Periodontal disease
Encyclopedia
Periodontitis is a set of inflammatory disease
s affecting the periodontium
, i.e., the tissues that surround and support the teeth
. Periodontitis involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent loss of teeth
. Periodontitis is caused by microorganism
s that adhere to and grow on the tooth's surfaces, along with an overly aggressive immune response against these microorganisms. A diagnosis of periodontitis is established by inspecting the soft gum tissues
around the teeth with a probe
(i.e. a clinical exam) and by evaluating the patient's x-ray films (i.e. a radiographic exam), to determine the amount of bone loss around the teeth. Specialists in the treatment of periodontitis are periodontists; their field is known as "periodontology" or "periodontics".
The word "periodontitis" comes from peri ("around"), odont ("tooth") and -itis ("inflammation").
Moreover, terminology expressing both the extent and severity of periodontal diseases are appended to the terms above to denote the specific diagnosis of a particular patient or group of patients.
If up to 30% of sites in the mouth are affected, the manifestation is classification as localized; for more than 30%, the term generalized is used.
fibers that have been lost, termed clinical attachment loss. According to the American Academy of Periodontology, the classification of severity is as follows:
Symptoms may include the following:
Patients should realize that the gingival inflammation and bone destruction are largely painless. Hence, people may wrongly assume that painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient.
in the body such as indicated by raised levels of C-reactive protein
and Interleukin-6. It is through this linked to increased risk of stroke
, myocardial infarction
, and atherosclerosis
. It also linked in those over 60 years of age to impairments in delayed memory and calculation abilities. Individuals with impaired fasting glucose and diabetes mellitus
have higher degree of periodontal inflammation, and often have difficulties with balancing their blood
glucose
level owing to the constant systemic inflammatory state, caused by the periodontal inflammation. Although no causative connection was proved yet, a recent study revealed an epidemiological
association between chronic periodontitis and erectile dysfunction
.
, i.e., the tissues that support the teeth. The periodontium consists of four tissues:
The primary etiology
(cause) of gingivitis is poor oral hygiene
which leads to the accumulation of a mycotic
and bacterial matrix at the gum line, called dental plaque
. Other contributors are poor nutrition
and underlying medical issues such as diabetes. New finger nick tests have been approved by the Food and Drug Administration
in the US, and are being used in dental offices to identify and screen patients for possible contributory causes of gum disease such as diabetes.
In some people, gingivitis progresses to periodontitis –- with the destruction of the gingival fibers
, the gum tissues separate from the tooth and deepened sulcus, called a periodontal pocket. Subgingival microorganism (those that exist under the gum line) colonize the periodontal pockets and cause further inflammation in the gum tissues and progressive bone loss. Examples of secondary etiology are those things that, by definition, cause microbic plaque accumulation, such as restoration overhangs and root proximity.
Smoking is another factor that increases the occurrence of periodontitis, directly or indirectly, and may interfere with or adversely affect its treatment.
Ehlers-Danlos Syndrome
is a periodontitis risk factor.
If left undisturbed, microbic plaque calcifies to form calculus, which is commonly called tartar. Calculus above and below the gum line must be removed completely by the dental hygienist or dentist to treat gingivitis and periodontitis. Although the primary cause of both gingivitis and periodontitis is the microbic plaque that adheres to the tooth surface, there are many other modifying factors. A very strong risk factor is one's genetic susceptibility. Several conditions and diseases, including Down syndrome
, diabetes, and other diseases that affect one's resistance to infection also increase susceptibility to periodontitis.
Another factor that makes periodontitis a difficult disease to study is that human host response can also affect the alveolar bone resorption. Host response to the bacterial-mycotic
insult is mainly determined by genetics; however, immune development may play some role in susceptibility.
According to some researches periodontitis may be associated with higher stress.
measures to prevent periodontal disease include:
Typically dental hygienists (or dentists) use special instruments to clean (debride) teeth below the gumline and disrupt any plaque growing below the gumline. This is a standard treatment to prevent any further progress of established periodontitis. Studies show that after such a professional cleaning (periodontal debridement), microbic plaque tend to grow back to pre-cleaning levels after about 3–4 months. However, it is advocated that the interval between dental check-ups should be determined specifically for each patient between every 3 to 12 months.
Nonetheless, the continued stabilization of a patient's periodontal state depends largely, if not primarily, on the patient's oral hygiene at home as well as on the go. Without daily oral hygiene
, periodontal disease will not be overcome, especially if the patient has a history of extensive periodontal disease.
Periodontal disease and tooth
loss are associated with an increased risk of cancer
.
A contributing cause may be low selenium
in the diet:
"Results showed that selenium has the strongest association with gum disease, with low levels increasing the risk by 13 fold."
The cornerstone of successful periodontal treatment starts with establishing excellent oral hygiene
. This includes twice daily brushing
with daily flossing. Also the use of an interdental brush (called a Proxi-brush) is helpful if space between the teeth allows. For smaller spaces a product called "Soft Picks" are an excellent manual cleaning device. Persons with dexterity problems such as arthritis
may find oral hygiene to be difficult and may require more frequent professional care and/or the use of a powered tooth brush. Persons with periodontitis must realize that it is a chronic inflammatory disease and a lifelong regimen of excellent hygiene and professional maintenance care with a dentist/hygienist or periodontist is required to maintain affected teeth.
to adequately complete. In addition to initial scaling and root planing, it may also be necessary to adjust the occlusion (bite) to prevent excessive force on teeth that have reduced bone support. Also it may be necessary to complete any other dental needs such as replacement of rough, plaque retentive restorations, closure of open contacts between teeth, and any other requirements diagnosed at the initial evaluation.
tooth sites where furcations
(areas between the roots) have been exposed.
may be needed to stop progressive bone loss and regenerate lost bone where possible. There are many surgical approaches used in treatment of advanced periodontitis, including open flap debridement, osseous surgery, as well as guided tissue regeneration and bone grafting. The goal of periodontal surgery is access for definitive calculus removal and surgical management of bony irregularities which have resulted from the disease process to reduce pockets as much as possible. Long-term studies have shown that in moderate to advanced periodontitis, surgically treated cases often have less further breakdown over time and when coupled with a regular post-treatment maintenance regimen are successful in nearly halting tooth loss in nearly 85% of patients.
