Inflammation of the supporting structures of the teeth.

Almost half of the US population older than 30 years of age is estimated to have chronic periodontitis, and 38% have moderate or advanced involvement.

Affects more than 1 in 5 adults.

A major cause of tooth loss.

Associated with diabetes mellitus, cardiovascular disease and preterm low birth weight.

Patients with diabetes are at greater risk for incident and prevalent chronic periodontitis and have more severe disease than in individuals without diabetes.

Improved diabetic control is associated with less severe disease and lower risk of progression, suggesting that the level of glycemia is the mediator of the relationship between diabetes and chronic periodontitis.

Inflamed supporting structures include periodontal ligaments, alveolar bone and cementum.

Can lead to loss of attachment caused by complete destruction of the periodontal ligament and alveolar bone.

Can lead to loosening and loss of teeth.

Causes a shift of in types and proportions of bacteria that exist along the gums.

Areas of involvement have anaerobic and microaerophilic gram negative flora.

Adult disease associated with Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Prevotella intermedia, despite the fact that 300 types of bacteria survive in the oral cavity.

Usually presents without other disorders but may be associated with immune deficiency disorders, leukemia, disease diabetes, Down syndrome, sarcoidosis, and states with altered neutrophil counts or function.

May be an etiological factor for infective endocarditic, lung abscess, brain abscess and may increase the risk of adverse pregnancy outcomes.

The daily use of teriparatide in conjunction with an oral surgical procedure improves clinical outcomes with greater resolution of alveolar bone defects, and accelerates osseous wound healing in the oral cavity (Bashutski JD et al). Periodontitis

Caused by microorganisms that adhere to and grow on the tooth’s surfaces, along with an over-aggressive immune response against these microorganisms.

A diagnosis is established by inspecting the soft gum tissues around the teeth with a probe and by evaluating the patient’s X-ray films to determine the amount of bone loss around the teeth.

Specialists in the treatment of periodontitis are periodontists

The field is known as periodontology or periodontics.

The classification system for periodontal diseases and conditions listed seven major categories of periodontal diseases:


Chronic periodontitis

Aggressive periodontitis

Periodontitis as a manifestation of systemic disease

Necrotizing ulcerative gingivitis/periodontitis

Abscesses of the periodontium

Combined periodontic-endodontic lesions

Sites of involvement are defined as the positions at which probing measurements are taken around each tooth.

Six probing sites around each tooth are recorded, as follows:







If up to 30% of sites in the mouth are affected, the manifestation is localized.

If more than 30% is affected, the term generalized involvement is used.

American Academy of Periodontology classification of severity is:

Mild: 1–2 mm (0.039–0.079 in) of attachment loss.

Moderate: 3–4 mm (0.12–0.16 in) of attachment loss.

Severe: ≥ 5 mm (0.20 in) of attachment loss.

In its early stages, periodontitis has very few symptoms.

Many individuals have significant disease progression before they seek treatment.

Symptoms may include: Redness or bleeding of gums while brushing teeth, using dental floss or biting into hard food.

Gum swelling that recurs.

Spitting out blood after brushing teeth.

Halitosis, and a persistent metallic taste in the mouth.

Gingival recession.

Deep pockets between the teeth and the gums.

Loose teeth

Gingival inflammation and bone destruction are largely painless.

Linked to increased inflammation in the body, as indicated by raised levels of C-reactive protein and interleukin-6.

It is linked through inflammation to increased risk of stroke, myocardial infarction, and atherosclerosis, and with age to impairments in delayed memory and calculation abilities.

Patients with diabetes mellitus have higher degrees of periodontal inflammation, and often more difficulty managing their blood sugar levels caused by the periodontal inflammation.

It is an inflammation of the periodontium.

The periodontium refers to tissues that support the teeth.

The periodontium consists of four tissues:

gum tissue,

cementum, or outer layer of the roots of teeth,

alveolar bone, or the bony sockets into which the teeth are anchored,

periodontal ligaments (PDLs), which are the connective tissue fibers that run between the cementum and the alveolar bone.

The primary cause of gingivitis is poor or ineffective oral hygiene.

Poor hygiene leads to the accumulation of a mycotic and bacterial matrix at the gum line, called dental plaque.

Other contributors are poor nutrition and diabetes.

In some , gingivitis progresses to periodontitis, with the destruction of the gingival fibers, the gum tissues separate from the tooth and deepened sulcus.

Subgingival microorganisms colonize the periodontal pockets and cause further inflammation in the gum tissues and progressive bone loss.

The excess restorative material exceeding the natural contours of restored teeth, called overhangs, and serve to trap microbic plaque, potentially leading to localized periodontitis.

Smoking is another factor that increases the occurrence of periodontitis, and may interfere with its treatment.

Ehlers–Danlos syndrome is a periodontitis risk factor.

If left undisturbed, microbial plaque calcifies to form calculus, which is commonly called tartar.

Calculus above and below the gum line must be removed completely to treat gingivitis and periodontitis.

Several conditions and diseases, including Down syndrome, diabetes, and other diseases that affect one’s resistance to infection, also increase susceptibility to periodontitis.

May be associated with stress, and occurs more often in people from the lower end of the socioeconomic strata.

As dental plaque or biofilm accumulates on teeth and below the gums, there is a shift from essentially streptococcus to an actinomyces dominant plaque in the biofilm.

