periodontal disease periodontal disease periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. in its early stage, called gingivitis, the gums become swollen and red and may bleed. it is considered the main cause of tooth loss for adults worldwide. in its more serious form, called periodontitis, the gums can pull away from the tooth, bone can be lost, and the teeth may loosen or fall out. bad breath may also occur. periodontal diseaseother namesgum disease, pyorrhea, periodontitisradiograph showing bone loss between the two roots of a tooth (black region). the spongy bone has receded due to infection under tooth, reducing the bony support for the tooth.pronunciationperiodontitis /ˌpɛrioʊdɒnˈtaɪtɪs/, pyorrhea /ˌpaɪəˈriːə/ specialtydentistrysymptomsred, swollen, painful, bleeding gums, loose teeth, bad breathcomplicationstooth loss, gum abscessusual onsetgetting gingivitiscausesbacteria related plaque build uprisk factorssmoking, diabetes, hiv/aids, certain medicationsdiagnostic methoddental examination, x-raystreatmentgood oral hygiene, regular professional cleaningfrequency538 million (2015) periodontal disease is generally due to bacteria in the mouth infecting the tissue around the teeth. factors that increase the risk of disease include smoking, diabetes, hiv/aids, family history, and certain medications. diagnosis is by inspecting the gum tissue around the teeth both visually and with a probe and x-rays looking for bone loss around the teeth. treatment involves good oral hygiene and regular professional teeth cleaning. recommended oral hygiene include daily brushing and flossing. in certain cases antibiotics or dental surgery may be recommended. clinical investigations demonstrate that quitting smoking and making dietary changes enhance periodontal health. globally 538 million people were estimated to be affected in 2015 and has been known to affect 10–15% of the population generally. in the united states nearly half of those over the age of 30 are affected to some degree, and about 70% of those over 65 have the condition. males are affected more often than females. signs and symptoms 1: total loss of attachment (clinical attachment loss, cal) is the sum of 2: gingival recession, and 3: probing depth in the early stages, periodontitis has very few symptoms, and in many individuals the disease has progressed significantly before they seek treatment. symptoms may include: redness or bleeding of gums while brushing teeth, using dental floss or biting into hard food (e.g., apples) (though this may also occur in gingivitis, where there is no attachment loss gum disease) gum swelling that recurs spitting out blood after brushing teeth halitosis, or bad breath, and a persistent metallic taste in the mouth gingival recession, resulting in apparent lengthening of teeth (this may also be caused by heavy-handed brushing or with a stiff toothbrush) deep pockets between the teeth and the gums (pockets are sites where the attachment has been gradually destroyed by collagen-destroying enzymes, known as collagenases) loose teeth, in the later stages (though this may occur for other reasons, as well) gingival inflammation and bone destruction are largely painless. hence, people may wrongly assume painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that person. periodontal disease associated conditions periodontitis has been linked to increased inflammation in the body, such as indicated by raised levels of c-reactive protein and interleukin-6. it is associated with an increased risk of stroke, myocardial infarction, atherosclerosis and hypertension. it also linked in those over 60 years of age to impairments in delayed memory and calculation abilities. individuals with impaired fasting glucose and diabetes mellitus have higher degrees of periodontal inflammation, and often have difficulties with balancing their blood glucose level owing to the constant systemic inflammatory state, caused by the periodontal inflammation. although no causal association was proven, there is an association between chronic periodontitis and erectile dysfunction, inflammatory bowel disease, heart disease, and pancreatic cancer. diabetes and periodontal disease a positive correlation between raised levels of glucose within the blood and the onset or progression of periodontal disease has been shown in the current literature. data has also shown that there is a significant increase in the incidence or progression of periodontitis in patients with uncontrolled diabetes compared to those who do not have diabetes or have well-controlled diabetes. in uncontrolled diabetes, the formation of reactive oxygen species can damage cells such as those in the connective tissue of the periodontal ligament, resulting in cell necrosis or apoptosis. furthermore, individuals with uncontrolled diabetes mellitus who have frequent exposure to periodontal pathogens have a greater immune response to these bacteria. this can subsequently cause and/or accelerate periodontal tissue destruction leading to periodontal disease. oral cancer and periodontal disease current literature suggests a link between periodontal disease and oral cancer. studies have confirmed an increase in systemic inflammation markers such as c-reactive protein and interleukin-6 to be found in patients with advanced periodontal disease. the link between systemic inflammation and oral cancer has also been well established. both periodontal disease and cancer risk are associated with genetic susceptibility and it is possible that there is a positive association by a shared genetic susceptibility in the two diseases. due to the low incidence rate of oral cancer, studies have not been able to conduct quality studies to prove the association between the two, however future larger studies may aid in the identification of individuals at a higher risk. systemic implications periodontal disease (pd) can be described as an inflammatory condition affecting the supporting structures of the teeth. studies have shown that pd is associated with higher levels of systemic inflammatory markers such as interleukin-6 (il-6), c-reactive protein (crp) and tumor necrosis factor (tnf). to compare, elevated levels of these inflammatory markers are also associated with cardiovascular disease and cerebrovascular events such as ischemic strokes. the presence of a wide spectrum inflammatory oral diseases can increase the risk of an episode of stroke in an acute or chronic phase. inflammatory markers, crp, il-6 are known risk factors of stroke. both inflammatory markers are also biomarkers of pd and found to be an increased level after daily activities, such as mastication or toothbrushing, are performed. bacteria from the periodontal pockets will enter the bloodstream during these activities and the current literature suggests that this may be a possible triggering of the aggravation of the stroke process. other mechanisms have been suggested, pd is a known chronic infection. it