Two processes are very important for periodontal disease: periodontal inflammation and periodontal degradation.
First, we will discuss the general inflammatory factors. Periodontal inflammations are then discussed that may or may not lead to or are associated with periodontal degradation.
Most periodontal diseases are caused by inflammation due to plaque. If diseases occur as a result of inflammation, we refer to periodontology as inflammatory tissue changes. These tissue changes are accompanied by the five general inflammatory symptoms:
- Rubor; redness of the tissues due to dilation of blood vessels in the inflammatory area;
- Tumor; swelling of the inflammatory area, the swelling is caused by the escape of moisture in the soft tissue (edema);
- Calor; elevated temperature of the ignition area;
- Dolor; pain caused inter alia by pressure from swollen tissues on the tips of sensory nerves (sensory nerves);
- Functio laesa; loss of function as a result of pain occurring during movement or reduced chewing function in the case of acute inflammation based on a dental element (see image below).
Initially the inflammation is limited to the gingiva, without causing irreparable damage. There is then gingivitis. With gingivitis the gums bleed easily after probing, the gums are swollen and have a red color. The connective tissue fibers are affected; this eliminates the orange effect of the buccal gingiva. The transition from fixed gingiva to alveolar mucosa is no longer clearly visible. The sulcus is inflamed, but the epithelial attachment remains in the same place. Gingivitis is a very slow process, but in general there are few pain complaints. The patient sometimes indicates that the gums bleed quickly (eg when brushing their teeth). Radiologically there are no abnormalities in the periodontium. Gingivitis can still heal well at this stage, without lasting damage. Treatment consists of the removal of dental plaque and proper information about oral hygiene.
If the inflammation of the gingiva lasts longer, the deeper parts of the periodontium (jawbone, periodontal ligament and cement) may also become involved in the inflammation. Periodontal bone degradation then occurs and the epithelial attachment is lost. When the deeper parts of the periodontium also become inflamed, we speak of periodontitis. The inflammation can be treated, but a full recovery to the original periodontal bone level is no longer possible. The main symptom of periodontitis is that the epithelial attachment is lost, causing the sulcus to become deeper. A pocket is created, which is inflamed. A pocket is therefore a pathologically deepened sulcus. A pocket does not always have to be inflamed, but this is the case with periodontitis. We see the periodontal bone loss on the X-rays. With a pocket probe the depth of the pocket can be measured (see image below).
If the sulcus is deepened, it may be a pocket or a pseudopocket. With a pocket, displacement and bone loss have occurred. Pockets can be subdivided into:
- Supra-alveolar pocket, where the bottom of the pocket is coronal (top) of the alveolar bone edge, and the infra-alveolar pocket, where the bottom of the pocket is apical (bottom) of the alveolar bone edge.
- With a pseudopocket there is no bone loss, but the gingiva is swollen. Due to the swelling, the gums lie higher against the element, creating a deepened (false) pocket (see image below).
We have already seen that periodontitis can be accompanied by serious bone breakdown, which can even expose the furcation. Bone loss can occur in two directions:
- Horizontal bone loss: bone loss occurring parallel to a line drawn through the enamel-cement boundary points of two neighboring elements;
- Angular bone loss: bone loss that is not parallel to the enamel-cement boundary.
Infra-alveolar pockets and angular bone loss make it difficult for the dental hygienist to clean the bottom of the pocket with instruments. The prognosis of the relevant dental element can therefore become worse.
Because gingivitis and periodontitis are usually chronic in nature, they are hardly accompanied by complaints or symptoms that are clearly visible to the patient. However, the patient can complain about bleeding gums and teeth becoming longer (gum recession). The degree of recession is the distance between the enamel dentin border and the gingival border (see image below).
Over time, when a lot of jaw bone has been lost, teeth become mobile (their mobility increases). Depending on the severity of the periodontitis, the element can become movable in the mesiodistal direction, buccolingual (or palatal) direction and occlusoapical direction, or a combination of these three. The elements can migrate (move) at an advanced stage. In the upper teeth you often see a fanning out of the front. The elements can also grow. The tooth necks are now exposed by, on the one hand, pulling up the gums and, on the other hand, sagging the element. Patients regularly complain about sensitivity to heat and cold.
