Articles

Periodontal Disease

Introduction

In adults, chronic destructive periodontal disease becomes responsible for more loss of teeth than caries, particularly in the aged. (1) Periodontal disease is the general term used to describe all diseases involving the supporting structures of the teeth. The most common form of periodontal disease begins as an inflammation of the marginal gingiva and is known as gingivitis. It is generally painless, however gums may bleed upon brushing. As the disease spreads, it involves the periodontal ligament and alveolar bone. As alveolar bone is resorbed, the periodontal ligament attachment between the tooth and bone is lost. 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, which may become mineralized (calculus). This accumulation may be prevented by appropriate oral hygiene, including tooth brushing, flossing, and use of antibacterial mouth rinses. Poorly fabricated or deteriorating restorations may contribute through overextended or inadequate margins. Acute and chronic inflammation of the gingiva is initiated by local irritation and microbial invasion.

The two major predisposing factors for periodontal diseases are poor oral hygiene and increasing age. (2) Other factors include hormonal effects, with exacerbation of 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) In particular, those with neutrophil defects (such as Chediak-Higashi syndrome, agranulocytosis, cyclic neutropenia, and Down syndrome) have a higher incidence of periodontal disease. (6)

Periodontitis is a group of disorders that are broken into classifications of adult periodontitis, localized juvenile periodontitis, acute necrotizing ulcerative gingivitis, (ANUG), and necrotizing ulcerative periodontitis. Adult periodontitis is most frequently associated with Porphoyromonas gingivalis, Prevotella intermedia, and other gram-negative organisms. Localized juvenile periodontitis is associated with Actinobacillus actinomycetemcomitans, Capnocytophaga, Eikenella corrodens, and other anaerobes. It is known to cause rapid, severe pocketing and bone loss. ANUG involves sudden inflammation of the gingivae with necrosis, tissue loss, pain, bleeding, and halitosis and is associated with P. intermedia and spirochetes. (7) There is usually associated fever, malaise, and regional lymphadenopathy. (8) ANUG and necrotizing ulcerative periodontitis are frequently seen in patients with HIV infection. Some of these cases may even progress to a gangrene like lesion of oral soft tissue and bone known as necrotizing stomatitis.

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. (9) Professional care can also delay progression of periodontal disease because the dentist or hygienist can remove plaque and calculus from subgingival areas generally not reached by the patient. Professional care alone, however, is inadequate to prevent periodontal disease. (10)

Certain drugs, notably the anticonvulsant, phenytoin and the calcium channel blocker, nifedipine, may cause a fibrous hyperplasia of the gingiva, which may cover teeth, interfere with eating, and be unsightly. A similar condition may also occur in patients with idiopathic familial gingival fibromatosis. Surgical management is used for both, however, a change in medication may be appropriate for the drug-induced form.

Statistic

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

[span class=alert]The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.[/span]

In periodontitis, the destructive process progresses insidiously. Unlike pulpal infection in which drainage is frequently obstructed, periodontal infections drain freely, and patients experience little or no discomfort. (11)

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. The patient may experience a fever and regional lymphadenopathy as well.

General

    Pressure or itchy feeling in gums and between teeth Bad taste in mouth Hot and cold sensitivity Vague pains in jaws Gingiva is inflamed and bleeds readily Pus may be expressed by digital pressure Eventual loosening of teeth and exfoliation

Treatment Options

Conventional

Therapy is directed at the causative microflora and consists of removal of plaque and calculus, debridement of the pocket lining and superficial infected cementum, and elimination of other contributing factors. (12)

General treatment to stop the progression of periodontal disease is a combination of patient attention to tooth and gum care, with daily brushing with fluoride containing tooth paste, flossing, use of antibacterial mouth rinses, and regular visits for professional cleaning, and replacement of defective restorations.

Treatment of ANUG includes local debridement and lavage with oxidizing agents. This usually brings relief of pain within 24 hours. Antibiotic therapy may also be indicated. (13)

Nutritional Supplementation


Coenzyme Q10 (CO-Q10)

Several studies have been published reporting that therapy with coenzyme Q10 can provide remarkable improvements in patients with 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. (14)

In another study, 29 patients with verified periodontal disease, as defined by patients having a bone score of 1.0-4.0 and a pocket depth of 2.5-5.2 mm, were examined for the specific activity of the succinate dehydrogenase-coenzyme Q10 reductase in mitochondria 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 augment the deficiency. (15)

The results of another study indicate that the topical application of coenzyme Q10 to gingival tissue is also therapeutically beneficial. Ten adult male patients with periodontitis participated and 30 periodontal pockets were selected. During the first 3 weeks, the patients did not receive any periodontal therapy except the topical application of CoQ10. After the first 3-week period, root planning and subgingival scaling were performed in all sites. CoQ10 was applied in 20 of the pockets once a week for a period of 6 weeks. Soybean oil was applied to the remaining 10 sites as a control.

In the first 3-week period, significant reductions in gingival crevicular fluid flow, probing depth and attachment loss were found only at CoQ10-treated sites. After mechanical subgingival debridement, significant decreases in the plaque index, gingival crevicular fluid flow, probing depth, and attachment loss were found both at the CoQ10-treated and control sites. However, significant improvements in the modified gingival index, bleeding on probing and peptidase activity derived from periodontopathic bacteria were observed only at CoQ10-treated sites. These results suggest that topical application of CoQ10 improves adult periodontitis not only as a sole treatment but also in combination with traditional nonsurgical periodontal therapy. (16)


Folic Acid

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 significantly 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. (17)

In a similar test, 30 women with gingival inflammation during pregnancy were treated for one 28-day period during the 32nd week of their pregnancy. The same protocol with groups A, B, and C was also used in this study. The outcome was also the same, with women in group C (folic acid mouthwash) exhibiting highly significant improvement in gingival index scores, but no significant changes in plaque index. (18)

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 min before expectorating. 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). (19) These results also indicate that folic acid mouthwash appears to have an influence on gingival health through local rather than systemic influence.


