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¿Qué es la enfermedad periodontal?                
 

La enfermedad periodontal es una infección bacteriana de las encías que destruye las fibras de incersión de la placa dental y el hueso de soporte que mantiene los dientes en la boca. La principal causa de esta enfermedad es la placa bacteriana, una película pegajosa, incolora que se forma constantemente en los dientes. Las toxinas producidas por la bacteria en la placa inflaman las encías, provocando la infección. El estado menos severo se conoce como gingivitis, conforme avanza la enfermedad se forman bolsas estas se llenan de infección y destruye mas tejido, hueso y los dientes eventualmente se aflojan y se pierden.

 

¿Cuáles son los síntomas de la enfermedad periodontal?
 

     • Sangrado al cepillarse o al usar el hilo dental.
     • Encías que van dejan al descubierto las raíces de los dientes.
     • Encías enrojecidas, agrandadas y fácilmente móviles.
     • Dientes móviles y que se empiezan a separar.
     • Pus entre la encía y el diente.
     • Mal aliento persistente.
     • Cambios en la posición de la mordida de los dientes.
     • Cambios en los ajustes de las prótesis removibles.
     • El incremento de espacio entre los dientes.
 

Sin embargo es posible tener la enfermedad periodontal sin notar ninguno de estos signos, por está razón es importante solicitar una evaluación periodontal.
 

¿Qué otros factores contribuyen a la enfermedad periodontal?
 

     Diabetes.
     Las enfermedades periodontales pueden ser más severas en diabéticos no controlados.
     Enfermedades sistémicas.
     La enfermedades que interfieren con el sistema inmunológico del cuerpo
     pueden empeorar la condición de las encías.
     Embarazo y pubertad.
     Algunos cambios hormonales pueden provocar que las encías se tornen rojas,
     blandas y sangren fácilmente.
     Estrés.
     Puede ocasionar que al cuerpo se le dificulte combatir una infección,
     incluyendo las periodontales.
     Medicamentos.
     Algunas drogas como los anticonceptivos orales, antidepresivos y ciertos medicamentos para el corazón.
     Apretamiento ó rechinamiento de los dientes.
     Esos hábitos pueden ejercer mucha presión en el tejido de soporte de los
     dientes y acelerar la destrucción de los tejidos.
     Fumar.
     Las personas que usan tabaco crean mayores posibilidades de adquirir
     enfermedades periodontales.
     Mala alimentación.
     Una dieta baja en nutrientes provoca que el cuerpo tenga dificultades de
     combatir infecciones.

¿Cuál es el tratamiento para la enfermedad de las encías?
 

En las etapas iniciales de la enfermedad de las encías, el tratamiento consiste en remover la placa y cálculos de las bolsas alrededor de los dientes puliendo y alisando las raíces. Así se eliminan las bacterias y los irritantes que causan la inflamación.

Normalmente el tratamiento permite que la encía se adhiera de nuevo al diente o se contraiga lo suficiente para eliminar la bolsa. En la mayoría de los casos de la enfermedad periodontal inicial requiere un raspado, alisado radicular y una buena higiene oral para obtener resultados satisfactorios.
 

¿Los casos más avanzados pueden requerir tratamiento quirúrgico?
 

En casos todavía más avanzados donde pueden existir dientes flojos, se tratara ajustando la mordida, por ejemplo, uniendo los dientes con férulas temporales para reducir el movimiento obteniendo más comodidad y mejor función. Los tratamientos adicionales pueden incluir Ortodoncia o la colocación de aparatos protésicos.
 

¿Quien hace el tratamiento periodontal?
 

Los periodoncistas tienen entrenamiento extenso y avanzado para tratar la enfermedad periodontal, deben prepararse académicamente mínimo dos años después de haberse graduado como odontólogos. Como especialistas dedican su tiempo, energía y habilidades para atender a la gente que necesita el tratamiento de las encías. La Periodoncia es una de las ocho especialidades reconocidas por la Asociación Dental Americana (ADA).
 

¿Cómo puede prevenirse la enfermedad periodontal?
 

La visitas regulares al dentista, la limpieza diaria mantendrá el sarro a un mínimo, sin embargo no lo prevendrá totalmente. La limpieza profesional, por lo menos dos veces al año es necesaria.
 

Consulte a un especialista, el le mostrará la manera de tener un cuidado con sus dientes y una mejor salud dental por medio del hábito del cepillado y la utilización del hilo dental.

 