Most alternative “at-home” gum disease treatments involve injecting anti-microbial solutions, such as hydrogen peroxide
, into periodontal pockets via slender applicators or oral irrigators. This process disrupts anaerobic microorganism colonies and is effective at reducing infections and inflammation when used daily. A number of potions and elixirs that are functionally equivalent to hydrogen peroxide are commercially available but at substantially higher cost. However, such treatments do not address calculus formations, and so are short-lived, as anaerobic microorganism colonies quickly regenerate in and around calculus.
In a new field of study, calculus formations are addressed on a more fundamental level. At the heart of the formation of subgingival calculus, growing plaque formations starve out the lowest members of the community, which calcify into calcium phosphate salts of the same shape and size of the original, organic bacilli. Calcium phosphate salts (unlike calcium phosphate; the primary component in teeth) are ionic
and adhere to tooth surfaces via electrostatic attraction. Smaller, free-floating calcium phosphate salt particles are equally attracted to the same areas, as are additional calcified microorganism, growing calculus formations as unorganized, yet strong, “brick and mortar” matrices. The microscopic voids in calculus formations house new anaerobic microorganism, as does the top “diseased layer”.
Because the root cause of subgingival calculus development is ionic attraction, it was hypothesized that the introduction of oppositely charged particles around the formations may chelate calcium phosphate salt components away from the matrix, thus reducing the size of subgingival calculus formations. To accomplish this, a sequestering agent solution consisting partly of sodium tripolyphosphate
(STPP) and sodium fluoride
(charge -1) was tested on a patient with burnished and new subgingival calculus at a depth of 6 mm. The patient delivered the solution using an oral irrigator, once a day, for 60 days. The results were the successful elimination of all calculus formations studied. This test was conducted using a subgingival endoscopic camera (perioscope) by an independent periodontist.
The promise of this new, alternative treatment is to keep subgingival calculus at bay, in concert with traditional periodontal treatments. In this way, periodontitis may be controlled by the patient, and complete restoration of dental health can be a collaborative effort between the patient and the dental professional.
Additionally, Periodontitis can be treated in a noninvasive manner by means of Periostat (subantimicrobial dose of doxycycline), an FDA-approved, orally-administered drug that has been shown to reduce bone loss. Its mechanism of action in part involves inhibition of Matrix metalloproteinases (such as collagenase), which degrade the extracellular matrix under inflammatory conditions. This ultimately can lead to reduction of aveolar bone-loss in patients with periodontal disease (as well as patients without periodontitis).
. This is a thin "measuring stick" that is gently placed into the space between the gums and the teeth, and slipped below the gum-line. If the probe can slip more than 3 millimeters below the gum-line, the patient is said to have a gingival pocket if no migration of the epithelial attachment has occurred or a periodontal pocket if apical migration has occurred. This is somewhat of a misnomer, as any depth is in essence a pocket, which in turn is defined by its depth, i.e., a 2 mm pocket or a 6 mm pocket. However, it is generally accepted that pockets are self-cleansable (at home, by the patient, with a toothbrush) if they are 3 mm or less in depth. This is important because if there is a pocket which is deeper than 3 mm around the tooth, at-home care will not be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach 6 and 7 mm in depth, the hand instruments and cavitrons used by the dental professionals may not reach deeply enough into the pocket to clean out the microbic plaque that cause gingival inflammation. In such a situation the bone or the gums around that tooth should be surgically altered or it will always have inflammation which will likely result in more bone loss around that tooth. An additional way to stop the inflammation would be for the patient to receive subgingival antibiotics (such as minocycline
) or undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so that they become 3 mm or less in depth and can once again be properly cleaned by the patient at home with his or her toothbrush.
If a patient has 7 mm or deeper pockets around their teeth, then they would likely risk eventual tooth loss over the years. If this periodontal condition is not identified and the patient remains unaware of the progressive nature of the disease then, years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain.
According to the Sri Lanka
n tea labourer study, in the absence of any oral hygiene activity, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment (>2 mm/year). 80% will suffer from moderate loss (1–2 mm/year) and the remaining 10% will not suffer any loss.
has a prevalence
of 30–50% of the population, but only about 10% have severe forms.
Like other conditions that are intimately related to access to hygiene and basic medical monitoring and care, periodontitis tends to be more common in economically disadvantaged populations or regions. Its occurrence decreases with higher standard of living. In Israel
i population, individuals of Yemen
ite, North-Africa
n, South Asia
n, or Mediterranean origin have higher prevalence of periodontal disease than individuals from Europe
an descent.
Presumably, individuals living in East Asia
(e.g. Japan, South Korea and Taiwan) have the lowest incident of periodontal disease in the world.
s and affects more than 80% of dogs aged three years or older. The prevalence of periodontal disease in dogs increases with age but decreases with increasing body weight; i.e., toy and miniature breeds are more severely affected. Systemic disease may develop because the gums are very vascular (have a good blood supply). The blood stream carries these anaerobic microorganisms, and they are filtered out by the kidney
s and liver
, where they may colonize and create microabscesses. The microorganisms traveling through the blood may also attach to the heart
valves, causing vegetative endocarditis
(infected heart valves). Additional diseases that may result from periodontitis includes chronic bronchitis
and pulmonary fibrosis
.
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
s affecting the periodontium
Periodontium
Periodontium refers to the specialized tissues that both surround and support the teeth, maintaining them in the maxillary and mandibular bones. The word comes from the Greek terms peri-, meaning "around" and -odons, meaning "tooth." Literally taken, it means that which is "around the tooth"...
, i.e., the tissues that surround and support the teeth
Tooth
Teeth are small, calcified, whitish structures found in the jaws of many vertebrates that are used to break down food. Some animals, particularly carnivores, also use teeth for hunting or for defensive purposes. The roots of teeth are embedded in the Mandible bone or the Maxillary bone and are...
