Examining the relationship between gingivitis and periodontal disease

Gingivitis

Periodontal disease

Periodontitis

Onset of gingivitis

Other diseases

Four stages

There are two primary types of periodontal disease. One is described as gingivitis and is relatively mild. It can be treated successfully and usually it is done so by a brisk oral treatment. Untreated, gingivitis can proceed to develop into a more destructive periodontal disease that can affect the individual's overall health and welfare. It is much more difficult to treat and much more destructive. Many experts believe that periodontal disease is always preceded by gingivitis but several studies have provided other sources that should be considered before making such a statement.

Periodontal disease

Periodontal disease can best be described as a disease of the gums and mouth that is often times evidenced, or preceded by gingivitis. In earlier years experts often claimed that "gingivitis always precedes periodontitis" (Page & Schroeder, 1976, p. 235), but over time, that method of thinking has changed. Since that time a number of different studies have found connections between different diseases and periodontal disease, and other studies have shown that there is not necessarily a strong a connection between gingivitis and periodontal disease. This paper will examine the relationships between gingivitis and periodontal disease in an effort to determine whether the current literature confirms or negates the statement that destructive periodontal disease is not necessarily preceded by gingivitis.

Periodontitis

In preparation for that examination it is necessary to determine the difference between gingivitis and the more advanced form of periodontal disease. Gingivitis is commonly referred to as a plaque disease and is a non-destructive form of periodontal disease, it mostly concerns the plaque build-up in an individual's mouth. If it is not treated correctly, it can progress to a destructive form called periodontal disease or periodontitis. Gingivitis does not always lead to periodontitis, but when it does progress to that stage other infections and diseases can take root. One recent study showed that "periodontal disease has been linked to cardiovascular disease and to a lesser extent stroke" (Meta-anlaysis, 2003, p. 77). Another study determined that "periodontal disease is associated with an increased risk of adverse pregnancy outcomes" (Hullah, Turok, Nauta, Wai Yoong, 2008, p. 406). Theories and studies abound that link periodontal disease to other diseases, yet there seems to be few modern studies that conclusively find that gingivitis and periodontal disease go hand in hand.

One theory shows that "since bacteria are prime agents in periodontal disease, it could enter the blood stream through the cavities or contribute to the swelling of arteries" Saini, Saini, Saini, 2010, p. 159) and another article states "The suggestion has recently been made that bacterial biofilms not only are commonly associated with many chronic infections but also are much more resistant to antibiotics than freely circulating bacteria" (Costerton, Stewart, Greenberg, 1999, p. 1319). Certainly connections between periodontal disease, especially the more destructive form, can be linked to a variety of other maladies. However, that does not necessarily prove that a patient must contract periodontal disease before contracting the others. Equally as certain is the fact that gingivitis will oftentimes lead to a more destructive form of periodontal disease, and that many experts believe that it will most likely lead to that more destructive form.

Other diseases

One diabetes expert recently reported that "diabetes has long been believed to be a risk factor for periodontal disease…results of a new study show that the reverse might also be true" (Milone, 2008, p. 2). With the rising number of diabetic diagnosis throughout the world, discovering that such a disease could be a harbinger of periodontal disease is not an earth-shattering revelation, and would most certainly be a viable conclusion. It does not preclude gingivitis from being a contributing factor, but it does add an additional factor to each periodontal discovery.

Much of the literature that already states that the viewpoint that gingivitis leads to periodontal disease is not technically correct. In fact, one May 2010 study just determined that the "primary cause of periodontal diseases is dental plaque which is a whitish sticky paste that attaches on oral surfaces" (Robinson, 2010, p. 289).

Of course, a strong statement such as the one the study made would ordinarily be touted and contested from the rooftops, except that in this case the periodontal disease the study used was in animals. Does this study assist those humans who are searching for root causes amongst homosapiens? Most likely not, but the fact that the study showed plaque could be a primary reason behind periodontal diseases could be looked at from the human perspective and tested for veracity or confirmation in humans.

The current literature shows that another potential cause of periodontal disease is Sjogren Syndrome. There are "scientific production in literature concerning the correlation between SS and periodontal disease reports…(but) until 2003, researchers denied these relationships and stated that the SS onset did not have an impact on the risk of periodontal disease" (Scardina, Ruggieri, Messina, 2010, p. 290).

Scardina et al.'s study showed differently, it showed that there was a possible correlation to Sjogren Syndrome and the more destructive form of periodontal disease. Their findings preclude the statement that gingivitis always precedes periodontal disease.

These studies do not necessarily mean that gingivitis does not have any effect whatsoever on the development of periodontal disease, many of the studies do show a positive correlation. However, there are plenty of studies that show how other factors should be considered as well. One recent report showed that "the microbial etiology of gingivitis and marginal periodontitis is unanimously accepted, but several other factors have to be considered" (Paunica, Dumitriu, Mogos, Georgescu, Mogos, 2009, p. 342).

One of the strongest correlations between periodontal disease and another disease that could have heavy implications as to whether periodontal disease progresses is the correlation and relationship between diabetes and periodontal disease.

