Periodontal Disease

Dental diagnosis
Overview

Untreated gingivitis can progress to the point where the gingival attachment fibers to tooth and bone are lost; and beyond that to the point where bone destruction results (Figure 1). This bacterial illness is called periodontal disease (or periodontitis), and is the number one cause of tooth loss in adults. It is also referred to as gum disease and by the antiquated term, pyorrhea.

Periodontal disease

Figure 1: Advanced periodontal disease. If more than 40% of the tooth-supporting (alveolar) bone has been destroyed by periodontal disease, the disease is considered severe, or advanced. Allowing the disease to progress to this point introduces significant general health risks.

Periodontal disease is not curable. However, it can be controlled indefinitely through treatment by a dental professional, excellent home care, and regular follow-up. Evidence from both the medical and dental professional literature that periodontal disease and certain systemic illnesses are related, and that treating periodontal disease in the dentist’s chair before it progresses may prevent expensive medical treatment and life-threatening illness.


Video: Periodontal Disease


Video: Periodontal Disease (Espanol)

How is this dental diagnosis established?

Periodontal disease (or periodontitis) is diagnosed when a breakdown of the periodontal supporting tissues (gums, periodontal ligament and bone) is discovered. Attachment loss is the term used to describe breakdown of the gingival attachment fibers (and in more advanced periodontal disease, the periodontal ligament fibers). It is diagnosed by using a periodontal probe to measure the depth of the pocket formed where the teeth emerge from the gums. Early periodontal disease may not be evident on X-ray images (radiographs), even though the bone may be softened by the disease process. Moderate to severe periodontal disease is evident on X-ray images, which show obvious bone loss.

A patient with active periodontal disease is diagnosed through the presence of bleeding upon light periodontal probing. The gums may be red (erythematous) to bluish-purple (cyanotic) in color at infected sites, and will generally appear puffy due to the presence of fluid in the tissues. Instead of a stippled appearance, the surface of the gums will appear shiny and smooth due to an accumulation of inflammatory fluid.

Treatment options
Treatment of periodontitis may involve one or more options.

Treatment of periodontal disease may involve scaling, root planing, soft tissue laser debridement, and localized administration of antibiotics. Other treatment may be recommended.

Current treatments for periodontal disease are considered non-specific. This means they are not generally targeted at any particular species of periodontal bacteria. The majority of periodontal treatment consists of mechanically eliminating as many bacteria as possible from the affected periodontal pockets, and thoroughly cleaning the tooth surfaces to eliminate calculus, pits, ledges and other root surface irregularities in which bacteria tend to thrive. This non-specific protocol continues to be practiced because it is currently the most effective way available to treat the illness.

Research demonstrates that current periodontal therapy is successful at decreasing inflammation, and improving vascular (blood vessel) health—both locally and systemically. There is significant variability in the success of treatment, because of the lack of certainty about specific causative factors, contributing factors, and host-defense factors. The most important factors in assuring long-term success with periodontal treatment are the patient’s understanding about the significance of their illness, their motivation to prevent its progression and their own oral hygiene efforts to control the disease.

Depending on the severity of the periodontal disease when diagnosed, treatment options may be surgical or non-surgical. Non-surgical periodontal treatments include scaling and root planing to remove bacterial plaques and calculus, and establish smooth root cementum which is less conducive to bacterial colony formation; localized antibiotic administration, to help eliminate bacteria and the destructive acids and enzymes from sites which continue to be inflamed (some of which are produced by the patient’s immune response); and periodontal splinting, to stabilize loose teeth which have lost a significant amount of bone. When periodontal disease is under control, it is usually necessary to undergo regular periodontal maintenance to prevent progression of the disease.

Surgical periodontal treatment may involve open flap curettage (debridement), in which the gums are surgically elevated off of the underlying bone to allow access for specialized cleaning instruments. Unhealthy bone may be removed as part of that procedure, and the gums may be re-positioned to allow the patient and dental professionals better access for cleaning the teeth (known as apical positioning of the gums). For areas of localized periodontal disease, Guided Tissue Regeneration (GTR) may be performed. This generally involves surgical removal of diseased tissue, and placement of bone and/or soft tissue grafts in the affected area.

If the gums recede as a result of periodontal disease (or following treatment for it), the dentist may recommend applying topical fluoride gel to the exposed tooth roots, to reduce the chance of developing decay. Exposed tooth roots lack the benefit of a dense enamel covering. Topical fluoride can be applied in the dental office, by the patient at home, or both, depending on the patient’s risk factors for getting gumline cavities. Exposed tooth roots can also be sensitive—especially to temperature changes and sweets. Desensitizing medications can be applied to sensitive teeth, and the dentist may recommend using sensitivity formula toothpaste until symptoms improve.

