Periodontal disease

Periodontal diseases are a group of diseases that affect the tissues that support and anchor the teeth. Left untreated, periodontal disease results in thedestruction of the gums, alveolar bone (the part of the jaws where the teetharise), and the outer layer of the tooth root.

Periodontal disease is usually seen as a chronic (long-term) inflammatory disease. An acute (short-term) infection of the periodontal tissue may occur, but is not usually reported to the dentist. The tissues that are involved in periodontal diseases are the gums, which include the gingiva, periodontal ligament, cementum, and alveolar bone. The gingiva is a pink-colored mucus membrane that covers parts of the teeth and the alveolar bone. The periodontal ligament is the main part of the gums. The cementum is a calcified structure thatcovers the lower parts of the teeth. The alveolar bone is a set of ridges from the jaw bones (maxillary and mandible) in which the teeth are embedded. Themain area involved in periodontal disease is the gingival sulcus, a pocket between the teeth and the gums. Several distinct forms of periodontal diseaseare known. These are gingivitis, acute necrotizing ulcerative gingivitis, adult periodontitis, and localized juvenile periodontitis. Although periodontaldisease is thought to be widespread, serious cases of periodontitis are not common. Gingivitis is also one of the early signs of leukemia in some children.

Gingivitis is an inflammation of the outermost soft tissue of the gums. The gingivae become red and inflamed, loose their normal shape, and bleed easily.Gingivitis may remain a chronic disease for years without affecting other periodontal tissues. Chronic gingivitis may lead to a deepening of the gingivalsulcus. Acute necrotizing ulcerative gingivitis is mainly seen in young adults. This form of gingivitis is characterized by painful, bleeding gums, and death (necrosis) and erosion of gingival tissue between the teeth. It is thought that stress, malnutrition, fatigue, and poor oral hygiene are among the causes for acute necrotizing ulcerative gingivitis.

Adult periodontitis is the most serious form of the periodontal diseases. Itinvolves the gingiva, periodontal ligament, and alveolar bone. A deep periodontal pocket forms between the teeth, and the cementum and the gums. Plaque, calculus, and debris from food and other sources collect in the pocket. Without treatment, the periodontal ligament can be destroyed and resorption of thealveolar bone occurs. This allows the teeth to move more freely and eventually results in the loss of teeth. Most cases of adult periodontitis are chronic, but some cases occur in episodes or periods of tissue destruction.

Localized juvenile periodontitis is a less common form of periodontal diseaseand is seen mainly in young people. Primarily, localized juvenile periodontitis affects the molars and incisors. Among the distinctions that separate this form of periodontitis are the low incidence of bacteria in the periodontalpocket, minimal plaque formation, and mild inflammation.

Herpes infection of the gums and other parts of the mouth is called herpeticgingivostomatitis and is frequently grouped with periodontal diseases. The infected areas of the gums turn red in color and have whitish herpetic lesions.There are two principal differences between this form of periodontal diseases and most other forms. Herpetic gingivostomatitis is caused by a virus, Herpes simplex, not by bacteria, and the viral infection tends to heal by itselfin approximately two weeks. Also, herpetic gingivostomatitis is infectious toother people who come in contact with the herpes lesions or saliva that contains virus from the lesion.

Pericoronitis is a condition found in children who are in the process of producing molar teeth. The disease is seen more frequently in the lower molar teeth. As the molar emerges, a flap of gum still covers the tooth. The flap of gum traps bacteria and food, leading to a mild irritation. If the upper molarfully emerges before the lower one, it may bite down on the flap during chewing. This can increase the irritation of the flap and lead to an infection. Inbad cases, the infection can spread to the neck and cheeks.

Trench mouth is an acute, necrotizing (causing tissue death), ulcerating (causing open sores) form of gingivitis. It causes pain in the affected gums. Fever and fatigue are usually present also. Trench mouth, also known as Vincent's disease, is a complication of mild cases of gingivitis. Frequently, poor oral hygiene is the main cause. Stress, an unbalanced diet, or lack of sleep are frequent cofactors in the development of trench mouth. This form of periodontal disease is more common in people who smoke. The term "trench mouth" wascreated in World War I, when the disease was common in soldiers who lived inthe trenches. Symptoms of trench mouth appear suddenly. The initial symptomsinclude painful gums and foul breath. Gum tissue between teeth becomes infected and dies, and starts to disappear. Often, what appears to be remaining gumis dead tissue. Usually, the gums bleed easily, especially when chewing. Thepain can increase to the point where eating and swallowing become difficult.Inflammation or infection from trench mouth can spread to nearby tissues ofthe face and neck.

Periodontitis is a condition in which gingivitis has extended down around thetooth and into the supporting bone structure. Periodontitis is also called pyorrhea. Plaque and tarter buildup sometimes lead to the formation of large pockets between the gums and teeth. When this happens, anaerobic bacteria growin the pockets. The pockets eventually extend down around the roots of the teeth where the bacteria cause damage to the bone structure supporting the teeth. The teeth become loose and tooth loss can result. Some medical conditionsare associated with an increased likelihood of developing periodontitis. These diseases include diabetes, Down syndrome, Cohn's disease, AIDS, and any disease that reduces the number of white blood cells in the body for extended periods of time.

