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Periodontitis: symptoms, prevention

by Josephine Andrews
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Periodontitis is a chronic inflammatory disease of the periodontium. It is usually caused by bacterial plaque (biofilm, plaque), especially in old age. As a result of the inflammation, the teeth may ache and the gums bleed more easily. If left untreated, periodontitis can also lead to tooth loss. Find out everything you need to know about the symptoms, causes and treatment of periodontitis.

Periodontitis: description

Periodontitis is a chronic inflammatory disease of the periodontium (gum bed, periodontium) that leads to a loss of periodontal supporting tissue . These include gums, cementum, periodontium and jawbones:

The cementum is a thin mineral layer that surrounds the tooth root. The root of the tooth is in a bony compartment called the alveolus. The periodontium lies between the alveolar bone and the root of the tooth. It is a kind of connective tissue whose fibers (Sharpey fibers) suspend the tooth in the alveolus. The tooth is therefore not firmly seated in its compartment – on the contrary, it can withstand different loads, such as chewing, due to the loose suspension. The gums (gingiva) close off the periodontium from the outside. The gingival groove runs between the loosely suspended tooth and the adjacent gum.

Periodontitis is characterized by three characteristics:

  • Loss of the periodontium, recognizable by the gums receding from the tooth (clinical attachment loss, CAL) and a reduction of jawbone visible on X -ray
  • Presence of periodontal pockets
  • bleeding gums

Periodontitis is considered a widespread disease – it is the most common tooth or mouth disease after caries. In principle, people of any age can develop periodontitis. However, the risk of developing the disease increases with age. People over the age of 35 are more likely to lose teeth to periodontitis than to tooth decay.

What is periodontal disease?

The term periodontal disease is an outdated term, but it is still often used colloquially. It describes the same clinical picture as periodontitis. However, some dentists also use the term for non-inflammatory gum recession (gingival recession).

forms of periodontitis

In 1999, scientists developed an international classification of periodontal diseases, which has also been recommended in Germany since 2001. Accordingly, periodontitis was classified as either chronic, aggressive, necrotizing or as a manifestation of a systemic disease. However, for a few years there has been a new classification that includes the following three forms of periodontitis :

  • periodontitis
  • necrotizing periodontitis
  • Periodontitis as a manifestation of systemic diseases

periodontitis

The vast majority of patients have a kind of simple periodontitis. The earlier categories “chronic periodontitis” and “aggressive periodontitis” are combined under this term. It has been shown that there is no scientifically sound justification for distinguishing between these two forms.

“Chronic periodontitis” (old name: adult periodontitis) used to be the name given to the most widespread, slowly progressing form of the disease, which mostly affects people over the age of 35. The much rarer, rapidly progressive “aggressive periodontitis” has been diagnosed primarily in children and young adults.

staging and grading

A patient’s periodontitis is described in more detail according to its stage (“staging”) and its degree (“grading”):

>> Staging : Staging is based on the severity of the periodontitis at the time of diagnosis and the dentist’s assessment of how complex the treatment will be. Relevant here is, for example, how much the gums have already receded from the teeth, how much bone tissue has already been lost according to X-ray findings and how many teeth have already fallen out as a result of periodontitis. Four stages are possible (stages I to IV).

>> Grading : The grade of the disease describes the (probable) progression of periodontitis, which can be slow (grade A), moderate (grade B) or rapid (grade C). For this purpose, the dentist uses the patient’s medical history (anamnesis) to assess the progress of the disease at the time of diagnosis. However, other aspects are also included in the grading. Among other things, the dentist estimates how the periodontitis will progress in the future and to what extent the general state of health of the patient and other factors (such as smoking) could have a negative impact on the disease.

Necrotizing periodontitis

Necrotizing ulcerative periodontitis (NUP) is a rare but particularly contagious form of disease that progresses rapidly. It is accompanied by pronounced bleeding from the gums, tissue death (necrosis), ulcers in the gums between the teeth and pain. In addition, there is bad breath, swollen lymph nodes and so-called pseudomembranes (formed as a result of inflammation from dead tissue cells and do not have an orderly fine-tissue structure).

NUP is based on an infection with bacteria that also romp around in the oral cavity of healthy people, but have increased excessively in the affected patients. This often happens, for example, in HIV patients with their weakened immune system. Necrotizing periodontitis is therefore sometimes also called HIV-associated periodontitis .

