Periodontal disease - Wikipedia

Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, ... Periodontaldisease FromWikipedia,thefreeencyclopedia Jumptonavigation Jumptosearch MedicalconditionPeriodontaldiseaseOthernamesGumdisease,pyorrhea,periodontitisRadiographshowingbonelossbetweenthetworootsofatooth(blackregion).Thespongybonehasrecededduetoinfectionundertooth,reducingthebonysupportforthetooth.PronunciationPeriodontitis/ˌpɛrioʊdɒnˈtaɪtɪs/,pyorrhea/ˌpaɪəˈriːə/SpecialtyDentistrySymptomsRed,swollen,painful,bleedinggums,looseteeth,badbreath[1]ComplicationsToothloss,gumabscess[1][2]CausesBacteriarelatedplaquebuildup[1]RiskfactorsSmoking,[3]diabetes,HIV/AIDS,certainmedications[1]DiagnosticmethodDentalexamination,X-rays[1]TreatmentGoodoralhygiene,regularprofessionalcleaning[4]MedicationoralFrequency538million(2015)[5] Periodontaldisease,alsoknownasgumdisease,isasetofinflammatoryconditionsaffectingthetissuessurroundingtheteeth.[4]Initsearlystage,calledgingivitis,thegumsbecomeswollenandredandmaybleed.[4]Itisconsideredthemaincauseoftoothlossforadultsworldwide.[6][7]Initsmoreseriousform,calledperiodontitis,thegumscanpullawayfromthetooth,bonecanbelost,andtheteethmayloosenorfallout.[4]Badbreathmayalsooccur.[1] Periodontaldiseaseisgenerallyduetobacteriainthemouthinfectingthetissuearoundtheteeth.[4]Factorsthatincreasetheriskofdiseaseincludesmoking,[3]diabetes,HIV/AIDS,familyhistory,andcertainmedications.[1]DiagnosisisbyinspectingthegumtissuearoundtheteethbothvisuallyandwithaprobeandX-rayslookingforbonelossaroundtheteeth.[1][8] Treatmentinvolvesgoodoralhygieneandregularprofessionalteethcleaning.[4]Recommendedoralhygieneincludedailybrushingandflossing.[4]Incertaincasesantibioticsordentalsurgerymayberecommended.[9]Globally538millionpeoplewereestimatedtobeaffectedin2015andhasbeenknowntoaffect10-15%ofthepopulationgenerally.[6][7][5]IntheUnitedStatesnearlyhalfofthoseovertheageof30areaffectedtosomedegree,andabout70%ofthoseover65havethecondition.[4]Malesareaffectedmoreoftenthanfemales.[4] PlaymediaVideosummary(script) Contents 1Signsandsymptoms 1.1Associatedconditions 1.1.1DiabetesandPeriodontalDisease 2ClinicalSignificance 2.1InadequateNutritionandPeriodontalDisease 3Causes 4Mechanism 5Classification 5.11999classification 5.1.1Severity 5.1.2Extent 5.22017classification 5.2.1Staging 5.2.2Grading 6Prevention 7Management 7.1Initialtherapy 7.2Reevaluation 7.3Surgery 7.4Localdrugdelivery 7.5Systemicdrugdelivery 7.6Adjunctivesystemicantimicrobialtreatment 7.7Maintenance 7.8Other 8Prognosis 9Epidemiology 10History 11Societyandculture 11.1Etymology 11.2Economics 12Otheranimals 13Footnotes 14Externallinks Signsandsymptoms[edit] 1:Totallossofattachment(clinicalattachmentloss,CAL)isthesumof2:Gingivalrecession,and3:Probingdepth Intheearlystages,periodontitishasveryfewsymptoms,andinmanyindividualsthediseasehasprogressedsignificantlybeforetheyseektreatment. Symptomsmayinclude: Rednessorbleedingofgumswhilebrushingteeth,usingdentalflossorbitingintohardfood(e.g.,apples)(thoughthismayalsooccuringingivitis,wherethereisnoattachmentlossgumdisease) Gumswellingthatrecurs Spittingoutbloodafterbrushingteeth Halitosis,orbadbreath,andapersistentmetallictasteinthemouth Gingivalrecession,resultinginapparentlengtheningofteeth(thismayalsobecausedbyheavy-handedbrushingorwithastifftoothbrush) Deeppocketsbetweentheteethandthegums(pocketsaresiteswheretheattachmenthasbeengraduallydestroyedbycollagen-destroyingenzymes,knownascollagenases) Looseteeth,inthelaterstages(thoughthismayoccurforotherreasons,aswell) Gingivalinflammationandbonedestructionarelargelypainless.Hence,peoplemaywronglyassumepainlessbleedingafterteethcleaningisinsignificant,althoughthismaybeasymptomofprogressingperiodontitisinthatperson. Associatedconditions[edit] Periodontitishasbeenlinkedtoincreasedinflammationinthebody,suchasindicatedbyraisedlevelsofC-reactiveproteinandinterleukin-6.[10][11][12][13]Itisassociatedwithanincreasedriskofstroke,[14][15]myocardialinfarction,[16]atherosclerosis[17][18][19][20][21][22][23]andhypertension.[24]Italsolinkedinthoseover60yearsofagetoimpairmentsindelayedmemoryandcalculationabilities.[25][26]Individualswithimpairedfastingglucoseanddiabetesmellitushavehigherdegreesofperiodontalinflammation,andoftenhavedifficultieswithbalancingtheirbloodglucoselevelowingtotheconstantsystemicinflammatorystate,causedbytheperiodontalinflammation.[27][28]Althoughnocausalassociationwasproven,thereisanassociationbetweenchronicperiodontitisanderectiledysfunction,[29]inflammatoryboweldisease,[30]heartdisease,[31]andpancreaticcancer.[32] DiabetesandPeriodontalDisease[edit] Apositivecorrelationbetweenraisedlevelsofglucosewithinthebloodandtheonsetorprogressionofperiodontaldiseasehasbeenshowninthecurrentliterature. Datahasalsoshownthatthereisasignificantincreaseintheincidenceorprogressionofperiodontitisinpatientswithuncontrolleddiabetescomparedtothosewhodonothavediabetesorhavewell-controlleddiabetes.Inuncontrolleddiabetes,theformationofreactiveoxygenspeciescandamagecellssuchasthoseintheconnectivetissueoftheperiodontalligament,resultingincellnecrosisorapoptosis.Furthermore,individualswithuncontrolleddiabetesmellituswhohavefrequentexposuretoperiodontalpathogenshaveagreaterimmuneresponsetothesebacteria.Thiscansubsequentlycauseand/oraccelerateperiodontaltissuedestructionleadingtoperiodontaldisease.