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 gum line, 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.
Healthy gingiva is pink in colour and the sulcus depth ranges from zero to three millimetres – measured from the tip of the gingival margin to the base of the sulcus. The attachment fibers connecting the gums to the teeth, and the teeth to the bone are intact. The gums are resilient, and neither bleed nor hurt when being probed. The gums are resilient, and neither bleed nor hurt when being probed.
During meals, food debris accumulates in the sulcus. When mixed with mouth bacteria, and proteins from saliva, plaque and less-obvious biofilm are formed. Both are harmful to teeth and periodontal structures.
Lack of proper support for the jaw joints may cause them to ache, pop and click. Periodontal bacteria can enter the body’s circulatory system through leaky blood vessels. Once inside, the bacteria can lead to blood clots, and inflamed vessels – which constrict in diameter, leading to strokes, heart attacks, and poor circulation in the extremities.
Periodontal disease begins in the “gingival sulcus,” a cuff of soft tissue around the necks of the teeth Where they emerge through the gums.
Left in place on the teeth, bacterial plaque and biofilm begin to mineralize, forming hardened deposits called “calculus” – which can only be removed with dental instruments.
In response to the increased bacteria adjacent to the soft gingiva, the body sends immune cells and healing cells to the area by way of circulation. The increased blood flow to the gingiva produces red, enlarged and tender gum tissues – a reversible condition known as “gingivitis,” in which the periodontal attachment fibers remain intact.
Continuous exposure to acids and enzymes from plaque bacteria and the body’s immune response to them eventually causes the periodontal attachment to be lost – an irreversible condition known as “periodontitis”. The sulcus depth increases to the point where the patient can no longer destruction of tooth-supporting bone.
Smoking impairs blood flow, and can significantly interfere with the patients’ ability to fight bacterial infection. Other factors may be involved.
Generalized periodontitis affects all of the teeth. They may loosen, appear unnaturally long and unattractive, and may ultimately be lost.
When multiple back teeth are lost, the front teeth may be unable to support closing forces of the jaw muscles. They begin to tip and move. The cheeks begin to collapse inward where the back teeth are missing, and the lack of proper support for the jaw joints may cause them to ache, pop and click.
Gingivitis and Periodontitis
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 a 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 the 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. The gingival crevicular fluid contains various immune proteins and cells like neutrophils, complement proteins, and antibodies.
Within the mouth, there are some 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.
Dysbiosis or State of Imbalance
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 signalling and together they create a complex system where some bacteria work on tunnelling between the microcolonies and to the surface 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 its 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 activates osteoclasts in the bone, which start to dissolve the bone supporting the tooth, loosening it even more.
Symptoms of Gingivitis
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 is usually made by looking for swollen or bleeding gums, probing 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 the use of antimicrobial agents like mouthwashes, can help prevent the formation of dental plaque, but in severe cases, antibiotics and surgery might be needed.