Related diagnoses
Oral and systemic health issues can lead to strokes or heart attacks.

Periodontal disease (periodontitis) has been linked to a number of systemic health problems such as strokes and heart attacks.

Periodontal disease has been positively associated with certain system-wide illnesses. It is believed that long-standing (chronic) inflammation anywhere in the body (including the mouth) is capable of increasing the production of a substance called C-Reactive Protein (CRP) in the liver and blood vessel walls. Studies have shown elevated levels of CRP to be a greater predictor of heart disease than elevated cholesterol. Other studies suggest that certain bacteria found in the mouth can cause blood vessels to decrease in diameter, imparing blood flow and encouraging clot formation.

There are other bacterial illnesses of the mouth, which can produce inflammation of the gums (gingivitis) and tooth decay (also called caries). Untreated gingivitis leads to periodontal disease, and exposure of tooth roots from receded gums may occur (gingival recession). Exposed tooth roots can be very sensitive to temperature changes (dentin hypersensitivity).

In teeth which have lost a significant amount of supporting (alveolar) bone, tooth mobility can result. This is known as secondary occlusal trauma. Sometimes bacteria that infect the pockets around teeth will find their way into or under the tooth, causing an abscess. Untreated periodontal disease can result in loss of multiple teeth, a condition known as edentulism. Poorly controlled diabetes is a factor in the progression of periodontal disease, and may also be a contributing factor to development of the disease. Active periodontal disease also contributes to poor control of blood sugar (glycemic control) among diabetics.

Author: Thomas J. Greany, D.D.S.
Editor: Ken Lambrecht
This page was reviewed by members of our review board.

This page was last updated on September 22, 2016.

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Caries
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Desensitizing Medications
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Diabetes
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Fluoride Treatments
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Gingival Recession
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Localized Antibiotic Administration
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Periodontal Maintenance
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Periodontal Stabilization Splints
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Scaling and Root Planing
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Background information

Periodontal disease, tooth loss, and cancer risk in male health professionals: a prospective cohort study
Michaud, Dominique S., ScD, et al.
Lancet Oncology
2008 9: 550-558

A Prospective Study of Periodontal Disease and Pancreatic Cancer in US Male Health Professionals
Michaud, Dominique, S., et al.
Journal of the National Cancer Institute
2007 99 (2): 171-175

Anaerobic dental flora and the acute coronary syndrome
Rubenfire, Melvyn A., et al.
Coronary Artery Disease
2007 18 (2): 111-116

Histologic Evaluation of an Nd:YAG Laser-Assisted New Attachment Procedure in Humans
Yukna, Raymond A. DMD, et al.
The International Journal of Periodontics & Restorative Dentistry
2007 27 (6): 577-587

Prognosis Revisited: A System for Assigning Periodontal Prognosis
Kwok, Vivien and Caton, Jack G.
Journal of Periodontology
2007 78 (11): 2063-2071

The detection of eight putative periodontal pathogens in adult and rapidly progressive periodontitis patients: An institutional study
Joshi, Vinayak, M. and Vandana, K.L.
Indian Journal of Dental Research
2007 18 (1): 6-10

The Effect of Androgen Deprivation Therapy on Periodontal Disease in Men With Prostate Cancer
Famili, Pouran, et al.
The Journal of Urology
2007 177 (3): 921-924

Full-mouth Tooth Extraction Lowers Systemic Inflammatory and Thrombotic Markers of Cardiovascular Risk
Taylor, B.A., et al.
Journal of Dental Research
2006 85 (1): 74-78
Editor’s notes: More evidence that cardiovascular risks associated with chronic periodontal disease end when the periodontal disease ends. This article does not advocate edentulating patients.

Identification of oral bacteria associated with crevicular epithelial cells from chronic periodontitis lesions
Colombo, Andrea Vieira, et al.
Journal of Medical Microbiology
2006 55: 609-615

Periodontal infections and cardiovascular disease: The heart of the matter
Demmer, Ryan T., PhD and Desvarieux, Moise, MD, PhD
The Journal of the American Dental Association
2006 137: 14S-20S
Notes: Supplement to the Journal

Periodontal Infections and Coronary Heart Disease
Spahr, A., DDS, et al.
Archives of Internal Medicine
2006 166: 554-559

Protective effects of grapeseed proanthocyanidins against oxidative stress induced by lipopolysaccharides of periodontopathogens
Houde, V., et al.
Journal of Periodontology
2006 77 (8): 1371-1379

