Symptoms of periodontal disease include red and swollen gums, gums that bleed while brushing, persistent bad breath, receding gums, and loose teeth. Smoking, certain illnesses (such as diabetes), older age, stress, and other factors increase the risk for periodontal disease.
If you have periodontal disease, your dentist may refer you to a periodontist, a dentist who specializes in treating this condition. Without proper treatment, periodontal disease can lead to tooth loss.
Consistent good dental hygiene can help prevent gingivitis and periodontitis. If you smoke, you should quit. Smoking is a major risk factor for gum disease. The American Dental Association recommends that everyone:
Scaling and root planing is the first approach for treating periodontal disease. This procedure is a deep cleaning to remove bacterial plaque and calculus (tartar). Scaling involves scraping tartar from above and below the gum line. Root planing will smooth the root surfaces of the teeth. Your dentist will reevaluate the success of this treatment in follow-up visits. If deep periodontal pockets and infection remain, periodontal surgery may be recommended.
Periodontal disease and heart disease share certain common risk factors, such as smoking and diabetes. Untreated or inadequately controlled moderate-to-severe periodontal disease may increase the risk for heart disease. However, according to the American Heart Association:
In general, periodontists and cardiologists recommend that:
Periodontal disease is disease of both gums and bone. The word "periodontal" means "around the tooth." Periodontal disease is a an inflammatory disease of the gum and tissues that surround and support the teeth. If left untreated, periodontal disease will lead to bone loss, which can lead to tooth loss.
The periodontium is the part of the mouth that consists of the gum and supporting structures. It is made up of the following parts:
The structure of the tooth includes outer layers made of enamel and cementum. The inner layers include dentin, pulp and other tissues, blood vessels, and nerves. The cementum covers the root and is embedded in the bony jaw. Above the gum line, the tooth is protected by the hard enamel shell.
Periodontal diseases are generally divided into two groups:
Gingivitis is an inflammation of the gingiva, or gums. It is characterized by tender, red, swollen gums that bleed easily and may cause bad breath (halitosis). Gingivitis can be treated by good dental hygiene, proper diet, and stopping smoking. Untreated gingivitis can lead to periodontitis.
Periodontitis is an inflammation of the supporting tissues of teeth that occurs when the gum tissues separate from the tooth and sulcus, forming periodontal pockets. Periodontitis is characterized by:
There are different forms of periodontal disease. The most common include:
Chronic periodontitis is the most common type of periodontitis. It can begin in adolescence but the disease usually does not become clinically significant until people reach their mid-30s.
Aggressive periodontitis, as the name suggests, begins fast and damages quickly. It can occur as early as childhood and can lead to severe bone loss and tooth loss by the time people reach their early 20s.
Periodontitis can also be associated with a number of systemic diseases, including type 1 and type 2 diabetes, Down syndrome, AIDS, rheumatoid arthritis, and several rare disorders of white blood cells.
Necrotizing Periodontal Disease
Acute necrotizing ulcerative gingivitis (ANUG) is an uncommon acute infection of the gum tissue. It is characterized by painful and bleeding gums, bad breath, and rapid onset of pain. If left untreated, necrotizing periodontal disease can spread throughout the facial areas (cheeks, jaw) and cause extensive damage. Necrotizing periodontal disease is usually associated with stress or systemic health conditions such as AIDS and malnutrition.
Periodontal disease is caused by dental plaque, which contains harmful bacteria. The mouth is full of bacteria but they tend to be harmless varieties. Periodontal disease usually develops because of an increase in bacteria quantity in the oral cavity and a change in balance from harmless to disease-causing bacteria. These harmful bacteria increase in mass and thickness until they form a sticky residue called plaque.
Plaque begins to form within a minute after you finished brushing your teeth. Plaque is a type of biofilm, composed of bacteria encased in a sticky extracellular matrix. When plaque growth accumulates to excessive levels, it will cause inflammation and infection of periodontal structures.
When plaque is allowed to remain in the periodontal area, it becomes mineralized and transforms into calculus (commonly known as tartar). This material has a rock-like consistency and grabs onto the tooth surface. Tartar is much more difficult to remove than plaque, which is a soft mass. Once tartar has formed, it must be professionally removed by a dental practitioner.
Most adults have some form of gum disease but are unaware of it. The main risk factors for periodontal disease include:
Periodontitis typically occurs as people get older and is most common after age 35.
