Basic Guide to Oral Health Education and Promotion. Alison Chapman
Chapter 4 Periodontal disease
Learning outcomes
By the end of this chapter you should be able to:
1 Define periodontitis and list the primary and secondary factors in its development.
2 List the signs, symptoms, and features of the condition, and explain its management.
3 Define necrotising ulcerative gingivitis (NUG), its causes and treatment.
4 Define peri‐implant mucositis and peri‐implantitis, and their causes and treatment.
WHAT IS PERIODONTITIS?
Periodontitis (Figure 4.1) describes the inflammation and gradual destruction of the periodontium (the supporting structure of the tooth).
Slowly progressing periodontitis was previously called chronic periodontitis, and rapidly progressing disease was called aggressive periodontitis. However, it is now thought that they are variations of the same disease process.
Periodontitis may look like gingivitis, but can be distinguished by:
Periodontal probing (depth of pocket is greater than 3 mm).
X‐rays, which show loss of bone support.
Loose teeth (potentially).
Damage is not reversible.
Remember! It is important that the oral health educator (OHE) can distinguish between gingivitis (the continual but superficial inflammation of the gingivae), and periodontitis (the destruction of the periodontium).
Figure 4.1 Adult periodontal disease.
Source: Alison Chapman.
Who does it affect?
In the UK Adult Dental Health Survey (2009), only 17% of dentate adults showed no evidence of periodontal disease at the most stringent threshold [1].
Good periodontal health was more common among adults under 45 years old than in older age groups. For example, 20% of dentate adults aged between 25–34 years had very healthy periodontal tissues compared with 14% between 45– 54 years, and 10% above 55 years [1]. Twenty‐one percent of dentate adults from managerial and professional occupation households had very healthy periodontal tissues compared with 16% of adults of intermediate occupations, and 12% of manual occupation households [1].
A growing body of research also suggests that there is an association between periodontitis and certain systemic (body) conditions, such as adverse pregnancy outcomes and type 2 diabetes [2].
Studies have also shown a link between periodontitis and coronary heart disease, and people with heart disease have an increased risk of periodontal disease. Acute coronary syndrome, high blood pressure (hypertension), and high cholesterol have also been associated with periodontal disease [3]. The more severe the periodontitis, the greater the risk of heart problems.
Primary causes of periodontitis
Periodontitis is often, but not always, a progression of gingivitis, and is primarily caused by the enzymes and toxins of mature plaque bacteria, which gradually break down the tissues of the periodontium in a susceptible host [4].
For most patients, gingivitis does not progress to periodontitis, but 10–15% of patients are susceptible to periodontitis [3]. The onset of periodontitis in these patients is thought to be due to a genetic abnormality, which causes a change in the behaviour of cytokines (substances which regulate the movement of immune system cells), and subsequent destruction of bone. This genetic basis explains why periodontitis frequently affects members of the same family. Current thinking is that with periodontal disease, 20% of tissue damage is due to the direct effects of plaque by‐products on tissues and 80% due to indirect effects, i.e. host destruction triggered by the body’s own white blood cells [5].
Secondary risk factors in the development of periodontitis
Secondary factors are important in the development of periodontitis, and include:
Smoking – the most important risk factor. Periodontal disease is more common in smokers than non‐smokers [2]. Treatment response in smokers is also poorer than non‐smokers. Smoking is thought to:Reduce blood flow in the gingivae.Reduce white blood cell mobility and function.Impair healing.Increase inflammatory substances (cytokines).
Poor oral hygiene – failure to clean effectively, leading to plaque accumulation.
Age – older people are more likely to have periodontitis, due to being exposed to plaque for a longer period than younger patients, and older people do not heal as easily.
Plaque retention factors – poorly finished/worn fillings, dentures, crowns, bridges, partially erupted/impacted teeth, and supragingival/subgingival calculus (see Chapter 2).
Crowding and malocclusion – one of the reasons for carrying out orthodontic treatment in childhood is to improve access to tooth surfaces and the ability to clean them, and prevent periodontal disease from occurring later. Bone loss associated with malocclusion is usually localised and not associated with poor oral hygiene.
Carious cavities – plaque‐retentive ledges.
High frenulum insertion – usually found buccally on lower anteriors. The frenulum is a fold of mucous membrane, which limits the movement of the lower lip. If the insertion of the membrane is high on the gingivae, it can prevent effective oral hygiene and cause gingival recession.
Systemic conditions (see Chapter 8) – for example, patients with diabetes, Down’s syndrome, immunological disorders, and those who experience hormonal changes (e.g. during pregnancy and puberty).
Features of periodontitis
Features of periodontitis include:
Often occurs in middle age.
Usually progresses slowly.
Can have unpredictable bursts of activity (active phases may need clinical intervention).
Can result from the progression of gingivitis, but not always – many people have gingivitis for years but do not develop periodontitis.
Patients can present with no obvious visual clinical signs (in some cases, the tissues can look quite healthy). Only pocket probing and radiographs will identify the loss of supporting structures.
Signs of periodontitis
Dental professionals in the UK have a duty of care to diagnose the disease in its early stages.
In the early stages of the disease, the dental professional will notice:
A variable degree of gingivitis. Some patients still have gingivitis, others not.
Bleeding on deep probing.
The presence of subgingival calculus.
Gingival recession.
Bone