Periodontal diseases encompass a range of conditions affecting the tissues surrounding teeth, including the gums and supporting structures.
Periodontitis isn’t a single entity; it’s a spectrum of diseases. This umbrella term signifies inflammation of the tissues that support teeth, namely the periodontal ligament, cementum, and alveolar bone.
Unlike gingivitis, which mainly affects the surface tissues, periodontitis triggers a loss of connection between the tissues and the tooth’s root. This detachment results in a deepening of the space between the gums and the tooth, creating a periodontal pocket. As this pocket forms, the junctional epithelium (a layer of cells) migrates along the root’s surface, leading to bone loss or gum recession, and sometimes both.
If left untreated, periodontitis can escalate, weakening the structure that holds teeth and making them prone to abscess formation. This condition not only impacts comfort but also aesthetics. Teeth lose their functional efficiency, and in extreme cases, they may even fall out or need extraction due to severe infections.
Advancing from Gum Disease to Periodontitis
When it comes to the journey from gingivitis to periodontitis, science is still deciphering the specifics. The transition from surface inflammation to deeper tissue involvement isn’t fully understood yet.
Enlargement of periodontal pockets
In periodontitis, the inflammation marches deeper into the attachment apparatus, leading to the creation of periodontal pockets. This is a result of thickening sulcular epithelium infiltrating the connective tissue beneath.
The deepening pockets can be attributed to the breakdown of collagen fibers within the gingival connective tissue. Enzymes like collagenase, released by some plaque bacteria and inflammatory cells, play a role in this process.
The junctional epithelium elongates and parts ways with the tooth root’s surface. Plaque bacteria release substances that attract neutrophils (a type of white blood cell) into the gingival sulcus. This interaction results in the pus often seen in advancing periodontal disease.
Periodontal bone loss
The onset of periodontitis involves the downward migration of the junctional epithelium and the loss of alveolar crest bone (the bone supporting teeth). Bone is dynamic, undergoing a constant process of resorption and formation.
When resorption outpaces formation, we experience a net loss of bone. This bone loss in the crestal region is termed periodontal bone loss. Interestingly, there’s some evidence linking systemic bone thinning, as seen in conditions like osteoporosis, to increased alveolar bone loss and tooth loss.
As periodontal disease takes hold, the periodontal tissues house plasma cells and lymphocytes.
- Plasma cells play a pivotal role in antigen-antibody reactions, a fundamental aspect of our immune system. These reactions trigger a chain of events that attract more inflammatory cells to the scene. These cells produce active molecules that further break down the collagen fibers in the periodontal connective tissue.
- Lymphocytes, when activated by plaque bacteria, release lymphokines, another class of active proteins. These substances have a ripple effect on the inflammatory system, including signaling osteoclasts to kick off bone resorption.
The interplay of bacterial plaque and inflammatory cells also yields prostaglandins, culprits that stimulate bone resorption. Together, these factors, alongside activated complement, contribute to the bone loss we observe in periodontitis.
The mechanisms behind bone resorption might just offer hints for innovative treatments. Nonsteroidal anti-inflammatory drugs that target prostaglandins could potentially curb the bone loss associated with periodontitis.
Nature of Periodontal Disease
Periodontal disease is considered to be episodic. This means that the disease isn’t a continuous march; it has active phases marked by tissue bleeding, bone and tissue loss, and deepening pockets, followed by periods of quiet remission. During these inactive phases, the disease lies dormant, and pockets remain stable.
Keep in mind that periodontal disease is site-specific, not affecting all teeth simultaneously. Certain teeth might remain untouched. This could be linked to the varying potency of plaque biofilm in different areas of the mouth. The site-specific nature can result in new disease sites or exacerbate damage in existing ones.
Types of Periodontitis
The American Academy of Periodontology has organized periodontitis into several categories based on various factors. These include the cause, clinical appearance, progression, and response to treatment. There are seven recognized categories, each likely representing distinct bacterial infections with similar symptoms:
1. Chronic Periodontitis
This is the most common form of periodontitis and progresses slowly. It involves inflammation and gradual destruction of the periodontal ligaments and alveolar bone.
Chronic periodontitis isn’t a sudden occurrence; it might start lurking in adolescence and continue its course if untreated. Clinically, it doesn’t typically raise red flags until around 35 years of age. However, significant pocketing and bone loss can pop up at any age.
Unlike some other periodontal diseases, chronic periodontitis doesn’t have ties to systemic health issues or host defense abnormalities. The disease’s momentum can be controlled through treatment or the body’s natural defenses, bringing the burst of activity to a halt.
Cause: Mainly due to poor oral hygiene, which leads to bacterial plaque buildup.
Symptoms: Pocket formation, gum recession, bone loss, tooth mobility.
Treatment: Professional cleaning, scaling, root planing, maintenance of good oral hygiene.
