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Periodontal disease

Periodontal disease: description

Periodontal disease is one chronic inflammatory disease of the gums (Dental bed, periodontium) that become one Loss of paraodontal support tissue leads. These include gums, root cement, periodontal membrane and jawbones:

The root cement is a thin mineral layer that surrounds the tooth root. The root of the tooth is in a bony compartment, the so-called alveolus. The periodontal membrane lies between the alveolar bone and the tooth root. It is a type of connective tissue whose fibers (Sharpey fibers) hang the tooth in the alveolus. The tooth is not firmly seated in its compartment - rather, thanks to the loose suspension, it can withstand various loads such as chewing. The gums (gingiva) close off the teeth holding apparatus from the outside. The gum furrow runs between the loosely suspended tooth and the adjacent gums.

Periodontitis is through three characteristics marked:

  • Loss of the periodontium, recognizable by the receding of the gums from the tooth (clinical loss of attachment, CAL) and a breakdown of the jawbone visible in the X-ray
  • Presence of gingival pockets
  • Bleeding gums

Periodontal disease is considered to be Widespread disease - After tooth decay, it is the most common tooth and mouth disease. In principle, people of any age can develop periodontitis. However, the risk of illness increases with age. People over the age of 35 lose teeth more often because of periodontitis than because of tooth decay.

What is Periodontal Disease?

The term periodontal disease is an outdated term, but it is still often used colloquially. It describes the same clinical picture as periodontal disease. However, some dentists also use the term for non-inflammation-related receding gums (gingival recession).

Forms of periodontal disease

In 1999, scientists developed an international classification of periodontal diseases, which has also been recommended in Germany since 2001. Accordingly, periodontitis was classified as either chronic, aggressive, necrotizing or a manifestation of a systemic disease. However, for a few years there has been a new classification, the following one three forms of periodontal disease includes:

  • Periodontal disease
  • necrotizing periodontal disease
  • Periodontitis as a manifestation of systemic diseases

How sick teeth make you sick

  • Immune system in constant stress

    An inflammation in the mouth can be tricky: Often you don't feel any of it. A dead tooth or an inflammation of the tooth supporting structure (periodontitis) can put a permanent strain on the immune system without causing pain. Again and again, bacteria from the focus of inflammation or inflammatory messenger substances spread over the blood throughout the body. This has far-reaching consequences.
  • Periodontal disease drives up blood pressure

    An inflamed periodontal apparatus, for example, increases blood pressure. According to a meta-analysis by University College London, people with moderate periodontal disease have a 22 percent increased risk of arterial hypertension. In people with severe periodontal disease, the risk increased by as much as 49 percent. This means that bad teeth are an independent risk factor for high blood pressure.
  • Sick teeth, sick heart

    The blood vessels not only suffer from higher blood pressure, inflammatory messengers from the mouth can also damage the arteries directly: they calcify. This increases the risk of a heart attack. Sometimes bacteria migrate from the mouth to the heart region and cause inflammation there - for example endocarditis (inflammation of the inner lining of the heart) or inflammation of the heart valves.
  • Periodontitis endangers the brain

    The blood vessels that supply the brain are also damaged by chronic inflammation in the mouth. This increases the risk of a stroke. In periodontal patients, it is two to three times higher than usual. By the way, men under the age of 60 should pay particular attention to their dental care. For them, the connection between oral hygiene and the risk of stroke is particularly pronounced.
  • Bad oral hygiene leads to liver cancer

    Well-groomed pearly whites could even keep cancer away - at least that seems to be the case with liver cancer. In a UK study, subjects with poor oral hygiene had a 75 percent higher risk of liver cancer. Researchers suspect that the microbiome in the mouth and intestines may play a role in cancer development. Dental care does not appear to have any effect on other types of cancer.
  • Diabetes from Bad Teeth?

    Doctors also suspect a connection between periodontitis and type 2 diabetes. Because cytokines from the oral cavity slow down the absorption of blood sugar into the body cells. The blood sugar level rises - and with it the risk of diabetes. The dilemma: The connection can be reciprocal: Diabetics have poor wound healing and blood circulation, which in turn favors inflammation in the mouth.
  • Premature labor

    Women with periodontal disease are more likely to give birth prematurely than women with healthy teeth and gums. According to an American study, their risk of premature birth increases 7.5 times. The scientists suspect that the released inflammatory substances get into the uterus and trigger labor there early.
  • Misalignment of the jaw causes pain

    When the TMJ becomes stuck, pain can radiate to the neck or back. Up to 20 percent of Germans suffer from such craniomandibular dysfunction (CMD). This has nothing to do with oral hygiene, but those who have their pearly whites checked regularly by the dentist can avoid this complication with a suitable splint.
  • Proper care protects!