Smoking is the major preventable risk factor for periodontal disease. Smoking can cause bone loss and gum recession even in the absence of periodontal disease. The risk for periodontal disease increases with the number of cigarettes smoked per day. Smoking cigars and pipes carries the same risks as smoking cigarettes.
Smokeless tobacco will cause localized damage to gums in the area where the tobacco is held in the mouth. It will also change the soft tissue cells to become pre-cancerous. Smokeless tobacco may cause oral cancer.
Long-term abuse of alcohol and certain types of illegal drugs (amphetamines) can damage gums and teeth.
Malnutrition is a risk factor for periodontal disease. A healthy diet, including eating fruits and vegetables rich in vitamin C, is important for good oral health.
Psychological stress can cause the body to release inflammatory hormones that may trigger or worsen periodontal disease. In addition, when people are feeling stressed out they tend to take poorer care of their health, including regular brushing and flossing.
Female hormones affect the gums, and women in particular are susceptible to periodontal problems.
Gingivitis may flare up in some women a few days before they menstruate, when progesterone levels are high. Gum inflammation may also occur during ovulation. The female hormone progesterone dilates blood vessels, which causes inflammation and blocks the repair of collagen, the structural protein that supports the gums.
Hormonal changes during pregnancy can cause gingivitis or aggravate existing gingivitis. Gingivitis typically worsens around the second month of pregnancy and reaches a peak in the eighth month. Pregnancy-related gingivitis usually resolves within a few months of delivery. Because periodontal disease may increase the risk for low-weight infants and cause other complications, it is important for pregnant women to see a dentist.
Estrogen deficiency after menopause reduces bone mineral density, which can lead to bone loss. Bone loss is associated with both periodontal disease and osteoporosis (loss of bone density). The hormonal changes associated with menopause can cause dry mouth (xerostomia), which can lead to tooth and gum problems.
Periodontal disease often occurs in members of the same family. Genetic factors play a role in making some people more susceptible to periodontal disease. This is most true with aggressive periodontitis. If one child is found to have periodontal disease, all siblings should be checked for the disease.
There is a strong two-way association between diabetes (both type 1 and 2) and periodontal disease. People with diabetes who have poorly controlled blood sugar (glucose) levels are at high risk of developing many kinds of infections, including periodontal disease. There is also evidence that periodontal disease may adversely affect blood sugar (glycemic) control, which can increase the risk for other health complications.
Periodontal disease and heart disease share common risk factors (smoking, older age, diabetes) but it is not yet clear if having one condition increases the risk of developing the other (see Complications section of this report).
Other Medical Conditions
A number of medical conditions can increase the risk of developing gingivitis and periodontal disease. They include conditions that affect the immune system such as HIV/AIDS, leukemia, Down syndrome, and autoimmune disorders (Crohn disease, multiple sclerosis, systemic lupus erythematosus). There is also evidence that severe periodontal disease may increase the risk of developing certain autoimmune disorders, such as rheumatoid arthritis.
Gingival overgrowth can be a side effect of many drugs including certain types of oral contraceptives, antidepressants, and heart medications. Any drug that has a side effect of dry mouth can increase the risk for gum disease.
If you take a bisphosphonate drug such as alendronate (Fosamax) discuss with your dentist any potential risks from dental procedures (such as extractions and implants) that involve the jawbone.
Oral bisphosphonates, which are used to treat osteoporosis, have in rare cases caused osteonecrosis (bone destruction) of the jaw. (Intravenous bisphosphonates, which are used in cancer treatment, are more likely to cause osteonecrosis.) Your dentist or oral surgeon may need to take special precautions when performing dental surgery. In any case, be sure to inform your dentist of all medications you take.
Lack of oral hygiene, such as not brushing or flossing regularly, encourages bacterial buildup and plaque formation.
Poorly Contoured Restorations
Poorly contoured restorations (fillings or crowns) that provide traps for debris and plaque can also contribute to periodontitis.
Abnormal tooth structure can increase the risk for periodontal disease.
Wisdom teeth, also called third molars, can be a major breeding ground for the bacteria that cause periodontal disease. Periodontitis can occur in wisdom teeth that have broken through the gum as well as teeth that are impacted (buried). Adolescents and young adults with wisdom teeth should have a dentist check for signs of periodontal disease.
