What is Periodontal Disease?

Periodontal disease, also known as gum disease, is one of the most common diseases in humans. It is a bacterial infection that destroys not only the fibers that attach the gum around our teeth, but also the bone that supports our teeth. Studies over the years have shown that up to 80 percent of people in the United States have early signs of periodontal disease, while 10 percent of adults from ages 18 to 64 have severe disease.

For most people, the disease process starts with dental plaque accumulating on our teeth. This is a sticky, colorless film that is made up of more than 400 species of bacteria. Whether or not you get periodontal disease will then depend on which bacteria are present in your mouth and how your body reacts to this bacteria. Factors that influence this reaction include:

• Genetics
• Congenital immunodeficiencies
• Age
• Medications
• Tobacco/smoking
• Stress
• Bruxism (grinding your teeth)
• Acquired immune defects
• Acquired endocrine diseases
• Acquired inflammatory diseases
• Nutritional deficiencies

How Do I Know if I Have Periodontal Disease?

The majority of people coming to my office have no idea that they have periodontal disease until their general dentist makes the diagnosis and refers them to me for treatment. Some people will come directly to me because they are starting to have symptoms. Even though up to 80 percent of the population have some form of periodontal disease, most people are unaware that they have it. The reason for this is simple. Periodontal disease is not painful until it gets to the advanced stages.

Gingivitis is the earliest form of periodontal disease that causes your gums to become red and bleed easily. They may even become slightly swollen, but there is usually little or no discomfort. If left untreated, gingivitis can proceed to periodontitis. In the early or mild stage of periodontitis, the attachment fibers and bone that support our teeth start to deteriorate. In the moderate to advanced stages, more bone and tissue is destroyed and teeth often become loose. If left untreated, periodontal disease can lead to tooth loss and may be a contributing factor to certain health problems including cardiovascular disease (CVD), preterm delivery and respiratory disease. As with cardiovascular disease, this may also be caused by the release of certain biochemical mediators, such as C-reactive protein, during periodontal disease.

To find out if you have periodontal disease, your dentist will need to measure the space between your gum and tooth. As I mentioned earlier, our gums are attached to our teeth by fibers. There is also a collar of gum around every tooth that can easily be measured in millimeters. When our gums are healthy, those measurements will be between one and three millimeters. If gingivitis is present, the gums will swell and those measurements will usually increase to four or five millimeters. In the presence of periodontitis, those measurements may be even higher.

Your dentist will also need current x-rays to see what has happened to the bone supporting your teeth. With gingivitis, there will be no bone loss around the teeth. On the other hand, if you have periodontitis, your x-rays will show how much bone you have lost. Together with your measurements, x-rays, clinical assessment and health history, your dentist can tell if you have periodontal disease. He or she will also be able to tell what stage it is in and how it can be treated.

How is Periodontal Disease Linked to Overall Health?

Over the years we have begun to realize that oral and systemic health, as well as oral and systemic disease, are linked in several ways. We have known about some of these for a long time, such as the interrelationship between periodontal disease and diabetes mellitus. People with uncontrolled diabetes are more likely to have periodontal infections. In turn, these infections may cause diabetics to have difficulty maintaining a normal blood-sugar level.

There are other related conditions, which we are only beginning to understand and which are still being researched. These include cardiovascular disease, respiratory disease, and the process of pregnancy and childbirth.

Cardiovascular disease (CVD)

Approximately 20 percent of Americans have one or more types of heart disease. In my own practice, which is mostly adults with periodontal disease between the ages of 35 and 70, a significantly higher percentage have cardiovascular disease than in the general population. There have been many studies, dating back to 1987, that look at the relationship between periodontal disease and cardiovascular disease. One such study found that patients with recent CVD had significantly more dental infections than people without CVD. Other studies have shown a positive association between periodontal disease and CVD/stroke, as well as a positive association between CVD and tooth loss due to periodontal disease.

In another study, men with periodontal disease were found to be at greater risk for CVD than men without periodontal disease. Yet other studies found that in a Native American population, the risk of CVD increased by 168 percent among those who had periodontal disease. In other populations, the risk of stroke was found to be 2.8 times greater where periodontal disease was present. Studies are being done to determine if the treatment of periodontal disease reduces the risk of CVD.