As dental plaque or biofilm accumulates motile bacteria is also seen more frequently.

Iinflammation sets in the gingiva initially, and causes gingivitis, which represents inflammation confined to the soft tissues above the bone level.

Gingival inflammation will not progress to periodontitis, unless in the presence of local conditions or generalized host susceptibility.

When the immune system’s response to plaque accumulation shifts from a predominantly neutrophilic mediated response to lymphocytic and plasma cell-mediated response periodontist occurs.

The gingiva swelling, redness and a tendency to bleed and modifies the environment, leading to changes in the composition of the biofilm

The biofilm composition is predominantly a gram-negative environment, with periodontal pathogens emerging: including A. actinomycetemcomitans, P. gingivalis, T. Forsythia, T denticola, F nucleatum, P micros, P.intermedia, P. nigrecens, E. nodatum and S. constellates.

The major bacterial association to chronic periodontitis is with P. Gingivalis.

P. Gingivalis’ virulence allows it to elude defense mechanism and perpetuate inflammation inside the periodontium. leading to the attachment of the gingiva to the tooth with deepening pockets and bone loss around the teeth.

When untreated periodontitis progresses unevenly over time but results in loss of function, tissue destruction, and tooth loss.

To prevent periodontal disease:

Brushing properly at least twice daily, directing the toothbrush bristles underneath the gumline, helps disrupt the bacterial-mycotic growth and formation of subgingival plaque.

Flossing daily and using interdental brushes as well as cleaning behind the last tooth, the third molar, in each quarter.

Using an antiseptic mouthwash.

Regular 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.

Dental care debrides teeth below the gumline to disrupt any plaque growing below the gumline, preventing further progress of established periodontitis.

After periodontal debridement, microbial plaque to grows back to precleaning levels after about three to four months.

Stabilization of periodontal state depends largely, if not primarily, on the patient’s oral hygiene at home.

Periodontal disease and tooth loss are associated with an increased risk, in male patients, of cancer.

Contributing causes may be high alcohol consumption or a diet low in antioxidants.

Treatment starts with establishing oral hygiene: twice-daily brushing with daily flossing, use of an interdental brush, and picks with soft rubber bristles provide excellent manual cleaning.

It must a lifelong regimen of excellent hygiene and professional maintenance care with a dentist/hygienist or periodontist is required to maintain affected teeth.

The initial removal of microbial plaque and calculus is necessary to establish periodontal health, and involves nonsurgical cleaning below the gumline with scaling and root planing.

Scaling and root planing involves the use of specialized curettes to mechanically remove plaque and calculus from below the gumline.

It may also be necessary to adjust the occlusion to prevent excessive force on teeth that have reduced bone support.

It may be necessary to complete any other dental needs.

Nonsurgical scaling and root planing are usually successful if the periodontal pockets are shallower than 4–5 mm.

Pocket depths of greater than 5–6 mm which remain after initial therapy, with bleeding upon probing, indicate continued active disease.

This is especially true in molar tooth sites where areas between the roots have been exposed.

If nonsurgical management fails periodontal surgery may be required to stop progressive bone loss and regenerate lost bone.

Surgical approaches used in the treatment of advanced periodontitis include: open flap debridement and bone surgery, as well as guided tissue regeneration and bone grafting.

Periodontal surgery provides access for calculus removal and management of bony irregularities to reduce pockets as much as possible.

In moderate-advanced periodontitis, surgery leads to decrease breakdown over time and, with a maintenance regimen, it is successful in nearly halting tooth loss in nearly 85% of patients.

Maintenance care involves regular checkups and cleanings every three months to prevent repopulation of periodontitis causing microorganisms, and to closely monitor affected teeth so early treatment can be rendered if the disease recurs.

Doxycycline improves indicators of disease progression.

Doxycycline,at small dosage, inhibits matrix metalloproteinases, which degrade the teeth’s supporting tissues under inflammatory conditions.

A periodontal probe measures severity of periodontal disease when placed into the space between the gums and the teeth, and slipped below the gumline.

If the probe can slip more than 3 mm below the gumline, the patient is said to have a gingival pocket if no migration of the epithelial attachment has occurred.

If a pocket is deeper than 3 mm around the tooth, professional care is required.

When the pocket depths reach 6 to 7 mm in depth, the bone or the gums around that tooth should be surgically altered or inflammation will result in more bone loss around that tooth.

With 7-mm or deeper pockets, patients would likely risk eventual tooth loss over the years.

In the absence of any oral hygiene, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment of greater than 2 mm/year.

In the absence of any oral hygiene about 80% will suffer from moderate loss (1–2 mm/year) and the remaining 10% will not suffer any loss.

Periodontitis is the second most common dental disease worldwide, after dental decay.

Has a prevalence of 30–50% of the population, but only about 10% have severe forms.

Chronic periodontitis affects about 750 million people or about 10.8% of the population as of 2010.

Tends to be more common in economically disadvantaged populations or regions.

Results in estimated worldwide productivity losses of about US$54 billion yearly.

Systemic disease may develop as the blood stream carries these anaerobic micro-organisms, and they are filtered out by the kidneys and liver, where they may colonize and create microabscesses.

The microorganisms traveling via the bloodstream may also attach to the heart valves, causing vegetative infective endocarditis.

Additional diseases that may result from periodontitis include chronic bronchitis and pulmonary fibrosis.

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