Periodontitis is a major public health problem that is poorly understood and requires significant behavioural change... which is why community pharmacy is well placed to tackle it

 

 

Far from being a purely cosmetic problem, periodontitis is the leading cause of tooth loss and has been linked with life-threatening diseases, including heart disease, stroke and diabetes. NHS figures state that around 10 to 15 per cent of UK adults have severe periodontitis, but at least half have its forerunner – gingivitis. In fact, the latest Adult Dental Health Survey (2009) for the Office for National Statistics found that up to 83 per cent of the population have some signs of gum disease.

Periodontitis occurs when gingivitis progresses to the tissues that join the teeth to the gums (the periodontium) and the supporting bone. As a result, a pocket forms between tooth and gum, which over time can cause the tooth to loosen and eventually fall out. The first sign of gum disease is usually bleeding gums during brushing, while the gums may appear red and swollen. Other symptoms include a bad taste in the mouth, halitosis, pain, loose teeth and difficulty eating. But in most cases, periodontitis progresses gradually and painlessly, with no obvious symptoms.

The majority of Britons could improve their oral health routine

Dentists should check for signs of gum disease, but a recent YouGov survey found that 20 per cent of dentists do not regularly inspect their patients’ gums during dental check-ups.

“Periodontitis is a silent disease; the majority of people do not know that they have it, but it is devastating if not diagnosed and treated early,” says Professor Iain Chapple, head of periodontology at the University of Birmingham School of Dentistry. “It has a significant negative impact on quality of life. It causes aesthetic and speech issues, as well as eating difficulties, which can lead to poor nutritional status.”

Risk factors

The British Dental Health Foundation (BDHF) says that gum disease is always caused by a build-up of plaque on the teeth. A poor oral hygiene routine is therefore a major risk factor, but there are other factors involved. Smoking increases the risk by raising the level of harmful bacteria in plaque, as well as reducing blood flow to the gums and periodontium, making them more prone to inflammation.

People with diabetes and those with an impaired immune system, such as cancer patients undergoing chemotherapy or people with HIV, are also more vulnerable to the disease. Dry mouth (xerostomia) is another risk factor, as saliva helps to control levels of oral plaque.

However, according to Professor Chapple, around half of periodontitis cases have a genetic basis. Plaque and genetics are the main risk factors for periodontitis, he says. “Every patient is different in the level of plaque reduction needed to control or prevent periodontitis. A lucky 10 per cent of the population are resistant to periodontitis although their teeth may be covered with plaque, while some with high oral hygiene levels and very little plaque will still get periodontitis.”

This theory is backed up by findings from the latest Adult Dental Health survey. Three-quarters of adults who took part reported brushing their teeth twice a day, while 78 per cent had been told or shown how to clean their teeth by a dental professional.

Despite this, 45 per cent had periodontal pocketing of more than 4mm, indicating early periodontitis, while a further 8 per cent had moderate periodontitis (4-6mm) and 7 per cent had extensive periodontitis (6-9mm) – suggesting that oral hygiene alone is not always sufficient at preventing periodontitis. That said, the survey also showed that the majority of Britons could improve their oral health routine. Just 31 per cent of people regularly used mouthwash and only 22 per cent used floss or interdental brushes.

Treatment and prevention

Gum disease can be prevented and treated in cases where pockets measure up to 3mm by practising good oral hygiene. Deeper pockets require dental treatment, as brushing alone will not reach the bottom. NHS Choices and the BDHF advise:

• Brushing for two to three minutes twice a day
• Using an electric toothbrush if possible
• Using toothpaste containing fluoride
• Cleaning between the teeth with floss or interdental brushes.

“We recommend three simple steps to help avoid dental disease: Brush teeth twice a day for two minutes using fluoride toothpaste, cut down on sugary foods and drinks, and visit the dentist as often as they recommend,” says BDHF chief executive Dr Nigel Carter.

While this is simple in theory, according to Chapple, treating gum disease requires a great deal of patient education and motivation. He argues that individuals with severe periodontitis or those who are genetically susceptible to the disease may have to brush for longer than the recommended two to three minutes.

“We have to ask patients to change their behaviour and this can be very difficult,” he says. “A significant number of people don’t brush every day or twice a day and two minutes twice a day is not long enough for a patient with periodontitis. I tell patients at high risk of periodontitis to brush for five to six minutes twice a day. This is challenging and takes commitment; it is simply not a priority for many people.”

Using an antiseptic mouthwash helps to prevent gum disease by controlling plaque build-up, while mouthwashes containing chlorhexidine can be recommended for the management of gum disease and gum infections. Chlorhexidine is not suitable for women who are pregnant or breastfeeding, and should only be used for short periods – Chapple advises two to three days – as regular use can cause tooth staining. AE (ethyl lauroyl arginate) offers an alternative to chlorhexidine that doesn’t cause staining and is suitable for regular use.

 

 

Systemic disease links

An increasing body of research has shown that periodontal disease has co-morbidities with systemic diseases, including heart disease, stroke and diabetes, making it a significant public health problem. Up to 91 per cent of patients with heart disease in the US have periodontitis, compared to 66 per cent of people with no heart disease.

Some experts dispute that there is a causal link between cardiovascular disease and gum disease, arguing that any co-morbidity is due to the fact that the conditions have similar risk factors. But according to the BDHF, Streptococcus bacteria can enter the circulation via periodontal pockets where they provoke an inflammatory response, which, in turn, promotes the development of atherosclerosis.

There is growing evidence to support this theory, including a study published in the Journal of the American Heart Association in November 2013, which found that the risk of atherosclerosis reduced as gum health improved, while atherosclerosis indicators increased in line with a decline in periodontal hygiene.

In the case of diabetes, inflammation that starts in the mouth may impair the body’s ability to regulate blood glucose. Conversely, high blood glucose promotes bacterial growth, making periodontitis a complication of diabetes. A study published in the Journal of Periodontology in 2007 revealed that advanced forms of gum disease could contribute to the development of pre-diabetes – a precursor of type 2 diabetes.

Periodontal disease has also been associated with asthma. A 2013 study in the Journal of Periodontology suggested that adults with gum disease were five times more likely to develop asthma than those without, even when other factors such as age, body mass index and smoking were taken into account.

There is also a strong link with pregnancy complications, miscarriage and pre-term birth, while other links have been suggested with psoriasis, rheumatoid arthritis, impotence and some types of cancer. “Periodontitis is the commonest chronic human inflammatory disease and it increases the risk of inflammation in other areas,” explains Chapple.

Awareness of links between oral health and systemic health is low. Sixty-seven per cent of women did not believe gum disease could increase the risk of premature birth in a survey during last year’s National Smile Month. “People see the health of their mouth and the health of their body as two very different things, but it is becom- ing increasingly clear that this just isn’t the case,” says Nigel Carter.

A good oral care routine requires commitment...

Health inequalities

According to Chapple, gum disease is more prevalent in lower socio-economic groups. In its oral health inequalities policy, the British Dental Association (BDA) states that “an unacceptable and growing chasm exists in the UK between those with good and poor dental health”. It argues that improving oral health should be part of the Government’s wider public health strategy.

“Pharmacists are the first line of defence. A lot of patients won’t go to see a dentist or will only go when they have trouble, but they might seek advice at the pharmacy for bleeding gums, for example,” says Chapple. “Pharmacists are a huge untapped resource; people need to know which mouthwash to use and how to floss or use interdental brushes – and pharmacists are ideally placed to provide this information.”