. Periodontitis involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent loss of teeth
Tooth loss
Tooth loss is when one or more teeth come loose and fall out. Tooth loss is normal for deciduous teeth , when they are replaced by a person's adult teeth. Otherwise, losing teeth is undesirable and is the result of injury or disease, such as mouth trauma, tooth injury, tooth decay, and gum disease...
. Periodontitis is caused by microorganism
Microorganism
A microorganism or microbe is a microscopic organism that comprises either a single cell , cell clusters, or no cell at all...
s that adhere to and grow on the tooth's surfaces, along with an overly aggressive immune response against these microorganisms. A diagnosis of periodontitis is established by inspecting the soft gum tissues
Gingiva
The gingiva , or gums, consists of the mucosal tissue that lies over the mandible and maxilla inside the mouth.-General description:...
around the teeth with a probe
Periodontal probe
A periodontal probe is an instrument in dentistry commonly used in the dental armamentarium. It is usually long, thin, and blunted at the end. The primary purpose of a periodontal probe is to measure pocket depths around a tooth in order to establish the state of health of the periodontium...
(i.e. a clinical exam) and by evaluating the patient's x-ray films (i.e. a radiographic exam), to determine the amount of bone loss around the teeth. Specialists in the treatment of periodontitis are periodontists; their field is known as "periodontology" or "periodontics".
The word "periodontitis" comes from peri ("around"), odont ("tooth") and -itis ("inflammation").
Classification
The 1999 classification system for periodontal diseases and conditions listed seven major categories of periodontal diseases, of which the last six are termed destructive periodontal disease because they are essentially irreversible. The seven categories are as follows:- GingivitisGingivitisGingivitis is a term used to describe non-destructive periodontal disease. The most common form of gingivitis is in response to bacterial biofilms adherent to tooth surfaces, termed plaque-induced gingivitis, and is the most common form of periodontal disease...
- Chronic periodontitisChronic periodontitisChronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation of the periodontal tissues that is caused by accumulation of profuse amounts of dental plaque.-Diagnosis:...
- Aggressive periodontitisAggressive periodontitisAggressive periodontitis describes a type of periodontal disease and includes two of the seven classifications of periodontitis:# Localized aggressive periodontitis # Generalized aggressive periodontitis...
- Periodontitis as a manifestation of systemic diseasePeriodontitis as a manifestation of systemic diseasePeriodontitis as a manifestation of systemic diseases is one of the seven categories of periodontitis as defined by the American Academy of Periodontology 1999 classification system. At least 16 systemic diseases have been linked to periodontitis...
- Necrotizing ulcerative gingivitis/periodontitis
- Abscesses of the periodontiumAbscesses of the periodontiumAbscesses of the periodontium are localized acute bacterial infections classified primarily based on location.-Types:There are four types of abscesses associated with the periodontal tissues:# gingival abscesses# periodontal abscesses...
- Combined periodontic-endodontic lesionsCombined periodontic-endodontic lesionsCombined periodontic-endodontic lesions are localized, circumscribed areas of bacterial infection originating from either dental pulp, periodontal tissues surrounding the involved tooth or teeth or both.-Source of infection:...
Moreover, terminology expressing both the extent and severity of periodontal diseases are appended to the terms above to denote the specific diagnosis of a particular patient or group of patients.
Extent
The extent of disease refers to the proportion of the dentition affected by the disease in terms of percentage of sites. Sites are defined as the positions at which probing measurements are taken around each tooth and, generally, six probing sites around each tooth are recorded, as follows:- mesiobuccalCommonly used terms of relationship and comparison in dentistryThere are numerous commonly used terms of relationship and comparison that refer to different aspects of teeth and are frequently utilized in articles about dentistry...
- mid-buccal
- distobuccal
- mesiolingual
- mid-lingual
- distolingual
If up to 30% of sites in the mouth are affected, the manifestation is classification as localized; for more than 30%, the term generalized is used.
Severity
The severity of disease refers to the amount of periodontal ligamentPeriodontal ligament
The periodontal fiber or periodontal ligament, commonly abbreviated as the PDL, is a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which it sits...
fibers that have been lost, termed clinical attachment loss. According to the American Academy of Periodontology, the classification of severity is as follows:
- Mild: 1–2 mm of attachment loss
- Moderate: 3–4 mm of attachment loss
- Severe: ≥ 5 mm of attachment lo
Signs and symptoms
In the early stages, periodontitis has very few symptoms and in many individuals the disease has progressed significantly before they seek treatment.Symptoms may include the following:
- Redness or bleeding of gums while brushing teethToothTeeth are small, calcified, whitish structures found in the jaws of many vertebrates that are used to break down food. Some animals, particularly carnivores, also use teeth for hunting or for defensive purposes. The roots of teeth are embedded in the Mandible bone or the Maxillary bone and are...
, using dental flossDental flossDental floss is made of either a bundle of thin nylon filaments or a plastic ribbon used to remove food and dental plaque from teeth. The floss is gently inserted between the teeth and scraped along the teeth sides, especially close to the gums. Dental floss may be flavored or unflavored, and...
or biting into hard food (e.g. apples) (though this may occur even in gingivitis, where there is no attachment loss) - Gum swelling that recurs
- spiting out blood after brushing teeth
- HalitosisHalitosisHalitosis is a term used to describe noticeably unpleasant odors exhaled in breathing. Halitosis is estimated to be the third most frequent reason for seeking dental aid, following tooth decay and periodontal disease.- General :...
, or bad breath, and a persistent metallic taste in the mouth - Gingival recession, resulting in apparent lengthening of teeth. (This may also be caused by heavy handed brushing or with a stiff tooth brush.)
- Deep pockets between the teeth and the gums (pockets are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as collagenasesCollagenasesCollagenases are enzymes that break the peptide bonds in collagen.They assist in destroying extracellular structures in pathogenesis of bacteria such as Clostridium. They are an exotoxin and help to facilitate the spread of gas gangrene...