2. Aggressive Periodontitis
Aggressive periodontitis is characterized by its rapid and aggressive nature, affecting otherwise healthy individuals, often at a young age. It involves the swift loss of gum attachment and alveolar bone, leading to severe bone destruction.
Symptoms: Severe bone loss, early tooth loss, inflammation.
Treatment: Aggressive periodontal therapy, antibiotics, scaling, root planing.
3. Prepubertal Periodontitis
Prepubertal periodontitis is a rare form that occurs in children before puberty. This type requires early intervention, as it can lead to the premature loss of primary teeth.
Cause: Genetics, immune system abnormalities.
Symptoms: Severe bone loss, tooth mobility, inflammation.
Treatment: Aggressive periodontal therapy, antibiotic treatment, addressing underlying genetic or immune factors.
4. Early-Onset Periodontitis
Affects young adults, typically between the ages of 20 and 35. Early detection and treatment are crucial to prevent extensive damage.
Cause: Genetics, specific bacteria.
Symptoms: Severe bone loss, inflammation, tooth mobility.
Treatment: Aggressive periodontal therapy, antibiotics, scaling, root planning, and lifestyle adjustments.
5. Rapidly Progressing Periodontitis
Also known as “acute necrotizing ulcerative gingivitis,” (ANUG) it’s characterized by rapid tissue destruction. It often occurs during times of stress or immune system compromise. Symptoms include pain, ulceration, and gum tissue necrosis.
Cause: Poor oral hygiene, stress, smoking.
Symptoms: Pain, ulceration, gum tissue necrosis.
Treatment: Antibiotics, professional cleaning, improving oral hygiene.
6. Refractory Periodontitis
Refractory periodontitis refers to cases where periodontal disease does not respond well to treatment. Despite treatment efforts, attachment loss continues. This type requires advanced periodontal therapy, careful monitoring, and potentially adjustments to the treatment approach.
Cause: Bacterial resistance, immune system issues.
Symptoms: Continued attachment loss despite treatment.
Treatment: Advanced periodontal therapy, close monitoring.
7. Necrotizing Ulcerative Periodontitis:
Necrotizing ulcerative periodontitis involves tissue necrosis and ulceration, often leading to painful oral sores.
Cause: Immune system compromise, stress, and poor oral hygiene.
Symptoms: Pain, ulceration, foul odor, gum tissue necrosis.
Treatment: Antibiotics, professional cleaning, improving oral hygiene.
8. Periodontitis as a Manifestation of Systemic Disease:
Periodontitis can also be a manifestation of underlying systemic conditions like diabetes or immune disorders. The disease’s severity is exacerbated by the systemic condition, impacting gum health.
Cause: Underlying systemic conditions impacting oral health.
Symptoms: Gum inflammation, rapid attachment loss.
Treatment: Managing the systemic condition, periodontal therapy.
Each type of periodontitis presents distinct challenges and requires tailored treatment approaches. Consulting a dental professional is essential for accurate diagnosis and effective management through options such as scaling and root planning, using antibiotics, tissue regeneration, pocket reduction surgery (flap surgery), or even dental implants for tooth replacement.
What are Periodontal Pockets?
A periodontal pocket is a deeper-than-normal space between the gums and teeth. It’s a common feature in all types of periodontal disease, and while the clinical appearance might be similar, the diseases themselves differ in terms of causes, progression, and response to treatment.
What causes the periodontal pocket depth to increase from periodontitis?
Two reasons can lead to an increase in probing pocket depths:
- Gingival Enlargements: These pockets result from the gingival margin moving upwards due to inflammation or swelling. They are unrelated to bone loss and are often associated with systemic conditions.
- Periodontal Pockets: These pockets are born from a more sinister process – progressive tissue destruction and bone loss. They are directly related to the damage that periodontitis inflicts.
Are there different types of periodontal pockets?
Periodontal pockets can also be categorized into suprabony (above the bone crest) and infrabony (extending into the bone). They develop as a result of bacterial challenge from plaque biofilms, causing the loss of surrounding connective tissues. This destructive process includes collagen loss, migration of the junctional epithelium, and swelling of the gingiva. Inflammation adds to the complexity, leading to a cascade of changes.
How do you determine the severity of periodontitis based on pocket depth?
- Slight – 1-2 mm
- Moderate – 3-4 mm
- Severe – more than 5mm depth
What is inside a periodontal pocket?
The periodontal pocket isn’t an empty space; it’s a hub of activity. It’s filled with subgingival plaque biofilm, housing a variety of bacteria, some of which can survive in this sheltered environment. These biofilms release toxins that contribute to the toxic nature of the pocket. The pocket also contains calculus, formed from the hardened plaque biofilm. Additionally, pus, a concoction of dead cells and serum products, can accumulate in these pockets. The contents of the pocket can adversely affect the tooth’s root surfaces and even hinder epithelial adherence.