Periodontal disease is influenced by many factors, but most often it is caused by the deposition of bacterial plaque. Therefore, daily oral hygiene and periodic checkups at the dentist’s office are essential.

The oral cavity is a very complex environment, and the ailments and diseases that dentistry deals with are not limited to the structures of the teeth. Very often the disease process attacks the so-called periodontium, which consists of:

1. Gingiva: free (marginal) and attached (alveolar)
2. Periosteum
3. Alveolar bone
4. Root cement

Periodontal structure

In order to thoroughly understand the causes, course and consequences of periodontal diseases, it is worth getting acquainted with its structure. Particularly important from the point of view of the development of periodontal diseases is the so-calledgingival groove. It is located between the gingival margin and the tooth surface, to which it adheres like a collar. Its bottom is lined with a delicate connecting epithelium. This epithelium forms during the development and eruption of teeth. Once destroyed,it cannot be rebuilt. Therefore, examining the groove depth is the basic method of diagnosing periodontal diseases, and the presence of deep pockets should prompt us to see a doctor as soon as possible.

Periodontal development

The periodontium is formed during thetooth eruptionprocess . It is especially important to establish a connection between the gum and the tooth in the cervical area. This connection remains constant until the age of 25-30 and decreases with age. This process is calledsenile periodontal atrophyand consists of a gradual, even lowering of the gum level and exposing the necks of the teeth. Usually it isasymptomaticor is accompanied by slightloosening of the teeth. On the X-ray image, you can then see a horizontal bone loss (as if the entire alveolar process was decreasing evenly).

Periodontal functions

The periodontium acts as a specificsupport for the teeth. It supports them, protects them, nourishes them and enables them to fulfill all functions, it takes part in, for example:

• chewing food,
• I’m speaking
• provides an appropriate aesthetic appearance,
• it is a natural barrier and protection against the penetration of microorganisms into the body.

Oral cavity and periodontal disease

The oral cavity is home to a huge number of microbes. There is a constant war between our immune system and bacteria. Usually the fight ends in a draw so that the microbes only function in a limited number without causing disease. Our body has some effective means of defense, which include:

• The mucosa– which lines the entire mouth, is a barrier against bacterial attacks.
• Exfoliation of the epithelium– bacteria that have successfully colonized the oral cavity are quickly removed along with the exfoliating epithelium.
• Substances contained in saliva– they have bactericidal properties, neutralize toxins and bind substances necessary for the functioning of bacteria, so that they are inaccessible to microorganisms.
• The mechanisms of the immune system– they rely on the production of antibodies against “intruders”, phagocytosis, i.e. direct devouring of microorganisms by specialized cells.

Unfortunately, bacteria also have very effective means of attack. They intensify the destruction of periodontal tissues both directly and indirectly. They produce directly:

• Enzymes– destroying proteins and other substances that build periodontal tissues.
• Toxins:
  • Exotoxins– substances produced by bacteria and secreted by them into the surrounding environment, e.g. leukotoxin affects the impairment of the defensive response by destroying the cells responsible for it.
  • Endotoxins– are part of the bacterial cell membranes and are released into the environment during their breakdown. These substances enhance the breakdown of periodontal tissues, hinder their regeneration and impair the immune response.

In the first stage of the periodontium-bacteria war, theblood vessels widen(this may be manifested by bleeding while brushing the teeth). Later, the presence of the bacteria attracts the immune cells responsible for the first line of defense – the so-called macrophages and neutrophils thateat up some bacteriaand transmit the enemy signal to more specialized cells.Lymphocytes, in turn, produce antibodies specifically directed against species of microbes roaming the oral cavity. There are also secreted substances and enzymes, the side effect of which isthe destruction of periodontal tissues.At this stage, the gums are usuallyseverely swollenand caneven bleed spontaneously.