Problemas en las encías

Muchas personas no se dan cuenta cuán común son las enfermedades periodontales (alrededor del diente) que comienzan lesionando las encías. Tres (3) de cuatro (4) adultos poseen algún tipo de esta enfermedad. En la mayoría de los casos, no produce dolor y por consiguiente, dicho problema pasa desapercibido. Sin embargo, su temprana detección y tratamiento son extremadamente importantes, debido a que la enfermedad periodontal termina con la vida del diente (movilidad, infección, extracción).
Estos pequeños comentarios dan algunas respuestas a las preguntas más comunes sobre esta enfermedad y pueden servirle de guía para obtener una buena salud periodontal. Recordamos a Ud., que es una enfermedad crónica, que su profesional tratará de frenar la evolución para salvarle sus piezas dentales y que éstas permanezcan el mayor tiempo posible en su boca. Sus dientes son más valiosos que cualquier reemplazo que su Odontólogo pueda ofrecerle.
¿De qué se trata?.. piorrea, paradentosis, periodoncia, movilidad dental, periodontítis, etc.. Los problemas en las encías son infecciones provocadas por una película de bacterias (“placa dental”), que se adhiere a la superficie dental justo en el límite con las encías. Puede ocurrir a cualquier edad, pero por lo general es frecuente después de los 40 años de edad. En los primeros estadíos de la enfermedad, denominada gingivitis, las encías se tornan rojizas y sangran con facilidad. A medida que avanza la infección hacia el hueso que soporta a los dientes, recibe el nombre de periodontítis, y en este momento puede provocar un daño irreversible. Cuando avanza más todavía, el hueso y los tejidos que soportan al diente son destruidos provocando la caída o la extracción dental.
¿Qué provoca los problemas?..: son provocados por las bacterias que se adhieren en forma de película, organizándose en la llamada “placa dental”. Es pegajosa y se forma constantemente; en caso de no remover esta placa en forma diaria con el cepillado, libera toxinas que irritan, inflaman e infectan a la encía. Más adelante estas toxinas destruyen la encía y provocan que los tejidos se separen del diente y formen un espacio profundo: “bolsas”. Estas bolsas, de hecho acumulan más bacterias dando lugar a un círculo vicioso que agrava la situación, migrando hacia la raíz del diente y dándole apariencia de dientes mucho mas grandes, cuando lo que sucede es que el hueso se reabsorbe y desciende (o asciende en dientes sup.) la encía.

 

                            Diente sano
                                Gingivitis
                                        Periodontitis
                    Infeccion de las encias

La Periodoncia es una rama de la Odontología que se encarga del estudio y tratamiento de los tejidos que rodean y dan soporte a los dientes; Existen múltiples alteraciones que pueden afectar a estos tejidos, entre los más comunes está la gingivitis (inflamación crónica de las encías), y la periodontitis (pérdida parcial o total del hueso soporte). Los tratamientos periodontales actuales utilizan un sin número de nuevas técnicas y materiales que permiten conservar los dientes por más tiempo y en mejores condiciones.

¿Es verdad que con la edad esta uno predeterminado a perder sus dientes?
La principal causa responsable de la pérdida de dientes es la enfermedad periodontal, esta produce una pérdida gradual del hueso que soporta al diente, produciendo la caída de los mismos. Evitar este padecimiento es tan fácil como mantener un adecuado control de placa bacteriana y acudir regularmente con el dentista. Recuerde que un buen cuidado de su boca le permite mantener los dientes para toda su vida.

                            

                 Un adecuado tratamiento parodontal a tiempo evita
                            la perdida de hueso de soporte y encía.

 ¿Cómo se tratan los padecimientos de las encías?
Actualmente existen una gran variedad de innovadoras técnicas y materiales en periodoncia que permiten controlar y mejorar las condiciones de las encías y del hueso de soporte. Injertos óseos y gingivales así como una gran variedad de técnicas facilitan y mejoran considerablemente el pronóstico de estos padecimientos.

 
 
Antes
Después

Injertos óseos y gingivales se realizan en algunas ocasiones para preservar las estructuras de soporte de los dientes o para impedir la pérdida severa de hueso en la zona de extracción de una pieza dental, lo que permite sustituir al diente perdido de una mejor y más fácil manera.

                        



                                                            

                   

                             Tratamiento periodontal con LASER:

                 Antes/Before                     Despues/After

 

Thanks to its bactericidal effect the laser can quickly and thoroughly decontaminate gingival pockets: this produces a significant reduction of bacteria and avoids a long and uncomfortable recovery. Through the natural analgesic and biostimulating effects of laser irradiation, patients usually have minimal post-operative discomfort. The diode laser is useful for the treatment of:

  • Laser soft tissue curettage
  • Laser removal of diseased, infected, inflamed, and necrosed soft tissue within the periodontal pocket
  • Removal of highly inflamed edematous tissue affected by bacteria penetration of the pocket lining and junctional epithelium
  • Sulcular debridement (removal of diseased or inflamed soft tissue in the periodontal pocket to improve clinical indices including: gingival index, gingival bleeding index, probe depth, attachment loss and tooth mobility).
  •                                                                                        

                 

                                                                 Periodontal Disease

Highlights

Symptoms of Periodontal Disease

Symptoms of periodontal disease include red and swollen gums, persistent bad breath, and gum recession and loose teeth. Smoking, certain types of illnesses (diabetes), older age, and other factors increase the risk for periodontal disease. If you have periodontal disease, your dentist may refer you to a periodontist, a dentist who specializes in treating this condition.

Practice Good Dental Hygiene

Consistent good dental hygiene can help prevent gingivitis and periodontitis. The American Dental Association recommends that everyone:

Mouthwashes

According to the American Dental Association, antimicrobial mouthwashes may provide additional oral health benefits for preventing and reducing gingivitis and plaque. However, they are not a substitute for daily brushing and flossing.

Complications

Uncontrolled periodontal disease is associated with:

Introduction

Periodontal disease refers to a group of problems that arise in the sulcus, the gap between the gum and the tooth.

What is the Periodontium?