Researchers are studying the association between periodontal disease and heart disease. These two conditions share common risk factors (such as smoking and diabetes). However, some studies suggest that the link between periodontal disease and heart disease involves more than shared risk factors. An inflammatory response, which occurs in both periodontal disease and heart disease, may be the common element.
According to the American Heart Association, there is currently not enough evidence to prove that periodontal disease increases the risk for heart disease or stroke, or that treating gum disease can help prevent these cardiac conditions. The U.S. Preventive Services Task Force does not recommend including periodontal disease among the factors used for estimating a healthy person's risk of developing heart disease.
Cardiologists and periodontists currently encourage each other to monitor both conditions in their patients. Periodontists recommend that people who have periodontal disease and at least one risk factor for heart disease have an annual medical exam to check their heart health. Cardiologists suggest that people with atherosclerosis and heart disease have regular periodontal exams.
Diabetes is not only a risk factor for periodontal disease. Periodontal disease itself can worsen diabetes, both type 1 and type 2, and make it more difficult to control blood sugar.
Bacteria that reproduce in the mouth can also be carried into the airways in the throat and lungs, increasing the risks for respiratory diseases such as pneumonia. These bacteria can also worsen chronic lung conditions such as emphysema.
Bacterial infections that cause moderate-to-severe periodontal disease in pregnant women may increase the risk for premature delivery and low birth weight infants. The bacteria from gum disease and tooth decay may trigger the same factors in the immune system that cause premature dilation and contractions.
Women should have a periodontal examination before becoming pregnant or as soon as possible thereafter. Because women with diabetes are at higher risk for periodontal disease, it is especially important that they see a dentist early in pregnancy. Doctors are still not sure if treating periodontal disease can improve birth outcomes. In any case, periodontal treatment is safe for pregnant women.
Symptoms or periodontal disease typically progress over time and include:
Abnormally bulging, protruding, or swollen gums are a possible sign of disease.
Pain is usually not a symptom, which partly explains why the disease may become advanced before treatment is sought and why some people avoid treatment even after periodontitis is diagnosed.
The dental practitioner typically performs a number of procedures during a routine dental exam to check for periodontal disease. If periodontal disease is suspected, your dentist may refer you to see a periodontist. A periodontist is a dentist who specializes in the diagnosis and treatment of periodontal disease.
The dentist will first take a medical history to reveal any past or present periodontal problems, and any medications or underlying diseases that might be contributing to the problem. The dentist will also ask questions about your daily oral hygiene regimen (brushing, flossing).
Inspection of the Gum Area
The dentist inspects the color and shape of gingival tissue on the cheek (buccal) side and the tongue (lingual) side of every tooth. Redness, puffiness, and bleeding upon probing indicate inflammation and possible periodontal disease.
Periodontal Screening and Recording (PSR)
PSR is a painless procedure used to measure and determine the severity of periodontal disease:
These measurements help determine the condition of the connective tissue and amount of gingival overgrowth or recession.
Testing Tooth Movement
Tooth mobility is determined by pushing each tooth between two instrument handles and observing any movement. Mobility is a strong indicator of bone support loss.
X-rays are taken to show any loss of bone structure supporting the teeth.
According to the American Academy of Periodontology, treatment for periodontal disease should focus on achieving oral health in the least invasive and most cost-effective manner. Your dentist or periodontist will usually begin with a non-surgical approach (scaling and root planing), then reevaluate your condition in follow-up visits. If infection or deep periodontal pockets remain, surgical treatment may be recommended.
Periodontal treatment approaches can basically be categorized as:
In addition to treatment in a dentist office, regular dental visits and cleanings (usually every 3 months for the first year and every 4 to 6 months thereafter, if the disease is eradicated) are important for maintenance as is practicing good oral hygiene at home.
Scaling and Root Planing
Scaling and root planing is a deep cleaning to remove bacterial plaque and calculus (tartar). It is the cornerstone of periodontal disease treatment and the first procedure a dentist will use. Scaling involves scraping tartar from above and below the gum line. Root planing will smooth the root surfaces of the teeth.
The dentist may apply a topical anesthetic or inject a local anesthetic to numb the area before beginning the procedure. Both ultrasonic and manual instruments are used to remove calculus. The ultrasonic device vibrates at a high frequency and helps loosen and remove calculus. A high-pressure water spray is then used to flush out the debris.