[33] OralCancerandPeriodontalDisease Currentliteraturesuggestsalinkbetweenperiodontaldiseaseandoralcancer.StudieshaveconfirmedanincreaseinsystemicinflammationmarkerssuchasC-ReactiveProteinandInterleukin-6tobefoundinpatientswithadvancedperiodontaldisease.Thelinkbetweensystemicinflammationandoralcancerhasalsobeenwellestablished. Bothperiodontaldiseaseandcancerriskareassociatedwithgeneticsusceptibilityanditispossiblethatthereisapositiveassociationbyasharedgeneticsusceptibilityinthetwodiseases. Duetothelowincidencerateoforalcancer,studieshavenotbeenabletoconductqualitystudiestoprovetheassociationbetweenthetwo,howeverfuturelargerstudiesmayaidintheidentificationofindividualsatahigherrisk.[34] Systemicimplications Periodontaldisease(PD)canbedescribedasaninflammatoryconditionaffectingthesupportingstructuresoftheteeth.StudieshaveshownthatPDisassociatedwithhigherlevelsofsystemicinflammatorymarkerssuchasInterleukin-6(IL-6),C-ReactiveProtein(CRP)andTumorNecrosisFactor(TNF).Tocompare,elevatedlevelsoftheseinflammatorymarkersarealsoassociatedwithcardiovasculardiseaseandcerebrovasculareventssuchasischemicstrokes.[35] Thepresenceofawidespectruminflammatoryoraldiseasescanincreasetheriskofanepisodeofstrokeinanacuteorchronicphase.Inflammatorymarkers,CRP,IL-6areknownriskfactorsofstroke.BothinflammatorymarkersarealsobiomarkersofPDandfoundtobeanincreasedlevelafterdailyactivities,suchasmasticationortoothbrushing,areperformed.Bacteriafromtheperiodontalpocketswillenterthebloodstreamduringtheseactivitiesandthecurrentliteraturesuggeststhatthismaybeapossibletriggeringoftheaggravationofthestrokeprocess.[36] Othermechanismshavebeensuggested,PDisaknownchronicinfection.Itcanaidinthepromotionofatherosclerosisbythedepositionofcholesterol,cholesterolestersandcalciumwithinthesubendotheliallayerofvesselwalls.[37]Atheroscleroticplaquethatisunstablemayruptureandreleasedebrisandthrombithatmaytraveltodifferentpartsofthecirculatorysystemcausingembolizationandtherefore,anischemicstroke.Therefore,PDhasbeensuggestedasanindependentriskfactorforstroke. Avarietyofcardiovasculardiseasescanalsobeassociatedwithperiodontaldisease.PatientswithhigherlevelsofinflammatorymarkerssuchasTNF,IL-1,IL-6andIL-8canleadtoprogressionofatherosclerosisandthedevelopmentandperpetuationofatrialfibrillation,[38]asitisassociatedwithplateletandcoagulationcascadeactivations,leadingtothrombosisandthromboticcomplications. Experimentalanimalstudieshaveshownalinkbetweenperiodontaldisease,oxidativestressandcardiacstress.Oxidativestressfavoursthedevelopmentandprogressionofheartfailureasitcausescellulardysfunction,oxidationofproteinsandlipids,anddamagetothedeoxyribonucleicacid(DNA),stimulatingfibroblastproliferationandmetalloproteinasesactivationfavouringcardiacremodelling.[39] ClinicalSignificance[edit] InadequateNutritionandPeriodontalDisease[edit] Periodontaldiseaseismultifactorial,andnutritioncansignificantlyaffectitsprognosis.Studieshaveshownthatahealthyandwell-balanceddietiscrucialtomaintainingperiodontalhealth.Nutritionaldeficienciescanleadtooralmanifestationssuchasthoseinscurvyandricketsdisease. Differentvitaminswillplayadifferentroleinperiodontalhealth: VitaminC:Deficienciesmayleadtogingivalinflammationandbleeding,subsequentlyadvancingperiodontaldisease VitaminD:Deficienciesmayleadtodelayedpost-surgicalhealing VitaminE:Deficienciesmayleadtoimpairedgingivalwoundhealing VitaminX:Deficienciesmayleadtogingivalbleeding Nutritionalsupplementsofvitaminshavealsobeenshowntopositivelyaffecthealingafterperiodontalsurgeryandmanyofthesevitaminscanbefoundinavarietyoffoodthatweeatwithinaregularhealthydiet. Therefore,vitaminintakes(particularlyvitaminC)anddietarysupplementsnotonlyplayaroleinimprovingperiodontalhealth,butalsoinfluencetherateofboneformationandperiodontalregeneration.However,studiessupportingthecorrelationbetweennutritionandperiodontalhealtharelimited,andmorelong-termresearchisrequiredtoconfirmthis. [40] Causes[edit] Periodontitisisaninflammationoftheperiodontium,i.e.,thetissuesthatsupporttheteeth.Theperiodontiumconsistsoffourtissues: gingiva,orgumtissue, cementum,orouterlayeroftherootsofteeth, alveolarbone,orthebonysocketsintowhichtheteethareanchored,and periodontalligaments(PDLs),whicharetheconnectivetissuefibersthatrunbetweenthecementumandthealveolarbone. ThisX-rayfilmdisplaystwolone-standingmandibularteeth,thelowerleftfirstpremolarandcanine,exhibitingseverebonelossof30–50%.Wideningoftheperiodontalligamentsurroundingthepremolarisduetosecondaryocclusaltrauma. Theprimarycauseofgingivitisispoororineffectiveoralhygiene,[41]whichleadstotheaccumulationofamycotic[42][43][44][45]andbacterialmatrixatthegumline,calleddentalplaque.Othercontributorsarepoornutritionandunderlyingmedicalissuessuchasdiabetes.[46]Diabeticsmustbemeticulouswiththeirhomecaretocontrolperiodontaldisease.