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07/03/2024

All You Need to Know About Periodontitis and Systemic Diseases – A Comprehensive Guide 

An Dental
gum disease singapore
Periodontal disease has been linked to various systemic issues.

In recent years, the relationship between oral health and overall systemic well-being has emerged as a focal point of scientific inquiry. The human body operates as a complex ecosystem wherein each component influences and interacts with others. Within this interconnected health system, the connection between periodontal issues—specifically, diseases affecting the gums and supporting structures of the teeth—and systemic issues has garnered significant attention from researchers and healthcare professionals alike.

Numerous studies have illuminated the far-reaching implications of periodontal health beyond the confines of the oral cavity. Increasingly, evidence suggests that periodontal or gum diseases may serve as more than merely localised afflictions but rather as potential indicators or contributors to systemic conditions, including cardiovascular diseases, diabetes, respiratory illnesses, adverse pregnancy outcomes, and even neurodegenerative disorders

In Singapore, a large-scale study [1] conducted by the Health Promotion Board found that almost 85% of adults experienced mild to moderately severe periodontal disease. Another survey [2] by the Ministry of Community Development, Youth and Sports revealed that approximately one-third of older adults living in the community were completely toothless (edentulous), indicating dental caries and periodontal disease as primary causes of tooth loss. 

Periodontitis typically emerges in individuals around their fourth decade of life, with its prevalence escalating with age. It is anticipated that periodontitis will persist as a significant public health concern globally, and in Singapore, the oral health risk factor [3] will continue as the population ages. 

edentulous
Singapore’s ageing population has a high incidence of toothlessness due to untreated periodontal or gum disease.

In this comprehensive guide on periodontal disease and systemic issues, we aim to provide a holistic understanding of how periodontal health intersects with systemic wellness. Moreover, this guide endeavours to guide readers—whether healthcare professionals, researchers, or individuals seeking to optimise their health—with evidence-based strategies to promote oral and systemic well-being. 

What is periodontal disease?

Before we delve into the complicated connection between oral health and overall well-being, we must first understand periodontal disease.

Periodontal disease, also known as gum disease or periodontitis, is a severe chronic inflammation of the gums and other support structures of the teeth. There are 4 stages of gum disease; these are:

  • Stage 1, Gingivitis: gingivitis is the earliest stage of periodontal disease. It is characterised by swollen and red gums that may bleed while brushing. Gingivitis is reversible as there is still no bone loss.
  • Stage 2, Mild Periodontitis: mild periodontitis occurs when bacteria enter beneath your gums. This affects the supporting structures of the teeth and may cause the gums to pull away from the teeth. 
  • Stage 3, Moderate Periodontitis: untreated moderate periodontitis results in the destruction of support structures such as gums, ligaments, bones, and other structures of the teeth. Moderate periodontitis is accompanied by pain, bad breath, and infection.
  • Stage 4, Advanced Periodontitis: advanced periodontitis occurs when there is severe bone loss, resulting in loose teeth that eventually dislodge and fall out.
gum disease stages
There are 4 stages of periodontal disease, each advancing in severity.

How does periodontitis affect systemic health?

The oral-systemic connection is a complex interplay between oral health and overall systemic well-being, with various mechanisms influencing systemic health. One crucial aspect is inflammation – a common link between periodontal disease and systemic conditions. Chronic inflammation in the oral cavity can lead to the release of pro-inflammatory mediators [4] into the bloodstream, which may contribute to systemic inflammation and exacerbate conditions such as cardiovascular diseases, diabetes, and neurodegenerative disorders.

Bacterial translocation is another key mechanism in the oral-systemic connection. Periodontal pathogens can enter the bloodstream through the gingival tissue or during dental procedures, which can lead to bacteremia [5]. Once in circulation, these bacteria can travel to distant sites in the body and trigger inflammatory responses, which may exacerbate existing systemic conditions or contribute to developing new ones.

gum disease
Periodontal disease is a chronic inflammatory condition affecting the gums and supporting structures of the teeth.

Furthermore, immune responses play a critical role in mediating the oral-systemic connection. The immune system's response to oral pathogens and inflammation can have far-reaching effects on systemic health. Dysregulation [6] of the immune response in the oral cavity may lead to systemic immune dysregulation, which may increase susceptibility to infections and inflammatory diseases throughout the body.

