A Tour around Periodontal Disease

(Date of publication 28 February 2005)

Which do you think is the most common disease in the world – heart disease, cancer, osteoarthritis? How about malaria or AIDS, which infect many millions every year? Well, the dubious honour goes to periodontal disease, which gradually destroys the supporting structures of the teeth and affects more than 70% of adults in the developed world. Unlike most medical problems, prevention and control depends upon the sufferer; without an effective oral hygiene routine, progression is inevitable. This Texas practitioner's site defines all the relevant terms and clearly illustrates the stages of the disease. More general information about risk factors, diagnosis and treatment is provided by the US National Institute of Dental and Craniofacial Research.

The initial stage of periodontal disease is gingivitis – inflammation of the gums (gingivae) as a result of irritation by plaque and tartar (calculus). Instead of being a healthy pink in colour, the gums become swollen and red, with a tendency to bleed easily. The process begins at the gum margin and is generally painless, so is often overlooked by the patient, especially when localised. If neglected, much of the gingival tissue becomes involved, as in this photograph, and magnification reveals a characteristically heavy infiltration of inflammatory cells.

The good news is that gingivitis is completely reversible. Scaling and polishing is usually necessary to remove tartar both above and below the gumline, and this should be followed by regular and thorough oral hygiene. Teeth must be brushed twice a day and flossed at least once, but the technique employed is important; every surface of every tooth must be cleaned. Many dental surgeons recommend the Bass technique for brushing, which is illustrated on this page. When flossing, it is important to move the floss gently up and down the surfaces of the teeth and not to 'saw' in and out, to avoid injuring the gum tissue. The spool and loop methods of flossing are outlined here. An effective oral hygiene routine is particularly important for pregnant women because the associated hormonal changes greatly exaggerate the gingival response to bacteria in dental plaque.

Untreated gingivitis progresses to periodontitis, in which the periodontal ligament and bony socket are gradually destroyed. The gingivae lose their attachment to the roots of the teeth, pockets deepen and bone is gradually resorbed. Eventually the teeth become so loose that they drift and may even fall out. Two fairly advanced cases are illustrated in the photographs here and here. Treatment virtually always involves scaling and root planing to remove calculus deposits, as well as oral hygiene instruction, and may include topical or systemic antibiotics. In some cases pockets may be surgically eliminated to facilitate effective cleaning. There is a series of videos (complete with sound – ignore the text at the top!) showing flap surgery to remove a pocket and a bony defect on the Interactive Periodontology site. The videos work really well with broadband, but may not be for those of a nervous disposition....

One major factor affecting the incidence and progression of periodontal disease is smoking. It appears that tobacco smoke may suppress the body's immune response to the accumulation of dental plaque, as well as being associated with deeper pockets, more rapid progress of the disease and a poorer response to treatment. On a more general note, this site is particularly useful for anyone whose curiosity about periodontal disease has been aroused, because other pages provide a wealth of information on many different aspects of the condition.

One of the most interesting features of this disease is its relationship to other pathological processes. For example, periodontitis seems to influence the occurrence and severity of coronary artery disease, and to increase the risk of heart attack or stroke. Two hypotheses have been put forward to explain the link: firstly, that periodontal pathogens enter the bloodstream, invade vessel walls and cause atherosclerosis, and secondly, that periodontal infections increase plasma inflammation, as indicated by raised levels of fibrinogen, C-reactive protein and cytokines. Earlier this month, a study in the journal Circulation claimed to have found the first direct association between cardiovascular disease and four bacterial pathogens widely believed to be involved in periodontal disease.

Diabetes mellitus sufferers have a higher risk of developing periodontal disease, but it also appears that periodontal disease may exacerbate diabetes, by causing problems in controlling blood sugar levels. This can lead to complications such as vision problems, nerve damage, kidney disease and cardiovascular disease. Moreover, the effect is quite substantial; diabetics with severe periodontal disease are six times more likely to suffer from poor glycaemic (blood sugar) control than diabetics with either mild periodontal disease or none at all. The subject is comprehensively covered in this .pdf article from the Journal of the Canadian Dental Association.

Bizarrely, periodontal disease can even have an effect on the unborn. Expectant mothers with the condition are seven times more likely to give birth to a premature, low birth-weight baby, according to a study of 2,000 pregnant women at the University of North Carolina. In cases where more than 30% of the mouth is affected, the risk is even higher.

Therefore health reasons alone provide a strong motivation for regular dental checks and rigorous, thorough oral hygiene. However, perhaps the greatest incentive is to avoid ending up with a mouth like this!

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