Periodontal Disease

Introduction

What should I know about Periodontal Disease?

Periodontal disease is the term that is used to describe all of the diseases that involve the supporting structures of the teeth such as the gums and bones. In adults, chronic destructive periodontal disease becomes responsible for more loss of teeth than cavities, particularly in the aged. (1)

The most common form of periodontal disease begins as an inflammation of the gingiva and is known as gingivitis. It is generally painless, however gums may bleed upon brushing. As the disease spreads, it deepens and actually involves the periodontal ligament and alveolar bone. When this happens the ligament that attaches the tooth to the bone is lost. After that the soft tissue separates from the tooth surface causing a pocket with bleeding upon probing and chewing. Occasionally, an acute inflammation occurs, with the production of pus and the formation of a periodontal abscess. Ultimately, tooth extraction may become necessary if extreme bone loss, tooth mobility, and recurrent abscesses occur. Periodontal infections usually localize in oral soft tissue and very seldom spread into deeper structures of the face and neck.

Gingivitis and periodontitis are diseases associated with accumulation of bacterial plaque. This plaque may become mineralized and harden. We all know that this can be prevented by appropriate oral hygiene, including tooth brushing, flossing, and use of antibacterial mouth rinses. Acute and chronic inflammation of the gingiva can be caused by irritation and also by the invasion of bacteria.

There are several factors that lead to periodontal disease. The two major predisposing factors are poor oral hygiene and increasing age. (2) Other factors include hormonal effects, with a worsening of the disease activity during puberty, menstruation, and pregnancy. (3) , (4) Diabetes mellitus causes an increased incidence, particularly in juvenile diabetic patients. Finally, various genetic disorders are associated with an increased incidence of periodontal disease. (5)

It has been known for two decades that brushing and flossing can prevent the development and progression of periodontal disease by removing bacterial plaque deposits. Mechanical interdental cleaning (e.g. flossing) and tooth brushing appear to be more effective than tooth brushing alone or antimicrobial mouth rinses in reducing gingivitis. (6) Professional care can also delay progression of periodontal disease because the dentist or hygienist can remove plaque and calculus from the areas that are difficult to reach. Professional care alone, however, is inadequate to prevent periodontal disease. (7) Thus we all need to take responsibility for our own oral health and develop some good preventive habits.

Statistic

World Health Organization, 2005.

  • Periodontal disease affects 10%-15% in adult populations worldwide.

The Centers for Disease Control, National Diabetes Fact Sheet, 1998.

    Periodontal disease occurred in 30% of people with diabetes Type 1 over 19 years old.

Signs and Symptoms

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In periodontitis, the destructive process progresses slowly and so there is not usually any real discomfort. (8) Associated feelings may include a variety of symptoms which relate to the infection.

In cases of gingivitis, often the only symptom may be bleeding with tooth brushing or probing. The gingiva may appear red or bluish red. In acute necrotizing ulcerative gingivitis, symptoms include acute or sudden inflammation of the gingiva, with pain, necrosis, tissue loss, and bleeding. Occasionally this is also accompanied by a fever.

General

  • Pressure or itchy feeling in gums and between teeth
  • Bad taste in mouth
  • Hot and cold sensitivity
  • Vague pains in jaws
  • Gum line is inflamed and bleeds easily
  • Pus may ooze if pressure is applied to the gums
  • Eventual loosening and loss of teeth

Treatment Options

Conventional

The usual treatment is aimed at the cause of periodontal disease. A good dental cleaning to remove plaque and to clean the infected areas is usually a requirement. Sometimes antibiotics are recommended for infection. General maintenance requires attention to gum and tooth care as recommended by the dentist in charge. Often the use of an antibacterial mouthwash will help as well.