) - Loose teeth, in the later stages (though this may occur for other reasonsOcclusal traumaOcclusal trauma is a dental term that refers to the damage incurred when teeth are left in traumatic occlusion without proper treatment.When the maxillary and mandibular dental arches approach each together, as they do, for example, during chewing or at rest, the relationship between the opposing...
as well)
Patients should realize that the gingival inflammation and bone destruction are largely painless. Hence, people may wrongly assume that painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient.
Effects outside the mouth
Periodontitis has been linked to increased inflammationInflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
in the body such as indicated by raised levels of C-reactive protein
C-reactive protein
C-reactive protein is a protein found in the blood, the levels of which rise in response to inflammation...
and Interleukin-6. It is through this linked to increased risk of stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
, myocardial infarction
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
, and atherosclerosis
Atherosclerosis
Atherosclerosis is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol...
. It also linked in those over 60 years of age to impairments in delayed memory and calculation abilities. Individuals with impaired fasting glucose and diabetes mellitus
Diabetes mellitus
Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...
have higher degree of periodontal inflammation, and often have difficulties with balancing their blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
glucose
Glucose
Glucose is a simple sugar and an important carbohydrate in biology. Cells use it as the primary source of energy and a metabolic intermediate...
level owing to the constant systemic inflammatory state, caused by the periodontal inflammation. Although no causative connection was proved yet, a recent study revealed an epidemiological
Epidemiology
Epidemiology is the study of health-event, health-characteristic, or health-determinant patterns in a population. It is the cornerstone method of public health research, and helps inform policy decisions and evidence-based medicine by identifying risk factors for disease and targets for preventive...
association between chronic periodontitis and erectile dysfunction
Erectile dysfunction
Erectile dysfunction is sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual performance....
.
Causes
Periodontitis is an inflammation of the periodontiumPeriodontium
Periodontium refers to the specialized tissues that both surround and support the teeth, maintaining them in the maxillary and mandibular bones. The word comes from the Greek terms peri-, meaning "around" and -odons, meaning "tooth." Literally taken, it means that which is "around the tooth"...
, i.e., the tissues that support the teeth. The periodontium consists of four tissues:
- gingivaGingivaThe gingiva , or gums, consists of the mucosal tissue that lies over the mandible and maxilla inside the mouth.-General description:...
, or gum tissue; - cementumCementumCementum is a specialized calcified substance covering the root of a tooth. Cementum is excreted by cells called cementoblasts within the root of the tooth and is thickest at the root apex. These cementoblasts develop from undifferentiated mesenchymal cells in the connective tissue of the dental...
, or outer layer of the roots of teeth; - alveolar boneDental alveolusDental alveolus are sockets in the jaws in which the roots of teeth are held in the alveolar process of maxilla with the periodontal ligament. The lay term for dental alveoli is tooth sockets...
, or the bony sockets into which the teeth are anchored; - periodontal ligamentPeriodontal ligamentThe periodontal fiber or periodontal ligament, commonly abbreviated as the PDL, is a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which it sits...
s (PDLs), which are the connective tissueConnective tissue"Connective tissue" is a fibrous tissue. It is one of the four traditional classes of tissues . Connective Tissue is found throughout the body.In fact the whole framework of the skeleton and the different specialized connective tissues from the crown of the head to the toes determine the form of...
fibers that run between the cementum and the alveolar bone.
Etiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....
(cause) of gingivitis is poor oral hygiene
Oral hygiene
Teeth cleaning is part of oral hygiene and involves the removal of dental plaque from teeth with the intention of preventing cavities , gingivitis, and periodontal disease. People routinely clean their own teeth by brushing and interdental cleaning, and dental hygienists can remove hardened...
which leads to the accumulation of a mycotic
Mycosis
A mycosis is a fungal infection of animals, including humans. Mycoses are common, and a variety of environmental and physiological conditions can contribute to the development of fungal diseases...
and bacterial matrix at the gum line, called dental plaque
Dental plaque
Dental plaque is a biofilm, usually a pale yellow, that develops naturally on the teeth. Like any biofilm, dental plaque is formed by colonizing bacteria trying to attach themselves to a smooth surface...
. Other contributors are poor nutrition
Nutrition
Nutrition is the provision, to cells and organisms, of the materials necessary to support life. Many common health problems can be prevented or alleviated with a healthy diet....
and underlying medical issues such as diabetes. New finger nick tests have been approved by the Food and Drug Administration
Food and Drug Administration
The Food and Drug Administration is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments...
in the US, and are being used in dental offices to identify and screen patients for possible contributory causes of gum disease such as diabetes.
In some people, gingivitis progresses to periodontitis –- with the destruction of the gingival fibers
Gingival fibers
The gingival fibers are the connective tissue fibers that inhabit the gingival tissue adjacent to teeth and help hold the tissue firmly against the teeth...
, the gum tissues separate from the tooth and deepened sulcus, called a periodontal pocket. Subgingival microorganism (those that exist under the gum line) colonize the periodontal pockets and cause further inflammation in the gum tissues and progressive bone loss. Examples of secondary etiology are those things that, by definition, cause microbic plaque accumulation, such as restoration overhangs and root proximity.
Ehlers-Danlos Syndrome
Ehlers-Danlos syndrome
Ehlers–Danlos syndrome is a group of inherited connective tissue disorders, caused by a defect in the synthesis of collagen . The collagen in connective tissue helps tissues to resist deformation...
is a periodontitis risk factor.
If left undisturbed, microbic plaque calcifies to form calculus, which is commonly called tartar. Calculus above and below the gum line must be removed completely by the dental hygienist or dentist to treat gingivitis and periodontitis. Although the primary cause of both gingivitis and periodontitis is the microbic plaque that adheres to the tooth surface, there are many other modifying factors. A very strong risk factor is one's genetic susceptibility. Several conditions and diseases, including Down syndrome
Down syndrome
Down syndrome, or Down's syndrome, trisomy 21, is a chromosomal condition caused by the presence of all or part of an extra 21st chromosome. It is named after John Langdon Down, the British physician who described the syndrome in 1866. The condition was clinically described earlier in the 19th...