[47]NewfingerpricktestshavebeenapprovedbytheFoodandDrugAdministrationintheUS,andarebeingusedindentalofficestoidentifyandscreenpeopleforpossiblecontributorycausesofgumdisease,suchasdiabetes. Insomepeople,gingivitisprogressestoperiodontitis–withthedestructionofthegingivalfibers,thegumtissuesseparatefromthetoothanddeepenedsulcus,calledaperiodontalpocket.Subgingivalmicroorganisms(thosethatexistunderthegumline)colonizetheperiodontalpocketsandcausefurtherinflammationinthegumtissuesandprogressiveboneloss.Examplesofsecondarycausesarethosethingsthat,bydefinition,causemicrobicplaqueaccumulation,suchasrestorationoverhangsandrootproximity. Theexcessrestorativematerialthatexceedsthenaturalcontoursofrestoredteeth,suchasthese,aretermed"overhangs",andservetotrapmicrobicplaque,potentiallyleadingtolocalizedperiodontitis. Smokingisanotherfactorthatincreasestheoccurrenceofperiodontitis,directlyorindirectly,[48][49][50]andmayinterferewithoradverselyaffectitstreatment.[51][52][53]Itisarguablythemostimportantenvironmentalriskfactorforperiodontitis.Researchhasshownthatsmokershavemoreboneloss,attachmentlossandtoothlosscomparedtonon-smokers.[54]Thisislikelyduetoseveraleffectsofsmokingontheimmuneresponseincludingdecreasedwoundhealing,suppressionofantibodyproduction,andthereductionofphagocytosisbyneutrophils[54] Ehlers–DanlossyndromeandPapillon–Lefèvresyndrome(alsoknownaspalmoplantarkeratoderma)arealsoriskfactorsforperiodontitis. Ifleftundisturbed,microbialplaquecalcifiestoformcalculus,whichiscommonlycalledtartar.Calculusaboveandbelowthegumlinemustberemovedcompletelybythedentalhygienistordentisttotreatgingivitisandperiodontitis.Althoughtheprimarycauseofbothgingivitisandperiodontitisisthemicrobialplaquethatadherestothetoothsurfaces,therearemanyothermodifyingfactors.Averystrongriskfactorisone'sgeneticsusceptibility.Severalconditionsanddiseases,includingDownsyndrome,diabetes,andotherdiseasesthataffectone'sresistancetoinfection,alsoincreasesusceptibilitytoperiodontitis. Periodontitismaybeassociatedwithhigherstress.[55]Periodontitisoccursmoreofteninpeoplefromthelowerendofthesocioeconomicscalethanpeoplefromtheupperendofthesocioeconomicscale.[56] Geneticsappeartoplayaroleindeterminingtheriskforperiodontitis.Itisbelievedgeneticscouldexplainwhysomepeoplewithgoodplaquecontrolhaveadvancedperiodontitis,whilstsomeotherswithpoororalhygienearefreefromthedisease.Geneticfactorswhichcouldmodifytheriskofapersondevelopingperiodontitisinclude: Defectsofphagocytosis:personmayhavehypo-responsivephagocytes. Hyper-productionofinterleukins,prostaglandinsandcytokines,resultinginanexaggeratedimmuneresponse. Interleukin1(IL-1)genepolymorphism:peoplewiththispolymorphismproducemoreIL-1,andsubsequentlyaremoreatriskofdevelopingchronicperiodontitis.[54] Diabetesappearstoexacerbatetheonset,progression,andseverityofperiodontitis.[57]Althoughthemajorityofresearchhasfocusedontype2diabetes,type1diabetesappearstohaveanidenticaleffectontheriskforperiodontitis.[58]Theextentoftheincreasedriskofperiodontitisisdependentonthelevelofglycaemiccontrol.Therefore,inwellmanageddiabetesthereseemstobeasmalleffectofdiabetesontheriskforperiodontitis.However,theriskincreasesexponentiallyasglycaemiccontrolworsens.[58]Overall,theincreasedriskofperiodontitisindiabeticsisestimatedtobebetweentwoandthreetimeshigher.[57]Sofar,themechanismsunderlyingthelinkarenotfullyunderstood,butitisknowntoinvolveaspectsofinflammation,immunefunctioning,neutrophilactivity,andcytokinebiology.[58][59] Mechanism[edit] Asdentalplaqueorbiofilmaccumulatesontheteethnearandbelowthegumsthereissomedysbiosisofthenormaloralmicrobiome.[60]Asof2017itwasnotcertainwhatspeciesweremostresponsibleforcausingharm,butgram-negativeanaerobicbacteria,spirochetes,andviruseshavebeensuggested;inindividualpeopleitissometimesclearthatoneormorespeciesisdrivingthedisease.[60]Researchin2004indicatedthreegramnegativeanaerobicspecies:Aggregatibacteractinomycetemcomitans,Porphyromonasgingivalis,BacteroidesforsythusandEikenellacorrodens.[54] Plaquemaybesoftanduncalcified,hardandcalcified,orboth;forplaquesthatareonteeththecalciumcomesfromsaliva;forplaquesbelowthegumline,itcomesfrombloodviaoozingofinflamedgums.[60] Thedamagetoteethandgumscomesfromtheimmunesystemasitattemptstodestroythemicrobesthataredisruptingthenormalsymbiosisbetweentheoraltissuesandtheoralmicrobecommunity.Asinothertissues,Langerhanscellsintheepitheliumtakeupantigensfromthemicrobes,andpresentthemtotheimmunesystem,leadingtomovementofwhitebloodcellsintotheaffectedtissues.Thisprocessinturnactivatesosteoclastswhichbegintodestroybone,anditactivatesmatrixmetalloproteinasesthatdestroyligaments.[60]So,insummary,itisbacteriawhichinitiatesthedisease,butkeydestructiveeventsarebroughtaboutbytheexaggeratedresponsefromthehost'simmunesystem.[54] Classification[edit] Personwithperiodontitis Seealso:Listofperiodontaldiseases Therewereseveralattemptstointroduceanagreed-uponclassificationsystemforperiodontaldiseases:in1989,1993,1999,[61]and2017. 