Also called: Gum Disease, Gum Infection
Periodontal disease (also called gum disease or gum infection) is mild to severe inflammation and infection of the gums, tissues and bones supporting and anchoring teeth to the jaw. Gum disease is the primary reason for tooth loss in older adults.
Periodontal disease is typically caused by a build-up of harmful bacteria on the teeth and gums. The bacteria interact with acids and food particles in the mouth to form plaque, a sticky film on the surface of teeth and gums. When plaque remains on the teeth it can harden into tartar (calculus). Tartar that forms below the gum line can only be removed by a dental hygienist in a professional cleaning.
The bacteria that cause plaque and tartar also trigger a response from the body’s immune system. As a result, gums can become inflamed, red and sensitive. They may also bleed when touched or brushed. Periodontal disease may also cause persistent bad breath, loose teeth and other symptoms. However, in its early stages, periodontal disease often occurs without any noticeable symptoms, making diagnosis difficult.
The mildest and most common form of periodontal disease is gingivitis, which is inflammation or swelling of the gums. Gingivitis can be classified by the underlying cause or causes of the condition. These include weakened immune systems, poor diet, hormonal changes in women, oral fungus or viruses or as a result of taking certain medications.
Gingivitis sometimes, but not always, worsens into a more severe form of periodontal disease called periodontitis. In this condition gums pull away from the teeth, forming periodontal pockets that trap bacteria and food particles. Over time, periodontitis can lead to the destruction of gum and bone tissue, which may eventually cause the teeth supported by that periodontal tissue to fall out or have to be pulled.
The major classifications of periodontitis include chronic periodontitis, aggressive periodontitis, periodontitis caused by systemic disease, periodontitis associated with pupal infection, necrotizing ulcerative periodontitis and periodontitis as a result of developmental or acquired deformities.
Periodontal disease has been linked to increased risk of developing cardiovascular disease, including stroke and heart attack. In addition, studies have shown that pregnant women with the disease may be at higher risk of premature or low-birth weight babies.
Some people are at greater risk of contracting the disease, including those with poor oral hygiene or poor nutrition. Smokers, women, people with diabetes and those with a family medical history of periodontal disease are also at higher risk.
A dentist diagnoses periodontal disease using x-rays, dental examinations and dental histories. A probe is used to determine the level of gum and bone damage by measuring the depth of the periodontal pockets formed between the teeth and gums (sulcus).
Treatment methods depend on the type and severity of the periodontal problem. For mild gingivitis, this usually involves debridement or deep cleaning of the teeth and roots (scaling and root planing) as well as polishing the teeth so the smooth surface will be more resistant to bacteria growth. More vigilant home oral care may be recommended, including more frequent brushing and flossing and the use of specialized mouth rinses.
For more advanced periodontal disease, patients may be referred to a dentist who specializes in periodontal care (periodontist). In severe cases a variety of surgical procedures may be considered, including flap surgery, gum grafts, bone grafts or guided tissue regeneration.
In most people, periodontal disease can be prevented with proper oral hygiene. This includes brushing at least twice a day, flossing once a day, avoiding sugary foods and having regular dental check-ups.
About periodontal disease
Periodontal disease, more commonly called gum disease, is inflammation and infection of the tissues and bones surrounding teeth. Also known as gum infection, it is the most common cause of tooth loss, especially among older adults in the United States. Except for those who may be genetically more susceptible to periodontal problems, the disease can be prevented through regular brushing and flossing (oral hygiene).
Periodontal means “surrounding the tooth.” Periodontal tissue, membranes and bones help anchor and cradle the teeth into the jaw and keep teeth aligned and secure by fitting snugly against and between each tooth.
Healthy gums (gingiva) act as barriers to keep germs and infection from entering the bloodstream through crevices or periodontal pocketsthat can develop between the gums and teeth. Diseased or infected gum tissue can become swollen and die. When that happens, the gums pull away from the teeth (receding gums) and open a pathway for bacteria to enter blood vessels.
The presence of bacteria in the tissues (mucous membranes) of the mouth is normal. Those bacteria, along with food particles and acids in the mouth, interact and cause the growth of plaque, a sticky film that clings to the surface of teeth. Plaque build-up can sometimes feel like tiny ridges or bumps on the otherwise smooth surface of teeth.
