Periodontal Disease

Periodontal disease is gingivitis (inflammation of periodontal tissues) or periodontitis (destruction of supporting connective tissues). Diagnosis is by examination and dental x-rays. Treatment initially consists of antibiotics. More advanced periodontal disease may require debridement and restorative surgery.

Geriatric Essentials

• Periodontal disease becomes common with aging; risk factors include inadequate oral hygiene, infrequent dental examinations, salivary gland dysfunction, frequent snacking, and removable partial dentures.
• Symptoms, signs, diagnosis, and treatment are similar to those in younger people.

The periodontium provides a supporting structure for teeth, including gingivae, alveolar bone, cementum, and periodontal ligaments (see Figure 104-1). Periodontal disease develops when bacteria adherent to tooth plaque penetrate periodontal tissues, leading to an inflammatory response (gingivitis; see Photo 104-4) and destruction of connective tissues (periodontitis).

The incidence of periodontal disease increases with aging, but periodontal disease is not exclusively a disorder of the elderly. Risk factors are the same as those for caries and also include type 2 diabetes, which becomes common with aging and can cause an exaggerated inflammatory response with poor healing. Additionally, drugs (eg, diuretics, anticholinergics, certain antidepressants, antipsychotics) that reduce saliva production reduce lubricatory and antimicrobial proteins that protect the oral tissues.

Symptoms and Signs

The cardinal sign of gingivitis is gingivae that bleed and are edematous. Without treatment, gingivitis can progress to periodontitis, which is destruction of alveolar bone and the periodontal ligament, resulting in loss of tooth support and increased tooth mobility. Another sign of periodontitis is deep (> 3 mm) periodontal pockets. A pocket is created when the attachments between the cementum and the alveolar ligament are lost. Progression of gingivitis to periodontitis occurs slowly and episodically, with frequent asymptomatic periods.

Diagnosis

Diagnosis is made by examination and periodic dental x-rays.

Treatment

Initial treatment is with antibiotics. The drug chosen should cover mixed anaerobic and facultative bacteria; options include tetracycline 250 mg qid for 7 to 21 days, doxycycline 100 mg bid for 14 to 21 days, metronidazole 250 mg tid for 5 to 14 days, clindamycin 300 mg qid for 7 to 10 days, and amoxicillin/clavulanate 250 mg tid for 10 to 14 days. Subtherapeutic doses of doxycycline (20 mg bid) reduce the inflammation associated with progressive destructive periodontitis and can be continued as needed for up to 9 mo after the initial course. Alternatives are local-delivery antimicrobial systems that use fibers or gels impregnated with tetracycline, doxycycline, or chlorhexidine placed at sites of gingival inflammation and periodontal breakdown. These treatments can arrest inflammation and prevent further tissue breakdown, but they do not reverse the bone destruction that has already occurred.

More advanced periodontal disease may require debridement to remove the inflammatory tissue and surgery to restore the normal gingival and bony architecture. Wound healing after periodontal surgery is slower in the elderly, but the rates for long-term healing and regeneration are probably the same as those for younger people.

Some evidence suggests that periodontal disease increases risk for cardiovascular disease, cerebrovascular disease, and aspiration pneumonia. Cause-and-effect associations have not been demonstrated. However, periodontal disease and gingivitis may produce adverse effects on other organ systems susceptible to bacterial colonization and chronic inflammation.

Prevention

Prevention involves measures applicable to all age groups and is identical to that for preventing caries. Toothbrushing becomes more important with aging because the gingivae tend to recede and more plaque accumulates between teeth. Irrigation systems (water jet oral irrigators) or a prescription antimicrobial mouth rinse (eg, 0.12% chlorhexidine gluconate) may help. Regular use of antimicrobial rinses can cause taste changes and may stain teeth and composite resin dental restorations, so daily use for > 2 wk should be supervised by a dentist. Professional prophylaxis can remove tenacious stains from teeth, but resin restorations may be permanently discolored.

This topic was last updated September 2005.