Several factors play a role in the development of periodontal disease. The most important are age and oral hygiene. The number and type of bacteria present on the gingival tissues also play a role in the development of periodontaldiseases. The presence of certain species of bacteria in large enough numbersin the gingival pocket and related areas correlates with the development ofperiodontal disease. Also, removal of the bacteria correlates with reductionor elimination of disease. In most cases of periodontal disease, the bacteriaremain in the periodontal pocket and do not invade surrounding tissue.

The mechanisms by which bacteria in the periodontal pocket cause tissue destruction in the surrounding region are not fully understood. Several bacterialproducts that diffuse through tissue are thought to play a role in disease formation. Bacterial endotoxin is a toxin produced by some bacteria that can kill cells. Studies show that the amount of endotoxin present correlates with the severity of periodontal disease. Other bacterial products include proteolytic enzymes, molecules that digest protein found in cells, thereby causing cell destruction. The immune response has also been implicated in tissue destruction. As part of the normal immune response, white blood cells enter regionsof inflammation to destroy bacteria. In the process of destroying bacteria,periodontal tissue is also destroyed.

Gingivitis usually results from inadequate oral hygiene. Proper brushing of the teeth and flossing decreases plaque buildup. The bacteria responsible forcausing gingivitis reside in the plaque. Plaque is a sticky film that is largely made from bacteria. Tartar is plaque that has hardened. Plaque can turn into tartar in as little as three days if not brushed off. Tartar is difficultto remove by brushing. Gingivitis can be aggravated by hormones, and sometimes becomes temporarily worse during pregnancy, puberty, and when the patientis taking birth control pills. Interestingly, some drugs used to treat otherconditions can cause an overgrowth of the gingival tissue that can result ingingivitis because plaque builds up more easily. Drugs associated with this condition are phenytoin, used to treat seizures; cyclosporin, given to organ transplant patients to reduce the likelihood of organ rejection; and calcium blockers, used to treat several different heart conditions. Scurvy, a vitaminC deficiency and pellagra, a niacin deficiency, can also lead to bleeding gums and gingivitis.

The initial symptoms of periodontitis are bleeding and inflamed gums, and badbreath. Periodontitis follows cases of gingivitis, which may not be severe enough to cause a patient to seek dental help. Although the symptoms of periodontitis are also seen in other forms of periodontal diseases, the key characteristic in periodontitis is a large pocket that forms between the teeth and gums. Another characteristic of periodontitis is that pain usually doesn't develop until late in the disease, when a tooth loosens or an abscess forms.

Diagnosis is made by observation of infected gums. Usually, a dentist is theperson to diagnose and characterize the various types of periodontal disease.In cases such as acute herpetic gingivostomatitis, there are characteristicherpetic lesions. Many of the periodontal diseases are distinguished based onthe severity of the infection and the number and type of tissues involved.

Diagnosis of periodontitis includes measuring the size of the pockets formedbetween the gums and teeth. Normal gingival pockets are shallow. If periodontal disease is severe, jaw bone loss will be detected in x-ray images of the teeth. If too much bone is lost, the teeth become loose and can change position. This will also be seen in x-ray images.

Tartar can only be removed by professional dental treatment. Following treatment, periodontal tissues usually heal quickly. Gingivitis caused by vitamin deficiencies is treated by administering the needed vitamin. There are no useful drugs to treat herpetic gingivostomatitis. Because of the pain associatedwith the herpes lesions, patients may not brush their teeth while the lesionsare present. Herpes lesions heal by themselves without treatment. After theherpetic lesions have disappeared, the gums usually return to normal if goodoral hygiene is resumed. Pericoronitis is treated by removing debris under the flap of gum covering the molar. This operation is usually performed by a dentist. Surgery is used to remove molars that are not likely to form properly.

Treatment for trench mouth starts with a complete cleaning of the teeth, removal of all plaque, tartar, and dead tissue on the gums. For the first few days after cleaning, the patient uses hydrogen peroxide mouth washes instead ofbrushing. After cleaning, the gum tissue will be very raw and rinsing minimizes damage to the gums that might be caused by the tooth brush. For the firstfew days, the patient should visit the dentist daily for checkups and then every second or third day for the next two weeks. Occasionally, antibiotic treatment is used to supplement dental cleaning of the teeth and gums. Surgery may be needed if the damage to the gums is extensive and they do not heal properly.

Treatment of periodontitis requires professional dental care. The pockets around the teeth must be cleaned, and all tartar and plaque removed. In periodontitis, tartar and plaque can extend far down the tooth root. Normal dental hygiene, brushing and flossing, cannot reach deep enough to be effective in treating periodontitis. In cases where pockets are very deep (more than one quarter inch deep), surgery is required to clean the pocket. This is performed ina dental office. Sections of gum that are not likely to reattach to the teeth may be removed to promote healing by healthy sections of gum. Abscesses aretreated with a combination of antibiotics and surgery. The antibiotics may be delivered directly to the infected gum and bone tissues to ensure that highconcentrations of the antibiotic reach the infected area. Abscess infections, especially of bone, are difficult to treat and require long term antibiotictreatments to prevent a reoccurrence of infection.

Periodontal diseases can be easily treated. The gums usually heal and resumetheir normal shape and function. In cases where they don't, prostheses or surgery can restore most of the support for proper functioning of the teeth.

Most forms of periodontal disease can be prevented with good dental hygiene.Daily use of a toothbrush and flossing is sufficient to prevent most cases ofperiodontal disease. Tartar control toothpastes help prevent tartar formation, but do not remove tartar once it has formed.

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