Plaque that remains on the teeth for more than two to three days hardens or calcifies into tartar (calculus). As tartar and plaque build up on teeth and remain lodged next to the gums, the bacteria normally present in the mouth (especially the harmful bacteria responsible for disease) multiply and release toxins that cause the body’s immune system to signal infection in the gums. This leads to swollen (inflamed), red and bleeding gums.
The infection associated with periodontal disease can happen on or around one tooth or several teeth. It occurs most often in areas where it is difficult for toothbrushes and floss to clean, such as the molars, in teeth next to bridges and implants or where there are ill-fitting dentures or misaligned, impacted or crooked teeth. As the immune system fights the infection, a painful pocket of pus (an abscess) can sometimes form in the gums or between teeth.
Left untreated, gum disease can eventually lead to erosion of the periodontal ligaments and alveolar bones that anchor teeth to the jaw. Without that vital periodontal support, the teeth can loosen over time and may have to be pulled.
According to the National Institutes of Health (NIH), 80 percent of adults in the United States have some form of periodontal disease. The majority have the milder and more common form called gingivitis, which involves inflammation and irritation of the gums and is reversible with treatment. Periodontal pockets of 1 to 3 millimeters (mm) are typical for gingivitis.
According to the American Dental Association (ADA), 20 to 30 percent of adults may have the more severe form of periodontal disease called periodontitis.The infection attacks the gums as well as the underlying bones and tissue supporting the teeth. As the disease progresses, larger pockets begin to form between the teeth and gums as the infected, swollen gum tissue pulls away from teeth and die.
Periodontal disease is sometimes called a “silent threat” to good oral health because it can have no or only minor symptoms. Those who forego regular (twice yearly) dental check-ups are at greater risk of bone or tooth loss from periodontal disease. This is because a dentist can spot the warning signals when examining the teeth and gums and recommend professional and home treatment options.
For those with periodontal disease, some unrelated diseases and conditions can worsen or aggravate the gum and bone inflammation and erosion. Smokers and those with uncontrolled diabetes or HIV/AIDS may experience more severe gum disease and heal less quickly following gum treatment. Pregnancy increases the likelihood of gum inflammation and some studies have shown a link between periodontal disease and premature and low-birth weight babies. Studies have also linked periodontal disease to other systemic conditions, including diabetes, heart disease and respiratory disease.
Periodontal disease can impact patients’ lifestyles as well as their overall health. The social stigma attached to tooth loss and persistent bad breath can affect the quality of life of an individual. A 2000 oral health report conducted by the U.S. Surgeon General’s Office found that low self-image and self-esteem and overall social and psychological well being are adversely affected by oral diseases.
Those with advanced periodontal diseases often:
- Smile less or not at all to hide missing, discolored or deformed teeth
- Have limited food choices because of chewing or biting difficulties
- Don’t enjoy meals
- Avoid certain social settings and intimate contact with others
Types and differences of periodontal disease
Gingivitis and periodontitis are the two major forms of periodontal disease.Gingivitisis inflammation of the gums (gingiva). It is the first stage of periodontal disease that may or may not progress to more severe forms.
Gingivitis can be divided in a number of ways. In general, the conditions may be classified based on the apparent underlying cause, including:
- Plaque induced. Caused by prolonged buildup of plaque on teeth and gums. This is typically caused by poor oral hygiene. Plaque, a sticky film composed mostly of bacteria that forms on teeth, must be removed daily through brushing and flossing. After two to three days, the plaque hardens or calcifies into tartar (calculus). This rock hard substance must be scraped off with dental instruments.
- Non-plaque induced.This category includes specific viral, fungal, mechanical or allergic causes. For instance, herpes simplex viruses can cause a painful gingivitis in which the gums turn bright red and there are white or yellow sores inside the mouth. The episodes typically subside in two weeks. Oral thrush (candidiasis) is a fungal infection that can cause gingivitis. A thin film coats the inside of the mouth and the gums bleed when wiped. It is treatable with anti-fungal medications. Poorly fitted dentures, an impacted tooth and similar mechanisms can cause pockets to form in the gums, which may lead to inflammation and infection. On rare occasions, allergies can cause the gums to become inflamed.