    If you take proper care of your teeth every day, you can prevent many complications. Brushing your teeth twice a day removes the bacterial coating and, according to a Korean study, reduces the risk of heart attacks by 9 percent. You can also get the spaces between your teeth clean with dental floss or interdental brushes. You should also go to the dentist at least once a year to check your teeth and have your teeth professionally cleaned if necessary.

Periodontal disease

The vast majority of patients have simple periodontal disease, so to speak. This term is used today to combine the former categories of "chronic periodontitis" and "aggressive periodontitis". It has been shown that there is no scientifically sound justification for a distinction between these two forms.

"Chronic periodontitis" (old name: adult periodontitis) used to be the most widespread, slowly progressing form of the disease, which mostly affects people over the age of 35. The much rarer, rapidly progressing "aggressive periodontitis" has been diagnosed mainly in children and young adults.

Staging and grading

According to its stage ("staging") and its degree ("grading") the periodontitis of a patient is described in more detail:

>> Staging: The staging depends on the severity of the periodontal disease at the time of diagnosis and the dentist's assessment of how complex the treatment will be. Relevant here are, for example, how much the gums have already receded from the teeth, how much bone tissue has already been lost according to the X-ray findings and how many teeth have already fallen out as a result of periodontitis. Four stages are possible (stages I to IV).

>> Grading: The degree of the disease describes the (probable) progression of periodontitis, which can be slow (grade A), moderate (grade B) or rapid (grade C). To do this, the dentist assesses the progression of the disease at the time of diagnosis based on the patient's medical history (anamnesis). However, other aspects are also incorporated into the grading. Among other things, the dentist assesses how periodontitis will progress in the future and to what extent the general state of health of the patient and other factors (such as smoking) could have a negative effect on the disease.

Necrotizing periodontal disease

Necrotizing ulcerating periodontal disease (NUP) is a rare but particularly contagious form of disease that progresses rapidly. It is associated with profuse bleeding gums, tissue death (necrosis), ulcers in the gums between the teeth and pain. In addition, there is bad breath, swollen lymph nodes and so-called pseudomembranes (arise as a result of inflammation from dead tissue cells and do not have an orderly fine-tissue structure).

The NUP is based on an infection with bacteria that romp around in the oral cavity of healthy people, but have increased excessively in the affected patients. This often happens, for example, with HIV patients with their weakened immune system. The necrotizing periodontal disease is therefore sometimes also HIV-associated periodontal disease called.

Necrotizing ulcerative periodontitis (NUP) and necrotizing ulcerative gingivitis (NUG) are collectively referred to as necrotizing periodontal disease designated. They are at different stages of the same infection: As long as the gums are affected alone, the dentist will diagnose a NUG. If the inflammatory and degradation processes spread to the jawbone and the connective tissue between the root cement and the bone (periodontal bone), he speaks of NUP.

Periodontitis as a manifestation of systemic diseases

Sometimes periodontitis occurs as part of a systemic disease (general disease). It is not always easy to determine whether the disease is causing periodontitis or rather whether it is contributing to the development of "normal" periodontitis originating from plaque.

The following systemic diseases are known to occur Affect inflammation of the gums and so essential to one Loss of periodontal supporting tissue contribute:

  • genetic diseases such as Down syndrome, severe neutropenia (lack of neutrophils), Papillon-Lefèvre syndrome, Cohen syndrome, epidermolysis bullosa, Ehlers-Danlos syndrome, systemic lupus erythematosus, glycogen storage disease, etc.
  • Acquired immunodeficiency diseases: acquired neutropenia, HIV
  • inflammatory diseases such as acquired epidermolysis bullosa, inflammatory bowel diseases (e.g. Crohn's disease, ulcerative colitis)

There are also general illnesses that cause the Influence the course of periodontal disease can. These include:

  • Diabetes mellitus
  • Obesity (obesity)
  • osteoporosis
  • rheumatoid arthritis and osteoarthritis
  • emotional stress and depression
  • Smoking (nicotine addiction)

There are also systemic diseases which, independently of periodontitis, can lead to the destruction of the periodontium, which sometimes looks like periodontitis. This can be the case with squamous cell carcinoma in the mouth or granulomatosis with polyangiitis (Wegener's disease).