In addition to complaints in the mouth, periodontitis affects the body of the patient. Research has shown that persons with generalized (all elements occurring) periodontitis have a mild form of anemia. The body constantly tries to remedy the inflammation and that requires a lot. Periodontitis is also a factor that can contribute to the development of diabetes. Patients with diabetes mellitus are often unable to “adjust” with insulin.
Necrotizing ulcerative gingivitis (NUG)
Sometimes a insidious and painless condition can suddenly become acute and severe. An example of this is the necrotizing ulcerative gingivitis (necrotizing is dying, ulceration is ‘fester’). The inflammatory image of NUG shows the following specific characteristics.
- Ulceration and necrosis show a yellowish-white batter on the gingiva. This batter consists of fibrin, dead epithelial cells, white blood cells and microorganisms.
- The interdental papilla is affected and crater formation can occur. The degradation can occur around the entire element; the gingiva is painful and bleeds easily.
- There is also a strong fetor ex ore (very bad breath). The patient feels sick and has an elevated temperature; the local lymph nodes in the head and neck area are often swollen (see image below).
Periodontitis can be transformed locally around a tooth with deep pockets into a periodontal abscess This is a sudden flare-up of chronic inflammation in the deep pocket, which results in pus formation (foul taste in the mouth), swelling and pain. Usually such an abscess occurs at the bottom of a deep pocket. Because the gingival border lies fairly tightly around the tooth, the pus cannot flow out of the pocket easily. The pressure can cause the tooth or molar to become loose and be painful when touched. A periodontal abscess can occasionally flash, after which another quiet period follows.
In addition to inflammatory abnormalities of the periodontium, the following abnormalities are mentioned here.
Local juvenile periodontitis (LJP)
With local juvenile periodontitis periodontal degradation occurs at a very young age, namely between 13 and 20 years. In a short time a lot of bone and adhesion are lost in the area of the first molars and / or incisives. Yet there are no or hardly any signs of inflammation. It is therefore of great importance to also check the approximate pockets of the first molars and incisives in children during the periodic mouth examination. When assessing bitewing photos, bone level is also considered. This deviation can thus be diagnosed early.
Microbiological research has shown that an increased number of Aa’s (Aggregatibacter actinomycetemcomitans) in the oral cavity can be detected in patients with LJP. Part of the treatment is therefore to investigate this A.a. presence. To demonstrate this, a bacterial culture can be done on material from the mouth.
Gingiva recession is a situation where the gingiva border has been moved to apical. No pockets need to be present. The root surfaces become visible and the tooth necks can become temperature sensitive in those places.
Recession can occur throughout the mouth or in some places. Sometimes the cause of the recession cannot be indicated, but often incorrect brushing is the cause. Too hard and / or too long horizontal scrubbing, a too hard toothbrush and an abrasive toothpaste are known aggravating factors. Often we see the most recession with elements that are ecto-stemic (outside the tooth row). A recession of a few millimeters does not yet cause serious functional problems. Many patients do complain about sensitive teeth. The root is no longer completely covered by the withdrawal of the gums. If you brush too hard, the soft root cement will disappear quickly. The root dentine is directly exposed to the oral environment. The pulp can be stimulated by sweet / sour and by temperature differences via the dentine channels. This is experienced as a pain sensation (see image below).
The cleft is a special form of recession. This is a local constriction of the gingiva that can extend into the alveolar mucosa. The cleft can occur with both healthy and unhealthy gingiva. A narrow part of the root is exposed. Here too, no clear causes can be given. However, the brushing method, the position of the element, a small width of the gingiva and a trauma due to incorrect occlusion seem to have an influence (see image below).
As we have seen before, endogenous factors can aggravate periodontal disease. Certain use of medication can also lead to gingivitis. This is the case, for example, with the use of diphantoin, a medicine for epilepsy patients, that causes gingiva hyperplasia. Hyperplasia means an increase in size. We then speak of gingivitis medicamentosa. The swelling makes it more difficult to clean the teeth properly. The hyperplasia becomes more serious and the patient can end up in a vicious circle.