Periodontitis

(Pyorrhea)
By James T. Ubertalli, DMD, Hingham, MA
Reviewed/Revised Apr 2024

Pathophysiology | Risk Factors | Classification | Symptoms and Signs | Diagnosis |

Treatment | Key Points

Periodontitis is a chronic inflammatory oral disease that progressively destroys

the tooth-supporting apparatus. It usually manifests as a worsening of gingivitis
and then, if untreated, with loosening and loss of teeth. Other symptoms are rare
except in patients with HIV infection or in whom abscesses develop, in which case
pain and swelling are common. Diagnosis is based on inspection, periodontal
probing, and x-rays. Treatment involves dental cleaning that extends under the
gingival (gum) tissues and a vigorous home hygiene program. Advanced cases
may require antibiotics and surgery.

Pathophysiology of Periodontitis
Periodontitis develops when gingivitis, usually with abundant plaque and calculus (a concretion of bacteria,
food residue, saliva, and mucus with calcium and phosphate salts) beneath the gingival margin, has not
been adequately treated. In periodontitis, deep pockets form in the periodontal tissue and can harbor
anaerobic organisms that do more damage than those usually present in simple gingivitis. Colonizing
organisms include Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Eikenella corrodens,
and many gram-negative bacilli.

The organisms trigger chronic release of inflammatory mediators, including cytokines, prostaglandins, and
enzymes from neutrophils and monocytes. The resulting inflammation affects the periodontal ligament,
gingiva, cementum, and alveolar bone. The gingiva progressively loses its attachment to the teeth, bone
loss begins, and periodontal pockets deepen. With progressive bone loss, teeth may loosen, and gingiva
recedes. Tooth migration is common in later stages, and tooth loss can occur.

Risk Factors for Periodontitis

Modifiable risk factors that contribute to periodontitis include

Plaque
 Smoking
Obesity
Diabetes (especially type 1)
Emotional stress
Vitamin C deficiency (scurvy)
Addressing these conditions can improve the treatment outcomes of periodontitis.

Classification of Periodontitis
The American Academy of Periodontology's (1) classification of periodontal diseases and conditions
distinguishes 3 forms of periodontitis:

Necrotizing periodontitis
Periodontitis as a direct manifestation of systemic disease
Periodontitis

Necrotizing periodontitis
Necrotizing periodontitis is a particularly virulent, rapidly progressing disease characterized by

Necrosis or ulceration of the interdental papillae

Bleeding gingiva
Pain
Necrotizing periodontitis typically occurs in patients with an impaired immune system and thus is often
called HIV-associated periodontitis because HIV is a common cause (1). Clinically, it resembles acute
necrotizing ulcerative gingivitis combined with generalized aggressive periodontitis. Patients may lose 9 to
12 mm of attachment in as little as 6 months.

In some patients, inflammation also involves the oral cavity, causing necrotizing stomatitis or a life-
threatening variant, noma (cancrum oris).

Periodontitis as a direct manifestation of systemic disease

Periodontitis as a direct manifestation of systemic disease is considered in patients who have
inflammation disproportionate to plaque or other local factors and who also have a systemic disease.
However, distinguishing whether a disease is causing periodontitis or contributing to plaque-induced
periodontitis is often difficult.

Systemic diseases associated with hematologic disease that can manifest as periodontitis include

Acquired neutropenia
Agranulocytosis
Leukemias
 Lazy leukocyte syndrome
Hypogammaglobulinemia
Systemic diseases associated with genetic disorders that can manifest as periodontitis include

Familial and cyclic neutropenia

Down syndrome
Leukocyte adhesion deficiency syndromes
Papillon-Lefèvre syndrome
Chédiak-Higashi syndrome
Histiocytic syndromes
Glycogen storage disease
Infantile genetic agranulocytosis
Ehlers-Danlos syndrome (types IV and VIII)
Hypophosphatasia
Cohen syndrome
Crohn disease
Periodontitis
Disease severity is classified as stage I through IV, and rate of progression as grade A through C (1).

Periodontitis can begin anywhere between early childhood and older adulthood. In 2009, approximately
47% of the population was affected with some degree of periodontitis; 64% of adults ≥ 65 years had
moderate or severe periodontitis (2).

Important severity factors include

Amount of loss of attachment (of soft tissue to teeth)

Depth of pockets
Amount of bone loss seen on x-ray

Other periodontal conditions

Other periodontal conditions included in the AAP designations are periodontal abscesses, periodontitis
associated with endodontic lesions, developmental or acquired deformities and conditions, and peri-
implant diseases.

Periodontal abscesses are accumulations of pus that usually occur in pre-existing pockets, sometimes
related to impacted foreign material. Tissue may be rapidly destroyed, risking tooth loss.