Treatment of Periodontal Disease and the Risk of Preterm Birth
Michalowicz, Bryan S. DDS, et al.
The New England Journal of Medicine
2006 355 (18): 1885-1894

Purpose and problems of periodontal disease classification
van der Velden, Ubele
Periodontology 2000
2005 39 (1): 13-21

Associations Between Periodontal Disease and Risk for Atherosclerosis, Cardiovascular Disease, and Stroke. A Systematic Review.
Scannapieco, Frank A., et al.
Annals of Periodontology
2003 8 (1): 38-53

The etiology and prevalence of gingival recession
Kassab, Moawia M., DDS, MS, et al.
The Journal of the American Dental Association
2003 134 (2): 220-225

Comparison of C-Reactive Protein and Low-Density Lipoprotein Cholesterol Levels in the Prediction of First Cardiovascular Events
Ridker, Paul M. MD, et al.
The New England Journal of Medicine
2002 347 (20): 1557-1565

Periodontic and orthodontic treatment in adults
Ong, Marianne M.A., BDS, MS and Wang, Hom-Lay, DDS, MSD
American Journal of Orthodontics & Dentofacial Orthopedics
2002 122 (4): 420-428

Acute-phase inflammatory response to periodontal disease in the US population
Slade, G.D., et al.
Journal of Dental Research
2000 79: 49-57

Biofilm: A New View of Plaque
Overman, Pamela R., RDH, MS
The Journal of Contemporary Dental Practice
2000 1 (3): 18-29

Role of bacterial proteinases in matrix destruction and modulation of host responses
Potempa, Jan, et al.
Periodontology 2000
2000 24 (1): 153-192

Periodontal diseases in the United States population
Oliver, R.C., et al.
Journal of Periodontology
1998 69 (2): 269-278

Periodontal splinting with wire and composite resin. A revised approach.
Greenfield, D.S. and Nathanson, D.
Journal of Periodontology
1980 51 (8): 465-468

5 Natural Remedies for Healthy Gums
Wong, Cathy, ND, CNS
Alternative Health News Online web site
Last viewed: 7/15/2016

Actisite® Drug Monograph (PDF, 348K)
The Journal of the American Dental Association
Editor’s notes: Actisite drug monograph reviewed.

American Academy of Periodontology Statement on Periodontal Disease and Preterm Low Birthweight
American Academy of Periodontology web site
Last viewed: 7/15/2016

Arestin® USFDA Clinical Trials
U.S. Food and Drug Administration web site
Last viewed: 9/23/2010

Diabetes and Periodontal Disease
American Academy of Periodontology web site
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Gum Disease and Heart Disease
American Academy of Periodontology web site
Last viewed: 7/15/2016

Gum Disease and Women
American Academy of Periodontology web site
Last viewed: 7/15/2016
Editor’s notes: Article addresses gender-specific oral health concerns of women.

PerioChip® Home Page
Dexcel Pharma PerioChip web site
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Editor’s notes: Manufacturer’s web site

Periodontal Disease and Systemic Health
American Academy of Periodontology web site
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Periodontal Disease Is Associated With Brachial Artery Endothelial Dysfunction, and Systemic Inflammation (PDF, 264K)
Salomon Amar, et al.,
Arteriosclerosis, Thrombosis and Vascular Biology

Porphyromonas gingivalis Genome Project
Porphyromonas gingivalis Genome Project web site
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Risk Factors for the Periodontal Diseases
American Academy of Periodontology web site
Last viewed: 7/15/2016
Editor’s notes: Discusses relationship between chronic bacterial infection of the gums, and the response of the liver (making proteins like CRP) which inflame arteries and promote blood clot formation.

Information you may wish to read before making a decision on treatment

Mythbusters and Wisdom Teeth
Dodson, Thomas B., DMD, MPH
The American Journal of Public Health
2008 98 (4): 581-582

Effects of EDTA Gel Preconditioning of Periodontally Affected Human Root Surfaces on Chlorhexidine Substantivity—an SEM study
Ahmed Y. Gamal and Jason M. Mailhot
Journal of Periodontology
2007 78 (9): 1759-1766

Intrauterine Growth Restriction, Low Birth Weight, and Preterm Birth: Adverse Pregnancy Outcomes and Their Association With Maternal Periodontitis
Fernanda Mafra Siqueira, et al.
Journal of Periodontology
2007 78 (12): 2266-2276

Treatment of Periodontitis and Endothelial Function
Tonetti, Maurizio S., et al.
The New England Journal of Medicine
2007 356 (9): 911-920