1999classification[edit] The1999classificationsystemforperiodontaldiseasesandconditionslistedsevenmajorcategoriesofperiodontaldiseases,[61]ofwhich2–6aretermeddestructiveperiodontaldisease,becausethedamageisessentiallyirreversible.Thesevencategoriesareasfollows: Gingivitis Chronicperiodontitis Aggressiveperiodontitis Periodontitisasamanifestationofsystemicdisease Necrotizingulcerativegingivitis/periodontitis Abscessesoftheperiodontium Combinedperiodontic-endodonticlesions Moreover,terminologyexpressingboththeextentandseverityofperiodontaldiseasesareappendedtothetermsabovetodenotethespecificdiagnosisofaparticularpersonorgroupofpeople. Severity[edit] The"severity"ofdiseasereferstotheamountofperiodontalligamentfibersthathavebeenlost,termed"clinicalattachmentloss".Accordingtothe1999classification,theseverityofchronicperiodontitisisgradedasfollows:[62] Slight:1–2 mm(0.039–0.079 in)ofattachmentloss Moderate:3–4 mm(0.12–0.16 in)ofattachmentloss Severe:≥5 mm(0.20 in)ofattachmentloss Extent[edit] Thissectiondoesnotciteanysources.Pleasehelpimprovethissectionbyaddingcitationstoreliablesources.Unsourcedmaterialmaybechallengedandremoved.(November2018)(Learnhowandwhentoremovethistemplatemessage) The"extent"ofdiseasereferstotheproportionofthedentitionaffectedbythediseaseintermsofpercentageofsites.Sitesaredefinedasthepositionsatwhichprobingmeasurementsaretakenaroundeachtoothand,generally,sixprobingsitesaroundeachtootharerecorded,asfollows: Mesiobuccal Mid-buccal Distobuccal Mesiolingual Mid-lingual Distolingual Ifupto30%ofsitesinthemouthareaffected,themanifestationisclassifiedas"localized";formorethan30%,theterm"generalized"isused. 2017classification[edit] The2017classificationofperiodontaldiseasesisasfollows:[63][64][65] Periodontalhealth,gingivaldiseaseandconditions Periodontalhealthandgingivalhealth Clinicalgingivalhealthonanintactperiodontium Clinicalgingivalhealthonanintactperiodontium Stableperiodontitis Nonperiodontitisperson Gingivitis-Dentalbiofilminduced Associatedwiththedentalbiofilmalone Mediatedbysystemicandlocalriskfactors Druginducedgingivalenlargement. Gingivaldiseases-Nondentalbiofilminduced Genetic/developmentaldisorders Specificinfections Inflammatoryandimmuneconditions Reactiveprocesses Neoplasms Endocrine,nutritionalandmetabolic Traumaticlesions Gingivalpigmentation. Periodontitis Necrotizingperiodontaldiseases NecrotizingGingivitis NecrotizingPeriodontitis NecrotizingStomatitis Periodontitisasamanifestationofsystemicdisease Periodontitis Otherconditionsaffectingtheperiodontium (PeriodontalManifestationsofSystemicDiseasesandDevelopmentalandAcquiredConditions) Systemicdiseaseofconditionsaffectingtheperiodontalsupporttissues OtherPeriodontalConditions Periodontalabscesses Endodontic-periodontallesions Mucogingivaldeformitiesandconditions GingivalPhenotype Gingival/SoftTissueRecession LackofGingiva DecreasedVestibularDepth AberrantFrenum/muscleposition GingivalExcess AbnormalColor Conditionoftheexposedrootsurface Traumaticocclusalforces PrimaryOcclusalTrauma SecondaryOcclusalTrauma Toothandprosthesisrelatedfactors Localizedtooth-relatedfactors Localizeddentalprostheses-relatedfactors Peri-implantdiseasesandconditions Peri-implanthealth Peri-implantmucositis Peri-implantitis Peri-implantsoftandhardtissuedeficiencies Staging[edit] Thegoalsofstagingperiodontitisistoclassifytheseverityofdamageandassessspecificfactorsthatmayaffectmanagement.[65] Accordingtothe2017classification,periodontitisisdividedintofourstages;afterconsideringafewfactorssuchas: Amountandpercentagebonelossradiographically Clinicalattachmentloss,probingdepth Presenceoffurcation Verticalbonydefects Historyoftoothlossrelatedtoperiodontitis Toothhypermobilityduetosecondaryocclusaltrauma[65] Grading[edit] Accordingtothe2017classification,thegradingsystemforperiodontitisconsistsofthreegrades:[66] GradeA:Slowprogressionofdisease;noevidenceofbonelossoverlastfiveyears GradeB:Moderateprogression;<2mmofbonelossoverlastfiveyears GradeC:Rapidprogressionorfutureprogressionathighrisk;≥2mmbonelossoverfiveyears Riskfactorsaffectingwhichgradeapersonisclassifiedintoinclude:[66] Smoking Diabetes Prevention[edit] Dailyoralhygienemeasurestopreventperiodontaldiseaseinclude: Brushingproperlyonaregularbasis(atleasttwicedaily),withthepersonattemptingtodirectthetoothbrushbristlesunderneaththegumline,helpsdisruptthebacterial-mycoticgrowthandformationofsubgingivalplaque.[citationneeded] Flossingdailyandusinginterdentalbrushes(ifthespacebetweenteethislargeenough),aswellascleaningbehindthelasttooth,thethirdmolar,ineachquarter[citationneeded] Usinganantisepticmouthwash:Chlorhexidinegluconate-basedmouthwashincombinationwithcarefuloralhygienemaycuregingivitis,althoughtheycannotreverseanyattachmentlossduetoperiodontitis.[citationneeded] Regulardentalcheck-upsandprofessionalteethcleaningasrequired:Dentalcheck-upsservetomonitortheperson'soralhygienemethodsandlevelsofattachmentaroundteeth,identifyanyearlysignsofperiodontitis,andmonitorresponsetotreatment. Typically,dentalhygienists(ordentists)usespecialinstrumentstoclean(debride)teethbelowthegumlineanddisruptanyplaquegrowingbelowthegumline.Thisisastandardtreatmenttopreventanyfurtherprogressofestablishedperiodontitis.Studiesshowthataftersuchaprofessionalcleaning(periodontaldebridement),microbialplaquetendstogrowbacktoprecleaninglevelsafteraboutthreetofourmonths.Nonetheless,thecontinuedstabilizationofaperson'speriodontalstatedependslargely,ifnotprimarily,ontheperson'soralhygieneathome,aswellasonthego.Withoutdailyoralhygiene,periodontaldiseasewillnotbeovercome,especiallyifthepersonhasahistoryofextensiveperiodontaldisease.