Periodontal diseases – risk factors

Periodontal diseases are a very complex group. Usually, it is the combination of at least several factors that triggers their formation. Nevertheless, in all cases, a general pattern can be discerned – for these to occur it is necessary to upset the balance between the body’s defenses and the amount and virulence of the bacteria present in the plaque. Therefore, the main factor predisposing to periodontitis isplaque.Genetic factors, smoking, stress and osteoporosis also play a significant role.

Periodontal disease risk factors:

1. Dental plaque– plays a major role in the development of most periodontal diseases. As early as 1965, studies showed that failure to brush your teeth for three weeks causes gingivitis, which, however, disappears when the plaque is removed.

Bacterial plaque occurs in the form ofsoft deposits firmly adhering to the tooth surface, supra- and subgingival, other soft tissues, as well as prosthetic restorations and orthodontic appliances. It is the habitat of bacteria (which account for as much as 50-90% of its mass). It affects the development and dynamics of inflammatory processes, as well as the host’s immune response. It is hard to imagine, but 2¹⁰¹¹bacteria can be present in 1 g of the plate.

Bacterial plaque is formed through several steps. First, on the clean surface of the teeth,sticky saliva proteins(the so-called acquired casing) are deposited, which are colonized by the firstbacteria after a few hours.There are numerous interactions between bacteria, so that one displaces the other. The result of this competition is the formation of a maturebacterial plate, full of microorganisms that are very harmful to the body.

2. Smoking– is considered to be one of themost important risk factors for periodontal diseasebecause

• promotes the deposition of dental plaque (i.e. the habitat of bacteria),
• creates favorable conditions for anaerobic bacteria, which are particularly dangerous for the periodontium,
• increases the production of pro-inflammatory substances and proteolytic enzymes,
• It also contributes to the impairment of the body’s immune response.

3. Genetic factors– affect thebody‘s ability to fight plaque bacteria. A substance called the cytokine Il-1β plays a very important role in immune responses. It is a substance produced by the body that stimulates it to produce a greater inflammatory response. In principle, it playsan important protective function, in a way cheering the body to defend itself. Unfortunately, in people with a specific genotype, a potentially beneficialcytokineit over-drives the inflammatory process, which destroys not only microbes but also surrounding tissues. Other genetically conditioned factors include abnormal structure of collagen in the gingiva and periodontium, and slow regeneration or incorrect connections between cells at the bottom of the gingival fissure.

4. Age– in old age the risk of periodontal diseases increases. It is related to thereduced immunityof the body and the effect of dental plaque that accumulates over the years.

5. Gender– periodontal diseases are more common inmen.This, however, is not so much related to the gender itself, but rather to specific social conditions – men more often

• smoke cigarettes more often,
• they consume alcohol more often,
• they maintain oral hygiene worse,
• they are less frequent at check-ups at the dentist’s

6. Social status– people with ahigher social status, governmentj, suffer from periodontal diseases. This is associated with a better diet, more frequent dental checkups, and more careful oral hygiene.

7. Stress– it has two effects on periodontal tissues. On the one hand,hormonessecreted during long-term stressful situations reduce the body’s immunity, on the other hand, in such situations there are oftenhygiene and nutritional negligence, etc.

8. Systemic diseases– general health has an impact on the condition of periodontal tissues. People suffering from the following diseases should be especially vigilant:

• Diabetes mellitus– people suffering from this disease very often suffer from serious ailments from periodontal tissues. This is because diabetes interferes withthe immune system, making the body less able to cope with infections. Additionally, there are so-called microangiopathies responsible for poorer blood supply to tissues. In turn, the collagenase enzyme responsible for “cutting” collagen is excessively active in diabetics, causing progressive destruction of the periodontium.
• Osteoporosis– is associated with the intensification of the resorption of bone structures (e.g. the alveolar process).
• AIDS– impairs the immune system, causing recurrent infections within the periodontal tissues.
• Down syndrome– also associated with impaired immunity.

