Periodontal Disease Periodontal (gum) disease is: Chronic bacterial infections around the teeth and gums caused by bacteria residing in the plaque that forms on our teeth includes gingivitis and periodontitis They mainly infect the gums and bone supporting the teeth o Bacteria invade the gingival epithelium o Leads to destruction of the supporting tissue Periodontal disease can affect one tooth or many teeth It begins when the bacteria in plaque (the sticky, colourless film that constantly forms on your teeth) causes the gums to become inflamed Left untreated, they can lead to tooth loss. Gingivitis is: The mildest form of periodontal disease Affects 69% of the population o But only 5% of the population are completely free from inflammation Reddening, swelling and bleeding of the gums o Appears 5-20 days after bacterial plaque develops There may be little or no discomfort Gingivitis is often caused by inadequate oral hygiene Gingivitis is reversible with treatment and good oral home care. Periodontitis is: Untreated gingivitis o When destruction of the collagen fibres of the periodontal ligament occur Plaque spreads and bacteria grow below the gum line o Pockets form around the tooth in which bacteria can proliferate and are difficult to reach Up to 35% of the population may be suffering from the disease o 22% have the milder form o 13% - moderate to severe Toxins produced by the bacteria in plaque irritate the gums The toxins stimulate a chronic inflammatory response in which the body in essence turns on itself, and the tissues and bone that support the teeth are broken down and destroyed Gums separate from the teeth, forming pockets (spaces between the teeth and gums) that become infected As the disease progresses, the pockets deepen and more gum tissue and bone are destroyed Often, this destructive process has very mild symptoms Eventually, teeth can become loose and may have to be removed o It is the most common form of tooth loss in adults Causes of Periodontal Disease Harmful bacteria increase in mass and thickness until they form a film known as plaque. Bacterial plaque o many surfaces of the body are covered by plaque (bioform) but it is shed o teeth are very susceptible to bacteria on plaque as it is a non shedding surface in a warm moist area In healthy mouths, plaque itself actually provides some barrier against outside bacterial invasion. When it accumulates to excessive levels, however, plaque adheres to the surfaces of the teeth and adjacent gingiva and causes cellular injury, with subsequent swelling, redness, and heat. When plaque is allowed to remain in the periodontal area, it transforms into calculus (commonly known as tartar). This material has a rock-like consistency and adheres tenaciously to the tooth surface. o The colour and hardness vary depending on the age of the material and extrinsic factors, such as tobacco use. It is much more difficult to remove than plaque, which is a soft amorphous mass. Calculus produces injury and inflammation that eventually destroys the support structures and bone and can lead to tooth loss. – periodontal disease is exacerbated by: o poor oral hygiene not brushing teeth or brushing them in the wrong way o Smoking o Genetic predisposition o Pregnancy and puberty due to sensitive gums because of Many of these are because hormonal fluctuations they suppress the immune o Stress system o Chronic clenching or grinding of teeth Speeds up rate of destruction to Bone/gums if infection already present o Diabetes Increases systemic cytokine production o Poor nutrition o Other systemic diseases o Age The Bacteria that Cause Periodontal Disease Not all bacteria cause periodontal disease There are approx 300 species of bacteria in our mouth but only a fraction will cause problems Most bacteria that do are thought to be gram negative or anaerobic pathogens o These have a number of virulence factors (something produced by the bacteria that can cause disease in its host) o These tend to be much more damaging than gram positive or aerobic bacteria – e.g. salmonella, the plague o They have a more complex double cell wall structure that makes it difficult for the immune system to attack o They are also difficult for antibiotics to penetrate o They tend to initiate more severe inflammation/immune system reactions than gram positive bacteria Because of the lipopolysaccharide nature of their outer membrane – has a toxic effect on the body, resulting in high fever, inflammation etc o They are able to exchange genetic material from species to species – thereby fostering beneficial mutations such as antibiotic resistance The Aetiology Evidence suggests that periodontal