Risk Factors
More than 75% of American adults have some form of gum disease, but according to a major survey, only 60% have any significant knowledge about the problem. It should be noted that gum inflammation and ulcers are common and not all people with these problems develop periodontal disease. Still about 30% of people are genetically susceptible to periodontal disease. Other factors also put individuals at higher risk.
Abnormal Oral Environment
Lack of Oral Hygiene. Lack of oral hygiene encourages bacterial buildup and plaque formation.
Sugar and Acid. The bacteria that cause periodontal disease thrive in acidic environments. Therefore, eating sugars and other foods that increase the acidity in the mouth increase bacterial counts.
Poorly Contoured Restorations. Poorly contoured restorations (fillings or crowns) that provide traps for debris and plaque can also contribute to its formation.
Anatomical Tooth Abnormalities. Abnormal tooth structure can increase the risk.
Age
Children and Adolescents. Gingivitis, in varying degrees, is nearly a universal finding in children and adolescents. In rare genetic cases, children and adolescents are subject to destructive forms of the disease. Researchers have also observed some of the organisms seen in periodontal disease in young children without signs of gum problems. Healthy children, however, do not, generally harbor two primary periodontal bacteria, P. gingivalis and T. denticola.
The disease is also uncommon in teenagers. According to one survey, only 1% of 14- to 17-year-olds have any sign of actual periodontal disease.
Adults. One survey reported that 3.6% of adults between the ages 18 and 34 had periodontal disease. A 2000 New Zealand study, however, reported that one in seven 26-year-olds (about 14%) had signs of well-established periodontal disease. (It should be noted that populations may differ in their risk.) As people age, the risk for periodontal disease increases. Over half of American adults have gingivitis surrounding three to four teeth and 30% have significant periodontal disease surrounding an average of three to four teeth. In a study of people over 70 years old, 86% had at least moderate periodontitis and over a quarter of them have lost their teeth.
Female Hormones
About three-quarters of periodontal office visits are made by women, even though women tend to take better care of their teeth then men do. Female hormones affect the gums, and women are particularly susceptible to periodontal problems. Hormone-influenced gingivitis appears in some adolescents, in some pregnant women, and is occasionally a side effect of birth control medication.
Before Menstruation. Gingivitis may flare up in some women a few days before they menstruate when progesterone levels are high. Progesterone dilates blood vessels causing inflammation, and blocks the repair of collagen, the structural protein that supports the gums.
Pregnancy. Hormonal changes during pregnancy can aggravate existing gingivitis, which typically worsens around the second month and reaches a peak in the eighth month. Pregnancy does not cause gum disease, and simple preventive oral hygiene can help maintain healthy gums. Any pregnancy-relate gingivitis usually resolves within a few months of delivery. (It should be noted that existing periodontal disease in pregnant women may actually have some harmful effects.)
Oral Contraceptives. One study reported that taking oral contraceptives containing the synthetic progesterone desogestrel (but not dienogest, another common progesterone) increased the risk for periodontal disease.
Menopause. During menopause, some women may develop a rare condition called menopausal gingivostomatitis, in which the gums are dry, shiny, and bleed easily. At that time, women may experience abnormal tastes and sensations (e.g., salty, spicy, acidic, burning) in the mouth. Osteoporosis is related to estrogen loss after menopause and is also associated with bone loss.
Family Factors
Periodontal disease often occurs in members of the same family. Genetics, intimacy, hygiene, or a mixture of factors may be responsible. Studies have found that children of parents with periodontitis were 12 times more likely to have the bacteria thought to be responsible for causing plaque and, eventually, periodontal disease.
Genetic Factors. According to a 2000 study, not environment or poor hygiene, but genetic factors may play the critical role in half the cases of periodontal disease. Up to 30% of the population may have some genetic susceptibility to periodontal disease. For example, some people with severe periodontal disease have genetic factors that affect an immune factor known as interleukin-1 (IL-1), a cytokine involved in the inflammatory response. Such individuals are up to 20 times more likely to develop advanced periodontitis than those without such genes. Early onset and rapidly progressive periodontal disease also have strong genetic components.
Intimacy. Intimate partners and spouses of people with periodontal disease may also be at risk. Researchers have found that the bacteria P. gingivalis may be contagious after exposure to an infected person over a long period of time. There is no risk from short exposure, such as after a fast kiss or when sharing an eating utensil.
Smoking and Nicotine
Smoking is the single major preventable risk factor for periodontal disease, and can cause bone loss and gum recession even in the absence of periodontal disease. A number of studies indicate that smoking and nicotine increase inflammation by reducing oxygen in gum tissue and triggering an over-production of immune factors called cytokines (specifically ones called interleukins), which in excess are harmful to cells and tissue.
Furthermore, when nicotine combines with oral bacteria, such as P. gingivalis, the effect produces even greater levels of cytokines and eventually leads to periodontal connective tissue breakdown. Studies suggest that smokers are 11 times more likely than nonsmokers to harbor the bacteria that cause periodontal disease and four times more likely to have advanced periodontal disease. In one study more than 40% of smokers lost their teeth by the end of their lives.
The risk of periodontal disease increases with the number of cigarettes smoked per day. Smoking cigars and pipes carries the same risks as smoking cigarettes. Exposure to second-hand smoke is also associated with a 50% to 60% increased risk for developing periodontal disease, according to a 2001 study. Fortunately, when smokers quit, their periodontal health gradually recovers to a state comparable to that of nonsmokers.