The dentist will use manual instruments called scrapers and curettes to scrape away any remaining plaque or calculus and smooth and clean the tooth crown and root surfaces. Finally, the dentist will polish the tooth using abrasive paste that also has fluoride applied to a spinning instrument with a rubber cap. Polishing produces a smooth surface, making it temporarily harder for plaque to adhere.
At the time of scaling and root planing, your dentist may recommend the use of antibiotic medications.
Antibiotics for periodontal disease come in various forms. They may be taken as a prescription mouthwash rinse, or placed topically directly into the pockets being treated as dissolving gels, threads, or microchips into the periodontal pockets. In some cases, the dentist may prescribe a short course of systemic antibiotics with low-dose tetracycline, doxycycline, or amoxicillin with metronidazole.
Flap Surgery (Periodontal Pocket Reduction)
Surgery allows access for deep cleaning of the root surface, removal of diseased tissue, and repositioning and shaping of the bones, gum, and tissues supporting the teeth. The basic procedure is known as flap surgery. It is performed under local anesthesia and involves:
For several days following surgery, you should rinse your mouth with warm salt water to help reduce swelling. Post-surgical discomfort is usually treated with over-the-counter medications such as ibuprofen or the application of ice packs.
In cases of excessive gingival recession, the periodontist may perform a gum (gingival) graft to cover the area of exposed root. There are various ways to perform the tissue graft:
A synthetic graft has also been developed, however, various studies have shown that bone additives and growth factors give better results than synthetic grafts.
In some cases of severe bone loss, the surgeon may attempt to encourage regrowth and restoration of bone tissue that has been lost through the disease process. This involves bone grafting:
Guided tissue regeneration is a more advanced technique that may be used along with bone grafting:
A surgical procedure performed to expose more of the tooth. It involves readjusting the gum and bone levels by removing small sections of bone and resewing the gums into a new position to allow more tooth exposure.
An option for people who have lost teeth to periodontal disease. Dental implants are an artificial type of tooth root used for permanent prosthetic teeth. Implants are screws placed into the jawbone. Prosthetic teeth are attached to the implants.
In addition to regular visits to a dentist, the best prevention for periodontal disease takes place at home. Healthy habits and good oral hygiene, including daily brushing and flossing, are critical in preventing gum disease and maintaining good oral health after periodontal treatment.
Correct tooth brushing is the first defense against periodontal disease. Here are some tips for brushing correctly:
If brushing after each meal is not possible, rinsing the mouth with water after eating can help reduce bacteria.
A vast assortment of brushes of varying sizes and shapes are available, and each manufacturer makes its claim for the benefits of a particular brush. Look for the American Dental Association (ADA) seal on both electric and regular brushes.
Electric toothbrushes, particularly those with a stationary grip and revolving tufts of bristles, can be helpful, especially for people with physical disabilities. However, in general, studies have reported no major differences between electric and manual toothbrushes in their ability to remove plaque. If a regular toothbrush works, it isn't absolutely necessary to buy an electric one.
The major benefit of electric toothbrushes is that you do not have to be a good brusher to remove the plaque. The other benefit is that most electric brushes have a built-in timer, which identifies when the recommended time to brush your teeth (2 minutes) is up. Most people who brush manually do not brush their teeth long enough.
The most important factor in buying any toothbrush, whether electric or manual, is to choose one with a soft head. Soft bristles get into crevices easier, do not irritate the gums and are gentler on the enamel, thereby reducing the risk of exposing teeth below the gum line compared to hard brushes.
Be sure to rinse your toothbrush with water after each use. Toothbrushes should be replaced every 1 to 3 months. Worn bristles are less effective at removing plaque, and old toothbrushes may become breeding grounds for bacteria. To prevent the spread of infection, never share toothbrushes.
The use of dental floss, either waxed or unwaxed, is critical in cleaning between the teeth where the toothbrush bristles cannot reach. You can floss before or after brushing; what is important is to floss daily. To floss correctly:
If you have trouble flossing, some devices may help:
Toothpastes are a combination of abrasives, binders, colors, detergents, flavors, fluoride, humectants, preservatives, and artificial sweeteners. Avoid highly abrasive toothpastes, especially if your gums have receded. The objective of a good toothpaste is to reduce the development of plaque and eliminate periodontitis-causing bacteria.