- Related to systemic factors. Gingivitis may be related to a body-wide condition or disease. A wide variety of systemic conditions can affect the development gingivitis, including pregnancy and menopause, which affect hormone levels. Fluctuating hormones can dilate blood vessels in the gums or, in the case of menopause, cause bone loss that can weaken the jaw bones supporting the teeth.
Systemic diseases that can cause gingivitis include diabetes, HIV and leukemia. People with compromised immune systems (such as those infected with HIV) may battle opportunistic infection throughout their bodies, including the gums. Adults and children with cancer of the white blood cells (leukemia) experience gingivitis associated with red bleeding gums when leukemia cells invade the gums. Gingivitis may be one of the first signs of leukemia in many cases.
- Drug induced. Some medications can cause an overgrowth of gum tissue, making plaque removal more difficult. These include blood pressure and heart rhythm drugs, antiseizure medication and drugs taken to reduce organ rejection. Birth control pills can also cause gum irritation due to a change in hormonal balance.
- Malnutrition induced. Malnourishment can weaken the immune system so the body is less able to fight off infections, including gum disease. In addition, a rare vitamin C deficiency (scurvy) and niacin deficiency (pellagra) can cause inflamed, bleeding gums. This gingivitis usually clears up with a balanced diet.
A patient’s gingivitis may fall into more than one category. For instance, patients who take medications (or are experiencing menopause) and neglect their oral health increase their chances of developing gingivitis. This classification is more specific than the traditional classification system, which included pregnancy gingivitis, acute necrotizing ulcerative gingivitis (also called “trench mouth”) and linear gingival erythema (also called “HIV gingivitis”). Acute necrotizing ulcerative gingivitis is more common in younger patients with poor oral hygiene.
In addition to these classifications, gingivitis may be described as diffuse (patchy), desquamative (peeling), suppurative (pus forming) and hemorrhagic (bleeding).
Periodontitis, the second type of periodontal disease, is inflammation and/or infection of the gums and the surrounding tissues and bones. It is the more severe stage of periodontal disease and typically includes permanent loss of the bone and/or tissue supporting the teeth. The beginning stage of periodontitis may have pockets of 3 to 5 millimeters (mm). The more severe forms can have pockets of 6 mm and up. The classifications of periodontitis include:
- Chronic (or slowly progressive) periodontitis. Occurs over time and can have periodic episodes of infection at one or multiple sites in the mouth. This is also called adult periodontitis. Bone and tissue is slowly lost as the bacterial infection persists.
- Aggressive (or early onset) periodontitis. Occurs in younger adults, usually before age 35. Hormonal changes in males and females at puberty can trigger gum inflammation that worsens with poor oral hygiene. It starts rapidly and advances quickly, ravaging bone and tissue. There can be periods where the destruction subsides or the condition improves only to be followed by another episode of rapid bone loss. This is also called localized periodontitis, rapid periodontitis or prepubertal periodontitis.
- Periodontitis caused or influenced by systemic disease. Affects patients with existing diseases such as leukemia, genetic disorders and other disorders where there are not enough white blood cells.
- Periodontitis associated with pupal infection. Abscesses (painful pockets of pus) in the gums or periodontal tissue caused by acute infection. This is also common in third molars (wisdom teeth) that become impacted.
- Necrotizing ulcerative periodontitis. Occurs when soft gum and connective tissue die because of uncontrolled infection. Those with compromised immune systems (e.g., HIV, AIDS) or who are malnourished typically have this form. There can be intense jaw pain and rapid destruction of the bone. Necrotic gums turn gray or black as harmful bacteria multiply at rapid rates.
- Developmental or acquired deformities. Lesions or fractures in the root or tooth or gum deformities causing inflammation and infection. This includes abnormal tooth positions or root fractures and infection around dental restorations and appliances such as implants (periimplantitis).