can aid in the promotion of atherosclerosis by the deposition of cholesterol, cholesterol esters and calcium within the subendothelial layer of vessel walls. atherosclerotic plaque that is unstable may rupture and release debris and thrombi that may travel to different parts of the circulatory system causing embolization and therefore, an ischemic stroke. therefore, pd has been suggested as an independent risk factor for stroke. a variety of cardiovascular diseases can also be associated with periodontal disease. patients with higher levels of inflammatory markers such as tnf, il-1, il-6 and il-8 can lead to progression of atherosclerosis and the development and perpetuation of atrial fibrillation, as it is associated with platelet and coagulation cascade activations, leading to thrombosis and thrombotic complications. experimental animal studies have shown a link between periodontal disease, oxidative stress and cardiac stress. oxidative stress favours the development and progression of heart failure as it causes cellular dysfunction, oxidation of proteins and lipids, and damage to the deoxyribonucleic acid (dna), stimulating fibroblast proliferation and metalloproteinases activation favouring cardiac remodelling. during sars covid 19 pandemic, periodontitis was significantly associated with a higher risk of complications from covid‐19, including icu admission, need for assisted ventilation and death and increased blood levels of markers such as d‐dimer, wbc and crp which are linked with worse disease outcome. clinical significance inadequate nutrition and periodontal disease periodontal disease is multifactorial, and nutrition can significantly affect its prognosis. studies have shown that a healthy and well-balanced diet is crucial to maintaining periodontal health. nutritional deficiencies can lead to oral manifestations such as those in scurvy and rickets disease. different vitamins will play a different role in periodontal health: vitamin c: deficiencies may lead to gingival inflammation and bleeding, subsequently advancing periodontal disease vitamin d: deficiencies may lead to delayed post-surgical healing vitamin e: deficiencies may lead to impaired gingival wound healing vitamin k: deficiencies may lead to gingival bleeding nutritional supplements of vitamins have also been shown to positively affect healing after periodontal surgery and many of these vitamins can be found in a variety of food that we eat within a regular healthy diet. therefore, vitamin intakes (particularly vitamin c) and dietary supplements not only play a role in improving periodontal health, but also influence the rate of bone formation and periodontal regeneration. however, studies supporting the correlation between nutrition and periodontal health are limited, and more long-term research is required to confirm this. causes periodontitis is an inflammation of the periodontium, i.e., the tissues that support the teeth. the periodontium consists of four tissues: gingiva, or gum tissue, cementum, or outer layer of the roots of teeth, alveolar bone, or the bony sockets into which the teeth are anchored, and periodontal ligaments (pdls), which are the connective tissue fibers that run between the cementum and the alveolar bone. this x-ray film displays two lone-standing mandibular teeth, the lower left first premolar and canine, exhibiting severe bone loss of 30–50%. widening of the periodontal ligament surrounding the premolar is due to secondary occlusal trauma. the primary cause of gingivitis is poor or ineffective oral hygiene, which leads to the accumulation of a mycotic and bacterial matrix at the gum line, called dental plaque. other contributors are poor nutrition and underlying medical issues such as diabetes. diabetics must be meticulous with their homecare to control periodontal disease. new finger prick tests have been approved by the food and drug administration in the us, and are being used in dental offices to identify and screen people for possible contributory causes of gum disease, such as diabetes. in some people, gingivitis progresses to periodontitis – with the destruction of the gingival fibers, the gum tissues separate from the tooth and deepened sulcus, called a periodontal pocket. subgingival microorganisms (those that exist under the gum line) colonize the periodontal pockets and cause further inflammation in the gum tissues and progressive bone loss. examples of secondary causes are those things that, by definition, cause microbic plaque accumulation, such as restoration overhangs and root proximity. the excess restorative material that exceeds the natural contours of restored teeth, such as these, are termed "overhangs", and serve to trap microbic plaque, potentially leading to localized periodontitis. smoking is another factor that increases the occurrence of periodontitis, directly or indirectly, and may interfere with or adversely affect its treatment. it is arguably the most important environmental risk factor for periodontitis. research has shown that smokers have more bone loss, attachment loss and tooth loss compared to non-smokers. this is likely due to several effects of smoking on the immune response including decreased wound healing, suppression of antibody production, and the reduction of phagocytosis by neutrophils ehlers–danlos syndrome and papillon–lefèvre syndrome (also known as palmoplantar keratoderma) are also risk factors for periodontitis. if left undisturbed, microbial plaque calcifies to form calculus, which is commonly called tartar. calculus above and below the gum line must be removed completely by the dental hygienist or dentist to treat gingivitis and periodontitis. although the primary cause of both gingivitis and periodontitis is the microbial plaque that adheres to the tooth surfaces, there are many other modifying factors. a very strong risk factor is one's genetic susceptibility. several conditions and diseases, including down syndrome, diabetes, and other diseases that affect one's resistance to infection, also increase susceptibility to periodontitis. periodontitis may be associated with higher stress. periodontitis occurs more often in people from the lower end of the socioeconomic scale than people from the upper end of the socioeconomic scale. genetics appear to play a role in determining the risk for periodontitis. it is believed genetics could explain why some people with good plaque control have advanced periodontitis, whilst some others with poor oral hygiene are free from the disease. genetic factors which could modify the risk of a person developing periodontitis include: defects of phagocytosis: person may have hypo-responsive phagocytes. hyper-production of interleukins, prostaglandins and cytokines, resulting in an exaggerated immune response. interleukin 1 (il-1) gene polymorphism: people with this polymorphism produce more il-1, and subsequently are more at risk of developing chronic periodontitis. diabetes appears to