Diseases Associated with Periodontal Disease
Diabetes. Much evidence exists on the link between type 1 and 2 diabetes and periodontal disease. People with these diseases have 15 times the risk of the nondiabetic population. Diabetes causes abnormalities in blood vessels and high levels of specific inflammatory chemicals, such as interleukins, that significantly increase the chances of periodontal disease. High levels of triglycerides (which are common in type 2 diabetes) appear to impair periodontal health. A high blood sugar level, which is the hallmark of diabetes, has even been associated with severe periodontal disease in people without diabetes, according to a 2000 study. Obesity, which is common in type 2 diabetes, may also predispose a person to gum disease. Studies in 1999 and 2000 suggest controlling both type 1 and 2 diabetes may also help reduce periodontal problems.
Osteoporosis. Osteoporosis (loss of bone density) has been associated with periodontal disease in postmenopausal women. There is some evidence that some treatments for osteoporosis, such as bisphosphonates, may reduce bone loss, including the bony structures that support the teeth.
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| Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density. |
Herpes-Related Gingivitis. Herpes virus is a common cause of gingivitis in children and has become increasingly common in adults. It typically starts out with a purplish color and "boggy" sensation in the gums (especially inside). Multiple blisters may form across the mucus membranes in the mouth and gums, followed by ulcers. They usually resolve in seven to 14 days.
HIV-Associated Gingivitis. HIV-associated gingivitis has been reported in 15% to 50% of patients with AIDS. HIV positive individuals harbor larger numbers of periodontal bacteria (candida albicans, P. gingivalis, black-pigmented anaerobic rods, and A. actinomycetemcomitans) than people without HIV. Severe pain is characteristic, along with odor, spontaneous bleeding, ulcers, and swollen, bright red gums. The inflammation never recedes, but halitosis and acute episodes can be managed by conventional cleaning treatments. Its severest form, known as necrotizing stomatitis, can be diagnostic for AIDS; in addition to bleeding, the gums in the front of the mouth are a yellowish-gray color, and bone thrusts out.
Autoimmune Diseases. Autoimmune conditions (e.g., Crohn's disease, multiple sclerosis, rheumatoid arthritis, lupus erythematosus, CREST syndrome) have been associated with a higher incidence of periodontal disease. Some research suggests that periodontal disease may even play some causal role. For example, one 2002 study suggested that P. gingivalis, one of the major bacteria in periodontal disease, was associated with destructive processes in the brain leading to multiple sclerosis. Still, much more research is needed to determine any possible association between these diseases.
Other Diseases. People with a number of other diseases are also at higher risk for periodontitis include leukemia and other cancers, tuberculosis, syphilis, Wegener's granulomatosis, amyloidosis, and many genetic disorders.
Vitamin C Deficiencies
Vitamin C helps the body repair and maintain connective tissue, and its antioxidant effects are important in the presence of tissue-destroying oxidants in periodontal disease. A large 2000 study found that people who consumed less than the recommended daily allowance of vitamin C, 60 mg (about one orange), were one and a half times more likely to develop severe gingivitis than those who consumed more than 180 mg each day. (It should be noted that smoking also depletes vitamin C supplies.)
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Click the icon to see an image of the benefits of vitamin C. |
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Click the icon to see an image of the sources of vitamin C. |
Ethnic, Socioeconomic, and Geographic Factors
Dental disease is most likely to affect the poor. Children and the elderly suffer the worst oral care, and ethnic minorities follow. A 2002 study reported that the amount of oral bacteria was greater in people who visited their dentist least and when educational levels were low. Ethnicity played no role. It is distressing enough that 44 million Americans lack medical insurance, but almost two and a half times that number (108 million Americans) lack dental insurance. In one survey in five states (Arizona, California, Hawaii, Oregon, and Wisconsin), the rate of total tooth loss was less than 20%, while in three states (Kentucky, Louisiana, and West Virginia) it was greater than 40%.
Drug-Induced Gingivitis
Gingival overgrowth can be a side effect of nearly 20 different drugs, most commonly phenytoin (Dilantin), cyclosporine (Sandimmune), and a short-acting form of the calcium channel blocker nifedipine (Procardia).
Other Causes of Gum Inflammation
A number of other conditions can also cause gum inflammation, and some have been associated with periodontal disease. They include the following:
- Mouth breathing.
- Psychologic stress. A review of studies in 2000 that investigated the association between psychological stress and periodontal disease confirmed the impact of stress on the immune system. Thus, stress can probably influence chronic inflammatory diseases, like periodontitis. Psychological stress should therefore be assessed before and during treatment. As of yet, however, there is no definite proof of that stress leads to periodontal disease.
- Alcohol abuse. One study reported a higher incidence of periodontal disease, tooth decay, and possibly precancerous areas in patients at a rehabilitation center for alcohol abuse.
- Canker sores (aphthous ulcers).
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Click the icon to see an image of a canker sore. |
- Self-injury in psychologically disturbed patients.
- Hereditary gingival fibromatosis. A rare genetic disease associated with both gum overgrowth and hairiness. It is often associated with gingivitis and periodontal disease.
- Desquamative gingivitis. With this condition the outer layer of the gum tissue desquamates (peels away), exposing an acutely red surface. It usually occurs as a result of an allergic reaction or of skin diseases such as lichen planus, benign mucous membrane pemphigoid, bullous pemphigoid, and pemphigus vulgaris. (Bacteria may also play a role in this gum disease.) This condition generally resolves when the underlying problem is treated. It is fairly common in middle-aged women.
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