Periodontitis is a chronic inflammatory disease affecting the supportive structures of the teeth, including the gingiva, periodontal ligament, cementum, and alveolar bone. Originating from untreated gingivitis, it leads to progressive tissue destruction, tooth mobility, and eventual tooth loss if not adequately managed.
This severe gum infection is not only a dental concern but also a systemic health risk due to its established links with cardiovascular disease, diabetes, and adverse pregnancy outcomes.
Etiology: Understanding the Causes of Periodontitis
Bacterial Plaque Biofilm
The principal cause of periodontitis is the accumulation of pathogenic dental plaque, a biofilm rich in Gram-negative anaerobic bacteria such as:
- Porphyromonas gingivalis
- Aggregatibacter actinomycetemcomitans
- Treponema denticola
- Tannerella forsythia
These bacteria trigger a chronic inflammatory response, damaging the periodontal attachment apparatus.
Contributing Risk Factors
- Inadequate oral hygiene
- Tobacco use
- Uncontrolled diabetes mellitus
- Genetic predisposition
- Stress and immunosuppression
- Hormonal fluctuations (e.g., pregnancy)
- Malaligned teeth or faulty restorations
- Systemic diseases impacting immune function
Disease Progression: From Healthy Gums to Periodontitis
- Gingivitis: Reversible inflammation limited to the gums.
- Initial Periodontitis: Slight connective tissue attachment and bone loss.
- Moderate Periodontitis: Progressive tissue destruction, 4–6 mm pocket depths.
- Severe Periodontitis: Deep pockets (>6 mm), mobility, extensive bone loss.
- Tooth Loss: Resulting from complete breakdown of support structures.
Clinical Signs and Symptoms of Periodontitis
- Bleeding on brushing or flossing
- Persistent halitosis (bad breath)
- Red, swollen, or tender gums
- Gum recession exposing root surfaces
- Loose or shifting teeth
- Pus discharge from the gingival sulcus
- Altered bite or occlusion
Classification of Periodontitis (2017 AAP/EFP Framework)
Staging
- Stage I: Initial periodontitis, minor clinical attachment loss (CAL)
- Stage II: Moderate periodontitis with up to 5 mm probing depth
- Stage III: Severe periodontitis with vertical bone loss and tooth mobility
- Stage IV: Advanced destruction with >5 teeth lost and functional impairment
Grading
- Grade A: Slow progression, no risk factors
- Grade B: Moderate progression, possible risk modifiers (e.g., smoking)
- Grade C: Rapid progression with systemic impact
Diagnostic Approach
Clinical Examination
- Periodontal probing: Measurement of pocket depths
- Bleeding on probing (BOP): Indicator of active inflammation
- Mobility and furcation involvement assessment
Radiographic Assessment
- Intraoral periapical radiographs: To detect bone loss
- Panoramic imaging: For generalized view of dental and osseous structures
Microbiological and Biomarker Analysis
- Subgingival plaque sampling
- Salivary inflammatory markers: IL-1β, TNF-α, and prostaglandin E2
Pathophysiology: The Destructive Immune Response
Periodontitis results from a dysregulated host immune response rather than a direct bacterial attack. The key components of tissue destruction include:
- Cytokines: IL-1, IL-6, TNF-α triggering inflammation
- Prostaglandins (PGE2): Promoting bone resorption
- Matrix metalloproteinases (MMPs): Breaking down collagen fibers
- Osteoclast activation: Causing irreversible bone loss
Periodontitis and Systemic Health
The chronic inflammation characteristic of periodontitis is associated with systemic conditions, including:
- Cardiovascular diseases: Endothelial dysfunction and increased C-reactive protein
- Type 2 diabetes: Bi-directional relationship; worsened glycemic control
- Pregnancy complications: Increased risk of preterm labor and low birth weight
- Rheumatoid arthritis: Elevated systemic inflammatory markers
Treatment Strategies for Periodontitis
Non-Surgical Therapy
- Scaling and Root Planing (SRP): Mechanical debridement of subgingival calculus
- Topical antimicrobials: Chlorhexidine chips, doxycycline gels
- Systemic antibiotics (only for specific aggressive or refractory cases):
- Amoxicillin and Metronidazole
- Azithromycin
Surgical Interventions
- Flap surgery: Access to deep pockets for thorough cleaning
- Osseous surgery: Bone recontouring
- Guided tissue regeneration (GTR): Use of membranes to promote regrowth
- Bone grafting: Replacing lost alveolar bone with graft material
Maintenance Therapy
- Supportive periodontal therapy (SPT) every 3 months
- Reinforcement of oral hygiene practices
- Monitoring of pocket depths and clinical attachment
Preventive Measures to Avoid Periodontitis
- Twice-daily brushing with fluoride toothpaste
- Interdental cleaning using floss or interdental brushes
- Regular dental check-ups and cleanings
- Smoking cessation programs
- Diabetes control and nutritional balance
- Use of antimicrobial mouth rinses under professional guidance
Frequently Asked Questions
Q1. Can periodontitis be reversed?
No, unlike gingivitis, the damage from periodontitis is irreversible. However, progression can be halted and managed effectively with timely treatment.
Q2. How often should one visit the dentist for periodontal care?
Patients with periodontitis should receive periodontal maintenance every 3–4 months.
Q3. Does periodontitis always cause pain?
No, periodontitis often progresses silently, with pain manifesting only in advanced stages or during acute infections.
Q4. Are surgical procedures necessary for everyone?
Not always. Mild to moderate periodontitis can often be managed non-surgically. Surgery is reserved for deep pockets and extensive bone loss.
Q5. Is periodontitis contagious?
While not contagious like a cold, the bacteria associated with periodontitis can be transmitted through saliva between close contacts.
Periodontitis is a serious and progressive gum disease that demands timely intervention. It not only compromises oral function and aesthetics but also contributes to systemic health deterioration. Effective management includes precise diagnosis, customized treatment, and long-term maintenance. By integrating optimal oral hygiene, risk factor control, and professional care, we can safeguard periodontal health and prevent irreversible tooth loss.