[citationneeded] Management[edit] ThissectionfromapanoramicX-rayfilmdepictstheteethofthelowerleftquadrant,exhibitinggeneralizedseverebonelossof30–80%.Theredlinedepictstheexistingbonelevel,whereastheyellowlinedepictswherethegingivawaslocatedoriginally(1–2mmabovethebone),priortothepersondevelopingperiodontaldisease.Thepinkarrow,ontheright,pointstoafurcationinvolvement,orthelossofenoughbonetorevealthelocationatwhichtheindividualrootsofamolarbegintobranchfromthesingleroottrunk;thisisasignofadvancedperiodontaldisease.Thebluearrow,inthemiddle,showsupto80%bonelossontoothNo.21,andclinically,thistoothexhibitedgrossmobility.Finally,thepeachoval,totheleft,highlightstheaggressivenaturewithwhichperiodontaldiseasegenerallyaffectsmandibularincisors.Becausetheirrootsaregenerallysituatedveryclosetoeachother,withminimalinterproximalbone,andbecauseoftheirlocationinthemouth,whereplaqueandcalculusaccumulationisgreatestbecauseofthepoolingofsaliva,[citationneeded]mandibularanteriorssufferexcessively.Thesplitintheredlinedepictsvaryingdensitiesofbonethatcontributetoavagueregionofdefinitiveboneheight. Thecornerstoneofsuccessfulperiodontaltreatmentstartswithestablishingexcellentoralhygiene.Thisincludestwice-dailybrushingwithdailyflossing.Also,theuseofaninterdentalbrushishelpfulifspacebetweentheteethallows.Forsmallerspaces,productssuchasnarrowpickswithsoftrubberbristlesprovideexcellentmanualcleaning.Personswithdexterityproblems,suchaswitharthritis,mayfindoralhygienetobedifficultandmayrequiremorefrequentprofessionalcareand/ortheuseofapoweredtoothbrush.Personswithperiodontitismustrealizeitisachronicinflammatorydiseaseandalifelongregimenofexcellenthygieneandprofessionalmaintenancecarewithadentist/hygienistorperiodontistisrequiredtomaintainaffectedteeth. Initialtherapy[edit] Removalofmicrobialplaqueandcalculusisnecessarytoestablishperiodontalhealth.Thefirststepinthetreatmentofperiodontitisinvolvesnonsurgicalcleaningbelowthegumlinewithaprocedurecalled"rootsurfaceinstrumentation"or"RSI",thiscausesamechanicaldisturbancetothebacterialbiofilmbelowthegumline.[54]Thisprocedureinvolvestheuseofspecializedcurettestomechanicallyremoveplaqueandcalculusfrombelowthegumline,andmayrequiremultiplevisitsandlocalanesthesiatoadequatelycomplete.InadditiontoinitialRSI,itmayalsobenecessarytoadjusttheocclusion(bite)topreventexcessiveforceonteeththathavereducedbonesupport.Also,itmaybenecessarytocompleteanyotherdentalneeds,suchasreplacementofrough,plaque-retentiverestorations,closureofopencontactsbetweenteeth,andanyotherrequirementsdiagnosedattheinitialevaluation.ItisimportanttonotethatRSIisdifferenttoscalingandrootplaning:RSIonlyremovesthecalculus,whilescalingandrootplaningremovesthecalculusaswellasunderlyingsofteneddentine,whichleavesbehindasmoothandglassysurface,whichisnotarequisiteforperiodontalhealing.Therefore,RSIisnowadvocatedoverrootplaning.[54] Reevaluation[edit] Nonsurgicalscalingandrootplaningareusuallysuccessfuliftheperiodontalpocketsareshallowerthan4–5 mm(0.16–0.20 in).[67][68][69]Thedentistorhygienistmustperformare-evaluationfourtosixweeksaftertheinitialscalingandrootplaning,todetermineiftheperson'soralhygienehasimprovedandinflammationhasregressed.Probingshouldbeavoidedthen,andananalysisbygingivalindexshoulddeterminethepresenceorabsenceofinflammation.Themonthlyreevaluationofperiodontaltherapyshouldinvolveperiodontalchartingasabetterindicationofthesuccessoftreatment,andtoseeifothercoursesoftreatmentcanbeidentified.Pocketdepthsofgreaterthan5–6 mm(0.20–0.24 in)whichremainafterinitialtherapy,withbleedinguponprobing,indicatecontinuedactivediseaseandwillverylikelyleadtofurtherbonelossovertime.Thisisespeciallytrueinmolartoothsiteswherefurcations(areasbetweentheroots)havebeenexposed. Surgery[edit] Ifnonsurgicaltherapyisfoundtohavebeenunsuccessfulinmanagingsignsofdiseaseactivity,periodontalsurgerymaybeneededtostopprogressivebonelossandregeneratelostbonewherepossible.Manysurgicalapproachesareusedinthetreatmentofadvancedperiodontitis,includingopenflapdebridementandosseoussurgery,aswellasguidedtissueregenerationandbonegrafting.Thegoalofperiodontalsurgeryisaccessfordefinitivecalculusremovalandsurgicalmanagementofbonyirregularitieswhichhaveresultedfromthediseaseprocesstoreducepocketsasmuchaspossible.Long-termstudieshaveshown,inmoderatetoadvancedperiodontitis,surgicallytreatedcasesoftenhavelessfurtherbreakdownovertimeand,whencoupledwitharegularpost-treatmentmaintenanceregimen,aresuccessfulinnearlyhaltingtoothlossinnearly85%ofdiagnosedpeople.[70][71] Localdrugdelivery[edit] Localdrugdeliveriesinperiodontologyhasgainedacceptanceandpopularitycomparedtosystemicdrugsduetodecreasedriskindevelopmentofresistantfloraandothersideeffects.[72]Ametaanalysisoflocaltetracyclinefoundimprovement.[73]Localapplicationofstatinmaybeuseful.