Risk factors and causes of periodontal disease
Bacteria, plaque and tartar build-up on the teeth are the primary causes of periodontal disease. Poor oral hygiene (such as failing to brush at least twice daily and flossing once a day) allows plaque to remain on the teeth and gums. Over time, bacteria release toxins that lead to inflammation, swelling and redness that, if not corrected, may be followed by bone and gum tissue erosion.
A number of factors can increase a person’s risk of developing periodontal disease. These include:
- Smoking. Tobacco use (including smoking and chewing) weakens the immune system, reduces oxygen in the gum tissue and makes it easier for harmful bacteria in the mouth to grow. Smokers also typically do not heal as quickly following periodontal surgery and are more likely to have severe or chronic periodontal conditions.
- Heredity. The American Academy of Periodontology estimates that 30 percent of adults – even those with good oral hygiene habits – may develop periodontal problems due to their genetic makeup.
- Diabetes. Swollen, red and sensitive gums are among the symptoms of both type 1 and 2 diabetes, which are disorders in the body’s ability to break down sugar (glucose). Those with diabetes heal less quickly and are vulnerable to numerous infections, including gingivitis and periodontitis.
- Drug use. Prescription and over-the-counter medications can complicate periodontal disease. Saliva is a cleansing agent that flushes out bacteria. Some medications (e.g., antidepressants, cold medicines, antihistamines) cause saliva to dry up, allowing harmful bacteria to grow in the mouth. Other medications can suppress the immune system, affecting the body’s ability to prevent and fight off periodontal disease (e.g., antiseizure drugs, calcium channel blockers). The American Dental Association has warned that use of the illegal drug methamphetamine (“meth”) causes rapid deterioration of the teeth and gums leading to a condition known as “meth mouth.” Gingivitis develops quickly and is typically followed by tooth loss because of the high acid levels in methamphetamine. Other illegal drugs can contribute to nutritional or immune system problems that can lead to periodontal disease.
- Hormones. Progesterone and estrogen are hormones that regulate the female reproductive system. They can also enlarge blood vessels in the gums and cause gingivitis. Women who are pre-menstrual (when progesterone levels are highest), pregnant or taking birth control pills (oral contraceptives) often experience gum inflammation and are at greater risk of periodontal disease. Some studies have shown a link between periodontal disease and premature or low-birth weight babies. Post-menopausal women who have bone loss due to lack of the estrogen hormone (osteoporosis) may be at risk for periodontal bone loss as well. Because of this, older women are more likely to lose teeth (called edentulism).
- Nutrition. A poor diet or malnourishment causes a breakdown in the entire immune system and makes it easier for bacteria in the mouth to multiply. Lack of vitamin C (scurvy) and the nutrient niacin (pellagra) causes bleeding and sore gums. Also, diets high in sugars (sodas, candy, sweets) create acidity in the mouth and provide fuel for plaque and bacteria to thrive.
- Viral infections. Certain kinds of herpes viruses, such as those that cause herpes simplex, chicken pox and shingles, may trigger rapid growth of harmful bacteria or help suppress the immune system.
- Intimacy. Since the bacteria that cause periodontal disease flow through the mucous membranes and saliva in the mouth, sustained intimate contact such as long kisses may transmit the bacteria to others.
- Stress. Stress makes it more difficult for the immune system to fight all types of infection, including gum infections. The extra force applied to the gums and periodontal bones by clenching and grinding the teeth (bruxism) may worsen any periodontal disease that is present. Bruxism is frequently associated with stress.
Signs and symptoms of periodontal disease
Periodontal disease is sometimes called a “silent threat” to oral health because there may be no visible symptoms, yet harmful bacteria are growing in tiny crevices in the mouth. Healthy gums are pink and fit snugly against the teeth.
The general symptoms of periodontal problems are:
- Swollen, red or sensitive gums
- Gum pain
- Gums that bleed when brushing or flossing teeth
- Bad breath (halitosis) that does not go away after brushing and/or use of mouthwash
- A bad taste in the mouth
- An abscess or pus on the gums, indicating infection
- Receding gums, making the teeth look longer
- Pockets or spaces between the teeth and gums
- Loose or shifting teeth
- Patchy or peeling gums
Severe cases of periodontitis may have black or gray gums indicating death of gum tissue (necrosis).