The part of the mouth that consists of the gum and supporting structures is called the periodontium. It is made up of the following parts:

The structure of the tooth includes dentin, pulp and other tissues, blood vessels, and nerves imbedded in the bony jaw. Above the gum line, the tooth is protected by the hard enamel covering.

 

Periodontal Disease

Periodontal diseases are generally divided into two groups:

The process starts with bacteria. Even in healthy mouths, the sulcus is teeming with bacteria, but they tend to be harmless varieties. Periodontal disease develops usually because of two events in the oral cavity: an increase in bacteria quantity and a change in balance of bacterial types from harmless to disease-causing bacteria. These harmful bacteria increase in mass and thickness until they form a film called plaque.

In healthy mouths, plaque itself actually provides some barrier against outside bacterial invasion. When it accumulates to excessive levels, however, plaque sticks to the surfaces of the teeth and adjacent gums 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 grabs onto the tooth surface. It is much more difficult to remove than plaque, which is a soft mass.

The most important component leading to the disease process, however, is the body's persistent immune response to the bacterial plaque. Specific immune factors are released that cause inflammation and damage that eventually destroys the support structures and bone and can lead to tooth loss.

Gingivitis

Gingivitis is an inflammation of the gingiva, or gums. Is nearly always chronic, but an acute form infrequently occurs.

Chronic Gingivitis. Ordinary chronic gingivitis affects over 90% of the population. It is characterized by tender, red, swollen gums that bleed easily and may be responsible for bad breath (halitosis) in some cases. Treatment is very effective if initiated early in the course of gingivitis. Without good management, however, the problem can progress.

Periodontitis

Periodontitis is characterized by the following:

Gingivitis precedes periodontitis, although it doesn't always lead to this more severe condition. In fact, some research suggests it is an entirely different disease. There are different categories of periodontal disease, including:

Chronic Periodontitis. Chronic periodontitis (also referred to as adult periodontitis) may begin in adolescence as a slowly progressing disease that becomes clinically significant in the mid-30s and continues throughout life. Some dentists question whether it is a chronic, unrelenting condition and instead suggest that it waxes and wanes depending on the response of the immune system.

Aggressive Periodontitis. Aggressive periodontitis (also referred to as early onset periodontitis) often occurs in young people. It is subdivided according to whether it begins before or after puberty. Immune deficiencies and a genetic link have been shown to be possible factors for all types of aggressive periodontitis. If the condition is localized and treated, the outlook is positive. People with severe and widespread aggressive periodontitis are at high risk for tooth loss.

Disease-Related Periodontitis. Periodontitis can also be associated with a number of systemic diseases, including type 1 diabetes, Down syndrome, AIDS, and several rare disorders of white blood cells.

Acute Necrotizing Periodontal Disease. Acute necrotizing periodontal disease is an acute infection in the gums. It is characterized by:

Stress, poor diet, smoking, and viral infections are predisposing factors for this acute necrotizing periodontal disease.

Symptoms

In general, symptoms progress over time and include:

Abnormally bulging, protruding, or swollen gums are a possible sign of disease.

 

 

 

 

 

 

Pain is usually not a symptom, which partly explains why the disease may become advanced before treatment is sought and why some patients avoid treatment even after periodontitis is diagnosed.

Causes

Periodontal disease is marked by bacterial overgrowth. However, a persistent immune response to chronic infections in the mouth is believed to play a major role in gum destruction.

 

 

 

Bacterial Culprits

Reachers have found more than 350 species of microorganisms in the typical healthy mouth. Periodontal infections are linked to fewer than 5% of these species. Healthy and disease-causing bacteria can generally be grouped into two categories:

Following are some of the bacteria most implicated in periodontal disease and bone loss:

Some bacteria are related to gingivitis, but not plaque development. They include various streptococcal species.

The Autoimmune and Inflammatory Response

Evidence indicates that periodontal disease is an autoimmune disorder, in which immune factors in the body attack the person's own cells and tissue -- in this case, those in the gum. It appears to work like this:

Studies suggest that this inflammatory response may have damaging effects not only in the gums but also in organs throughout the body, including the heart.

Viral Causes

Certain herpes viruses (herpes simplex and varicella-zoster virus, the cause of chickenpox and shingles) are known causes of gingivitis. Other herpes viruses (cytomegalovirus and Epstein-Barr) may also play a role in the onset or progression of some types of periodontal disease, including aggressive and severe chronic periodontal disease. All herpes viruses go through an active phase followed by a latent phase and possibly reactivation.

These viruses may cause periodontal disease in different ways, including release of tissue-destructive cytokines, overgrowth of periodontal bacteria, suppressing immune factors, and initiation of other disease processes that lead to cell death.

Risk Factors

More than 75% of American adults have some form of gum disease, but according to a major survey, only 60% have any significant knowledge about the problem. Gum inflammation and ulcers are common, and not all people with these problems develop periodontal disease. Still, about 30% of people are genetically susceptible to periodontal disease. Other factors also put individuals at higher risk.

Oral Environment

Lack of Oral Hygiene. Lack of oral hygiene encourages bacterial buildup and plaque formation.

Sugar and Acid. The bacteria that cause periodontal disease thrive in acidic environments. Therefore, eating sugars and other foods that increase the acidity in the mouth increase bacterial counts.

Poorly Contoured Restorations. Poorly contoured restorations (fillings or crowns) that provide traps for debris and plaque can also contribute to its formation.