[74] Systemicdrugdelivery[edit] Systemicdrugdeliveryinconjunctionwithnon-surgicaltherapymaybeusedasameanstoreducethepercentageofthebacterialplaqueloadinthemouth.Manydifferentantibioticsandalsocombinationsofthemhavebeentested;however,thereisyetverylow-certaintyevidenceofanysignificantdifferenceintheshortandlongtermcomparedtonon-surgicaltherapyalone.Itmaybebeneficialtolimittheuseofsystemicdrugs,sincebacteriacandevelopantimicrobialresistanceandsomespecificantibioticsmightinducetemporarymildadverseeffects,suchasnausea,diarrhoeaandgastrointestinaldisturbances.[75] Adjunctivesystemicantimicrobialtreatment[edit] Thereiscurrentlylow-qualityevidencesuggestingifadjunctivesystemicantimicrobialsarebeneficialforthenon-surgicaltreatmentofperiodontitis.[76]Itisnotsurewhethersomeantibioticsarebetterthanotherswhenusedalongsidescalingandrootplaning).  Maintenance[edit] Oncesuccessfulperiodontaltreatmenthasbeencompleted,withorwithoutsurgery,anongoingregimenof"periodontalmaintenance"isrequired.Thisinvolvesregularcheckupsanddetailedcleaningseverythreemonthstopreventrepopulationofperiodontitis-causingmicroorganisms,andtocloselymonitoraffectedteethsoearlytreatmentcanberenderedifthediseaserecurs.Usually,periodontaldiseaseexistsduetopoorplaquecontrolresultingfrominappropriatebrushing.Thereforeifthebrushingtechniquesarenotmodified,aperiodontalrecurrenceisprobable. Other[edit] Mostalternative"at-home"gumdiseasetreatmentsinvolveinjectingantimicrobialsolutions,suchashydrogenperoxide,intoperiodontalpocketsviaslenderapplicatorsororalirrigators.Thisprocessdisruptsanaerobicmicro-organismcoloniesandiseffectiveatreducinginfectionsandinflammationwhenuseddaily.Anumberofotherproducts,functionallyequivalenttohydrogenperoxide,arecommerciallyavailable,butatsubstantiallyhighercost.However,suchtreatmentsdonotaddresscalculusformations,andsoareshort-lived,asanaerobicmicrobialcoloniesquicklyregenerateinandaroundcalculus. Doxycyclinemaybegivenalongsidetheprimarytherapyofscaling(see§initialtherapy).[77]Doxycyclinehasbeenshowntoimproveindicatorsofdiseaseprogression(namelyprobingdepthandattachmentlevel).[77]Itsmechanismofactioninvolvesinhibitionofmatrixmetalloproteinases(suchascollagenase),whichdegradetheteeth'ssupportingtissues(periodontium)underinflammatoryconditions.[77]Toavoidkillingbeneficialoralmicrobes,onlysmalldosesofdoxycycline(20 mg)areused.[77] Phagetherapymaybeanewtherapeuticalternative.[78] Prognosis[edit] Dentistsanddentalhygienistsmeasureperiodontaldiseaseusingadevicecalledaperiodontalprobe.Thisthin"measuringstick"isgentlyplacedintothespacebetweenthegumsandtheteeth,andslippedbelowthegumline.Iftheprobecanslipmorethan3 mm(0.12 in)belowthegumline,thepersonissaidtohaveagingivalpocketifnomigrationoftheepithelialattachmenthasoccurredoraperiodontalpocketifapicalmigrationhasoccurred.Thisissomewhatofamisnomer,asanydepthis,inessence,apocket,whichinturnisdefinedbyitsdepth,i.e.,a2-mmpocketora6-mmpocket.However,pocketsaregenerallyacceptedasself-cleansable(athome,bytheperson,withatoothbrush)iftheyare3 mmorlessindepth.Thisisimportantbecauseifapocketisdeeperthan3 mmaroundthetooth,at-homecarewillnotbesufficienttocleansethepocket,andprofessionalcareshouldbesought.Whenthepocketdepthsreach6to7 mm(0.24to0.28 in)indepth,thehandinstrumentsandultrasonicscalersusedbythedentalprofessionalsmaynotreachdeeplyenoughintothepockettocleanoutthemicrobialplaquethatcausesgingivalinflammation.Insuchasituation,theboneorthegumsaroundthattoothshouldbesurgicallyalteredoritwillalwayshaveinflammationwhichwilllikelyresultinmorebonelossaroundthattooth.Anadditionalwaytostoptheinflammationwouldbeforthepersontoreceivesubgingivalantibiotics(suchasminocycline)orundergosomeformofgingivalsurgerytoaccessthedepthsofthepocketsandperhapsevenchangethepocketdepthssotheybecome3 mmorlessindepthandcanonceagainbeproperlycleanedbythepersonathomewithhisorhertoothbrush. Ifpeoplehave7-mmordeeperpocketsaroundtheirteeth,thentheywouldlikelyriskeventualtoothlossovertheyears.Ifthisperiodontalconditionisnotidentifiedandpeopleremainunawareoftheprogressivenatureofthedisease,thenyearslater,theymaybesurprisedthatsometeethwillgraduallybecomelooseandmayneedtobeextracted,sometimesduetoasevereinfectionorevenpain. AccordingtotheSriLankantealaborerstudy,intheabsenceofanyoralhygieneactivity,approximately10%willsufferfromsevereperiodontaldiseasewithrapidlossofattachment(>2 mm/year).About80%willsufferfrommoderateloss(1–2 mm/year)andtheremaining10%willnotsufferanyloss.[79][80] Epidemiology[edit] Mainarticle:Epidemiologyofperiodontaldiseases Disability-adjustedlifeyearforperiodontaldiseaseper100,000 inhabitantsin2004.[81]  nodata  <3.5  3.5–4  4–4.5  4.5–5  5–5.5  5.5–6  6–6.5  6.5–7  7–7.5  7.5–8  8–8.5  >8.5 Periodontitisisverycommon,andiswidelyregardedasthesecondmostcommondentaldiseaseworldwide,afterdentaldecay,andintheUnitedStateshasaprevalenceof30–50%ofthepopulation,butonlyabout10%havesevereforms. Chronicperiodontitisaffectsabout750 millionpeopleorabout10.8%oftheworldpopulationasof2010.[82] Likeotherconditionsintimatelyrelatedtoaccesstohygieneandbasicmedicalmonitoringandcare,periodontitistendstobemorecommonineconomicallydisadvantagedpopulationsorregions.Itsoccurrencedecreaseswithahigherstandardofliving.InIsraelipopulation,individualsofYemenite,North-African,SouthAsian,orMediterraneanoriginhavehigherprevalenceofperiodontaldiseasethanindividualsfromEuropeandescent.