Adult population, especially in developing countries, suffer from some form of periodontal disease or what is commonly known as gum disease.
As periodontal disease is currently the main cause of tooth loss compared to dental caries, oral healthcare professionals are now spending more time treating this disease than before.
I tend to term periodontal disease as elusive because a person with this disease will not have any pain in order to come running to the oral healthcare professional for treatment.
When this person does visit the oral healthcare professional, the disease may have progressed into deeper tissues of the periodontium and becomes irreversible.
Tooth structure
The tooth is attached to the alveolar bone by the attachment apparatus which consists of the gingiva, root cementum, periodontal ligament and the alveolar bone.
The periodontal ligament acts as a “shock absorber” to cater for the high masticatory load that is produced during chewing.
Periodontal disease causes the destruction of the attachment apparatus of the tooth.
Every day, a sticky, almost invisible film forms on the teeth surfaces.
As it matures without removal by proper oral hygiene, it matures into what is called oral plaque biofilm and this biofilm is the primary etiology of periodontal disease.
It is said that there are more than 650 species of bacteria present in our mouths and many of these bacteria will play a role in the initiation and progression of periodontal disease, especially when it multiplies outside the normal range.
Oral plaque biofilm can be seen particularly at the gingival margins and in the areas between the teeth. The bacteria within the plaque biofilm produces bacterial byproducts, which in turn will activate our immune system to release inflammatory mediators that make the gums red, swollen and bleed easily.
This inflammatory process initiated by our own immune system, if it continues unimpeded, will lead to the destruction of periodontal ligament and supporting alveolar bone leading the tooth to become loose.
Bone destruction
Symptoms of gum disease will be bleeding gums, migration of teeth, receding gums, mouth malodour or halitosis (bad breath), taste disturbances and tooth loss as the disease progresses.
The periodontal pocketing will harbour multiple anaerobic bacteria causing the destruction of the supporting structures of the tooth, especially the alveolar bone into which the root of the tooth is embedded.
There will be radiographic changes indicating the destruction of alveolar bone.
Periodontal disease in the early stages, only involving the supra gingival areas is called chronic gingivitis and when it progresses into the roots of teeth via periodontal pocketing involving the sub gingival areas and affecting the periodontal ligament and alveolar bone, it is called chronic periodontitis.
Gingivitis is reversible if early treatment is sought but periodontitis is irreversible and can only be prevented from causing further damage by periodontal treatment.
It is unfortunate that what is lost due to periodontal disease especially the alveolar bone is hard to gain back.
Affecting the young
Children who have temporary or permanent teeth may not be as susceptible to periodontitis as compared to adults.
Usually, gingivitis in children will not progress to periodontitis.
This may be due to the better immune response in children to the bacterial infection in plaque biofilm. However, if the child has any existing disease or genetic disorders which can lead to the child being immunocompromised, gingivitis can progress into the deeper tissues to become periodontitis.
Genetic disorders like Down’s syndrome can cause severe periodontal destruction in children.
Aggressive periodontitis, which has a hereditary predisposition, can occur in young adults even when their oral hygiene and plaque biofilm control are good.
These young adults will lose their teeth, especially their molars, rapidly as the disease progresses.
Link with systemic disorders
The relationship between periodontal disease and several systemic disorders is worrying our profession as the disease is rampant in the adult population worldwide.
Smoking is a contributory factor in the development of periodontal disease.
The vasoconstriction caused by smoking on the gingival blood vessels may play a role in the disease process.
Ongoing research and scientific papers over the last decade have linked periodontal disease to systemic conditions like diabetes mellitus, arthrosclerosis and cardiovascular diseases, strokes, osteoarthritis, respiratory tract and lung infections, obesity, renal disorders and pregnancy.
Research shows that diabetics are more susceptible to periodontal disease, which in turn has been implicated to poorer glycemic control in these individuals.
Many disease entities like Alzheimer’s, some cancers and inflammatory conditions like rheumatoid arthritis also have an association with periodontal disease and research on this association is ongoing.
Managing the problem
The main clinical periodontal parameters that we assess are the plaque and gingival bleeding scores and periodontal pocket depths before we can embark on any non-surgical or surgical interventions.
This will give us baseline information on the stage of disease progression, which is then used for post periodontal treatment evaluation.
Radiographic evaluation of the hard structures can also be done to evaluate, among other findings, the alveolar bone levels.
The management of periodontal disease will consist of removing the bacterial plaque biofilm from the mouth along with any deposits in the supra gingival and sub gingival parts of the teeth and making the roots of the teeth as clean and deposit-free as possible.
This procedure is known as scaling and root planning or debridement, which reduces the bacterial load in the mouth by removing deposits that are contaminated by bacteria.
Other local contributing factors which can act as traps for bacterial plaque biofilm will also have to be addressed.
The systemic host mediating factors may require referral to our medical colleagues, if the patient is not already under medical care.
Oral healthcare professionals should always have a good rapport with their medical colleagues in the management of patients’ with systemic conditions.
To maintain this lowered level of bacterial load, it is imperative to give your patients proper oral hygiene instructions tailored to individual patients’ needs.
Surgical intervention is only carried out when periodontal disease is still persistent and refractory in areas of the dentition and the oral hygiene of the patient has improved and at an acceptable level.
Mouth rinses like chlorhexidine, which is categorised as a “gold standard” antibacterial agent and has excellent antibacterial effect can be used as an adjunct to mechanical oral hygiene like tooth brushing and flossing.
These mouth rinses are especially useful in individuals with poor manual dexterity like in patients who have had a stroke.
It is also useful in patients who are in intensive care, mentally and physically challenged; caregivers can maintain oral hygiene with these antimicrobial agents.
Oral hygiene and Covid-19
The management of periodontal disease is even more important during this pandemic.
Periodontal disease is an inflammatory disease and the added burden of dealing with another inflammatory condition such as the Covid-19 viral invasion will be challenging for the patient’s immune system.
A situation of concern is when a Covid-19 patient is on a ventilator in the intensive care unit; the patient’s oral hygiene becomes the least priority in the management of this very ill patient.
This neglect in oral hygiene will cause an accumulation of bacterial plaque biofilm in the patient’s oral cavity leading to the progression of periodontal infection and further destruction of the periodontal tissues.
This increase in the bacterial load in the oral cavity will be an additional burden on the patient’s immune response, which is already burdened by a very pathogenic virus infection.
It has been reported that patients on ventilators are more susceptible to bacterial pneumonia due to the tracking of accumulated periodontal pathogens from the oral cavity along and into the ventilator tubes to the lungs.
Patients on ventilators for Covid-19 which is a respiratory viral infection will be further compromised with this spread of bacterial infection into the respiratory system.
It is thus recommended that oral healthcare professionals should also be involved in the overall management of patients afflicted by Covid-19 along with the frontline caregivers.
The use of chemical plaque biofilm control agents like chlorhexidine will benefit patients in the intensive care units in the management of their oral hygiene.
The prevention of the disease is literally in your hands and together with oral healthcare professionals, we can try and identify the disease early and prevent it from causing damage to the tooth-supporting tissue, thus preventing tooth loss and improving quality of life.
So, schedule regular visits to your oral healthcare professional and treat oral health as an important aspect of your life.
With the present pandemic facing mankind, oral hygiene has never been more important in daily life.
Dr Dasan Swaminathan is a professor of periodontology. For more information, email starhealth@thestar.com.my. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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