Anatomical Tooth Abnormalities. Abnormal tooth structure can increase the risk.

Wisdom Teeth. Wisdom teeth, also called third molars, can be a major breeding ground for the bacteria that cause periodontal disease. In fact, for patients in their 20s, periodontal disease is most likely to occur around the wisdom teeth. Periodontitis can occur in wisdom teeth that have broken through the gum as well as teeth that are impacted (buried). Periodontal disease can also be present even in patients with wisdom teeth who do not have any symptoms. Adolescents and young adults with wisdom teeth should have a dentist check for signs of periodontal disease.

Age

Children and Adolescents. Gingivitis, in varying degrees, is nearly a universal finding in children and adolescents. In rare genetic cases, children and adolescents are subject to destructive forms of the disease. Researchers have also observed some of the organisms seen in periodontal disease in young children without signs of gum problems. Healthy children, however, do not generally harbor two primary periodontal bacteria, P. gingivalis and T. denticola. The disease is also uncommon in teenagers.

Adults. As people age, the risk for periodontal disease increases. Over half of American adults have gingivitis surrounding 3 - 4 teeth, and 30% have significant periodontal disease surrounding 3 - 4 teeth. In a study of people over 70 years old, 86% had at least moderate periodontitis, and over a quarter of them had lost their teeth.

Female Hormones

About three-quarters of periodontal office visits are made by women, even though women tend to take better care of their teeth than men. Female hormones affect the gums, and women are particularly susceptible to periodontal problems. Hormone-influenced gingivitis appears in some adolescents, in some pregnant women, and is occasionally a side effect of birth control medication.

Before Menstruation. Gingivitis may flare up in some women a few days before they menstruate, when progesterone levels are high. Gum inflammation may also occur during ovulation. Progesterone dilates blood vessels causing inflammation, and blocks the repair of collagen, the structural protein that supports the gums.

Pregnancy. Hormonal changes during pregnancy can aggravate existing gingivitis, which typically worsens around the second month and reaches a peak in the eighth month. Pregnancy does not cause gum disease, and simple preventive oral hygiene can help maintain healthy gums. Any pregnancy-related gingivitis usually resolves within a few months of delivery. Because periodontal disease can increase the risk for low-weight infants and cause other complications, it is important for pregnant women to see a dentist.

Oral Contraceptives. Some studies report that oral contraceptives containing the synthetic progesterone desogestrel (but not dienogest, another common progesterone) increase the risk for periodontal disease.

Menopause. Estrogen deficiency after menopause reduces bone mineral density, which can lead to bone loss. Bone loss is associated with both periodontal disease and osteoporosis. Bone loss in the alveolar bone (which holds the tooth in place) may be a major predictor of tooth loss in postmenopausal women. Periodontal disease is the main cause of alveolar bone loss. During menopause, some women may also develop a rare condition called menopausal gingivostomatitis, in which the gums are dry, shiny, and bleed easily. Women may also experience abnormal tastes and sensations (such as salty, spicy, acidic, and burning) in the mouth.

Family Factors

Periodontal disease often occurs in members of the same family. Genetics, intimacy, hygiene, or a mixture of factors may be responsible. Studies have found that children of parents with periodontitis are 12 times more likely to have the bacteria thought to be responsible for causing plaque and, eventually, periodontal disease.

Genetic Factors. Genetic factors may play the critical role in half the cases of periodontal disease. Up to 30% of the population may have some genetic susceptibility to periodontal disease.

Intimacy. Intimate partners and spouses of people with periodontal disease may also be at risk. Researchers have found that the bacteria P. gingivalis may be contagious after exposure to an infected person over a long period of time. There is no risk from short exposure, such as after a fast kiss or when sharing an eating utensil.

Smoking and Nicotine

Smoking is the single major preventable risk factor for periodontal disease. The habit can cause bone loss and gum recession even in the absence of periodontal disease. A number of studies indicate that smoking and nicotine increase inflammation by reducing oxygen in gum tissue and triggering an over-production of immune factors called cytokines (specifically ones called interleukins). In excess, cytokines are harmful to cells and tissue.

Furthermore, when nicotine combines with oral bacteria, such as P. gingivalis, the effect produces even greater levels of cytokines and eventually leads to periodontal connective tissue breakdown. Smokers may be more than 10 times more likely than nonsmokers to harbor the bacteria that cause periodontal disease and are also more likely to have advanced periodontal disease.

The risk of periodontal disease increases with the number of cigarettes smoked per day. Smoking cigars and pipes carries the same risks as smoking cigarettes. Exposure to secondhand smoke may also be associated with an increased risk for developing periodontal disease, according to one study. Fortunately, when smokers quit, their periodontal health gradually recovers to a state comparable to that of nonsmokers.

Some research also indicates that regular cannabis (marijuana) smoking also increases the risk of periodontal disease.

Diseases Associated with Periodontal Disease

Diabetes. Much evidence exists on the link between type 1 and 2 diabetes and periodontal disease. Diabetes causes changes in blood vessels, and high levels of specific inflammatory chemicals such as interleukins, that significantly increase the chances of periodontal disease. High levels of triglycerides (which are common in type 2 diabetes) also appear to impair periodontal health. Obesity, common in people with type 2 diabetes, may also predispose a person to gum disease. Controlling both type 1 and 2 diabetes may help reduce periodontal problems. For children with diabetes, good oral hygiene should begin at a young age.

