Etiology of Periodontal Diseases
A Patient Focused Explanation
After patiently waiting in the chair, the dentist comes in to look at your mouth. After completing his examination, he tells you that you are starting to show signs of periodontal disease. I know you are probably thinking “perio who-a-what?! I have a disease?!” Let me explain to you just what the doctor is trying to tell you about the health of your mouth.
Periodontal disease is an infection of the periodontium. Periodontium is just a fancy word that means the gingiva (gums), cementum (external layer of the roots of teeth), periodontal ligament (fibers attaching the roots of the teeth to the bone) and alveolar bone (bone that makes up your jaws). These four structures combine to hold your teeth in to your jaws. Refer to image #1 above for a visual. When the teeth are in health, there is no infection occuring in any of these structures mentioned. Image #2 above is demonstrating the sturctures of teeth in health.
There are two different types or "stages" of periodontal disease known as gingivitis and periodontitis. Gingivitis is a bacterial infection that only affects the gingiva (gums). This type of infection results in REVERSIBLE damage to the periodontium! Refer to image #3 above to see an example of gingivitis. On the other hand, periodontitis is a bacterial infection of all four structures of the periodontium, and unfortunately this damage is IRREVERSIBLE. Refer to image #4 above to see an example of moderate periodontitis. Gingivitis can last for a short period of time (acute gingivitis) or can last for months or years (chronic gingivitis). In many cases, gingivitis may persist for years without progressing to periodontitis. The body's immune response to the plaque biofilm is the primary cause of destruction seen in periodontitis. The bacteria in the biofilm are extremely resistant to antibiotics, antimicrobials, and the body's immune system. Once the gingivitis progresses to periodontitis, and bone is lost, there is no going back to health.
Now, you may be thinking why does all of this happen in the first place? What causes periodontal disease? The answer is biofilm. Biofilm is defined as a living film, containing a well-organized community of bacteria that grows on a surface. Biofilms occur naturally in the environment such as the slime on fish tanks or on rocks in a stream. Biofilms form on any solid surface that is exposed to a bacteria-containing fluid. In the body, biofilms can be found on pacemakers, artificial joints, medical/dental implants and teeth. In the mouth, another word for a biofilm that I'm sure you have heard before, is plaque. In a healthy mouth, the gums around a single tooth can contain 100 to 1,000 different bacteria! In gingivitis 1,000 to 100,000 bacteria can be found, and in periodontitis 100,000 to 100,000,000 bacteria can be found around the gums of one, single tooth!! All of these bacteria cluster together to form colonies. The bacteria communicate with other bacteria and signal others to join their colony. Eventually, this biofilm of numerous bacteria becomes mature. In regaurds to your mouth, it only takes 7 days for biofilm to become mature on your teeth above the gums! After 3-12 weeks, the biofilm starts to form underneath your gums! This mature biofilm is what initiates periodontal disease. There are also some other factors that contribute to a persons susceptibility to periodontal disease. These factors are known as local contributing factors because they contribute to the disease process that was initiated by the biofilm. They may increase the risk of developing disease and increase the risk of developing a more severe disease. A few examples are dental calculus, faulty dental restorations (fillings, crowns, etc.), and dental decay.
So how do these factors increase the risk of disease? They can...
1) Increase biofilm retention (how well the biofilm is adhering to the tooth)
-Dental Calculus. This mature, hardened plaque has an irregular, rough surface that is covered with disease-causing bacteria. As the calculus builds up, plaque control becomes difficult and the retention becomes stronger.
-Tooth Morphology (Shape of the teeth). Sometimes teeth develop with very prominant grooves or concavities that can harbor bacteria which will increase biofilm retention. Also, if there is decay present that goes untreated, a hole is left in the tooth surface that also harbors bacteria and allows them to multiply without being disturbed. On the other hand, if a decayed tooth is restored poorly and there are overhangs of material, it can be very difficult or impossible to clean properly, leading to an increase in biofilm retention.
2) Increase biofilm patogenicity (the ability of the bacteria in the biofilm to cause disease)
- A biofilm that has matured will have a greater ability to cause disease versus a biofilm that has just developed on your teeth. Biofilm becomes mature when it is able to grow without being disturbed. As mentioned earlier, it only takes 7 days for biofilm to become mature on the teeth above the gums!