[83]Periodontitisisfrequentlyreportedtobesociallypatterned,i.e.peoplefromthelowerendofthesocioeconomicscalesuffermoreoftenfromitthanpeoplefromtheupperendofthesocioeconomicscale.[56] History[edit] Anancienthominidfrom3millionyearsagohadgumdisease.[84]RecordsfromChinaandtheMiddleEast,alongwitharchaeologicalstudies,showthatmankindhassufferedfromPeriodontaldiseaseforatleastmanythousandsofyears.InEuropeandtheMiddleEastarchaeologicalresearchlookingatancientplaqueDNA,showsthatintheancienthunter-gathererlifestyletherewaslessgumdisease,butthatitbecamemorecommonwhenmorecerealswereeaten.TheOtziIcemanwasshowntohavehadseveregumdisease.[citationneeded]Furthermore,researchhasshownthatintheRomaneraintheUK,therewaslessperiodontaldiseasethaninmoderntimes.Theresearcherssuggestthatsmokingmaybeakeytothis.[85] Societyandculture[edit] Etymology[edit] Theword"periodontitis"(Greek:περιοδοντίτις)comesfromtheGreekperi,"around",odous(GENodontos),"tooth",andthesuffix-itis,inmedicalterminology"inflammation".[86]Thewordpyorrhea(alternativespelling:pyorrhoea)comesfromtheGreekpyorrhoia(πυόρροια),"dischargeofmatter",itselffrompyon,"dischargefromasore",rhoē,"flow",andthesuffix-ia.[87]InEnglishthistermcandescribe,asinGreek,anydischargeofpus;i.e.itisnotrestrictedtothesediseasesoftheteeth.[88] Economics[edit] ItisestimatedthatlostproductivityduetosevereperiodontitiscoststheglobaleconomyaboutUS$54 billioneachyear.[89] Otheranimals[edit] Periodontaldiseaseisthemostcommondiseasefoundindogsandaffectsmorethan80%ofdogsagedthreeyearsorolder.Itsprevalenceindogsincreaseswithage,butdecreaseswithincreasingbodyweight;i.e.,toyandminiaturebreedsaremoreseverelyaffected.RecentresearchundertakenattheWalthamCentreforPetNutritionhasestablishedthatthebacteriaassociatedwithgumdiseaseindogsarenotthesameasinhumans.[90]Systemicdiseasemaydevelopbecausethegumsareveryvascular(haveagoodbloodsupply).Thebloodstreamcarriestheseanaerobicmicro-organisms,andtheyarefilteredoutbythekidneysandliver,wheretheymaycolonizeandcreatemicroabscesses.Themicroorganismstravelingthroughthebloodmayalsoattachtotheheartvalves,causingvegetativeinfectiveendocarditis(infectedheartvalves).Additionaldiseasesthatmayresultfromperiodontitisincludechronicbronchitisandpulmonaryfibrosis.[91] Footnotes[edit] ^abcdefgh"GumDisease".NationalInstituteofDentalandCraniofacialResearch.February2018.Retrieved13March2018. ^"GumDiseaseComplications".nhs.uk.Retrieved13March2018. 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Externallinks[edit] ClassificationDICD-10:K05.4MeSH:D010518DiseasesDB:29362ExternalresourcesMedlinePlus:001059 Medicineportal CanadianAcademyofPeriodontology—Whatisperiodontitis? Periodontaldiseaseandbraces.OrthodonticsAustralia. vteDentistryinvolvingsupportingstructuresofteeth(Periodontology)Anatomy Periodontium Alveolarbone Biologicwidth Bundlebone Cementum Freegingivalmargin Gingiva Gingivalfibers Gingivalsulcus Junctionalepithelium Mucogingivaljunction Periodontalligament Sulcularepithelium Stippling DiseaseDiagnoses Chronicperiodontitis Localizedaggressiveperiodontitis Generalizedaggressiveperiodontitis Periodontitisasamanifestationofsystemicdisease Periodontosis Necrotizingperiodontaldiseases Abscessesoftheperiodontium Combinedperiodontic-endodonticlesions Infection A.actinomycetemcomitans Capnocytophagasp. F.nucleatum P.gingivalis P.intermedia T.forsythia T.denticola Redcomplex Entamoebagingivalis(amoebic) Trichomonastenax Other Calculus Clinicalattachmentloss Edentulism Fremitus Furcationdefect Gingivalenlargement Gingivalpocket Gingivalrecession Gingivitis Horizontalbonydefect Lineargingivalerythema Occlusaltrauma Periodontalpocket Periodontaldisease Periodontitis Plaque Verticalbonydefect Treatmentandprevention Periodontalexamination Ante'slaw Brushing Bleedingonprobing Chlorhexidinegluconate Flossing Hydrogenperoxide Mouthwash Oralhygiene Tetracycline Triclosan Hostmodulatorytherapy TreatmentConventionaltherapy Debridement Scalingandrootplaning Fullmouthdisinfection Fullmouthultrasonicdebridement Surgery Apicallypositionedflap Bonegraft Coronallypositionedflap Crownlengthening Freegingivalgraft Gingivalgrafting Gingivectomy Guidedboneregeneration Guidedtissueregeneration Enamelmatrixderivative Implantplacement Lateralpediclegraft Openflapdebridement Pocketreductionsurgery Socketpreservation Sinuslift Subepithelialconnectivetissuegraft Tools Curette Membrane Probe Scaler Importantpersonalities TomasAlbrektsson FrankBeube Per-IngvarBrånemark RobertGottsegen GaryGreenstein JanLindhe BrianMealey PrestonD.Miller WilloughbyD.Miller CarlE.Misch JohnMankeyRiggs JaySeibert JørgenSlots PaulRoscoeStillman DennisP.Tarnow Hom-LayWang JamesLeonWilliams W.J.Younger Otherspecialties Endodontology Orthodontology Prosthodontology vteOralandmaxillofacialpathologyLips Cheilitis Actinic Angular Plasmacell Cleftlip Congenitallippit Eclabium Herpeslabialis Macrocheilia Microcheilia Nasolabialcyst Sunpoisoning Trumpeter'swart Tongue Ankyloglossia Blackhairytongue Caviartongue Crenatedtongue Cunnilingustongue Fissuredtongue Foliatepapillitis Glossitis Geographictongue Medianrhomboidglossitis