Necrotizing ulcerative periodontitis (NUP) and necrotizing ulcerative gingivitis (NUG) are collectively referred to as necrotizing periodontal diseases . They are different stages of the same infection: as long as the gums alone are affected, the dentist will diagnose NUG. If the inflammatory and degradation processes spread to the jawbone and the connective tissue between the root cementum and the bone (periodontal ligament), he speaks of NUP.

Periodontitis as a manifestation of systemic diseases

Sometimes periodontitis occurs as part of a systemic disease (general disease). It is not always easy to determine whether the disease causes the periodontitis or whether it contributes to the development of “normal” periodontitis caused by plaque.

It is known that the following systemic diseases can influence inflammation of the periodontium and thus contribute significantly to a loss of periodontal supporting tissue :

There are also general diseases that can influence the course of periodontitis . These include:

  • diabetes mellitus
  • Obesity (Obesity)
  • osteoporosis
  • rheumatoid arthritis and osteoarthritis
  • emotional stress and depression
  • smoking (nicotine addiction)

There are also systemic diseases that, independent of periodontitis , can lead to the destruction of the periodontium, which sometimes looks like periodontitis. This can be the case, for example, with squamous cell carcinoma in the mouth or granulomatosis with polyangiitis (Wegener’s disease) .

Periodontitis: Symptoms

Those affected by periodontitis usually have hardly any symptoms at the beginning. Pain occurs only with necrotizing periodontitis. There are no typical periodontitis symptoms (colloquially: periodontosis symptoms). However, some signs may indicate periodontitis:

  • bleeding gums
  • red and swollen gums
  • Receding gums (gingival recession)
  • exposed and sensitive tooth necks
  • foul breath
  • unpleasant taste, especially when pus drains from the inflamed areas
  • loose teeth, misaligned teeth

These signs are based on two other characteristics of the disease:

On the one hand, as mentioned above, periodontitis is usually preceded by inflammation of the gums (gingivitis), which persists and makes the gums particularly sensitive. In this case, patients also have other atypical pain when brushing their teeth.

On the other hand, the gingival groove expands due to the degradation of the periodontium, especially the alveolar bone. This furrow deepens unnoticed and periodontal pockets form. Bacteria can now penetrate even more easily and cause inflammation. As a result, there is increased bleeding, discharge of pus, bad breath and, in the advanced stage, loosening of teeth.

Periodontitis: causes and risk factors

Periodontitis usually begins insidiously with inflammation of the gums ( gingivitis ). Their main cause is poor oral hygiene :

Inadequate or incorrect tooth brushing causes deposits to form on the teeth ( plaques ), especially at the transition between the tooth and the gums. The plaques consist of food residues, saliva , bacteria and their metabolites. Initially, the rubbers are soft; over time, however, they become hard – tartar forms. Its rough surface makes it easier for bacteria to attach to teeth. In order to get the germs under control and prevent them from penetrating the tissue, the immune system starts superficial inflammatory processes in the gums – the patient has gingivitis.

From gingivitis to periodontitis

Sometimes gingivitis heals. However, if the inflammation lasts longer, it can happen that the bacteria finally defeat the body’s defenses and gain the upper hand: they penetrate deeper into the tissue, the inflammation becomes chronic and gradually spreads to the periodontium – periodontitis results:

Due to the persistent inflammation, the gums separate from the teeth and periodontal pockets form between the tooth and gums These can be several millimeters, sometimes even more than a centimeter deep and are difficult to clean. This is why bacterial plaque can easily form here, which is called calculus after hardening (similar to tartar = hardened plaque above the gums).

The calculus and bacteria in the periodontal pockets can trigger further inflammation, which gradually spreads to the various components of the periodontium. At some point, even the jawbone around the teeth can be affected and subsequently degraded. The teeth become loose and can cause problems or even pain when chewing. Finally, there is a risk of tooth loss .

Many factors are involved

Periodontitis is considered a multifactorial disease – i.e. a disease that does not have a single cause, but rather several factors are involved in its development. The immune system plays a central role here: whether someone develops periodontitis and how it progresses depends to a large extent on the body’s defenses.