A recent study determines that "the prevalence of diabetes mellitus (DM) and periodontal disease/periodontitis (PD) is high, and the association of these two as risk factors influencing each other has been recognized and is extensively documented" (Acharya, Satyanarayan, Thakur, 2010, p. 70). This is another disease that is correlated to periodontal disease, and with that correlation is additional evidence that gingivitis does not always preclude the more destructive form of periodontal disease. Many periodontal therapists have for the last few years known and espoused the fact that patients who took care of their oral health faced far fewer health related challenges than those that did not. One 2002 study professed "health professionals need to be cognizant of the effect dental health can have on systemic diseases and refer for treatment when appropriate to ensure that optimum oral and systemic health is achieved for their patients" (Greenwell, Bissada, 2002, p 2581). Another study showed how "poor oral hygiene, gingivitis and periodontal disease are the most important risk factors for the development of white spot lesions" (Noble, 2008, p. 25). Still another study was undertaken to determine what effect, if any, daily treatment would have on the occurrence of gingivitis with the results being as what many expected. The study found that "gingivitis is often caused by inadequate oral hygiene, which leads to plaque buildup" (Type, 2008). If it were true that gingivitis always leads to periodontal disease, then it is probably safe to assume that the health of a person is almost always affected if the individual does not take care of his or her oral responsibilities. If the individual is taking care of their oral hygiene responsibilities then the four stages of periodontal disease progression could be alleviated.

Four stages

Those four stages proceed from gingivitis "used to describe soft tissue inflammatory changes" (Bellows, 2004, p. 16) and when "periodontitis is diagnosed (when) attachment loss has occurred" (Bellows, p. 16). According to Bellows there is a grading system that allows the dentist to judge how far along the disease has progressed. Depending on how far the disease is, allows for certain treatments. If done successfully, the initial stages of periodontal disease is arrested and gingivitis then no longer proceeds to the more destructive forms of the disease. Since there are four distinct stages to periodontal disease any of which could possibly be corrected, does that not also mean that contracting gingivitis (which is very prevalent in society) does not always mean that it will progress to periodontal disease and it may also mean that periodontal disease is not always preceded by gingivitis.

The fact that many of these studies tend to confirm that many very serious diseases go hand in hand with periodontal disease is just one reason why it may be necessary to conduct additional studies to confirm or negate the thesis of this paper. With the variance of doubt playing through the available literature, more conclusive findings may be appropriate. This is especially true since periodontal disease and gingivitis can both be causes of other maladies including the fact that even newborn babies can be affected. One recent study determined that "birth weight, height, and head and chest circumference of babies born of mothers with established periodontal disease were significantly lower than those who were born of mothers with healthy periodontal condition, gingivitis and initial periodontal disease" (Shirmohammadi, Pourabbas, Bilan, Chitsazi, 2009, p. 102).

This particular study provides further evidence (though certainly not conclusive in nature) that gingivitis does not necessarily precede periodontal disease. If the birth differences were more similar than what the study showed, then one could surmise that gingivitis and periodontal disease were the precursors to the more destructive levels of periodontal disease. However, since the numbers are so dissimilar, many experts could point to the findings and say that such numbers allow for some leeway regarding the question at hand.

Another study determined that an even slighter difference in gingivitis and the more advanced form of periodontal disease might be examined. The study found that the "autoimmune response to HSP60 may exert in periodontitis lesion, and suggest that perhaps subtle differences in the balance of cytokines may result in different disease expression" (Honda, Domon, Okui, Kajita, Amanuma, Yamazaki, 2006, p. 35). Knowing that a cytokine imbalance might be the source behind whether an individual develops gingivitis or the more destructive form of periodontitis might be the key to unlocking the secrets of periodontal progression. It might also provide evidence that certain cytokines not associated with gingivitis might be the reason(s) behind such progression. It might be that not only do certain cytokines reside in the gingival connective tissue, but that the plaque that builds up in those same areas is the primary source of inflammatory reactions that can bring about periodontal disease. One study that looked at the relationships of gingivitis, cytokines and other bacterial-associated gingival found that "with accumulation of plaque on teeth, it appears that a bacterial stimulus induces the expression of MCP-1 in mononuclear phagocytes and endothelial cells" (Graves, 1999, p. 482).

If it is true that the MCP-1 induces inflammatory responses then the protein found in those cells could be a source of concern regarding the progression of gingivitis. Monocyte attraction of the protein profoundly affects the gingival connective tissue.

Conclusion

The available literature abounds with examples and studies showing the connections (slight and otherwise) between periodontal disease and gingivitis. At the same time it also shows connections between, diabetes, pregnancy, smoking and non-smoking, obesity, gingivitis and the most destructive form of periodontitis. There are far too many of these connections to ignore, and far too many connections to conclusively state that gingivitis always precedes periodontal disease. Many experts may be able to point to this study or that in order to provide evidence of their particular stance, however, the wide myriad of available literature does not conclusively evidence any particular stance or viewpoint. The literature does provide a number of avenues of discovery as well as a number of contemplative ideas and thoughts for the researchers following the problem of progressive periodontal disease. Many experts have professed their own viewpoint and at the very least has provided academia with a problem that individuals can certainly sink their teeth into.