What is the relationship between periodontal disease and different systemic conditions?

The relationship between periodontal disease and systemic conditions is multifaceted, with growing evidence suggesting various interconnections between oral health and overall systemic well-being. 

Periodontitis and Cardiovascular Disease 

Research indicates a potential association between periodontal disease and an increased risk of cardiovascular diseases such as heart disease, stroke, and atherosclerosis. Chronic inflammation triggered by periodontal pathogens may contribute to endothelial dysfunction, arterial plaque formation, and systemic inflammation, exacerbating cardiovascular risk.

Atherosclerosis, characterised by the accumulation of calcium and fatty materials in artery walls leading to plaque formation and arterial hardening, poses significant risks, including angina, myocardial infarction, stroke, and aneurysm. These complications collectively contribute to cardiovascular diseases, which remain the primary cause of global mortality. The connection between periodontal disease and atherosclerotic cardiovascular disease (ACVD) is underscored by bacterial involvement in both conditions, which suggests a direct or indirect mechanistic link independent of other established risk factors. 

A consensus report [7] by the joint American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) workshop emphasises the imperative for dental practitioners to recognise periodontitis as a risk factor for ACVD and to alert patients accordingly. Furthermore, individuals with periodontitis and additional ACVD risk factors should be encouraged to seek medical evaluation. Addressing modifiable lifestyle factors such as smoking, hypertension, and obesity through collaborative efforts between dental and medical professionals can potentially mitigate the risk of both periodontal disease and ACVD, thereby promoting holistic health improvements that extend beyond oral health.

Atherosclerosis
Atherosclerosis is characterised by plaque accumulation in the arteries, leading to narrowing and hardening, which can increase the risk of heart disease and stroke. 

Periodontitis and Diabetes 

Studies [8] suggest that individuals with diabetes are at a higher risk of developing periodontal disease. Conversely, untreated periodontal disease may adversely affect glycemic control in diabetic patients. The inflammatory response associated with periodontitis can exacerbate insulin resistance and contribute to poor diabetes management.

Patients with diabetes must understand that they face an elevated risk of developing periodontal disease. Furthermore, they should be informed that if they do develop periodontal disease, managing their blood sugar levels may become more challenging, and they are at increased risk for complications such as cardiovascular and kidney diseases. 

Therefore, individuals with diabetes should undergo a comprehensive oral examination, including a thorough assessment of periodontal health. Additionally, patients with diabetes should be screened for other potential oral complications, such as dry mouth, burning mouth syndrome, and candida infections.

Diabetes periodontal diseases link
Diabetes may increase the risk and severity of periodontal disease, and periodontal disease can adversely affect glycemic control in individuals with diabetes. 

Periodontitis and Respiratory Illnesses

Periodontal disease has been linked to respiratory conditions such as pneumonia, chronic obstructive pulmonary disease (COPD), and even COVID-19. Oral pathogens can be aspirated into the lungs, potentially exacerbating existing respiratory conditions or increasing susceptibility to respiratory infections. Periodontitis and respiratory infections share common inflammatory pathways and risk factors, such as smoking, heightening susceptibility to infections by compromising the immune system and vascular function. 

Research [9] highlights the strong correlation between smoking and both acute and chronic respiratory infections like pneumonia. Moreover, smoking significantly influences the onset and progression of periodontitis by altering the composition of oral bacteria and promoting the colonisation of periodontal pathogens. When combined with poor oral hygiene, smoking exacerbates the risk of pulmonary diseases. 


gum disease lung disease
Periodontal disease has been linked to various respiratory illnesses, such as pneumonia and COPD.

Thus, it is crucial to implement interventions aimed at reducing oral biofilm accumulation, such as using chlorhexidine rinses to control dental biofilms and minimising aerosol production during dental procedures to lower the risk of aspiration. However, further investigation and research are still in progress to better understand the relationship between the severity of periodontal diseases and the susceptibility to respiratory infections.

Periodontal Disease and Adverse Pregnancy Outcomes
 

Pregnant women with untreated periodontal disease may face an increased risk of adverse pregnancy outcomes. Periodontal disease affects approximately 40% of pregnant mothers [10]. As a result of the hormonal changes during pregnancy, such as elevated oestrogen and progesterone levels, 50 to 70% [11] of women are more susceptible to gingivitis, which makes them more vulnerable to contracting periodontal disease as compared to non-pregnant women. 