Diagnosis methods for periodontal disease
Dentists diagnose periodontal disease using a combination of methods recommended by the American Dental Association. These may include:
- Dental history (including medical history). Evaluations of the type and duration of symptoms, other systemic conditions present (such as heart disease, diabetes or pregnancy), oral hygiene habits, prescription drug use and other factors.
- Full-mouth x-ray. An x-ray performed in the dental office that shows all of the teeth, gums and alveolar bones connected to the jaw. The film can show if, and how extensively, the underlying periodontal ligaments, alveolar bones and gum tissue have been damaged.
- Periodontal examination. Measures the depth of periodontal pockets formed between the gums and teeth (sulcus) with a periodontal probe, a thin measuring rod with a rounded tip and notches indicating millimeters. It is placed at six points around the tooth: three sites on the inner (tongue) side of the tooth and three positions on the outer (facing the cheek) side.
The dentist inserts the tip of the probe into the pocket along the side of the tooth until it meets resistance. A depth of 1 to 3 millimeters is normal. Anything above that requires treatment; the higher the number, the deeper the pocket, the more severe the periodontal disease. The dentist typically focuses on areas where gums bleed when touched or probed with dental instruments, where there are loose or shaky teeth, or where the gum line has receded exposing the surface of the roots (cementum).
- Tooth mobility. Gently shaking the tooth. If there is movement, it could be an indication of bone or tissue loss.
Some dentists may perform a relatively quick screening procedure developed by the ADA for early detection of periodontal disease. Called the Periodontal Screening and Recording (PSR) system, the screening method is performed during a person’s twice yearly dental checkup. The dentist examines each tooth looking for deep pockets and bleeding.
If problems are found, a more complete examination follows. If treatment is necessary, a patient will return periodically for a comprehensive periodontal evaluation to assess pockets, bleeding and changes in gum and bone tissue prior to and following scaling and root planing (deep cleaning), surgeries or antibiotic treatment.
Treatment options for periodontal disease
Once a dentist has diagnosed periodontal disease, there may be different treatment options depending on the type and severity of the condition. A good home oral care regimen of brushing twice daily and flossing to remove food and plaque is always a key component of the treatment plan. The dentist or dental hygienist may recommend brushing after every meal, which may require taking a toothbrush to work. Patients with advanced, severe or chronic periodontal disease may be referred to a specialist (periodontist) for surgical treatment.
Examples of treatments for the milder form of periodontal disease (gingivitis) include:
- Scaling. Scraping the teeth to remove all plaque and tartar (similar to the preventive cleanings performed every six months). Scaling is better than brushing and flossing because it gets to debris that may be trapped under the gum line. The hygienist probes and scrapes the tooth. This procedure that can be painful or uncomfortable for some, especially if gums are already sensitive. A topical analgesic, which numbs the nerves and usually eases the pain, can be swabbed onto the gums prior to and during cleaning. For hyper sensitive patients, stronger measures, such as anesthesia, may be used. An ultrasonic device, which sends out sound waves on high frequencies to break down plaque and tartar, may also be used.
- Polishing. Buffing the tooth surface. Plaque has more difficulty forming on a smooth surface.
- Root planing.A deep cleaning of the root (cementum) eliminates crevices, holes or uneven surfaces that can harbor bacteria and plaque.
- Antibiotics. Mouthwashes and toothpastes containing antibiotics. The dentist may prescribe antibioticmouth rinses,which kill bacteria on contact when swished in the mouth, or toothpastes that use antimicrobial agents to inhibit bacterial growth.
Some patients may require deep cleaning (debridement) more often than twice yearly (perhaps every three months or sooner) depending on how aggressively the disease progresses. Since deep cleanings take longer than a regular (twice yearly) cleaning, the hygienist typically cleans quadrants of the mouth during one of four appointments.
Those who have had certain procedures or who have some conditions (e.g., total joint replacements, rheumatoid arthritis, certain cardiovascular disorders) should inform their dentist. A dose of antibiotics taken an hour before the dental appointment may be required for these individuals. A periodontal deep cleaning can cause the harmful bacteria being scraped off the teeth and roots to flow into the bloodstream, leading to potentially life-threatening complications.