9. Harmful factors related to previous dental treatment– they increase the deposition of bacterial plaque or directly penetrate the periodontal tissues. Belong to them;

• poorly made fillings– overhanging, incomplete, too high (they overload periodontal tissues);
• poorly performed prosthetic restorations.

10. Abnormalities in the structure of the oral cavity:

• Incorrect bite– teeth crowded together, traumatic bite, etc.
• Incorrect attachment of the frenulum of the lips, tongue, cheeks– attachments of the lip frenulum are especially important. If such a frenulum attaches too close to the gingival margin, any lip movement (speech, eating, etc.) will cause periodontal microtrauma that will accumulate over time.
• Giant language.

Periodontal diseases – causes

Periodontal disease is a very diverse group. Some are associated with the presence of plaque, others are genetically determined or associated with general diseases, medications or hormone fluctuations. It is not worth quoting the entire classification here, because this is the knowledge that the attending physician should have. However, it is worth knowing what can modify their course:

• the presence of plaque,
• related to the endocrine system (in adolescence, related to the menstrual cycle, in diabetes),
• related to blood diseases (e.g. inleukemia),
• aggravated by drugs (antiepileptics – phenytoin),
• aggravated by eating disorders,
• associated with an infection in the mouth,
• genetically determined,
• in the course of general diseases,
• caused by injuries,
• allergic reactions.

Does any of the following descriptions fit your situation? If so, read the description of the disease that may apply to you, and below you will find a brief description of the condition in question.

Periodontal diseases – types

Gingivitis caused only by plaque

CAUTION!!!This inflammation is themost common!First, it attacks the gingival margin (that is, the part that is in direct contact with the plaque). Is characterised by:

• bleeding
• swelling
• reddening of the gums.

However, these changes are reversible and disappear after the plaque is removed.

Pubertal gingivitis

It is associated with changes in the levels of hormones in the body. Thus, an amount of plaque that previously did not cause any symptoms during puberty can lead to serious inflammation. Fortunately, the changes go back as your hormone levels normalize.

Gingivitis associated with the menstrual cycle

It usually appears around the ovulation period and appears as easily bleeding, bright red lesions on the interdental papillae. This inflammation regresses after ovulation.

Pregnancy tumor

It appears during pregnancy in the form of a mushroom-like, reddened elevation. It is most often located in the maxilla, on the interdental papillae or on the gingival margin. Retracts after giving birth.

Gum symptoms in diabetes

Diabetes mellitus is a systemic disease that affects the functioning of the entire body, including periodontal tissues. Gingivitis associated with diabetes mellitus is very similar to that caused by plaque. It most often occurs in children with decompensated diabetes mellitus type I. To control gingivitis, sugar levels must first be normalized. On the other hand, oral hygiene and treatment of inflammation improves the general condition of patients.

Gum symptoms in leukemia

In acute leukemias in the oral cavity, petechiae and erosions appear on the mucosa. The gums are red, with signs of an inflammatory process, they bleed. Leukemia is often accompanied by gingival growths that begin in the area of ​​the interdental papillae and extend across the edge to the entire gum. Lymph nodes are enlarged.

Gum symptoms with certain medications

During therapy with some drugs, drug-induced inflammation (usually proliferative) occurs. These drugs include:

• anticonvulsants (e.g. phenytoin)
• immunosuppressants, used after transplantation (e.g. cyclosporine)
• calcium channel blockers, used in cardiovascular diseases (e.g. nifedipine, verapamil),
• contraceptives.

Drug-induced hyperplastic gingivitis usually begins 3 months after the start of therapy. The lesions are located in the frontal section of the mouth.

Gum disease caused by bacteria

They are very often combined with sexually transmitted infections –gonorrhea ,syphilisor streptococcal infections. Characteristically, local lesions in the oral cavity are accompanied by general symptoms – malaise and increased temperature. There is also increasing bleeding from the gums, which may be accompanied by the formation of abscesses.

Gum disease caused by viruses

The most common culprit of these diseases is theherpesvirus HSV1, which manifests itself during periods of decreased immunity.