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. (20) In a similar study, 11 healthy, non-smoking men were placed on a controlled diet that contained less than 5 mg/day ascorbic acid. The diet was then supplemented with 60 mg/day ascorbic acid for 2 weeks, 0 mg/day ascorbic acid for 4 weeks, 600 mg/day ascorbic acid for 3 weeks and 0 mg/day ascorbic acid for 4 weeks. During times of depletion or supplementation, no changes in plaque build-up, mucosal pathologies or probing depths were noted. However, gingival inflammation fluctuated during these periods and was directly related to ascorbic acid status. The study suggests that periodontal disease, particularly crevicular bleeding may be influenced by ascorbic acid. (21)

Another study was designed to evaluate the possible effect of plasma ascorbic acid (AA) levels on the severity of periodontal disease. The periodontal condition of 75 subjects with a low plasma levels of AA (< or = 25 mumol/l) was compared with that of 75 control subjects (plasma level > or = 50 mumol/l). Dietary survey data revealed that individuals with low plasma AA consumed diets that provided approximately 53 mg of ascorbic acid daily while individuals with higher plasma AA levels consumed diets that provided about 77 mg of ascorbic acid daily. The results revealed that 5% of the subjects with low plasma AA levels and 18% of subjects with high AA levels had healthy periodontal tissues. The proportion of sites in which bleeding after probing and a probing pocket depth of 4 mm or over were observed was significantly higher in individuals with low plasma ascorbic acid levels. Sixty percent of those with low plasma ascorbic acid levels had pathological pockets of 4 mm or more compared to 37% of subjects with higher plasma ascorbic acid levels. (22)

Herbal Supplementation


Tea Tree Oil

During World War II, tea tree oil was issued worldwide to soldiers for use as a disinfectant and the Australian Army actually exempted leaf cutters from military service in order to maintain production of the tea tree oil. (23) Also during World War II, tea tree oil was routinely incorporated into machine "cutting" oils in Australian ammunition factories, where it was said to have reduced the number of infections resulting from abrasions on the hands of workers caused by metal filings. The production of tea tree oil in Australia was deemed an "essential" industry during WWII.

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. (24)

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. (25) , (26) The ability of tea tree oil to disrupt the permeability barrier of cell membrane structures and the accompanying loss of chemiosmotic control is the most likely source of its lethal action at minimum inhibitory levels. (27) Reports suggest that P. aeruginosa is less sensitive than other bacteria listed and may develop tolerance to the oil. (28)


Green Tea

Green tea has long been used in much of the world as a popular beverage and a respected medicinal agent. An early Chinese Materia Medica lists green tea as an agent to promote digestion, improve mental faculties, aid in dental hygiene, decrease flatulence, and regulate body temperature. The earliest known record of consumption is around 2700 B.C. Ceremonies, celebrations, relaxation time, and ordinary meals usually consist of tea in most parts of the world, except the United States, where coffee has become the most popular beverage.

Green tea is an antioxidant that is used in promoting cardiovascular health (29) , (30) reducing serum cholesterol levels in laboratory animals and humans. (31) , (32) Studies suggest that green tea contains dietary factors that help decrease the development of some infectious diseases and dental caries. (33) , (34) , (35) Green tea also has diuretic, stimulant, astringent, and antifungal properties. (36) Green tea has also been reported to enhance immunity. (37)

Green tea reportedly has antioxidant properties (38) and the ability to protect against oxidative damage of red blood cells. (39) Antioxidants protect cells and tissues against oxidative damage and injury. (40) Green tea’s antioxidant effects seem to be dependent upon the polyphenol (catechin) fraction. (41) , (42) It is important to note that the addition of milk to any tea may significantly lower the antioxidant potential. (43)

Acupuncture & Acupressure

Liu Zhong, et al. applied acupuncture on the following points: Li Dui (ST 45) on the stomach channel, Er Jian (LI 2) on the large intestine channel, and Tai Xi (KI 3) on the kidney channel. The needles used were No.28 of 1 cun (=1/3 cm) length and three-edged. After routine sterilization of the acupoints and the needles, 1ml of blood-letting from the Li Dui and Er Jian points was performed after pricking with the three-edged needle. The reinforcing needling method was used on the Tai Xi point afterwards. The needles were retained for 30 minutes. They were manipulated once every minute. Acupuncture was performed once every other day. Seven sessions constituted one course of treatment. The results showed that 63 cases (64.29%) were resolved, 29 cases (29.59%) improved, and 6 cases had no effect. (44)

Traditional Chinese Medicine

Periodontal Disease

Extensive information regarding the treatment of this health condition using Traditional Chinese Medicine is available through the link above.

Diet & Lifestyle

Reduce or eliminate sugar and refined carbohydrates

Floss regularly

Clinical Lab Assessment

Some of the following laboratory testing can provide information necessary for diagnosis and treatment. In addition, the tests listed may also give insight to functional metabolism and functional nutrient status in the body.

C-reactive protein (CRP Thyroid Profile)

An abnormal serum glycoprotein produced by the liver during acute inflammation, CRP has been used to detect or monitor inflammatory processes. CRP disappears rapidly when inflammation subsides; thus it is a reliable measure of current inflammatory process. Recent advances in technology, not yet in common use, provide a very high sensitivity in the measure of this important marker of inflammatory processes.

Calcium, Total

Nutritional calcium levels have been implicated in periodontal disease. (45) Monitoring may be useful.

References

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