, diabetes, and other diseases that affect one's resistance to infection also increase susceptibility to periodontitis.
Another factor that makes periodontitis a difficult disease to study is that human host response can also affect the alveolar bone resorption. Host response to the bacterial-mycotic
Mycosis
A mycosis is a fungal infection of animals, including humans. Mycoses are common, and a variety of environmental and physiological conditions can contribute to the development of fungal diseases...
insult is mainly determined by genetics; however, immune development may play some role in susceptibility.
According to some researches periodontitis may be associated with higher stress.
Prevention
Daily oral hygieneOral hygiene
Teeth cleaning is part of oral hygiene and involves the removal of dental plaque from teeth with the intention of preventing cavities , gingivitis, and periodontal disease. People routinely clean their own teeth by brushing and interdental cleaning, and dental hygienists can remove hardened...
measures to prevent periodontal disease include:
- BrushingToothbrushThe toothbrush is an oral hygiene instrument used to clean the teeth and gums that consists of a head of tightly clustered bristles mounted on a handle, which facilitates the cleansing of hard-to-reach areas of the mouth. Toothpaste, which often contains fluoride, is commonly used in conjunction...
properly on a regular basis (at least twice daily), with the patient attempting to direct the toothbrush bristles underneath the gum-line, to help disrupt the bacterial-mycoticMycosisA mycosis is a fungal infection of animals, including humans. Mycoses are common, and a variety of environmental and physiological conditions can contribute to the development of fungal diseases...
growth and formation of subgingival plaque. - Flossing daily and using interdental brushes (if there is a sufficiently large space between teeth), as well as cleaning behind the last tooth, the third molar, in each quarter.
- Using an antiseptic mouthwashMouthwashMouthwash or mouth rinse is a product used to enhance oral hygiene. Some manufacturers of mouthwash claim that antiseptic and anti-plaque mouth rinse kill the bacterial plaque causing cavities, gingivitis, and bad breath. Anti-cavity mouth rinse uses fluoride to protect against tooth decay...
. Chlorhexidine gluconateChlorhexidine gluconateChlorhexidine is a chemical antiseptic. It is effective on both Gram-positive and Gram-negative bacteria, although it is less effective with some Gram-negative bacteria. It has both bactericidal and bacteriostatic mechanisms of action, the mechanism of action being membrane disruption, not ATPase...
based mouthwash in combination with careful oral hygiene may cure gingivitis, although they cannot reverse any attachment loss due to periodontitis. - Using a 'soft' tooth brush to prevent damage to tooth enamel and sensitive gums.
- Using periodontal trays to maintain dentist-prescribed medications at the source of the disease. The use of trays allows the medication to stay in place long enough to penetrate the biofilms where the microorganism are found.
- Regular dental check-ups and professional teeth cleaning as required. Dental check-ups serve to monitor the person's oral hygiene methods and levels of attachment around teeth, identify any early signs of periodontitis, and monitor response to treatment.
Typically dental hygienists (or dentists) use special instruments to clean (debride) teeth below the gumline and disrupt any plaque growing below the gumline. This is a standard treatment to prevent any further progress of established periodontitis. Studies show that after such a professional cleaning (periodontal debridement), microbic plaque tend to grow back to pre-cleaning levels after about 3–4 months. However, it is advocated that the interval between dental check-ups should be determined specifically for each patient between every 3 to 12 months.
Nonetheless, the continued stabilization of a patient's periodontal state depends largely, if not primarily, on the patient's oral hygiene at home as well as on the go. Without daily oral hygiene
Oral hygiene
Teeth cleaning is part of oral hygiene and involves the removal of dental plaque from teeth with the intention of preventing cavities , gingivitis, and periodontal disease. People routinely clean their own teeth by brushing and interdental cleaning, and dental hygienists can remove hardened...
, periodontal disease will not be overcome, especially if the patient has a history of extensive periodontal disease.
Periodontal disease and tooth
Tooth
Teeth are small, calcified, whitish structures found in the jaws of many vertebrates that are used to break down food. Some animals, particularly carnivores, also use teeth for hunting or for defensive purposes. The roots of teeth are embedded in the Mandible bone or the Maxillary bone and are...
loss are associated with an increased risk of cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
.
A contributing cause may be low selenium
Selenium
Selenium is a chemical element with atomic number 34, chemical symbol Se, and an atomic mass of 78.96. It is a nonmetal, whose properties are intermediate between those of adjacent chalcogen elements sulfur and tellurium...
in the diet:
"Results showed that selenium has the strongest association with gum disease, with low levels increasing the risk by 13 fold."
Management
Oral hygiene
Teeth cleaning is part of oral hygiene and involves the removal of dental plaque from teeth with the intention of preventing cavities , gingivitis, and periodontal disease. People routinely clean their own teeth by brushing and interdental cleaning, and dental hygienists can remove hardened...
. This includes twice daily brushing
Toothbrush
The toothbrush is an oral hygiene instrument used to clean the teeth and gums that consists of a head of tightly clustered bristles mounted on a handle, which facilitates the cleansing of hard-to-reach areas of the mouth. Toothpaste, which often contains fluoride, is commonly used in conjunction...
with daily flossing. Also the use of an interdental brush (called a Proxi-brush) is helpful if space between the teeth allows. For smaller spaces a product called "Soft Picks" are an excellent manual cleaning device. Persons with dexterity problems such as arthritis
Arthritis
Arthritis is a form of joint disorder that involves inflammation of one or more joints....
may find oral hygiene to be difficult and may require more frequent professional care and/or the use of a powered tooth brush. Persons with periodontitis must realize that it is a chronic inflammatory disease and a lifelong regimen of excellent hygiene and professional maintenance care with a dentist/hygienist or periodontist is required to maintain affected teeth.