3) Cause direct damage to the periodontium (damage to the teeth and supporting structures)
-Food Impaction. Food that gets stuck between the teeth during chewing can cause the gums to pull away from the tooth. This can lead to changes in the gum tissue that make it harder for you to clean in between your teeth properly.
-Improper use of self-care aids. Dental aids such as tooth picks, when used incorrectly, can cause trauma to the structures of the periodontium.
-Faulty Restorations. Restorations like crowns, removable prosthesis, etc. that are ill-fitting can impinge on the tissues in the mouth and cause damage.
-Habits such as thrusting your tongue forward or breathing through your mouth also cause damage to the periodontium.
-Occlusion. Occlusion is the fitting together of the upper teeth and the lower teeth when the jaws are closed together. There are normal forces produced while chewing food known as functional occlusal forces and there are forces produced when the teeth are occluding and you are not chewing food known as parafunctional occlusal forces. Parafunctional occlusal forces occur when you clench or grind your teeth together. Excessive occlusal forces cause trauma to the periodontium.
Frequently Asked Questions
1) Is periodontal disease associated with geting older?
Yes, the severity of periodontal disease does increase with age. As an individual lives longer, the chances increase that they will be exposed to risk factors for periodontal disease such as systemic illness, medications, and stress. Periodontal disease is also the leading cause of tooth loss in adults older than 45 years old.
2) How can I control the biofilm that forms on my teeth and prevent periodontal disease?
The best way to control plaque biofilm is by physical destruction by brushing, flossing, using mouthwash and by scheduling routine dental appointments for professional removal. Doing this will prevent periodontal disease.
3) What are the signs that I would see if my gums become unhealthy?
Your gums my appear red, swollen, and may bleed. They may also be tender to the touch. If these symptoms persist despite your best efforts at daily home care, consult your dentist.
Reflection
I feel good about answering questions that patients may have about their teeth and oral health. It is very important to me to be able to communicate with patients in a way that they can understand what I am trying to educate them on. The terms used in dentistry can be like another language, and while it is important to be able to use these terms when communicating with other dental professionals, it is equally as important to be able to explain to the patient what is going on in their mouth in a way that they can understand. While working with two doctor's whose second language was english, I was often the one explaining to the patient, what the doctor had just said, but in a way that they could understand without sounding as technical. I feel like it is important to take the chance when a patient has a question, to educate them to the best of your knowledge. A patient that understands their condition, wheather they're in a state of health or disease, will be much more compliant!
**Images retrieved from google.com/images**
Periodontal disease is an infection of the periodontium. Periodontium is just a fancy word that means the gingiva (gums), cementum (external layer of the roots of teeth), periodontal ligament (fibers attaching the roots of the teeth to the bone) and alveolar bone (bone that makes up your jaws). These four structures combine to hold your teeth in to your jaws. Refer to image #1 above for a visual. When the teeth are in health, there is no infection occuring in any of these structures mentioned. Image #2 above is demonstrating the sturctures of teeth in health.
There are two different types or "stages" of periodontal disease known as gingivitis and periodontitis. Gingivitis is a bacterial infection that only affects the gingiva (gums). This type of infection results in REVERSIBLE damage to the periodontium! Refer to image #3 above to see an example of gingivitis. On the other hand, periodontitis is a bacterial infection of all four structures of the periodontium, and unfortunately this damage is IRREVERSIBLE. Refer to image #4 above to see an example of moderate periodontitis. Gingivitis can last for a short period of time (acute gingivitis) or can last for months or years (chronic gingivitis). In many cases, gingivitis may persist for years without progressing to periodontitis. The body's immune response to the plaque biofilm is the primary cause of destruction seen in periodontitis. The bacteria in the biofilm are extremely resistant to antibiotics, antimicrobials, and the body's immune system. Once the gingivitis progresses to periodontitis, and bone is lost, there is no going back to health.
