Periodontitis

Periodontitis is an inflammatory disease affecting the supporting tissues of the teeth. It is a common cause of tooth loss, particularly in the adult population.

Terminology

Different forms of periodontitis are recognized. The terms 'chronic periodontitis' and 'aggressive periodontitis' have been removed from the 2017 consensus classification system, though they are still commonly used in clinical practice ¹.

The term apical periodontitis refers to a localized form of bony inflammation occurring around the tooth apex, most commonly in response to infection within the dental pulp system. It usually has a different etiology, clinical presentation and management to the form of periodontitis described here.

Epidemiology

The prevalence of periodontitis in Australia is estimated at 22.9%. The prevalence increases with age and reaches 60.8% above age 75. There is a slightly higher prevalence in the male population ².

Diagnosis

The diagnosis can usually be made clinically. On clinical examination, there are gingival pockets surrounding the teeth, and bleeding on probing. Deeper pockets are associated with more advanced disease. Plain x-rays, i.e. orthopantomogram (OPG) and intra-oral x-rays, can be used to quantify the degree of bone loss and stage the disease according to agreed classification criteria.

Clinical Presentation

The disease can be localized or generalized, affecting all of the teeth. In the earlier stages, there are usually no symptoms. Gingival bleeding and erythema is common and reflects poor disease control. In advanced disease, the teeth become mobile and tooth loss eventuates ³.

Radiographic features

Periodontal disease is typically diagnosed clinically and with the aid of intra-oral radiographs which display better image quality than an OPG. Follow up radiographs are often useful to assess the adequacy of treatment over time. 

Periodontitis can often be identified on an OPG. In the early stages, there may be no radiographic signs, as a threshold level of demineralization needs to occur before radiologic signs are evident. The earliest radiographic change is the loss of the crestal bone, the triangle of bone that is normally seen between neighboring teeth. Bone loss around the teeth can be horizontal or vertical (adjacent and parallel to the tooth root). Bone loss may also be seen in the space between the roots of a molar tooth ⁴.

Precipitating factors such as overhanging dental restorations or large deposits of calculus can often be identified.

Treatment and prognosis

The goal of treatment is to prevent the progression of the disease, as pre-existing bone loss generally cannot be recovered. The mainstay of treatment is professional scaling to clean the root surface of calculus and plaque, in conjunction with vigorous oral hygiene at home. Severely affected teeth need to be extracted. Removal of precipitating factors such as smoking, and control of diabetes are also important aspects of management. Periodontal surgery is often reserved for resistant or more advanced cases ³.