|
|
| (11 intermediate revisions by 2 users not shown) |
| Line 1: |
Line 1: |
| __NOTOC__ | | __NOTOC__ |
| {{Periodontitis}} | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
| {{CMG}}
| |
| | |
| {{Infobox_Disease | | | {{Infobox_Disease | |
| Name = Periodontal disease | | | Name = Periodontal disease | |
| Line 8: |
Line 6: |
| Caption = This x-ray shows significant bone loss between the two roots of a tooth. The spongy bone has receded due to infection under tooth, reducing the bony support for the tooth. | | | Caption = This x-ray shows significant bone loss between the two roots of a tooth. The spongy bone has receded due to infection under tooth, reducing the bony support for the tooth. | |
| }} | | }} |
| ==Overview==
| | {{Periodontitis}} |
| '''Periodontitis''', formerly known as '''Pyorrhea alveolaris''', is the name of a collection of inflammatory [[disease]]s affecting the tissues that surround and support the [[teeth]]. Periodontitis involves progressive loss of the bone around teeth which may lead to loosening and eventual loss of teeth if untreated. Periodontitis is caused by [[bacteria]] that adhere to and grow on tooth surfaces ([[Dental plaque|microbial plaque]] or [[biofilm]]s), particularly in areas under the gum line. Periodontitis is very common in most populations but the severe forms of the disease are less common. [[Dentist]]s diagnose periodontitis by inspecting the tissues around the teeth with a probe and by [[radiograph]]s to detect bone loss around the teeth. Although the different forms of periodontitis are bacterial diseases, a variety of factors affect the severity of the disease. Important "risk factors" include smoking, poorly controlled [[diabetes]], and inherited (genetic) susceptibility.
| | {{CMG}} |
| | |
| == [[Etiology]] ==
| |
|
| |
|
| Periodontitis is an inflammation of the [[periodontium]], or one of the four tissues that support the teeth in the mouth:
| | {{SK}} Pyorrhea alveolaris |
|
| |
|
| * the [[gingiva]], or gum tissue
| | ==[[Periodontitis overview|Overview]]== |
| * the [[cementum]], or outer layer of the roots of teeth
| |
| * the [[dental alveolus|alveolar bone]], or the bony sockets into which the teeth are anchored
| |
| * the [[periodontal ligament]]s (PDLs), which are the [[connective tissue]] fibres that connect the cementum and the gingiva to the alveolar bone.
| |
|
| |
|
| [[Image:Periodontalboneloss.JPG|275px|thumb|left|This [[radiograph|X-ray film]] displays two lone-standing [[mandible|mandibular]] teeth, #21 and #22, or the lower left first premolar and canine, exhibiting severe bone loss of 30-50%. Widening of the [[periodontal ligament|PDL]] surrounding the [[premolar]] is due to [[occlusal trauma|secondary occlusal trauma]].]] | | ==[[Periodontitis pathophysiology|Pathophysiology]]== |
| If left untreated, periodontitis causes progressive bone loss around teeth, looseness of the teeth and eventual tooth loss. Periodontitis is a very common disease affecting approximately 50% of U.S. adults over the age of 30 years. Periodontitis is thought to occur in people who have preexisting [[gingivitis]] - an inflammation that is limited to the soft tissues surrounding the tooth and does not cause attachment or bone loss. The cause of gingivitis is the accumulation of a bacterial matrix at the gum line, called [[dental plaque]]. In some people, gingivitis progresses to periodontitis - the gum tissues separate from the tooth and, with loss of periodontal ligaments, form a periodontal pocket. Subgingival bacteria (those that exist under the gum line) that exist in periodontal pockets can cause further inflammation in the gum tissues and further loss of attachment and bone.
| |
|
| |
|
| If left undisturbed, bacterial plaque calcifies to form [[dental calculus|calculus]]. Calculus above and below the gum line must be removed completely by the dental hygienist or dentist to treat gingivitis and periodontitis. Although the primary cause of both gingivitis and periodontitis is the bacterial plaque that adheres to the tooth surface, there are many other modifying factors. One of the most predominant risk factors of periodontal disease is tobacco use. Another very strong risk factor is one's genetic susceptibility. Several conditions and diseases, including [[Down syndrome]], [[diabetes]], and other diseases that affect one's resistance to infection also increase susceptibility to periodontitis.
| | ==[[Periodontitis causes|Causes]]== |
|
| |
|
| Another factor that makes periodontitis a difficult disease to study is that human host response can also affect the alveolar bone resorption. Host response to the bacterial insult is mainly determined by genetics, however immune development may play some role in susceptibility.