Periodontal Health and the Heart
Stephenson, Joan PhD
Journal of the American Medical Association
2006 295 (15)

The Effect of EDTA in Attachment Gain and Root Coverage (PDF, 115K)
Kassab, Moawia M., DDS, MS, et al.
Compendium of Continuing Education in Dentistry
2006 27 (6): 353-361

Periodontal Therapy Reduces the Rate of Preterm Low Birth Weight in Women With Pregnancy-Associated Gingivitis
Lopez, Nestor J., et al.
Journal of Periodontology
2005 76 (11): 2144-2153

Researchers Find Nine Risk Indicators for Tooth Loss
No author specified
American Academy of Periodontology web site
Last viewed: 7/15/2016
2005 11
Editor’s notes: Among the risks cited for tooth loss, 39% of patients in the study said they had never had a dental prophylaxis or periodontal maintenance visit.

Subantimicrobial dose doxycycline (SDD) improves probing parameters associated with periodontitis
Paquette, David DMD, MPH, DMSc
The Journal of Evidence-Based Dental Practice
2005 5 (3): 151-153

Position Paper: Systemic Antibiotics in Periodontics (PDF, 148K)
Slots, Jorgen, Dr., et al.
Journal of Periodontology
2004 75 (11): 1553-1565

Subantimicrobial Dose Doxycycline Enhances the Efficacy of Scaling and Root Planing in Chronic Periodontitis: A Multicenter Trial
Preshaw, Philip M. Dr., et al.
Journal of Periodontology
2004 75 (8): 1068-1076

Translating findings of systematic reviews into consensus statements on periodontal therapy
The Journal of the American Dental Association
2004 135 (8): 1099-1107
Notes: Submitted by the American Academy of Periodontology

Position Paper—Diagnosis of Periodontal Diseases (PDF, 172K)
American Academy of Periodontology web site
Last viewed: 7/15/2016
2003

Position Paper: Periodontal Maintenance (PDF, 101K)
Cohen, Robert E. Dr., et al.
Journal of Periodontology
2003 74 (9): 1395-1401

Periodontal Infections Contribute to Elevated Systemic C-Reactive Protein Level
Noack, Barbara, et al.
Journal of Periodontology
2001 72 (9): 1221-1227

Predictable peri-implant gingival aesthetics: surgical and prosthodontic rationales
Kois, J.C., and Kan, J.Y.
Practical Procedures in Esthetic Dentistry
2001 13 (9): 691-698

Predictable single-tooth peri-implant esthetics: five diagnostic keys
Kois, J.C.
Compendium of Continuing Education in Dentistry
2001 22 (3): 199-206

Identification of periodontal pathogens in atheromatous plaques.
Haraszthy, V.I., et.al.
Journal of Periodontology
2000 71 (10): 1554-1560

Invasion of Human Coronary Artery Cells by Periodontal Pathogens
Dorn, Brian R., et al.
Infection and Immunity
1999 67 (11): 5792-5798

A classification system for loss of papillary height
Nordland, W.P. and Tarnow, D.P.
Journal of Periodontology
1998 69 (10): 1124-1126

Antimicrobial Susceptibilities of Porphyromonas gingivalis, Prevotella intermedia, and Prevotella nigrescens spp. Isolated in Spain
Andres, Maria T., et al.
Antimicrobial Agents & Chemotherapy
1998 42 (11): 3022-3023

The Interproximal height of Bone: A Guidepost to Esthetic Strategies and Soft Tissue Contours in Anterior Tooth Replacement (PDF, 54K)
Salama, Henry, DMD, et al.
The Journal of Practical Periodontics and Aesthetic Dentistry
1998
Notes: PDF of the article originally submitted to The Journal of Practical Periodontics and Aesthetic Dentistry for the Anthology Edition in 1998.

Maintenance care and supportive periodontal therapy
Ramfjord
Quintessence International
1993 24 (7): 465-471

Are Essential Oils Safe?
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C-Reactive Protein—A Predictor of Heart Disease—Is Elevated in Patients with Periodontal Disease
American Academy of Periodontology web site
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Editor’s notes: Media Statement

Endocarditis Prophylaxis Information
American Heart Association web site
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Laser Treatment for Gum Disease
American Academy of Periodontology web site
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Laser-assisted Periodontal Regeneration in Humans (PDF, 428K)
Yukna, R.A., et al.
Millennium Dental Technologies web site
Last viewed: 7/15/2016
Editor’s notes: Manufacturer’s web site. Article from the Proceedings of the 81st General Session of the International Association of Dental Research (IADR); June 25–28, 2003.