Gum disease caused by fungi

Mycoses rarely attack a healthy body, and usually appear in situations of reduced immunity (long antibiotic therapy, diabetes, steroid therapy, reduced salivation, AIDS). They appear as white patches on the tongue, gums and cheek mucosa. These tarnishes can be wiped off, revealing a red or bleeding surface.

Hereditary fibromatosis of the gums

It is one of the most common inherited gum disease. It is characterized by significant gingival overgrowths that can even cover the entire tooth crowns. It is accompanied by difficult tooth eruption.

Allergic reactions

Oral allergic reactions are relatively rare. They are difficult to diagnose (additional specialist examinations are needed). In the event of a sudden onset of inflammatory symptoms, it is worth considering whether you have recently started using a new toothpaste or rinse.

Mechanical damage

They can occur during dental treatment, but most often such damage is the result of incorrect brushing or flossing techniques. If we have noticed gum recession in our country in the absence of symptoms of inflammation, it is worth carefully analyzing the way we clean.

Chronic periodontitis

It is the most common periodontal disease in adults, caused by the presence of bacteria in the dental plaque. It is characterized by the occurrence of:

• swelling and recession of the gums,
• three-tooth pockets,
• bleeding
• alveolar bone loss,
• increased mobility of the teeth (they can rotate).

The inflammatory process is slow but systematic. There may be periods of exacerbation.

Aggressive periodontitis

It most often attacks young people under 30, who are generally healthy. Often the disease is familial and may be associated with the presence of hereditary defects in the immune system. Destructive processes progress very quickly, although there are also periods of sudden regression of the disease.

Necrotizing ulcerative gingivitis and periodontitis

It is caused by an acute bacterial infection, but is also associated with other additional factors (stress, malnutrition, smoking, injuries, previous infections). Is characterised by:

• necrosis and ulceration of the tops of the interdental papillae and the edges of the gum,
• severe pain (spontaneous or when touched),
• bleeding gums
• bad breath (halitosis)
• temperature, malaise, enlarged lymph nodes,

The inflammatory process can spread from the gingiva to the entire periodontium, causing necrosis of the periodontium and even of the alveolar bone (this is usually the case in immunocompromised patients or with previous infections). Symptoms are: deep ulceration, pain, and the edges of the gums are covered with a yellow-white or grayish, membranous coating.

Abscesses

1. Gingival abscess– appears as a red, smooth and shiny ridge around the gum.
2. Periodontal abscess– locates among the tissues of the three-tooth pocket and leads to the destruction of periodontal tissues and bones. You may notice the presence of a deep periodontal pocket from which pus is draining. The tooth may be mobile and sensitive to the percussion.
3. Acute periodontal abscess– is a painful obstruction that occurs in the projection of the tooth root. After pressure, purulent discharge may come out of the gingival pocket. It is accompanied by the feeling of “blowing” the tooth from the socket and increased mobility.
4. Chronic periodontal abscess– associated with less severe symptoms, as the abscess periodically empties through a fistula. The mouth of the fistula is visible as a tiny point from which pus oozes periodically.
5. Pericoronal abscess– is formed around the tissues surrounding the crown, most often an incompletely erupted tooth. It mainly concerns wisdom teeth. There is soreness, redness and even trismus and difficulty swallowing.

Periodontal diseases – symptoms

Despite the wide variety of periodontal diseases, some symptoms are common to virtually all individuals, e.g .:

• reddening of the gums,
• contour change (swelling or recession),
• profuse exudate from the gingival fissure,
• bleeding.

Detailed symptoms are given in the descriptions of individual diseases (in the section onperiodontal diseases).

Periodontal disease – visit to the dentist

Periodontal diseases are a very diverse group and therefore constitute a challenge for dentists. Determining what exactly is wrong with the patient requires a veryin-depth interview and examination. So it’s not surprising when your doctor asks you about things like:

• general diseases (e.g. diabetes, cardiovascular diseases,AIDS),
• lifestyle (e.g. eating habits, stimulants, stress),
• hereditary diseases.