| | ==[[Periodontitis differential diagnosis|Differentiating Periodontitis from other Diseases]]== |
|
| |
|
| ==Signs and Symptoms== | | ==[[Periodontitis epidemiology and demographics|Epidemiology and Demographics]]== |
| Symptoms may include the following:
| |
| *occasional redness or bleeding of gums while brushing [[teeth]], using dental floss or biting into hard food (e.g. apples) (though this may occur even in gingivitis, where there is no attachment loss)
| |
| *occasional gum swellings that recurs
| |
| *[[halitosis]], or bad breath, and a persistent metallic taste in the mouth
| |
| *gingival recession, resulting in apparent lengthening of teeth. (This may also be caused by heavy handed brushing or with a stiff tooth brush.)
| |
| *deep pockets between the teeth and the gums ([[gingival and periodontal pockets|pockets]] are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as ''[[collagenases]]'')
| |
| *loose teeth, in the later stages (though this may occur for other [[occlusal trauma|reasons]] as well)
| |
|
| |
|
| Patients should realize that the gingival inflammation and bone destruction are largely painless. Hence, people may wrongly assume that painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient.
| | ==[[Periodontitis risk factors|Risk Factors]]== |
|
| |
|
| ==Prevention== | | ==[[Periodontitis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| Daily [[oral hygiene]] measures to prevent periodontal disease include:
| |
| *[[toothbrush|brushing]] properly on a regular basis (at least twice daily), with the patient attempting to direct the toothbrush bristles underneath the gum-line, so as to help disrupt the bacterial growth and formation of subgingival plaque and calculus.
| |
| *[[flossing]] daily and using interdental brushes (if there is a sufficiently large space between teeth), as well as cleaning behind the last tooth in each quarter.
| |
| *using an antiseptic [[mouthwash]]. [[Chlorhexidine gluconate]] based mouthwash or [[hydrogen peroxide#Therapeutic use|hydrogen peroxide]] in combination with careful oral hygiene may cure gingivitis, although they cannot reverse any attachment loss due to periodontitis. (Alcohol based mouthwashes may aggravate the condition).
| |
| *regular dental check-ups and professional teeth cleaning as required. Dental check-ups serve to monitor the person's oral hygiene methods and levels of attachment around teeth, identify any early signs of periodontitis, and monitor response to treatment.
| |
| *[[Oil pulling]], an [[alternative medicine]] procedure, performed on an empty stomach. <ref> http://www.johcd.org/pdf/Effect_of_Oil_Pulling_on_Plaque_and_Gingivitis.pdf</ref>.
| |
|
| |
|
| Typically dental hygienists (or dentists) use special instruments to clean (debride) teeth below the gumline and disrupt any plaque growing below the gumline. This is a standard treatment to prevent any further progress of established periodontitis. Studies show that after such a professional cleaning (periodontal debridement), bacteria and plaque tend to grow back to pre-cleaning levels after about 3-4 months. Hence, in theory, cleanings every 3-4 months might be expected to also prevent the initial onset of periodontitis. However, analysis of published research has reported little evidence either to support this or the intervals at which this should occur.<!--
| | ==Diagnosis== |
| --><ref name="Cochrane2005recall">{{cite journal | author=Beirne P, Forgie A, Clarkson J, Worthington HV | title=Recall intervals for oral health in primary care patients | journal=Cochrane Database for Systematic Reviews | year=2005 | pages=CD004346 | volume= | issue=2 | issn= 1469-493X | pmid = 15846709}}</ref>
| | [[Periodontitis history and symptoms|History and Symptoms]] | [[Periodontitis physical examination|Physical Examination]] | [[Periodontitis laboratory findings|Laboratory Findings]] | [[Periodontitis x ray|X Ray]] | [[Periodontitis other imaging findings|Other Imaging Findings]] | [[Periodontitis other diagnostic studies|Other Diagnostic Studies]] |
| Instead it is advocated that the interval between dental check-ups should be determined specifically for each patient between every 3 to 24 months.<!--
| |
| --><ref name="NHS-NICE">{{cite web | author=National Institute for Health and Clinical Excellence | authorlink=National Institute for Health and Clinical Excellence| title=NICE guidance issued on frequency of dental check-ups | date=27 Oct, 2004 | url=http://www.library.nhs.uk/oralhealth/viewResource.aspx?resID=64336 | publisher=National Library for Health (UK) | accessdate=2006-05-07}}</ref><!--
| |
| --><ref name="BBCnews2004">{{cite news |author= BBC News |url=http://newswww.bbc.net.uk/1/low/health/3950587.stm
| |
| |title=Call for tailored dental checks - Routine six-monthly dental check-ups should become a thing of the past, new guidance recommends |date=Wednesday, 27 October, 2004 |accessdate=2006-05-07}}</ref> | |
|
| |
|
| Nonetheless, the continued stabilization of a patient's periodontal state depends largely, if not primarily, on the patient's [[oral hygiene]] at home if not on the go too. Without daily [[oral hygiene]], periodontal disease will not be overcome, especially if the patient has a history of extensive periodontal disease.