Periodontitis associated with endodontic lesions involves a communication between the pulp and
periodontal tissues.
In developmental or acquired deformities and conditions, faulty occlusion, causing an excessive
functional load on teeth, plus the requisite plaque and gingivitis may contribute to progression of a
particular type of periodontitis characterized by angular bony defects.
Classification references
1. Caton JG, Armitage G, Berglundh T, et al: A new classification scheme for periodontal and peri-implant
diseases and conditions – Introduction and key changes from the 1999 classification. J Periodontol 89(S1), 2018.
[Link]
2. Eke PI, Dye BA, Wei L, et al: Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent
Res 91(10):914-920, 2012. doi: 10.1177/0022034512457373

Symptoms and Signs of Periodontitis

Pain is usually absent unless an acute infection forms in one or more periodontal pockets or if HIV-
associated periodontitis is present. Impaction of food in the pockets can cause pain at meals. Abundant
plaque along with redness, swelling, and exudate are characteristic. Gums may be tender and bleed easily,
and breath may be foul. As teeth loosen, particularly when only one third of the root is in the bone,
chewing becomes painful.
 Periodontitis

Diagnosis of Periodontitis
Clinical evaluation
Sometimes dental x-rays
Inspection of the teeth and gingiva combined with probing of the pockets and measurement of their depth
are usually sufficient for diagnosis. Pockets deeper than 4 mm indicate periodontitis.

Dental x-rays reveal alveolar bone loss adjacent to the periodontal pockets.

Treatment of Periodontitis
Treatment of risk factors
Scaling and root planing
 Sometimes oral antibiotics, antibiotic packs, or both
Surgery or extraction
Modifying risk factors, such as poor oral hygiene and smoking, improves outcomes. For patients with
diabetes, adequate control of blood glucose levels is important.

For all forms of periodontitis, the first phase of treatment consists of thorough scaling (professional
cleaning with hand or ultrasonic instruments) and root planing (removal of diseased or toxin-affected
cementum and dentin followed by smoothing of the root) to remove plaque and calculus deposits.
Thorough home oral hygiene is necessary and includes careful brushing and flossing to help clean. It may
include chlorhexidine swabs or rinses. A dental hygienist should help teach the patient how to do these
procedures. The patient is reevaluated after 3 weeks. If pockets are no deeper than 4 mm at this point, the
only treatment needed is regular cleanings. Sometimes a flap of gum tissue is made to allow access for
scaling and planing of deeper parts of the root.

If deeper pockets persist, systemic antibiotics can be used. A common regimen is amoxicillin 500 mg orally
3 times a day for 10 days. In addition, a gel containing doxycycline or microspheres of minocycline can be
placed into isolated recalcitrant pockets. These medications are resorbed in 2 weeks.

Another approach is to surgically eliminate the pocket and recontour the bone (pocket
reduction/elimination surgery) so that the patient can clean the depth of the normal crevice (sulcus)
between the tooth and gingiva. In certain patients, regenerative surgery and bone grafting are done to
encourage alveolar bone growth. Splinting of loose teeth and selective reshaping of tooth surfaces to
eliminate traumatic occlusion may be necessary. Extractions are often necessary in advanced disease.
Contributing systemic factors should be controlled before initiating periodontal therapy.

Many patients with necrotizing ulcerative periodontitis due to HIV (HIV-associated periodontitis) respond
to combined treatment with scaling and planing, irrigation of the sulcus with povidone-iodine (which the
dentist applies with a syringe), regular use of chlorhexidine mouth rinses, and systemic antibiotics, usually
metronidazole 250 mg orally 3 times a day for 14 days (1, 2).

Localized aggressive periodontitis requires periodontal surgery plus oral antibiotics (eg, amoxicillin 500 mg
4 times a day or metronidazole 250 mg 3 times a day for 14 days).

Treatment references
1. Caton JG, Armitage G, Berglundh T, et al: A new classification scheme for periodontal and peri-implant
diseases and conditions – Introduction and key changes from the 1999 classification. J Periodontol 89(S1), 2018.
[Link]
2. Loesche WJ, Syed SA, Laughon BE, Stoll J: The bacteriology of acute necrotizing ulcerative gingivitis. J
Periodontol 53: 223–230, 1982. doi: 10.1902/jop.1982.53.4.223

Key Points
 Periodontitis is an inflammatory reaction triggered by bacteria in dental plaque.
There is loss of alveolar bone, formation of deep gum pockets, and eventually loosening
of teeth.
Treatment involves scaling and root planing and sometimes antibiotics and/or surgery.

Periodontitis Acute Necrotizing Ulcerative Gingivitis (ANUG)