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Periodontal Disease
 

Periodontal Disease Introduction

:periodontitis.gif Periodontal disease, or periodontitis, is an inflammation of the periodontium, which is made up of the periodontal ligament, the gingival (gum), cementum and the alveolar bone. [1] Periodontal disease is closely linked to gingivitis and can almost be considered the progression from gingivitis (inflammation of the gingiva, or gums). Gingivitis is most commonly caused by poor dental hygiene, which leads to the accumulation of plaque, or calculus. One unique factor of periodontal disease is the necessary presence of microorganisms, such as Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans. Both of which appear to be more important than plaque deposits.

Conditions or diseases that can predispose to periodontitis, other than poor oral hygiene, include [1];

  • Diabetes mellitus
  • Conditions with low numbers of a certain type of white blood cell called neutrophils (these cells help kill bacteria)
  • Crohn's disease (a type of inflammatory bowel disease)
  • Hypophosphatasia
  • Chediak-Higashi syndrome

Vitamin C deficiency can lead to the development of scurvy. Periodontal infections and gingival swelling are also characteristics of this nutritional deficiency. [2]

There are subtypes of periodontitis that are less common:

  • Localized juvenile periodontitis occurs in healthy adolescents and results in more rapid bone loss. This condition is likely due to a defect in a specific type of white blood cells that kills bacteria. [1]
  • HIV-associated periodontitis is very progressive and is characterized by pain, intense redness of the gum and spontaneous bleeding.
  • Prepubertal and rapidly progressive periodontitis are two other, less common types of the disease.

Periodontal Disease Symptoms


Patients with periodontitis generally present with gingivitis first (inflammation of the gingiva or gum).  Gingivitis is characterized by red, inflamed gums at the neck of the tooth. [3]  There is also noticeable swelling of the gum between the teeth, as well as bleeding with impacts such as brushing the teeth.  There is usually no pain.

However, when the condition progresses to periodontal disease after a course of years with gingivitis, the patient will experience more severe signs and symptoms. Pain is again not present unless there is an acute local infection, or food becomes impacted in the area. The condition can result in sensitivity to hot and cold substances, facial pain, and halitosis (foul breath). [4]

A visit to the dentist often reveals calculus deposits below the gum line. [1] The gum becomes detached from the a given tooth, and deep pockets form in the periodontium. These pockets are measured by depth using a probe. Plain film radiographs may reveal bone destruction as well. Pockets exceeding six millimeters, paralleled with bone loss demonstrated by x-ray, are diagnostic of periodontal disease. As the disease progresses, the patient can notice receding gum lines and loosening of the teeth. There may also be an evident exudate from the affected area.

Periodontal Disease Statistics

  • Most patients are diagnosed with periodontal disease after 35 years of age. [1]
  • The rates are; 15% at 10 years of age, 38% at 20 years of age, 46% at 35 years of age and 54% at age fifty. [5]
  • Males are more affected than females and the severity of disease is usually worse. [5]
  • Factors that are inversely related to periodontal disease include increasing level of education and income, and urban dwellers. [6]

Periodontal Disease Treatment

Treatment of periodontal disease requires specific dental procedures combined with systemic therapy, depending on concomitant disorders and the severity of the condition. In all patients, the roots of the affected teeth must be scaled and planed to remove deposits of calculus. [1] Patients generally return after 3 months. If pockets are less than three to four millimeters, then no other treatment is initiated. However, if the pockets exceed this level upon measurement, then the patient is prescribed antibiotic therapy. Further dental procedures can be performed i.e. eliminate deep pockets and recontour the alveolar bone, splint the loose teeth, and extractions if necessary; mostly in severe cases.

Patients will be instructed to floss daily, get regular professional dental cleanings, brush with a diluted hydrogen peroxide solution, and use an antiseptic mouth rinse. Research has shown that smoking can also play a significant role in this disease. A 10 year study revealed that smoking increases the frequency of diseased sites in the periodontium, and that subjects who quit smoking decreased the level of destruction of the alveolar bone. [7] Therefore, patients should be instructed in smoking cessation, if indicated.

Supplements helpful for Periodontal Disease

Vitamin C

The importance of vitamin C for periodontal health is documented by the effects in a nutritional deficiency syndrome of this vitamin, called scurvy. As mentioned above, scurvy can cause swelling of the gingiva and subsequent infections. If a patient has this condition, vitamin C therapy is indicated. Furthermore, vitamin C helps prevent and treat periodontitis by increasing gingival praline and hydroxyproline content, increases mucopolysaccharide synthesis, reduces subsequent bacterial invasion, and decreases gingival bleeding. [8]

Clinical research has shown that patients with low levels of vitamin C are predisposed to early stage gingivitis. [9] Periodontal disease in patients with the genetic disorder, Chediak-Higashi syndrome, has been effectively treated with vitamin C therapy. [10]

Folic acid

Folic acid is an important nutrient to consider for the treatment of periodontal disease. Numerous studies have shown that using folic acid in the form of either mouth rinse or pill has been effective in periodontitis treatments. [11-13] One study specifically showed that gingival inflammation was reduced when subjects used a folic acid mouth rinse.