| | ==Treatment== |
| | [[Periodontitis medical therapy|Medical Therapy]] | [[Periodontitis surgery|Surgery]] | [[Periodontitis primary prevention|Primary Prevention]] | [[Periodontitis secondary prevention|Secondary Prevention]] | [[Periodontitis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Periodontitis future or investigational therapies|Future or Investigational Therapies]] |
|
| |
|
| == Treatment of established disease == | | ==Case Studies== |
| [[Image:Generalized perio -touched up.jpg|450px|thumb|left|This section from a panoramic [[radiograph|X-ray film]] depicts the teeth of the lower left quadrant, exhibiting generalized severe bone loss of 30-80%. The '''red line''' depicts the existing bone level, whereas the '''yellow line''' depicts where the bone was originally, prior to the patient developing [[periodontal disease]]. The '''pink arrow''', on the right, points to a ''furcation involvement'', or the loss of enough bone to reveal the location at which the individual roots of a molar begin to branch from the single root trunk; this is a sign of advanced periodontal disease. The '''blue arrow''', in the middle, shows up to 80% bone loss on tooth #21, and clinically, this tooth exhibited gross mobility. Finally, the '''peach oval''', to the left, highlights the aggressive nature with which periodontal disease generally affects mandibular incisors. Because their roots are generally situated very close to each other, with minimal [[Commonly used terms of relationship and comparison in dentistry|interproximal]] bone, and because of their location in the mouth, where plaque and calculus accumulation is greatest because of the pooling of [[saliva]], mandibular anteriors suffer excessively. The '''split in the red line''' depicts varying densities of bone that contribute to a vague region of definitive bone height.]] | | [[Periodontitis case study one|Case #1]] |
| If good [[oral hygiene]] is not yet already undertaken daily by the patient, then twice daily [[toothbrush|brushing]] with daily [[flossing]], [[mouthwash]]ing and use of an interdental brush needs to be started. Technique with these tools is very important. Aged persons may find that use of these interdental devices more necessary and easier, since the gaps between the teeth may become larger.
| |
| | |
| A dental hygienist or a [[periodontist]] can use professional scraping instruments, such as scalers and currettes to remove bacterial plaque and [[Calculus (dental)|calculus]] (formerly referred to as tartar) around teeth and below the gum-line. There are devices that use a powerful ultra-sonic vibration and irrigation system to break up the bacterial plaque and calculus. Local anesthetic is commonly used to prevent discomfort in the patient during this process.
| |
| | |
| It is difficult to induce the body to repair bone that has been destroyed due to periodontitis. Much depends on exactly how much bone was lost and the architectural configuration of the remaining bone. '''Vertical defects''' are those instances of bone loss where the height of the bone remains somewhat constant except in the localized area where there is a steep, almost ''vertical'' drop. '''Horizontal defects''' are those instances of more generalized bone loss, resulting in anywhere from mild to severe loss of initial bone height.
| |
| Sometimes [[bone graft]]ing [[surgery]] may be tried, but this has mixed success. Bone grafts are more reliable in instances of vertical defects, where there might be a sufficient "hole" within which to place the added bone. Horizontal defects are rarely if ever able to be grafted properly, as there is nowhere to secure the bone.
| |
| | |
| Dentists sometimes attempt to treat patients with periodontitis by placing tiny wafers dispensing antibiotics underneath the gumline in affected areas. However, the general scientific consensus is that antibiotic treatment is of minimal value in treating bone loss due to periodontitis. It may help to recover about one millimeter of bone, but it is questionable if this is of significant therapeutic value.
| |
| | |
| Alternatively, regular subgingival flushing with an anti-calculus composition can dissolve subgingival calculus (tartar) thus facilitating natural healing without surgery. This process is widely used for supragingival tartar via tartar-control toothpastes. Subgingival application of an anti-calculus composition requires a subgingival syringe or an oral irrigator.
| |
| | |
| One such anti-calculus composition (Periogen) contains Sodium Tripolyphosphate, Tetrapotassium Pyrophosphate, [[sodium bicarbonate]], [[Citric Acid]] and [[sodium fluoride]].
