Gingivitis and periodontitis – causes, symptoms, diagnosis, treatment, pathology

Gingivitis and periodontitis – causes, symptoms, diagnosis, treatment, pathology


With gingivitis, gingiva refers to the gums,
and -itis refers to inflammation, so gingivitis is inflammation of the gums. With periodontitis, peri- means around, and
odon-, refers to the tooth, so it’s inflammation and destruction of the supporting structures
around the teeth. Broadly speaking, the two are on a spectrum
starting with simple gingivitis on one end, and if the process doesn’t get treated,
it can develop into more severe disease – periodontitis, which is on the other end of the spectrum. Let’s start by building a model of a tooth
and its surrounding structures. In the mouth, the bone beneath the bottom
row of teeth is the mandible, and the bone above the top row of teeth is the maxilla. Both bones have an alveolus, or socket, for
each tooth. The socket is lined on the inside by a periodontal
ligament. Protecting the alveolus on the outside, is
a layer of soft, supportive tissue called the gingiva, or gums, that sits on top of
the bone. The tooth itself can be roughly divided into
two parts. The first part is the root, and it sits within
the alveolus. The root is covered by a bonelike substance
called cementum, and that’s what the periodontal ligament’s fibers attach to. Next, there’s a short zone called the neck,
which is the transition between the root and the crown. The crown is the visible part of the tooth
that protrudes from the gingiva, and it’s covered in enamel. Enamel has such a high mineral content that
it’s the hardest substance in the human body. The portion of gingiva that sticks up and
is not anchored to the tooth is sometimes called the free gingiva, and the space between
the free gingiva and the crown is called the gingival crevice or gingival sulcus. A watery substance called gingival crevicular
fluid flows into this space in small amounts. Gingival crevicular fluid contains various
immune proteins and cells like neutrophils, complement proteins, and antibodies. Within the mouth there are a number of bacterial
organisms. In a healthy mouth, there is a balance of
commensal bacteria that compete with each other, and they are all kept in check by immune
factors in the mouth. Gingivitis and periodontitis represent a state
of imbalance or dysbiosis. This is when there’s a relative increase
in pathogenic bacteria either because of a lack of competition with other commensal bacteria
or because of an ineffective immune response in the mouth. The pathogenic bacteria form dental plaque
which is a sticky collection of bacteria, proteins from saliva, and dead cells from
the lining of the mouth. Individual bacteria multiply and form many
small microcolonies that coalesce, creating a layer of dental plaque – which is a type
of biofilm. Compared to a microcolony, the bacteria in
a biofilm communicate with each other via chemical signaling and together they create
a complex system where some bacteria work on tunneling between the microcolonies and
to the surface in order to bring in a steady supply of food. As an analogy, if bacteria were ants, then
a microcolony would be a tiny group of ants, each doing it’s own thing, whereas a biofilm
would be an ant farm with complex tunnels and rooms, and each ant carrying out a specialized
task. Some tooth surfaces like the portion of the
tooth just outside the gingiva are hard to brush dental plaque away from. If dental plaque above the gingiva keeps building,
the bacteria within that biofilm can invade beneath the gingiva where it becomes very
difficult to reach with brushing. Eventually, it can form a hard mass, called
a dental calculus. Dental calculus creates a nice space for bacterial
plaque formation, because it’s hard to remove, and from there bacteria can enter the gingival
sulcus and cause gingival inflammation, or gingivitis. Damaged gingival cells release inflammatory
signals that recruit neutrophils to the area, and those neutrophils can release harmful
chemicals that kill bacteria, as well as damage the nearby tissue. Fortunately, simple gingivitis is a reversible
condition, and the damaged tissue can heal over time as long as the infection is stopped
and treated. In periodontitis, the process of dysbiosis
is often more extreme – with even more disease-causing bacteria flourishing in the mouth. One classic hypothesis suggests that the first
step in periodontitis is the presence of the so-called orange-complex of bacteria, which
includes gram-negative anaerobic bacteria like Fusobacterium nucleatum and Prevotella
intermedia. Once these orange-complex bacteria are established,
the next step is the presence of the so-called red-complex of bacteria, which includes Tannerella
forsythia, Treponema denticola and, its most notorious member, Porphyromonas gingivalis
or P. gingivalis for short. Another line of thinking suggests that rather
than these red-complex bacteria being the specific culprits, it’s the overall change
in the bacterial community that these bacteria trigger that tips the scale toward periodontitis. Either way, the pathogenic bacteria within
the subgingival dental plaque create a periodontal pocket and damage gingival cells in the process. Local mast cells and nerves release chemicals
like histamine and substance P which cause dilation of local blood vessels, resulting
in swelling of the gingiva. Damaged gingival cells release additional
cytokines like interleukin-1, which brings more immune cells to the area, like neutrophils
and macrophages. The body’s immune response causes even more
damage to the gingiva and periodontal ligament, ultimately loosening the tooth. That one notorious bacterium P. gingivalis,
is also known for impairing the immune cells from effectively killing bacteria. This helps other pathogenic bacteria to overgrow
as well – kind of like a thief that destroys the police station and allows other thieves
to flourish in a city. The immune response also delivers more blood
flow to the damaged tissue, and that provides nutrients for the bacteria. Together, the bacteria and immune response
end up in a positive-feedback loop where the expanding infection causes an increased immune
response, which doesn’t destroy the bacteria but provides the bacteria with more fuel to
grow. The immune response also activate osteoclasts
in the bone, which start to dissolve the bone supporting the tooth, loosening it even more. Symptoms of gingivitis typically include redness,
swelling, and bleeding – especially after brushing or flossing. Some people though experience no symptoms,
especially in the early stages of infection. Severe disease that progresses to periodontitis
can result in tooth loss. Diagnosis of gingivitis and periodontitis
are usually made by looking for swollen or bleeding gums, probing of each gingival sulcus
to determine how deep it is, and X-rays to evaluate the bone level. With inflammation and destruction, the sulcus
becomes deeper as the periodontal pocket expands. Treatment depends on how severe the infection
is. Daily brushing and flossing, and use of antimicrobial
agents like mouthwashes, can help prevent the formation of dental plaque, but in severe
cases antibiotic and surgery might be needed. All right, as a quick recap… Gingivitis is caused by infection and inflammation
of the gingiva that can grow to involve the tooth supporting structures, which is called
periodontitis. When dental plaque builds up near the gumline,
it can allow bacteria to invade toward the root of the tooth. Diagnosis is done via visual inspection, X-rays,
and probing the gums, and treatment of severe cases may include removal of the infected
tissue, antibiotics, and surgery.