Research [12] suggests that periodontal disease during pregnancy is associated with preterm birth and/or low birth weight. The periodontopathogenic bacteria present in gingival plaque can directly affect the foetus through bacteremia. Mothers with periodontal disease have a significantly higher risk of delivering preterm or low birth weight babies compared to those with healthy gums, with the possibility of a seven times [13] increased risk. Therefore, early detection of periodontal disease in pregnant women is crucial to reduce the incidence of preterm birth and low birth weight.

Periodontal Disease and Neurodegenerative Disorders 

Neurodegenerative diseases encompass a range of progressive conditions affecting the central nervous system (CNS), such as Alzheimer's, Parkinson's, and multiple sclerosis, with inflammation playing a pivotal role in their development and advancement. Periodontitis, characterised by inflammation from oral biofilms surrounding tooth-supporting tissues, is recognised as a chronic inflammatory disorder contributing to systemic inflammation. It affects various tissues around the teeth, including gums, cementum, periodontal ligament, and alveolar bone, initiated by dysbiotic biofilms, potentially leading to systemic inflammation. 

Emerging research [14] suggests a possible link between periodontal disease and neurodegenerative disorders such as Alzheimer's disease. Chronic inflammation and bacterial components from periodontal pathogens may contribute to neuroinflammation, neurodegeneration, and cognitive decline. 

gum disease Alzheimer’s
Neurodegenerative diseases such as Alzheimer’s have been linked to periodontal disease.

Who is at risk for periodontal disease? 

Understanding the common risk factors associated with periodontal disease is essential for maintaining optimal oral health and preventing the onset or progression of this prevalent condition. Common risk factors that can increase an individual's susceptibility to periodontal disease include: 

  • Poor oral hygiene: inadequate oral hygiene practices, such as irregular brushing and flossing, allow plaque (a sticky film of bacteria) to accumulate along the gumline and teeth. Over time, plaque hardens into tartar, leading to gum inflammation (gingivitis) and, if left untreated, may even progress to periodontal disease.
  • Smoking and tobacco use: tobacco products, including cigarettes, cigars, and chewing tobacco, significantly elevate the risk of periodontal disease. Smoking weakens the immune system's ability to combat infections, reduces blood flow to the gums, and impairs tissue healing, which can make smokers more susceptible to gum infections and periodontitis.
  • Genetic factors: genetic predisposition [15] can influence an individual's susceptibility to periodontal disease. Certain genetic variations may affect immune responses to bacterial plaque, making some individuals more prone to gum inflammation and periodontitis than others, even with adequate oral hygiene practices.
  • Hormonal changes: hormonal fluctuations during puberty, pregnancy, menstruation, and menopause can impact gum health. Elevated levels of progesterone and oestrogen can make gums more sensitive to plaque, resulting in increased inflammation and a higher risk of developing periodontal disease during these stages.
  • Systemic diseases: as discussed in the previous section, chronic systemic conditions such as diabetes, cardiovascular diseases, and others like rheumatoid arthritis and HIV/AIDS can compromise the immune system's ability to fight infections and regulate inflammation. Individuals with these conditions are at an increased risk of developing gum infections and periodontal disease.
  • Certain medications: some medications [16], such as anticonvulsants, immunosuppressants, and antihypertensive drugs, can have side effects that affect gum health. 
  • Stress: chronic stress can weaken the immune system and exacerbate inflammation throughout the body, including in the gums. Prolonged stress may impair the body's ability to combat gum infections, contributing to the development or progression of periodontal disease.
poor oral hygiene
Poor oral hygiene can lead to the accumulation of plaque and tartar, increasing the risk of periodontal disease due to bacterial inflammation and infection in the gums.

By recognising these common risk factors and taking proactive steps to address them through regular visits to an experienced periodontist in Singapore and diligent oral hygiene practices, individuals can mitigate their risk of developing periodontal disease and maintain optimal oral health.

What are the symptoms of periodontal disease?