| |
| | |
| In the composition, tetrapotassium pyrophosphate (TKPP) is a cleaning agent designed to clear away [[biofilm]]s in order to facilitate chemical access to [[calculus]]. [[sodium tripolyphosphate]] (STPP) acts as the anti-calculus agent, activated by Sodium Fluoride (.04%), providing a chelating action on the structure of the calculus.
| |
| | |
| Sodium Bicarbonate and Citric Acid are product activators which assist in dissolving the composition in water for periodontal delivery via a subgingival syringe or oral irrigator with a periodontal tip.
| |
| | |
| == Assessment and prognosis ==
| |
| Dentists or dental hygienists "measure" periodontal disease using a device called a [[periodontal probe]]. This is a thin "measuring stick" that is gently placed into the space between the gums and the teeth, and slipped below the gum-line. If the probe can slip more than 3 millimetres length below the gum-line, the patient is said to have a "gingival pocket" around that tooth. This is somewhat of a misnomer, as any depth is in essence a pocket, which in turn is defined by its depth, i.e., a 2 mm pocket or a 6 mm pocket. However, it is generally accepted that pockets are self-cleansable (at home, by the patient, with a toothbrush) if they are 3 mm or less in depth. This is important because if there is a pocket which is deeper than 3 mm around the tooth, at-home care will not be sufficient to cleanse the pocket, and professional care should be sought. When the pocket depths reach 5, 6 and 7 mm in depth, even the hand instruments and cavitrons used by the dental professionals cannot reach deeply enough into the pocket to clean out the bacterial plaque that cause gingival inflammation. In such a situation the pocket or the gums around that tooth will always have inflammation which will likely result in bone loss around that tooth. The only way to stop the inflammation would be for the patient to undergo some form of gingival surgery to access the depths of the pockets and perhaps even change the pocket depths so that they become 3 or less mm in depth and can once again be properly cleaned by the patient at home with his or her toothbrush.
| |
| | |
| If a patient has 5 mm or deeper pockets around their teeth, then they would risk eventual tooth loss over the years. If this periodontal condition is not identified and the patient remains unaware of the progressive nature of the disease then, years later, they may be surprised that some teeth will gradually become loose and may need to be extracted, sometimes due to a severe infection or even pain.
| |
| | |
| According to the Sri Lankan Tea Labourer study, in the absence of any oral hygiene activity, approximately 10% will suffer from severe periodontal disease with rapid loss of attachment (>2 mm/year). 80% will suffer from moderate loss (1-2 mm/year) and the remaining 10% will not suffer any loss.<!--
| |
| --><ref name="JclinPeriodontol1995-Preus">{{cite journal | author=Preus HR, Anerud A, Boysen H, Dunford RG, Zambon JJ, Loe H | title=The natural history of periodontal disease. The correlation of selected microbiological parameters with disease severity in Sri Lankan tea workers | journal=J Clin Periodontol | year=1995 | pages=674-8 | volume=22 | issue=9 | id=PMID 7593696}}</ref><!--
| |
| --><ref name="ComDentOralEpidemiol1984-Ekanayaka">{{cite journal | author=Ekanayaka A | title=Tooth mortality in plantation workers and residents in Sri Lanka | journal=Community Dent Oral Epidemiol | year=1984 | pages=128-35 | volume=12 | issue=2 | id=PMID 6584263}}</ref>
| |
|
| |
|
| ==Related Chapters== | | ==Related Chapters== |
| Line 92: |
Line 43: |
| * [[Head and neck anatomy]] | | * [[Head and neck anatomy]] |
| * [[Osteoimmunology]] | | * [[Osteoimmunology]] |
|
| |
| == Further reading ==
| |
| * {{cite journal|last=Pihlstrom|first= BL|coauthors=Michalowicz BS, Johnson NW|year=2005|title=Periodontal diseases|url=|journal=Lancet|issn=0140-6736|volume=366|issue=9499|pages=1809-20|pmid=16298220}}
| |
|
| |
|
| {{Periodontology}} | | {{Periodontology}} |
| Line 113: |
Line 61: |
| [[pt:Doença periodontal]] | | [[pt:Doença periodontal]] |
|
| |
|
| | [[Category:Disease]] |
| [[Category:Oral pathology]] | | [[Category:Oral pathology]] |
| [[Category:Infectious disease]]
| | |
| [[Category:Periodontology]] | | [[Category:Periodontology]] |
| | |
| {{WikiDoc Help Menu}} | | {{WikiDoc Help Menu}} |
| {{WikiDoc Sources}} | | {{WikiDoc Sources}} |
