Periodontitis

Periodontitis is a serious gum infection that damages the soft tissue around teeth and can destroy the bone that supports them, potentially leading to tooth loss. While common and affecting millions of people worldwide, this condition is largely preventable with proper care and treatable when caught early.

Table of contents

• What is periodontitis?
• Stages of the disease
• Recognizing the symptoms
• Causes and risk factors
• How periodontitis is diagnosed
• Treatment options
• Prevention and self-care
• Potential complications
• Connection to other health conditions

What is periodontitis?

Periodontitis is a severe gum infection that damages the soft tissue around teeth and, without treatment, can destroy the bone that supports your teeth^[1]. This condition is common but can usually be prevented. It’s often the result of not taking care of your mouth and teeth properly^[1].

The disease is a chronic inflammatory condition triggered by bacterial microorganisms. It involves severe chronic inflammation that causes the destruction of the tooth-supporting structures and can lead to tooth loss^[7]. About 4 in 10 U.S. adults 30 years or older had some form of periodontitis in 2009-2014^[4].

Periodontitis is more likely to happen as you age. It’s most common in people over 30, though it can affect anyone with poor oral hygiene^[6]. Some people are also more genetically prone to periodontitis than others. If your biological parents or grandparents have a history of gum disease, you’re more likely to develop it as well^[6].

• Gums
• Periodontal ligament
• Alveolar bone
• Teeth

Stages of the disease

The breakdown of tissues around your teeth happens gradually. In fact, most people don’t experience pain with gum disease, especially during the early stages. So, it’s important to know the warning signs^[2].

Gingivitis is the earliest stage of gum disease. It starts with red, puffy gums that may bleed when you brush or floss. At this stage, there’s no bone loss. As a result, gingivitis is totally reversible with proper treatment^[2]. The mildest form of gum disease is an inflammatory condition where the gums become red, swollen, and may easily bleed^[4].

Mild periodontitis develops when bacteria have seeped beneath your gums, affecting the supporting bone. Your gums may pull away from your teeth, creating pockets around them. Plaque and bacteria hide in these pockets, where your toothbrush and floss can’t reach^[2].

Moderate periodontitis occurs when, left untreated, bacteria begin to erode the ligaments, soft tissues, and bone that hold your teeth in place. You may notice bad breath and pus (infection) around your gum line. Some people develop pain at this stage^[2].

Advanced periodontitis is the most severe stage. As periodontal disease worsens, bone loss continues. This can cause your teeth to become loose and eventually fall out^[2].

When treated early enough, gum disease is reversible. But if you’ve already lost bone around your teeth due to infection, the disease is too advanced to reverse. However, you can manage it with proper treatment and consistent, diligent oral hygiene^[2].

Recognizing the symptoms

Gum disease can often become serious before a person notices that they have symptoms. A yearly dental checkup can help to detect and prevent this condition^[4]. Healthy gums are firm and fit snugly around teeth. The color of healthy gums can vary, ranging from light pink in some people to dark pink and brown in others^[1].

Often, periodontal disease doesn’t hurt, so you may have no idea that you have the disease. Catching periodontitis early helps prevent complications^[6].

Symptoms of periodontitis can include:

• Swollen or puffy gums
• Bright red, dark red, or dark purple gums
• Gums that feel tender when touched
• Gums that bleed easily
• A toothbrush that looks pink after brushing your teeth
• Spitting out blood when brushing or flossing
• Bad breath that won’t go away^[1]
• Pus between your teeth and gums
• Loose teeth or loss of teeth
• Painful chewing
• New spaces that develop between your teeth that look like black triangles
• Gums that pull away from your teeth, making your teeth look longer than usual (called receding gums)
• A change in the way your teeth fit together when you bite^[1]

Causes and risk factors

The main cause of periodontitis is poor oral hygiene. Bacteria create plaque and tartar that cling to your teeth surfaces. If you don’t clean your teeth as well or as often as you should, bacteria travel down beneath your gum line, where your toothbrush and floss can’t reach. These harmful bacteria wear away the tissues that support your teeth, leading to infection, bone loss, and tooth loss^[6].

Dental plaque that is not removed every day can harden and form tartar, and tartar build-up can lead to gum disease. Only a professional cleaning by a dentist or dental hygienist can remove tartar^[3].