Sanguinaria canadensis (Bloodroot)

Sanguinaria canadensisis an herb found in the Appalachian Mountains in the eastern United States. The root of this plant contains certain constituents that have medicinal activity. The primary active constituent in this herb is sanguinarine, and has shown effectiveness as a mouth rinse. [14]

In one study, adult patients with periodontal disease who received a toothpaste and mouth rinse containing Sangiunaria extract had significantly fewer bleeding sites at subsequent dental examinations. [15] Another study showed that Sanguinaria can actually inhibit the ability of bacteria to adhere, thus preventing plaque formation. [16]

Flavonoids

Flavonoids are compounds found in colored fruits and vegetables that assist with collagen stabilization. Flavonoids also synergize the effects of vitamin C, and could be taken to augment the effect of vitamin C noted in the section above. Specific effects of flavonoids in periodontal health include, decreasing membrane permeability, inhibition of mast cell degranulation, and the cross-linking of collagen fibers. These processes ultimately inhibit the destruction of collagen, a common characteristic of periodontitis. [17, 18] In addition, specific flavonoids have demonstrated in animal study to delay the growth of plaque and alveolar bone resorption. [19]

CoEnzyme Q10

This nutrient has demonstrated effectiveness for the treatment of periodontal disease in a placebo-controlled double blind study. Patients took either Coenzyme Q10 or placebo over a 3 week duration. [20] The patients taking CoQ10 showed improvements in pocket depth, purulent exudates, tooth mobility, gingival swelling, bleeding, redness, pain, and itching.

References

1. Merck Manual of Diagnosis. Merck Research Laboratories, Whitehouse Station, NY, 1999: 768-769.

2. Robbins et al. Pocket Guide to Robbins Pathologic Basis of Disease, 6th Ed. WB Saunders Company, Philadelphia, PA 1999;239.

3. Merck Manual of Diagnosis. Merck Research Laboratories, Whitehouse Station, NY, 1999: 766.

4. Handbook of Signs and Symptoms. Springhouse Corp, Springhouse, PA, 1998:282.

5. Murray M and Pizzorno J. Encyclopedia of Natural Medicine, 2nd Ed. Prima Publishing, Rocklin, CA 1998;722.

6. Carranza F. Glickman’s Clinical Periodontology. WB Saunders, Philadelphia, PA, 1984.

7. Bergstrom et al. A 10 year prospective study of tobacco smoking and periodontal health. J Periodont 2000;71(8);1338-1347.

8. Fantana M. Vitamin C (ascorbic acid): clinical applications for oral health-a literature review. Compend Contin Educ Dent 1994;15:916-929.

9. Leggott PJ et al. The effect of ascorbic acid depletion and supplementation on periodontal health. J Periodont 1986;57(8):480-485.

10. Stephens C and Snyderman R. Cyclic nucleotides regulate the morphologic alterations required for chemotxis in moncytes. J Immunol 1982;128:1192-1197.

11. Vogel RI et al. The effect of topical application of folic acid on gingival health. J Oral Med 1978;33(1):20-22.

12. Pack A and Thomson P. Effects of extended systemic and topical folate supplementation on gingivitis of pregnancy. J Clin Periodont 1982;9:275-280.

13. Pack A. Folate mouthwash: Effects on established gingivitis in periodontal patients. J Clin Periodont 1984;22:619-628.

14. Grossman E et al. A clinical comparison of antibacterial mouth rinses: effects of chlorhexidine, phenolics, and snaguinarine on

dental plaque and gingivitis. J Periodontal 1989;60:435-440.

15. Tenenbaum et al. Effectiveness of a Sanguinarine regime after scaling and root planning. J Periodont 1999;70(3):307-311.

16. Godowski KC. Antimicrobial action of sanguinarine. J Clin Dent 1989;1:96-101.

17. Rao C et al. Influence of bioflavonoids on the metabolism and cross linking of collagen. Ital J Biochem 1981;30:259-270.

18. Pearce F et al. Effect of quercetin and other flavonoids on antigen-induced histamine secretion from rat intestinal mast cells. J Alerg Clin Immunol 1984;73:819-823.

19. Gineste M et al. Influence of 3-methoxy 5,7,3’,4’-tetrahydroxyflava (ME) on experimental periodontitis in the golden hamster. J Biol Bucale 1984;12:259-265.

20. Wilkinson EG et al. Bioenergeitcs in clinical medicine. VI. Adjunctive treatment of periodontal disease with coenzyme Q10. Research Communications in Chemical Pathology and Pharmacology 1976 14(4);715-719.