37 Replies to “Gingivitis and periodontitis – causes, symptoms, diagnosis, treatment, pathology”

  1. Many things forgotten in this video : Plaque induced gingivitis, hormonaly dependant, blood disease corelated, dermatose related, Drug induced, viral, gingivostomatitis ulcerosa, genetic, Plaque unrelated such as streps and gonococcus, alergic, traumatic or other gingivitis. Important toxins that the bacteria produce such as leukotoxin and many others.

  2. Osmosis, you guys are great. I always hope the subject I'm learning about has an Osmosis video to watch. Thank you!

  3. Anyone else suffer with really bad breath because of periodontal disease?
    Not sure if it's the disease, bacteria, or the blood from my bleeding gums.

  4. Im going to the dentist tomarrow because i keep spitting out blood and it hurts alot when i brush, my teeth feel really tight and my gums are blood red and the gum line is going up, im 100 percent sure its gingivitis

  5. I went to the dentist a few weeks ago & was diagnosed with periodontitis. didn't seem to matter how often I brushed my teeth (at least 3x a day) or flossed (at least 1x a day). Now I have to go every 3-4 months for treatment that's costing me $$$ I can't really afford w/out tightening my belt big time. Someone told me about oil pulling (swishing coconut oil around your mouth for about 15-20 minutes every day) to repair some of the damage. Tried it tonight–not a fantastic experience–but I'm desperate. I can't reverse the damage at this point but don't want to make it worse. . . .

  6. Does this mean oilpulling can help battle this stuff because it sucks out the bacteria and then you spit it out?

  7. Probing to measure pockets is old technology. I understand it caused the tissue to separate from the root of the tooth causing more serious periodontal problems. Why didn’t they show the results of the treatment? Possibly because it didn’t work and caused more serious problems? I don’t trust the doctors program now. Expect them to be more current and they don’t seem to be up to date.

  8. I’ve had gingivitis for a while, but it never went farther than that(because of regular trips to the dentist)

    About a week ago I decided to begin to treat it

    I brushed, flossed, and used mouthwash twice a day and I already notice a difference

    My gun are less swollen and red(now more of a dark pink)
    My teeth are whiter and my breath smells better my gums also now bleed a lot less

    Please remember to take care of you teeth, don’t take them for granted

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