The immune system is influenced by various internal and external factors, which therefore also affect the development and progression of periodontitis. These risk factors include in particular:

  • hereditary predisposition : Some people are more prone to periodontitis than others due to a hereditary predisposition. Due to a genetic defect, your body produces an excessive number of messenger substances that promote inflammation (cytokines).
  • Smoking : The risk of periodontitis is two to seven times higher in smokers than in non-smokers – the smoke weakens the body’s defenses and impairs the periodontium. And the more someone smokes, the more severe the disease. In addition, it is often only discovered later in smokers because the vasoconstrictive effect of nicotine often suppresses bleeding gums as a typical symptom. Last but not least, smoking reduces the chances of success of periodontitis treatment because it delays the healing of wounds in the mouth.
  • Diabetes : People with diabetes are also significantly more susceptible to periodontitis. Especially if the diabetes is poorly controlled (i.e. the blood sugar values ​​are too often or permanently too high), this weakens the resistance of the periodontium. As a result, inflammation occurs more frequently, which also heals poorly due to diabetes.
  • psychological stress : It weakens the immune system and can thus trigger or accelerate periodontitis.
  • Pregnancy : The hormonal changes during pregnancy can promote inflammation of the periodontium. Therefore, expectant mothers have an increased risk of periodontitis.
  • Diseases of the immune system (eg AIDS): They weaken the body’s defenses, which has a negative effect on the development and course of periodontitis.
  • Certain medications : Some medications can trigger gum growth and thus pave the way for periodontitis. This applies, for example, to antihypertensive drugs and drugs that are given after an organ transplant to counteract rejection reactions of the immune system.

Marginal and apical periodontitis

As mentioned above, periodontitis almost always develops as a result of gingivitis (often involving risk factors) and thus starts at the gum line. Then one speaks of marginal periodontitis .

Much less common is apical periodontitis , which starts at the tip of the tooth root (apex) and the surrounding tissue:

The dental pulp (dental pulp) fills the inside of the tooth and contains nerves and blood vessels. It is connected to the rest of the vascular and nervous systems as well as to the periodontium via a hole at the tip of the tooth root (foramen apicalis) and small side canals. If the tooth pulp becomes inflamed by caries, the pathogens can spread through the root canal, get into the tooth bed (periodontium) via the small side canals and also start an inflammation here – apical periodontitis develops.

Tooth-preserving measures such as root canal treatment also harbor an increased risk of periodontitis, for example due to instruments inserted too deeply. Overfilling or insufficient filling of the root canal can also lead to apical periodontitis. Last but not least, the periodontium can be damaged by a blow or impact, which can promote periodontitis.

Periodontitis: contagious?

Like any bacterial infection, periodontitis is contagious. Therefore, the life partner should also pay attention to possible periodontitis symptoms. Under certain circumstances, certain bacteria can be transmitted when kissing or sharing cutlery, drinking bottles or glasses, even if no periodontitis breaks out. This in turn depends on the risk factors involved. Caution is also required with infants: mothers and fathers with periodontitis can transmit the pathogens to their child.

Periodontitis: Diagnosis and Examination

anamnese

In order to clarify a possible periodontitis, the dentist first collects his medical history (anamnesis) in conversation with the patient. For example, he can ask the following questions:

  • Do you have a toothache in certain places? Does this pain only occur when touched?
  • Do your gums bleed often, especially after brushing your teeth?
  • How many times a day do you brush your teeth? Do you floss?
  • Have friends or relatives told you about bad breath?
  • Do some teeth feel loose?
  • Do you have any illnesses, such as rheumatism or diabetes?
  • What medications are you taking (e.g. blood thinners)?
  • Do you smoke?
  • Are you currently feeling stressed and overwhelmed?
  • Are similar complaints common in your family? Do you know about periodontitis/periodontal disease in your parents?

General assessment

Next, the doctor examines the oral mucosa, the teeth and the condition of the periodontium. He pays attention to known periodontitis symptoms such as gum pockets, exposed tooth necks or bad breath. He will also feel the nearby lymph nodes in the jaw. They can be painful and enlarged in inflammatory processes under pressure.

It is important to assess the gums: Normally, they are firmly attached to the substrate and cannot be moved. It is pale pink and is usually two millimeters above the boundary line between enamel and cementum (enamel-cementum boundary, SZG) on the tooth. However, if the gums have receded – either to the enamel-cementum junction or even below – this indicates periodontitis. Swollen and clearly reddened gums are also suspicious.

