The teeth are surrounded and supported by the peridontium, consisting of the gingival tissue, alveolar bone, cementum, and periodontal ligaments. Periodontal disease is the process and conditions which cause damage to the peridontium. Overtime, without the supportive structures of the peridontium, the teeth become mobile and are lost. Tooth loss is devastating, negatively impacting aesthetics, mastication, and speech.
What is a healthy periodontal state?
A healthy periodontal state is achieved by a diet low in sugars and acids and consistent oral hygiene involving correct tooth brushing and flossing techniques.
In healthy patients, strong periodontal ligaments firmly attach the cementum of teeth to pink gums, and the alveolar bone is at a healthy height. There is no inflammation. Between the gingiva and the tooth, there is a 1 – 3 mm physiological sulcus that normally displays no signs of bleeding or inflammation.
What is gingivitis?
Gingivitis is primarily caused by the accumulation of dental plaque, a sticky film of bacteria and their byproducts, on the teeth and gums. Poor oral hygiene is a common contributing factor, but other factors such as hormonal changes (e.g., pregnancy, puberty), certain medical conditions, and medications can also increase susceptibility to gingivitis. Due to the bacteria and calculus in the gingiva, there is bleeding upon gentle probing of the gingival tissues or toothbrushing. The gums are dusky red, tender, swollen and inflamed. They may even recede. The good news is that gingivitis is usually reversible with proper oral hygiene practices, including regular brushing, flossing, and professional dental cleanings to remove calculus. With dietary modifications and improved oral hygiene, gingivitis is reversible.
How does calculus form?
Within hours after brushing, a protective coat called dental pellicle forms on enamel, crowns and bridges. It consists mostly of glycoproteins and proteins, but also can contain lipids and other macromolecules. It has several important functions. It lubricates the oral environment during chewing and speech.
It maintains mineral homeostasis. The levels of calcium are high, and over-precipitation of calcium phosphate. The acquired salivary pellicle acts as a barrier to protect the enamel from demineralising agents and acid attack.
Components of the salivary pellicle determine the colonisation of early bacteria.
There is ongoing research into the modification of the acquired salivary pellicle by diet to enhance the protective and antimicrobial properties. Vegetable oils such as coconut oil can be used to enhance the anti-erosive effects and caries preventative effects of acquired salivary pellicle. The uptake of dairy proteins is said to increase the antimicrobial and anti-erosive effects of an acquired salivary pellicle.
or patients with inadequate oral hygiene, dead cells, food debris and microorganisms can form a soft coating known as material alba. If the patients drinks soft drinks, there are repeated acid attacks to remove pellicle protection. Within 24 hours, invasive bacteria may adhere and colonise tooth structures. The initial colonisers of the salivary pellicle are usually Streptococcus species and Actinomyces species. Streptococcus species typically release glucans which then promote the colonisation of other species. Bacterial species such as Streptococci will also secrete a protective slimy layer. Over 48 hours, this yellowish – grey substance called dental plaque or dental biofilm matures and becomes more resilienton the teeth.
Over days to weeks, if plaque is not removed, minerals from saliva can combine with plaque to form a harder, more yellow substance called tartar/ calculus. Plaque and tartar will results in vascular changes and intercellular gap formation that leads to increased amounts of gingival crevicular fluids (GCF). Adhesion molecules attract polymorphonuclear neutrophils to the site of the lesion. T lymphocytes alter the fibroblasts of the affected area. This causes collagen fibre breakdown which opens the space for infiltrates. Leukocyte aggregation and B cells then change the junctional epithelium and sulcular epithelium.
If the patient fails to to remove the biofilm and calculus, the bacteria penetrate deeper into the tissues and surrounding periodontium. This causes gingivitis and further progression into bone is known as periodontitis.
Review questions on gingivitis
What causes gingivitis?
Biofilm becomes a concentrated environment for the bacteria (within 24 hours) Bacteria produce toxins irritating the gums and causing inflammation (within 48 hours) Biofilm mineralises to form calculus - which will then require professional cleaning. (days to weeks)
How long does biofilm take to form?
How long does it take for gingivitis to resolve?
What is periodontitis?
As the immune system defends against the bacteria, there is more inflammation causing the pocket depths deepen and there may be early to moderate bone loss. This may lead to the loss of attachment of the periodontium. This chronic, irreversible inflammatory state is known as periodontitis. Not every patient with gingivitis will progress onto have periodontitis. In advanced periodontitis, there is irreversible loss of attachment of the periodontium and bone loss. When severe supporting alveolar bone is lost, this can eventually lead to tooth loss.
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