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Periodontitis (pyorrhea) is a severe form of gingivitis in which the inflammation of the gums extends to the supporting structures of the tooth.

• Plaque and tartar build up between the teeth and gums, then spread to the bone under the teeth.
• The gums swell and bleed, the breath smells bad, and teeth become loose.
• Doctors take x-rays and measure the depth of pockets in the gums to determine how severe periodontitis is.
• Repeated professional cleanings and sometimes dental surgery and antibiotics are needed.

Periodontitis is one of the main causes of tooth loss in adults and is the main cause in older people. Infection erodes the bone that holds the teeth in place. The erosion weakens the attachments and loosens the teeth. An affected tooth may eventually fall out or need to be pulled (extracted).

Causes

Most periodontitis results from a long-term accumulation of plaque and tartar on the teeth and the gums. Pockets form between the teeth and gums and extend downward between the root of the tooth and the underlying bone. These pockets collect plaque in an oxygen-free environment, which promotes the growth of aggressive forms of bacteria. If the disease continues, eventually so much bone is lost that the tooth may become painfully loose.

Did You Know... Periodontitis is the main cause of tooth loss in older people.

Periodontitis: From Plaque to Tooth Loss Healthy gums and bone hold the tooth firmly in place. Plaque buildup irritates the gums, and they become inflamed. In time, the gums pull away from the tooth, creating a pocket that fills with more plaque. The pockets get deeper, and the plaque hardens into tartar. More plaque accumulates on top. Tartar moves down to the root of the tooth and eventually destroys the bone supporting the tooth. Without this support, the tooth loosens and falls out.

The rate at which periodontitis develops differs considerably, even among people with similar amounts of tartar. That is because plaque contains different types and numbers of bacteria and because people have different responses to the bacteria. Periodontitis may produce bursts of destructive activity that lasts for months followed by periods when the disease apparently causes no further damage.

Many diseases and disorders—including diabetes mellitus, Down syndrome, Crohn's disease, leukopenia, and AIDS—can predispose a person to periodontitis. In people with AIDS, periodontitis progresses quickly.

Symptoms and Diagnosis

The early symptoms of periodontitis are bleeding, red gums, and bad breath (halitosis). Dentists measure the depth of the pockets in the gums with a thin probe, and x-rays show how much bone has been lost. As more and more bone is lost, the teeth loosen and shift position. Frequently, the front teeth tilt outward. Periodontitis usually does not cause pain until the teeth loosen enough to move while chewing or until an abscess (a collection of pus) forms.

Understanding Halitosis Halitosis (bad breath) is most often caused by gum disease due to a combination of food lodged between the teeth and poor oral hygiene. Odors from foods that contain volatile oils, such as onions and garlic, pass from the bloodstream into the lungs and are exhaled. Oral hygiene cannot remove these odors. Certain diseases in other areas of the body also cause bad breath. Liver failure gives the breath a mousy odor, kidney failure makes the breath smell like urine, and severe, uncontrolled diabetes makes the breath smell like nail polish remover (acetone). A collection of pus (abscess) in the lungs may cause very severe halitosis. Bad breath is not caused by poor digestion. However, rarely, a tumor in the esophagus or stomach may cause foul-smelling liquid or gas to be regurgitated into the mouth. Physical causes can be corrected or removed. For example, people can stop eating garlic, onions, and other spiced foods and can improve their oral hygiene. Daily use of a tongue scraper to clean the top and back of the tongue is effective. Many deodorant mouthwashes and sprays are available. One of the best active ingredients in these products is chlorophyll. The effects of most of these products, however, do not last more than a couple of hours. Imagined halitosis: Halitosis that is imagined is called psychogenic halitosis. People believe that their breath smells bad when it actually does not. This problem may occur in people who tend to exaggerate normal body sensations. Sometimes psychogenic halitosis is caused by a serious mental disorder, such as schizophrenia. People with obsessive thoughts may have an overwhelming sense of feeling dirty. People with paranoia may have the delusion that their organs are rotting. Such people may believe that their breath smells bad. Some people with psychogenic halitosis may be helped by having a doctor or dentist assure them that they do not have bad breath. If the problem continues, they may benefit from seeing a psychotherapist.

Treatment

Unlike gingivitis, which usually disappears with good self-care, periodontitis requires repeat professional care. People using good oral hygiene can clean only ¹/₁₂ inch (2 to 3 millimeters) below the gum line. Dentists can clean pockets up to ¹/₅ inch (4 to 5 millimeters) deep using scaling and root planing, which thoroughly remove tartar and the diseased root surface. For pockets of ¼ inch (5 millimeters) or more, surgery is often required. Dentists or periodontists may access the tooth below the gum line surgically (periodontal flap surgery) to thoroughly clean the teeth and correct bone defects caused by the infection. Dentists or periodontists may also remove part of the infected and separated gum (a gingivectomy) so that the rest of the gum can reattach tightly to the teeth and people can then remove the plaque at home.

Dentists may prescribe antibiotics (such as amoxicillinSome Trade Names
AMOXIL TRIMOX
or metronidazoleSome Trade Names
FLAGYL
), especially if an abscess has developed. Dentists may also insert antibiotic-impregnated materials (filaments or gels) into deep gum pockets, so that high concentrations of the drug can reach the diseased area. Periodontal abscesses cause a burst of bone destruction, but immediate treatment with surgery and antibiotics may allow much of the damaged bone to grow back. If the mouth is sore after surgery, a chlorhexidineSome Trade Names
HIBICLENS
mouth rinse used for 1 minute twice a day may be temporarily substituted for brushing and flossing.

Last full review/revision October 2008 by James T. Ubertalli, DMD