Initial therapy
Removal of microbic plaque and calculus is necessary to establish periodontal health. The first step in the treatment of periodontitis involves non-surgical cleaning below the gumline with a procedure called scaling and debridement. In the past, Root Planing was used (removal of cemental layer as well as calculus). This procedure involves use of specialized curettes to mechanically remove plaque and calculus from below the gumline, and may require multiple visits and local anesthesiaLocal anesthesia
Local anesthesia is any technique to induce the absence of sensation in part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It allows patients to undergo surgical and dental procedures with...
to adequately complete. In addition to initial scaling and root planing, it may also be necessary to adjust the occlusion (bite) to prevent excessive force on teeth that have reduced bone support. Also it may be necessary to complete any other dental needs such as replacement of rough, plaque retentive restorations, closure of open contacts between teeth, and any other requirements diagnosed at the initial evaluation.
Reevaluation
Multiple clinical studies have shown that non-surgical scaling and root planing is usually successful if the periodontal pockets are shallower than 4–5 mm (See articles by Stambaugh RV, Int J Periodontics Rest Dent, 1981 or Waerhaug J, J Periodontol, 1978). It is necessary for the dentist or hygienist to perform a reevaluation 4–6 weeks after the initial scaling and root planing, to determine if the patient's oral hygiene has improved and inflammation has regressed. Probing should be avoided at 4–6 weeks, and an analysis by gingival index should determine the presence or absence of inflammation. Three monthly reevaluation of periodontal therapy should involve periodontal charting as a better indication of the success of treatment, and to see if other courses of treatment can be identified. Pocket depths of greater than 5-6mm which remain after initial therapy, with bleeding upon probing, indicate continued active disease and will very likely lead to further bone loss over time. This is especially true in molarMolar (tooth)
Molars are the rearmost and most complicated kind of tooth in most mammals. In many mammals they grind food; hence the Latin name mola, "millstone"....
tooth sites where furcations
Furcation defect
In dentistry, a furcation defect is a term used to describe bone loss, usually a result of periodontal disease, affecting the base of the root trunk of a tooth where two or more roots meet...
(areas between the roots) have been exposed.
Surgery
If non-surgical therapy is found to have been unsuccessful in managing signs of disease activity, periodontal surgerySurgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
may be needed to stop progressive bone loss and regenerate lost bone where possible. There are many surgical approaches used in treatment of advanced periodontitis, including open flap debridement, osseous surgery, as well as guided tissue regeneration and bone grafting. The goal of periodontal surgery is access for definitive calculus removal and surgical management of bony irregularities which have resulted from the disease process to reduce pockets as much as possible. Long-term studies have shown that in moderate to advanced periodontitis, surgically treated cases often have less further breakdown over time and when coupled with a regular post-treatment maintenance regimen are successful in nearly halting tooth loss in nearly 85% of patients.
Maintenance
Once successful periodontal treatment has been completed, with or without surgery, an ongoing regimen of "periodontal maintenance" is required. This involves regular checkups and detailed cleanings every three months to prevent re-population of periodontitis-causing microorganism, and to closely monitor affected teeth so that early treatment can be rendered if disease recurs. Usually periodontal disease exists due to poor plaque control, therefore if the brushing techniques are not modified, a periodontal recurrence is probable.Alternative treatments
Periodontitis has an inescapable relationship with subgingival calculus (tartar). The first step in any procedure is to eliminate calculus under the gum line, as it houses destructive anaerobic microorganisms that consume bone, gum and cementum (connective tissue) for food.Most alternative “at-home” gum disease treatments involve injecting anti-microbial solutions, such as hydrogen peroxide
Hydrogen peroxide
Hydrogen peroxide is the simplest peroxide and an oxidizer. Hydrogen peroxide is a clear liquid, slightly more viscous than water. In dilute solution, it appears colorless. With its oxidizing properties, hydrogen peroxide is often used as a bleach or cleaning agent...
, into periodontal pockets via slender applicators or oral irrigators. This process disrupts anaerobic microorganism colonies and is effective at reducing infections and inflammation when used daily. A number of potions and elixirs that are functionally equivalent to hydrogen peroxide are commercially available but at substantially higher cost. However, such treatments do not address calculus formations, and so are short-lived, as anaerobic microorganism colonies quickly regenerate in and around calculus.
In a new field of study, calculus formations are addressed on a more fundamental level. At the heart of the formation of subgingival calculus, growing plaque formations starve out the lowest members of the community, which calcify into calcium phosphate salts of the same shape and size of the original, organic bacilli. Calcium phosphate salts (unlike calcium phosphate; the primary component in teeth) are ionic
Ionic crystal
An ionic crystal is a crystal consisting of ions bound together by their electrostatic attraction. Examples of such crystals are the alkali halides, including potassium fluoride, potassium chloride, potassium bromide, potassium iodide, sodium fluoride, and other combinations of sodium, caesium,...
and adhere to tooth surfaces via electrostatic attraction. Smaller, free-floating calcium phosphate salt particles are equally attracted to the same areas, as are additional calcified microorganism, growing calculus formations as unorganized, yet strong, “brick and mortar” matrices. The microscopic voids in calculus formations house new anaerobic microorganism, as does the top “diseased layer”.
Because the root cause of subgingival calculus development is ionic attraction, it was hypothesized that the introduction of oppositely charged particles around the formations may chelate calcium phosphate salt components away from the matrix, thus reducing the size of subgingival calculus formations. To accomplish this, a sequestering agent solution consisting partly of sodium tripolyphosphate
Sodium tripolyphosphate
Sodium triphosphate is an inorganic compound with formula Na5P3O10. It is the sodium salt of the polyphosphate penta-anion, which is the conjugate base of triphosphoric acid. It is produced on a large scale as a component of many domestic and industrial products, especially detergents...
(STPP) and sodium fluoride
Sodium fluoride
Sodium fluoride is an inorganic chemical compound with the formula NaF. A colorless solid, it is a source of the fluoride ion in diverse applications. Sodium fluoride is less expensive and less hygroscopic than the related salt potassium fluoride....