Nutritional Suplementation


Coenzyme Q10 (CO-Q10)

Several studies have been published reporting that therapy with coenzyme Q10 can provide remarkable improvements in periodontal disease. In one of the first studies of its kind, 18 patients with periodontal disease and measurable pockets were treated on a double-blind basis with coenzyme Q10 and or matching placebo. The patients treated with coenzyme Q10 recorded substantial improvements in pocket-depth, periodontal health, calculus, and plaque scores compared to the placebo patients. (9)

In another study, 29 patients with verified periodontal disease were examined for the specific activity of the succinate dehydrogenase-coenzyme Q10 reductase in cells of their gingival tissue. All 29 patients showed a deficiency, which ranged from 20 to 63%. For corresponding blood samples, 24 of 28 patients (86%) were found to have deficiencies ranging from 20 to 66%. This research indicates that patients with periodontal disease frequently have significant gingival and leucocytic deficiencies of coenzyme Q10. The leucocytic deficiency indicates a systemic nutritional imbalance, which is not likely caused by neglected oral hygiene. A gingival deficiency could predispose these tissues to periodontitis and this disease could even worsen the deficiency. (10)


Folic Acid

Folic acid mouthwash: One of the first studies to evaluate whether or not folic acid could affect oral hygiene was conducted on women with gingivitis in pregnancy. In a double-blind study, 30 women were randomly divided into three groups. Group A received placebo mouthwash and tablets; Group B received placebo mouthwash and 5 mg folic acid tablets; Group C received folic acid mouthwash and placebo tablets. Supplementation lasted for two 14-day periods during the 4th and 8th month of pregnancy. Each woman took one tablet daily and rinsed twice daily for 1 min with the mouthwash. During the 8th month, the women in group C (folic acid mouthwash) exhibited a highly significant improvement in gingival index scores. The results of this study indicate that direct topical application of folic acid in the form of a mouthwash produced highly significant improvement in gingival health in pregnancy although there was no improvement in the plaque index. On the other hand, oral, systemic folic acid supplementation did not produce any improvements. (11)

Another study was designed to determine the effects of folate mouthwash on established gingivitis in non-pregnant adults. In this double-blind study, 60 subjects with visible gingival inflammation around greater than 6 teeth, were randomly assigned to control or experimental groups. Subjects used 5 ml of mouthwash twice daily for 4 weeks, rinsing for 1 minute. The test mouthwash contained 5 mg folic acid per 5 ml. All patients had a complete oral exam at the outset, and then the trial ran for a period of 4 weeks. At the end of the 4 weeks, the group using the folic acid mouthwash exhibited a significant decrease in the number of color change sites (from 70 to 56%) and in bleeding sites (from 48 to 29%) compared with control group (color: from 67 to 66%; bleeding: from 37 to 39%). (12)


Vitamin C

Vitamin C deficiency has been shown to play a role in the development of gingivitis. When humans are placed on ascorbic acid deficient diets there is increased edema, redness, and swelling of the gingiva, which are probably due to deficient collagen production by gingival blood vessels. (13)

Herbal Suplementation


Tea Tree Oil

Tea tree oil has historically been used in many conditions including the treatment of acne, aphthous stomatitis, tinea pedis, boils, burns, carbuncles, corns, gingivitis, herpes, empyema, impetigo, infections of the nail bed, insect bites, lice, mouth ulcers, pharyngitis, psoriasis, root canal treatment, ringworm, sinus infections, skin and vaginal infections, thrush, and tonsillitis - a literal panacea for topical infectious conditions. Also, as early as 1930, the antiseptic properties of the plant were recognized by the Australian dental profession, and when used in a water-pick device tea tree oil and water may be an effective agent in the management of gum disease. (14)

The therapeutic use of tea tree oil is largely based on its antiseptic and antifungal properties. This claim is supported by its efficacy against a wide range of organisms including Candida albicans, Propionibacterium acnes, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermis, Streptococcus pyrogenes, Trichomonas vaginalis, and Trichomonas mentagrophytes. (15) , (16)