disease may be an autoimmune disorder It appears to work as follows: The bacteria that form plaque and tartar release toxins that stimulate the immune system to over produce powerful infection-fighting factors called cytokines. Ordinarily, cytokines are important for healing. In excess, however, they can cause inflammation and severe damage. Cytokines of particular importance in periodontal disease are known as tumor necrosis factor-alpha (TNF-alpha) and interleukin-1beta and interleukin 4 (IL-1 and IL4), which are very active in the mouth. In excess, these cytokines overproduce an enzyme called collagenase, which breaks down proteins, including the connective tissue that holds teeth in place. o It tends to be a very localized extreme response – causing lots of localized damage o This damage then allows bacteria to burrow in further and cause greater immune response – and so on It is the bodies own defense system that causes the damage associated with the disease – not the bacteria themselves o It is similar to arthritis in its effects on tissue and bone but the aetiology is infectious rather than auto immune Studies suggest that this inflammatory response may have damaging effects not only in the gums but also in organs throughout the body The Link between Periodontal Disease and Other Systemic Chronic Diseases Periodontal disease has been shown to be a risk factor in some serious chronic diseases o CHD o Preterm births o Diabetes The mouth is the gateway to the body o If bacteria proliferate AND MUTATE here they have free access to the blood stream and every system of the body o The junctional endothelium is a unique hard/soft tissue barrier It is permeable and allows through internal immune complexes such as leucocytes, antibodies etc However some bacteria can get through. If bacteria get through they can pass into adjacent connective tissue/blood stream Gingival crevicular fluid (GCF) also assists in this protection o It is a fluid that contains immuno complexes such as leucocytes o In times of infection it becomes mixed with bacteria and debris from damaged tissues. o These are then able to pass through into the blood stream Chronic inflammation leads to free radical release o Free radicals are actually a C-reactive protein (CRP) is a systemic marker of inflammation o It is produced in the liver o It is found in patients with CHD o It has also been found in patients with periodontal disease – CHD patients are more likely to have higher levels, and therefore more severe inflammation, if they have periodontal disease Periodontal Disease and Cardiovascular Disease The strength of association between the 2 is comparable with that of smoking and genetics/heredity There is a one and a half- to four-fold increased risk for heart disease in people with periodontal disease. o The four-fold risk was in men with extensive gum disease, bleeding from every tooth In one study, 85% of heart attack patients had periodontal disease compared to 29% of people with no heart problems Periodontal disease has also been associated with stroke In addition, high cholesterol blood levels have been associated with both chronic periodontal disease and coronary artery disease Several proposed mechanisms for the connection o All based around the inflammatory theories o It appears that immune factors causing the elevated CRP levels are released into the blood stream during periodontal disease and cause injury in the arteries supplying blood to the heart. o Other evidence suggests that the bacteria itself may play a direct role in arterial injury. Either way, the same bacterium found in mouth plaque have been found in arterial plaques They are associated with plaque ulceration and thrombosis The immune response also promotes platelet aggregation which can lead to clotting and thrombosis Unfortunately, treating and eliminating periodontitis does not appear to have any effect on preventing heart disease o Some experts believe that there is no actual causal relationship, but that common factors induce inflammation and damage resulting in diseases in the blood vessels and in the gums Periodontal Disease and the Sex Hormones Periodontal disease is often more prolific at times of hormonal change such as: o Pregnancy o Puberty o Menopause o When taking the oral contraceptive pill Links have been established between periodontal disease and preterm births o Gingivitis often appears in 2nd month of gestation and reach max severity 1 month before delivery – (this may not be at 8 months as it may initiate premature labour) o The ratio of gram neg. bacteria to gram positive changes during pregnancy o Research indicates that the bacteria