Now, you may be thinking why does all of this happen in the first place? What causes periodontal disease? The answer is biofilm. Biofilm is defined as a living film, containing a well-organized community of bacteria that grows on a surface. Biofilms occur naturally in the environment such as the slime on fish tanks or on rocks in a stream. Biofilms form on any solid surface that is exposed to a bacteria-containing fluid. In the body, biofilms can be found on pacemakers, artificial joints, medical/dental implants and teeth. In the mouth, another word for a biofilm that I'm sure you have heard before, is plaque. In a healthy mouth, the gums around a single tooth can contain 100 to 1,000 different bacteria! In gingivitis 1,000 to 100,000 bacteria can be found, and in periodontitis 100,000 to 100,000,000 bacteria can be found around the gums of one, single tooth!! All of these bacteria cluster together to form colonies. The bacteria communicate with other bacteria and signal others to join their colony. Eventually, this biofilm of numerous bacteria becomes mature. In regaurds to your mouth, it only takes 7 days for biofilm to become mature on your teeth above the gums! After 3-12 weeks, the biofilm starts to form underneath your gums! This mature biofilm is what initiates periodontal disease. There are also some other factors that contribute to a persons susceptibility to periodontal disease. These factors are known as local contributing factors because they contribute to the disease process that was initiated by the biofilm. They may increase the risk of developing disease and increase the risk of developing a more severe disease. A few examples are dental calculus, faulty dental restorations (fillings, crowns, etc.), and dental decay.
So how do these factors increase the risk of disease? They can...
1) Increase biofilm retention (how well the biofilm is adhering to the tooth)
-Dental Calculus. This mature, hardened plaque has an irregular, rough surface that is covered with disease-causing bacteria. As the calculus builds up, plaque control becomes difficult and the retention becomes stronger.
-Tooth Morphology (Shape of the teeth). Sometimes teeth develop with very prominant grooves or concavities that can harbor bacteria which will increase biofilm retention. Also, if there is decay present that goes untreated, a hole is left in the tooth surface that also harbors bacteria and allows them to multiply without being disturbed. On the other hand, if a decayed tooth is restored poorly and there are overhangs of material, it can be very difficult or impossible to clean properly, leading to an increase in biofilm retention.
2) Increase biofilm patogenicity (the ability of the bacteria in the biofilm to cause disease)
- A biofilm that has matured will have a greater ability to cause disease versus a biofilm that has just developed on your teeth. Biofilm becomes mature when it is able to grow without being disturbed. As mentioned earlier, it only takes 7 days for biofilm to become mature on the teeth above the gums!
3) Cause direct damage to the periodontium (damage to the teeth and supporting structures)
-Food Impaction. Food that gets stuck between the teeth during chewing can cause the gums to pull away from the tooth. This can lead to changes in the gum tissue that make it harder for you to clean in between your teeth properly.
-Improper use of self-care aids. Dental aids such as tooth picks, when used incorrectly, can cause trauma to the structures of the periodontium.
-Faulty Restorations. Restorations like crowns, removable prosthesis, etc. that are ill-fitting can impinge on the tissues in the mouth and cause damage.
-Habits such as thrusting your tongue forward or breathing through your mouth also cause damage to the periodontium.
-Occlusion. Occlusion is the fitting together of the upper teeth and the lower teeth when the jaws are closed together. There are normal forces produced while chewing food known as functional occlusal forces and there are forces produced when the teeth are occluding and you are not chewing food known as parafunctional occlusal forces. Parafunctional occlusal forces occur when you clench or grind your teeth together. Excessive occlusal forces cause trauma to the periodontium.
Frequently Asked Questions
1) Is periodontal disease associated with geting older?
Yes, the severity of periodontal disease does increase with age. As an individual lives longer, the chances increase that they will be exposed to risk factors for periodontal disease such as systemic illness, medications, and stress. Periodontal disease is also the leading cause of tooth loss in adults older than 45 years old.
2) How can I control the biofilm that forms on my teeth and prevent periodontal disease?
The best way to control plaque biofilm is by physical destruction by brushing, flossing, using mouthwash and by scheduling routine dental appointments for professional removal. Doing this will prevent periodontal disease.
3) What are the signs that I would see if my gums become unhealthy?
Your gums my appear red, swollen, and may bleed. They may also be tender to the touch. If these symptoms persist despite your best efforts at daily home care, consult your dentist.
Reflection
I feel good about answering questions that patients may have about their teeth and oral health. It is very important to me to be able to communicate with patients in a way that they can understand what I am trying to educate them on. The terms used in dentistry can be like another language, and while it is important to be able to use these terms when communicating with other dental professionals, it is equally as important to be able to explain to the patient what is going on in their mouth in a way that they can understand. While working with two doctor's whose second language was english, I was often the one explaining to the patient, what the doctor had just said, but in a way that they could understand without sounding as technical. I feel like it is important to take the chance when a patient has a question, to educate them to the best of your knowledge. A patient that understands their condition, wheather they're in a state of health or disease, will be much more compliant!
**Images retrieved from google.com/images**