There will probably also be questions related to the current dental treatment:

• How often are follow-up visits?
• What is the cause of tooth loss?
• Was oral surgery performed (if so, what)?
• Has the patient received orthodontic treatment?
• Does he have any problems with the temporomandibular joints (pain, limited movement, crackling, jumping etc.)?
• Has he noticed any habits (e.g. grinding his teeth, biting a pen, etc.)?

Later, you can expect a series of questions directly regarding the reason for reporting to the doctor’s office:

• What exactly are the ailments? When did they start?
• Are there any gingival bleeding (spontaneous / after brushing)?
• How has oral hygiene been maintained so far?

Then the doctor will proceed to the examination. In addition tothe intraoral examination, it may also happen that thelymph nodesare also examined (they are good indicators of an ongoing infection). In the oral cavity, in addition to the traditional inspection with a mirror and a probe, we can also meet with:

• Examination of the gingival fissure– a special instrument called a periodontometer or periodontal probe is used for this (it resembles a probe, but is ended with a tiny ball and has a carefully calibrated measuring cup). It is used to examine the depth of the pockets, the presence of stone, exudate, pus, bleeding, etc.
• Examination of the presence of bleeding from the interdental papillaafter examination with a periodontometer.
• Examination of the degree of tooth mobility– the doctor will gently check the degree of tooth mobility with the help of fingers or a finger and an instrument.

Most likely, it will also be necessary without an X-ray image, which provides a lot of important information that is invisible to the naked eye.

Periodontal diseases – treatment

Treatment of periodontal diseases is intertwined with their prevention. The basis is home hygiene, which allows the reduction of bacterial plaque – the main cause of these diseases: tooth brushing, the use of additional hygiene utensils (threads,interdental brushes, irrigators, etc.), the use of rinses. A similar role is played by professional prophylaxis procedures, such as supragingival or subgingival scaling, sandblasting or irrigation. However, hygiene procedures alone may not be enough in many cases.

Surgical treatment

Surgical treatment includes the following procedures:

1. Curettage– a procedure under local anesthesia consisting in the removal of diseased tissues (epithelium, cement, remains of stone and granulation tissue). These tissues contain bacteria and their toxins.
2. Gingivectomy– a procedure performed on the gums to remove pockets and improve the shape of the gums.
3. Osteoplasty– a procedure aimed at improving the shape of the alveolar process (e.g. when there are bone spurs or before making a permanent prosthetic restoration).
4. Enlargement of the gum zone– this procedure is performed in order to obtain an additional zone that protects periodontal tissue against injuries (e.g. when there is constant gingivitis despite good hygiene, when the patient experiences discomfort while chewing or brushing the teeth, when an aesthetic defect is observed).
5. Westibuloplasty– it is a procedure consisting in deepening the too shallow mouth of the mouth.
6. Covering gum recession– covers the places where the gums have lowered with tissue.
7. Treatments on the frenulum– consists in either the removal or plasticization of an incorrectly shaped frenulum

Periodontal tissue regeneration

Periodontal diseases often lead to irreversible tissue damage. Treatments aimed at improving the condition (e.g. removal of periodontal pockets) eliminate specific problems, but do not lead to full regeneration of damaged tissues. To overcome these inconveniences, a number of preparations have been invented that stimulate the restoration of periodontal structures. These preparations in combination with special surgical techniques give very good results.They have the following properties:

• are biologically acceptable by the patient’s body,
• facilitate the formation of a stable clot,
• prevent the migration of epithelial and connective tissue cells to the wound (these tissues would form a scar, and yet it is about restoring full-fledged periodontal structures – e.g. bones, ligaments, root cement, etc., and not scarring),
• “Reserve” a place for regenerating tissues,
• stimulate cells to divide.