Periodontitis, a severe gum infection that damages the soft tissue and destroys the bone that supports your teeth, often presents with the following symptoms:

  • Bleeding gums: gums that bleed easily, especially during brushing, flossing, or eating, may indicate periodontitis. This bleeding is often more pronounced than what occurs with mild gingivitis.
  • Red, swollen, tender gums: inflammation of the gums is one of the hallmark symptoms of periodontal disease. When bacteria in plaque and tartar build up along the gum line, the body's immune response triggers inflammation, causing the gums to become swollen, red, and tender to the touch. This inflammation is often more pronounced than what is typically observed in cases of mild gingivitis, indicating a more advanced stage of gum disease.
  • Receding gums: periodontitis can cause the gums to pull away or recede from the teeth, exposing more of the tooth's surface and creating a “long-tooth” [17] appearance.
  • Gum pocket formation: deep pockets can develop between the teeth and gums as the gum tissue pulls away from the teeth. These pockets trap food debris and bacteria, contributing to further infection and bone loss.
  • Loose or shifting teeth: as periodontitis progresses, the bone supporting the teeth may deteriorate, causing teeth to loosen or shift [18]  in position. This can affect your bite and lead to tooth loss if left untreated.
  • Changes in bite alignment: changes in how your teeth fit together when you bite or chew may occur as periodontitis progresses. This can lead to discomfort or difficulty chewing.
  • Sensitive or painful teeth: teeth affected by periodontitis may become sensitive to hot or cold temperatures and may ache or feel tender to the touch.

It is important to note that periodontitis can progress without causing noticeable symptoms, especially in its early stages. Regular dental check-ups and professional cleanings are essential for detecting and treating periodontal disease before it leads to irreversible damage. 

Therefore, if you notice any of these symptoms, it is essential to seek prompt evaluation and treatment from an experienced periodontist to prevent further progression of periodontitis and preserve oral health.

Periodontitis swollen, red gums
Swollen, red gums are a common sign of periodontitis, indicating inflammation and infection of the gum tissues. 

Is halitosis or persistent bad breath a sign of periodontitis?

Halitosis or persistent bad breath [19] can signify periodontitis. When periodontal disease progresses, bacteria accumulate in the deep pockets that form between the gums and teeth. These bacteria produce foul-smelling byproducts, leading to persistent bad breath. Additionally, the presence of gum inflammation and infection can contribute to halitosis. 

While bad breath can have various causes, including poor oral hygiene, dietary habits, and certain medical conditions, it is important to consider periodontitis as a potential underlying cause, especially if other symptoms of gum disease, such as swollen or bleeding gums, are present. Seeking evaluation and treatment from a periodontist is crucial for addressing the root cause of halitosis and preventing further complications associated with periodontitis.

Periodontitis halitosis
Halitosis, or persistent bad breath, can be a symptom of periodontitis caused by bacterial buildup in the mouth.

Can pus formation be a symptom of periodontitis?

Yes, pus formation [20]  can be a symptom of advanced periodontitis. As periodontal disease progresses, the infection within the gums can accumulate pus in the pockets that form between the gums and teeth. This is known as periodontal abscesses. Pus is a thick, yellowish fluid composed of dead white blood cells, bacteria, and tissue debris. It is a sign of active infection and inflammation in the gum tissues.

The presence of pus indicates that the body is actively fighting the infection but also suggests that it has reached an advanced stage. Pus formation can be accompanied by other symptoms of periodontitis, such as swollen, red, tender gums, bleeding gums, loose teeth, and changes in bite alignment. If you notice pus around your gums or between your teeth, you must seek prompt evaluation and treatment from a periodontist. Ignoring this symptom can lead to further progression of periodontal disease, increased risk of tooth loss, and potential complications for your overall oral health.

How can you prevent periodontal disease? 

Periodontal disease is a common and potentially serious condition that demands proactive measures to mitigate its impact. By following the strategies discussed in this section, you can fortify your defences against periodontal disease and pave the way for a lifetime of healthy gums and overall well-being.

Proper oral hygiene practices

Maintaining good oral hygiene is paramount in preventing periodontal disease. You must brush your teeth at least twice daily using fluoride toothpaste and a soft-bristled toothbrush. Additionally, daily flossing helps remove plaque and debris from between the teeth and along the gum line, where a toothbrush may not reach effectively. Proper technique is crucial; you should brush gently in circular motions and angle the bristles towards the gumline to remove plaque effectively without causing damage to the gums.