Osteoporosis and Osteonecrosis. Osteoporosis (loss of bone density) has been associated with periodontal disease in postmenopausal women.

There have been a few reports of osteonecrosis (bone decay) of the jaw in patients who take oral bisphosphonate drugs such as alendronate (Fosamax). However, almost all cases of osteonecrosis of the jaw associated with bisphosphonate drugs occur during or after the use of intravenous bisphosphonates, usually given as part of treatment for bone cancer or other cancers that have spread to the bone. Symptoms of osteonecrosis of the jaw include loose teeth, exposed jawbone, pain or swelling in the jaw, gum infections, and poor healing of the gums.

 

 

 

 

 

 

 

 

Osteoporosis is a condition marked by progressive loss of bone density, thinning of bone tissue, and increased risk of fractures. Osteoporosis may result from disease, dietary or hormonal deficiency, or advanced age. Regular exercise and vitamin and mineral supplements can reduce and may even reverse loss of bone density.

As a precaution, the American Dental Association (ADA) recommends that patients who are prescribed or are to receive bisphosphonate drugs get a thorough dental exam before beginning drug therapy, or as soon as possible after beginning therapy. The ADA also recommends that patients who take oral bisphosphonate drugs should discuss with their dentists any potential risks from dental procedures (such as extractions and implants) that involve the jawbone. In any case, be sure to inform your dentist if you are taking a bisphosphonate drug. Your dentist or oral surgeon may need to take special precautions when performing dental surgery.

Herpes-Related Gingivitis. Herpes virus is a common cause of gingivitis in children and has become increasingly common in adults. It typically starts out with a purplish color and "boggy" sensation in the gums. Multiple blisters may form across the mucus membranes in the mouth and gums, followed by ulcers. They usually resolve in 7 - 14 days.

 

 

 

 

 

HIV-Associated Gingivitis. HIV-associated gingivitis has been reported in 15 - 50% of patients with HIV or AIDS. HIV-positive individuals harbor larger numbers of periodontal bacteria (candida albicans, P. gingivalis, black-pigmented anaerobic rods, and A. actinomycetemcomitans) than people without HIV. Severe pain is characteristic, along with odor, spontaneous bleeding, ulcers, and swollen, bright red gums. The inflammation never recedes, but halitosis and acute episodes can be managed by conventional cleaning treatments. Its severest form, known as necrotizing stomatitis, can be diagnostic for AIDS. In addition to bleeding, the gums in the front of the mouth are a yellowish-gray color, and bone thrusts out.

Autoimmune Diseases. Autoimmune conditions (Crohn's disease, multiple sclerosis, rheumatoid arthritis, lupus erythematosus, CREST syndrome) have been associated with a higher incidence of periodontal disease. Some research suggests that periodontal disease may even play some causal role. Still, more research is needed to determine a definitive association between these diseases.

Other Diseases. People with tuberculosis, syphilis, Wegener's granulomatosis, amyloidosis, and many genetic disorders are also at higher risk for periodontitis.

Vitamin C Deficiencies

Vitamin C helps the body repair and maintain connective tissue, and its antioxidant effects are important in the presence of tissue-destroying oxidants in periodontal disease. Research indicates that vitamin C deficiency contributes to periodontal disease. Vitamin C levels are especially depleted in smokers. Eating citrus fruits high in vitamin C (such as grapefruit) may be helpful for patients with periodontitis.

 

Ethnic, Socioeconomic, and Geographic Factors

Dental disease is most likely to affect the poor. Children and the elderly suffer the worst oral care, and ethnic minorities follow. In the United States, the lack of access to dental insurance is a contributing factor.

Drug-Induced Gingivitis

Gingival overgrowth can be a side effect of nearly 20 different drugs, most commonly phenytoin (Dilantin), cyclosporine (Sandimmune), and a short-acting form of the calcium channel blocker nifedipine (Procardia).

Other Causes of Gum Inflammation

Several other conditions can also cause gum inflammation, and some have been associated with periodontal disease. They include:

Image of a canker sore.

Complications

The ultimate outcome of uncontrolled periodontal disease is tooth loss. As the destructive factors cause the breakdown of bone and connective tissue, teeth lose their anchor.

Bad Breath

A much less severe but nevertheless distressing problem caused by periodontal disease is bad breath, although coatings on the tongue may contribute more to bad breath than periodontal disease.

Heart Disease and Stroke

Studies have reported that people who have heart disease have a 1.5 - 4 times increased risk for periodontal disease. (The risk is highest for patients with extensive gum disease, bleeding from every tooth.) Acute coronary syndrome, high blood pressure (hypertension), and high cholesterol have also been associated with periodontal disease.

Periodontal disease has also been linked to stroke and coronary artery disease (CAD). The more severe the periodontitis, the greater the risk for heart problems. However, it is still not clear whether periodontal disease is a risk factor for stroke or a marker that reflects various risk factors common to both conditions.

 

 

 

 

 

 

 

 

A stroke is caused by a loss of blood circulation to areas of the brain. The blockage usually occurs when a clot or piece of atherosclerotic plaque breaks away from another area of the body and lodges within the blood vessels of the brain.

