Periodontitis is a cumulative condition. Once bone is lost, it is almost impossible to regain it, and most patients lose additional tooth-supporting (alveolar) bone over a period of years. Therefore, the worst effects of periodontitis are seen more commonly in older individuals in comparison to younger individuals.

The bone destruction seen in periodontitis can be fairly even, and can result in receding gum lines. However, more frequently, crevices are seen between an individual tooth and its socket, and these crevices are known as periodontal pockets. Shallow periodontal pockets can deepen, eventually becoming deep enough to jeopardize the socket’s support of the adjacent tooth.

Symptoms of Periodontal Disease
Periodontal disease is usually painless until late in the disease process, when the teeth are so loose that some discomfort may occur while chewing. Retention of food in a pocket site may provoke a sudden burst of microbial growth that can result in a painful abscess. At other times, the anterior teeth may become so loose that they separate and the patient may visit the dentist because of the resulting poor esthetics. However, under ordinary circumstances, it is bleeding upon brushing and/or concern over halitosis that brings the patient to the dentist. A thorough dental examination should find any existing pockets. If these pockets bleed upon probing, the tissue is inflamed and warrants therapeutic intervention.

Anatomy and Physiology

The periodontium includes the gums (gingivae), the bone of the tooth socket, and the periodontal ligament, which is a thin layer of connective tissue that holds the tooth in its socket and acts as a cushion between the tooth and the adjacent bone.

Other Risk Factors for Periodontal Diseases

There are several local, systemic, and environmental risk factors which influence the onset, progression and treatment of periodontal disease. Local risk factors include preexisting disease as evidenced by deep probing depths and plaque retentive areas associated with defective dental restorations. Systemic and environmental risk factors identified by large epidemiological studies, such as diabetes and smoking. Any medical condition that affects host antibacterial defense mechanisms, such as human immunodeficiency virus (HIV) infection and neutrophil disorders, will predispose an individual to periodontal disease.

Diagnosis of Periodontal Disease

Periodontal disease is a quietly progressive disease, usually doing most of its damage before it is diagnosed. Periodontitis occurs when the plaque-induced inflammatory response in the tissues results in actual loss of collagen attachment of the tooth to the bone and loss of bone, with some deep periodontal pockets extending the entire length of the tooth root (15 to 20 mm) and possibly resulting in tooth loss. Pocketing is the term given to the pathologic loss of tissue between the tooth and the gingival tissue, and as these pockets become deeper and larger, more harmful periodontal pathogens can occupy these pockets
Clinical Diagnosis

  • Visualization
  • Periodontal Probing
  • Dental Radiographs
  • Gingival Crevicular Fluid flow
  • Pocket Temperature
  • Microbiological Diagnosis

Microbiologic diagnosis is not commonly used in the management of periodontal disease. However several methodologies exist that allow for identification and quantification of periodontal pathogens. These include the use of: darkfield and phase contrast microscopy to identify spirochetes (which are present in almost everyone) and other motile organisms in plaque samples; an immunologic staining reagent specific for the organism in question; cultural methods; DNA probes; and specific enzyme assays.

Bad Breath (Halitosis)

Halitosis (or bad breath) affects 50 to 65% of the population. 90% of halitosis cases are thought to originate from mouth sources, with contributing factors being poor oral hygiene, periodontal disease, the mucous coating on the tongue, impacted food between the teeth, defective dental restorations, and infections of the throat. The other 10% may be due to systemic disorders, such as a peptic ulcer that is associated with an infection, lung infections, liver and kidney disease, diabetes mellitus, cancer, or may even be psychosomatic in nature (a person’s imagination). Also, reduced salivary flow may worsen halitosis.  Most cases of halitosis have been shown to originate from sulfur gases (e.g., hydrogen sulfide and methyl mercaptan) produced by oral bacteria.

Treatment consists of oral hygiene and the identification and treatment of any underlying infections. Additionally, mouthwashes and toothpastes containing essential oils are often recommended to help prevent oral bacterial overgrowth. Other nutritional supplements that can help are: folic acid, vitamin C, vitamin E, selenium, zinc and coenzyme Q10.

Prevention and Treatment

The standard of care for the treatment of gingivitis and periodontal disease includes:

  1. Removal of bacteria (i.e., the source of inflammation) by mechanical cleaning
  2. Providing and training patients to maintain optimal oral hygiene
  3. Dietary evaluation and nutritional counseling and/or supplementation
  4. Maintenance and optimization of host immune defenses
  5. The use of the best available oral health care products

Although patients with advanced periodontal disease can be effectively treated, it is certainly more desirable to take precautions early on, before the damage is done. Patient motivation and compliance are major obstacles to an effective preventive program, which can be dramatically improved when high risk patients are informed about their condition. Likewise, the dental professional needs to know when to proceed more aggressively with therapy, and can benefit from considering future risk in making this recommendation.

Significant periodontal research has provided evidence that chronic periodontitis is treatable. However, once periodontal tissue is lost, complete restoration of these tissues are limited, and is dependent upon the specific circumstances. The majority of periodontal treatments are aimed at arresting the progression of the disease in an attempt to prevent tooth loss; it has also been shown that the majority of individuals that have sought periodontal treatment significantly reduce their risk of tooth loss. However, there are those cases of periodontitis, even if adequately treated, still continue to progress and have poor prognoses. Why do some patients have excellent outcomes, while others do not? This answer may be found in the host response to the disease, as well as the individual’s nutritional status.