Regular dental check-ups

Routine dental check-ups and professional cleanings are essential for preventing and managing periodontal disease. Dentists or gum specialists like periodontists can assess the health of the gums, detect early signs of periodontal disease, and provide personalised recommendations for oral hygiene and preventive care. Professional cleanings remove tartar buildup, which cannot be removed through brushing and flossing alone, which helps prevent the progression of gum disease.

regular periodontist visits
Regular visits to dentists or periodontists can help maintain oral health and minimise the risk of periodontal disease

Lifestyle modifications

Certain lifestyle factors can influence the risk of periodontal disease. Avoiding tobacco use, including smoking and chewing tobacco, is crucial, as tobacco products significantly increase the risk of gum disease and can hinder treatment outcomes. Maintaining a balanced diet rich in fruits, vegetables, lean proteins, and whole grains promotes oral health and can help prevent periodontal disease. Limiting sugary snacks and beverages reduces the risk of cavities and gum inflammation.

By implementing these preventive strategies and incorporating them into a comprehensive oral hygiene routine, individuals can effectively reduce their risk of developing periodontal disease and maintain optimal oral health. 

How do periodontists treat gum disease? 

Periodontists are dental specialists who specialise in the prevention, diagnosis, and treatment of periodontal disease and other conditions affecting the gums and supporting structures of the teeth. They often utilise a combination of professional interventions and ongoing maintenance to manage periodontal disease effectively. Here are some common treatments for periodontal disease:

  • Scaling and root planing (deep cleaning): this non-surgical procedure involves removing plaque and tartar (calculus) from above and below the gum line and smoothing the root surfaces to remove bacterial toxins. Scaling and root planing help eliminate bacteria and promote gum tissue healing.
scaling and root planing
Dental scaling and root planing remove plaque and tartar from above and below the gum line.
  • Pocket reduction surgery: in cases where deep pockets have formed between the gums and teeth due to periodontal disease, periodontists may recommend pocket reduction surgery [21] (also known as flap surgery or periodontal flap surgery). During this procedure, the gum tissue is folded back to remove bacteria and smooth irregular surfaces of damaged bone. The gum tissue is then repositioned to reduce the size of the pockets and promote gum attachment to the teeth.
pocket reduction surgery
Periodontal flap surgery removes bacteria from below the gums.
  • Bone grafts: in advanced cases of periodontal disease where bone loss has occurred, periodontists may recommend bone grafting [22] to regenerate lost bone tissue and support the teeth. Bone grafts involve placing synthetic or natural bone material in areas of bone loss to stimulate new bone growth and improve the stability of the teeth.
bone graft gum disease
Bone grafting may be necessary for individuals with dental bone loss due to periodontal disease.
  • Guided tissue regeneration: this surgical procedure [23] regenerates lost gum tissue and bone around the teeth affected by periodontal disease. A barrier membrane is placed between the gum tissue and bone to prevent gum tissue from growing into the area while allowing bone to regenerate.
guided tissue regeneration
Guided tissue regeneration helps to regenerate lost bone and gum tissue.
  • Gingival grafts: in cases of gum recession due to periodontal disease, periodontists may perform gingival grafting [24] to cover exposed tooth roots and protect them from further damage. Gingival grafts involve taking tissue from the roof of the mouth or another donor source and placing it over the exposed roots.
gum recession
Gingival grafts are performed when tooth roots are left exposed due to advanced gum disease.
  • Antibiotic therapy: in some cases, antibiotics may be prescribed, either orally or topically, to control bacterial infections associated with periodontal disease. Antibiotics may be used as adjunctive therapy alongside other treatments to enhance their effectiveness.
  • Ongoing maintenance: following treatment, patients with periodontal disease require regular periodontal maintenance visits to monitor their gum health, remove plaque and tartar, and prevent disease recurrence. These maintenance visits typically occur every three to four months and are essential for the long-term management of periodontal disease.

Overall, periodontal treatment aims to control the infection, restore gum health, and prevent further damage to the teeth and supporting structures. By working closely with your periodontist and following their recommended treatment plan, individuals with periodontal disease can achieve improved oral health and maintain their natural teeth for as long as possible.

If you have periodontal disease or want a thorough dental checkup from an experienced periodontist, you may visit An Dental and schedule your dental checkup to receive expert guidance for optimising your oral health. 