Transientlingualpapillitis Glossoptosis Hypoglossia Lingualthyroid Macroglossia Microglossia Rhabdomyoma Palate Bednar'saphthae Cleftpalate High-archedpalate Palatalcystsofthenewborn Inflammatorypapillaryhyperplasia Stomatitisnicotina Toruspalatinus Oralmucosa–Liningofmouth Amalgamtattoo Anginabullosahaemorrhagica Behçet'sdisease Bohn'snodules Burningmouthsyndrome Candidiasis Condylomaacuminatum Darier'sdisease Epulisfissuratum Erythemamultiforme Erythroplakia Fibroma Giant-cell Focalepithelialhyperplasia Fordycespots Hairyleukoplakia Hand,footandmouthdisease Hereditarybenignintraepithelialdyskeratosis Herpangina Herpeszoster Intraoraldentalsinus Leukoedema Leukoplakia Lichenplanus Lineaalba Lupuserythematosus Melanocyticnevus Melanocyticorallesion Molluscumcontagiosum Morsicatiobuccarum Oralcancer Benign:Squamouscellpapilloma Keratoacanthoma Malignant:Adenosquamouscarcinoma Basaloidsquamouscarcinoma Mucosalmelanoma Spindlecellcarcinoma Squamouscellcarcinoma Verrucouscarcinoma Oralfloridpapillomatosis Oralmelanosis Smoker'smelanosis Pemphigoid Benignmucousmembrane Pemphigus Plasmoacanthoma Stomatitis Aphthous Denture-related Herpetic Smokelesstobaccokeratosis Submucousfibrosis Ulceration Riga–Fededisease Verrucavulgaris Verruciformxanthoma Whitespongenevus Teeth(pulp,dentin,enamel) Amelogenesisimperfecta Ankylosis Anodontia Caries Earlychildhoodcaries Concrescence Failureoferuptionofteeth Densevaginatus Taloncusp Dentindysplasia Dentinhypersensitivity Dentinogenesisimperfecta Dilaceration Discoloration Ectopicenamel Enamelhypocalcification Enamelhypoplasia Turner'shypoplasia Enamelpearl Fluorosis Fusion Gemination Hyperdontia Hypodontia Maxillarylateralincisoragenesis Impaction Wisdomtoothimpaction Macrodontia Methmouth Microdontia Odontogenictumors Keratocysticodontogenictumour Odontoma Densindente Opencontact Prematureeruption Neonatalteeth Pulpcalcification Pulpstone Pulpcanalobliteration Pulpnecrosis Pulppolyp Pulpitis Regionalodontodysplasia Resorption Shovel-shapedincisors Supernumeraryroot Taurodontism Trauma Avulsion Crackedtoothsyndrome Verticalrootfracture Occlusal Toothloss Edentulism Toothwear Abrasion Abfraction Aciderosion Attrition Periodontium(gingiva,periodontalligament,cementum,alveolus)–Gumsandtooth-supportingstructures Cementicle Cementoblastoma Gigantiform Cementoma Eruptioncyst Epulis Pyogenicgranuloma Congenitalepulis Gingivalenlargement Gingivalcystoftheadult Gingivalcystofthenewborn Gingivitis Desquamative Granulomatous Plasmacell Hereditarygingivalfibromatosis Hypercementosis Hypocementosis Lineargingivalerythema Necrotizingperiodontaldiseases Acutenecrotizingulcerativegingivitis Pericoronitis Peri-implantitis Periodontalabscess Periodontaltrauma Periodontitis Aggressive Asamanifestationofsystemicdisease Chronic Perio-endolesion Teething Periapical,mandibularandmaxillaryhardtissues–Bonesofjaws Agnathia Alveolarosteitis Buccalexostosis Cherubism Idiopathicosteosclerosis Mandibularfracture Microgenia Micrognathia Intraosseouscysts Odontogenic:periapical Dentigerous Buccalbifurcation Lateralperiodontal Globulomaxillary Calcifyingodontogenic Glandularodontogenic Non-odontogenic:Nasopalatineduct Medianmandibular Medianpalatal Traumaticbone Osteoma Osteomyelitis Osteonecrosis Bisphosphonate-associated Neuralgia-inducingcavitationalosteonecrosis Osteoradionecrosis Osteoporoticbonemarrowdefect Paget'sdiseaseofbone Periapicalabscess Phoenixabscess Periapicalperiodontitis Stafnedefect Torusmandibularis Temporomandibularjoints,musclesofmasticationandmalocclusions–Jawjoints,chewingmusclesandbiteabnormalities Bruxism Condylarresorption Mandibulardislocation Malocclusion Crossbite Openbite Overbite Overeruption Overjet Prognathia Retrognathia Scissorbite Maxillaryhypoplasia Temporomandibularjointdysfunction Salivaryglands Benignlymphoepitheliallesion Ectopicsalivaryglandtissue Frey'ssyndrome HIVsalivaryglanddisease Necrotizingsialometaplasia Mucocele Ranula Pneumoparotitis Salivaryductstricture Salivaryglandaplasia Salivaryglandatresia Salivaryglanddiverticulum Salivaryglandfistula Salivaryglandhyperplasia Salivaryglandhypoplasia Salivaryglandneoplasms Benign:Basalcelladenoma Canalicularadenoma Ductalpapilloma Monomorphicadenoma Myoepithelioma Oncocytoma Papillarycystadenomalymphomatosum Pleomorphicadenoma Sebaceousadenoma Malignant:Aciniccellcarcinoma Adenocarcinoma Adenoidcysticcarcinoma Carcinomaexpleomorphicadenoma Lymphoma Mucoepidermoidcarcinoma Sclerosingpolycysticadenosis Sialadenitis Parotitis Chronicsclerosingsialadenitis Sialectasis Sialocele Sialodochitis Sialosis Sialolithiasis Sjögren'ssyndrome Orofacialsofttissues–Softtissuesaroundthemouth Actinomycosis Angioedema Basalcellcarcinoma Cutaneoussinusofdentalorigin Cystichygroma Gnathophyma Ludwig'sangina Macrostomia Melkersson–Rosenthalsyndrome Microstomia Noma OralCrohn'sdisease Orofacialgranulomatosis Perioraldermatitis Pyostomatitisvegetans Other Eaglesyndrome Hemifacialhypertrophy Facialhemiatrophy Oralmanifestationsofsystemicdisease Authoritycontrol:Nationallibraries Spain Germany Israel UnitedStates Japan 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