Ingredients contained in toothpastes may include:
Antimicrobial mouthwashes help prevent and reduce plaque and gingivitis. Fluoride mouthwashes help provide additional protection against tooth decay:
A well-balanced and nutritious diet is important for good oral health. Limit sugary foods and between-meal snacks. Be sure to brush and floss after every meal. It is also important to drink lots of water to help increase saliva and flush away plaque.
Smoking, and any kind of tobacco use, is a main risk factor for periodontal disease. For smokers, quitting is one of the most important steps toward regaining periodontal health.
Try to incorporate relaxation technique or other stress management strategies into your life. Emotional and psychological stress play a role in periodontal disease.
Aarabi G, Eberhard J, Reissmann DR, Heydecke G, Seedorf U. Interaction between periodontal disease and atherosclerotic vascular disease--fact or fiction? Atherosclerosis. 2015;241(2):555-560. PMID: 26100678 www.ncbi.nlm.nih.gov/pubmed/26100678.
Ameet MM, Avneesh HT, Babita RP, Pramod PM. The relationship between periodontitis and systemic diseases - hype or hope? J Clin Diagn Res. 2013;7(4):758-762. PMID: 23730671 www.ncbi.nlm.nih.gov/pubmed/23730671.
American College of Obstetricians and Gynecologists Women's Health Care Physicians; Committee on Health Care for Underserved Women. Committee Opinion No. 569: oral health care during pregnancy and through the lifespan. Obstet Gynecol. 2013;122(2 Pt 1):417-422. PMID: 23969828 www.ncbi.nlm.nih.gov/pubmed/23969828.
American Dental Association. Brushing your teeth. Mouthhealthy.org website. www.mouthhealthy.org/en/az-topics/b/brushing-your-teeth. Accessed June 2, 2017.
American Heart Association. Dental health and heart health. Heart.org website. www.heart.org/HEARTORG/HealthyLiving/Dental-Health-and-Heart-Health_UCM_459358_Article.jsp#main. Accessed June 2, 2017.
Bascones-Martínez A, González-Febles J, Sanz-Esporrín J. Diabetes and periodontal disease. Review of the literature. Am J Dent. 2014;27(2):63-67. PMID: 25000662 www.ncbi.nlm.nih.gov/pubmed/25000662.
Centers for Disease Control and Prevention. Community water fluoridation. CDC.gov website. www.cdc.gov/fluoridation/index.html. Updated October 4, 2016. Accessed June 2, 2017.
Chapple IL, Genco R; Working group 2 of the joint EFP/AAP workshop. Diabetes and periodontal diseases: consensus report of the joint EFP/AAP workshop on periodontitis and systemic diseases. J Clin Periodontol. 2013;84(4 Suppl):S106-S112. PMID: 23631572 www.ncbi.nlm.nih.gov/pubmed/23631572.
Eberhard J, Jervøe-Storm PM, Needleman I, Worthington H, Jepsen S. Full-mouth treatment concepts for chronic periodontitis: a systematic review. J Clin Periodontol. 2008;35(7):591-604. PMID: 18498383 www.ncbi.nlm.nih.gov/pubmed/18498383.
Friedewald VE, Kornman KS, Beck JD, et al. The American Journal of Cardiology and Journal of Periodontology Editors' Consensus: periodontitis and atherosclerotic cardiovascular disease. Am J Cardiol. 2009;104(1):59-68. PMID: 19576322 www.ncbi.nlm.nih.gov/pubmed/19576322.
Javed F, Warnakulasuriya S. Is there a relationship between periodontal disease and oral cancer? A systematic review of currently available evidence. Crit Rev Oncol Hematol. 2016;97:197-205. PMID: 26343577 www.ncbi.nlm.nih.gov/pubmed/26343577.
Klokkevold PR. Treatment of aggressive and atypical forms of periodontitis. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, eds. Carranza's Clinical Periodontology. 12th ed. St Louis, MO: Elsevier Saunders; 2015:chap 40.
Laudenbach JM, Simon Z. Common dental and periodontal diseases: evaluation and management. Med Clin North Am. 2014;98(6):1239-1260. PMID: 25443675 www.ncbi.nlm.nih.gov/pubmed/25443675.
Lee JH, Shin MS, Kim EJ, Ahn YB, Kim HD. The association of dietary vitamin C intake with periodontitis among Korean adults: Results from KNHANES IV. PLoS One. 2017;12(5):e0177074. PMID: 28489936 www.ncbi.nlm.nih.gov/pubmed/28489936.