Buildup of dental plaque is the number one cause of periodontal disease. Plaque contains many different kinds of bacteria that can potentially infect your gums. That’s why you’re more likely to get gum disease if you have poor oral hygiene. In some people, genes play a role in gum disease by changing the way their immune system responds to bacteria^[2].

Risk factors that can increase your chances of developing periodontitis include:

• Smoking and tobacco use: Smokers are much more likely to develop periodontitis than non-smokers. Smoking weakens the immune system and makes it harder for your gums to heal^[7]. About 62% of U.S. adults 30 years or older who are current smokers had periodontitis in 2009-2014^[4].
• Diabetes: Diabetics whose blood sugar is not managed have a higher risk of developing periodontitis^[7]
• Poor oral hygiene^[2]
• Genetics: Some people may have more of a genetic predisposition to suffering gum disease than others^[7]
• Age: Periodontitis is more common as people age. About 60% of adults 65 years or older had periodontitis in 2009-2014^[4]
• Hormonal changes such as with pregnancy or menopause^[4]
• Stress: Mental and emotional stress can weaken the immune system and lower the resistance of the gums to harmful bacteria^[7]
• Poor diet: An unhealthy diet high in processed foods and refined carbohydrates increases the tendency for gums to become inflamed^[7]
• Autoimmune diseases, including lupus, scleroderma, and Crohn’s disease^[2]
• Medications with oral side effects^[4]

How periodontitis is diagnosed

Dentists typically diagnose periodontitis during routine examinations^[6]. To tell whether you have periodontitis and how severe it is, your dentist may:

Review your medical history to identify any factors that could be linked to your symptoms. Examples include smoking or taking certain medicines that cause dry mouth^[9].

Examine your mouth to look for plaque and tartar buildup and check for easy bleeding. Your dentist will examine your gums for signs of inflammation^[6].

Measure the depth of pockets between your gums and teeth by placing a tiny ruler called a dental probe between your teeth and gumline. Pockets are measured at several places in your upper and lower gums. In a healthy mouth, the pocket depth is usually between 1 and 3 millimeters. Pockets deeper than 4 mm may indicate periodontitis. Pockets deeper than 5 mm cannot be cleaned well with routine care^[9].

Take dental X-rays to check for bone loss in areas where your dentist sees deeper pockets^[9]. An x-ray can show if there is any bone loss as a result of gum disease^[3].

Your dentist may assign a stage and a grade to periodontitis based on how severe the disease is, the complexity of treatment, your risk factors, and your health. Then a treatment plan is made^[9].

Your dental professional may also refer you to a periodontist, a specialist in the diagnosis and treatment of gum disease, who may provide other treatment options not provided by your dentist^[3].

Treatment options

Periodontitis treatment depends on the severity of the condition. Options include nonsurgical and surgical procedures. Your dentist should refer you to a gum specialist (periodontist) unless your disease is mild^[6].

The goal of treatment is to thoroughly clean the pockets around teeth and prevent damage to surrounding gum tissue and bone. You have the best chance for successful treatment when you also have a daily routine of good oral care, manage health conditions that may impact dental health, and stop tobacco use^[9].

The main goal of treatment is to control the infection. The number and types of treatment will vary depending on how far the disease has progressed^[3].

Nonsurgical treatments

Healthcare providers may treat milder cases with nonsurgical procedures or lifestyle changes^[6]. If periodontitis isn’t advanced, treatment may involve less invasive procedures, including:

Scaling removes tartar and bacteria from your tooth surfaces and below your gumline^[9]. All bacterial deposits (plaque and tartar) are removed from accessible areas of the teeth, and the teeth are then polished and treated with fluoride^[14].

Root planing helps remove plaque and tartar below the gum line. If necessary, the dentist will also remove all bacterial deposits and tartar from the root surfaces and gum pockets^[14].

Antibiotics may be prescribed. Your dentist may prescribe oral antibiotics to fight infection, or they may place topical antibiotics under your gums to target the affected area^[6]. In some cases, antibiotics are prescribed to deal with active or persistent gum infections that have not responded to oral-hygiene measures^[14].

Oral hygiene instructions are provided. Your dentist and hygienist will show you how to clean your teeth properly and remove plaque and tartar^[6].