from periodontal disease may trigger the same factors in the immune system as genital and urinary tract infections do. These biologic substances called prostaglandins and tumor necrosis factor produce inflammation in the cervix and uterus that can cause premature dilation and contractions o Another theory is that before a baby is delivered, the gestational membranes rupture The process is not understood but it is thought to be cytokine mediated Bacterial infection – cytokine presence can be caused by bacterial infection Infection may also lead to birth defects o Virulent bacteria can cross the placenta and harm the foetus Periodontal Disease and Diabetes Diabetes is thought to excacerbate periodontal disease but the relationship may be two way periodontal disease may exacerbate or even cause diabetes o Some evidence has suggested that the bacteria causing periodontal disease may enter the blood stream and activate cytokines, which then may destroy cells in the pancreas, where insulin is produced o One study found that treating periodontal disease reduced the need for insulin in some people with diabetes Periodontal disease appears to exacerbate some of the symptoms of diabetes o Retinopathy – pro-inflammatory cytokines involved in the pathogenesis Effect on Respiratory Disease Bacteria that reproduce in the mouth can also be carried into the airways of throat and lungs, increasing the risks for respiratory diseases and worsening chronic lung conditions, such as emphysema Management of Periodontal Disease Improved oral hygiene o Only affective above the gum line o Not effective in treating periodonitis Professional scaling and polishing Surgical removal of the diseased tissue Eating regularly Avoiding odiferous foods, drugs and other substances Chewing sugar free gum Using mouth wash Nutritional and Lifestyle Management Reduction in amount and frequency of sugar intake – obviously Increase insoluble fibre intake o Fiber helps to cleanse the teeth, similar to a dog's bone or biscuit. whole grains, Beans, Rice, brown, vegetables Increase consumption of natural antibacterials o Ginger, garlic Vitamin C o Protects gum tissue against cell damage and speeds healing. Brushing with vitamin C powder can minimize gum inflammation and bleeding. Leading Food Sources of vitamin C: Cabbage, red, Tangerines & other mandarins, Peppers, bell, red, Oranges, Strawberries, Kiwi fruit, Potatoes Antioxidants o Co Q 10 Research shows that the gums of people with periodontal disease are often significantly deficient in CoQ10, and some evidence suggests that topical or oral CoQ10 may be effective in slowing the disease process o Flavonoids Flavonoids are powerful antioxidants and may enhance immunity, helping to keep gum-attacking bacteria in check. Leading Food Sources of flavonoids: Broccoli, Grapefruit, white, Apples, Oranges, Pomegranates, Limes, Chocolate, Soybeans, Lemons, Tomatoes, Onions, Carrots, Blueberries o Vitamin E Can be applied topically. Open a capsule of vitamin E and rub the oil on inflamed gums to aid healing and alleviate pain. Teeth/bone minerals – magnesium, manganese, calcium, boron Herbs o Can be taken as teas – twice per day blueberries, echinacea, goldenseal and rosehip have been found to be helpful o Mouthwash – twice per day Echinacea, goldenseal (endangered species – so worth trying to find an alternative for now), myrrh – but DO NOT swallow, tea tree oil, manuka honey o Tincture Should be used acutely not over time Every two hours for a few days Daily Dental Care Correct tooth brushing, mouth cleansing, and flossing Brushing Guidelines. First use a dry brush – for about 1.5 minutes. One study reported that when people brushed their teeth without toothpaste first, using a soft dry brush, their plaque deposits were reduced by 67% and gum bleeding dropped by 50%. Place the brush where the gum meets the tooth, with bristles resting along each tooth at a 45-degree angle. Begin by dry brushing the inside of the bottom row of teeth, then the inner top teeth, and last the outer surfaces. Wiggle the brush back and forth so the bristles extend under the gum line. Scrub the broad, biting surfaces of the back teeth. A paste is then applied and the teeth should be rebrushed in the same way. The tongue should be scrubbed for a total of about 30 seconds. One should rinse the toothbrush thoroughly and then tap it on the edge of the sink at least five times to get rid of debris. Flossing should finish the process. A mouthwash may also be used If brushing after each meal is not possible, rinsing the mouth with water after eating can reduce bacteria by 30%.
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