(charge -1) was tested on a patient with burnished and new subgingival calculus at a depth of 6 mm. The patient delivered the solution using an oral irrigator, once a day, for 60 days. The results were the successful elimination of all calculus formations studied. This test was conducted using a subgingival endoscopic camera (perioscope) by an independent periodontist.
The promise of this new, alternative treatment is to keep subgingival calculus at bay, in concert with traditional periodontal treatments. In this way, periodontitis may be controlled by the patient, and complete restoration of dental health can be a collaborative effort between the patient and the dental professional.
Additionally, Periodontitis can be treated in a noninvasive manner by means of Periostat (subantimicrobial dose of doxycycline), an FDA-approved, orally-administered drug that has been shown to reduce bone loss. Its mechanism of action in part involves inhibition of Matrix metalloproteinases (such as collagenase), which degrade the extracellular matrix under inflammatory conditions. This ultimately can lead to reduction of aveolar bone-loss in patients with periodontal disease (as well as patients without periodontitis).
Prognosis
Dentists and dental hygienists measure periodontal disease using a device called a periodontal probePeriodontal probe
A periodontal probe is an instrument in dentistry commonly used in the dental armamentarium. It is usually long, thin, and blunted at the end. The primary purpose of a periodontal probe is to measure pocket depths around a tooth in order to establish the state of health of the periodontium...
. This is a thin "measuring stick" that is gently placed into the space between the gums and the teeth, and slipped below the gum-line. If the probe can slip more than 3 millimeters below the gum-line, the patient is said to have a gingival pocket if no migration of the epithelial attachment has occurred or a periodontal pocket if apical migration has occurred. This is somewhat of a misnomer, as any depth is in essence a pocket, which in turn is defined by its depth, i.e., a 2 mm pocket or a 6 mm pocket. However, it is generally accepted that pockets are self-cleansable (at home, by the patient, with a toothbrush) if they are 3 mm or less in depth. This is important because if there is a pocket which is deeper than 3 mm around the tooth, at-home care will not be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach 6 and 7 mm in depth, the hand instruments and cavitrons used by the dental professionals may not reach deeply enough into the pocket to clean out the microbic plaque that cause gingival inflammation. In such a situation the bone or the gums around that tooth should be surgically altered or it will always have inflammation which will likely result in more bone loss around that tooth. An additional way to stop the inflammation would be for the patient to receive subgingival antibiotics (such as minocycline
Minocycline
Minocycline is a broad-spectrum tetracycline antibiotic, and has a broader spectrum than the other members of the group. It is a bacteriostatic antibiotic, classified as a long-acting type...
) or undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so that they become 3 mm or less in depth and can once again be properly cleaned by the patient at home with his or her toothbrush.
If a patient has 7 mm or deeper pockets around their teeth, then they would likely risk eventual tooth loss over the years. If this periodontal condition is not identified and the patient remains unaware of the progressive nature of the disease then, years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain.
According to the Sri Lanka
Sri Lanka
Sri Lanka, officially the Democratic Socialist Republic of Sri Lanka is a country off the southern coast of the Indian subcontinent. Known until 1972 as Ceylon , Sri Lanka is an island surrounded by the Indian Ocean, the Gulf of Mannar and the Palk Strait, and lies in the vicinity of India and the...
n tea labourer study, in the absence of any oral hygiene activity, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment (>2 mm/year). 80% will suffer from moderate loss (1–2 mm/year) and the remaining 10% will not suffer any loss.
Epidemiology
Periodontitis is very common, and is widely regarded as the second most common disease worldwide, after dental decay, and in the United StatesUnited States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
has a prevalence
Prevalence
In epidemiology, the prevalence of a health-related state in a statistical population is defined as the total number of cases of the risk factor in the population at a given time, or the total number of cases in the population, divided by the number of individuals in the population...
of 30–50% of the population, but only about 10% have severe forms.
Like other conditions that are intimately related to access to hygiene and basic medical monitoring and care, periodontitis tends to be more common in economically disadvantaged populations or regions. Its occurrence decreases with higher standard of living. In Israel
Israel
The State of Israel is a parliamentary republic located in the Middle East, along the eastern shore of the Mediterranean Sea...
i population, individuals of Yemen
Yemen
The Republic of Yemen , commonly known as Yemen , is a country located in the Middle East, occupying the southwestern to southern end of the Arabian Peninsula. It is bordered by Saudi Arabia to the north, the Red Sea to the west, and Oman to the east....
ite, North-Africa
Africa
Africa is the world's second largest and second most populous continent, after Asia. At about 30.2 million km² including adjacent islands, it covers 6% of the Earth's total surface area and 20.4% of the total land area...
n, South Asia
South Asia
South Asia, also known as Southern Asia, is the southern region of the Asian continent, which comprises the sub-Himalayan countries and, for some authorities , also includes the adjoining countries to the west and the east...
n, or Mediterranean origin have higher prevalence of periodontal disease than individuals from Europe
Europe
Europe is, by convention, one of the world's seven continents. Comprising the westernmost peninsula of Eurasia, Europe is generally 'divided' from Asia to its east by the watershed divides of the Ural and Caucasus Mountains, the Ural River, the Caspian and Black Seas, and the waterways connecting...
an descent.
Presumably, individuals living in East Asia
East Asia
East Asia or Eastern Asia is a subregion of Asia that can be defined in either geographical or cultural terms...
(e.g. Japan, South Korea and Taiwan) have the lowest incident of periodontal disease in the world.
In other animals
Periodontal disease is the most common disease found in dogDog
The domestic dog is a domesticated form of the gray wolf, a member of the Canidae family of the order Carnivora. The term is used for both feral and pet varieties. The dog may have been the first animal to be domesticated, and has been the most widely kept working, hunting, and companion animal in...
s and affects more than 80% of dogs aged three years or older. The prevalence of periodontal disease in dogs increases with age but decreases with increasing body weight; i.e., toy and miniature breeds are more severely affected. Systemic disease may develop because the gums are very vascular (have a good blood supply). The blood stream carries these anaerobic microorganisms, and they are filtered out by the kidney
Kidney
The kidneys, organs with several functions, serve essential regulatory roles in most animals, including vertebrates and some invertebrates. They are essential in the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid–base balance, and...
s and liver
Liver
The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...