The dentist then assesses the status of the teeth. Missing or filled teeth, implants, crowns and other dentures are noted. He also checks visible tartar (plaque) and tests tooth sensitivity. To do this, he sprays cold water, especially on teeth suspected of having periodontitis.

Periodontal Screening Index (PSI)

The Periodontal Screening Index (PSI) is a special dental examination that people with statutory health insurance are entitled to every two years. The dentist (or a specially trained dental hygienist) examines the gums for periodontal pockets – in adults for each tooth, in children usually only for a lower and upper incisor and the first molars.

A special instrument is used, the WHO probe . It has a longer, angled tip that works like a ruler. The probe is marked black at a height between 3.5 and 5.5 millimeters. There is a small ball at the end of the tip.

For the examination, the dentist divides the teeth into six parts (sextants) – three sextants per jaw . Then he checks with the probe at four to six points per tooth how far he can penetrate into the gum line at the gum line. Depending on the pocket depth, five grades from 0 to 4 are possible. They are called PSI codes . Only the worst (i.e. highest) PSI code is documented for each sextant. Here’s what the codes say:

  • A PSI index of 0 means healthy gums.
  • If the dentist determines the PSI code 1 and/or 2 one or more times, this indicates gingivitis.
  • PSI code 3 indicates moderate periodontitis.
  • PSI code 4 indicates severe periodontitis.

Probing depth, BOP and PB index

In order to check whether there is a periodontal pocket and how deep it is ( probing depth ), the dentist inserts the WHO probe (or a similar probe) very carefully between the tooth and the gum. The measured probing depth says something about the inflammatory activity in the tissue.

If the gums bleed when probing, this indicates inflammation. The dentist documents this as a positive BOP ( BOP = bleeding on probing ). Healthy gums, on the other hand, do not normally bleed (BOP negative). However, the BOP index can also be positive in smokers without inflammation. The reason is the poor blood circulation in the gums caused by nicotine.

Like the BOP index, the PB index (papillary bleeding index) is also suitable for assessing the periodontium and clarifying the suspicion of periodontitis. The papillae are the free “gum tips” between adjacent teeth. If they become inflamed, they begin to bleed when gently pressed with the probe. The following applies: the heavier the bleeding, the stronger the inflammation. According to this, dentists distinguish five degrees of severity from 0 (no bleeding) to 4 (heavier, flowing bleeding).

Assessing the condition of the gums using a probe can be difficult because the probe penetrates the tissue very easily if the gums are inflamed and teeth are loose. It can thus penetrate quickly below the actual depth of the pocket. This can make it difficult for the dentist to assess the course and healing of periodontitis.

furcation involvement

In contrast to the other teeth, the front and back molars usually have more than one root. This division of a tooth root is called a furcation (e.g. two tooth roots are referred to as bifurcation). In the case of advanced periodontitis, the jawbone can also dissolve between or below the divided roots of a tooth – called furcation involvement .

To determine their severity, dentists test how far they can insert a curved probe between the forks of a tooth’s roots. There are three possible degrees of severity : If the probe can penetrate up to three millimeters, this is grade I furcation involvement. If it can penetrate deeper, it is grade II. If it is possible to probe completely between the roots, the dentist records grade III.

tooth mobility

In the case of periodontitis, the teeth become loose due to the breakdown of the periodontium – the teeth therefore become more mobile than they normally are. The dentist can determine this by measuring the static and dynamic tooth mobility:

  • Static tooth mobility : The doctor checks how far a tooth can be deflected with a probe and fingertip. Four grades are possible here – from grade 0 (normal tooth mobility) to grade 3 (the tooth can be moved back and forth by more than two millimeters with tongue and lip pressure alone).
  • dynamic tooth mobility : It indicates how well a tooth can slow down the forces acting on it (e.g. from chewing). This can be determined with a measuring device, such as the Periotest device. A measuring piston hits the occlusal surface like a plunger. The device precisely measures the time between tooth contact and deceleration.

roentgen

On X-rays, the dentist can see whether, how much and where jawbone tissue has already been broken down as a result of periodontitis. This is not only important for the precise diagnosis, but also for the planning of therapy.

Conventional X-rays involve a certain level of radiation exposure for the patient. For this reason, a more modern and low-radiation X-ray method is used in some dental practices – digital volume tomography (DVT) . With this, very precise 3D X-ray images of the jaw can be created with a low radiation dose. including all major structures such as nerves.