Periodontal disease: symptoms

With periodontitis, those affected usually have hardly any symptoms at the beginning. Pain occurs only with necrotizing periodontitis. There are no typical periodontal symptoms (colloquial: periodontal symptoms). However, some signs can indicate periodontal disease:

  • Bleeding gums
  • reddened and swollen gums
  • Gum recession (gingival recession)
  • exposed and sensitive tooth necks
  • putrid bad breath
  • unpleasant taste, especially when pus drains from the inflamed areas
  • loose teeth, misaligned teeth

These signs are based on two other disease characteristics:

On the one hand, as mentioned above, periodontitis is usually preceded by inflammation of the gums (gingivitis), which persists and makes the gums particularly sensitive. In this case, patients also have otherwise untypical pain when brushing their teeth.

On the other hand, the gum furrow widens due to the breakdown of the periodontium, especially the alveolar bone. This furrow deepens unnoticed and gum pockets form. Here bacteria can penetrate even more easily and cause inflammation. As a result, there is increased bleeding, pus evacuation, bad breath and, in an advanced stage, loosening of teeth.

Periodontal disease: causes and risk factors

Periodontitis usually begins insidiously with one Inflammation of the gums (Gingivitis). Their main cause is poor oral hygiene:

Insufficient or incorrect toothbrushing causes deposits to form on the teeth (Plaques), especially at the transition between tooth and gum. The plaques consist of food residues, saliva, bacteria and their metabolic products. At first the toppings are soft; over time, however, they become hard - tartar develops. Its rough surface makes it easier for bacteria to attach to teeth. In order to get the germs under control and to prevent their penetration into the tissue, the immune system starts superficial inflammatory processes in the gums - the patient has inflammation of the gums.

From gingivitis to periodontal disease

Sometimes inflammation of the gums heals up. If the inflammation persists, however, it can happen that the bacteria eventually defeat the body's defenses and gain the upper hand: They penetrate deeper into the tissue, the inflammation becomes chronic and gradually spreads to the gums - periodontitis results:

As the inflammation persists, the gums separate from the teeth and form Gingival pockets between tooth and gum. These can be several millimeters, sometimes even over a centimeter, and are difficult to clean. Therefore, bacterial plaque can easily form here after solidification Concrements (analogous to tartar = solidified plaque above the gums).

The concretions and bacteria in the gingival pockets can set in motion further inflammations, which gradually spread to the various components of the periodontium. At some point even the Jawbone around the teeth may be affected and subsequently be broken down. The Teeth loosen and can cause problems when chewing or even pain when chewing. Finally threatens Tooth loss.

Many factors are involved

The periodontal disease is considered to be multifactorial disease - So as a disease that does not have a single cause, but several factors are involved in its development. The immune system plays a central role here: the body's defenses determine whether someone develops periodontitis and how it progresses.

The immune system is influenced by various internal and external factors, which thus also affect the development and course of periodontitis. To this Risk factors count above all:

  • hereditary predisposition: Some people are more prone to periodontal disease than others because of a hereditary predisposition. Due to a genetic defect, your body produces an excessive amount of messenger substances that promote inflammation (cytokines).
  • Smoke: The risk of periodontitis is two to seven times higher in smokers than in non-smokers - the smoke weakens the body's defenses and affects the teeth supporting system. And the more someone smokes, the more severe the disease. In addition, it is often only discovered later in smokers because the vasoconstricting effect of nicotine often suppresses bleeding gums as a typical symptom. Last but not least, smoking reduces the chances of success of periodontal treatment because it delays wound healing in the mouth.
  • diabetes: Diabetic people are also significantly more susceptible to periodontal disease. Especially when the diabetes is poorly controlled (the blood sugar levels are too often or permanently too high), this weakens the defenses of the teeth supporting apparatus. As a result, inflammations occur more frequently, which, due to diabetes, also heal poorly.
  • psychological stress: It weakens the immune system and can trigger or accelerate periodontitis.
  • pregnancy: The hormonal changes during pregnancy can promote inflammation of the gums. Therefore, expectant mothers have an increased risk of periodontal disease.
  • Immune system disorders (e.g. AIDS): They weaken the body's defenses, which has a negative effect on the development and course of periodontitis.
  • certain drugs: Some medicines can cause gum growths and pave the way for periodontal disease. This applies, for example, to antihypertensive agents and to drugs that are given after an organ transplant to counteract rejection reactions of the immune system.