An inflammatory response may be the common element. This is an over-reaction of the immune system that causes injury to tissues in the body. Patients with heart conditions and periodontal disease may have elevated levels of C-reactive protein (CRP), which indicates inflammation is present. Some research indicates that this inflammatory response can also cause injury in the arteries supplying blood to the heart.

Other evidence suggests that the periodontal disease bacteria themselves -- particularly P. gingivalis, T. denticola, T. forsythia, and streptococci species -- may be associated with thicker carotid arteries (a predictor of heart attack and stroke), regardless of C-reactive protein levels. It is still not clear if periodontal disease actually causes heart disease.

It is also not clear if treating gum disease can reduce the risks of heart disease and improve health outcomes for patients with periodontal disease and vascular heart problems. Studies have been mixed, but research is ongoing.

Effect on Diabetes

 

 

Diabetes is not only a risk factor for periodontal disease -- periodontal disease itself can worsen diabetes and make it more difficult to control blood sugar.

Effect on Respiratory Disease

Bacteria that reproduce in the mouth can also be carried into the airways in the throat and lungs, increasing the risks for respiratory diseases and worsening chronic lung conditions, such as emphysema.


See an image of emphysema.

Effect on Pregnancy

 

Many studies strongly indicate that bacterial infections that cause moderate-to-severe periodontal disease in pregnant women can increase the risk for premature delivery and low birth weight infants. The more severe the infection, the greater the risk to the baby. Research indicates that bacteria from gum disease and tooth decay may trigger the same factors in the immune system, which can then cause premature dilation and contractions.

 

 

 

 

Women should have a periodontal examination before becoming pregnant or as soon as possible thereafter. Because women with diabetes are at higher risk for periodontal disease, it is especially important that they see a dentist early in pregnancy. Doctors are still not sure if treating periodontal disease can improve birth outcomes. In any case, periodontal treatment is safe for pregnant women.

 

Prevention

Healthy habits and good oral hygiene are critical in preventing gum disease. Regular and effective tooth brushing and mouth washing, however, are effective only above and slightly below the gum line. Once periodontal disease develops, more intensive treatments are needed.

Dietary Changes

It is important to reduce both the quantity and, in particular, the frequency of sugar intake. Avoid snacks and drinks with sugar (other than natural sugars found in fruits and vegetables). Eat sugar-containing foods with meals, ideally followed by brushing. Since fruit juices can also cause tooth erosion in children, parents should emphasize milk and water.

Quitting Smoking

Smoking plays a significant role in many cases of chronic periodontal disease. For smokers, quitting is one of the most important steps toward regaining periodontal health.

Fluoride Treatments

Fluoride treatment in children has helped to account for the decline in periodontal disease in adults. Because fluoride prevents decay, back molars, which keep the teeth in place, are spared, and are thus less vulnerable to bacteria. Even before teeth first erupt, babies' gums should be wiped clean with a bit of gauze bearing a dab of fluoride toothpaste. Supplementation with fluoride tablets or drops may be recommended for children 6 months or older who drink unfluoridated water or who are at risk for dental problems. A prescription from the child's pediatrician or dentist is required.

Some dentists recommend a fluoride gel for adult patients who are still at risk for tooth decay or sensitivity, but extra fluoride is generally not necessary for adults who use fluoride toothpaste.

Dental Examinations

Periodontitis is a silent disease. People with the disease rarely experience pain and may not be aware of the problem. A periodontal examination by a general dentist once or twice a year should reveal any incipient or progressive problems. A full mouth series of x-rays is advised every 2 - 3 years. This will alert the dentist to early bone loss and other disorders of the oral cavity.

Dentists now often perform Periodontal Screening and Recording (PSR) using a probe to measure gum pockets. Previously performed only by periodontists, this procedure is now encouraged as part of a regular dental examination. The dentist will identify any areas where deep pocketing has occurred, where the health of the gingiva appears compromised, and where there is undue mobility of teeth. It is the general dentist's responsibility to identify periodontal disease and inform the patient. If the condition is severe, the dentist may want to refer the patient to a periodontist.

Daily Dental Care

Correct tooth brushing, mouth cleansing, and flossing should be everyone's defense against periodontal disease. (However, good hygiene is probably not enough to prevent periodontal disease in many people. Regular visits to a dentist are extremely important, especially for high-risk individuals.)

Brushing Guidelines. The following are some recommendations for brushing:

If brushing after each meal is not possible, rinsing the mouth with water after eating can reduce bacteria by 30%.

Toothbrushes. A vast assortment of brushes of varying sizes and shapes are available, and each manufacturer makes its claim for the benefits of a particular brush. Look for the American Dental Association (ADA) seal on both electric and regular brushes.

In spite of the wide variety of nonelectric toothbrushes, both in shape and bristle design, a study of eight brands found no significant differences in effectiveness among them.

Electric toothbrushes, particularly those with a stationary grip and revolving tufts of bristles, can be advantageous for some people with physical disabilities. Electric toothbrushes with heads that move back and forth up to thousands of times a minute remove significantly more plaque than ordinary brushes. Even more high-tech brushes are now available that use sound waves to remove plaque.

In general, studies have reported no differences between electric and manual toothbrushes in their ability to remove plaque. However, if a regular toothbrush works, it isn't necessary to buy an expensive electric one.