These preparations include: barrier membranes (mechanical): titanium and collagen, enamel matrix proteins (the so-called biological membrane), calcium sulphate. Materials that enable periodontal regeneration also include implant materials. These are:

• Autogenous boneimplants – the implant is taken directly from the patient’s body (e.g. from another place in the oral cavity, hip bone, bone marrow). They are very effective.
• Allogenic bone implants – theimplant is taken from another human organism (most often from a cadaver) and subjected to a multi-stage processing.
• Heterogeneous implants –usually made of bovine bones, from which all organic components are removed.
• Alloplastic implants –made of bone substitute materials (e.g. ceramics, bioglass, polymers).

Laser biostimulation

In the treatment of periodontal diseases, lasers are used not only to cut tissue during surgery. Their wide range of properties has also been used to obtainthe biostimulation effect,which consists in stimulating positive changes in tissues and obtaining ananti-inflammatory and analgesic effect– it is associated with the improvement of microcirculation. The laser stimulates cells responsible for the regeneration of bones, cement and soft tissues. CAUTION !!! Biostimulation is only a supportive procedure, it will not replace oral hygiene and full treatment!

When to use biostimulation?

• after scaling,
• after surgical operations (curettage etc.),
• when it is difficult to extract wisdom teeth,
• as an anti-inflammatory treatment,
• in the treatment of hematomas,
• in paresthesia (hypoaesthesia) after anesthesia,
• after tooth extraction.

When is laser biostimulation not allowed?

• in neoplastic diseases,
• when there are proliferative changes,
• in gingivitis and hyperplastic gingivitis,
• Pregnant,
• in people with a pacemaker,
• in cardiovascular failure.

Antibiotic therapy

Currently, there is a strong emphasis on not overusing antibiotics. Antibiotics are not the “golden mean” that will solve all problems, and their use has many side effects.Therefore, the use of antibiotics is indicated only in cases of:

• ulcerative gingivitis and periodontitis,
• rapid exacerbation of chronic periodontitis,
• periodontitis in people with general diseases (leukemia,diabetes, Down’s syndrome, AIDS, etc.),
• aggressive periodontitis,
• periodontitis that persists despite long and varied treatment
• before and after selected surgical procedures.

CAUTION!!! Antibiotics can only be taken as directed by a doctor!

Periodontal diseases – home treatment

Home treatment should focus on improving oral hygiene and fulfilling the doctor’s recommendations. You can additionally use:

1. Methods aimed at reducing pain and inflammation have been described in the home treatment ofcaries,
2. Infusions of herbs(such as chamomile, elderflower, calendula, mallow, linden, mint leaves, sage, thyme herb, thyme, oak bark or cinquefoil rhizome) or herbal mixtures. Rinse mouth with lukewarm infusion three times a day.
3. Anti-inflammatory pastes(e.g. Parogencyl, Forever-Bright, Biodent, Colodent-Paradont, TC Chamosaldent). In order for the anti-inflammatory ingredients of the toothpastes to work better, it is worth not rinsing the mouth after evening washing.
4. Sachol-gel for use asan adjuvantin the treatment of periodontitis, herpetic inflammation of the oral mucosa and other inflammatory diseases of the mucous membranes. Other gels with a similar effect (Baikadent, Bobodent, Dentinox, Pelogel, Salumin, Trascodent).
5. Rinses– (Skinsept oral, Corsodryl, Lacalut, Hascosept Eludril) ATTENTION !!! Rinses containing chlorhexidine should not be used for more than 3 weeks!
6. Garlic– Eating fresh garlic is not likely to alleviate the symptoms of inflammation, but it can stimulate the immune system. The essential oil in garlic consists mainly of alliin, which, when crushed, turns into allicin. This substance is effective in killing bacteria.

CAUTION!!! A varied diet and a healthy lifestyle have a significant impact on theprevention and treatment of periodontal diseases.It is especially important to avoid smoking. It is also worth consuming vegetables and fruits rich in vitamin C. It is involved in the formation of collagen – one of the main components that build periodontal tissues.