Green Tea

Green tea reportedly has antioxidant properties (17) and the ability to protect against oxidative damage of red blood cells. (18) Antioxidants protect cells and tissues against oxidative damage and injury. (19) It is important to note that the addition of milk to any tea may significantly lower the antioxidant potential. (20)

References

  1. Greenspan JS. Oral manifestations of disease, In: Fauci AS, Braunwald E, Isselbacher KJ et al eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:185-186.
  2. Orofacial odontogenic Infections. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 5th ed. Philadelphia: Churchill Livingstone; 2000:690-698.
  3. Salvi GE, Lawrence HP, Offenbacher S, et al. Influence of risk factors in the pathogenesis of periodontitis. Peiodontal 2000. 1997;14:173.
  4. View Abstract: Genco RJ. Current view of risk factors for periodontal diseases. J Periodontol. 1996;67(suppl 10):1041.
  5. Hart TC, Korman KS. Genetic factors in the pathogenesis of periodontitis. Periodontol 2000. 1997;14:202.
  6. View Abstract: Caton JG, Blieden TM, Lowenguth RA, et al. Comparison between mechanical cleaning and an antimicrobial rinse for the treatment and prevention of interdental gingivitis. J Clin Periodontol. 1993;20:172-178.
  7. U.S. Preventive Services Task Force, Guidelines from Guide to Clinical Preventive Services, (second Edition) 1996, Counseling to Prevent Dental and Periodontal Diseases. Williams & Wilkins: 1996.
  8. U.S. Preventive Services Task Force, Guidelines from Guide to Clinical Preventive Services, (second Edition) 1996, Counseling to Prevent Dental and Periodontal Diseases. Williams & Wilkins: 1996.
  9. View Abstract: Wilkinson EG, et al. Bioenergetics in clinical medicine. VI. adjunctive treatment of periodontal disease with coenzyme Q10. Res Commun Chem Pathol Pharmacol. Aug1976;14(4):715-9.
  10. View Abstract: Hansen IL, et al. Bioenergetics in clinical medicine. IX. Gingival and leucocytic deficiencies of coenzyme Q10 in patients with periodontal disease. Res Commun Chem Pathol Pharmacol. Aug1976;14(4):729-38.
  11. View Abstract: Pack AR, Thompsen ME. Effects of topical and systemic folic acid supplementation on gingivitis in pregnancy. J Clin Periodontol. Oct1980;7(5):402-14.
  12. View Abstract: Pack AR. Folate mouthwash: effects on established gingivitis in periodontal patients. J Clin Periodontol. Oct1984;11(9):619-28.
  13. View Abstract: Nakamoto T, et al. The role of ascorbic acid deficiency in human gingivitis--a new hypothesis. J Theor Biol. May1984;108(2):163-71.
  14. Penfold AR, et al. Some notes on the Essential oil of M. alternifolia. Aust J Dent. 1930;417-418.
  15. View Abstract: Mann CM, et al. The outer membrane of pseudomonas aeruginosa NCTC 6749 contributes to its tolerance to the essential oil of melaleuca alternifolia. Lett Appl Microbiol. Apr2000;30(4):294-7.
  16. View Abstract: Carson CF, et al. Efficacy and safety of tea tree oil as a topical antimicrobial agent. J Hosp Infect. Nov1998;40(3):175-8.
  17. Cheng TO. Antioxidants in Chinese Green Tea. J Am Coll Cardiol. Apr1998;31(5):1214.
  18. View Abstract: Grinberg LN, et al. Protective Effects of Tea Polyphenols against Oxidative Damage to Red Blood Cells. Biochem Pharmacol. Nov1997;54(9):973-78.
  19. View Abstract: Halliwell B. How to Characterize an Antioxidant: An Update. Biochem Soc Symp. 1995;61:73-101.
  20. View Abstract: Hertog MG, et al. Antioxidant Flavonols and Ischemic Heart Disease in a Welsh Population of Men: The Caerphilly Study. Am J Clin Nutr. May1997;65(5):1489-94.