References 

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2. Chiu, C.-T., Malhotra, R., Tan, S. M., Lim, J., Chan, A., Teoh, K. H., Gan, S. T., & Saito, Y. (2017). Dental health status of community-dwelling older Singaporeans: Findings from a nationally representative survey. Gerodontology, 34(1), 57–67. https://doi.org/10.1111/ger.12218 

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6. Suárez, L. J., Garzón, H., Arboleda, S., & Rodríguez, A. (2020). Oral dysbiosis and autoimmunity: From local periodontal responses to an imbalanced systemic immunity. A review. Frontiers in Immunology, 11, 591255. https://doi.org/10.3389/fimmu.2020.591255 

7. Tonetti, M. S. (2013). Van Dyke TE and on behalf of working group 1 of the joint EFP/AAP workshop. Periodontitis and atherosclerotic cardiovascular disease: consensus report of the Joint EFP. In AAP Workshop on Periodontitis and Systemic Diseases. J Clin Periodontol (Vol. 40, No. 14, pp. S24-9). 

8. Graves, D. T., Ding, Z., & Yang, Y. (2020). The impact of diabetes on periodontal diseases. Periodontology 2000, 82(1), 214–224. https://doi.org/10.1111/prd.12318 

9. Brock, M., Bahammam, S., & Sima, C. (2022). The relationships among periodontitis, pneumonia and covid-19. Frontiers in Oral Health, 2. https://www.frontiersin.org/articles/10.3389/froh.2021.801815 

10. Salih, Y., Nasr, A. M., Ahmed, A. B. A., Sharif, M. E., & Adam, I. (2020). Prevalence of and risk factors for periodontal disease among pregnant women in an antenatal care clinic in Khartoum, Sudan. BMC Research Notes, 13(1), 147. https://doi.org/10.1186/s13104-020-04998-3 

11. TETTAMANTI, L., LAURITANO, D., NARDONE, M., GARGARI, M., SILVESTRE-RANGIL, J., GAVOGLIO, P., & TAGLIABUE, A. (2017). Pregnancy and periodontal disease: Does exist a two-way relationship? Oral & Implantology, 10(2), 112–118. https://doi.org/10.11138/orl/2017.10.2.112 

12. Moliner-Sánchez, C. A., Iranzo-Cortés, J. E., Almerich-Silla, J. M., Bellot-Arcís, C., Ortolá-Siscar, J. C., Montiel-Company, J. M., & Almerich-Torres, T. (2020). Effect of per capita income on the relationship between periodontal disease during pregnancy and the risk of preterm birth and low birth weight newborn. Systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 17(21), 8015. https://doi.org/10.3390/ijerph17218015 

13. Teshome, A., & Yitayeh, A. (2016). Relationship between periodontal disease and preterm low birth weight: Systematic review. Pan African Medical Journal, 24(1). https://doi.org/10.11604/pamj.2016.24.215.8727 

14. Alvarenga, M. O. P., Frazão, D. R., de Matos, I. G., Bittencourt, L. O., Fagundes, N. C. F., Rösing, C. K., Maia, L. C., & Lima, R. R. (2021). Is there any association between neurodegenerative diseases and periodontitis? A systematic review. Frontiers in Aging Neuroscience, 13, 651437. https://doi.org/10.3389/fnagi.2021.651437 

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16. Golob Deeb, J., Lyons, D. J., Laskin, D. M., & Deeb, G. R. (2020). Severe drug-induced gingival enlargement and periodontitis: A case series with clinical presentation and management. Oral and Maxillofacial Surgery Cases, 6(1), 100143. https://doi.org/10.1016/j.omsc.2020.100143 

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19. Halitosis(Bad breath). (2020, February 28). https://www.hopkinsmedicine.org/health/conditions-and-diseases/halitosis-bad-breath 

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21. Why do i need osseous surgery? (n.d.). Cleveland Clinic. Retrieved February 25, 2024, from https://my.clevelandclinic.org/health/treatments/24886-osseous-surgery 

22. Ferraz, M. P. (2023). Bone grafts in dental medicine: An overview of autografts, allografts and synthetic materials. Materials, 16(11), 4117. https://doi.org/10.3390/ma16114117 

23. Wolff, L. F. (2000). Guided tissue regeneration in periodontal therapy. Northwest Dentistry, 79(6), 23–28, 40. 

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