, where they may colonize and create microabscesses. The microorganisms traveling through the blood may also attach to the heart
Heart
The heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...
valves, causing vegetative endocarditis
Endocarditis
Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves . Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or even on intracardiac devices...
(infected heart valves). Additional diseases that may result from periodontitis includes chronic bronchitis
Bronchitis
Acute bronchitis is an inflammation of the large bronchi in the lungs that is usually caused by viruses or bacteria and may last several days or weeks. Characteristic symptoms include cough, sputum production, and shortness of breath and wheezing related to the obstruction of the inflamed airways...
and pulmonary fibrosis
Fibrosis
Fibrosis is the formation of excess fibrous connective tissue in an organ or tissue in a reparative or reactive process. This is as opposed to formation of fibrous tissue as a normal constituent of an organ or tissue...
.
See also
- Actinomyces naeslundiiActinomyces naeslundiiActinomyces naeslundii are Gram positive rod shaped bacteria that occupy the oral cavity. They have been implicated in periodontal disease and root caries. These bacteria are also associated with good oral health...
, a kind of bacterium - Calculus (dental)Calculus (dental)In dentistry, calculus or tartar is a form of hardened dental plaque. It is caused by the continual accumulation of minerals from saliva on plaque on the teeth...
, tartar - CampylobacterCampylobacterCampylobacter is a genus of bacteria that are Gram-negative, spiral, and microaerophilic. Motile, with either unipolar or bipolar flagella, the organisms have a characteristic spiral/corkscrew appearance and are oxidase-positive. Campylobacter jejuni is now recognized as one of the main causes...
, a kind of bacterium - Candida albicansCandida albicansCandida albicans is a diploid fungus that grows both as yeast and filamentous cells and a causal agent of opportunistic oral and genital infections in humans. Systemic fungal infections including those by C...
, a kind of micetum - Chronic periodontitisChronic periodontitisChronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation of the periodontal tissues that is caused by accumulation of profuse amounts of dental plaque.-Diagnosis:...
- Dental ImplantDental implantA dental implant is a "root" device, usually made of titanium, used in dentistry to support restorations that resemble a tooth or group of teeth to replace missing teeth....
- Dental plaqueDental plaqueDental plaque is a biofilm, usually a pale yellow, that develops naturally on the teeth. Like any biofilm, dental plaque is formed by colonizing bacteria trying to attach themselves to a smooth surface...
, bacterial biofilm that clings to teeth - EdentulismEdentulismEdentulism is the condition of being toothless to at least some degree; it is the result of tooth loss. Loss of some teeth results in partial edentulism, while loss of all teeth results in complete edentulism....
, condition of one or more missing teeth - Epidemiology of periodontal diseasesEpidemiology of periodontal diseases-Prevalence of Periodontal Diseases in Adults:Many studies look at the prevalence of “advanced periodontitis”, but have differing definitions of this term. Generally though, severe forms of periodontitis do not seem to affect more than 15% of the population of industrialized countries. The...
- GingivitisGingivitisGingivitis is a term used to describe non-destructive periodontal disease. The most common form of gingivitis is in response to bacterial biofilms adherent to tooth surfaces, termed plaque-induced gingivitis, and is the most common form of periodontal disease...
, inflammation of the gums - Gum graftGum graftA gingival graft is a generic name for any of a number of surgical periodontal procedures whose combined aim is to cover an area of exposed tooth root surface with grafted oral tissue...
, a type of gum surgery, to replace lost gum tissue - HalitosisHalitosisHalitosis is a term used to describe noticeably unpleasant odors exhaled in breathing. Halitosis is estimated to be the third most frequent reason for seeking dental aid, following tooth decay and periodontal disease.- General :...
, bad breath due to oral bacteria - Head and neck anatomyHead and neck anatomyHead and neck anatomy focuses on the structures of the head and neck of the human body, including the brain, bones, muscles, blood vessels, nerves, glands, nose, mouth, teeth, tongue, and throat...
, biological composition above the shoulders - LANAP, Laser Assisted New Attachement Procedure
- Oral hygieneOral hygieneTeeth cleaning is part of oral hygiene and involves the removal of dental plaque from teeth with the intention of preventing cavities , gingivitis, and periodontal disease. People routinely clean their own teeth by brushing and interdental cleaning, and dental hygienists can remove hardened...
, how to promote good health of the mouth - Oral microbiologyOral microbiologyOral microbiology is the study of the microorganisms of the oral cavity and the interactions between the oral microorganisms with each other and with the host. Of particular interest is the role of oral microorganisms in the two major dental diseases: dental caries and periodontal disease.The mouth...
, study of the microorganisms of the oral cavity - OsteoimmunologyOsteoimmunologyOsteoimmunology is the study of the interface between the skeletal system and the immune system, comprising the “osteo-immune system”...
, studies the immune system with respect to bones - Periodontist
- Tooth lossTooth lossTooth loss is when one or more teeth come loose and fall out. Tooth loss is normal for deciduous teeth , when they are replaced by a person's adult teeth. Otherwise, losing teeth is undesirable and is the result of injury or disease, such as mouth trauma, tooth injury, tooth decay, and gum disease...
External links
- Advanced stage of gum disease is periodontitis Gum disease causes and treatment
- Mayo Clinic
- OralDNA Labs, a Quest Diagnostics Company, providing DNA-PCR salivary diagnostics to advance wellness in dentistry
- Absolute Smile — Periodontal Disease in Profile
- Canadian Academy of Periodontology — What is periodontitis?
- Maladies parodontales - Etat général Le Courrier du Dentiste; Août 2011
- Healthy behaviors equal healthy gums — An article from ADA (American Dental Association)
- Gum disease in dogs treatment & symptoms — Dog health care sheet on spotting the symptoms of gum disease in dogs.
- Periodontal disease in dogs and cats — Blue Cross Animal Hospital's write up on peridontal disease.