More tests

Further examinations may be necessary, especially if periodontitis is very severe or does not respond adequately to therapy. For example, laboratory tests can determine which types of bacteria are involved in the disease.

Other tests check the fluid in the gum line. In the case of periodontitis, typical endogenous proteins are found there – enzymes that are released by defense cells or come from dead tissue cells: In a quick test, the doctor can detect aspartate aminotransferases (released when cell death occurs), matrix metalloproteinases (from inflammatory cells) or alkaline phosphatases (from bone cells). and secure the diagnosis of periodontitis.

Genetic tests can be used to detect the genetic defect that leads to overproduction of the inflammatory messenger substance interleukin 1. However, the doctor will only arrange for this examination in very rare cases of particularly aggressive periodontitis.

Periodontal disease: treatment

Periodontal treatment requires several visits to the dentist. The dentist first explains and demonstrates to the patient what good oral hygiene looks like – including how to properly brush your teeth with a toothbrush and clean the spaces between your teeth with dental floss or interdental brushes. The dentist also takes care of cleaning the gum pockets and removing tartar.

Some periodontitis patients also require treatment with antibiotics. Surgical interventions can also be useful.

You can find out more about the various therapeutic measures for gingivitis in the article Periodontitis: Treatment .

Periodontitis: course of the disease and prognosis

The bacterial infection of the periodontium, which underlies periodontitis, can result in various complications – such as a periodontal abscess . This is an encapsulated accumulation of pus in the tooth area with pronounced tissue breakdown, which impairs the hold of the tooth. Such abscesses can form in untreated periodontitis and spread to surrounding tissue if left untreated. In addition, the bacteria involved in the abscess can spread through the bloodstream in the body.

Above all, apical periodontitis (periodontitis apicalis) can also lead to the following problems:

  • Apical granuloma : granulation tissue (vessels, nerves, connective tissue) replaces the original tissue. Growth leads to further bone and root dissolution
  • Apical cyst : A fluid-filled cavity, usually harmless.
  • Sclerosing osteitis : symptomless thickening of the bone tissue in the jaw at the expense of the bone marrow.
  • Apical abscess : Very painful and purulent inflammation. It can be acute or chronic and can spread to other parts of the body if left untreated.

sequelae

Periodontitis is considered a chronic disease that should be treated and checked at regular intervals. If you do nothing, the periodontitis bacteria and inflammatory substances can cause further damage in the body via the blood vessel system.

For example, there is a connection between periodontitis and cardiovascular diseases : periodontitis bacteria and inflammatory substances can contribute to hardening of the arteries (arteriosclerosis) and thus increase the risk of heart attack and stroke. Bacteria from the oral cavity are also often involved in inflammation of the inner lining of the heart ( endocarditis ), which usually also affects the heart valves. Patients with artificial heart valves are particularly prone to infections with periodontitis bacteria . Patients with artificial knee or hip joints are also susceptible to such infections because the bacteria can easily attach themselves to the implants.

It has been known for a long time that diabetes and periodontitis are closely related: on the one hand, diabetes promotes the development of periodontitis, especially if the blood sugar levels are poorly controlled. On the other hand, an existing periodontal inflammation can impair the effect of the blood sugar-lowering hormone insulin and thus make it difficult for diabetics to control the blood sugar level.

There are also negative effects during pregnancy : If a mother-to-be suffers from periodontitis, this can favor premature birth and a low birth weight in the child.

Periodontitis: Prevention

Various measures can prevent the development of periodontitis. They are also important in the case of an existing gum disease in order to stop it from spreading.

Brush your teeth carefully!

Careful oral hygiene can significantly reduce the risk of periodontitis. First and foremost, this includes brushing your teeth properly : brush your teeth at least twice a day, preferably in the morning and evening. In order not to attack the tooth enamel, you should always wait half an hour after eating. Also make sure to change your toothbrush regularly (every six to eight weeks), especially after an infection.

Dentists and dental assistants can show you how to brush your teeth properly and advise you on the choice of toothbrush, toothpaste, mouthwash, etc.!

Don’t forget the interdental spaces!

