complications such as cardiovascular and kidney disease.
• As part of their initial evaluation, patients with type 1, type 2 and gestational diabetes (GDM) should receive a thorough oral examination, which includes a comprehensive periodontal examination.
• For all newly diagnosed type 1 and type 2 diabetes patients, subsequent periodontal examinations should occur (as directed by the dental professionals) as part of the ongoing management of their diabetes. Even if no periodontitis is diagnosed initially, annual periodontal review is recommended.
• Diabetes patients presenting with any overt signs and symptoms of periodontitis, including loose teeth not associated with trauma – spacing or spreading of the teeth – and/or gingival abscesses or gingival suppuration, require prompt periodontal evaluation.
Gum disease is very common it affects more than half of adults with natural teeth. We can treat this via a dentist or hygienist and in the early stages the effects can be reversed.
There are three main types of gum disease: gingivitis, periodontitis and acute necrotising ulcerative gingivitis (ANUG).
If you have gingivitis, your gums become irritated by plaque, which is a mixture of food, bacteria and bacterial waste products that can build up on your teeth. If you don t clean plaque off your teeth regularly, your gums will become red, swollen and shiny, and they may bleed. This is the early stage of gum disease and is completely reversible. If you remove the plaque, your gums will recover. But if you don t clean the plaque off your teeth, the gingivitis may develop into periodontitis.
If you don t get treatment for gingivitis, your gums may begin to pull away from your teeth, leaving small pockets. These pockets trap plaque that you can’t reach with a toothbrush. Over time, the plaque will harden to become tartar (calculus). Plaque and tartar build-up can cause further irritation, which may gradually spread to the bone structures around your teeth. As time goes on, the pockets can get deeper and more difficult to clean, and your gum and bone may shrink. This is called periodontitis.
If your gums shrink, they can expose some of the roots of your teeth, making them sensitive. And if you have bone loss, your teeth may become loose. If you don t get treatment for a number of years, your teeth may fall out, or need to be taken out by a dentist.
It’s rarely possible to make the bone structures grow back, so periodontal pockets aren t generally reversible. However, if you receive the appropriate treatment and make sure you floss and brush your teeth well, the progress of the disease can be stopped.
Acute necrotising ulcerative gingivitis
ANUG, also known as ‘trench mouth’, is a severe type of gum disease that develops suddenly. It can be treated with good dental hygiene, including brushing your teeth twice a day, and antibiotics.
Symptoms of gum disease
You may not know that you have gum disease. Often it’s not painful and you might not get any symptoms. This is one of the reasons why it’s important that you attend regular check-ups with your dentist.
Usually the first signs of gingivitis are?
bleeding gums when you brush your teeth
red and swollen gums
If gingivitis has developed into periodontitis, you may have?
a bad taste in your mouth
a wobbly tooth or teeth
gum abscesses (pus that collects under your gum)
The symptoms of ANUG include?
painful ulcers that develop suddenly and bleed easily
a receding of the V-shaped bits of gum between your teeth
feeling generally unwell
If you have any of these symptoms, you should see your dentist straight away.
Causes of gum disease
Gum disease happens when plaque builds up around teeth that aren t cleaned properly. This is more likely to happen if you find it difficult to clean your teeth well, for example if you wear braces or dentures, or have irregularities in your teeth that you can’t reach with a toothbrush.
There are other factors that can make you more likely to get gum disease, for example if you smoke or have diabetes. You may also be more likely to get gingivitis during hormonal changes, such as during pregnancy or puberty.
Diagnosis of gum disease
Your dentist will ask about your symptoms and examine you. He or she may also ask you about your medical history.
Gingivitis can usually be diagnosed just by your dentist looking at your teeth. But if your dentist thinks you have periodontitis, he or she may look at your mouth more thoroughly and check for gum disease using a periodontal probe. This is used to measure how far your gum has pulled away from your teeth. Your dentist will do this by putting the probe beside each tooth and underneath your gum line to check how well your gums are attached to your teeth.
You may also need to have X-rays to check the condition of your teeth and jaw bone.
Treatment of gum disease
The type of treatment you have will depend on how severe your gum disease has become. We can treat you from dental hygiene or dentist.
If you have gingivitis, your dentist or hygienist will clean your teeth thoroughly with a gritty toothpaste using an electric toothbrush and special instruments called scalers. This type of thorough cleaning is called scaling. Your hygienist may also recommend an antiseptic mouthwash that will help to prevent plaque forming, and will help you learn how to brush and floss your teeth properly.
If gingivitis has developed into periodontitis or you have ANUG, you may need more extensive scaling to remove plaque and tartar from the periodontal pockets. This can require several appointments. Your dentist or hygienist may need to inject a local anaesthetic into your gums before the scaling. This will completely block the feeling from your gums, and you will remain awake during the treatment. Your dentist or hygienist will monitor the size of the periodontal pockets during the following months to make sure the treatment has been successful and the periodontitis isn’t getting any worse.
You may need to have gum surgery if your gum disease is very severe, but this is rare. Your dentist may refer you to a periodontologist for this. There are a number of types of surgery that can help to build your gum tissue back up after it has shrunk from gum disease. If you need more information, ask your dentist.
Prevention of gum disease
You can prevent gum disease by controlling the amount of plaque and tartar that builds up on your teeth. Regular visits to your dentist or hygienist, brushing and flossing your teeth properly and stopping smoking will help to do this.
Dental floss or inter-dental brushes can remove plaque and small bits of food from between your teeth and under your gum line areas that a manual toothbrush can’t reach. You may prefer to use an electric toothbrush. There is some evidence to suggest that certain types of electric toothbrush may be more efficient at removing plaque than manual toothbrushes. It s important to use the correct technique, so ask your dentist or hygienist for advice.
Some antiseptic mouthwashes reduce the amount of plaque bacteria when combined with regular brushing. However, there isn’t enough evidence to say whether mouthwash can help to prevent gum disease. If you do use an antiseptic mouthwash, it’s important that you don’t use it for too long as it can stain your teeth. Always read the information on the mouthwash box or bottle and if you have any questions, ask your dentist or hygienist for advice.
Even thorough brushing and flossing can’t remove every trace of plaque. Most people have irregularities in their teeth where plaque can build up out of reach and harden into tartar. This can only be removed by your dentist or hygienist during scaling.
Future research should focus upon specific aspects, in order to provide solid scientific information in several different areas:
Randomised clinical trials, evaluating the effects of periodontal therapy on glycemic control, are needed, with larger numbers of subjects and longer-term follow up. If results are substantiated; adjunctive periodontal therapies (including antimicrobial drugs) subsequently need to be evaluated.
• Cardiovascular diseases.
Well-designed intervention trials on the impact of periodontal treatment on prevention of atherosclerotic cardiovascular diseases, using hard clinical outcomes, such as reductions in myocardial infarction rates and re-vascularisation procedures are needed.
• Adverse pregnancy outcomes.
Well-designed intervention trials on the impact of periodontal treatment on prevention of adverse pregnancy outcomes should be carried out in specific risk populations, using well defined measures of exposure and effective periodontal interventions, which should be rendered in adequate time frames during pregnancy.
• Other systemic conditions.
Large prospective epidemiological studies on diverse populations are needed to substantiate emerging data that associates periodontal disease with systemic diseases and conditions other than diabetes, atherogenic vascular diseases and adverse pregnancy outcomes. When substantiated there is a need for well-designed intervention studies to ascertain any putative benefits from periodontal interventions upon quality of life and true endpoints for the relevant systemic condition.
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