Marginal and apical periodontitis

As mentioned above, periodontitis almost always develops as a result of inflammation of the gums (often involving risk factors) and thus starts from the gum line. Then one speaks of marginal periodontal disease.

It is much rarer apical periodontal diseasestarting from the apex of the tooth and the surrounding tissue:

The tooth pulp (tooth pulp) fills the tooth inside and contains nerves and blood vessels.It is connected to the rest of the vascular and nervous system as well as to the tooth support apparatus via a hole in the apical foramen and small side canals. If the pulp becomes inflamed due to caries, the pathogens can spread through the root canal, enter the tooth bed (periodontium) through the small side canals and also start an inflammation here - apical periodontitis develops.

Tooth-preserving measures such as root canal treatment also involve an increased risk of periodontitis, for example if instruments are inserted too deeply. Overfilling or insufficient filling of the root canal can also lead to apical periodontitis. Last but not least, the periodontal membrane can be damaged by a blow or impact, which can promote periodontitis.

Periodontal Disease: Contagious?

Like any bacterial infectious disease, periodontal disease is contagious. Therefore, the life partner should also pay attention to possible symptoms of periodontal disease. Under certain circumstances, certain bacteria can be transmitted when kissing or sharing cutlery, drinking bottles or glasses, even if periodontitis does not break out. This in turn depends on the respective risk factors. Caution is also advised with infants: mothers and fathers with periodontitis can transmit the pathogen to their child.

Periodontal disease: diagnosis and examination

anamnese

To clarify a possible periodontitis, the dentist first collects the patient's medical history (anamnesis) in conversation with the patient. For example, he can ask the following questions:

  • Do you have toothache in certain places? Does this pain only occur when you touch it?
  • Do your gums bleed a lot, especially after brushing your teeth?
  • How often do you brush your teeth a day? Do you use dental floss?
  • Have friends or relatives told you about bad breath?
  • Do some teeth feel loose?
  • Are you aware of any illnesses, such as rheumatism or diabetes?
  • What medications do you take (e.g. blood thinners)?
  • Do you smoke?
  • Do you feel stressed and overwhelmed at the moment?
  • Are similar complaints common in your family? Do you know of periodontitis / periodontitis in your parents?

General assessment

Next, the doctor examines the lining of the mouth, the teeth and the condition of the teeth holding apparatus. He pays attention to known periodontal symptoms such as gingival pockets, exposed tooth necks or bad breath. He will also palpate the nearby jaw lymph nodes. Inflammatory processes can cause pain and enlargement under pressure.

It is important to assess the gums: Normally, it is firmly attached to the subsurface and cannot be moved. It is pale pink and is usually two millimeters above the boundary line between tooth enamel and root cement (enamel-cement boundary, SZG) on the tooth. However, if the gums have receded - either up to the enamel-cement border or below - this indicates periodontitis. Swollen and clearly reddened gums are also suspect.

The dentist then assesses the dental status. Missing or filled teeth, implants, crowns and other dentures are noted. He also checks visible tartar (plaque) and tests tooth sensitivity. To do this, he sprays cold water mainly on teeth that are suspected of having periodontitis.

Periodontal Screening Index (PSI)

The Periodontal Screening Index (PSI) is a special dental examination that people with statutory health insurance are entitled to every two years. The dentist (or a specially trained dental hygienist) examines the gums Gingival pockets - in adults with every tooth, in children mostly only with one lower and upper incisor and the first molars.

A special instrument is used here, the WHO probe. It has a longer, angled tip that works like a ruler. The probe is marked in black at a height of between 3.5 and 5.5 millimeters. There is a small ball at the end of the tip.

