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Dental Health and Dementia: More than Forgetfulness

Course Number: 566

Epidemiology and Pathogenesis of Periodontal Disease

Periodontal diseases include inflammatory diseases of the supporting structures around the teeth--the gingiva, periodontal ligament, alveolar bone, and cementum.45,46 The two most common forms of periodontal disease are gingivitis and periodontitis.31 Gingivitis is a non-specific inflammatory disease associated with the accumulation of dysbiotic bacterial biofilm.47 All patients are susceptible to gingivitis with cessation of oral hygiene measures. Further, for many patients, gingivitis is a precursor to more serious, irreversible forms of periodontal diseases.47 Removal of biofilm and local etiologic factors results in the reversal of gingivitis symptoms and reduces local and systemic levels of inflammatory markers in patients with gingivitis.47-49

Periodontitis is generally believed to be a bacterially-initiated disease in which the host immune-inflammatory response results in destruction of the alveolar bone and soft tissues supporting the teeth.50,51 Periodontal disease progression is generally slow to moderate. Average clinical progression of periodontal disease is approximately 0.1mm of attachment loss and 0.2 teeth lost annually.52 In longitudinal investigations, groups with fastest and slowest disease progression differed considerably with regard to demographics and underlying health conditions.52 Increased rapidity of attachment loss is associated with decreased access to comprehensive dental care as well as certain local and/or systemic factors.52 In an updated classification system from the American Academy of Periodontitis (AAP) and European Federation of Periodontitis (EFP), individuals are classified with a Stage and Grade to characterize disease severity and risk of future disease progression.51,53 Periodontitis Stages I-IV are determined based upon a patients’ current disease presentation, including attachment loss, alveolar bone levels, and tooth loss, and the Stage may be modified by case complexity.51,53 Periodontitis Grades A-C are selected based upon risk factors and direct or indirect evidence of the pace of disease progression.51,53 The prevalence of periodontitis has been estimated to be over 42% of U.S. adults over 30 years of age.31 Of those individuals, 7.8% had severe periodontitis.31 Further, severe periodontitis was most prevalent among adults 65 years or older, Mexican Americans, non-Hispanic blacks, and smokers. 31 In fact, periodontitis prevalence among US adults is nearly 4-fold greater than that of diabetes mellitus54and over 6-fold greater than that of coronary artery disease.55 Given the highly prevalent nature of periodontitis, identification of periodontal disease and consideration during assessment and therapy for systemic diseases is critical. Disease progression and tissue destruction occurs through host-mediated inflammatory pathways,56 which may vary based upon genetic and other risk factors.57-60 The result is a chronic immune-inflammatory disease that may pose a significant systemic burden for individuals.61