More aggressive non-surgical treatment options include:
- Local antibiotics. Deliver medications to the infection site to control bacteria. Antiseptic “chips,” antibiotic gels and micro-spheres can be placed into the periodontal pockets after root planing and scaling. These items deliver antibacterial medication in slowly-released doses (one to seven days) directly to the infection site to control bacteria growth.
- Broad spectrum antibiotics. Periodic doses of antibacterial drugs. For severe infection, some dentists may prescribe broad-spectrum antibiotic pills for 10 to 14 days. However, there is uncertainty over how effective these drugs are in controlling periodontal disease compared to medications that deliver antibiotics directly to the infection site. Of more concern is that the risk that the anaerobic bacteria that causes periodontal disease can build up a resistance to the antibiotic and make the drugs less effective in fighting off other, more harmful bacterial infections.
- Enzyme suppressors. Drugs to block periodontal issue erosion. There are prescription drugs that suppress the growth of the enzymes that destroy gum and bone tissue when the body’s immune system reacts to periodontal infections.
More severe periodontal cases – where deep pockets of 5 millimeters (mm) or more are present – may not respond to the typical treatment regimen and surgery may be required. There are several possible procedures:
- Flap surgery. Also called gum flap surgery, this procedure involves cutting a flap in the gums and pealing the tissue back to expose the roots to more thorough scaling and planing. The periodontist can also reshape the alveolar bone or put in splints to support weakened areas.
- Curettage. Scraping bacteria off of gum tissue using a sharp instrument called a curette.
- Gum grafts. When healthy gums have eroded or died, it may be necessary to cover the exposed roots with tissue taken from the roof of the mouth (palate). The periodontist cuts a piece of palate tissue and sews (sutures) it onto the gum line. Donor tissue may also be used for this procedure.
- Bone grafts. If the alveolar bones that anchor teeth to the jaw are destroyed by the infection, the periodontist may attempt to repair the damage by attaching a piece of the patient’s own bone or synthetic bone material to the site. This provides a more stable anchor for the teeth and may help prevent tooth loss.
- Guided tissue regeneration. Periodontists attempt to stimulate new bone growth by placing a mesh of biocompatible material into the area of the bone graft between the bone and gum.
The effectiveness of each of these treatments or surgeries varies depending on oral hygiene and smoking habits of the patient and whether there are other underlying systemic diseases.
After periodontal surgery, the patient may undergo maintenance therapy with additional deep cleanings and/or medications to prevent recurrence of the infection.
Prevention methods for periodontal disease
Brushing twice daily and flossing once a day removes plaque. However, when the plaque is allowed to remain on the teeth for longer than two to three days, it moves below the gum line onto the root and hardens into a substance called tartar (calculus). Toothbrushes and dental floss cannot remove tartar.
In most cases, the following prevention methods can help:
- Regular dental visits. Dental checkups and cleanings every six months will allow a dental hygienist, a professional trained in the care and cleaning of teeth, or dentist to examine the teeth and gums for signs of inflammation, bleeding, receding gums or dental pockets. The hygienist uses special instruments to scrape above and below the gum line removing plaque and tartar.
- Eating a healthy, balanced diet. This includes foods rich in calcium (for strong bones and teeth) and vitamin C, an immune system booster that helps fight off all infections, can aid in both treatment and prevention of periodontal disease.
- Quitting smoking (or not starting). Smoking is the most significant risk factor for developing periodontal disease. Smokers also take longer to heal following gum surgery.
Questions for your doctor
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their dentist the following questions related to periodontal disease:
- Am I at risk for periodontal disease?
- How can I prevent or reduce my risk of periodontal disease?
- What type of periodontal disease do I have?
- Does my condition run in the family? Should my children be tested?
- Why won’t my halitosis go away even though I’m brushing and flossing?
- Why are my gums bleeding?
- Am I at risk for losing my teeth due to periodontal disease?
- How does smoking contribute to dental problems?
- Could any medications I’m currently taking affect my periodontal problem?
- Are there types of toothbrushes and/or floss that might benefit me?
- Should I use specialized toothpastes and/or mouth rinses?
- Are there any medications that might be appropriate for me?