For individuals with average dexterity, a four- or five-rowed, soft, nylon-bristled toothbrush is sufficient. The most important factor in buying any toothbrush, electric or manual, is to choose one with a soft head. Soft bristles get into crevices easier and do not irritate the gums, thereby reducing the risk of exposing teeth below the gum line compared to hard brushes.

Toothbrushes should be replaced every 1 - 3 months. Not only do they become breeding grounds for bacteria, but the worn bristles are less effective at removing plaque.

Toothpaste. The objective of a good toothpaste is to reduce the development of plaque and eliminate periodontal-causing microorganisms without destroying the organisms that are important for a healthy mouth. All brands should show ADA approval. Even a good toothpaste, however, cannot be delivered past 3 mm below the gum line, where periodontitis develops.

Toothpastes are a combination of abrasives, binders, colors, detergents, flavors, fluoride, humectants, preservatives, and artificial sweeteners. Avoid highly abrasive toothpastes, especially for individuals whose gums have receded.

Ingredients contained in toothpastes may include:

Mouthwashes. The American Dental Association recommends (in addition to daily brushing and flossing) antimicrobial mouthwash to help prevent and reduce plaque and gingivitis, and fluoride mouthwashes to help provide additional protection against tooth decay.

Flossing. The use of dental floss, either waxed or unwaxed, is critical in cleaning between the teeth where the toothbrush bristles cannot reach. In spite of this, nearly two-thirds of people do not floss.

To floss correctly, the following steps may be helpful:

Here are some tips in choosing the right floss or flossing device:

Producing Saliva and Drinking Water. Saliva is important for diluting the toxins created by plaque. Drinking at least 7 glasses of water a day helps reduce inflammation in the mouth by producing more saliva. Increasing water intake is particularly important as one ages, when less saliva is produced.

Diagnosis

The dental practitioner typically performs a number of procedures to determine a diagnosis of periodontal disease.

Medical History

The dentist will first take a medical history to reveal any past or present periodontal problems, any underlying diseases that might be contributing to the problem, and any medications the patient is taking. After noting the general state of oral hygiene, the dentist may ask about the quality of home dental care.

Physical Examination

Inspection of the Gum Area. The dentist inspects the color and shape of gingival tissue on the cheek (buccal) side and the tongue (lingual) side of every tooth and compares these qualities to the healthy ideal. Redness, puffiness, and bleeding upon probing indicate inflammation. If the gum formation between teeth is blunt and not pointed, acute necrotizing periodontal disease may be indicated.

Periodontal Screening and Recording (PSR). PSR is a painless procedure used to measure and determine the severity of periodontal disease:

These measurements help determine the condition of the connective tissue and amount of gingival overgrowth or recession.

Testing Tooth Movement. Tooth mobility is determined by pushing each tooth between two instrument handles and observing any movement. Mobility is a strong indicator of bone support loss.

X-rays. X-rays are taken to show any loss of bone structure supporting the teeth. Eighteen x-rays make up the full mouth series necessary for diagnosis.

Treatment

Studies support the effectiveness of active treatment combined with a strict maintenance program for patients with periodontal disease. In one study, for example, people with periodontal disease who were inconsistent in caring for their gums after treatment had nearly six times the risk for tooth loss as those who were very vigilant.

Some dentists have reported a success rate of 85% when professional treatment and good home maintenance are combined. Treatment helps nonsmokers more than smokers, particularly when pockets are deep and persistent. Some studies suggest that periodontal treatment in people with type 2 diabetes helps improve blood sugar levels. Whether treatment will help reduce other health risks, including heart attack and stroke, is unknown.

Treatment Goals. Once periodontal disease has been identified, the goals of treatment are:

Treatment Phases. To achieve these goals, there are various approaches:

After the active treatment is completed and the mouth is in a relative state of health, the patient should have regular cleanings lasting 45 minutes to 1 hour, about every 3 months. These may be done by the dental hygienist, the periodontist, or the general dentist. The patient may alternate between them. Home care, of course, must be continued.

Antibiotics Before Treatment. In cases where the individual has a mitral valve prolapse or history of rheumatic heart disease, pretreatment with an appropriate antibiotic is required before any dental work, including cleaning. This is necessary to prevent the possibility of bacterial endocarditis, which can be life threatening.

Deep Cleaning: Scaling and Root Planing

Scaling, polishing, and sometimes curettage are used to manage periodontal disease. They are usually accomplished in a series of three to four visits spaced about a week apart. (Patients might ask their dentist about the gas nitrous oxide, which is helpful for many patients and may reduce the visits to a single one.) The dental hygienist or practitioner generally uses both ultrasonic and manual instruments to remove calculus.

After the cleaning procedure, the dentist will check the pocket depths around the teeth after the cleaning process has been completed. Further treatment needs are determined by the results of these initial sessions:

Finally, the dental hygienist or practitioner should offer thorough instructions on home care to insure the removal of bacteria on a daily basis. This includes proper use of the toothbrush, paste, mouth rinses, floss, floss threaders, and proxabrushes. Home care can effectively eliminate the plaque above the gums and down to 2 mm below the gums.

Gingival Curettage

Gingival curettage removes the soft tissue lining of the periodontal pockets in order to completely eliminate bacteria and diseased tissue. It may be used along with scaling and root planing, but achieves a deeper and more complete cleaning. Evidence indicates, however, that it does not contribute any additional benefits beyond simple scaling and planing.