Theories about the link between CVD and periodontal disease

It is clear that many studies demonstrate a link between CVD and periodontal disease, however more research is needed to more thoroughly understand this correlation. At present, there are two prevailing theories that attempt to explain the biology of this relationship.

The first theory is that there are specific oral bacteria that enter the bloodstream in people with periodontal disease and cause clots that lead to heart attack and stroke. The second theory is that the bacteria associated with periodontal disease are responsible for eliciting an inflammatory cell mediator called C-reactive protein. This mediator is known to form deposits in injured blood vessels, which, through a series of biological events, contributes to atheroma (plaque) formation. The atheroma may cause atherosclerosis, which is partial or complete blockage of a coronary artery as it grows in size.

Respiratory disease

Periodontal disease may be a risk factor for respiratory diseases as well. Pneumonias are caused by a variety of infectious agents and can be life threatening. Inhaling bacteria that normally colonize the mouth and throat can cause bacterial pneumonia. This is especially prevalent in medically compromised individuals, such as alcoholics and diabetics, who are at a higher risk. The bacteria responsible for respiratory diseases have been found in the dental plaque of medical intensive-care patients who tend to have poor oral hygiene. It is also possible that breathing in oral bacteria can have a deleterious effect on chronic obstructive pulmonary disease (COPD).

Gingivitis and pregnancy

We also know that gingivitis is often exacerbated during pregnancy and is usually at its worst in the eight month. This is most likely due to increased levels of progesterone and its affect on the body’s small blood vessels. It may also be due to hormonal changes altering tissue metabolism. As a periodontist, it is quite common for me to see pregnant women complaining that their gums are bleeding significantly more than before they became pregnant. They may even arrive in my office with one or more pyogenic granulomas, otherwise known as pregnancy tumors. These are small, noncancerous, growths at the gum-line caused by inflammation.

In the United States, one of every ten pregnancies results in preterm delivery (less than 37 weeks) and low birth weight (less than 5.5 pounds). Approximately two-thirds of preterm births are a result of premature labor or preterm membrane rupture. The other third is due to induced labor or delivery by cesarean section.

There is new evidence that suggests an association between periodontal infection and spontaneous preterm birth (SPB). Human studies have shown that periodontal infection can impair fetal growth, although how this happens is not completely understood. As with cardiovascular disease, this may also be caused by the release of certain biochemical mediators, such as C-reactive protein, during periodontal disease. These specific mediators are known to cause preterm delivery in humans. There is also evidence that infection may be a contributing factor to SPB. In one study, mothers of preterm low birth weight babies had significantly more periodontal disease without other risk factors compared to mothers having babies of normal birth weight. The interrelationship between periodontal disease and pregnancy reinforces the need for women to see their dentist regularly before and during pregnancy.

Treatment of Periodontal Disease

To reiterate, it is important to see your dentist or periodontist if you are at risk for respiratory diseases, cardiovascular disease, diabetes, or you are planning to become pregnant.

The treatment for periodontal disease will depend on several factors, including the severity of the disease and your overall health. It may begin with culturing the dental plaque to determine which bacterial pathogens are present and which antibiotics will be effective against them. Treatment options include scaling and root planing, followed by re-evaluation, at which time new pocket measurements are taken. Scaling and root planing is the mechanical removal of plaque and calculus (tartar) that has accumulated on the tooth surface. This is done using special instruments that actually smooth the root surface to eliminate bacterial byproducts called endotoxins. We usually see an improvement in the gums as early as two to three weeks later. The extent of improvement will depend on the severity of periodontal disease.

In addition to systemic antibiotics (antibiotics that travel throughout the body), there are now fibers and gels that contain antibiotics or antimicrobials that can be placed directly in the pockets between the gums and teeth. If there has been enough bone deterioration, periodontal surgery may be recommended to eliminate the bacteria, reduce the pockets to a healthy level, correct the damage to the bone and tissues, and even regenerate lost bone. An extremely important phase of periodontal therapy is regular dental cleanings set up in intervals, depending on your degree of periodontal disease and other health factors.

Current knowledge and continuing research of the relationship between periodontal disease and the other systems of the body, is underway. This new research will show us the way to better dental and overall health.