For the examination, the dentist divides the teeth into six parts (sextants) - three sextants per jaw. Then he uses the probe at four to six places per tooth to check how far he can penetrate the gum groove on the gum line. Depending on the pocket depth, five grades from 0 to 4 are possible PSI codes called. Only the worst (i.e. highest) PSI code is documented for each sextant. The codes say the following:

  • A PSI index of 0 means healthy gums.
  • If the dentist detects PSI code 1 and / or 2 one or more times, this is an indication of gingivitis.
  • PSI code 3 indicates moderate periodontitis.
  • The PSI code 4 indicates severe periodontitis.

Probing depth, BOP and PB index

To check whether there is a gingival pocket and how deep it is (Probing depth), the dentist inserts the WHO probe (or a similar probe) very carefully between the tooth and the gum. The measured probing depth says something about the inflammatory activity in the tissue.

If the gums bleed when probing, it indicates inflammation. The dentist documents this as a BOP positive (BOP = bleeding on probing). Healthy gums, on the other hand, do not usually bleed (BOP negative). However, the BOP index can be positive for smokers even without inflammation. The reason is the nicotine-related poor blood flow to the gums.

Like the BOP index, the PB index (papillary hemorrhage index) to assess the tooth support system and clarify the suspicion of periodontitis. The papillae are the free "gum lobes" between neighboring teeth. If they become infected, they will start bleeding when you gently press the probe. The following applies: the stronger the bleeding, the stronger the inflammation. According to this, dentists differentiate between five degrees of severity from 0 (no bleeding) to 4 (heavy, flowing bleeding).

Assessing the condition of the gums using a probe can be difficult because the probe penetrates the tissue very easily if the gums are inflamed and teeth are loose. It can quickly penetrate below the actual pocket depth. This can make it more difficult for the dentist to assess the course and healing of periodontitis.

Furcation involvement

In contrast to the rest of the teeth, the anterior and posterior molars usually have more than one root. This division of a tooth root is called Furcation (For example, two tooth roots are referred to as bifurcations). With advanced periodontitis, the jawbone can also dissolve between or below the divided roots of a tooth - Furcation involvement called.

To determine its severity, the dentist tests how far he can travel between the root bifurcations of a tooth with a curved probe. Possible are three degrees of severity: If it can penetrate up to three millimeters with the probe, it is a first degree furcation involvement. If he can penetrate deeper, grade II is present. If it can be probed completely through between the roots, the dentist notes grade III.

Tooth mobility

With periodontitis, the teeth loosen due to the breakdown of the periodontium - the teeth become more mobile than they normally are. The dentist can determine this by measuring the static and dynamic tooth mobility:

  • static tooth mobility: The doctor checks how far a tooth can be deflected with a probe and fingertip. Four grades are possible here - from grade 0 (normal tooth mobility) to grade 3 (the tooth can be moved back and forth by more than two millimeters with tongue and lip pressure alone).
  • dynamic tooth mobility: It indicates how well a tooth can decelerate forces (e.g. from chewing). This can be determined with a measuring device, such as the Periotest device. A volumetric flask hits the chewing surface like a plunger. The device precisely measures the time between tooth contact and braking.

roentgen

On x-rays, the dentist can see whether, how much and where in the jaw bone tissue has already broken down as a result of periodontitis. This is important not only for an exact diagnosis, but also for therapy planning.

Conventional X-rays involve a certain amount of radiation exposure for the patient. That is why a more modern and low-radiation X-ray procedure is used in some dental practices - the Digital volume tomography (DVT). This allows very precise 3D x-ray images of the jaw to be made with a low radiation dose. including all important structures such as nerves.

More tests

Particularly if periodontitis is very difficult or does not respond adequately to therapy, further examinations may be necessary. For example, laboratory tests can be used to determine which types of bacteria are involved in the disease.

Other tests check the fluid in the gum line. In the case of periodontitis, typical endogenous proteins are found there - enzymes that are released by immune cells or come from dead tissue cells: In a quick test, the doctor can detect aspartate aminotransferases (released in the event of cell death), matrix metalloproteinases (from inflammatory cells) or alkaline phosphatases (from bone cells) and secure the diagnosis of periodontal disease.

The genetic defect that leads to an overproduction of the inflammatory messenger substance interleukin 1 can be detected in genetic tests. However, the doctor will only initiate this examination in very rare cases of particularly aggressive periodontitis.