Lockhart PB, Bolger AF, Papapanou PN, et al. Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association?: a scientific statement from the American Heart Association. Circulation. 2012;125(20):2520-2544. PMID: 22514251 www.ncbi.nlm.nih.gov/pubmed/22514251.
Lula EC, Ribeiro CC, Hugo FN, Alves CM, Silva AA. Added sugars and periodontal disease in young adults: an analysis of NHANES III data. Am J Clin Nutr. 2014;100(4):1182-1187. PMID: 25240081 www.ncbi.nlm.nih.gov/pubmed/25240081.
Mark AM. Diabetes and oral health. J Am Dent Assoc. 2016;147(10):852. PMID: 27528509 www.ncbi.nlm.nih.gov/pubmed/27528509.
Michaud DS, Liu Y, Meyer M, Giovannucci E, Joshipura K. Periodontal disease, tooth loss, and cancer risk in male health professionals: a prospective cohort study. Lancet Oncol. 2008;9(6):550-558. PMID: 18462995 www.ncbi.nlm.nih.gov/pubmed/18462995.
National Institute of Dental and Cranofacial Research. Periodontal (gum) disease: causes, symptoms, and treatments. Nidcr.nih.gov website. www.nidcr.nih.gov/OralHealth/Topics/GumDiseases/PeriodontalGumDisease.htm. Updated September 2013. Accessed June 2, 2017.
Papathanasiou E, Palaska I, Theoharides TC. Stress hormones regulate periodontal inflammation. J Biol Regul Homeost Agents. 2013;27(3):621-626. PMID: 24152831 www.ncbi.nlm.nih.gov/pubmed/24152831.
Perry DA. Epidemiology of periodontal diseases. In: Perry DA, Beemsterboer PL, Essex G, eds. Periodontology for the Dental Hygienist. 4th ed. St Louis, MO: Elsevier Saunders; 2014:chap 3.
Perry DA. Plaque biofilm control for the periodontal patient. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, eds. Carranza's Clinical Periodontology. 12th ed. St Louis, MO: Elsevier Saunders; 2015:chap 45.
Polyzos NP, Polyzos IP, Mauri D, et al. Effect of periodontal disease treatment during pregnancy on preterm birth incidence: a metaanalysis of randomized trials. Am J Obstet Gynecol. 2009;200(3):225-232. PMID: 19254578 www.ncbi.nlm.nih.gov/pubmed/19254578.
Preshaw PM, Chambrone L, Novak KF. Smoking and periodontal disease. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, eds. Carranza's Clinical Periodontology. 12th ed. St Louis, MO: Elsevier Saunders; 2015:chap 10.
Ramseier CA, Warnakulasuriya S, Needleman IG, et al. Consensus Report: 2nd European workshop on tobacco use prevention and cessation for oral health professionals. Int Dent J. 2010;60(1):3-6. PMID: 20361571 www.ncbi.nlm.nih.gov/pubmed/20361571.
Rosenberg ES, Torosian J. Esthetics and periodontics. In: Aschheim KW, ed. Esthetic Dentistry: A Clinical Approach to Techniques and Materials. 3rd ed. St Louis, MO: Elsevier Mosby; 2015:chap 14.
Tinanoff N. Periodontal diseases. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, eds. Nelson Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier; 2016:chap 313.
Tonetti MS, Van Dyke TE; Working group 1 of the joint EFP/AAP workshop. Periodontitis and atherosclerotic cardiovascular disease: consensus report of the Joint EFP/AAP workshop on periodontitis and systemic diseases. J Clin Periodontol. 2013;40 Suppl 14:S24-S29. PMID: 23627332 www.ncbi.nlm.nih.gov/pubmed/23627332.
Touger-Decker R, Mobley C; Academy of Nutrition and Dietetics. Position of the Academy of Nutrition and Dietetics: oral health and nutrition. J Acad Nutr Diet. 2013;113(5):693-701. PMID: 23601893 www.ncbi.nlm.nih.gov/pubmed/23601893.
US Preventive Services Task Force. Using nontraditional risk factors in coronary heart disease risk assessment: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151(7):474-482. PMID: 19805770 www.ncbi.nlm.nih.gov/pubmed/19805770.
Reviewed By: Michael Kapner, DDS, General Dentistry, Norwalk, CT. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.