Surgery (Open Flap Curettage)

Surgery allows access for deep cleaning of the root surface, removal of diseased tissue, and repositioning and shaping of the bones, gum, and tissues supporting the teeth. Surgical procedures vary depending on the individual diagnosis and needs of the patient. The basic procedure is known as open flap curettage. It involves:

There is some debate about whether this procedure is any more effective in preventing disease progression than non-surgical therapies, such as low-dose doxycycline, short-term antibiotics, or antibiotic gels. Some studies have reported that although surgical treatment reduced pocket depth more than non-surgical therapies for at least a year after the procedure, benefits from surgery do not persist beyond 5 years, except in very deep pockets.

Postsurgery Pain and Discomfort. Post-surgery discomfort is usually managed easily with over-the-counter medications such as ibuprofen. If discomfort is severe, stronger analgesics may be prescribed. Some patients experience sensitivity to hot or cold temperatures from exposed roots. These problems can be managed with topical fluoride treatments or, in severe cases, with dental restoration.

Techniques and Materials for Restoring Gum Tissue and Bone

Guided Tissue Regeneration. A more advanced technique, called guided tissue regeneration, is used to stimulate bone and gum tissue growth:

Bone Grafting. In some cases of severe bone loss, the surgeon may attempt to encourage regrowth and restoration of bone tissue that has been lost through the disease process. This involves bone grafting:

Enamel Matrix Protein Derivative. Amelogenin is a derivative of a major protein in the structure (the matrix) of enamel that helps stimulate gum tissue growth. A gel containing amelogenin (Emdogain) is applied during surgery and forms a coat over the roots of the teeth. The gel itself dissolves after 2 days, leaving the active substance behind. Studies report that it is safe and may significantly reduce the effects of periodontal disease.

Cosmetic and Gum Grafting Treatments

Gum grafting techniques can also be very useful for improving the looks of the gum as well as adding support to the teeth. During this procedure, the periodontist takes gum tissue from the palate or another donor source to cover the exposed root in order to even the gum line and reduce sensitivity. Other procedures are available to improve the look of the gums and teeth. The gum line can be sculpted to improve uneven or excess gums and to cover exposed roots as gums recede.

Implants

Periodontists report that they are achieving great success with tooth implants in patients who have lost teeth due to periodontal disease. The average cost for a single implant is high, however, and one implant requires 5 - 7 months for completion.

Medications

Antibiotics are often used in combination with surgery, curettage, or alone to eliminate or prevent disease-causing bacteria after periodontal procedures. They are being investigated in oral forms as well as in topical forms that are applied directly to the gum. Increasingly, dental professionals are finding that local application of antibiotics is more effective than periodontal surgery alone. They may even prove to be an alternative to surgery.

Oral Antibiotics at Standard Doses

Antibiotics given orally and at standard doses have some limited applications for periodontal disease. They are typically given for an acute infection. Long-term use of antibiotics is advised for the control of juvenile periodontitis, refractory periodontitis, rapidly progressing periodontitis, and prepubertal periodontitis. (Long-term use of oral antibiotics is generally not advised due to the risks of bacterial resistance.) Specific antibiotics used in periodontal disease include:

Direct Delivery of Antibiotics to the Gums

Topical application of antibiotics to the gum surface does not affect the entire body like oral antibiotics do, and they are preferred whenever possible. Studies suggest that, in combination with scaling and planing, any of these approaches are very effective for periodontal health.

Low-Dose and Chemically Modified Tetracyclines

Subantimicrobial Dose Doxycycline (Periostat). Subantimicrobial dose doxycycline (SDD) is a term used for a treatment that uses very low doses (20 mg) of doxycycline (Periostat). Although doxycycline is a tetracycline antibiotic, the doses used are too low to affect bacteria. However, at these dose levels, the drug blocks matrix metalloproteinases (MMPs) -- enzymes that destroy the connective tissues holding the teeth. Periostat is taken twice a day for months.

There is some concern that such long-term use may pose a risk for the development of antibiotic-resistant bacteria or other, still unknown, adverse effects. The doses used in this treatment, however, are too low to have any effect on bacteria, so this risk may be very low. In fact, several 12-month studies report significant improvements in tooth attachment and pocket depth with no increased incidence of side effects. [Taking a common nonsteroidal anti-inflammatory drug, such as aspirin or ibuprofen (Advil) along with doxycycline, may enhance the effectiveness of this treatment.]

Chemically Modified Tetracyclines. Other tetracyclines are being developed that inhibit MMPs but have no antibiotic properties, which would, theoretically, avoid possible long-term problems with antibiotic resistance.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs are drugs that block factors that cause inflammation and pain.

These drugs are used not only for relieving pain in periodontal disease but also for slowing the disease process. NSAIDs block inflammatory enzymes triggered by cytokines, which are important immune factors in periodontal disease. A number of NSAIDs are being investigated for their benefits in reducing gingivitis and slowing progression of periodontal disease. Investigators are also studying rinses, creams, and other topical forms of NSAIDs. Long-term use of NSAIDs can cause stomach problems, such as ulcers and bleeding, and possible heart problems.

   

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Dr. Javier Saldívar Villarreal
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