Surgical treatments

In situations with very advanced periodontitis, the deeper gum pockets that remain can generally be successfully reduced only with surgical treatment^[14]. Surgical options may include:

Pocket reduction surgery: Sometimes, a surgical procedure is carried out to remove plaque bacteria and deposits within periodontal pockets and on the root surfaces. Under local anesthesia, the gum is raised and the root surfaces are cleaned to ensure that all tartar and plaque accumulations are removed^[14].

Regenerative periodontal therapy: This approach involves using either proteins or bone-replacement grafts and membranes to reconstruct bone that has been lost because of periodontitis^[14].

Soft tissue grafts: These procedures may be used to help treat gum recession^[9].

Aftercare and maintenance

The long-term success of periodontal treatment depends on two factors: the patient’s own oral hygiene and regular care from their dentist or periodontist^[14]. After the first phase of treatment has been completed, your dentist will need to review the condition of your gums at regular intervals to check that the inflammation has been halted and has not returned. The frequency of your follow-up appointments will depend on the severity of disease and your individual risk of disease progression. Follow-up visits are usually scheduled for every three to six months^[14].

Prevention and self-care

Inflammation of the gums is neither normal nor inevitable. Gum diseases—gingivitis and periodontitis—can be prevented by looking after your teeth and gums. This means adopting good habits in oral hygiene and getting regular professional check-ups (at least once a year)^[7].

The basic elements of good oral hygiene are:

Brush your teeth at least twice a day, in the morning and at night, for at least two minutes each time. Use a soft-bristled toothbrush and fluoride toothpaste. Hold your toothbrush at a 45-degree angle to your gums and use gentle, circular motions^[7].

Floss daily to remove plaque and food particles from between your teeth and under the gumline. Clean between teeth at least once a day using interdental brushes (also known as interproximal brushes) and dental floss if the gaps are too small for brushes^[7].

Use antimicrobial mouthwash. After brushing your teeth, antiseptic mouthwashes may be used as they can prevent plaque accumulation for up to 12 hours^[7].

Schedule regular dental checkups for professional cleanings and examinations. Your dentist will recommend how often to have routine checkups. Many people should see their dentists once or twice a year^[21].

Quit smoking. Smoking or other tobacco use is a major risk factor. Quitting smoking is strongly advised^[7].

Maintain a balanced diet. A diet rich in vitamins and minerals strengthens the immune system, aiding in the fight against infections. Seniors should limit sugary and acidic foods, as these can worsen gum disease^[15]. Vitamins C and D, calcium, and antioxidants are vital nutrients that support strong and healthy gum tissue^[20].

Drink plenty of water. Staying hydrated helps wash away bits of food and bacteria, keeping your smile clean and healthy. It also promotes saliva production, which has natural antibacterial properties^[20].

Manage stress levels. Mental and emotional stress can weaken the immune system and lower the resistance of the gums to harmful bacteria^[7].

Potential complications

Left untreated, periodontitis could lead to complications like:

• Gum or tooth abscesses
• Gum pain
• Gum recession
• Loose teeth
• Tooth loss^[6]

Periodontitis and cavities (tooth decay) are the two leading causes of tooth loss^[4]. It’s the leading cause of tooth loss among adults^[2].

Often, periodontal disease doesn’t hurt, so you may have no idea that you have the disease. Catching periodontitis early helps prevent complications. See a dentist as soon as possible if you have symptoms, and even if you don’t have any symptoms^[6].

Connection to other health conditions

Beyond oral health, periodontal disease has been linked to other health complications^[6]. Evidence of the association of periodontitis with systemic conditions is mixed^[5].

Diabetes: Periodontal disease and diabetes are considered to have a bidirectional relationship: hyperglycemia (high blood sugar) has an effect on oral health and periodontitis has an effect on glycemic control^[5]. Diabetics whose blood sugar is not managed have a higher risk of developing periodontitis, and patients with periodontitis have a higher risk of suffering diabetes^[7]. Untreated periodontitis can also make other chronic conditions, such as diabetes, worse^[4].

Cardiovascular diseases: Although a causal relationship has not been established, the presence of periodontal disease has been associated with various cardiovascular diseases including heart attack, high blood pressure, and hardening of the arteries^[5].

The treatment of one disease (diabetes or periodontitis) has a positive effect on the treatment of the other. It is important that people with diabetes are examined by a dentist to see if they have periodontitis, and patients with periodontitis should be tested for diabetes by their doctor^[7].