Interdental spaces are particularly susceptible to caries and periodontitis because they are difficult to access for a toothbrush. Therefore, use interdental brushes , dental floss or dental floss sticks to clean them . Their regular use can prevent dangerous dental plaque in the narrow spaces. If you are unsure how to use the small cleaning aids correctly, ask your dentist!

Take the preventive medical check-ups!

Even if you are not suffering from any symptoms, you should attend the six-monthly recommended check-ups at your dentist. This is because periodontitis symptoms often only appear when the disease has already progressed. During the check-up, the teeth and gums are carefully checked. The earlier periodontitis is detected, the easier it is to stop.

If you have already had periodontitis or are at increased risk of it, you should have your teeth cleaned professionally at regular intervals . The dentist (or dental hygienist) carefully removes the bacterial plaque – including in the spaces between the teeth – and smoothes the tooth surfaces by polishing. It also makes sense to fluoridate the teeth, especially on endangered tooth surfaces (e.g. exposed tooth necks), in order to make the tooth enamel harder and thus more resistant.

You can discuss the number of annual professional tooth cleanings with your dentist. Please note that the costs for the PZR are not covered by statutory health insurance.

Quit smoking!

Smoking impairs the blood circulation in the gums and is therefore a decisive risk factor for the development of periodontitis. So you better stop it or at least limit your tobacco consumption to prevent periodontitis. It is also advisable to abstain from smoking if you already have inflammation of the gums – it makes treatment easier and reduces the risk of further dental and other diseases.

Eat a balanced diet!

A healthy, balanced diet can prevent periodontitis. Make sure you don’t eat candy, chocolate, or other sugary foods and drinks throughout the day. Too much sugar attacks the teeth, promotes tooth decay and ultimately also increases the risk of periodontitis. Ideally, you should snack with the main meals and pay attention to thorough oral hygiene in the evening.

If you are clearly overweight, you should consult a nutritionist or an appropriate counseling center.

Have known diseases treated!

The development and course of periodontitis also depend on the general state of health: A weakened immune system increases the risk of periodontitis. The connection between some diseases such as diabetes and periodontitis has been scientifically proven. If you have an illness, you should ask your dentist whether this can increase your risk of periodontitis and whether you should therefore pay particular attention to preventive measures.

For example, as a diabetic, you should make sure that your blood sugar levels are well adjusted. Calcium and vitamin D are recommended for women with osteoporosis . If you have any questions about this, you can contact your family doctor or a specialist in internal medicine.

risk of relapse

There are various factors that influence the risk of periodontitis (recurrence). The researchers Lang and Tonetti have presented a model that divides patients into three risk groups. For this purpose, a dentist determines various values ​​and as a result receives a low, moderate or high risk of recurrence for the respective patient:

  • Bleeding tooth surfaces : If more than 25 percent of the examined teeth bleed after a probing (BOP), the patient has a high risk of developing periodontitis again. At less than ten percent, the risk is low.
  • Probing depth over five millimeters : This value usually only influences the risk of periodontitis recurrence in connection with other factors (such as BOP). Teeth with a gingival groove that is more than five millimeters deep can remain stable in the mouth for a long time. The risk of recurrence increases as the number of bags in the mouth increases. From eight pockets, the scheme of Lang and Tonetti indicates a high risk.
  • Tooth Loss : Patients who have lost more than eight teeth due to previous illnesses or accidents are at high risk of periodontitis recurrence. This risk remains low with up to four missing teeth.
  • Bone loss/age : Using an X-ray, the doctor determines the ratio of bone loss to root length and divides the result by the patient’s age. The calculated value provides information about the risk of periodontitis recurrence: a value between 0 and 0.5 indicates a low risk, a value between 0.5 and 1.0 indicates a moderate risk and a result above 1.0 indicates a high risk.
  • Underlying diseases : Some underlying diseases increase the risk of periodontitis (again), eg poorly controlled diabetes, rheumatism and HIV. But a genetic predisposition, through which the body produces and releases excessively pro-inflammatory substances, for example, also plays a role.
  • Smoking : Former smokers who have stopped smoking for more than five years and non-smokers have a low risk of recurrence. Anyone who smokes up to 19 cigarettes a day has a moderate risk. If patients smoke more than 20 cigarettes a day, the risk of periodontitis increases significantly.

With the help of this scheme, an individual overall risk can be calculated for each patient. The number of recommended annual appointments for supportive periodontitis therapy (SPT) is primarily based on the result .

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