Periodontitis is an inflammatory condition that affect support f of tooth, leading to weakening of tooth support. If not treated adequately in timely manner with regular maintenance, it can be a principle cause of tooth loss in these individuals.
It is important to know how periodontitis become a problem in some individuals. The understanding of cause and related process also guides treatment and maintenance of periodontitis.
Periodontal diseases are mainly of two types:
- Gingivitis: involves inflammation of gums
- Periodontitis: involves inflammation and loss of tooth supporting structures like periodontal ligament and/or bone.
Gingivitis is caused by inadequate tooth cleaning, which results in retention of dental plaque around the gingiva for an extended period of time. As a result, the microorganisms become more complex and initiate the process of gingival inflammation.
Brushing and flossing (interdental brushing) removes plaque adequately and resolve the situation.
Periodontitis involves deeper structure and is irreversible damage of tooth support compared to reversible damage with periodontitis.
While the plaque start the gingivitis (inflammation of gingiva), the progression to periodontitis is determined by individual susceptibility (body’s response determines further destruction). People with equal level of plaque retention, do not show equal level of periodontal destruction.
Before we discuss about individual susceptibility, it is important to understand plaque:
Plaque is a mass of microorganisms. Unlike other micro-organisms in the body, plaque is attached to a hard, non-shedding surface (i.e. tooth or root surface) and is always surrounded by fluid (saliva). This environment gives plaque a perfect opportunity to form “Biofilm”.
Biofilm is a community of different micro-organisms which co-operates to support survival of biofilm. The micro-organisms are surrounded by sticky, glue-like matrix or intermicrobial matrix which provides fluid channels for diffusion of fluids and nutrients but prevents penetration of antiseptics (mouthwashes), antibiotics and host defence mechanism that may aim to eliminate the biofilm.
Plaque starts inflammatory process, which involves migration of host defence cells towards the biofilm to fight and eliminate biofilm. The biofilm against these host defence cells still survives by virtue of its complex structure and intermicrobial matrix. The host defence fight, which is directed towards a failed attempt of biofilm elimination, causes destruction of its own tissue (tooth support).
It is this host defence that determines the nature of destruction. In simple words, more the body fights against the biofilm, the more damage to the tooth supporting structures take place, rather than biofilm elimination.
The periodontal disease progresses very slowly over many years. The rate of disease progression varies from 0.1 to 1 mm destruction per year in aggressive cases and 0.01 to 0.1 mm destruction per year in chronic cases. While exceptions may exist, it takes many many years for a disease to become advance. It surely does not happen over night,over a fortnight or even a few months or couple of years…….. As a general pattern seen in epidemiological studies in developed countries, approximately 10-15% of population would get advanced periodontitis.
The host response is governed by following factors that primarily determines nature of periodontal destruction:
- Genetics: which is by and large the principle intrinsic (host’s own) characteristic that determines periodontal destruction
- Poor oral hygiene over long time period: generally if the hygiene is poor for long term, it would allow longer time for disease progression.
- Smoking: it is the most common elective factor that makes periodontitis worse.
- Uncontrolled diabetes: the effect of high sugar enhances body’s host cells to fight more (hyperinflammatory response due to advanced glycation end products in scientic words) leading to more damage. A general analogy would be children becomig hyper-active under the effect of sugar would cause more damage.
- Obesity: Effect is similar to Diabetes. it is hard to separate from diabetes in reseach as type II diabetes and obesity are closely linked.
- Stress: Extreme stressful events (divorse, long term financial stress, death of close-ones) or even more appropriately coping behaviour after the stressful events determines the nature of periodontal destruction. Due to ethical reasons, we dont have huge data on this aspect. Poor oral hygiene (brushing and flossing may be a last priority during this hard-to-cope stressful time) and smoking (people may tend to smoke as a coping behaviour) would also contribute to disease progression.
- Age: More general form of periodontitis (chronic periodontitis) would manifest in older age which is around mid-life. One of the reasons would be impaired healing potential with increasing age fail to contain the damage caused by inflammation and as a result disease become apparent. In the early ages, whatever we do wrong do not show up that quickly due to rapid healing response, as we get older — things start coming to the surface. same may be true for periodontal diseases.
- Plaque induces early inflammatory response which manifests as inflammatory gingival lesion or gingivitis (plaque – induced gingivitis).
- Plaque being biofilm resist its elimination against host response.
- In the fight to eliminate plaque, body damages itself. More intense is the fight, bigger is the damage – genetics, smoking, diabetes, obesity, stress, age are known factors that may affect the disease progression.
- While plaque (biofilm) is present, it is not possible for body to heal around periodontal pockets.
Thus the primary purpose of the treatment is to disrupt the biofilm structure of plaque and prevent from it forming during early events of healing.